Following the First World War, some physicians felt that there must be an organic brain disturbance underlying what were then called war neuroses, which seemed unlike “normal” neuroses in many ways.68 The term “shell shock” was coined with the notion that the brains of these soldiers had been mechanically deranged by the repeated concussion of the new high-explosive shells introduced in this war. There was as yet no formal recognition of the delayed effects of the severe trauma of soldiers who endured shells and mustard gas for days on end, in muddy trenches that were filled with the rotting corpses of their comrades.69
Recent work by Bennet Omalu and others has shown that repeated concussion (even “mild” concussions that do not cause a loss of consciousness) can result in a chronic traumatic encephalopathy, causing memory and cognitive impairment; this may well exacerbate tendencies to depression, flashbacks, hallucination, and psychosis. Such chronic traumatic encephalopathy, along with the psychological trauma of war and injury, has been linked to the rising incidence of suicide among veterans.
That there may be biological as well as psychological determinants of PTSD would not have surprised Freud—and the treatment of these conditions may require medication as well as psychotherapy. In its worst forms, though, PTSD can be a nearly intractable disorder.
The concept of dissociation would seem crucial not only to understanding conditions like hysteria or multiple personality disorder but also to the understanding of post-traumatic syndromes. There may be an instant distancing or dissociation when a life-threatening situation occurs, as when a driver about to crash sees his car from a distance, almost like a spectacle in a theater, with a sense of being a spectator rather than a participant. But the dissociations of PTSD are of a more radical kind, for the unbearable sights, sounds, smells, and emotions of the hideous experience get locked away in a separate, subterranean chamber of the mind.
Imagination is qualitatively different from hallucination. The visions of artists and scientists, the fantasies and daydreams we all have, are located in the imaginative space of our own minds, our own private theaters. They do not normally appear in external space, like the objects of perception. Something has to happen in the mind/brain for imagination to overleap its boundaries and be replaced by hallucination. Some dissociation or disconnection must occur, some breakdown of the mechanisms that normally allow us to recognize and take responsibility for our own thoughts and imaginings, to see them as ours and not as external in origin.
It is not clear, however, that such a dissociation can explain everything, for quite different sorts of memory may be involved. Chris Brewin and his colleagues have argued that there is a fundamental difference between the extraordinary flashback memories of PTSD and those of ordinary autobiographic memory and have provided much psychological evidence for such a difference. Brewin et al. see a radical distinction between autobiographic memories, which are verbally accessible, and flashback memories, which are not verbally or voluntarily accessible but may erupt automatically if there is any reference to the traumatic event or something (a sight, a smell, a sound) associated with it. Autobiographic memories are not isolated—they are embedded in the context of an entire life, given a broad and deep context and perspective—and they can be revised in relation to different contexts and perspectives. This is not the case with traumatic memories. The survivors of trauma may be unable to achieve the detachment of retrospection or recollection; for them the traumatic events, in all their fearfulness and horror, all their sensorimotor vividness and concreteness, are sequestered. The events seem to be preserved in a different form of memory, isolated and unintegrated.
Given this isolation of traumatic memory, the thrust of psychotherapy must be to release the traumatic events into the light of full consciousness, to reintegrate them with autobiographic memory. This can be an exceedingly difficult and sometimes nearly impossible task.
