War-zone Exposure Research Articles

Moral injury in post-9/11 combat-experienced military veterans: A qualitative thematic analysis.

War zone exposure is associated with enduring negative mental health effects and poorer responses to treatment, in part because this type of trauma can entail crises of conscience or moral injury. Although a great deal of attention has been paid to posttraumatic stress disorder and fear-based physiological aspects of trauma and suffering, comparatively less attention has been given to the morally injurious dimension of trauma. Robust themes of moral injury were identified in interviews with 26 post-9/11 military veterans. Thematic analysis identified 12 themes that were subsumed under four categories reflecting changes, shifts, or ruptures in worldview, meaning making, identity, and relationships. Moral injury is a unique and challenging clinical construct with impacts on the individual as well as at every level of the social ecological system. Recommendations are offered for addressing moral injury in a military population; implications for community public health are noted. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Gender differences in mental health outcomes among Afghanistan veterans exposed to war zone trauma.

Research has sought to identify whether women have an increased risk of developing mental health problems following military trauma compared to men, but the results are mixed. This study examined gender differences in a range of mental health outcomes within three levels of war zone trauma exposure and investigated gender differences in risk and protective factors associated with clinical mental health problems. Using data from a cross-sectional, postdeployment survey, a sample of Norwegian veterans of recent military operations in Afghanistan (N = 6,205, 8.3% women) were sorted according to reported war zone trauma exposure level (low, medium, high), then assessed for symptoms of posttraumatic stress disorder (PTSD), posttraumatic distress, anxiety, depression, insomnia, and alcohol problems. The findings revealed that men who reported low war zone exposure had lower levels of posttraumatic distress symptoms than women, d = -0.20, p = .040, but were more likely to report symptoms of alcohol problems within the low, d = 0.33, p < .001; medium, d = 0.39, p < .001; and high, d = 0.37, p = .049, exposure groups; however, these differences disappeared when all symptom variables were combined into one clinical mental health problem variable. Women with a clinical mental health problem were less likely to report war zone exposure than men, OR = 0.93, 95% CI [0.90, 0.97], p = .001. Findings suggest that although gender differences in mental health symptoms exist, male and female veterans with mental health problems may share more similarities than previously recognized.

Screening for PTSD and TBI in Veterans using Routine Clinical Laboratory Blood Tests

Post-traumatic stress disorder (PTSD) is a mental disorder diagnosed by clinical interviews, self-report measures and neuropsychological testing. Traumatic brain injury (TBI) can have neuropsychiatric symptoms similar to PTSD. Diagnosing PTSD and TBI is challenging and more so for providers lacking specialized training facing time pressures in primary care and other general medical settings. Diagnosis relies heavily on patient self-report and patients frequently under-report or over-report their symptoms due to stigma or seeking compensation. We aimed to create objective diagnostic screening tests utilizing Clinical Laboratory Improvement Amendments (CLIA) blood tests available in most clinical settings. CLIA blood test results were ascertained in 475 male veterans with and without PTSD and TBI following warzone exposure in Iraq or Afghanistan. Using random forest (RF) methods, four classification models were derived to predict PTSD and TBI status. CLIA features were selected utilizing a stepwise forward variable selection RF procedure. The AUC, accuracy, sensitivity, and specificity were 0.730, 0.706, 0.659, and 0.715, respectively for differentiating PTSD and healthy controls (HC), 0.704, 0.677, 0.671, and 0.681 for TBI vs. HC, 0.739, 0.742, 0.635, and 0.766 for PTSD comorbid with TBI vs HC, and 0.726, 0.723, 0.636, and 0.747 for PTSD vs. TBI. Comorbid alcohol abuse, major depressive disorder, and BMI are not confounders in these RF models. Markers of glucose metabolism and inflammation are among the most significant CLIA features in our models. Routine CLIA blood tests have the potential for discriminating PTSD and TBI cases from healthy controls and from each other. These findings hold promise for the development of accessible and low-cost biomarker tests as screening measures for PTSD and TBI in primary care and specialty settings.

Trauma-Related Psychopathology in Iraqi Refugee Youth Resettled in the United States, and Comparison With an Ethnically Similar Refugee Sample: A Cross-Sectional Study.

BackgroundConflict in Iraq has displaced millions of refugee youth. Warzone exposure and forced migration have unique acute and chronic impacts on youth, yet effects of exposure may not be universal across diverse refugee groups. Understanding how youth from various refugee groups are differentially affected by stress and trauma is critical to allocate resources and implement screening measures with the goal of providing early intervention.MethodTo identify the effects of warzone exposure and forced migration, a convenience sample of 48 Iraqi refugee youth ages 6–17 was assessed within the first month of arrival to the United States. Youth provided self-reported severity of posttraumatic stress and anxiety symptoms; symptom severity was then compared with an existing sample of 135 Syrian refugee youth to explore whether refugee youth of different nationalities experience the same effects of warzone exposure and forced migration. These data are the baseline for a longitudinal developmental study of refugee health, which also includes parental data.ResultsSeverity of separation anxiety and negative alterations in cognition and mood were the greatest symptomatic concerns in Iraqi refugee youth. Thirty-eight percent of responding Iraqi youth showed possible indication of an anxiety disorder. Severity of posttraumatic stress symptoms was lower in Iraqi youth compared to Syrian youth. For both Iraqi and Syrian refugee youth, separation anxiety was the most significant concern, with more than 80% of both samples showing a possible indication of clinically significant separation anxiety.ConclusionThe present observational study indicated that Iraqi refugee youth experience a range of anxiety and posttraumatic stress symptoms following warzone exposure and forced migration; posttraumatic stress symptoms were less severe in Iraqi versus Syrian youth. Comparing refugee youth of different nationalities is of particular importance, as our results demonstrate that findings from one refugee population cannot easily be generalized to another. Clinical and research efforts should prioritize interventions to address separation anxiety in refugee youth, which was of concern in both samples.

Working in a Physically Dangerous Work Environment: Employee Vitality and Sustainable Behavior

There is a limited understanding of the antecedents and consequences of employee vitality during war zone exposure. The current study is one of the first ones to investigate the direct effects of perceived danger on employee vitality by collecting data from Afghanistan, one of the most dangerous countries in the world. Furthermore, it was investigated how employee vitality affects sustainable behavior at the workplace. The hypotheses of the study have been tested by using data from two surveys collected from 192 employees working in small-sized private businesses in Afghanistan. The results indicate that high levels of perceived danger negatively impact employee vitality at work. In addition, we found that employees with vitality engage in more pro-environmental behavior in the workplace. The engagement of vital employees in pro-environmental behavior is higher among those employees who have a high level of environmental awareness. This paper concludes by presenting the limitations and implications of this study, as well as highlighting potential avenues for future research.

Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study.

We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era. For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service. Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard. Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.

Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools

PurposeStudies show that conflict can negatively affect psychological health. The Syrian crisis is 8 years old and yet little is known about the impact of the conflict on the well-being of Syrians who remain. This gap was addressed by conducting an empirical study on the mental health burden of Syrian children in two areas of the country.Methods492 children between 8 and 15 years were randomly selected from schools in Damascus and Latakia. The incidence of psychological disorder symptoms was measured using self-report screening instruments, the Children’s Revised Impact of Event Scale (CRIES-8) and the Revised Children’s Anxiety and Depression Scale (RCADS-25). Simultaneously, sociodemographic and traumatic event information was collected. Binary logistic regression was used to identify factors that influence the development of post-traumatic stress disorder (PTSD) symptoms.ResultsIn our sample, 50.2% of students were internally displaced and 32.1% reported a negative experience. 60.5% of those tested had at least one probable psychological disorder with PTSD the most common (35.1%), followed by depression (32.0%), and anxiety (29.5%). Binary logistic regression indicated that PTSD symptoms were predicted by: living in Damascus [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.51–3.69], being female (1.54, 1.02–2.34), having depression and anxiety (2.55, 1.48–4.40), and the negative experiences; displacement and daily warzone exposure (1.84, 1.02–3.30 and 2.67, 1.08–6.60).ConclusionsSyrian children are experiencing traumatic events and war-associated daily stresses that are hugely impacting psychological well-being. Our data offer guidance for mental health providers regarding risk factors and highlights the use of the school system to reach suffering children.

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003–2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., “index”) Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.

Psychosocial rehabilitation after war trauma with adaptive disclosure: Design and rationale of a comparative efficacy trial

BackgroundPosttraumatic stress disorder (PTSD) from warzone exposure is associated with chronic and disabling social and occupational problems. However, functional impairment is rarely assessed or targeted directly in PTSD treatments, which instead focus on symptom reduction. Trauma-related contributors to diminished functioning, including guilt, shame, and anger resulting from morally compromising or loss-based war experiences, are also underemphasized. The goal of this clinical trial is to fill a substantial gap in the treatment of military-related PTSD by testing a modified Adaptive Disclosure (AD) therapy for war-related PTSD stemming from moral injury and traumatic loss focused on improving psychosocial functioning AD. Method and designThis paper describes the rationale and design of a multi-site randomized controlled trial comparing AD to Present-Centered Therapy (PCT). We will recruit 186 veterans with PTSD, who will be assessed at baseline, post-treatment, and 3- and 6-months post-treatment. Primary outcomes are functional changes (i.e., functioning/disability and quality of life). Secondary outcomes are mental health variables (i.e., PTSD, depression, guilt, shame). We hypothesize that veterans treated with AD will experience greater improvements in all outcomes compared to those treated with PCT. DiscussionThis trial will advance knowledge in rehabilitation research by testing the first therapy specifically designed to address psychosocial functioning among veterans with war-related PTSD. The results may improve the quality of mental health care for veterans by offering an ecologically sound treatment for experiences that are uniquely impactful for war veterans.

Links Between Stressful Life Events and Proactive and Reactive Functions of Aggression

ABSTRACTRecently, more attention has been devoted to understanding how stressful life events might relate to proactive and reactive aggression. Findings suggest that stressful life events are more strongly linked to reactive, than proactive, aggression; however, it is unclear whether the impact of stressful life events on proactive and reactive aggression might vary as a function of the level of exposure to or type of stressful life event. The current study examined how level of exposure to stressful life events (i.e., witnessed, experienced, and learned about) and stressful life event types (i.e., war zone exposure, sexual victimization, interpersonal violence, and other trauma exposure) related to proactive and reactive aggression. The sample was comprised of 500 undergraduate students (M = 18.96, SD = 1.22, 49.6% male) recruited from a Midwestern university. Findings indicated that all three levels of stressful life event exposure (i.e., experienced, witnesses, and learned) were associated with reactive aggression; however, only witnessed stressful life events were associated with proactive aggression. Clinical implications and future directions are discussed.

Disturbed EEG sleep, paranoid cognition and somatic symptoms identify veterans with post-traumatic stress disorder.

BackgroundChronic post-traumatic stress disorder (PTSD) behavioural symptoms and medically unexplainable somatic symptoms are reported to occur following the stressful experience of military combatants in war zones.AimsTo determine the contribution of disordered EEG sleep physiology in those military combatants who have unexplainable physical symptoms and PTSD behavioural difficulties following war-zone exposure.MethodThis case-controlled study compared 59 veterans with chronic sleep disturbance with 39 veterans with DSM-IV and clinician-administered PTSD Scale diagnosed PTSD who were unresponsive to pharmacological and psychological treatments. All had standardised EEG polysomnography, computerised sleep EEG cyclical alternating pattern (CAP) as a measure of sleep stability, self-ratings of combat exposure, paranoid cognition and hostility subscales of Symptom Checklist-90, Beck Depression Inventory and the Wahler Physical Symptom Inventory. Statistical group comparisons employed linear models, logistic regression and chi-square automatic interaction detection (CHAID)-like decision trees.ResultsVeterans with PTSD were more likely than those without PTSD to show disturbances in non-rapid eye movement (REM) and REM sleep including delayed sleep onset, less efficient EEG sleep, less stage 4 (deep) non-REM sleep, reduced REM and delayed onset to REM. There were no group differences in the prevalence of obstructive sleep apnoeas/hypopnoeas and periodic leg movements, but sleep-disturbed, non-PTSD military had more EEG CAP sleep instability. Rank order determinants for the diagnosis of PTSD comprise paranoid thinking, onset to REM sleep, combat history and somatic symptoms. Decision-tree analysis showed that a specific military event (combat), delayed onset to REM sleep, paranoid thinking and medically unexplainable somatic pain and fatigue characterise chronic PTSD. More PTSD veterans reported domestic and social misbehaviour.ConclusionsMilitary combat, disturbed REM/non-REM EEG sleep, paranoid ideation and medically unexplained chronic musculoskeletal pain and fatigue are key factors in determining PTSD disability following war-zone exposure.Declaration of interestNone.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

The relationship between course of PTSD symptoms in deployed U.S. Marines and degree of combat exposure.

Large cohort studies suggest that most military personnel experience minimal posttraumatic stress disorder (PTSD) symptoms following warzone deployment, an outcome often labeled resilience. Very low symptom levels, however, may be a marker for low exposure, not resilience, which requires relatively high-magnitude or high-frequency stress exposure as a precondition. We used growth mixture modeling (GMM) to examine the longitudinal course of lifetime PTSD symptoms following combat exposure by disaggregating deployed U.S. Marines into upper, middle, and lower tertiles of combat exposure. All factor models fit the data well; Tucker-Lewis Index (TLI) and comparative fit index (CFI) values ranged from .91 to .97. Three distinct trajectories best explained the data within each tertile. The upper tertile comprised True Resilience (73.2%), New-Onset Symptoms (18.3%), and Pre-existing Symptoms (8.5%) trajectories. The middle tertile also comprised True Resilience (74.5%), New-Onset Symptoms (16.1%), and Pre-existing Symptoms (9.4%) trajectories. The lower tertile comprised Artifactual Resilience (86.3%), Pre-existing Symptoms (7.6%), and New-Onset Symptoms (6.1%) trajectories. True Resilience involved a clinically significant symptom increase followed by a return to baseline, whereas Artifactual Resilience involved consistently low symptoms. Conflating artifactual and true resilience may inaccurately create the expectation of persistently low symptoms regardless of warzone exposure.

Warzone stressor exposure, unit support, and emotional distress among U.S. Air force pararescuemen.

Combat exposure is associated with increased mental health symptom severity among military personnel, whereas unit support is associated with decreased severity. However, to date no studies have examined these relationships among U.S. Air Force pararescuemen (PJs), who have a unique and specialized career field that serves in both medical and combatant capacities. Cross-sectional self-report survey. Self-reported survey data regarding depression symptoms, posttraumatic stress disorder (PTSD) symptoms, perceived unit support, and exposure to traditional combat experiences (e.g., firefights) and medical consequences of combat (e.g., injuries and human remains) were collected from 194 PJs in seven rescue squadrons. Levels of combat exposure were compared with previously published findings from combat units, and levels of medical exposure were compared with previously published findings among military medical professionals. Medical exposure intensity showed a stronger relationship with PTSD severity (?=.365, p=.018) than with combat exposure intensity (?=.136, p=.373), but neither combat nor medical exposure was associated with depression severity (?s<.296, ps>.164). Unit support was associated with less severe PTSD (?=?.402, p<.001) and depression (?=?.259, p=.062) symptoms and did not moderate the effects of combat or medical exposure. Medical stressors contribute more to PTSD among PJs than do traditional combat stressors. Unit support is associated with reduced PTSD and depression severity regardless of intensity of warzone exposure among PJs.

Cortisol response to cosyntropin administration in military veterans with or without posttraumatic stress disorder

Studies have demonstrated altered sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis to its direct regulators in veterans with posttraumatic stress disorder (PTSD), but little is known about the adrenal response to hormonal stimulation in PTSD. An increased cortisol response to synthetic corticotropin-releasing factor (CRF) was recently found to be associated with war-zone deployment and not PTSD specifically. To more accurately assess whether there is altered adrenocortical responsivity to hormonal stimulation in relation to war-zone deployment or PTSD, we performed the low-dose cosyntropin stimulation test in a sample of 45 male veterans: 13 war-zone exposed veterans with chronic PTSD (PTSD+), 22 war-zone exposed veterans without chronic PTSD (PTSD-), and 10 veterans not exposed to a war-zone and without chronic PTSD (non-exposed). Plasma cortisol and ACTH were measured at baseline and at intervals over a one hour period following intravenous administration of 1μg of cosyntropin. A significant main effect of group (PTSD+, PTSD-, non-exposed) on the cortisol response to cosyntropin was observed. Cosyntropin-stimulated plasma cortisol levels were significantly higher in the PTSD+ and PTSD- groups compared to the non-exposed group. A significant main effect of group was also observed on peak cortisol levels. These findings suggest that war-zone exposure itself has persistent effects on adrenocortical activity.

DELAYED‐ONSET PTSD AFTER COMBAT: THE ROLE OF SOCIAL RESOURCES

Delayed‐onset posttraumatic stress disorder (DPTSD) has been under medico‐legal debate for years. Previous studies examining the prevalence and underlying mechanisms of DPTSD have yielded inconclusive findings. This study examined the role of social resources and warzone exposure in DPTSD. Six hundred and seventy‐five Israeli veterans from the 1982 Lebanon War, 369 with antecedent combat stress reaction (CSR) and 306 without CSR, were assessed prospectively, 1, 2, and 20 years after the war. Veterans were divided into 4 groups, according to the time of first PTSD onset (first onset at 1983, 1984, and 2002 and no‐PTSD onset). Participants completed self‐report questionnaires tapping various social resources (social network support, family environment, military company environment, homecoming reception), as well as subjective and objective warzone exposure. Our results show that a significant portion (16.5%) of the veterans reported DPTSD. As hypothesized, social resources were found to be implicated in DPTSD. Interestingly, however, social resources accounted for long—not short—delays in PTSD onset. In addition, higher levels of both objective and subjective battle exposure were associated with a more immediate PTSD onset. Finally, CSR was found to be the most powerful predictor of DPTSD. Theoretical and clinical implications of these findings are discussed.

Posttraumatic Stress Symptomatology as a Mediator of the Relationship Between Warzone Exposure and Physical Health Symptoms in Men and Women

The mediating role of posttraumatic stress symptomatology (PSS) on the association between warzone exposure and physical health symptoms in 7 bodily systems (cardiovascular, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, and pulmonary) was examined. We also examined if mediation effects varied as a function of sex. A sample of 317 U.S. Gulf war veterans was assessed for warzone exposure, PSS, and physical health symptoms 10 years after deployment. PSS was significantly associated with postdeployment physical health in all symptom categories when accounting for predeployment health (with effect sizes ranging from a 1.27-1.64 increase in the likelihood of postdeployment physical health symptoms with a 1 standard deviation increase in the PSS symptoms). PSS severity mediated the relationship between warzone exposure and postdeployment symptoms in all physical health domains (with percent mediation ranging 44%-75%). A significant Warzone Exposure × PSS interaction emerged for 5 outcomes such that the effect of PSS on physical health was stronger for veterans reporting lower warzone exposure. No significant interactions with sex emerged. These findings suggest the important influence of PSS on physical health symptoms for both men and women.

Gender Differences in Traumatic Event Exposure and Mental Health Among Veteran Primary Care Patients

This study evaluated gender differences in lifetime traumatic events, PTSD, and depression among VA primary care patients. Participants were 865 adults attending primary care at one of four VA health centers (n = 681 males, 184 females). Mental health findings included: male PTSD 12.3% vs. female PTSD 9.2% (p > 0.05); male depression 15.9% vs. female depression 29.3% (p < 0.001). Men reported more war zone exposure (p < 0.001). Women reported more physical and sexual victimization (p < 0.001). Male logistic regression equations determined PTSD was associated with disability (OR = 3.42; 1.74-6.72, 95% CI) and war zone exposure (OR = 7.14; 3.82-13.30, 95% CI); depression was associated with war zone exposure (OR = 2.27; 1.40-3.68, 95% CI) and interpersonal violence (OR = 1.75; 1.10-2.79, 95% CI). Female PTSD was associated with sexual victimization (OR = 4.50; 1.20-16.80, 95% CI); depression was not predicted. We discuss findings in terms of the crucial need to improve identification and management of PTSD within VA primary care settings.

Posttraumatic stress disorder and standardized test-taking ability.

Given the widespread use and high-stakes nature of educational standardized assessments, understanding factors that affect test-taking ability in young adults is vital. Although scholarly attention has often focused on demographic factors (e.g., gender and race), sufficiently prevalent acquired characteristics may also help explain widespread individual differences on standardized tests. In particular, this article focuses on the role that posttraumatic stress symptoms (PSS) potentially play in standardized academic assessments. Using a military sample measured before and after exposure to war-zone stressors, the authors sought to explain test-taking ability differences with respect to symptoms of PTSD on two cognitive tasks that closely match standardized test constructs. The primary method for this analysis is based on an item response theory with covariates approach. Findings suggest that the effect for PSS is significant on both tasks, particularly for those who experience the highest levels of PSS following war-zone exposure. Findings provide potentially valuable information regarding the nature of the relationship between PSS and verbal and logical reasoning test performance.

Introduction to Special Section: Understanding the impact of the wars in Iraq and Afghanistan

This issue of the Journal of Traumatic Stress contains a special section on the wars in Iraq and Afghanistan. These wars and related events have had a global impact at multiple levels, ranging from individuals to society as a whole. Consequently, public recognition of posttraumatic stress disorder (PTSD) and other readjustment problems resulting from warzone exposure has increased. A query for the term “PTSD” conducted on January 6, 2010 usingGoogle’s news archive search found that the number of English language articles increased from 811 in 2001 (when the United States first went to war in Afghanistan), to 1,160 in 2003 (when the U.S. entered Iraq), to 3,480 in 2009. As public attention has increased, societal response has grown as well. Substantial resources have been committed to help individuals deal with the emotional toll of war. In the United States, for example, the Departments of Veterans Affairs andDefense have implemented large-scale surveillance programs to monitor the mental health of returning service members

Civilian Women at War: Psychological Impact Decades After the Vietnam War

Civilian women working in war zones may be vulnerable to posttraumatic stress reactions for decades. Some four decades since the Vietnam war, little is understood of how non-national civilian women have made sense of their experiences both in a war zone and returning to a hostile society and how this has affected their mental well-being over a lifetime. Female entertainers employed by Western allied forces during the Vietnam conflict completed the Posttraumatic Stress Checklist-Military (PCL-M), the Revised Impact of Event Scale (IES-R), and the General Health Questionnaire (GHQ-12) in response to war zone exposure categories of life threat, sexual discrimination and abuse, and personal trauma. The majority of participants were asymptomatic of posttrauma stress according to the PCL-M and IES-R. However, decades later, 9% of participants met diagnostic criteria for PTSD according to the PCL-M, suggesting that civilian women exposed to war zones may be symptomatic for decades.