PTSD in history, other cultures

The National Institute of Mental Health defines PTSD as "an anxiety disorder that can develop after exposure to one or more terrifying events in which grave physical harm occurred or was threatened". What I would like to find out is the relationship between culture, the nature of modern war, and PTSD, if there is a significant relationship at all.

(1) Is PTSD prevalent in other cultures/countries? Is it a major issue primarily in industrialized countries, or is it present in all cultures engaged in conflict? Russia has a serious problem managing PTSD among combat veterans returning from Chechnya, but this would seem to indicate that PTSD is a consequence of industrialized war.

(2) Are there historical references to PTSD in history prior to modern warfare? How was it perceived and managed? Was it particular to certain cultures or present throughout the history of war? The Iliad makes a reference to what appears to be PTSD -- Ajax loses a duel, comes under a "spell" from Athena, slaughters a herd of sheep thinking they are the enemy, and then kills himself. Is this an ancient reference to PTSD? If so, it would seem, so far, that PTSD is a product of Western culture.

(3) If PTSD is particular to a certain cultural arch-type or form of warfare, is it therefore a product of social construction?

(4) If it's a social construct, would PTSD treatment be more effective by addressing the underlying cultural variables rather than specific individuals (not to say, of course, that those individuals suffering from it should be refused treatment on a case-by-case basis).

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(1) Is PTSD prevalent in other cultures/countries? Is it a major issue primarily in industrialized countries, or is it present in all cultures engaged in conflict? Russia has a serious problem managing PTSD among combat veterans returning from Chechnya, but this would seem to indicate that PTSD is a consequence of industrialized war.

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Answer part one: yes

Answer supposition part two: no

Case Studies: Rwanda -- hardly industrial

Congo -- Ditto

There are plenty of others.

Do cultural mores help define what constitutes trauma? Probably in that what is terribly horrific in one place could be a minor hiccup in another.

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Originally Posted by Tom Odom

Answer part one: yes

Answer supposition part two: no

Case Studies: Rwanda -- hardly industrial

Congo -- Ditto

There are plenty of others.

Do cultural mores help define what constitutes trauma? Probably in that what is terribly horrific in one place could be a minor hiccup in another.

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Well, I think that has more to do with the how PTSD is defined. It seems to me that there are only a handful of effects that can occur to people as far as stress and trauma are concerned, but that there are a myriad reasons/triggers for why they happen. Are there historical references to PTSD prior to the 19th century? I think an interesting case study would be the Thirty Years War, the Crusades, or any of the Roman or Mongol campaigns.

You may have trouble finding any information on this, simply because the definition of PTSD is itself pretty recent. I can name any number of PTSD-type cases from the Civil War in the US alone, and I'm also sure you could find a huge number of anecdotal stories from many cultures predating that.

I suspect (though I'm not an anthro type...Marc's better qualified to speak to this possibly) that many tribal cultures had their own cultural mechanisms to deal with what we now call PTSD. Warrior societies, vision/spirit quest rituals, and even something as seemingly unrelated as the berserkers might all have been tools to deal with those who were shocked or disturbed by combat. Some tribal cultures also had social "outs" for those who weren't keen on combat (and in many cases the actual demand for warriors was low enough that it was a self-selecting process).

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Originally Posted by Steve Blair

You may have trouble finding any information on this, simply because the definition of PTSD is itself pretty recent. I can name any number of PTSD-type cases from the Civil War in the US alone, and I'm also sure you could find a huge number of anecdotal stories from many cultures predating that.

I suspect (though I'm not an anthro type...Marc's better qualified to speak to this possibly) that many tribal cultures had their own cultural mechanisms to deal with what we now call PTSD. Warrior societies, vision/spirit quest rituals, and even something as seemingly unrelated as the berserkers might all have been tools to deal with those who were shocked or disturbed by combat. Some tribal cultures also had social "outs" for those who weren't keen on combat (and in many cases the actual demand for warriors was low enough that it was a self-selecting process).

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Do you think American society in general lacks any of those "outs", whether for those who are not "keen on combat", or for those who have mental injuries because of combat?

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Originally Posted by AmericanPride

Well, I think that has more to do with the how PTSD is defined. It seems to me that there are only a handful of effects that can occur to people as far as stress and trauma are concerned, but that there are a myriad reasons/triggers for why they happen. .

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That is what I just said with:

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Do cultural mores help define what constitutes trauma? Probably in that what is terribly horrific in one place could be a minor hiccup in another.

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Again you don't have to look far for a non-industrial scenario. Rwanda and the Congo are current examples where psychological trauma is rampant and long lasting.

Steve is on the mark in suggesting the Civil War. Try Jerry Linderman's Embattled Courage.

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Originally Posted by AmericanPride

Do you think American society in general lacks any of those "outs", whether for those who are not "keen on combat", or for those who have mental injuries because of combat?

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I'd second Tom's suggestion of looking at Rwanda and the Congo. There is also some very good material from South Africa.

Part of the problem with all of this is that the definition of PTSD is too fluffy - it's based on a phenotypic definition rather than on a neurological one. From my (rather limited) reading of the literature, PTSD appears to refer to a neurological process that bypasses the neo-cortex and stores memories, or associations, directly in the hipocampus of the brain (or, at least, with a strong connection to that area).

Let me tell you a story (Anthropologists are ALWAYS telling stories :D). In a certain tribe living nowadays in South Africa and Tanzania, the manhood ritual involved circumcision - usually with a rather dull iron knife at the age of 12 or so. This was followed with a requirement hat the "candidate" stand immersed in a cold stream for about an hour or so. No, to my mind, having parts of your anatomy slowly sawed off and then being put into cold water for an hour or so will, in all probability, induce a major system shock. Someone who had a genetic predisposition to PTSD, i.e. a likelihood of pain bypassing their neo-cortex, would probably die as a result of this ritual. So, in his culture, PTSD would not be as prevalent as in other cultures that don't select against it.

Marc

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having parts of your anatomy slowly sawed off and then being put into cold water for an hour or so will, in all probability, induce a major system shock.

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we call that "apply ice to affected area" IOT reduce swelling...and in all probability give it a little primitive novocain lovin'. I'm thinking I'd want the cold stream treatment prior to the, uh, surgical procedure.

As to the whole PTSD aspect of the thing….naw. Folks in the third world, dependant on culture, are pretty much programmed through repeated events and annealed to physical hardship. We’re just “softer” here for a variety of reasons….e.g. very few of us don’t kill/dress our food, air conditioning (cable TV, etc) is viewed as a right, not a privilege, and my $100 Doc Martins protect my feet way better than those ratty old flip flops. IMO physical “toughness” goes a long way in combating PTSD.

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Originally Posted by Vic Bout

IMO physical “toughness” goes a long way in combating PTSD.

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and I'd add that mental toughness and /or being mildly sociopathic helps as much or more...

:D, though I think I recall LTC(R) Grossman saying something about SOF guys being sociopaths....but sociopaths in a good, sheepdog-like way.

It seems to me that you have excluded some key factors by the way in which you have formulated the problem. I would suggest that you go back and think some about the boundary conditions you have given.

For instance, why does PTSD have to be related to industrialized warfare, or the West, or cultural constructs? Why can't it be related to the human psyche and the nature of extreme violence against others and what it does to the human spirit?

You're approaching the problem as a social scientist. Try to think outside your box and approach it as a theologian or psychologist. Think mind / heart / will / volition rather than moray / social framework / common deliverance of society / date and time.

Then, it might be that you are opposed to this given some set of pre-commitments you have, and I am not commenting on whether this is a good thing or not, just observing. The way you have formulated the problem is significant.

Another way of saying this might be as follows. You could take your thesis and conclude that since you have found evidence of ancient Japanese warriors who suffered from PTSD that it must therefore be related to warfare with a sword.

I'm not trying to be insulting, but rather just to challenge your basic set of presuppositions.

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Originally Posted by Vic Bout

:D, though I think I recall LTC(R) Grossman saying something about SOF guys being sociopaths....but sociopaths in a good, sheepdog-like way.

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After all, we can't really bark; we gotta bite to get the point across to the wolves... ;)

A colleague and friend who worked in Cambodia, after the UN supervised election, approx. ten years ago, found that the whole nation has been traumatised.

I would suggest that PTSD features in machete conflicts, for example child soldiers in West Africa. Western knowledge of this is dependent on access, language skills etc (prompting what books are there in French, Algeria?). More likely is population movement to the West, so enabling visibility in their writings, asylum procedures (court proceedings eg Zimbabwe in the UK) and the work of such bodies as the UK (name unsure of) Medical Foundation for Victims of Torture.

davidbfpo

Jonthan Shay's book "Odysseus in America" and "Achilles in Vietnam" are probably the two best books I've read on the subject. Shay uses examples from Greek mythos as a lens to examine PTSD and combat trauma.

My memory fails me, but I believe there was a "compare and contrast" work out there, that addressed Luftwaffe vs. USAAC efforts to deal with "combat fatigue.

I also saw an interesting History Channel series that, (despite it's main theme of attempting to prove that God doesn't exist,) showed how Hebrew warriors cleansed themselves, mentally, morally and physically, after battle.

I'm particularly interested in at what point does "PTSD" change from being a normal reaction to sustained stress, and start being a genuine disease. I'm also wondering how PTSD can be "spread" through suggestion.

I am a pretty emotional guy, and I have a non-combat MTBI from a few years ago, and I swear nearly everywhere I go, medic types try to push a PTSD classification on me, despite never having been exposed to a situation that could be remotely classified as stressful during OIF I.

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Originally Posted by Vic Bout

:D, though I think I recall LTC(R) Grossman saying something about SOF guys being sociopaths....but sociopaths in a good, sheepdog-like way.

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I think that's because to a great extent SOF has taken the place of warrior societies in what could be considered the military tribal culture.

Grossman has some interesting points, but he gets too wrapped up in himself at times (and some of his social guilt ideas) and misses some important considerations. If you look at many of the Plains Indian cultures, most of them had a warrior society (or two...or three) that served to 'select' the more combat-prone (and capable) members of the tribe to serve as what might be considered full-time combatants. They were often the first (and last) line of defense for the community. But within that framework there were cleansing rituals and ways of dealing with the effects of combat that we really no longer have (at least in what could be considered a formal, ritualized sense). In a related note, I've also seen commentary that direct flights from the combat zone to "home" with no decompression period have greatly accelerated the impact of PTSD-type issues. Sometimes it's worth remembering that WW2 guys had to (for the most part) take ships home...and had time with their buddies to talk about what they'd seen and done (if they so chose).

Most elite units develop similar rituals over time. One thing I'd be interested in seeing is a comparison of PTSD rates between members of SOG and (say) a line battalion in the 9th ID during 1969. On a side note, I seem to recall reading in a couple of places that the PTSD/combat fatigue rate skyrocketed in Vietnam during the drawdown...as combat became rarer (it might have been in Shay's first book, although I know Kieth Nolan has addressed this in a couple of his books in a slight way).

I don't think PTSD is related to industrialized warfare...at least not directly. I might be more inclined to suspect that its recognition and possible increase is due more to industrialized societies losing touch with their earlier coping mechanisms...but that's just a suspicion.

The saying I recall hearing is toughness in another term for training and training is another term for reducing the unknowns. The unknowns become the psychological outliers that generate trauma. There does seem to be a correlation between level of training and incidence of PTSD.

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I'm particularly interested in at what point does "PTSD" change from being a normal reaction to sustained stress, and start being a genuine disease.

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The DSM IV distinguishes between Acute Stress Disorder and Post Traumatic Stress Disorder, with the main difference being duration of symptoms. I think the thing to remember is that trauma is relative. For lack of a better analogy, stress is an emotional gas that will expand to fill the volume of its container. Training, experience, toughness, or whatever you want to call it will give you a larger “container”. Also, I can’t find the citation, but recall reading the estimate that 30 to 35% of soldiers experience acute or chronic PTSD. The rate among cops is somewhere north of 40%.

In my observation, the quantity and quality of training do favorably affect the number of PTSD cases by driving that number down.

However, I've noticed that it is impossible to predict what event will send even the strongest will around the bend. I've seen people blow off mind numbing events and seen a crying child send an old experienced soldier into la-la land. No way to tell what will be the proverbial straw...

That 30-40% figure also tracks with my observation over the years. I believe that figure is telling. If about that percentage have Sociopathic tendencies (and I suggest they do), they're unlikely to get combat related PTSD; stands to reason that an approximately equal percentage have the reverse of Sociopathy and are therefor going to be highly prone to develop PTSD.

Psychological selection for combat suitability should be viable -- if not right now, then soon...

The first thing I have to point out is that PTSD is what a lot of doctors would call a “trash can diagnosis.” It's a diagnosis that fits such a wide array of symptoms it is not particularly useful diagnostically. I've met several psychiatrists who see it as their professions “chronic prostatitis.” PTSD in and of itself is more of a grouping of symptoms and syndromes which are similar in root and form. It is an attempt to put a name on something that is so complicated and convoluted that it is all but impossible to identify and classify. (I'll be explaining this in a minute. ) Although I do believe it is a useful term, I believe that it is doing harm with so many not acknowledging the terms lack of utility. PTSD has always been around in one form or another. Although, I bet it was less common in certain culture due to culture, upbringing (different societies perceive different things as traumatic) and to an extent genetics. PTSD is very misunderstood.


Starting off, we have to remember that it is caused by a variety of different factors. These can best be broken down into the following groups: psychological and neurological (which for our discussion will include both physiological and chemical issues.) What makes understanding this so difficult, is that both of these react to each other. The neurochemistry greatly effects your psychological make up, while your psychological makeup can effect your neurochemistry.


When you begin to explore the psychological components, I really think the best way to begin to understand the behavior, is to analyze an animal rather than a human. Let's say you adopt a 3 year old dog from the pound. From the first day you bring him home you start to notice certain behaviors. When you take out the ironing board, the dog runs for a corner. The dog never wants to sit with you or for that matter anyone. Rather he prefers to be off to the side in a position where he can view all present parties. As stand-offish as this dog is, when ever you leave the dog becomes very agitated. I believe the causes of the dogs behavior are very obvious. Although it may seem odd to compare the recovery of a dog from years of abuse, I believe it is a very good parallel. The dog has learned certain responses to situations. These responses were often proper in a hostile environment, but now, in the safe environment, they are not appropriate. The rehabilitative treatment of the dog in many ways is not that different from the way we would treat humans. It all centers around breaking and/or changing learned responses. (marct – this is sort of what you are getting at.) (part of the reason we don't want to get into to much neurology, is that we don't know what in the ----- is going on. We have a few good ideas, but we really know so very little.)


Learned responses are both psychological and chemical in nature (I won't go into this, it will turn into a ten page paper on neuroanatomy and neurochemistry.) This makes them very difficult to change, if this can be done. High levels of training in many ways can be viewed as somewhat of an inoculation. We are controlling the creation of certain learned responses which are necessary for survival in a hostile environment. Hopefully these learned responses will be adequate and prevent inappropriate responses from being learned in combat. Also, it gives a soldier experience so when they encounter the real thing, they are not quite so out of their depth (Sorry for restating the obvious which has already been stated by other posters.) As Sergeant T pointed out, “The saying I remember hearing is toughness is another term for training and training is another term for reducing the unknowns. The unknowns become the psychological outliers that generate trauma. There does seem to be a correlation between level of training and incidence of PTSD.”


This deals with the more obvious PTSD symptoms. After this we start getting into the more complicated psychological (Ken's "la la land") and neurological roots (shell shock), which I'll try to post on later.



Adam L


Note: My knowledge and opinions do not come from any professional knowledge or experience. I have just spent a lot of time reading about this stuff. I know I am not using the proper terms at times, but this is for the sake of clarity and readability.

The Army says suicides are highest in 20 years.
http://www.cnn.com/2008/US/05/29/army.suicides/

How does this compare to comparable conflicts?

numbers can lead you astray. How many were in Theater; how many elsewhere in the world. How many in CONUS. Any combat tours? If so, how many? Where? What was the catalyst? Spousal problems? Money problems? Stress? Combat stress or other stress? How many male? How many Female?

IIRC, the current rate is still lower than the 19-25 non-military demographic in the US for males but higher for females. I also seem to recall reading somewhere that the in theater rate was lower than anyone expected and the majority were not in the two theaters.

Without detailed info, the raw number is borderline meaningless. The fact that it's the highest in 20 years is at least partly due to the fact that as a result of the surge the active duty end strength is higher than it has been in 20 years...

* That similarity is from memory (and I'm old, so it may be flaky). Not an issue to me but Google may be able to provide definitive numbers of a sort.

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Originally Posted by AmericanPride

The National Institute of Mental Health defines PTSD as "an anxiety disorder that can develop after exposure to one or more terrifying events in which grave physical harm occurred or was threatened". What I would like to find out is the relationship between culture, the nature of modern war, and PTSD, if there is a significant relationship at all.

(1) Is PTSD prevalent in other cultures/countries? Is it a major issue primarily in industrialized countries, or is it present in all cultures engaged in conflict? Russia has a serious problem managing PTSD among combat veterans returning from Chechnya, but this would seem to indicate that PTSD is a consequence of industrialized war.

(2) Are there historical references to PTSD in history prior to modern warfare? How was it perceived and managed? Was it particular to certain cultures or present throughout the history of war? The Iliad makes a reference to what appears to be PTSD -- Ajax loses a duel, comes under a "spell" from Athena, slaughters a herd of sheep thinking they are the enemy, and then kills himself. Is this an ancient reference to PTSD? If so, it would seem, so far, that PTSD is a product of Western culture.

(3) If PTSD is particular to a certain cultural arch-type or form of warfare, is it therefore a product of social construction?

(4) If it's a social construct, would PTSD treatment be more effective by addressing the underlying cultural variables rather than specific individuals (not to say, of course, that those individuals suffering from it should be refused treatment on a case-by-case basis).

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The first real description of PTSD like symptoms is read in the account of the aftermath of the Battle of Thermopalye.

PTSD is more than just a single or multiple experiences. PTSD can also be learned behavior that was positive at the time in that it allowed for survival but does not translate well when the individual returns to a "safe" environment. This learned behavior also has a physical presence where the fight or flight reaction is instaneous and bypasses normal though process.

PTSD treatment needs to be specific to the individual and the way each individual processes their experience is personal and unique. For some working through the issues in one on one counseling is key. With others the transition to group therapy is extremely important. Sometimes cognitive behavioral approach or reality therapy may be the model to use. In all truth there is no outright cure for PTSD. The focus of treatment is learning to live with it.

Frankly there is no one blanket treatment for PTSD either but it can be allieviated somewhat by the learning of new coping skills and with the stigma associated with it minimalized. The Army is making strides in this area by fielding Combat Stress Control Units to provide counseling and psychiatric care for soldiers and to debrief units after critical incidents.

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Originally Posted by Ken White

and I'd add that mental toughness and /or being mildly sociopathic helps as much or more...

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Mental flexibility may be more accurate. PTSD appears to be a processing memory problem more then anything else at this point in time. There were a few references to the SF community and PTSD on this thread, however keep in mind that an SF trooper that is diagnosed w/ PTSD would lose his Top Secret clearance, and thus no longer be an SF trooper. This combined with the fantastic team support that SF enjoys likely has more to do with the lower SF PTSD rates then anything else. When question 21 is removed, I will be curious to see if SF reported PTSD rates go up. Army battlemind training is a fantastic tool btw, speaking of preventative measures. The military is making great strides and deserves recognition for there role in improving the care for everyone w/ PTSD. Army behavioral Health is tops in this field, better then the VA.
Reed
P.S. Adam L.'s comments on PTSD being a cluster of symptoms and that understanding of the root cause is scarce is true. Unfortunately the entire DSM-IV operates the exact same way. So singling out PTSD for this is a little irrational. Reminds me of continued attempts to peg ADD on bad parenting. PTSD exists and now we need to discover the root causes to the best of our ability.

I have to be honest and say that I've not read it, but Roger Spiller, formerly a Prof at CGSC, thinks very highly of Ben Shephard's "A War of Nerves" Harvard Univ Press, 2001. Shephard focuses on 20th century soldiers so the book runs the gamut from WWI to the Faulklands and includes WWII Army Air Forces. Shephard "writes widely on psychiatry and its history," according to the book blurb.

Ben

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Originally Posted by Jayhawker

I have to be honest and say that I've not read it, but Roger Spiller, formerly a Prof at CGSC, thinks very highly of Ben Shephard's "A War of Nerves" Harvard Univ Press, 2001. Shephard focuses on 20th century soldiers so the book runs the gamut from WWI to the Faulklands and includes WWII Army Air Forces. Shephard "writes widely on psychiatry and its history," according to the book blurb.

Ben

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That makes sense. Roger was and is very big on the mental aspects and effects of combat/war. Jerry Linderman is another I wouuld recommend.

Tom

An interesting account of the after effects of battle is found in: "Reluctant Warriors - Israelis Suspended Between Rome and Jersualem" by Nathan Szajnberg (can be found on Amazon.Com). Dr. Szajnberg studed kibbutzniks enrolled in elite combat units of the IDF. The study focused on, "How do these citizen soldiers, residents in a democratic society, manage to be effective soldiers, yet maintain their humanity as men? How did their transitions from adolescence to young adulthood influence their inner lives, their views of life and the tense, tangled world in which they lived." The author, a psychoanalyst by profession, conducted a series of interviews during over two dozen trips during the Intifada.