Ami Neiberger-Miller’s brother was killed by a roadside bomb in Iraq — a shock that compounded her loss. “Both of my in-laws had cancer and passed away a few years ago, and my experience with their deaths was dramatically different from my brother’s death in Iraq to an IED [improvised explosive device].

A sudden military loss can be overwhelming,” said Neiberger-Miller, who works as public affairs director for TAPS (Tragedy Assistance Program for Survivors), a D.C. nonprofit that supports people dealing with the death of someone serving in the military.

Many experts now agree with what grieving family members such as Neiberger-Miller have been saying for years: Dealing with violent, unexpected death is different. This type of loss holds for death by car accident, homicide, suicide as well as being killed in a war or natural disaster.

Violent loss can increase the risk of debilitating reactions and poor health among survivors, and it can trigger intense grief often believed to be a type of post-traumatic stress disorder (PTSD), although many experts now think this intense grief is actually its own separate syndrome — which, for lack of a better name, is labeled “complicated” or “traumatic” grief.

“Complicated grief is a unique entity that seems to stand by itself,” Yuval Neria told The Washington Diplomat. Neria is a Columbia University professor and director of the Trauma and PTSD Program at the New York State Psychiatric Institute who recently surveyed New York City survivors of the 9/11 terrorist attacks to see how the trauma affected their overall health.

In research published in 2006, Neria and 10 colleagues found a high rate of health problems in 9/11 survivors a year after the World Trade Center Twin Towers went down. Of nearly 1,000 Manhattan medical patients surveyed, more than a fourth had lost someone in the attack. These survivors were twice as likely to have a mental health disorder compared to other patients. Nearly 30 percent had depression, 17 percent had PTSD, and almost 20 percent had chronic anxiety. In addition, physical health problems were three times more common, with many survivors reporting intense pain and lost workdays due to health issues.

The distinctive range of these New Yorkers’ symptoms could help to develop the concept of “complicated grief,” Neria’s paper said. “Our research suggests that special attention should be paid to patients who have experienced [traumatic] loss, since early detection and treatment may help to prevent long-term, chronic disease and higher mortality rates,” he said.

Neria and other re–search-ers presented their new take on trauma in Washington on March 30 at a symposium on PTSD and other disorders sponsored in part by NARSAD, the world’s leading charity dedicated to funding mental health research.

PTSD is an extreme brain response to a horrible experience. It can show up in obsessive thoughts, flashbacks, nightmares, hyper-vigilance and intense distress at reminders of the trauma. Sufferers may feel numb or suicidal, withdraw from society, or have angry outbursts.

Whether or not trauma triggers PTSD depends on many factors, according to researchers at the symposium. These can include a person’s genetic makeup, childhood experiences, personality, coping skills, belief systems, amount of lifetime exposure to trauma (it adds up), social support, and how much control a person thinks he or she has over life in general. But a key factor in PTSD is the nature of the trauma itself — how long, how much, and how bad it was.

Neria opened his address at the symposium with a personal story to explain this trauma theory. An Israeli veteran of the 1973 Yom Kippur War, Neria was part of a tank company of 70 soldiers, almost all of whom died in the first day of battle. When Neria became a health researcher, he wanted to examine soldier vulnerability and resilience. He discovered that about 14 percent of Yom Kippur soldiers had PTSD, but the rate of PTSD stood at 25 percent among Israeli soldiers who had been taken as prisoners of war (POW).

Thus the severity of trauma mattered, a notion that’s been reinforced by studies of other conflicts: In World War II, POWS had a 50 percent PTSD rate, and in the Korean War, POWS had a staggering 80 percent PTSD rate, reflecting the severe length and amount of abuse in their captivity.

Today, researchers are turning their attention to another hotbed of conflict: the Middle East. In April, Elie Karam and colleagues in Beirut examined the impact of war trauma on civilian mental health in the Arab world. Their study of 3,000 adults in Lebanon, published in the journal PLoS Medicine, found that one in four civilians had experienced a mental health disorder during their lifetime, but that figure varied depending on how directly the individuals had been touched by war.

In the study group, 55 percent had been civilians in a war zone, which increased their risk of developing an anxiety or mood disorder like PTSD by three-fold; 38 percent had been refugees, which increased their risk by six-fold; and 18 percent had witnessed a death or injury firsthand, which dramatically boosted the risk by 13-fold.

But what factors besides the actual trauma itself play a part in mental health disorders? In a 2005 study of civilian survivors of the Balkan wars in the former Yugoslavia, Dr. Metin Basoglu of King’s College London found that 33 percent of these survivors suffered from PTSD and 10 percent from depression. Of the factors associated with these disorders, bitterness, a sense of injustice, safety and loss of control over life appeared to be most important.

Similarly, Neria told the recent Washington symposium about a survey of Vietnam War veterans, which found that PTSD was much more prevalent among vets who felt the war had a negative impact on their lives as opposed to those who had an overall more positive appraisal of the war (70 percent compared to 18 percent).

More recently, PTSD is re-emerging as a major health issue among Iraqi war veterans, especially in light of investigations that have uncovered high suicide rates among vets returning from Iraq and Afghanistan.

In fact, nearly 20 percent of military service members who have returned from Iraq and Afghanistan — 300,000 in all — report symptoms of post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment, according to a new RAND Corp. study.

Dr. Robert Ursano, chairman of the Department of Psychiatry at the Uniformed Services University, who spoke at the Washington mental health symposium, said that many service members don’t seek professional help to avoid the stigma of looking “weak” or because they want to solve the problem on their own. “We have effective treatments,” Ursano emphasized, citing many promising new therapeutics in development through NARSAD research.

As a growing number of studies around the world indicate, addressing PTSD and its cousin, complicated grief, is critical not only to lessen the immediate pain of a sudden trauma or loss, but to prevent long-term health problems that would make an already tragic situation even worse.

About the Author

Carolyn Cosmos is a contributing writer for The Washington Diplomat.