Smaller right hippocampus in war veterans with posttraumatic stress disorder

Chronic stress can putatively cause damage in the human hippocampus, but evidence of damage has not been consistently shown in studies on hippocampal morphology in posttraumatic stress disorder (PTSD). We compared hippocampal volumes in PTSD patients and normal subjects. Using a 3D T1-weighted GRE magnetic resonance imaging sequence, we measured hippocampal volumes in 15 war veterans with combat-related chronic PTSD and 15 case-matched normal controls. Although war veterans, our PTSD subjects were not professional soldiers and were mobilized shortly before they were exposed to a very specific combat-related trauma over a 3-day period. In our study, the period between traumatic exposure and imaging was considerably shorter, on average, 9 years, compared with at least two decades in previous studies on subjects with combat-related PTSD. Moreover, our subjects were free of any comorbidity, treatment or medication. The right hippocampus was significantly smaller in PTSD subjects than in healthy controls. The left hippocampus was also smaller in PTSD subjects than in controls, but the difference was not significant. In all PTSD subjects, the right hippocampus was smaller than the left (on average, 7.88%). Our results show smaller volume of the right hippocampus in PTSD patients than in normal subjects.     

Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder.

BACKGROUND: Although sleep disturbances are commonly reported by individuals with posttraumatic stress disorder (PTSD), objective findings have been inconsistent, due in part to small sample sizes, comorbid psychiatric disorders, variations in the recentness of trauma exposure, and the use of PTSD subjects involved in psychiatric treatment. METHODS: A community sample of elderly males (n = 59) exposed to war trauma 28-50 years ago and free from sleep-affecting medications and disorders other than PTSD completed 3 nights of polysomnography. Of these participants, 30 met criteria for current PTSD; three were receiving supportive outpatient psychotherapy. RESULTS: Two statistically significant differences were observed: Those with PTSD had a higher percentage of rapid eye movement (REM) sleep and fewer arousals from non-REM sleep. The perceptions of sleep quality among the participants with PTSD were lower than the perceptions of non-PTSD participants. Although participants with untreated obstructive sleep apnea and sleep movement disorders were not included in the sample, many cases were detected on initial screening. Treatment resulted in improved sleep and increased feelings of well being. CONCLUSIONS: Alterations in REM and arousals characterized PTSD in this sample. When comorbid sleep disorders were ruled out, sleep was clinically similar across the groups. Trauma-related sleep disturbances that subjects reported as arising early in the course of the disorder appear to have declined over time.     

Homocysteine and serum lipids concentration in male war veterans with posttraumatic stress disorder

The evidence of increased cardiovascular disease (CVD) risk in posttraumatic stress disorder (PTSD) is accumulating. The present study aimed to determine whether chronic, combat-related PTSD is associated with serum lipid and homocysteine concentrations that could indicate higher CVD risk.The authors tested 66 war veterans with PTSD, 33 war veterans without PTSD, and 42 healthy volunteers for serum concentrations of homocysteine, total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and triglycerides. All the subjects were men and the analyses were adjusted for age, body mass index and smoking. Potential influences of depression, anxiety, and psychotic symptoms on the outcome measures were checked by introducing the scores from the Hamilton Depression Rating Scale (HAM-D-17), the Hamilton Anxiety Scale (HAMA), and the Positive and Negative Syndrome Scale (PANSS) into the overall statistical model.No differences in total cholesterol, LDL-C, HDL-C and triglycerides were found between the groups. Non-smoking PTSD war veterans had higher homocysteine concentrations (mean = 10.4 μmol/L, SD = 1.7) when compared to non-smoking war veterans without PTSD (mean = 8.2 μmol/L, SD = 4.0, P = 0.014) and both smoking (mean = 8.7 μmol/L, SD = 2.3, P = 0.008) and non-smoking healthy volunteers (mean = 8.8 μmol/L, SD = 2.2, P = 0.021).The results of our cross-sectional study are possibly confounded by many factors, especially behavioral and life-style related which are difficult to control comprehensively and might have influenced serum lipids and homocysteine concentration in a complex manner.An increase in the homocysteine concentration observed in the non-smoking PTSD patients needs further investigation with a carefully designed prospective study to confirm associated, possibly enhanced CVD risk.     

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.     

Hypocortisolism and increased glucocorticoid sensitivity of pro-Inflammatory cytokine production in Bosnian war refugees with posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with dysregulation of the hypothalamus pituitary adrenal (HPA) axis. Alterations include various responses to HPA axis stimulation, different basal hormone levels, and changes in glucocorticoid receptor (GR) numbers on lymphocytes. The functional significance of these latter changes remains elusive. METHODS: Twelve Bosnian war refugees with PTSD and 13 control subjects were studied. On 2 consecutive days, they collected saliva samples after awakening and at 11, 15, and 20 hours. Glucocorticoid (GC) sensitivity was measured by dexamethasone (DEX) inhibition of lipopolysaccharide (LPS)-induced interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) production in whole blood. RESULTS: The PTSD patients showed no cortisol response after awakening and had lower daytime cortisol levels (F = 14.57, p <.001). Less DEX was required for cytokine suppression in PTSD patients (IL-6: t = -2.82, p =.01; TNF-alpha: t = 5.03, p <.001), reflecting higher GC sensitivity of pro-inflammatory cytokine production. The LPS-stimulated production of IL-6, but not TNF-alpha, was markedly increased in patients (IL-6: F = 10.01, p <.004; TNF-alpha: F =.89, p =.34). CONCLUSIONS: In refugees with PTSD, hypocortisolism is associated with increased GC sensitivity of immunologic tissues. Whether this pattern reflects an adaptive mechanism and whether this is sufficient to protect from detrimental effects of low cortisol remains to be investigated.     

Neural correlates of associative learning and memory in veterans with posttraumatic stress disorder

Impaired attention and memory are symptoms frequently associated with posttraumatic stress disorder (PTSD). Although patients with PTSD frequently report memory difficulties and empirical research provides support for a memory deficit in PTSD, as of yet, no fMRI study has adequately investigated the neural correlates of learning and memory of neutral (i.e. not trauma related) material in patients with PTSD compared to controls. Twelve male veterans with PTSD, and twelve male veterans without PTSD, were recruited, and matched for age, region and year of deployment. Encoding and retrieval of 12 word-pair associates was assessed during fMRI in both experimental groups. Compared to controls veterans with PTSD revealed underactivation of the frontal cortex, and overactivation of the temporal cortex during the encoding phase. Retrieval of the paired associates resulted in underactivation of right frontal cortex, bilateral middle temporal gyri, and the left posterior hippocampus/parahippocampal gyrus in patients with PTSD. Deficits in memory performance in PTSD appear to be related to altered activity in fronto-temporal areas during both the encoding and retrieval phase of memory processing.     

Dissociation and posttraumatic stress disorder in Vietnam combat veterans.

OBJECTIVE: This study compared current dissociative symptoms and dissociation at the time of specific traumatic events in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and Vietnam combat veterans without PTSD. METHOD: Vietnam combat veterans who sought treatment for PTSD (N = 53) were compared to Vietnam combat veterans without PTSD (N = 32) who sought treatment for medical problems. Dissociative symptoms were evaluated with the Dissociative Experiences Scale. Dissociation at the time of a combat-related traumatic event was evaluated retrospectively with the modified Dissociative Experiences Questionnaire. The Combat Exposure Scale was used to measure level of combat exposure. RESULTS: There was a significantly higher level of dissociative symptoms, as measured by the Dissociative Experiences Scale, in patients with PTSD (mean = 27.0, SD = 18.0) than in patients without PTSD (mean = 13.7, SD = 16.0). This difference persisted when the difference in level of combat exposure was controlled with analysis of covariance. PTSD patients also reported more dissociative symptoms at the time of combat trauma, as measured retrospectively by the Dissociative Experiences Questionnaire (mean = 11.5, SD = 1.6) than non-PTSD patients (mean = 1.8, SD = 2.1). CONCLUSIONS: Dissociative symptoms are an important element of the long-term psychopathological response to trauma.     

Cerebral function in posttraumatic stress disorder during verbal working memory updating: a positron emission tomography study.

BACKGROUND: This study examined cerebral function in posttraumatic stress disorder (PTSD) during the updating of working memory to trauma-neutral, verbal information. METHODS: Ten PTSD and matched control subjects completed a visuoverbal target detection task involving continuous updating (Variable target condition) or no updating (Fixed target condition) of target identity, with updating activity estimated by condition comparison. RESULTS: Normal updating activity using this paradigm involved bilateral activation of the dorsolateral prefrontal cortex (DLPFC) and inferior parietal lobe. The PTSD group lacked this activation in the left hemisphere and was significantly different from control subjects in this regard, but showed additional activation in the superior parietal lobe, bilaterally. CONCLUSIONS: The pattern of parietal activation suggests a dependence on visuospatial coding for working memory representation of trauma-neutral, verbal information. Group differences in the relative involvement of the DLPFC indicate less dependence in PTSD on the executive role normally attributed to the left DLPFC for monitoring and manipulation of working memory content in posterior regions of the brain.     

Elevated rates of memory impairment in military service-members and veterans with posttraumatic stress disorder

Introduction: Studies investigating the neurocognitive effects of posttraumatic stress disorder (PTSD) routinely find “deficits” in various cognitive domains. However, the rate of cognitive impairment in individuals with PTSD remains unclear, as studies have focused on null hypothesis testing (NHT) and inferring patterns of impairment rather than empirically determining the rate of cognitive impairment in this sample. Method: This study examined rates of cognitive impairment using a domain-specific approach in non-treatment-seeking Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn service members and veterans with (n = 92) and without (n = 79) PTSD and without substance abuse/dependence who passed a performance validity measure and were matched on age, education, estimated IQ, and ethnicity. Chi-square analyses were used to compare the rate of cognitive impairment across groups based on normative scores using three cutoffs (?1, ?1.5, and ?2 SDs). NHT was also used to compare performances across groups. Results: Individuals with PTSD showed higher rates of impairment in memory (?1-SD cutoff) than controls, but equivalent rates of impairment in attention, processing speed, and executive functioning; no significant differences were found on NHT. Impairment in any domain was also more prevalent in PTSD (?1-, ?1.5-, and ?2-SD cutoffs). No differences were found on NHT or rates of impairment in individuals with PTSD with (n = 34) and without (n = 58) depression. Conclusions: Patients with PTSD were more likely to meet criteria for memory impairment and to show impairment in any domain than controls. Patients with PTSD and comorbid depression were no more likely to be impaired in any cognitive domain or to have lower scores on individual cognitive tasks than patients with PTSD alone. Clinicians noting cognitive impairment in individuals with PTSD should exercise caution before ascribing that impairment to another etiology if deficits are limited to memory.     

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.     

Interpersonal trauma, war zone exposure, and posttraumatic stress disorder among veterans with schizophrenia

The present study examined the prevalence of war zone exposure, interpersonal trauma and post-traumatic stress disorder (PTSD) in veterans with primary schizophrenia hospitalized on a VA inpatient psychiatric unit. Data were collected on a sample of male veterans (N=165) with a primary diagnosis of schizophrenia or schizoaffective disorder, who were consecutively admitted to a VAMC inpatient psychiatric unit. The prevalence of interpersonal trauma exposure and comorbid PTSD were assessed. Analyses also explored differences between those patients who had been identified with PTSD to those who screened positive but had not been previously identified as having PTSD. Ninety-six percent of the sample endorsed interpersonal trauma or exposure to a war zone. The prevalence of PTSD was 47% (n=78), although only 14% (n=11) of those who screened positive for PTSD had a diagnosis of PTSD in their medical record. Among those screening positive, having a chart diagnosis of PTSD was associated with more severe PTSD symptoms and combat exposure. Results suggest that PTSD is highly prevalent and under-diagnosed among veterans with schizophrenia. Increased assessment of trauma and PTSD in this population is warranted.     

Complicated grief in Bosnian refugees: associations with posttraumatic stress disorder and depression

Complicated grief is likely to be common among refugee populations exposed to war trauma. However, there have been few studies investigating the traumatic antecedents and correlates of complicated grief in refugees, and the relationship of that symptom pattern with other common disorders such as posttraumatic stress disorder (PTSD) and depression. We studied Bosnian refugees recruited from a community center in Sydney, Australia, with the sample being supplemented by a snowball method (N = 126; response rate, 86%). Measures included a trauma inventory, the Clinician Administered PTSD Scale (CAPS), the depression module of the Structured Clinical Interview (SCID), and the Core Bereavement Items (CBI). A dimension of traumatic loss derived from the trauma inventory was a specific predictor of complicated grief, with exposure to human rights violations being associated with images of the traumatic events surrounding the lost person. There was no link between PTSD and grief other than for a low-order association with the PTSD intrusion dimension. In contrast, depression was strongly associated with grief and its subscales. Only the subgroup with comorbid grief and depression reported higher levels of traumatic loss. The results suggest that complicated grief in refugees can become persistent and associated with depression. While PTSD and grief share common symptoms of intrusion, the two symptom domains are sufficiently distinct to warrant independent assessment of grief in refugee populations.     

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.     

Prevalence of posttraumatic stress disorder in wounded Vietnam veterans

Of 156 wounded Vietnam veterans evaluated for posttraumatic stress disorder (PTSD) by a questionnaire and a diagnostic interview in selected cases, 40% had a definite or probable lifetime diagnosis of PTSD. Of the 27 interviewed patients with lifetime PTSD, 81% currently met the PTSD criteria.     

Psychophysiological correlates of posttraumatic stress disorder in Vietnam veterans

We measured event-related brain potential (ERP) component amplitudes and heart rate (HR) to four intensities of randomly presented tones in two matched groups of drug-free male Vietnam veterans: 12 patients diagnosed with posttraumatic stress disorder (PTSD) and 6 normal combat veterans. Subjects were evaluated with structured diagnostic interviews and anxiety and depression rating scales. We found a significant group X intensity interaction for P2 peak amplitude at CZ. Subjects were classified as augmenters or reducers: positive P2 slopes as a function of stimulus intensity implying augmentation and negative slopes implying reduction. Nine of 12 PTSD subjects were reducers (sensitivity of 75%) and 5 of 6 normals were augmenters (specificity of 83.3%). By the third and fourth second following tone onset, the mean HR of PTSD subjects increased more than twice that of the normals. HR change scores were significantly responsive to the manipulation of stimulus intensity and to the difference between our two groups. P2 reduction differentiates Vietnam veterans with combat-related PTSD from combat veteran controls, and PTSD subjects are more autonomically arousable than their combat veteran peers.