Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd. 21

RESEARCH ARTICLE

Psychotraumatology in AntiquityPhilippe J. Birmes*†, Eric Bui, Rémy Klein, Julien Billard, Laurent Schmitt, Charlotte Allenou, Nicolas Job & Christophe Arbus

Laboratoire du Stress Traumatique (JE 2511) Université de Toulouse & CHU de Toulouse, Toulouse, France

Summary

From antiquity onwards, chroniclers have reported cases of agitation or stupor sometimes associated with terrifying

nightmares. Responses during the impact of a traumatic experience have attracted attention: terror, confusion and

disorganized behaviour during the fi re of Rome; the numbness of Patroclus, and loss of bowel and bladder control

among warriors. The same applies to the most obvious post-traumatic responses: the recurrent and intrusive dis-

tressing recollections of Gilgamesh, the dreams of battle in De Natura Rerum and the dissociative episodes concern-

ing Marius. Although symptoms of re-experience are perfectly described, the long-term dissociative symptoms and

their somatic components are also the object of unequivocal anecdotes. The scientifi c reading of the historical

studies of a clinical and seemingly isolated fact contributes towards the establishment of modern psychotraumatol-

ogy. Copyright © 2009 John Wiley & Sons, Ltd.

Received 16 October 2007; Accepted 28 November 2008

Keywords

antiquity; somatic symptoms; dissociation; psychotraumatology; traumatic stress

*Correspondence

Philippe J. Birmes, Laboratoire du Stress Traumatique (JE 2511), Université de Toulouse & CHU de Toulouse, Hôpital Casselardit Psychiatrie,

170, av. de Casselardit, TSA 40031, 31059 Toulouse Cedex 9, France.†Email: birmes.p@chu-toulouse.fr

Published online 15 January 2009 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/smi.1251

tology. According to the Diagnostic and Statistical

Manual of Mental Disorders, 4th edition, text revision

(DSM-IV; APA, 2000), acute stress disorder (ASD) and

post-traumatic stress disorder (PTSD) are anxiety dis-

orders that can develop following a trauma or a life-

threatening event. Such stressful events may occur in

particular during natural disasters or wars. As battles

and wars were part of everyday life in ancient times, it

is likely that psychotraumatology was not infrequent

in antiquity. However, despite references to warriors,

enemies and foes in ancient texts such as ‘Various

Dreams’ in the complete works of Hippocrates (1849),

the ‘father of medicine’, (ca 460–370 bc), medical trea-

tises by famous fi gures such as Celsus, Galen, Oribasius

and Pliny the Elder show no trace of psychotraumatic

Introduction

Over the past two decades, the scientifi c work in the

fi eld of traumatic stress to a large extent has been

inspired by the interest aroused in the United States by

the veterans of the Vietnam War. The concept had

developed gradually, evolving around three main steps:

(1) a scientifi c interest awakened by clinical case

reports; (2) the integration of repeatedly observed

symptoms into a syndrome using reliable criteria; and

(3) the individualization of an etiopathogenic specifi c-

ity corroborating clinical observations (Birmes,

Hatton, Brunet, & Schmitt, 2003). Throughout this

process, the scientifi c reappraisal of historical reports

has contributed to the rise of modern psychotrauma-

Psychotraumatology in Antiquity P. J. Birmes

22 Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd.

symptoms. The answer to this inconsistency may lie in

these symptoms being considered as normal emotional

responses to stress at the time. Indeed, although absent

from the medical textbooks of antiquity, evidence of

psychotraumatology is to be found in the historical

accounts of chroniclers who, for example, reported

cases of agitation or stupor sometimes associated with

terrifying nightmares (Birmes et al., 2003).

A historical review in search of symptoms induced

by trauma may therefore retrospectively uncover DSM

symptoms, but may also illustrate raw trauma responses,

which could enhance our current traumatology per-

spectives. A comparison between ancient accounts of

post-traumatic responses and modern diagnoses of

psychotraumatology could reveal symptoms over-

looked by current classifi cations. The aim of our study

is therefore to review the texts that date back to antiq-

uity in search of psychological and somatic symptoms

that might have occurred in the aftermath of traumatic

events in order to compare them to DSM criteria.

Method

We have conducted a review of literature dating back

to antiquity in search of all events that might have

accounted for stress-related symptoms: mass violence,

war, combat and disasters. A computerized search

(using MEDLINE, PILOTS and GALLICA) identifi ed

English- and French- language articles. PILOTS is a bib-

liographical database covering published international

literature on traumatic stress, and GALLICA is an

Internet server covering the digitized collections of the

Bibliothèque Nationale de France. We then selected

historical accounts and observations on the basis of

their descriptive power and extracted stress-related psy-

chological and somatic symptoms.

Results

Trauma-related psychological and somatic symptoms

highlighted by our search followed two main patterns:

(1) acute reactions; and (2) post-traumatic and long-

term responses.

(1) Acute reactions

Acute reactions found in the aftermath of mass vio-

lence, disasters and combats encompass two main types

of symptoms: panic and terror on the one hand, and

stupor and dissociation on the other.

Panic and terror

In mass violenceThe destruction of the city of Ur in the days of King

Ibisin (2026–2003 bc) and the death in battle of King

Urnamma (2111–2094 bc) help shed light on the per-

ception of trauma in antiquity (Ben-Ezra, 2004). Ur

was a city in ancient Sumer and was considered sacred

by the god Nanna. The ‘Lamentation for the destruc-

tion of Ur’ refers to traumatic events:

The righteous house they break up with pickaxe;

the people groan. The city they make into ruins;

the people groan. Its lady cries: ‘Alas for my city,’

cries: ‘alas for my house’. In its lofty gates, where

they were wont to promenade, dead bodies were

lying about; in its boulevards, where the feasts

were celebrated, scattered they lay. In all its

streets, where they were wont to promenade,

dead bodies were lying about. In its places, where

the festivities of the land took place, the people

lay in heaps. (Kramer, 1969)

In the same manner, the account of the death of

Urnamma contains an explicit description of the trau-

matic event, however this time, followed by a reference

to panic experienced by the inhabitants:

From the [. . . , the . . .] was [. . .] evenly in/on

the land. [The . . .] struck, the palace(s) was col-

lapsed. [The . . .] spread panic rapidly among its

Black-headed who dwelt there. [The . . .] estab-

lished its abandoned places in Sumer. In its vast

[. . .] cities are destroyed, the people are seized

with panic. Evil came upon Ur. (Fluckiger-

Hawker, 1999)

In disastersAs for civilian disasters, in his Annals, Tacitus (ca

56–117 ad), a senator and a historian of the Roman

Empire, describes the behaviour of the inhabitants

during the Great Fire of Rome (64 ad) (Crocq, 2004):

Added to this were the wailings of terror-stricken

women, the feebleness of age, the helpless inex-

perience of childhood, the crowds who sought to

save themselves or others, dragging out the

infi rm or waiting for them, and by their hurry in

the one case, by their delay in the other, aggravat-

ing the confusion. At last, doubting what they

Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd. 23

P. J. Birmes Psychotraumatology in Antiquity

should avoid or whither betake themselves, they

crowded the streets or fl ung themselves down in

the fi elds, while some who had lost their all, even

their very daily bread, and others out of love for

their kinsfolk, whom they had been unable to

rescue, perished, though escape was open to

them. (Tacitus, 1996)

This great civilian disaster gives insight into the

crowd’s terror, confusion and the desperate behaviour

that sometimes emerges among victims.

In combatsThe Second Punic War, referred to as ‘The War

Against Hannibal’, lasted from 218 to 201 bc and

involved combatants in the Western and Eastern Medi-

terranean area. It was the second of three major wars

between Carthage and the Roman Republic. In the

depiction of the Roman defeat at the lake of Trasimene,

Livy (59 bc to 17 ad), a Roman historian who wrote a

monumental history of Rome, reported clashes that

appeared unequalled:

In such a thick fog ears were of more use than

eyes; the men turned their gaze in every direction

as they heard the groans of the wounded and the

blows on shield or breastplate, and the mingled

shouts of triumph and cries of panic. (Livy, 1972)

Here again, the traumatic event is followed by a state

of panic among victims.

In a letter written 3000 years ago, a veteran of the

Pharaoh named Hori thus questioned a young and

inexperienced offi cer (Dyer, 2004):

You determine to go forward, though you don’t

know the way. Shuddering seizes you, the hair of your

head stands on end, your soul lies in your hand. Your

path is full of boulders and shingle, there is no passable

track, for it is all overgrown with thorns, neh-plants and

wolf ’s-pad. The ravine is on one side of you, the moun-

tain rises on the other. On you go, and guide your

chariot beside you, and fear that the horse will fall. The

sky is open, and you imagine that the enemy is behind

you. (Cottrell, 1968)

Sennacherib (705–681 bc), the King of Assyria,

relates his enemies’ terror following a massacre (Dyer,

2004):

The commander-in-chief of the King of Elam,

together with his nobles. I cut their throats like sheep.

As to the Sheiks of the Chaldeans, panic from my

onslaught overwhelmed them like a demon. They aban-

doned their tents and fl ed for their lives, crushing the

corpses of their troops as they went. [In their terror]

they passed scalding urine and voided their excrement

in their chariots. (Saggs, 1984)

Thus, in the aftermath of mass violence, combats and

disasters, feelings of panic, terror and helplessness have

been described in antiquity. Furthermore, disorganized

behaviour produced by such states of mind have also

been reported among the victims and witnesses of trau-

matic events.

Stupor and dissociation

Two other types of acute post-traumatic reactions

brought forward by our review are stupor and dissocia-

tion. Acute dissociative symptoms are included in the

ASD criteria: subjective sense of numbing, detachment,

absence of emotional responsiveness, reduction in

awareness of one’s surroundings, derealization, deper-

sonalization and dissociative amnesia (see Table I).

In disastersPliny the Younger, a lawyer, author and natural phi-

losopher of ancient Rome, recorded the reactions of

panic observed during the eruption of the Vesuvius (24

August 79 ad):

We were followed by a panic-stricken mob of

people wanting to act on someone elses’s deci-

sion in preference to their own (a point in which

fear looks like prudence), who hurried us on our

way by pressing hard behind a dense crowd. You

could hear the shrieks of women, the wailing of

infants, and the shouting of men; some were

calling their parents, others their children or

their wives. People bewailed their own fate or

that of their relatives, and there were some who

prayed for death in their terror of dying. (Pliny

the Younger, 1969)

Furthermore, he described his reaction while exposed

to danger while the walls of his house were splitting

apart:

We sat down in the forecourt of the house. I

don’t know whether I should call this courage or

folly on my part (I was only seventeen at the

Psychotraumatology in Antiquity P. J. Birmes

24 Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd.

time) but I called for a volume of Livy and went

on reading as if I had nothing else to do. Up came

a friend. When he saw us sitting there and me

actually reading, he scolded us both -me for my

foolhardiness and my mother for allowing it.

Nevertheless, I remained absorbed in my book.

(Pliny The Younger, 1969)

He did not feel that he was part of what was going

on: a state of total passivity that could be a result of

absence of emotional response.

In combatIn the Iliad (8th century bc), one of two ancient

Greek epic poems, with the Odyssey traditionally

attributed to Homer, the author relates the story of

Patroclus, close friend of Achilles, who helped lead the

battle against the Trojans. In the midst of battle he was

struck with what appears to be stupor:

Not only that, but the long-shadowed spear,

huge, thick and heavy with its head of bronze,

was shattered in Patroclus’ hands; the tasselled

shield with its baldric fell from his shoulder to

the ground; and King Apollo Son of Zeus undid

the corslet on his breast. Patroclus was stunned;

his shapely legs refused to carry him; and as he

stood there in a daze, a Dardanian called Euphor-

bus came close behind and struck him with a

sharp spear midway between the shoulders.

(Homer, 1950)

Here the decreased awareness of his surroundings

(e.g. ‘being in a daze’) might indicate a dissociative

reaction. Plutarch (46–120 ad), a Greek historian, biog-

rapher and essayist (with Roman citizenship), reported

the reactions of terror observed during the siege of

Syracuse by the Romans (213 bc): ‘When the Romans

fi rst attacked by sea and land, the Syracusans were

struck dumb with terror and believed that nothing

could resist the onslaught of such powerful forces’

(Plutarch, 1965). The besieged inhabitants experienced

a state of dumbness, which may also be a sign of

dissociation.

These passages suggest that symptoms that may refer

to acute traumatic reactions, such as being dazed or

feeling alienated from what was going on at the time,

were described in texts dating back as far as antiquity.

(2) Post-traumatic and long-term responses

Re-experiences are by far the most widely described

symptoms, doubtless because they are the most obvious

Table I. Diagnostic and Statistical Manual, 4th edition, criteria for acute stress disorder (APA, 2000)

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious

injury, or a threat to the physical integrity of self or others.

(2) The person’s response involved intense fear, helplessness or horror.

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative

symptoms:

(1) a subjective sense of numbing, detachment or absence of emotional responsiveness;

(2) a reduction in awareness of his or her surroundings (e.g. ‘being in a daze’);

(3) derealization;

(4) depersonalization;

(5) dissociative amnesia (i.e. inability to recall an important aspect of the trauma).

C. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions,

fl ashback episodes or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g. thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g. diffi culty sleeping, irritability, poor concentration, hypervigilance, exaggerated

startle response, motor restlessness).

F. The disturbance causes clinically signifi cant distress or impairment in social, occupational or other important areas of functioning, or

impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by

telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks, and occurs within 4 weeks of the traumatic event.

H. The disturbance is not because of the direct physiological effects of a substance (e.g. a drug abuse, a medication) or a general medical

condition, is not better accounted for by brief psychotic disorder and is not merely an exacerbation of a pre-existing Axis-I or Axis-II

disorder.

Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd. 25

P. J. Birmes Psychotraumatology in Antiquity

and the easiest to express and to objectify for the victims

and the witnesses.

Re-experiences

The most famous work of Mesopotamia, the Epic of

Gilgamesh, which dates back to the third millennium

bc, relates the journey of Gilgamesh, the renowned

King of Uruk in Mesopotamia. On witnessing the death

throes of his companion Enkidu, he sensed a profound

feeling of despair (Tomb, 1994):

I wept for him seven days and nights till the

worm fastened on him. Because of my brother I

am afraid of death, because of my brother I stray

through the wilderness. His fate lies heavy upon

me. How can I be silent, how can I rest? He is

dust and I too shall die and be laid in the earth

forever. I am afraid of death. (Sandars, 1972)

These intrusions may have persisted long after the

traumatic event for his friend’s death was to become an

impetus for his lifetime quest for eternal life. Some of

Plutarch’s works consist of biographies of famous men

or ‘Parallel Lives’. According to Tomb (1994), we dis-

cover that Gaius Marius (157–86 bc), a Roman general

and politician elected consul for an unprecedented

seven times during his career, presented traumatic

recollections:

But Marius himself, now worn out with toils,

deluged, as it were, with anxieties, and wearied,

could not sustain his spirits, which shook within

him as he again faced the overpowering thought

of a new war, of fresh struggles, of terrors known

by experience to be dreadful, and of utter weari-

ness. (Plutarch, 1973)

Plutarch also reported recurrent nightmares:

Tortured by such refl ections, and bringing into

review his long wandering, his fl ights, and his

perils, as he was driven over land and sea, he fell

into a state of dreadful despair, and was prey to

nightly terrors and harassing dreams. (Plutarch,

1973)

More painful recollections also appeared during a

highly agitated moment of delirium during which he

suffered from illusions:

Some, however, say that his ambitious nature

was completely revealed during his illness by

his being swept into a strange delusion. He

thought that he had the command in the

Mithridatic war, and then, just as he used to do

in his actual struggles, he would indulge in all

sorts of attitudes and gestures, accompanying

them with shrill cries and frequent calls to battle.

(Plutarch, 1973)

In ‘The Lament for Ur’, nightmares and dreams as a

response to the traumatic event (i.e. the destruction of

Ur) are also mentioned (Ben-Ezra, 2004):

At night a bitter lament having been raised unto

me, I, although, for that night I tremble, fl ed not

before that night’s violence. The storm’s cyclone

like destruction—verily its terror has fi lled me

full. Because of it’s [affl iction] in my nightly

sleeping place, in my nightly sleeping place verily

there is no peace for me; nor, verily, because of

its affl iction, has the quiet of my sleeping place,

the quiet of my sleeping place been allowed me.

(Kramer, 1969)

In the Iliad, Achilles falls prey to recollections con-

cerning his friend Patroclus who has been killed in

combat. These recollections are recurrent and cause

very agitated sleep:

But Achilles went on grieving for his friend,

whom he could not banish from his mind, and

all-conquering sleep refused to visit him. He

tossed to one side and the other, thinking always

of his loss, of Patroclus’s manliness and

spirit . . . of fi ghts with the enemy and adven-

tures on unfriendly seas. As memories crowded

in on him, the warm tears poured down his

cheeks. (Homer, 1950)

Homer dramatically conveys Achilles’s grief by enu-

merating his actions such as self-mutilation, weeping

and loss of appetite, and by describing his thoughts of

self-reproach and intrusive memories of the dead (Shay,

1994).

De Natura Rerum, literally meaning ‘On the Nature

of Things’, is an epic poem written around 50 ad by the

Roman poet and philosopher Lucretius (ca 99–55 bc)

in which traumatic dreams are also mentioned:

Psychotraumatology in Antiquity P. J. Birmes

26 Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd.

Whatever employment has the strongest hold on

our interest or has last fi lled our waking hours,

so as to engage the mind’s attention, that is what

seems most often to keep us occupied in dreams.

Generals lead their troops into action. Sailors

continue their pitched battle with the winds.

Very similar as a rule is the behaviour in sleep of

human minds, whose mighty machinations

produce massive feats. Kings take cities by storm,

are themselves taken captive, join in battle and

cry aloud as though their throats were being

slit—and all without stirring from the spot.

(Lucretius, 1994, p. 120)

Numbing and hyperarousal

Even if re-experiences are the most recurrent symp-

toms of post-traumatic responses found in texts dating

back to antiquity, others are also mentioned although

less frequently. Following the death of Enkidu, Gil-

gamesh embarked on a long period of wandering,

searching for everlasting life:

Siduri said to him why are your cheeks so starved

and why your face so drawn? Why is despair in

your heart and your face like the face of one who

has made a long journey? Yes, why is your face

burned from heat and cold, and why do you

come here wandering over the pastures in search

of the wind? (Sandars, 1972)

His feeling of helplessness and his aimless roaming

are at the forefront. Gilgamesh may indeed have been

suffering from a numbing of his general reactivity.

Finally, according to Plutarch, tormented by night-

mares and racked by insomnia, Marius drank heavily

in an attempt to fi nd sleep. It could be said that in this

case, alcohol abuse appeared as a consequence of his

trauma-induced hyperarousal: ‘And since above all

things he dreaded the sleepless nights, he gave himself

up to drinking-bouts and drunkenness at unseasonable

hours and in a manner unsuited to his years, trying thus

to induce sleep as a way of escaping his anxious

thoughts’ (Plutarch, 1973).

Dissociative symptoms

Lastly, dissociative symptoms are also found to be

a long-term consequence of traumatic events in

antiquity.

The Greek historian Herodotus (ca 484–425 bc)

describes a case of psychic traumatic blindness in an

Athenian warrior following the fear and terror he expe-

rienced during the battle of Marathon:

Epizelus, the son of Cuphagoras, an Athenian soldier,

was fi ghting bravely when he suddenly lost the sight in

both eyes, though nothing had touched him anywhere

neither sword, spear, nor missile. From that moment

he continued blind as long as he lived. I have heard that

in speaking about what happened to him he used to say

that he thought he was opposed by a man of great

stature in heavy armour, whose beard overshadowed

his shield; but the phantom passed him by, and killed

the man at his side. (Herodotus, 1996)

While Herodotus does not describe all of the

symptoms necessary for a diagnosis of PTSD under

DSM criteria, Epizelus has a lifetime sequelae (blindness)

as a consequence of exposure to combat at the Battle of

Marathon (Hudson, 1990).

A separate place must be given to the tragic end of a

hero in the Trojan war, ‘Ajax the Great’. Deprived of

the Arms of Achilles in favour of Ulysses, and over-

whelmed by rage, Ajax tried to slaughter the Greek

leaders he accused of deceit. However, in a bout of

‘madness’ sent by Athena, he slaughtered a fl ock of

sheep instead. Upon recovering his senses, he then

committed suicide (Sophocles, 1953). According to

Tritle (2000), Ajax could be described as suffering from

PTSD. Furthermore, references to the slaughtering of

animals and the ‘madness’ indicate a possible dissocia-

tive fl ashback.

Several anecdotes clearly present symptoms that are

greatly evocative of post-traumatic symptoms, some of

which are currently defi ned, as well as others that seem

to have been ‘overlooked’ by international classifi ca-

tions. Although devoid of any reference to medicine,

such disorders were already identifi ed and meticulously

described.

Discussion

We have reviewed ancient texts dating back to antiquity

in search of trauma-related psychological and somatic

reactions. Extracting psychiatric syndromes from

ancient anecdotes would not have been possible, yet

isolated and sometimes specifi c symptoms have been

pinpointed. Our search has yielded two types of symp-

toms: acute reactions on the one hand (panic, terror,

stupor and dissociation) and post-traumatic reactions

Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd. 27

P. J. Birmes Psychotraumatology in Antiquity

(re-experiences, numbness, hyperasousal, insomnia

and dissociative symptoms) on the other.

Acute reactions and ASD symptoms

The fi rst acute reactions highlighted by our search were

panic and terror, as in the destruction of Ur, after the

death of King Urnamma, during the Roman defeat at

lake Trasimene and other combat settings, and during

the Great Fire of Rome. An anthropological content

analysis of Homer’s ‘Iliad’ and ‘Odyssey’, considered to

be the staple text for the descriptions of ancient battles,

revealed the large number and variety of words used to

evoke fear (‘dread’, ‘terror’, ‘panic’, ‘alarm’, ‘anxiety’,

‘horror’, ‘fright’, ‘anguish’, ‘trembling’, ‘fear’, ‘scare’,

‘obsessive fear’, ‘apprehension’, ‘worry’, ‘shuddering’)

(Zaborowski, 2002), thus confi rming the importance of

such acute reactions in contexts of wars. With regard

to current classifi cations, these feelings of ‘panic’ or

‘terror’ fall under DSM criterion A2 (‘the person’s

response involved intense fear, helplessness, or horror’,

APA, 2000; see Table I). Reactions described by

Sennacherib (disorganized fl eeing and loss of sphincter

control on his enemies’ part) and Tacitus (Romans

fl eeing the Great Fire in confusion) may point to

peritraumatic distress. Peritraumatic distress describes

the emotional distress and physical symptoms of fear

and anxiety felt during a traumatic event: negative

emotions (fear, horror, etc.), perception of a life-

threatening element and bodily arousal (feelings of

personal life threat, loss of bowel and bladder control)

(Brunet et al., 2001). The DSM insists upon the impor-

tance of the immediate emotional impact (responses of

intense fear, helplessness or horror) as being an essen-

tial peritraumatic condition to the development of

PTSD. A growing number of investigators however

have argued that the current criterion A (2) is too nar-

rowly defi ned and should be expanded to include other

heightened negative emotions (e.g. anger, shame, grief)

and diminished emotional responses such as numbness

or shock (Weathers & Keane, 2007). Peritraumatic dis-

tress, including emotional distress and physical symp-

toms of anxiety (bodily arousal) experienced during a

traumatic event, signifi cantly related to PTSD measures

(Birmes, Daubisse, & Brunet, 2008; Jehel, Brunet,

Paterniti, & Guelfi , 2005; Simeon, Greenberg, Nelson,

Schmeidler, & Hollander, 2005).

Secondly, our review uncovered evidence of dissocia-

tion and stupor in the immediate aftermath of a trau-

matic event (Patroclus in combat or Syracuse’s

inhabitants during the Roman siege, and possibly Pliny

the Younger faced with the eruption of Vesuvius). Peri-

traumatic dissociation represents moments during

which the victim looses track of time or blanks out,

fi nding himself acting on ‘automatic pilot’, of not being

aware of things that happened during the event, and

confusion and disorientation were experienced during

exposure (Marmar, Weiss, & Metzler, 1998). These acute

dissociative experiences are also included in the current

DSM criterion B ‘dissociative symptoms’ for ASD (Table

I). There is a stongly signifi cant and relevant relationship

between peritraumatic dissociation and the development

of PTSD symptoms later on in life. Although this

outcome suggests that experiencing dissociation during

or shortly after a potentially traumatizing event increases

the probability of PTSD later on in life, this should not

be interpreted as proof of a causal relationship (Ben-

Ezra, Essar, & Saar, 2006; Birmes, Arrieu, Payen, Moron,

& Schmith, 1998; Lensvelt-Mulders et al., 2008; Panase-

tis & Bryant, 2003; Zoellner, Alvarez-Conrad, & Foa,

2002).

PTSD symptoms

The most frequent post-traumatic and long-term reac-

tions highlighted by our review are re- experiences: rec-

ollections of a friend’s death for Gilgamesh and Achilles,

and of war and mass violence for Marius and the inhab-

itants of Ur. These re-experiences are threefold: intru-

sive memories (Gilgamesh, Marius, Achilles), traumatic

nightmares (Marius, the inhabitants of Ur) and illu-

sions during a state of delirium (Marius). These symp-

toms clearly fi t the DSM criterion B for PTSD (APA,

2000; see Table II). The second set of post-traumatic

symptoms highlighted in our historical review involves

the modifi cation of general reactivity. Gilgamesh’s

aimless roaming suggests a numbness of his general

reactivity as described in the DSM criterion C for PTSD

(Table II). On the other hand, post-traumatic hyper-

arousal is also mentioned in texts dating back to antiq-

uity. Marius’ ‘anxious thoughts’ and ‘sleepless nights’

are indeed highly evocative of the criterion D for PTSD

(Table II). Lastly, it can be argued that Ajax’s dissocia-

tive fl ashback also fi ts the re-experience criterion of

the DSM-IV (criterion B). The main advantage of PTSD

symptoms is that all clinicians now acknowledge them.

When a patient consults following exposure to a trau-

matic event, few physicians omit to ask about

Psychotraumatology in Antiquity P. J. Birmes

28 Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd.

possible re-experiences and pathognomonic symptoms.

Although a minority of authors continue to question

their validity, the fact that Man started to write about

them as soon as he was able to describe his feelings or

observations following a traumatic experience should

contribute towards giving them strong substance. Yet,

on the one hand, some clinical forms appear more

complex than the standard triptych of re- experiences/

avoidance/hyperarousal, and on the other hand, for a by

no means insignifi cant number of victims, other catego-

ries of real post-traumatic symptoms may be expressed

and should also be recognized.

Other post-traumatic symptoms

Although these extracts of literature dating back to

antiquity reveal very characteristic ASD or PTSD symp-

toms, several reactions do not clearly fall under PTSD

DSM criteria.

Epizelus’ blindness of psychological origin suggests

hysterical or dissociative symptoms. Although dissocia-

tion and somatoform disorders do not belong to the

DSM criteria for PTSD, some authors have proposed a

specifi c clinical entity called complex PTSD (Herman,

1992; Shay, 2002) or disorders of extreme stress not oth-

erwise specifi ed (Pelcovitz et al., 1997; Roth, Newman,

Pelcovitz, Van der Kolk, & Mandel, 1997), and have

argued that many features of complex PTSD are mani-

festations of dissociation. Van der Hart, Nijenhuis, and

Steele (2005) thus described negative PTSD dissociative

symptoms (numbness, loss of perceptual or motor

functions, etc.) and positive PTSD dissociative symp-

toms (traumatic memories and nightmares that have

cognitive and somatosensory components, sensory dis-

tortions, etc.). Long-term dissociative symptoms and

their somatic components raise the question of their

inclusion in the diagnosis of PTSD. Van der Kolk et al.

(1996) showed that subjects who currently suffer from

Table II. Diagnostic and Statistical Manual, 4th edition, criteria for post-traumatic stress disorder (APA, 2000)

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious

injury, or a threat to the physical integrity of self or others.

(2) The person’s response involved intense fear, helplessness or horror. Note: In children, this may be expressed instead by disorganized or

agitated behaviour.

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

(1) recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. Note: In young children,

repetitive play may occur in which themes or aspects of the trauma are expressed;

(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content;

(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and

dissociative fl ashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-

specifi c re-enactment may occur;

(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event;

(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as

indicated by three (or more) of the following:

(1) efforts to avoid thoughts, feelings or conversations associated with the trauma;

(2) efforts to avoid activities, places or people that arouse recollections of the trauma;

(3) inability to recall an important aspect of the trauma;

(4) markedly diminished interest or participation in signifi cant activities;

(5) feeling of detachment or estrangement from others;

(6) restricted range of affect (e.g. unable to have loving feelings);

(7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children or a normal lifespan).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

(1) diffi culty falling or staying asleep;

(2) irritability or outbursts of anger;

(3) diffi culty concentrating;

(4) hypervigilance;

(5) exaggerated startle response.

E. Duration of the disturbance (symptoms in criteria B, C and D) is more than 1 month.

F. The disturbance causes clinically signifi cant distress or impairment in social, occupational or other important areas of functioning.

Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd. 29

P. J. Birmes Psychotraumatology in Antiquity

PTSD have signifi cantly increased rates of dissociation

and somatization symptoms compared with those who

no longer met criteria for PTSD. It must be said that

for some authors, such as Shay (2002), ‘complex PTSD

is a simple PTSD plus the destruction of the capacity

for social trust’, a fact that seems to have been con-

fi rmed by the return of veterans from the most recent

confl icts (Friedman, 2005).

Gilgamesh is described as showing ‘cheeks so starved’:

a sign of severe weight loss. It has been argued that

trauma late in life might lead to the onset of anorexia

nervosa in hypomanic- functioning subjects (Tobin,

Molteni, & Elin, 1995), or that eating disorders can be

the manifestations of an underlying PTSD (Torem &

Curdue, 1988). But the best explanation for weight loss

might also be a mood disorder. Apart from Gilgamesh’s

weight loss, references are also made in several anec-

dotes to feelings of ‘despair’ (Marius, Gilgamesh) or

grief (Achilles’, ‘tears poured down [his] cheeks’). In

these cases, several symptoms or modes of behaviour

can fi nd their origin in a mood disturbance such as

complicated bereavement or depression. Depression

may develop as a complication of PTSD and its

associated impairment. On the other hand, some

trauma victims develop PTSD, whereas others develop

major depression or substance use disorder, depending

on their pre-existing vulnerabilities (Breslau, 2002).

Marius suffered from alcohol abuse if not addiction.

Use of alcohol or drugs to relieve the distressing

symptoms of PTSD may increase the likelihood of

dependence. Previous research among Vietnam combat

veterans and civilian victims of traumatic events

generally found considerably stronger associations

between trauma exposure and alcohol use disorder

when PTSD was present than when it was absent

(Breslau, 2002).

Limits

PTSD symptoms thus seem to be present in antiquity.

However, we are unable to confi rm a ‘full PTSD diag-

nosis’ because authors were not likely to assess all DSM

criteria among their contemporaries. Our retrospective

diagnoses are based on historical evidence, and there-

fore inevitably biased. As we mentioned earlier, fi rstly,

several descriptions are not unequivocal and might

indicate other symptoms such as bereavement or a

depressive disorder for example. Secondly, a stylistic

bias might also have been introduced by the authors:

they may have exaggerated the symptoms to emphasize

the drama of their heroes’ lives. Even if causality

between trauma and ASD or PTSD symptoms seems

obvious in the presented anecdotes, our review has not

been able to establish any relationship between acute or

peritraumatic symptoms and later PTSD.

Little reference is made to Tritle’s (2000) ‘From

Melos to My Lai: War and survival’ in our review. In

his extensive work on war, Tritle does indeed argue that

Xenophon’s (soldier and a contemporary of Socrates,

ca 431–355 bc) portrayal of the Spartan Clearchus

(Xenophon, 2007) ‘provides us with the fi rst known

historical case of PTSD’. However, instead of referring

to DSM criteria, Tritle defi nes PTSD using criteria that

are not included in international classifi cations: ‘persis-

tent mobilization of the body and the mind for lethal

violence, with the potential for explosive danger’, ‘sui-

cidality’, etc. This could represent a clinical form of

complex PTSD, but the triptych of re-experiences/

avoidance/hyperaousal is not described.

Conclusion

Our historical survey shows that, even from the begin-

ning of antiquity, psychological responses to extreme

trauma have been the source of phenomenological

interest. Intrusive memories and arousal seem to have

been known always to follow exposure to traumatic

events (Weisaeth, 2002). These symptoms are notable

and attract attention because of what one experiences

when facing death. While confi rming the importance

of the specifi city of traumatic stress in chronological

clinical forms (peritraumatic, ASD and PTSD), we have

offered clinical descriptions that are previous to con-

temporary nosologies and could enhance our current

psychotraumatology perspectives. The clinical value of

the symptoms described lies in their great detail and the

pre cision of the historical anecdotes, and thus high-

lights their perfect overlap with modern psychotrauma-

tology. Thus, alongside the immediate reaction of

intense fear and horror, and the standard triptych of

re-experiences, avoidance and hyperarousal, the signs

of grief, despair, passivity, hysterical blindness and

other somatic and affective reactions should remind us

that the human responses to trauma remain varied and

complex, and necessitate great perspicacity on the clini-

cian’s part.

Psychotraumatology in Antiquity P. J. Birmes

30 Stress and Health 26: 21–31 (2010) © 2009 John Wiley & Sons, Ltd.

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