Prisoners of Hussein
The war in Iraq is over - or at least, the Hussein regime is history. As Iraqis celebrate, loot, and mourn the death of civilians, the American prisoners of war are free. Will they face lasting psychological scars from captivity in enemy hands?

POWs in the past have suffered posttraumatic stress disorder (PTSD), a group of disabling symptoms such as inability to concentrate, extreme vigilance, and exaggerated fearfulness.

It's too soon to know about the Iraq prisoners, says Terrence Keane, a PTSD expert at the Department of Veteran's Affairs Medical Center in Boston, because the conditions of captivity are uncertain. "We don't know if it was simply a matter of them being held, in which case psychologically we'd expect them to be doing fine. But if there were interrogations, threats, beatings or torture, keeping them awake or depriving them of food, it would a take more concerted effort to assist in recovery."

PTSD was listed as a psychological disease in 1980, largely because American veterans of the war in Vietnam had suffered flashbacks, inability to sleep or concentrate, and unexplained terrors long after their return. The diagnosis was later expanded to cover survivors of rape, natural disaster, factory explosion and other terrors.

The disorder can have lifetime impact, according to the National Center for PTSD: "The traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that retains its power to evoke panic, terror, dread, grief or despair."

Hallmarks of PTSD include:

An external triggering event that threatened death or injury.

Intrusive recollections of the traumatic event.

The use of behavioral, cognitive or emotional strategies to numb the pain and terror. (Some people try to avoid conditions that trigger intrusive thoughts. Others use "psychic numbing," which may cause them to withdraw from personal relationships.)

Posttraumatic stress disorder appears at high rates among some U.S. veterans. The U.S. National Vietnam Veterans Readjustment Survey, for example, found PTSD symptoms among 31 percent of men, and 27 percent of women. An additional 22 percent of men and 21 percent of women had partial PTSD at some point, so more than half of U.S. veterans of the war in Vietnam -- a total of about 1,700,000 people -- have experienced "clinically serious stress reaction symptoms," according to the National Center for PTSD.

The numbers were even more dramatic for American POWs from World War II and the Korean War. According to research published in 1997 (see "Posttraumatic Stress Disorder...." in the bibliography), 84 percent of U.S. prisoners held by Japan had PTSD symptoms at one time or another, and 59 percent were still suffering in the 1990s.

Data from Posttraumatic Stress Disorder in a Community Sample..., Brian Engdahl et al (see Bibliography)

Such numbers make PTSD look like a normal, not abnormal, response to the experience of combat and being a POW, says Brian Engdahl, a counseling psychologist at the Department of Veterans Affairs Medical Center in Minneapolis. Engdahl says he explains to veterans "that this is your mind and body's way of reacting to a life-threatening experience, that they are very permanent, painful memories that you will carry with you for rest of your life."

However, he argues that these reactions had an adaptive value in evolution. "Hypervigilance, the startle response, and avoidance of situations that appear related to the threat all helped our species survive, and they are still that way because they are 'wired,' to remember these things permanently, and be on guard against similar situation permanently."

POWs of Iraq
It's hard to know how PTSD will affect the small number of American warriors imprisoned by Iraq. "By and large, the main thing is how aversive the experience is," says Charles Figley, professor of social work and director of the psychological stress research program at Florida State University. Figley has studied the effects of wartime imprisonment since the 1970s.

A second factor, he adds, is less intuitive. Shorter captivity may not be better. Among people held in the same conditions, POWs "suffer more if they are released before they are able to accommodate to the experience. There is a transition period [after capture] when they are afraid, and then they begin to accommodate, begin to cope."

During this period, which may last 24 to 48 hours, he says, POWs figure out "what happened, why I'm here, what I need to do to get away, how can I survive this." After that point, Figley says, the trauma goes down, and "they are more likely to fare well after release."

August 15, 1945: Japanese POWs at Guam, stand with bowed heads after hearing Emperor Hirohito announce Japan's unconditional surrender. Photo: National Archives and Records Administration.

Training for captivity
Just as American soldiers are trained for war, they are also trained to stay sane and purposeful during the boredom and fear of captivity, says Figley. "The main problem in the initial period [after capture] is coping with so much time and uncertainty on your hands." U.S. military doctrine directs captured soldiers, he says, to "not compromise the mission [by revealing military secrets], to plan an escape, and memorize the [captors] so they can be prosecuted later. That helps them survive and thrive consistent with their ethics and morals. There is a mission there, and that's an example of keeping perspective, keeping hope alive, keeping active."

The Uniform Code of Military Justice, which governs the behavior of captured U.S. soldiers, has another purpose -- preventing the Stockholm Syndrome -- in which captives identify with their captors. In almost any social situation, Figley says, "There's a natural instinct to join mentally in the values and habits of those around you." Famously, after heiress Patty Hearst was kidnapped by a group of radicals in 1974, she joined them in a bank robbery. "We want to make sure [soldiers] don't cross the line, don't compromise the mission," says Figley.

A second group of resistance techniques consists of "'going to the movies' in your mind," says Figley. "They think through various movies and scenes from their lives, recalling a novel or running a route for exercise. ... it has a soothing effect, induces endorphins, you sigh and breath better... If you can keep your mind occupied and take mental breaks from the agony, that maintains hope."

So who prospers?
As you'd expect, the strong fare best as POWs. "Those who survive best are those who can control their minds, choose what to think about, keep their mind occupied, who have hope," says Figley. "That separates the people who survive and thrive from the people who have lasting negative mental health issues."

What happens after captivity also makes a difference, says Keane, who treats and studies PTSD in Boston. "The military is very sophisticated about issues of psychological trauma, about the pace of debriefing, about use of psychologists and psychiatrists, in the care that people receive in the short run.

Building on what has been learned since the war in Vietnam, Keane says, "clinicians are more frankly aware of the long-term effects of trauma, so the jubilation of return is coupled with concern about providing the right treatment, at the right time."

Nearing the end of the Bataan Death March, a thinning line of American and Filipino prisoners of war carry casualties in improvised stretchers as they approach Camp O'Donnell, a new Japanese POW camp, in April 1942 during World War II. On April 10, an estimated 70,000 POWs were forced to march 55 miles, 88 km, to San Fernando, then taken by rail to Capas, from where they walked the final 8 miles, 13 km, to Camp O'Donnell. An estimated 10,000 men died on the Death March from various causes including sickness, beatings, exhaustion and those who fell were bayoneted. Only 54,000 reached the camp. AP Photo

Old wounds
Behind the heavy coverage of war in Iraq is a reality that has had less attention: the images of war have triggered symptoms in people who have been exposed to trauma in the past. "It's very hard for other PTSD folks," says Keane, who runs a refugee mental health center at Boston University. "Refugees from Bosnia, Africa, Southeast Asia are struggling with the war, the fact you can't get away from the sights, sounds, scenes of the bombardment of Iraq." (More on the mental health of refugees.)

To deal with the symptoms, Keane suggests controlling the stimulus. "We try to help them manage the information. You don't need to buy the paper. You can tune the radio to a classical music station, try to be aware when the news comes on."

Like a moth to a flame, he says, however, people with PTSD "are drawn to it, but repelled by it, have this sense they have to watch it, and then get distressed." The pictures and thoughts of war, he says, "may instigate nightmares." Even anniversaries can trigger PTSD symptoms.

What are the psychological effects of being a civilian prisoner?

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