PTSD (again!): Nothing New Under the Sun?

Book being read, eds. N. Sekunda & B. Burliga, Iphicrates, Peltasts and Lechaeum, (Gdansk, 2014)

The article

A paper has just been publicised that is causing a mini-flurry of activity on many of the social media sites that I use. It is raising so many interesting questions and controversies that I thought it worth a mention. The paper is: W.K. Abdul-Hamid & J.H. Hughes, “Nothing New under the Sun:Post-Traumatic Stress Disorders in the Ancient World” and it puts forward the idea that PTSD can be found in the historical sources that go back further than ancient Greece or Rome, even further than the world of Homer or King Solomon. The researchers believe they have found proof that PTSD was present in the ancient civilisation of Assyria (c.1300 BC-609 BC), and their evidence is compelling on the surface of it. These are direct references from Assyrian medical texts:

“14.34 “If his words are unintelligible for three days […]his mouth [F…]and he experiences wandering about for three days in a row F…1.”

14.35 “He experiences wandering about (for three) consecutive (days)”; this means: “he experiences alteration of mentation (for three) consecutive (days).”

14.36 “If his words are unintelligible and depression keeps falling on him at regular intervals (and he has been sick) for three days F…]””

“19.32 If in the evening, he sees either a living person or a dead person or someone known to him or someone not known to him or anybody or anything and becomes afraid; he turns around but, like one who has [been hexed with?] rancid oil, his mouth is seized so that he is unable to cry out to one who sleeps next to him, ‘hand’ of ghost”

To which the researchers comment later on:

“Generally, the symptoms described fit the symptoms of post-traumatic stress disorder as we understand them now. The flashbacks of images of dead people, particularly those occurring at night (in the form of nightmares) and accompanied by fear, are an important symptom. The changes of mental state with fear, forgetfulness and depression are also symptoms that we see often in clinical practice.”

Now this observation has captured the minds of various media outlets see here, here, here, here, all saying the same thing – PTSD has been ever present for over 3,000 years.

We know, from the fiasco that followed the release of J. Crowley’s work last year, that to break from this party line will induce quite a backlash, and a quote from one outlet shows us why (full article here):

“Perhaps the knowledge that there is evidence of PTSD existing thousands of years ago might help dispel views that remain among some of those currently in the armed services (as well as members of the public) of the disorder being a sign of weakness and/or a myth.

It is certainly not something that has popped up recently and is unique to our own culture. Instead of macho denials we can admit that PTSD is a serious public health matter, and get on with making progress using modern medical techniques to try and help those affected.”

To criticise historical examples of PTSD is to spit in the face of modern sufferers, apparently. As I am a ‘believer’ of combat trauma being a universal human phenomenon (but not PTSD per se) it may seem a bit strange that I will say this, but this research paper is rather flawed.

The research that this paper utilises is not original, not that that is a problem at all because their discipline and audience is not ancient history but the history of medicine, and comes from a fascinating book titled Diagnoses in Assyrian and Babylonian Medicine (see page 351 in particular). In this book there is a small (and I do mean small) section on PTSD which uses the exact same references with that of our paper – again this is not a problem, although it is a bit frustrating that a peer reviewed paper can get away without referencing the original primary source, with a secondary reference to the translation used . . . but I digress.

The book offers no explanation for the ‘diagnosis’ of historical PTSD, nor does it give any evidence that these symptoms quoted came from exposure to warfare or any specific stressful conditions. Whilst I do not question the author’s observations, nor integrity for that matter, I do question how valid an assumption it can be as a third party (like our article writers) to accept these observations as read when they have been given no surrounding context to each of the ancient medical observations.

Whilst our paper, using the book as its guide, does explore the Assyrian culture of medicine, and mental health which is fascinating to say the least, neither work attempts to place the ‘symptoms’ within the wider framework of Assyrian culture, Assyrian religion nor Assyrian warfare, to a satisfactory level. (Whilst the book could rightly be defended because PTSD is not its main focus, the article has no such defence.)

Different cultural factors – let’s talk about Epizelos

This is where the crux of the debate lies, for me at least. If we can accept that trauma is, by and large, a repercussion of a biological reaction to a negative stimuli (stress, fear, imminent death, violence, fight-flight-freeze, whatever else you wish to call it), then it is fair to present PTSD as a possible human universal. However, PTSD is not a direct repercussion of this reaction. We know that there are a multitude of factors that impact the diagnosis, or a person’s susceptibility to it, so it must be accepted that social factors are equally as important to understand, rather than the bare bones of biological stress and fear.

To give a slightly abstract example, but one I have always been interested in and one our article also uses, there was an ancient Greek soldier named Epizelos who fought at the battle of Marathon (during a war that our paper confusingly calls the Marathon Wars, or to you and I the Persian Wars/Invasions):

“Epizelus, the son of Cuphagorus, an Athenian soldier, was fighting bravely when he suddenly lost sight of both eyes, though nothing had touched him anywhere – neither sword, spear, nor missile. From that moment he continued blinded as long as he lived. I am told that in speaking about what happened to him he used to say that he fancied he was opposed by a man of great stature in heavy armour, whose beard overshadowed his shield but the phantom passed him by and killed the man at his side.” p.551 from the article

This episode is often described as the first historical incident of combat-trauma, and therefore PTSD. Whilst the first point is quite plausible, without going into a long winded argument about source analysis/integrity, the second one is harder to swallow.

It first arrived as a possibility around the end of the First World War when a letter was written to Science (5th September 1919) quoting the reference above and asking if this was “perchance, the first account of ‘shell-shock’?”. This innocent question was strangely taken as proof by later writers that Epizelos was indeed the first example- the letter is even referenced as evidence in some works on the topic!- and the label has stuck ever since, changing to the label of PTSD when the time was right. For a brilliant account of the history behind the use of Epizelos for this diagnosis I advise Helen King’s article on the matter “Recovering Hysteria from History: Herodotus and the first case of ‘shell-shock'” (just google it).

Anyway, the point around Epizelos is that he is the first account we have of a direct experience evoking a psychosomatic state of blindness from a combat situation, ergo combat-induced trauma. However, PTSD is not just combat trauma – it is a “disorder” (a word which some people are pushing to be removed from the name). For something to be a disorder it must be a problem, really. A problem that is determined by the culture that has set the parameters of normality, of health, and of mental stability, and this is where the trouble comes in to the PTSD debate. Epizelos did very well out of his trauma, he was famous, he was embraced as a hero, he entered a prestigious realm of ‘disability’ akin to those touched by the gods such as prophets and poets. As King points out, Epizelos’ blindness occurs when Epizelos is exhibiting andreia (his manliness, his bravery and courage), thus it is almost a symbol of his prowess and heroism. The fact that he went blind, and saw a phantom was in no way seen as a sign of mental instability, nor of a problematic disorder.

Epizelos’ vision of the bearded phantom warrior is often cited as a hallucination, proof of his mental instability, similar to that claimed in our paper on the Assyrians regarding ghosts. But again this raises the question, is the seeing of ghosts/divinities (or the description of seeing ghosts/divinities) a sign of instability in a culture where these elements were as real as you or I? At a time when the people had a living and working relationship with this entities?

The Greeks understood ‘madness’, and could spot it very well, but Epizelos was not dismissed as mad so he must, at the very least, have created a narrative which conformed to social possibilities and maybe even norms. It reminds me of Sokrates who famously claimed to hear divine voices (shock, PROOF of mental illness!). His critics did not have a major problem with this, although it was unusual it was not unheard of (priestesses of Delphi being the prime example). Their issue came because no-one else could talk with these divinities, they only spoke with Sokrates. So the problem was not the hearing of voices which was within the realms of social norms and possibilities, but the selfish nature of the relationship Sokrates had with them which was not within the realms of acceptability.

Back to the article

So, without going into an in depth critique of an interesting and provoking paper, a few points arise that are problematic and deserve mentioning:

– We have the problem of context.

Unlike Epizelos, these Assyrian examples are not shown to be directly linked with experience, and therefore any direct factors remain speculative until proven otherwise.

– Symptoms are equally likely to derive from other problems.

The book Diagnoses describes how some of the symptoms are just as likely to be from ethanol poisoning (p. 438). And nightmares have other factors than just trauma, although in my personal opinion this is actually quite good evidence for trauma.

– There is not enough effort to show how the nature of warfare in the Assyrian period can create the right environment for PTSD, inclusive of the numerous factors that modern research is highlighting.

– There is a blind acceptance that trauma is trauma is trauma; or that war is war and trauma is trauma. There is trauma in modern war so it must be the same as trauma in ancient war.

It’s a nice idea, but as our tiny example of Epizelos shows, the long term experience of trauma is dictated by huge social factors and to compare modern soldiers with ancient is grossly unfair and quite dismissive of the modern sociological problems that our veterans are struggling with, as well as their own individual psycho-social pressures and influences. (This critique is not aimed at the paper, which does not go into this really, but at the media reaction and the coming narrative).

– This paper needed more historical assistance.

Although they thank the author of Diagnoses, Professor JoAnn Scurlock, for comments on earlier drafts I feel her input could have been better utilised. There is no reference to some of the hugely influential books on PTSD in ancient warfare, which admittedly focus on Greece more than any other culture. But the works of L. Tritle (Melos to My Lai) and J. Shay (Achilles in Vietnam, and Odysseus in America) went some way to approach the issues of universality in military history, whilst the equally evoking works of J. Crowley (“Beyond the Universal Soldier”) and A. Melchior (“Caesar in Vietnam”) have very effectively critiqued the universality of this approach; something this paper could have used as a guiding point.

– It suffers with a common problem in the debate at the moment, it only focuses on military PTSD (although, to be fair, it does reference an ancient Greek example of two women which they claim exhibit PTSD symptoms, but again without context).

The non-universalist side of the PTSD debate (the relativists) often falls apart because it is so military-centric. One example would be modern research into head injuries from explosions and their links with PTSD (something used in Melchior’s brilliant article) becomes quite irrelevant when we know that PTSD is also caused by events such as rape, or watching a traumatic event unfurl. Whilst explosions may be a factor, due to their unquestionable ability to initiate a fear response and the propensity for head injuries, they cannot realistically be pointed at as a sole cause for PTSD.

– It uses the term PTSD. Controversial, I know.

I appreciate the desire to use history to help modern people, and I applaud the projects that have used Greek theatre or Homer’s poetry to help veterans talk about their experiences in the safety of a non-direct examination of combat and trauma, and, to be frank, I think this should continue to expand. However, the term PTSD is historically obstructive. It sets a predetermined framework which researchers are using to justify their own, predetermined, conclusions. We find PTSD because we know what it looks like, and we know it must be there, who cares if the wider evidence brings into question the validity of such a concrete set of diagnostic criteria!

– It makes the strange observation that Epizelos was suffering with psychogenic mutism, hopefully this is a typing error made twice, or it is possibly an attempt to make Epizelos fit the descriptions of the Assyrian texts. Either way, Epizelos was never mute according to our source, he went blind and, by the sounds of it, he could not shut up about it!

– People have already linked the Epic of Gilgamesh with the portrayal of PTSD, and the epic dates from somewhere in the 3rd millenium BC, meaning that this paper has not found the earliest references – if we believe that they are present in the epic.

Conclusion, of sorts

All of this aside, the article is worth a read and the conversation deserves to be widened to include other possibilities: prime amongst them being that PTSD should not be set in stone as a diagnosis just yet, and that it should not be used as a diagnosis outside of its own cultural context.

This paper is not the first of its kind (scientists writing about the history of PTSD), nor will it be the last because PTSD is such an engrossing and emotive topic of discussion. But I hope that more scientists branching in to the area of ancient PTSD will heed the words of psychologist Nigel Hunt when he was describing memory narratives:

“If we wish to understand memory, we must understand the social context in which people live and have lived. In order to do this psychologists should consult with historians, sociologists, and others to build the social world through which people have lived.”

N. Hunt, & S. McHale, ‘Memory and Meaning: Individual and Social Aspects of Memory Narratives’, Journal of Loss and Trauma,,13, (2008) pp. 55-6.