How to prevent turning trauma into a disaster?
Authors: Maaike De Vries
Journal: World Psychiatry (2006)

There are many reasons why war does not do good to mankind. Amidst them are mental health consequences. Murthy and Lakshminarayana review studies that demonstrate the psychological impact of hostilities, stress and exposure to shocking events. The message is twofold. War may cause significant and pervasive psychopathology in civilians. At the same time, the majority of people in the theatre are rather resilient. Notwithstanding the war situation, they do not develop problems such as post-traumatic stress disorder (PTSD), anxiety or depression.

This is also seen in military personnel who are deployed in overseas peacekeeping operations. The vast majority of soldiers return home safe and healthy. They are often self-contented. They were able to do the duties they were trained for, they were given an opportunity to contribute to a safer world and they often have experienced bonding with colleagues. The reverse of the medal consists of a small, but significant part of military personnel who are faced with a great diversity of health problems. About one out of every five soldiers develops post-deployment symptoms (1).

Military deployment and trauma are often bracketed together. Problematic health status in military personnel is often attributed to PTSD, not only by laymen. This is not surprising, because the concept of PTSD originates from the problematic aftermath of the Vietnam War. In 1980, PTSD was introduced as a diagnostic entity in the DSM. However, equalling PTSD and military health problems would be simplistic. About a quarter of post-deployment symptoms can be explained by PTSD, but other main concerns are medically unexplained physical symptoms, anxiety, depression and substance misuse.

In the 1990s, the need for a broader view was demonstrated in studies in Gulf War veterans. The American and British army were confronted with large groups of military servicemen, returning from the first Persian Gulf War, reporting ill health. They were dog-tired and suffered from a wide range of symptoms. In fact, these military experienced health complaints which are common in the general population. They suffered the same health problems although much more frequent as compared to civilians and military who were not sent to the Persian Gulf (2).

There was a lot of speculation on and rumour about the causes of Gulf War related illness. An unequivocal causal factor, e.g. exposure to harmful substances, has never been found. At that time, Dutch United Nations (UN) soldiers returned from deployment in Cambodia. Their health was also troublesome. Research showed that 17% of the ex-servicemen suffered from severe fatigue. PTSD was observed in less than 2% (3).

Post-deployment symptoms may be severe, persistent and chronic. They actually show striking similarities with the whether: the state of today is the strongest predictor for tomorrow's situation. A part of Gulf War and Cambodia veterans has significant complaints and is not able to get rid of them. War also leaves tracks in the long-term. Twenty-five years after deployment in Lebanon, about 15% of Dutch UN veterans still reported impaired psychological well-being (4).

Murthy and Lakshminarayana emphasize that research on the long-term course of stress-related symptoms and syndromes is needed. They are right in the sense that large scale epidemiological research on post-trauma psychopathology is relatively scarce. But the studies that have been performed yield rather unambiguous results: war impacts on humans in varying degrees.

Here we enter the field of psychosocial care, a promising area which is experiencing a growth. Evidence and best practices have been showing the value of and need for psychosocial care, although knowledge gaps exist. For example, evidence based treatment of medically unexplained physical symptoms is still lacking. Concerning early psychological interventions following trauma, we know what does not work, but we do not know what is effective.

Conflict and war may be a fact of life. There will always be trauma, distress and horror, but we can prevent turning trauma into a disaster. That is why we need to conduct research on these issues and that is why we need to invest in psychosocial care.