Delayed and immediate onset posttraumatic stress disorder

Summary The current study examined the role battle experiences and personal resources play in the development of combat-related posttraumatic stress disorder (PTSD). For this purpose, battle experiences (battle stress, military unit environment) and personal resources (coping styles, causal attribution) were assessed two years after the 1982 Lebanon War in three groups of male Israeli frontline soldiers: 1. soldiers who sought treatment 6 months or more after the war (delayed PTSD); 2. soldiers who sought treatment during the war (immediate PTSD); and 3. control soldiers. Findings indicated that both immediate and delayed PTSD casualties reported similar and higher levels of battle stress than control subjects. In addition, delayed PTSD casualties evinced less personal resouces than control subjects, and immediate PTSD casualties evinced still less personal resources than delayed PTSD casualties. The theoretical implications of the findings were discussed.This study was supported by the U.S. Army Medical Research and Development Command, Grant No.DAMD17-87-G-7002. The views, opinions, and findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by other documentation.     

A neurosurgeon in Iraq: A personal perspective

The practice of neurosurgery in a war zone provides enormous challenges and risks for the individual surgeon working in such an austere and hostile environment, but also provides a unique opportunity to treat a high volume of severe penetrating and blast injuries to the head, neck and the spine. The purpose of this article is to present the author's personal experiences and perspective as a military neurosurgeon working in the US Airforce Hospital in Balad (the 332nd Expeditionary Medical Group) Iraq in for 3 months in 2004. Strategies for managing the mass casualties, and the severe penetrating craniofacial trauma are presented and the reasons for the low mortality of troops injured in Iraq are discussed.     

Combat-related posttraumatic stress disorder among second-generation Holocaust survivors: preliminary findings

The authors assessed the impact of the Nazi Holocaust on the course and symptoms of posttraumatic stress disorder (PTSD) among Israeli combat stress reaction casualties. They examined a sample of 96 such casualties of the 1982 Lebanon War whose parents had gone through the Nazi Holocaust and compared them to casualties who did not have such family history for 3 consecutive years beginning 1 year after their participation in the war. Results showed that 2 and 3 years after their participation in the 1982 Lebanon War, the children of Holocaust survivors, i.e., "second-generation" casualties, had higher rates of PTSD than did the control subjects, as well as a somewhat different clinical picture. Clinical and methodological implications of the findings are discussed.     

Children's trauma and adjustment reactions to violent and nonviolent war experiences

OBJECTIVE: According to most studies, more than half of children exposed to war meet criteria for posttraumatic stress disorder (PTSD). Although we know that children are adversely affected by atrocities of war, we do not know which specific war events are associated with children's stress reactions. For example, it is unclear whether differences exist in response to violent versus nonviolent war-trauma experiences. This study examined the relationship of violent and nonviolent war experiences to children's trauma reactions and adjustment in a group of children from Bosnia. METHOD: During the 1994 siege in Sarajevo, 791 children aged 6 to 16 years participated in a study of trauma experience and response, in which assessment questionnaires (Impact of Event Scale, PTSD Reaction Index, Children's Depression Inventory, Child Behavior Checklist, and War Experience Questionnaire) were completed by children and their teachers. RESULTS: In this sample 41% had clinically significant PTSD symptoms. Children were adversely affected by exposure to both violent and nonviolent war-traumas. An additive effect of trauma exposure on trauma reactions was also found. However, many war experiences were not associated with children's adjustment and trauma reactions. CONCLUSIONS: Additive effects of violence and deprivations during war may overwhelm the coping skills of children and leave them vulnerable to externalizing and internalizing adjustment difficulties and symptoms of PTSD.     

Trauma and suicidality in war affected communities

PurposeThe aim was to assess whether experiences of war trauma remain directly associated with suicidality in war affected communities when other risk factors are considered.Materials and methodsIn the main sample 3313 participants from former Yugoslavia who experienced war trauma were recruited using a random sampling in five Balkan countries. In the second sample 854 refugees from former Yugoslavia recruited through registers and networking in three Western European countries. Sociodemographic and data on trauma exposure, psychiatric diagnoses and level of suicidality were assessed.ResultsIn the main sample 113 participants (3.4%) had high suicidality, which was associated with number of potentially traumatic war experiences (odds ratio 1.1) and war related imprisonment (odds ratio 3) once all measured risk factors were considered. These associations were confirmed in the refugee sample with a higher suicidality rate (10.2%).Discussion and conclusionsNumber of potentially traumatic war experiences, in particular imprisonment, may be considered as a relevant risk factor for suicidality in people affected by war.     

Reactions to combat stress in Israeli veterans twenty years after the 1982 Lebanon war

During the war or shortly thereafter, the most common manifestation of combat induced psychopathology is combat stress reaction (CSR). The long-term consequences of CSR have so far received little scientific attention. The aim of this study was to examine whether CSR is a marker for long-term PTSD and other psychiatric comorbidities. Two groups of veterans from the 1982 Lebanon war were assessed 20 years after the war: one comprised 286 CSR casualties and the other comprised 218 matched non-CSR soldiers. Participants were assessed for PTSD, psychiatric symptomatology, social functioning, physical health, and postwar life events. Twenty years after the war, veterans with antecedent CSR reported more PTSD, psychiatric symptomatology and distress, social dysfunction, and health problems than did non-CSR veterans. We conclude that CSR should be seen as a marker for long-term psychiatric distress and impairment. In addition, the implications of combat-related trauma are broad and varied, and go beyond the narrow scope of PTSD.     

Trauma in war and political persecution: expanding the concept

A contextual understanding of the concept of trauma is proposed through a study of its meaning in a Latin American context facing war and political repression. This article explores the contributions of narrative and liberation psychology to understanding politically based trauma. It critiques the relationship between the concept of trauma and the diagnosis of posttraumatic stress disorder. It analyzes how Colombian human rights activists make sense of the political persecution and trauma in their work. The author argues that the kind of experiences that these activists have endured go beyond the category of stress and can best be understood as traumatic within the context of the current medium-intensity war in Colombia.     

Attachment and traumatic stress in female holocaust child survivors and their daughters

OBJECTIVE: During the Holocaust, extreme trauma was inflicted on children who experienced it. Two questions were central to the current investigation. First, do survivors of the Holocaust still show marks of their traumatic experiences, even after more than 50 years? Second, was the trauma passed on to the next generation? METHOD: Careful matching of Holocaust survivors and comparison subjects was employed to form a research study design with three generations, including 98 families with a grandmother, a mother, and an infant, who engaged in attachment- and trauma-related interviews, questionnaires, and observational procedures. RESULTS: Holocaust survivors (now grandmothers) showed more signs of traumatic stress and more often lack of resolution of trauma than comparison subjects, but they were not impaired in general adaptation. Also, the traumatic effects did not appear to transmit across generations. CONCLUSIONS: Holocaust survivors may have been able to protect their daughters from their war experiences, although they themselves still suffer from the effects of the Holocaust.     

Aftermath: the implicit processes of integrating traumatic experience in the poetry of Siegfried Sassoon

The creation of narratives often allows individuals to bear witness to traumatic events. This study looked at connections between the processing of traumatic, affect laden experience and levels of symbolization and symmetry within the context of poetic expression. The sample for this pilot study is composed of selected works by Siegfried Sassoon (1886-1967), a British soldier-poet of the Great War. The language of the poems reflected the deepening trauma of the war experience by showing a progression toward paranoid (concrete)/symmetrical experiences. As the years passed and the poet was able to process the memory of the events, the poetry reflected a more balanced shift toward integration of depressive (symbolic)/asymmetrical experience. In terms of affect, the most significant changes were seen after Sassoon left the front and witnessed the flagrant dichotomy between civilian and military life. The results suggest a way in which traumatic events are processed. The routine horror and brutality of the Western Front initially lay outside of the realm of language and symbols and were thus highly concrete and unprocessed experiences. Time, place, and identity collapsed in on itself, leading to the increase of symmetrical experience, while the extreme "us versus them experience" of the trenches can be seen in the balance of asymmetrical experience. The study has implications for the treatment of war trauma, suggesting that writing provides a vehicle through which events can be processed and an internal sense of balance can be approached.     

Unresolved grief in combat veterans with PTSD

Clinicians have documented the importance of loss of comrades during combat as a significant source of distress. However, empirical studies have not focused on unresolved grief as a possible outcome of combat experiences. Consequently, unresolved grief has often been treated "after the fact" in the context of treating PTSD and depressive symptoms. In this study, we therefore, sought to demonstrate the prominence of combat-related grief-specific symptoms in a sample of Vietnam veterans being treated for PTSD. Our results indicated that indeed this sample of veterans reported high levels of grief-specific symptoms comparable to that found in bereaved individuals whose spouse had recently died, verifying its prominence as an important component of combat-related stress. Furthermore, grief severity was uniquely associated with losses of comrades during combat whereas no such relationship was shown for trauma or depressive symptoms. The latter finding suggested that in fact higher levels of grief stemmed from interpersonal losses during the war and was not simply an artifact of current general distress level.     

Vietnamese boat refugees: the influence of war and flight traumatization on mental health on arrival in the country of resettlement

A consecutive cohort of 145 adult Vietnamese refugees were personally interviewed and completed the Symptom Checklist 90 R self-rating scale on arrival in Norway. Sixty-two percent had witnessed bombing, fires and shooting, 48% had witnessed other people being wounded or killed and 36% had been involved in life-threatening situations or had been wounded in the war. Nearly all war trauma variables but none of the escape or refugee camp variables were significantly related to mental health 7 years after the end of the war. War trauma was significantly associated with mental health, also when age, gender and previous mental problems were controlled for. These results and our clinical experience indicate that clinicians treating refugees should address such traumatic experiences specifically.     

Dimensions of posttraumatic stress disorder among Vietnam veterans

DSM-III criteria and clinical models of stress are used to identify discrete dimensions of posttraumatic stress disorder. The authors test the hypothesis that war trauma differentially affects four dimensions of posttraumatic stress--intrusive imagery, hyperarousal, numbing, and cognitive disruption--by studying data from 251 Vietnam veterans probability sampled in seven sites. The hypothesis was confirmed. Different dimensions of stress symptomatology are found to vary across individuals exposed to different types of war trauma. Stress responses to war trauma also differ by race of the veteran. The relationship between stressors and symptomatology change over time, indicating specific experiences are related to particular long-term patterns of posttraumatic stress disorder.     

Psychosocial intervention for war-affected children in Sierra Leone

BACKGROUND: There are no psychosocial interventions to address both educational needs and psychological distress among displaced children in post-conflict settings. AIMS: To assess the psychosocial status of displaced children enrolled in the Rapid-Ed intervention; and to determine whether the Rapid-Ed intervention alleviated traumatic stress symptoms that interfere with learning among war-affected children in Sierra Leone. METHOD: A randomly selected sample of 315 children aged 8-18 years who were displaced by war were interviewed about their war experiences and reactions to the violence before and after participating in the 4-week Rapid-Ed intervention combining basic education with trauma healing activities. RESULTS: High levels of intrusion, arousal and avoidance symptoms were reported at the pre-test interviews conducted 9-12 months after the war. Post-test findings showed statistically significant decreases in intrusion and arousal symptoms (P<0.0001), a slight increase in avoidance reactions (P<0.0001) and greater optimism about the future. CONCLUSIONS: The findings suggest potential for combining basic education with trauma healing activities for children in post-conflict settings, but confirmatory studies using a control group are needed. Conducting research in post-conflict settings presents unique challenges.     

Mental health among older refugees: the role of trauma,discrimination, and religiousness

Objectives: The aim of this study was to examine, first, how past traumatic stress and present acculturation indices, and discrimination are associated with mental health; and, second, whether religiousness can buffer the mental health from negative impacts of war trauma.

Method: Participants were 128 older (50–80 years) Somali refugees living in Finland. They reported experiences of war trauma and childhood adversities, and filled-in questionnaires of perceived ethnic discrimination, religiousness (beliefs, attendance, and observance of Islamic faith), and symptoms of posttraumatic stress disorder (PTSD), depressive (BDI-21), psychological distress (GHQ-12), and somatization (SCL-90).

Results: Symptom-specific regression models showed that newly arrived refugees with non-permanent legal status and severe exposures to war trauma, childhood adversity, and discrimination endorsed greater PTSD symptoms, while only war trauma and discrimination were associated with depressive symptoms. Results confirmed that high religiousness could play a buffering role among older Somalis, as exposure to severe war trauma was not associated with high levels of PTSD or somatization symptoms among highly religious refugees.

Conclusion: Health care should consider both unique past and present vulnerabilities and resources when treating refugees, and everyday discrimination and racism should be regarded as health risks.     

Media triggers of post-traumatic stress disorder 50 years after the Second World War

Post-traumatic stress disorder (PTSD) may present many years after the original trauma. Case studies of two elderly patients are described. Both had experienced life-threatening combat situations and witnessed intense suffering during the Second World War. Marked distress was triggered by the media commemorating the fiftieth anniversary of the end of the war. PTSD patients often avoid talking of their traumatic experiences because of associated distress. Without taking a military and trauma history from elderly patients the diagnosis is likely to be missed. © 1997 John Wiley & Sons, Ltd.     

Quality of care after early childhood trauma and well-being in later life: child Holocaust survivors reaching old age

The link between deprivation and trauma during earliest childhood and psychosocial functioning and health in later life was investigated in a group of child Holocaust survivors. In a nonconvenience sample 203 survivors, born between 1935 and 1944, completed questionnaires on Holocaust survival experience and several inventories on current health, depression, posttraumatic stress, loneliness, and attachment style. Quality of postwar care arrangements and current physical health independently predicted lack of well-being in old age. Loss of parents during the persecution, year of birth of the survivors (being born before or during the war), and memories of the Holocaust did not significantly affect present well-being. Lack of adequate care after the end of World War II is associated with lower well-being of the youngest Holocaust child survivors, even after an intervening period of 60 years. Our study validates Keilson's (1992) concept of "sequential traumatization," and points to the importance of aftertrauma care in decreasing the impact of early childhood trauma.     

'The moment I became born-again the pain disappeared': the healing of devastating war memories in born-again churches in Mbarara District, Southwest Uganda

In southwest Uganda, many people who suffer from devastating war experiences become born-again Christians. This article describes the therapeutic functions of the churches and the experiential transformations associated with becoming born-again. The discourse of the born-again churches gives people another orientation toward the future, based on the Bible, that also provides them with a different perception of the past. Whereas people remain silent about their war experiences in everday life, the churches offer their members a public space to express their suffering. In these churches, feelings of trust and solidarity are restored. Many aspects of the churches' activities can also be found in western trauma therapies.     

Exposure to war trauma and PTSD among parents and children in the Gaza strip

Objective Exposure to war trauma has been independently associated with posttraumatic stress (PTSD) and other emotional disorders in children and adults. The aim of this study was to establish the relationship between ongoing war traumatic experiences, PTSD and anxiety symptoms in children, accounting for their parents’ equivalent mental health responses. Methods The study was conducted in the Gaza Strip, in areas under ongoing shelling and other acts of military violence. The sample included 100 families, with 200 parents and 197 children aged 9–18 years. Parents and children completed measures of experience of traumatic events (Gaza Traumatic Checklist), PTSD (Children’s Revised Impact of Events Scale, PTSD Checklist for parents), and anxiety (Revised Children’s Manifest Anxiety Scale, and Taylor Manifest Anxiety Scale for parents). Results Both children and parents reported a high number of experienced traumatic events, and high rates of PTSD and anxiety scores above previously established cut-offs. Among children, trauma exposure was significantly associated with total and subscales PTSD scores, and with anxiety scores. In contrast, trauma exposure was significantly associated with PTSD intrusion symptoms in parents. Both war trauma and parents’ emotional responses were significantly associated with children’s PTSD and anxiety symptoms. Conclusions Exposure to war trauma impacts on both parents’ and children’s mental health, whose emotional responses are inter-related. Both universal and targeted interventions should preferably involve families. These could be provided by non-governmental organizations in the first instance.     

The long-term consequences of war: the experience of World War II

Seven hundred and thirty-one World War II and Korean War veterans completed a questionnaire about their experiences and their current psychological reactions to the war. Nineteen percent scored above the cut-off points for both the General Health Questionnaire and the (war-related) Impact of Event Scale, demonstrating that, even over 50 years after the event, many veterans still experience problems relating to their war experiences. Psychological distress was in part directly related to particular experiences, but intrusion and avoidance both played an important role as mediating variables. Other factors, such as prisoner of war (POW) status, type of service, rank, and illness were also considered. The findings indicate that the effects of a traumatic experience such as war can persist into later life.