The Psychological Effects of War

Table of Contents

ABSTRACT

1. INTRODUCTION

2. AIM OF THE THESIS

3. METHODOLOGY

4. RESULTS OF THE THESIS: LITERATURE REVIEW
4.1. BASIC CONCEPTS
4.2. ASPECTS OF WAR TRAUMA WHICH LEAD TO PSYCHOLOGICAL TRAUMA.
4.3. EFFECTS OF WAR TRAUMA
4.4. POST TRAUMATIC STRESS DISORDER (PTSD)
4.4.1. DIAGNOSTIC CRITERIA FOR PTSD (Diagnostic and Statistical manual for Mental Disorders: DSM-5)
4.4.2. STRUCTURAL BRAIN ABNORMALITIES IN PTSD.
4.4.3. TRANSGENERATIONAL TRANSMISSION OF TRAUMA AND VIOLENCE
4.4.4. RISK FACTORS IN THE DEVELOPMENT OF PTSD IN WAR TRAUMA AND TORTURE SURVIVORS
4.4.5. PROTECTIVE FACTORS IN THE DEVELOPMENT OF PTSD IN SURVIVORS OF WAR TRAUMA AND TORTURE
4.5. TREATMENT OF WAR TRAUMA
4.6. MANAGEMENT OF WAR TRAUMA
4.7. AUTHOR’S PERSONAL EXPERIENCE IN THE SOUTH SUDAN CRISIS

5. SUMMARY OF THE RESULTS

6. DISCUSSION

7. CONCLUSION

8. RECOMMENDATIONS

9. BIBLIOGRAPHY

ABSTRACT

From the South Sudan conflict to the war in Syria and the violent conflict in Myanmar, it is an inevitable reality that people will continue to experience war trauma, which will - in some cases - escalate to post-traumatic stress disorder and other major psychological disorders. This thesis sets out to examine war trauma, based on its psychological effects, treatment and management. It elaborates on post-traumatic stress disorder (PTSD), the risk and protective factors therein. Moreover, it derives information from various academic sources that will help expound on war trauma.

It also intends to use the trauma therapy sessions which were conducted by the author, on South Sudanese refugees and nationals in South Sudan, Kenya and Uganda as practical experiences in evaluating this thesis with the expectation that it will serve as a contribution to academics and also provide the much needed information on war trauma to governments, military defense departments, psychiatrists, psychologists, counselors and all relevant stakeholders in this field.

With the escalation of wars and conflict, around the world, there has been an upsurge of refugees and immigrants in and outside Europe. This has sparked various debates, thereby creating an interest on the effects war has on military personnel, workers and civilians, in conflict areas. Having interacted with some of these groups at a personal and professional level, the author brings on board some of these unique experiences.

KEY WORDS: War, trauma, post-traumatic stress disorder (PTSD), refugees, immigrants.

1. INTRODUCTION

The American Psychological Association refers to trauma as an emotional response to events that can be deemed as terrible, such as accidents, rape incidents or natural disasters. Shock and denial normally happen, immediately after the event. They are quite typical. However, individuals may experience long term reactions, including unpredictability in emotions, flashbacks, relationships that are strained and even physical symptoms like nausea and headaches. These feelings are normal, but for some individuals, their day to day lives get affected, thus it is imperative that psychologists find constructive ways to assist them manage their emotions.^[1]

Contrary to popular belief, psychological trauma is treatable and manageable. People who have experienced trauma, due to their change in, mostly, behavior and everyday habits, have in some instances experienced stigma from the communities they live; depending on the kind of myths that surround it. Trauma is, however, better managed in developed countries, because most of these myths have been demystified and there is also advancement in medical research regarding it. Also, the kind of support availed by governments, plays a major role.

For example, in the United Kingdom, the National Institute for Health and Care Excellence (NICE), which is managed by the Royal College of Psychiatrists, provides guidance and advice, nationally, on how to improve people’s health and social care; which includes mental health. These are then accompanied by evidence, which is found in its resources. This information can be used by health care industry players like general practitioners, local government, public health professionals and members of the public.^[2]

The Canadian Best Practices is another one-stop shop portal that can be utilized by health professionals, decision makers related to health and also for the general public. It comprises of multiple sources of information that are credible and trusted, as it provides links to resources and solutions that can be utilized for health promotion purposes and in preventing diseases in populations and various communities.^[3]

On the other hand, the Guide to Clinical Preventive Services (Recommendations of the US Preventive Services Task Force - USPSTF), provides recommendations for screening, counseling and preventive medication, in which it presents the clinical considerations for each topic discussed; which can be accessed by both the public and health practitioners. It comprises of 64 preventive services which are presented in an easy-to-use table format that has been summarized. Clinicians can also educate their patients on appropriate preventive services and also links to tools on how they can improve their practices. USPSTF is an independent group of experts in primary care and prevention that reviews, in a systematic manner, the effectiveness of evidence and also develops recommendations for clinical preventive services.^[4]

The above are just but a few of some of the ways, governments, as they work with health practitioners, can assist their citizens in managing not only their mental health, but also their overall well-being. When people experience trauma, not all will recognize that they are experiencing it, depending on various factors; like the intensity of the trauma and the awareness of it. For those who do not, people around them might point out that there is a change in their behavior.

According to the National Center for PTSD (2017)^[5], there are different kinds of trauma, which include:

· War and combat related trauma

This is trauma that emanates directly from war related causes and it affects civilians, professionals working in these areas, as well as military personnel, which includes war veterans. It can include women and children undergoing sexual abuse – for example in Bosnia, Darfur or the Congo - military sexual trauma, witnessing deaths of loved ones, loss of body functioning, among others.^[6]

· Terrorism

When mass violence occurs, it can lead to injuries, deaths, and psychological distress. As a result, this can lead to trauma of those affected by it, directly or indirectly. With terrorist groups like the Al-Qaeda, Alshabaab, ISIS/ISIL (Islamic State of Iraq and the Levant) recruiting members from all over the world, this has also seen a rise in terrorist attacks, in the recent past.^[7]

· Violence and abuse

This refers to the effects of child abuse, domestic violence, and sexual assault on all genders, especially in war zones. During such periods, people are normally vulnerable, thereby becoming easy targets for potential abusers.^[8]

· Disasters

These include both man-made and natural disasters. For example, the recent hurricanes in the US, namely: Harvey, Irma and Maria; the Las Vegas tragedy, which has been deemed as the worst mass shooting in American history, in which 58 people lost their lives and hundreds others injured. Also, the recent California wildfires, which, according to CNN (2017), have left at least 36, people dead, thousands homeless and close to 6,000 buildings destroyed.^[9]

2. AIM OF THE THESIS

War trauma and PTSD is proving to be a recurrent phenomenon, judging from previous and current conflicts, worldwide. Since majority of the people are affected either directly or indirectly, it has now turned into a global problem, which requires various strategies to tackle it. This thesis aims to make an emphasis on how war trauma occurs, its psychological effects which can turn into post-traumatic stress disorder (PTSD), how to diagnose an individual with PTSD, the risk and protective factors involved, including its treatment and management. It will then utilize diverse scientific sources of information relating to this and the author’s previous practical experiences in three African countries. Recommendations will then be proffered as a way of advancing knowledge.

3. METHODOLOGY

The methodology described in the thesis emanated from existing literature and research. A literature review and research was carried out, in which various databases were used. These included PubMed (US National Library of Medicine National Institutes of Health), Cochrane database of systematic reviews, Science Direct and other academic journals derived from Google Scholar. In these, evidence-based information on war trauma and its psychological effects was obtained, which included reviews on post-traumatic stress disorder (PTSD), as a major focus. The genetic component of psychological trauma was also discussed, as well as its treatment and management. This review encompassed people of all ages, including children, families and communities in different parts of the world, as well as war veterans.

These databases were sorted out in order of relevance, using the key words: war trauma, trauma, PTSD, diagnostic criteria for PTSD according to the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), the risk and protective factors for PTSD, its effects on the brain, refugees and PTSD, torture and PTSD, PTSD treatment and management. 50-plus articles on war trauma met the above criteria; however, at least 38 reviews were utilized to achieve the desired outcome. Studies that were not relevant to the topic discussed were not included in the thesis.

The results of various studies, previously carried out by researchers were also included in the different sections of the dissertation, to compare the reviews, so as to achieve its objective. Some of the results from the reviews were conclusive, while others were not. The reasons as to why some were not, was also explained, as per the information provided in the articles by the authors.

INCLUSION AND EXCLUSION CRITERIA STRATEGY

The studies which met the following criteria were used:

- People of various age groups.
- Reviews that were evidence based.
- Journal articles that had information on trauma and war trauma.

Studies that dealt with traumatic brain injury (also referred to as trauma) from physical injuries were excluded, as well as those that did not deal with war trauma or PTSD.

4. RESULTS OF THE THESIS: LITERATURE REVIEW

4.1. BASIC CONCEPTS

The online Oxford dictionary, defines trauma (Pronunciation /ˈtrɔːmə/) as, “A deeply distressing or disturbing experience.” It also defines it as, “An emotional shock following a stressful event or a physical injury, which may lead to long-term neurosis.”^[10]

War is defined by the Oxford Living Dictionaries as, “A state of armed conflict between different countries or different groups within a country, a state of competition or hostility between different people or groups or a sustained campaign against an undesirable situation or activity.”^[11]

According to Silove (1999:187), war and different forms of torture occur on a large scale basis, in various countries, which results in deaths, while leaving survivors with disabilities.^[12] According to Amnesty International, over 150 countries all over the world have had human rights violations taking place and the ratio of civilians affected by these wars, compared to the military manpower; continue to rise.^[13]

Severe trauma can result from war, especially among civilian populations. This can lead to experiences where individuals feel that their lives are endangered after witnessing violence that is extreme, being separated from loved ones or after undergoing detention in a concentration camp as during World War 2 when detention camps had been set up in Poland in areas like Sobibor and Auschwitz (Johnson and Thompson 2007:37).^[14] From these positions, it is important to know how the mind of the potential victim works during the war. The daily experiences of war grow from a steady state of mind, in an individual, which then relapses into trauma.

Psychological trauma is a unique individual experience of a reaction to an event in which his/her ability to integrate the emotional experience is overwhelmed or the experience poses a threat to life. Thus, a situation develops to psychological trauma, when the individual’s ability to cope is overwhelmed, thereby leading to the person fearing death, annihilation, mutilation or psychosis; and may feel inundated emotionally, cognitively and physically.^[15]

Jon Allen, a psychologist at the Menninger Clinic in Houston, Texas and author of Coping with Trauma: A Guide to Self-Understanding indicates that there are two components of trauma: objective and subjective. He explains it as, “It is the subjective experience of the objective events that constitutes the trauma… The more you believe you are endangered, the more traumatized you will be… Psychologically, the bottom line of trauma is overwhelming emotion and a feeling of utter helplessness. There may or may not be bodily injury, but psychological trauma is coupled with physiological upheaval that plays a leading role in the long-range effects” (p.14).^[16]

According to Mieli (2015: 7)^[17], the severity of the psychological effects of trauma is more if it was caused by human factors (like wars, political violence, genocides). Also, if it is repeated, unpredictable, multifaceted, sadistic, undergone in childhood (like the case of child soldiers) and is perpetrated by a care giver.

Sigmund Freud, the father of Psychology, mentioned that trauma is at the origin of human sexuality and life; that is at the very centre of the human being. It affects how the unconscious forms, the symptoms that an individual has and the individual’s responses to it. What exactly, are the consequences of a trauma that has been unleashed by radical violence, which is aimed at annihilating the subject itself? How can we, clinically, approach these kinds of traumas?^[18]

From the economic, metapsychological point of view, trauma is explained as an experience that goes beyond the limits of the pleasure principle, which, in a bid to minimize the amount of tension that is necessary for life to exist, regulates the psychic apparatus. Once a traumatic event is registered, it can lead to heightened tension which is unable to find a proper discharge route, thereby resulting in pain or displeasure. This way, it brings forth the “beyond” of the pleasure principle, which is associated with a drive satisfaction that is infused with the libidinal and death drives.^[19]

Clinical evidence has been able to prove, that according to Freud’s hypothesis of the “summoning of traumas,” trauma is not isolated. It is normally associated with other sets of traumas which go back to birth, sometimes even earlier, traversing generations. It is with taking this into account, that power that is being exerted by a particular trauma can get toned down (Mieli 2015).^[20] Therefore, an individual’s subjective experience of war trauma needs to be woven back into the other traumas experienced by the person.

Traumatic neuroses, including war neurosis, which releases symptoms, gives voice nachträglich, a posteriori to trauma experienced in the past, condenses and incorporates them, causing a restoration in their disruptive potential. Thus, in the sequence of traumas that have taken place in the individual, the current trauma becomes the first step in the construction process, creating an opportunity for it.^[21]

From the various definitions and positions, there is a need to elaborate on the causes, effects, treatment and management of trauma in a comprehensive format as this thesis sets out to do.

4.2. ASPECTS OF WAR TRAUMA WHICH LEAD TO PSYCHOLOGICAL TRAUMA.

The current war and conflict zones of the world include South Sudan, Yemen, Syria, Egypt, Afghanistan, Iraq, Libya and Israel-Palestine border disputes; which have resulted in the displacement of thousands of people internally, plus creating refugees, who flee to other countries, for fear of their lives as it is currently happening in Syria. Countries have also experienced genocides as a result of these conflicts and they include Rwanda, Cambodia and Bosnia. These conflicts psychologically affect people of all ages and gender.

Childhood exposure to war trauma is a common occurrence. A report published in 2002, estimated that in the preceding decade, more than two million children were killed in wars, and many more, were victims or had witnessed violence that accompanied wars. Exposure to traumatic experiences in childhood results in mental health consequences in adulthood. For example, the Adverse Childhood Study has been able to prove that there is a dose-response relationship between adverse experiences in childhood and adult mental health.^[22]

Abadi, et al., mention that with nearly 30 years of war, conflict and instability, a country like Afghanistan has experienced an estimated 3.7 million displaced people, human casualties numbering 100,000, since 2001, high poverty rates and major damages to their infrastructure.^[23] As a result, vast majority of the Afghanistan population has likely experienced traumatic events that are war- related. Research shows that 40% of Afghans have experienced at least 8–10 traumatic events, in a span of 10 years, and 14.1%, 11 or more. Symptoms of psychological distress and psychopathology are associated with war-related trauma. Greater exposure to war trauma is correlated with higher levels of psychological symptoms.^[24]

Veronese, et al. (2017: 364-365)^[25], state that in the Palestinian territory, there has been military occupation and territorial dispossession for the last 70 years, which has also seen continuous bouts of violence. Children living in the Gaza strip have been identified as having been the most affected by the ongoing warfare and military violence. In 2014 the United Nations Children’s Fund, UNICEF reported that over 400,000 children were in dire need of immediate psychosocial and child protection following attacks by the Israeli. Many children in the Gaza strip have been diagnosed with PTSD (Post Traumatic Stress Disorder), various psychiatric disorders, like depression, anxiety and other forms of psychological distress.

Psychological studies which have been done in the occupied Palestinian territories (oPt), indicate that exposure experienced is from military violence, bombardments, imprisonment and demolitions of houses, with psychiatric sequelae and syndromes related to trauma. A significant number of Palestinian children reported moderate to severe post-traumatic reactions (41%), accompanied by high levels of anxiety and behavioral problems (27%).^[26]

Children were also affected by psychological impairments, which included the fear of leaving home (28%), fear of soldiers (47%) and nightmares due to the chronic violence. A very high rate of PTSD was identified in the children at Gaza. Up to 55% suffered from acute PTSD in areas that had heavy violence. 54.7% of children there had experienced at least one traumatic event in their life; 34.1% of these, being male refugees who had PTSD symptoms.^[27]

Torture is also a common occurrence. When war is taking place, it normally results in trauma. This mostly occurs in places where there are violations of human rights. It is used as a tool to coerce, repress, punish or humiliate. Whenever there is a breakdown in civil order, war and torture often takes center stage. Thus, those who have experienced these kinds of trauma are subject to being discriminated against, persecuted and forced into exile.^[28]

Studies have been able to prove that there is a strong association between exposure to severe war-related trauma and pathology in personality; which can be explained, in part or whole by “reverse causation.” This means that people who have a personality disorder, have a higher chance of being exposed to severe war trauma, due to their vulnerability. However, there is also the possibility that participants in such studies had already developed an interpersonal dysfunction after getting exposed to severe war trauma in adulthood.^[29]

South Sudan is one of the African countries that have experienced major episodes of war and conflict, from its first civil war in 1955 to the current unrest, which is a result of factors ranging from traditional cattle raiding, ethnic violence and political facets. Leaders fighting for power have also exacerbated the situation, resulting in widespread violence. Deficiency in development, especially in the rural areas, has also brought about tensions and violent conflicts. Easy access to guns and decentralization has also played a role in fortifying ethnic identities.^[30]

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^[1] “Trauma.” American Psychological Association. http://www.apa.org/topics/trauma. Accessed 30 Oct. 2017.

^[2] “NICE Clinical Guidelines developed by NCCMH 2001-2016.” Improving the lives of people with mental illness. http://www.rcpsych.ac.uk/workinpsychiatry/nccmh/niceclinicalguidelines.aspx. Accessed 30 Oct. 2017.

^[3] “Canadian Best Practices Portal.” Public Health Agency of Canada. http://cbpp-pcpe.phac-aspc.gc.ca. Accessed 30 Oct. 2017.

^[4] “About the USPSTF.” U.S. Preventive Services TASK FORCE. https://www.uspreventiveservicestaskforce.org. Accessed 30 Oct. 2017.

^[5] “PTSD: National Centre for PTSD.” U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/public/types/war/index.asp#.WeRK0b9Spe8.email. Accessed 30 Oct. 2017.

^[6] Ibid.

^[7] Ibid.

^[8] Ibid.

^[9] Park, Madison, et al. “California fires: Almost 6,000 buildings destroyed, 36 people killed.” CNN. http://edition.cnn.com/2017/10/13/us/california-fires-updates/index.html. Accessed 30 Oct. 2017.

^[10] “Definition of trauma.” Oxford Living Dictionaries. https://en.oxforddictionaries.com/definition/trauma. Oxford University Press, 2017. Accessed 5 Oct. 2017.

^[11] “Definition of war.” Oxford Living Dictionaries. https://en.oxforddictionaries.com/definition/war. Oxford University Press, 2017. Accessed 5 Oct. 2017.

^[12] Silove, D. “The psychological effects of torture, mass human rights violations, and refugee trauma: Towards an integrated conceptual framework.” The Journal of Nervous and Mental Disease. 1999, pp.187.

^[13] “International Federation of Red Cross and Red Crescent Societies.” World disasters report. Oxford, England: Oxford University Press, 1998.

^[14] Johnson, Howard and Andrew Thompson. “The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review.” Clinical Psychology Review, Vol.28, Issue 1 (Jan. 2008), pp. 37.

^[15] Ibid

^[16] Allen, Jon G. Coping with Trauma: A Guide to Self-Understanding. Washington, DC: American Psychiatric Press, 1995, pp.14.

^[17] Mieli, P. “Trauma and war trauma: A .clinical approach” Issues in Psychoanalytic Psychology. Vol.37, 2015, pp. 7.

^[18] Ibid.

^[19] Ibid.

^[20] Ibid.

^[21] Ibid.

^[22] Llabre M. Maria, et al. “Psychological Distress in Young Adults Exposed to War-related Trauma in Childhood.” Journal of Clinical Child & Adolescent Psychology. Taylor and Francis Group LLC. Vol.44, Issue 1, 2015, pp. 169.

^[23] Abadi et al. “Examining human rights and mental health among women in drug abuse treatment centers in Afghanistan.” International Journal of Women’s Health. file:///C:/Users/Mwari/Downloads/IJWH-28737-examining-human-rights-violations-among-women-in-drug-abuse_040212.pdf. 24 Apr. 2012. Accessed 30 Oct. 2017.

^[24] Wildt, Hillary, et al. “War Trauma, Psychological Distress and Coping among Afghan Civilians Seeking Primary Health Care.” International Perspectives in Psychology: Research, Practice, Consultation. Vol.6, No.2, 2017, pp. 81.

^[25] Veronese, et al. “We must cooperate with one another against the Enemy: Agency and activism in school-aged children as protective factors against ongoing war trauma and political violence in the Gaza strip.” Child Abuse and Neglect. Vol.70, 2017, pp. 364-365.

^[26] Ibid.

^[27] Ibid.

^[28] Johnson, Howard and Andrew Thompson. “The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: a review.” Clinical Psychology Review, Vol.28, Issue 1 (Jan. 2008), pp. 37.

^[29] Munjiza, et al. “Severe war-related trauma and personality pathology: a case-control study.” BMC Psychiatry. Vol.10. No.100, 2017, pp.8.

^[30] Grawert, Elke and Christine Andra. “Brief 48: Oil Investment and Conflict in Upper Nile State, South Sudan.” Bonn International Center for Conversion. https://www.files.ethz.ch/isn/164128/BICC_brief_48.pdf. Accessed 31 Oct 2017.