The development and maintenance of post-traumatic stress disorder (PTSD) in civilian adult survivors of war trauma and torture: A review

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Abstract

This review provides a comprehensive and critical summary of the literature as to the development and maintenance of post-traumatic stress disorder (PTSD) following civilian war trauma and torture. Prevalence rates are reviewed and predictors are discussed in terms of risk factors, protective factors, and factors that maintain PTSD. Most epidemiologically sound studies found relatively low rates of PTSD. There is good evidence of a dose–response relationship between cumulative war trauma and torture and development and maintenance of PTSD. There is also some evidence that female gender and older age are risk factors in development of PTSD. Some refugee variables may exacerbate symptoms of PTSD and contribute to their maintenance. Preparedness for torture, social and family support, and religious beliefs may all be protective against PTSD following war trauma and torture. Applicability of the concept of PTSD to non-western populations and areas for much needed further study are discussed.

Section snippets

Background

Warfare and torture occur on a large scale in many countries resulting in widespread death and disability (Silove, 1999). According to Amnesty International (1997), human rights violations have been recorded in over 150 countries worldwide and the number of civilians affected by war in comparison to military personnel is rising (International Federation of Red Cross and Red Crescent Societies, 1998). War can lead to a range of severely traumatic experiences among civilian populations. For

Aims

Despite the possibly wide ranging and complex psychological effects of torture and war trauma (Gorst-Unsworth & Goldenberg, 1998), this review will focus on PTSD because this condition has been most commonly studied in relation to these atrocities (Rosner, Powell, & Butollo, 2003).

This review will comprehensively and critically assess the literature regarding the prevalence and predictors of PTSD following civilian war trauma and torture. It will therefore expand on the illustrative selection

Search strategy and inclusion/exclusion criteria

Extensive electronic searches of the PsychInfo, Web of Science and PILOT data bases were conducted within the date parameters of 1970–2005 using the terms: PTSD; civilian; prevalence; refugee; epidemiology; war and torture. Manual searches of the bibliographies of articles and of the Journal of Traumatic Stress were also conducted. Forty eight studies were found pertaining to the development and maintenance of PTSD in civilian survivors of war trauma and torture (see Appendix A for a summary).

The prevalence of PTSD in civilian adult survivors of war trauma and torture

Studies reporting prevalence of PTSD following torture and war trauma vary in their sampling and assessment methods. Some studies are conducted on site in the country where the trauma has occurred, other studies examine refugee or displaced populations. Some studies report current levels of PTSD whereas others assess for PTSD over the course of a life time (see Appendix A for a summary).

Dose–response relationship

Few studies have investigated the risk factors for developing PTSD following torture as a distinct variable. Three studies have documented a dose–effect relationship between cumulative torture experience and PTSD. Mollica, Mcinnes, Pham et al. (1998), Molloca, Mcinnes, Poole et al. (1998) found this relationship in their sample of Vietnamese ex-political detainees. However, their measure of cumulative torture did not take into account qualitative differences in the kinds of torture or

Protective factors in the development of PTSD in civilian adult survivors of war trauma and torture

A series of studies have investigated protective factors in torture survivors in Turkey. Basoglu, Paker, Ozmen et al. (1994), Basoglu, Paker, Paker et al. (1994), Basoglu et al., 1996, Basoglu et al., 1997 consistently found that preparedness for torture is a protective factor in terms of the distress experienced during torture and the development of subsequent PTSD. Furthermore, contrary to the dose–effect findings of previously mentioned studies, Basoglu, Paker, Ozmen et al. (1994), Basoglu,

The maintenance of PTSD in civilian adult survivors of war trauma and torture

Only two studies looked at the maintenance of PTSD following torture specifically. Basoglu, Paker, Ozmen et al. (1994) and Basoglu and Paker (1995) examined long-term traumatic stress response in survivors of torture in Turkey. The mean time since release from captivity was 41 months. They found that long term PTSD was not predicted by the frequency of exposure, but by the perceived severity of the torture. In addition, Basoglu, Paker, Ozmen et al. (1994), Basoglu, Paker, Paker et al. (1994)

The cross-cultural applicability of PTSD

Civilian survivors of war trauma and torture described in the literature largely originate from non-western cultures. Attempts have been made in some of the above studies to validate instruments by translating and back-translating into the language used among the study population (Cardozo et al., 2000, Scholte et al., 2004). Psychometric properties have also been gained for the use of some measures in the relevant countries (ElSarraj et al., 1996). Some authors defend their instruments by

Discussion

Research pertaining to development and maintenance of PTSD in civilian survivors of war trauma and torture has been described and evaluated (see Appendix A for a summary of studies). In addition to difficulties with the application of PTSD to non-western groups, methodological difficulties have included small sample sizes and non-random focus on specific populations. This has limited the generalisability of findings. Studies have also been limited by the use of self-report measures and symptoms

Areas for further research

As suggested above, it is possible that rates of PTSD vary with the sampling method employed by the study. Further research may therefore investigate differences in risk of developing PTSD and prevalence of PTSD between refugees and community samples affected by similar traumas. Furthermore, whether there are differences in the traumas experienced between these two groups.

The finding in a western sample that the apparently increased vulnerability of females to developing PTSD could instead be

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