War and mental health: a brief overview

British Medical Journal, July 22, 2000 by Derek Summerfield

About 40 violent conflicts are currently active and nearly 1% of the people in the world are refugees or displaced persons. Over 80% of all refugees are in developing countries, although 4 million have claimed asylum in western Europe in the past decade. Many wars are being played out on the terrain of subsistence economies; most conflict involves regimes at war with sectors of their own society--generally the poor and particular ethnic groups, such as the ethnic Albanians in Kosovo. Atrocity--extrajudicial execution, torture, disappearances, and sexual violation--generates terror, which maximises control over whole populations, as does the intentional destruction of the fabric of social, economic, and cultural life. Community leaders, health workers and facilities, schools, academics, places of worship, and anyone who speaks out for human rights and justice are often targets. In many regions such war is a factor in the daily lives and decision making of a whole society.

Individual effects

There is no such thing as a universal response to highly stressful events. However, somatic presentations such as headaches, non-specific pains or discomfort in torso and limbs, dizziness, weakness, and fatigue are central to the subjective experience and communication of distress wrought by war and its upheavals worldwide. This does not mean that these people do not have psychological insights but that somatic complaints reflect traditional modes of help seeking and also their view of what is relevant to bring to a medical setting.[1] Some researchers see somatic symptoms as physiological responses driven by stress; others emphasise their communicational element--these may be the only available expressions of the collective distress of powerless and persecuted people denied societal acknowledgment and reparation.[2]

Though the impact of combat on soldiers has been studied since the American civil war, the medical literature on civilians has burgeoned only in the past two decades. It is still based mainly on clinic populations of war refugees who have reached the West. One exception is Northern Ireland, one of the few conflicts from which comprehensive medical records are available. Over the past 30 years there has been no evidence of a significant impact on referral rates to mental health services.[3] The current literature is dominated by post-traumatic stress disorder, the successor to formulations such as "concentration camp syndrome" "survivor syndrome" and "war neurosis" Although post-traumatic stress disorder is reported to be prevalent worldwide in populations affected by war, the assumption that a Western diagnostic entity captures the essence of human response to such events anywhere, regardless of personal, social, and cultural variables, is problematic.[4] Features of post-traumatic stress disorder are often epiphenomenal and not what survivors are attending to or consider important: most of them remain active and effective in the face of continuing hardship and threat.[5] Thus uncritical application of diagnostic checklists for post-traumatic stress disorder may generate large overestimates of the numbers needing treatment.

Although some victims do develop significant psychiatric and social dysfunction, the relation between. traumatic experiences and outcomes is not clearcut. A prewar history of psychological vulnerability is a risk factor.[6] Recent research shows that secondary consequences of war--on family, social, and economic life--are important predictors of psychological outcomes.[7] In Iraqi asylum seekers in London, poor social support was more closely related to depression than was a history of torture.[8] Unquestionably, the major protective factor is the presence of a community able to provide mutual support and nurture problem-solving strategies.

Onwards from the classic study of Freud and Burlingham in 1943, the literature shows the positive effects of family attachment and other supports in buffering the impact of war on children.[9] Their emotional wellbeing remains reasonably intact for as long as parents or other caregivers can cope with the pressures of their situation.[10]

Physical ill health or disability has been cited as a risk factor for psychological dysfunction, but generalisations are difficult For instance, a study of 72 war wounded combatants in Nicaragua did not indicate that a severe disability, such as paraplegia or amputation, made subsequent psychological dysfunction more likely.[11] More studies are needed, not least because of uncleared mines (over 20 million in Angola, Afghanistan, and Cambodia alone) which will continue to maim for decades.[12]

The question of long term effects of war on mental health is beyond the scope of this overview but has been discussed elsewhere.[13]

War as collective experience

Current concepts of trauma are in line with the tradition in Western biomedicine and psychology to regard the singular human being as the basic unit of study and to prescribe technical solutions.[5] But war is not a private experience, and the suffering it engenders is resolved in a social context Fundamental to processing atrocious experience is the social meaning assigned to it, including attributions of supernatural, religious, and political causation. Thus members of a terrorised social group who find that what has happened to them is incomprehensible, and that their traditional recipes for handling crises are useless, are particularly likely to feel helpless and uncertain what to do. When war so routinely targets the social fabric, community structures may not be able to fill their customary role as a source of support and adaptation. Terror causes mistrust, which, as intended, further weakens communities. In situations of social crisis or breakdown there may be other consequences with deleterious effects: violation of unprotected women, alcohol abuse, prostitution for survival's sake.