Thursday, January 17, 2013

Concussion and PTSD in the Ancient World


The Ludovisi Battle Sarcophagus depicting Roman conquest
of Barbarians, 2nd - 3rd century CE.  Photographed at the 
Palazzo Altemps, Museo Nazionale Romano, in Rome Italy
by Mary Harrsch.
After I suggested in my review of "Semper Fidelis"  that the antagonist in Ruth Downie's novel, a brutal Centurion named Geminus, may have been suffering from PTSD, Ruth sent me a link to a very thoughtful post by Dr. Dorothy King  entitled  "PTSD in Antiquity."  (Sadly, it is no longer online.)

In my review, I cited a post by Dr. Jonathan Eaton who had generally dismissed the probability that many ancient soldiers suffered from PTSD because modern research points to PTSD being most prevalent in soldiers experiencing explosive events (like IEDs, land mines or booby traps).  He theorizes that since gunpowder or other explosive material was generally not used in ancient warfare, such explosive events did not occur so the probability that PTSD could develop was quite low.  He also pointed to the death-filled environment of the ancient world as something that he felt would desensitize ancient peoples to the trauma of warfare.

Dr. Eaton's viewpoint may have reflected a study done in 2011 by C.W. Hoge. In it, the researchers followed 2,525 soldiers and questioned them three to four months after their return from a year-long deployment in Iraq.

"Of the majority of soldiers who suffered no combat injuries of any sort, 9.1 percent exhibited symptoms consistent with PTSD. This allows a baseline for susceptibility of roughly 10 per cent of the population.  A slightly higher number (16.2 per cent) of those who were injured in some way, but suffered no concussion, also experienced symptoms. As soon as concussive injuries were involved, however, the rates of PTSD climbed dramatically. Although only 4.9 percent of the troops suffered concussions that resulted in complete loss of consciousness, 43.9 percent of these soldiers noted on their questionnaires that they were experiencing a range of PTSD symptons.  Of the 10.3 per cent of the unit who suffered concussion resulting in confusion but retained consciousness, more than a quarter (27.3 per cent) suffered symptoms. This suggests a high correlation between head trauma and the occurrence of subsequent psychological problems." - Aislinn Melchior, Caesar in Vietnam: Did Roman Soldiers Suffer from Post-Traumatic Stress Disorder

 Melchior admits that concussion is not the only risk factor for PTSD but says it is so strongly correlated that it suggests the incidence of PTSD may have risen sharply with the arrival of gunpowder, shells, and plastic explosives.

"In Roman warfare, wounds were most often inflicted by edged weapons. Romans did of course experience head trauma, but the incidence of concussive injuries would have been limited both by the types of weapons they faced and by the use of helmets." - Aislinn Melchior, Caesar in Vietnam: Did Roman Soldiers Suffer from Post-Traumatic Stress Disorder

In his footnotes, Melchior speculates that the Romans designed their helmets with an eye to blunting the force of the blows they most often encountered.  Although Peter Connolly argued that the helmet design in the Republican period suggested a crouched fighting stance, Melchior disagrees suggesting the change in helmet design at that point may have signaled instead a shift in the role of troops from performing assaults on towns and fortifications when the empire was expanding and the blows would more often rain from above to the defense and guarding of the frontiers.

Melchior, like Eaton, also speculates that death was so common in the ancient world that it desensitized many of its residents to the prospect of unexpected death.

But in his 1999 paper entitled "The Cultural Politics of Public Spectacle in Rome and the Greek East in 167-166 BCE"  Jonathan C. Edmondson points out that when King Antiochus IV introduced Roman-style gladiatorial combats in Syria in 166 BCE, the Syrians were terrified rather than entertained.
"In time gladiatorial contests came to be accepted and even popular, but only after Antiochus had instituted a local variation whereby fights sometimes ended as soon as a gladiator was wounded."
This hardly sounds like people desensitized to death.

Dr. King also disagrees pointing to the fact that she, a diagnosed victim of PTSD, had never experienced an explosive event and she knew of a military general diagnosed with PTSD that had never been near explosive devices either.  She was particularly impressed with the research of Jonathan Shay summarized in his book " Achilles in Vietnam: Combat Trauma and the Undoing of Character . 


Shay's work has now been made into a poignant documentary entitled "Odysseus in America." 

In another of King's articles, "The Rage of Achilles and PTSD". King discusses what she feels (and I concur) are clear examples of PTSD in the ancient texts.  Her post opens with a moving passage from Homer:


Then said Achilles, "Son of Atreus, king of men Agamemnon, see to these matters at some other season, when there is breathing time and when I am calmer. Would you have men eat while the bodies of those whom Hector son of Priam slew are still lying mangled upon the plain? Let the sons of the Achaeans, say I, fight fasting and without food, till we have avenged them; afterwards at the going down of the sun let them eat their fill. As for me, Patroclus is lying dead in my tent, all hacked and hewn, with his feet to the door, and his comrades are mourning round him. Therefore I can think of nothing but slaughter and blood and the rattle in the throat of the dying."
Iliad 19.226
Then she goes on to examine descriptions of the behaviors of such ancient military men as a Greek warrior at Marathon, Leonidas at Thermopylae, Alexander the Great and Gaius Marius, all supported by quotes from the ancient sources.

So, I was gratified to find another scholar with personal experience with PTSD who also disagrees with Eaton and Melchior.   

Recently, scholars studying cuneiform medical texts left behind by ancient Mesopotamians point to passages describing mental disorders expressed by soldiers and even a king during the Assyrian Period (1300–609 BCE) when military activity was extremely frequent and brutal. The King of Elam is said to have had his mind changed.  Soldiers were described as suffering from periods where they were forgetful, their words were unintelligible, they would wander about, and suffer regular bouts of depression.

"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..." - Translation by Scurlock and Andersen, Diagnoses in Assyrian and Babylonian Medicine

"As seen in the cases of military casualties, the signs and symptoms of the victim were attributed by the ancient Mesopotamians to ghosts, as was the case with many mental and psychosomatic disorders seen during that period. It looks as if, in the case of military casualties, the responsible ghosts were usually assumed by the treating ašipu to be the ghosts of the enemies whom the patient had killed during military operations..."

"...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. - Walid Khalid Abdul-Hamid and Jamie Hacker Hughes, Nothing New under the Sun: Post-Traumatic Stress Disorders in the Ancient World (2015)

I would like to take all of their observations just a few steps further and point to even more recent findings that I feel call into question the "explosive events as the primary cause of PTSD" theory.

I think the results of the autopsy of one of the NFL players who recently committed suicide is particularly significant.  The news reported that the individual had significant brain damage from repeated concussions suffered not from explosive events but from the impacts experienced during a series of football games.  If you consider the repeated impacts ancient soldiers experienced in set piece battles where tight formations were used, such as Greek or Macedonian phalanxes or Roman maniples, the probability of the occurrence of repeated concussions similar to those experienced by modern football players is quite high.  The news program went on to interview the football player's family and they discussed how he had deteriorated mentally from an outgoing, very social individual to a sullen, withdrawn person who no longer found life fulfilling.  As the spouse of a war veteran who has been permanently disabled by severe PTSD, I found the symptoms described by the football player's family all too familiar.

I also think Eaton and Melchior dismiss too readily the psychological aspects of PTSD in the ancient world because of their observations that the ancient world was a far more brutal environment than we have now (outside of inner city ghettos).  They point out how people were surrounded by death because of disease, accidents without proper medical treatment, and entertainments that featured the orchestrated deaths of both people and animals.  I propose that observed deaths occurring in a venue where the observer and the participants are separated both by physical barriers and social hierarchy (most human victims were criminals, prisoners of war, "Others" so to speak, or slaves, those whose social status separated them from the vast number of citizens in the audience) are distinctly different when compared to violent deaths of friends, family members, and comrades, your "band of brothers," fighting right beside you in a person-to-person battle scenario.

Furthermore, ancient executions were designed to further distance the audience from the victim through the use of mythological reenactments or by placement outside the city.

"Crucifixions were usually carried out outside the city limits thus stressing the victims rejection from the civic community. Because of the absence of bloodshed out of an open and lethal wound, which evoked the glorious fate of warriors, this type of death was considered unclean, shameful, unmanly, and unworthy of a freeman. In addition the victim was usually naked. Essential, too, was the fact that the victim lost contact with the ground which was regarded as sacrilegious." - J.J. Aubert, "A Double Standard in Roman Criminal Law?" from "Speculum Juris: Roman Law as a Reflection of Social and Economic Life in Antiquity"

We also cannot forget the medical personnel either.  Following the Vietnam War, many veterans (both male and female) who served in a medical capacity were later found to be suffering from PTSD.  The medical environment of an ancient treatment facility following a major ancient battle was far worse than in a modern field hospital.  Ancient surgeons attempted to treat often thousands of wounded in a relatively short time compared to only handfuls at a time during the Vietnam conflict.  Ancient physicians were surprisingly quite skilled, especially Roman military surgeons, but they had little but herbal compounds (and honey if the Romans listened to the Egyptian physicians) to ward off infections.  Their patients' mortality rate was much higher than the relatively low mortality rate experienced in Vietnam.  So, how could they have escaped the effects of PTSD, often after years of service, not "just" 6 - 12 months - more than enough to trigger PTSD in modern warfare?

Psychotherapist Alan Greaves in his paper, "Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review" points out that identifying the characteristic behaviors associated with PTSD in an ancient culture is particularly problematic because of socio-cultural factors such as social taboos on men crying or the abrogation of suicide.

"...we do not know how common or acceptable somatisation or the outward expression of any of the other psychological symptoms of PTSD would have been in ancient Greece, which in itself was made up of many differing local cultures or communities."

Greaves does acknowledge, though, that there is enough description in historical sources to point to a recognizable human response to traumatic stress in earlier ages.

"...the fact that PTSD has been identified, to various degrees and variously expressed, across different ethnic and cultural groups does indicate that the human species is naturally predisposed towards reaction formation following episodes of traumatic stress. As discussed above, there would appear to be some evidence that Conversion Disorder was present in Greece in the 1st millennium BC, even if finding similar evidence for PTSD is a more complicated matter because of the nature of our sources and its symptoms and definition. The sheer  prevalence of PTSD across modern populations adds further weight to the argument that it has  been a feature of human experience for a considerable  period of our history, even if the precise form of its expression has varied across contemporary and historical cultures." - Alan Greaves, "Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review"

However, in a 1996 study of emotion, Fischer and Manstead argue: ‘there are both cross-cultural similarities and differences in emotion.’ There is, therefore, no universal human reaction that can be predicted in all circumstances of traumatic stress, but neither are our reactions entirely culturally determined. Bearing in mind the very different incidences and presenting symptoms in different cultures, can we  possibly ever know what PTSD, or any of the other post-traumatic conditions discussed above, would have looked like in ancient Greece?

Perhaps, not. I sometimes wonder, though, if modern scholars think that ancient people just didn't value their lives as much as we do, since they did not shrink from casualties as high as 50,000 in a single military engagement or investment of an enemy city.  But if you've ever looked at some of the poignant grave goods found in ancient burials or studied the reliefs and inscriptions on ancient funerary monuments, I think you will conclude that we are only separated by time, not by our shared human nature.

References:

Abdul-Hamid, W. K., & Hughes, J. H. (2014). Nothing New under the Sun: Post-Traumatic Stress Disorders in the Ancient World. Early Science and Medicine19(6), 549-557. doi:10.1163/15733823-00196p02

Aubert, J.-J, & Sirks, A. J. (2002). A double standard in Roman criminal law? In Specvlvm ivris: Roman law as a reflection of social and economic life in antiquity. Ann Arbor, MI: The University of Michigan Press.

Cook, J. (2012). Crucifixion as Spectacle in Roman Campania. Novum Testamentum, 54(1), 68-100. Retrieved from http://www.jstor.org.libproxy.uoregon.edu/stable/23253630

Edmonson, J. C. (1999). The cultural politics of public spectacle in Rome and the Greek East in 167-166 BCE. Studies in the History of Art56, 76-95.

Fischer, A. and Manstead, A. H. 1996. Emotions. In A. Kuper and J. Kuper (eds.), The Social Science  Encyclopaedia 2nd ed., 239-240. London, Routledge.


Greaves, A. M. (2008). Post Traumatic Stress Disorder (PTSD) in Ancient Greece: A Methodological Review. Warfare and Society in the Ancient Eastern Mediterranean. Retrieved from https://www.academia.edu/6897230/Post-Traumatic_Stress_Disorder_PTSD_in_Ancient_Greece_A_Methodological_Review

A. Melchior (2011). Caesar In Vietnam: Did Roman Soldiers Suffer From Post-Traumatic Stress Disorder. Greece & Rome, 58(2), 209-223. Retrieved from http://www.jstor.org.libproxy.uoregon.edu/stable/41306157

JoAnn Scurlock and Burton Andersen, Diagnoses in Assyrian and Babylonian Medicine: Ancient Sources, Translations, and Modern Medical Analyses (Urbana and Chicago: University of Illinois Press, 2005), Pp. xxiii + 879.







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