Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis

BACKGROUND: It has been argued that post-traumatic stress disorder (PTSD) is a timeless condition, which existed before it was codified in modern diagnostic classifications but was described by different names such as 'railway spine' and 'shellshock'. Others have suggested that PTSD is a novel presentation that has resulted from a modern interaction between trauma and culture. AIMS: To test whether one core symptom of PTSD, the flashback, has altered in prevalence over time in soldiers subjected to the intense stress of combat. METHOD: Random selections were made of UK servicemen who had fought in wars from 1854 onwards and who had been awarded war pensions for post-combat disorders. These were studied to evaluate the incidence of flashbacks in defined, at-risk populations. RESULTS: The incidence of flashbacks was significantly greater in the most recent cohort, veterans of the 1991 Persian Gulf War; flashbacks were conspicuous by their absence in ex-servicemen from the Boer War and the First and Second World Wars. CONCLUSIONS: Although this study raises questions about changing interpretations of post-traumatic illness, it supports the hypothesis that some of the characteristics of PTSD are culture-bound. Earlier conflicts showed a greater emphasis on somatic symptoms.