‘In thy faint slumbers I by thee have watched,
And heard thee murmur tales of iron wars,
Speak terms of manage to thy bounding steed,
Cry “Courage! To the field!” And thou hast talk’d
Of sallies and retires, of trenches, tents,
Of palisadoes, frontiers, parapets,
Of basilisks, of cannon, culverin,
Of prisoners’ ransom and of soldiers slain,
And all the currents of a heady fight.
Thy spirit within thee hath been so at war
And thus hath so bestirred thee in thy sleep,
That beads of sweat have stood upon thy brow
Like bubbles in a late-disturbèd stream.’

A person with a literary background may recognise this speech as an excerpt from Henry IV Part 1, published in the late 16th century by William Shakespeare. Lady Percy is asking her husband, Hotspur, what she can do to help him since he has returned from the war with nightmares.

For someone with an interest in mental health, however, this disturbed sleep pattern may fit the description of what we now know as Post-Traumatic Stress Disorder (PTSD) symptoms. To quote the Mayo Clinic website:

“Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.”

Whether or not we were aware of it at the time, PTSD has been present throughout human history. The Greek historian Herodotus was one of the first to document this.

Herodotus referred to a Greek soldier named Epizelus, who lost his eyesight in the Battle of Marathon in 490 BC. Surgeons examined him and found that he had not received a wound at all, yet he recounted that:

‘a gigantic warrior, with a huge beard,
which shaded all his shield, stood over against him; but the ghostly
semblance passed him by, and slew the man at his side.’

Many mental health professionals believe this to be the first account of hysterical blindness as a result of wartime trauma, or PTSD, almost 2500 years ago.

Strangely though, this is not the first reference to the effects of PTSD. Ancient Mesopotamian tablets from 1300 BC describe soldiers as being visited by “ghosts they faced in battle”. Iceland’s saga of Gisli Súrsson also details “that the hero dreams so frequently of battle scenes that he dreads obscurity and cannot stay alone at night”. The Indian epic Ramayana recounts PTSD-like symptoms in the demon, Marich. Even the Bible details the effects of PTSD in Deutoronomy 20 verses 1-9. The real revelation, though, is the Epic of Gilgamesh.

The Epic of Gilgamesh is the first recorded piece of literature detailing the life and adventures of the semi-legendary Mesopotamian king, Gilgamesh. In the chronicle, Gilgamesh’s friend Enkidu dies, forcing Gilgamesh to confront his own mortality. After a period of mourning, he rushes between various locations terrified that he too must die some day. Although he did not receive a diagnosis at the time, his behaviour may now be recognised as PTSD.

This event took place in 2100 BC. To put that into context, there were still woolly mammoths alive in Siberia at the time!

Take another step forward in history and wartime PTSD is referenced again. This time in Geoffroi de Charny’s Livre de chevalerie. The ‘Book of Chivalry’ was a type of manual for knights in the 14th century, detailing the ideal behaviour of a good, Christian knight. It contains a description of a man, safe from the war, who may still be ‘beset by great terrors’.

Later, in the late 1600s, a Swiss physician, Dr Johannes Hofer, coined the term ‘nostalgia’ to describe Swiss soldiers who suffered from despair and homesickness, along with classic PTSD symptoms such as sleeplessness and anxiety. Similar diagnoses were made in German, British and Spanish soldiers, with the Austrian physician, Josef Leopold Auenbrugger, referencing it further still in 1761.

After the US Civil War, Dr Jacob Mendez Da Costa determined (incorrectly) that soldiers were suffering from an overstimulation of the heart’s nervous system, and the condition became known as ‘soldier’s heart’, ‘irritable heart’, or ‘Da Costa’s syndrome’.

Then we arrive at WWI and the condition that became coined as ‘Shell Shock’. Hospitals were set up for traumatised soldiers who could no longer fight, and the phenomenon began to become far more apparent. By WWII, the condition had become known as ‘Battle Fatigue’. It wasn’t until the Vietnam war in the 70s that the diagnosis of ‘Post-Traumatic Stress Disorder’ came about.

So, what does this mean? Well, in many ways, though fascinating, it’s not a surprise. Mental health has been a factor for as long as humans have existed and had thought processes. It is by no means a new phenomenon. Our recognition of the issue has changed though and, by extension, our understanding and treatment of other mental health conditions.

In Ancient Greece, for example, doctors simply did not treat any symptoms they did not understand: one can safely assume that Epizelus did not receive therapy. De Charny’s recommendation in the Book of Chivalry was devotion to God and further chivalry, which, while noble, was unlikely to have any great effect on PTSD symptoms. More concerning though were the attitudes of the generals in later centuries. During WWI, hospitals were set up for ‘Shell Shock’, but many generals believed this to be simply a lack of moral fibre, with the prescription being increased discipline to set an example. Many court-martials were brought about on the basis of shell shock, with some soldiers even being executed by a firing squad. Even post-war treatment was ill-understood.

To this day, the Rambo movies seem to represent the ideal held for PTSD in veterans, wrongfully depicting sufferers as violent and ‘unstable’, when the reality is far less newsworthy but significantly more traumatic for the individual.

Today, we recognise that PTSD does not just apply to veterans, but also to those who have experienced trauma in other ways such as by violence, accident, or abuse, both mental and physical. We also recognise its prevalence and the need for effective treatment.

Rather than chivalry or execution, a modern doctor is more likely to describe various forms of therapy or medication to suppress the oft-cited ‘Fight or Flight’ mechanism, help with anxiety and depression, or help with nightmares or hallucinations. To put it simply, we’ve come a long, long way from Gilgamesh.

Reviewed by Dr Christiane Wildgrube MD, Consultant Psychiatrist, MRCPsych

January 2022.