MILITARY MEDICINE, 167, 5:427, 2002
Acute Stress Reactions after Submarine Accidents
Guarantor: Jarle Eid, PhD
Contributors: Jarle Eid, PhD; Bj0m Helge Johnsen, PhD
The aim of the present study was to explore contextual and
individual factors associated with acute stress reactions in
three Norwegian submarine crews exposed to different signif-
icant peacetime maneuver accidents. Approximately 2 to 3
weeks after the accidents, crew members completed the Cop-
ing Style Questionnaire, the General Health Questionnaire,
the Impact of Event Scale, and the Post-Traumatic Symptom
Scale. Although exposed subjects (N = 47) revealed more post-
traumatic stress symptoms than nonexposed crew members
on shore leave (N = 7), they showed less acute stress reactions
than survivors from a surface ship accident in the Norwegian
Navy. Inspection of individual cases revealed that 4% of the
exposed submariners showed high loads of acute stress symp-
toms. Unit cohesion and habitual coping styles emerged as
resilience factors, whereas previous exposure to critical in-
cidents and personal experience of not coping in the acci-
dent situation emerged as vulnerability factors, explaining
32% of the acute stress reactions reported by submarine
crew members.
Introduction
ubmarine duty is widely recognized as one of the most
S stressful and psychologically demanding forms of military
service. Salient stressors includeextremely smallworkand liv-
ing space, absence of day/night cues, confinement, isolation
from all interactions with the externalworld, monotony in rou-
tine, extended separationfrom family members, and prolonged
and potentially dangerous operational responsibilities. 1 Stillan-
other issue is the complicated and potentially hazardousnature
ofsubmarineescapeequipment and procedures, tragically dem-
onstratedin the case ofthe Russiannuclearsubmarine Kursk in
the BarentsSeain August2000.Oneconsequence ofthis highly
specialized workenvironment is that submariners have to pass
a rigorous selection and training program- to sustain optimal
performance in critical sttuations." Thus, it has been proposed
that submarines constitutes a specialized form ofhigh-reliabil-
ity military organization characterized by the careful selection
and training of personnel, highly specialized organizational
structures, and a unique organizational culture that reflects the
operational demands of submarine service.'
This unique and demanding work environment has led to
speculation about long-term negative health effects after sub-
marine service. However, follow-up studies of American and
Britishsubmarinershavenot revealed increasedmortality rates
or negative long-term effects on physical or mental health in
former submarine crew members.v" One possible explanation
for these findings is that the rigorous selection and training
procedures associated with submarine service have resulted in
morehomogeneous and hardy personality traits or coping strat-
The Royal Norwegian Naval Academy and University ofBergen, Bergen, Norway.
This manuscript wasreceived for review in July 2001 andwasaccepted for publi-
cation in October 2001.
Reprint & Copyright © byAssociation ofMilitary Surgeons ofU.S., 2002.
427
egies in the submarine population. Studies of successful sub-
marine personnel from the U.S. and South African navies have
revealed heterogeneous personality trait profiles that clustered
around the mean for other normal populations sampled': how-
Downloaded from https://academic.oup.com/milmed/article-abstract/167/5/427/4915768 by guest on 18 September 2018
ever, more than one-third of them obtained diagnostic scale
scores indicating higher levels of antisocial, obsessive-compul-
sive, or avoidant personality traits'.
Theseresults mightindicatethat habitual coping stylescould
playa moresignificant rolein successful adaptation to subma-
rine life than certain personality traits. Studies of Norwegian
submarine crew members have revealed that factors such as
interpersonal orientation, achievement motivation, and habit-
ual coping strategieswere predictors ofcoping during long and
stressfulmissions." Together, these findings couldindicate that
specific personality traits, habitual coping strategies, and inter-
personalbehavior couldexplain howsubmarine crew members
are able to adapt to extreme conditions and cope with chronic
stress in low-intensity situations over longperiods oftime. 1,4,7
However, littleis known about acute stress reactionsin sub-
marinecrewmembers afterexposure to severe stressors such as
traumatic events. With the exception of a Russian study of
social adjustment in submarinecrewmembers from the Komso-
molets disaster" (a Russian atomic submarine that was ship-
wrecked after an accidentin the North Sea in 1989), there have
been no systematic studies ofacute stress reactionsand mental
health problems in submarine crewmembers exposed to acci-
dents at sea. Follow-up studies of military maritime accidents
with surface ships have revealed that contextual factors (e.g.,
social role) and individual factors (e.g., coping style) were asso-
ciatedwith a higher load of acute stress reactions. 10
In addition, previous exposure to traumatic events has also
been identified as a predictor ofpost-traumaticstress reactions
in fatal military training accidents. 11 Given the potentially fatal
consequences ofsystemfailure in a submerged submarineafter
a collision at sea, it couldbe hypothesized that even a relatively
moderate accidentwith no serious personnel injuries couldbe
perceived as a highly stressful and threatening experience by
the crew members involved. In addition to possible adverse
long-term health effects, post-traumatic stress reactions could
affect the performance of individual crew members and the
operational capacity ofthe submarine.
The present study of three different Norwegian submarine
crews exposed to accidents at sea in submerged submarines
represented an opportunity to explore three research questions:
1. Do peacetime accidentsat sea result in acute stress reac-
tions in exposed submarine crewmembers? Fromour pre-
vious discussion of the risk factors associated with sub-
marine service, we would expect that crew members
exposed to accidentsat sea would showmoreacute stress
reactions than nonexposed submarine controls.
2. Furthermore, would submarine crewmembers exposed to
accidents at sea reveal equally high levels of acute stress
Military Medicine, Vol. 167, May 2002
428
reactions as naval personnel from a surface warship ex-
posedto a fatal trainingaccident? Because the submarine
is a high-reliability military organization with special em-
phasis on careful selection and intensive training of per-
sonnel, we would expect that submarine crew members
would reveal less acute stress reactions compared with
other groups of naval personnel exposed to fatal training
accidents.
3. Finally, would specific contextual (e.g., social role and
team cohesion) or individual (e.g., level ofprofessional ex-
perience, habitual coping strategies, perceived factualcop-
ing, appraisal of the accident, and previous exposure to
traumatic events) factors be associated with more acute
stress reactions or decreased quality of life in exposed
submarine crew members?
Methods
Situations
The submarine accidents occurred from 1996 to 1999 and
involved three different submarine crews operating conven-
tional diesel-powered Norwegian NATO submarines of the
Kobben and VIa class. In the first accident, a submarine crew
(N = 16) wasinvolved in two collisions withina l-weekperiod. In
the first instance, the submarinehit an underwater sea barrier
while submerged to about 300 feet. A few days later, the same
crewexperienced a maneuver accidentwhile on their wayto the
naval base. In the second accident, another submarine crew
(N = 19) was involved in a collision witha civilian freight ship in
a Norwegian fjord. Finally, a third submarine crew (N = 12) hit
an underwatersea barrier while on a routine mission. Because
of significant damage, all submarines involved had to be re-
paired and were inoperational for several months after the ac-
cidents. Although these situations were potentially hazardous
and highly unexpected, the submarine crew members acted
according to standard shipboard emergency procedures and
were ableto control the situation,leaving no crew members with
physical injuries after the accidents.
Subjects
Three groups of Navy personnel participated in the present
study. The first group, exposed crew members (N = 47), con-
sisted of 35 officers and 12 conscripts (all male) who had been
exposed to one of the three submarine accidents described
above. (In the Royal Norwegian Navy, conscripts have 12months
ofcompulsory service and can sign up foradditional periods as
mates on navalships.) Toensure confidentiality and full partic-
ipation from the exposed crew members, age, marital status,
and educational background of the exposed submariners were
not identified. However, an agerange ofapproximately 20 to 35
years, with conscripts significantly younger than officers, is
usually seen in Norwegian submarinecrews. Officers had more
submarine service (mean = 41.89 months; SD = 28.83) than
conscripts (mean = 16.83months; SD = 11.92) [Fl1,45) = 8.46,
P < 0.01]. In total, 34.0% (N = 16) ofthe exposed crew members
had previously also experienced other fatal accidents.
Furthermore, the exposed crew members were compared with
a control group of nonexposed crew members (N = 7) from the
same submarineswhowere offduty at the timeofthe accident.
Military Medicine, Vol. 167, May 2002
Acute Stress Reactions after Submarine Accidents
Finally, the exposed crew members were also compared with
group of male shipwreck survivors (N = 78) from a Norwegian
Navy frigate that shipwrecked in a winterstorm offthe coast of
western Norway. In this shipwreck, one person died and nine
crewmembers were injured. Although not manylives were lost,
this accident was considered to be the mostsignificant shipping
accident in Norwegian waters in manyyears and the most dev-
astating accident in the Norwegian Navy sinceWorld War11. 10
Questionnaires
Subjects completed four self-rating questionnaires. The 30-
item Coping Style Questionnaire 12 represents subjects' general
Downloaded from https://academic.oup.com/milmed/article-abstract/167/5/427/4915768 by guest on 18 September 2018
coping style, not coping witha specific event. Thequestionnaire
rates (on a scale of 1-4) coping on three dimensions: task-
focused, emotion-focused, and avoidance-focused coping. The
ImpactofEvent Scale (IESI3) measures the frequency of symp-
toms on two dimensions often reported aftertrauma. Theintru-
sion dimension consists ofsymptoms such as intrusive memo-
ries, thoughts, and emotions. Theavoidance dimension reflects
symptoms relatedto avoiding memories, places, and denial. The
questionnaire was scored 0, 1, 3, and 5 according to standard
scoring procedures." In agreement with previous studies,14,15
scoreson the IES-Intrusion > 19or the IES-Avoidance > 19were
used to identify individual cases ofhigh symptom load.
In addition, the Post-Traumatic Symptom Scale 10-item ver-
sion (PTSS-10 16), scored 1 (never) to 7 (very often), was also
administered. This is a Norwegian questionnaire assessing 10
common symptoms related to post-traumatic stress disorders.
In contrast to the IES, the PTSS-10 also includes items related
to hyperarousal (e.g., item 1, sleeping problems, and item 4,
startle reactions). 17 The Norwegian versions ofthe Coping Style
Questionnaire, the IES, and the PTSS-10 haveshowngood psy-
chometric characteristics, with Chronbach's a of >0.81 and a
4-monthtest/retest reliability of >0.52.18
Furthermore, the 30-item General Health Questionnaire
(GHQ-30) was alsoadministered. 19 Thisquestionnaire, scored 0
to 3 (Likert scores), is meant to identify psychological problems
and is used as a measure ofchange in mental health or quality
oflife.20 Finally, the following demographic variables were mea-
sured: submarineexperience (months), lengthofduty on board
this particular submarine (months), previous exposure(s) to
traumatic or fatal accidents, appraisalofcurrent accident com-
pared with previous experiences (rated more, equally, or less
stressful), self-reported coping (rated very poor [0] to excellent
[5]), and sense ofcohesion withfellow crew members (rated very
poor [0] to excellent [5]).
Procedure
Crew members received the questionnaires at their service
stations approximately 2 weeks after the submarine accidents.
Although participation was voluntary, a response rate of 1000/0
was obtained from the crew members involved. All question-
naires were completed in private and returned to a contact
officer in a sealed envelope. On all occasions, subjects were
informed that the purpose of these studies was to study stress
reactions in military crews after maritime accidents.
Results
No differences were found among the three submarine crews
on the contextual and individual variables or on the symptom
Acute Stress Reactions after Submarine Accidents 429

scales.Thus, all submarine crewmembers exposed to the acci- exposed crewmembers revealed a high load of post-traumatic
dents at sea were pooled togetherin the analysispresentedhere. stress symptoms, indicated byscoreson the IES-Intrusionscale
of> 19.
Contextual and Individual Characteristics
Exposed crewmembers' average experience from submarine Bivariate Statistics
service was 35.49 months (SD = 27.75), with 11.23 months Pearsoncorrelation coefficients and one-way analysisofvari-
(SD = 11.32) of service at their present submarine. On a five- ance were calculated to examine the bivariate relations between
pointscale, mean unit cohesion was rated 4.2 (SD = 0.54) forall contextual factors (e.g., team cohesion and social role) and in-
submarines pooled together. When examining habitual coping dividual factors (e.g., habitual coping strategies, situationalcop-
styles in exposed crew members, mean scores on the Coping ing, previous exposure to traumatic events, level ofprofessional
Style Questionnaire were 23.42 (SD = 4.65) on problem-focused experience, and appraisal ofthe situation) on acute stress reac-

Downloaded from https://academic.oup.com/milmed/article-abstract/167/5/427/4915768 by guest on 18 September 2018

coping, 21.49 (SD = 3.65) on emotion-focused coping, and tions and mental health.
16.90 (SD = 2.86) on avoidance-focused coping (Table I). Ex- First, the relation between contextual factors and symptom
posed crew members revealed less preference for avoidance- scores was examined. Unit cohesion was negatively associated
focused coping than nonexposed crew members (p < 0.001), with scores on the PTSS-10 [r(47) = -0.35, p < 0.05], the
whereastheypreferred moreproblem-focused coping than ship- IES-Intrusion dimension [r(47) = -0.34, P < 0.05], the IES total
wrecksurvivors (p < 0.001). score[r(47) = -0.33, P < 0.05], and the GHQ-30 [r(35) = -0.42,
When asked about their personal evaluation of the present P < 0.01], indicating that exposed crewmembers whorated unit
accident, 68% (N = 21) ofthe exposed crewmembers rated this cohesion more favorably revealed less acute stress reactions
experience as the "worst accident ever experienced"; however, and better mental health. Officers and conscripts showed no
770/0 (N = 24)1 reported "excellent" or "very good" coping during
differences in symptom scores.
the critical situation. (Only crewmembers from the secondand Second, the relationbetween individual factors and symptom
third submarine accidents were asked this question; thus, total scores was examined. Emotion-focused coping was positively
N = 31 persons.) No differences between officers and conscripts associated with the PTSS-10 [r(47) = 0.33, P < 0.05], and prob-
were found on any ofthe demographic variables. lem-focused coping was negatively associated withscoreson the
IES-Avoidance dimension [r(47) = -0.37, P < 0.01], indicating
Acute Stress Reactions and Mental Health that habitual coping styleswere linkedto symptom reporting. In
Two weeks after the accident, exposed crewmembers scored addition, coping in the accidentsituation was negatively corre-
5.64 (SD = 5.65) on the IES-Intrusion, 4.28 (SD = 4.11) on the lated with the IES-Avoidance dimension [r(31) = -0.46, P <
IES-Avoidance, and 9.91 (SD = 8.72) on the IES total scale. 0.01], the IES total score [r(31) = -0.42, P < 0.05], and the
Furthermore, exposed crewmembers scored 17.77 (SD = 7.5) GHQ-30 [r(19) = -0.53, P < 0.05], indicating that crewmem-
on the PTSS-10 and 22.54 (SD = 8.93) on the GHQ-30 (Table I). bers who coped successfully in the accident situation showed
Exposed crew members revealed higher levels of acute stress less symptom reporting.
reactions (p < 0.06) measured by the PTSS-10 compared with Furthermore, exposed crew members who also had experi-
nonexposed crewmembers. Furthermore, exposed crewmem- enced previous traumatic events (N = 16) were compared with
bers showed lower scores on all symptoms measures (p < 0.01) exposed crewmembers without previous experience from trau-
compared withthe shipwreck survivors. Finally, an examination matic events (N = 31). One-way analysis of variance revealed
of individual scores on the IES revealed that 4% (N = 2) of the that exposed crewmembers withprevious experience from trau-

TABLE I
MEAN SCORES AND STANDARD DEVIATIONSFOR EXPOSED AND NONEXPOSED SUBMARINE CREW MEMBERS AND SHIPWRECK
SURVIVORS ON HABITUAL COPING STILE, ACUTE STRESS REACTIONS, AND QUALITI OF LIFE MEASURED 2 WEEKS AFTER THE EVENTS

Exposed Submarine Nonexposed Submarine Shipwreck

Crew Members (N = 47) Crew Members (N = 7) Survivors (N = 78)
Habitual coping style
Problem-focused coping 22.9 (4.7) 22.3 (4.5) 19.4 (4.7)a
Emotion-focused coping 20.4 (4.4) 17.9 (2.3) 21.1 (3.1)
Avoidance-focused coping 18.6 (4.3) 25.3 (4.5)a 17.8 (3.1)
Acute stress reactions
IES-Intrusion 5.6 (5.7) 2.3 (2.2) 12.4 (6.7)a
IES-Avoidance 4.3 (4.1) 2.6 (3.0) 10.1 (5.7)a
IES total 9.9 (8.7) 4.9 (5.0) 22.5 (10.5)a
PTSS-10 17.8 (7.5) 12.1 (3.0)b 23.0 (9.6)e
Quality of life
GHQ-30 22.8 (8.9) NAd 57.2 (11.6)a

a p < 0.001.
b P < 0.05.
e p < 0.01.
dNA, not available.

Military Medicine, Vol. 167, May 2002

430 Acute Stress Reactions after SubmarineAccidents

matic eventsrevealed moreacute stress reactions,measured by
the PTSS-10 (mean = 21.75;SD = 9.9), compared with exposed
crew members without experience from traumatic events
(mean = 15.71,SD = 4.93) lf11,45) = 7.85, P < 0.01]. Exposed
crewmemberswho had experienced previous traumatic events
also scored higher on the PTSS-10 (mean = 21.75; SD = 9.92)
than submarine crew members on shore leave not involved in
the accidents (mean = 12.14; SD = 2.97) lf11,21) = 6.17, P <
0.05]. In addition, exposed crew members with previous trau-
matic experiences also revealed higher scores on the IES-Intru- acute stress reactions with substantially improved outcomes
sion dimension (mean = 7.66; SD = 7.41) compared with sub-
and low perceived coping in the situation were associatedwith
higher levels of symptom reporting.
One strikingaspect ofthe present study is the relatively sim-
ilar levels ofqualityoflife and lowlevels ofacute stress reactions
that emerged across the three submarine accidentpopulations.
This finding is quite different from follow-up studies after civil-
ian maritime accidents, which have revealed long-lasting and
negative health effects. 2 I,22 However, systematic studies of mil-
itary maritime accidents have revealed relatively low levels of
overtime.10,23 A possible explanation for this low level of acute

Downloaded from https://academic.oup.com/milmed/article-abstract/167/5/427/4915768 by guest on 18 September 2018

marine crew members on shore leave not involved in the
stress reactions was seen in the relatively coherent picture of
accidents (mean = 2.29; SD = 2.21) at a level close to signifi-
long submarine experience, high unit cohesion, and habitual
cance (p < 0.08). Finally, individual factors such as level of
submarine experience and appraisal of the accident were not coping styles found across the three different submarine acci-
associated with any of the outcome measures in the exposed dent groups, indicating a well-trained and highly selected group
group of submarine crewmembers. of military personnel from a high-reliability military organiza-
tion." Previous studies havealsofoundthat unit cohesion could
Multivariate Analysis serve as a resilience factor in military settings." The rigorous
In the subsequent analysis, the contextual and individual selection and training, togetherwith the visible leadership and
factors were entered in a multiple regression analysis with well-established command structures in submarine crews,
PTSS-10 as the outcome variable. Personalexperience ofcoping couldplayan importantrolein strengtheningunit cohesion and
in the critical situation emerged as a significant predictor of successful adaptation to highly stressful situations.26
acute stress reactions, with more satisfied subjects showing Our findings also indicatethat individual factorswererelated
fewer stress reactions than subjects less satisfied with their to acute stress reactions. In agreementwiththe stress-appraisal
coping behavior. This factor explained 17% of the variance in framework of Lazarusand Folkman," we found that subjective
acute stress reactions. Furthermore, exposureto previous crit- appraisal of coping behavior in the accident situation was re-
ical incidents also emerged as a significant predictor of acute lated to acute stress reactions in submarine crewmembers. As
stress reactions, with previously exposed subjects showing expected, problem-focused coping was negatively associated
more stress reactions than subjects with no previous exposure with acute stress reactions. This is in agreementwith previous
to criticalincidents. Together, these twofactors explained 32% research indicating that problem-focused coping in general
of the variance in acute stress reactions (Table II). serves as a resilience factor." However, the finding that emo-
tion-focused coping was related to acute stress reactions but
avoidance-focused coping was not was contrary to our previous
Discussion flndings.":" On the other hand, wealso foundthat the group of
This first systematic study of acute stress reactions in sub- nonexposed submariners revealed an evenhigherlevel ofavoid-
marine crewmembers exposed to an accident at sea revealed a ance-focused coping, indicating that avoidance-focused coping
relatively coherent picture characterized by low levels of acute strategies couldrepresent a salient coping strategy, as previous
stress reactions and few mental health complaints. Exposed personality profiles of submarine personnel have tndtcated.!?
crew members showed less symptom reporting than survivors Furthermore, these results showed that submariners previ-
from a Norwegian Navy shipwreck but higher levels of acute ously exposed to a life-threatening event showed increased lev-
stress symptoms than a group of nonexposed submarine con- els of symptoms. This was evident in comparison with crew
trols. Froma total of47 exposed crewmembers, only2 individ- members not previously involved in life-threatening accidents
uals showed a relatively high load of acute stress reactions. and with submarine controls (t.e., crewmembersfrom the same
Furthermore, contextual factors such as high unit cohesion submarine whowereon leave at the time ofthe accident). Sim-
were associated with lower scores on the symptom scales. In ilar findings have been reported in studies of other military
addition, individual factors such as previous exposure to trau- accidents." In a study ofsurvivors ofa navyshipwreck, service
matic events, habitual coping styles (e.g., high scores on emo- men with a history of repeated exposure showed increased
tion-focused coping and lowscores on problem-focused coping), scoreson both post-traumatic stress disorder-specific symptom
scales and a quality-of-life scale (the GHQ-30). In the present
study, the effect ofprevious exposurewas evident onlyin post-
TABLE IT traumatic stress disorder symptom-specific questionnaires.
VARIABLESEXPLAINING ACUTE STRESS REACTIONS AS MEASURED The finding of increased symptoms in the preexposed group
BYTHE PTSS-10 (N = 31) could be viewed as a function of a sensitization process in that
group. The process of sensitization represents a facilitation of
Variable b SE f3 responding caused by increased arousal in the central nervous
Personal experience of coping -6.10 2.78 -0.59 a system." Thus, repeated exposureto life-threatening and fear-
Previous exposure to critical incidents 3.61 1.40 0.51 a eliciting situations could be seen as a form of sensitization
R2 = 0.36, adjusted R2 = 0.29 [F(3,27) = 5.1, p < 0.01]. produced by an unconditional stimuli.32,33 The aversive uncon-
a p < 0.05. ditionalstimulicouldactivateor primethe organismto respond

Military Medicine, Vol. 167, May 2002

Acute Stress Reactions after Submarine Accidents
with increased post-traumatic stress disorder symptoms, thus
contributing to the biological factors associated with increased
susceptibility to post-traumatic stress disorder. 34,35
This explanation is further strengthened by the fact that the
traumatic situations share similarities with the laboratory set-
tings for sensitization studies. According to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition, crite-
rion A for post-traumatic stress disorder, the subject should
have been exposed to a situation characterized by highly aver-
sive, salientstimuli ofhighintensity. Symptoms such as intru-
sive memories (criterion B), avoidance symptoms (criterion C),
and increased physiological reactivity (i.e., startle response and
hypervigilance: criterion D) when confronted with reminders of
the traumaticevent alsoshouldbepresent. 36 Laboratory studies
ofsensitization use repeated exposure tohighly aversive stimuli,
which causes avoidant behavior and increased arousal in ex-
posed subjects.
Although the presentresults could be interpreted as an effect
of sensitization, another possible explanation lies in the in-
creased symptom scores in the repeated exposure group as a
result of incubation." These data indicate that a conditioning
stimulus could increase in strength over time, although the
unconditional stimuli were inhibited. This could result in in-
creased symptoms in subjectspreviously exposed to life-threat-
ening situations, although the unconditional stimuli are no
longer present.
One limitation of the present study is the rather small and
highly selected sample of only male subjects. This highly spe-
cialized military sample was not representative of most other
groups exposed to traumatic events. However, to investigate
vulnerability and resilience factors in symptom development, a
homogeneous sample is preferable to control premorbidity and
comorbidity factors. 11 Thus, studies of highly trained and se-
lected samples such as naval crews offer an advantage in this
respect. This is a strong aspect that increases the potential
relevance of the individual and contextual factors identified in
the present study.
Acknowledgment
This study is part of an ongoing research program in military psychol-
ogy and leadership funded by a research grant from the Norwegian De-
partment of Defense.
References
1. Moes GS, Johnson WB, Lall R: Personality characteristics of successful Navy
submarine personnel. Milit Med 1996; 161: 239-42.
2. van Wijk C: Submarine escape: the effect of training on anxiety. Milit Med 1998;
163: 68-70.
3. Slaven GM, Windle CM: Cognitive performance over 7 days in a distressed sub-
marine. Aviat Space Environ Med 1999; 70: 604-8.
4. Schrier 1M: Extreme conditions beneath the sea: potential stressors on board
submarines during long periods of underwater patrol. Med Corps Int 1989; 2:
11-6.
5. Charpentier P, Ostfeld AM, Hadjimichael OC, Hester R: The mortality of US
nuclear submariners, 1969-1982. J Occup Med 1993; 35: 501-9.
6. Inskip H: The mortality of Royal Naval submariners 1960-1989. J R Nav Med Serv
1997; 83: 19-25.
7. van Wijk C, Waters AH: Personality characteristics of South African Navy sub-
marine personnel. Milit Med 2000; 165: 656-8.
431
8. Sandal GM, Endresen 1M,Varnes R, Ursin H: Personality and coping strategies
during submarine missions. Milit Psychol1999; 11: 381-404.
9. Bochenkov M, Maklakov AG, Mukhin AP, Chermianin SV: Dynamics of social-
psychological and psychophysiological state of seamen from the atomic subma-
rine Komsomolets in post-stress period. Psikhologicheskii Zhumal 1995; 16:
52-63.
10. Eid J, Johnsen BH, Thayer J: Post-traumatic stress symptoms following ship-
wreck of a Norwegian Navy frigate: a longitudinal perspective. Pers Individ Differ
2001; 30: 1283-95.
11. Eid J: Early Predictors of PTSD Symptom Reporting: The Significance of Contex-
tual and Individual Factors. Doctoral dissertation. Bergen, Norway, University of
Bergen, 2000.
12. Joseph S, Williams R, Yule W: Crisis support, attributional style, coping style and
post-traumatic symptoms. Pers Individ Differ 1992; 13: 1249-51.
Downloaded from https://academic.oup.com/milmed/article-abstract/167/5/427/4915768 by guest on 18 September 2018
13. Horowiz M, Wilner N, Alvarez W: Impact of Event Scale: a measure of subjective
stress. Psychosom Med 1979; 41: 209-18.
14. Horowitz MJ: Stress Response Syndromes, Ed 2. Northvale, NJ, Jason Aronson,
1986.
15. Weiseeth L: Torture of a Norwegian ship's crew: the torture, stress reactions and
psychiatric after-effects. Acta Psychiatr Scand 1989; 80(supp1355): 63-72.
16. Weiseeth L, Mehlum L: Appendix 3. In Mennesker Traumer og Kriser [People,
Trauma and Chrisis], pp 254-5. Edited by Welseeth L, Mehlum L. Oslo, Norway,
Universitetsforlaget, 1993.
17. Thulesius H, Haakanson A: Screening for post traumatic stress disorder symp-
toms among Bosnian refugees. J Trauma Stress 1999; 12: 167-74.
18. Eid J, Thayer J, Johnsen BH: Measuring post-traumatic stress symptoms: a
psychometric evaluation of symptom- and coping questionnaires based on a
Norwegian sample. Scand J Psychol1999; 40: 101-8.
19. Goldberg DP: The Detection of Psychiatric Illness by Questionnaire: A Technique
for the Identification and Assessment of Non-Psychotic Psychiatric Illness. lon-
don, Oxford University Press, 1972.
20. Malt U, Mogstad TE, Refnin IB: Goldeberg's General Health Questionnaire. J
Norw Med Assoc 1989; 109: 1391-4.
21. Elklit A: De psykologiske reaktioner og eftervirkninger hos ofre for transport-
katastrofer til S0S [Psychological stress in victims from maritime transportation
accidents]. Nord Psykol 1996; 48: 1-20.
22. Eriksson NG, Lundin T: Early traumatic stress reactions among Swedish survi-
vors of the mls Estonia disaster. Br J Psychiatry 1996; 169: 713-6.
23. Lundin T: Collision at sea between two Navy vessels. Milit Med 1995; 160: 323-5.
24. Bierly PE, Spender JC: Culture and high reliability organizations: the case of the
nuclear submarine. J Manage 1995; 21: 639-56.
25. Bartone PT, Adler AB: Cohesion over time in a medical peacekeeping task force.
Milit Psychol 1999; 11: 85-107.
26. Ursano RJ, Grieger TA, McCarroll JE: Prevention of posttraumatic stress: con-
sultation, training and early treatment. In Traumatic Stress, pp 441-62. Edited
by van der Kolk BA, McFarlane AC, Weiseeth L. New York, Guilford Press, 1996.
27. Lazarus RS, Folkman S: Stress: Appraisal and Coping. NewYork, Springer, 1983.
28. Larsson G, Hayward B: Appraisal and coping processes immediately before ejec-
tion: a study of Australian and Swedish pilots. Milit Psychol 1990; 2: 63-78.
29. Johnsen BH, Laberg JC, Eid J: Coping strategies and mental health problems in
a military unit. Milit Med 1988; 163: 599-602.
30. Johnsen BH, Eid J, Laberg JC, Thayer J: The effect of sensitization and coping
style on posttraumatic stress symptoms and quality of life: two longitudinal
studies. Scand J Psycho12002; 43: 181-8.
31. Thompson RF, Spencer WA: Habituation: a model phenomenon for the study of
neuronal substrates of behavior. Psychol Rev 1966; 73: 16-43.
32. Petronovich L: A two factor dual-process theory of habituation and sensitization.
In Habituation, Sensitization and Behavior, pp 17-55. Edited by Peeke KVS,
Petronovitch L. Orlando, FL, Academic Press, 1984.
33. Johnsen BH, Hugdahl K: Brain asymmetry and autonomic conditioning: sensi-
tization control. Integr Physiol Behav Sci 1994; 29: 395-405.
34. Yehuda R: Linking the neuroendocrinology of post-traumatic stress disorder with
recent neuroanatomic findings. Semin Clin Neuropsychol 1999; 4: 256-65.
35. Yehuda R: Biological factors associated with susceptibility to posttraumatic
stress disorder. Can J Psychol1999; 44: 34-9.
36. Diagnostic and Statistical Manual of Mental Disorders, Ed 4. Washington, DC,
American Psychiatric Association, 1994.
37. Eysenck HJ, Kelly MJ: The interaction of neurohormones with Pavlovian A and
Pavlovian B conditioning in the causation of neuroses, extinction, and incubation
of anxiety. In Cognitive Processes and Pavlovian Conditioning in Humans, pp
251-82. Edited by Davey G. Chichester, UK, John Wiley & Sons, 1987.
Military Medicine, Vol. 167, May 2002