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Chapter 17 the PRISONER of WAR The Prisoner of War Chapter 17 THE PRISONER OF WAR ROBERT J. URSANO, M.D.* AND JAMES R. RUNDELL, M.D.† INTRODUCTION THE PRISON EXPERIENCE Nature of Captivity Adaptation and Coping Social Isolation Psychiatric Symptoms During Captivity RESISTANCE SEQUELAE OF THE POW EXPERIENCE Medical Illness Psychiatric Illness Personality Change PREDICTORS OF PSYCHIATRIC DISTRESS Severity of Captivity Predisposition Social Supports READJUSTMENT Repatriation and Reintegration Organizers in Adult Personality Development Recovery TREATMENT OF POSTREPATRIATION ILLNESS Medical Disorders Psychiatric Disorders FAMILY ISSUES SUMMARY AND CONCLUSION *Colonel (ret), United States Air Force, Medical Corps, Flight Surgeon; Professor and Chairman, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland †Major, United States Air Force, Medical Corps; Chief, Consultant Liaison of Psychiatry, 89th Medical Group/SGHA, Andrews AFB, Maryland; former Consultant for Psychiatry, Office of the Surgeon General; Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland 431 War Psychiatry Artist Unknown Prisoner Interrogation circa 1943 This sketch is part of an extensive collection of captured German art from World War II in the possession of the U.S. Army Center for Military History. It graphically depicts the questioning of barefoot prisoners of war in what appears to be an underground bunker. Art: Courtesy of US Army Center of Military History, Washington, DC. 432 The Prisoner of War INTRODUCTION That trauma can be accompanied or followed by ing repatriation, has implications for psychiatric psychiatric sequelae is well-established.1–4 The de- planning for future wars and for treatment of other gree of severity of a traumatic event is positively stressor-related psychiatric illnesses. In this chap- associated with potential for psychopathology.3,5–9 This ter, the literature on the psychiatric effects of the is not a one-to-one association, however. Social POW experience, coping behaviors, psychiatric supports, cultural variables, and personality also symptoms during imprisonment, psychiatric play roles. The prisoner of war (POW) experience can sequelae after repatriation, etiologic factors produc- be one of the most traumatic situations in human ing postrepatriation psychopathology, treatment of experience. The study of coping during captivity, as the psychiatrically ill former POW, and the effects of well as psychological health and pathology follow- imprisonment on the family will be reviewed. THE PRISON EXPERIENCE Nature of Captivity stressful regardless of any intent to deprive or de- mean a captured soldier. There is no one POW experience. For example, In order to describe and quantify the stress fac- the average duration of POW imprisonment during tors of the Vietnam-era POW experience, Ursano the Vietnam conflict was substantially longer than and colleagues reviewed debriefing reports and during World War II and the Korean conflict. Many medical questionnaires completed by repatriated POWs were held captive in Vietnam for 6 to 7 years. Vietnam-conflict POWs immediately after release.5 In addition, the severity of conditions was greater One section of the medical questionnaire included in World War II Pacific Theater POW camps than in questions on the methods used by the North Viet- European Theater prisons.10–16 In contrast, the POW namese to control the prisoner’s behavior. Each experience in the Persian Gulf War was generally question was answered on a four-point scale that no more than 30 days with some, but not all, POWs ranged from “never” to “very often.” Debriefing experiencing torture and others fearing death from reports were coded for frequency and type of mal- bombings by the Allies. It is important to remember treatment. Using a factor analytic technique, seven that repatriated POWs are a subset of those who are stress factors were identified: (1) psychological mal- lost, captured, and imprisoned. They are the survi- treatment, (2) physical torture and maltreatment, vors. Nothing is known about the group that never (3) solitary confinement, (4) interrogation, (5) threats returned. The nature of captivity plays an impor- and denials of privileges, (6) high resister status, tant role in determining psychiatric responses both and (7) duration of maltreatment. during imprisonment and following repatriation. The acute and chronic stresses of captivity must The types of stressors to which POWs are exposed be differentiated. At times, the difference has been are dependent on the cultural and socioeconomic referred to as stress (acute) and strain (chronic). status of the captors, the geography, the climate, Basic animal studies highlight this distinction. endemic diseases, the circumstances of capture (air- Young hamsters separated from their mothers (acute crew ejection, large group surrender, etc.), the po- stress) will initially display hyperarousal and make litical climate, and the degree of resistance offered a “separation call.” This is eventually followed by the POW.17 The degree of stress caused by these (chronic stress) by withdrawal and absence of a experiences depends on the physical conditions, separation call.19 Cassem and Hackett have re- the psychological experience, degree of maltreat- ported a similar pattern of psychological response ment, interpersonal issues, and the individual and in humans following the specific stressor of myo- cultural appraisal of events.18 The role of culture cardial infarction.20 An initial period of anxiety and itself as a stressor is frequently overlooked.18 Expo- autonomic hyperactivity is followed by withdrawal sure to a country with limited resources, different and neurasthenia. rules of interpersonal and group relations, and dif- Readily reversible hyperarousal is a common ferent day-to-day personal and work habits can be initial reaction in combat.21 In contrast, a consistent 433 War Psychiatry observation in men exposed to chronic combat is tions, confessions, isolation, boredom, demoraliza- neurasthenia, withdrawal, defeatism, and isolation. tion about the uncertainty of the situation, and the A neurasthenic appearance in POWs after prolonged need to make decisions regarding resistance and captivity was described22 by Greenson in World compliance. The hypervigilant state is replaced by War II POWs23 and by Strassman in Korean conflict apathy, dysphoria, and gradual movement toward POWs.24 Both noted an apathy syndrome that was accommodation to the situation. During this long felt to be adaptive in the POW environment. With- phase, POWs often engage in self-developed physi- drawal and detachment increased the chances of cal fitness programs, group communication, resis- survival. In this way, energy was conserved and the tance, humor, creativity through projects and fanta- POW was less likely to stand out, challenge the sies (learning a language, collaboration, fantasizing captors, and elicit threats and torture. about the future, planning escape or sabotage), and Looking at Minnesota Multiphasic Personality also helping other POWs. Inventory (MMPI) measures, Ursano et al25 found The period of repatriation and the subsequent that withdrawal and detachment were related to life-long process of reintegration have unique stres- successful coping only in the high but submaximal sors and adaptational strategies as well. They are stress Vietnam-conflict POW group (those captured discussed later in the chapter. after 1969). In the maximum stress group, with- drawal and apathy were also present but they were Adaptation and Coping not predictive of successful coping. In this maxi- mum POW stress group, denial, repression, and The stressors of the POW environment are many; suspiciousness were associated with better coping. often they are terrifying and inhuman, and always This suggests that cognitive coping strategies may they are filled with the unexpected29,30 as is shown be important in maximal stress settings after with- in Exhibit 17-1. Biological stressors can be extreme drawal from the environment has been attempted. and vary with both the geographic location and the With the passage of time, withdrawal and neuras- demeanor of the captors. Psychological stress, in- thenia may be less helpful and other strategies such cluding social isolation, is variable. Physiologic as fantasizing and pondering family concerns more stress and emotional duress were both significantly useful.26 higher in POWs held captive in the Pacific Theater The stages of the POW captivity experience are as during World War II than in POWs held in follows: capture, imprisonment, confinement, the European Theater. Maltreatment is directly repatriation, and reintegration. Each stage has related to the extent to which an enemy country sees unique stressors.27,28 For instance, at the time of the POW as politically valuable. In Vietnam, after capture, POWs must gain quick emotional control, 1969, conditions improved and torture and mal- deal with fears of death, and attend to the tasks treatment of the POWs decreased. This change necessary for survival. Expectations of rescue fade corresponded with the recognition by North Viet- quickly after removal from the capture site; usually nam that the POWs could be an important political the prisoner is bound and/or blindfolded. A sense of tool. disbelief may result from the rapid sequence of Survival during the POW experience is most events and the radical change in roles from combat- related
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