A Short History of PTSD: From Thermopylae to Hue, soldiers have always had a disturbing reaction to war.
(Article by Steve Bentley, from the Voice of the Vietnam Veterans of America, feature in the MAR/APR 2005 issue. Original print date, JAN 1991. Source.)
Post-traumatic Stress Disorder (PTSD) is defined by the American Psychiatric Association as an anxiety (emotional) disorder which stems from a particular incident evoking significant stress. PTSD can be found among survivors of the Holocaust, of car accidents, of sexual assaults, and of other traumatic experiences such as combat. The fact is, PTSD is a new name for an old story—war has always had a severe psychological impact on people in immediate and lasting ways. PTSD has a history that is as significant as the malady itself. It’s been with us now for thousands of years, as incidents in history prove beyond a doubt.
Three thousand years ago, an Egyptian combat veteran named Hori wrote about the feelings he experienced before going into battle: “You determine to go forward… . Shuddering seizes you, the hair on your head stands on end, your soul lies in your hand.”
History tells us that among the Egyptians, Romans, and Greeks, men broke and ran in combat circumstances—in other words, the soldiers of antiquity were no less afraid of dying.
For instance, the Greek historian Herodotus, in writing of the battle of Marathon in 490 B.C., cites an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier “was wounded in no part of his body.” So, too, blindness, deafness, and paralysis, among other conditions, are common forms of “conversion reactions” experienced and well-documented among soldiers today.
Herodotus also writes of the Spartan commander Leonidas, who, at the battle of Thermopylae Pass in 480 B.C., dismissed his men from joining the combat because he clearly recognized they were psychologically spent from previous battles. “They had no heart for the fight and were unwilling to take their share of the danger.” (Herodotus tells of another Spartan named Aristodemus who was so shaken by battle he was nicknamed “the Trembler”—he later hanged him- self in shame.)
One thousand years later, things had changed very little at the front. The Anglo Saxon Chronicle recounts a battle in 1003 A.D. between the English and the Danes in which the English commander Alfred reportedly became so violently ill that he began to vomit and was not able to lead his men.
We also know PTSD doesn’t confine itself strictly to the war experience. Samuel Pepys was an Englishman who lived in London during the 1600s. His surviving diary provides an excellent record of the development of PTSD. In writing of the Great Fire of London in 1666, Pepys recounts people’s terror and frustration at being unable to protect their property or stop the fire. Pepys writes: “A most horrid, malicious, blood fire… . So great was our fear… . It was enough to put us out of our wits.”
Although his own home was untouched, Pepys was unable to sleep for days after the fire. He scrawls: “Both sleeping and waking, and such fear of fire in my heart, that I took little rest.” Two weeks later, Pepys writes: “[M]uch terrified in the nights nowadays, with dreams of fire and falling down of houses.”’ The diary reports general feelings of anger and discontent over the next four months. Pepys then records that news of a chimney fire some distance away “put me into much fear and trouble.”
It appears Swiss military physicians in 1678 were among the first to identify and name that constellation of behaviors that make up acute combat reaction or PTSD. “Nostalgia” was the term they used to define a condition characterized by melancholy, incessant thinking of home, disturbed sleep or insomnia, weakness, loss of appetite, anxiety, cardiac palpitations, stupor, and fever.
German doctors diagnosed the problem among their troops at about the same time as the Swiss. They referred to the condition as heimweh (homesickness). Obviously, it was strongly believed the symptoms came about from the soldiers longing to return home.
In time, French doctors termed the same symptoms maladie du pays, and the Spanish, confronted with the same reactions among their soldiers, called it estar roto (literally, “to be broken”).
During the siege of Gibraltar in 1727, a soldier who was part of the defense of the city kept a diary. In it, there is mention of incidents in which soldiers killed or wounded themselves. He also describes a state of extreme physical fatigue which had caused soldiers to lose their ability to understand or process even the simplest instructions. In this state, the soldiers would refuse to eat, drink, work, or fight in defense of the city, even though they would be repeatedly whipped for not doing so.
The French surgeon Larrey described the disorder—what we now call PTSD—as having three dif ferent stages. The first is heightened excitement and imagination; the second is a period of fever and prominent gastrointestinal symptoms; the final stage is one of frustration and depression.
During the American Civil War, military physicians diagnosed many cases of functional disability as the result of fear of battle and the stresses of military life. This included a wide range of illnesses now known to be caused by emotional turbulence, including paralysis, tremors, self-inflicted wounds, nostalgia, and severe palpitations—also called “soldier’s heart” and “exhausted heart.” It was reportedly surprising to some Civil War physicians that soldiers on normal leave often collapsed with emotional illness at home, even when they had shown no symptoms of mental debilitation before they had left the fighting.
Many consider the Civil War the first step on the road to modern warfare. Civil War soldiers made the first frontal assaults into repeating rifles and pistols, as well as the Gatling gun and delayed-time artillery rounds that allowed air bursts. Civil War technology also included telescopic sights and rifles with spiral barrels that greatly increased their accuracy and destructiveness in battle.
The immediate result was that psychological symptoms became so common, field commanders as well as medical doctors pleaded with the War Department to provide some type of screening to eliminate recruits susceptible to psychiatric breakdown. Military physicians, at a loss to treat the problems, simply mustered the extreme cases out during the first three years of the war. “They were put on trains with no supervision, the name of their home town or state pinned to their tunics, others were left to wander about the countryside until they died from exposure or starvation,” reports Richard A. Gabriel, a consultant to the Senate and House Armed Services Committees and one of the foremost chroniclers of PTSD.
Gabriel’s research tells us that in 1863 the number of insane soldiers simply wandering around was so great, there was a public outcry. Because of this, and at the urging of surgeons, the first military hospital for the insane was established in 1863. The most common diagnosis was nostalgia. The government made no effort to deal with the psychiatrically wounded after the war and the hospital was closed. There was, however, a system of soldiers’ homes set up around the country. Togus, Maine, was designated as the eastern branch of this system, and in 1875, its director noted that, strangely enough, the need for the hospital’s services seemed to increase rather than decrease.
For civilians in the 1800s, the growth of the industrial era created large companies with machinery operated by workers who often had injury-producing accidents. Train wrecks became common.
Author Charles Dickens was involved in a railway accident at Staplehurst in Kent, England, on June 9, 1865. He suffered symptoms which today would be diagnosed as PTSD. Dickens described the horrifying scene in a letter: “[T]wo or three hours work … amongst the dead and dying surrounded by terrific sights…” Sometime after, he wrote he was “unsteady” and said, “I am not quite right within, but believe it to be an effect of the railway shaking.”
Railway accident victims began suing the railroads. Lawyers for the railway companies fought back with the term “compensation neurosis,” which charged that litigants were trying to get something for nothing.
This discounting of effects of the trauma by charging the victim with having ulterior motives was also common in the military. “It is by lack of discipline, confidence, and respect that many a young soldier has become discouraged and made to feel the bitter pangs of homesickness, which is usually the precursor of more serious ailments,” commented the assistant surgeon general in 1864, reflecting the sentiment that most who suffered signs and symptoms of war trauma were, in fact, malingering.
Unfortunately, the attitude that combat veterans with psychological problems are really malingerers trying to gain economically is still with us today. That attitude, combined with veterans’ pride and distrust, accounts for the fact that, while a Research Triangle Institute study concludes 830,000 Vietnam veterans have full-blown or partial PTSD, only 55,119 have filed claims, and the adjudication boards have only believed 28,411 (July 1990) of those claimants.
Emotional stress builds very fast on a battlefield, and if there is no permissible emotional outlet, the soldier will “convert” his symptoms into physiological conditions. Gabriel, who was an active intelligence officer for 22 years, offers Maj. Marcus Reno and his soldiers as a classic example of the breakdown of men in battle. Major Reno’s troops served as a blocking force for Gen. George Armstrong Custer at the Battle of Little Big Horn. The battle had hardly begun when Reno himself became a psychiatric casualty. The major’s Indian scout, Yellow Knife, was struck square in the face by a bullet, which sent his blood, flesh, and brains spattering all over Reno, who immediately went into shock. He began foaming at the mouth, and his eyes rolled wildly in his head. He uttered sounds which made no sense.
Some of Reno’s men were so paralyzed with fear, they couldn’t defend themselves. They were so terrified, in fact, the Indians thought them cowards and refused to kill them. Maj. Myles Moylan was found later by the cavalry rescue force, “blubbering like a whipped urchin, tears coursing down his cheeks.”
Some of the soldiers reported they hallucinated during the fight, seeing columns of soldiers approaching and hearing voices when there were none. Others entered into states of shock approaching stupor from the emotional exhaustion generated by fear. About the only thing that didn’t happen to Reno’s men during the battle was desertion, but this was because there was simply no place to go.
The first army in history to determine that mental collapse was a direct consequence of the stress of war and to regard it as a legitimate medical condition was the Russian Army of 1905 in their war with the Japanese. Gabriel states that Russian attempts to diagnose and treat battle shock represent the birth of military psychiatry. The Russians’ major contribution was their recognition of the principle of proximity, or forward treatment. Although it’s believed by most armies today that the Russians were right in treating psychiatric casualties close to the front, with the goal of returning them to the fight, the recorded rate of those who returned to battle suggests the method was not very successful. In actuality, less than 20 percent were able to return to the front.
The brutalities of WWI produced large numbers of the psychologically wounded. Unfortunately, what little had been learned up to then was forgotten. The only American experience with psychiatric casualties that anyone remembered was when American soldiers under the command of Gen. John J. Pershing in Mexico exhibited an abnormally high rate of mental illness. Consequently, the medical establishment set out once again to recreate the wheel. This time, they began by attributing the high psychiatric casualties to the new weapons of war; specifically, the large-caliber artillery.
It was believed the impact of the shells produced a concussion that disrupted the physiology of the brain; thus the term “shell shock” came into fashion.
Although WWI generated stress theories based on models of the mind, such as Freud’s “war neurosis,” these theories never gained wide acceptance. Quite simply, Freud postulated “war neurosis” was brought about by the inner conflict between a soldier’s “war ego” and his “peace ego.”
Another diagnosis at the time which gained little currency was neurasthenia: “The mental troubles are many and marked; on the emotional side, there are sadness, weariness, and pessimism; repugnance to effort, abnormal irritability; defective control of temper, tendency to weep on slight provocation; timidity. On the intellectual side, lessened power of attention, defective memory and will power….”
By the end of World War I, the United States had hundreds of psychiatrists overseas who were beginning to realize that psychiatric casualties were not suffering from “shell shock.” These psychiatrists came to comprehend it was emotions and not physiological brain damage that was most often causing soldiers to collapse under a wide range of symptoms. Unfortunately, they continued to believe this collapse came about primarily in men who were weak in character.
During WWI, almost two million men were sent overseas to fight in Europe. Deaths were put at 116,516, while 204,000 were wounded. During the same period, 159,000 soldiers were out of action for psychiatric problems, with nearly half of these (70,000) permanently discharged.
Harking back to military medicine during the Civil War, psychiatrists concluded that the answer to psychological casualties was to more thoroughly screen those entering the military. Based on this, the main effort to reduce WWII psychological casualties was to focus on sifting through draftees in order to weed out those predisposed to break down in combat. The military used the best available psychiatric testing and rejected no fewer than five million men for military service.
In World War II, the ratio of rear-area support troops to combat troops was twelve to one. In the four years of war, no more than 800,000 soldiers saw direct combat, and of these, 37.5 percent became such serious psychiatric cases, they were permanently discharged. In the U.S. Army alone (not counting Army air crews), 504,000 men were lost to the fight for psychiatric reasons. Another 1,393,000 suffered symptoms serious enough to debilitate them for some period.
It became clear it was not just the “weak” in character who were breaking down. This is reflected in the subtle change in terminology that took place near the end of World War II when “combat neurosis” began to give way to the term “combat exhaustion.” Author Paul Fussell says that term as well as the term “battle fatigue” suggest “a little rest would be enough to restore to useful duty a soldier who would be more honestly designated as insane.” While the name change showed movement away from psychopathology, it didn’t keep the military model of “predisposition plus stress equals collapse” from working its way back into military medicine.
Fussell was a 20-year-old Army lieutenant and the leader of a rifle platoon in France. He was severely wounded in 1945 and came home to earn a Ph.D. from Harvard. In the preface to his highly acclaimed book, Wartime, he writes, “For the past 50 years the allied war has been sanitized and romanticized almost beyond recognition by the sentimental, the loony patriotic, the ignorant, and the bloodthirsty—I have tried to balance the scales.”
Fussell quickly cuts to the heart of the war experience, reminding us that those who fight are at once young, athletic, credulous, and innocent of their own mortality. He points out that the populace is naive to their pain and suffering. Fussell quotes Bruce Catton: “A singular fact about modern war is that it takes charge. Once begun it has to be carried to its conclusion and carrying it there sets in motion events that may be beyond men’s control. Doing what has to be done to win, men perform acts that alter the very soil in which society’s roots are nourished.”
Astonishingly, Catton was writing about the Civil War, which Fussell in turn characterizes as “long, brutal, total, and stupid”—something that can be said about any war when we fully realize that before society’s roots can be altered, soldiers’ very souls are seared by the acts they witness and perform.
The denial and naivete of the populace as to what war really is becomes a dynamic underlying the trauma of soldiers: “[S]evere trauma was often the result of the initial optimistic imagination encountering actuality.” Many Vietnam veterans can attest it’s a long way from the jungles of Vietnam to Disneyland (America). That is just about as far as Erich Maria Remarque knew it to be from the Western Front to home in WWI: “Now if we go back we will be weary, broken, burnt out, rootless, and without hope. We will not be able to find our way anymore. And men will not understand us… . We will be superfluous even to ourselves; we will grow older, a few will adapt themselves, some others will merely submit, and most will be bewildered.”
Fussell points out all wars are boyish and are fought by boys who are useful material for the sharp edge of war, but only for a short time: “[A]fter a few months they’ll be dried up and as soldiers virtually useless—scared, cynical, debilitated, unwilling… .”
While the average age in the military during WWII was 26, it was the 18-year-olds who were up front. “Among the horribly wounded the most common cry was ‘mother!’” Replacements got hit before anyone knew their names, “forlorn figures coming up to the meat grinder and going right back out of it like homeless waifs, unknown and faceless to us,” said poet James Dickey.
Fussell notes the detachment may be heartless but it makes it possible for sensitive people to survive the war relatively undamaged. While it’s true that we detach ourselves from war in order to survive, it’s also clear that the act of detachment is itself a kind of willed destruction. It’s the price paid; it’s why we never learn. The psychic numbing necessary to survive combat is not something you step into and out of easily. You can’t do it halfway.
The attitude is betrayed by phrases such as, “It’s just dead meat,” “Kill ’em all and let God sort ’em out,” or “Bomb Hanoi, Bomb Saigon, Bomb Disneyland, Bomb everything.” This attitude is about as tangible a thing as you can find. It is all consuming and pervades the soul. You carry it with you when you leave the battlefield. You carry it home, where you live with it. You share it with your family and your friends and your kids, and ultimately with your society. And it is poisonous, exceedingly poisonous—and it alters “the very soil in which society’s roots are nourished.”
At the close of WWI, Edmund Wilson looked out over London and said, “No one pretends to give a damn anymore—unless they are one’s close friends or relatives—whether people are killed or not… . The long-continued concentration on killing people whom we rarely confront, the suppression of the natural bonds between ourselves and these unseen human creatures, is paid by repercussions. The spitefulness and fear and stifled guilt, in our immediate personal relations… . Our whole world is poisoned now.”
It takes time and effort to overcome such detachment—some people never do. To look at any of it is to look at all of it. It can be overwhelming. It may be the reason Kurt Vonnegut took 23 years to tell us about his experience during the fire bombing of Dresden, just as it took Fussell 50 years to say, “Now there has been much talk about ‘The Good War,’ the justified war, the necessary war, and the like, that the young and innocent could get the impression that it really was not such a bad thing after all. It’s thus necessary to observe it was a war and nothing else, and thus stupid and sadistic, a war, as Cyril Connally said, ‘of which we are ashamed, a war…which lowers the standard of thinking and feeling…which is as obsolete as drawing and quartering; further, a war opposed to every reasonable conception of what life is for, every ambition of the mind or delight of the senses.’”
Of course, the same can be said for the Korean War. In Korea, 1,587,040 served—33,629 were killed in combat and 103,284 were wounded. Of the 198,380 who were actually in combat, 24.2 percent were psychiatric casualties. In other words, the chances of being a psychiatric casualty in Korea was 143 percent better than the chances of being killed.
In Vietnam, 2.8 million served. Given the nature of guerrilla warfare, it is hard to estimate the number exposed to hostile fire. However, the Research Triangle Institute’s Vietnam readjustment study concludes 480,000 have full-blown PTSD and another 350,000 have partial PTSD.
The British psychiatrist R.D. Lang has written that an insane response to an insane situation is sane behavior. Working with schizophrenics, he concluded many were the way they were because of massive double-bind situations they were put in—telling them one thing while their reality and treatment were the opposite. For instance, the religious child grows up being told, “Thou shalt not kill,” until he is drafted and the message becomes, “Kill, kill, kill!”
Gabriel writes in No More Heroes, a study of madness and psychiatry in war, that contrary to what is in the movies, television, and the military, it is not only the weak and cowardly who break down in battle. In reality, everyone is subject to breaking down in combat, “perhaps most telling, not only are there no personalities or demographic factors which are associated with psychiatric collapse; neither are there any factors associated with heroism. It’s impossible to predict which soldiers will collapse and which will behave bravely.” A soldier who is brave one day may well be a psychological basket case the next. Gabriel states flatly, “There is no statistical difference in the rates of psychiatric breakdown among inexperienced troops and battle-hardened veterans.” When all is said and done, all normal men are at risk in war.
Gabriel believes there is enough evidence from studies done after WWII to suggest it is only those who are already mentally ill, about two percent of the population, who don’t break down in battle. In other words, only the sane can go insane; the already insane remain that way. “Perhaps it is simply that while collective insanity can destroy normally sane men, it cannot reverse individual insanity,” writes Gabriel.
This idea, that all normal men have a breaking point and all combat veterans will fall off a continuum at recovering, from mild to severely pathological, has been called the endurance model. It looks at war madness as a form of adaptation. The task for therapists and psychiatrists is to unravel the sense behind the symptomatology, acute or chronic, that is observed in veterans today: “Fatigue and listlessness, depression, startle reactions, recurrent nightmares, phobias and fears involving situations associated with trauma, mixtures of impulse behavior, unsteadiness in human relationships and projects of all kinds (including work or study), that may take the form of distrust, suspiciousness, and outbursts of violence.”
Robert J. Lifton is a psychiatrist based at Yale University, and he is renowned for his work with trauma patients, including Vietnam veterans. His response to the illness model (soldiers in their conflictive “neurotic” state become afraid to die and afraid to kill) is he doesn’t see not wanting to die or kill as being very “neurotic” and that, in fact, perhaps mankind can use a little more of this attitude. Lifton points out this model worked in WWII because the Nazis were so obviously evil: “Those soldiers that broke down, who were afraid to die and afraid to kill on behalf of this crusade, could be quite comfortably viewed as neurotic.”
The dynamics were different in Vietnam, where conditions of the war were such that moral revulsion combined with psychological conflict lead to both acute and delayed reactions. Lifton writes, “[M]onths or even years after their return to this country, many Vietnam vets combined features of the Traumatic Stress Syndrome with preoccupation with questions of meaning—concerning life, and ultimately, all other areas of living.”
Lifton argues that in the search to understand the soldiers’ traumatic stress reaction, doctors should focus on the death and destruction that actually took place and its related questions of meaning, rather than invoke the idea of “neurosis.”
“At the heart of the traumatic syndrome—and of the overall human struggle with pain—is the diminished capacity to feel, or psychic numbing. There is a close relationship between psychic numbing … and death-linked images of denial (‘If I feel nothing, then death is not taking place’), or ‘I see you dying but I am not related to you as your death.’”
In order to survive, soldiers undergo a radical reduction in their sense of the actuality of things. One example is Canadian bomber-pilot J.D. Harvey on his return from rebuilding Berlin in 1960: “I could not visualize the horrible death my bombs … had caused here. I had no feeling of guilt. I had no feeling of accomplishment.”
Lifton tells us this happens in order for the soldier to avoid losing his sense completely and permanently. “He undergoes a reversible form of symbolic death in order to avoid a permanent physical or psychic death.”
Having closed off and numbed themselves in order to survive, soldiers are then faced with the task of working their way back toward humanity. The struggle is to “re-experience himself as a vital human being.” However, it is not all that easy, for “one’s human web has been all too readily shattered, and in rearranging one’s self-image and feelings, one is on guard against false promises of protection, vitality, or even modest assistance. One fends off not only new threats of annihilation but gestures of love or help.”
This goes to the heart of current concerns about PTSD—that, paradoxically, its tremendous incidence in Vietnam was ultimately a sign of the sanity of those who fought in the war. Otherwise, why be disturbed by the killing, by the stuff of war? But ever after, in peacetime, the reconstruction of “the human web” becomes more and more implausible: if societies are sane—if, in fact, they are civilized—why are there wars?
The arguments are circular. The question of PTSD is always thrust back upon us. The reason there are wars is because most societies are not civilized, but might be someday. There are “cures” offered in the best of societies for PTSD, programs that are established to reintegrate sane men and women into the established order. But always the absolute cure to the eradication of symptoms of PTSD is to eradicate their causes. We are disturbed by war, and justly so.
As we know it today, Post-traumatic Stress Disorder is marked by a re-experiencing of the trauma in thought, feeling, or dream content, which is in turn evidenced by emotional and psychological numbing. Today, PTSD is characterized by depression, loss of interest in work or activities, psychic and emotional numbing, anger, anxiety, cynicism and distrust, memory loss and alienation, and other symptoms. And why not?
Who would not be alienated from the scenes of death witnessed by soldiers? The point is that throughout history, men and women have acted to suppress the horrors that they’ve seen. It’s time we recognize that for what it is—as not only the outward manifestation of PTSD, but the clearest evidence we have that wars are destructive in other ways than in body counts. It takes many years for even the most sane among us to arrive at what we have seen and wanted to forget.
Psychiatrist Victor Frankel survived internment in four Nazi concentration camps during WWII. It would be quite a few years before he wrote his book, Man’s Search for Meaning. In the book, he states clearly that “an abnormal response to an abnormal situation is normal behavior.” In other words, if some things don’t make you crazy, then you aren’t very sane to begin with.
Unfortunately, it’s an idea whose time has not yet come.