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Civilian Populations: Mental Health Impact of War


Child soldier with rifle and teddy bear backpack - Liberia ... U.S. Civil War. Child soldiers in Mozambique: Effect of length of time with armed group ... – PowerPoint PPT presentation

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Title: Civilian Populations: Mental Health Impact of War

Civilian PopulationsMental Health Impact of War
Modern Warfare
  • Most casualties are civilians
  • Psychological warfare and terror target civilians
  • Landmines and cluster bombs
  • Child soldiers
  • Mass rape
  • Disappearances
  • Torture
  • Massacres
  • Ethnic cleansing and genocide

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Health Costs of War - Iraq
  • gt1,000,000 Iraqi civilian deaths (Roberts et al.)
  • Malnutrition and infectious disease
  • Refugee crisis 4-5 million displaced
  • Destruction of health care system
  • Iraqi doctors
  • 34,000 in 2003
  • 18,000 have fled
  • 2000 killed

Extremely Traumatized Population in Iraq
  • Saddams Reign of Terror
  • Iran-Iraq War 1,000,000 dead
  • Gulf War I 200,000 dead, infrastructure
  • Sanctions widespread malnutrition and
    infectious disease, 500,000 children dead
  • Continued Bombing
  • Gulf War II

Mental Health Impact of Mass Violence
  • Prevalence of mental disorders increases
  • During wartime
  • In postconflict settings
  • Significant proportion of population affected
  • WHO estimates 1/3 to 1/2 diagnosable disorders
  • Most had no prior mental health problems
  • Resilience of more than half the population

Vulnerable Groups
  • Children
  • Women
  • Elderly and disabled
  • Refugees and internally displaced

Wide Variety of Symptoms and Syndromes
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Depression
  • Complicated bereavement
  • Substance abuse disorders
  • Poor physical health
  • Fear, anxiety, physiological arousal
  • Somatization disorders
  • Dissociative disorders
  • Arrest or regression of normal childhood

Psychosomatic Presentation
  • Patients in many cultures tend to express
    psychological problems as physical symptoms.
  • Obtain care and support, while avoiding stigma of
    mental illness
  • Back pain, headaches, pelvic pain, GI symptoms,
    cardiac symptoms, TMJ, skin, prostate, etc.

  • Decades of armed conflict and population
  • Two well-conducted, multi-cluster,
    population-based studies
  • Cardozo et al., JAMA, 2004
  • PTSD 42, depressive symptoms 68, anxiety
    symptoms 72
  • Scholte et al., JAMA, 2004
  • PTSD 20, depressive symptoms 39, anxiety
    symptoms 52
  • Risk factors number of traumatic events, female
  • Sources of support religion and family

Gaza Community Mental Health Center
  • Survey of children aged 10-19 (Sarraj Quota
  • 33 PTSD symptoms requiring psychological
  • 49 moderate PTSD symptoms
  • 16 mild PTSD symptoms
  • only 3 had no symptoms
  • Children living in camps had symptom prevalence
    several times greater than children living in
  • Most prevalent traumas
  • witnessing funerals (95)
  • witness to shooting (83)
  • seeing injured or dead strangers (67)
  • family member injured or killed (62)

Northern Sri Lanka
  • Area of 30 years continued conflict (Somasundaram
    and Jamunanatha, 2002)
  • 41 Somatization
  • 27 PTSD
  • 26 Other anxiety disorders
  • 25 Major depression

Post-conflict communitiesDe Jong et al., Lancet,
Applicability of PTSD to Developing World
  • PTSD was developed in Western cultural context
  • Basic neurobiology of PTSD independent of culture
  • Psychopathology consistent across cultures
  • Manner in which mental health services need be
    provided may differ greatly

Oklahoma City and Nairobi
  • Comparison of civilians exposed to terrorist
    bombings (North et al., 2005)
  • Similar psychopathology, including prevalence of
    PTSD and other mental health disorders
  • Female gender and preexisting psychiatric
    condition significant risk factors in both groups
  • Coping responses very different
  • Americans used psychiatric treatment, medications
    and alcohol
  • Kenyans used support and debriefing groups,
    religious counseling

Mental Health Impact of War on Children
  • Depression
  • PTSD
  • Anxiety
  • Conduct Disorder
  • Abnormal attachment
  • Violent and exploitative behavior
  • Meaninglessness, worthlessness
  • Malnutrition impairs brain development

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Impact of War and Sanctions on Children in Iraq
  • 2003 study (prior to current war) 40 think life
    is not worth living most of the time
  • Fear, insomnia, nightmares, helplessness,
  • Begging, stealing, prostitution
  • Collapse of education system
  • Brain development stunted by malnutrition
    exacerbates PTSD
  • Association of Psychologists of Iraq 2006 study
  • Countrywide survey of 1000 children
  • 92 had learning impediments
  • 50 were in a critical state of fear

Child Soldiers
  • May live dominated by fear of pain or death
  • Often beaten and desensitized by exposure to
    horrific violence
  • May be forced to take drugs
  • May assimilate and enjoy looting and killing
  • Often commit atrocities, even against own
    families and villages
  • Viewed as expendable, used for most dangerous
    jobs mine clearing, human shields, guarding
    dangerous checkpoints
  • Used for sexual services

Child soldier - Thailand
Child soldier with rifle and teddy bear backpack
- Liberia
Child soldiers Russian White Army, 1918
Child Soldier U.S. Civil War
Child soldiers in MozambiqueEffect of length of
time with armed group
  • Childrens moral responsiveness after their
    liberation is largely determined by the length of
    time spent in the armed group (Boothby Knudsen,
    Scientific American, 2000).
  • Less than six months Initially displayed
    aggressive behavior and distrust of adults. These
    reactions quickly subsided and children defined
    themselves as victims rather than as members of
    the military group. PTSD and remorse were common.
  • One year or more Had substantially changed
    self-concepts, which became solidly intertwined
    with those of their captors. They continued to
    use violence as the principal means of exerting
    social control and influence.

Impact of War on Women
  • Women more affected than men exposed to same
    trauma in most studies
  • May turn to prostitution to survive
  • High HIV infection rates
  • Poor obstetrical care in conflict zones
  • More miscarriages
  • Higher maternal and infant mortality
  • Belief that women are legitimate spoils of war

Gender-based Violence
  • Systematic mass rape
  • Humiliation
  • Ethnic cleansing
  • Forced pregnancy
  • Forced miscarriage
  • Sexual enslavement
  • Mutilation

Especially Vulnerable Women
  • Pregnant women and women with small children
    unable to move quickly and quietly
  • Women in societies where they lack basic rights
  • Refugee women separated from income and

Women in Sudan
  • Internally displaced women in Darfur
    (International Medical Corps, 2005)
  • 31 major depressive disorder
  • 63 symptoms of depression
  • Suicide rate 100 times that expected in the
    general population

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Comfort women - WWII
PTSD and the Perpetuation of Conflict
  • Anger outbursts
  • Emotional numbing
  • Hypervigilance
  • Distrust and paranoia
  • Preoccupation with enemy
  • Isolation and despair

PTSD and the Perpetuation of Conflict
  • Neurophysiological basis for symptoms
  • Poor affect regulation
  • Decreased emotional intelligence
  • Traumatized population
  • Psychic numbing
  • Extrapolate behavior from individual to

Recurrence of Armed Conflict
  • Mental illness caused by psychological trauma is
    associated with feelings of hatred and desire for
  • Kosovo (Lopes Cardozo et al., J Traumatic Stress
  • Afghanistan (Lopes Cardozo et al., JAMA 2004)
  • Openness to reconciliation and feelings of
    revenge correlated with presence of PTSD
  • Ugandan Congolese Child soldiers (Bayer et al.,
    JAMA 2007)
  • Effective treatment of psychological trauma may
    help prevent recurrence of violence

Cairo Declaration on Mass Violence and Mental
Health - World Psychiatric Association, 2005
  • Violence is a major public health problem with
    important mental health implications
  • Violence does not help to solve problems but
    begets violence and brings with it poverty,
    hunger, disease and fear
  • Unless properly addressed, the psychosocial
    consequences of violence will negatively affect
    future generations
  • Psychiatry and behavioral sciences can contribute
    to the understanding of the complexroots of
    violence and to the formulation of interventions
    that can prevent violence
  • Terrorism, by itself, is not a mental illness but
    a phenomenon often associated with oppression and
    absence of opportunities for free expression or

Appropriate Delivery of Mental Health Services -
International Efforts
  • UN Inter-Agency Standing Committee (IASC)
    Guidelines on mental health and psychosocial
    support in emergency settings
  • International Society for Traumatic Stress
    Studies (ISTSS)/RAND Corporation Guidelines
    for mental health training of primary health
    workers in conflict-affected developing countries

Evidence-Based Approaches to Mental Health
  • Comprehensive Mental Health Program in
    Bosnia-Herzegovina (Mooren et al., J Clin Psychol
  • Systematic assessment of efficacy
  • Multicenter outcome studies of counseling
  • Mental Health Action Plan (Mollica et al., Lancet
  • Evidence-based plan for addressing mental health
    in complex emergencies
  • Utilizes primary care providers, traditional
    healers, and relief workers
  • Research agenda

  • To understand resilience and recovery
  • To understand the wide variety of symptoms and
  • To determine the effectiveness of various
    approaches to providing mental health care
  • To reach all of the ill persons and provide
    mental health services
  • To understand the root causes of war and social
    violence and work toward prevention