How old is post-traumatic stress disorder?

It is very hard, and very weird to try to get a handle on how human health has changed between the 19th century and today. Obviously, the way we live has changed dramatically. But understanding how that impacts health (or doesn't) is complicated by the fact that healthcare, science, and public health research changed dramatically during those years, as well.

And all that science hasn't happened in a vacuum. The names we give various disorders change. Whether or not we consider something to be a disorder, at all, might change. And our cultural understanding changes, too—especially when it comes to mental illness.

At the Mind Hacks blog, Vaughn Bell has an excellent breakdown of two recent studies that try to put the modern diagnosis of post-traumatic stress disorder (PTSD) into a cultural and historical context. Many people assume that PTSD is just a new name for something that has always existed—look at shell shock, which made it onto Downton Abbey last season. But these new papers suggest that the distinction between what soldiers experienced in the past and what they experience today might go deeper than naming conventions.

The diagnosis of PTSD involves having a traumatic experience and then being affected by a month of symptoms of three main groups: intrusive memories, hyper-arousal, and avoidance of reminders or emotional numbing ... there has been a popular belief that PTSD has been experienced throughout history but simply wasn’t properly recognised. Previous labels, it is claimed, like ‘shell shock’ or ‘combat fatigue’, were just early descriptions of the same universal reaction.

But until now, few studies have systematically looked for PTSD or post-trauma reactions in the older historical record. Two recent studies have done exactly this, however, and found no evidence for a historical syndrome equivalent to PTSD.

A study just published in the Journal of Anxiety Disorders looked at the extensive medical records for soldiers in the American Civil War, whose mortality rate was about 50-80 greater than modern soldiers fighting in Iraq and Afghanistan. In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.

Read the rest at Mind Hacks

David Dobbs adds some more context to Bell's post at the Neuron Culture blog.


  1. First thing I’d do is compare the records of todays’s armies. Do Iranian or Iraqi soldiers suffer from PTSD? 

  2. War is a horrible, horrible thing.  When you fight a war, you have to do terrible, inhuman things.  It’s just the nature of the beast.  There are only two ways to do these things without massive psychological trauma:  Either be a total sociopath, or be absolutely sure that you are morally justified in your actions.

    When soldiers returned from WWII and saw photos of the Nazi death camps, saw just how much of the map had been overrun by Axis armies, it was pretty simple to say “Whatever I may have done, my family is only alive and free right now because I did those things.”

    When soldiers returned from Korea and Vietnam and Iraq, they saw that they were there for political reasons, and that nothing they did really mattered that much to the society they lived in, well, that leaves a mark.

    1. I disagree with your view that politics has an effect. People who are raped, survive robberies, or see a friend or family member killed in an accident also suffer from PTSD. It isn’t just a wartime disorder. And it isn’t guilt. If it was, that would imply that the civilians who get the disorder (twice as many women as men) get it because they feel guilty from a traumatic event. I doubt that.

      1. I would respectfully argue that all three of the examples you provided DO, in fact, lead to tremendous feelings of guilt and shame.  (“If I’d only fought back harder/been able to get there in time/done X differently…”)

        I’m also quite certain that societal pressures exacerbate these.  I don’t want to give the impression that I’m defending anything, but I can’t help thinking that molestation was probably a more traumatic experience for a boy in 1950s America than it was in say, ancient Greece or Rome. 

      2. The point he’s making about politics is that if there is a legitimate (or seemingly legitimate) reason for the terrible things you experienced, that can make it easier to deal with.

        None of your counter-examples work because for people who are raped, survive robberies, or see a friend being killed (or accidentally kill someone themselves, or… list goes on) there is not a comparable legitimate reason for any of those things happening. It’s pretty much the same thing – there was no reason for those things to happen. No justification will ever make up for it.

        As another example, note that people who justify murdering someone to themselves with a reason that, to their deranged mind, is legitimate probably don’t get PTSD. Or to make it political again, a freedom fighter is probably not going to get PTSD after they assassinate (aka murder) a terrible dictator in cold blood. Not that they can’t, of course, it’s just much less likely than people who are sent into war zones and all their friends get blown to bits right in front of them for no particularly legitimate reason.

    2. But troops who fought in World War 2 still had PTSD. It just wasn’t given the name “PTSD” at the time. It was called “combat stress” or “combat fatigue.”

        1. I would rather go with the “nowadays We diagnose it better (and hopefully deal with it better)” train of thought. In WW1, people would be regularly shot by their own side when they refused to go back to the trenches after their traumatic experiences.

        2. Is modern PTSD substantially different from what was observed in soldiers of previous generations though?    In the WWI era, soldiers with posttraumatic symptoms were said to be suffering from “shell-shock”.   Not that it was a universally accepted diagnosis.  Hundreds of WWI soldiers reporting these symptoms were shot for cowardice (especially among British soldiers).   There was also a preexisting term defined for traumatized soldiers in the 19th century known as “soldier’s heart”.     The notion that these soldiers weren’t just faking (and jailed or executed as a result) took a LONG time to overcome.    Many of the British soldiers executed for cowardice weren’t formally pardoned until nearly a century after their deaths.

        3. Which full article?  The Vaughn Bell blog post doesn’t say much more of substance than the quote excerpted above.

           The Frueh and Smith article on Civil War diagnoses is behind a paywall at $36 a peek, as is the McNally response, as is the Ben-Ezra article on trauma in antiquity.

          While I find the subject interesting, and believe I see serious flaws in the arguments as summarized here, I’m reluctant to shell out $30-$100 of my entertainment money towards advancing an argument on the Internet.

          If you’ve read the journal articles, would you be willing to digest them and write a more complete post summarizing them in your view?

  3. I have also read that the long trip home from the Pacific and European theaters may have helped as combatants shared a kind of group catharsis.

    Today (as in Vietnam too) you can be in a war zone on Tuesday and at your front door by Thursday.

    1.  Actually, it’s worse than that. Some people are asking, and I think some articles have already been written about, what are we doing to soldiers psychologically that drive to work every day, pilot drones, and then go home like nothing happened. Every. single. day.

  4. “A study just published in the Journal of Anxiety Disorders looked at the extensive medical records for soldiers in the American Civil War, whose mortality rate was about 50-80 greater than modern soldiers fighting in Iraq and Afghanistan. In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.”

    There is no reason to assume that a higher mortality rate automatically equates with “many more terrifying experiences”.  For example, a higher mortality rate can result from the same amount of trauma, but poorer sanitary conditions and medical care.

    1.  I’m curious as to how much trauma is overwhelmed by making it out alive.  Is there a tipping point?  Can something be SO terrible that just realizing you’ve survived it is enough of a shock to get past it?

    2. In other words, there would have been many more having terrifying experiences but despite the higher rates of trauma and mentions of other mental problems, there is virtually no mention of anything like the intrusive thoughts or flashbacks of PTSD.

      In a world where there are no movies or television and even photographs are rare, how many triggers would there be?

  5.  I don’t see any indications that either study looked at the work of Jonathan Shay – but then I don’t have full access to either journal and can’t see their bibliographies. I’d submit that Shay’s work on literary sources like Sophocles’ *Ajax* might be relevant to this question.

  6. The discussion of PTSD and Complex PTSD is generally focussed on men who have been in wars, which misses the point that many people who have survived a life threatening/traumatic incident like  a natural disaster, or a crime against their person like armed robbery, hostage taking, sexual assault, domestic violence, the murder of a loved one , etc. also develop PTSD and (c)PTSD. There is not much discussion about the PTSD of the survivors of recent tsunamis, for example.

    Female survivors of PTSD are generally dismissed as “hysterical” or melancholic, with ongoing symptoms dismissed under the catch-all of Borderline Personality Disorder, particularly as their (pre 20th century)accounts of sexual assault, molestation and domestic violence were minimized by the male professionals they had sought help from (see: Freud).
    Silencing of victims is not a new tactic.

    Judith Herman (author of Trauma and Recovery) and Bessel Van Der Kolk have both studied trauma and PTSD extensively, and dismiss the concept that PTSD is a 20th century  disorder.

  7. It is also the case that the lives people live during peace time are dramatically different now then they were 60 years ago. If your work consists of getting up early to do physical labour each day it’s conceivable that your mental state might be different than a city slicker. Alternatively if you’re working alone a lot more, then psychological issues might not be such a big deal, as you don’t have social pressures to deal with. So it could be that PTSD happened but didn’t hinder people as much.
    Third option: everyone had PTSD since so many woman were sexually abused, and the crime rate was higher etc. So maybe it didn’t get noticed because that was just life. (If you think of the middle ages in Europe, this argument really gains weight.)

  8. PTSD is a first-world, middle class, 20th century  problem. When your life is nasty, brutish and short, going to war is actually a change for the better. During the Civil War civilians used to watch battles for entertainment. People went to see hangings for the same reason. They weren’t as squeamish about killing and death the way we are today. It was a natural part of life.

    1. And parents didn’t used to care about their kids as much back when the infant and child mortality rate was much higher, right?

      1. A thousand years ago you wouldn’t have been under similar circumstances is XZ’s point. There were no similar circumstances.

  9. If you read military history, many survivors of big battles demonstrate pretty clear signs of PTSD. Rorke’s Drift in 1879, for example, is chock full of men who were suffering from very obvious signs of severe PTSD. The second in command, Bromhead, never even wrote about the battle and certainly never talked about it. The Little Big Horn too had many survivors who had pretty bad cases of PTSD. The ranking officer, Marc Reno, drank something like 22 gallons of whiskey in 11 days immediately following the battle. PTSD is a new term for a very old problem. 

    1. Aha! Yes, first thing I’d do would be to compare records from wars around the same time, then fan out through history. The Boer war, for example, being between WWI and the US Civil War, all three of which have been called the first modern war. That war where the German soldiers rode trains to Paris (wtf, France?) Napoleon’s work probably left some records, &c. Civil coroner reports might contain mentions of PTSD…

      Lara Croft: I want you to list every “he’s not been right since the war” ever mentioned in Greek history.
      Butler: There’s liable to be thousands!
      Lara Croft: Then we’ll read thousands.

  10. The status and integration of the military in wider society might play a role in how soldiers deal with their experiences. Did Aztec warriors suffer PTSD?

  11. Having suffered from PTSD I can only sympathise.
    I was nearly killed by an idiot car driver, weeks later I could hardly walk at the side of a road without being terrified, years later I was still having nightmares.
    Eventually the insurance coughed up for a psychologist, a lovely little old Polish lady – I now wish I’d paid for it myself to get it straight away!

  12. I’ve thought about this particular question before, though I wasn’t aware that the history of the PTSD phenomenon was being questioned.

    I think the answer is that they’re looking in the wrong damn place.  I doubt people in the mid-1800s typically thought of weird behavior or intrusive thoughts as in any way a medical  issue; why would they have put them in medical case notes?  “His leg amputation healed, so he’s fine now.  Discharged.”  Those would have been a matter for prayer, personal journals, or in very very rare cases, consulting an “alienist”.

    If you were to look back at journals and accounts from people’s families, I think you’d find something completely different.  Read James Thurber’s comedic telling of his family’s story “The Night the Bed Fell”, for instance, and under the comedy you find a Civil War veteran who in the 1920s, 60 years later, is still hyper-sensitive to imagined threats, keeps an old pistol around at all times, flies into rages, and wakes up in the middle of the night thinking he’s under attack.  That sounds rather like the (stereotypic) modern aftermath of combat PTSD to me.

    It’s possible that having the shakes for weeks, or years, or decades after combat might have been taken for granted. 

    [Edited: added missing space in “any way”]

  13. It was called “shell shock” during WW1 and “soldier’s melancholy” during the Civil War. (A lot of Civil War vets dealt with it using opiates and the newly invented hypodermic needle.) I’m sure it’s been around a lot longer. PTSD wasn’t medicalized until the 19th century, but you can recognize in many earlier sources.

    1. That’s not what the article says. The symptoms are different.

      I just read Brin’s Dogma of Otherness, and now I realize a lot of that goes on in BB threads. 

      1. Which article are you talking about? The Bell blog entry doesn’t say
        much more than is quoted above.  If you have access to the full journal article, in that case it would help to be more specific.  Exactly which article of the several, and in what way does it report the symptom profile to be different?

        It appears to me most of the discussion here is people talking past each other, but that’s nothing new in any setting or context.

  14. For one thing, the vast majority of people living through ptsd are womyn, not men, and not soldiers in particular.

    For another thing, warfare has changed a lot more than bashings, rape, torture, etc. have changed. In the American Civil War, most battles lasted less than a day, and the longest were only about three days. In the First World War, most battles lasted months, and soldiers could spend weeks in the trenches before being rotated out. It would probably make more sense to compare survivors of slave plantations with survivors of Nazi death camps, than to compare survivors of different wars. I’m sure each of these can mess up people’s stress responses, but not the same way.

  15. I think these researchers are fundamentally misunderstanding PTSD and how it affects the brain. PTSD is a much more likely to be experienced by someone whose brain had been under a constant barrage of stress hormones for some time. That simply wasn’t so for people who experienced combat before the dawn of modern warfare, when battles simply did not last as long and there was often a group cooling down as soldiers journeyed home. If you were to look at the records left by abused children or battered women from the same eras, I think that you would not find that PTSD is a modern phenomenon, it is only modern in its affecting of soldiers.

    Also, it does say that soldiers were disproportionately likely to suffer from substance abuse. While that is clinically not diagnosable as PTSD, it is definitely a symptom of trauma. These researchers are looking to far into the DSM and not far enough into the humans who experienced trauma.

    1. PTSD can result from a single traumatic incident. PTSD is differentiated from Complex PTSD, which is usually the result of chronic, ongoing trauma such as domestic violence, a hostage taking of long duration, etc. PTSD and (c)PTSD are the same — but they are also different. One horrible terrifying incident has a different effect on the brain than days, weeks, months or years of prolonged, unrelenting stress, abuse, etc.

      1. Good point (about PTSD and Complex PTSD being different). Quite a lot of information about PTSD take only into account the single incident kind of PTSD and don’t really meantion Complex PTSD and the symptoms of that at all.

        Complex PTSD, especially for small children facing abuse and neglect, changes the brain. I don’t think that has changed to suddenly become a “modern” thing. It’s just that we now recognize it, children suffering from it aren’t just some “bad apples”.

        People in general want to think of “bad things happening” as something to be put behind you, something that doesn’t affect you at all anymore. They don’t want to hear that something is still haunting you, especially if it happened decades ago. It’s one thing if it is something physical, but mental… you are supposed to just “get over it”. So I’m not at all surprised if there aren’t that much of medical reports about PTSD historically… you want romanticised stories about war heroes, not write about somebody still waking up to the war decades after it ended.

  16. Just a few miles from here, on what is now the campus of Edinburgh Napier University, is one of the sites where WWI victims of ‘shellshock’, including some who later gained fame as war poets, were treated. They had one other common feature; they – and everyone else treated for shellshock – were all Officers. Other soldiers suffering from shellshock were, mostly, shot by a firing squad – “pour encourager les autres”.

    Finding similar symptoms documented from earlier wars would be complicated by the differing military expecatations and reactions of the time; which would have impacted on the surviving ‘sample’. I assume that the WWI approach, however inequitable, was more progressive than previous approaches; so it’s possible that only the mildest cases of PTSD survived earlier conflicts, with the most severe cases being left on the battlefield.

  17. George Carlin on Euphemisms …

    “I don’t like words that hide the truth. I don’t like words that conceal reality. I don’t like euphemisms, or euphemistic language. And American English is loaded with euphemisms.

    Cause Americans have a lot of trouble dealing with reality. Americans have trouble facing the truth, so they invent the kind of a soft language to protect themselves from it, and it gets worse with every generation. For some reason, it just keeps getting worse. I’ll give you an example of that.

    There’s a condition in combat. Most people know about it. It’s when a fighting person’s nervous system has been stressed to it’s absolute peak and maximum. Can’t take anymore input. The nervous system has either (click) snapped or is about to snap.

    In the first world war, that condition was called shell shock. Simple, honest, direct language. Two syllables, shell shock. Almost sounds like the guns themselves.

    That was seventy years ago. Then a whole generation went by and the second world war came along and very same combat condition was called battle fatigue. Four syllables now. Takes a little longer to say. Doesn’t seem to hurt as much. Fatigue is a nicer word than shock. Shell shock! Battle fatigue.

    Then we had the war in Korea, 1950. Madison avenue was riding high by that time, and the very same combat condition was called operational exhaustion. Hey, we’re up to eight syllables now! And the humanity has been squeezed completely out of the phrase. It’s totally sterile now. Operational exhaustion. Sounds like something that might happen to your car.

    Then of course, came the war in Viet Nam, which has only been over for about sixteen or seventeen years, and thanks to the lies and deceits surrounding that war, I guess it’s no surprise that the very same condition was called post-traumatic stress . Still eight syllables, but we’ve added a hyphen! And the pain is completely buried under jargon. Post-traumatic stress disorder.

    I’ll bet you if we’d of still been calling it shell shock, some of those Viet Nam veterans might have gotten the attention they needed at the time. I’ll betcha. I’ll betcha.”

    1. Newsflash: George Carlin is a stand up comic. His opinion on the matter is uninformed, uneducated blather.

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