AFTER MORE THAN two years of relentless bombing in Gaza, the conflict in the Middle East has widened again.

Recent US and Israeli air strikes on Iran mark a dangerous escalation, extending the cycle of violence to countries such as Lebanon, the UAE, Qatar, Kuwait, Bahrain and Saudi Arabia.

Shellshocked communities across the region are under constant threat, while many expatriates have been trapped by the cancellation of flights. More than 300 Irish peacekeeping troops are based with UNIFIL in southern Lebanon, as that country also faces airstrikes.

While the headlines focus on military targets and geopolitical strategy, war’s most enduring consequences are often less visible. Long after the bombs fall, the psychological wounds remain, which raises questions about trauma and the lasting human cost of conflict.

A little over a year ago, I ventured to Mexico City to attend a conference of the World Psychiatric Association. One of the speakers was Professor Nikos Christodoulou, a Greek psychiatrist and Chair of the World Psychiatric Association Section of Disaster Psychiatry. He described how there are somewhere between 400 and 500 natural disasters worldwide every year. Indeed, in the decade leading up to 2015, around 1.5 billion people were affected by them. Acute distress was reported in up to half of the survivors, of whom 30-40% progressed over time to a clinical diagnosis such as post-traumatic stress disorder (PTSD) or major depression.

A few factors play a role in this. PTSD is, of course, more common in people directly impacted by a disaster, especially if it’s man-made. Anxiety is higher in those with prolonged geographical displacement.

How we respond as a society is predictable enough; we goes through stages, from pre-disaster, to heroic (where some people step up to help) to honeymoon/community-cohesion (where everyone is nicer than usual to each other) to disillusionment (where it’s gone on a bit too long and people are getting fed up) to trigger events (such as anniversaries), to reconstruction (as society heals). This is what happened in our communities during the Covid 19 pandemic.

Since Trump and Netanyahu’s conflict with Iran started, the UN Secretary General, António Guterres, has appealed for “serious diplomatic negotiations”. Meanwhile, the UN and the WHO have their disaster response plans, which typically include the phases of prevention, mitigation, preparedness, response and recovery. On an individual level, resilience plays a role; some will cope better than others, but most people will react normally to abnormal circumstances.

So, where does PTSD come into it? It’s a term often overused in popular culture. And because psychiatric and psychological conditions might otherwise dissolve into mere fragmented opinion, professionals prefer specific criteria for any diagnosis.

One such entity is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is what a specialist psychiatrist or psychologist would typically use to determine the presence or absence of PTSD, based on a thorough assessment set against the criteria.

First is the person’s exposure to actual or threatened death, serious injury or sexual violence, either through: (1) direct experience; (2) personally witnessing it happening to another person; (3) learning of it happening to a family member or close friend; or (4) repeatedly being personally exposed to the details of the traumatic event. The recent experiences of many in the Middle East would certainly qualify.

Second is the presence of one or more “intrusion” symptoms, such as recurrent distressing memories, dreams, nightmares or flashbacks. Third is persistent “avoidance” of people, places or cues associated with the traumatic event. Those traumatised by war might avoid news and media, crowded or unpredictable environments, public transport, or places with loud noises such as construction sites.

Fourth is negative thinking or low mood beginning shortly after the traumatic event. Fifth is a marked increase in “arousal” beginning or worsening after the traumatic event, for example, intense anxiety, irritability, angry outbursts, reckless or self-destructive behaviour, hypervigilance, an exaggerated startle response, disrupted sleep or poor concentration.

According to the DSM-5, the symptoms must last at least one month and cause clinically significant distress or impairment in day-to-day functioning. Finally, the symptoms can’t be better explained by street drugs, alcohol or another medical condition.

The likelihood of developing PTSD on foot of a war depends to some degree on your role in it. Civilians, soldiers and healthcare workers will have different experiences and supports. It is estimated that around 9.7% of US veterans develop PTSD at some point during their lives; this is only slightly higher than for the general population. Conversely, at least two recent meta-analyses have found that almost a quarter of civilians caught up in war develop PTSD, especially in low- and middle-income countries. These figures are consistent with earlier epidemiological studies of PTSD (and also with what Professor Christodoulou told us all in Mexico). And it’s of little surprise that PTSD rates are even higher in children exposed to war.

Keeping in mind our brave Irish peacekeeping troops based with UNIFIL in southern Lebanon, soldiers tend to fare a little better than civilians exposed to war. But there are lots of influencing factors. Gender plays a role in whether former soldiers develop PTSD, with a 13% lifetime risk in females compared to 6% in males. Older former soldiers are less prone to PTSD, and, in line with this, the war they fought in plays a role.

The lifetime risk of PTSD for World War II and Korean War veterans is 3%, compared to 10% for Vietnam, 21% for Desert Storm and 29% for the more recent wars in Iraq and Afghanistan. But this needs to be taken with a pinch of salt because, if former soldiers with PTSD have a shorter life expectancy (due to correlating injuries and health conditions), their underrepresentation in later surveys will make their rates of PTSD seem lower than they really are.

Other factors include whether they are actually deployed, any pre-existing mental health problems, their military occupation or speciality, the politics and social acceptance of the war, its location and the nature of the enemy.

As wars deepen, the provision of healthcare becomes more of a problem. Among the many aid agencies operating in war-torn countries are Médecins Sans Frontières (MSF) and the International Red Cross.

This kind of work comes at a cost to healthcare workers and others in terms of the risk of PTSD, actual physical harm or even death. One report by the International Committee of the Red Cross examined 655 violent incidents in the context of healthcare across 16 countries to which the Red Cross provided input over two-and-a-half years. Effective healthcare to thousands of wounded or sick people was found to be frequently “suspended, withdrawn or rendered impossible by violent events” because of damage to hospitals by explosive weapons or forcible entry by fighters, the hijacking of ambulances or the threatening, kidnapping, injury or death of healthcare workers.

According to the report, around a third of the violent events were committed by forces armed by a state, while a further third were perpetrated by other armed groups. Incidents where explosive weapons were deployed had the most profound effect. A third of events involved international NGOs, a quarter involved local health-care services, and a sixth involved the Red Crescent or Red Cross. Some 1,834 people participating in the delivery or receipt of healthcare were killed or wounded, of whom around a fifth were already ill. Healthcare workers comprised 8.7% of those casualties. There was also infrastructural damage to hospitals and other health-care facilities (17.7% of events), and to ambulances (4.9%). The authors unsurprisingly concluded that “the right of the wounded and the sick to health care” is not being respected.

There are various treatments available for PTSD, but the prevailing wisdom is that it can be harmful to rush in with immediate psychological debriefing after a traumatic event. Despite this caution, politicians often like to be seen to provide emergency counsellors. Moreover, not all psychologists agree that this is, on balance, harmful. Still, the WHO has an entire manual designed for the provision of psychological first aid (PFA) to people following a serious crisis event.

PFA involves humane, supportive and practical assistance for distressed people in ways that respect their dignity, culture and abilities. The best immediate support is often very practical and based on problem solving. Access to clean water, food, clothing, shelter and protection, and basic communication may be the most helpful first steps in a war situation.

In due course, trauma-focused psychotherapy can be helpful, where the person talks through their traumatic experience to process their feelings and reach a point of acceptance. Treatment might include cognitive behavioural therapy (CBT), cognitive processing therapy (CPT), eye movement desensitisation and reprocessing (EMDR), exposure therapy, and various medications, including antidepressants.

But by far the best course of action is for governments to stop bombing each other’s citizens in the first place and to favour meaningful diplomacy instead.

Dr Stephen McWilliams is a consultant psychiatrist at St John of God University Hospital, Stillorgan, Co Dublin, a Clinical Associate Professor at the School of Medicine, University College Dublin, and an Honorary Clinical Senior Lecturer at RCSI University of Medicine and Health Sciences.

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