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New Worlds: PTSD

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We’re nearly done with our discussion of mental health because I’m nearly at the limits of what I can talk about with any kind of confidence. But before that concludes, there’s one specific condition I’d like to look at more closely . . . because arguably, it’s one more of our characters should be suffering from.

That “arguably” isn’t just me hedging: the uncertainty is real. Our understanding of what’s currently called post-traumatic stress disorder (PTSD) is constantly evolving; five or ten years from now, it’s entirely possible a reader will be rolling their eyes at the things I say here. (It’s entirely possible now, since I am not a specialist on this topic.) What causes it, who’s more likely to develop it, how it can be treated — all of these things are moving targets.

Especially since this is one of the places where we can potentially see the effect of culture on mental illness. Before PTSD, it was battle fatigue; before that, shell shock; before that, soldier’s heart . . . did PTSD exist in the more distant past?

There are certainly claims that it did, with scholars trawling the historical record for traces and finding them in everything from Shakespeare to Viking berserkers. As I mentioned before, though, the evidence for mental health in the literary record is often slim enough and malleable enough that you’ll tend to find the diagnosis you’re looking for. That some people sometimes had psychological conditions akin to what we now call PTSD is extremely likely. But was it common and widespread among soldiers and warriors?

I tend to side with those who argue that no, it probably wasn’t, for several overlapping reasons. We rarely know what the common people thought, but the elites of the past wrote a lot about war, and while they sometimes mention e.g. being haunted by the ghosts of dead comrades (which some count as evidence of PTSD), the overall message tends to be that war is awesome. It is the thing that makes a man truly a man, the crucible from which he emerges stronger and more capable. This message is pervasive enough that it’s hard for me to buy that they were all putting a brave face on what was actually a traumatizing experience, one that left many of them psychologically scarred; I think it’s more likely that they were not in fact scarred in the ways we see today.

Contrast that attitude with the war experiences recorded in the last century or so, which are more likely to tell you that war is hell. Some people still react to it well, feeling that it transforms them into stronger versions of themselves, but that’s not the dominant cultural narrative anymore. On top of that, while members of the warrior aristocracies of yore could feel they were being initiated into a realm shared by their fathers and grandfathers and peers, soldiers returning home now are more likely to be surrounded by civilians with no direct experience of combat. It’s more isolating — at least in places like the U.S.; I have no idea what it’s like in countries where military service is mandatory — and potentially more traumatizing as a result.

Why did the narrative change? A lot of reasons, I suspect, including things like the expansion of our “sphere of empathy,” making it less broadly acceptable to dehumanize enemy combatants and civilians — the extent to which we do that today is nothing on past centuries — but a whole chunk of it may come down to technology. And for that, let’s look at the factors that seem to increase the likelihood of PTSD.

After all, not everybody comes out of these experiences with long-term trauma — not even people who underwent the same experience. There are personal factors that can influence this, but in terms of the event itself, two things are noteworthy. Last I heard, current research suggests you’re more likely to develop PTSD if:

1) the traumatizing event took you by surprise, and/or

2) you were helpless to do anything in response to the trauma.

Now let’s look at the history of war. (PTSD can develop in lots of contexts other than war, and the above factors go some way toward indicating why, but war is the easy one to look at.)

Even in historical accounts of ancient or medieval armies accidentally running into each other on the march, relatively few of those battles were going to go from zero to widespread violence in a matter of seconds. “Running into each other” would more commonly have taken the form of scouts returning at a dead sprint to report that the enemy force was nearby, and everyone scrambling to get ready for the battle that could not be avoided. Ambushes could certainly hit faster and harder if properly staged, but the majority of clashes would be preceded by the combatants drawing up into battle array. You had some amount of time to prepare, some ability to see your enemy coming.

For a completely different scenario, consider both Iraq and Vietnam, two theatres of conflict legendary for the frequency with which attacks hit out of nowhere. An IED blows up a truck; riflemen pop out of the underbrush and start picking soldiers off. Both of those wars have produced a lot of PTSD, and both of them feature an environment in which it feels like danger could strike from anywhere, at any time. Is it any wonder that hypervigilance, a characteristic symptom of PTSD, is common among those who have spent time in that environment?

As for the helplessness, think of World War I. Soldiers on the front lines had to hunker down while artillery barrages hammered the area for hours or even days, unable to do a single thing other than wait for it to be over. Artillery in general has greatly increased the likelihood that you might be killed by something far outside your own range of response — meaning that instead of facing someone at the length of a spear or a sword, where your own strength and skill can make a difference, your survival depends more on factors like luck and the tactical decisions someone else has made.

My (admittedly non-specialist) suspicion is that modern warfare has made war more traumatizing in the ways most likely to produce PTSD. The process has been going on for a while, as gunpowder made it easier for us to kill each other en masse and at great range, but it’s really picked up steam in the recent past. Combined with those other cultural factors — greater empathy for other people, civilians as a higher proportion within the peer group — it makes for a very different experience.

So bringing that back around to the starting question . . . should more of our characters have PTSD as a consequence of the plot?

The answer in any given case is going to depend on the circumstances. A character trained for combat who sees the enemy coming will probably be less vulnerable than the civilian attacked out of nowhere. The nature of the combat can make a difference, melees of the sort we love to write into our novels being a different beast from long-range weapons. Personal factors play in, too, as some people are more psychologically resilient than others, while cultural factors will affect what narrative the character builds around the events. And remember, this isn’t just about combat: torture, abuse, vehicular accidents, disasters, and more can all produce short-term or long-term psychological trauma.

Probably the broad answer to that question above is “yes.” Many authors put their characters through absolute hell, and relatively few truly explore the effects that hell might leave behind. Which is understandable; sometimes we just want the adventure and don’t want to grapple with the reality that such an adventure would be goddamned scary. But when we’re looking to up the drama and increase the stakes, sometimes it’s worth bearing in mind that we don’t have to crank the event dial to 11. A lower setting can still leave a mark . . . and paying attention to the after-effects can make the trauma hit so much harder.

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13 thoughts on “New Worlds: PTSD”

  1. Battles were always noisy, at least from what I understand coming from reading in latin and greek literature.

    But at least from the time of cannon on, warfare seems to have increased the LOUD in volume, range and duration. The effects of the non-stop barrages for days of Mehmed II’s cannon at the fall of Constantinople were prominent in the writing of the literate who survived the siege.

    That alone will damage nervous systems, not to mention hearing.

    I’ve read that earlier societies seem to have had ceremonies for those returned from war/battle, to cleanse them, return them to non-killing life. Is that true?

    1. I read something recently about the effects of a noisy environment (e.g. living by a busy highway or an airport) on health, yeah — it’s not good for you. Our instincts are too primed to be listening for predators, I guess, and so lots of sound means we’re always on alert. One of the things I’m looking forward to with the switch toward electric vehicles is our roads getting less noisy; the EV my family got last year is wonderfully quiet.

      re: the rituals, I don’t actually know! I’ve seen that claim, too; I think it was at A Collection of Unmitigated Pedantry, in which case I trust Devereaux to be right about it for the societies he knows well. But I can’t actually name off any such ritual myself. I’d believe it, but without being able to cite at least one example, I’m hesitant to go around saying it’s true.

      1. And then, I just saw this on Slate, by a historian, in regard to the meme that won’t die re men thinking of the Roman Empire, and military trauma:

        [ …. “There were very few Romans who had positions of authority, and even fewer of them that were any good at wielding power. Most of them were forced to go on military adventures that they didn’t want to go on, and they basically sat in the background while everyone else did the work. Cicero, the famous Roman orator, spent a long time trying to avoid any military service whatsoever,” said Lushkov. “There’s a trauma inherent with prolonged military service. We don’t have great evidence on PTSD in Rome, but it must’ve been prevalent. It’s not all fun and games. There’s an aspect of humanity in Roman society that we tend to lose track of, even if we’re thinking about the privileged elite.” …. ]

        As far as Brett’s concerned, he KNOWS what he knows, but not so much … outside of that and / or certain military warfare and armament … sometimes, as with the history of the War of the Rebellion and a lot about the Medieval Eras.

        Of course I know nothing about the games he loves to devote so much time and space to, which I care nothing about at all.

        1. “it must’ve been prevalent”

          . . . yeah, I’m suspicious of claims like that. Not just with regard to PTSD, but all kinds of things we consider so obvious and natural that it’s hard to conceive of anyone thinking differently. But I literally just finished reading a book (The Foul and the Fragrant by Alain Corbin) that talks about evolving attitudes toward bad smells and the things that produce them in France between the seventeenth and nineteenth centuries, and dear god, no, people back then did not think remotely the way we do about the stenches of feces, urine, and decay, they did not react to them the way we do, they held beliefs about them which are utterly unimaginable to most people today. We assume those things must be inherently repugnant, because we are automatically repelled by them, but in fact that’s the product of a long shift in social conditioning. So to say “warfare, which was extremely different two thousand years ago in both its conduct and the social attitudes toward it, must of course have produced the same kind of psychological results that it does today” is a pretty shaky assertion, to my mind.

          1. It would be very difficult for me, at least, to counter your:

            [ “So to say “warfare, which was extremely different two thousand years ago in both its conduct and the social attitudes toward it, must of course have produced the same kind of psychological results that it does today” is a pretty shaky assertion, to my mind.” ]

            As much as innate characteristics among human beings transmit through time and cultures, such as cruelty for cruelty’s sake, love of beauty for beauty’s sake, selfishness, compassion, envy, generosity, love of our children, hatred for our relatives, etc., it remains equally true, “the past is a foreign country.”* Which is a good part of why it is, for me, at least, an endless fascination.

            * Thank you, L.P. Hartley

      2. “I’m looking forward to with the switch toward electric vehicles is our roads getting less noisy; the EV my family got last year is wonderfully quiet.”

        This only applies at low speeds, and I think modern ICEs have been getting pretty quiet too. Above some speed, maybe 30 MPH, most of the noise is coming from tire and wind resistance. A highway or arterial or stroad will be noisy even if all electric cars. (And trucks.)

        (Also will be polluted — no tailpipe emissions, but majority of particulates come now from tire and brake wear.)

  2. Wow, what a great essay! I never considered this question before, but now my mind is whirling with the implications. I think you’re absolutely right. In his book In An Unspoken Voice, Peter Levine talks about how physical motion can counteract the feeling of helplessness in (or even just after) a potentially traumatizing situation. His example involved moving his arms to “snap out” of the freeze fear response after a bicycle accident he was in, something which may also help someone with PTSD when they have flashbacks or intrusive thoughts.

    I also remember reading about a study that suggested that playing the video game Tetris within a few hours of a traumatizing event could reduce the incidence of PTSD. This makes a lot of sense with what you’re saying: with swords or spears, a soldier is constantly doing something, and is focused on one enemy soldier right in front of him, whereas, as you said, after the invention of artillery, a soldier is just waiting around helplessly to see if the next shell is going to kill him.

    As Foxessa mentioned, I wonder if we’ll even one day find that the concussive force of bombs and firearms itself causes physical brain damage that might contribute to PTSD?

    I also wonder if, even though PTSD was probably rarer for soldiers in the past, if it was much more common for civilians, given that war was more likely to mean mass enslavement, rape, systematic killing of a portion of the civilian population, and/or the inevitable famine and disease outbreaks that followed.

    1. I have no doubt that the survivors of massacres, mass enslavements, and so forth were traumatized. Trauma can take a variety of forms, though, and I think e.g. the aftermath of famine and disease was more likely to be about grief than the specific constellation of symptoms we call PTSD — you’re less afraid that starvation is going to ambush you out of nowhere.

      It’s all speculation, though, since the kinds of people subjected to that treatment left virtually no records, and the people who did leave records generally didn’t care what their victims thought.

  3. I suspect military-related PTSD was less likely as a result of melee combat. With the possible (and only possible, primarily due to class-related considerations of what was actually put in what passes for a historical record) exception of the English army during the Hundred Years’ War, the substantial majority of virtually all armies prior to the Treaty of Ghent — worldwide, not just in Europe — inflicted/suffered their casualties via disease… and second place was up-close-and-personal, not-just-whites-of-the-eyes-but-hairs-of-the-nostrils distance. Siege and other distance weaponry was rare. And that makes a difference in the incidence of what we now class as PTSD under DSM-V categories. (Which, as our essayist wisely notes, will no doubt change in a decade.)

    This is not to minimize PTSD resulting from rape and other highly personal/direct assaults at all; it is only to note that the “remote cause” aspect seems to increase the probability (and require different treatments, etc.; there’s no one “PTSD,” and I say that having had supervisory and/or monitoring responsibility for Vietnam-era POWs). There’s a higher instance from IEDs and sniper attacks than from clearing houses in beautiful downtown Baghdad (once upon a time, it was…). According to professional colleagues back when the term “PTSD” was not yet in use, the simultaneously impersonal-but-yet-intentional nature of ranged combat made things worse, especially when not originating from a rigid formation. Of course, they were basing things on experiences in Pacific Island warfare, Korea, and Vietnam, so there were a lot of other variables to consider too — the most important of which is simply that we now have records of what the infantry grunt thinks/thought and didn’t prior to the late seventeenth century in Europe.

    We both know more about and pay more attention to the experiences and feelings of The Great Unwashed than did historians drawn from the literate classes when literacy was far from universal. Small surprise that records even of the seige of Constantinople provide only insight from which we can infer how WE’D feel, but not into a nameless soldier on the wall a few meters from the Adrianople gate.

    1. Yeah, there will always be the asterisk on this that we only have the elite perspective in almost all cases before maybe a couple hundred years ago.

      1. Given the reliability problems, I’d say that at best there’s a third-son-of-a-nobelman’s scrawled note attached to an asterisk… even as late as the Crimean War.

        Example: To my knowledge — and I’ve looked — there’s not one post-battle reminiscence of the Battle of Lepanto (1571; ignore the egregiously inaccurate Wikithingy article and go find a book) that was not written by, and from the perspective of, an officer-equivalent. Now that’s a great perspective to have on the battle itself, as the vast majority of the “common sailors” were barely looking over their own gunwales. It’s not so great a perspective to learn anything about the individual experiences of the battle itself, let alone individual responses afterward, precisely because those officer-equivalents did have individual agency… and were more likely to be able to swim than were the common sailors (and were the only ones who could write things down)…

  4. I’m late to the party here, but just wanted to add a thought.

    My sister was a doctor in a clinic which dealt with a great many recent immigrants, including those from developing and war-torn countries, and one of the things she came to believe over the course of a large number of years is that depression, anxiety, and PTSD occurred at pretty much the rate that you would expect, but were not recognised, named, or culturally acknowledged as such, especially in some of the cultures where people simply didn’t react to the notion of mentall illness & trauma in the same way – it was seen as something deeply, profoundly shameful that no “normal” person would have. Instead, these were culturally diagnosed as “acceptable” illnesses.

    I would say, given this context, it’s probably not possible to assert that other cultures felt and suffered significantly differently in history. It may only be possible to say that it was named and considered differently.

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