On July 28, 1914, the Austro-Hungarian Empire declared war on Serbia, thus firing the opening salvo in the First World War. By the time the armistice was declared on November 11, 1918, some 8.5 million soldiers and seven million civilians on all sides had been killed. In addition, as many as 25 percent of soldiers had suffered psychological and neurological injury—including “shell-shock,” a newly-minted syndrome of nightmares, hysterical tics, anxiety, insomnia, obsessive thoughts, hallucinations and delusions.
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Treatment ranged from the inadequate at best to the contemptuous at worst and some 65 percent of shell-shocked soldiers were sent back to the front.
One hundred years later, psychiatrists are still struggling to treat the symptoms of what is now known as Post-Traumatic Stress Disorder or PTSD—and not just in combat soldiers but in other survivors of disasters, accidents, terrorist attacks and abuse, all of which has become keenly relevant as Operation Protective Edge enters its third week.
“Everything has been tried, from medication to all types of therapies,” says Yair Bar-Haim, head of the School of Psychological Sciences at Tel Aviv University and director of the University’s new Center on PTSD and Resilience. But medication has not proven particularly effective, and the best treatments — including Prolonged Exposure Therapy, a form of cognitive behavioral therapy in which sufferers recount the trauma, over and over—may not be widely available.
These treatments are based mainly on one-on-one scenarios, where a highly-qualified therapist provides treatment to one patient over 20 or more sessions, Bar-Haim explains. But as many as 20 to 30 times as many people suffer from PTSD as actually receive treatment, mainly because of the lack of trained therapists.
Combat soldiers may not seek out treatment because avoidance is itself one of the symptoms of PTSD, he says. “So people try to avoid reminders of the trauma, including the psychologist who pushes their nose into it.”
Now new research indicates that some people may be more susceptible than others to PTSD if their parents underwent traumatic events too. How could that be?
Post-Traumatic Stress Disorder first entered the medical vernacular in 1980, when it was officially included in the Diagnostic and Statistical Manual of Mental Disorders in the wake of the Vietnam War. Sufferers usually experience three clusters of symptoms: Re-experiencing (flashbacks, nightmares, intrusive thoughts); hyper-arousal (constant vigilance, feeling easily startled); and avoidance (evading reminders of the traumatic event, feeling emotionally numb, or mood changes including depression).
According to Bar-Haim, between five to eight percent of Israeli soldiers engaged in “low-intensity combat”—facing stone-throwers in the territories, for example—may develop PTSD. In a full-scale war, such as the U.S. invasions of Iraq and Afghanistan, the rate of PTSD among soldiers may rise to between 10 to 20 percent.
Some of those may be predisposed to the condition—either because of earlier childhood abuse or witnessing of violence, repeated exposure to war or civil unrest - or because they may have inherited a vulnerability to trauma from their own parents.
A recently-published study on children of Holocaust survivors, conducted by neuroscientist Rachel Yehuda, director of the traumatic stress studies division at Mount Sinai School of Medicine in New York, indicates that predisposition may be transmitted via epigenetic means. "Epigenetic" refers to the control of genes - they are turned on and off by the binding of chemicals secreted by the body, which change with circumstance.
Take identical twins with the same genes: throughout life they may accumulate such chemical modifications—which lead to differences in the way that their genes are expressed, and possible differences in their susceptibility to disease.
Thus the chromosomes of parents who survived the Holocaust and experienced PTSD may be modified by not by mutation but by chemicals that turn genes on or off. These changes may be inherited, possibly increasing the risk of depression or PTSD in the children of survivors.
Bar-Haim’s research indicates that predisposition to PTSD may be genetic as well. In a 2013 study of 1,085 Israeli infantry soldiers, he and his colleagues found that those soldiers with greater vigilance towards threats—a tendency associated with higher risk of anxiety and depression—were less likely to develop PTSD following deployment. Those soldiers also carried a variant of a gene controlling the transport of a brain chemical called serotonin, which regulates mood, appetite and sleep.
By contrast, those soldiers who tend to avoid threats were more likely to develop PTSD following deployment.
Children at war
Even in the absence of genetic susceptibility, children in war may be at greater risk of PTSD if their mothers also show symptoms, according to a 2013 study led by Vered Kaufman-Shriqui of Ben Gurion University of the Negev. That study, of 167 mothers of preschoolers (aged 4 to six-and-a-half) living in Beer Sheva during the three-week-long 2008/2009 IDF Operation Cast Lead, found that eight percent of mothers and 21 percent of children screened positive for PTSD in the wake of missile attacks from Gaza.
Affected children were more jumpy and fearful of separation, and they were also more likely to develop psychosomatic reactions such as diarrhea and constipation.
“Children are referred to us when they are symptomatic—highly irritable, crying, sometimes with regression in development,” says child psychiatrist Gal Meiri of Soroka University Medical Center in Beersheva and a co-author of the study. “In extreme cases, small infants or toddlers stop talking for a few weeks or a few months.”
He and his team offer psychotherapy—primarily in the form of play therapy—to affected children, and usually involve the mothers and if possible fathers in the treatment as well.
“If the parent is having severe post-traumatic symptoms, then of course we recommend the mother or the father to go to therapy for themselves,” he adds. “We explain that this is really important for their own child’s emotional and mental health.” But even here there are difficulties in offering treatment to all of those affected. “All the mental health system, and especially in the peripheral areas like in Beer Sheva, are having problems of manpower,” Meiri says.
A chronic condition
Improving treatment of PTSD is one of the primary goals of the Hopeful Dawn Foundation, a charitable group dedicated to research and prevention of the disorder among war veterans in the U.S., Israel and elsewhere. Under the auspices of the Foundation, Bar-Haim and Yuval Neria, Professor of Medical Psychology at Columbia University Medical Center in New York City, will be developing two research centers to investigate the genetics and molecular biology of PTSD, and build programs in cognitive psychology and treatment efficacy testing.
“The challenges are quite clear,” Bar-Haim says. “PTSD is chronic, and we get more and more people into the cycle of the disorder as we speak, just because of the nature of PTSD and the violent nature of humans.”
Ultimately, though, there is only one sure-fire way of preventing combat-related PTSD. “The best prevention for combat-related PTSD is to refrain from starting the war,” he says. “This is a very strong preventative measure that could be taken at the level of the leaders. It also has other benefits: Less people die, and it’s good for the economy.”