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NEW YORK (Reuters Health) - Chris Cramer, 62, was a fledgling war correspondent when one spring day 30 years ago he got much closer to the battle than he'd ever intended.
Just back from Rhodesia, now Zimbabwe, his boss at the BBC had asked him to fly to Tehran, where militants were holding dozens of Americans hostage at the U.S. embassy.
But as he went to pick up his visa in London on April 30, 1980, he jumped out of the frying pan and into the fire: Six gunmen stormed the Iranian embassy, taking Cramer and 25 other people hostage.
"I lasted two days before I became sick -- well, I actually feigned a heart attack to get out," said Cramer, now global editor of multimedia at Reuters in New York.
While the experience left his body unscathed, his mental health was in tatters.
"I went through real anguish for a couple of years," he said. "I had flashbacks, I had extraordinary claustrophobia, which I'd never had before. For several years, I did not go to a cinema, I did not go into an elevator. If I ever went into a restaurant, I positioned myself near the door for a fast exit. For many, many months after the incident I checked under my car every morning before driving it. I was a basket case, I was a mess."
It is becoming increasingly clear that there is nothing unique about Cramer's case. In fact, a 2003 survey found, more than a quarter of war correspondents struggle with post-traumatic stress disorder, or PTSD.
That's just shy of the 30 percent of Vietnam veterans who have suffered the mental breakdown, and nearly four times higher than in the general population, according to the U.S. Department of Veterans Affairs. And there are signs that journalists may be facing more dangers now than ever, putting both their physical and mental health at risk.
"There are a lot of undetected emotional problems in the profession," said Dr. Anthony Feinstein, a psychiatrist at the University of Toronto, Canada, and one of the first to explore the psychological toll of war reporting. "Some of the big organizations are very aware of it, but many are not."
Like many of his colleagues, Cramer didn't seek help for his problems, although talk therapy is known to be a highly effective treatment.
"The last thing you wanted to do in those days was to admit to your boss that you kind of lost your nerve," he said. "Newsrooms were very macho places, you know."
That assessment rings true with Bruce Shapiro, who heads the Dart Center for Journalism and Trauma at Columbia University in New York.
Last month, the center hosted a panel discussion with ABC correspondent Bob Woodruff, who survived a roadside bombing in Iraq, to help raise awareness about journalists' safety. The discussion took place following Donald Margulies' play Time Stands Still, about two journalists whose relationship shatters after a catastrophic assignment.
"Until about 10 years ago, no one had looked at the impact of covering difficult stories on journalists," Shapiro told Reuters Health. "The thinking was, we have to be tough to do this assignment, and if you can't do that, get out of the kitchen."
Although reporters, and war correspondents in particular, are a hardy bunch, Shapiro added, some do break down, and often start self-medicating with drugs or alcohol.
"I have talked to many journalists who've gotten derailed by psychological injuries," he said. "I have seen people who are no longer able to meet deadlines, who are haunted and wake up every night, and people who go the opposite direction and race toward danger."
Research shows, unsurprisingly, that the greater the exposure to violence, suffering and death, in particular involving children, the more likely people are to break down.
And those situations are exactly what many journalists -- along with aid workers, firefighters, policemen and soldiers -- have to deal with as part of their job.
"To go to a place like Haiti after the earthquake and see the kids digging for their parents... it's going to affect you," said Dr. Matthew J. Friedman, who directs the National Center for PTSD at the U.S. Department of Veterans Affairs.
"It's human nature to basically soldier on," he added. "On the one hand it is adaptive to shut down emotionally, but that comes at a very high price."
Not everybody who witnesses a traumatic event up close -- a fatal car crash, a murder -- develops PTSD; according to the VA, about eight percent of men and 20 percent of women do so. Exposure to war, high-intensity assignments or longer time in the field will up the risk further.
Replacing quaint terms like shell shock and battle fatigue, the American Psychiatric Association first defined PTSD in 1980 in its Diagnostic and Statistical Manual of Mental Disorders, often called the bible of mental illness.
The diagnosis includes a trio of distressing symptoms that must remain for at least a month. The first part is re-living the traumatic event, for instance as frequent flashbacks or nightmares, or as extreme physiological reactions to everyday things like reading a book. The second is avoidance -- such as going out of your way not to get near the local playground or, say, eschewing the smell of charred meat on a barbecue -- and a "numbing" toward other people and positive emotions. And the third is being revved up all the time, looking for potential signs of danger.
A person with PTSD often experiences depression, too. On his website www.conflict-study.com, Feinstein, supported by CNN and Chris Cramer, has created a confidential self-assessment tool that journalists can use to probe their mental health.
Sometimes the symptoms will dissolve by themselves, as they did for Cramer, though only after shattering his dreams of overseas reporting. Today he is a manager with Reuters and the president of the International News Safety Institute, an organization that promotes safety for people in the media.
"If I had known then what I know now," he said, "I would have taken myself off to the shrink and probably had several of them."
David Loyn, a long-time international development correspondent with the BBC in London, is one of the journalists who chose to get help. On a tumultuous trip to Afghanistan in 1996, Loyn saw a man get executed on the street for the crime of stealing his television camera.
"I was on my knees begging for his life and telling this police officer that he shouldn't shoot him on my account," Loyn told Reuters Health. "It was not a good day. For that, I sought professional counseling. I wasn't badly affected, but I was pretty shaken up."
He said once the initial reluctance to seeking help is overcome, the healing process gets much easier.
"I don't think trauma counseling is a very complicated business. The important message is that journalists need to own this for ourselves. And if we own it, and if we support each other, then you can ultimately push the psychiatric intervention slightly further down the line."
The most effective treatment for PTSD remains old-fashioned talk therapy -- either by re-living the trauma in safe settings to extinguish the gut-level fear reaction, or as cognitive-behavioral therapy, which aims to adjust emotions by changing old thought patterns.
"PTSD is not going to ruin your career," said Friedman of the VA. "What will ruin it is not getting treatment. This has been a major paradigm shift in the military."
Many high-quality studies have compared targeted talk therapy to supportive counseling alone, and guidelines uniformly recommend the former. One 2010 report that pooled earlier research, for instance, found therapists using so-called prolonged exposure treatment could expect their patients to do better than those who got plain counseling 86 percent of the time. And the effects lasted at least a year.
What is still a matter of research is how soldiers and journalists who've dealt successfully with PTSD will respond if they go back in, and whether pre-assignment training can fortify them in the first place. "We're just dipping our toes into this whole are of resilience right now," said Friedman.
When Loyn got back to London from Afghanistan, he met several traumatized colleagues who had just returned from a Balkan torn by the Bosnian war. It was clear to his managers at the BBC that something had to be done, and the result was one of the first support programs for journalists covering conflict zones.
Since then, several large news organizations have set up their own systems, including the CNN, the Australian Broadcasting Corporation and Reuters.
Kate Nowlan, the CEO of U.K.-based CiC, which has handled trauma support for Reuters since 2006, said she was initially met with some skepticism. But that has changed. Lately the company's phones, manned by therapists and trauma experts, have been ringing off the hook.
And the calls don't only come from journalists stationed in conflict zones. Sometimes it's the local cop reporter on the line, or the photographer sent out to cover a fire and ending up with some lurid pictures stuck in her mind.
"People are aware of the effects of trauma," Nowlan said. "You don't have to hide it anymore."
But awareness and decreasing stigmatization might not fully explain CiC's busy lines. A more ominous possibility, backed by experts, is that reporting is also becoming a more dangerous line of work.
According to Elana Newman, a psychologist at the University of Tulsa, Oklahoma, and the Dart Center's research director, war correspondents face growing threats of kidnapping, murder and death or injuries from IEDs or mortar attacks. (See linked factbox for more details.)
"I believe that as journalists are increasingly the targets of deliberate acts of violence in warzones," she said, "the mental health consequences will become more dire for more journalists."
And foreign correspondents aren't the only ones paying the price. In fact, data from the Committee to Protect Journalists, a New York-based nonprofit, show nearly 90 percent of journalists who are killed for their stories are local reporters and photographers from countries like Iraq, Russia or Mexico.
"They don't have PTSD because they are not 'post,'" Newman said. "They are living it daily."