For a holistic approach to POW trauma

July 7, 2014

The full circumstances of U.S. soldier Bowe Bergdahl's captivity have yet to be revealed. During his tour of duty in Afghanistan in 2009, Bergdahl was captured by the Taliban and held in captivity for five years until a controversial prisoner exchange led to his release on May 31. Bergdahl has been accused of deserting his post and advocating the release of Afghani prisoners.

"We do know that he suffered horrific conditions, tortured and kept in a metal cage in darkness for weeks on end," said Prof. Zahava Solomon, an Israel Prize laureate, Professor of Social Work and Psychiatric Epidemiology at Tel Aviv University's School of Social Work, and head of the newly founded Center of Excellence for Mass Trauma Research, established by the Israel Science Foundation. "His identification with the enemy could be seen as a form of Stockholm Syndrome, according to which tortured individuals identify with their perpetrators and take on their beliefs as a means of survival and empowerment. In a way, it is reminiscent of victims of child abuse, who may identify with their parents and continue the cycle of abuse as adults themselves.

"On the other hand, maybe he really was a conscientious objector, as some have said, having high ideals and high morals, and he started to identify with the people he saw as victims – vulnerable locals in poor conditions," Prof. Solomon says. "It is impossible to say conclusively."

In a new study conducted with Dr. Sharon Dekel of Harvard University's Department of Psychiatry and slated for publication in the Journal of Psychiatric Research, Prof. Solomon examines the co-morbid effects of war captivity and war trauma on prisoners of war. While symptoms of psychological illness are often pigeon-holed as specific individual disorders, Prof. Solomon argues against a narrow "tunnel vision" in treating POWs such as Bergdahl, who remains in rehabilitation.

A uniquely large sample

Prof. Solomon's new study follows the progress of several hundred ex-prisoners of war captured by the Syrians and Egyptians in the 1973 Yom Kippur War, with a specific eye toward the co-morbid interplay between Post-Traumatic Stress Disorder (PTSD) and depressive symptoms. These former combat soldiers were held captive for between one and nine months, interrogated under horrific conditions, electrocuted, raped, burned with cigarettes, told Israel had been conquered, and placed in solitary confinement.

Prof. Solomon has treated the same subjects – hundreds of Israel Defense Forces soldiers captured during Israel's 1973 Yom Kippur War – over more than 40 years. The POWs, their spouses, and their children were interviewed and observed at three specific points of time (1991, 2003, 2008) over 17 years, utilizing diagnostic tools and questionnaires. Two groups of combat veterans, 275 former prisoners of war (ex-POWS) and matched combatants (controls), were assessed.

Prof. Solomon found that while depression and PTSD seem to be different long-term manifestations of traumatic stress, they are both parts of a common general traumatic stress construct. "Despite the fact that they were released 40 years ago, these men feel and behave as if they are still in captivity," said Prof. Solomon. "With PTSD, they have recurrent nightmares, are startled easily by noise, triggered by anything in the news or media reminiscent of their experiences, abusive to their spouses and children, re-enact their trauma and are overprotective. Meanwhile, they also exhibit clear depressive symptoms."

No silver bullet

Statistical analysis from the study indicated that PTSD increased in ex-POWs over time, while it remained stable among traumatized ex-combatants. The researchers observed a clear relationship between PTSD and depression, with one disorder mediating the symptoms of the other at different points in time.

"The effect of psychological trauma is like cancer – it metastasizes," said Prof. Solomon. "You cannot treat a person only according to PTSD, an anxiety disorder, or depression, an effective disorder, because then the treatment itself becomes ineffective. Sometimes they overlap, but they are also quite different. This is a major challenge for clinicians, who must not be blinded or restricted by their textbook categories. There is no silver bullet, unfortunately, but it is crucial to treat people accurately and with sensitivity, according to current knowledge, and continue the research to enable more effective treatment."

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