Psychological consequences of continuous traumatic stress

The exposure to continuous traumatic stress (CTS) such as community-based violence or on-going terrorist attacks has a number of different psychological health consequences, such as Continuous Traumatic Stress Response (CTSR), Fear of Crime (FOC), Posttraumatic Stress Disorder (PTSD), Complex Posttraumatic Stress Disorder (CPTSD), Substance Use Disorders (SUD) and aggressive behavior (Diamond et al., 2013; Eagle & Kaminer, 2013; Eagle & Ka-miner, 2015; Ertl, 2016; Fowler et al., 2009; Lahad & Leykin, 2010; Somer & Ataria, 2015;

Roach, 2013; Weierstall et al., 2013b).

1.2.1 Anxiety-related psychological symptoms

The most investigated trauma health consequence is PTSD, which involves the reliving of the traumatic incident, avoiding trauma-memories and hyperarousal, symptoms which can mani-fest after a single event. Rates of PTSD correlate with the levels of trauma exposure and can, for example, range for areas of ongoing terrorist acts range from 5-8% (Isrealis) to 37% (Pal-estinians) (Pat-Horenczyk et al., 2007, Pat-Horenczyk et al., 2009).

The diagnosis of CPTSD was adopted so as to capture the impact of prolonged, endur-ing exposure to a traumatic settendur-ing in which multiple and repetitive events occurred as with prisoners of war in captivity or concentration camps, and in conditions of forced sex slavery, child abuse and inescapable domestic violence. The impact of this form of traumatization is very different to that of single incident exposure with somatic problems, dissociative tenden-cies, a propensity towards substance abuse, identity related difficulties and relational prob-lems, often linked to repetition of abusive relational dynamics, in addition to aspects of PTSD (Herman, 1992).

General!Introduction!

CTSR, in comparison to PTSD, is characterized by the absence of trauma-reliving and pronounced hypervigilance and avoidance, which are partly adaptive, partly maladaptive, since it is a reaction to ongoing threat instead of past traumatic events that people face who are living in prolonged conflict zones or in pervasively violent community environments. (Di-amond et al., 2013; Eagle & Kaminer, 2013; Somer & Ataria, 2015).

Fear of Crime (FOC) represents another possibly exaggerated response to risk, with the aim to accommodate to a reality of threat in order to survive in inescapable crime ridden environments (Eagle & Kaminer, 2015; Jackson, 2004). Both, CTSR and FOC, indicate peo-ple's anxiety levels concerning potential exposure to another traumatic incident or to crime and represent the degree to which they are preoccupied with the risk, which at the same time may limit their ability to operate within their environment. Villarreal and Silva (2006), during their research in Brazil's favelas found FOC to be associated with higher levels of social cohe-sion. Similar conditions are found in the low-income areas in South Africa, where 60% of inhabitants report that they mistrust their neighbors, but at the same time would not "turn in"

or identify other community members to the authorities out of a sense of loyalty (Nuttman-Shwartz & Shoval-Zuckerman, 2016). Which again, paradoxically, erodes the implementation of the rule of law (Browning, Feinberg, & Dietz, 2004).

1.2.2 Aggression-related psychological symptoms

The attempt to avoid further victimization may see individuals engage in polarised ways, which means either socially withdraw themself or become perpetrators themselves with the male population more often being the perpetrators (Diamond et al., 2013; Eagle & Kaminer, 2015; Roach, 2013; Villarreal & Silva, 2006; Weierstall et al., 2013b). Survival in situations of continuous danger demands an action-oriented adaption, which can take the form of not only reactive or proactive aggression (Hamner, Latzman, & Chan, 2015), but even of appeti-tive aggression (Elbert, Moran, & Schauer, 2016), which is characterized by an attraction to

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violence and an enjoyment of cruel behavior itself. The development of appetitive aggression has shown adaptive in the context of war, where it was associated with higher social status and military rank (Crombach, Weierstall, Hecker, Schalinski, & Elbert, 2013; Hecker, Her-menau, Mädl, Schauer, & Elbert, 2013), higher closeness to fellows (Haer, Banholzer, Elbert,

& Weierstall, 2013), and as long as PTSD symptom levels are still moderate, it has a protec-tion effect on the development of a full PTSD after the end of the war (Hecker et al., 2013;

Weierstall, Castellanos, Neuner, & Elbert, 2013a; Weierstall, Huth, Knecht, Nandi, & Elbert, 2012a; Weierstall, Schaal, Schalinski, Dusingizemungu, & Elbert, 2011; Weierstall, Scha-linski, Crombach, Hecker, & Elbert, 2012b).

In the context of continuous community and gang violence, appetitive aggressive indi-viduals have shown to maintain high levels of functioning despite the existence of PTSD symptoms (Weierstall et al., 2013c). In addition, women seem to prefer men with high levels of appetitive aggression as a short-term mate, especially in the fertile window of their men-strual cycle (Giebel, Weierstall, Schauer, & Elbert, 2013). Since young men in the age-group of 15-29 years committs the majority of violence, the advantage of being appealing to a po-tential mate by showing an enjoyment for cruelty, is not to be underestimated. The forming of youth gangs or the joining of gangs, which usually happens after the start of puberty, often has to do with a "better access" to females (Hinsberger et al., 2016, unpublished data). The downside of (appetitive) aggression is that even after conflict has ended, and the adaptation would not be necessary anymore, levels of perpetrated violence remain high (Crombach &

Elbert, 2014; Mueller-Bamouh, Ruf-Leuschner, Dohrmann, Schauer, & Elbert, 2016; Sayer et al., 2010; Teten et al., 2010; Thomas et al., 2010) and thus integration into society is difficult (Schauer & Elbert, 2010; Sommer et al., 2016).

Aggressive behavior is not only though a matter for soldiers, ex-combatants or gang-sters: Jakupcak and Tull (2005) found that civilian men with PTSD symptoms experience

General!Introduction!

more anger and hostility and more often express these emotions outwardly in the form of (in-timate partner) violence in comparison to non-traumatized men, even if their levels of aggres-sion were lower than those found in veterans of war.

1.2.3 Substance abuse

Another serious mental health problem in the context of ongoing violence are substance use disorders. The suffering of PTSD symptoms can increase the risk of substance misuse as a means to self-medicate (Burnett-Zeigler, et al., 2011; Voisin, Patel, Hong, Takahashi, & Gay-lord-Harden, 2016). Fifth grade African American students reported using substances when they felt tense and were faced with difficulties, while 17% of the 11 to 12 year-olds reported to have consumed alcohol in order to help them cope (Cooley-Strickland et al., 2009). There is a large mismatch between the problem of excessive alcohol use in war and crime-affected societies and the availability of services to support addicts (Ertl, 2016). Alcohol and drugs act as violence "enablers", as well leading to the committing of violence (Taft et al., 2005), be it from war to community violence, or from child abuse to intimate partner violence and vio-lence against children (Arseneault, Moffitt, Caspi, Taylor, & Silva, 2000; Saile, Ertl, Neuner,

& Catani, 2014; Sriskandarajah, Neuner, & Catani, 2015).

South African study participants (Hinsberger et al. 2016, unpublished data) reported using drugs in order to make them less scared of being caught by the police or of gang rivals, and to feel "stronger" and more confident to commit certain types of crime, for example, house break-ins and gang fights. "Tik" (street name of Crystal Meth or methamphetamine) is one of the drugs used to produce such feelings and effect. Since Crystal Meth has a very stimulating effect on users, it is often followed by the use of "Dagga" (a local name for mari-juana) and/or Mandrax (methaqualone), which have a sedative effect. Drugs helped the study participants not only to face their challenges, but also to regulate their emotions as well as their sleeping cycle.

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There is a lack of therapeutic studies of patients with PTSD and SUD since patients that show signs of alcohol or drug abuse usually get excluded from the study trial. If they are not excluded then dropout rates are usually high, as well as the costs of treatment, and thera-pists often fear substance consumption would increase with therapy (Ertl, 2016).