Colonial War: When the Years Rekindle the Suffering—A Pilot Study

: For more than 150 years, traumatic stress has been a recurrent topic of medical and psychological studies, in which war-related experiences remain to be addressed. Although veterans have been considered a high-risk group for the development of stress-related diseases, the impact of aging on the trauma process is an unexplored ﬁeld. This study aimed to analyze the aging-related factors that may inﬂuence the emergence of traumatic stress symptoms in war veterans. The clinical data of 29 Colonial War Portuguese veterans were veriﬁed in order to identify the main diagnoses, and the frequency of health service use. Through thematic analysis of the transcripts of 10 interviews with veterans diagnosed with Post Traumatic Stress Disorder (PTSD), the main symptoms and factors that led them to mental health services were identiﬁed. In addition, a literature review on mental health and psychological trauma was conducted to provide an overview of the knowledge on this topic. Aging seems to be an opportunity to face conﬂicts which have been kept hidden throughout veterans’ lives. Social stigmatization and the non-recognition of traumatic stress as a disease inﬂuenced the Portuguese veterans’ silence, which could be broken with the aging process. Retirement, physical illness, death of close friends or family members, and loss of autonomy may contribute to the onset of trauma-related symptoms.


Introduction
The Colonial War was a conflict between the Portuguese Army and emerging nationalist movements in Portugal's African colonies between 1961 and 1974. This was a conflict that the Africans called a National Liberation War, and the Portuguese called the Overseas War or the Colonial War. Briefly, after World War II, the European countries were forced to promote the process of decolonization of different dominated areas. The Portuguese government did not accept an end to the colonies. Meanwhile, nationalist movements were organized in several African countries to fight the war. For 13 years, violent conflicts affected the two continents, including deaths, rapes and consequences that marked both sides of the war [1].
Although there are studies about the consequences of the Colonial War on the Portuguese population, they are usually focused on political and social issues, and research on the mental health of the Portuguese veterans, especially regarding the factors involved in development of Posttraumatic Stress Disorder (PTSD), remains scarce. The few existing studies in this area have pointed out that Portuguese veterans present high rates of PTSD, as well as more physical complaints and health care visits than the general population [2,3]. However, the years that separate the war from the suffering expressed by veterans arouses interest in discussing the variables that influence this past and present trauma.
When collecting data for a study on war trauma and somatic symptoms in Portuguese Colonial War veterans, it was evident that most of them had sought professional help after retirement, thirty or forty years after the war. This finding led to the consideration of the impact of aging in the process of traumatic stress, since some aging-related experiences, such as retirement, physical illness, the deaths of close friends or relatives and loss of autonomy may contribute to the onset of trauma-related symptoms in war veterans [3,4].
Recognizing that the establishment of psychological trauma depends on a set of factors, from the traumatic event to the reaction of the victim's social and family context, this study aimed to investigate the factors involved in the trauma process of the Portuguese veterans, a population which suffered the consequences of war when Portugal did not accept traumatic stress as a disease. We hypothesized that the social context had an influence on the hiding of posttraumatic stress symptoms, and that the common physical disabilities of aging allowed the Portuguese veterans to seek professional help. The identification of the factors that influence the emergence of war trauma-related symptoms may contribute to the development of interventions aimed at war veterans, as well as to the improvement of mental health policies in the military context.

Materials and Methods
This study consisted of three stages: (1) the analysis of clinical data of 29 war veterans enrolled at the Center for the Prevention and Treatment of Psychogenic Trauma (CPTTP), of the Coimbra University Hospital Center (CHUC), in Portugal; (2) semi-structured interviews with 10 Portuguese war veterans diagnosed with PTSD; (3) a narrative literature review on war trauma and the mental health of the Portuguese Colonial War veterans.
Although there were 39 veterans enrolled at the CPTTP, only 29 allowed access to their clinical data. The aim of this analysis was to identify the main diagnoses and symptoms presented by the Portuguese veterans, as well as the frequency they resorted to the use of health services. The clinical data provided information on a national level, making it possible to verify the medical history of the sample. It should be noted that, theoretically, all Portuguese veterans enrolled at the CPTTP presented complaints suggesting traumatic stress. However, according to the 29 clinical data, 10 of them were diagnosed with PTSD. Thus, the interview sample consisted of 10 war veterans.
The interviews, which lasted around 50 min, were divided into two parts: first, in order to encourage sharing of experiences, the Portuguese veterans were invited to report their experiences in the military context, as well as how they dealt with the post-war period. As in an informal conversation, the points of interest were questioned by the interviewer (author) in order to understand their social and cultural contexts before, during and after the Colonial War. The second part of the interview consisted of a questionnaire about the patient's physical health. For this purpose, Part D of the Portuguese version of the Diagnostic Interview for Genetic Studies [5] was applied to evaluate the prevalence of somatic symptoms. Even with the objective of obtaining direct answers, the reporting of their experiences was allowed. A thematic analysis [6] was performed to identify patterns, such as common physical symptoms and the factors that may have influenced their traumatic memories. All participants gave their informed consent before they participated in the study. Participants were informed that they could stop the interview at any time. In order to ensure that the participants had assistance in case of feeling distress, the interviews took place on the days when the participants had a psychiatric consultation. The study was conducted in accordance with the WMA International Code of Medical Ethics.
The literature review aimed to present the history of the concept of trauma, an overview of PTSD in the military context, and factors that may be related to the emergence of symptoms during aging. Considering that the focus was on the consequences of the Colonial War, this part favored Portuguese authors, since they are attuned to the social, historical, political, and cultural context. In addition, the authors included were chosen for their knowledge, as well as their direct bond with the Portuguese veterans-such as their physicians, psychiatrists, family members, or for being veterans of the same war. Other works were considered when written by authors indisputably relevant to this field, or because they are recent studies on specific points of the discussion.

Results
The sample identified in the analysis of clinical data consisted of males between 65 and 75 years old. The scholarly and social status were not included in the Portuguese health system. According to these data, 10 Portuguese veterans were diagnosed with PTSD, 14 with Depression and/or Anxiety, 1 with complaints of tension, nervousness, and anxiety, and 4 with Somatization. Despite the small number of the last diagnosis, based on the listed symptoms 16 other veterans presented somatic symptoms (Table S1). Sleep disturbance, impotence, chronic pain, functional alteration of the stomach, vertigo, headaches, and cough, when not explained by organic disease, may suggest a relation to somatic symptoms. This survey indicates that the war veterans are often resort to health services; since the computerization of data on the health system in Portugal began between 2011 and 2012, these patients presented an average of 11.5 visits to the health services (data access: September 2016).
The interview sample consisted of 10 retired men between 67 and 75 years old, 8 had completed high school and 2 had completed a bachelor's degree. The interviews disclosed the feelings and fears of the Portuguese veterans who reported their participation in warrelated events and the increase of symptoms in recent years. Although 4 participants were diagnosed with sleep disturbance, the physical health questionnaire pointed out that 9 presented this condition. Sleep disturbance was the main complaint of the sample. All veterans related retirement and the signs of aging to the rise of nightmares and intrusive thoughts about the Colonial War. The aging-related experiences, such as retirement, diminished physical capacity, lack of vitality, sedentary lifestyle, death of close friends and relatives, idleness, and decrease of social activities were described as triggers for warrelated memories and stress reactions. The intrusive memories and the need to talk about war-related experiences were emphasized by the interviewees, although most of them (n = 6) did not mention the words "trauma" and "PTSD", sometimes using expressions such as "my condition", "this", "my problem" or even "war problem", which may be interpreted as an attempt to dissociate or to detach them from the war.
The findings of this study are corroborated by the literature. Portuguese war veterans present high rates of Depression, Anxiety and PTSD, as well as recurrent health care visits [7][8][9]. Hoge et al. [10] found a high prevalence of PTSD (16.6%) among U.S. veterans, as well as a greater number of visits to health services and high somatic symptom severity. According to their study, the association between PTSD and the indicators of physical health independent of physical injury. Concerning the physical complaints, fatigue, sleep disturbance and pain are frequent symptoms in this population, being associated with avoidant coping strategies [2,3,8]. Health conditions and the great access to health services were referred to as related to war experiences, especially when added to appraisal of hostile societal homecoming, social stigmatization, and reduced perceived social support [4]. The aging factor remains an unexplored topic, even in the international literature [11], being rarely mentioned as a trigger of stress symptoms. Although aging was not the focus, studies have identified retirement, physical disability, loss of autonomy, and death of spouse and close friends as stress factors in Colonial War veterans [3,4,12]. In a study aimed at exploring the variables associated with health care visits among Portuguese veterans, Começanha and Maia [2] found retirement as an impact factor on the perception of symptoms, increasing physical complaints and impairing quality of life.
The first studies on psychological trauma pointed out that the fear experienced when enduring a violent event could provoke a set of symptoms and impairments in victim's life [13,14]. Evidence has shown that studies on psychological trauma had become more relevant with the wars and the need to describe soldiers' symptoms [15,16]. The Portuguese authors who worked directly with the Colonial War veterans highlighted the violent nature of war, the stigmatization of mental diseases and limited social support as the reasons that led to the development of PTSD in this population [17,18], with the most frequent complaints being the intrusive distressing memories and the perception of losing control [18][19][20].
Realizing the high prevalence of PTSD in war veterans [10,11], recent studies have pointed out retirement, sedentary lifestyle, social environment, and health conditions as factors that influence the development of stress-related diseases [3,[21][22][23]. Regardless of the approach, the studies on psychological trauma indicate that its establishment is dependent on a set of factors, such as stress perception, social support, and coping strategies [12,16]. Considering this concept of trauma, aging may be an aggravating factor since health and social functioning are further impaired at this stage of life.

Discussion
Research on psychological trauma was stimulated by the works on railway accidents of John Erichsen (1866), Edwin Morris (1867), Carl Moeli (1881), Hebert Page (1883) and Jean-Martin Charcot (1889). While most studies were focused on the brain injury caused by railway accidents, these authors realized that there were more consequences than physical injuries. On summarizing their findings [24] (p. 21), it was found that trauma is a consequence of intense fear-"characteristically, fear plus the element of surprise -, that is an assault equivalent to physical violence".
Although the interest in traumatic stress became more prevalent with railway accidents, wars have played a significant role in the development of knowledge about trauma. Many researchers (Freud; Myers; Kardiner; Young; McCaslin; Wessely) dedicated themselves to studying war trauma and understanding its causes, its consequences and the factors that influence recovery after violent events. Charles Myers (1915) was the first to apply the term "shell-shock" in medical literature, a term used to designate a set of symptoms presented by soldiers such as fatigue, confusion, nightmares and impaired sight and hearing when no obvious cause could be identified. Shell-shock had become a pressing medical and military problem during World War I, causing countless psychiatric casualties. Myers found shell-shock in soldiers that were not directly exposed to the war, which led him to believe in an emotional cause for the traumatic stress [16].
Abram Kardiner started his career with the treatment of traumatized veterans and, during the World War II, published The Traumatic Neuroses of War (1941), detailing the symptoms of his patients. Kardiner perceived that patients with traumatic neurosis developed a state of hypervigilance and marked physiological reaction-sensitivity to temperature, pain and stimuli. According to him, traumatic neurosis is characterized by a fixation on trauma and "is accompanied by irritability, explosive and unpremeditated aggressive reactions that often alternate with reactions of pathological tenderness and a loss of interest in the world" [24] (pp. 89-90). Kardiner suggested that these reactions aim to protect against traumatic memories [16]. It is worth mentioning that Janet [14] studied traumatic memories and stated that they are recoverable, but often the patients prefer to hide these memories from the others and themselves, which make them difficult to overcome.
Correia [17], while talking about the Colonial War, mentioned the association between traumatic stress and cowardice, referring that some veterans understand traumatic stress as a late expression of cowardice. Correia also remarked that opportunism in the military context, where there were cases of soldiers faking traumas in order to leave the battlefield, may be the main reason for the discrediting of traumatic stress, leading soldiers and veterans to deny their suffering and symptoms.
Another aspect that should be considered when studying psychological trauma is that the violent nature of war may pervert values, and when the survival instinct dominates rationality, the traumatic effects may be cumulative and progressive [17]. This notion is in accordance with the Erikson [25] theory of epigenesis, in which personality development is presented as emerging at critical or decisive times, as a lifelong integrative process. Erikson argued that moral development occurs throughout life, a position that can be related to positive or negative outcomes.
Soldiers are confronted with several moral and ethical challenges in war, which can cause moral injury. "Moral injury involves an act of transgression that creates dissonance and conflict because it violates assumptions and beliefs about right and wrong and personal goodness" [26] (p. 698). This topic was addressed by Ferrajão [3], who verified that the failure to assimilate war experiences within existing self-schemas led Portuguese veterans to appraise their behavior in war as a stable personality characteristic, describing themselves as immoral individuals. According to him, moral injury is related to a discrepancy between pre-and post-war identity. Nash and Litz [27] (p. 368) emphasized that moral injury "is not merely a state of cognitive dissonance, but a state of loss of trust in previously deeply held beliefs about one's or others' ability to keep the shared moral covenant". In agreement with this theory, Shay [28] indicated the capacity for trust as an aspect which may create a barrier in the treatment of veterans. As McCaslin, Turchik, and Hatzfeld [29] (p. 414) highlighted: "Delivering a high-quality treatment to veterans with PTSD and other trauma-related conditions requires awareness not only of evidence-based treatment practices but also of military-related stressors and the underlying military cultural context in which they occur".
The military cultural context is an important factor that influences the way the victims interpret and deal with their traumatic experiences. Freud [30], seeking to explain group psychology, studied the psychological mechanisms involved within mass movements, using as an example the Church and the Army. Freud proposed that the belief of the group members that their leader loves them and considers all of them as equals serves to stimulate the sense of community, ensuring the bond among the members and justifying demands and lack of independence. Recognizing the group mind as an important influencer of the soldiers' behavior is essential to understand the consequences of war experiences and the reasons that lead soldiers and veterans to hide their suffering. Therefore, war trauma is a present theme in debates about PTSD, thereby contributing to the improvement of the support programs for veterans. Nevertheless, Albuquerque [31], addressing shell-shock in Portugal, referred to the lack of studies and health services for satisfying the demands of the country. Fortunately, this situation is changing and publications on traumatic stress have increased throughout the last few years, helping to incite discussions and provide psychiatric and psychological treatment for Portuguese veterans.

Traumatic Memories, War and Aging
The traumatic memories' conception is a starting point for realizing how violent events may disturb soldiers' minds and remain latent for so long. According to Reis [32], a traumatic memory is a memory registered as signs of perception or sensory impressions, which manifests itself on the body. This theory argues that traumatic memory is a memory connected to the senses, a memory connected to the body. In the same sense, Seligmann-Silva [33] characterized trauma as a memory of a past that does not pass, stating that the scars of a traumatic event make the event continuous.
In a recent study, Osório et al. [34], to further understand the relationship between combat experiences and PTSD symptoms, investigated whether specific elements of operational deployment were related to stress symptoms. Their findings indicated that violent combat is significantly associated with both intrusive distress memories and numbing symptoms. "It is likely, therefore, that exposure to violent combat events contributes to the development of intrusive memories, nightmares, distress, and physiological reactivity 6 months after completing an operational deployment" [34] (p. 06). This statement corroborates what was found in the thematic analysis of the interviews with Portuguese veterans. The veterans reported intrusive thoughts and nightmares related to disturbing events such as violent battles, witnessing the death of comrades, and recovering dead bodies as the main images of their mind and dreams.
"Especially at night, I see the river, the muddy water and some terrible things. Sometimes I see his eyes, his eyes turning blue. It was not the eyes; it was like a wheel below his eyes. That . . . after seeing that . . . his brain, seeing something leaking down here and . . . And I had to clean and attach with a tape glue". (Robert, page 4, line 24 of his interview) In contrast to those who consider war experiences as determinant for the PTSD diagnosis, Simon Wessely, in an interview for The Telegraph [35], talked about his father, and stated: "He was different but he was fine. War didn't define him and he didn't need help-although he was as stubborn as a mule. His experiences had changed him but not in a pathological sort of way". In the same sense, Sales [20] (p. 389), who is responsible for the Psychiatry Department at the Military Hospital in Coimbra, Portugal, asserted that some Portuguese veterans were able "to integrate the traumatic memories without falling ill", while others keep reporting "the presence of intrusive images, sounds, affections, memories, that control their lives and their way of acting, reacting, being and thinking" after so many years since the war.
Nijdam and Wittmann [36] (p. 42) proposed that there is a process of conditioning in the PTSD development. As they claimed, stimuli that were previously neutral are laden with emotion at the time of the traumatic event and when the traumatized person is faced with one of these conditioned stimuli, the memory of the trauma is evoked. This process would be responsible for the maintenance of the PTSD and can be related to the avoidance behaviors. "However, such avoidance would make the person even more anxious and tense to think of the traumatic event in the future and thus reinforce the fear responses in the long run". In line with this theory, Pereira [37] had defined trauma as a consequence of the impossibility of assimilating certain physical experiences, indicating that it is possible to overcome violent experiences through thought, verbalization, consciousness and symbolization of the event. The narrative is often mentioned as a means of accessing traumatic experiences and helping patients in the recovery process. Victims of trauma must seek professional help, which sometimes is a lengthy process for veteransfrom the recognition of the symptoms to their confrontation.
The difficulty of war veterans in identifying signs of traumatic stress is pointed out as a consequence of the military context, which influences their values and beliefs, as well as the reactions of their families and their social environment. Soldiers are often described as brave and indestructible, especially in the past, as in the case of Colonial War veterans. In addition to the expectations of family and society, traumatic stress was out of discussion for the three decades after the Colonial War. Portuguese law only recognized war trauma as a disease in 1999, providing society with more knowledge about traumatic stress, and thereby decreasing social stigmatization. However, although the current scenario is different from that faced by veterans of the Vietnam and Colonial Wars, there are soldiers and veterans who are reluctant to seek help [38,39]. In order to change this, it is necessary "to remove the stigma that is associated with PTSD and to encourage soldiers, sailors, Marines and airmen who encounter these problems, to seek help" [40] (n.p.).
The military context influences the response to trauma from the delay of the onset of symptoms-by the need to be prepared for battle-to the search for help when the symptoms appear-by the social stigma associated with PTSD. However, these are not the only reasons. The acceptance of trauma as a disease and the dissemination of information about treatments available for psychological trauma, specifically war trauma, also helped veterans and their families identify symptoms and seek mental health services.
Although knowledge and information have proven to be essential tools for raising awareness about mental health care, they do not fully explain why veterans and their families reported the absence of symptoms that, with aging, have arisen. Therefore, this study set out to answer: Why do so many Portuguese veterans seek help after so many years? How can diseases of aging be distinguished from symptoms resulting from trauma? These questions are not simple to answer, but it is possible to establish a framework of possibilities considering some factors: • Retirement: Retirement is a turning point in human life that can affect physical and mental health, as well as the one's in society. Although retirement is a disturbing phase of life, the reason that led to retirement is the relevant factor for mental health. According to Kypraiou et al. [21] (p. 1639), "in many cases voluntary retirement has positive or neutral effects, whereas mandatory retirement may lead to negative health and social effects". Furthermore, "social isolation and stress factors may be higher among retired employees whose job was everything". For veterans, accepting retirement is often difficult, because everything they know about themselves is based on the image of a soldier, even for those who left military service after war and spent their life in a "regular job". The change of identity, the adaptation to a new lifestyle, the time for thinking and the distance from coworkers (often related to their social lives) were pointed out as inducers of Portuguese veterans confront their thoughts, their memories, and their fears. The interviews conducted in the current study indicated a relation between the retirement and the onset of symptoms, such as intrusive thoughts and hyper-arousal facing sounds and images.
"Some years ago, for example, if I heard an ambulance sound, an ambulance or a siren of anything, I was fine. Now I think this affects me. When I hear a siren, I am affected". (Patrick, page 2, line 1 of his interview) • Sedentary Lifestyle: It is well known that aging is associated with physical and mental decline. Elderly people are more affected by chronic diseases, sensorial decline, physical limitations, social isolation and mental health issues. However, there are factors that can aggravate such cases and, although they seem to be the consequence, they can be the cause of the emergence of mental health problems. According to a Brazilian study [23], mental illness, low education, unemployment and male gender were associated with sedentary behavior, which in turn leads to worse quality of life and early mortality. Likewise, a study aimed at determining the prevalence and factors associated with depressive characteristics in elderly people in China [22] concluded that depression is more prevalent in physically inactive people. "Regular physical exercise can reduce the risk of depression in the elderly. [ . . . ] Good health status is a protective factor of depression" (p. 5).
"Some symptoms appear more or less at this time [ • Social Environment: Shao et al. [22], in addition to relating a sedentary lifestyle to depression, pointed out social interaction as means of protecting mental health, which was corroborated by the interviews conducted in this study. Portuguese veterans highlighted the role of social support in coping with adversities and adapting to the different stages of life. They mentioned the importance of social support after the war, saying that the suffering was exacerbated by the way their families and society created expectations about soldiers and forgot them after the battle. Furthermore, the veterans reported that support over the course of aging is critical for them to recognize their problems and seek treatment. As Shao et al. [22] (p. 6) summarized: "Active social relationships and support help the elderly relieve the adverse effects that stressful events have on health. It can also encourage the elderly to seek prevention or appropriate medical treatment and better adhere to medication or treatment plan and become less involved in unhealthy or negative behavior".
• Health Conditions: The mental health of elderly people is affected in different ways, from physical limitations to the feeling of the end of their lifespan. Depression is associated with retirement, physical disability, and a sedentary lifestyle, which may be a consequence or the cause. Furthermore, although there are symptoms commonly related to traumatic experiences (nightmares, avoidance, startle reaction, anxiety-in addition to somatic symptoms that they can be associated with), in elderly people these symptoms can be confused with the expected health conditions that come with aging.
In these cases, attention should be more focused on the patient than on symptoms. Through a narrative that connects symptoms to life events, the patient may be able to explain his malaise. However, the boundary between physical and psychological pain is not easily identified, which can make it difficult for veterans to receive effective treatment.
"Diagnostic problems which arising from somatic symptoms, the patient's resistance in expressing emotional complaints or psychological interpretations and the physician's concern about the imperative need to exclude organic disease, or his insensitivity to detect psychosocial issues, can determine a late request for psychiatric treatment". [ Many years separate the concept of shell-shock from the PTSD diagnosis, and the perception of the psychological suffering has changed during this time, allowing those affected by trauma to seek help. Portuguese Colonial War veterans are situated between the refusal of the diagnosis and the call for the renouncement of the stigma related to mental diseases. The changes in the Portuguese laws and society's awareness about war trauma have incited discussions that led to increased support for veterans. However, this is a lengthy process and, in a culture in which a man must protect and care for his family, diseases (especially those related to mental health) are not easily accepted. In health services, as at the CPTTP of the CHUC, the role of the social environment in the veterans' interpretation about war and its consequences is evident, influencing their treatment and recovery process.
In this perspective, Maia [18] (p. 271) highlighted the social support as one of the best predictors of overall well-being, mentioning the fact that "it is especially in situations of stress that this protective factor can be assessed". The psychologist stated that "studies with victims have consistently demonstrated that adequate support is related to adaptation, while absence of support is a predictor of PTSD". Nevertheless, for Portuguese veterans, as well as for many soldiers, the expression of emotional conflicts is often not well accepted in the family and social environments. Regardless of the reasons, the impossibility of sharing their stories prevents the representation of the trauma.
"I cannot show these problems. If I talk about them, she [his wife] does not know how to deal with, she does not want to know". (John., page 8, line 18 of his interview) The affective structure available within the family is related to the way of interpreting, dealing with, and feeling traumatic stress. "The family and social validation of symptoms influences how the patient expresses himself, how he converts a private experience into a public manifestation" [41] (p. 252).
All of these factors seem to be involved in the late manifestation of symptoms, in attempts to deny suffering and in the delay in seeking help. Nevertheless, aging can also be considered a trigger to break the veteran's silence. The Portuguese veterans referred to the fact that they were tired of remaining secluded, that free time had served to revive feelings related to intense moments of their lives, that the symptoms of aging had led them to think about their past, and that (for most of them) talking about war had been remarkably reassuring. Since Portuguese law only recognized war trauma as a disease in 1999, veterans had to deal with the consequences of their experiences without medical or social validation for more than 20 years. Therefore, aging came along with information, medical validation and social awareness that contributed to allowing the suffering and symptoms to come to light.

Conclusions
Retirement and idleness influenced the perception of the symptoms of Portuguese veterans, who became more attentive to their thoughts and surrendered to the memories of the past. With aging, war memories became stronger and physical disabilities allowed the search for professional help, taking Portuguese veterans to mental health services. Studies have shown that the aging process makes it difficult to determine the origin of symptoms and, therefore, the diagnosis of PTSD must be the result of a thorough evaluation. Considering the aging-related characteristics, in order to avoid diagnostic errors and delays in the treatment of patients, it is essential that health professionals are attentive to complaints and test results, but also to psychosocial factors.
As a qualitative and cross-sectional study, there are limitations that must be mentioned. First, the limited sample. The CPTTP covers a small part of Portuguese veterans who have sought professional help in recent years. However, although it is not considered a representative sample, the results are in line with the literature in the area. Second, the semi-structured interviews were designed with the aim of addressing other aspects of war trauma, which may have left out factors that would have been highlighted if aging were the focus of the survey. Finally, the literature review on psychological trauma was comprehensive, but not systematic. Despite these limitations, this study revealed another side of the Colonial War, and the influence of aging on the trauma process.
Although the interviews did not focus on aging, aging-related problems were the factors that made this study possible. Aging as a possibility mechanism of coping with trauma is an interesting topic, and in the case of war trauma it raises a wide range of questions about personality traits, the stigma of mental illness, society's expectations, and the need to deal with problems kept silent for so long. Further studies are needed, with larger samples and longitudinal design in order to differentiate the normal symptoms of aging from those resulting from traumatic experiences. Randomized clinical trials can be an effective means of determining the factors involved in the trauma and aging processes.