The study collected information about the history of trauma among 125 victims in Mitrovicë district who had been exposed to torture or massive violence. Around 40% of them were affiliated with KLA and 20% had been in a combat or cross-fire situation. We did not obtain further information to define their affiliation with KLA, therefore we don’t know whether they were the combatants, informers or civilians who helped KLA members, etc. Civilians could be caught in the cross-fire situation too. Self-selection bias in the sample may exist although we do not know what proportion of population was affiliated with the KLA during the wartime.
One of the most frequent symptoms among the study population was pain; this was often present together with PTSD. The situation is not clear-cut – a lot of symptoms are frequent among those who do not have PTSD diagnosis. Our results showed that there is often a substantial overlap between pain, PTSD and emotional disturbance (such as frequent anger or feelings of hatred and aggressiveness). Many studies have also shown comorbidity of PTSD and somatic symptoms such as pain. One of explanations that has been given for this comorbidity is that pain and PTSD emerge from shared biological diatheses [23
Pain is often regarded as secondary symptom to PTSD rather than a separate response to trauma. PTSD has been considered to be an affective disorder, but our results showed that the participants with pain and PTSD tended to have the same score for the affective dimension of pain as the participants without PTSD. On the other hand, there were differences; those with PTSD had a higher score for sensory dimensional pain than those without PTSD. We do not have any neurobiological explanation of this phenomenon from our study, but the literature does suggest that there may be neurobiological consequences of traumatic stress, and comorbid mental problems [24
]. In the present study, in which physical and injury examination conducted by medical doctors was compared with participants’ oral reports, the overall pain rating was strongly associated with having at least one injury, whereas the association with PTSD was weaker. In our previous publication, we reported the most frequent bodily locations of injuries, which also correspond to the most frequent bodily location of pain complaints in this paper. This indicates that at least some of pain complaints in this study could be simply attributed to the actual injuries suffered. The problems may have been exacerbated by the sensitization of peripheral receptors following injury, which can be responsible for post-injury pain hypersensitivity [26
]. Mental and physical residual effect to torture and massive violence-related trauma are complicated and vary widely according to an individual’s physical condition and coping skill as well as environmental factors like the kind of support available. It is difficult to say how many of the pain complaints in our study participants were secondary symptoms in response to PTSD and how many were direct and separate responses to physical damage or poor bodily functioning due to torture and physical punishment.
However, we did find indications that factors other than physical injury do play a role, because particular pain locations were also related to various aspects of negative emotional processing. Previous studies have shown similar connections [27
]. Anger was the strongest predictor of pain in our sample, and anger-induced pain occurred more persistently in head, chest and abdomen. Our study also found an association that has not been previously described, between crying and chest and abdominal pain experience within 2 weeks preceding the survey, which was associated with greater score for affective dimensional pain. However, pain after crying was found to be associated with injury, as 42% of participants had injuries of the chest due to torture or other types of physical punishment. It is possible that anger and crying make certain muscles so tense that this causes pain due to previous physical damage which may not have been treated adequately. But it is also likely that the experience of negative emotion and desire for relief could influence the pain effect, and pain-related emotions can influence pain perception and pain-related physiological response [30
In all discussions of symptoms related to trauma it must be borne in mind that cross-cultural studies have shown that these symptoms are experienced and expressed in different ways by people from different cultures and different genders. For example, in some cultural settings pain complaints can be a verbal expression of depression. This could lead to misleading results [31
]. However, one strength of our study is that the physical examinations and clinical diagnoses of PTSD were carried out on the basis of DSM-IV criteria by three experienced medical doctors who come from the same ethnic and cultural background as the study participants.
One aspect of our study was a consideration of how far anger and hatred influenced the experience of pain and PTSD among victims. Victims of torture and massive violence in Kosovo do not only suffer from the mental and physical effects of their experience, but feel strongly that they have been treated unjustly. More than half of participants experienced hatred and a desire for revenge – even though one fifth of them stated that the perpetrators had been prosecuted. There are some encouraging trends; for example it has been shown that in 2000, 54% of men of Albanian ethnicity in Kosovo felt hatred toward the Serbs, compared with 88.7% in 1999 [18
]. However, figures for the general population hide the fact that there may be many people in post-war Kosovo who, like the participants in our study, are still filled with anger, hatred and a desire for revenge. It seems that many victims have found no major emotional outlet enabling them to handle unbearable suffering. In some cultural contexts, repressed anger turns inward, resulting in self-harm. In other cultural contexts, depression or feelings of inferiority turn outwards and are converted into rage or hatred which often erupts in violence and leads to destruction. Such emotional hurt can be very contagious for family members and friends. It has been observed in Kosovo and other similar settings in the Balkans that there has been a rapid growth of consumption of analgesics and antidepressants and that the use of analgesics and the frequency of medical visits were significantly higher in the presence of PTSD and major depression [34
]. Half of our study participants were taking medications against depression and anxiety during the time of the survey, but these seemed to have failed to relieve their symptoms. It is well-known that psychiatric symptoms affect the effectiveness of treatment for pain [6
] and that chronic pain is often refractory to treatment [36
]. Health professionals need to bear in mind that the presence of negative emotions such as anger and hatred may limit the efficacy of medications for PTSD. These emotions may also reduce the efficacy of pain management, which is important as pain is often inadequately treated and can become one of the most costly and disabling conditions. More clinical attention should be given to anger-hatred management in individuals with pain [29
]. International guidelines for treatment of torture victims suggest that addressing emotional factors would improve the treatment outcome in many cases [37
]. Interventions specifically focused on depression and pain management using medication regulating the mood and the perception of pain alone might well fail in victims of torture and massive violence; therefore a stress management approach that includes relaxation training, cognitive restructuring, and problem-solving skills combined with physiotherapy or art therapy are recommended to improve the residual symptoms of PTSD [40
Pain management is of vital importance, whether the cause is a result of physical injury or is at least partly emotional. Patients with comorbidity of mental disorders and painful physical symptoms show more emotional distress, poorer physical functioning and lower rates of help seeking [7
]. They also have worse prospects in the labor market and more financial problems and disability [43
]. Overall pain scores were higher in those who had changed jobs or stopped doing jobs or going to school due to depression or injury. These risks were higher in the presence of neck and shoulder or upper limb pain, which can lead to consequences that make employment and coping with practical activities especially difficult. The results published earlier showed that there were more than 50% who had been injured on their head, 20% on neck or shoulder and 15% on upper back [15
]. Shoulder and back muscles are often the first body location affected by tension. This may lead to more pain in the neck and shoulders or upper limbs. This could be relevant to our earlier observation that, among female participants, having more emotional disturbances affected the handgrip strength – which is needed for many types of work.
Persistent difficulty falling or staying asleep is one of clinical criteria for PTSD, but it also occurred in 41 participants (32%) in the study who had not been diagnosed with PTSD. It is possible that some of sleep disturbance was attributable to present life stressors. Besides confirming the association between pain and negative mood and poor sleep quality [44
], our study also indicated for the first time an association between anger, military or police phobia and self-reported sleep disorder. Since the Serbian police and paramilitary were responsible for most of the attacks at their homes and on the streets, many of the victims had reported police or military phobia. Our result is in line with the literature suggesting that sleep disorders are associated with war-related exposure [45
]. Previous study demonstrated that awaking thresholds depend on the severity of depression and anxiety in war-related PTSD patients [49
]. Therefore, we recommend integrating “Exposure Therapy”, which has been proven to be effective in the treatment of PTSD, anxiety disorder and specific phobia, in the rehabilitation intervention [50
Suicide ideation was extremely high and was related to PTSD and emotional disturbances such as feelings of anger, hatred and recent crying, as well as higher pain score. Recently, Wenzel T et al.
] reported that suicide ideation was related both to past stressful experience (depression) and present social stressors (unemployment) among the general population in Kosovo. Many participants in our study were not only suffering from trauma in the past but also had no jobs and felt hopeless at the time of the study, so these could be the factors contributing to the recurrent suicide thoughts.
It will be of great benefit if research can refine current understanding of the interaction between pain and emotional processing in the brain and its connection with other physical and psychological variables after trauma. Understanding the inter-relationships among injury history, location of pain, reduction of muscle strength and other functional disability, poor career outcomes and their impact on the post-war economy will be crucial for developmental work.
There will be a need to continue with health interventions in the Balkan region. Many problems need to be addressed, ranging from heavy consumption of analgesics and antidepressants, sleep impairment, unemployment to suicide rate. As our study shows, the situation is frequently complicated by comorbidity of mental and/or physical problems. It is evident that treatments need to address cognitive and emotional integration and the residual effect of injury. Further research is also warranted to define appropriate outcome measures, and evaluate the effect of different intervention modalities which aim to reduce the psychopathology and physical and emotional suffering in the post-war setting [42
Many of our study participants and their relatives were affiliated with Kosovo Liberation Army (KLA). Some KLA members who were once freedom fighters now enter into the law enforcement agencies and politics in Kosovo. Collective emotions play a critical role in shaping individual and societal responses to conflicting events and ultimately influence the success or failure of resolution and post-conflict reconciliation attempts [56
]. Bar-Tal D further suggest that up-regulating hope and down-regulating hatred can have constructive implications in the post-reconciliation stage of intragroup conflict [56
]. It is very unfortunate that provocative actions of authorities in both Pristina and Belgrade have lead to re-experiencing of trauma and violent clashes in Mitrovicë in the post-war era.
Current findings point to several issues that must be addressed in future research. One is the question of how representative a sample can be in this setting. The study participants were a self-selected sample among the victims of torture and massive violence identified in a household survey. There were many others who fulfilled the same criteria, but chose not to come to the clinic for further examinations. A second source of bias which is inevitable in a post-conflict setting is that a study sample can only include people who have survived, and have stayed in Kosovo. We found few people who had undergone torture or abuse during the first decade of Slobodan Milošević’s administration until 1996. This was most likely because many of those most terrified had gone into exile and settled down abroad. Survival bias inevitably exists in a cross-sectional study in a post-conflict setting.
Besides the inevitable bias in sample selection, there may have been bias among physicians arising from the fact that we used a clinical diagnosis of PTSD as the “gold standard”, and did not investigate PTSD in a dimensional perspective using a standard questionnaire. The study is also limited by the fact that for military or police phobia, sleep disorder as well as suicide ideation we had to rely on self-reporting. The assessment of pain was important for the current study. The standard McGill Pain Questionnaire (MPQ) has been proven to be able to assess different dimensions of pain in many different cultural settings [13
]. Although cross-cultural adaptation was taken into account, clinimetric testing was not undertaken in Kosovo. Therefore the interpretation of the results focused on the overall pain rating index rather than the affective and sensory dimensions of pain.