University of Virginia Health System

War Coping Mechanisms

Healthy guidelines for increasing stress or anxiety levels

< March 25, 2003 > The war has come home, if not physically, then certainly in stress and anxiety levels.
Not only is the media keeping up a constant barrage of images from Iraq but many cities now have a stepped-up police and military presence, pharmacies are advertising potassium iodide to counter radioactivity and the Department of Homeland Security is matter-of-factly telling you how to protect yourselves and your homes from chemical attacks.

This new life has a price.

"These threats and danger signals are being pumped through the media at this rapid pace, and it serves to really drive people's fear and anxiety levels way up," says Stephen Maren, associate professor of psychology and neuroscience at the University of Michigan in Ann Arbor.

"Our natural response to threat is to mobilize the fear response, which has all sorts of physiological consequences," he adds.

One New Jersey massage therapist says that her business has literally doubled in the few days since the war began.

"People are more psychologically vulnerable," adds Alan Hilfer, director of psychological training at Maimonides Medical Center in New York City. "People are more vigilant. They're startling easier. Anxiety is higher and our threshold is lower."

Part of it is the feeling of sheer helplessness in the face of events that are so far away but which nevertheless hit home hard.

"When you feel like you don't have any control over the situation, that predisposes anyone to higher levels of anxiety," Maren says.

Those feelings are then worsened by the images and reports of the fierce fighting and increased death tolls this past weekend.

"When things don't live up to expectations, it results in negative psychological states. And in some sense that's what we're facing now," Maren says. "The US military spokespeople were clearly hyping a very confident stance and now, although they are saying everything meets with expectations, nonetheless it does feel like we've come up short of expectations. And that just generally upsets people."

Those who lived through the terrorist attacks in New York City or Washington, D.C., and those who served during the 1991 Gulf War may be particularly vulnerable, experts say.

"It's important to have memories of bad things to protect us from future occurrences but sometimes it almost gets overly active so that you end up with post-traumatic stress disorder or shell shock," Maren says. "If you elaborate these fear memories and it works too well, you can hear a car backfire and have a flashback."

Even the televised images from Iraq could trigger a flashback, Maren adds.

For the "average" person, the stress could manifest in headaches, backaches, upset stomach, anxiety, colds, difficulty focusing or concentrating, changes in appetite, increased irritability, and fatigue.

"It's all predicated on how one interprets or perceives or thinks about what's put before them," says Joshua Klapow, an associate professor of psychology and healthcare organization and policy at the University of Alabama at Birmingham. "We're going to have varying levels of stress and anxiety, which means people are going to have to do different things to cope successfully."

Even though everyone has their own individual way of coping, there are some basic guidelines to consider during these stressful times:

• Pay attention to your physical well-being, Klapow advises. That means getting enough sleep, eating properly, and doing what you can to boost your immunity. Exercise and relaxation techniques such as meditation, prayer, yoga, or diaphragmatic breathing can be particularly helpful.
  
  
• Stick to your usual routine as much as possible. "To combat distress, we have to try to keep the environment as normal as it has been, because it decreases cues to the brain of the stressful situation," Klapow says.
  
  
• Keep busy and distract yourself. "Make yourself preoccupied and occupied all the time but not with war news," Hilfer advises. "If you think about this all of the time and you're particularly vulnerable, you'll make a mess out of yourself."
  
  
• Seek out family and friends, bearing in mind that different people will have different preferences for "war talk."
  
  
• Limit—but do not eliminate—information from the war. "People don't need to be informed every minute of the day," Hilfer cautions. "They need to be able to take breaks, dose out other news a little more judiciously in their lives. Listen every now and then but don't be addicted to it."
  
  
• Realize that even if you "successfully" cope, you may not feel good. "This stressful time is not necessarily going to feel good even if you do all the things you can do to manage stress," Klapow says. "It's not going to make it go away. It is going to increase your chances of building resilience and living through this."
  
  
• If you are doing everything you can to manage your stress levels and yet are continuing to feel extremely anxious and are not able to function normally, consider seeking professional help.

Always consult your physician for more information.

Helping Kids Cope With Worries of War

Parents can do much to keep anxiety at bay

Some children jump at the wail of a siren or the roar of an airplane overhead, wondering if it could be an enemy attack.

Some cannot sleep at night because of fears of war and terrorism.

Others struggle to figure out why their country has invaded another country when so many people protested against the war.

Psychologists and other experts say these reactions are typical of many children of a generation suddenly thrust into a collective state of anxiety as the war with Iraq intensifies.

Some younger children are blessed with blissful ignorance and the magical power of illusion.

"Kids' anxiety has been through the roof," says Saunders, director of the Manhattan Mental Health Center. "Kids are bewildered. They're wondering if anybody in their family is going to get hurt or if there's going to be another 9/11."

How parents can best respond depends, of course, on the age of the children as well as their temperament, interest, and knowledge of war and possible terrorism, experts say.

Some, like Richard Gallagher, director of the Parenting Institute at the New York University Child Study Center, say preschool-age children should be shielded from news of the war and possible terrorism.

But that is not always possible, with ubiquitous media coverage making even some very young children well aware of the war in Iraq and possible terrorism threats at home.

"It's important to let the child give you hints and follow a child's lead in what they are ready to talk about," says Judith Myers-Walls, an associate professor and human development specialist at Purdue University's Department of Child Development and Family Studies.

With young children, simple reassurance can be vital, Myers-Walls says. "I think telling kids, 'No matter what, I will do everything I can to keep you safe and no matter what happens, I love you' is all they need to know," she says.

Younger children, psychologists say, can easily confuse fantasy, reality, and historic events.

"The terrorism level is 'high' and then they see the bombing on TV, and they get mixed up," says Los Angeles psychologist Robert R. Butterworth. Since the Sept. 11, 2001, terrorist attacks, he says, "all the images of all these terrible things happening kind of get all mixed together in their psyche."

Parents should conduct "child's war briefings"—with clear, understandable explanations of news, suggests Butterworth, a nationally recognized expert on helping kids cope with war and terrorism.

Then they should give children a chance to share their feelings, he adds. He has used maps, toy tanks, soldiers, and aircraft to explain war to children.

"The crucial point for parents is not blocking out the war news to children, but explaining war facts truthfully to children according to their age and emotional development," Butterworth says.

How young is too young?

"A lot of parents will say, 'My child is only 5 years old, and I don't want to ruin their outlook on life," he says. "But other preschool or kindergarten kids are talking about it, so if the kids are not hearing information from parents, which is reality, they may be getting a distorted reality from someone else."

Certainly, overexposure to violent images is a risk for children at any age, so parents should set limits on the amount of news coverage kids watch, child psychologists say.

But trying to avoid all coverage or talk of war can also send the wrong message.

By doing this, Myers-Walls says, "Parents have given the impression that this is a taboo subject. And pretty soon, you've got neither side talking to the other and not helping to support each other through a tough situation."

Myers-Walls suggests parents seek "teachable moments" to talk with their children about values, fundamental principles, morality, faith, and hope for a better, safer world.

Avoid stereotyping by religion or nationality, she says, and speak of bad actions, not bad people.

"Help children understand that people can choose their behaviors," she says. "Even if they have done something bad in the past, they can choose to do something good in the future."

Other expert tips on helping children cope with war and the threat of terrorism include the following:

• Stick to routines and schedules. Keep kids involved in activities such as sports, arts and crafts, school groups, and religious observances.
  
  
• Be honest and talk in terms children can understand. Explain it is very unlikely their school or house, for instance, will become terrorism targets. But do not make unrealistic promises—for instance, that no more planes will crash or no one else will get hurt.
  
  
• Tell children of steps being taken to protect them by family, schools, police, firefighters, and the military.
  
  
• Avoid glorifying war or minimizing its horrors.
  
  
• Help children understand the United States is not angry with the Iraqi people, but its leaders. Avoid stereotypes; explain that most Muslim—and other—people are peace-loving and friendly.
  
  
• Acknowledge and validate your child's reactions, fears, and thoughts. Make clear you know that their questions and concerns matter and are appropriate.
  
  
• Stay in touch with your child's school to find out about lessons related to terrorism or war, and to ask about fears or questions a child may have raised. For younger children, contact day-care centers or preschools to find out if your child is exposed to topics such as terrorism and war.
  
  
• Get together more often as a family through shared activities and increase one-on-one activities such as playing games.
  
  
• Get help for a child if you detect signs of excessive anxiety or stress that might signal a need for counseling. Warning signs can include physical symptoms such as:
  
  
  • headaches or stomachaches
    
    
  • preoccupation with war, fighting, or terrorism
    
    
  • significant changes in behavior
    
    
  • depressed or irritable moods
    
    
  • trouble sleeping or nightmares
    
    
  • changes in appetite
    
    
  • social withdrawal
    
    
  • recurring fears or anxiety about leaving parents to go to school

Always consult your child's physician for more information.

Online Resources

(Our Organization is not responsible for the content of Internet sites.)

American Psychosomatic Society

Centers of Disease Control and Prevention (CDC)

National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH)

US Department of Health and Human Services

US Department of Veterans Affairs (VA)

Veterans Services Organizations, Department of Veteran Affairs

For more information on post-traumatic stress disorder, anxiety, and depression, please visit the Mental Health Diseases health information module on this Web site.

In Other News About Your Health:

Stressed Vets at Higher Risk for Autoimmune Disease

Link found with post-traumatic stress disorder

The psychological and physical toll of war on veterans' health may be more serious than previously thought.

A new study finds that veterans who experience post-traumatic stress disorder (PTSD) are more likely to suffer from a host of autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, and Graves disease.

The findings build on previous research that has shown combat exposure has both physical and psychological health consequences that can be long-lasting and debilitating.

Researchers from the New York Academy of Medicine examined the 20-year medical histories of 1,972 male veterans who served in the US Army during the Vietnam War.

The study found that while 54 men had PTSD, more than double that number had PTSD coupled with another psychiatric disorder such as schizophrenia, depression, paranoia, or hysteria, indicating that Vietnam veterans often suffer from multiple mental illnesses.

The data also showed that 17 percent to 19 percent of those with PTSD had an autoimmune disease. Veterans with PTSD and a secondary mental diagnosis had the highest rates of autoimmune disease—they were three times more likely to develop an autoimmune disease than veterans without it.

"Autoimmune diseases are relatively rare, but they're very devastating. When you look at the PTSD group it tends to jump out at you—you wonder where is this coming from?" says lead author Dr. Joseph Boscarino, senior scientist at the academy's Division of Health and Science Policy.

Boscarino presented his findings at last weekend's meeting of the American Psychosomatic Society in Phoenix.

PTSD is a common illness among veterans who served in combat, with between 15 percent and 30 percent experiencing the disorder.

The following are the most common symptoms of PTSD. However, each individual may experience symptoms differently. Symptoms may include:

• irritability
  
  
• violent outbursts
  
  
• trouble working or socializing
  
  
• flashbacks or intrusive images
  A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.
  
  
• losing touch with reality
  
  
• reenacting the event for a period of seconds or hours or, very rarely, days

The symptoms of PTSD may resemble other psychiatric conditions. Always consult your physician for a diagnosis.

"This [study] is consistent with the health literature which shows that stress [caused by a traumatic event] is associated with worse health outcomes," says Suzanne Mazzeo, a professor of psychology at Virginia Commonwealth University.

Boscarino says that because the data used in the study are now 15 years old, the prevalence of autoimmune disease among veterans is probably underestimated by his analysis.

"I would expect the prevalence of autoimmune disease among PTSD-positive veterans would be significantly higher if the follow-up exams were conducted today," he says.

Boscarino's findings are good news for Vietnam veterans who often struggle to receive benefits and healthcare coverage for disorders that are not obviously connected to their military service, says Len Selfon, director of the Veterans Benefits Program for the Vietnam Veterans Association of America. Research on the link between psychological illnesses such as PTSD and physical illness is murky, he says.

The US Department of Veterans Affairs (VA) weighs epidemiological and clinical evidence to decide which medical conditions should be covered by the VA's insurance, Selfon says.

This study helps show a medical nexus between PTSD and autoimmune problems that may encourage the VA to apply healthcare coverage to these disorders, he says.

"This study is going to be helpful clinically for people being treated for PTSD and autoimmune disease. For the purposes of veterans receiving healthcare and benefits, it's important to link these disorders," Selfon says.

Always consult your physician for more information.

Triggers of PTSD

The event(s) that triggers PTSD may be:

• something that occurred in the person's life.
  
  
• something that occurred in the life of someone close to him/her.
  
  
• something the person witnessed.

Examples include:

• military combat
  
  
• serious accidents (such as car or train wrecks)
  
  
• natural disasters (such as floods or earthquakes)
  
  
• man-made tragedies (such as bombings, a plane crash)
  
  
• violent personal attacks (such as a mugging, rape, torture, being held captive, or kidnapping)
  
  
• abuse in childhood

Always consult your physician for more information.