Is post-traumatic stress disorder universal?

Jason Crowley, an academic from Manchester Metropolitan University, has been considering the question of whether post-traumatic stress disorder (PTSD) is a universal experience for soldiers returning from war – as is generally believed – or whether it is culturally specific.

The label PTSD to describe a particular set of symptoms was coined in the 1970s, when the condition was observed in veterans returning from Vietnam, though the phenomenon itself was first identified in soldiers returning from the first world war, when it was referred to as “shell shock”.

Many historians argue that, because the experience of warfare is always horrific, soldiers must always have suffered from PTSD, even if there was no name for the condition. In this interpretation, tales such as the Iliad and the Odyssey are stories of heroes psychologically damaged by war.

Crowley, however, takes a contrary view. He argues:

“The 20th-century soldier, for example in Vietnam, was susceptible to PTSD not because he was psychologically weak, but because he was exposed to a range of conditions closely associated with PTSD. He was often exhausted and sleep-deprived when he met his enemy. He fought socially and physically isolated from his comrades. He faced threats he could not counter and, perhaps most crucially, when he killed he transgressed the peaceful norms he’d been raised to cherish.”

In contrast, none of these applied to the ancient Greek soldier, who was acting in accordance with traditional morality that required him to kill enemies and who would not have been sleep-deprived or physically isolated.

“In short,” writes Crowley, “the conditions required for PTSD are present in the modern case study but absent in the ancient. And that means PTSD is not universal, it is historically and culturally specific.”

It’s a fascinating debate. I don’t know enough about history to know if he’s right or not about the ancient Greeks, but I am fairly sure that he’s right to say PTSD is “historically and culturally specific”, although I think a better phrase would be “context-specific”. In other words, if you take two groups of people who have experienced a trauma, but they experience them in different contexts, one group may be more likely to suffer PTSD than the other.

How does this relate to birth trauma? Even now, most work on PTSD relates to soldiers rather than to people who have been traumatised in other ways. But you can see that it’s possible to extrapolate Crowley’s argument to other situations. In the case of birth, for example, a sizeable minority of women experience difficult or even dangerous births, where they are in a lot of pain, or they haemorrhage badly, or suffer physical damage, such as fourth-degree tears, or they come close to losing their baby.

Not all of these women, however, go on to suffer PTSD. And the common factor among those who do seems to be about context: research studies repeatedly find that the affected women will mention a midwife or obstetrician who spoke unkindly to them, or was physically rough with them, and they also talk about a lack of communication. “Nobody told me what was going on – I thought I [or my baby] was dying” or is a frequent comment. They also speak of babies being whisked away immediately after birth, and not knowing where they are, or why they’ve gone.

Equally, they may say that nobody listened to them – that they thought there was a problem with the labour, but staff weren’t interested. One woman I spoke to for my book insisted to midwives that she was ready to give birth, but they refused to believe her – until moments before the baby was born.

What that suggests is that even in the most difficult of births, trauma can be avoided if staff make the time to communicate with women about what is happening to them.

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