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Mental Health Aspects of 
Prolonged Combat Stress in Civilians
A National Center for PTSD Literature Review

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Posted On: January 20, 2001          Updated On: January 19, 2002
© Terence T. Gorski, 2001

Mental Health Aspects of Prolonged Combat Stress in Civilians

A National Center for PTSD Literature Review
<Read It On The National Center for PTSD Website>

Following the events of September 11th, America braced itself for a war against terrorism. Americans have been told by the government on several occasions to be on alert for future attacks and have experienced widespread fear from unknown sources of Anthrax. Several weeks after the terrorist attack, America went to war against Afghanistan. With the onset of the war came the fear of retaliation. These events create a prolonged exposure to ongoing multiple incident stressors that are different from single incident disasters as Americans report ongoing fear and threat.

What types of traumatic events 
do civilians experience during war?

Typically when we think about being exposed to traumatic events during a war, we think of the experiences of the military, for example, being fired upon, becoming a prisoner of war, sustaining an injury, or witnessing serious injury or death. However, civilians who are not directly involved in the war effort are also frequently confronted with war related stressors

Some typical civilian stressors including life threat; being bombed, shot at, threatened, or displaced; being confined to one's home; losing a loved one or family member; suffering from financial hardships; and having restricted access to commodities such as food, water, and other supplies as a result of war. Particularly horrific stressors experienced by some civilians during war include: torture, beatings, rape, forced labor, witnessing sexual abuse or violence to a family member, and mock execution.

What are the effects of 
war-zone stressors on civilians?

Most of the evidence on the effects of war on civilians has been conducted on refugee samples and people who were displaced as a result of war. Relative to other war-exposed civilians, these individuals’ experiences may be more severe due to the hardships of not only the situations that led to their exile, but also to stressors experienced in refugees camps and the process of resettlement. In general, refugees exhibit high rates of PTSD and depression as well as other psychiatric problems, particularly if they were tortured (de Jong, Scholte, Koeter, & Hart, 2000). For example, in a survey of Bosnians from a refugee camp in Croatia who experienced on average more than six traumatic events, approximately one-third had depression and one-quarter had PTSD. Twenty percent met criteria for both disorders. Refugees with both depression and PTSD were five times as likely to report being physically disabled, compared with refugees with no psychiatric symptoms (Mollica et al., 1999).

PTSD and other problems are prevalent in nonrefugee samples as well. An article featured in a recent issue of the Journal of the American Medical Association reported on PTSD in survivors of war or mass violence in four low-income countries in (de Jong, et al., 2001). Rates of PTSD were 37.4% in Algeria, 28.4% in Cambodia, 17.8% in Gaza, and 15.8% in Ethiopia. These rates are considerably higher than the US population rate of 8% (Kessler, Sonnega, Bromet, & Nelson, 1995). One suggested explanation for the high rate in Algeria is that the terrorist attacks were still ongoing when PTSD was assessed. Several risk factors for PTSD were identified, including torture and the experience of trauma after the age of 12.

Results from refugees and impoverished countries may be difficult to generalize to Western cultures. However, findings from more industrialized settings such as Israel and Beirut may be relevant. Studies from the Gulf War suggest that there was a marked rise in stress during early weeks of the war for all ages that dropped off within a few weeks (Milgram, 1994). For example, data were collected on all casualties that arrived in the emergency departments of 12 local hospitals after actual missile attacks and false alarms. Almost 75% of admissions were for stress reactions or unjustified atropine injections. The highest number of psychological casualties occurred during the first two missile attacks, after which the numbers declined (Bleich, Dycian, Koslowsky, Solomon, & Weiner, 1992). Another study found that while approximately half of a sample reported sleep problems during the war, there was significant improvement 30 days after the war ended (Askenasy & Lewin, 1996). Similar results were found in a study of following the 1982 Lebanon-Israel war. Almost 12,000 Israelis were interviewed regarding their mood on eleven different occasions between 1979 and 1984. Outbreak of war coincided with an increase in depression. Depressed mood peaked at the time of the Palestinian massacre at the refugee camps, then dropped below baseline, even though conflict continued. Thus, many civilians respond to prolonged war with various stress symptoms, but as time passes people seem to be resilient and stress levels return to normal.

What are the long-term effects of exposure to war stress among civilians?

Although most civilians who are exposed to war stress will not develop long-term mental health problems, some will, particularly if they have been exposed to severe stressors. Much research on this topic has been conducted with Holocaust survivors. In a study of 124 Jewish Holocaust survivors, 46% met criteria for PTSD. In a community sample of Israelis age 75 and older, 27% of male and 18% of female Holocaust survivors met criteria for PTSD as compared to 4% percent of males and 8% of females who did not experience the Holocaust (Landau & Litwin, 2000). Thus, it is clear that the prevalence of PTSD will persist throughout their lifetimes. Similarly, data from a long term follow up study of civilians in Holland 50 years after World War II indicates that 4% of the population exposed to a war related event has PTSD, as compared to 1.5% of non-exposed individuals (Bramsen & van der Ploeg, 1999).

Is exposure to war stressors in civilians 
associated with physical health problems?

There is accumulating evidence that PTSD is associated with long-term physical health problems. In terms of the research on civilians exposed to war, there is good evidence from an epidemiological study of civilians in Beirut that exposure to war events is associated with higher mortality rates. Men exposed to five or more traumas were more than twice as likely to die than non-exposed men, while women exposed to five or more traumas were almost three and a half times as likely to die than non-exposed women (Sibai, Fletcher, & Armenian, 2001). In a previous study on heart disease and wartime stressors, it was found that people with heart disease were five times more likely to have crossed the "green-line" (demarcation lines which divide the capital of Beirut into two sectors and separate the belligerent parties) than patients without heart disease heart, suggesting that there is a relationship between heart disease and war time stress (Sibai, Armenian, & Alam, 1989). There is also evidence that war may effect the immune system as evidenced by a sample of women from Croatia in which displaced women had altered psychological, hormonal and immunological activity (Sabioncello et al., 2000).

How do children respond to prolonged stress?

Most research on the effects of prolonged stress on civilians has been carried out with adult samples. The literature that is available suggests that children, just as adults, are affected but that the majority will not suffer from long term consequences. For example, following the period of SCUD missile attacks in Israel during the Gulf War, children ages 10-15 were asked to described what they thought life would be like for children their age next year. Their dominant perception was positive (73%). However, children who reported greater postwar reactions also held more pessimistic views (Schwarzwald, Weisenberg, Soloman, & Waysman, 1997). Several months after the war children ages 10-15 reported that they were more concerned about traffic accidents, relations with friends, and their studies than with missile attacks (Greenbaum, Erlich, & Toubiana, 1993). A one year follow up of children showed that high school students from high risk areas reported no war symptoms, except sensitivity to loud noises which was reported by about one fifth of children (Klingman, 1995). As is the case with adults, children living in refugee camps experienced more psychological problems than non-refugee children (Paardekooper, de Jong, & Herman, 1999).


The goal of this review is to describe how civilians respond to prolonged stress such that it might be possible to predict the effects of the War on Afghanistan on U.S. civilians. However, there is not a sufficient body of research on other events that resemble the present circumstances in the United States upon which to draw. Therefore, research on refugees and low-income countries was reviewed as well as research on the Gulf War. The literature on children was reviewed separately.

Overall, it appears as though while many civilians may be impacted in the short run, the long term expectation is that most people will be resilient. Studies on both children and adults following the Gulf War indicated that stress levels returned to normal shortly after the end of the war. 

A consistent finding is that people who experience more extreme stress will display more severe symptoms than those who experience only a threat of violence or less intense exposure. Thus, Americans who directly experienced or witnessed the terrorist attacks, had a close friend or family member killed, or who are at greater risk for becoming infected with Anthrax, will likely exhibit more extreme stress responses. And, for this subset of civilians, there reactions may be intense and long lasting. In the event that Americans become displaced by the war (for example, as a result of bombings taking place in the United States), it is likely that these people will also report more extreme stress responses.


Askenasy, J. & Lewin, I. (1996). The impact of missile warfare on self-reported sleep quality. Part 1. Sleep, 19, 47-51

Bleich, A., Dycian, A., Koslowsky,M., Solomon, Z., & Weiner, M. (1992). Psychiatric implications of missile attacks on a civilian population. Journal of the American Medical Association, 268, 613-615.

Bramsen, I. & van der Ploeg, H. (1999). Fifty years later: The long term psychological adjustment of ageing World War II survivors. Acta Psychiatrica Scandinavica, 100, 350-358.

de Jong, J., Komproe, I., Van Ommeren, M., El Masri, M., Araya, M., Khaled, N., van de Put, W., & Somasundarum, D. (2001). Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Journal of the American Medical Association, 286, 555-562.

de Jong, J., Scholte, W., Koeter, M., & Hart, A. (2000). The prevalence of mental health problems in Rwandan and Burundese refugee camps. Acta Psychiaticar Scandinavica, 102, 171-177.

Greenbaum, C., Erlich, C., & Toubiana, Y. (1993). Settler children and the Gulf War. In N.A. Fox & L.A. Leavitt (Eds.), The psychological effects of war and violence on children (pp. 109-130). Hillsdale, NJ: Erlbaum.

Hobfoll, S., Lomranz, J., Eyal, N., Bridges, A., & Tzemach, M. (1989). Pulse of a nation: Depressive mood reactions of Israelis to the Israel-Lebanon War. Journal of Personality and Social Psychology, 56, 1002-1012.

Kessler, R., Sonnega, A., Bromet, E., & Nelson, C (1995). Posttraumatic stress disorder in the National Comorbidity Study. Archives of General Psychiatry, 52, 1048-1060.

Klingman, A. (1995). Israeli children's responses to the stress of the Gulf War. School Psychology International, 16, 303-313.

Landau, R. & Litwin, H. (2000). The effects of extreme early stress in the very old age. Journal of Traumatic Stress, 13, 473-487.

Milgram, N. (1994). Stress and coping in Israel during the Persian Gulf War. Journal of Social Issues, 49, 103-123.

Mollica, R., McInnes, K., Sarajlic, N., Lavelle, J., Sarajlic, I., & Massagli, M. (1999). Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. Journal of the American Medical Association, 282, 433-439.

Paardekooper, B., de Jong, J., & Herman, J. (1999). The psychological impact of war and the refugee situation on South Sudanese children in refugee camps in Northern Uganda: An exploratory study. Journal of Child Psychology and Psychiatry, 40, 529-536.

Sabioncello, A., Kocijan-Hercigonja., Rabatic, S., Tomasic, Jeren, T., Matijevic, L., Rijavec, M., & Dekaris, D. (200). Immune, endocrine, and psychological responses in civilians displaced by war. Psychosomatic Medicine, 62, 502-508.

Schwarzwald, J., Weisenberg, M., Soloman, Z., & Waysman, M. (1997). What will he future bring? Thoughts of children after missile bombardment. Anxiety, Stress, and Coping, 10, 257-267.

Sibai, A., Armenian, H., & Alam, S. (1989). Wartime determinants of arteriographically confirmed coronary artery disease in Beirut. American Journal of Epidemiology, 130, 623-631.

Sibai, A., Fletcher, A., & Armenian, H. (2001). Variations in the impact of long-term wartime stressors on mortality among the middle aged and older population in Beirut, Lebanon, 1983-1993. American Journal of Epidemiology, 154, 128-137.


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