Mental Health Aspects
of Prolonged Combat Stress in Civilians
A National Center for PTSD
It On The National Center for PTSD Website>
Following the events of September 11th,
America braced itself for a war against terrorism. Americans have been
told by the government on several occasions to be on alert for future
attacks and have experienced widespread fear from unknown sources of
Anthrax. Several weeks after the terrorist attack, America went to war
against Afghanistan. With the onset of the war came the fear of
retaliation. These events create a prolonged
exposure to ongoing multiple incident stressors that are different from
single incident disasters as Americans report ongoing fear and threat.
What types of traumatic
do civilians experience during war?
Typically when we think about being exposed to
traumatic events during a war, we think of the experiences of the
military, for example, being fired upon, becoming a prisoner of war,
sustaining an injury, or witnessing serious injury or death. However,
civilians who are not directly involved in the war effort are also
frequently confronted with war related stressors.
Some typical civilian stressors including life
threat; being bombed, shot at, threatened, or displaced; being confined
to one's home; losing a loved one or family member; suffering from
financial hardships; and having restricted access to commodities such as
food, water, and other supplies as a result of war. Particularly
horrific stressors experienced by some civilians during war include:
torture, beatings, rape, forced labor, witnessing sexual abuse or
violence to a family member, and mock execution.
What are the effects
war-zone stressors on civilians?
Most of the evidence on the effects of war on
civilians has been conducted on refugee samples and people who were
displaced as a result of war. Relative to other war-exposed civilians,
these individuals’ experiences may be more severe due to the hardships
of not only the situations that led to their exile, but also to
stressors experienced in refugees camps and the process of resettlement.
In general, refugees exhibit high rates of PTSD and depression as well
as other psychiatric problems, particularly if they were tortured (de
Jong, Scholte, Koeter, & Hart, 2000). For example, in a survey of
Bosnians from a refugee camp in Croatia who experienced on average more
than six traumatic events, approximately one-third
had depression and one-quarter had PTSD. Twenty percent met criteria for
both disorders. Refugees with both depression and PTSD were five
times as likely to report being physically disabled, compared with
refugees with no psychiatric symptoms (Mollica et al., 1999).
PTSD and other problems are prevalent in
nonrefugee samples as well. An article featured in a recent issue of the
Journal of the American Medical Association reported on PTSD in
survivors of war or mass violence in four low-income countries in (de
Jong, et al., 2001). Rates of PTSD were 37.4% in
Algeria, 28.4% in Cambodia, 17.8% in Gaza, and 15.8% in Ethiopia. These
rates are considerably higher than the US population rate of 8% (Kessler,
Sonnega, Bromet, & Nelson, 1995). One suggested explanation for the
high rate in Algeria is that the terrorist attacks were still ongoing
when PTSD was assessed. Several risk factors for PTSD were identified,
including torture and the experience of trauma after the age of 12.
Results from refugees and impoverished countries
may be difficult to generalize to Western cultures. However, findings
from more industrialized settings such as Israel and Beirut may be
relevant. Studies from the Gulf War suggest that
there was a marked rise in stress during early weeks of the war for all
ages that dropped off within a few weeks (Milgram, 1994). For
example, data were collected on all casualties that arrived in
the emergency departments of 12 local hospitals after actual missile
attacks and false alarms. Almost 75% of admissions were for stress
reactions or unjustified atropine injections. The highest number
of psychological casualties occurred during the first two missile
attacks, after which the numbers declined (Bleich, Dycian, Koslowsky,
Solomon, & Weiner, 1992). Another study found that while approximately
half of a sample reported sleep problems during the war, there was
significant improvement 30 days after the war ended (Askenasy
& Lewin, 1996). Similar results were found in a study of following
the 1982 Lebanon-Israel war. Almost 12,000 Israelis were interviewed
regarding their mood on eleven different occasions between 1979 and
1984. Outbreak of war coincided with an increase in depression.
Depressed mood peaked at the time of the Palestinian massacre at the
refugee camps, then dropped below baseline, even though conflict
continued. Thus, many civilians respond to prolonged war with various
stress symptoms, but as time passes people seem to be resilient and
stress levels return to normal.
What are the long-term
effects of exposure to war stress among civilians?
Although most civilians who
are exposed to war stress will not develop long-term mental health
problems, some will, particularly if they have been exposed to severe
stressors. Much research on this topic has been conducted with
Holocaust survivors. In a study of 124 Jewish
Holocaust survivors, 46% met criteria for PTSD. In a community sample of
Israelis age 75 and older, 27% of male and 18% of female Holocaust
survivors met criteria for PTSD as compared to 4% percent of males and
8% of females who did not experience the Holocaust (Landau &
Litwin, 2000). Thus, it is clear that the prevalence of PTSD will
persist throughout their lifetimes. Similarly, data
from a long term follow up study of civilians in Holland 50 years after
World War II indicates that 4% of the population exposed to a war
related event has PTSD, as compared to 1.5% of non-exposed individuals (Bramsen
& van der Ploeg, 1999).
Is exposure to war
stressors in civilians
associated with physical health problems?
There is accumulating evidence that PTSD
is associated with long-term physical health problems. In terms
of the research on civilians exposed to war, there is good evidence from
an epidemiological study of civilians in Beirut that exposure
to war events is associated with higher mortality rates. Men
exposed to five or more traumas were more than twice as likely to die
than non-exposed men, while women exposed to five or more traumas were
almost three and a half times as likely to die than non-exposed women (Sibai,
Fletcher, & Armenian, 2001). In a previous study on heart disease
and wartime stressors, it was found that people with heart disease were
five times more likely to have crossed the "green-line"
(demarcation lines which divide the capital of Beirut into two sectors
and separate the belligerent parties) than patients without heart
disease heart, suggesting that there is a
relationship between heart disease and war time stress (Sibai,
Armenian, & Alam, 1989). There is also evidence that war
may effect the immune system as evidenced by a sample of women
from Croatia in which displaced women had altered psychological,
hormonal and immunological activity (Sabioncello et al., 2000).
How do children respond
to prolonged stress?
Most research on the effects of prolonged stress
on civilians has been carried out with adult samples. The literature
that is available suggests that children, just as
adults, are affected but that the majority will not suffer from long
term consequences. For example, following the period of SCUD
missile attacks in Israel during the Gulf War, children ages 10-15 were
asked to described what they thought life would be like for children
their age next year. Their dominant perception was positive (73%).
However, children who reported greater postwar reactions also held more
pessimistic views (Schwarzwald, Weisenberg, Soloman, & Waysman,
1997). Several months after the war children ages 10-15 reported that
they were more concerned about traffic accidents, relations with
friends, and their studies than with missile attacks (Greenbaum, Erlich,
& Toubiana, 1993). A one year follow up of children showed that high
school students from high risk areas reported no war symptoms, except
sensitivity to loud noises which was reported by about one fifth of
children (Klingman, 1995). As is the case with adults, children living
in refugee camps experienced more psychological problems than
non-refugee children (Paardekooper, de Jong, & Herman, 1999).
The goal of this review is to describe how
civilians respond to prolonged stress such that it might be possible to
predict the effects of the War on Afghanistan on U.S. civilians.
However, there is not a sufficient body of
research on other events that resemble the present circumstances in the
United States upon which to draw. Therefore, research on refugees
and low-income countries was reviewed as well as research on the Gulf
War. The literature on children was reviewed separately.
Overall, it appears as though while
many civilians may be impacted in the short run, the long term
expectation is that most people will be resilient. Studies on both
children and adults following the Gulf War indicated that stress levels
returned to normal shortly after the end of the war.
A consistent finding is that people
who experience more extreme stress will display more severe symptoms than
those who experience only a threat of violence or less intense exposure.
Thus, Americans who directly experienced or witnessed the terrorist
attacks, had a close friend or family member killed, or who are at
greater risk for becoming infected with Anthrax, will likely exhibit
more extreme stress responses. And, for this
subset of civilians, there reactions may be intense and long lasting. In
the event that Americans become displaced by the war (for example, as a
result of bombings taking place in the United States), it is likely that
these people will also report more extreme stress responses.
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