Shell Shock – Lessons for Today

On 1 November, to commemorate the centenary of the Battle of the Somme, one of the defining events of World War One (WW1) – I talked at a meeting of the Glamorgan Family History Society about my research on psychological trauma and combat stress. The centenary of the Great War has frequently reminded us of the tremendous suffering in the trenches and the enduring impact it had on the soldiers’ physical and mental health. In my journeys through the WW1 medical case records of the National Hospital for the Paralysed and Epileptic (today the National Hospital for Neurology and Neurosurgery) and the Charité Psychiatric Department in Berlin, I came across hundreds of shell shock cases, soldiers who had been psychologically scarred by their war experiences.

The case records provide a harrowing account of soldiers’ experience of trench warfare, their physical and mental exhaustion. They allow us to enter a world which – since the last veterans of World War One  have passed away – is now inaccessible through living memory. The nature of modern industrialised warfare – with its new weapons, bigger armies, increasing casualty figures and anonymity of fighting – had considerably increased the stresses imposed on the individual soldier. Static or trench warfare, as opposed to mobile warfare, often forced the soldier to remain in one position for days – sometimes barely able to move, because any twitch turned him into an easy target for enemy snipers. Boredom and monotony, passivity and a lack of distraction were the result; the soldier was left alone with his thoughts and fears. There was also the sight of destruction, of mutilated bodies and of corpses; and the relentless shelling – sometimes going on for hours and hours, day on day. Men exposed to these stresses were under continuous pressure.

When the pressure became unbearable – which could occur after a single particularly traumatising event or as a cumulative effect of the many weeks and months in the trenches – many soldiers collapsed mentally and were admitted to casualty clearing stations and field hospitals. It is estimated that more than 80,000 British servicemen suffered such a breakdown. Some of them – probably the more severe and enduring cases – were admitted to specialist hospitals at home.

Some men who were admitted to the National Hospital at Queen Square had developed the typical symptoms of shell shock: paralyses, shaking, stuttering, deafness and fits. Others, unable to get away physically from the enemy fire, had escaped into a different mental space, a state between sleep and wakefulness that enabled them to keep a certain distance from the outward world. This temporary withdrawal from the horrors of warfare – which modern psychiatrists would put into the diagnostic category of ‘dissociative states’ –  served to protect the individual from the intense emotional states of fear and helplessness.

While some soldiers slipped in and out of dream-like states, others gradually lost all contact with the real world: they developed strange ideas, behaved in odd ways and had experiences nobody else shared. These psychotic symptoms were not an active, conscious survival or coping strategy: rather, they overwhelmed the individual and replaced reality with an alternative world. Some psychotic states could have a temporary problem-solving and wish-fulfilling function, and serve as an escape from a disturbing life situation. Karl Jaspers, the German psychiatrist and philosopher, provided the classical account of this phenomenon in his General Psychopathology: ‘Through delusions and hallucinations the individual’s fears, needs, hopes and wishes seem to become alive and real. […] Reactive psychosis serves as a defence, a refuge, an escape as well as wish fulfilment. It derives from a conflict with reality which has become intolerable’.

Some of these psychotic experiences could take an epidemic course – spreading from one soldier to the next. The Angels of Mons – a cloud of angelic warriors that appeared at Mons and halted the German advance against a vastly outnumbered British force – were the most famous occurrence, but many other similar legends of supernatural warriors, magic castles and mysterious clouds developed during the World War One.

The idea that traumatic experiences could trigger psychotic states was very much at odds with traditional psychiatric thinking: psychosis was believed to be a chronic disorder – inevitably leading to intellectual decline and requiring lifelong confinement to a mental institution; yet, many soldiers who developed psychotic ideas recovered within a short period of time.  In fact, most people’s concept of psychosis has remained rather monolithic until the present time: there is mental normality on one side and insanity, considered to be a chronic problem, on the other. The cases of shell shock psychosis, and their often impressive recoveries, tell another story: life events can trigger psychosis – and although the psychotic illness can, subsequently, take a chronic course, it can also be limited to a single, brief episode.

This is one of the relevant medical lessons of World War One, which has been confirmed by later epidemiological work into the triggers and course of psychosis.

There are other interesting lessons about the links between stress and mental illness that the members of the Glamorgan Family History Society were particularly interested in:

• Many soldiers did not develop shell shock while serving at the front; in fact, quite a few breakdowns occurred whilst soldiers were on leave or just before they were due to be sent to the front line. Another trigger not directly related to combat was marital infidelity. In all these cases of breakdown during home leave, admission to a shell shock hospital had a potentially life-saving function, preventing the return of the soldier to the trenches.
• Many civilians (including children) developed shell shock symptoms during World War One. Common triggers were air raids, explosions in munitions factories (e.g. in Silvertown), but also minor tribulations such as falls or work-related injuries.
• Most soldiers entering the medical system with psychological trauma were never sent back to the front line. British and German doctors concluded that such cases would not be able to stand the strain of active service without relapsing and therefore recommended the vast majority of servicemen for discharge from their military duties.
• Psychological therapies developed for shell shock symptoms were promising, at least in the short run. Today, up to a third of patients who see their family physicians complain of medically unexplained symptoms – and these functional syndromes – many of them similar to those developed by World War One soldiers – are usually chronic and difficult to treat, constituting one of the major public health and socio-economic challenges of our time.
• Post-traumatic reactions are culturally dependent (functional seizures were more common among German soldiers as compared to British soldiers); the cultural dependence of psychological reactions to adversity plays an ever increasing role in the current humanitarian crisis.

When the Allied offensive was halted in November 1916, more than 1,000,000 Commonwealth, French and German soldiers had been wounded, captured, or killed. In the patient records of shell shock hospitals in London and Berlin I often encountered soldiers who were traumatised in the same battle – just on different sides of the frontline. They had all witnessed immeasurable suffering, and had been psychologically scarred. They were victims of the epidemic of trauma that at some point threatened to overshadow all other medical problems of the war. These individual histories reveal the human condition, the basic human reactions to fear and loss that transcend all political and ideological differences.