Before PTSD had a name, the condition was recognized under dozens of different labels, and the treatments ranged from rest and talking to electric shocks and drug-induced comas. The diagnosis of Post-Traumatic Stress Disorder didn’t officially exist until 1980, when it was added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders. Everything before that point was a patchwork of theories, improvised therapies, and often punitive approaches shaped more by military needs than patient welfare.
The Civil War: “Soldier’s Heart”
The first widely documented cases of trauma symptoms in American soldiers came during the Civil War. Physician Jacob Da Costa described a syndrome of chest pain, palpitations, shortness of breath, and rapid heartbeat in combat veterans. The condition was called “irritable heart” or “soldier’s heart,” and doctors debated whether it was a genuine heart disease or something else entirely. Some believed the symptoms pointed to damaged heart muscle, while others argued it was a functional disorder, meaning the body mimicked the signs of physical exertion even while the soldier was at rest.
Treatment was minimal by modern standards. Soldiers were typically removed from duty and given rest, sometimes with mild sedatives. The prevailing medical framework had no vocabulary for psychological trauma, so the condition was treated as a cardiovascular problem. Many soldiers were simply discharged as unfit for service.
World War I: Shell Shock and Electrotherapy
The massive scale of trench warfare in World War I produced thousands of soldiers with symptoms that couldn’t be explained by physical injury: mutism, tremors, paralysis, deafness, and uncontrollable anxiety. The term “shell shock” emerged, initially based on the theory that the concussive force of artillery explosions had physically damaged the brain. When soldiers who had never been near an explosion developed the same symptoms, that explanation fell apart.
Treatments varied enormously and often depended on the soldier’s rank. Officers were more likely to receive gentler care. The most famous example is the “talking cure” practiced by William Rivers at Craiglockhart, a British hospital for officers, where patients were encouraged to discuss their experiences. Some facilities experimented with dream therapy, drawing on early psychoanalytic ideas, though many soldiers found it intrusive and resisted.
For enlisted men, treatments were frequently harsher. “Re-education” could mean anything from singing lessons for soldiers who had lost their speech to banging a poker on a coal scuttle beside the bed of a man with hysterical deafness. Hypnosis and intensive massage were used to try to reawaken afflicted senses. Ether was sometimes administered to relax patients and make them more suggestible. The most notorious approach was electrotherapy, known as the Kaufmann treatment in Germany and Austria. Doctors applied painful electric shocks on the premise that they could jolt soldiers out of their symptoms. The practice disturbed not only soldiers but other physicians, who worried it was more punishment than medicine. Many men with trauma symptoms later said they felt incarcerated rather than treated.
Psychoanalysis and Freud’s Influence
Sigmund Freud’s theories shaped how an entire generation of clinicians understood war trauma. Freud had identified repression as a core psychological mechanism in 1909 and called it “the corner-stone on which the whole structure of psycho-analysis rests.” His framework proposed that traumatic memories could be pushed out of conscious awareness as a defense mechanism but would resurface in dreams, anxiety, and obsessive behaviors. If repression was used repeatedly, Freud argued, the person would develop a neurosis.
Applied to war, this theory suggested that soldiers were caught between the primal survival instincts of combat and the moral expectations of civilized society. The conflict between these forces created unbearable internal tension. The psychoanalytic treatment was, in essence, talking: the patient was guided to bring repressed memories back into consciousness, process them, and integrate them. This approach was slow, labor-intensive, and available to very few soldiers. But it planted the seed for every trauma therapy that followed, establishing the idea that revisiting and working through painful memories was central to recovery.
World War II: Drugs, Sleep, and Electroshock
By the Second World War, the condition had been rebranded as “combat fatigue” or “combat exhaustion,” and the military had learned one critical lesson from WWI: delays in psychiatric treatment caused preventable losses of manpower. Speed became a priority. The goal was to return soldiers to duty as quickly as possible.
One of the signature techniques of this era was narcosynthesis, developed by psychiatrists Roy Grinker and John Spiegel. A soldier was injected with a barbiturate, typically sodium amytal or sodium pentothal, to induce a light sleep. In this sedated, suggestible state, the patient was guided through an interview about the traumatic event. The idea was that the drug lowered psychological defenses enough for the soldier to relive and release emotions tied to the trauma. Clinicians reported that withdrawn or catatonic patients sometimes responded to this technique when nothing else worked, and it became an accepted tool for treating acute anxiety and hysteria caused by combat.
Electroshock therapy also became common practice during WWII. The rationale came from a psychiatric theory developed in the early 1900s: because people with epilepsy seemed less likely to develop certain psychotic symptoms, inducing seizures might correct other psychological abnormalities. Doctors applied electrical current to the brain to trigger controlled seizures, which they believed could shock patients out of depression or dissociative states. Drug-induced seizures had been tried earlier but were more violent and harder to control, so electrical methods were preferred. Some facilities also used formaldehyde as a treatment, though evidence for its effectiveness was nonexistent. These were blunt instruments applied with little understanding of what was actually happening in the brain.
Vietnam and the Birth of Peer Support
The Vietnam War changed the trajectory of trauma treatment, largely because veterans themselves demanded it. Unlike soldiers from previous wars, Vietnam veterans returned to a divided society that offered little recognition or support. Many developed severe psychological symptoms but found the existing VA system inadequate or dismissive.
Out of this frustration came “rap groups,” informal peer counseling sessions where veterans met to talk about their experiences. These groups typically ran for about a year and were facilitated by psychiatrists or social workers, though the real therapeutic engine was the veterans themselves. Analysis of these groups found that the most discussed issues were anger, impulse control, guilt, depression, and struggles in personal relationships. The sessions moved between current life problems and memories of Vietnam, and the primary therapeutic tools were ventilation (getting things off your chest), identification with others who had been through the same thing, and peer support. Remarkably, the groups functioned similarly regardless of the facilitator’s experience or approach, suggesting it was the peer connection that mattered most.
These rap groups became a prototype for modern group therapy for trauma. They also helped build the political pressure that led to PTSD being recognized as a formal diagnosis in 1980.
1980: PTSD Gets a Name
The inclusion of PTSD in the DSM-III in 1980 was a turning point. For the first time, the diagnosis required a specific “stressor criterion”: the patient had to have experienced “a recognizable stressor that would evoke significant symptoms of distress in almost everyone.” The manual further specified that the event had to be “generally outside the range of usual human experience.” This language was imperfect and would be debated and revised for decades, but it accomplished something crucial. It established that trauma-related suffering was a legitimate medical condition with identifiable symptoms, not a character flaw or a sign of weakness.
With a formal diagnosis came formal research, and with research came the first evidence-based treatments. The medications with the strongest evidence for PTSD are two specific antidepressants that boost serotonin activity in the brain, sertraline and paroxetine, which remain the only two drugs with FDA approval specifically for PTSD. These became available in the 1990s and represented the first pharmacological tools designed around an actual understanding of the condition rather than a strategy of sedation or induced seizures.
What Changed Over Time
The arc of PTSD treatment is a story of slow recognition. For more than a century, the same cluster of symptoms kept appearing under different names: soldier’s heart, shell shock, war neurosis, combat fatigue. Each generation of doctors rediscovered the condition and improvised treatments based on the medical theories available to them. Some of those treatments, like the talking cure, pointed in the right direction. Others, like electrotherapy and barbiturate-induced abreaction, prioritized speed and military utility over the patient’s wellbeing.
The consistent thread is that effective treatment required two things the medical establishment was slow to provide: acknowledgment that the suffering was real, and time to process it. Early treatments that worked, from Rivers’ conversations with officers at Craiglockhart to the Vietnam-era rap groups, shared a common feature. They gave traumatized people a space to revisit what had happened to them in the presence of someone who took their experience seriously. The treatments that failed tended to treat the symptoms as a nuisance to be shocked, sedated, or disciplined away.