On the night of 28 February 1667, six months after the Great Fire had reduced much of London to ash, the naval administrator Samuel Pepys wrote a short, unguarded sentence in his diary: “It is strange to think how to this very day I cannot sleep a night without great terrors of fire.” Pepys was not a soldier. He had no wound to show. Yet his entry, with its recurrent nightmares, persistent hypervigilance and intrusion of fire-related imagery into his daily life, is one of the earliest longitudinal records of what a modern clinician would immediately recognise as post-traumatic stress disorder (PTSD). Three and a half centuries before DSM-III codified the diagnosis in 1980, a civilian Londoner was already describing it from the inside.
This is the heart of a review essay I published earlier this year in BMJ Medical Humanities, tracing the core symptoms of PTSD across roughly four millennia from Mesopotamian cuneiform laments (circa 2027–2003 BCE) to contemporary psychiatric classifications. The findings complicate a story we tend to tell ourselves: that PTSD is a creature of modern warfare, born in Vietnam, diagnosed in the late twentieth century. It is not. What is modern is the name, not the wound.
A remarkably stable core
Intrusive re-experiencing, avoidance, alterations in cognition and mood, hyperarousal: the four symptom clusters that define PTSD in DSM-5-TR appear, with striking consistency, across vastly different cultures and epochs. The Mesopotamian survivor of Ur records insomnia, tremors and intrusive images of corpses. The Athenian warrior Epizelus, according to Herodotus, goes blind at Marathon after witnessing a comrade fall with no physical injury. Achilles oscillates between grief-driven rage and emotional numbing. Lady Macbeth sleepwalks, obsessively washing imagined blood from her hands. These are not retrospective diagnoses. Applying DSM or ICD criteria to Gilgamesh would be an anachronism. But read as a phenomenological archive, these sources suggest something important: the human nervous system responds to overwhelming threat in a relatively conserved way. Amygdala hyperactivation, hippocampal dysfunction and disruption of the hypothalamic-pituitary-adrenal axis are not a cultural construction.
From the trenches to the city
One of the most consequential shifts in the history of trauma has been the slow, reluctant recognition that civilians suffer too. For most of the nineteenth and early twentieth centuries, post-traumatic conditions were understood almost exclusively through the lens of soldiers: Da Costa’s “irritable heart” in American Civil War veterans, “railway spine” in survivors of industrial accidents, Myers’s “shell shock” in the trenches of the First World War. The body of the traumatised person was, by default, a male military body. And yet the historical record tells a different story. Pepys’s diary is one example among many. In the Second World War, terms such as “bombing neurosis” emerged to describe the paralysing anxiety, flashbacks and insomnia of civilians under the Blitz. Survivors of concentration camps developed what Niederland later called “survivor syndrome”. Children who had lived through air raids, deportations and displacement presented symptoms indistinguishable from those of combat veterans.
The formal recognition of civilian trauma came even later. It took Henry Kempe’s Battered Child Syndrome (1962) and Ann Burgess and Lynda Holmstrom’s “Rape Trauma Syndrome” (1974) to establish, in the face of considerable social discomfort, that trauma is not the preserve of battlefields. Once that boundary fell, PTSD could finally be codified in DSM-III as a universal human response rather than a soldier’s complaint.
Three paradigm shifts
The review identifies three major transitions in how Western culture has explained post-traumatic suffering. Between roughly 1600 and 1900, moral and religious interpretations gave way to organic ones: trauma became a lesion, not a sin. Between 1876 and 1920, thanks to Charcot, Janet and Freud, the organic model yielded to a psychodynamic one. And between 1915 and 1980, the military-specific framework slowly expanded into a universal one.
Each shift brought genuine gains. It is better to be treated as ill than condemned as a coward. But each also brought losses. The medicalisation of trauma, for all its benefits, risks reducing to a checklist what earlier generations described as “the loss of a world”, “a shaking of the soul”, or the rupture between a person and their meaningful context. The eighteenth-century diagnosis of nostalgia Johannes Hofer’s 1688 account of Swiss mercenaries dying of homesickness, captured a relational and existential dimension of trauma that our current criteria, focused on internal cognitive states, can miss.
DSM and ICD: Complementary, not rival
Contemporary clinicians inherit a useful tension. DSM-5-TR offers granularity four clusters, twenty symptoms, multiple specifiers, well suited to research and detailed case formulation. ICD-11 offers parsimony, three core clusters, six essential symptoms, better suited to rapid screening and international communication, and it introduces Complex PTSD as a distinct diagnosis. The epidemiological consequences are not trivial. Dutch data suggest lifetime DSM-5 PTSD prevalence of around 11%, while ICD-11 identifies around 1% for PTSD and 1.6% for Complex PTSD. Same population, different maps. The sensible response is not to pick a winner but to use both frameworks where they each do useful work.
A warning from history
The story of trauma is also a story of institutional resistance. At the 1916 Munich Congress, German psychiatry rejected Oppenheim’s “traumatic neurosis” largely for insurance and economic reasons. In Italy, shell-shocked soldiers were branded scemi di guerra, punished as cowards and subjected to faradic currents. These are not curiosities: they are reminders of how fragile the right to care becomes when the only evidence of suffering is clinical.
Contemporary debates about the threshold of Criterion A, about microaggressions, about the boundary between resilience and disorder, echo these older controversies. The lesson is not that every distress is PTSD. It is that the history of trauma has repeatedly punished the vulnerable for political and financial convenience and that vigilance against that pattern is part of good practice.
What this means today
Recognising the historical continuity of trauma does three useful things. It reduces stigma by reframing post-traumatic suffering as a universal human response, not a personal weakness. It cautions against both over-medicalisation and minimisation. And it invites clinicians to hold categorical diagnosis and existential meaning together, rather than treating the former as a replacement for the latter.
Samuel Pepys did not have a name for what kept him awake in 1667. We do. That is progress provided we remember that the name is a tool, not the thing itself.
