MULTIPLE TRAUMATISATION AS A RISK FACTOR OF POST-TRAUMATIC STRESS DISORDER

Paper presents a part of results obtained in 1998 within action study of the psychological effects of war traumatisation in Republika Srpska. Special attention is paid to the additional impact of multiple exposure to war sufferings regarding the degree of the traumatisation (the loss of loved ones, direct life threat, the participation in combats, and the testimony of the death of other people). 229 persons were assessed in 8 towns of Republika Srpska. The comparison of the results of refugees and domicile persons at the Reaction Index – Revised speaks in favour of their significantly higher vulnerability even after three years after the end of war. Total degree of the traumatisation, as well as the symptoms of intrusion, avoidance, and hyperarousal are significantly more frequent. In 42.5% of refugees (in relation to 26.7% of domicile persons) there is PTSP risk. The intensification of criteria proves that 17% of refugees are at high risk (in relation to 5.2% of the domiciled). It is obvious, that refuge presents traumatic event for many people, and not only chronic burden. The results suggest that the effect of direct jeopardy, combat stress, and the testimony of somebody else’s death are fading in time, but that the culmination of tangible, social, and human losses in refuge is serious risk factor for mental health.


INTRODUCTION
During the war in Bosnia and Hercegovina adults and children were often directly and indirectly exposed to broad spectrum of traumatic or severely stressful events and circumstances.About one third of the population of the Republika Srpska (420.000) are refugees or internally displaced persons.The majority of men spent several years on the frontlines.About 12.000 persons were killed and several thousand people were declared "missing".After the loss of nuclear family member or close persons, direct threat to life, wounding or witnessing violence, life goes on in a very unstable socio-economic environment.
After direct and indirect exposure to high-magnitude trauma, stressful and protracted post-war period came.We face the long lasting consequences of the traumatic war experiences, then chronic stresses which originate from the destroyed socio-economic and physical infrastructure, economic slump, unemployment, political instability and from the uncertain future.
The existence within this area goes beyond the concepts of crisis and stress.One could say that it is a crisis of life stile.As the time is passing, the consequences of cumulative exposure to traumatic events, unprocessed experiences and postwar adversities become more apparent (depression, suicides, complicated grief reactions, psychosomatic complaints, substance abuse, family violence).
Social support is a very significant protective factor in coping with war-related traumatic experiences (Kleber & Brom, 1992;Shalev et al., 1998).Unfortunately, except family support which is powerful clue in our society, there are many reasons for the suspicion that educational, social and health sector were paid proper and sufficient attention to the mental health promotion, prevention, treatment and rehabilitation of traumatised war victims.The system of the mental health care services had many shortcomings even before the war.All resources were directed toward the development of the mental health services on the secondary level of the health care.Vast majority of the mental health professionals were attached to the psychiatric hospitals and to the psychiatric wards of general hospitals.Mental health services were functioning within the medical model of the health care.There are no Centres for the crisis intervention, clubs, group work, self-help groups, SOS line etc.Concepts and practice community psychology and psychiatry had no solid grounds in the reality of the Republika Srpska.
Apparently, displacement as accumulated loss presents an even more powerful risk factor of PTSD occurence and persistence.In a sample of Afghan and Cambodian refugees who live in the USA, the reported PTSD prevalence ranges from 45% to 86% (Carlson & Rosser-Hogan, 1993;Cheung, 1994;Malekzai et al., 1996;Blair, 2000).According to the results, accumulated traumas (especially death of close persons) and stressors, the adaptation on new social enviroment significantly increase vulnerability (Joseph et al., 1997 ).
There is not much data on PTSD prevalence in adults within the territory of former Yugoslavia.However, reported PTSD prevalence among refugees in collective centres was ranging from 26% to 35% (Harvard Program in Refugee Trauma, 1996;Powell et al., 2000), and among Croatian soldiers it ranged from 14% to 31% (Gustovic-Ercegovac & Komar, 1994).Posttraumatic stress is also present within non displaced population: three years after the war in Bosnia and Herzegovina, 10-18% of that population in Banja Luka and Sarajevo -i.e.those who were not displaced -suffer from PTSD (Powell et al., 2000).
In the present contribution we are interested in the effect of displacement and accumulated war-related traumas on the persistence of PTSD symptoms in the postwar circumstances in Republika Srpska.

Hypotheses
1. We expect the risk of chronic PTSD in displaced persons to be significantly higher than in those who were not displaced, and symptoms to be signiicantly more frequent.
2. Displaced persons who experienced (a) the loss of close persons or (b)direct life threat or (c) witnessed somebody's death or (d) had combat exposure -would more frequently have PTSD symptoms than non-displaced persons who experienced similar traumatic events.
3. Displaced persons who experienced (a) the loss of close persons or (b) direct life threat or (c) witnessed somebody's death or (d) had combat exposurewould more frequently have PTSD symptoms than displaced persons who had not experienced those traumatic events.

METHOD
In 1998, the Foundation for Training, Research and Public Works of the Republika Srpska supported by World bank, engaged a team of clinical psychologists for the project "Demobilisation and Reintegration".They conducted an actionable research of the traumatisation level in participants of the employment program, mainly refugees and veterans, and provided them with psycho-educational training and counseling.Out of the extensive research project, only the results relevant to the observation of the effect of displacement and other war related events on the persistence of PTSD are extracted here.The assesment was conducted in groups (20-30 subjects).Subjects were promised full anonymity.We advised them that the results of the study will not assist them in terms of finding employment and that the analysis of group results will be used in the creation of the psychological assistance program.

Sample
The selection of the sample of 299 unemployed subjects was performed by the Employment Bureaues.All subjects -180 males (78.6%) and 49 females (21.4%)were assessed with the extensive psychodiagnostic battery.Less than a half of the sample -94 (41%) -were refugees and displaced persons (Mean age = 36.2;SD = 7.34).The average age of 135 non-displaced subjects is lower (Mean age = 32.9;SD = 5.36).About 45% of participants were soldiers.Most of the subjects have completed secondary school (78.2%).About a half of the sample (51.8%) were married.
Most of the participants were directly exposed to a broad spectrum of potentially traumatic or severely stressful war-related events and circumstances: 1. Death of loved one or close persons child -2.6% spouse -3.9% father -13.5% mather -5.About 40 percent of the participants and 52 percent of the refugees underwent accumulated losses of close family members.

Instruments
Inventory of life events includes 65 stressful traumatic war-related and post-war experiences, facilitating the identification of cumulative exposure (Pynoos et al., 1998) .
The Reaction Index-Revised (Pynoos et al., 1998) is a 17-item self-report scale of posttraumatic stress symptoms experienced during the past month.The scale is an updated version of the widely used UCLA Reaction Index (Pynoos et al., 1987), and is consistent with DSM-IV PTSD criteria.Its 17 items assess the presence of symptoms in the last month, to be answered on a standard 5-point Likert-type rating scale (0=never, 1=rarely, 2=sometimes, 3=often, 4=almost always), keeping in mind the traumatic experience (Criterion A).The authors reported high internal consistency (Chronbach's Alpha = .92)and moderate to strong convergent validity (.37 -.63).The correlation of this instrument with CAPS is reported as r = 0.929 and diagnostic validity was 0.9 (Blanchard et al., 1996).The authors identify a total scale score of 35 or above as falling within the clinically distressed range.

RESULTS
The results reported that symptoms of intrusion, avoidance and hyper-arousal in displaced group are significantly more frequent over the past three years after the war than in a population of non-displaced persons (Table 1).The first hypotesis is confirmed.Persons considered at risk for posttraumatic stress disorder were those who fulfilled the DSM IV criteria by answering the questions with "2","3" or "4" as follows: • Criterion B -symptoms of re-experiencing (on at least 1 out of 5 items) • Criterion C -symptoms of avoidance (on at least 3 out of 7 items) • Criterion D -symptoms of hyper-arousal (on at least 2 out of 5 items) In assessing persons at high risk for PTSD, the same principle was used, although only the answers of level "3" and "4" were considered.
On the basis of the self-report, 42.5% of the displaced subjects (compared to 26.7% of non-displaced ) were at risk for PTSD according to DSM IV criteria.
Approximately 17% of the displaced group, as opposed to 5.2 % of nondisplaced subjects, are at high risk of PTSD.Exlusive of displacement, subjects at risk for PTSD (N= 76, i.e. 33.2% of all participants) had experienced multiple traumatisation (an average of 8.4 war events).
Approximatelly one half of this group reported more than 8 of potentially traumatic events (Table 3).The analysis of statistically significant differences in terms of frequency of PTSD symptoms between refugees and non-displaced (Scheffe's test of multiple comparisons in Table 4) confirms hypothesis 2 on the whole.There are statistically significant differences in the level of the traumatisation between displaced subjects who experienced (a) the loss of the close persons or (b) combat exposure or (c) direct life threat or (d) wittnesing death and non-displaced subject who underwent same war events.But, our findings suggest that exposure to direct life threat, combat exposure and witnessing death in refugees and displaced persons (multiple traumatisation) does not lead to more frequent symptoms three years after war.We found the level of PTSD symptoms in refugees and displaced persons only in the case of the death of loved one (close persons).
There were no statistically significant differences in the level of PTSD symptoms between non -displaced subjects who were and were not exposed to death of close persons or (b) direct life threat or (c) combat exposure or (d) witnessing death.Accordingly, only hypothesis 3a is confirmed.

DISCUSSION
Refugee expiriences during the war is obviously serious risc factor for PTSD occurence and persistence.The symptoms of intrusion, avoidance and hyper-arousal in refugees are significantly more frequent three years after the war than in a population of non-displaced persons.
Displacement itself presents an accumulation of material, psychological and social losses.Loss of close persons, especially family members, obviously increases vulnerability, i. e. leads to more frequent PTSD symptoms, particularly in the refugees and displaced persons.The significant effect of this painful experience on the frequency of PTSD symptoms three years after the war can be explained by : • The effect of frequent postwar stressors and secondary adversities that occurred after refuge and displacement, which became "triggers" in the process of reactivating the original traumatic experiences (Blair, 2000;Blanchard et al., 1996;Vlajković, 1988;Vlajković et al., 1997;Pynoos et al., 1998).
• Struggle to meet basic personal and family needs can act as barrier to processing past expiriences and aggravate normal mourning and coping with loss (Rando, 1993).
• Loss reminders, "empty situations" and secondary adversities after the death of close persons are probably more frequent than trauma reminders (reminders on immediate life threat, witnessing violence or combat experiences).
The present results show that additional exposure to direct life danger, combat experiences, witnessing death in the displaced population does not, in most cases, increase vulnerability three years after the end of the war.The longlasting traumatogenic effects of the exposure to those events are not so obvious either within refugees, or within non-displaced group.It seems that, except in the case of traumatic death of loved one, the impact of certain war-related traumas fades as time goes on.
This somewhat contradicts the findings of other researchers on the impact of cumulative war experiences, particulary when they consider effects witnessing to violence (Kleber & Brom, 1992;Joseph et al., 1997;Blair, 2000;Cheung, 1994).
It should not be forgotten that the (non-) existence of statistically significant differences in terms of the frequency of symptoms still does not show the (non-) existence of differences in terms of the severity of symptoms and their impact on the mental health.Symptoms that appear could rarely be very intensive and can seriously disturb psychosocial functioning.

CONCLUSION
Psychological consequences of war cannot be reduced only to PTSD.But, these findings provide important indications of possible and practical interventions in war areas.In the creation of the programs of psychosocial support in community and clinical work, one should pay special attention to a very vulnerable group, i.e. displaced persons who have experienced the death of close persons.Unfortunately, we can say, with no doubt, that curent resources and their network are not capable, as well as their number of mental health professionals and quality of their training, or the diversity of established social and health services to meet the post-war needs in the field of the mental health of the traumatised population in Republika Srpska.There is an ongoing, but quite slow reconstruction of the organization of the mental health and social services.Hopefully, Centres planned for mental health will be community-oriented and prevention-focused.

Table 3 .
The exposure to potentially traumatic and stress war and postwar experiences in the group of subjects at risk for PTSD

Table 4 .
Cumulative effects of war events during displacement: total PTSD scores *means that are statistically different from the means reported in group 4