Psychological consequences of war trauma and postwar social stressors in women in Bosnia and Herzegovina

Aim

To assess the consequences of psychotrauma in civilian women in Herzegovina who were exposed to prolonged and repetitive traumatic war events and postwar social stressors.

Methods

The study included a cluster sample of 367 adult women, divided into two groups. One group (n = 187) comprised women from West Mostar who were exposed to serious war and posttraumatic war events. The other group (n = 180) comprised women from urban areas in Western Herzegovina who were not directly exposed to war destruction and material losses, but experienced war indirectly, through military drafting of their family members and friends. Demographic data on the women were collected by a questionnaire created for the purpose of this study. Data on trauma exposure and posttraumatic stress disorder (PTSD) symptoms were collected by Harvard Trauma Questionnaire (HTQ) – Bosnia-Herzegovina version. General psychological symptoms were determined with Symptom Check List-90-revised (SCL-90-R). Data on postwar stressors were collected by a separate questionnaire.

Results

In comparison with the control group, women from Western Mostar experienced significantly more traumatic events (mean ± standard deviation [SD], 3.3 ± 3.2 vs 10.1 ± 4.9, respectively, t = 15.91; P<0.001) and had more posttraumatic symptoms (12.3 ± 10.3 vs 21.2 ± 10.9, respectively, t = 8.42; P<0.001). They also had significantly higher prevalence of PTSD (4.4% vs 28.3%, respectively; χ² = 52.56; P<0.001). The number of traumatic events experienced during the war was positively associated with postwar stressful events both in the West Mostar group (r = 0.223; P = 0.002) and control group (r = 0.276; P<0.001). Postwar stressful events contributed both to the number and intensity of PTSD symptoms and all general psychological symptoms measured with SCL-90 questionnaire, independently from the number of experienced traumatic war events.

Conclusion

Long-term exposure to war and postwar stressors caused serious psychological consequences in civilian women, with PTSD being only one of the disorders in the wide spectrum of posttraumatic reactions. Postwar stressors did not influence the prevalence of PTSD but they did contribute to the intensity and number of posttraumatic symptoms.There are few studies investigating how political violence in a community influences women, and those that do exist mostly deal with refugees (1,2). Epidemiologic research into consequences of war trauma established that posttraumatic stress disorder (PTSD), although the most frequent, was rarely the only psychological disorder among the general population of war-stricken countries (3-6) and that women had noticeably poorer mental health than the rest of the population (2,7). Studies investigating psychological consequences of military and civil trauma confirmed the correlation between the nature and intensity of trauma, previous traumatic experience, and psychological consequences (8-11).Because of its brutality, the war in Bosnia and Herzegovina has become the paradigm for traumatic experience, with the constant need for psychological and psychiatric help for victims long after its end. Previous research and local health care have mostly been focused on men, and preventive and therapeutic activities have targeted primarily the population of war veterans. However, there is no doubt that chronic war stress caused serious psychological problems in women in war-affected areas, although clinical experience about this problem is scarce. The reason why little is known about mental health of women in Bosnia and Herzegovina is that a relatively small number of psychotraumatized women seek psychiatric or psychological help (12). Previous research and local health care system dealt mostly with male population, which is the reason why most preventive and curative actions have been directed at veteran population. However, chronic war stress has doubtlessly had deep consequences on psychological health of women as well (13). Literature data and personal clinical experience indicate that clinical identification of PTSD is frequently hampered by gender prejudices, including the tendency to overlook traumatic nature of violence against women along with associated posttraumatic symptoms (14).The war did not affect all areas of Bosnia and Herzegovina equally. In some parts of the country, it was more intense and lasted longer than in others. The whole city of Mostar was a battlefield and suffered heavy destruction and human losses on everyday basis. Today, it is divided into Western Mostar and Eastern Mostar, and still struggles with devastated infrastructure and economic resources. On the other hand, urban areas in Western Herzegovina, although not too far from Mostar, were spared from everyday destruction and the civilian population was not directly exposed to life threatening situations. Also, postwar social and economic deprivation in that area has not been so pronounced as in Mostar.We expected that women exposed to war atrocities in Bosnia and Herzegovina would suffer posttraumatic psychological consequences and that a significant percentage of women in Mostar would develop posttraumatic disorders (PTSD, posttraumatic symptoms, and general psychological symptoms) as a reaction to traumatic experiences. We also expected that the percentage of women with posttraumatic disorders would be smaller in areas only indirectly affected by the war. Since postwar social stressors make the recovery more difficult, we also expected that women who were exposed to additional postwar social stressors would have more difficult recovery and more pronounced posttraumatic disorders.The aim of this study was to determine the degree of posttraumatic symptoms and symptoms of other mental disorders in women who were living in war-stricken areas for several years, determine the correlation between the number and intensity of posttraumatic symptoms and the intensity of psychotrauma, and establish the influence of postwar stressors on the manifestation and duration of posttraumatic and general psychological symptoms.