War Related Trauma

War Violence

  • Immediate effects (occur during battle/severe stressors):
    • Continuous circulating norepinephrine, epinephrine, and cortisol (stress hormones) keep the body in a constant alarmed state (e.g., jumpiness, hyper vigilance, sleep disruption, appetite suppression). Soldiers are purposefully taxed in order to remain alert and prepared.
    • “Battle fatigue” can be treated and mitigated through debriefing after combat, keeping the unit cohesion, and returning soldiers to fighting as soon as possible.
    • Some features of severe incapacitating war-zone stress reactions may include severe restlessness, agitation, withdrawal from others, stuttering, confusion, nausea, vomiting, and suspiciousness. In general, symptoms are considered “severe” if they persistently interfere with adequate performance in combat.
    • It can be difficult to identify normal versus pathological reactions to war stress.
  • Acute adaptation (spans from when soldier is objectively safe until one month in U.S.):
    • Many soldiers who initially display distress gradually adapt and recover normal functioning during the months returning home from combat.
  • Chronic phase (lifetime debilitation): [1] [2] [3]
    • Often soldiers with chronic impairment are diagnosed with posttraumatic stress disorder (PTSD).
    • Symptoms can be delayed and develop months or years later.
    • Those with chronic PTSD are at greater risk for developing depression, substance abuse, aggression, and other disorders.
    • The prevalence and risk of PTSD is high and increases with risk factors including gender, age, relationship status, prior combat exposure, and prior interpersonal trauma [4] [5] [6].
    • There is a higher incidence for PTSD in those experiencing combat and/or assault in general population (N = 2493) [7].
    • Combat veterans with PTSD may have higher rates of aggression than adults with non-combat PTSD. The prevalence of violence among individuals with PTSD ranged from 7.5% among United States adults to between 8.6% – 19.5% among post-9/11 United States veterans.
    • Combat veterans:
        • Experience the highest rate of PTSD (41.8%) compared to other traumatic events [9],
        • are seven times more likely to meet criteria for PTSD compared to other traumas [9],
        • are 4.5 times more likely to have delayed onset of PTSD [9],
        • and have higher rates of substance abuse than others with non-combat PTSD [1] [2] [3].
    • In the United States, the Department of Veterans Affairs provides two evidence-based psychotherapies for PTSD throughout the entire VA health care system. These two treatments are Cognitive Processing Therapy and Prolonged Exposure Therapy [10].

Refugee Trauma [11] [12]

  • There is an estimated total of 51.2 million individuals forcibly displaced worldwide due to persecution, conflict, generalized violence, or human rights violations [8].
  • Traumatic experiences include, but are not limited to, war violence, forced isolation, torture, threats to life (individual and family members), and rape.
  • Rates of PTSD in refugee populations range from 4% – 86%.
  • There is a challenge of culturally-relevant treatment.

[1] Corrigan, P. W., & Watson, A. C. (2005). Findings from the National Comorbidity Survey on the frequency of violent behavior in individuals with psychiatric disorders. Psychiatry Research, 136, 153-162.

[2] Elbogen, E. B., Johnson, S. C., Wagner, H. R., Sullivan, C., Taft, C. T., & Beckham, J. C. (2014). Violent behaviour and post-traumatic stress disorder in US Iraq and Afghanistan Veterans. British Journal of Psychiatry. Advance online publication. doi: 10.1192/bjp.bp.113.134627

[3] MacManus, D., Dean, K., Jones, M., Rona, R. J., Greenberg, N., Hull, L., Fahy, T., Wessely, S., & Fear, N. T. (2013). Violent offending by UK military personnel deployed to Iraq and Afghanistan: A data linkage cohort study. Lancet, 381, 907-917. 

[4] Wolfe, J., Erickson, D. J., Sharkansky, E. J., King, D. W., & King, L. A. (1999). Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis. Journal of Consulting and Clinical Psychology, 67(4), 520.

[5] Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs Health Care, 2002–2008. American Journal of Public Health, 99(9), 1651.

[6] Polusny, M. A., Kumpula, M. J., Meis, L. A., Erbes, C. R., Arbisi, P. A., Murdoch, M., … & Johnson, A. K. (2014). Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan. Journal of Psychiatric Research, 49, 1-9.

[7] Helzer, J. E., Robins, L. N., & McEvoy, L. (1987). Post-traumatic stress disorder in the general population. New England Journal of Medicine, 317(26), 1630-1634.

[8] UNHCR. (2013). Global Trends 2013. Retrieved from http://www.unhcr.org/5399a14f9.html#_ga=1.261748494.2079002410.1409240285

[9] Prigerson, H. G., Maciejewski, P. K., & Rosenheck, R. A. (2001). Combat trauma: Trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. The Journal of Nervous and Mental Disease, 189(2), 99-108.

[10] Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., … & Foa, E. B. (2010). Dissemination of evidence‐based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Traumatic Stress, 23(6), 663-673.

[11] Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365(9467), 1309-1314.

[12] Bolton, E. (2015). PTSD in refugees. Retrieved from http://www.ptsd.va.gov/professional/trauma/other/ptsd-refugees.asp