PTSD, post-traumatic stress disorder: history, science and treatment, from Italy's 'war fools' to Vietnam veterans

⚠️ Disclaimer. This article is for general and historical information. I am not a doctor or a psychotherapist: I do not make diagnoses and I do not recommend medical treatments. In the clinical sections I simply report what the scientific literature and international guidelines say, citing the sources. Nothing that follows replaces a professional assessment. If you recognise the symptoms described in yourself or someone close to you, contact your GP or a specialist. In an emergency in Switzerland call 144 or 112. La Main Tendue / Die Dargebotene Hand answers on 143, and Pro Juventute helps young people on 147.

In my work I often meet people who have lived through something terrible: fraud victims who lost everything, people who were stalked, families looking for the truth about a death. And as a historical researcher and collector I have read many soldiers' letters and postcards and seen photographs of men back from the front staring into the void. Post-traumatic stress disorder runs through both sides of my work.

As in the other articles on this blog, the method is investigative: separating what the sources say from what we read into them, distinguishing established facts from interpretations, and flagging where research is still open.

What PTSD is: the current definition

PTSD (post-traumatic stress disorder) is a condition that can develop after exposure to a traumatic event. There are two reference classification systems today, with similar but not identical definitions.

The American Psychiatric Association's DSM-5

In DSM-5 (2013, revised as DSM-5-TR in 2022), PTSD is no longer classed among anxiety disorders but in a dedicated chapter on trauma- and stressor-related disorders. The diagnosis requires:

DSM-5 also includes a dissociative subtype (with feelings of detachment from oneself or unreality) and a delayed expression specifier, when the full criteria are met at least six months after the event.

A detail that concerns my field directly: criterion A includes repeated exposure through work to aversive details, as with first responders or officers investigating child abuse. Exposure through media and photographs counts only if it is work-related.

The World Health Organization's ICD-11

ICD-11, in force since 1 January 2022, takes a leaner approach centred on three elements: re-experiencing the trauma in the present (vivid memories, flashbacks, nightmares), avoidance, and a persistent sense of current threat (hypervigilance, startle).

The most important innovation is complex PTSD, a separate diagnosis that adds three areas of "disturbances in self-organisation" to the PTSD symptoms:

• difficulty regulating emotions;
• a deeply negative self-image, with shame, guilt and a sense of failure;
• persistent difficulties in relationships.

Complex PTSD is typically associated with prolonged or repeated trauma from which escape is difficult or impossible: domestic violence, childhood abuse, torture, captivity, slavery.

How common it is

The World Health Organization's World Mental Health Surveys provide the broadest data available:

The most important conclusion is also the most reassuring: most people who experience trauma do not develop PTSD. The same surveys show that trauma involving interpersonal violence, and sexual violence in particular, carries the highest risk. Women develop the disorder about twice as often as men.

A note on method: can we diagnose the past?

Before turning to history, a rule I always apply: you do not make a diagnosis across centuries. The same goes, for that matter, for living people who have never been examined.

Historians of psychiatry have debated this for decades. On one side are those who, like US psychiatrist Jonathan Shay (Achilles in Vietnam, 1994), read the Iliad alongside the testimony of Vietnam veterans and found striking similarities. On the other are historians such as Ben Shephard (A War of Nerves, 2000), Edgar Jones and Simon Wessely (Shell Shock to PTSD, 2005), and anthropologist Allan Young (The Harmony of Illusions, 1995), who stress that symptoms themselves change from one era to another, shaped by culture, medicine and social expectations.

The most cautious position, which I adopt in this article, is this: psychological suffering after terrible events has long been documented, but PTSD as a diagnostic category is a modern construct. Ancient sources show us compatible reactions, not diagnoses.

Ancient sources: what they really say

A Swiss chapter: soldiers' "nostalgia"

One chapter of this story concerns Switzerland directly. In 1688, in Basel, the medical student Johannes Hofer published a dissertation entitled Dissertatio medica de nostalgia oder Heimwehe. He coined the word nostalgia, from the Greek nóstos (return) and álgos (pain), to describe an illness affecting Swiss people far from home, soldiers among them.

The symptoms he described were very physical: loss of appetite, insomnia, palpitations, fever, dejection, and in severe cases even death. Over the following centuries "nostalgia" became a fully fledged military diagnosis: during the Napoleonic Wars army doctors documented thousands of cases. According to a tradition reported by Jean-Jacques Rousseau in his Dictionnaire de musique (1768), Swiss mercenaries were forbidden to sing the Ranz des vaches, the Alpine herders' call, because it stirred an unbearable longing for home. The story is hard to verify, but it says a lot about how the phenomenon was perceived.

Nostalgia is not PTSD: it is above all uprooting, not trauma. But it is the first time European medicine acknowledged that war and distance can make a soldier's mind and body ill without any visible wound.

The nineteenth century: railways, irritable hearts and traumatic neuroses

The 19th century brought new catastrophes, and new diagnoses:

The debate running through this period would reach the Great War intact: do the symptoms have a physical cause, are they psychological, or are they faked to obtain compensation? The same question would return in the trenches, with far graver consequences.

1914-1918: shell shock, war neuroses and Italy's "scemi di guerra"

A new war, a new kind of suffering

The First World War exposed millions of men to something no earlier war had produced on this scale: months of immobility in trenches under artillery bombardment, with no chance to flee or respond. Many soldiers broke down with dramatic symptoms: uncontrollable tremors, mutism, deafness, blindness or paralysis without injury, bizarre gaits, confusion, terror at the slightest noise.

In February 1915 British psychologist Charles Myers published an article in The Lancet that popularised the term shell shock. Myers initially suspected physical damage caused by the blast wave of explosions. It soon became clear that many soldiers with the same symptoms had never been near an explosion.

Doctors, discipline and electric "cures"

Armies faced a dilemma: were these men ill, cowards or malingerers? The answers were often brutal.

• Faradisation, the application of painful electric shocks, was used to "cure" mutism and paralysis. In Britain neurologist Lewis Yealland described his methods in Hysterical Disorders of Warfare (1918). In Germany the method of Fritz Kaufmann was well known.
• In Austria, in 1920, a commission of inquiry examined allegations against psychiatrist Julius Wagner-Jauregg over the electrical treatment of soldiers. Sigmund Freud was asked for his opinion. Wagner-Jauregg was cleared and in 1927 received the Nobel Prize in Medicine for something else entirely: treating general paresis with malaria.
• In Britain, at Craiglockhart hospital in Scotland, psychiatrist W. H. R. Rivers tried an approach based on listening instead. His patients included the poets Siegfried Sassoon and Wilfred Owen.

The "scemi di guerra": the Italian case

In Italy, soldiers who returned from the front with these disorders were called "scemi di guerra", roughly "war fools", by ordinary people. The expression says it all: not an illness but a disgrace.

What historical research tells us:

Italian historians, including Bruna Bianchi, Antonio Gibelli and Andrea Scartabellati, have identified some features of the "Italian case":

• Italian psychiatry was dominated by positivism and by the idea of hereditary predisposition and degeneration, a legacy of Cesare Lombroso's school. Breakdown was often blamed on a pre-existing weakness in the soldier, not on the war.
• Suspicion of malingering was constant. Many soldiers were classed as "degenerates" or malingerers and sent back to the front.
• Military justice was among the harshest in Europe. According to figures cited by Avvenire on the basis of studies by Enzo Forcella and Alberto Monticone, about 750 soldiers were shot after trial. Irene Guerrini and Marco Pluviano documented at least 300 summary executions, including decimations, and consider the figure an underestimate. We do not know how many of these men were in fact soldiers who had broken down psychologically: the sources, often incomplete, do not allow that question to be closed.

The investigator's lesson. Asylum case files are extraordinary sources, but they must be read knowing who wrote them and with what prejudices. A doctor convinced that breakdown meant "degeneration" recorded the facts through that lens. The same applies to military court records. It is the same principle I applied to interrogation records in the article on Hitler's death: who asks the questions, and for what purpose, shapes what ends up on paper.

Pardons, a century later

Other countries have confronted this chapter. The United Kingdom, through the Armed Forces Act 2006, granted posthumous pardons to the 306 soldiers executed for military offences such as desertion and cowardice, many of whom would now be considered traumatised. New Zealand (2000) and Canada (2001) took similar steps, and France in 2012 allowed the names of executed soldiers to be added to war memorials. In Italy the issue has been raised in Parliament several times, but according to the sources I consulted no general rehabilitation has been enacted.

The Second World War: "every man has his breaking point"

Between the wars, US psychiatrist Abram Kardiner published The Traumatic Neuroses of War (1941), a study of Great War veterans that anticipated many elements of what would become PTSD.

During the Second World War people spoke of combat fatigue or battle exhaustion, less stigmatising terms than shell shock. Some key developments:

• The principle of proximity, immediacy and expectancy, already developed in the First World War: treat soldiers close to the front, straight away, with the explicit expectation that they would return to their unit.
• The idea that anyone can break down. US military psychiatrists John Appel and Gilbert Beebe concluded in 1946 that every soldier has a limit and that, after prolonged combat, breakdown becomes almost inevitable. Breakdown was no longer a sign of individual weakness but a predictable consequence of exposure.
• Stigma had not disappeared, though. In August 1943, in Sicily, General George Patton slapped two soldiers hospitalised for psychological disorders, accusing them of cowardice. The incident caused a scandal and Patton was forced to apologise.
• Studying civilian survivors. After the war, psychiatrist William Niederland described "survivor syndrome" among survivors of the Nazi concentration camps.

In 1952 the first edition of the American diagnostic manual, DSM-I, introduced "gross stress reaction". But in 1968 DSM-II removed it. War trauma vanished from the official classification just as the United States was fighting in Vietnam.

Vietnam: the battle for a name

A different war, a different homecoming

The Vietnam War had features that, according to many scholars, contributed to delayed and chronic disorders:

• The individual one-year tour: soldiers arrived and left alone, not with their unit, and were back home within hours, with no period of transition alongside their comrades.
• A war without a front line, with ambushes, mines, and difficulty telling combatants from civilians.
• A hostile or indifferent homecoming, in a divided country, without the recognition given to veterans of earlier wars.

Shay described the moral trauma of soldiers who feel betrayed by those in command, or forced to act against their own values. Research today calls this moral injury, a distinct concept but often intertwined with PTSD.

From rap groups to DSM-III

Recognition did not come from veterans alone. In the same years nurse researcher Ann Burgess and sociologist Lynda Holmstrom described "rape trauma syndrome" (1974), and the women's movement brought to light the consequences of domestic violence and child abuse. In 1992 psychiatrist Judith Herman, in Trauma and Recovery, proposed the concept of complex trauma, which would become ICD-11's complex PTSD.

How many veterans suffered from it? An example of how data get corrected

The figures on Vietnam veterans are an excellent example of how science revises its own estimates:

The reanalysis cross-checked veterans' accounts against military records to verify actual combat exposure, and estimated that the original study had overstated the rates by about 40%. But it also confirmed a strong link between intensity of exposure and PTSD risk. Even the most cautious estimates therefore indicate that hundreds of thousands of veterans suffered from it.

The investigator's lesson. A testimony, however sincere, must always be compared with independent sources. Not because the witness is lying, but because memory, especially after trauma, reconstructs. It is the same logic as the OSINT approach I describe in the article on what an OSINT analyst does.

What happens in the brain

Neuroscientific research has identified some recurring elements, though many questions remain open:

One particularly elegant experiment is the twin study by Gilbertson and colleagues (Nature Neuroscience, 2002): among identical twin pairs in which only one had served in Vietnam, a smaller hippocampus was present in the twin who had not fought as well, if his veteran brother had severe PTSD. This suggests that a smaller hippocampus may be, at least in part, a pre-existing vulnerability factor, not only a consequence of trauma. It is a good example of why causality must always be tested.

Traumatic memory

For someone like me who gathers testimony, this point is crucial. Traumatic memory tends to be:

• fragmented: vivid sensory details such as a smell, a sound or an image, alongside gaps and a confused timeline;
• intrusive: it comes back unbidden, often triggered by seemingly neutral cues;
• hard to tell in order.

This leads to a practical rule: an inconsistent account or one with gaps is not, in itself, a sign of lying. Conversely, a confident, detailed account is no guarantee of accuracy. That is why modern interviewing techniques, such as the cognitive interview, try to gather memories without suggesting answers, a topic I touched on when discussing HUMINT in the article on intelligence disciplines.

Risk and protective factors

Why, faced with the same event, do some people develop PTSD and others not? Research points to a combination of factors:

The "after" factor is the most modifiable. Being believed, supported and not left alone makes a real difference. It is also the bitterest lesson from the history of Italy's war fools and Vietnam veterans: the society that received them with contempt or indifference deepened their wound.

Exposed professions

Some professions involve repeated exposure: first responders, police, healthcare workers, the military, war correspondents. A study by Anthony Feinstein and colleagues (American Journal of Psychiatry, 2002) of 140 journalists who had covered armed conflict found a lifetime PTSD prevalence of 28.6%, much higher than among colleagues who had never worked in war zones. As a photographer, that figure strikes me: those who document also pay a price. And it holds, on a different scale, for those who investigate violence and abuse.

How PTSD is treated

This section summarises what the guidelines and scientific literature report. It is not treatment advice: the choice of treatment always rests with the doctor or psychotherapist, together with the patient.

What the guidelines recommend

The main international guidelines, including those of the UK's NICE (2018), the World Health Organization and the US Department of Veterans Affairs (2023), agree on several points:

What does not work or is not recommended

• Single-session psychological "debriefing" immediately after trauma, meaning making everyone recount the event in the following days, is not recommended: systematic reviews found no benefit, and in some studies it was even harmful. In the first days, psychological first aid is more helpful: safety, calm, practical support, contact with loved ones.
• Benzodiazepines are advised against for PTSD by the US Department of Veterans Affairs guideline, as are cannabis-based products.
• MDMA-assisted therapy, much discussed in the media, was rejected by the US FDA in August 2024, which asked for further studies because of methodological limitations in the research submitted. Research on psychedelics continues, but it is not an approved treatment today.

The most important message

According to the scientific literature, PTSD can be treated. Many people improve significantly with appropriate therapy, even years after the trauma. WHO surveys show that some cases resolve within a few months, but that average symptom duration is longer than previously thought: waiting for it to pass on its own is not a strategy.

When to seek help, and from whom

See a professional if, more than a month after a traumatic event:

• memories, nightmares or flashbacks keep intruding;
• you avoid places, people or activities so as not to think about it;
• you feel constantly on alert, irritable, unable to sleep;
• you feel detached from others, guilty or "different";
• you use alcohol, medication or drugs to feel better;
• your work, relationships or daily life are suffering.

In Switzerland:

In short

The history of PTSD is a history of long disbelief. For centuries, those who came back from war or catastrophe with invisible wounds were called nostalgic, hysterical, degenerate, cowardly, "fools". Medicine took a long time to listen. The asylum files, the letters from the front, the photographs I keep in my collections tell of men who asked only to be believed.

If you recognise yourself in what you have read, the first step is not an investigation: it is a call to your doctor or to 143. If you are the victim of a crime, in Switzerland it is a matter for the police and the judicial authorities, not for a private investigator: contact 117 or your nearest police station, and a victim support centre for help. In every case, psychological support comes first.

Main sources: American Psychiatric Association, DSM-5 (2013) and DSM-5-TR (2022); World Health Organization, ICD-11 (in force since 2022); Benjet and colleagues, Psychological Medicine (2016); Koenen and colleagues, Psychological Medicine (2017); Abdul-Hamid and Hughes, Early Science and Medicine (2014); Herodotus, Histories, VI, 117; J. Hofer, Dissertatio medica de nostalgia (Basel, 1688); R. J. Daly, British Journal of Psychiatry (1983); C. Myers, The Lancet (1915); B. Bianchi, La follia e la fuga (2001); M. Romano, Firenze University Press (2020); E. Forcella and A. Monticone, Plotone di esecuzione (1968); I. Guerrini and M. Pluviano, Le fucilazioni sommarie nella Prima guerra mondiale (2004); A. Kardiner, The Traumatic Neuroses of War (1941); J. Shay, Achilles in Vietnam (1994); B. Shephard, A War of Nerves (2000); E. Jones and S. Wessely, Shell Shock to PTSD (2005); A. Young, The Harmony of Illusions (1995); history of the International Society for Traumatic Stress Studies; Kulka and colleagues, NVVRS (1990); Dohrenwend and colleagues, Science (2006); Gilbertson and colleagues, Nature Neuroscience (2002); Feinstein and colleagues, American Journal of Psychiatry (2002); NICE NG116 (2018); VA/DoD Clinical Practice Guideline for PTSD (2023).