Fireside Friday: April 24, 2020

Hey folks! Fireside this week, but next week, to celebrate the one-year anniversary of the blog (the first post went up May 3rd) we’re diving into a look at Helm’s Deep in both the book and the film, to match the treatment I gave the Siege of Gondor last summer.. Operational planning, pillaging as a strategy, the small-army siege playbook, cavalry-on-cavalry engagements and even more logistics. But since we are doing that next week, I want to take this week to take a bit of a brief year in review, then I am going to muse a bit on the question of post-traumatic stress disorder in the ancient world, which had come up in the comments in response to last week’s trip through Bertran de Born.

So, Year-in-Review. As I write this, I’ve gotten just short of 650,000 page views since starting the blog (I am quite sure, by the time you read this, we will have passed that number), which is a lot more interest than I expected when I started! There’s a lot of month-to-month traffic variation, but over the last six months, the site has averaged 25,000 unique visitors each month according to the wordpress back-end. December was our busiest month, followed by March. The most popular thing, by far is the Siege of Gondor series, with more than 165,000 views over six posts. The least popular thing (excluding very recent stuff) has been poor Cicero and my brief essay on class and status in the early Church. So go read those!

But I am really blown away by how this project gone so far. There is pretty much always an active discussion going on in the comments (which I read, even if I do not always have time to respond) and it has also been a delight to see my ideas turned over (and perhaps beat up on a bit) on twitter, reddit and the like. And I’m of course grateful to my growing Patreon campaign – up to 86 patrons as I write this – whose patronage goes towards supporting my academic research (currently planning a number of book acquisitions, but also for funding academic conferences, should they still exist when the current crisis subsides). Having that crowd-funded research micro-grant really does give me a lot more confidence in sticking with my research plans even as the academic job world is out sick, quite possibly for several years.

The nerd, pictured in his natural habitat. Although I must confess, the absolutely awesome Lewis Chessmen mug there belongs to my better half.

For this Fireside’s musing, I want to answer a question I actually get quite frequently: was there post-traumatic stress disorder (PTSD) in the ancient (or medieval) world? And I’m going to tilt at that particular question here in a fireside in part because the absence of evidence doesn’t quite make for a riveting collections post and arguments from silence must always be cautious. And I should note that what follows is my impression from a fairly wide reading of the ancient sources; it is not a comprehensive review of them. But here we go:

I cannot speak for all pre-modern, ancient or medieval armies. But for the periods where I have read a wide chunk of the primary source material, I’d say there is vanishingly little evidence that people in the ancient Mediterranean or medieval Europe experienced PTSD from combat experience in the way that modern soldiers do.

(Editor’s note (4/27): Based on quite a bit of the discussion, I think people are being very slippery with their definition of PTSD. PTSD is more than feeling bad about being in a war, or grief at the loss of a buddy. Here are the diagnostic guidelines. Note how a diagnosis requires one intrusion symptom (involuntary and instrusive memories, dreams, flashbacks, marked physiological reactions) and persistent avoidance of stimuli associated with the trauma and two negative alterations in cognition and mood associated with the trauma and two marked alterations in arousal and reactivity associated with the trauma. A lot of the examples being cited in the comments do not come anywhere near meeting that criteria. As I read and understand that, an individual who is voluntarily recounting the trauma – much less re-exposing themselves to it by going out to fight again – without significant reactions (read the guidelines – these are really very significant reactions) doesn’t fit the criteria. They may well have another form of mental wound, mind you; grief, fear, loss, guilt and so on are all very real things. But they do not, by our current medical definition, have this wound. Specificity here is necessary because we aren’t asking a question about grief or loss or guilt – feelings which all humans feel at one point or another – but about a very specific mental wound that combat (or other trauma) may inflict.)

That is often not the impression that you would get from a quick google search (though it does seem to be the general consensus of the range of ancient military historians I know) and that goes back to arguments ex silentio. A quick google search will turn up any number of articles written by folks who are generally not professional historians declaring that PTSD was an observed phenomenon in the deep past, citing the same small handful of debatable examples. But one thing you learn very rapidly as a historian is that if you go into a large evidence-base looking for something, you will find it.

That’s not a species of research positivity – it’s a warning about confirmation bias, especially if you do not establish a standard of proof before your investigation. It is all too easy to define down your definition of ‘proof’ until the general noise of the source-base looks like proof. In this case, we have to ask – before we go looking – what would evidence of PTSD in ancient societies (I’m going to start there because it is where I am best informed) look like?

Well, ancient societies engaged in a lot of warfare. Among the citizenry – the sort of fellows who write to us and are written about in our sources – combat experience was almost ubiquitous. That only really changes as we get into the Roman Empire, as violence levels both decline generally and are pushed to the frontier via a professional army. The percentage of veterans in the citizen population (again, citizen here is an important caveat, but then those fellows basically are our primary source base) probably equaled that of the WWI generation in Britain or France, except all the time (there’s a point in the Second Punic War where the Roman censors went through the entire rolls, checking to see how many had managed to avoid military service and found only a few thousand in a citizen body of c. 150,000 adult males). So what ought we expect from our sources? We should expect to see signs of PTSD everywhere. It should be absolutely pervasive in a source-base produced almost entirely by, for and about combat veterans, in societies where military mortality exceeded modern rates by a robust margin.

And it simply isn’t there. There is one very frequently cited account in Herodotus (Hdt. 6.117) of a man named Epizelos experiencing what is generally understood as ‘conversion disorder’ (which used to be badly labeled ‘hysterical blindness’) in combat. Without being wounded he went blind at a sudden terror in battle and never recovered his sight. Herodotus terms it a θῶμα – a ‘wonder’ or ‘marvel,’ a word that explicitly implies the strange uncommonness of the tale. Herodotus is concerned enough about how exceptional this sounds that he is quick not to vouch for its veracity – he brackets the story (beginning and end) noting that it was what he was told (by someone else) that Epizelos used to say happened to him. In short, this was uncommon enough that Herodotus distances himself from it, so as not to be thought as a teller of tall-tales (though Herodotus is, in fact, a teller of tall tales).

This one example – cited endlessly and breathlessly in internet articles – is remarkable not because it is typical, but because it is apparently very unusual (also, it is my understanding – with the necessary caveat that I am not an expert – that while conversion disorder is a consequence of emotional trauma, it is not clear that it is associated with PTSD more generally). Meanwhile, in the war literature of the Romans, in their poetry (including that by folks like Horace, who fought in quite terrible battles), in the military literature of the Greeks, in the reflections of Xenophon (both on his campaigns and his commands), in the body of Greek lyric poetry…all of it – nothing. It is simply not there – not as a concern that such a condition might befall someone, nor a report that it had done so. Nothing. The lacuna baffled me for years.

My impression is that the medieval literature looks much the same: a few scattered passages that, if you squint hard enough, might be PTSD set against a vast backdrop of nothing in a society where literature was dominated by the war-fighting class. More examples than in the classical corpus (but then the medieval corpus is much larger; oddly, the examples I’ve seen all seem to concern crusading particularly), but nothing close to what we would expect given a literary tradition absolutely dominated by military aristocrats and their (often clerical) families. I call this my impression, because the medieval corpus is both much larger and I have read much less of it; but if there is a hidden reservoir of accounts showing clear symptoms of PTSD, I have not found it yet. I was always struck that – despite the fact that monastic life was often a destination for medieval military aristocrats troubled by their life of violence – none of the monastic rules I have read (admittedly, not all of them), which often have guidelines for abbots to deal with difficult monks, have had anything about how to deal with the symptoms of PTSD.

Now that’s not to say there isn’t grief at loss, mind you! The lamentations of defeat, the sorrow of losing a loved one (even in victory), the misery of war – that you find in the ancient texts in abundance. It occupies literary topoi, it is depicted in artwork, it gets entire tragedies to stretch out in, it is addressed by great big political speeches, it sits at the cornerstone of the Iliad‘s narrative (one reason, no doubt, that the Iliad remains a useful text for soldiers working through their experiences). But the persistent symptoms of PTSD, no. I haven’t been able to find one ‘flashback’ or combat-memory related dissociative episode in ancient literature. You might argue that they simply weren’t recorded, but that strikes me as unlikely in societies where other forms of war-damage were so fiercely valorized and which would have often seen – as with Epizalos – such symptoms as divine omens. There should be dozens and dozens of them. These are societies with active medical literature, after all!

I think the evidence strongly suggests that ancient combatants did not experience PTSD as we do now. The problem is that the evidence of silence leads us with few tools with which to answer why. One answer might be that it existed and they do not tell us – because it was considered shameful or cowardly, perhaps. Except that they do tell us about other cowardly or shameful things. And the loss and damage of war – death, captivity, refugees, wounds, the lot of it – are prominent motifs in Greek, Roman and European Medieval literature. War is not uniformly white-washed in these texts – not every medieval writer is Bertran. We can’t rule out some lacuna in the tradition, but given just how many wails and moans of grief and loss there are in the corpus it seems profoundly unlikely. I think we have to assume that it isn’t in the sources because they did not experience it or at least did not recognize the experience of it.

The more interesting potential question is why. Considering all of the competing theories for that, I think, would take its own collections post. But for my part, I tend to think the difference lies in part on the moral weight placed on warfare – it was viewed not generally a necessary evil in these societies, but a positive good – which may have meant there was less sense that what had taken place was trauma at all. If that is the case, the emergence of PTSD would speak to improvement in our society: we have become more averse to violence and do it less, and as a consequence, feel it more. If you will permit me, we have more wounded warriors because we have fewer dead ones, on account of having fewer wars in general.

But I also suspect that the raw ubiquity of the experience mattered too. For most men who went to war in the ancient world, there wasn’t likely to be the sense that they couldn’t discuss their experiences, or that their family or peers wouldn’t understand. Their family and peers were there experiencing it right alongside them, and nearly everyone in their social circle had shared the same experiences. And all of those people were telling them that what they experienced was good, right and appropriate, that it was a mark of growth and manhood – again, not trauma, but positive development. That may have aided in the transition back into civilian life.

Moreover, these societies tended to have rituals surrounding the transition out of war. There were ritual purifications for a Greek or Roman army returning from battle. Offerings to be made to the gods for survival or triumph. Priests who could tell you “if you are bothered, do this and it will be ok.” In the medieval world too, there were religious experts who could tell you the rituals necessary to come back to a right relationship with both God and your society. Of course many veterans turn to religion for comfort, but most modern religious traditions respond with the same ‘yes, but…’ and ‘necessary evil’ approach. For the Roman miles or the medieval knight, there was no such ambiguity: do these rituals and all is well. Placebos are powerful and I suspect that sort of thing also aided the transition from war to peace, providing a sense of closure that it is hard for our societies to provide (I suppose the Roman would merely suggest that we were foolish to stop doing rituals which had obviously worked so well).

Alright, that’s a long, grim discussion. Now, recommendations, starting with this video from Lloyd (Lindybeige) trying to work out spear combat with some field experiments. I think this kind of experimental archaeology is important, but I want to temper the conclusions it reaches here. Now I don’t think it is fatal to these experiments that not everyone here is super experienced because no less authority than Xenophon tells us training is not a must for spear-and-shield in formation (Xen. Cyrop. 2.1-9-16, discussed more by me here).

No, my main issue is the size and spacing of the formations. And I know this is hard, because getting a whole lot of people together to try something out is extremely difficult. But the fact is spear-and-shield close-combat was normally done in fairly large units: hundreds and thousands, not a dozen. And now, both the question of the spacing between lines and the density of the press and the force of the press are all subjects of lots of debate. But where we are given spacing (in the Hellenistic period, for Roman and Macedonian armies admittedly using swords and pikes) it is fairly tight (the Romans have a bit more space) both side to side and front to back. There is a limit to how far you can go backwards or to the sides (along with a very clearly fearsome expectation in most of these societies that a man stand his place). I particularly wonder about this given Lloyd’s dismissal of fighting ‘shield to shield.’ The issue is, we have sources – Tyrtaeus most notably – who tell us that happened. If we cannot understand why, I might suggest that it is we, and not the Greeks, who are missing something.

And so I wonder in these exercises what changes if we add 5 or 7 more ranks. What does it mean when someone can’t retreat? When the space behind you is occupied (one suggestion I have seen is that overarm grip is valuable because, while tiring, it puts the butt of the spear in the air rather than in your buddy). And what does it mean for shield-presses and the like when you have not only the physical weight, but the morale-weight of seven fellows behind you. People in crowds, in dense masses, move and behave very differently from individuals. What I’d love to see is to get the kind of turnout you see for something like American Civil War reenactments: to get a few hundred people, in protective kit, with shields and boffer spears and see how this all works on the scale it really happened in.

All of that sounds very negative and I don’t want to be down on Lloyd – he’s doing good work and creating an evidence base for future, more detailed investigation. The video is well worth a watch.

Another recommendation is this blog post detailing the latest phase of work combing through archaeological materials in the archives of the Lugdunum museum looking for graffiti on pot sherds. It is always worth remembering, when thinking about the ancient evidence, that we often gain as much these days digging in museums as we do in the ground. There is a tremendous amount of unpublished or underpublished material lurking in museum collections all over the Mediterranean world.

And finally, a book recommendation. This week I’m going to recommend Nevile Morley’s Metrpolis and Hinterland: The City of Rome and the Italian economy: 200 B.C. – A.D. 200 (1996). New copies can be expensive, but you can get used copies fairly easily. Morley is driving a very particular argument in this book, suggesting a way that the cities of antiquity might have driven growth in their hinterlands, arguing that cities such as Rome were more than just parasites. That argument fits in to a long-standing debate as part of the nature of the ancient economy. But I think beyond that, Morley’s book – which is quite readable – is a useful introduction to thinking in complex ways about the ancient economy. It forces you to think about settlement patterns, land-use, trade (both overland and by sea) and how all of those factors shaped the human terrain of Rome and Italy (and everywhere else too). It’s a great book if you are doing pre-modern world-building and want to think a bit more deeply about the world of peasants and commoners (for this, read it together with our previous recommendation, Erdkamp’s The Grain Market to get a better sense of how Morley’s big economic picture translates to day-to-day activities in the countryside).

73 thoughts on “Fireside Friday: April 24, 2020

  1. When did experience with war stop being a near-universal thing? At least among the literate classes?

    1. Certainly in the middle ages, because the literate class was the clergy. 🙂

      1. Except for all the knights who became monks, the literate nobility and the literate merchant class, all of whom had experience of war and wrote about it.

  2. Hey, Brett. I’ve read elsewhere that the behavior of Norse berserkers is a possible example of Medieval PTSD- they’re described as lacking affect, but also prone to sudden unprovoked rage, along with delusions and self-harm. I’m curious how you reconcile this with your argument above. Thanks!

  3. In addition to the factors you’ve named, I think the nature of the combat itself is probably relevant. My reading on PTSD (combat-related and otherwise) has given me the distinct impression that you are more likely to suffer it in situations where 1) the trauma hits you without warning and 2) you feel helpless in the face of it. This is why it was such a huge issue in Vietnam: the nature of the fighting there meant there were very few nice, organized battles, and a whole lot of ambushes out of nowhere. The same is true for the Middle East today, with IEDs and the like. Not to say that ambushes never happened in the ancient past — but when battles are more likely to consist of organized army units clashing against one another with some amount of maneuvering and preparation beforehand, you’re not being taken by surprise and you don’t feel as helpless. Ergo, less PTSD. Weaponry may also play a role: an archer can shoot fairly far, but (movies notwithstanding) not nearly as far as a well-developed firearm can, much less modern artillery. Which means you’re not being hit out of the blue by a weapon you never even saw coming.

    Obligatory caveat: I am not a psychology expert, just citing what I’ve been told by people who are (when I was researching the subject for my own work). And I do like the factors you name here, particularly the ones about the social response, both pre-conditioning and re-integration afterward. We tend to assume that the experience of the modern West is somehow a universal statement on human experience in general, and forget how much of our psychological response to things is very much culturally shaped.

    1. I came here to post basically this. Modern warfare may simply be more stressful than earlier warfare due to violence being more unexpected and soldiers feeling more helpless in the face of it.

      I think there’s also a third factor: time. The simple amount of time modern soldiers can feel in danger. If you’re fighting only pitched battles they can be hideously dangerous but the total amount of time any individual soldier feels in danger is going to be relatively short. If you are CONSTANLY on guard against snipers, IEDs, artillery, etc. for very long periods of time then that’s a very different experience of war.

      1. Yes — which is why PTSD doesn’t just show up in combat veterans; it’s also hugely prevalent among victims of domestic abuse, who have to live 24/7 with the fear of what might happen.

      2. I had the same thought about time, largely from having read Why Zebras Don’t Get Ulcers, by Robert Sapolsky. There’s just such a huge difference between a time-bound threat and a threat that doesn’t go away.

  4. Thank you for the great post as always! I know it’s only a fireside post, but there are a few things not discussed that I’d love to hear your thoughts on.

    Is it possible that PTSD might be a result of a change in the fighting rather than people’s approaches to it? Does the rise of PTSD coincide with the introduction of a particular technology (say artillery, or the machine gun)?

    In a similar vein, could the overall experience of a campaign be an influence as well? Has the length of a campaign changed significantly since earlier times, or the frequency or duration of combat?

    That’s probably enough material for a whole new post to be honest, if you have any answers off the top of your head that’d be great 🙂

  5. Thanks: this is an extremely interesting post. One thought I had, though, was: might it be possible for the lack of evidence to indicate that what we would see as PTSD was so widespread that it would be seen as being a normal part of life and hence not something to be talked about? If everyone has gone through a series of traumatic wartime experiences, and reacted accordingly, it’s not an abnormal thing to be observed and discussed, but a fact of life to just try to cope with.

    I suppose the counterargument to this, though, would be that PTSD can vary wildly in its effects. So we would see more cases discussed of traumatised people whose behaviour was abnormal.

    1. The argument Bret makes against this is that there are other common negative effects of war which are discussed a lot in literature, like losing a friend to it.

  6. Interesting question. My first inclination was to think the 18th century, when war became a much more professional affair. But then one thinks of the 18th century and Revolutionary and Napoleonic Wars, when the combatants mobilised very high proportions of their populations, and war involved everyone from Cadiz to Moscow.

    The answer, I think, is that war ceased to be routine in the 19th century.

    On the post – I think it pertinent to note first that most pre-modern societies are routinely violent – parents hit children, teachers hit pupils, servants are hit. Village quarrels are often violent. Animals are slaughtered in the streets. Violence is normal, expected and unshocking. A second point is that modern warfare involves a lot of concussion. Much PTSD may be the result of brain injury

    1. It has been pointed out that the women’s suffrage movement started in late Victorian Britain: a highly peaceful society, where men were no longer likely to die in combat, but women were still likely to die in childbirth. Nothing like “we’re not both dying any more” to really make inequality obvious.

      1. And indeed, women would regularly bring up death in childbirth when arguing against the claim that they were not full citizens because they did not fight.

      2. And indeed, women would regularly bring up death in childbirth when arguing against the claim that they were not full citizens because they did not fight.

  7. They did get 50 or 100 people with partisans and rotelle and half harness together at WMAW last year. Paul Bardunias could probably send you the videos of that part of the event.

  8. About PTSD, I wonder also whether the (relative) lack of control over one’s circumstances is a factor. I would expect that a form of warfare in which casualties are primarily at range, with the primary form of defence on both sides being concealment and cover, would be different from a form of warfare in which casualties are primarily hand-to-hand in close order units, and where available defences are fight or flight.

    Tolkien in trying to make pre modern warfare like the warfare he was familiar with, gives the Nazgul a morale-sapping aura, the description of which is that the army knows they’re there but they’re too far away to be easily seen.

    1. The Battle of Sudden Flame in the Silmarillion is basically a WW1 offensive. Morgoth launches chemical attack to disorganise or drive away the defenders. Then sends in tanks and shock troops with flamethowers (merged in dragons and balrogs). Then massed infantry. Slaughter and gains in the first days, then the defenders gather their reinforcements, and a months-long grind ensues. Only artillery is missing from the picture.

  9. I wonder if the reported absence of PTSD is because modern battles are longer (how long did the Battle of the Somme last?), larger, and combatants are much more isolated from each other (has anybody compared PTSD rates for, say, tank crews vs infantry?).

    The ancient battles that may have most closely related modern battles in duration might be sieges, vs battles in the field. Certainly, being in the besieged city would be highly stressful, and would likely include people who were not in the warrior class. Are there any writings from the besieged that may indicate PTSD?

    1. That’s exactly what I was thinking.

      In Citizen Soldiers, Stephen Ambrose compares the combat experience between the American Civil War and WWII. One thing he notes is that in WWII soldiers were more isolated from each other because they were in constant contact with the enemy 24/7. On the other hand, in the ACW, even after an intense day of fighting, units would fall back to their camps and recover somewhat before the next day of combat. I don’t believe anything resembling PTSD is really referenced (warning: not something I can say with confidence) with regard to ACW vets, so I strongly agree that the ‘constant combat’ kind of warfare is probably a major reason for the emergence of PTSD.

      As for sieges, i’m not sure about siege warfare in the ancient world, but in the medieval world, sieges rarely lasted for a very long time. The attackers would send an ultimatum demanding surrender within a given time frame. Within the stated time, either the besiegers would be forced to retreat by the defenders allies, or the defenders would realize the siege could not be broken and surrender. As a result, I don’t think PTSD from sieges in the Medieval era would be very common.

      1. Soldier’s heart.

        It was not only noticed, it was diagnosed.

        Let us note that it generally sprung from the later campaigns, as in Grant’s relentless pursuit of Lee’s forces, where the war had fewer breaks.

  10. What percentage of ancient men who saw military service saw combat? What’s the tooth-to-tail ratio of the Roman army? Are we talking about most men having experience hauling baggage and digging ditches but relatively few, still, on the front lines?

    1. Mostly tooth. The non-combatant arm of a Roman army is small – estimates vary (our sources don’t much care about non-coms), but much *much* smaller than modern forces. And in many ancient armies, the ‘attendants’ who we might assume are non-coms (like Spartan helots or the Roman accensi) may have actively defended camps or had other para-combat duties. More tail in the Middle Ages, but generally ‘tooth’ strongly outnumbers tail in the pre-modern.

      1. Also, presumably the tail consists of lower-class people (like the helots) who the literate elites never interact with except in a master-slave relationship…

      2. Thanks. This is meandering a bit off topic, but was that standard? Spartans, for example, self-promoted as a warrior elite – did they actually have a low tooth-to-tail, or were they just misrepresenting their non-elite arm as a non-combatant arm? Or instead of the Spartans, actually competent armies: what about Parthians, with their preponderance of cavalry, or Phoenicians, and the logistics involved in providing for elephants?

      3. OGH* did a long series of post about the Spartans, including all the lesser troops fighting with them. Tl;dr: Spartans weren’t all that. Or even very much of that.

        He did at least one post about elephants too, I think.

        * Our Gracious Host

  11. That’s a really interesting piece about PTSD. I have read somewhere that one hypothesis on why soldiers today have a much higher rate of PTSD that soldiers from WW2 did that they go from combat to civilian life much more often and abruptly than in WW2. Which sort of fits with what you’re saying here; sharper distinctions between “wartime” and “peacetime” lead to more (or any?) cases of PTSD.

    An oft-repeated refrain from veterans is that regular people couldn’t understand because we weren’t there, or that they have trouble readjusting. It makes sense that regular people could understand and help adjust if everyone had been there. It makes me wonder if WW2 veterans had it easier than Iraq veterans because so many more people went overseas during WW2 and thus knew what was what.

    And wow, that’s a lot of nerd cred in that picture. Nice to see that you have my favorite book in your hands!

    1. Speaking for myself, when I got back there was a surrealness to everything. I did have a transition period of a couple of weeks but I didn’t do a lot of adjustments during it, the military was in a hurry to get us processed out. To be fair, this was early 2005 and the military had stop lost a number of us so there was a lot of pressure to get us out in the world.

      Afterward, there was a period when civilian life just didn’t feel “Real” for a lack of a better term and I think that might have contributed to the emotions I was feeling. It didn’t help that I would be standing in the grocery line and suddenly realize that hey right about now people I knew would be doing their morning patrol and I wasn’t there. Which made me feel incredibly dissociated from… Well, everything.

      I got through it eventually with the help of family and friends but that first year was amazingly rough at times.

      1. I’m glad you got through it.

        I don’t want to – at all – minimize in this the difficult of coming back from deployments. I think it is important for people who don’t have contact with folks who serve much (I myself have not served, but – being a military historian – many of my friends and colleagues have, and they have often been very candid about the experience) to realize that coming back involves not one thing but many things, of which PTSD may only be one. I’ve read and talked to service members who experienced it as a sense of dislocation, or of a loss of comradeship, or as survivors guilt, while not having the heavier symptoms of PTSD. But their struggles were still very real, as of course, were yours.

        I’m glad you got through it. Thank you for your service.

  12. just ordered the morley book — thanks for the recommendation! working on hellenistic-tech level world building and trying to make it near-historical (esp after your lambaste of ASOIF’s urban/rural disparity and lack of sustainability)

  13. Is it possible, that with death ever present in everyone’s lives, not just from violence, but also disease and starvation, that everyone had PTSD all the time? That the reason people didn’t notice PTSD was like the proverbial fish that doesn’t know what water is?

    Yeah, I think that’s probably a bit of a stretch. What was the earliest period where we read literary accounts of what can now be identified as PTSD? the 30 Years War/ Early Modern Period? Ottoman/Safavid wars? Napoleonic Wars? Crimean War and American Civil War? Russo Japanese War. The earlier it is, the less plausible my hypothesis becomes.

    1. The problem there is that medicine also became more organized. For instance, the American Civil War produced it, and it was diagnosed as “soldier’s heart.” But an earlier doctor would probably not have been so precise. (And could easily have assumed, as was originally assumed for soldier’s heart, that the soldiers had actually damaged their hearts through carrying all that heavy equipment.)

    2. Interesting musing there. I think if it was that ubiquitous, it would show up in the accounts of veterans and non-veterans alike, or show in fictional characterizations like Greek tragedies, medieval plays, various epic poems, and even just the diaries of the literate few. The actual diagnosable criteria OGH mentioned in the lead-in don’t seem to show up in parallel in the writings of Aristophanes, Arrian, Homer, Ovid, etc. that I can remember off the dome. (off the dome- I took classics quite a while ago)

      Wouldn’t more characters, fictional and historical, be stressed over related stimuli if they had what we consider to be PTSD? There are people who have experienced trauma and show negative effects for it (Herakles takes great pains to try to absolve himself of a crime he physically but not consciously committed, but he’s not always waking up in a cold sweat over it), but no notable examples of people with altered moods AND avoidance of stimuli AND flashbacks AND/OR other symptoms.

      I agree that life was far rougher, and people were very much more in touch with the precarious nature of health and mortality. Trauma was almost assuredly common, but color me convinced with what our host presents in the the actual analogous diagnoses showing up extremely rarely.

  14. >And now, both the question of the spacing between lines and the density of the press and the force of the press are all subjects of lots of debate. But where we are given spacing (in the Hellenistic period, for Roman and Macedonian armies admittedly using swords and pikes) it is fairly tight (the Romans have a bit more space) both side to side and front to back.

    This is a debate that fascinates me, especially as often the spacing recommended in the primary sources is much more than is used by re-enactors, and there seems to be some degree of general applicability across the pre-modern period. So, if you look at Fourquevaux’s “Instructions for the warres. Amply, learnedly, and politiquely, discoursing the method of militarie discipline”, originally published in 1548 (alhough I’m using the 1589 translation), he recommends a spacing of one “pace” for the width each man occupies when fighting and a space of one pace between each rank when fighting. However, he also clear envisions each man taking up a pace in depth as well as a pace between the ranks:

    >The space which euerie Souldier must occupie marching in single order must bee three paces, in bataile 2, and when he fighteth 1. The distance from one ranke vnto another being in single order must be 4. paces, and being placed in battaile 2. and in fight one. So that the said 21. men being in battaile will occupie 42. paces in fronte, and the 20. rankes will occupie 60. in length

    I’ve checked the original (, and the numbers are correct. That is to say, with two paces between each rank, the formation is 60 paces deep instead of 40, something which implies that each man occupied a space of one pace as well. I’m assuming here that the “pace” used by Fourquevaux was meant to be roughly equal to a yard, rather than the 16th century “geometric pace”, which was equal to five feet, since that broad a spacing is virtually unheard of AFAIK.

    The spacing of files is, unsurprisingly, close to that of the Macedonian phalanx, but the gap between the ranks is only similar to Polybius’s 4 cubit figure for phalangite and weapon. Possibly something has been lost in translation from the 2nd century BC to the authors of the 1st and 2nd century AD or there was a minor difference in how Hellenistic and Early Modern pike warfare worked.

    In any case, we know that Fourquevaux’s spacing between the ranks must reflect reality, rather than blindly following Arrian or Aelian, since Blaise de Monluc’s account of the Battle of Ceresole matches up with the idea of there being space between ranks quite well:

    >The Germans came up to us at a very round rate, insomuch that their Battail being very great, they could not possibly follow; so that we saw great windows in their body, and several Ensigns a good way behind, and all on a suddain rush’d in among them, a good many of us at least, for as well on their side, as ours, all the first Ranks, either with push of Pikes or the Shock at the encounter, were overturn’d; neither is it possible amongst Foot to see a greater fury; the second Rank and the third were the cause of our victory; for the last so pushed them on, that they fell in upon the heels of one another, and as ours press’d in, the Enemy was still driven back: I was never in my life so active and light as that day, and it stood me upon so to be; for above three times I was beaten down to my knees.

    For Monluc to be able to get back to his feet three times during the battle and for his being “active and light” to be a positive addition to the battle, there must have been sufficient space between the ranks that it wasn’t a total crush, and there must also have been space to move backwards as well.

    Leaving pike formations aside, Vegetius’ 3 feet spacing between files also suggests a larger space, although this time between files rather than ranks, than is generally allowed. The dominant idea of a shieldwall, where each shield is locked with the next, is impossible with this spacing. Vegetius could, of course, be cribbing from Hellenistic manuals, but the general lack of depictions of overlapping shield walls (the first person to mention the Bayeux Tapestry gets to explain how it’s possible to fight with only 30-45cm of space per man) and implied rarity of them in written sources (they only show up in very limited occasions in Scandinavian sagas and poetry vs the commonality of more generic formations, for instance) suggest to me that overlapping shields was less common than a 3 foot spacing for each file. Which does, in the end, change the perception of how battles were fought significantly.

  15. Have been archive binging on this blog recently and had a comment about the Fremen series that I thought I’d post here.

    I think there’s a nugget of truth to the Fremen mirage: oppressed underclasses tend to make bad soldiers and you don’t get much of an oppressed underclass in Fremen style societies, often simply because they HAVE to be relatively egalitarian since there aren’t enough resources to support social stratification.

    So for a society like Sparta the available manpower per capita is fairly low since a lot of the population is helots who’d love to eat the ruling class raw and thus are not only generally not terribly motivated soldiers (although of course the were used as soldiers but that was more out of desperation than anything) but are a permanent fifth column. Similarly slavery hurt the South a lot militarily since that was a big chunk of manpower they couldn’t draw on and having slaves made unconventional warfare a lot harder since you had to hold territory or the slaves would run away.

    Very high levels of inequality are bad for military performance but elites often don’t care since more inequality is good for them and this does things like make the Spartan elites resist reform even as lack of reform was killing their available manpower (similar stuff in Rome with the Gracchi).

    A lot of Fremen societies are more egalitarian out of simple poverty and that helps with military performance.

    This lets a lot of Fremen-type socieitiea field a lot more motivated warriors per capita than many settled societies.

    Of course settled societies had a lot of OTHER advantages (such as being so much bigger that per capita measures didn’t matter so much, I’m reminded of the Rif War in which the Spanish/French army was of comparable size to the entire population of the Rif).

    But a lot of settled societies that punched above their weight military were relatively egalitarian. In Medieval terms, yeoman man better soldiers than serfs so having lots of yeoman would make a society more powerful militarily (all else being equal).

  16. It’d be interesting to look at the Byzantine sources, since they (following St. Basil of Caesarea) forced returning soldiers to do three years of penance before returning to Communion—just like bandits who had killed their victims. If social endorsement of violence was why the (Latin) medievals and antiquity experienced no PTSD, then the Byzantines probably would not have been spared it. Especially not when their conflicts were far more violent than Latin Christian ones. (If you believe war is inherently evil, you tend not to think it can be conducted in an ethical manner. See also wars in the Sinosphere—Confucianism also believes war is inherently evil—which routinely made even Late Medieval and Early Modern wars, in the West, let alone Early and High Medieval ones, look like tickle-fights.)

  17. What is your take on Lindybeige’s video re battle fatigue? He too mentions Epizelos, but mentions this was rare. He has three explanations: the first is the same as yours, i.e. a transition from a moral framework that views violence as good to one that views it as bad (though he doesn’t go into the postwar cleansing rituals); the other two are that a) ancient war involved standing in close formation with your friends and family rather than isolated from most of your army, and b) modern war is incredibly loud because of artillery. Do you think the latter two explanations are reasonable?

  18. Hi Brett,
    Thanks for the perspective on PTSD. May I also point out that modern warfare is far more concussive than ancient times. Certainly the din of battle has been around for thousands and thousands of years, but the sheer, deafening, concussive force of gunpowder arms is impossible to underestimate as a psychological effect. I speak from personal experience, having been on both the giving and receiving ends of large scale explosives. It seem, in my amateur opinion, to generally follow that the improvement pattern of gunpowder arms generally predicts the emergence of PTSD and its forerunners in Western Society.

  19. While Americans fight in wars, there was no war on American soil since the Civil War. For someone in Europe, reading news about covid-19 and learning that most New Yorkers have no washing mashine and don’t prepare meals at home is mind-boggling. This kind of society is possible only where people forget what war is like. I think that contributes to occurence of PTSD. Peace and high living standards at home, then suddenly dirt, blood and sweat, and those people using various device to make holes in you. It must be a shock. In Europe, the further to east you go, the more distrustful people are, and each country has its wars, war movies and local conflicts it teaches about.

      1. I never said it would. Rather, it’s the kind of lifestyle which is only possible in a country that doesn’t know wars. Same with eating out repeatedly. As soon as there’s something dangerous on streets your life falls apart.

        Europeans remember wars, but they were no better than US at remembering pandemics. Only Asia and Australia knew how to prepare, and I mean mostly Taiwan, South Korea and Vietnam and not China. Africa is powerless to do anything.

    1. Does New York provide a large enough sample?

      Bear in mind that if you divided the US into the New York City dwellers and the rest of the country, the city by itself would top the list of most infected countries (owing, in part, to outright fraud by the city) and the rest would not make the list of the top ten.

      1. Outright fraud?

        Is this reference to mayor and governor blowing off the disease in the early weeks and telling people to go about their lives as normal? Or something we’re not seeing in the news?

      2. Thanks for perpetuating a shutdown argument on a military history blog. I really needed more of that in my inbox.

    2. Amateur opinion here: People can also suffer PTSD from having very uncertain, violent upbringings or home situations and those things coincide heavily with poverty and poor quality of life. The contrast thing makes a certain kind of sense, but I think there’s a lot more to it than just the contrast between a white picket fence and a foxhole. Barons, dukes, counts, princes, etc. all lived in comparatively nice residences but were called out into the muck to fight for their lord, and Dutch burghers with nice row houses still donned their helmets and grabbed their pikes in the 17th century, and without much evidence of PTSD.

  20. First, I just want to thank you for taking the time and effort to put these articles together. They have become a highlight of my week and I’ve enjoyed reading your insights into the past and the lives of the people who lived it.

    Did the physician Galen ever write about medical conditions related to combat or trauma that we would today place under the category of mental health issues? I thought I remember reading that the use of lithium salts in treating mental health conditions was well known to Greek and Roman physicians, and while I cannot recall where I saw it mentioned, I thought I remembered that the Romans had what we may call psychiatric homes for veterans (this could just be a pop-history misunderstanding though).

    Or even more generally, how was mental health treated/understood in regards to the systems of beliefs, knowledge, and culture of Rome? Did it differ from the other contemporary cultures of the Mediterranean?

  21. Why would anyone even have to speculate about this? Of course they did. What the fuck.

  22. Found this blog post on Hacker News.

    I am not a historian, but I think a lot of required analysis is missing here. What the text clearly demonstrates is that in ancient times there was a lot less “PTSD due to war losses” mentioned (almost zero) than one would expect by comparing to modern times. There is a question of “why” asked, but unfortunately without enough supporting evidence for the potential answers. Yes, different organization of war units and different battle strategy may be the reason, but so far this is only a guess. Even the “when did this change” question (which would help the argument, e.g., by correlating the changes in how the wars go, or in the general lifestyle) is answered very incompletely.

    Finally, let’s not forget that PTSD is caused not only by the loss of close friends during the war. So a good question would be whether the primary historical sources of various times contain depictions of flashbacks and other PTSD symptoms of non-military origin, associated with e.g. near-drowning accidents, fires, etc. If not, then it is indeed a strange discovery.

    1. I have heard that the event most likely to cause PTSD is being in a mass shooting.

      Historically, that would be the danger of a raid. Perhaps you had a little more warning, but still it’s the eruption of violence in ordinary life and places of security, and helplessness. And raids were commonplace in many eras. Did the victims of the Viking era suffer it?

  23. Dr. Jonathan Shay, who helped treat US war veterans, identified one major factor in Vietnam that caused soldiers to suffer PTSD – being away from fellow soldiers whom they knew and cared about. It turns out that combat creates intense bonds of affection between soldiers on the same side when they’re working together to fight a common enemy and save each other from death. Soldiers in Vietnam were reassigned and shuffled about at random, being treated more like random, one-size-fits-all equipment rather than human beings and were forced to fight away from soldiers they’d bonded with and alongside soldiers who were complete strangers. PTSD was much higher as a result. When the Iraq War came along, soldiers were consistently assigned to the same unit for a while, and PTSD rates in high-stress situations reduced.

    Here’s a link to Dr. Shay’s book – he’s got a second one called “Odysseus in America”

    In the Iliad, it’s the loss of Patroclus, Achilles’ cousin (and lover) that really sends him over the edge and gives him something close to PTSD, and Great Achilles isn’t really close to anyone else. If the typical Greek phalanx from classical times included people who knew each other fighting together, PTSD would be limited due to the bonding over shared losses and the presence of close friends and family in the phalanx. I assume that something similar applies to medieval knights, don’t know about European infantry.

  24. I wonder if Richard Kaeuper would disagree with the conclusions drawn in this post. After reading a great deal of medieval literary, historical, and legal texts, he concluded that ‘it is hard to escape the sense that knightly bravado was sometimes a covering for fear, in effect whistling past the graveyard. Perhaps those whose hands carry out the killing and destroying in any society suffer late night thoughts about widespread destruction and the shedding of human blood, about retribution and final justice’ (Kaeuper, Holy Warriors, 21). My sense is that Kaeuper’s collected works contain enough evidence to indicate that both those who participated in and those who suffered from the consequences of medieval warfare did indeed suffer from something akin to ‘trauma’, even if they lacked the ‘PTSD’ label we have come to adopt.

    1. I’ve updated the post with the following paragraph, which I think responds to your point:

      Based on quite a bit of the discussion, I think people are being very slippery with their definition of PTSD. PTSD is more than feeling bad about being in a war, or grief at the loss of a buddy. Here are the diagnostic guidelines( ). Note how a diagnosis requires one intrusion symptom (involuntary and instrusive memories, dreams, flashbacks, marked physiological reactions) and persistent avoidance of stimuli associated with the trauma and two negative alterations in cognition and mood associated with the trauma and two marked alterations in arousal and reactivity associated with the trauma. A lot of the examples being cited in the comments do not come anywhere near meeting that criteria. As I read and understand that, an individual who is voluntarily recounting the trauma – much less re-exposing themselves to it by going out to fight again – without significant reactions (read the guidelines – these are really very significant reactions) doesn’t fit the criteria. They may well have another form of mental wound, mind you; grief, fear, loss, guilt and so on are all very real things. But they do not, by our current medical definition, have this wound. Specificity here is necessary because we aren’t asking a question about grief or loss or guilt – feelings which all humans feel at one point or another – but about a very specific mental wound that combat (or other trauma) may inflict.

      1. I appreciate the reply and the update. I do still disagree somewhat with both your premise and the implications you draw from this premise, but perhaps I am misunderstanding.

        I think that your argument is that there were no literary representations in the past that check off symptoms A. through H. of the DSM’s definition of PTSD. It follows that, because these representations are not in evidence—because trauma from, say, war was not represented in a manner aligned with symptoms A. through H., at a time in which this definition had not yet been made meaningful in any way by any one, at a time in which psychiatry as a field did not exist—we can and should hold this absence of evidence to be a useful point of reference when attempting to explain humanity’s evolving reaction to warfare.

        Specifically, you argue that this point of reference aligns well with your corresponding argument that warfare—in general, for more than a millennium of history, until more ‘modern’ times—held ‘moral weight’, and that those suffering, generally, viewed warfare and its consequences as ‘good’, ‘right’, and ‘appropriate’.

        It is this latter point which, I suppose, is counter to Kaeuper’s work. I don’t know philosophies of language well enough to explain my difficulty with former point regarding PTSD and its presence in the past. Is this the referential fallacy? Regardless, I didn’t find this particular point persuasive.

      2. an individual who is voluntarily recounting the trauma

        is, by definition, the one who’s going to be recorded. How would we detect the people who didn’t recount their experiences because they had PTSD?

      3. I can actually speak to why PTSD is tricky to discern in literature and historical testimonies, but given my STEM sensibilities this is probably a topic you might want to discuss with me first before me posting anything here.

        I’m searchable by name, fairly high profile on the internet and have a professional Linkin page too.

  25. One angle you might try, when investigating PTSD, is looking at the occurrence of non-military PTSD. (Which I have.) You could try to see what sorts of things people think cause non-military PTSD, then compare that with wars that have many confirmed cases of PTSD, and see what they have in common. And then look back at wars in the past, and see whether they have the characteristics that tend to cause PTSD.

    To bring up a few perhaps-relevant points from my personal experience:
    – the things happened suddenly, shockingly, when I was unprepared
    – I had no control over what was going on, and could not think of anything to do, and there were no people to turn to or resources available that would tell me anything other than “we prefer to pretend you don’t exist”
    – I realized that everything I had been told about this situation, and to some extent the world, was wrong, and that the people that I had trusted were either cluelessly spouting nonsense, or knowingly sacrificing people in my situation
    – disgust and revulsion from people I had thought were my friends, when they found out
    – being cut off from the community I had been part of, with no support network to replace it
    – never feeling safe or secure, never knowing who’s a friend or enemy

    These points seem like they might apply more to modern wars than ancient wars. In particular, the rarity of war and the rate of technological change mean that the broader culture can’t prepare people from childhood for what they encounter on the battlefield. And soldiers make up a tiny fraction of the population. It’s possible for generations of a family to never have experience with war. Let alone any experience with the kind of war we’ll be fighting in 20 years (whatever that may be).

    But perhaps it would be worth looking at historical wars where there was a sudden, surprising development? Where the surviving defeated soldiers had their world-view shattered?

  26. Copying top comment from HN dicussion:

    xcellent counterpoint from r/AskHistorians (paragraph breaks added for legibility): [1]

    > Cross-cultural psychologists have observed that, regardless of cultural background, people who suffer persistent emotional disturbances in the wake of a traumatic event exhibit intrusive memory symptoms in some form. Here in the US, these are closely related to what we commonly call “flashbacks.” For the Romans, people experiencing intrusive memories were said to be haunted by ghosts. These individuals show up in historical, philosophical, and even medical texts.

    > Josephus, who was an outsider to Roman culture, also describes this phenomenon in his history of The Great Revolt. Those haunted by ghosts are constantly depicted showing many symptoms which would be familiar to the modern PTSD sufferer. Insomnia, depression, mood swings, being easily startled, frequent eye movement, alertness all day and night, paranoia, avoidance of crowds, suicidal thoughts/attempts, loss of appetite, shaking/shivering, self-hatred, and impulsive violence have all turned up in association with these individuals.

    > Since in almost every case the person experiencing these things had made himself an object of public shame, the “ghosts” in question often came in the form of those he had killed or wronged in the past. These would either appear spontaneously to the sufferer, or would come in the form of vivid, frightening nightmares.

    > The key component to these experiences, as with modern cases of PTSD, was that the sufferer had no control over his own symptoms. Thoughts or vivid memories would occur unexpectedly and uncontrollably. It is easy to see why the Romans, who were religiously superstitious to begin with, would attribute such things to the foul play of malicious spirits.


  27. ” What I’d love to see is to get the kind of turnout you see for something like American Civil War reenactments: to get a few hundred people, in protective kit, with shields and boffer spears and see how this all works on the scale it really happened in.”

    The annual Pennsic War of the Society for Creative Anachronism features battles with something like a thousand fighters a side. That includes forces with spears, although I don’t think I have ever seen anything much like a phalanx. A more common formation would be a shield wall of men armed with sword or mace, spears behind it.

  28. Dante’s description of his (fictionalized self’s) reaction to having to pass through a fire at the end of the Purgatorio sounds a bit like PTSD: ” I became like one who in the grave is laid. Clasping my hands together, over them I bowed, and watched the fire, while vivid images I formed
    of human bodies I had once seen burned.” It doesn’t tick all the boxes, but it does sound like a flashback coupled with a strong desire to avoid the stimulus. But it’s not at all clear that those burned bodies had anything to do with combat, so I suppose this doesn’t really get us closer to knowing whether combat-related PTSD was a thing prior to modern times.

  29. Bert — I’ve been reading for a few weeks now, and linking to your articles in forums I read. Hope that helps drive further readership.

    1. How many battle days did the average legionnaire see? They didn’t fight months long battles as in WWI

  30. Hi
    Only discovered this today but have read all the LotR articles already! Would you ever consider pulling them all together into an actual book?
    Looking forward to reading more

  31. Did you see Lindybeige’s video on Combat Fatigue, ( ) ? One of the interesting things he raises (8 minutes in) is that soldiers can get “fought out”, i.e. just having experienced too much combat to be really efficient any longer, and that this could be maybe 400 days (British numbers) or 200-240 days (U.S.) in World War 2. I wonder how this applies to antiquity? It probably can’t have been _as_ bad (or having people in a legion for 20 years would have been inefficient), but perhaps it could be part of posting the veteran Triarii in the third line, if they just didn’t have all that much fight left in them any longer?

    Overall, I believe you’re right about both the moral aspect and the home support aspect. I imagine Vietnam took a bigger toll than World War 2 because of that – coming home as a hero after having fought in a war that seemed important and meaningful could still leave you with appalling experiences you never wanted to think of or talk about ever again, but it’s surely better than being called a baby-killer. Also, helps a lot if many of the people you know have been through the same experiences, so that you know that they understand, even if you don’t talk about it.

    Since this is a nerdy forum, the Space Elves in WH40K are interesting – they are a race with a high propensity towards intense emotion, but they also have to try to keep it in check for supernatural reasons. This means that when they go to war, they don the aspects of mythological creatures and are considered by everyone basically a separate person. They can then do all the appalling, horrible, glorious things they do in war, and afterwards, ritually drop their warrior persona and return to civilian life. Except for those few that get stuck in the role (Exarchs), which is kinda a big deal for an immortal.

    Also: If it’s correct that people didn’t used to get PTSD to any significant amount, when _did_ it become more prevalent? Early modern period with mass armies and conscription? Surely it must have happened before WW1, such as in the American Civil War (which is supposedly well documented)? Lindybeige’s suggestion about the loudness and duration of combat is also interesting – a pitched battle in antiquity was surely a truly horrible experience, but at least it’s somewhat brief.

  32. Sound points on PTSD in pre-modern combatants: PTSD is post-TRAUMATIC stress disorder, after all, and trauma is something that occurs outside of the bounds of expectations. With societies where every adult man could reasonably expect to be exposed to combat, and the societies themselves were structured to abet a state of constant war, I entirely believe that combat PTSD would be less of an issue. I’m sure it still happened, but at a rate of incidence far, far below what our sources would detect.

    That said, PTSD doesn’t only happen as the result of combat. People get it from car crashes, from sexual assault, from sufficiently traumatic personal loss — I imagine civilian life might have seen a roughly equivalent amount of PTSD as we do in the modern day. The disorder occurs as a response to trauma, and we have precious few indications that either pre-modern societies had defeated trauma as a malady or that we as a species have changed in our ways of cognition that drastically. Now, why weren’t those recorded? Well, likely for much the same reasons we need to really go hunting to find sources that MIGHT be referencing people on the autism spectrum, or with attention disorders, or many other mental conditions. Our understanding of the human mind is a very modern phenomenon. In this particular field, we know now much more than once we did — and, consequently, record things that might otherwise have passed unremarked.

  33. since you’re always suggesting books to us, allow me to suggest “The Wheel of Time” series to you. it would fit in really well with the above picture. I’m sure i’m not the first to make the suggestion. you should heed all of us who have, when you get time of course

    1. P.S. you can then decide yourself whether or not the “Aiel” fit into the fremen mirage trope. (i personally don’t believe they do, but i can see at a glance why some might think they lean that way)

  34. What about the Assyrians? There was a study that posited that their soldiers suffered from PTSD.

    “”The sorts of symptoms after battle were very clearly what we would call now post-traumatic stress symptoms.

    “They described hearing and seeing ghosts talking to them, who would be the ghosts of people they’d killed in battle – and that’s exactly the experience of modern-day soldiers who’ve been involved in close hand-to-hand combat.

    As the study’s abstract states, the researchers also found instances of soldiers reporting “flashbacks, sleep disturbance and low mood.””

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