Trauma reactions have been documented for at least four millennia in Mesopotamian texts, epics, biblical narratives, theatrical works, and medical writings. PTSD, by contrast, entered the DSM-III only in 1980. Forty-five years of clinical categorization versus forty centuries of narrated suffering is not merely a matter of scientific delay: it is a matter of framing. And framing, whether to medicalize or to recognize, is never neutral.
In the cuneiform laments composed after the destruction of Ur, between 2027 and 2003 BCE, someone writes in the first person about nights spent “trembling” among corpses, unable to sleep, overwhelmed by images that would not stop returning. Herodotus recounts the story of Epizelus, the Athenian warrior who survived the Battle of Marathon (490 BCE), struck by sudden blindness despite having suffered no physical wound after witnessing the death of a companion beside him. Six months after the Great Fire of London in 1666, Samuel Pepys wrote in his diary that he could no longer sleep a single night without “great terrors of fire.” Lady Macbeth, in 1606, walks in her sleep trying to wash away invisible bloodstains from her hands.
Anyone reading these fragments today through the lens of a psychiatry textbook would say: here is PTSD. Intrusions, avoidance, hypervigilance, cognitive and affective alterations. The four symptom clusters of the fifth edition of the Diagnostic and Statistical Manual.
But there is a question worth asking before closing the diagnostic box: what exactly happened in 1980, when the DSM-III first introduced Post-Traumatic Stress Disorder into its list of mental illnesses? Was it a scientific discovery, the delayed recognition of a pathological entity that had always existed, or was it the translation of something far older and far more human into the language of biomedical psychiatry? And if it was the latter, what was gained, and what was lost, in that translation?
The most interesting finding emerging from a long-term historical analysis is not the continuity of the symptoms although that continuity is striking, but the radical discontinuity of the interpretations. Across history, post-traumatic reactions have been understood as:
Each framework did not merely describe suffering: it produced, regulated, punished, or treated it in radically different ways. During the First World War in Italy, soldiers with post-traumatic symptoms were labeled scemi di guerra (“war fools”), confined in asylums, and subjected to faradic currents as both therapy and discipline. In Germany, at the Munich Congress of 1916, the psychiatric community formally rejected Oppenheim’s concept of “traumatic neurosis.” The stated reason was scientific. The actual reason, historically documented, was economic: recognizing traumatic neurosis would have opened insurance compensation claims and weakened the war effort.
Anyone who still believes that psychiatric diagnostic categories emerge from a neutral convergence of clinical evidence should revisit that congress. Then they should ask themselves what is happening today in debates surrounding burnout, disability certifications, trauma from microaggressions, or diagnoses that legitimize access to welfare services or, conversely, stigmatize those who receive them.
The implicit assumption behind every diagnostic manual is that, with its publication, the history of interpretive errors has ended. Before came superstition, moralism, theories of damaged spinal cords, Freudian metaphors. Now comes science: four clusters, operational criteria, temporal thresholds, specifiers.
A careful historical analysis suggests something very different. The DSM-5 and the ICD-11, the two systems currently in use, do not even agree with each other. The former includes four symptom clusters and twenty symptoms; the latter three clusters and six core symptoms. In the same Dutch population sample, PTSD prevalence according to DSM-5 was 1.3%, while according to ICD-11 it was 1.0%, with an additional 1.6% classified as “complex PTSD” a category not recognized by the DSM. The same suffering individual, in the same population, either is or is not “ill” depending on which manual one opens.
This is not a technical detail. It is evidence that the diagnostic category is not a photograph of a natural reality, but an operational convention constructed for specific purposes: research, compensation, access to services, clinical communication. A useful convention, perhaps even a necessary one in certain contexts. But still a convention.
What historical analysis reveals most powerfully and what contemporary clinical language risks obscuring, is that pre-DSM frameworks often captured dimensions of traumatic suffering that current categories no longer know how to name.
The “nostalgia” described by Johannes Hofer in 1688, for example, was more than a list of symptoms. It was the recognition that one can suffer to the point of illness through the loss of a place, a landscape, a community. Trauma as a rupture between the individual and the world that sustains them, rather than dysfunction within an isolated brain. Today, when we speak of refugees, forced migrants, or communities displaced by war or climate change, we may realize that the old concept of “nostalgia” perhaps expressed something more precise than our current “negative alterations in cognition and mood.”
Another example: conversion manifestations — paralysis, aphonia, psychogenic blindness — abound in the writings of Charcot, in Egyptian papyri, and in Herodotus. Today they have been excluded from the core of PTSD and relegated to somatic symptom disorders or functional neurological disorders. But the question remains: does this separation represent scientific progress, or the fragmentation of a once-unified understanding of how the body speaks suffering? When a patient today develops dissociative non-epileptic seizures after an assault, we refer her to a functional neurologist; two thousand years ago, she might have been recognized as someone carrying in her body the weight of an experience too overwhelming to contain. Modern categories may treat more effectively, but they may also perceive less.
The political point, before it is even a clinical one, is this: if the same constellations of trauma reactions appear in Gilgamesh, Achilles, Job, seventeenth-century Swiss mercenaries, survivors of the American Civil War, civilians enduring the London Blitz, and Vietnam veterans, then calling them a “disorder” is a choice, not an observation.
It is the choice to frame a consistent human response to experiences that exceed the organism’s capacity for integration as something dysfunctional, abnormal, and in need of correction. Yet a response that recurs with such regularity across cultures, genders, ages, and historical contexts is anything but abnormal. It is profoundly, stubbornly, inevitably human. It is what happens to human beings when they are exposed to what human beings should not be exposed to.
Saying this does not deny suffering. It means precisely the opposite: recognizing that such suffering is real, severe, and capable of destroying lives and that this is exactly why it deserves not to be reduced to an ICD code. The nightmares of those returning from war, the intrusive images experienced by witnesses of femicide, the hypervigilance of those raised in violent households are not malfunctions of a broken mechanism: they are the ways in which the human psyche responds to what has been done to it. Pathologizing them shifts attention away from the context that produced them and toward the body that carries them.
If the archaeology of trauma teaches clinicians anything, it is three things.
First. Wars have always accelerated medical recognition of trauma, while civilian suffering, that of women, children, survivors of domestic violence, and refugees, has often waited decades to be taken seriously. Kempe’s “battered child syndrome” dates to 1962. Burgess and Holmstrom’s “rape trauma syndrome” appeared in 1974. Diagnostic systems move slowly when victims are not wearing the right uniforms.
Second. Every time a category is codified, a conflict emerges over who is entitled to enter it. PTSD today is a gateway to treatment, compensation, pensions, and social recognition. But it is also a gate that someone decides to open or close: the more restrictive criteria of ICD-11 exclude individuals whom DSM-5 would recognize. Behind every threshold lies a politics of suffering.
Third. The historical continuity of symptoms does not legitimize the DSM: it relativizes it. To say “PTSD has existed for four thousand years” is equivalent to saying “PTSD does not exist in the way we currently define it; rather, something else exists that we now choose to call PTSD.” Categories are tools. Tools are used as long as they remain useful, and discarded when they betray the purposes for which they were created.
This is not an argument for abolishing PTSD as a diagnosis, nor for returning to moralistic interpretations or coercive treatments. It is an argument for remembering that diagnostic categories are useful conventions, not truths. It is about using the DSM as one uses a map, while remembering that the map is not the territory. It is about accompanying every diagnosis with the question: what happened to this person? rather than only: what does this person have?
The ancients who wrote about Achilles, Gilgamesh, or Job did not possess a DSM. They possessed something different, perhaps less efficient, but also less reductive. They possessed a way of seeing that did not separate individual suffering from the historical, communal, moral, and existential context in which that suffering emerged. They could recognize trauma as the weight of history borne by the individual body, rather than dysfunction of the individual body within history.
That capacity is not obsolete. It is precisely what contemporary psychiatry needs today if it wishes to avoid reducing human experience to a series of administrative codes. The task is not to choose between science and humanism, between category and narrative, between neurobiology and meaning. It is to hold them together, with the awareness that every time a clinician writes “F43.1” in a patient’s chart, they are performing an act backed by forty-five years of history and four thousand years of prehistory, and those four thousand years are still speaking.
—-
Citation: Paganin, W. (2026). Core symptoms of PTSD across four millennia: a phenomenological and nosographic analysis – from ancient Mesopotamian texts to modern psychiatric classifications. Medical Humanities (BMJ). https://doi.org/10.1136/medhum-2025-013623