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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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