Time heals some wounds, but not necessarily for PTSD patients
A study shows that even 35 years is not enough for some patients to shake off post-traumatic stress, especially former prisoners of war.
Gilad Shalit's return from Gaza has stirred up memories other former prisoners have tried to forget. Some have discussed their ordeals in the media, others have stayed home, wrestling with their memories. Israel has plenty of experience in treating such patients. Follow-up studies reveal new characteristics that accompany familiar post-traumatic syndrome - characteristics that make the captivity experience a unique traumatic event.
A long-term follow-up study in Israel reflects the uniqueness of post-trauma among former prisoners. The study, underway since 1991 at a laboratory headed by Tel Aviv University Prof. Zahava Solomon, winner of the Israel Prize for Social Work Research, examines the effect of captivity on Israeli soldiers taken prisoner in the Yom Kippur War.
The study's third and most recent round, carried out in 2008, found that 35 years after the war there is an increased risk of "delayed post-trauma," which erupts long after captivity. By definition, post-trauma is an anxiety disorder. About 8 percent of us experience it after a traumatic event - whether a natural disaster, war, traffic accident or something else. The phenomenon is characterized by three groups of symptoms: flashback, avoidance symptoms and overreaction to certain stimuli.
According to "The Diagnostic and Statistical Manual of Mental Disorders," published by the American Psychiatric Association, post-trauma is diagnosed when the symptoms last longer than a month. Most often the disorder erupts around the time of the traumatic event. If more than six months elapse since the event, it is described as delayed disorder.
The Israeli study diagnosed outbreaks among former prisoners even 30 years after their captivity. "This is a phenomenon that resembles a time bomb," Solomon says. "The seeds of the disorder are sown as the event occurs but the subjects manage to summon resources and strengths that prevent an immediate collapse. In contrast to other delayed phenomena like mourning for someone close, in which the repression can lead to a more severe outbreak, in post-trauma a delayed reaction is usually less severe."
Participants in the study who were captives, as compared to soldiers who fought in the Yom Kippur War and were not taken prisoner, were diagnosed at various points in time with 3.5 to 15 times more signs of post-trauma. The main predictor of an outbreak of post-traumatic syndrome was not linked to the pressure applied in captivity, including torture and starvation, but to the threat the subject felt while in captivity.
Fifteen years ago Prof. Judith Lewis Herman of Harvard University described a unique post-trauma mechanism typical of released captives - "complex post-trauma." According to Dr. Danny Harush, a clinical psychologist, lecturer and researcher at Solomon's laboratory, "When a person goes through prolonged traumatic stress every day, the post-traumatic repercussions can be at the level of personality, not just symptoms."
Herman's work showed that profound post-trauma is liable to change personality structure. "This has to do with changes in emotional regulation and the perception of the self, as well as changes in the personality system and interpersonal relations," says Harush. "This is a multidimensional change in a person's life, beyond flashbacks or nightmares." The Israeli study diagnosed the phenomenon among 15 percent of the former captives.
One interesting phenomenon in the 2008 study is that post-traumatic syndrome can be passed on to people close to the sufferer; these people develop secondary traumatic stress. In a study at Solomon's laboratory by a team headed by Dr. Tsachi Ein-Dor, director of research laboratories and junior faculty at the Herzliya Interdisciplinary Center, the researchers compared 85 released captives from the Yom Kippur War to 72 subjects of the same age who had fought in the same units but were not taken prisoner. According to the findings published in July 2010 in The Journal of Counseling Psychology, the risk of secondary symptoms among prisoners' wives was higher by 21 to 50 percent.
Making them nervous
Ein-Dor explains that a captive who returns to his family is liable to pass on his trauma. According to Solomon, "A tremendous emotional burden accumulates in the close relationship patterns with the person who has undergone captivity. Sometimes there are feelings of an inability to help when the person who returns from captivity becomes dependent on his family. The situation can lead to the development of secondary stress symptoms."
The risk for transmitting the trauma to others among released captives has to do with personality structure. "The anxious type usually shares his trauma, talks about it and externalizes it in a way that makes it difficult for the people around him, and in these cases the risk of secondary traumatization is higher," says Ein-Dor. "But a restrained type who is used to acting on his own and not sharing the trauma with the people around him reduces the risk of secondary traumatization."
In the 2008 study, it was found that freed prisoners suffer from more health problems than the control group and develop illnesses that are not part of their family histories such as diabetes.
The captivity experience itself can lead to post-trauma symptoms in only about one-third of the captives. Most are defined as immune and do not develop the symptoms. "We know that people have unimaginable resources and strengths that protect them even from trauma," says Harush. "Among Israeli former captives, too, there is an impressive amount of strength - we can see various aspects of both pathology and strength."
Indeed, some former captives not only recover but come out ahead. There is a phenomenon called "post-traumatic growth" in which, explains Harush, "a person not only manages to survive without falling apart but even grows from the difficult situation he experienced in captivity, in the sense of discovering the strength within him and viewing life as a renewed opportunity."
Studies have even shown that the more difficult a person perceives his captivity, the greater the chance for post-traumatic growth, though researchers are still divided. According to Solomon, this is an attractive concept, "But actually it's a problematic concept that can be seen in few cases, and we don't know if this is an illusion or a phenomenon that exists in reality."