- Research article
- Open Access
- Open Peer Review
Fear of nuclear war increases the risk of common mental disorders among young adults: a five-year follow-up study
© Poikolainen et al; licensee BioMed Central Ltd. 2004
- Received: 27 November 2003
- Accepted: 30 September 2004
- Published: 30 September 2004
Evidence on the relation between fear of war and mental health is insufficient. We carried out a prospective cohort study to find out whether fear of nuclear war is related to increased risk of common mental disorders.
Within two months preceding the outbreak of Persian Gulf War in January 1991, 1518 adolescents [mean age 16.8 years, SD 0.9] filled in a self-administered questionnaire. Of the 1493 respondents, 47% gave their written informed consent to participate in the follow-up study. There were no material differences between those who chose to respond anonymously and those who volunteered to give their name and address for the follow-up study. In 1995, the response to the follow-up questionnaire was 92%. Common mental disorders were assessed by 36-item version of the General Health Questionnaire [GHQ]. A score 5 or higher was considered to indicate caseness. We excluded 23 cases which had used mental health services in the year 1991 or earlier and two cases with deficient responses to GHQ. This left 626 subjects for analysis [400 women].
After adjusting for significant mental health risk factors in logistic regression analysis, the risk for common mental disorders was found to be significantly related to the increasing frequency of fear for nuclear war, high scores of trait anxiety and high scores of immature defense style. Elevated risk was confined to the group reporting fear of nuclear war once a week or more often [odds ratio 2.05; 95% confidence interval 1.29–3.27].
Frequent fear of nuclear war in adolescents seems to be an indicator for an increased risk for common mental disorders and deserves serious attention.
- Trait Anxiety
- Common Mental Disorder
- General Health Questionnaire
- General Health Questionnaire Score
- Defence Style
Risks of war and terrorism are threatening our health, both directly in actual life and also indirectly by the increasingly violent content of video games and other forms of entertainment. How does this affect mental health? Earlier during the cold war period, fear of war was found to be common among adolescents, and more prevalent among girls than boys [1–5]. Little is known about the influence of fear of war on mental health of adolescents. On one hand, it has been argued that worrying about nuclear war is related to positive aspects of mental health . On the other, fear of nuclear war has been found to associate with several measures of psychological distress in cross-sectional studies [4, 7–9]. To our knowledge, no follow-up studies have been published. However, high perceived risk of nuclear war might be related not only to transient psychological distress but also to more long-term mental disorder among vulnerable adolescents. We have followed up a cohort of adolescents first studied during the period of increasing international tension before the outbreak of the Persian Gulf War in January 17, 1991, and report here on the relation between fear of nuclear war at that time and incident common mental disorders five years later.
Between December 4, 1990, and January 16, 1991, 1518 adolescents from five high schools in Helsinki and five in Jyväskylä, Finland, representing a cross-section of school entrance requirement levels filled in a self-administered questionnaire during an ordinary classroom hour. Of the 1493 respondents, 709 (47%) gave their written informed consent to participate in the follow-up study. There were no significant differences between those who chose to respond anonymously and those who volunteered to give their name and address for the follow-up study with respect to baseline predominance of mature, immature or neurotic defence styles, trait anxiety, trait depression, the number of positive and that of negative life-events, self-esteem, coherence of future, or availability of social support. Anonymous respondents reported less somatic symptoms than those who gave informed consent to follow up. The absolute difference in the symptom score was not very large, however. The mean scores (SE) were 21.8 (0.22) and 22.8 (0.29) for men, 24.2 (0.23) and 25.0 (0.23) for females, respectively . Of the 709 subjects who gave signed consent, two were excluded from the follow-up due to deficient completion of the baseline questionnaire, and one died. The sample eligible for follow-up comprised 706 subjects. In 1995, the response to the follow-up questionnaire was 92%. Design and sample has been described earlier in more detail .
We excluded 23 cases who reported having used mental health services in the year 1991 or earlier and two cases with deficient responses to GHQ. This left 626 subjects for analysis, of whom 400 were women. At the baseline, the age range was 15 to 19 years (mean 16.8, SD 0.9).
Baseline examination in 1990
Frequency of fearing nuclear war during past four weeks (scores in parentheses) was assessed by a question with six options: not at all (0), less than once a week (0.5), 1–2 times a week (6), 3–5 times a week (16), almost daily (22) and daily (28).
The Defence Style Questionnaire (DSQ) consisted of 72 statements assessing possible conscious derivatives of 20 defences. It is based on the 88-item version of the Bond's Defense Style Questionnaire . Andrews et al.  reviewed the items to make the labelling consistent with the Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised, DSM-III-R) by the American Psychiatric Association . The defence styles were grouped into three levels: mature, neurotic, and immature defence styles. Individual defences are (mature:) sublimation, humour, anticipation, suppression, (neurotic:) undoing, altruism, idealisation, reaction formation, (immature:) projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalisation and somatization .
The Trait Anxiety Inventory was used to measure trait anxiety as a general tendency of feeling . Trait anxiety is used to screen neurotic anxiety problems and vulnerability for anxiety disorders.
Depressive trait  was assessed by questions following the style, scoring and response options of the Trait Anxiety Inventory. The questions dealt with a general tendency to have obvious depressive mood.
An abbreviated version of the Life Event Checklist  consisted of 20 defined life events considered to be the most common ones among Finnish adolescents and of four open items. Number of negative and that of positive life events was analysed.
The Somatic Symptom Score is an abbreviated 14-item version of an original 18-item score used earlier in Finnish studies on adults and adolescents . The 14 items comprised physical symptoms common in adolescence but only rarely associated with a physical disease, such as headache, abdominal pains, fatigue or weakness, lack of energy, diarrhoea or irregular bowel function. Respondents were asked "Have any of the following symptoms bothered you, and how often during the last six months?" The response options were never, sometimes, quite often, and often or continuously.
The self-esteem scale by Rosenberg  consists of ten items measuring the self acceptance aspect of self-esteem. Rosenberg relates positive self-esteem to many social and interpersonal consequences such as less shyness and depression, more assertiveness, and more extra-curricular activities. The response scorings were inverted so that a high total score indicated high self-esteem.
Coherence of future was measured by three items (no. 11, 22 and 27) from the Sense of Coherence Scale  relating to the meaningfulness and manageability of one's own personal future.
Social support was ascertained by asking "Do you have a significant other person with whom you may discuss your personal activities and problems?".
Social class assessment was based on father's occupation or on mother's occupation when the father was not living in the family of the adolescent. Use of the City of Helsinki Social Group Classification divided the sample into four categories: (i) professionals, managers and higher administrative or clerical employees, (ii) lower clerical employees, (iii) skilled workers, and (iv) unskilled workers.
Follow-up examination in 1995
The General Health Questionnaire (GHQ) [21, 22] is a measure for common mental disorders . It is a widely used and well-validated self-administered test. The GHQ focuses on discontinuities in normal functioning and the experience of new phenomena of a distressing nature. It covers feelings of strain, depression, inability to cope, anxiety-based insomnia, lack of confidence and other psychological problems . GHQ has been found to be very accurate at detecting anxiety and depression with anxiety . We employed the 36-item version, which is derived from the original 60-item questionnaire by excluding items measuring somatic symptoms . We applied the standard scoring method, counting the two highest response options as pathological. As commonly done earlier [27, 28], a score 5 or higher was considered to indicate common mental disorders. Treatment contacts with mental health professionals before the follow-up examination were ascertained in 1995.
Data were analysed with SPSS 11. Logistic regression was used to model the relationship between assumed risk factors and high GHQ score [5 or more]. Initial models included sex, social class, availability of social support [dichotomous variables], age, self-esteem, coherence of future, number of positive and that of negative life-events, neurotic, immature and mature defence styles, trait anxiety, trait depression, somatic symptom score [continuous variables]. Second-level interactions were studied by adding product terms to the models. Because of missing values, the number of cases was lower than 626 in some analyses.
Only significant [p < 0.05] confounders remained in the final models. To evaluate relative risk, fear of nuclear war and the significant confounders were categorised and odds ratios with their 95% confidence interval were estimated.
Logistic regression analysis, General Health Questionnaire score on unit change in all potential explanatory variables (n = 607)
Frequency of fearing nuclear war
Social class II
Social class III
Social class IV
Number of positive life events
Number of negative life events
Coherence of future
Mature defense style
Neurotic defense style
Immature defense style
Somatic symptom score
Logistic regression analysis, General Health Questionnaire score on unit change in significant explanatory variables (n = 621)
Frequency of fearing nuclear war
Immature defense style
Logistic regression analysis, General Health Questionnaire (GHQ) score on categorized significant explanatory variables (n = 626)
Number of cases
Odds ratio (95% confidence interval)
GHQ ≥ 5
Fear of nuclear war
less than once a week
once a week or more
≥ 32 < 38
Immature defense style
≥ 3.3 < 4.0
A positive association was found between frequent fear of nuclear war at baseline examination and common mental disorders among adolescents in a five-year follow up. The temporal order of exposure and response suggest that this relation could be causal. Our measure for common mental disorders, the GHQ, rates recent change (within the past month) in mental health at follow-up examination, i.e. incident problems. False positives might have included individuals with mild or transient psychological disturbance, which should have biased the association towards the null. Still, the relation was significant. However, some caveats should be discussed.
Could the association be due to some confounding factors? We controlled for several potential confounders. Those, known to increase or decrease the risk of mental disorders, included neurotic, immature and mature defence styles [29–31], trait anxiety [32, 33], trait depression [34, 35], life-events [36, 37], somatic symptom score , self-esteem , coherence of future [40, 41] and social support [42, 43]. Nevertheless, on one hand there always remains the possibility of bias due to some unknown or otherwise not controlled variable, and, on the other, one cannot be sure that such a variable would also be an actual confounder in the data set at hand. In our data, the close correspondences of unadjusted and adjusted risk ratios suggest that no material residual confounding remained .
Adolescents not willing to answer a mental health questionnaire may have more mental health risk factors and problems than participants. However, we found no significant differences between the anonymous and identifiable respondents in possible mental health risk factors analysed except that anonymous respondents reported slightly more somatic symptoms than those who identified themselves. The difference was, however, small in absolute terms (data presented above in section on design). This suggests that subjects with high risk were not underrepresented in the present sample.
The degree of perceived threat of nuclear war may depend on several factors, such as (i) actual presence and size of the nuclear weapon arsenal, (ii) actual political tensions and threats, (iii) media coverage of the former, (iv) mental, conscious and unconscious processing of information, and (v) psychological developmental influences specific to adolescence.
Part of the fear may be based on realistic evaluation of the threat. Our baseline examination was carried out within two months before the outbreak of the Persian Gulf War in January 1991 and before the reductions in nuclear weapon arsenals in the United States and in Russia started. A quote from a novel describing the life experience of one teen-age girl during the pre-detente period may be illustrative:
"One was obliged to think about something important. One was obliged to think about the crisis between China and Soviet Union. A war could break out, the World War III and nuclear fallout would burn everything. The familiar fear for war pressed me inside so that it was difficult to breathe."
Laura Honkasalo. Sinun lapsesi eivät ole sinun. Jyväskylä: Gummerus, 2001, p. 132.
But similar experiences were not unknown among boys either, as witnessed by a seasoned cook from New York:
"I grew up thinking the Big One could come at any moment, and this country – or fear of it, the way my country reacted to the threat – radicalized, marginalized, and alienated me in ways that still affect me."
Alan Bourdain. A cook's tour in search of the perfect meal. London: Bloomsbury, 2001. p. 80.
Widespread media coverage on any potential danger may bring about considerable increase in perceived fear . Mass media have been found to be the most important source of information about the issue of nuclear war among adolescents in Finland .
Perceptions of the threat of nuclear war as well as other dangers are processed mentally. Conscious or unconscious intentions are often projected to or mixed with dangerous external events, and they may distort the association between the actual threat of war and perceived fear. There is growing evidence that violent films and video games may trigger fear, aggression and violence among adolescents vulnerable to such content , and perceived fear of nuclear war might cause mental distress in vulnerable adolescents in similar vein.
Studies on the prevalence of fearing or worrying about nuclear war during periods of low political tension suggest that this phenomenon is common in adolescence and disappears or at least diminishes later in life . Cognitive maturation and lessening of egocentrism seem to explain why fears with a major irrational component decrease from early adolescence to adulthood .
Global threats may vary in time as well as in their appraisal. In addition to old risks of nuclear war and aircraft hijacking, international terrorism and biological warfare loom at present. How should we handle these risks? We might inquire into the fears of our patients, appraise the risks realistically, point out that widespread media coverage tends to exaggerate the risks, and, as Durodié and Wessely  point out, suggest that we should not become victims of our fears.
A clear positive association was found between fear of nuclear war and common mental disorders among adolescents. Fear of nuclear war may either be a risk indicator produced by an underlying vulnerability to psychopathological process or have a more direct causal role in the onset of mental disorder among adolescents. In either case, frequent fear of nuclear war in adolescence seems to be an indicator for an increased risk for common mental disorders that deserves serious attention.
We thank the men and women who completed the study questionnaires. We also thank Riitta Kanerva who contributed to the planning of the baseline examination and Tuuli Pitkänen for participating in the planning, data collection and data management of the follow-up examination. This study was partly funded by the Medical Research Council of the Academy of Finland. We are grateful for the constructive comments from the reviewers.
- Solantaus T, Rimpelä M, Taipale V: The threat of war in the minds of 12–18-year-olds in Finland. Lancet. 1984, 1: 784-5. 10.1016/S0140-6736(84)91289-3.View ArticlePubMedGoogle Scholar
- Chivian E, Robinson JP, Tudge JR, Popov NP, Andreyenkov VG: American and Soviet teenagers' concerns about nuclear war and the future. New Engl J Med. 1988, 319: 407-13.View ArticlePubMedGoogle Scholar
- Stillion JM, Goodrow H, Klingman A, Loughlin M, Morgan JD, Sandsberg S, Walton M, Warren WG: Dimensions of the shadow: children of six nations respond to the nuclear threat. Death Studies. 1988, 12: 227-251.View ArticleGoogle Scholar
- Hamilton SB, van Mouwerik S, Oetting ER, Beauvais F, Keilin WG: Nuclear war as a source of adolescent worry: relationships with age, gender, trait emotionality, and drug use. J Soc Psychol. 1988, 128: 745-763.View ArticlePubMedGoogle Scholar
- Nurmi JE: Experience of the threat of war among Finnish adolescents: effects on thinking about the future, and comparison of methods. Med War. 1988, 4: 199-210.View ArticlePubMedGoogle Scholar
- Tizard B: Old and new paradigms: research on young people's response to the nuclear threat. J Adolescence. 1989, 12: 1-10. 10.1016/0140-1971(89)90085-7.View ArticleGoogle Scholar
- Solantaus T, Rimpelä M: Mental health and the threat of nuclear war: a suitable case for treatment?. Int J Mental Health. 1986, 15: 261-75.View ArticleGoogle Scholar
- Thompson J: The psychosocial aspects of nuclear threat and nuclear war: analogies from disaster research. In: Effects of Nuclear War on Health and Health Services. Report of the WHO Management Group on the follow-up of resolution WHA36.28. Fortieth World Health Assembly, provisional agenda item 30. World Health Organization A40/11. 18 March 1987 [Mimeographed]Google Scholar
- Poikolainen K, Kanerva R, Lönnqvist J: Threat of nuclear war increases anxiety and psychosomatic symptoms among adolescents. Eur Child Adolesc Psychiatry. 1994, 3: 46-51.View ArticleGoogle Scholar
- Poikolainen K, Aalto-Setälä T, Marttunen M, Tuulio-Henriksson A, Lönnqvist J: Predictors of somatic symptoms: a 5-year follow-up of adolescents. Arch Dis Childhood. 2000, 83: 388-92. 10.1136/adc.83.5.388.View ArticleGoogle Scholar
- Bond MP, Vaillant JS: An empirical study of the relationship between diagnosis and defense style. Arch Gen Psychiatry. 1986, 43: 285-8.View ArticlePubMedGoogle Scholar
- Andrews G, Pollock C, Stewart G: The determination of defence style by questionnaire. Arch Gen Psychiatry. 1989, 46: 455-60.View ArticlePubMedGoogle Scholar
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 1987, Washington, DC: APA, 3Google Scholar
- Tuulio-Henriksson A, Aalto-Setälä T, Poikolainen K, Lönnqvist J: Psychological defense styles from adolescence to young adulthood: a follow-up study. J Am Acad Child Adolesc Psychiatry. 1997, 36: 1148-53. 10.1097/00004583-199708000-00024.View ArticlePubMedGoogle Scholar
- Spielberger CD, Gorsuch RL, Lushene RE: STAI Manual for the State-Trait Anxiety Inventory. 1970, Palo Alto: Consulting Psychologists PressGoogle Scholar
- Broadman K, Erdmann AJ, Wolff HG: Cornell Medical Index Health Questionnaire, Manual [Revised 1956]. 1956, New York: Cornell University Medical CollegeGoogle Scholar
- Johnson JH, McCutcheon SM: Assessing life stress in older children and adolescents: preliminary findings with the Life Events Checklist. In: Stress and anxiety. Edited by: Sarason IG, Spielberger CD. 1980, Washington, D.C.: Hemisphere Publishing, VII: 111-125.Google Scholar
- Aro S: Stress, morbidity, and health-related behaviour. A five-year follow-up study among metal industry employees. Scand J Soc Med. 1981, 25 Suppl: 1-130.Google Scholar
- Rosenberg M: Society and the adolescent self-image. 1965, Princeton, NJ: Princeton University PressView ArticleGoogle Scholar
- Antonovsky A: Unraveling the mystery of health: how people manage stress and stay well. 1988, San Francisco: Jossey BassGoogle Scholar
- Goldberg DP: The detection of psychiatric illness by questionnaire. Institute of Psychiatry, Maudsley Monographs. 1972, London: Oxford University PressGoogle Scholar
- Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, Rutter C: The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med. 1997, 27: 191-7. 10.1017/S0033291796004242.View ArticlePubMedGoogle Scholar
- Weich S, Lewis G: Poverty, unemployment and common mental disorders: population based cohort study. BMJ. 1998, 317: 115-9.View ArticlePubMedPubMed CentralGoogle Scholar
- Wall TD, Bolden RI, Borrill CS, Carter AJ, Golya DA, Hardy GE, Haynes CE, Rick JE, Shapiro DA, West MA: Minor psychiatric disorder in NHS trust staff: occupational and gender differences. Br J Psychiatry. 1997, 171: 519-523.View ArticlePubMedGoogle Scholar
- McDowell I, Newell C: Measuring health: a guide to rating scales and questionnaires. 1987, New York: Oxford University PressGoogle Scholar
- Aalto-Setälä T, Poikolainen K, Tuulio-Henriksson A, Marttunen M, Lönnqvist J: Predictors of mental distress in early adulthood: a five-year follow-up of 709 high-school students. Nord J Psychiatry. 2002, 56: 121-5. 10.1080/080394802753617935.View ArticlePubMedGoogle Scholar
- Tarnopolsky A, Hand DJ, McLean EK, Roberts H, Wiggins RD: Validity and uses of a screening questionnaire (GHQ) in the community. Br J Psychiatry. 1979, 134: 508-515.View ArticlePubMedGoogle Scholar
- Huppert FA, Gore M, Elliott BJ: The value of an improved scoring system (CGHQ) for the general health questionnaire in a representative community sample. Psychol Med. 1988, 18: 1001-1006.View ArticlePubMedGoogle Scholar
- Bond MP, Vaillant JS: An empirical study of the relationship between diagnosis and defense style. Arch Gen Psychiatry. 1986, 43: 285-8.View ArticlePubMedGoogle Scholar
- Pollock C, Andrews G: Defense styles associated with specific anxiety disorders. Am J Psychiatry. 1989, 146: 1500-1502.View ArticlePubMedGoogle Scholar
- Soldz S, Vaillant GE: A 50-year longitudinal study of defense use among innner city men: a validation of the DSM-IV defense axis. J Nerv Ment Dis. 1998, 186: 104-111. 10.1097/00005053-199802000-00006.View ArticlePubMedGoogle Scholar
- Angst J, Vollrath M: The natural history of anxiety disorders. Acta Psychiatr Scand. 1991, 84: 446-52.View ArticlePubMedGoogle Scholar
- Gustavsson JP, Pedersen NL, Åsberg M, Schalling D: Origins of individual differences in anxiety proneness: a twin/adoption study of the anxiety-related scales from the Karolinska Scales of Personality [KSP]. Acta Psychiatr Scand. 1996, 93: 460-469.View ArticlePubMedGoogle Scholar
- Kandel DB, Davies M: Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry. 1986, 43: 255-262.View ArticlePubMedGoogle Scholar
- Gotlib IH, Lewinsohn PM, Seeley R: Symptoms versus a diagnosis of depression: differences in psychosocial functioning. J Consult Clin Psychol. 1995, 63: 90-100. 10.1037//0022-006X.63.1.90.View ArticlePubMedGoogle Scholar
- Goodyer IM, Kolvin I, Gatzanis S: The impact of recent undesirable life events on psychiatric disorders in childhood and adolescence. Br J Psychiatry. 1987, 151: 179-84.View ArticlePubMedGoogle Scholar
- Brown GW: Life events and affective disorder: replications and limitations. Psychosom Med. 1993, 55: 248-259.View ArticlePubMedGoogle Scholar
- Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV 3rd, Brody D: Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994, 3: 774-9. 10.1001/archfami.3.9.774.View ArticlePubMedGoogle Scholar
- King CA, Naylor MW, Segal HG, Evans T, Shain BN: Global self-worth, specific self-perceptions of competence, and depression in adolescents. J Am Acad Child Adolesc Psychiatry. 1993, 32: 745-52.View ArticlePubMedGoogle Scholar
- Petrie K, Brook R: Sense of coherence, self-esteem, depression and hopelessness as correlates of reattempting suicide. Br J Clin Psychol. 1992, 31: 293-300.View ArticlePubMedGoogle Scholar
- Suominen S, Helenius H, Blomberg H, Uutela A, Koskenvuo M: Sense of coherence as a predictor of subjective state of health: results of 4 years of follow-up of adults. J Psychosom Res. 2001, 50: 77-86. 10.1016/S0022-3999(00)00216-6.View ArticlePubMedGoogle Scholar
- Stansfeld SA, Gallacher JE, Sharp DS, Yarnell JW: Social factors and minor psychiatric disorder in middle-aged men: a validation study and a population survey. Psychol Med. 1991, 21: 157-67.View ArticlePubMedGoogle Scholar
- Viinamäki H, Kontula O, Niskanen L, Koskela K: The association between economic and social factors and mental health in Finland. Acta Psychiatr Scand. 1995, 92: 208-13.View ArticlePubMedGoogle Scholar
- Greenland S, Robins JM: Identifiability, exchangeability, and epidemiological confounding. Int J Epidemiol. 1986, 15: 413-419.View ArticlePubMedGoogle Scholar
- Slovic P: Perception of risk. Science. 1987, 236: 280-285.View ArticlePubMedGoogle Scholar
- Villani S: Impact of media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001, 40: 392-401. 10.1097/00004583-200104000-00007.View ArticlePubMedGoogle Scholar
- Gleisner JW: The threat of nuclear war: a study of some of the psychological effects on adults. Med War. 1986, 2: 7-17.View ArticlePubMedGoogle Scholar
- Elkind D: Egocentrism in adolescence. Child Dev. 1967, 38: 1025-34.View ArticlePubMedGoogle Scholar
- Durodié B, Wessely S: Resilience or panic? The public and terrorist attack. Lancet. 2002, 360: 1901-2. 10.1016/S0140-6736(02)11936-2.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/4/42/prepub
This article is published under license to BioMed Central Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.