There is a story in my family of my grandfather's homecoming from the Korean War. His father, a medic in the German army in World War I, took him into his study. "You saw horrible things over there," he told his son. "But you have to forget them. When you leave this room, you just don't think about it anymore."
I can't say whether my grandfather took this advice, but he kept his memories to himself; my mother didn't know he was a Korean war vet until well into her teen years. Still, whatever he saw in Korea didn't go away. Two years ago, when he was seriously ill in the hospital, my grandfather woke up in tears. Why, he asked my dumbfounded mother, had he lived through the war when all of his buddies had died?
I was stacking frozen corpses like cordwood, he said. Was there a reason I was spared?
The silence of my grandfather and his father was long the norm for returning combat veterans. But there are hints — in literature, in ancient texts — that warriors have always had these feelings. Psychiatrists believe that what we now know as posttraumatic stress disorder (PTSD) is universal, and very old. Shakespeare wrote about the symptoms. So did ancient Mesopotamians and ancient Greeks. So did medieval knights and Florence Nightingale.
PTSD may manifest differently from culture to culture and across time, said Terence Keane, a psychiatrist at the Boston University School of Medicine and the associate chief of staff in research and development at the Veterans Administration Boston Healthcare System. But there's a biological substrate at the disorder's core.
"Something has happened in the brain and in the central nervous system that has caused a permanent change, or a relatively permanent change, in how they feel, how they think and how they behave," Keane told me.
This explains why hints of trauma show up in war writings dating back thousands of years. And it would be easy, now, to show you some examples. Look, I could write: Here's an ancient text describing nightmares. Here's one describing suicidal behavior, flashbacks, guilt. Poor saps. Too bad they didn't have the Diagnostic and Statistical Manual to solve their problems.
But I'm wary. Why did my grandfather live, while his friends ended their lives in terror in the cold of a Korean peninsula winter? What do you do next, after surviving something like that? These aren't questions answered in a psychiatry manual.
So this is what I want you to keep in mind: The point of looking back into the past to understand PTSD isn't to feel superior to the ignorant people of earlier times who didn't understand the role of the hypothalamic-pituitary-adrenal axis in PTSD. It's not to imply that we have solved the problem of trauma. It's to understand the common psychology linking humanity across time and distance. And it's to learn what the people of the past might have to teach us about recovery from war.
The case for ancient PTSD
The Diagnostic and Statistical Manual (DSM) 5 defines PTSD as a cluster of symptoms that occurs after someone is exposed to death, serious injury, sexual assault or the threat thereof. Symptoms include re-experiencing the trauma, as in nightmares or intrusive memories, avoiding talk or triggers, negative mood and thoughts and unusual patterns of arousal, such as hyper-vigilance or problems concentrating. Between 15 percent to 30 percent of people with combat experience have serious problems with these symptoms afterward, Keane said. The greater the exposure to trauma, the more likely a person is to have long-term problems.
Some researchers have noted an additional factor that often plays a role in combat PTSD, specifically: Moral injury. This term, first coined by VA psychiatrist Jonathan Shay, refers to a betrayal of "what's right"—no matter what that might mean in a particular culture—by a legitimate authority figure in a high-stakes situation. (Other researchers use the same term to refer to a person not living up to his or her own ideals in a life-or-death situation.)
Shay, author of "Achilles in Vietnam: Combat Trauma and the Undoing of Character" (Simon & Schuster, 1995), sees moral injury in combat as an issue dating back at least to Homer's Iliad, the epic poem about the siege of Troy that's dated to around the eighth century B.C. The poem opens with the commander of the Greek army, Agamemnon, taking a captive woman, Briseis, from the warrior Achilles. Achilles, offended by this betrayal of "what's right" in Greek military culture, refuses to fight. He withdraws from all but his close companion, Patroclus — until Patroclus is killed and Achilles goes mad with grief, killing Patroclus' killer Hector and desecrating the corpse.
Achilles' berserker rage echoes the experiences of the Vietnam War veterans Shay worked with for 20 years at a Boston VA outpatient clinic. Many saw their ideals crumble in combat. One soldier whose story is retold in "Achilles in Vietnam" describes watching for hours as suspected Vietcong unloaded boats in the South China Sea. Finally, he and his comrades got the order to shoot. They unloaded their weapons into the boats. When daylight came, they learned they'd killed a group of fishermen and children.
To add to the horror, the military leadership assured the soldiers that everything was fine — and then gave them awards for their valor. Shay's patient got a Combat Infantryman Badge for his participation, an award that is supposed to mark a soldier's experience of ground combat. The betrayal of getting kudos for killing civilians shook the soldier to his core.
After such a betrayal, Shay told me, veterans report feeling as attacked as if their actual life was at risk. Often, they retreated into themselves, trusting only a few men in their immediate unit and developing almost maternal feelings of protectiveness toward these trusted brothers-in-arms. When a beloved friend was killed, the survivors often went into a berserk state, sometimes committing atrocities that horrified them later. It's hard not to see the parallels with the grief-stricken, revenge-obsessed Achilles, dragging Hector's corpse around Troy's city walls.
Restoring trust, treating PTSD
Ancient cultures often write of visitations by ghosts and spirits after battle.
The oldest reported text describing something like PTSD comes from Mesopotamia during the Assyrian dynasty, which was in power between 1300 B.C. and 609 B.C. Medical cuneiform texts provide records of an Assyrian soldier haunted by the "spirits" of those he'd killed, researchers reported in December 2014 in the journal Early Science and Medicine. The symptoms might ring familiar in modern psychiatrists' ears: depressed mood, poor sleep, flashbacks to battle.
Attributing trauma to the spirit world might seem like ignorant superstition, but Vietnam veterans often speak of seeing their dead friends and enemies in dreams, Shay said.
"I have been twisting the arms of historians, saying, look, if you are interested in the subject of combat trauma in past eras or across cultures and you're only looking for a medicalized picture, you're probably not going to find it very much," Shay said. "But where you see intrusions of the supernatural, that may be — and I'm not saying it always is or must be — the spin-off of a post-traumatic syndrome."
There's no doubt that the modern medical definition of PTSD is a godsend. Likewise, modern treatments can truly help: Cognitive behavioral therapy, mindfulness meditation, and therapy that challenges skewed thinking patterns are all crucial tools for the treatment of trauma.
"So much of what happens in a war zone, for example, is chance," Kean said. "It's almost random and it's out of your individual control. If you feel like 'Bad things happened, therefore it was my failure,' it is a particularly difficult problem to recover."
But PTSD isn't a diagnosis without problems. In discussions of how to update the criteria for the disease in the 5th edition of the DSM, psychiatrists debated whether to change the name from posttraumatic stress disorder to posttraumatic stress injury, with some arguing that military members are less likely to seek help for a "disorder" than for an "injury." Others argued that it's the military culture, not psychiatric nomenclature, that needs to change.
The popular conception of PTSD treatment needs an overhaul, too, Shay said.
"There's model that involves the stereotype: a white-coated mental health professional saying, 'You, Mr. Veteran, you've got a problem, and I'm here to help.'" Shay said. "That is not a winning starting point."
In this era of understanding the brain as just another organ, it's easy to fall into the trap of thinking of PTSD as a defect, something fixable with the right mental attitude. It's easy to lose sight of the human suffering at the heart of this disorder: The real corpses, the real horror of watching friends suffer and die, the real pain of wondering for the rest of your life, "Why not me?"
"A level of critique of the PTSD category involves its dangerous potential for medicalizing human suffering; that is, for reducing the social and moral implications of traumatizing events, such as war or genocide, to a strictly professional, even biological, set of consequences," psychiatrists Devon Hinton and Roberto Lewis-Fernandez wrote in a 2010 review of cross-cultural research on PTSD. "This critique suggests that, by emphasizing the 'reality' of PTSD as a universal biopsychological category, research on PTSD may have unintentionally and paradoxically helped decrease social and moral responsiveness to these events. The suffering associated with the Rwandan genocide, for example, cannot be reduced to the PTSD experience."
This is a gap that the words of people who lived hundreds or thousands of years ago may help fill. In the last several years, the Department of Defense has approved hundreds of readings of ancient Athenian war plays on military bases around the country. The first, in 2008, was a reading of two Sophocles plays, "Ajax," and "Philoctetes," both about Trojan war veterans. The post-play discussion between the Marine audience and the actors went on for three hours before it had to be shut down, according to the New York Times.
"Prior to the advent of modern scientific medicine, it doesn't mean that nobody ever did anything about combat trauma," Shay said. "They did it differently. I think there's still plenty to learn from it, and honestly, I think that the medical model that involves a clinician and a patient alone in a room with the door closed is not the optimum model for recovery from war trauma. Not even close."