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.







9 comments:

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.