Turkish Cypriot veterans ’ and non-ending psychological war : Post-traumatic stress disorder , suicidal ideations , and hopelessness

The aim of the current study was to investigate the severity and presence of PTSD symptoms and the relationship between PTSD and suicidal ideation and hopelessness level among Turkish Cypriot war veterans who were in 1958, 1963, and 1974 Cyprus wars with Greek Cypriots. It was hypothesized that, PTSD symptoms increase the risk of suicidal behaviour and the level of hopelessness. The sample of this study formed from 61 Turkish Cypriot veterans who were fought in 1958, 1963, and 1974 Cyprus wars with Greek Cypriots. There are 4 section of this study. They are respectively, Sociodemographic Form which was structured by researcher to get general information, ClinicianAdministrated PTSD Scale (CAPS) which diagnoses the PTSD criteria’s, Beck Hopelessness Scale (BHS) to determine the hopelessness level, and Suicidal Behavior Scale (SBS) to investigate the suicidal ideations. The data were gathered from veterans who live in Nicosia, Famagusta, and Kyrenia. The results of this study as it was expected showed that, 86,9% of Turkish Cypriot veterans showed higher level of PTSD symptoms and relatedly they have higher suicidal ideations or attempts and hopelessness. It was indicated that, even after 40 years of war, the effects of PTSD could be seen on veterans.


Introduction
The history of Post-Traumatic Stress Disorder comes from 1000 B.C. when the Egyptian combat veteran who called as Hori, wrote his feelings before going into battle.In 1941, Abram Kardiner defined trauma as injury.The reason is, when it is handled from psychological side, it is an adaptation injury which causes individuals to be spoiled, disorganized, or shattered.In addition to this, he mentioned that it is an injury to the ego and explained that, trauma is occurred because of the sudden and overwhelming traumatic situations such as fatigue, a sudden pain, a slight accident, a fractured skull, arteriosclerosis, or a brain tumour (Kardiner, 1941).
During World War I, shell shock which is explained as war crisis was observed by psychiatrists and they developed first aid to recover the level of weeping, screaming, memory loss, physical paralysis, and lack of responsiveness on soldiers (Ringer & Brandell, 2011).
Additionally, Vietnam War was very effective on soldiers that trigger to develop chronic problems such as capacity to cope with, and functioning, and social life.As those symptoms increased, Lifton and Shatan organized 'rap groups' which all occurred by Vietnam veterans and identified 27 common symptoms of traumatic neurosis.These symptoms were also included in the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Ringer & Brandell, 2011).
After Vietnam War, veterans showed severe symptoms.Therefore, psychological trauma, first, was identified on Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as Post-Traumatic Stress Disorder in 1980.The important key concept for this disorder was defined as; it etiologically occurs but not the reason of inherited, such as traumatic neurosis.People who are diagnosed as PTSD have a traumatic event such as natural disaster, atomic bombings, war, rape, the Nazi Holocaust or human-made disasters.In addition, these traumatic events are different from stressors such as divorce, failure or serious illness.The reason is, people who expose to a traumatic event, their ability for adaptation is overwhelmed.The PTSD criterion in DMS-III was revised in DSM-III-R in 1987, DSM-IV in 1994, DSM-IV-TR in 2000, and DSM-V in 2013 (Amir, Kaplan & Kotler, 1996;Koroglu, 2013).
In DSM-5, PTSD is not stated under the Anxiety Disorder, it is categorized under the Traumaand-Stressor-Related-Disorders.A person his or herself can be exposed to traumatic event or heard the close relative is exposed to be affected.. Unpleasant details about the event can be reexperienced highly, but this event mustn't be heard from a television, media, or film.The term of sexual violation were added instead of threat to the physical integrity of self or others.The criterion B is about re-experience of traumatic event and it was changed to only one symptom is enough to be diagnosed for criterion B. Additionally, the triggered involuntary, ruminations, and flashbacks is indicated as a dissociation (Koroglu, 2013;Sar, 2010).
The criterion C defines avoidance of stimulus.This criterion states the symptom of avoidance from the relative events of the stimulus.The other symptoms such as avoided activities, diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, and sense of foreshortened future were moved to the criterion D. Newly, event related self-blame and high level of fear, despair, and dread were added into the D criterion.Into the E criterion, angry feelings which were in the D criterion were changed as aggressive feelings and moved to the E criterion.Newly, not avoiding from harming the self, instead harming the self of symptom was added into the criterion E (Koroglu, 2013;Sar, 2010).
Generally, PTSD is a typical mental health disorder which is occurred by the reason of direct experience or witnessing the life-threatening events.Direct experiences or witnessing lifethreatening events cause for harm on ego which it couldn't overcome that stress easily.Exposing to a traumatic event from television, radio or even hearing others who expose to a trauma could be reason to Post-Traumatic Stress Disorder.The effectiveness of traumatic events on people is related with the intensity of that event.However, a person's strength in front of that traumatic event depends on his or her hereditary, developmental features, the strengths of ego and his or her preparedness in front of such an event.Briefly, the effect of PTSD could be change by person to person (Ozturk & Ulusahin, 2011).
The reason of war history, from generation to generation the citizens of Cyprus had been affected from the impression of war.Therefore, as causalities of physical loss could be seen, psychological effects could be found on Cypriots as well.Veterans, their partner and children are still under the effect of war.During collecting information from Turkish Cypriot war veterans, most of them indicated that, they are still under the effect of war.Thus, Post-Traumatic Stress Disorder which occurs because of trauma could be comprised on the citizens of Cyprus.Some people can be affected from a trauma lower level, some people can be affected seriously whereas some people can be affected positively which leads to positive personal and psychosocial running in their lives (Blix, Hansen, Birkeland, Nissen & Heir, 2013).
Cyprus was separated into two parts as South and North Cyprus.Now, in South part Greek Cypriots live and in North part Turkish Cypriots live in.Cypriot citizens who were living in the South Cyprus before 1974 were displaced to North Cyprus.In Northern Cyprus studies with Turkish veterans and citizens the findings signed that displaced citizens and veterans showed higher level of PTSD than non-displaced individual The prevalence range of PTSD level was between 3,5% and 86% among displaced individuals (Ergun, Cakici, & Cakici, 2008).In another study, which was done in 2015 in Northern Cyprus with Turkish veterans, it was indicated that 48% of Turkish Cypriot veterans and 6% of Erenkoy Turkish Cypriot veterans showed the PTSD symptoms.These results stated that, even after 40 years of war history, the level of PTSD symptoms remains the same (Simsek & Cakici 2015).
Lots of studies about PTSD state that, PTSD has an impact on disability, work related impairment, somatic disturbances, decreasing the quality of life, suicidality, medical illness, spouse or partner distresses, impaired intimacy, and social dysfunction.Marshall and his colleagues (2001) was investigated the association between the comorbid symptoms and PTSD.That is, it was aimed to examine the relationship among PTSD symptoms, level of disability, and comorbid psychiatric disorders.The results show that, comorbid symptoms which are suicidal ideations, anxiety disorder, and major depressive disorder are associated with post-traumatic stress disorder highly.As it is stated, Post-Traumatic Stress Disorder has greater functional impairment on health-related quality of life.Richardson, Long, Pedlar, and Elhai (2010) conducted a research to investigate the impact of PTSD severity and depression on healthrelated quality of life (HRQoL) with 120 World War II and Korean War veterans and which PTSD symptoms cluster of re-experiencing, avoidance and hyper arousal are related with HRQoL.The results show that, PTSD has greater effect on HRQoL which represents the significant association between PTSD and HRQoL.In addition, when it has a negative effect on health, it also triggers social life such as social isolation (Richardson, Long, Pedlar, & Elhai, 2010).
Epidemiological studies indicate that, there is positive relationship between post-traumatic stress disorder which is diagnosed as anxiety disorder in DSM-IV and suicidal ideation and attempt.In a study which was conducted to assess whether there is any association between anxiety disorders (generalized anxiety disorder, agoraphobia, simple phobia, social phobia, panic disorder, and post-traumatic stress disorder) and suicidal ideation and attempt.The results indicated that, there is a positive association between suicidal ideation and attempts and PTSD (Sareen, Houlahan, Cox & Asmundson, 2005).Some of the symptoms of PTSD such as avoidance symptom cluster and re-experiencing are significantly associated with suicidal ideation.Lemaire and his colleague Graham (2010) indicated that PTSD has positive association with suicidal ideation and the symptoms of avoidance symptoms cluster and re-experiencing have positive relation with suicidal ideation (Lemaire and Graham, 2010, 235).
Hopelessness causes aggressive behaviours towards others or self-harm.Even hopelessness elevates the risk of attempting suicide and death.Besides psychological effects, hopelessness triggers physical health such as incident cancer.It is also positively correlated with anxiety and anxiety disorders.Hopelessness is a diagnostic symptom for depression on Diagnostic and Statistical and Manual of Mental Disorders-IV (DSM-IV).However, it is alone have an effect on people for psychological and physical health (Mair, Kaplan & Everson-Rose, 2012).
The aim of the current study was to investigate the severity and presence of PTSD symptoms and the relationship between PTSD and suicidal ideation and hopelessness level among Turkish Cypriot war veterans who were in 1958, 1963, and 1974 Cyprus wars with Greek Cypriots.It was hypothesized that, PTSD symptoms increase the risk of suicidal behaviour and the level of hopelessness.

Population and Sample
In this research, 61 Turkish Cypriot veterans, who were took place during the 1958, 1963 and 1974 wars zone in Cyprus.Participants are a member of The Turkish Resistance Organization.
The current study includes 61 Turkish Cypriot veterans, who battled with Greek Cypriots during 1958, 1963, and 1974 Cyprus wars.The participants' age range is between 58 and 87 and the mean age is 73.6±6.3.Age of initiation to military service was in age range between 11 and 34 and the mean score of age was calculated as 20.9±7.04.Also the years of being in military service was between 2 and 41 years with the mean score 11±7.04.

Instruments
In this study Socio-Demographical Information Form, Clinician-Administrated PTSD Scale (CAPS), Beck Hopelessness Scale (BHS), and Suicide Behaviour Scale (SBS) were used.

Socio-Demographic Information Form
This form was formed by the researcher to gather information about veterans, age, pre and post education level and pre and post marital status in between war and after.In addition to these variables veterans were asked whether they were exposed to a traumatic event and the type of trauma that they experienced.

Clinician-Administrated PTSD Scale (CAPS)
Clinician-Administrated PTSD Scale (CAPS) is a scale which is applied by clinicians to determine Post Traumatic Stress Disorder.CAPS was developed by Blake, Keane, Wine, Mora, Taylor & Lyons (1995) and its Turkish reliability and validity study was done by Aker, Ozeren, Basoglu, Kaptanoglu, Erol & Buran (1999).The CAPS is high standard PTSD scale which has 30 structured interview items that correspond to the DSM-IV (American Psychiatric Association 1994) criteria for PTSD.It is also able to be used to diagnose last past month, lifetime or past week for diagnosis PTSD.Additionally, questions assess 17 PTSD symptoms and their effects on social, occupational functioning, severity, frequency and intensity of five associated symptoms.
Test-retest reliabilities range from .77-.96 for three symptom clusters and .90-.98 for the 17item core symptom scale.Test-retest reliability (kappa) for PTSD diagnosis was .63,with 83% agreement.The global severity correlation was 0.89 and kappa is 1.0 (National Center of PTSD, 1995).

Beck Hopelessness Scale (BHS) (referans)
This scale was formed by Beck, et al. and occurred by 20 questions which were aimed to determine the level of hopelessness towards the future.Beck Hopelessness Scale is originated by 3 factors which are loss of motivation, emotions about future and expectations about future.The validity and reliability of this scale was done by Seber, et al.The reliability of this scale was found high significant (0.737, p < 0.001).The validity of this scale was found high significant as well (0.651, p < 0.001).The Cronbach alpha was found 0.86 (Seber, Dilbaz, Kaptanoğlu & Tekin, 1993).

Suicidal Behavior Scale (SBS)
This scale was formed by Linehan and Nilensen in 1981.From this scale, the minimum degree is 0 and the maximum degree is 14.The highest degree indicates a serious suicide behavior.The Turkish version of reliability and validity assessment was done by Bayam, Dilbaz, Bitlis, Holat, and Tuzer et al.The results showed that, the reliability and validity of this scale is high and the degree of Cronbach alpha was found as 0.73 (Bayam et al., n.d).

Procedure
All of the information and data was collected by face-to-face interviews from the member of The Turkish Resistance Organisation who live in Nicosia, Famagusta, and Kyrenia.Those veterans were fought in 1958, 1963, and 1974 Cyprus wars.The testing procedure was shaped as; assessing the traumatic events during the wars which are 1958, 1963, and 1974 and the effect of those traumas to the veterans' hope, suicidal ideation, and PTSD.

Results
In the effective sample, majority of veterans were not student while they were soldier 47,5%, (n꞊32) and 37,7% (n꞊23) of them were in the high school.70,5% (n꞊43) of veterans are the members of Turkish Resistance Organization, and 67,2% (n꞊41) of them was enrolled into this organization by their friends.Most of the Turkish Cypriot veterans were not injured during the war 77,0% (n꞊47).16,4% (n꞊10) of them were injured which required outpatient treatment and only 6,6% (n꞊4) of them were life threatening injured.Lots of the veterans were witnessed friend's injury during war 80,3% (n=49) and they are were their close friends 41,0% (n=25).
72,1% (n=44) of veterans were witnessed their friends' death during war and most of them 52,5% (n=32) were very prepared to be witnessed such events.Additionally, also lots of them 34,4% (n=21) were not prepared such events that occurred during war.29,5% (n=18) of them caused someone's death and 65,6% (n=40) expected to kill someone in the war time.Turkish Cypriot veterans were highly committed to the aim of war in Cyprus 88,5% (n=54).Most of the veterans aren't regret because of their behaviors that they did during war times 90,8% (n=55) and veterans who are regret because of their behaviors and had an impact of others during war times are very low 3,3% (n=2).1,6% (n=1) of veteran was exposed to non-sexual attack from his relative and 19,7% (n=12) of veterans were exposed to non -sexual attack by other people such as enemies.The results show that, none of them were exposed to sexual attack by close relatives or other people.29,5% (n=18) of veterans were exposed to be taken captured while 6,6% (n=4) of them were exposed to torture during war.
Most of the veterans 62,3% (n=38) were exposed to being starved.Most of the Turkish Cypriot veterans 75,4% (n=46) were affected from a traumatic event.Additionally 4,9% (n=3) of them were affected by being starved and 3,3% (n=2) of them were affected when their communication and transportation rights were violated during the war times.
A Pearson's Correlation was conducted to investigate the relationship between Post-Traumatic Stress Disorder Symptoms, the level of hopelessness, the risk of suicidal behavior.The results have shown that, there are positive correlation and it indicates that, as the number or PTSD symptoms increases, hopelessness level (r=0,426, p=0.01) and the risk of suicidal ideations increase (r=0,426, p=0,01).symptoms and age (r=0,317, p=0.013).
A Pearson's correlation was analyzed to examine the relationship between the number of Post-Traumatic Stress Disorder symptoms and hopelessness level.The results have indicated that, there is a positive correlation between number of PTSD symptoms and the hopelessness level.That is, while the number of PTSD symptoms increase, the level of hopelessness increase (p=0.001,r=0,426, N=61).A Pearson's correlation was conducted to investigate the association between the number of PTSD symptoms and suicidal behavior.The outcome of the study states that, there is a positive correlation between the number of PTSD symptoms and suicidal behavior.Therefore, this consequence points out that, the elevated number of PTSD symptoms trigger the suicidal behavior to increase (p=0.001,r=0,424, N=61).
In the present study, the mean score of witnessing friend's injury during war and hopelessness, suicidal behavior, and the existence of PTSD were compared by Independent Samples Test.It was found that there was statistically significant differences between the witnessing friends' injury during war and suicidal ideation (p=0.38).Furthermore, there is a significant difference between witnessing friends' injury during war and the existence of PTSD (p=0.016).These results show that, participants, who witnessed friend's injury during war has suicidal behavior and Post-Traumatic Stress Disorder.In the current study, the mean score of the number of PTSD symptoms and job were compared by One-Way ANOVA.The between subject effects show that there was a significant differences between the mean score of the number of PTSD symptoms and job (p=0.021).In the advance analysis with Tukey, it was found that, the differences were between government official and tradesman (p=0,37).These results indicate that, government officials who are under the assurance of government show lower PTSD symptoms than tradesman.In the present study, suicidal behavior and non-sexual attack by close relatives during war were compared by Chi-square.It was found that, there was a significant difference between suicidal behavior and non-sexual close relatives (p=0.008).Veterans who were exposed to nonsexual attack during war have suicidal ideation.
In the current study results, the number of PTSD symptoms and non-sexual attack by close relatives during war were compared by Chi-square.It was found that, there was a significant difference between the number of PTSD symptoms and non-sexual close relatives (p=0.008).Veterans who were exposed to non-sexual attack during war more PTSD symptoms.
The number of PTSD symptoms and exposing starved during war were compared by Chisquare.It was found that, there was a significant difference between the number of PTSD symptoms and exposing starved during war (p=0.00).The results indicated that, Turkish Cypriot veterans, who were exposed to be starved because of the war situations, PTSD levels are higher.

Discussion
The aim of the current study was to examine the presence and severity of Post-traumatic Stress Disorder and the related suicidal behavior and hopelessness level among Turkish Cypriot veterans who conflicted during 1958, 1963, and 1974 Cyprus war with Turkish Greek Cypriots.
The results of this study as it was expected showed that, Turkish Cypriot veterans who were battled during 1958, 1963, and 1974 Cyprus wars showed higher level of PTSD symptoms and relatedly they have higher suicidal ideations or attempts and hopelessness.This means that, the level of PTSD increases the risk of suicidal behavior and the level of hopelessness.Elevated suicidal behavior among veterans is associated with PTSD diagnosis and additionally, hopelessness which is also the symptom of depression is higher level when there is stronger PTSD (Panagioti, Gooding & Tarrier, 2012).
In this study, there is a positive correlation between the number of PTSD symptoms and suicidal ideation and the number of PTSD symptoms and hopelessness.These results indicate that, the elevated presence of PTSD symptoms lead to the greater suicidal ideations among veterans.Additionally, veterans who have more PTSD symptoms show severe hopelessness.The literature also shows that, elevated severity of PTSD increases the risk of completed suicide (Gradus, Qin, Lincoln, Miller, Lawler, Sorensen & Lash, 2009).
Other studies which was done in Northern Cyprus with Turkish veterans show the similar results with these results.In one study, which was done in 2015, indicated that higher level of PTSD on Erenkoy veterans (Simsek & Cakici, 2015).Another study states that, displaced individuals from South Cyprus showed higher level of PTSD than non-displaced participants (Ergun et al., 2008).Additionally, both of these study's results strengthen the fact that, even after 40 years of wars, the effect of PTSD symptoms still remains.
The current findings also underscore that, 86,9% of veterans diagnosed the criteria of PTSD whereas veterans, who battled in Vietnam war, have the 80% of high risk of PTSD..This result indicates that most of the veterans still have the effects of war.Additionally, veterans have these symptoms over 41 years that the war finished.In contrast with this study's results, the veterans who were in Iraq war, only 25% of them have PTSD symptoms and Vietnam veterans have the PTSD symptoms since 40 years (Goodson, Helstrom, Halpern, Ferenschak & Gillihan, 2011).As a support of these results, Durai et al. (2011) indicates that, PTSD symptoms insist 65 years after trauma (Durai, Chopra, Coakley, Llorente, Kirchner, Cook & Levkoff, 2011).This results show that, PTSD symptoms even last over 40 years.
It was expected that, PTSD symptoms, suicidality, and hopelessness level are higher on veterans who had killing experiences than who hadn't.Previously, Maguen and his colleagues demonstrate that, PTSD and suicidal ideation are twice elevated on veterans who have killing experiences than who haven't (Maguen, Metzler, Bosch, Marmar, Knight & Neylan, 2012).In another study finding is consistent with the result of previous research that, the impression of killing someone during war increases the risk factor of suicidal ideation and self-harm which is also mediated by PTSD symptoms and depression (Maguen, Luxton, Skopp, Gahm, Reger, Metzler & Marmar, 2011).However in our study results, it was found that, killing during war doesn't have any effect on the severity and presence of PTSD, suicidal ideation and the level of hopelessness.
In addition, PTSD was found lower level on veterans who are older.This means that, while the age is increasing, the level of PTSD is decreasing.The data of other study findings support that, older age veterans have lower level of PTSD symptoms than middle age veterans (Frueh, Grubaugh, Acierno, Elhai, Cain & Magruder, 2007).In contrast to these findings, PTSD was found higher level on veterans, who experienced an traumatic event and diagnosed as PTSD.Additionally, similar to these findings, it was indicated that, Vietnam veterans, Hispanics and especially Puerto Rican showed higher level of PTSD symptoms (Durai, et al., 2011).
Nearly all of the Turkish Cypriot veterans had been exposed to traumatic events during Cyprus wars.One of those traumatic events was witnessing friends' injury.Results showed that, the existence of PTSD and suicidal behaviors have been shown on veterans who witnessed friends' injury during war.Additionally, results also indicated that, veterans who exposed nonsexual attacks during war time, they separately have elevated PTSD symptoms and suicidal behavior.Prigerson and his colleagues examined that, exposing to a traumatic grief which could be friends of suicide victims has an effect of suicidal ideation (Prigerson, Bridge, Maciejewski, Beery, Rosenheck, Jacobs, Bierhals, Kupfer & Brent, 1999;1995).After 15 years of terrorism, soldiers who exposed to those terrorist incidents, 29,6% of them still showed the PTSD symptoms and 16,6% of them showed depressive symptoms with the PTSD symptoms (Guloglu & Karaırmak, 2012).

Conclusion
Taken as a whole, this pattern of findings confirms that, Post-traumatic Stress Disorder has an influence on the risk of suicidal ideation and the level of hopelessness.As the literature indicates, veterans who experience PSTD have higher risk of suicidal behaviors and their hopelessness level is higher as well.Traumatic events that occur during war have a greater impact to increase the PTSD symptoms.The reason is, they still have re-experienced those traumatic events even after 40 years later from Cyprus war.As the results showed, 86,9% of Turkish Cypriot veterans have PTSD symptoms.Additionally, PTSD symptoms decrease while the age increases.To sum up, consistently with the literature, there is a significant relationship between PTSD and suicidal behavior and hopelessness.The education level doesn't have an impact on traumatic events.Higher educated and lower educated veterans show the similar level of PTSD symptoms.As a reason of this is that, they indicate that, veterans had exposed to haunted traumatic events.To illustrate, one of the veteran explained that, he still hears the blood smells around.Another of them indicated that, he saw death people whose faces were all ruined.These kinds of traumatic events doesn't related with education, because they are all effective incidents.
Although the war in Cyprus finished long time ago, psychological effects are still present.The psychological war is still going on in the minds' of Turkish Cypriot veterans.

Table 1 .
Correlation between Number of Post-Traumatic Stress Disorder Symptoms , Hopelessness Level Correlation was conducted to investigate the relationship between the number of PTSD symptoms, age, initiating veteran age, and time interval of being veteran.The consequences indicate that, there is a negative correlation between the number of PTSD

Table 2 .
The Comparison between the Mean Scores of Witnessing Friends' Injury during War and Hopelessness, Suicidal Behavior, and the Existence of Post-Traumatic Stress Disorder

Table 3 .
Comparison between the Mean Score of the number of Post-Traumatic Stress Disorder