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.

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." 

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 and Melchior.   I would like to take her 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, the symptons described by the football player's family sounded 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 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, your "band of brothers," 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 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?

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."

Quoting from a 1996 study of emotion by Fischer and Manstead: ‘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:

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

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

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.



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