431

The Prisoner of War

Chapter 17

THE PRISONER OF WAR

ROBERT J. URSANO, M.D.* AND JAMES R. RUNDELL, M.D.†

INTRODUCTION

THE PRISON EXPERIENCE

Nature of Captivity

Adaptation and Coping

Social Isolation

Psychiatric Symptoms During Captivity

RESISTANCE

SEQUELAE OF THE POW EXPERIENCE

Medical Illness

Psychiatric Illness

Personality Change

PREDICTORS OF PSYCHIATRIC DISTRESS

Severity of Captivity

Predisposition

Social Supports

READJUSTMENT

Repatriation and Reintegration

Organizers in Adult Personality Development

Recovery

TREATMENT OF POSTREPATRIATION ILLNESS

Medical Disorders

Psychiatric Disorders

FAMILY ISSUES

SUMMARY AND CONCLUSION

*Colonel (ret), United States Air Force, Medical Corps, Flight Surgeon; Professor and Chairman, Department of Psychiatry, Uniformed Services

University of the Health Sciences, Bethesda, Maryland

†Major, United States Air Force, Medical Corps; Chief, Consultant Liaison of Psychiatry, 89th Medical Group/SGHA, Andrews AFB, Maryland;

former Consultant for Psychiatry, Office of the Surgeon General; Associate Professor, Department of Psychiatry, Uniformed Services

University of the Health Sciences, Bethesda, Maryland
War Psychiatry

432

Artist Unknown Prisoner Interrogation circa 1943

This sketch is part of an extensive collection of captured German art from World War II in the possession

of the U.S. Army Center for Military History. It graphically depicts the questioning of barefoot prisoners

of war in what appears to be an underground bunker.

Art: Courtesy of US Army Center of Military History, Washington, DC.
433

The Prisoner of War

INTRODUCTION

That trauma can be accompanied or followed by

psychiatric sequelae is well-established.1–4 The degree of severity of a traumatic event is positively

associated with potential for psychopathology.3,5–9 This

is not a one-to-one association, however. Social

supports, cultural variables, and personality also

play roles. The prisoner of war (POW) experience can

be one of the most traumatic situations in human

experience. The study of coping during captivity, as

well as psychological health and pathology following repatriation, has implications for psychiatric

planning for future wars and for treatment of other

stressor-related psychiatric illnesses. In this chapter, the literature on the psychiatric effects of the

POW experience, coping behaviors, psychiatric

symptoms during imprisonment, psychiatric

sequelae after repatriation, etiologic factors producing postrepatriation psychopathology, treatment of

the psychiatrically ill former POW, and the effects of

imprisonment on the family will be reviewed.

THE PRISON EXPERIENCE

Nature of Captivity

There is no one POW experience. For example,

the average duration of POW imprisonment during

the Vietnam conflict was substantially longer than

during World War II and the Korean conflict. Many

POWs were held captive in Vietnam for 6 to 7 years.

In addition, the severity of conditions was greater

in World War II Pacific Theater POW camps than in

European Theater prisons.10–16 In contrast, the POW

experience in the Persian Gulf War was generally

no more than 30 days with some, but not all, POWs

experiencing torture and others fearing death from

bombings by the Allies. It is important to remember

that repatriated POWs are a subset of those who are

lost, captured, and imprisoned. They are the survivors. Nothing is known about the group that never

returned. The nature of captivity plays an important role in determining psychiatric responses both

during imprisonment and following repatriation.

The types of stressors to which POWs are exposed

are dependent on the cultural and socioeconomic

status of the captors, the geography, the climate,

endemic diseases, the circumstances of capture (aircrew ejection, large group surrender, etc.), the political climate, and the degree of resistance offered

by the POW.17 The degree of stress caused by these

experiences depends on the physical conditions,

the psychological experience, degree of maltreatment, interpersonal issues, and the individual and

cultural appraisal of events.18 The role of culture

itself as a stressor is frequently overlooked.18 Exposure to a country with limited resources, different

rules of interpersonal and group relations, and different day-to-day personal and work habits can be

stressful regardless of any intent to deprive or demean a captured soldier.

In order to describe and quantify the stress factors of the Vietnam-era POW experience, Ursano

and colleagues reviewed debriefing reports and

medical questionnaires completed by repatriated

Vietnam-conflict POWs immediately after release.5

One section of the medical questionnaire included

questions on the methods used by the North Vietnamese to control the prisoner’s behavior. Each

question was answered on a four-point scale that

ranged from “never” to “very often.” Debriefing

reports were coded for frequency and type of maltreatment. Using a factor analytic technique, seven

stress factors were identified: (1) psychological maltreatment, (2) physical torture and maltreatment,

(3) solitary confinement, (4) interrogation, (5) threats

and denials of privileges, (6) high resister status,

and (7) duration of maltreatment.

The acute and chronic stresses of captivity must

be differentiated. At times, the difference has been

referred to as stress (acute) and strain (chronic).

Basic animal studies highlight this distinction.

Young hamsters separated from their mothers (acute

stress) will initially display hyperarousal and make

a “separation call.” This is eventually followed

(chronic stress) by withdrawal and absence of a

separation call.19 Cassem and Hackett have reported a similar pattern of psychological response

in humans following the specific stressor of myocardial infarction.20 An initial period of anxiety and

autonomic hyperactivity is followed by withdrawal

and neurasthenia.

Readily reversible hyperarousal is a common

initial reaction in combat.21 In contrast, a consistent
War Psychiatry

434

observation in men exposed to chronic combat is

neurasthenia, withdrawal, defeatism, and isolation.

A neurasthenic appearance in POWs after prolonged

captivity was described22 by Greenson in World

War II POWs23 and by Strassman in Korean conflict

POWs.24 Both noted an apathy syndrome that was

felt to be adaptive in the POW environment. Withdrawal and detachment increased the chances of

survival. In this way, energy was conserved and the

POW was less likely to stand out, challenge the

captors, and elicit threats and torture.

Looking at Minnesota Multiphasic Personality

Inventory (MMPI) measures, Ursano et al25 found

that withdrawal and detachment were related to

successful coping only in the high but submaximal

stress Vietnam-conflict POW group (those captured

after 1969). In the maximum stress group, withdrawal and apathy were also present but they were

not predictive of successful coping. In this maximum POW stress group, denial, repression, and

suspiciousness were associated with better coping.

This suggests that cognitive coping strategies may

be important in maximal stress settings after withdrawal from the environment has been attempted.

With the passage of time, withdrawal and neurasthenia may be less helpful and other strategies such

as fantasizing and pondering family concerns more

useful.26

The stages of the POW captivity experience are as

follows: capture, imprisonment, confinement,

repatriation, and reintegration. Each stage has

unique stressors.27,28 For instance, at the time of

capture, POWs must gain quick emotional control,

deal with fears of death, and attend to the tasks

necessary for survival. Expectations of rescue fade

quickly after removal from the capture site; usually

the prisoner is bound and/or blindfolded. A sense of

disbelief may result from the rapid sequence of

events and the radical change in roles from combatant to captive.

The phase of imprisonment includes the initial

“breaking-in” and transport to the final confinement site. The POW is forced to adapt to a lower

plane of existence and becomes aware of losing

his usual supports and prestige. Feelings of longing for freedom, wishes for sympathy, dissociation, and fantasizing about home or retaliation

are common in this phase. This is also the period

of hyper-vigilance, alertness, orienting to sur

roundings, and attending to detail. The last two can

form the basis of a reassuring sense of familiarity

over time.

The third phase of the POW experience, confinement, is characterized by exploitative interrogations, confessions, isolation, boredom, demoralization about the uncertainty of the situation, and the

need to make decisions regarding resistance and

compliance. The hypervigilant state is replaced by

apathy, dysphoria, and gradual movement toward

accommodation to the situation. During this long

phase, POWs often engage in self-developed physical fitness programs, group communication, resistance, humor, creativity through projects and fantasies (learning a language, collaboration, fantasizing

about the future, planning escape or sabotage), and

also helping other POWs.

The period of repatriation and the subsequent

life-long process of reintegration have unique stressors and adaptational strategies as well. They are

discussed later in the chapter.

Adaptation and Coping

The stressors of the POW environment are many;

often they are terrifying and inhuman, and always

they are filled with the unexpected29,30 as is shown

in Exhibit 17-1. Biological stressors can be extreme

and vary with both the geographic location and the

demeanor of the captors. Psychological stress, including social isolation, is variable. Physiologic

stress and emotional duress were both significantly

higher in POWs held captive in the Pacific Theater

during World War II than in POWs held in

the European Theater. Maltreatment is directly

related to the extent to which an enemy country sees

the POW as politically valuable. In Vietnam, after

1969, conditions improved and torture and maltreatment of the POWs decreased. This change

corresponded with the recognition by North Vietnam that the POWs could be an important political

tool.

Survival during the POW experience is most

related to the degree of injury at the time of capture

and the availability of food, shelter, and medical

care. For example, 4% of Canadian POWs in World

War II died in European prison camps and 27% in

the much worse Pacific prisons.31 The conditions of

captivity are strongly influenced by the nature of

the combat prior to capture, the economic conditions of the enemy, and whether the POW is seen as

politically valuable. Though not all POW experiences are comparable and a single POW experience

varies with time, it appears that personality flexibility positively influences survival potential and

adaptability. Rigidity is less adaptive. It is not clear

whether coping behaviors during captivity affect

postrepatriation psychopathology. Ursano25 found

no relationship between postrepatriation psycho-
435

The Prisoner of War

EXHIBIT 17-1

STRESSES OF CAPTIVITY

Physical

Crowding

Diarrhea

Epidemic diseases

Exhaustion

Forced labor

Infectious organisms

Injuries

Medical experimentation

Nutritional deprivation

Sleeplessness

Torture

Weather extremes

Wounds

Psychological

Boredom

Close long-term affiliation

Confinement

Danger

Family separation

Fear/terror

Guilt

Humiliation

Isolation

Threats

Unpredictability

pathology and resistance stance, “marginal coping” during captivity, or feeling benefited from the

POW experience after return.

Exhibit 17-2 summarizes POW coping behaviors.14,21,22,28–39 Nardini’s10 experience with many of

the 12,000 surviving World War II Pacific Theater

prisoners of war of the Japanese led him to conclude

that there were several attributes that allowed these

12,000 men to survive (there were another 18,000

who did not survive). These included: strong motivation for life, good general intelligence, good constitution, emotional insensitivity or well-controlled

and balanced sensitivity, preserved sense of humor, strong sense of obligation to others, controlled

fantasy life, courage, successful resistance, opportunism, military experience, and luck.

The POW’s personality also affects adaptation

and coping. In the crew of the USS Pueblo, held by

North Korea in 1968, immaturity, passive-dependency, and obsessive-compulsiveness were associated with poor adjustment.1

 Ford and Spaulding40

examined crew members of the Pueblo just after

their release. Men who did well during captivity

often had personalities described as “healthy” or

“schizoid.” They used a wide variety of ego defenses, particularly faith, reality testing, denial, rationalization, and humor. Men who handled the

stress poorly were frequently diagnosed as being

passive-dependent and were more limited in the

number of ego defenses they used.

Schizoid behavior and introversion have been

reported to be more adaptive than obsessive-compulsive, passive-dependent, or immature behaviors.1,31 Passive-dependency has been singled out as

a particularly maladaptive response.1,31,41 Induction of dependency is advantageous to camp leaders in imposing their will.41 The psychological state

of the POW during captivity has been described as

dependency, debility, and dread (DDD).42 Identification of adaptive personality characteristics requires further study. It is clear that personality

resiliency and the ability to tolerate passivity is

positively related to optimal adaptation.43-45

Jones38 reviewed six books written by former

POWs who had been held in North Vietnamese

prison camps. He identified coping strategies that

sustained the POWs during imprisonment, all having in common that each man had a standard of

behavior he set for himself. Ideals that were commonly reported as sustaining were: (a) loyalty to

country (remembering their heritage, focusing on

their patriotic duty to resist), (b) idealizing their

family (hoping to return with a feeling of having

been worthy of them), and (c) alliance with fellow

prisoners (communications, mutual support, cooperative resistance).

Maintaining military bearing32 is reported to be

an important adaptive behavior. During the Vietnam conflict, identification with military ideals

unified POWs in spirit and in their determination.

The chain of command formalized and solidified

the prisoner society in the camps. The need for

internal security became more important as the

need for communication privacy grew within the

POW system. The Military Code of Conduct, which

was modified after the Vietnam conflict, provided

guidelines for the prisoners of war.

Probably the single most important adaptive behavior in all POW situations is communication.

During the Vietnam conflict, a tap code was devel-
War Psychiatry

436

EXHIBIT 17-2

PRISONER OF WAR COPING MECHANISMS

Emphasizing the Greater Good

Caring for another

Feeling closer to God

Focusing on the good

Loyalty to country/family/POW group

Motivation for life

Survival for some purpose

Defenses

Denial

Humor

Intellectualization

Obsessional thinking

Rationalization

Relationship to Captors

Collaboration

Cultivating relationships with captors

Resistance

Study guards’ habits and use the knowledge to

gain favor

Withdrawal

Social

Buddy system

Chain of command

Code of conduct

Communication

Group activities

Group affiliation

Military experience

Peer pressure

Withdrawal

Conscious Efforts

Acceptance of fate

Communication

Control of panic

Discipline

Flexibility

Maintaining self-respect

Maintaining military social structure

Physical fitness

Realistic expectations

Repetitive behaviors

Rituals

Self-development activities

“Talking to family”

Well-controlled sensitivity

Will to live

Psychological/Fantasy

Apathy

Dissociation

Fantasies of retaliation

Fatalism

Hope

Idealized expectations of post-release life

Introversion

Passive-dependence

Personality flexibility

Psychological regression

oped using a 5 X 5 arrangement of the alphabet (the

letter k was not used). The row and column of a

letter could then be communicated. Ingenious

mechanisms were used to spread messages. Coughing, sweeping, and tapping were all important means

of using the code. Additionally, the ability to express one’s rage in hidden forms—the now historic

picture of the Pueblo crew demonstrating a common American gesture of contempt—can provide

release from pent-up rage and hostility. There is a

fine line, however, between appropriate resistance

and provocative resistance (eg, resistance that unnecessarily increases torture and maltreatment).

Such poor-coping high resisters often feel they must

never comply even to trivial requests. They can

bring torture on themselves and their comrades.

Social Isolation

Social isolation and solitude, usually with darkness and silence, are prominent aspects of the POW

camp experience. These experiences can greatly
437

The Prisoner of War

contribute to the traumatic stress of captivity.3 Psychological aspects of isolated living in the Antarctic

and other contained environments can shed some

light on the POW’s social isolation, although there

are important differences. The most important difference is that the Antarctic experience is voluntary

and the POW experience is not.

Participant observers in expeditions to the Antarctic report that social issues are more important

than environmental ones in maintaining the well

being of the crew. For example, in one study, the

individual’s adjustment to the group, the “sameness”

of the environment, and the absence of social supports were each more significant than coldness,

danger, and other environmental hardships in determining psychological adjustment.46 The number

of sexual remarks made by Antarctic crew members

correlated with marital status.47 The order of frequency of sexual remarks were most frequent in

those who were separated, followed by newly married, bachelors, and happily married (high to low).

Singer39 reviewed journalistic accounts written

by former Vietnam-era POWs who had spent a

great deal of time in solitary confinement. Several

mental phenomena were prominent: (a) propensity

to review one’s life with remorse and guilt, (b) recall

of the past in vivid detail, (c) recall of unused

academic or intellectual training, (d) extraordinarily vivid dreams with prolonged recall upon awakening, (e) intense, vivid, long-enduring fantasies

(sometimes lasting days), and (f) a splitting of attention and awareness.

The firmer a POW’s resistance stance, the more

time is spent in isolation. In Vietnam, the greater

the POW’s duration of isolation, the greater the risk

of resulting psychopathology.33,48 Cause and effect

relationships, however, are unclear. Resistant,

higher ranking, and older POWs spend more time

in solitary confinement and are tortured more often

because of their leadership and resistance activities.

However, it may also be true that individuals whose

personality allows them to survive prolonged solitary confinement are more likely to maintain persistent resistance.

The relationship of social isolation to postrepatriation psychiatric morbidity has been considered

by several authors. However, it is difficult to separate out the unique contributions of any one stressor to the development of psychopathology. High

social isolation correlates with greater captivity

stress in general. Ursano5

 and Hunter6 both report

greater rates of psychopathology among those POWs

who spent the greatest time in solitary confinement.

Hunter examined 100 former Vietnam conflict POWs

and concluded that no definitive statement could be

made as to any specific psychiatric disorders resulting from social isolation. However, it was found

that former POWs from Vietnam who experienced

prolonged periods of isolation had significantly

more guilt, ambivalence, suggestibility, superego

development, and need for achievement than other

former POWs.49–52

Psychiatric Symptoms During Captivity

Many psychiatric signs, symptoms, and defense

mechanisms have been reported by POWs retroEXHIBIT 17-3

PSYCHIATRIC SIGNS AND SYMPTOMS

RETROSPECTIVELY REPORTED BY

PRISONERS OF WAR

Anxiety

Appetite loss

Boredom

Confusion

Decreased communication

Defeatism

Dependency

Disorganized self-concept

Dissociation

Dysphoric mood

Fear

Guilt

Hyperarousal

Hypersomnia

Hypervigilance

Hypoarousal

Hyporesponsiveness

Hyposomnia

Identification with aggressor

Neurasthenia

Out-of-body experiences

Panic

Regressive behavior

Resignation

Startle response

Suicidal ideation

Weight loss
War Psychiatry

438

spectively during debriefings. The distinction between an adaptive coping response and a psychiatric symptom may not be clear. Some POWs experience psychiatric symptoms that may lessen their

survival chances, increase their suffering, or lay the

groundwork for postrepatriation psychopathology.

Symptoms such as anxiety, boredom, and dysphoria

are common (Exhibit 17-3).1,2,22,27,28,31,37

The prevalence of psychiatric diagnoses in POWs

during imprisonment is unknown. Some prisoners

do appear to meet criteria for major depression.

Anxiety disorders are common. Anticipatory or

conditioned anxiety may evolve into panic attacks

or an exaggerated startle response. Slightly more

than one half of the crew of the Pueblo admitted to

significant anxiety or depression during captivity.1

Psychotic withdrawal has also been reported.53

Organic mental syndromes are of substantial concern. These may be the result of head trauma

during aircrew ejection or torture, food and water

deprivation, or untreated physical illnesses such as

infections.

In Vietnam- and Korean-conflict POWs, high resistance was seen more often among those who

were older, held captive longer, experienced longer

periods of solitary confinement, and received

harsher treatment by captors.33,48 The high resister

may also provoke more mistreatment. For example,

in Vietnam, POWs who resisted the Oriental custom of bowing were severely punished. In general,

these individuals had difficulty adjusting to the

need to be passive and compliant. Their rigidity

sometimes made life more dangerous for their fellow prisoners as well.

In 1957 Schein54 examined 759 POWs shortly

after repatriation from Korean prison camps. He

compared men who (a) collaborated, (b) actively

resisted, and (c) took a neutral course. Both resisters and collaborators had significantly longer internments, had been in service longer, were older,

and more intelligent. Additionally they showed

more psychopathic deviance (Pd scale of the MMPI).

Resisters and collaborators, however, did not differ

significantly from one another. No differences

among the groups were found in rank, civilian

occupation, religion, location of home community,

or number of parents present in the home.

Singer55 studied collaboration and resistance after the Korean conflict using projective psychological testing. She reported the counter-intuitive finding that resisters and collaborators were more alike

than different. Both showed less capacity to remain

uninvolved with the environment. She suggested

that what distinguished resisters and collaborators

was not individual variables but rather which group

they chose to attach to.

Ursano et al25 identified high resisters in the

maximum stress group of Vietnam U.S. Air Force

POWs. The high resisters were older, more senior

in rank, pilots, and had spent more days as a prisoner. Using MMPI data, the high resisters showed

greater energy, were more outgoing and extroverted,

and showed less repression, constraint, and denial.

In addition, the high resisters were more likely to

experience conflict with authority, be more independent, and less socially conforming. In general,

therefore, the high resister tended to be independent, energetic, less likely to bind his energy through

cognitive mechanisms, and less attached to the

group. These findings are in agreement with those

from the Korean conflict.55,56

In a study of Vietnam era POWs, Hunter and

Phelan,9 found that only one of several personality

traits, need for achievement, correlated with resistance posture. Ursano et al25 examined high resisters who were successful and those who were unsuccessful based on peer ratings (“marginal copers”).

They showed that the unsuccessful high resister in

Vietnam was similar to the successful high resister

demographically but had a greater need to dominate. The unsuccessful high resister was more like

the “marginal coper” group. These findings highlight the utility of separating high resisters into

successful and unsuccessful groups as identified by

their peers. Future studies should distinguish the

“good” high resister and the “poor” high resister

who might be compelled to resist and put others at

risk.

During the Korean conflict, the concept of “brainwashing” received a great deal of attention with

prisoners of the Chinese communists. At the time,

the common opinion was that the communists were

adept at, and scientific about, inducing collaboration. Some individuals, even after release from

Chinese prisons, continued to repeat false confessions, insist on their guilt, praise the justice and

leniency they had received, and expound communist doctrine.57 During the Vietnam conflict, no

repatriated POWs could clearly be identified as

collaborators in the same sense as the Korean conRESISTANCE
439

The Prisoner of War

flict with the exception of one U.S. Marine who

voluntarily remained in Vietnam for several years

after the war ended.

The term, “brainwashing,” has a mystical, magical quality to it. Even when the concept was popular, there was a call for replacing the term with a

more elaborate model of interrogation and indoctrination.58 Many of the “brainwashing” reports of the

era are so emotionally charged they are worthless in

expanding scientific knowledge about collaboration.54 Emotionally laden reports appeared on both

ends of the opinion spectrum, some maintaining

that no one could resist Chinese brainwashing techniques and some saying that individuals who collaborated with the enemy to any degree were cowards. Extensive study by Segal and others33 showed

there was no magical “brainwashing.” The term,

“coercive persuasion,” was subsequently adopted

and is more descriptively correct. Productive studies of collaboration and resistance as psychological

and interpersonal processes developed from this

debate.

Collaboration (and resistance) is a continuum of

behaviors, not an all-or-none phenomenon. POWs

collaborate in varying degrees. Most commit trivial

acts such as signing peace petitions. A small number may engage in more persistent behaviors such

as writing, signing, and soliciting signatures for

peace petitions, delivering anti-American lectures

to fellow prisoners, or aiding in indoctrination programs.56 Those POWs who collaborate with the

enemy do so in part to eliminate the threat of mistreatment and to receive the benefits of preferential

treatment.33

The concept of collaboration has limited utility

except in extreme cases. In Vietnam, all POWs were

“broken.” For most, this was a profoundly guiltinducing experience. As a result of the recognition

of every individual’s breaking point, new strategies

to resist interrogation were based on repetitive fallback positions and giving minor nonsignificant information when resistance was no longer possible.

Part of the importance of the communication network and of the military organization in the POW

camp was its ability to provide relief from guilt

through knowledge that others had broken. In

addition, communication fostered the development

of guidelines on resistance stance.

The captor’s goals are important in determining

how POWs are treated. Disrupting the POWs’ organizations and their military command through the

isolation of prisoner leaders and commanders decreases the POWs’ sense of unity and ability to

buffer stress and develop coping strategies. Inducing dependency, debility, and dread (DDD)42 in the

individual POW further produces hyporesponsiveness, disruption of time-spanning processes,

and disorganization of the self-concept. These may

render the prisoner more susceptible to the captor’s

influence and demands.

Medical Illness

The first follow-ups of World War II POWs by

Cohen and Cooper12 found significantly greater

mortality in Pacific Theater prisoners primarily due

to accidents and tuberculosis. No excess mortality

was seen in the European group. Gastrointestinal

disorders, psychological problems, ophthalmic

changes, cardiac disorders, and the effects of malnutrition and tuberculosis were also noted. Similar

increased mortality rates were reported in Australian Pacific Theater POWs.13 The next study by

Nefzger,14 in the mid-1960s, showed that the early

excess mortality was decreasing in the Pacific group.

However, Korean conflict POWs still had excess

mortality.

In the mid-1960s, Beebe, using both records and

questionnaires, assessed medical and psychiatric

morbidity in the same World War II and Korean

POWs.11 The U.S. Army veterans taken prisoner in

SEQUELAE OF THE POW EXPERIENCE

the two World War II theaters of action and in the

Korean conflict were compared to each other and to

controls on the number of hospital admissions between 1946 and 1965 (1954–1965 for Korean conflict

POWs), as well as the number of symptoms, amount

of disability, and psychosocial maladjustment in

1966 to 1967. Sequelae of the POW experience were

found to be both somatic and psychiatric, and were

greatest in Pacific Theater POWs. In European

Theater POWs, only psychiatric sequelae were apparent in 1966 to 1967. In the 1970s follow-up,

Keehn15 found no excess mortality.

Although somatic problems were most prevalent

in the early years after liberation,11 they persist even

today for Pacific Theater veterans.59 Tennant found

higher rates of duodenal ulcers in former Pacific

Theater POWs than in a group of noncombat controls, even at 40 years after World War II.60 This

excess medical morbidity correlates with reported

weight loss and nutritional deficiency syndromes
War Psychiatry

440

during the POW period. Current nonspecific somatic symptoms, such as fatigue, are more common

in World War II Pacific Theater POWs and in Korean conflict POWs than in non-POW veterans of

the same eras.11 Throughout these studies, the psychiatric signs and symptoms remained the more

persistent postliberation findings for both Pacific

and European groups.

The findings of greater psychiatric than medical

morbidity and the differences between Pacific

and European Theater POWs were also evident

when Veterans Administration (VA) disability

award trends, hospital admission rates, and responses on the Cornell Medical Health Index were

examined.

There has been considerable debate over the potential etiologic significance of organic factors in

post-traumatic psychiatric disorders of POWs

and concentration camp survivors. The term,

“concentration camp syndrome,” was used to describe concentration camp survivors who show

emotional lability, dysphoria, depression, anxiety,

insomnia, nightmares, intellectual deterioration,

and/or neurasthenia. Eitenger proposed that while

psychosocial factors are important in the etiology

of these symptoms, nutritional deficiencies,

head trauma, infections, etc. also play an important

role in reducing the resiliency of the brain, decreasing the ability to cope flexibly with captivity, and

to recover normally.61 However, he was examining concentration camp survivors who suffered the

most extreme deprivation. Most POWs, except

some in the Pacific Theater in World War II, did

not suffer the extreme levels of deprivation of the

concentration camp. There is both considerable

agreement62,63 and disagreement61,64,65 over the degree to which biological factors should be emphasized. No findings supportive of the “KZ (concentration camp) syndrome” were seen in Vietnam-era

POWs.66 It appears most likely that the “KZ syndrome” symptoms of organic impairment are related to the most extreme malnutrition and physical

trauma that were seen in the concentration camps of

World War II.

Psychiatric Illness

Psychiatric responses to the POW experience include a number of disorders as well as less well

defined personality changes.44,67,68 In the following

section, the psychiatric responses seen in POWs are

briefly reviewed.

Post-Traumatic Stress Disorder

The fact that traumatic stress can be followed by

psychiatric sequelae is well established.3,4 The recurrent combination of intrusive and avoidant symptoms present in individuals with the diagnosis of

post-traumatic stress disorder (PTSD) is well documented in groups of former POWs from several

theaters of war up to 40 years after release.69–71 In

one study, 67% to 85% of surviving former World

War II POWs were found to have met criteria for

PTSD at some time since repatriation.69 The sample,

however, may have been biased because the subjects were solicited by mail. Their psychiatric status

may not be representative of former POWs who did

not volunteer or former World War II POWs at

large. However, the results suggest that PTSD is

common following severe POW experiences. White

found that 85% of his group of POWs from Japanese

camps had suffered at least moderately severe

PTSD.72 Japanese POW camp survivors have consistently been reported to have PTSD symptoms

more frequently than other POW groups and the

symptoms have been more severe.13,73–78 Speed et

al76 found the strongest predictors of PTSD were the

proportion of body weight lost and the degree of

torture. In perhaps the best designed follow-up,

Page75 found high rates of persistent PTSD almost

50 years postrepatriation, particularly in Pacific

Theater POWs, when compared to a control group.

PTSD may be acute, chronic, or delayed.69,79 Although some studies suggest that the risk of PTSD

decreases with time,69 there is some evidence of a

late-onset PTSD80 that may differ from early-onset

PTSD in etiology and course. Late-onset PTSD may

be more likely to be related to symbolic functioning

and the use of war experiences as a symbol of

present ongoing conflicts.81 For example, one Vietnam-era POW presented 10 years after repatriation

with anxiety and obsessional symptoms occurring

at a time of family conflicts over the raising of

children. The former POW was experiencing increased recall of the conflict and anger he felt at his

roommate in prison for doing things that annoyed

him. At that time, he could not respond to his

roommate’s behavior because they needed each

other. The recall of this experience was explained

by the former POW’s present life conflicts. It was

these present life conflicts that were being expressed

in the recall of the memories of the POW experience.

Chapter 16, Chronic Post-Traumatic Stress Disorder, discusses this in greater detail.
441

The Prisoner of War

Post-traumatic stress disorder shows considerable comorbidity with other post-traumatic psychiatric disorders. Alcohol abuse is diagnosed in 41%

to 64% of patients with PTSD; depression is diagnosed in 8% to 72%.67 The relationship of drug

abuse, antisocial personality disorder and other

personality disorders to PTSD is not yet clear. Most

studies do not control enough variables to make an

accurate assessment. Because POWs undergo prolonged physiologic stress, a high frequency of

medicopsychiatric illness and psychophysiologic

symptoms are also common.

The MMPI has been used both clinically and for

research on former POWs. In a 1986 study comparing World War II POWs of the Pacific Theater with

those held in Europe, the highest elevations were

found in Pacific POWs on scales measuring hysteria

(Hs), depression (D), hypochondriasis (Hy),

psychasthenia (Pt), and schizophrenia (Sc).69 Both

groups were clearly distinguishable from a nonPOW control group. There have been attempts to

develop an MMPI subscale for PTSD in POWs. This

scale has been used in Vietnam conflict and World

War II veterans. In one study it could not distinguish Japanese from European POW veterans, although PTSD was diagnosed clinically more often

in POWs from the Pacific Theater.73

Adjustment Disorder

There is a continuum of response to stress. While

major psychiatric illness is frequently studied, minor psychopathology, normal responses to stress,

and movement toward psychological health are not

well studied.81 Adjustment disorders should be

more closely examined as a paradigm for responses

to stress. Identification of stressor-related minor

psychopathology may reveal a potential focus for

psychotherapy. Just as with major psychiatric diagnoses, the frequency of occurrence of adjustment

disorder following the POW experience is positively correlated with the duration and severity of

captivity.82

In a 1981 study of repatriated U.S. Air Force

Vietnam conflict POWs, Ursano et al found that

adjustment disorders and marital/occupational

problems occurred in 17.2% to 18.2% of the sample

at repatriation and in 9.2% to 15.8% at 5-year followup.53 These were the most common psychiatric diagnoses. Hall and Malone closely followed six

former POWs and their families for 3 years following return from North Vietnam and found that most

experienced cognitive, social, work, emotional, and

family difficulties for the first 2 years.83 These

problems, in general, eventually resolved and no

major psychiatric illnesses occurred in any of these

men.

Depression

Paykel’s review of the literature in 1978 revealed

that the presence of traumatic events increases subsequent lifetime risk for depression 2-fold and for

suicide 6-fold.84 Although some studies suggest

that the prevalence of depression may decline after

the first years following a traumatic event,85,86 the

prevalence of major depression in World War II

Pacific Theater POWs remains higher than in a nonPOW control group even 40 years after release.87,59

Studies of MMPIs in repatriated POWs reveal elevated depression scales.88 Page et al,59 using a

large national sample of World War II POWs (Europe and Pacific), Korean-era POWs and non-POW

comparison groups, found elevated depressive

symptomatology on the CES(D) (Center for Epidemiological Studies [Depression]) scale decades after repatriation. POWs who were younger, less

well-educated, and who had received harsher treatment were more likely to report depression.75

Depression also frequently accompanies PTSD.67

A history of concurrent or past depression is seen in

8% to 72% of PTSD patients.89–93 Many PTSD patients respond to antidepressant medications. It is

important to differentiate major depression in the

former POW from: (a) PTSD, (b) adjustment disorder with depressed mood, (c) subaffective clinical

depression (RDC [Research Diagnostic Criteria]

“minor depression”),94 (d) organic mood disorder

secondary to nutritional, toxic, or traumatic factors,

and (e) the neurasthenic syndrome commonly reported during and after traumatic events.

Psychoactive Substance Use Disorders

Alcohol misuse appears to be more common in

former POWs than demographically related

groups.11,12,14,15 Studies that control for demographic,

socioeconomic, and precaptivity psychiatric history, however, are few. There are morbidity data

and other evidence that alcohol abuse is problematic in many former POWs, and should be carefully

considered during medical and psychiatric examinations. Kluznik et al reported that 40 years after

World War II, a postwar diagnosis of alcoholism
War Psychiatry

442

was present in 50 of 188 POWs from the Pacific

Theater who volunteered for medical and psychiatric examination.69 Of that group, 67% also had a

history of PTSD; therefore, the alcoholism may have

been primary or secondary. Alcohol use can be a

form of self-medication95–99 and may suppress nightmares, diminish autonomic hyperactivity, and foster more pleasant nontraumatic fantasies.97 Alcohol

excess frequently accompanies PTSD (41%–

80%).70,87,89–92

There are few studies of postrepatriation drug

abuse in POWs. Potential confounding variables

that must be addressed in any such study include

demographic data, socioeconomic status, precaptivity substance use, precaptivity prevalence of

psychiatric disorders, concurrent psychiatric illness,

and presence or absence of captivity-related pain

syndromes. Drug abuse following trauma may also

represent self-medication of another psychiatric

disorder such as depression,100 an independent phenomenon, or continuation of a preexisting psychoactive substance use disorder. Concurrent drug

abuse has been reported in 16% to 50% of veterans

with PTSD.89–92

Anxiety Disorders

Before DSM-III and the diagnostic category, posttraumatic stress disorder, the most frequent diagnoses given to psychiatrically ill former POWs were

anxiety reaction, anxiety state, and anxiety neurosis.11 Anxiety disorders other than PTSD remain

frequent in former World War II POWs (143 of 188

in one study).31,69,101 Generalized anxiety disorder

was most frequently reported (103 of 188) in this

group. There was a large degree of overlap with

PTSD. In some studies, up to 95% of patients with

PTSD meet criteria for at least one other DSM-III-R

anxiety disorder.52,74 Panic attacks and panic disorder are frequent in persons exposed to trauma. Up

to half of patients with PTSD also have panic attacks.102

Somatoform Disorders

Somatoform disorders, psychophysiologic disorders, and psychiatric disorders due to physical

illness associated with POW treatment have all been

reported. In one study, 8 of 188 former World War

II POWs met criteria for somatization disorder

(Briquet’s Syndrome), though the severity was usually mild.69 Interestingly, psychophysiologic disorders present prior to the POW experience do not

always recur postrepatriation.34 Fictitious disorder

has been reported in individuals claiming to be

POWs. Three men who claimed they were former

POWs in Vietnam and reported symptoms of PTSD

were found to have never been POWs.103 For this

reason, verifying military history is an important

part of the assessment process.

Other Psychiatric Disorders

Adult antisocial behavior, obsessive-compulsive

disorder, intermittent explosive disorder, bipolar

disorder, schizotypal features, and other psychotic

disorders have been reported after trauma.69,89–92

However, it is unlikely that these disorders are

causally related to the POW experience. None of

the reports on these disorders adequately control

for pre-trauma variables such as psychiatric predisposition, socio-demographic data, or psychoactive

substance use patterns.

Personality Change

Personality changes resulting from the POW experience need not be pathological. Many former

POWs report that they benefited from captivity,104

redirecting their goals and priorities and moving

toward psychological health.34,105,106 Particular

MMPI profiles have been related to particular POW

stressors.107 In the same manner as the development

of psychopathology during and after captivity,

nonpathologic personality change appears to be

dependent on the nature and severity of the experience at least as much as preexisting personality. As

mentioned before, in World War II and Korean

conflict POWs a profound apathy syndrome was

noticed.23,24 In contrast, Vietnam-era POWs studied

by Ursano34 showed movement toward character

rigidity, decreased interpersonal relatedness,

heightened drive to achieve, and the experience of

time pressure. Such changes are neither pathological nor beneficial in and of themselves. Sutker et

al107–109 studying Korean conflict POWs found suspiciousness, apprehension, confusion, isolation,

detachment, and hostility. Eberly et al110 found

persistent elevated negative affect in World War II

POWs 40 years postcaptivity that he interpreted as an

adaptational change to accommodate the captivity.

Ursano34 and Bettelheim41 have discussed possible reasons for the different personality shifts

based on intrapsychic and adaptational shifts. These

two types of changes (apathy and rigidity/energy/

interpersonal distance) may serve similar adaptive
443

The Prisoner of War

functions, but which type of change develops may

depend on the circumstances of imprisonment, such

as the amount of physical torture, chronicity (Vietnam-era POWs experienced longer imprisonments

than Korean-era POWs), level of deprivation, opportunity for active and passive expressions of aggression, and the types of threats experienced by

the POW. These variables depend on the type of

war, socioeconomic conditions of the enemy, political climate, and culture of the captors.

From the intrapsychic perspective, conflict within

the ego and superego can be seen as the result of

heightened aggressive drives bound up during the

captivity situation. Such drives are then discharged

through the demanding punitive elements of the

superego and/or the ambitious, hard-driving pursuit of goals and ideals embodied in the ego ideal.

The apathy syndrome seen in Korean conflict POWs

may be partially explained as the result of the punitive superego’s victory in this intra-superego conflict. In contrast, heightened aggressive drives can

also be discharged in the service of the ego-ideal. In

this case, determination, character rigidity, and interpersonal distance may be the result.

PREDICTORS OF PSYCHIATRIC DISTRESS

Severity of Captivity

The severity of captivity is a result of both the

duration of imprisonment and the degree of maltreatment and deprivation. The length of captivity

alone is not a good measure of captivity severity.

World War II Pacific Theater POWs were exposed

to significantly greater physical, environmental, and

psychological stress than were European Theater

POWs. Only 40% of 30,000 POWs held by the

Japanese survived the war.10 Disease and malnutrition were common.11,14 Mortality, owing largely to

tuberculosis, was also higher just after repatriation

in the Pacific Theater group.14 Accidents and liver

cirrhosis remained significantly more common for

many years. Beebe found a higher number of medical and psychiatric symptoms, disability, and maladjustments in Pacific POWs than in European Theater POWs.11 The former group continues to have

higher hospital admission and illness rates. Higher

rates of liver cirrhosis suggest a higher frequency of

several hepatic diseases and alcoholism in the Pacific group.14,16 Page75 has found continued high

rates of psychiatric and medical morbidity in the

Pacific group into the 1980s.

In Vietnam, POWs captured prior to 1969 had

both longer captivity and substantially more deprivation, torture, and maltreatment.5,6 Wheatley et

al7 and Ursano et al53 demonstrated a greater degree of psychiatric readjustment problems in repatriated U.S. Air Force POWs captured before 1969

than in those captured after 1969. Pre-1969 captives

had a higher frequency of psychiatric diagnoses

and abnormal MMPI scales. The overall MMPI

profiles of pre-1969 captives also deviated farther

from normal than those captured post-1969 on the

initial MMPI. Pre-1969 captives showed increased

repression, a higher level of denial, greater suspicion, and more distrust. The post-1969 captives’

second MMPI profile 5 years later was lower and

looked more like aircrew norms. In contrast, the

profile of pre-1969 captives had remained essentially unchanged.

Similar findings were reported by Benson et al,8

in U.S. Navy and U.S. Army Vietnam era POWs. He

divided POWs into four groups: (1) officers captured prior to 1969, (2) enlisted personnel captured

prior to 1969, (3) officers captured after 1969, and (4)

enlisted personnel captured after 1969. These groups

were observed for differences in immediate and

delayed post-traumatic psychopathology. Enlisted

personnel exhibited significantly more postrepatriation psychopathology than commissioned

personnel. Significant improvement was noted between the first and the fifth year follow-up only in

officers captured after 1969. These results indicate

that after controlling for officer-enlisted status,

greater captivity stress, as measured by the duration and intensity of captivity, was associated with

more negative psychiatric outcome. Vietnam conflict POWs who were exposed to more prolonged

isolation had higher rates of psychiatric disorder

than did those who experienced more limited solitary confinement.111 This further indicates the importance of the severity of the captivity experience

as a major predictor of psychiatric disturbance.

Predisposition

Determining the role of precaptivity psychopathology and the contribution of genetic, developmental, and interpersonal factors is a difficult process.112 When examining a patient psychiatrically,

the data are retrospective and subject to the effects
War Psychiatry

444

of being filtered over time. The most valuable

sources of information to address this issue are

written sources prior to the trauma, such as medical

records and evaluations.

In addition to individual developmental factors

and the role played by recall of traumatic childhood

events, certainly genetic predisposition to psychiatric illness helps determine the phenotypic presentation of an individual following trauma. Life events

can precipitate major depressive episodes in susceptible individuals.111,113 A person who is genetically predisposed to mood disorders is certainly at

higher risk for depression after having been a POW

than a person not genetically predisposed to mood

disorders. To address the more interesting question of trauma as a cause of psychiatric illness, this

information must be controlled.

Ursano34,44 examined six repatriated Vietnam conflict POWs who had been coincidentally evaluated

psychiatrically before their captivity. Using the

precaptivity psychiatric data, he found that preexisting pathology or identifiable predispositions to

psychiatric illness were neither necessary nor sufficient for the development of psychiatric illness after

repatriation. Further data on the question of predisposition is provided by studies of captured Vietnam era U.S. Air Force fliers. Fliers are selected for

their health and are screened for psychiatric illness.

Pre-1969 captives were demographically comparable to the post-1969 group and, in fact, might have

been expected to show less illness because they

were slightly older and more mature. In fact, they

had more psychiatric illness. Because this correlates with the greater degree of stress experienced

by this group, these data further support the role of

stress over predisposition in the development of

psychopathology after severe trauma. Together,

these data support the view that psychiatric illness

may develop after the POW experience without

preexisting illness or identifiable predispositions.

Most post-traumatic stress disorder theories have

underestimated the role of adult personality growth

and resiliency and overestimated the role of preexisting personality in determining the outcome of

the POW experience.7,45

Social Supports

The importance of social interactions, social supports, group activities, and social isolation during

captivity has been discussed. Social factors may be

as important as environmental ones in determining

coping ability during imprisonment and after return.57 Recovery from captivity includes the repatriation experience which requires adapting to

changes in life directions, career, friendships, and

sometimes marital status. These stressors are in

addition to the need to psychologically integrate

the POW experience into one’s life story. Most

researchers believe that the more external support

available to a former POW, the more likely a positive adjustment will occur.

Davidson studied nonclinical groups of Holocaust survivors in Israel and England in order to

evaluate the importance of social support systems

in protecting concentration camp survivors from

psychiatric morbidity and in facilitating recovery.114

The subjects of the study were 15 men and 15 women

who had been in a concentration camp for 1 to 2

years and had lost virtually all their family members. From interviews of these individuals, he drew

two conclusions: (1) supportive bonds have a mitigating and protective influence in the aftermath of

the traumatic situation, preserving personality functioning, and (2) the definition of psychic trauma

should include social trauma.

Both captivity and reunion with the family are

stressful for the POW. Lack of reintegration into the

family and society appears to result in higher rates

of psychopathology.6,115 The POW/MIA spouse

must first adapt to the absence and unknown status

of the active duty member and then adjust to the

return. For many POW couples, the readjustment is

a difficult transition of reestablishing complementary and supportive roles in family authority and

nurturance structures.

READJUSTMENT

Repatriation and Reintegration

As mentioned earlier, most former POWs readjust without clinically significant psychopathology.

Some actually use the experience to move toward

greater psychological health. Sledge et al104 identified a distinct group of Vietnam POWs who felt they

had benefited from the experience. Those individuals who experienced the greatest stress during captivity were most likely to believe they gained psychologically from the experience. Thus, the

subjective sense of having benefited from the experience of being a POW correlated positively with

the harshness of the experience.
445

The Prisoner of War

The stages of repatriation and reintegration are

not synonymous with “recovery” in the sense of

resolution of psychiatric signs and symptoms. The

repatriated POW emerges from what is likely to be

a prolonged period of emotional blunting, monotony, apathy, withdrawal, and deprivation, into

a rapidly paced series of medical evaluations, family reunions, and public relations activities. The

brief period of euphoria upon release is quickly

replaced by a period of overstimulation. There may

be an attempt to make up for things denied during

captivity by activities such as overeating. Initially,

released POWs are frequently compliant with the

requests of the military and their physicians. But

over several days to weeks, they usually begin to

take a more active and independent stance.27,28 There

is a tendency for the repatriated POW to minimize

potential psychological and psychosocial problems

caused by his captivity.

In addition, most repatriated POWs, including

those from the Persian Gulf War, have had little

experience dealing with the media. The media are

a substantial stressor that can have lifelong effects if

a later, “Wish-I-had-never-said,” statement is broadcast around the world. It is very important to both

shield the POW and his family from early intrusive

media coverage and to offer training in the management of media requests. This was routinely done

for the POWs of the Persian Gulf War. Reminding

POWs and their families that it is perfectly acceptable for them to say, “No,” can be a most important

intervention.

After the tumultuous postrelease period, gradual

readjustment and reintegration may continue

throughout life. Reintegration occurs gradually

and the process is subject to reorganization with

changing life circumstances.

Organizers in Adult Personality Development

Personality does not stop developing at the end

of childhood or even adolescence.116 The fact that

most neurophysiological and neuroanatomic development is finished before adulthood may provide some protection from radical departures in

adult personality, but it is clear from animal studies

that changes do occur in neurophysiology and even

neuroanatomy during adulthood.19

Renee Spitz discussed “organizers” of psychological development—important experiences that

structure feelings, thoughts, and behaviors of the

present and thus influence future development and

psychology.117 The oedipal phase and childhood

traumatic events are two examples. These organizing events are evident in psychotherapy when the

therapist and patient identify organizing principles

of past experience that are used to guide present

behavior. It is useful to conceptualize adult traumas, such as being a POW, as a potential independent organizer of adult personality development.34

The experience may induce psychopathology or

personality growth, or it may resonate with themes

already present from earlier organizing events or

periods. Later, the symbolic recall of the POW

events is the result of a current event activating this

“organizer.” The recall serves as a symbolic vehicle

to express the current conflicts and anxieties.

Recovery

Some data support the idea that recovery is faster

when POW trauma is less severe. Wheatley and

Ursano7 found that post-1969 POW returnees experienced more complete and rapid return toward

normal and toward expected baseline than did

POWs who were captured before 1969. The study of

recovery as a process is one of the areas of much

needed research. Concentration camp survivors

have relatively few instances of complete recovery.118 They continue to experience less stable working lives, more frequent job changes, more frequent

domicile changes, longer sick leaves, and more frequent and long-lasting hospitalization periods than

controls.6 World War II Pacific Theater POWs continue to have more medical and psychiatric morbidity and slower rates of clinical recovery than European Theater POWs.73 In 188 former World War II

POWs examined in 1986, 29% were considered to

have fully recovered, 39% still reported mild psychiatric symptoms, and 8% had no recovery or had

deteriorated, as seen in Table 17-1.69 Recently, Page59

has documented the persistence of high rates of

PTSD and depression in World War II Pacific Theater POWs almost 50 years after their captivity.

Supportive social bonds appear to mitigate and

protect the ex-POW from long-term psychiatric

dysfunction.114 There may be disillusionment with

dreams, hopes, and fantasies about what postcaptivity life would be like.119 A supportive family and

social environment can help blunt that disappointment. Lack of social supports (eg, divorce, loss of

idealized lifestyle, death of family or friends) can

significantly increase the risk for psychopathology

in the postrepatriation period.

At the end of the Persian Gulf War, the first U.S.

female prisoner of war returned home. The unique

aspects of recovery for women POWs will be of

increased concern in future conflicts.
War Psychiatry

446

TABLE 17-1

LIFETIME PSYCHIATRIC DIAGNOSES AND ILLNESS COURSES OF 188 FORMER WORLD WAR II

PRISONERS OF WAR

Adapted with permission from Kluznik JC, Speed N, VanValkenburg C, Magraw R. Forty-year follow-up of United States prisoners

of war. Am J Psychiatry. 1986;143:1444.

Medical Disorders

Diagnosis and treatment of medical disorders

from POW captivity is always the first order of

business. These disorders can cause psychiatric

symptoms that may mimic psychiatric disorders

and have significant morbidity and mortality. Repatriated U.S. Marine POWs from Vietnam (N=26) had

an average of 12 medical diagnoses at the time of their

return, representing 155 separate diagnostic entities.120 The 77 U.S. Army repatriated Vietnam-era

POWs accumulated 1,149 diagnoses and 386 separate diagnostic entities.121 The most frequent medical diagnoses made in follow-up medical evaluations of repatriated U.S. Air Force POWs from

Vietnam were orthopedic, cardiac, and neurologic.122

World War II and Korean conflict POWs had

higher mortality rates following release than

TREATMENT OF POSTREPATRIATION ILLNESS

Table17-1 is not shown because the copyright permission granted to the Borden Institute, TMM, does

not allow the Borden Institute to grant permission to other users and/or does not include usage in

electronic media. The current user must apply to the publisher named in the figure legend for

permission to use this illustration in any type of publication media.
447

The Prisoner of War

nonprisoner control groups, owing largely to tuberculosis and effects of physical trauma.14,15 This

excess mortality began to rapidly decline during

the first decade following release. However, a current trend toward excess deaths due to liver cirrhosis is emerging, another line of evidence suggesting

alcohol misuse remains a problem.14,15 The confounding factors of malnutrition and parasite infection limit the interpretability of these data. Eitenger

compared Norwegian concentration camp survivors and the general population and found significant excess: overall mortality, unstable occupations,

job changes, frequency of hospitalizations, sick periods, sick leaves, and the duration of hospitalizations in the concentration camp group.123

Nutritional deficiency and physical trauma during captivity increase the risk for postrepatriation

medical and psychiatric sequelae.6,14,15,60,120,124,125

Eitenger maintained that the development of what

appeared to be a neurotic outcome, the KZ Syndrome, is actually the result of the extreme organic

stressors in the concentration camps.61

Because POWs can have lifelong medical morbidity, frequent attention to physical and medical

status is important. Yearly physical examinations

and monitoring for long-term effects of vitamin

deficiencies and malnutrition are important parts

of psychiatric follow-up.

Psychiatric Disorders

Debriefing after initial release from captivity126,127

is now standard treatment. In addition, providing

time to learn about how the world has changed

and time to become reacquainted with family in a

protected environment is important. Briefings to

learn how to handle the media are also very important. Group meetings will facilitate discussions

and abreaction as well as sharing information about

the normal recovery process. This reentry process

must be well planned and usually takes one to two

weeks or more if possible. Often politics and the

POWs’ desire to get home shorten this desirable

protected stage of recovery. Educating the POW,

his or her family, and national leaders may be

necessary.

When psychiatric illness exists following captivity, it must be treated. Adjustment disorders are

important to diagnose because their evaluation often reveals one or more foci for brief psychotherapy.

Treatment is directed toward preventing the development of more severe chronic psychopathology,

decreasing the vulnerability to future psychiatric

illness, and providing symptomatic relief.

Many forms of psychotherapy have been used in

the treatment of post-traumatic stress disorder: supportive, brief focal, behavioral, cognitive, cognitive-behavioral, and long-term insight oriented. The

choice of therapy depends on the patient’s ability to

make use of the treatment as a problem-solving

method. Psychodynamic treatments may be of particular import in chronic and late onset PTSD. Five

of 12 Cambodian concentration camp survivors who

completed a PTSD treatment program combining

heterocyclic antidepressants and supportive psychotherapy no longer met criteria for the disorder128

and symptoms improved in three others. Intrusive

symptoms improved more than avoidant symptoms. There have also been numerous reports of

spontaneous PTSD symptom resolution 1 to 2 years

after repatriation.69,83

Some post-traumatic stress disorder symptoms

may respond to antidepressant medications. Although no well-controlled studies exist, several case

reports and descriptive studies suggest that

monoamine oxidase inhibitors, heterocyclicantidepressants, and a triazolo benzodiazepine

(Alprazolam) are effective in ameliorating PTSD

symptoms in some patients.95,97,128–133 The high degree of overlap between PTSD and depression,

coupled with the response of some PTSD patients to

antidepressant medications, suggests that when

there is a positive response to antidepressant medication, it may be because a depressive component is

being treated. Many patients, however, say that

specific PTSD symptoms such as nightmares, autonomic hyperactivity, and avoidance behaviors improve with drug treatment. In any case, it is important to look for depression. (See Chapter 16 for a

further discussion of the pharmacotherapy of PTSD.)

The treatment of depression after trauma must

take into account the nature of the symptoms (psychological vs neurovegetative), the presence of a

past or family history of depression, the meaning of

the traumatic event to the patient, the psychosocial

situation at the time of the depression, and the

psychological significance of the precipitants of the

depressive episode. The particular treatment(s)

selected will depend on the biologic vulnerability

to depression, severity of neurovegetative symptoms and signs, suitability for psychotherapy, and

presence of other psychiatric disorders.

Because alcohol and perhaps other psychoactive

substances are often misused following traumatic

events, examiners must look closely for behavioral,

physiologic, and laboratory evidence of psychoactive substance misuse. Serum glutamic-oxalocetic

transaminase (SGOT), serum glutamic-pyruvic tran-
War Psychiatry

448

saminase (SGPT), uric acid, triglyceride level, mean

corpuscular volume (MCV), hematocrit, and serum

gamma-glutamyltranferase (GGT) are valuable in

the assessment of current alcohol use. Substance

misuse following trauma may be a primary disorder, or as self-medication for the symptoms of other

psychiatric disorders.67,134

Postrepatriation psychiatric illness may be delayed or episodic.64 PTSD can be acute, recurrent,

chronic, or delayed; alcohol and drug abuse can

have similar patterns; depression can be a single

episode, recurrent, episodic, or chronic. When recovery appears to have occurred after return home,

it may or may not be a permanent condition.

Whether recurrent or delayed illnesses are related

to symbolic retraumatizations is unknown, but

should be considered when evaluating a former

POW for treatment.

and 22, and 90% prior to the age of 25.138 A clinical

sample of mid-teenage children of concentration

camp survivors had more behavioral disturbances

and less adequate coping behavior than a clinical

control group.139 A study comparing current effects

of long-term father absence during and after the

Vietnam conflict due to long-term absence (MIA–

missing in action) and temporary absence (POW)

revealed significant differences in the children. Both

nervous symptoms and community relations were

more impaired in the former group.140

All of these studies suffer major methodological

flaws but should serve as reminders of the potential

impact of major life events as they are mediated

through parents to children. Adolescents may be

particularly sensitive to family tension. Their distress is often visible and can be disruptive in both

the family and community.

POW families that present for treatment are frequently in crisis. The resumption of precaptivity

roles may be difficult for a mother who has successfully exercised both parental roles for several years,

when father has additional individual psychiatric

symptoms and/or medical problems, and the children have become accustomed to having their

mother to themselves. Treatment focuses on preserving family unity, enhancing the family system,

and encouraging individual member development.141,142

FAMILY ISSUES

The effect of imprisonment and release on family

members and the family system itself can be profound and enduring or minor and transient. One

study of POW wives indicated that during the period of captivity, psychological and psychophysiological symptoms were common.135 Psychological

issues included desertion, ambiguity of role, repressed anger, sexuality, censure, and social isolation. Separation anxiety, role distortion, and sleep

disorders were common in the children. Male children were significantly more affected than female

children.

McCubbin et al interviewed families of 215 U.S.

Army, U.S. Navy, and U.S. Marine Corps POWs

approximately 1 year prior to the POWs’ release.136

Normal patterns of coping with husband/father

absence were disrupted by the unprecedented and

indeterminate length of captivity. The social acceptance, stability, and sense of continuity that are

taken for granted in the intact family were lacking

or severely taxed in the POW family.

Parental preoccupation and overprotectiveness

are potential reasons for the occasional presence of

higher degrees of overt psychopathology in children of persons exposed to trauma than in the

original victim.137,138 In a study of the offspring of

psychiatrically hospitalized concentration camp

survivors, 70% had psychopathology severe enough

to require hospitalization between the ages of 17

SUMMARY AND CONCLUSION

The POW has suffered the most severe stressors

of war. Repatriated POWs are a select group of

survivors who have been able to adapt to captivity

and maintain morale, hope, and health for months

to years. The ability to communicate with other

POWs during captivity is the most important coping strategy. The creative ways in which communication has been established and the content of what

is communicated are the basis of many of the POW

coping strategies.

Repatriation itself is a stressful event. The POW

is faced with the outside world’s view of his behavior and situation. He may face a changed world

and certainly has much information to catch up

on. Some events cannot be “caught up”: the birth

of a child, the death of a parent, a wife who de-
449

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cided to seek a divorce, or the operational experience necessary to remain current in a profession. These are real losses to which the returning

POW must accommodate. Most former POWs adjust well. For some, the experience serves as a

personality-organizing focus that results in movement toward emotional growth and maturity,

others show no psychological change, while still

others develop psychopathology. When psychiatric illness occurs following repatriation, the severity of the trauma and the status of social supports play a large role. Most psychopathology

decreases with time, though recurrent, episodic,

delayed, and chronic presentations of most of the

reported post-traumatic psychiatric disorders are

reported.

The stresses on the families of the POW are manifold, both during captivity and after repatriation. The

family and the military community are critical elements in the recovery and readaptation of the POW.

Post-traumatic stress disorder, depression,

psychoactive substance abuse, somatopsychic disorders, and psychiatric disorders due to captivity-induced medical problems are all seen in returned POWs.

The coexistence of two or more of these is the rule.

Which is primary or secondary is usually less important than identifying and treating each. Individual

psychotherapy (short- and long-term), family therapy,

pharmacotherapy, and medical treatment for other

diseases and injuries that may have resulted from

captivity are all important parts of the medical treatment and follow-up of the former prisoner of war.

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