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In Sudan, traditional healing practices are common. One such practice is Traditional Uvulectomy (TU), which involves the removal of the uvula from children under the age of five using a sharp knife or a thread made from horsetail (Abdalla et al., 2024). Culturally, it is believed that removing the uvula can prevent choking and diarrhea (Abdalla et al., 2024). This practice is deeply rooted in cultural tradition and is supported by local mothers. However, TU carries significant health risks, primarily due to the use of non-sterilized tools (Abdalla et al., 2024). To address these risks, it is recommended that traditional healers increase public awareness of the detrimental consequences of TU while respecting cultural beliefs and traditions (Abdalla et al., 2024).

Abdalla, D., Mohammed, Z., Satti, E., Osman, A., Alrawa, S. S., Abdalla, S., Ibrahim, D., Balla, S. A., & Hussien Mohamed Ahmed, K. A. (2024). Traditional uvulectomy; practice and belief among Sudanese children in Khartoum hospitals: A multi-center cross-sectional study. International Journal of Pediatric Otorhinolaryngology, 176, 111822–111822. https://doi.org/10.1016/j.ijporl.2023.111822

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(Embassy of the Republic of The Sudan, 2024)

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Sudan, an ancient country with a deep passion for sports, has a long history of athletic pursuits (Embassy of the Republic of The Sudan, 2024). From equestrianism and swimming to wrestling during the colonial period, the Sudanese have continuously inherited and developed a strong sporting spirit. Football is the most popular sport, loved by all Sudanese people (Embassy of the Republic of The Sudan, 2024). Clubs in Khartoum, such as Hilal, Mareikh, and Morada, are leading the trend. Since the establishment of the Football Federation in 1936, Sudan's sports industry has flourished. Sudan joined FIFA in 1948 and became a member of the Confederation of African Football in 1957, marking the official integration of Sudanese football into the global arena (Embassy of the Republic of The Sudan, 2024).

Embassy of the Republic of The Sudan. (2024). Sport. Embassy of the Republic of the Sudan | the Hague, the Netherlands. https://www.sudanembassy.nl/sport/

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Sudan is a multilingual country. Arabic, as the primary language for much of the population, is one of the official languages in Sudan, alongside English (Al-Shahi et al., 2024). Arabic is widely used in government operations, business activities, and urban life (Al-Shahi et al., 2024). The linguistic landscape in Sudan is complex, encompassing three families of African languages: Afro-Asiatic, Nilo-Saharan, and Niger-Congo. Within the Afro-Asiatic family, Arabic and the Beja language (also known as Bedawi) are prominent. To overcome language barriers, Sudanese people often possess multilingual skills, with Arabic and English being the most commonly spoken second languages, which facilitates cultural exchange (Al-Shahi et al., 2024).

Al-Shahi, A. S. , Sikainga, . Ahmad Alawad , Unit, . Economist Intelligence , Sabr, . Mohy el Din , Spaulding, . Jay L. and Collins, . Robert O. (2024). Sudan | history - geography. In Encyclopædia Britannica. https://www.britannica.com/place/Sudan

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Table of Contents

Audio File: National anthem of Sudan

Sudan, country located in northeastern Africa. The name Sudan derives from the Arabic expression bilād al-sūdān ("land of the blacks"), by which medieval Arab geographers referred to the settled African countries that began at the southern edge of the Sahara. For more than a century, Sudan-first as a colonial holding, then as an independent country-included its neighbour South Sudan, home to many sub-Saharan African ethnic groups. Prior to the secession of the south in 2011, Sudan was the largest African country, with an area that represented more than 8 percent of the African continent and almost 2 percent of the world's total land area.

Since ancient times the Sudan region has been an arena for interaction between the cultural traditions of Africa and those of the Mediterranean world. Islam and the Arabic language achieved ascendancy in many northern parts of the region, while older African languages and cultures predominated in the south.

The country became independent in 1956 and has had numerous changes in government since then. Successive regimes found it difficult to win general acceptance from the diverse political constituencies. An early conflict arose between those northern leaders who hoped to impose unity upon the nation through the vigorous extension of Islamic law and culture to all parts of the country and those who opposed this policy; the latter included the majority of southerners and those northerners who favoured a secular government.

From 1955 until 1972 there prevailed a costly and divisive civil war, fought largely in the south but punctuated by violent incidents in the north. The Addis Ababa Agreement of 1972 ended the conflict only temporarily, and in 1983 the civil war resumed. By this time the comparative lack of economic development in the south had become a new source of regional grievance, and northern leaders' continuing attempts to Islamize the Sudanese legal system proved an even more potent source of discord. Attempts to end the civil war included numerous discussions, cease-fires, and agreements but yielded very little success until 2005, when the Comprehensive Peace Agreement ended the warfare. It also granted southern Sudan semiautonomous status and stipulated that a referendum on independence for the south would be held in six years. The results of the vote, held in January 2011, were overwhelmingly in favour of independence, and South Sudan was declared an independent country on July 9, 2011.

Sudan's capital, Khartoum, is located roughly in the centre of the country, at the junction of the Blue Nile and White Nile rivers. It is part of the largest urban area in Sudan and is a centre of commerce as well as of government.

Mohy el Din Sabr Jay L. Spaulding The Editors of Encyclopaedia Britannica Jay L. Spaulding The Editors of Encyclopaedia Britannica

Land

Sudan is bounded on the north by Egypt, on the east by the Red Sea, Eritrea, and Ethiopia, on the south by South Sudan, on the west by the Central African Republic and Chad, and on the northwest by Libya.

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Relief

Sudan is mainly composed of vast plains and plateaus that are drained by the Nile River and its tributaries. This river system runs from south to north across the entire length of the east-central part of the country. The immense plain of which Sudan is composed is bounded on the west by the Nile-Congo watershed and the highlands of Darfur and on the east by the Ethiopian Plateau and the Red Sea Hills ( ʿAtbāy). This plain can be divided into a northern area of rock desert that is part of the Sahara; the western Qawz, an area of undulating sand dunes that merges northward into the rock desert; and a central-southern clay plain.

Most of northern Sudan is a sand- or gravel-covered desert, diversified by flat-topped mesas of Nubian sandstone and islandlike steep-sided granite hills. In south-central Sudan the clay plain is marked by inselbergs (isolated hills rising abruptly from the plains), the largest group of which forms the Nuba Mountains (Jibāl Al-Nūbah). The western plain is composed primarily of Nubian sandstones, which form a dissected plateau region with flat-topped mesas and buttes. The volcanic highlands of the Marrah Mountains rise out of the Darfur Plateau farther west to elevations between approximately 3,000 and 10,000 feet (900 and 3,000 metres) above sea level. These mountains form the Nile-Congo watershed and the western boundary of the clay plain.

In northeastern Sudan the Red Sea Hills region is an uplifted escarpment. The scarp slope facing the Red Sea forms rugged hills that are deeply incised by streams. The escarpment overlooks a narrow coastal plain that is 10 to 25 miles (16 to 40 km) wide and festooned with dunes and coral reefs. Farther south the eastern uplands constitute the foothills of the Ethiopian highland massif.

Drainage and soils

The Nile River system is the dominant physical feature, and all streams and rivers of Sudan drain either into or toward the Nile. It enters the country as the White Nile (Baḥr Al-Abyaḍ) in the southeast, about 60 miles (100 km) south of Kūstī, and maintains an extremely low gradient until it is joined by the Blue Nile (Baḥr Al-Azraq) at Khartoum. The Blue Nile, which rises in the Ethiopian Plateau, contributes much of the floodwaters of the White Nile. After the confluence of the White and Blue Niles at Khartoum, the river flows in a great northward-curving course and is known simply as the Nile (Nahr Al-Nīl). Throughout much of the country, however, drainage does not reach the Nile; the rivers of the southwest infrequently reach the Baḥr Al-Ghazāl system, and to the north most hill groups initiate seasonal watercourses that are lost in the surrounding plains.

The surface of the deserts in the north and northeast are either bare rock, a mantle of bare waste, or sandy expanses of mobile dunes known as ergs. In the semiarid zone of north-central Sudan, the layer of rock waste is slightly modified to form immature soils; in the Qawz region, soils are brownish red and of low fertility. Alluvial soils occur at the desert deltas of Al-Qāsh (the Gash) and Barakah rivers, along the White and Blue Niles, and in the alluvial plains of the many small rivers radiating from the Marrah Mountains. The alkaline soils of the south-central plain are heavy cracking clays. The soil of the Gezira ( Al-Jazīrah) plain south of Khartoum is deep-cracking uniform clay that has been deposited during the annual inundations of the Blue Nile.

Climate

In northernmost Sudan, northerly winds prevail for most of the year, and rainfall is rare. To the south of this the seasons are characterized by the north-south oscillation of the boundary between moist southerly air and dry northerly air. In winter the north winds of the tropical air mass blow across Sudan. These winds are relatively cool and dry and usually bring no rain. Sometime around May, the moist southerly air of the southern maritime air mass moves northward across the country. Because of this, central and southern Sudan have rainy seasons, the total lengths of which vary according to their latitude.

Sudan is a hot country. The central and eastern areas have the highest mean annual temperatures, typically ranging from the mid-90s to mid-100s F (mid-30s to low 40s C). In the west and northwest of the country, the highest mean temperatures generally range from the mid-80s to mid-90s F (low to mid-30s C). The highest temperatures normally occur just before the rainy season. The mean minimum temperatures in most of the country range from the high 60s to high 70s F (low to mid-20s C); in the west and northwest, mean minimum temperatures are a little lower, ranging from the high 50s to high 60s F (mid-10s to low 20s C).

Precipitation varies from almost nothing in the north and centre to 20-30 inches (500-750 mm) annually in the south. Along the Red Sea the climate is alleviated by sea breezes, and most of the rain falls during winter. In southern Sudan, precipitation usually occurs during the summer months. Dust storms are common in the north and centre, often occurring before rainstorms in the late spring and early summer.

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Sudan | History, Map, Area, Population, Religion, & Facts

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Sudan, country located in northeastern Africa. The name Sudan derives from the Arabic expression bilād al-sūdān ("land of the blacks"), by which medieval Arab geographers referred to the settled African countries that began at the southern edge of the Sahara.

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Sudan is a multicultural and culturally rich country with two major population groups: Arabic in the north (39% of the population) and Black Africans in the south (52% of the population) (Queensland Health, 2011). Within these two groups, there are hundreds of tribes and ethnic groups, demonstrating the diversity of ethnicity. In addition, unique semi-nomadic peoples such as the Beja also make up a certain proportion of Sudan’s population, further enriching the country’s ethnic culture (Queensland Health, 2011). In Sudan, ethnicity is a complicated term that is frequently linked to cultural affinities (Queensland Health, 2011).

Queensland Health. (2011). Community Profiles for Health Care Providers - Sudanese profile. https://www.health.qld.gov.au/__data/assets/pdf_file/0031/157378/sudanese2011.pdf.

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It is reported that 77% of Sudanese migrants in Australia have experienced discrimination, including in housing and race-based harassment (Bruck et al., 2021). Furthermore, their traumatic experiences also limit their opportunities to integrate into society and secure employment (Abur and Mphande, 2020). These issues highlight a key social determinant of health identified by the World Health Organization (WHO): social inclusion and non-discrimination. Research indicates that social inclusion is associated with a reduction in disease prevalence and an extension of life expectancy. For Sudanese refugees, robust social networks provide essential support, helping them find employment, address financial challenges, and ultimately contribute to better overall health (Australian Institute of Health and Welfare, 2024). Addressing discrimination and promoting inclusion are vital to the well-being of this vulnerable population.

Abur, W., & Mphande, C. (2020). Mental Health and Wellbeing of South Sudanese-Australians. Journal of Asian and African Studies, 55(3), 002190961988029. https://doi.org/10.1177/0021909619880294

Australian Institute of Health and Welfare. (2024). Social determinants of health. Australian Institute of Health and Welfare; Australian Government. https://www.aihw.gov.au/reports/australias-health/social-determinants-of-health

Bruck, D., Atem Deng, S., Kot, B., & Grossman, M. (2021). Sleep difficulties among South Sudanese former refugees settled in Australia. Transcultural Psychiatry, 58(2), 136346152090312. https://doi.org/10.1177/1363461520903122

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(Migrant and Refugee Women’s Health Partnership, 2019)

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For me, the most relevant aspect of Culturally Responsive Clinical Practice is recognizing the impact of refugee-like experiences (Migrant and Refugee Women’s Health Partnership, 2019). I feel empathetic and have understood deeply the challenges they face, such as mental and physical trauma and post-traumatic disorders (Migrant and Refugee Women’s Health Partnership, 2019). With this knowledge, I now realize the importance of providing more person-centered care. For example, when caring for refugees with PTSD, I should listen with patience and sensitivity. This understanding is essential in the workplace because it helps me better consider my patients' needs and continuously adjust my nursing plan to ensure a safer and more comfortable care environment.

Migrant and Refugee Women’s Health Partnership. (2019). Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds COMPETENCY STANDARDS FRAMEWORK FOR CLINICIANS. Migrant and Refugee Women’s Health Partnership. https://culturaldiversityhealth.org.au/wp-content/uploads/2019/02/Culturally-responsive-clinical-practice-Working-with-people-from-migrant-and-refugee-backgrounds-Jan2019.pdf

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Principle health issue that refugees face

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Principle health issue that refugees face

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Before migrating to Australia, a significant proportion of Sudanese refugees had resided in refugee camps or regions afflicted by conflict for a long time. Therefore, mental health issues, especially Post-Traumatic Stress Disorder (PTSD), are common among Sudanese refugees (Abur and Mphande, 2020). PTSD is a diagnosable condition characterized by persistent fear, anxiety, and recollections of a traumatic experience (Australian Institute of Health and Welfare, 2024). Due to cultural taboos and a lack of awareness of mental illness, mental health issues are often neglected in Sudan (Abur and Mphande, 2020). Therefore, a mental health assessment should be conducted upon arrival to identify those affected by PTSD and related trauma. These individuals should be referred to specialized torture and trauma services to ensure that they have access to professional mental health services, including counseling, psychotherapy, and medication (Victorian Foundation for Survivors of Torture Inc (Foundation House) , n.d.).

Abur, W., & Mphande, C. (2020). Mental Health and Wellbeing of South Sudanese-Australians. Journal of Asian and African Studies (Leiden), 55(3), 412–428. https://doi.org/10.1177/0021909619880294

Australian Institute of Health and Welfare. (2024). Mental Health. Australian Institute of Health and Welfare. https://www.aihw.gov.au/mental-health

History of Posttraumatic Stress Disorder. (2016, September). History of PTSD and Trauma Diagnoses - Shell shock to the DSM. Trauma Dissociation. http://traumadissociation.com/ptsd/history-of-post-traumatic-stress-disorder.html

Victorian Foundation for Survivors of Torture Inc (Foundation House) . (n.d.). Australian Refugee Health» Primary Care for People of Refugee Backgrounds. Australian Refugee Health Practice Guide. https://refugeehealthguide.org.au/

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Historical names for PTSD in civilian and miliary use
PTSD was well-recognized after rail crashes and combat in the 19th century, but was believed to be a physical injury. License: CC BY-4.0

Posttraumatic Stress Disorder first became the diagnosis we know today in 1980, when it was included in the Anxiety Disorders section of the DSM-III psychiatric manual.[3], [7] Before 1980, Posttraumatic Stress was described and diagnosed under a variety of different names in both medical literature, and the ICD-6 (1948) and DSM-I (1952) diagnostic manuals. [1], [2], [14], [18]

Early History of PTSD

Ancient texts The Iliad of Homer and The Odyssey both describe soldiers traumatized by war.[8]:39-40

In Shakespeare's King Henry IV, written in 1598, the character of Hotspur suffers from post-traumatic nightmares. [8]:39-40, [12]:5-7

Post-Traumatic Neurosis was the term used in Britain for over two hundred years, and symptoms were described even earlier, e.g., in literature, and others form of art. [12]:5-7

1761: PTSD-like symptoms described among soldiers by Austrian physician Josef Leopold, who calls it nostalgia. Soldiers report missing home, feeling sad, sleep problems, and anxiety. This model of psychological injury persists into the U.S. Civil War.[9]

1813: a traumatized girl is described as suffering from what is known today as "repetitive dissociative attacks" including re-enacting behavior of invading French soldiers in Vilnuis, Lithuania. An early medical account of trauma.[8]:40

Crimean War years: 1853-1856 (Britain, France, Russia, and others)

Soldiers are frequently incapacitated with "irritable heart", but no physical heart problems are found. They are treated with rest and light duties. [16]:16

Many years after the end of the Crimean War, traumatized veterans are recognized as suffering from Da Costa syndrome or Effort syndrome, although neither name is used until long after the war. [15]:455

1860: The first understanding that a traumatic event could cause psychological as well as physical injury. People traumatized by accidents on railways were referred to as having Railroad Spinal Syndrome by the English surgeon Frederick Erichsen. [14]:2, [15]:624 Erichsen believed concussion of the spine to be the cause of the accident survivors' "fear, fright and alarm".[15]:624 [12]:10

1863: Goya, a painter created Los Desastres de la Guerra [The Disasters of War] to illustrate atrocities (rather than heroic feats); many of which he saw during the French invasion of Spain in 1808. [8]:40

U.S. Civil War years: 1861-1865

Music by veteran Jacob George, who viewed Soldier's Heart, the American Civil War term, as more appropriate than 'PTSD' for the Moral Injuries of war.

Irritable heart is used to describe PTSD in civil war soldiers.[15]

1865: Unrelated to war, writer Charles Dickens wrote of experiencing "railway shaking" and a phobia of train travel after being traumatized in a railway accident, and witnessing people dying [12]:7

1870: Soldier's Heart is described by Charles Samuel Myers, a British military psychiatrist. [8]:20, [9]

1871: Da Costa, an army surgeon in the U.S. civil war, states that Soldier's Heart involves almost constant traumatic neurosis, with some experiencing sudden paralysis or loss of sensation (traumatic hysterical neurosis) - now known as Functional Neurological Symptom Disorder or Dissociative Conversion Disorder.[8]:20, [9], [15]

1878: Psychic trauma is a term proposed by Eulenberg for emotional shock leading to concussion of the brain.[8]:41

1879: Denial of PTSD: compensation neurosis is a term introduced by Rigler following an increase in disability after railway accidents that occurs with the introduction of compensation laws in Prussia (8 years beforehand).[8]:20

License: public domain

1882: In France, Jean-Martin Charcot uses the terms "Névrose Traumatique" and "Hystérie Traumatique" (Traumatic Neurosis and Traumatic Hysteria) to classify patients with post-traumatic symptoms, regarding them to have an "inherited predisposition". He claims that physical injury could produce psychological symptoms. Charcot later made significant contributions to the current understanding of Dissociation and Dissociative Identity Disorder (Multiple Personality Disorder). [2]:624

1883: John Putnam claimed that many cases of "Railroad Spine Syndrome" were actually Hysterical Neuroses (hysteria).[2]:624, [12]:10

1885: Surgeon Henry Page discounts any spinal cause for PTSD symptoms, stating that nervous shock, which had previously been considered just a symptom, was psychological but caused the body's nervous system to malfunction. He introduces the terms Nervous shock and Functional Disorder.[15]

1885-1889: Traumatic Neurosis was used by Hermann Oppenheim, a German neurologist, to describe PTSD symptoms. Oppenheim claimed there was a physical "disturbance" in the cerebrum (within the brain). This began the use of word trauma in psychiatry, rather than solely in surgery.[2]:624, [8]:20

1889: George Miller Beard introduces the term "neurasthenia" (nervous exhaustion) which includes insomnia, fatigue, headaches and emotional problems including depression, neurasthenia becomes a recognized effect after trauma [15]:455

1896: The Aetiology of Hysteria and Studies on Hysteria what becomes known as the "seduction theory", an account of the damaging effects of child sexual abuse on females, which is based his patients. [21]:3-4

PTSD 1900-1939

Boer War years: 1899-1902 (Britain, South Africa)

Soldiers in the Boer War with PTSD symptoms are often diagnosed with disorderly action of the heart (DAH), the new name for "irritability of the heart" during the war. Anemia is believed to be a major contributor. [16]:10

1900: Surgeon Anthony Bowlby notes the high number of soldiers incapacitated with headaches and pains or muscle paralysis, often diagnosing rheumatism rather than recognizing these as post-traumatic responses. He remarks on the lack of mental disorders. [16]:10

Dr Morgan Fincuane describes Boer War soldiers with healed gunshot wounds remaining debilitated due to nerve and muscle problems that are "associated with pyschical [mental/psychological] symptoms" similar to nervous shock after railway accidents. Soldiers are considered to have "railway spine". [16]:12

1904: An official report on the health of Boer War troops concludes that carrying heavy weights on large marches is responsible. "Excitement or nervousness of going under fire" is recognized as resulting in DAH returning to previous sufferers. [16]:10

1905: Denial of child sexual abuse: Freud publicly abandons his deeply unpopular "seduction theory" which linked child sexual abuse with mental illness, and presents an alternate theory, the Oedipus complex , which describes the reports of childhood sexual abuse as 'fantasy' caused by 'unconscious' childhood wishes for sex, and causing the resulting emotional conflicts. [21]:4, [8]:44 Freud still acknowledges that child sexual trauma is harmful, but few people research it until the 1970s. [8]:44 In modern times, the Oedipus complex, and many of Freud's views on women, have been challenged by new evidence, with new theories have been put forward; alternatively those loyal to Freud's writings have discarded parts, substituted them for Lacan's metaphorical reinterpretations, or reconceptualized his theory (e.g., Bion). [22], [23]

1911: Swiss psychiatrist Eduard Stierlin studies effects of natural disasters, a rail accident and a mining disaster, finding lasting PTSD symptoms, he states traumatic neurosis has no predisposition and the key causes are violent emotions and fright.

1914: The first description of PTSD syptoms in rescue personnel, based on the aftermath of explosions on French ships.[8]:45

World War I years 1914-1918

In 1941, Abram Kardiner proposed that the various civilian and military versions of PTSD were the same condition. License: CC BY-4.0

1915: Charles Myers uses the term "shell-shock" to describe PTSD in medical literature, later recognizing it in soldiers never directly in combat. The term was already in common use; high explosives used in this war were believed to cause brain damage, resulting in symptoms like panic and sleep problems. [8]:45, [9], [13]:76 Traumatic [physical] Brain Injury and PTSD remain a common combination in veterans today, with some overlapping symptoms. [5]:280

1916-1917: Moerchen suggests trauma or shock can cause abnormal biological responses in the central nervous system, which isn't recognized in mainstream psychiatry under 80 years later. [8]:45

Reactions are divided into shell shock, which had sudden onset, and combat exhaustion which had gradual onset, with a loss of energy. Some saw shell shock as a "disorder of will" to be dealt with by disciplinary action, and quick return to duty. [8]:46-47

German psychiatrists in Berlin found many soldiers suffered from motor and sensory symptoms (which today would be Functional Neurological Symptom Disorder) but few had PTSD symptoms. Many are diagnosed with hysteria, viewed as caused by an individual's predisposition, not war trauma. Doctors note that such physical responses produce an "illness gain": protecting the soldier's life (by removal from combat) and self-esteem. [8]:46-47

1926: Denial of PTSD - German psychiatrist Bonhoeffer produces a study claiming almost all cases of "traumatic neurosis" occurring in the war are a "social illness" in patients with an inherent weakness who are motivated by compensation from health insurance. German veterans with "traumatic neurosis" are no longer given compensation. [8]:20

Traumatized World War I veterans will later lead to American Abram Kardiner publishing The Traumatic Neuroses of War (in 1941), this work later influences the 1980 DSM-III PTSD criteria. Like Pierre Janet and Sigmund Freud, Kardiner suggests the traumatized veteran acts as if still in the traumatic situation. [8]:48

In Russia, Pavlov notes the effects of inescapable shock in his dogs, who are traumatized when trapped in his flooded labatory, including the double approach-avoidance conflicts in trauma. [8]:48

1926: Sigmund Freud recognizes feelings like fright as a cause of traumatic neurosis, regarding helplessness and powerlessness as essential in trauma (but not present in other stressful events). [8]:49

1932: Sandor Ferenczi faces strong oppositon when presenting a paper on the dynamics of child sexual trauma, expanding on the seduction theory abandoned by Freud. The paper is only published years after his death. [8]:44

PTSD 1940-1980

Civilians use a London subway station as a bomb shelter during a World War II air raid. © IWM. View license.

World War II years 1939-1945

1940: Charles Myers (a British army psychiatrist) recognizes that "shell shock" is a poorly chosen term, which should be divided into shell concussion (now known as Traumatic Brain Injury) and shell shock itself. Myers recognizes that fright and horror often occur before shell shock, that can result from emotional stress rather than only exploding missiles, and that it can cause hysteria, neurasthenia and psychiatric illnesses.[12]:8

1941: Kardiner states that battle neurosis, battle fatigue, combat exhaustion and shell shock are the same: "the common acquired disorder consequent on war stress", and suggests that traumatic neuroses in peacetime is the same condition.[12]:8

Combat exhaustion is used to describe the gradual onset of PTSD symptoms, anxiety and physical responses to trauma. Fear and anxiety are higher than in World War I due to factors like "mechanized terror", unpredictability, and more deadly weaponry. "Psychiatric caualties" make up 20-50% of discharges. [8]:49

Forward psychiatry, a mix of "preventative and therapeutic interventions" developed during World War I, is rediscovered as psychiatric casuality escalate. [8]:47, [8]:49-50

The support of colleagues, comrades and neighbors is found to be both preventative and curative for traumatized troops, leading to group psychotherapy approaches for civilians in post-war years. [8]:50

1948: A health diagnostic manual, the International Classification of Diseases (ICD) produced by the World Health Organization, includes a section of mental disorders for the first time in it's ICD-6 version. The mental health section is based on diagnostic manuals developed by the American Armed Forces and Veterans Association, [13]:118-120, [17]:40, [18] The first PTSD-like diagnosis is called Acute situational maladjustment, code 326.3. Three kinds are listed: Abnormal excitability under minor stress; Combat fatigue; and Operational fatigue [17]:40, [18].

Korean War years: 1950-1953

Forward psychiatry is relearned again. [8]:49-50

World War II and its aftermath results in descriptions of war-traumatized civilians and war trauma responses which are not the result of combat or Prisoner of War (POW) experiences, e.g., civilian responses to bombings, concentration camp effects, politican oppression, torture, death camps, and effects of living under hostile, military occupation e.g., German occupation of other countries. These post-traumatic responses are often ignored in America psychiatry; American war traumas had been primarily overseas. The impact of mass trauma in civilians appears transient: during post-war years: they were able to return to work and establish families. [8]:50

Some war-traumatized civilians experience gradual deterioration; work published by researchers - some of whom are survivors of the concentration camps - is largely ignored in psychiatry and viewed as of "historical" interest. [8]:50

1952: Diagnostic and Statistic Manual of Mental Disorders, now known as Gross Stress Reaction is included in the first edition of the DSM-I, the U.S.A.'s new psychiatric manual. Gross Stress Reaction is within the "Transient Situational Personality Disorders" and describes a PTSD-like "reservible reaction" that occurs in someone with no existing personality disorder. Causes can be either severe physical demands or extreme emotional stress resulting from either (1) combat, or (2) civilian catastrophe. [1]:53

1953: The Kinsey Institute releases a study that reports child sexual abuse occurs in 25% of females, but claims it is "not likely to do the child any appreciable harm". [21]:5

1954: Hermann and Thygesen describe concentration camp syndrome, which they believe to be physical rather than psychological - and regard as an accelerated aging process. Signs include emotional disturbances, vegetative symptoms, intellectual deterioration and visible physical decline. [8]:50

1955: Weinberg's child sexual abuse research claims the prevelance is 9 cases per million in the U.S., and the incest rate is 1 case per million - figures that are based on court cases only, and conflict with the Kinsey Institute's finding. The link to PTSD and other mental disorders is not recognized. [21]:5-6

Vietnam War years: 1955-1975

1958: Venzlaff publishes a study of victims of Nazi persecution in Germany, suggesting that the extreme stress (traumatic stress) causes a "life event-based personality change". Over 30 years later, in 1992, the World Health Organization adds Enduring Personality Change After Catastrophic Experiences to its ICD-10 diagnostic manual - this disorder is now known as Complex PTSD. [8]:51

1960: Harald Wolff questions the effect of catastrophic stress on lifespans, pointing out that uninjured U.S. veterans imprisoned by the Japanese had triple the rate of accidental death, and those who experienced the most severe stress had 7 times as many admissions to veterans' hospitals. [8]:50

1961: Survivor syndrome is a term coined by Niederland, who emphasizes survivor guilt and the inability to grieve for those killed while in concentration camps. Eitinger notes the lowered capacity to tolerate stress in later life, and the additional Complex PTSD-like symptoms of survivors, including chronic anxiety, inability to experience pleasure or establish new interpersonal relationships, and reduced ability to work. [8]:51

1961: Denial of PTSD. Unrelated to war, Miller introduces the term Accident Neurosis which refers to PTSD symptoms as exaggerated or faked (malingered) in order to gain compensation. Miller claims symptoms disappear once compensation is gained. [12]:10-11

1962: Dr Henry Kempe et al. publish The Battered Child Syndrome, describing post-traumatic symptoms in children. [21]:5

1968: The World Health Organization includes the Transient situational disturbance category in its the ICD-8 diagnostic manual, replacing the term Acute situational maladjustment. This includes the PTSD-like diagnoses of Combat fatigue and Gross Stress Reaction, and the non-trauma related Adjustment reaction; the earlier ICD-7 version made no changes relevant to PTSD. [19], [13]

1968: DSM-II diagnostic manual is published in America, with PTSD symptoms also recognized as a Transient Situational Disturbance called Adjustment reaction of adult life. This covers the impact of both traumatic and non-traumatic events (which will later keep the name Adjustment Reaction). Importantly, the effects of trauma are no longer considered a "personality-related" disorder. The condition is described as expecting to improve "as the stress is reduced," with another, unnamed disorder suggested for those with longer term symptoms, making this closer to Acute Stress Disorder than PTSD. [2]:48-49

Rape Trauma Syndrome: 1974

The Vietnam war and the women's movement lead to greater public interest and more research. Variants of PTSD described include Post-Vietnam syndrome, Abused Child Syndrome and Battered Women Syndrome. [13]:61, [12]:12

1974: Ann Burgess and Lynda Lytle Holstrom describe Rape Trauma Syndrome, commenting that the flashbacks and nightmares resembled "traumatic neuroses" from war. [15]:457

1974: U.S. passes the Child Abuse Prevention and Treatment Act, requiring mandatory reporting for cases of child abuse. [21]:6

1975: The key American psychiatric textbook, The Comprehensive Textbook of Psychiatry by Kaplan, Freedman and Sadock, is updated and repeats Weinberg's estimate of incest occurring in only 1 in a million children, ignoring the far higher rates found in other research. [21]:6

1977: Acute reaction to stress with predominant disturbance of emotions, consciousness, or psychomotor disturbance or mixed included in the ICD-9 diagnostic manual.

1978: Charles Figley, himself a Vietnam veteran, publishes Stress disorders among Vietnam veterans, the first edited book about PTSD in Vietnam veterans. [13]:61

PTSD Diagnosis: 1980 onwards

1980: psychiatric manual published, including Post-traumatic Stress Disorder as a separate diagnosis for the first time. PTSD is in the Anxiety Disorders section. The DSM-III contains diagnostic criteria for the first time. The traumatic event that caused PTSD is expected to be "outside the range of usual human experience", and examples of trauma list both civilian and military combat trauma. PTSD is described as more likely to be severe and last longer if the trauma is of "human design", rather than an accident. No direct mention is made of domestic violence or child abuse. "Dissociative-like states" are referred to as a rare consequence of PTSD, a separate Dissociative Disorders section is also created. [3]:236-238, [6]

1987: The DSM-III-R is published, revising the PTSD diagnostic criteria. Avoidance symptoms are now required for diagnsosis, and symptoms must last a least one month. It also states that "intense fear, terror or helplessness" is typically experienced during the trauma. [3]:247-251

1992: The ICD-10 manual is published, including three post-traumatic conditions: Acute stress reaction (lasting under a month after the trauma), Post-traumatic stress disorder (occurring for at least a month after the trauma), both considered Anxiety Disorders, and (Enduring Personality Change After Catastrophic Experiences: a more complex, long-lasting disorder now known as Complex PTSD, classed as an adult Personality Disorder). EPCACE lasts at least two years and is characterized by "a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of "being on edge" as if constantly threatened, and estrangement". [11]

1994: psychiatric manual published, adding Acute Stress Disorder, a post-traumatic disorder that is similar to PTSD but begins very soon after trauma and is often short term. [4] Complex PTSD is left out, but it's symptoms are briefly mentioned in the description of PTSD. [11]

1995: Compassion fatigue, also known as Secondary Traumatic Stress Disorder is named by Charles Figley, which involves PTSD-like symptoms in professionals helping those with PTSD. This was first recognized in the 1970s and referred to as "burnout". It is not considered a diagnosis. [15]

2013: DSM-5 published. Changes include moving Posttraumatic Stress Disorder and Acute Stress Disorder from the Anxiety Disorders section to a newly-created Trauma and Stressor-related Disorders section. A dissociative subtype of PTSD is introduced. Complex PTSD is left out (again). [5],[10]

Historical names for PTSD

Post-Traumatic Neurosis was the term used in Britain for over 200 years. [12]:5

1761: "nostalgia" is used to describe PTSD-like symptoms among soldiers by Austrian physician Josef Leopold.[9]

1860: Railroad Spinal Syndrome by the English surgeon Frederick Erichsen for people traumatized by railway accidents. [14]:2, [15]:624 Clevenger later proposes the name Erichsen's Disease in 1889.[12]:10

Many historical names for PTSD refer to parts of the body.
View image credits. License: CC BY-4.0

1865: Writer Charles Dickens wrote of experiencing "railway shaking" and a phobia of train travel after being traumatized by a railway accident. [12]:7

1878: Psychic trauma is a term proposed by Eulenberg for emotional shock leading to concussion of the brain.[8]:41

1882: "Névrose Traumatique" and "Hystérie Traumatique" (Traumatic Neurosis and Traumatic Hysteria) are used in France by Jean-Martin Charcot to refer to post-traumatic symptoms. [2]:624

1883: John Putnam claims many cases of "Railroad Spine Syndrome" are actually Hysterical Neuroses (hysteria).[2]:624, [12]:10

1885: Nervous shock and Functional Disorder were terms introduced by surgeon Henry Page. [15]

1885-1889: Traumatic Neurosis was used by Hermann Oppenheim, a German neurologist, to describe PTSD symptoms. This began the use of word trauma in psychiatry, rather than solely in surgery.[2]:624, [8]:20

1899-1902: Boer War. Irritable heart is renamed disordered action of the heart (DAH) and is frequently diagnosed. [16]:10

1914-1918: Combat stress is studied during World War I (the Great War).[8]:38

1915: Charles Myers uses the term "shell-shock" in medical literature [13]:76

World War I: "disorderly action of the heart", "neurocirculatory asthenia", and "neurasthenia" are used. [8]:20, [15]

World War II: 1941: Kardiner state that that battle neurosis, battle fatigue, combat exhaustion and shell shock are the same as each other, and the same condition as traumatic neuroses in peacetime.[12]:8

1948: Acute situational maladjustment is the PTSD-like diagnosis introduced in the World Health Organization's ICD-6 diagnostic manual, more specific names listed are Abnormal excitability under minor stress, Combat fatigue and Operational fatigue [17]:40, [18]

1952: Gross Response Syndrome is a PTSD-like diagnosis included in the American DSM-I psychiatric manual. [1]:53

1954: Concentration camp syndrome is described, involving a mix of PTSD symptoms with physical and intellectual decline. [8]:50

1961: Survivor syndrome is a term coined by Niederland, based on symptoms of concentration camp survivors. [8]:51

1962: Battered Child Syndrome is used to describe post-traumatic symptoms in children. [21]:5

1968: Adjustment reaction of adult life is included in the DSM-II psychiatric manual, a disorder that covers both PTSD and Adjustment Disorders. [2]:48-49

Early 1970s: Post-Vietnam syndrome, Rape Trauma Syndrome, Abused Child Syndrome, Battered Women Syndrome (BWS) are among the variants of PTSD described. [12]:12, [13]:6

1977: Trauma-based disorders are called Acute reaction to stress in the ICD-9 manual, which also includes Dissociative [conversion] disorders. Catastrophic stress, Exhaustion delirium and Combat fatigue are listed are alternative terms. The PTSD-like diagnoses are predominant disturbance of emotions, predominant disturbance of consciousness, fugues fulfilling the above criteria, predominant psychomotor disturbance and agitation states, stupor fulfilling the above criteria. [20]

1980: Post-traumatic Stress Disorder becomes a separate diagnosis with the publication of the American Psychiatric Association's DSM-III psychiatric manual. [3]:236

1992: The ICD-10 manual is published, introducing two new post-traumatic disorders besides PTSD; Enduring Personality Change After Catastrophic Experiences (EPCACE), which is another name for Complex PTSD, and Acute stress reaction (which lasts only a few days after the trauma). [11]

1994: Acute Stress Disorder is introduced with the DSM-IV's publication, a reaction to trauma that is similar to PTSD but short term. [4]

1995: Compassion fatigue, also known as Secondary Traumatic Stress Disorder is named by Charles Figley, which involves PTSD-like symptoms in professionals helping those with PTSD. [15]

2013: DSM-5 published, A dissociative subtype of PTSD is introduced. [5]

A History of PTSD in the DSM

DSM-I (1952)
The first edition of the DSM psychiatric manual recognized both civilian and military experiences could cause Posttraumatic Stress Disorder, although it was described as a brief reaction rather than a potentially long-term disorder.

DSM-I PTSD: Gross stress reaction - Code 000-x81
Under conditions of great or unusual stress, a normal personality may utilize established patterns of reaction to deal with overwhelming fear. The patterns of such reactions differ from those of neurosis or psychosis chiefly with respect to clinical history, reversibility of reaction, and its transient character. When promptly and adequately treated, the condition may clear rapidly. It is also possible that the condition may progress to one of the neurotic reactions. If the reaction persists, this term is to be regarded as a temporary diagnosis to be used only until a more definitive diagnosis is established. This diagnosis is justified only in situations in which the individual has been exposed to severe physical demands or extreme emotional stress, such as in combat or in civilian catastrophe (fire, earthquake, explosion, etc.). In many instances this diagnosis applies to previously more or less "normal" persons who have experienced intolerable stress. The particular stress involved will be specified as (1) combat or (2) civilian catastrophe.

PTSD was combined withadjustment disorders in the second edition of the DSM, and placed in the Transient Situational Disturbances category.

Transient Situational Disturbances
"This major category is reserved for more or less transient disorders of any severity (including those of psychotic proportions) that occur in individuals without any apparent underlying mental disorders and that represent an acute reaction to overwhelming environmental stress. A diagnosis in this category should specify the cause and manifestations of the disturbance so far as possible. If the patient has good adaptive capacity his symptoms usually recede as the stress diminishes. If, however, the symptoms persist after the stress is removed, the diagnosis of another mental disorder is indicated."

Disorders in this category were classified by age, the only example relevant to PTSD is:

DSM-II PTSD (1968): Adjustment reaction of adult life - Code 307.3

"Example: Resentment with depressive tone associated with an un-wanted pregnancy and manifested by hostile complaints and suicidal gestures."

"Example: Fear associated with military combat and manifested by trembling, running and hiding."

"Example: A Ganser syndrome associated with death sentence and manifested by incorrect but approximate answers to questions."

Importantly, the DSM-II no longer categorizes the effects of trauma as a personality-related disorder. The condition is described as expecting to improve "as the stress is reduced," with another, unnamed disorder suggested for those with longer term symptoms, making this closer to Acute Stress Disorder than PTSD. [2]:14-49

Post-traumatic Stress Disorder becames a separate diagnosis in the year 1980, with two pages of description included, plus a page stating the diagnostic criteria and subtypes. PTSD could be diagnosed in both children and adults and was classed as anAnxiety Disorder.

DSM-III Diagnostic criteria for Post-traumatic Stress Disorder (1980)

A. Existence of a recognizable stressor that would evoke significant symptoms of distress in almost everyone.

B. Reexperiencing of the trauma as evidenced by at least one of the following:

(1) recurrent and intrusive recollections of the event

(2) recurrent dreams of the event

(3) sudden acting or feeling as if the traumatic event were reoccurring, because of an association with an environmental or ideational stimulus

C. Numbing of responsiveness to or reduced involvement with the external world, beginning some time after the trauma, as shown by at least one of the following:

(1) markedly diminished interest in one or more significant activities

(2) feeling of detachment or estrangement from others

(3) constricted affect

D. At least two of the following symptoms that were not present before the trauma:

(1) hyperalertness or exaggerated startle response

(2) sleep disturbance

(3) guilt about surviving when others have not, or about behavior required for survival

(4) memory impairment or trouble concentrating

(5) avoidance of activities that arouse recollection of the traumatic event

(6) intensification of symptoms by exposure to events that symbolize or resemble the traumatic event

Two PTSD subtypes were listed:

Post-traumatic Stress Disorder, Acute (code 309.80)

A. Onset of symptoms within six months of the trauma.

B. Duration of symptoms less than six months.

Post-traumatic Stress Disorder, Chronic or Delayed (code 309.81) - Either of the following, or both:

(1) duration of symptoms six months or more (chronic)

(2) onset of symptoms at least six months after the trauma (delayed) [3]:235-237

A significant change from the DSM-II PTSD criteria was that PTSD could now be diagnosed in someone with an existing personality disorder, and was recognized as more likely to occur in someone with a pre-existing mental disorder. The traumatic events recognized as causes for PTSD is described as outside the range of usual human experience, the examples listed were rape, assault, military combat, terrorism,bombing, torture, death camps, natural disasters (floods, earthquakes), and accidental man-made disasters (car accidents involving death or serious physical injury, airplane crashes, large fires). It was recognized that the risk of PTSD varied with the type of trauma: "Some [traumatic] stressors frequently produce the disorder (e.g., torture) and others produce it only occasionally (e.g., car accidents)." [3]:236
Types of trauma now known to cause PTSD which are were not listed in the original PTSD critieria include life-threatening illness, and witnessing trauma. [5]:272-274 Trauma triggers leading to worsening symptoms were recognized as situations or activities that resemble or symbolize the original trauma (e.g., cold snowy weather or uniformed guards for death-camp survivors, hot, humid weather for veterans of the South Pacific). [3]:236-237
The DSM-III recognized PTSD as having many possible complications, such as interpersonal relationship problems (described as caused by emotional numbing),"self-defeating behavior or suicidal actions" can resulting from the depression, emotional instability, or guilt caused by PTSD. Other disorders that could develop after PTSD were listed as Anxiety, Depressive, or Substance Use Disorders (e.g., alcoholism), and Organic Mental Disorder (e.g., resulting from a trauma involving a physical head injury).

This revision to the DSM occurred only 7 years after PTSD became a separate diagnosis. Significant changes include increased emphasis onavoidance symptoms, with the previous numbing criterion now included in the avoidance criterion, symptoms must last at least a month, and a recognition of differences in PTSD symptoms in children.

DSM-III-R Diagnostic Criteria for Post-Traumatic Stress Disorder (1987) - code 309.89

A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence.

B. The traumatic event is persistently reexperienced in at least one of the following ways:

(1) recurrent and intrusive distressing recollections of the event (in young children, repetitive play in which themes or aspects of the trauma are expressed)

(2) recurrent distressing dreams of the event

(3) sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon awakening or when intoxicated)

(4) intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma

C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

(1) efforts to avoid thoughts or feelings associated with the trauma

(2) efforts to avoid activities or situations that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma (psychogenic amnesia)

(4) markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills)

(5) feeling of detachment or estrangement from others

(6) restricted range of affect, e.g., unable to have loving feelings

(7) sense of a foreshortened future, e.g., does not expect to have a career, marriage, or children, or a long life.

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) exaggerated startle response

(6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator)

E. Duration of the disturbance (symptoms in B, C, and D) of at least one month. [6]:250-251

Specify delayed onset if the onset of symptoms was at least six months after the trauma.
Several new types of trauma were recognized in the DSM-III-R description of PTSD including witnessing another person's trauma, and in some cases "learning about a serious threat or harm to a close friend or relative, e.g., that one's child has been kidnapped, tortured, or killed" but this does not include "simple bereavement". Also recognized was the effect of a trauma anniversary. Additional symptoms recognized as a potential consequence of PTSD include forgetting an important part of the trauma (psychogenic amnesia, now called Dissociative Amnesia), trauma-related hallucinations, and a sense of a foreshortened future. The mind-body link involving physical reactions to trauma triggers/reminders is now recognized and included as a symptom. Survivor guilt is described in the text, but no longer considered a symptom of PTSD. [6]:247-251

Significant changes from the DSM-III include the introduction ofAcute Stress Disorder, a post-traumatic disorder which can only be diagnosed for symptoms lasting less between up to 4 weeks. Symptoms of Acute Stress Disorder are slightly different to those of PTSD and begin within a month of trauma. [4] There were no differences in the PTSD Diagnostic criteria between the DSM-IV and its DSM-IV-TR revision, which was published in 2000, although the description text was updated. [4]:467-468

DSM-IV Criteria for Posttraumatic Stress Disorder (1994) - code 309.81

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma

(2) efforts to avoid activities, places, or people that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) markedly diminished interest or participation in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect (e.g., unable to have loving feelings)

(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) difficulty falling or staying asleep

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.[4]:467-468

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor [4]:427-429

The main change to the PTSD diagnosis since the DSM-III-R was adding the A2 criterion, which required the person to report feeling intense fear, helplessness, or horror during rather than after the trauma(s), although this criterion was removed with the publication of the DSM-5 in 2013. An additional change in the DSM-IV was adding criterion F - which requires either significant distress or impairment resulting from the PTSD symptoms. The DSM-IV's PTSD section included information of prevalance for the first time, which was listed as affecting around 8% of the U.S. population in the 2000 version. [4]:463-468
Complex PTSD was not included in the DSM-IV-TR as a diagnosis, but PTSD's Associated Features and Disorders section of the DSM-IV-TR included a description of it, along with the types of trauma known to cause Complex PTSD:

"The following associated constellation of symptoms may occur and are more commonly seen in association with an interpersonal stressor (eg, childhood sexual or physical abuse, domestic battering): impaired affect modulation; self-destructive and impulsive behavior; dissociative symptoms; somatic complaints; feelings of ineffectiveness, shame, despair, or hopelessness; feeling permanently damaged; a loss of previously sustained beliefs; hostility; social withdrawal; feeling constantly threatened; impaired relationships with others; or a change from the individual's previous personality characteristics." [4]:465

Several significant changes were made, including introducing aDissociative Subtype for PTSD. Children under 6 years old have separate diagnosis criteria. [5]:270-281 See DSM-5 Diagnostic criteria and PTSD changes between the DSM-IV & DSM-5.

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History of PTSD and Trauma Diagnoses - Shell shock to the DSM

# data[].attributes.attachment_link.description
Posttraumatic Stress Disorder first became the diagnosis we know today in 1980, when it was included in the Anxiety Disorders section of the DSM-III psychiatric manual.[3], [7] Before 1980, Posttraumatic Stress was described and diagnosed under a variety of different names in both medical literature, and the ICD-6 (1948) and DSM-I (1952) diagnostic manuals.