Long-Term Consequences of War Captivity in Military Veterans

Numerous studies on the health and functioning of veterans and former prisoners of war have shown that the experience of war captivity is one of the most difficult human experiences. Captivity is often characterized by extremely difficult and inhumane conditions, as well as exposure to various forms of both psychological and physical abuse. Such traumatic experiences can lead to serious psychological consequences that can last for years, even decades after release from captivity. The aim of this paper is to present a brief overview of research that points to the specifics of wartime captivity and the long-term psychological consequences in veterans of former camp detainees, as well as the consequences suffered by their families and factors that, apart from the intensity of the trauma, contribute to the emergence and persistence of psychological disorders. From the presented research, it can be concluded that former prisoners of the camp represent an extremely vulnerable group of the social community and require long-term appropriate treatment, while the needs of veterans’ families should not be neglected, with the necessity of including spouses and children in psychological and psychosocial treatments.


Introduction
Traumatic events can happen in any situation, but they are usually isolated incidents with a clear end, and the victim typically has a way out of the problem. In the case of captivity, the victim is exposed to repeated traumatic events and situations from which there is no way out, and the victim is entirely dependent on their abusers, who have tremendous power in these situations over the victim. At the same time, an imprisoned person never knows how long this terrible situation will last. The captors, the abusers, control the entire life of the detainee, deciding what the victim will eat, when and if they will sleep, whether they will wear clothes, and whether they can communicate with anyone. Additionally, a detainee is exposed to various forms of abuse and torture, causing a sense of fear of imminent death, whereby the abuser decides whether to keep the detainee alive. Captivity creates a dominant feeling of fear and loss of all autonomy, often leading, especially in the case of long-term captivity, to a loss of the will to live and a desire to end it. As a result, captivity is considered one of the most difficult human experiences [1]. Numerous studies in the field of psychotraumatology point to the importance of this topic in public health. It is crucial to identify disorders that occur as a result of trauma and to acknowledge the vital role of the social community and support in the recovery process for those affected. This has consistently been confirmed as a significant factor in predicting successful recovery [2]. It is well known from the results of a series of studies

Materials and Methods
The literature search was conducted following the PRISMA Guidelines, utilizing the PubMed, Google Scholar, SCOPUS, and Web of Science databases. The search criteria focused on comprehensive articles in the English language, employing specific keywords, their combinations, and related terms. The inquiry encompassed the concepts of "war captivity" OR "veterans" OR "ex-POW" OR "former prisoners of war" AND "psychological consequences" OR "mental disorder" OR "predictors of mental disorder", as well as "PTSD in veterans and family", "veterans marital problems", "secondary traumatization of veterans" and "veterans' wives mental disorder." To optimize the retrieval of pertinent articles, a truncation approach was employed. Initially, 521 articles were identified through a search of titles and abstracts. After a thorough evaluation of the title and abstract, 390 articles were eliminated due to their lack of relevance. Upon scrutinizing the full text of the remaining papers, an additional 15 were excluded as they did not align thematically with the focus of this review. Following the exclusion of 8 duplicates, the study incorporated works that explored the nuances of trauma resulting from war captivity, encompassing investigations on the long-term ramifications and predictive factors contributing to the development and persistence of psychological disorders, as well as the challenges encountered within the families of veterans. A comprehensive array of scholarly works was included, comprising original scientific articles, meta-analyses, literature reviews, and relevant books. In total, a selection of 114 pertinent references was made, comprising 100 original research articles, 3 review articles, and 11 books.
The initial section of the study aimed to provide a thorough depiction of the unique aspects of traumatic experiences during captivity. In this context, older publications were also consulted, chosen based on their efficacy in describing this specific type of traumatization. The subsequent section of the study focused on examining the psychological consequences of captivity in veterans, with a particular emphasis on identifying predictors of mental disorders that contribute to their onset and enduring manifestation. The final section of the study elucidated the psychotrauma-related repercussions impacting the functionality of spousal and familial relationships, along with the secondary traumatization experienced by spouses and offspring of traumatized veterans.

War Captivity-How Is It Different from Other Traumatic Experiences?
Research on war captivity regularly highlights the intensity of the psychotrauma caused by this type of traumatization due to its specific characteristics [5]. It is emphasized that the basic feature of captivity is traumatization directed towards the person, within which the captive is attempted to be humiliated, injured, and broken. Authors highlight a particular type of relationship that arises between the victim (the captive) and the abuser (the captor), which they call a situation of forced control. Various forms of abuse and torture take place on a personal level, and the captive has a sense of complete lack of control over their life. The uncertain situation in which the captive finds themselves intensifies the effect of each individual stressor and leads to a cumulative effect of individual stressful events [1,6,7]. One of the characteristics that distinguishes captivity from most other traumatic situations is that it usually involves prolonged and repeated traumatization that can last for months, and even years. It has been observed that during captivity, individuals go through several phases, each representing a distinct stressor. These phases include capture, detention, the phase of release from captivity and return to their environment, and finally, the phase of reintegration. The authors note that during capture, individuals who were previously in the role of soldiers or combatants must quickly transition to a different role, establish emotional control, confront fears of death, behave in accordance with the new situation, and adjust their behavior in order to survive. Shortly after being captured, the hope of avoiding captivity vanishes, and a sense of despair and disbelief emerges as a result of the series of new events to which the person, now a detainee, is subjected. The individual quickly faces the new reality in which their functioning is forcefully diminished, dealing with the loss of freedom and status. After their release from captivity, those who have survived it encounter a new traumatic experience, that of reintegrating into civilian life [7]. Another characteristic of captivity is the loss of communication with the outside world, the absence of any information, and the loss of connections with loved ones. In captivity, conditions are often extremely difficult, and captives may be exposed to extreme temperatures and unhygienic conditions, and are often deprived of basic needs for food, water, medical care, etc. [1,8]. The stay in solitary confinement, where captives are often placed in a dark room in silence without the ability to communicate with other captives, is described as one of the most traumatic experiences during captivity [9].
Numerous studies describe the experiences of prisoners of war from different wars, such as World War II, the Vietnam War, the Korean War, etc., and the various types of mistreatment and conditions that soldiers were exposed to even before being captured, through their participation in combat activities [10]. Combat trauma can also be intense and involve life-threatening situations, witnessing the suffering of comrades, and killing civilians. However, combat trauma differs in many ways from the situation in which soldiers find themselves after being captured and held in captivity. This traumatization is not directed at the person as soldiers are surrounded by their comrades, usually have the necessary equipment, medical care, and are not deprived of food and water, and most often are not deprived of information and communication [9,11,12].
A number of studies deal with the captivity of soldiers during World War II, and captivity that took place in the Pacific theater, in Japanese war camps, is highlighted as a particularly difficult traumatic situation, characterized by extremely harsh conditions, compared to captivity in the European theater [13,14]. One such study that examines the long-term effects of traumatic experiences in captivity is the one by Sutker and colleagues from 1993. The study included 36 American former prisoners of war and 29 veterans who were not prisoners of war. The vast majority of prisoners were exposed to extreme stressors during their captivity that followed severe combat experiences. Nearly 40% of them were wounded upon capture, many of them experienced neglect of basic bodily needs, and about 90% were exposed to starvation that led to malnutrition. They were housed in overcrowded conditions with extremely poor hygiene. Also, around 90% of them were exposed to extremely high temperatures. About 30% of the prisoners were confined to solitary cells. About 90% of them were forced to march to exhaustion, and the same number experienced physical abuse by beatings. Many witnessed death threats to other prisoners, as well as executions of other prisoners (about 90% of them). They were also subjected to endless, meaningless, and exhausting interrogations, psychological abuse, and about 70% of them were exposed to Allied attacks. [15]. The research conducted more than five decades after the captivity speaks of the horrors suffered by American prisoners of war during World War II. The study included 157 war veterans who were on average 20 years old at the time of their captivity. Some of the participants were held in the European theater, while the others were held in the Pacific theater. The study showed that the experiences of those who were held in the Pacific theater were significantly more brutal [16]. Research on the consequences of captivity among Australian veterans who were held in Japanese war camps also speaks of the harsh conditions and cruelty to which the prisoners were subjected. They were housed in inadequate facilities, had inappropriate clothing, and many suffered from infectious diseases and malnutrition during captivity. They were forced to march to exhaustion and were subjected to various forms of physical and psychological torture, interrogation, and severe punishment. The fact that 30% of the prisoners died during captivity speaks to the conditions and level of cruelty inflicted upon them [17].
In his work on the experiences of captivity during the Vietnam War, Hunter emphasizes that the initial assessments that the group of prisoners of war had almost identical traumatic experiences during captivity proved to be inaccurate. The observed differences in traumatic experiences were based on two important factors: location and time period of captivity. Thus, the author points out that experiences varied depending on whether the prisoners were held in South or North Vietnam, and significantly more severe experiences were had by those who were held captive until August 1969, which is explained by a crucial political moment. He describes the differences in the prisoners' accommodations, stating that in the south, prisoners were housed in bamboo cages, often chained up, while in the north, they were in masonry buildings, but were subjected to more significant torture. While in the south, their days were spent in cages except when doing cleaning work; those in the north were subjected to significant physical and psychological torture, and even 40% of them spent more than six months in solitary confinement, with 20% spending one to two years and some being locked up for four years [18]. In a paper that examines the consequences of torture endured by Israeli prisoners of war in Yom Kippur War camps, it is noted that they were subjected to starvation, dehydration, severe physical and psychological abuse, electric shocks, beatings, and were kept in small spaces [19].

Post-Traumatic Stress Disorder
In the context of the psychological consequences of traumatization, including those resulting from war captivity, the most commonly researched disorder is post-traumatic stress disorder (PTSD). Numerous studies have focused on factors that contributed to its development and persistence over years and even decades after release from captivity, comparing veterans who were camp prisoners with a comparable group of veterans who did not have that experience or with individuals from the general population [20]. However, in addition to PTSD, research also addresses the occurrence of other psychological disorders and predictors of their occurrence [17,21,22].
As every captivity has its own specificities and differs, among other things, in the conditions and intensity of traumatic stressors, the applied methods of torture and exhaustion, and the duration of captivity, research results indicate differences in the prevalence of PTSD and other mental disorders among the examined groups. The prevalence of PTSD decades after captivity is, in some studies, associated with the length of stay in captivity. Therefore, depending on the examined veteran population of former prisoners of war, it ranges from 5% to 15% (American veterans of World War II) and up to 80% (Korean War). The time spent in captivity has not been shown to be significant in some studies [13,14,23].
The treatment of prisoners has been shown in many studies to be the most significant predictor of the development and persistence of PTSD [24]. Exposure to extreme conditions and cruel treatment, as indicated by significant weight loss in some studies (which also indicates significant vulnerability to traumatization), also leads to psychological consequences that manifest as a high prevalence of PTSD in some groups of prisoners of war [16,25].
Based on the occurrence analysis of PTSD, whether it is of a lifetime or current nature, at the time of the research, individual symptoms and clusters of PTSD symptoms, and the association of certain clusters or symptoms with certain types of traumatic events that cause PTSD, as well as the intensity of PTSD in relation to the dominance of certain symptoms, are analyzed. In doing so, the fluctuation of symptoms in the chronic course of PTSD is emphasized, and the symptoms of avoidance behavior, that is, symptoms related to the avoidance of stimuli that remind one of the traumatic event and the circumstances associated with it, are highlighted as the most constant and resistant to therapeutic treatment [26]. Furthermore, in some studies, this group of symptoms is precisely linked to the experience of captivity and exposure to a greater number of traumatic stressors, while symptoms of increased arousal, for example, are associated with combat experience [27,28]. Traumatization during captivity is also associated with pronounced symptoms of emotional numbness, while some studies find a significant correlation between captivity and symptoms of re-experiencing trauma [29][30][31][32].
Studies have shown that avoiding memories of traumatic experiences, especially those that were extremely difficult or involved humiliation and extreme torture, is one of the most prominent symptoms in heavily traumatized veterans, which hinders their recovery [28]. Based on research results, these avoidance symptoms are primarily due to a strong sense of shame about the experiences and humiliation endured. On the other hand, strong feelings of shame are associated with the development of depression, suicidal urges, and psychotic symptoms [16,33].
Research also deals with the feeling of not belonging, and loneliness among war veterans, which is even more pronounced among veterans who have experienced captivity compared to those who have combat experience but were not in captivity. This is explained by the particularities of the captivity trauma, during which not only are prisoners often placed in solitary confinement, but they are also exposed to a specific relationship with their captors that takes place on a personal level, devoid of any empathy and humanity, which will result in a later feeling of insecurity and distrust in interpersonal relationships and lead to loneliness [1]. Some studies deal with the connection between loneliness among veterans and suicidal ideation and suicide attempts [34]. Studies indicate that a significant proportion of former camp prisoners have suicidal thoughts decades after captivity [35,36].
A longitudinal prospective study examined the existence of suicidal ideations at three time points (18,30, and 35 years after the war) in former war camp prisoners compared to veterans who were not camp prisoners [36]. Over time, an increase in suicidal ideation was observed in former camp prisoners, which was more common among them and was also contributed to by PTSD [37].
The occurrence of hallucinatory experiences in relation to the experience of captivity has also been examined [38,39]. In addition, research has shown a correlation between the occurrence of hallucinations and PTSD [40]. For example, avoiding symptoms that lead to social isolation and loss of close relationships with others, as well as the turning of the traumatized person to their inner world, is associated with the development of hallucinatory experiences [41]. Very intense symptoms of trauma re-experiencing can reach a psychotic level, as can symptoms of increased arousal that result in excessive caution and a feeling of being threatened [42,43]. Research involving former prisoners of war from the Yom Kippur War documented significantly more auditory hallucinations decades after captivity among former POWs with PTSD compared to those without PTSD and veterans who were not prisoners of war. In this case, the most significant contribution to hallucinatory experiences was made by intrusive PTSD symptoms [44].

Other Psychological Disorders
Besides the prevalence of PTSD in former prisoners, research also analyzes the occurrence of other mental disorders, usually by comparing participants with PTSD to those without PTSD. While some studies did not find any difference in the occurrence of other mental disorders among the groups with and without PTSD [45], others have shown that other mental disorders are more common in veterans who had or currently have PTSD [46,47].
One of the most common comorbid psychiatric disorders is depression, and research emphasizes the importance of recognizing depression and the poorer prognosis and more complicated clinical picture in the case of comorbidity of PTSD and depression [48,49]. The frequent development of depression in severely traumatized camp prisoners has been confirmed in numerous studies, which is, among other things, explained by the phenomenon of loss experienced by these veterans [50,51]. Studies suggest that through inhumane treatment by captors and harsh conditions in captivity, veterans with such painful experiences are faced with a loss of self-esteem, loss of trust in people, and faith in the world around them [52,53]. In addition to depression, the most common comorbid psychiatric disorders were panic disorder, alcoholism, and phobic disorders [47].
Besides the fact that the results of numerous studies link the occurrence of other mental disorders with PTSD, some studies have shown that there is a significant correlation between the experience of captivity, or the intensity of trauma, and the development of certain disorders [54]. At the same time, there was no significant correlation with the development of other disorders. For example, there was no significant difference in the lifetime prevalence of alcoholism in the group of prisoners compared to the general population, while depressive disorders and schizophrenia were more common in prisoners of war [22,55].
Studies confirm the vulnerability of former prisoners of war, even fifty years after their imprisonment. In a study that examined the psychological state of former prisoners during the COVID-19 pandemic, it was shown that the consumption of alcohol and marijuana, as well as smoking, increased in this population in order to alleviate their symptoms. This significant vulnerability is explained by deep, severe psychological changes resulting from severe traumatization as part of the interpersonal trauma that is characteristic of imprisonment [56]. In addition to the high prevalence of dissociative disorders in the first years after imprisonment found in studies, a higher prevalence of long-lasting persistent dissociative disorders was documented in former prisoners compared to a control group of veterans who were not prisoners of war [53]. Dissociative states are explained as a mechanism of a kind of escape from thoughts and memories of a near-death experience to which prisoners were exposed through various traumatic situations during their captivity [57]. Some studies do not find a higher prevalence of mental disorders in camp prisoners compared to veterans who were not prisoners. For example, a study that included three groups of camp prisoners and examined the prevalence of mental disorders four or five decades after World War II and the Korean War did not show that the intensity of trauma was a significant predictor of most mental disorders, but it was a significant predictor of the development and persistence of PTSD [58].

Personality Vulnerability, Socio-Demographic Factors, and Social Support as Predictors of Psychological Consequences
Aside from the conditions that prisoners are exposed to during captivity, such as the intensity of traumatic experiences, research also deals with other factors that can affect the outcomes of traumatization. Thus, certain behaviors during captivity and personality traits can contribute to surviving captivity [59]. Personality maturity, emotional stability, higher intelligence, opportunism, as well as optimism, courage, military experience, and belief in a good outcome contribute to survival [59][60][61]. On the other hand, immature, dependent, and passive personality traits with limited adaptive capacities have a greater chance of a poorer outcome and more severe consequences [62]. Studies also deal with the consequences of traumatization in individuals who are focused on the difficulties they face in relation to those who are focused on the emotional states that arise in stressful situations.
Studies have shown that individuals labeled as high sensation seekers, characterized by a willingness to take risks and enter risky situations, have a greater chance of a good outcome and easier survival compared to those who are low sensation seekers, and use more favorable defense mechanisms. It has been shown that these two types of personalities have completely different perceptions and subjective experiences of the same reality situations in captivity [63][64][65]. Numerous studies confirm the significance of immediate reactions to a traumatic event, highlighting feelings of shame and anger towards others during or after the trauma, as well as dissociative reactions [66,67]. Research shows that military preparedness and training for extreme situations also reduce the level of distress, and reduce the risk of developing psychological disorders [68].
Some research examines the factors that predict better outcomes for individuals exposed to severe trauma in captivity. For example, a study involving well-trained military personnel, specifically officers of the U.S. military, showed that they had a greater likelihood of coping better in situations of extreme stress and a lower likelihood of developing severe traumatic effects [69]. They were prepared, among other things, for various situations they might encounter if they were to become captive, such as exhaustive interrogations, solitary confinement, clandestine communication, and escape from captivity.
Apart from the factors related to the intensity of traumatic situations, personality characteristics, and immediate reactions to traumatic events, there are several other factors that affect the development, persistence, or chronicity of psychological consequences. Among the sociodemographic factors, the female gender, educational level, age at the time of traumatization, and marital status stand out as one of the most significant predictors of psychological consequences [70]. Adequate social support after release from captivity or return to normal civilian life has been shown to be a crucial factor in the results of numerous studies [71]. Reintegration into normal activities represents an extremely traumatic period after time spent in captivity. Many veterans experience complete social isolation upon returning from war, feel they cannot share their traumatic experiences with others, or encounter negative reactions from their environment, significantly increasing the risk of developing psychological disorders [72,73]. It has also been shown that later life stressors can contribute to the chronicity or onset of symptoms.
The age at the time of captivity is one of the factors that can contribute to the development of PTSD or can be a protective factor. Younger age, lack of life experience, and personality immaturity represent a greater risk for developing PTSD [58]. Studies also indicate that entering older age is a critical period when the risk for intensifying PTSD or reactivating it in already recovered veterans increases [74]. Retirement and poor financial status have also been shown to be predictors of PTSD [30,35]. Higher levels of education have been shown to be predictors of recovery from PTSD in veterans of the Yom Kippur War, including both prisoners of war and veterans who were not prisoners of war [75], For several decades after captivity, other factors contributed to the persistence of depression. Age, education, social support, and socio-economic status were found to be significant, with good socio-economic status being a protective factor in the development of depression [21,76]. A younger age at the time of captivity was associated with greater intensity of anxiety, or a higher prevalence of generalized anxiety disorder several decades after release from captivity in a study that included prisoners from World War II [76]. In addition to a younger age, lower levels of education and lack of social support were also significant predictors of depression several decades after the war in a study that included prisoners from both World War II and the Korean War [21]. Other studies have also shown that lack of social support is one of the most significant predictors of developing PTSD and other psychological disorders [49,[77][78][79][80].
In Table 1, 19 studies analyzing the impact of trauma intensity during captivity on long-term psychological consequences were presented, excluding other factors as predictors. Of the 19 studies, 14 included former prisoners of war and veterans without captivity experience as control groups. The examined associations included trauma intensity and the following long-term consequences: post-traumatic stress disorder (PTSD) and posttraumatic stress symptoms; depression; anxiety; suicidal ideation; auditory hallucinations; persistent dissociation; psychiatric and psychosomatic morbidity; PTSD and well-being; subjective sense of benefit; general psychiatric symptomatology; functional problems, and life disability. PTSD typically arises shortly after experiencing trauma. Lifetime PTSD is linked to a higher risk of lifetime panic disorder, major depression, alcohol abuse/dependence, and social phobia. Current PTSD is associated with an increased risk of current panic disorder, dysthymia, social phobia, major depression, and generalized anxiety disorder. Ex-POWs exhibited higher post-traumatic symptoms compared to controls at both measurement points, and these symptoms increased solely among ex-POWs from T1 to T2. Attachment anxiety and attachment avoidance increased over time among ex-POWs, while they slightly decreased or remained stable among controls. Furthermore, the rise in attachment anxiety and avoidance was positively linked to the increase in post-traumatic symptoms in both study groups. Table 2 shows 16 studies examining the association between trauma intensity during captivity and other factors with long-term consequences of traumatization. Apart from former prisoners of war, these studies included veterans without captivity experience as control groups. Among nine studies, former prisoners of war and veterans without captivity experience were included as control groups. The examined factors included sociodemographic factors; personal characteristics and coping with captivity; medical symptoms during captivity; military rank; social support; psychological responses during captivity (9); stressful life events, and subjective quality of life. The long-term consequences examined were PTSD (and PTSS); anxiety; depressive symptoms; negative affect; positive affect; somatic symptoms; interpersonal problems; PTSD and psychiatric comorbidity; retarded activity; subjective quality of life; health-related quality of life; health conditions, and mental health.  Among the ex-POWs, 23% met criteria for PTSD and were 10 times more prone to psychological deterioration in the 12-year period between the two assessments, compared to controls. Nearly 20% of ex-POWs who did not meet PTSD criteria in 1991 now met criteria in the current assessment, in contrast to nearly 1% of the controls. Younger age at captivity, loss of emotional control, higher subjective appraisal of suffering during captivity, and a greater number of PTSD symptoms in the 1991 assessment were predictive of current PTSD. Implication of both sensation seeking and the subjective appraisal of captivity in the long-term adjustment of ex-POWs.
Ex-POWs with low sensation-seeking tendencies displayed higher levels of PTSD symptoms, more severe psychiatric symptoms, and greater intensity in intrusive and avoidance behaviors. High and low sensation-seeking POWs also differed in their emotional experiences when taken prisoner, subjective evaluation of suffering in prison, coping strategies employed during captivity, and emotional states experienced.
Impact of POWs' demographic characteristics, military rank, and personal resources on rates of PTSD and resilience to captivity.
The results revealed higher MMPI profile patterns than anticipated based on previous research with pilots, along with a prevalence of current and lifetime PTSD at 33%, believed to be associated with the trauma of being a POW. WWII aviator POW survivors exhibited greater resilience to the effects of captivity compared to non-aviator WWII POW survivors of similar age, who generally possessed fewer advantages in education, military rank, and personal resources. Examination of relations between personal and military demographics and captivity stressors with mental health outcomes (post-traumatic stress symptomatology (PTSS), general distress, and interpersonal negativity).
Hierarchical multiple regression analyses revealed that being an officer acted as a protective factor in the relationships between physical torture and PTSS, psychological torture and PTSS, and psychological torture and interpersonal negativity. Investigation of the effect of self-perceived social support on the intensity of PTSD symptoms and mental health-related quality of life (MHRQoL) in veterans more than two decades after exposure to trauma.
The obtained results showed that veterans who had a more positive perception of social support after the events of the war had less intense PTSD symptoms and better MHRQoL. Evaluation of heterogeneity of changes over time and investigation of the contribution of trauma exposure (combat vs. war captivity), hardiness, and social support for depression trajectories.

Consequences for the Family
One of the most significant predictors of the development and persistence of PTSD and other psychological consequences of traumatization is social support. It has been observed that family and other close individuals represent the best protective factor for psychotraumatized individuals. Closeness, love, trust, and support that family members provide to the traumatized individual represent the most significant help to them in overcoming difficulties resulting from traumatization [82].
Long-term captivity leads to significant changes in human relationships, and attachment changes resulting from insecurity, anxiety, and loss of trust, even in the closest persons, resulting in the withdrawal and distancing of the traumatized person from their loved ones, who are expected to provide support and help at the same time [81,83,84]. Intensive traumatic experiences with severe psychological consequences, such as those experienced by veterans and former prisoners of war, make it difficult to receive support but also to provide support to the traumatized person, often resulting in serious difficulties in marital and family relationships, leading to psychological consequences for both spouses and offspring [85]. PTSD is often associated with difficulties in intimacy, trust, expressing emotions, aggressive behavior, loss of interest, and distancing from the environment, all of which contribute to poor marital adjustment and difficulties in the adjustment of the spouses of veterans with PTSD [86,87]. Research has shown that less severe symptoms of post-war stress make it easier to provide support to traumatized individuals [88].
The importance of the influence of the experience of confinement and PTSD on marital relationships is also evident in the results of studies that find a higher frequency of divorce in veterans who were prisoners of war compared to those who were not [89]. Marital adjustment is a complex concept that denotes a process that changes over time and refers not only to satisfaction within the marital relationship but also to the collaboration of partners, agreement on important life decisions, and the expression of affection, closeness, and emotions between partners [90,91]. Studies also indicate differences in marital adjustment among those with chronic PTSD compared to those with sudden-onset, delayed PTSD, where delayed PTSD in former prisoners of war is associated with lower levels of marital adjustment [92]. Often, within a marriage that is burdened with severe psychotrauma, the phenomenon of overprotectiveness arises. This phenomenon is characterized by the excessive protection of the traumatized veteran by their spouse, as well as the complete adaptation of family life to their needs. Such a relationship can lead to significant distress in the spouse, who takes on the role of protector for the veteran and their children from stressful family situations associated with symptoms of PTSD. In this process, wives often receive nothing in return and often develop feelings of helplessness and insecurity, which is further contributed to by the frequent loss of contact with others, or social isolation, of both the veteran with PTSD and their spouse [93,94]. As a result, wives of veterans often find themselves being judged by their surroundings and developing a sense of abandonment. The environment often condemns the display of anger and similar emotions by the veteran's spouse, interpreting them as betrayal of the veteran, thus making it impossible for them to express negative emotions, as they receive no understanding for the suffering and difficulties of their own [95].
Emotional engagement, empathy, compassion, and taking on all obligations and responsibilities without satisfaction and the possibility of relaxation can lead to a phenomenon of "compassion fatigue" in veteran's spouses, according to Figley [96]. Despite taking on all family responsibilities, wives of former prisoners often take a secondary position in the family and marriage "because they feel they are not entitled to equality with their hero spouses" [97].
In veteran's spouses, as well as in other close family members, secondary traumatization can occur, which means that symptoms similar to those of the primary traumatized person may develop, such as symptoms of avoiding stimuli that remind them of trauma, symptoms of increased arousal, and sleep difficulties. Studies show a clear correlation between PTSD symptoms in veteran spouses and PTSD symptoms in veteran prisoners of war [98,99]. Wives of former prisoners and other veterans may also develop depression, anxiety, and strong feelings of guilt, caused by living with a severely traumatized spouse who is often only physically present but emotionally distant and excluded from everyday life. Relationships are therefore burdened with a number of uncertainties about the functioning of marriage and family [100].
Severe trauma and its consequences inevitably affect not only marital relationships but also relationships of traumatized individuals with their children, often making them dysfunctional in their parenting role. Veterans with PTSD have no desire or interest in relationships with their children, or they exhibit overly controlling behavior [101,102]. This leads to extremely complex relationships that can leave a mark on the psychological development of children, where emotional numbness, absence, and distancing of the veteran contribute the most [103].
Research has shown that some veteran's children were not aware of the causes of their father's behavior until adulthood, but they remember his mental disorders and the dis-turbed dynamics of family relationships, where everything was subordinated to the father, and the family atmosphere was marked by fear, caution, and feelings of guilt [104]. Growing up with a father with pronounced attachment insecurities is marked by feelings of insecurity, loneliness, rejection, mistrust, and the development of a negative self-image [105].
Various mental disorders and disturbances can occur in children of veterans with PTSD, such as depression, anxiety, hyperactivity, and difficulties in social functioning. Some studies identify violent behavior of veterans as the cause of behavioral disorders and academic failure more than PTSD itself [106]. Research shows that adult offspring of former prisoners of war have a higher rate of PTSD, depression, anxiety, and attachment insecurities compared to offspring of veterans who were not prisoners of war [107]. The importance of psychotrauma in family dynamics and its impact on children is demonstrated by research, the results of which show that even in cases where a traumatized person has not developed a mental disorder and does not speak about the trauma experienced, trauma can still be transmitted to the child through parenting methods and growing up in a family atmosphere where a "secret" is kept and something important is not talked about [108]. Table 3 focuses on the consequences experienced by families of war veterans. The participants in the studies were veterans and their spouses; veterans and their children; women married to veterans; veterans and their families; spouses and children of veterans, and children of veterans. The research topics covered the quality of intimate relationships; problems in marital and family adjustment, parenting skills, and violent behavior; spouses' perception of marital relationships; predictors of divorce; secondary traumatization in veterans' spouses; paranoia in spouses and children of veterans; psychological difficulties in children of veterans; the experience of captivity and its consequences from the perspective of veterans' spouses; the association between veterans' aggressiveness and aggressive behavior in children; the quality of relationships between veterans and their children, and secondary traumatization in children of veterans.   The trauma experienced by veterans also affects the parents of traumatized soldiers, although such studies are significantly less frequent than those related to the secondary traumatization of veterans' wives or children [99]. In a study that deals with the conse-quences of traumatization in Vietnam veterans and the impact of their war experiences on their later family life and functioning, the importance of life educators and therapists is emphasized, along with the need for enhanced interventions at the family level [109]. Studies exploring motherhood in the context of various military conflicts are interesting. Udi Lebel, for example, discusses the victimological militarism of mothers of soldiers who were killed in action. Their tragedy and loss bring them an important position in society by perpetuating a culture of martyrdom, which can hinder recovery. Conversely, survivors who are severely traumatized, including former prisoners of war, are considered less valuable and rank lower on the heroism scale, resulting in reduced possibilities of social recognition, support, and respect [110].
The issue of respecting the families of traumatized veterans can also be viewed from a different perspective. If the family is considered the foundation of society, it becomes evident that, in the context of involving young people in the military forces, the importance of the family must not be neglected. It is within the family that attitudes are formed, and the groundwork for readiness to join military units is laid. The research authors discuss the relationship between the state, society, family, and parenting in the context of the family's sacrifice during wartime conflicts. They highlight the different positions of families of fatalities and survivors, as well as the varying ways in which families process their losses. Some families may grieve privately, while others, as many have undertaken, choose to engage socially and politically, actively participating in the struggle to bring their family members back from the battlefield [111].

Limitations to the Study
Limitations of this review should be acknowledged. Firstly, it is important to note that the scope of this review does not encompass articles that specifically focus on civilian detainees or prisoners. Secondly, this paper does not delve into the experiences of perpetrators of abuse, nor does it include individuals who provided support or witnessed the abusive acts. Despite the established responsibilities outlined in the Geneva Conventions, regrettably, violations of these conventions continue to persist. One noteworthy occurrence exemplifying this is the documented events described in General Taguba's report, which unveils the mistreatment of prisoners in Iraq. Published in 2004, this report, titled after its author, brings to light these unsettling actions [112]. In the context of preventing abuse in confinement and recognizing the subsequent repercussions for detainees and their families, it is crucial to underscore the significance of upholding the Geneva Conventions and the ensuing obligations they entail. It is imperative to abide by these obligations not only in the treatment of prisoners but also in ensuring adequate sanitary and health conditions within the bounds of captivity [113]. Furthermore, when discussing confinement, we must not disregard the importance of educating officers on the proper treatment of prisoners and their indispensable duty to safeguard detainees [114]. Lastly, this review paper does not delve into detailed descriptions of abuse among detainees or delve into the consequences faced by detainees who participated in or witnessed such abuse. It is essential to recognize these limitations in order to understand the specific boundaries of this study and the areas that were not explored in depth.

Conclusions
Numerous studies of the effects of trauma on war veterans have shown that the psychological effects of extremely severe traumatic experiences, such as the experience of captivity, can persist decades after exposure to traumatic events. It has also been shown that the occurrence of psychological disorders is influenced by a number of factors in addition to the intensity of the traumatic experience, with the importance of social support being particularly salient. In addition to concerns for veterans' health, it is important not to forget family members who are also affected by living with a severely traumatized person, as numerous consequences have been documented in these cases. Further research on this topic is needed to determine the best methods for preventing and treating mental health disorders in this vulnerable population.
It would be interesting to research veterans' families in the context of secondary traumatization, comparing socially active families with those that were not involved. Additionally, conducting research on the consequences of abuse in detention based on the testimonies of survivors would undoubtedly be beneficial. Moreover, exploring positive events during times of war would also be valuable to investigate.