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"

In my review, I cited a post by Dr. Jonathan Eaton who had basically dismissed the possibility that ancient soldiers did not suffer 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. King 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".  King includes three trailers in her post but this is my favorite.  The voiceover sounds like the highly respected actor, David Strathairn.

Then I followed King's link to an earlier post entitled "The Rage of Achilles and PTSD".  In it, King discusses what she feels (and I concur) are clear examples 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.   I would like to take her observations just a few steps farther and point to even more recent findings that I feel debunk 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, the symptons described by the football player's family sounded all too familiar.

I also think Eaton dismisses too readily the psychological aspects of PTSD in the ancient world because of his observations that the ancient world was a far more brutal environment than we have now (outside of inner city ghettos).  He points 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 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) is distinctly different when compared to violent deaths of friends, family members and comrades fighting right beside you in a person-to-person battle scenario.

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 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?

I sometimes wonder 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.

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James said...

Part of this post addresses something I've wondered about for a long time and which I talk of in a moment. Some background: Veteran, ancient romaphile, ancient history lover, and military history (nuts and bolts part esp.).
PTSD; beyond believing it exists I don't think I'm qualified to do anything but commentary and relation of personal experience. Since it seems to be largely mental it's hard to pin down what is self induced, what is organic, and what is purely uncontrolled mental problems. Also there are different manifestations of mental disfunction that almost lead one to think you're dealing with totally different things. I have seen men broken by combat, broken in the sense they almost cannot function as a basic human being period. Is that the same as flash backs, sudden great fear, bad dreams I don't know.
The explosive theory doesn't cut it. To my mind severe stress beyond anything a person even understand lays at the root. In the old stories you read alot about terror and peoples irrational behaviour when in that state. Well I'm rambling now so I'll try to make it short. The obvious difference between us in Nam and the Typical Roman soldier is that though we did fight at close quarters at times it was somewhat unexpected and we weren't really trained, had the equipment, or the famliarity of it compared to the Legionaire. Perhaps more later.

Mary Harrsch said...

Thanks, James, for your insight. What I have found to be most troubling about PTSD is that it is an insidious condition that sort of creeps up on you over time. Many victims of it are not mentally "broken" during the combat experience. Like Dr. King mentions in her posts, victims even excel during the stressful event, demonstrating exceptional control and personal courage. But the tension ultimately never leaves them and over time intensifies making them hyperaware of the slightest possibility of impending danger. This eventually leads to the unwillingness to engage in emotional relationships (because of fear of sudden loss) and the inability to sleep which in turn leads to other behavioral issues that affect daily living and social interaction.

My brother served two tours in Vietnam and after he eventually got out of the Army and came to visit me, he would still feel the need to arise early and walk the perimeter of our farm to ensure there were no enemy encroachments during the night even though we were over 30 miles from the nearest town out in the middle of the eastern Oregon desert.

My husband's condition expressed itself in explosive outbursts of rage for the slightest problem or inconvenience. He was stopped for a traffic infraction and he became so enraged at the officer that the officer was forced to call for backup. The only way I was able to extract him for what appeared to be a rapidly deteriorating situation was to place myself between him and the officers and insist that he get back in the vehicle. I eventually talked him down but its like living with a time bomb and not knowing what event will trigger it.

Once he finally agreed to seek help from the VA things have improved somewhat. He has a very conscientious health care team that monitors his physical health (he's also a victim of Agent Orange exposure) and mental health and medications and counseling have helped. If you are also a victim of PTSD I would highly recommend seeking out the specialists at the VA.

Unfortunately, for soldiers in the ancient world the condition, although recognized as abnormal, was not understood, neither its physical or mental effects, so treatment was never developed to my knowledge, or at least it was never documented in any surviving ancient texts.

James said...

No, I am not a sufferer but thank you for asking. I am fairly up on all the current diagnoses and behavioral descriptions. Any way yours is a difficult situation good luck. The ancients' understanding of mental health would probably surprise us. I'll bet they had alot of veterans "touched by the gods" on the streets, in the taverns, and living with brigands. Just not an interesting a subject for the writers we know.

Dr Jonathan Eaton said...

I enjoyed reading this thougtful post, on a topic which demands discussion. Just a point of clarification: nowhere do I suggest that PTSD did not occur in the ancient world. Indeed, I think it certainly did (hence my praise for Jonathan Shay's work). Nor do I think that PTSD is solely caused by concussive injuries (which it obviously isn't). However, recent research indicates that there is a link between some cases of PTSD and concussive injuries. For this reason, I think it is likely that PTSD was less prevalent in the ancient world than it has been over the last century or so. My argument is really about the need for historians to consider carefully how they use historical evidence to diagnose individuals in the past.

Mary Harrsch said...

Thank you Dr. Eaton for clarifying your post. I agree that modern historians should be cautious about diagnosing the mental state of individuals in the ancient past, especially since we have such fragmentary evidence to work with. I did think Dr. King did an excellent job of pointing to those passages that did reflect an understanding of mentally tortured individuals and connecting their state with exposure to the horrors of the battlefield. As you mention, this area of research does need more intensive examination, especially in light of the high numbers of PTSD and suicide being experienced by the military now. I firmly believe the past can be our best teacher.

Bart Boge said...

The only comment I'd add to the discussion is that the latest findings regarding CTE (chronic traumatic encephalopathy) seem to suggest that repeated sub-concussive blows to the head are as damaging or more damaging over time than periodic concussions. The implications for football are profound, as further research might damn the sport as we know it.

As it pertains to ancient warfare, violent and incessant jarring of the head while in tight formations could, over time, produce CTE-like symptoms in legionnaires or hoplites, even if none of the blows actually resulted in a full-blown concussion.

Also, it seems absurd to me that anyone would link PTSD to physical causes, i.e., heavy artillery rounds, I.E.D's, etc. I always considered it a purely psychological phenomenon brought about by periods of protracted emotional stress coupled with observing the horrors of was firsthand (casualties of "brothers in arms").

It almost defies logic to think that ancient soldiers did not real with PTSD the way modern combatants do.

Mary Harrsch said...

Bart, severe depression is one of the main symptoms of both CTE and PTSD so perhaps that is why the two conditions are often co-mingled. Depressed individuals often have the physical condition of a chemical imbalance in the brain as well so, although PTSD can occur without physical exposure to violence, it can eventually result in a physical condition requiring medical intervention.

War veterans may also be suffering from both emotional and physical trauma simultaneously. Vietnam veterans that endured explosions from land mines, artillery shells or repurposed bombs were not often treated for concussion if they did not exhibit any visible wounds. If they could get up and walk around afterward, they were considered good to go and the patrol or convoy continued on its way - at least that was my husband's experience as a combat engineer specializing in demolitions. In Vietnam they also did not have robots, protective suits or heavily armored vehicles that you saw in the film "The Hurt Locker" or the G4 series "Bomb Squad Afghanistan" either.

Unknown said...

Great article!

PTSD is becoming more widely accepted as a phenomena that occurs whenever there is any type of traumatic event that the brain cannot cope for.

More and more individuals in large car accidents, work accidents, or slip and falls, are being diagnosed with it. You can hardly say that a bloody roman war is less traumatic than a car accident.

Bart Boge said...

Up until just the last decade or so, the ethic in contact sports was "just walk it off" or "you just got your 'bell rung'--you'll be fine in a minute." Only now do we know that a blow to the head that causes a momentary loss of consciousness is a brain injury.

Roman Archaeology Timeline