To the Editor: Dr. Lifton writes in his thought-provoking article(June 2 issue) that "physicians have always been concerned withhow people survive trauma," arguing that survivors of mass trauma,such as the Vietnam and Iraq wars and the attacks on September11, 2001, had "collective psychological responses" and thattheir "psyches have often been decimated."1 This propositionis not supported by studies that were conducted after theseevents or by data on similar events in other countries. Studiesaimed at documenting the consequences of mass trauma suggestthat most exposed persons manifest impressive resilience orquick recovery from their initial responses to the trauma. Post-traumaticstress disorder (PTSD) developed in only a minority of thoseexposed to combat in Vietnam,2 Iraq, and Afghanistan.3 Similarfindings emerged in studies conducted after September 114 andin research on Israeli survivors of combat5 and terrorism.6
The awareness that exposure to trauma may result in elevatedrates of post-trauma reactions is important. However, physiciansconcerned with how people survive trauma can be reassured thatthe majority of the population is most likely to demonstratepsychological resilience, rather than psychopathology.
Yuval Neria, Ph.D. Raz Gross, M.D., M.P.H. Columbia University New York, NY 10032 ny126{at}columbia.edu
References
Lifton RJ. Americans as survivors. N Engl J Med 2005;352:2263-2265. [Free Full Text]
Dohrenwend BP, Neria Y, Turner JB, et al. Positive tertiary appraisals and posttraumatic stress disorder in U.S. male veterans of the war in Vietnam: the roles of positive affirmation, positive reformulation, and defensive denial. J Consult Clin Psychol 2004;72:417-433. [CrossRef][Web of Science][Medline]
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22. [Free Full Text]
Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. JAMA 2002;288:581-588. [Free Full Text]
Neria Y, Solomon Z, Ginzburg K, Dekel R, Enoch D, Ohry A. Posttraumatic residues of captivity: a follow-up of Israeli ex-prisoners of war. J Clin Psychiatry 2000;61:39-46. [Medline]
Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA 2003;290:612-620. [Free Full Text]
Dr. Lifton replies: In studies of survivors of war and the Holocaust— and in more general observations on the psychology ofthe self — I, too, have been impressed by the human capacityfor resilience.1,2 Much of my article was about that capacity,as manifested among survivors seeking illumination from theirexperience. But we best understand our species by recognizingnot only our resilience but also our vulnerability. This vulnerabilitywas greatest among those I spoke of as immediate survivors (ofcombat in Vietnam or Iraq or of proximity to the targets onSeptember 11, 2001), and it is evident in most studies of severetrauma. Though responses vary, many survivors experience profoundpsychological effects. Hoge et al., whose article is cited byDrs. Neria and Gross, reported a prevalence of PTSD of 12.7percent among U.S. troops in Iraq after they had been in threeto five firefights and of 19.3 percent after more than five.3The authors called this a conservative estimate, which did nottake into account the severely wounded; they recommended broaderscreening for PTSD.
Our awareness of human resilience should not cloud our recognitionof the assaults on the psyche brought about by war and otherforms of exposure to mass killing and dying.
Robert Jay Lifton, M.D. Harvard Medical School Boston, MA02115
References
Lifton RJ. The protean self: human resilience in an age of fragmentation. Chicago: University of Chicago Press, 1999.
Lifton RJ. Death in life: survivors of Hiroshima. Chapel Hill: University of North Carolina Press, 1991.
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22. [Free Full Text]
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