Over 5000 American flyers were downed in air operations over Southeast Asia from 1961 to 1973.1 Many were rescued by friendly forces; some were captured and spent more than eight years as prisoners of war (POWs). During their time in prison these men suffered from profound maltreatment. Before October 1969 the POWs in the prison camps of North Vietnam were kept in solitary confinement for months to years, and suffered torture, deprivation, and isolation from the outside world. After October 1969 conditions improved somewhat and torture dropped off considerably.
Beginning in April of 1973, North Vietnam released 566 United States servicemen who had been held captive.2 Of these, 325 were US Air Force personnel - all aviators and nearly all officers. Seven individuals had been released earlier for a total of 332 US Air Force repatriated prisoners of war (RPWs). Initial medical evaluation for "Operation Homecoming" took place at Clark Air Force Base in the Philippines. Here a large data base which included information about the captivity experience was collected on each individual. The USAF RPWs were then transported to designated bases in the US for further medical evaluation and treatment.
The stress of the prisoner of war captivity experience was manifold. Frequently POWs were tortured using the "ropes," a particular binding of the arms and legs to create pain.3 The POWs were often left in this position for long periods. Wounds sustained in ejection were manipulated during interrogation and medical attention was denied. Torture sessions were heralded by the rattle of keys in the hall or the screams of a comrade in an adjacent cell. The identification and quantification of the stressors of captivity can aid our understanding of the psychiatric consequences of trauma and terror.
STRESS OF CAPTIVITY
For 324 of the USAF repatriated prisoners of war debriefings were performed shortly after repatriation. The recorded and transcribed debriefings included a detailed account of all maltreatments and attempts to exploit the POW. We analyzed these debriefing reports to obtain measures of the stress of captivity. We identified the number and duration of all exploitation events and whether these involved maltreatment. Maltreatments were coded as
* Active (beatings, torture);
* Passive (forced standing or kneeling);
* Deprivation (denial of food, water, or medical care);
* Psychological (threats of death, observing or hearing others being tortured);
The use of solitary confinement after 1969 was infrequent and was therefore recorded as a separate index. Time spent in special punishment camps was also recorded as a separate index. Both the duration of solitary confinement and the percent weight loss were included as stress indicators. The duration of solitary confinement reported to medical personnel ranged from none to 7.5 years with a mean of more than 5 months. The percent weight loss for these POWs averaged 20.2%, ranging from 43.9% to 2.1 %. In addition, all awards and decorations given to the RPWs were cataloged and the highest award received was coded.
We reviewed all the medical questionnaires completed by the RPWs immediately upon repatriation at Clark Air Force Base. One section of 25 items related to the methods used by the North Vietnamese to control the POW's behavior. Responses for this section were available for 234 RPWs. These items included questions about the use of "actual physical punishment," "threatened physical punishment," "isolation," and other methods of coercion. Each question was answered on a four point Likert scale which ranged from "never" to "very often." One of these questions received essentially no positive responses and was dropped from further study.
All 43 stress indices were available for 234 RPWs. This included 157 (69.7%) of those shot down prior to 1969 and 77 (72.6%) of those shot down after 1969. A factor analysis with a principal axis solution and an equimax rotation was performed on these measures to yield seven stress factors (Table 1). Factor scores were computed for each individual. We compared the pre- and post- 1969 shootdown groups using a t or t' statistic depending upon the results of Bartlett's test for homogeneity of variance.
The seven identified stress factors (Table 2) indicate distinct stressor types in the POW experience. Factor I emphasizes psychological maltreatment intended to make the POW feel guilty and turn against his comrades. Factor II is a count of the number of maltreatments. Factor III indicates the time in solitary confinement and associated maltreatment. Factor IV highlights the characteristics of interrogation - the psychological stresses experienced by threats and actual harming of comrades and the promises of special favor. Factor V measures threats and denial of privileges. Factor VI lists the particular stresses associated with being singled out for punishment.
Factor VII is another measure of solitary confinement (as reported during debriefing) and is associated with the duration of maltreatment. The duration of solitary confinement is thus a complex stressor, heavily weighted on two separate factors. Its appearance on two separate factors may relate to the information having been collected at different times after repatriation or the context in which it was collected, debriefing versus medical evaluation.
Pre- and post-1969 shootdown groups differed significantly on all factors except Factor IV (Table 2). The pre- 1969 shootdown group had substantially more total stress as measured on the total factor score.
CONSEQUENCES OF CAPTIVITY
Previous work of our group1,4,5 has shown an increased rate of psychiatric morbidity in the highest stress group, the pre- 1969 shootdowns. The percentage of pre- 1969 RPWs with a psychiatric diagnosis increased from 23.2% at the time of repatriation to 27.1% at follow-up while the percentage in the post- 1 969 group decreased from 23.4% to 19.7%. These findings are supported by MMPI measures. In addition, however, the data indicate that most RPWs successfully coped with the extraordinary stresses of captivity. Both illness and resiliency must be studied following any major trauma or when examining the effects of terror. Some RPWs reported having benefited from their POW experience and some showed movement toward health after their experience.5·6 Usually accepted psychiatric predispositions to illness are neither necessary nor sufficient for the development of psychiatric illness after the extreme trauma of POW captivity.5 Similarly, other studies have shown that previous psychiatric morbidity is not necessary to the development of illness after the trauma of war in general.7-10
Mean Stress Factor Scores for Pre-1969 (N=157) and Post-1969 (N=77) RPWs
The POW experience, like other traumas which occur in adult life, may serve as an organizer in adult mental life in the same manner that Renee Spitz1 ' describes organizers in the first year of life, and as we think of the oedipal conflict and interpersonal relationships as organizers of mental and biological functioning.12"14 An organizer produces a particular clustering of affects, cognitions, and behaviors which can be released under appropriate stimulus - symbolic, environmental, or biological. The organization of mental life is the result of biological givens and the individual's history of significant interpersonal, biological, and contextual events. The study of the effects of the stresses of the prisoner of war experience and other aspects of combat must address under what conditions and in what individuals a new organizer can be formed in adult life.
1. Wheatley RD, Ursano Rl: Serial personality evaluations of repatriated U.S. Air Force Southeast Asia POWs. Aviation, Space and Environmental Medicine 1982; 53:251-257.
2. Hunter E: The Vietnam POW veterans, in Figley CR (ed): Stress Disorders Among Vietnam Veterans. New York, Brunner/ Mazel. 1978.
3 . U rsano RJ : Vietnam era prisoners of war : Studies of U.S. Air Force prisoners of war, in Sonnenberg S, Blank A, Talbot 1 (eds): The Trauma of War: Stress and Recovery in Vietnam Veterans. Washington, DC, American Psychiatric Press, 1985.
4. Ursano RJ, Boydstun JA, Wheatley RD: Psychiatric illness in U.S. Air Force Vietnam prisoners of war: A five-year followup. Am I Psychiatry 1981; 138:310-314.
5. Ursano RJ: The Vietnam era prisoner of war: Precaptivtty personality and the development of psychiatric illness. Am J Psychiatry 1981; 138:315-318.
6. Sledge WH, Boydstun JA, Rahe AJ: Selfconcept changes related to war captivity. Arch Gen Psychiatry 1980; 37:430-443.
7. Laufer RS: War trauma and human development: The Vietnam experience, in Sonnenberg IM, Blank AS Jr. Talbot J (eds): Stress and Recovery in Vietnam Veterans. Washington, DC, American Psychiatric Press. 1985.
8. Card JJ: Lives after Vietnam. Lexington, Massachusetts, Lexington Books. 1983.
9. Solomon Z, Oppenheimer B. Noy S; Subsequent military adjustment of soldiers who suffered from combat reaction in the Yom Kippur War. Israeli Battle Shock Casualties, i973 and 1982, Report NP-83-4. Washington. DC, Walter Reed Army Institute of Research, 1983.
10. Kettner B: Combat strain and subsequent mental health. Acta Psychiatr Scand 1972; (suppl) 230:5-107.'
11. Spitz R: The First Year of Life - Normal and Deviant Object Relations. New York, International University Press, 1965.
12. Loewald HW: Instinct theory, object relations and psychic functioning. / Am Psychoanal Assoc 1978; 26:493-506.
13. Hofer M: Relationships as regulators: A psychobiologic perspective on bereavement. Psychosom Med 1984; 46: 183-198.
14. Holloway HC, Ursano RJ: The Vietnam veteran: Metaphor, social context and metaphor. Psychiatry 1984; 47:103-108.
Mean Stress Factor Scores for Pre-1969 (N=157) and Post-1969 (N=77) RPWs