War creates mental suffering. Such a comment is hardly profound, but beneath the surface this statement contains much that is not obvious. What is mental suffering? How should people behave when exposed to the horror of conflict? What is normal in an abnormal situation, and what is abnormal? What expertise do I possess to address these questions? I have no direct, and little indirect, knowledge of the situation between the Israelis and Palestinians. Secondly, living in the UK, I, like most members of my generation, have had virtually no exposure to conflict, war or civil unrest. For some years, however, I have studied the psychological and physical health of members of the UK's armed forces. I have written on the psychological consequences of war and trauma, and continue to pursue a program of research in the field of war and psychiatry. Nevertheless, I approach this subject with no little humility.

Psychological Reactions to Trauma - Normal or Abnormal

The boundaries between the normal and abnormal are always problematic in mental health. We can all feel sad - that is normal. We are particularly likely to feel sad when exposed to adversity - e.g., bereavement, unemployment. Such feelings are part of being human. Some individuals react differently to the normal stresses and strains of life and become so depressed they have delusions of guilt and worthlessness and may attempt to take their own life. That is abnormal. But where do the boundaries lie?
This becomes even more complex when we consider psychological reactions not to the normal slings and arrows of fortune, but to stressors outside normal experience, (or normal from the perspective of a British university professor). How should people react to combat? To witnessing atrocities? To fearing for life and limb?
Two schools of thought have developed recently, catalyzed by the emergence of Post Traumatic Stress Disorder (PTSD) in the diagnostic canon of the American Psychiatric Association (DSM-III) in 1980. One view is that war creates psychiatric breakdown and this is an individual matter within the traditional scope of psychiatric diagnosis. Some of those "exposed" to trauma develop a long-term psychiatric disorder, namely PTSD, which has certain characteristics captured in the diagnostic canon. The argument goes that this is a universal reaction - a case of PTSD is a case of PTSD whether it arises in a British soldier returning from the Falkands War, or an American flier from the Pacific War against Japan. Some have even proposed a "universal trauma reaction", a stereotypic way in which humans respond to adversity. PTSD then is a psychiatric disorder, causing maladaptive responses in some people exposed to trauma.
Others reject this "individualization" of trauma. For them, the concept of a single disorder creates more problems than it solves. War affects society, and people become distressed, but this is not a psychiatric disorder. Sleeplessness, anxiety and hyperalertness are not abnormal; they are normal reactions in an abnormal situation. Distress is not a dysfunction. Treatment of the individual is not required, because the trauma affects an entire society. The correct responses are political and social, not therapeutic. Those who support this view react with disdain to the ahistorical concept of a "universal trauma reaction,i" viewing this as a "naïve and essentialist idea.5"

The Psychological Effects of War: A Longitudinal Perspective

Can we reconcile these positions? I will explore one particular study I consider crucial. One problem with much of the literature on this topic is that it is retrospective. People suffering distress are studied to find possible causal factors that often occurred many years ago. We must, therefore, pay particular attention to the few studies (because they are harder to conduct and far more expensive) that use a prospective longitudinal design. I draw attention to the work of George Vaillant, the undisputed master of long-term studies, who followed students attending Harvard University during World War II throughout their lives6.
The 1995 paper reported the 50-year outcome of this cohort and, despite its bias toward high socio-economic status and against ethnic minorities, it is important because of its completeness. The first thing to note is that shortly after the war, not many of the veterans had what would now be called PTSD. Only one out of the 152 veterans who served overseas clearly had PTSD and four more almost did. These five people all had very bad outcomes nearly 50 years later - two killed themselves, one was still symptomatic, one had been murdered, and one refused to have anything to do with the study. The first conclusion was that not very many of those with combat exposure developed a war-related psychiatric disorder, but for those who did, the outcome was very poor.
The next finding relates to "delayed" PTSD. Sixteen men had high combat exposure during the war, and reported no symptoms in 1946. In 1988, they still could not recall ever having had such symptoms. Other studies that assess so-called delayed PTSD also suggest this is an unusual phenomenon - what is often taken to be delay is usually delay in presentation, not experience (see 7, 8).
The third important conclusion was to be able to differentiate clearly between distress and disability. The symptoms of PTSD recorded in 1946 did not correlate with later depression, alcohol abuse or poor psychosocial adjustment. It was almost the opposite - those with high combat exposure continued to report symptoms of PTSD some 40 years later, but were also more likely to be in Who's Who in America, and enjoy a good psychosocial outcome. Although their physical health seemed worse, their mental health was not. We can see something similar in studies of civilian populations - a study in Nicaragua (Bracken and Summerfield) found very high rates of psychological symptoms and distress, which might lead the unwary to diagnose high rates of PTSD. But the majority of those with these symptoms continue to be well adjusted and function appropriately.9 A recent Israeli study could be interpreted along similar lines - high rates of symptoms and distress, but modest rates of psychiatric disorder, and low demands for treatment.10
What does this tell us? First, the importance of distinguishing between combat-related symptoms and actual disability. The men who had been in combat clearly maintained memories of it for the rest of their lives, but this did not affect their functioning and, indeed, almost certainly because of selection bias, they actually did better than those without combat exposure. My own interpretation of this study, other studies of the long-term outcomes of World War II combatants (Weisath, personal communication) and personal interviews, is that many who took part in it would never forget it and felt their lives had changed, but would equally strongly resist the suggestion they had developed any psychiatric disorder and, if asked, would do the same again.
On the other hand, the Harvard University studies also showed that those who definitely did have a psychiatric disorder associated with impairment soon after the war were a minority, but did badly.6

The Origins of PTSD and the Meaning of Trauma

Where did PTSD come from? The simple answer is the Vietnam War. This was a watershed in popular and professional understanding of the relationship between war and psychiatry. Paradoxically, it was a conflict in which the classic acute combat stress reactions were noticeable by their rarity, hence one should have expected fewer long-term psychiatric problems in returning servicemen than after the two world wars. The appearance in the post-Vietnam US of disturbed ex-servicemen became incorporated into the wider anti-war movement, and led to the introduction of a new disorder, PTSD, into DSM-III. Whether or not there was ever a real "epidemic" of psychiatric disorder in the returning service personnel is moot. Argument and counter-argument still rage. Perhaps the most balanced conclusion is encapsulated in the following quotation: "Vietnam, however, was easily America's most controversial war and, like the war itself, many claims and counter claims have been made regarding the soldiers who fought there. Perhaps paradoxically, the sheer amount of data collected may have helped sustain the controversies. So much has been written about this group of soldiers that it is possible to find data to support almost any position. Consequently, different researchers have come to opposite conclusions regarding the contemporary status of Vietnam veterans."11
I conclude that my original sentence - that PTSD is the result of the Vietnam War, is not strictly accurate. The true origins of PTSD lie in post-Vietnam America, and not the war itself.ii Why does this matter? Because so much of the ahistorical psychiatric understanding of trauma seems to assume that PTSD is an object in itself, always present, if not always recognized. Psychiatrists often vie with each other to produce ever earlier descriptions of conditions that might be PTSD - in the survivors of a Swiss avalanche in the 18th century, in the works of Shakespeare, even in Homer.
If PTSD really can only be understood as the result of a particular time and place - namely the effort of the US to come to terms with a lost war - then great caution must be exercised before assuming that PTSD is a given in any society exposed to trauma. Whatever the lessons of Vietnam, they cannot be applied uncritically to other wars, in other places, with other outcomes, let alone to whole civilian populations. I prefer to echo Glass in his comment that: "Each war produces its own varieties of psychological casualties" (quoted in 15). It is not clear that post-trauma symptoms described in other conflicts are not the same as PTSD. The symptoms of US soldiers in the American Civil War differed substantially from those we take as PTSD, while the condition of shell shock, often taken by amateur psychiatric historians to be one of the largest displays of PTSD, are manifestly not PTSD (they include altered consciousness, neurological signs, confusion, tremors, gait disorders and so oniii). Flashbacks, now seen as characteristic of PTSD, are common in traumatized soldiers from the 1991 Gulf War, but unusual among World War I psychiatric casualties, an observation that led Jones and myself to argue that cinema, in which the flashback is a powerful and simple device for organizing memory, has played a part in changing the nature of traumatic memory.18
PTSD and the Problems of Mental Health and Intervention

If there are differences of opinion about how we should comprehend distress induced by trauma, there will be similar differences about treatment. For those who view PTSD as the inevitable outcome of trauma and as a psychiatric disorder alongside depression or schizophrenia, the answer must come within the therapeutic framework, focusing on the individual. Sometimes the therapeutic approach goes beyond the individual, but remains within a conventional healing framework. The case for therapy is sometimes directed not just at treating individual psychiatric disorder, but at removing the root causes of the violence. The argument goes that traumatic experiences cause trauma symptoms, which produce a psychiatric disorder leading to abuse or violence that requires external intervention to break the cycle of trauma.
This philosophy underlies much Western aid to war-torn regions, where psychosocial aid programs, based on Western concepts of individual trauma, abound. At its crudest, practitioners look with horror on the tales of bloodshed and assume they must be accompanied by corresponding levels of PTSD. In the West, treatment of PTSD usually involves a combination of antidepressant medication and individual therapy, hence this is what is needed. If this cannot be delivered, it is because of logistical problems rather than any change in philosophy. On the other hand, there are those who have strongly criticized Western mental health aid programs, pointing out that they are rarely based on empirical evidence, are often neither desired nor requested, and are rarely rooted in local cultural practices. They are simply part of our desire to "do something" when we hear stories of humanitarian catastrophe. Many conventional aid programs are now known to have had unintended adverse consequences for local populations and it would be strange if mental health programs, even more problematic in their scope than food or relief programs, were trouble free.19 For some, these programs reflect Western thinking about trauma and distress rather than any needs of the local communities. Vanessa Pupavac, for example, has argued that in recent years, trauma victims have replaced famine victims in the Western public's imagination.20 While aid had in the past been based on political, moral or religious ideology, empathy and compassion now guide intervention.21 Recent decades have seen a major shift in our sense of what is emotionally right.22 From admiring emotional resilience, Western values have shifted to encourage emotional display. Some argue this has led to a rise in emotional distress and PTSD.iv Western mental health aid programs are as much a response to the changing views of trauma and emotion in the donor society as a considered response to the needs in the host society.23 The implicit doctrine of much Western psychiatric aid is to encourage emotional expression24 while, as Pupavac puts it, doubting resilience. One may legitimately question whether war-torn societies can afford this luxury.25

Treatment and its Failures

Mental health programs to war-torn countries are based on the assumption they improve mental health, and that if they worked in one setting, they can be assumed to be effective in another. But how effective have "donor" societies been in managing war-related trauma? The evidence for their success is not compelling. As historian Ben Shephard has illustrated, what we see is the remarkable diversity of treatment offered, and an equal diversity of claims made for success and failure. A coherent picture of therapeutic success has yet to emerge. One salutary example comes from the experience of the Veteran's Administration (VA) in the US, funded on a massive scale in the aftermath of the Vietnam War on the basis that its therapeutic services could heal the apparently traumatized veterans.
Much has been written about the VA experience but one thing is certain: Overall it was not a success. Many critics have pointed to its problems - Paul McHugh among the harshest but also most incisive: "A natural alliance grew up between patients and doctors to certify the existence of the disorder: patients received the privileges of the sick, while doctors received steady employment at a time when, with the end of the conflict in South East Asia hospital beds were emptying.26"
For whatever reason, and experiences from Israel and Croatia echo this, conventional Western psychiatric treatment used to treat other serious mental disorders - drugs, groups, therapy, inpatient facilities and so on - is not a record of therapeutic success.v
Have things changed? On the surface, perhaps. Considerable optimism is currently being expressed about the benefits of cognitive behavior therapy and antidepressants.vi The studies look impressive, but optimism has been expressed before in this field, only to be superseded by reality. Modern treatment assessment is vastly more sophisticated than that available in either world war, and perhaps modern Western psychiatry really has achieved what was not possible after the world wars, Korea or Vietnam. But as a historical perspective suggests caution, this is all the more reason for thinking carefully before exporting these treatment modalities.

Summary

Contemporary interest in post-trauma syndromes has grown dramatically. Whether people have become more susceptible to traumatic stress, or whether professionals have become more liable to diagnose traumatic stress disorders is probably unknowable. However, we should be wary of judging the past by our modern sensibilities. What can we say about the psychiatric outcome of war-related trauma? Evidence from long-term studies remains conflicting. In part, this is a result of methodology variations; early studies tended to be unreliable because of subjectivity and the absence of proper controls, while later investigations were flawed by the non-random selection of subjects and flawed evidence collection.
War changes you. Looking solely from the perspective of the soldier, of all possible adverse events, combat is the most easily remembered, and the most subjectively traumatic.31 Exposure to combat has a long-term deleterious effect on physical health. Its effect on mental health is more variable. Perhaps no one ever forgets. For a few, it is associated with the best years of their lives - afterward life becomes dull.32 For many, it remains an unpleasant memory, never forgotten, but also not interfering with a person's ability to function normally. Finally, for others, it is clearly associated with long-term psychological disorder.
The greater the intensity and duration of combat, the greater the chance of persistent psychiatric disorder. Those who participated in the most bitter fighting appear to suffer most in terms of psychiatric disorders, the ability to work effectively and maintain stable relationships. Even then, pre-service family and medical history can exercise an important predisposing effect. If people are affected by their war experiences, it usually starts early and lasts a long time. "Delayed" symptoms are more likely to reflect either a delay in seeking help or the exacerbation of continuing symptoms rather than genuine delayed onset. The longer the interval between war and the onset of symptoms, the harder it is to ascribe causality to the former. Psychiatric casualties who do not respond well to immediate treatment and whose symptoms become chronic do not have a good prognosis. Some post-combat syndromes do not recover with the passage of time, despite therapeutic interventions.
What can we conclude about the nature of PTSD? Is it really a valid psychiatric entity found across time and culture, representing a predictable but abnormal response to trauma? Or is it a Western, culture-bound syndrome, created to heal America's guilt over the Vietnam War and to assist in converting the perpetrators of violence into victims? Or is it a pathologization of normal distress? The truth lies somewhere in the middle. It seems to me that PTSD is substantially overdiagnosed. When we read that the majority of the inhabitants of New York City suffered PTSD in the aftermath of the September 11 attacks, the psychiatric concept has been stretched beyond any value and we are confusing normal distress with psychiatric disorder.

Conclusion

It seems likely that within war-affected populations (military or civilian), psychiatric labels can be appropriate, and indeed helpful, for those whose basic ability to function is affected and who might, indeed, be suffering from psychiatric disorders, requiring individuated treatments. But these individuals must be seen in the wider context. The finding that war changes all it touches does not mean everyone will develop psychiatric disorders, nor does it imply that Western-based psychiatric interventions are necessary or helpful. War is a politically driven social cataclysm affecting populations, and our responses must similarly be politically informed, population-based and locally determined.


i See 1. Bracken P. Post-modernity and post-traumatic stress disorder. Social Science and Medicine 2001; 53:733-743. and 2. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal 2001; 322:95-98. for clear articulations of this position, and 3. De Vries F. To make a drama out of trauma is fully justified. Lancet 1998;3351:1579-1581. and 4. Mezey G, Robbins I. Usefulness and validity of post-traumatic stress disorder as a psychiatric category. British Medical Journal 2001;323:561-563. for immediate rejoinders.
ii See 12. Young A. The Harmony of Illusions: Inventing Post-traumatic Stress Disorder. Princeton: Princeton University Press, 1995. for a seminal anthropological account of the origins of PTSD, and both Fleming and Scott 13. Fleming R. Post Vietnam Syndrome: Neurosis or Sociosis? Psychiatry 1985;48:122-139. 14. Scott W. PTSD in DSM-III: A case in the politics of diagnosis and disease. Social Problems 1990;37:294-310. for discussions of how the origins of PTSD lie in the anti-war movement in the US.
iii See 16. Micale M. Lerner P. eds. Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1860-1930. Cambridge: Cambridge University Press, 2001. For an authoritative historical account of the different experiences, manifestations and meanings of trauma in the different countries that were involved in the World War I, and 17. Shephard B. A War of Nerves, Soldiers and Psychiatrists 1914-1994. London: Jonathan Cape, 2000. for a comparative review of the psychological impacts of the wars of the 20th century on combatants.
iv It is essentially unknowable whether or not PTSD really has increased in modern society - but what cannot be disputed is that the use of the concept, the frequency of the diagnosis, and discussion of trauma and its effect, has all dramatically increased in the last two decades.
v See 27. Shalev A. Treatment of prolonged post traumatic stress disorder - learning from experience. Journal of Traumatic Stress 1997;10:415-422.and 28. Creamer M. M. Philip L. P; Biddle, Dirk; Elliott, Peter. Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: a cause for cautious optimism? Journal of Traumatic Stress 1999;12:545-558. for a balanced, but modestly more optimistic, view.
vi For a magisterial review 29. Foa E. Keane T. Friedman M. Guidelines for Treatment of PTSD. Journal of Traumatic Stress 2000;13:539-588, 30. Foa E. Keane T. Friedman M, eds. Effective treatments for PTSD. New York: Guildford Press, 2000.

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