Different shell, same shockBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5621 (Published 08 December 2017) Cite this as: BMJ 2017;359:j5621
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Re: Different Shell, Same Shock Stoyan Popkirov, Simon Wessely, Timothy R Nicholson, Alan J Carson, Jon Stone. 395: doi 10.1136/bmj.j5621
The article by Popkirov et al (1) makes important points about the cultural transmission of distress. However, two facts of context are open to challenge. In Table 1 it is stated that flashbacks, hypervigilance and avoidance symptoms were not encountered in shell shock. In a random sample of 367 servicemen awarded a war pension for a psychological disorder after the First World War, we found veterans who had these symptoms, though at a significantly lower level than reported for more recent conflicts (2).
The paper also states that ‘movement, sensory or speech disorders’ were commonly seen in shell shock. In the same sample of war pensioners, we found virtually no examples even though it was in the veteran’s financial interest to report such symptoms as this determined the level of compensation that they received. The explanation for this misconception lies not only with the popularity of Hurst’s film but also the fact that specialist neurological units have attracted study because of the quality of their clinical records. Chronic or severe cases of shell shock suffering from movement, sensory or speech disorders were disproportionately represented in these hospitals (3). Clinical reports of functional mutism, blindness, paresis or unusual gaits were published in contemporary medical journals because they were newsworthy. Arthur Hurst had the advantage of working at the Royal Victoria Hospital, Netley, where hundreds of wounded and sick soldiers arrived daily from France. Access to so many invalided servicemen enabled him to find shell-shocked soldiers with unusual movement disorders. Hurst filmed more than the 18 cases included in the final cut of War Neuroses, showing that he had an eye for the dramatic (4). Evidence from war pension files, based on repeated clinical assessments of ex-servicemen with shell shock, showed that the disorder was characterised by common, medically unexplained symptoms, which in the main did not provide compelling material for silent movies. Although originally conceived as a pedagogic tool to supplement medical lectures, Hurst’s film has flourished as a lasting cultural memorial to shell shock but one that is tainted by selection bias.
1. Stoyan Popkirov, Simon Wessely, Timothy R Nicholson, Alan J Carson, Jon Stone. Different Shell, Same Shock. BMJ 2017; 395: j5621
2. Jones E, Palmer IP, Wessely S. War pensions (1900-1945): changing models of psychological understanding. Br J Psych. 2002 180(4): 374-9.
3. Linden SC, Jones E. (2014), ‘Shell shock’ revisited: an examination of the case records of the National Hospital in London. Med Hist 2014 58(4): 519-45.
4. Jones E. War Neuroses and Arthur Hurst: a pioneering medical film about the treatment of psychiatric battle casualties, J Hist Med Allied Sci 2012 67(3): 345-73.
Professor of the History of Medicine and Psychiatry
King’s College London,
Institute of Psychiatry Psychology & Neuroscience
Cutcombe Street, London SE5 9RJ
Competing interests: No competing interests
My psychotherapy work includes working with veterans who suffer with PTSD, and often still do years after leaving the services. The stories that I hear are deeply personal and shocking. These individuals are (or were) proud, highly skilled, intelligent, courageous and resourceful. Many of them feel they have been deeply let down by ‘the system’. Most of them have been subjected to the perils of NHS PTSD ‘Treatment’. This comprises almost entirely of very high doses of antidepressants (often more than one type), supplemented with antipsychotics, anti-epilepsy drugs and sedatives. The effects of the drug cocktails they are prescribed are disabling and render it almost impossible to disentangle and successfully treat the effects of the extreme traumatic stress that they experienced in theatre - and whose effects still continue to haunt them. Some of them have been offered – and tried – CBT, though most find it not very helpful. Many of them have had issues with alcohol along the way – and of course the NHS likes to berate and chastise them for this.
For the authors to imply that people on prescribed cocktails of psychotropic drugs are ‘just’ suffering from ‘functional disorders’ (such as ‘dissociative seizures’ and blackouts) ‘if they let themselves get too worked up’ is reprehensible. Symptoms such as these are known serious adverse effects (side-effects and withdrawal/dose-change effects) of the neurotoxic drugs and drug cocktails that they are, or have been, taking ‘as prescribed’.
This statement in the article is particularly galling: ‘The presentations of shell shock were recognised as functional disorders, highlighting beyond any doubt that “hysteria” could affect men too, and in large numbers.’
Serious and disabling disruption of the functioning of the human nervous system can of course occur due to utterly overwhelming circumstances. Such nervous system disruption and chaos can also be caused and/or seriously exacerbated by neurotoxic chemicals and including prescribed drugs. This has been described as drug stress trauma syndrome:
Psychiatric Drugs as Agents of Trauma by Charles L. Whitfield, MD Excerpted from: The International Journal of Risk & Safety in Medicine 22 (2010) 195-207 DOI 10.3233/JRS-2010-0508 IOS Press Volume 22, Number 4, 2010
Competing interests: No competing interests
I read with interest the article on shell shock by Popkirov et al. As a member of the prescribed drug dependent and withdrawal community, the subject of neurological functional symptoms is often discussed because this descriptive label is often being assigned to the many and varied symptoms patients are experiencing as they try to withdraw from benzodiazepines, antidepressants and other psychiatric drugs. I have suffered for several years now after withdrawing from these drugs and am now physically disabled. Other descriptive labels applied include chronic fatigue syndrome, bodily distress disorder, somatisation, medically unexplained physical symptoms, the list is quite endless and often a variety is applied to the same symptoms experienced by a single patient. Prior to withdrawal, I used to imagine that these labels constituted a diagnosis of some sort but of course I now realise that they are anything but that. In fact they all seem rather arbitrary in nature. Patients who have been harmed by prescribed drugs do not like these labels and very firmly reject them. They would much prefer a label which more accurately related their symptoms to the drugs they have consumed and withdrawn from and which are the cause of their considerable distress and ill-health. I don't think this is unreasonable.
The many symptoms I have had to endure were described extensively by Professor Heather Ashton, formerly Newcastle University, in her very well known "Ashton Manual" and was based on her considerable experience with patients withdrawing from benzodiazepines in her withdrawal clinic. The term she and others have used for decades to describe the months or year of suffering was "protracted benzodiazepine withdrawal syndrome" but of course it is more accurate to describe it as a benzodiazepine drug-induced brain injury or iatrogenic harm.. For some reason the term PBWS seems to have fallen out of favour and has been replaced with descriptive labels which suggest the symptoms may be largely psychological in nature. Prof Ashton however did not subscribe to this view and nor did Prof Malcolm Lader, King's College, London. Both have extensive expertise in benzodiazepines and withdrawal. And so the descriptive labels now applied to the withdrawal symptoms and their aftermath do not even mention the class of drugs responsible. I find this extremely curious and perplexing.
I like the term "shell shock" because it gives some sort of clue as to the possible reason for the veterans' extreme distress even if it may not have been the exact cause of the symptoms in every case. At least you have a sense of the horrors of war which they were forced to endure and which caused their subsequent ill-health. Similarly I like the term PBWS because at least it gives a hint as to the cause of the distress and damage. And so I wonder who benefits from these newer descriptive labels. They certainly don't benefit those in the prescribed dependent community who find them in their medical notes and medical letters. In fact they only serve to cause deep distress as they omit the real reason for the patient's suffering. And so, I wondered, reading this article, how the heroes of World War 1 would feel about the term neurological functional symptoms being used to describe their "shell shock". I wonder what it would represent to them. Perhaps they would feel that the hell they went through was being erased out of the picture. That is certainly how I and many others feel about these labels. But perhaps these are not matters that are taken into consideration by those who decide the wording of the labels For them it is I assume just an administrative exercise with little consideration of the impact on those affected. For us, the known neurotoxic effects of the drugs on the brain are extremely significant and none of the current descriptive labels used even give a hint of them.
Competing interests: No competing interests