Posttraumatic stress disorder, hypnotizability, and imagery

Twenty-six Vietnam veterans were studied to determine the relationship between posttraumatic stress disorder and hypnotizability. The intensity of their posttraumatic stress disorder was measured by a self-report. Their hypnotizability scores, vividness of imagery scores, and symptomatic profiles were also ascertained. Veterans with low or no posttraumatic stress disorder scores had normal hypnotizability scores and normal imagery scores, whereas those with high posttraumatic stress disorder scores had high hypnotizability scores and high imagery scores. The authors conclude that either combat traumas enhanced hypnotic potential in some veterans or that veterans with excellent hypnotic potential to begin with were more susceptible to posttraumatic stress.     

Auditory hallucinations in combat-related chronic posttraumatic stress disorder

Intrusive images have been reported to occur in a broad range of people with posttraumatic stress disorder, but the frequency of intrusive auditory perceptions has rarely been addressed. This study compared five posttraumatic stress disorder veterans experiencing auditory hallucinations with 31 nonhallucinating veterans on demographic, military, postmilitary, and symptom variables. Veterans who reported auditory hallucinations had higher combat exposure and more intense posttraumatic stress disorder symptoms than the other veterans. These veterans also tended to be more refractory to treatment than veterans with no hallucinations. Clinical vignettes of the veterans with auditory hallucinations are given, and the implications of the results for a subgroup of chronic posttraumatic stress disorder veterans are discussed.     

Auditory hallucinations, posttraumatic stress disorder, and ethnicity

The occurrence of intrusive auditory perceptions has rarely been addressed in the study of posttraumatic stress disorder. This study examined the background of 59 individuals with combat-related posttraumatic stress disorder. Subjects with and without auditory hallucinations were compared on demographic military and symptom variables. The occurrence of hallucinations among veterans with posttraumatic stress disorder appears to be more frequent among subjects of Hispanic ethnicity. This may have been related to higher combat exposure or social stresses. The occurrence of hallucinations was unrelated to drug abuse and did not appear to be associated with any particular war.     

Frontline treatment of combat stress reaction: a 20-year longitudinal evaluation study

OBJECTIVE: The purpose of the study was to evaluate the long-term (20-year) effectiveness of frontline treatment provided to combat stress reaction casualties. METHOD: A longitudinal quasi-experimental design was employed. Participants were combat stress reaction casualties of the 1982 Lebanon War who received frontline treatment (N=79), comparable combat stress reaction casualties who did not receive frontline treatment (N=156), and matched soldiers who did not experience combat stress reaction (N=194). Subjects were asked which of the frontline treatment principles (proximity, immediacy, expectancy) were applied in their treatment, whether or not they returned to their unit after frontline treatment, and if so, whether they returned before or after they felt completely recovered. Outcome assessments included measures of posttraumatic and psychiatric symptoms and of social functioning. RESULTS: Twenty years after the war, traumatized soldiers who received frontline treatment had lower rates of posttraumatic and psychiatric symptoms, experienced less loneliness, and reported better social functioning than similarly traumatized soldiers who did not receive frontline treatment. In addition, a cumulative effect of application of frontline treatment principles was documented: the more principles applied, the stronger the effect on psychiatric outcomes. CONCLUSIONS: Frontline treatment is associated with improved outcomes even two decades after its application. This treatment may also be effective for nonmilitary precursors of posttraumatic stress disorder.     

Franklin Delano Jones, M.D., and war psychiatry

Through a long career that spanned three wars and important changes in patterns of health care, Franklin Delano Jones (1935-2005) provided medical and psychiatric care to the most vulnerable members of our society, civilian as well as military. Recognizing that individuals tend to forget lessons learned in stressful situations, he compiled and codified the essential practices of wartime psychiatry into comprehensive and accessible texts. His neutrality, persistence, and sharp intellect stabilized and strengthened American military psychiatry in the post-Vietnam era. His culminating achievement, War Psychiatry, which is the codified clinical intelligence of several generations of military psychiatrists, is an essential foundation for clinical practice and for research. This article explores Jones'ss contributions, particularly the variations in the presentation of combat stress, the efficacy of the principles of forward treatment, and a comprehensive understanding of posttraumatic stress disorder.     

The impact of social support,unit cohesion,and trait resilience on PTSD in treatment-seeking military personnel with PTSD: The role of posttraumatic cognitions

BackgroundThe personal resources of social support, unit cohesion, and trait resilience have been found to be associated with posttraumatic stress disorder (PTSD) severity among military personnel. However, the underlying mechanisms of these relationships are unclear. We hypothesized that negative posttraumatic cognitions, which are associated with PTSD, mediate the relationships between these personal resources and PTSD.MethodsThe relationship between PTSD symptom severity and a latent factor comprised of social support, unit cohesion, and trait resilience was evaluated using cross-sectional data from 366 treatment-seeking active duty military personnel with PTSD following deployments to or near Iraq or Afghanistan. Structural equation modeling (SEM) was used to test whether posttraumatic cognitions mediated this relationship.ResultsThe SEM model indicated that (1) a robust latent variable named personal resources (indicated by social support, unit cohesion, and trait resilience) was negatively associated with PTSD severity; (2) personal resources were negatively associated with negative posttraumatic cognitions; (3) negative posttraumatic cognitions fully mediated the association between personal resources and PTSD severity. The final SEM mediation model showed a highly satisfactory fit [χ² (22) = 16.344, p = 0.798; χ²/df = 0.743; CFI = 1; RMSEA = 0.000].ConclusionsThese findings suggest that among active duty military personnel seeking treatment for PTSD, personal resources (social support, unit cohesion, and trait resilience) may mitigate PTSD severity by reducing negative posttraumatic cognitions.     

Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels.

BACKGROUND: Exposure to uncontrollable stress reduces baseline plasma neuropeptide-Y levels in animals. We previously reported that baseline plasma neuropeptide-Y levels, as well as neuropeptide-Y responses to yohimbine, were lower in combat veterans with posttraumatic stress disorder, but we were unable to determine whether this was attributable to posttraumatic stress disorder or trauma exposure. The current report addresses this issue. METHODS: A) Baseline plasma neuropeptide-Y levels were measured in 8 healthy combat veterans compared to 18 combat veterans with posttraumatic stress disorder and 8 healthy nontraumatized subjects; and B) Baseline plasma neuropeptide-Y levels, trauma exposure, and posttraumatic stress disorder symptoms were assessed in 41 active military personnel. RESULTS: Plasma neuropeptide-Y was negatively associated with trauma exposure but not posttraumatic stress disorder symptoms in active duty personnel. Baseline neuropeptide-Y was reduced in combat veterans with and without posttraumatic stress disorder. CONCLUSIONS: Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels. Future studies must determine if neuropeptide-Y reactivity differentiates trauma-exposed individuals with and without posttraumatic stress disorder.     

Trauma and posttraumatic stress disorder in Australia: findings in the population sample of the Australian National Survey of Mental Health and Wellbeing

AIM: To investigate the distribution and risk factors for trauma and posttraumatic stress disorder in the Australian population sample taken for the 1997 National Survey of Mental Health and Wellbeing. METHODS: The confidentialised unit record file (CURF) was prepared by the Australian Bureau of Statistics from the survey sample of 10 641 adults. It was interrogated for the lifetime experience of specific trauma and the 12-month prevalence of posttraumatic stress disorder according to DSM-IV and ICD-10. Univariate and multivariate analyses were applied to quantify risks for traumatic experience and for DSM-IV posttraumatic stress disorder. RESULTS: Fifty-seven per cent of the population reported lifetime experience of the specified trauma. Men were more likely to experience most traumas and multiple traumas except for sexual assaults. The twelve-month prevalence of DSM-IV posttraumatic stress disorder in the overall adult population was 1.5%. It occurred in 3.8% of women and 2.0% of men who had experienced trauma. While female gender, youth, lower education and residence in poorer areas predicted posttraumatic stress disorder after trauma, multivariate analysis showed that the nature of trauma (especially sexual assault) predominated. Gender ceased to be a significant contributor to the risk of posttraumatic stress disorder when analysis controlled for type and number of trauma, and for the passage of time. CONCLUSION: Trauma is ubiquitous in the community and posttraumatic stress disorder is comparatively less common, persisting into the past year in 2.8% of those who have experienced lifetime trauma. The conventional models of female susceptibility to post-traumatic stress disorder are not supported in this sample. The type of trauma appears the most important determinant of progression to posttraumatic stress disorder. These com-munity prevalence statistics complement causal understanding that comes from studies of clinical and other special populations in which posttraumatic stress disorder and selection for treatment may be confounded.     

Occupation-induced posttraumatic stress disorders

The authors describe a variant of posttraumatic stress disorder that presents as a somatoform disorder. Applying clearly specified diagnostic criteria, they found that seven of 21 patients who were severely disabled by medically unexplained symptoms following occupational exposure to toxic substances had atypical posttraumatic stress disorder, while three patients had typical posttraumatic stress disorder and the remainder suffered from somatoform disorders. Analysis of these cases revealed specific exposure factors and personality characteristics that favor the development of atypical posttraumatic stress disorder. The authors discuss the theoretical, clinical, and therapeutic advantages of this diagnosis.     

The influence of precombat personality on posttraumatic stress disorder

Current work on posttraumatic stress has deemphasized the role of preexisting character in determining the response to life-threatening trauma. Drawing on case examples of Vietnam combat veterans, the authors illustrate how precombat personality often determines the meanings which traumatic combat events had for individual soldiers, and how these meanings in turn influence the way in which the subsequent stress disorder develops and is manifested. The interrelationships between character, combat behavior and posttraumatic stress are also discussed. The importance of this conceptual approach in the treatment of the disorder is emphasized.     

Psychotherapy with severely traumatized refugees

Severely traumatized refugees often have a complicated and chronic clinical course involving a posttraumatic stress disorder. The diagnosis and therapy of such patients faces many problems. Based upon observations of chronic posttraumatic stress disorder in refugees of many countries, the authors suggest treatment approaches.     

The effect of stress doses of hydrocortisone during septic shock on posttraumatic stress disorder in survivors

BACKGROUND: Exposure to intense physical and psychological stress during septic shock can result in posttraumatic stress disorder in survivors. Patients with chronic posttraumatic stress disorder often show sustained reductions in serum cortisol concentration. This investigation examines whether increasing serum cortisol levels with hydrocortisone treatment during septic shock reduces the incidence of posttraumatic stress disorder in survivors. METHODS: Patients (n = 20) were recruited from a prospective, randomized double-blind study on the hemodynamic effects of hydrocortisone during septic shock. Eleven patients had received placebo and nine stress doses of hydrocortisone. Posttraumatic stress disorder was diagnosed 31 months (median) after intensive care unit discharge using SCID-IV (DSM-IV-criteria). Furthermore, the number of categories of traumatic memory from ICU treatment was determined in both groups at that time. RESULTS: Only one of nine patients from the hydrocortisone group developed posttraumatic stress disorder, compared with seven of 11 patients in the placebo group (p =.02). There was no significant difference with regard to the number of categories of traumatic memory between the hydrocortisone and placebo groups. CONCLUSIONS: The administration of hydrocortisone during septic shock in a dosage similar to the endogenous maximal production rate was associated with a lower incidence of posttraumatic stress disorder in long-term survivors, which seems to be independent of the number of categories of traumatic memory.     

Posttraumatic stress disorder among frontline soldiers with combat stress reaction: the 1982 Israeli experience

One year after the 1982 Lebanon War, the authors assessed the prevalence, type, and severity of posttraumatic stress disorder in a large representative sample of Israeli soldiers who had been treated for combat stress reactions. Comparisons were made with a group of soldiers who had fought in the same battles but had not been treated for this reaction. A dramatically higher percentage of soldiers with combat stress reaction (59%) than of soldiers without combat stress reaction (16%) developed posttraumatic stress disorder. Age was significantly associated with posttraumatic stress disorder. The authors discuss the differential quality of posttraumatic stress disorder among both groups as well as the factors facilitating recovery.     

Combat experience and postservice psychosocial status as predictors of suicide in Vietnam veterans

The authors examined potential risk factors for suicide among 38 Vietnam veterans using 46 Vietnam veterans who died from motor vehicle accidents as a comparison group. The veterans were selected from Los Angeles County Medical Examiner's file (1977-1982). Data for these veterans were obtained from military service records, the coroner's reports, and the psychological autopsy conducted with the decedents' family members. No military service factor was associated with suicide. The characteristics of Vietnam veteran suicide cases were not substantially different from non-Vietnam veteran suicide cases with respect to known demographic risk factors. The psychological profile of Vietnam veteran suicide cases are also similar to non-Vietnam veteran suicide cases in most instances. Symptoms related to posttraumatic stress disorder were observed more frequently among suicide cases than accident cases. However, suicides were not associated with specific combat experiences or military occupation. The extent of combat experience in Vietnam per se as measured in this study is not a good predictor of suicide death.     

Reactivation of combat-related posttraumatic stress disorder

The authors conducted an exploratory study of the nature and course of reactivation of combat-related posttraumatic stress disorder. Experienced psychiatrists, they each independently assessed 35 men with recurrent combat-related posttraumatic stress disorder. Two major types of reactivated posttraumatic stress disorder, each representing a different degree of pathology, were delineated: uncomplicated reactivation and heightened vulnerability. The second category was further subdivided into specific sensitivity, moderate generalized sensitivity, and severe generalized sensitivity. The authors conclude that reactivation of war-related trauma is a complex phenomenon that may take different forms.     

Severity of combat-related posttraumatic stress disorder versus noncombat-related posttraumatic stress disorder: a community-based study in American Indian and Hispanic veterans

The goal of the study was to compare severity of combat-related posttraumatic stress disorder (PTSD) versus noncombat-related PTSD in a group known to have high rates of combat-related PTSD. Sample consisted of 255 male American Indian and Hispanic veterans with lifetime PTSD who were contacted in communities in 2 regions of the country. Measures of PTSD severity included current posttraumatic symptoms, remission from lifetime PTSD, lifetime severity of alcohol-drug related problems, and mental health treatment history. Our findings revealed that veterans with combat-related PTSD had more severe posttraumatic symptoms, were less apt to have remitted from PTSD during the last year, and-contrary to expectation-were less apt to have sought mental health treatment since military duty. In conclusion, combat-related PTSD was more severe, as compared with noncombat-related PTSD, in this group, on 2 out of 5 measures. A low rate of mental health treatment since military duty may have contributed to increased symptoms and a lower remission rate.     

Delayed and immediate onset posttraumatic stress disorder

Summary The current study examined the role battle experiences and personal resources play in the development of combat-related posttraumatic stress disorder (PTSD). For this purpose, battle experiences (battle stress, military unit environment) and personal resources (coping styles, causal attribution) were assessed two years after the 1982 Lebanon War in three groups of male Israeli frontline soldiers: 1. soldiers who sought treatment 6 months or more after the war (delayed PTSD); 2. soldiers who sought treatment during the war (immediate PTSD); and 3. control soldiers. Findings indicated that both immediate and delayed PTSD casualties reported similar and higher levels of battle stress than control subjects. In addition, delayed PTSD casualties evinced less personal resouces than control subjects, and immediate PTSD casualties evinced still less personal resources than delayed PTSD casualties. The theoretical implications of the findings were discussed.This study was supported by the U.S. Army Medical Research and Development Command, Grant No.DAMD17-87-G-7002. The views, opinions, and findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by other documentation.     

Posttraumatic stress symptoms in Navy personnel: prevalence rates among recruits in basic training

Individuals in the military are often required to endure high levels of stress as a result of demanding operational requirements or deployments. Individuals who enter the military with pre-existing mental health problems such as posttraumatic stress disorder (PTSD) are likely to be at heightened risk of adverse reactions to military stressors. The present study documents the prevalence of PTSD symptoms among new Navy recruits and compares the prevalence of PTSD symptomology among recruits to prevalence rates that have been reported for comparable civilian populations. Results suggest that 15 percent of new Navy recruits are experiencing measurable symptoms of posttraumatic stress. Prevalence of these symptoms among Navy recruits is comparable to that among civilian adolescent and young adult populations.     

Symptom patterns associated with posttraumatic stress disorder among Vietnam veterans exposed to war trauma

The authors tested whether the relationship between traumatic stress and posttraumatic stress disorder is captured more accurately by aggregating symptoms, as in DSM-III, or differentiating them into the subtypes of denial and reexperiencing. Their findings indicate that distinguishing between the responses of denial and reexperiencing is an alternative and potentially more useful approach for understanding posttraumatic stress disorder and its origins in war trauma than the comprehensive model proposed in DSM-III. The analysis suggests that biases in the current model of posttraumatic stress disorder may lead to underestimation of its prevalence. The authors conclude that reconsideration of what constitutes the disorder is warranted.     

Dimensions of posttraumatic stress disorder among Vietnam veterans

DSM-III criteria and clinical models of stress are used to identify discrete dimensions of posttraumatic stress disorder. The authors test the hypothesis that war trauma differentially affects four dimensions of posttraumatic stress--intrusive imagery, hyperarousal, numbing, and cognitive disruption--by studying data from 251 Vietnam veterans probability sampled in seven sites. The hypothesis was confirmed. Different dimensions of stress symptomatology are found to vary across individuals exposed to different types of war trauma. Stress responses to war trauma also differ by race of the veteran. The relationship between stressors and symptomatology change over time, indicating specific experiences are related to particular long-term patterns of posttraumatic stress disorder.