Book Review

Emotional Aftermath of the Persian Gulf War: Veterans, families, communities, and nations

N Engl J Med 1997; 336:1033-1034April 3, 1997

Article

Emotional Aftermath of the Persian Gulf War: Veterans, families, communities, and nations
Edited by Robert J. Ursano and Ann E. Norwood. 570 pp. Washington, D.C., American Psychiatric Press, 1996. $72.95. ISBN: 0-88048-652-X

The role of stressful life events in the development of illness is an important and evolving area of research. The emotional impact of wartime conflict, combat in particular, is an example. Many of the factors that make combat so tragic for the participants render it meaningful for the investigator. Most studies of stressful life events are necessarily retrospective, since exposure is rare and largely unpredictable. Conversely, combat typically occurs within a predictable time frame, and when soldiers are the subjects, considerable antecedent information, including behavioral and psychological data, is available. Wartime stress encompasses a broad range of life events in terms of severity, but specific combat events, including the emotional effects of wounds, are relatively quantifiable. The Gulf War added sex as a potential study variable, and as in Beirut and the former Yugoslavia, civilian populations also became a focus of inquiry. Emotional Aftermath of the Persian Gulf War makes use of both the distinctive and the more common characteristics of the Gulf War as the basis of a series of related chapters on the emotional aftermath of this conflict, which was unique in so many ways.

The book is interesting particularly for its point of view. The two editors and the majority of the contributors are faculty members at the Hebert School of Medicine of the Uniformed Services University in Bethesda, Maryland. The book has three broad sections. The first of these is largely devoted to issues highlighted by the Gulf War and includes one of the best chapters: a review of the effects of deployment of mothers and fathers to the Persian Gulf on the children and families remaining behind. Other interesting chapters in this section deal with the emotional impact of chemical and biologic weapons and the threat of missile attack on the civilian population of Israel.

Substantial portions of the book, including nearly all of the middle section, would be of interest to a very limited audience. This section focuses on issues relevant to military planning, including such practical details as mobilizing reservists, the special emotional needs of military families in Europe, and the details of medical preparation for psychiatric casualties in the Veterans Affairs medical system. One highly specialized but poignant chapter describes the emotional toll experienced by those charged with informing families that a relative had died in combat.

The final section focuses on the management of the emotional sequelae of war. Two chapters deal with post-traumatic stress disorders. The first concerns a survey of nearly 3000 returning soldiers conducted with the intent of examining the acute stages of emotional reintegration. The other reviews the long-term outcome of the treatment of veterans with severe post-traumatic stress disorders in the West Haven Veterans Affairs Hospital.

The chapters I have highlighted are the strength of this book. Unfortunately, the rest of the book does not meet the same standard. Much of the remaining material is based on anecdotal evidence and generalization from personal experience. Even when citations to related literature are given, it is often difficult to tell whether there is an evidentiary basis for the author's claims. An interesting discussion of prisoners of war is illustrative. The authors note that some returning prisoners of war felt in retrospect that they had benefited from the experience and that those who had felt the greatest stress as prisoners reported the greatest subsequent benefit. A few related citations are given, but despite the fact that this is an unexpected revelation, there is no presentation of the relevant findings and no indication of whether this is a consistent, robust finding.

There is a great deal to be learned from the Persian Gulf War about the emotional aftermath of wartime stress. This book has a few useful lessons, but much of its message is for a highly specialized audience.

John E. Helzer, M.D.
University of Vermont College of Medicine, Burlington, VT 05405