Traumatic memories of war veterans: Not so special after all q
Elke Geraerts a,*, Dragica Kozaric´-Kovačic´ b
, Harald Merckelbach a,c
,
Tina Peraica b
, Marko Jelicic a
, Ingrid Candel a
a
Department of Experimental Psychology, Maastricht University, Maastricht, The Netherlands
b
Department of Psychiatry, National Center for Psychotrauma, Dubrava University Hospital, Zagreb, Croatia
c
Faculty of Law, Maastricht University, Maastricht, The Netherlands
Received 15 December 2005
Available online 18 April 2006
Abstract
Several authors have argued that traumatic experiences are processed and remembered in a qualitatively different way
from neutral events. To investigate this issue, we interviewed 121 Croatian war veterans diagnosed with posttraumatic
stress disorder (PTSD) about amnesia, intrusions (i.e., flashbacks and nightmares), and the sensory qualities of their most
horrific war memories. Additionally, they completed a self-report scale measuring dissociative experiences. In contrast to
what one would expect on the basis of theories emphasizing the special status of traumatic memories, amnesia, and high
frequency intrusions were not particularly typical for our sample of traumatized individuals. Moreover, traumatic
memories were not qualitatively different from neutral memories with respect to their stability and sensory qualities.
The severity of PTSD symptoms was not significantly correlated with dissociative experiences. Our findings do not support
the existence of special memory mechanisms that are unique to experiencing traumatic events.
Ó 2006 Elsevier Inc. All rights reserved.
Keywords: Posttraumatic stress disorder; Trauma; Trauma-memory argument; Intrusions; Flashbacks; Dissociation; War veterans
1. Introduction
In clinical literature, there is little consensus about how victims remember traumatic experiences (e.g., Kihl-
strom, 2004; Loftus, 1997; McNally, 2003). According to one popular view, memories of traumatic events
have special properties that distinguish them from ordinary memories. Thus, many authors have argued that
traumatic memories are qualitatively different from other types of memories, involving unique mechanisms not
related to general memory functioning (e.g., van der Kolk, 1996, 1997; for a review, see Zoellner & Bittenger,
2004). For example, these authors assume that traumatic events are processed in a predominantly perceptual
fashion, leaving survivors with traumatic memories that are not readily accessible (i.e., dissociative or
Consciousness and Cognition 16 (2007) 170­177
Consciousness
and
Cognition
www.elsevier.com/locate/concog
1053-8100/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.concog.2006.02.005
q
Our title refers to a section entitled ``Traumatic memory: Not so special after all?'' in a chapter by Kihlstrom (in press).
*
Corresponding author. Fax: +31 433884196.
E-mail address: E.Geraerts@Psychology.Unimaas.NL (E. Geraerts).
psychogenic amnesia), and/or flashbacks that possess strong sensory qualities. This dissociative style of pro-
cessing would also create a substantial overlap between dissociative and posttraumatic stress disorder (PTSD)
symptoms. There are several versions of this theoretical stance (Brewin, Dalgleish, & Joseph, 1996; Ehlers &
Clark, 2000), but the core assumption they have in common is that trauma has a special impact on the way in
which memories of the traumatic event are organized. For that reason, this position has been dubbed the trau-
ma-memory argument (for a balanced discussion, see Kihlstrom, 1996, in press; Shobe & Kihlstrom, 1997; for
a reply, see Nadel & Jacobs, 1998).
Although the trauma-memory argument has gained popularity among many clinicians, some findings argue
against this view. As Pendergrast (1998) has pointed out, classic monographs like those of Spiegel and col-
leagues (Grinker & Spiegel, 1943/1945; Kardiner & Spiegel, 1941/1947) include only isolated case reports
of soldiers suffering from amnesia (see also Lilienfeld & Loftus, 1998). Moreover, more systematic studies sug-
gest that only a small minority of war victims report dissociative amnesia. For example, Kuch and Cox (1992)
studied 124 holocaust survivors and found that dissociative amnesia, with an estimated lifetime prevalence
rate of 3.2%, was quite rare in this group. Likewise, Merckelbach, Dekkers, Wessel, and Roefs (2003a,
2003b) found in a group of 29 Dutch concentration camp survivors only one survivor reporting mnemonic
experiences that might be taken as evidence for dissociative amnesia. The authors noted that in this case there
was a serious possibility that drug abuse contributed to the poor memory of the traumatic episode. Goodman
and co-workers found that 15.5% of victims of documented childhood sexual abuse (CSA) failed to report the
target incident during a telephone interview conducted approximately 13 years after the pertinent events
(Goodman et al., 2003; Goodman & Paz-Alonso, in press). However, non-disclosure dropped to 8.3% after
follow-up by a mailed questionnaire and a telephone interview.1
Both rates of reporting failure are clearly low-
er than those found in earlier, less meticulous studies of CSA victims (e.g., Williams, 1994). Even when one
accepts these lower rates of non-reporting, the question arises to what extent they do reflect genuine dissocia-
tive amnesia. People might not report the traumatic events for other reasons than amnesia (e.g., shame, ordin-
ary forgetting; see McNally, 2003). Recent literature is also critical about the idea that traumatic memories
invariantly produce flashbacks. For example, using patient archives, Jones et al. (2003) showed that flashbacks
were an uncommon symptom in generations of British war veterans before the 1980s.
So far, empirical support for the trauma-memory argument is not very compelling. On the other hand, the
studies cited above suffer from various shortcomings and thus, one could argue that they provide only subopti-
mal tests of the trauma-memory argument. One shortcoming is that it is not always clear whether the events (e.g.,
war experiences) were really traumatic to the participants (Jones et al., 2003). Another limitation is that the trau-
matic events often happened decades ago (Kuch & Cox, 1992; Merckelbach et al., 2003a, 2003b). That recency of
the traumatic event might be an important issue is suggested by a survey among earthquake survivors several
months after the 1999 earthquake in Turkey (Basoglu, Salcloglu, & Livanou, 2002). In that study, the authors
noted that 54% of the survivors said to experience flashbacks, while 23% said to experience dissociative amnesia.
These results seem to support the trauma-memory argument, but one weakness of this study is that it remains
unclear with what type of questions precisely the survivors were interviewed. Given the mixed results in this
domain and the popularity of the trauma-memory argument, there is an urgent need for more empirical data.
With this in mind, the current study was conducted. It relied on Croatian war veterans who had been con-
fronted with extremely aversive events. More specifically, our sample consisted of Croatian war veterans with
combat experiences during the Balkan wars in the early 1990s. All veterans had been exposed to conditions
meeting the criteria of traumatic events according to the fourth edition of the diagnostic and statistical manual
of mental disorders (DSM-IV; American Psychiatric Association, 1994, p. 27). That is, all had experienced or
observed ``an event or events that involved actual or threatened death or serious injury, or a threat to the phys-
ical integrity of self or others.'' Accordingly, self-reports of these war veterans about their traumatic memories
offer an opportunity to assess the virtues of the trauma-memory argument. Compared to PTSD patients who
survived the atrocities of World War II, our patients were relatively young people. Given that the quality of
memory self-reports may be affected by cognitive aging (Schwarz, Park, Kna¨uper, & Sudman, 1998), studying
1
Goodman and Paz-Alonso (in press) provide an in-depth analysis of these data, yielding a reduced estimate of 3.6% for the incidence of
traumatic amnesia.
E. Geraerts et al. / Consciousness and Cognition 16 (2007) 170­177 171
memory characteristics in young or middle-aged PTSD patients would probably yield more valid results than
interviewing older patients.
The aim of our study was to test the assumptions underlying the trauma-memory argument in this sample
of war veterans. We interviewed these veterans about the presence of flashbacks and about the accessibility
and sensory qualities of their traumatic memories. We also examined whether there was in this sample--as
the trauma-memory argument would predict--a substantial overlap between dissociative experiences and
PTSD symptoms.
2. Method
2.1. Participants
The study included 121 Croatian war veterans (2 women) with a mean age of 40.3 years (SD = 6.3; range:
30­55 years). The mean duration of their combat activity was 2.7 years (SD = 1.7; range: 1­5 years). An aver-
age of 12.7 years (SD = 3.4; range: 10­14 years) had elapsed since they had experienced combat trauma. Their
military and medical records suggested that many of them had been exposed to multiple traumas (e.g., com-
bat, imprisonment in detention camps, deportation, confrontation with killed family members, or missing
family members). Given these records and given the large scale on which war atrocities occurred during the
Balkan wars, we assume that most veterans had, indeed, been exposed to traumatic events they claimed to
have experienced. Still, we were not able to validate their traumatic war experiences. Similarly, we cannot rule
out that some veterans exaggerated their post-traumatic symptoms. Veterans were invited to participate in the
current study while seeking medical services in the Referral Centre for Stress-related Disorders in the Dubrava
University Hospital in Zagreb, Croatia. The diagnosis of current and chronic PTSD was made on the basis of
the structured clinical interview (SCID) for DSM-IV (First, Spitzer, Gibbon, & Williams, 1996) and the cli-
nician-administered PTSD scale (CAPS; Blake et al., 1995). Eighty-three participants (68.6%) were diagnosed
with PTSD of whom 41 (33.9%) had a comorbid diagnosis of major depressive disorder (MDD), while 38 par-
ticipants (31.4%) were diagnosed with a trauma-related anxiety disorder other than PTSD.
2.2. Historical background of the war in Croatia
Until 1990 Croatia was one of the regions constituting the Socialistic Federal Republic, Yugoslavia.
According to the Central Department of Statistics (Drzavni zavod za statistiku, 1991), Croatia had at that
point in time a population of five million people. In 1990, Serb forces together with the federal Yugoslav Army
began a war in Slovenia which spreaded to Croatia and lasted until June 30, 1996 (Sabor Republike Hrvatske,
1997). More than 250,000 Croatians were forced to flee their homes and live with host families (around 80%)
or in camps (around 20%). The war in Bosnia and Herzegovina made the problem even larger. By the end of
1993, many people of non-Serb nationality were forced to leave from Bosnia and Herzegovina and temporar-
ily settled in Croatia, mostly in Zagreb. The majority of them were children and women, of whom some had
been raped or had experienced other psychological traumas (Kozaric-Kovacic, Folnegovic-Smalc, & Skrinja-
ric, 1993; Kozaric-Kovacic, Folnegovic-Smalc, Skrinjaric, Szajnberg, & Marusic, 1995). Over one million peo-
ple or more than 20% of the total population of Croatia had to leave their homes, either as refugees or
displaced persons.
According to the data by the Office for the Imprisoned and Missing Persons, the total number of prisoners
of war (POW) in Serbian camps was 7666 (932 women). Besides the official camps, there were many informal
camps, among which transit camps. It is estimated that about 10,000 people have been hold in detention in
Serb POW camps. The need for psychological and psychiatric help and social support was and in still is sub-
stantial among war victims (Kozaric-Kovacic, Kocijan-Hercigonja, & Jambrosic, 2001).
2.3. Interview
Trained clinicians conducted the structured interview, consisting of a series of open-ended questions. Inter-
view questions were based on a protocol used in a previous study on Dutch survivors of WO II concentration
172 E. Geraerts et al. / Consciousness and Cognition 16 (2007) 170­177
camps (Merckelbach et al., 2003a, 2003b). Each participant was interviewed individually. The interview start-
ed with the interviewer asking the war veteran to pinpoint his/her most upsetting war experience. Veterans
were also instructed to select one relatively neutral event that happened to them during the war. Veterans were
encouraged to select neutral events that in terms of location, the people involved, and activities were compa-
rable to the upsetting war experience. The events veterans chose pertained to experiences like, for example,
``going to the market on a Friday morning,'' ``picking up my daughter from school on Easter,'' and ``going
to the church in Zagreb.'' After participants had selected a traumatic and a more neutral topic, they were
asked questions addressing the construct of dissociative amnesia. These questions were: ``Do you think that
memories of your most aversive war experience have been stable across your life?'' (with answers coded as
yes, no, or I don't know); ``Has the accessibility of your war memories changed across your life?'' (with answers
coded as no, it has always been the same; yes, it has decreased; yes, it has increased; or I don't know); and ``Has
there ever been a period in your life that the war memories were not fully accessible?'' (with answers coded as
yes, the memories were there, but I tried really hard not to think of them; yes, because memories were completely
lost; no, they have always been accessible; or I don't know). Following this, the veterans were asked if their
memories about relatively neutral events during the war had been stable across time. In addition, they had
to indicate whether their traumatic and neutral memories consisted of visual images, auditory images, olfac-
tory sensations, and/or bodily sensations (with answers coded as yes, no, or I don't know). The veterans were
also asked to what extent they suffered from flashbacks related to the war. Answers were coded as never, less
than once every month, monthly, weekly, 2­4 times a week, or daily. If flashbacks were indeed reported, partic-
ipants had to indicate whether they contained visual images, auditory images, olfactory sensations and/or
bodily sensations (with answers coded as yes, no, or I don't know). Finally, veterans were asked whether
the content of the flashbacks corresponded to the traumatic war events. Responses to this item were coded
as yes, no, sometimes, or I don't know. Similar questions were asked about veterans' nightmares of their most
upsetting war experiences.
2.4. Materials
Participants completed the dissociative experiences scale (DES; Cronbach's a = .96; Bernstein & Putnam,
1986), a 28-item self-report measure that asks respondents how often they experience dissociative symptoms
like derealization and depersonalization. Items are scored on 100-mm visual analogue scales (VASs). Scores
are averaged to obtain a mean DES score (range 0­100), with higher scores indicating higher levels of disso-
ciative symptoms.
3. Results
3.1. Dissociative amnesia
Table 1 shows the frequency of self-reported experiences that might be interpreted as evidence for dissocia-
tive amnesia. Fifty-six participants (46.3%) reported that their traumatic memories had always been accessible,
Table 1
Frequency (%) of self-reported changes in accessibility of war memories, the stability of traumatic and neutral memories, as well as the
sensory qualities associated with war and neutral memories (N = 121)
Traumatic memories Neutral memories
Accessibility Memories have always been accessible 56(46.3)
Memories were there, but one tried hard not to think of them 62(51.2)
Memories were completely lost 2(1.7)
I don't know 1(.8)
Stability 76(62.1) 66(54.6)
Sensory qualities Visual 106(87.6) 103(85.1)
Auditory 76(62.8) 79(65.2)
Olfactory 55(45.5) 60(49.6)
Bodily 53(43.8) 54(44.6)
E. Geraerts et al. / Consciousness and Cognition 16 (2007) 170­177 173
while 62 of them (51.2%) pointed out that the traumatic memories had always been there, but that there were
periods during which they had tried hard not to think of them. Two participants felt that there had been times
during which their traumatic memories had been inaccessible. Seventy-six participants (62.1%) indicated that
their most traumatic memories had been stable across time, while 66 veterans (54.6%) noted that their neutral
memories had been stable across the years (Sign Test: p = .27). This suggests that traumatic memories were
just as stable as memories of neutral events.
3.2. Sensory qualities
The lower part of Table 1 shows the number of participants attributing visual, auditory, olfactory,
and/or bodily features to their trauma and neutral memories. Sign Tests indicated that these two
types of memories were comparable with regard to the sensory characteristics attributed to them
(all p's > .19).
3.3. Flashbacks and nightmares
Table 2 shows self-reported frequency of flashbacks and nightmares. A majority of the veterans (74 and
69%, respectively) reported that these types of intrusions were experienced with a frequency of once every
week or less. We scored the frequency categories (anchors: 0 = never and 5 = daily) and then conducted a
paired samples t test to compare flashbacks and nightmares with each other. This showed that nightmares
were more frequently experienced than flashbacks: t(119) = 4.42, p < .001. Flashbacks, however, were more
often reported to mirror the adverse war events compared to nightmares (Sign Test: p = .001). Furthermore,
Sign Tests indicated that nightmares were reported to contain more visual details than flashbacks (p < .001),
while flashbacks were said to contain more auditory and olfactory information (p = .04 and p < .001,
respectively).
3.4. Dissociative experiences and PTSD symptomatology
The mean DES score (M = 34.5; SD = 21.8) in our sample was comparable to DES scores that have
previously been reported for PTSD samples (Van IJzendoorn & Schuengel, 1996). The mean CAPS score
in our sample was 56.55 (SD = 10.78). A Pearson correlation between these two measures failed to attain
significance (r = .11, p = .23). On the basis of their CAPS scores, we divided our sample into a subgroup
meeting the diagnostic criteria for PTSD (n = 88) and a group not meeting the diagnostic criteria for
PTSD (n = 33). These subgroups did not differ in terms of dissociative symptoms as indexed by the
DES: t(119) = 1.49, p = .14.
Table 2
Self-reported frequency (%) and sensory qualities of flashbacks and nightmares about adverse war events (N = 121)
Flashbacks Nightmares
Frequency
Never 10(8.3) 2(1.7)
Less than once every month 18(14.9) 6(5.0)
Monthly 29(24.0) 18(14.9)
Weekly 33(27.3) 57(47.1)
2­4 times a week 22(18.2) 26(21.5)
Daily 9(7.4) 12(9.9)
Sensory characteristics
Visual 84(69.4) 104(86.0)
Auditory 65(53.7) 52(43.0)
Olfactory 35(28.9) 14(11.6)
Bodily 61(50.4) 74(61.2)
174 E. Geraerts et al. / Consciousness and Cognition 16 (2007) 170­177
4. Discussion
Our findings do not support the idea that trauma invariably leads to dissociative amnesia and intrusions
with a strong sensory component. For example, the veterans in our study indicated that their traumatic
war memories had been just as stable across time as their more neutral memories. In our sample of 121 vet-
erans, only two veterans reported having experienced episodes during which their war memories had been
inaccessible. Interestingly, these two veterans conveyed that their neutral memories had been stable across
time. It should also be noted that these two veterans showed elevated scores on instruments tapping symptom
overreporting (Geraerts et al., 2006). Thus, it cannot be ruled out that they simulated their alleged amnesia
symptoms because of external incentives such as service-connected disability payments.
To our knowledge, this is the first study to show that relatively young veterans who have been exposed to
traumatic war experiences only 10­15 years ago, do only rarely--if at all--suffer from dissociative amnesia.
This is important because reports from the young or middle-aged participants in our sample are unlikely to
be confounded by the effects of cognitive aging (Schwarz et al., 1998). Our findings also concur with a growing
body of laboratory evidence indicating that high levels of emotional stress facilitate rather than undermine
memory (e.g., Cahill, Prins, Weber, & McGaugh, 1994; Jelicic, Geraerts, Merckelbach, & Guerrieri, 2004).
In more general terms, our results are in accordance with studies showing that dissociative amnesia is rel-
atively rare in, for example, concentration camp survivors (e.g., Merckelbach et al., 2003a; Schelach & Nach-
son, 2001; Wagenaar & Groeneweg, 1990). Indeed, in their thorough review of the literature, Pope, Barry,
Bodkin, and Hudson (2006) were able to locate only 13 explicit cases of dissociative amnesia, a statistic that
the authors left with reservations about the merits of the concept of dissociative amnesia. One could counter
that some theories--for example Freyd's (1996) betrayal trauma theory--do predict that traumatic events for
which anonymous enemies are responsible are well remembered, whereas traumas that contain an element of
betrayal by personal authority figures often fall prey to dissociative amnesia. In the context of the Balkan war
traumas, this is not a very convincing argument because many war veterans had faced deep loyalty conflicts
(e.g., choosing to flee with your children or leaving them behind to live in a host family). Although dissociative
amnesia was found to be rare in our group of war veterans, 51% of them indicated that they voluntarily tried to
suppress their traumatic memories. This corresponds to a study by Melchert and Parker (1997), who conclud-
ed that participants with memories of childhood abuse often referred to intentional avoidance of their abuse
memories when they were reporting that these memories had been inaccessible for some time. Thus, voluntary
thought suppression of traumatic memories should be taken into account when studying poor autobiograph-
ical memory for traumatic events. Further research along these lines is not only relevant to clinical practice,
but may also inform the triers of fact when they have to decide about, for example, the plausibility of disso-
ciative amnesia claims raised in court (Sparr & Bremner, 2005).
We found no evidence that traumatic memories are qualitatively different from relatively neutral memories
when it comes to the sensory characteristics attributed to them. That is, participants attributed a similar
amount of visual, auditory, olfactory, and bodily sensations to these two types of memories. We cannot com-
pletely rule out the possibility that the relatively neutral memories of our veterans were, in fact, memories with
very sad connotations. Meanwhile, other studies (e.g., Porter & Birt, 2001) on the phenomenology of traumat-
ic memories have also reported that such memories have many similarities with non-aversive memories in
terms of overall quality, clarity, or coherence, a finding that also argues against the special status that the trau-
ma-memory argument attributes to traumatic memories. A prominent view in clinical literature is that trau-
matic memories are stored at a lower, perceptual level, which would make them less coherent and more
fragmented than ordinary memories (e.g., Brewin, 2001; Ehlers & Clark, 2000). Of course, our findings are
at odds with this view, as are studies reporting that among undergraduates who have been exposed to trau-
matic events, those with PTSD do not rate their traumatic memory as less coherent and more fragmented
compared to those without PTSD (e.g., Berntsen, Willert, & Rubin, 2003).
We also examined to what extent our participants experienced high frequency intrusions. Only a minority
of veterans said to have flashbacks or nightmares on a daily basis or several times a week. Because reports
about the frequency of flashbacks and nightmares were based on retrospective estimates, the true frequency
of these intrusions might be inflated. Although especially flashbacks were reported as reflecting the distressing
war events quite adequately, many participants indicated that both their flashbacks and nightmares did not
E. Geraerts et al. / Consciousness and Cognition 16 (2007) 170­177 175
contain auditory, olfactory, or bodily impressions. This suggests that these two types of intrusive imagery do
not reflect the sensory elements of the traumatic events in an accurate way (VanOyen Witvliet, 1997). Again,
these findings are difficult to reconcile with models of PTSD in which flashbacks and nightmares are taken as
evidence for the perceptual organization of traumatic memories (e.g., Brewin et al., 1996; Ehlers & Clark,
2000).
Based on the assumption that dissociative symptoms are a direct consequence of trauma, several authors
have reasoned that PTSD symptoms are primarily dissociative in nature (e.g., Gershuny & Thayer, 1999).
Although DES scores found in our sample are comparable to those previously reported for clinical samples
(Van IJzendoorn & Schuengel, 1996), our results indicate that PTSD-related symptoms and dissociative expe-
riences are not necessarily intimately associated with each other. This is not an isolated finding. Both Yehuda
and colleagues (Yehuda et al., 1996) and Merckelbach et al. (2003a, 2003b) found in their samples of concen-
tration camp survivors that dissociative experiences and PTSD symptoms are largely distinct phenomena. As
our sample consisted of young and middle-aged veterans, our failure to find a straightforward connection
between dissociative experiences and PTSD symptomatology cannot be explained by a reduction of dissocia-
tive experiences due to aging.
Summing up, the present findings do not support the existence of special memory mechanisms that are
unique to traumatic events. We believe that the prospects of further research addressing the special status
of traumatic memories are not very good. A more promising avenue for further research would be to examine
how in some victims, the traumatic memory becomes the central component of their life narrative and in this
way contributes to PTSD-related symptoms (e.g., Berntsen et al., 2003).
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