Combat-related PTSD and psychosocial adjustment problems among substance abusing veterans

The purpose of this study were the following: a) to determine the prevalence of combat-related posttraumatic stress disorder (PTSD) symptoms among veterans seeking assistance at a Veterans Administration medical center substance abuse treatment facility, b) to examine the relative contribution of Vietnam war zone variables to PTSD symptom development, and c) to study psychosocial adjustment problems associated with Vietnam combat exposure and with PTSD symptoms among help-seeking substance abusing men. Of 489 male veterans presenting for treatment, 10.7% had significant Vietnam combat-related PTSD symptoms as measured by the Mississippi Scale for Combat-Related PTSD. Clinically significant PTSD symptoms occurred among 46% of the subsample of combat-exposed Vietnam veterans with substance abuse problems. Degree of combat exposure was the most important military stressor that distinguished Vietnam veterans with PTSD from those without PTSD, but the groups also differed on age of war zone duty, duration of war zone duty, and whether they were wounded. Veterans who served in Vietnam did not differ from veterans who had no war zone duty on various parameters of psychosocial adjustment. However, the subgroup of Vietnam veterans with PTSD symptoms reported significantly greater psychosocial adjustment problems than their counterparts who did not have PTSD. The deleterious effects associated with combat-related PTSD appeared to be confined to adjunctive psychiatric difficulties and unemployment and did not increase risk of arrests for antisocial conduct beyond that found for veterans without PTSD. Methodological and clinical implications of these findings are discussed.     

Multidimensional assessment of anger in Vietnam veterans with posttraumatic stress disorder.

This study examined the effects of combat exposure and posttraumatic stress disorder (PTSD) on dimensions of anger in Vietnam veterans. Vietnam combat veterans were compared with Vietnam era veterans without war zone duty on the Multidimensional Anger Inventory (MAI). Combat veterans were not significantly more angry than their veteran peers who did not serve in Southeast Asia. Additionally, various parameters of war zone duty were not highly associated with anger scores. However, combat veterans with PTSD scored significantly higher than veterans without PTSD on measures of anger arousal, range of anger-eliciting situations, hostile attitudinal outlook, and tendency to hold anger in. These results suggest that PTSD, rather than war zone duty, is associated with various dimensions of angry affect.     

Reactions to combat stress in Israeli veterans twenty years after the 1982 Lebanon war

During the war or shortly thereafter, the most common manifestation of combat induced psychopathology is combat stress reaction (CSR). The long-term consequences of CSR have so far received little scientific attention. The aim of this study was to examine whether CSR is a marker for long-term PTSD and other psychiatric comorbidities. Two groups of veterans from the 1982 Lebanon war were assessed 20 years after the war: one comprised 286 CSR casualties and the other comprised 218 matched non-CSR soldiers. Participants were assessed for PTSD, psychiatric symptomatology, social functioning, physical health, and postwar life events. Twenty years after the war, veterans with antecedent CSR reported more PTSD, psychiatric symptomatology and distress, social dysfunction, and health problems than did non-CSR veterans. We conclude that CSR should be seen as a marker for long-term psychiatric distress and impairment. In addition, the implications of combat-related trauma are broad and varied, and go beyond the narrow scope of PTSD.     

Combat veterans show normal discrimination during differential trace eyeblink conditioning, but increased responsivity to the conditioned and unconditioned stimulus

The question addressed in the present study was whether post-traumatic stress disorder (PTSD) results in associative learning impairments. To answer this question, differential trace eyeblink (EB) conditioning was studied in combat veterans with PTSD, combat veterans without PTSD, and non-combat veterans without PTSD. Veterans with PTSD showed normal EB discrimination, suggesting that associative learning is not impaired by PTSD. Veterans with PTSD also showed normal extinction. However, subjects with PTSD showed more EB conditioned responses (CRs), as well as increased CR amplitude. Increased response amplitude to the airpuff unconditioned stimulus presented alone (viz. the unconditioned response), as well as to the airpuff on CS+ trials during conditioning also occurred in the subjects with PTSD. These findings suggest increased reactivity in combat veterans with PTSD, compared to those without PTSD, but such heightened reactivity does not affect somatomotor associative learning.     

PTSD and social functioning

This longitudinal study assessed long term social functioning among two groups of Israeli soldiers: (a) front line soldiers who had been treated for combat stress reaction (CSR) during the 1982 Lebanon war (n = 213); and (b) matched controls who were front line soldiers participating in the same battles, but did not sustain a CSR (n = 116). Subjects were screened one, two, and three years after the war for PTSD and social functioning. Results indicated that CSR and PTSD casualties reported more problems in social functioning than controls. The link between PTSD and social functioning was stronger among PTSD veterans who had suffered an antecedent CSR episode. Time had a differential effect on the social functioning of CSR and control subjects.     

Psychological sequelae of war. A 3-year prospective study of Israeli combat stress reaction casualties

The long-term psychological sequelae of combat were assessed employing the Impact of Event Scale (IES) 1, 2, and 3 years after the 1982 Lebanon War. The following groups of Israeli veterans participated: combat stress reaction casualties (N = 213) and comparable controls (N = 116). For the purpose of the study, the subjects in each group were screened and further divided according to whether they did or did not suffer from posttraumatic stress disorder (PTSD). Results showed that elevated rates of distress were reported by both combat stress reaction and PTSD casualties at all three points in time. In both study groups the level of distress declined with time. Theoretical and methodological implications were discussed.     

Suicide and guilt as manifestations of PTSD in Vietnam combat veterans

OBJECTIVE: Although studies have suggested a disproportionate rate of suicide among war veterans, particularly those with postservice psychiatric illness, there has been little systematic examination of the underlying reasons. This study aimed to identify factors predictive of suicide among Vietnam combat veterans with posttraumatic stress disorder (PTSD). METHOD: Of 187 veterans referred to the study through a Veterans Administration hospital, 100 were confirmed by means of a structured questionnaire and five clinical interviews as having had combat experience in Vietnam and as meeting the DSM-III criteria for PTSD. The analysis is based on these 100 cases. RESULTS: Nineteen of the 100 veterans had made a postservice suicide attempt, and 15 more had been preoccupied with suicide since the war. Five factors were significantly related to suicide attempts: guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD. Logistic regression analysis showed that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide. For a significant percentage of the suicidal veterans, such disturbing combat behavior as the killing of women and children took place while they were feeling emotionally out of control because of fear or rage. CONCLUSIONS: In this study, PTSD among Vietnam combat veterans emerged as a psychiatric disorder with considerable risk for suicide, and intensive combat-related guilt was found to be the most significant explanatory factor. These findings point to the need for greater clinical attention to the role of guilt in the evaluation and treatment of suicidal veterans with PTSD.     

The effect of prior trauma exposure on the development of PTSD following spinal cord injury

Posttraumatic stress disorder (PTSD) occurs in only a subset of individuals who sustain traumatic spinal cord injuries (SCIs). Several previous studies have examined the effects of additive trauma on the development of PTSD and found that a history of prior trauma increases the risk for later development of PTSD. The present study examines additive trauma by investigating the effects of previous combat exposure on the development of PTSD following spinal cord injury. Significant differences in prevalence rates for current PTSD were found for the comparisons of war theater (both combat and noncombat) versus non-war theater veterans but not for the comparison between combat and noncombat war theater veterans. Moreover, for all the comparisons, no significant differences were found in lifetime PTSD diagnoses. This implies that veterans with SCI who served in a war zone have increased difficulty recovering from their PTSD following a spinal cord injury than do non-war theater veterans.     

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans

OBJECTIVE: Studies of soldiers from prior wars conducted many years after combat have shown associations between combat-related posttraumatic stress disorder (PTSD) and physical health problems. The current Iraq war has posed a considerable PTSD risk, but the association with physical health has not been well studied. METHOD: The authors studied 2,863 soldiers using standardized self-administered screening instruments 1 year after their return from combat duty in Iraq. RESULTS: Among all participants, 16.6% met screening criteria for PTSD. PTSD was significantly associated with lower ratings of general health, more sick call visits, more missed workdays, more physical symptoms, and high somatic symptom severity. These results remained significant after control for being wounded or injured. CONCLUSIONS: The high prevalence of PTSD and its strong association with physical health problems among Iraq war veterans have important implications for delivery of medical services. The medical burden of PTSD includes physical health problems; combat veterans with serious somatic concerns should be evaluated for PTSD.     

Learning and memory impairment in PTSD: relationship to depression

Memory function was studied in combat veterans with posttraumatic stress disorder (PTSD), combat veterans without PTSD, and noncombat veterans. The Vocabulary and Digit Span subtests of the WAIS and Logical Memory (LMS) and Verbal Paired Associates (VPAS) subtests of the Wechsler Memory Scale III were administered. Combat veterans with PTSD showed impaired memory on the LMS and VPAS compared to combat veterans without PTSD or noncombat veterans. Veterans with PTSD also showed lower WAIS Vocabulary subtest scores--but not digit span subtest scores--than combat veterans without PTSD or noncombat veterans. Medication status, co-morbid diagnosis, and age all failed to account for these memory differences, but when self-assessed depression--as measured by the Zung Self-Rating Depression Scale--or anxiety--as measured by the Spielberger State-Trait Anxiety Scale--was statistically removed, group differences on these memory measures were no longer significant. However, using a stepwise regression procedure, in which both anxiety and depression were employed to predict the LMS and VPAS scores, only the Zung scale reliably predicated performance. The present results, showing that PTSD is associated with general learning and memory impairments, is an important finding, but the specific effects of depression as a mediator of these deficits should be further studied.     

Decreased anterior cingulate volume in combat-related PTSD.

BACKGROUND: Neuroanatomical data point to functional relationships between the anterior cingulate cortex (ACC) and subcortical centers regulating fear, in particular, the amygdala. Functional brain imaging has disclosed divergent patterns of ACC activation in persons with posttraumatic stress disorder (PTSD). In addition, two preliminary structural imaging studies have found evidence of smaller ACC volume in PTSD. We explored associations between PTSD and ACC volume in a relatively large sample of adult combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed. METHODS: Subjects were US military combat veterans of the Vietnam and Gulf Wars recruited from two metropolitan areas served by allied Department of Veterans Affairs PTSD treatment/research centers. Anterior cingulate cortex volume was analyzed as a function of grouping factors with and without adjustment for body size. RESULTS: Posttraumatic stress disorder was associated with smaller anterior cingulate cortex volume. This effect persisted in subjects without histories of alcoholism, did not interact with cohort effects, and was not modified by adjustment for body size. CONCLUSIONS: Anterior cingulate cortex volume is substantially smaller in association with combat-related PTSD, a finding broadly consistent with cingulate hypofunctionality in that disorder.     

Disability compensation seeking among veterans evaluated for posttraumatic stress disorder

OBJECTIVE: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). METHODS: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. RESULTS: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans. CONCLUSIONS: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.     

The impact of Purple Heart commendation and PTSD on mortality rates in older veterans

Background: To determine whether having received a Purple Heart (PH) or having been diagnosed with posttraumatic stress disorder (PTSD) affected mortality in older veterans. Methods: We compared mortality rates of older veterans with a PH but without PTSD (PH+/PTSD?) to veterans with a PH and PTSD (PH+/PTSD+), veterans without a PH but with PTSD (PH?/PTSD+), and a comparison group without a PH or PTSD (PH?/PTSD?). Administrative data from the Veterans Integrated Service Network 16 were collected between 10/01/97 and 09/30/99 for veterans who were 65 years or older. Proportional hazards regression was used to compare the survival times for the four groups (n = 10,255) from entry into the study until death or study termination (9/30/2008). The Charleson co‐morbidity index was used to control for potential co‐morbid illness burden differences between the groups. Results: Older veterans with a PH (PH+/PTSD? and PH+/PTSD+) had significantly lower mortality rates than PH?/PTSD? veterans (hazard ratio [HR] = 0.6, 95% confidence interval [CI] 0.5 to 0.6, P<.0001; and HR = 0.5, 95% CI 0.4 to 0.7, P<.0001). The PH?/PTSD+ group had a higher mortality rate than the PH?/PTSD? group (HR = 1.1, 95% CI 1.0 to 1.2, P<.01). Conclusions: Veterans who had PH citations and survived into their seventh decade had half the mortality rate of veterans without PH citations with or without PTSD. Veterans with PTSD but without a PH had a significantly higher mortality rate compared to (PH?/PTSD?). Veterans who suffer combat injury without developing PTSD may provide a useful study population for determining the factors that confer resilience. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.     

Executive function and memory in posttraumatic stress disorder: a study of Bosnian war veterans.

The present study assessed neuropsychological functions related to attention, executive function and everyday memory in a group of men with a diagnosis of combat-related posttraumatic stress disorder (PTSD). Twenty Bosnian male combat veterans with a diagnosis of PTSD were tested using the Sustained Attention to Response Task, the Hayling Sentence Completion Test, the Trail Making Test, Rivermead Behavioral Memory Test and Wechsler Adult Intelligence Scale (verbal scales). Their performance was compared with age- and IQ-matched male war veterans with no PTSD. The study disclosed pervasive cognitive impairments with large effect sizes pertaining to attention, working memory, executive function, and memory. The effects did not appear to be attributable to alcohol abuse, loss of consciousness, or educational level. We speculate that, in the present group of combat veterans, PTSD was associated with dysfunction of a higher-level attentional resource which in turn affected the activity in other systems concerned with memory and thought.     

The Hawaii Vietnam Veterans Project: is minority status a risk factor for posttraumatic stress disorder?

The Hawaii Vietnam Veterans Project (HVVP) was congressionally mandated as a follow-up to the National Vietnam Veterans Readjustment Study (NVVRS) to assess current and lifetime prevalence of posttraumatic stress disorder (PTSD). The Hawaii Vietnam Veterans Project used the original two-stage NVVRS design in which a lay interview, conducted with a large sample, was followed by a clinical interview with a smaller subsample. Reported results are from the clinical subsample consisting of 100 Native Hawaiian and 102 American of Japanese ancestry veterans compared with white veterans from the NVVRS cohort. The major finding is that veterans of Japanese ancestry exhibited significantly lower prevalence of current full, current partial, and lifetime full PTSD than white veterans. Adjustment for age and war zone exposure did not eliminate most of these differences. These results indicate that minority status per se is not a risk factor for PTSD.     

Posttraumatic stress disorder and body mass index in military veterans. Preliminary findings

Introduction: Current management of posttraumatic stress disorder (PTSD) focuses on the psychiatric parameters of this condition. Little has been written about co-morbid overweight and obesity in PTSD. Methods: We used the database of the recently constituted PTSD program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia to assess and better understand the prevalence and severity of overweight and obesity among military veterans with PTSD. Variables assessed included age, decade of life, height, weight, sex, race, and severity and chronicity of PTSD. We used PTSD CheckList-Military Version (PCL-M) to assess current complaints and service-connected disability (SCD) to estimate the long-term severity of PTSD. Results: Of the 221 male veterans extracted from our PTSD database for purposes of this study, 144 (65.2%) were in the age range of 50 to 59 years consistent with Vietnam veterans dominating our study population. Their mean body mass index (BMI) was 30.2+/-5.8 kg/m(2) placing the typical veteran in the obese range. Far exceeding the current US population rate of 64.5%, 82.8% of our study population was either overweight or obese. Our sample had BMI measurements greater than those reported for non-PTSD veterans and also BMI measurements reported in the literature for veterans with PTSD. Current (PCL-M) and long-term (SCD) markers of PTSD did not relate to obesity. Conclusions: The prevalence of overweight and obesity among our veterans with PTSD far exceeded current US population findings and those of other veteran groups with and without PTSD. PTSD symptoms, whether assessed acutely or chronically, did not explain our findings. Prospective studies of PTSD and comorbidity are needed using larger study populations to better understand the relationships among PTSD, stress, and obesity.     

Delayed onset of posttraumatic stress disorder among male combat veterans: a case series.

OBJECTIVE: Authors investigated the nature of delayed-onset posttraumatic stress disorder (PTSD) among combat veterans. METHODS: PTSD, along with cognitive and emotional functioning, was assessed in a case series of elderly Australian war veterans. RESULTS: Fifteen elderly male subjects consecutively referred to an outpatient psychiatric clinic were identified as having PTSD with significantly delayed onset. In most cases, the onset of PTSD symptoms was associated with unrelated medical complaints, psychosocial stress, and/or mild cognitive impairment. CONCLUSION: Environmental stressors, coupled with age-related neurodegeneration, may potentially contribute to the late-life recrudescence or emergence of PTSD symptoms in veterans exposed to combat-related trauma.     

Subtle neurologic compromise as a vulnerability factor for combat-related posttraumatic stress disorder: results of a twin study

CONTEXT: Previous studies have demonstrated subtle neurologic dysfunction in chronic posttraumatic stress disorder (PTSD) manifest as increased neurologic soft signs (NSSs). The origin of this dysfunction is undetermined. OBJECTIVE: To resolve competing origins of increased NSSs in PTSD, namely, preexisting vulnerability factor vs acquired PTSD sign. DESIGN: Case-control study of identical twins. SETTING: A Veterans Affairs and academic medical center (ambulatory). PARTICIPANTS: A convenience sample of male Vietnam veteran twins with (n = 25) and without (n = 24) PTSD and their combat-unexposed identical (monozygotic) co-twins. INTERVENTIONS: Neurologic examination for 45 NSSs. MAIN OUTCOME MEASURE: Average scores for 45 NSSs, each scored on an ordinal scale from 0 to 3, masked to diagnosis and combat exposure status. RESULTS: There was a significant between-pair main effect of PTSD diagnosis (as determined in the combat-exposed twin) on average NSS score in the absence of a significant combat exposure main effect or diagnosis x exposure interaction. Combat veterans with PTSD had significantly higher NSS scores than combat veterans without PTSD. The "high-risk," unexposed co-twins of the former also had significantly higher NSS scores than the "low-risk," unexposed co-twins of the latter. This result could not be explained by age, number of potentially traumatic lifetime noncombat events, alcoholism, or the presence of a comorbid affective or anxiety disorder. The average NSS score in unexposed co-twins was not significantly associated with combat severity in combat-exposed twins. CONCLUSIONS: These results replicate previous findings of increased NSSs in Vietnam combat veterans with PTSD. Furthermore, results from their combat-unexposed identical co-twins support the conclusion that subtle neurologic dysfunction in PTSD is not acquired along with the trauma or PTSD but rather represents an antecedent familial vulnerability factor for developing chronic PTSD on exposure to a traumatic event.     

Psychological and marital distress in spouses of Vietnam veterans: Importance of spouses’ perceptions

Spouses of combat veterans with PTSD have greater psychological and marital distress than spouses of veterans without PTSD; however, few studies have examined how variables related to the spouses (e.g., cognitions) may play a role in their own distress. The current study examined spouses’ perceptions of combat veterans’ PTSD symptom severity in 465 spouses of veterans from the National Vietnam Veterans Readjustment Study. Spouses’ perceptions of veterans’ symptom severity were positively associated with spouses’ psychological and marital distress; furthermore, spouses’ perceptions fully mediated the effects of veterans’ self-reported PTSD severity on spouses’ distress. Additionally, for spouses who provided complete data with regard to their perceptions of veterans’ PTSD, distress was highest when they perceived high levels of symptoms but veterans reported low levels. These results highlight the importance of interpersonal perceptions in intimate relationships and provide preliminary groundwork for future research on cognitions in spouses of combat veterans with PTSD.