PTSD is a relatively new diagnosis, but Post-Traumatic Stress Disorder has been observed throughout decades of warfare. Here, tracing the history and our growing understanding of how the disorder affects soldiers are Matthew Friedman, executive director of the VA's National Center for PTSD; VA psychiatrist Andrew Pomerantz; and Col. Thomas Burke, director of mental health policy for the Dept. of Defense. These excerpts are from their extended FRONTLINE interviews.

Exec. Dir., VA National Center for Post-Traumatic Stress Disorder

…Can you talk about the term "Soldier's Heart" and how it connects to our understanding today about what is PTSD?

The term "Soldier's Heart" was first coined in the post-Civil War era when people were looking at these veterans returning from Civil War combat and trying to understand why they had been changed, because there was general recognition that they had been changed, and that many of those changes were not for the good. [And back then] there were two different models trying to explain this. One was a psychological model, and the other model was a physiological model.

Soldier's Heart comes from the physiological model, the observations that people's cardiovascular system in terms of their heart dynamics, their blood pressure, a pulse rate, seemed to be altered. We can now incorporate that under the PTSD construct, but starting with Soldier's Heart, Irritable Heart ... it was [Jacob Mendez] Da Costa, who I believe was a 19th-century cardiologist, who made these observations.

Then, in World War I, another physical explanation was shell shock, the notion being that being close to the big guns pounding out the artillery on both sides of the barbed wire in the trench warfare was somehow disrupting neuronal connections, so nerves were actually affected. Combat exhaustion, combat fatigue -- all of these are physical types of manifestations. Following the Gulf War, some people felt that the unexplained medical symptoms [were] on a continuum going back to Soldier's Heart, as you've asked.

The parallel trajectory is about the psychological models. And in the Civil War, it was very interesting; the psychological model was nostalgia. The notion was that a Vermonter who found himself with Sherman marching through Georgia who exhibited psychological symptoms was doing so because he was nostalgic for being back in Vermont. Being in this alien Georgia terrain was somehow psychologically so disconcerting that he was having these kinds of symptoms. So this was another model under the influence of the Freudian psychoanalytic school. This got transformed into notions of traumatic neurosis and on and on.

And what's really interesting about PTSD is that it incorporates both the physical manifestations -- and certainly our research has shown that people with PTSD have alterations in their physiology and even are at risk for medical problems as well as psychological problems -- and it incorporates, of course, the psychological symptoms. The first person who really discovered this was an American psychoanalyst [Abraham Kardiner] working with World War I veterans. ... And what he observed, in addition to the psychological distress that they were manifesting and that he was diagnosing as traumatic neurosis -- which was the term that was used for these symptoms in those days -- he also noticed that they were physiologically altered. Particularly he noticed that they were very jumpy, that unexpected loud noises would produce in them a startled reaction …

Tell me about the breakthrough concerning understanding how the mind and body connect.

Well, you know, this mind-body dualism that has infected medical thinking for centuries, since Descartes, if you will, is the notion that what happens in the mind doesn't affect the body. And hopefully everybody now recognizes that we're talking about the brain, and the brain is a part of the body. And it also is the part of the body that produces the phenomenology that we also talk about as mind.

And I'd say in the last 10, maybe 15 years, there has been extraordinary progress. And I'm proud to say that the National Center for PTSD has been at the forefront of this progress, showing that people with PTSD have alterations in certain structures of the brain. And they have alterations in how the brain processes information, particularly how it processes information perceived to be dangerous or information that might be reminiscent of a tour in Iraq or of other traumatic situations. So this really is becoming much clearer now in terms of why both the body and the brain are affected in people with PTSD and other post-traumatic problems.

Chief of mental health services for the VA in Vermont

…Did World War II vets talk about PTSD?

… The classic story for a World War II veteran is, [he] came home from the war, drank a little bit too much, maybe partied a little too much, got in some fights here and there, had a hard time settling down. Eventually, with a lot of support and perhaps [a] push from the family, he said, "OK, I'm done doing this," and then worked two jobs for the next 30, 40 years, sometimes having an occasional nightmare but basically having the whole experience shut off from the rest of [his] life -- "I put it behind me" -- not talking very much about it with family members or with others, many not associating with other veterans' groups or anything that might bring back some of the remembrance of what they went through.

And then many of those folks, as they reached retirement, as they developed illness, as they went through family stresses or they lost loved ones, suddenly would wake up one night in the middle of a nightmare saying, "Where'd this come from?" And I've seen many of those people from that moment on be plagued by symptoms. ...

It was a different world, it was a different culture that they came back to. It was a culture of a post-Depression era -- "We won the war; we're really great." ... When I ask them one of my standard questions -- "Have you ever talked with your family about what happened?" -- the answer is almost invariably no. Almost to a person, it's always "No, I haven't." "Well, why not?" Well, it's "They don't want to hear it; they wouldn't believe it; I don't want them feeling sorry for me; they haven't asked about it." When you ask their families if it ever gets that far, they say, "Well, we always [knew we] should never ask Dad that question; there were some things we just had to stay away from." ...

Society didn't want to hear it, you know. You don't want to hear that your hero who has just come back from winning the war is troubled by what he did over there and the people he bombed, the people he shot. People didn't want to hear that kind of thing. All anybody wanted to hear at the time was: "Isn't it wonderful? We won. We've saved the world. Thank you." ...

There's a fellow from the other side of the state that I see from time to time, who worked lots of jobs, had positions of authority, was very effective in his work. Within a week after he retired, he was just flooded with symptoms. "Where'd this come from? I have no idea what this is about. I remember these events, I remember how awfully it felt at the time, but I thought I put those behind me years ago. Why are they here now? Why are they back?"

It's a very common response from people who are just now reexperiencing stuff that they thought was long gone, long buried. The mind is a wonderful thing, what it can do. It can protect us from things that are too upsetting. And sometimes we get away with it; sometimes we don't. Sometimes it comes back years later. …

Sometimes people come back to these experiences at the end of their lives.

I think the best piece of work I ever did in treating anybody with PTSD was a Korean War veteran who had been a POW who had helped his fellow POWs escape. Part of the process of that was coming up behind somebody and putting a piece of cord around his neck and strangling him. This man lived with that image for his whole life. It would come to him occasionally while he was working, but not in a big way. When he was dying, I think the best thing that I was able to do for him was help him find a way to talk to his pastor about it. [A] pastor came from the local church and listened to the story and provided the kind of forgiveness that for this man only a pastor could do. Psychiatrists can't do that; we don't have that kind of power.

These people, their spirituality is deeply affected by what they've done. And I've seen many people when they are dying -- and I've done a lot of work with that population -- they start talking about things that happened 50 years ago. Many are looking for forgiveness. Some have given up looking for forgiveness. They just feel this is something that does not fit with how they've lived their lives. Part of the work of dying ... is putting your whole life in context, looking at how it all fits together, and for people like this, this doesn't fit. This is not how they lived. This is not how they were raised as children; it's not how they have functioned as adults. It's an interlude that lasted a year or two, and it does not fit anywhere. And it's very hard work. …

How do the services available now compare with what Vietnam, World War II, or Korean War vets got?

I think that the person returning from Iraq is going to see a mental health service that is more sophisticated in its knowledge about what to do to be of help to them. ... They won't necessarily find more resources, but hopefully they will find more effective resources than they did 30 years ago. ... People came home from Vietnam and [were told,] "Well, you're just crazy." They got put into this psych thing; they got treated with major tranquilizers. There were not a lot of specialized programs. So now at least we have specialized programs that not only are specialized but actually have some expertise. ...

One thing we know is that [today's] veteran, more than any other, has a much higher likelihood of actually being in combat. This war is everywhere, in the streets; there's no safe place. In Vietnam there were at least some safe places, relatively safe places that you could be. In Iraq there's no safe place. So people who are coming home will have been on peak alert for 365 days or more, will have had all of their senses tuned to the slightest disturbance, the slightest sound of trouble, so I think it's going to be a very sensitized population. It will have a much higher prevalence of people who have had bad things happen, who have seen combat, who have been in combat, who have lost people close to them, who have had the guy standing next to them blown up, the person in the Humvee sitting next to them blown up. We will see a lot more of that. …

Even the World War II veterans who won't say anything to their families, have never spoken to their friends, when they get going in a group of them who are all flooded with memories, they have a lot of stories to tell. They won't tell anybody else. And they will say: "It's because Joe understands. Nobody else would understand, and most people wouldn't believe it."

We're beginning to see some of that same trajectory with some of the Vietnam veterans who have been very productive citizens [and] who are now getting into their 50s and 60s. We're seeing more and more and hearing more and more of them coming into treatment saying: "I don't understand what's happening, you know? I've been doing fine all these years, and all of a sudden I'm having trouble. I don't understand." So I expect we will be seeing Vietnam-era people for the next 30 years. …

Director of Mental Health Policy, U.S. Dept. of Defense

…Historically, what has been the percentage of veterans suffering from PTSD?

The historical experience, for example with PTSD, of people who have been POWs [is] about 50 percent. Vietnam veterans, 25 to 30 percent had PTSD. Of Gulf War I veterans, 10 to 15 percent had PTSD. There was a study done that was published in the New England Journal of Medicine [Editor's Note: See the "Readings" section of this Web site for the study] ... that showed that about 15, 16, 17 percent of soldiers coming back from deployments to Iraq and Afghanistan reported symptoms consistent with anxiety depression or PTSD.

This was really a very unique study because it was done on soldiers almost immediately after they got off the plane. This wasn't a study done 10 years later. This was a study done immediately, or almost immediately, after exposure to the situation that you would expect to be the risk factor for PTSD. So comparing that 15, 16 percent to the 10 to 15 percent that we saw in Gulf War I, it wasn't surprising that there were soldiers coming back who were reporting these kinds of symptoms. We are concerned about those soldiers and want to provide the best possible care for those soldiers.

The other thing that the study showed is that some of the soldiers were reluctant to seek out that care. That's something that we need to work on: making sure that all of the soldiers who need care, because of what they have seen and been exposed to during their deployment to Iraq and Afghanistan, get the care that they need. …

What has driven this progress in our understanding of PTSD?

I think it's fair to say that the Vietnam veterans and the fact that they were so socially active, and that the Vietnam veterans' advocacy groups were so politically active, were very important in getting PTSD defined, getting research resources allocated for the research into PTSD, and getting it on the map politically. It was pressure from the Vietnam veterans' advocacy groups that really pushed the mental health community into defining PTSD and putting it into the DSM IV.

So you do think our treatment and understanding of PTSD has improved?

Certainly I think that that's true. I think that because the mental health community, because mental health as a science and as a medical art, has come such a long distance, we have more to offer. I think that there's also been awareness through the military physicians who have been around since Vietnam, ... and they have really worked to develop the doctrine and the organizational structures, the mental health resources to be a part of the combat force that goes into war.

For Gulf War I, [the Army] was using the new units, combat stress control units, that were structured and had a doctrine in training that allowed them to not be clinic-based, where the soldiers had to come away from where their units were deployed and come to a central location for care, but to take that care forward to where the units were, where the soldiers were, where they were being exposed to the things that were causing them problems. [These units] provide more proactive care, more preventive health ... and also a particular type of mental health care for soldiers with Acute Stress Disorders, with what we call combat and operational stress reactions.

This is a particular type of disorder, and it's treated far forward, near the soldier's unit. They pull them out of the violent situation that they are in to a safe place, but not very far away from their unit. They provide a very simple regimen of sleep, including medication for sleep if they need it; rest, a couple of, three days of rest; hot food; hot showers; clean uniforms. They keep them close to their unit, so that they can maintain that identity with their unit and so that they can also have chain of command.

Their commanders can come and visit them, and they maintain that sense of belonging in that social structure. That's important for making them feel like they're not a patient; they're not sick; they're not in a hospital. They're still part of their unit. They're treated with the expectation that they're going to get better in a couple of days and go back to work.

[But that was not always the case, was it? In the past, what was the procedure for soldiers suffering from PTSD?]

Our experience with that has gone back all the way to the First World War. They evacuated shell shock casualties, and a large proportion of them went [on] to develop chronic mental health disorders. [It was] the same experience [when] we looked at the experience from World War II and Korea and from Vietnam. The first Gulf War was the first time that the Army, the American Army, had tried to use the specific types of units with this specific type of training and doctrine in treating that particular kind of Acute Stress Disorder.

In the 10 years that has gone by, because of the successes in using that unit and that doctrine and the research, ... those units have been made a permanent, formal part of the Army's structure. So when the Army goes to war, they take their tent hospital with them, but they also take the combat stress control units with them. And that's a regular part of the way the Army does business.

The Marines are starting to adopt some of those Army structures and organization. [They are] adapting it to their own organization and culture, but they are starting to use the embedded, organic mental health resources and not just depend on the tent hospital system that the Navy provides to them.