PTSD Among Ukrainian Civilians in the Russia-Ukraine War
War is a scourge, especially when it seems unjust and unfounded, more senseless than otherwise. Yet war, one of the Four Horsemen of the Apocalpyse, has been with us since time immemorial, perhaps an evolutionary need among groups competing for limited resources during times of famine and disease, now arguably anachronistic.
Grasping the full toll of war on individuals and society is important both in order to make sure people in need get proper attention and to raise awareness of the costs in the hopes of moving the needle toward sustainable peace. Understanding the real-time impact of war trauma on civilians is necessary to shape humanitarian efforts and direct the allocation of resources. This is personally relevant for me and colleagues who engage in disaster response work and are interfacing with Ukrainian aid groups.
War and Civilians
We have a growing idea of how war affects veterans, following decades of partial awareness. For example, what we call now PTSD (post-traumatic stress disorder), has been know in the past by various names, including "shell shock", "battle fatigue," and most telling, "lack of moral fiber" (LMF).
Civilians during war are affected not only by direct trauma, losses of loved ones, loss of normal life, interruption in basic necessities like food and healthcare, disease and educational disruption, and uncertainty about the future, but also by forced migration and overwhelmed community resources. They face years of recovery, and due to stigma and culture, trauma is often never recognized and even denied in spite of what we know. We can empathize, as facing off with reality can be a challenge, and overplaying trauma has downsides. Most people who experience trauma, thankfully, do not develop clinically-significant problems, but many do.
The impact of war on civilians is less well studied, though research is picking up steam. A recent study of civilian survivors of the Balkan Wars looked back nine years later on PTSD symptoms, which shift from one year to the next, asking, "What sustains PTSD?" to identify areas of intervention. For example, researchers found that poor sleep eight years after the war predicted intrusive memories nine years after the war; focusing on such factors may interrupt the self-sustaining PTSD cycle.
Given the unprecedented access via tech platforms that allow real-time communication with civilians on the ground, looking at the impact of war while the war is happening is a grim yet appropriate focus. To that end, researchers in a paper published in Acta Psychiatrica Scandinavica (2023) report their findings on PTSD in civilians from a survey conducted six months into the Russian invasion.
Survey data was collected as part of the larger Mental Health of Parents and Children in Ukraine Study. Participants were parents at least 18 years of age, including 2,004 civilian respondents currently living in Ukraine across broad geographical areas. Data were collected between July 15 and September 5, 2022.
Researchers asked about war-related stressors, including 34 specific events1. Participants completed the International Trauma Questionnaire (ITQ-10), a self-report measure that covers diagnostic criteria for both PTSD and complex PTSD (cPTSD).
Core Findings on PTSD and War-Related Stressors Among Ukrainian Civilians
Respondents reported an average of over nine war-related stressors, the most common: hearing air raid sirens (99 percent), experiencing extreme financial hardship (74.6 percent), having to take shelter in an underground location (72.5 percent), seeing/hearing bombing and artillery fire (67.3 percent), and witnessing destruction of local infrastructure (64.1 percent).
Nearly 26 percent met criteria for PTSD, and on top of that, 14.6 percent met criteria for cPTSD, for a total of over 40 percent. Both PTSD and cPTSD were more likely among those with 20 specific stressors, including seeing dead bodies or body parts and having someone close missing.
Some were associated uniquely with PTSD, including being forced to move to another part of Ukraine and being shot at by enemy forces, while others were associated with cPTSD, such as having one's home damaged or destroyed and being forcibly separated from one's partner.
Neither age nor diagnosis was associated with the number of war-related stressors. Men reported more war-related stressors than women, by a small margin. Women had higher rates of cPTSD, with rates for PTSD equal to those of men. Those living in eastern Ukraine experienced more war-related stressors and higher overall PTSD and cPTSD rates. PTSD and cPTSD rates increased with number of war-related stressors (an expected dose-dependent effect typically observed in trauma and disaster response).
Thinking the Unthinkable
The overall rate of clinically significant PTSD was 40.5 percent, combining PTSD and cPTSD. This rate is higher than seen in prior studies of civilian trauma and may be related to using non-random sampling, or it may be because of factors unique to this conflict, or both. Future research will seek to address this question, including by tracking rates of PTSD and other problems and measures of resilience and post-traumatic growth as the war grinds on.
The findings are important in real time to direct humanitarian efforts happening right now. Rates of PTSD are higher, and treatment for PTSD is less intensive than for cPTSD. Understanding the risk factors helps guide allocation of scarce resources and can help with screening.
Evidence-based therapies for PTSD include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Prolonged Exposure, EMDR, Cognitive Processing Therapy (CPT), Narrative Exposure Therapy (NET), Present Centered Therapy (PCT), among others. cPTSD requires more intensive treatment, including Skills Training in Affective and Interpersonal Regulation (STAIRS), specifically designed for trating cPTSD. Additional treatments, including medication and nonmedication approaches, may also help.
Study authors conclude:
These findings indicate that post-traumatic stress reactions to the war will need to be a central focus of the humanitarian response effort; however, the provision of care to such a large and geographically dispersed population (within and outside Ukraine) will be a massive undertaking and will require developing innovative solutions to delivering mental health care.
References
34 War-related stressors
Please note, many of the following items depict highly traumatic experiences. Review with caution especially if you are likely to experience heightened distress.
I heard air raid sirens.
I experienced extreme financial hardship.
I had to take shelter in an underground location.
I heard or saw bombing or artillery fire.
I witnessed the destruction of local infrastructure.
I was unable to sleep for prolonged periods of time.
I lost my job (temporarily or for an extended period).
I heard or saw gunfire.
I was stopped by military patrols.
Someone close to me (e.g., parent, sibling, neighbour, friend) was physically hurt in the war.
Someone close to me (e.g., parent, sibling, neighbour, friend) had their home damaged or destroyed.
My loved ones were displaced.
Someone close to me (e.g., parent, sibling, neighbour, friend) died in the war.
I had to move to another part of Ukraine.
I was unable to access essential healthcare like medicines or visiting a doctor.
I saw dead bodies or mutilated body parts.
I was unable to access necessities like food, water, electricity, or heating.
My hometown was occupied by invading Russian forces.
Someone close to me (e.g., parent, sibling, neighbour, friend) went missing.
My home was damaged or destroyed.
I took part in defensive operations.
I was shot at by the enemy forces.
Someone close to me (e.g., parent, sibling, neighbour, friend) was kidnapped or held hostage.
I had to move to another country.
I was forcibly separated from my partner.
I had to touch dead bodies or mutilated body parts (e.g., moved or buried dead bodies).
I shot at the enemy forces.
I killed a member of the enemy forces.
I was forcibly separated from my children.
I or my partner experienced a miscarriage.
I was physically hurt in the war.
I was kidnapped or held hostage.
I was tortured.
I experienced sexual violence.
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ABOUT THE AUTHOR
Dr. Brenner is the co-author of three books Irrelationship: How We Use Dysfunctional Relationships to Hide from Intimacy, Relationship Sanity: Creating and Maintaining Healthy Relationships, and the most recent sequel [Feb 2023], Making Your Crazy Work For You: From Trauma and Isolation to Self-Acceptance and Love (Central Recovery Press). In addition, he is the author of the popular Psychology Today blog, ExperiMentations: Reflections on the Human Condition, with nearly 12 million views to date.