Interpersonal violence and its correlates in Vietnam veterans with chronic posttraumatic stress disorder

Two studies were conducted to investigate interpersonal violence in Vietnam veterans with posttraumatic stress disorder (PTSD). In study one, combat veterans with PTSD reported significantly greater occurrence of violent behaviors over the past year (22 acts) versus combat veterans without PTSD (.2 acts). Combat exposure had an independent positive association with interpersonal violence. In study two, variables related to current interpersonal violent behavior in 118 PTSD combat veterans were evaluated. In rank order of importance, lower socioeconomic status, increased aggressive responding and increased PTSD severity were related to interpersonal violence. These results suggest that combat veterans with PTSD exhibit greater interpersonal violence than combat veterans without PTSD, and that there are multiple factors in this population which determine violent behavior. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53: 859–869, 1997     

Current posttraumatic stress disorder and history of trauma in trichotillomania

Though some researchers and clinicians postulate that trauma and posttraumatic stress disorder (PTSD) may be implicated in the etiologic underpinnings of trichotillomania (TTM), very little research to date has examined such postulations. To address this gap in the literature, the current study assessed the prevalence of trauma and PTSD in 42 individuals seeking treatment for TTM. Relations between symptoms of PTSD and TTM also were examined, as were differences in TTM symptoms between those with and without PTSD. Findings revealed that approximately 76% reported a history of at least one traumatic event, and 19% met criteria for PTSD. Furthermore, negative correlations were demonstrated between symptoms of PTSD and characteristics of TTM, and the PTSD group reported less severe TTM characteristics. Findings suggest that the prevalence of PTSD in TTM may be higher than in the general population and that a history of greater number of types of traumas is associated with a longer duration of hair pulling as well as the scalp as the primary pulling site. The authors also speculate that in traumatized individuals, TTM may represent a form of coping vis-à-vis self-soothing or self-harm.     

A cluster analysis of symptom patterns and adjustment in Vietnam combat veterans with chronic posttraumatic stress disorder

This study investigated whether a subgroup of veterans with malignant posttraumatic stress syndrome, as described by Rosenheck (1985) and Lambert et al. (1996), could be identified via cluster analysis within two samples of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD). In the initial subsample (n = 157), four clusters were identified, including a subgroup that scored consistently higher on measures of interpersonal violence and current physical problems. Similar results were found in the cross-validation subsample (n = 156). These results provide support for the theoretical concept of malignant PTSD and suggest that veterans with chronic PTSD are not homogenous. Whereas some manifest extreme levels of both functional impairment and PTSD symptomatology, others exhibit markedly less functional impairment despite manifesting clinically significant levels of PTSD. Clinicians can consider this heterogeneity in their treatment decisions.     

Psychosocial buffers of traumatic stress,depressive symptoms,and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom: The role of resilience,unit support,and postdeployment social support

BackgroundLittle research has examined the role of protective factors such as psychological resilience, unit support, and postdeployment social support in buffering against PTSD and depressive symptoms, and psychosocial difficulties in veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF).Materials and methodsA total of 272 OEF/OIF veterans completed a survey containing PTSD and depression screening measures, and questionnaires assessing resilience, social support, and psychosocial functioning.ResultsLower unit support and postdeployment social support were associated with increased PTSD and depressive symptoms, and decreased resilience and psychosocial functioning. Path analyses suggested that resilience fully mediated the association between unit support and PTSD and depressive symptoms, and that postdeployment social support partially mediated the association between PTSD and depressive symptoms and psychosocial functioning.LimitationsGeneralizability of results is limited by the relatively low response rate and predominantly older and reserve/National Guard sample.ConclusionsThese results suggest that interventions designed to bolster unit support, resilience, and postdeployment support may help protect against traumatic stress and depressive symptoms, and improve psychosocial functioning in veterans.     

Role and treatment of early maladaptive schemas in vietnam veterans with PTSD

The role of early maladaptive schemas in understanding and treating post‐traumatic stress disorder (PTSD) was investigated. The first study examined the role of perceived adverse parenting and early maladaptive schemas in the development of PTSD in Australian and New Zealand Vietnam war veterans (n = 220). Veterans diagnosed with PTSD scored higher on the Young Schema Questionnaire (L3) and had higher scores on the Measure of Parental Style than veterans not diagnosed with PTSD. The results suggest that early maladaptive schemas have an important role in the development or maintenance of PTSD in Vietnam veterans. The second study measured at baseline, termination and 3 months the early maladaptive schemas, PTSD, anxiety and depression of war veterans (n = 54) participating in a PTSD group treatment programme that included schema‐focused therapy. Scores on the PTSD Checklist, the Hospital Anxiety and Depression Scale, and 17 schemas decreased significantly after treatment. Change scores for the schema treatment were compared with change scores of war veterans (n = 127) who had completed a manualized cognitive–behavioural therapy programme without schema‐focused therapy. Pre‐treatment measures were similar in both groups. Nevertheless, PTSD and anxiety improved more significantly for the schema‐focused therapy group. Together, these findings support the feasibility of schema‐focused therapy to assist veterans with PTSD. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message:

• War veterans with PTSD may have high levels of early maladaptive schemas.
• Early maladaptive schemas, possibly arising from adverse parenting, may be a vulnerability factor for PTSD.
• Addressing early maladaptive schemas, with schema‐focused therapy, should be considered within PTSD treatment programmes.

     

Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch Resistance veterans from World War II.

The extraordinary trauma experienced by Resistance veterans from World War II (WW II) and other veterans may be associated with an increased incidence of posttraumatic stress disorder (PTSD) and somatic morbidity, including cardiovascular disease (CVD). This study explored some relationships between current PTSD and CVD risk factors in 147 male Dutch WW II Resistance veterans. They were compared to 65 same-aged male patients with a recent myocardial infarction and 79 surgical patients. Of these subjects, WW II Resistance veterans scored highest on CVD risk factors (i.e., angina pectoris, type A behavior, life stressors, and vital exhaustion), except smoking. Fifty-six percent of these veterans were currently suffering from PTSD. They reported CVD risk factors, in particular type A behavior and vital exhaustion, more often than veterans without PTSD; they also reported more premorbid adverse living conditions. These data suggest that early sensitization to environmental stressors may be associated with a high prevalence of current PTSD and excess CVD risk factors in subjects exposed to extraordinary war-time trauma and that this may lead to vital exhaustion.     

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

Objectives

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

Methods

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

Results

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

Conclusions

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.     

Attachment organization in Vietnam combat veterans with posttraumatic stress disorder

Attachment organization in a combat-related PTSD sample was investigated and compared with previously published clinical and non-clinical samples. The association between insecure attachment and unresolved mourning classification (U-loss) and between U-loss and PTSD symptoms was investigated. Vietnam combat veterans diagnosed with PTSD and in treatment (N = 48) were administered the Adult Attachment Interview, the SCID-IV, and CAPS. The PTSD sample was like non-clinical samples in the incidence of secure attachment (50%), but were more commonly unresolved. Veterans with insecure attachment organizations were more likely than those with secure attachment to be classified U-loss. U-loss classification was associated with greater likelihood of comorbid anxiety disorders and PTSD avoidance/numbing symptoms. The results suggest that while insecure attachment organization is associated with unresolved mourning in response to loss, it is not differentially associated with combat-related PTSD. The relationship between U-loss and PTSD is discussed in light of current literature.     

Olfactory identification dysfunction, aggression and impulsivity in war veterans with post-traumatic stress disorder

BACKGROUND: Due to neuropsychological conceptualizations of orbitoprefrontal cortex (OFC) dysfunction underpinning impulsive aggression and the incidence of such behaviour in post-traumatic stress disorder (PTSD), this study aimed to explore olfactory identification (OI) ability in war veterans with PTSD as a probe of putative OFC dysfunction; and to explore the utility of OI ability in predicting aggressive and impulsive behavior in this clinical population.METHOD: Participants comprised 31 out-patient male war veterans with PTSD (mean=58.23 years, s.d.=2.56) recruited from a Melbourne Veterans Psychiatry Unit, and 31 healthy age- and gender-matched controls (mean=56.84 years, s.d.=7.24). All participants were assessed on clinical measures of PTSD, depression, anxiety, and alcohol misuse; olfactory identification; neurocognitive measures of dorsolateral prefrontal, lateral prefrontal and mesial temporal functioning; and self-report measures of aggression and impulsivity. RESULTS: War veterans with PTSD exhibited significant OI deficits (OIDs) compared to controls, despite uncompromised performance on cognitive measures. OIDs remained after covaring for IQ, anxiety, depression and alcohol misuse, and were significant predictors of aggression and impulsivity. CONCLUSIONS: This research contributes to emerging evidence of orbitoprefrontal dysfunction in the pathophysiology underlying PTSD. This is the first study to report OIDs as a predictor of aggression and impulsivity in this clinical population. It prompts further exploration of the potential diagnostic utility of OIDs in the assessment of PTSD. Such measures may help delineate the clinical complexity of PTSD, and support more targeted interventions for individuals with a greater susceptibility to aggressive and impulsive behaviors.     

Quantitative electroencephalography during rapid eye movement (REM) and non‐REM sleep in combat‐exposed veterans with and without post‐traumatic stress disorder

Sleep disturbances are a hallmark feature of post‐traumatic stress disorder (PTSD), and associated with poor clinical outcomes. Few studies have examined sleep quantitative electroencephalography (qEEG), a technique able to detect subtle differences that polysomnography does not capture. We hypothesized that greater high‐frequency qEEG would reflect ‘hyperarousal’ in combat veterans with PTSD (n = 16) compared to veterans without PTSD (n = 13). EEG power in traditional EEG frequency bands was computed for artifact‐free sleep epochs across an entire night. Correlations were performed between qEEG and ratings of PTSD symptoms and combat exposure. The groups did not differ significantly in whole‐night qEEG measures for either rapid eye movement (REM) or non‐REM (NREM) sleep. Non‐significant medium effect sizes suggest less REM beta (opposite to our hypothesis), less REM and NREM sigma and more NREM gamma in combat veterans with PTSD. Positive correlations were found between combat exposure and NREM beta (PTSD group only), and REM and NREM sigma (non‐PTSD group only). Results did not support global hyperarousal in PTSD as indexed by increased beta qEEG activity. The correlation of sigma activity with combat exposure in those without PTSD and the non‐significant trend towards less sigma activity during both REM and NREM sleep in combat veterans with PTSD suggests that differential information processing during sleep may characterize combat‐exposed military veterans with and without PTSD.     

A comparison of MMPI and MMPI-2 in PTSD assessment

A sample of 47 Vietnam veterans with the diagnosis of combat-related Post-Traumatic Stress Disorder (PTSD) was administered the MMPI and MMPI-2. Pairwise comparisons were performed on the clinical scales, Harris Lingoes subscales, and scales relevant to the assessment of PTSD. Correlational analyses were performed as well. Hit rates of high-point pairs were compared across the tests. The results suggest a high degree of congruence between tests. Differences were seen on evaluations of some scales between tests that may influence interpretation and treatment.     

Combat-related post-traumatic stress disorder etiology: replicated findings in a national sample of Vietnam-era men

To examine the generality of recent findings on PTSD etiology in help-seeking Vietnam combat veterans, replication was attempted with data from a national study of Vietnam-era men that included combat veterans. Use of a Guttman scaling technique for assessing combat exposure was found to be robust for use with a national nonclinical sample as well. In addition, multiple regression analysis was used to examine predictive relationships between premilitary adjustment, military adjustment, combat exposure, and post-traumatic stress disorder (PTSD). Results obtained from the national sample showed the same patterning as that reported from the smaller clinical sample. Combat exposure was related significantly to PTSD symptomatology, while premilitary adjustment was not. A previously identified discriminant function, composed of psychological symptoms not found in the DSM III criteria for PTSD, also was cross-validated.     

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.     

The interaction of posttraumatic stress disorder and depression among older combat veterans

The question whether depression is related to trauma as part of posttraumatic stress disorder (PTSD) itself or whether it represents autonomous symptoms occurring separately (from PTSD) has not been answered. We addressed two issues: (a) What is the relationship between PTSD and depression as measured by continuous measures on outcomes? and (b) By removing depression components from the PTSD diagnosis, what is the impact on standard outcomes? Older veterans from World War II or Korea were interviewed and given self-report measures on PTSD and depression. The CAPS-1 and the MMPI-D were used as the continuous measures for PTSD and depression. The outcome measures were health status, overall adjustment, social support, and physiological status. Results showed that depression influenced health status and social support: PTSD did not contribute to the equation. The CAPS-1 also was further divided into CAPS-PTSD and CAPS-D (depression) based on item content. For adjustment and health status, PTSD asserted a greater influence; for social support and heart rate, depression was the greater influence. Discussion addressed the fact that depression is an important consideration in the expression of PTSD.     

Relationship between scores on anger measures and PTSD symptomatology,employment, and compensation-seeking status in combat veterans

The interrelationship between the theoretically related constructs of anger and posttraumatic stress disorder (PTSD) symptoms was examined in a group of 42 combat veterans with PTSD using a multimeasure assessment strategy. Scores on several anger measures were found to be quite high in this sample and were significantly correlated with PTSD symptomatology. Furthermore, anger measures were found to be related to employment status independent of PTSD severity, but were not related to disability compensation-seeking status. Clinicians are advised to be aware of the potential implications for physical health and interpersonal functioning, and to incorporate anger management strategies into treatment plans for this population. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53: 871–878, 1997     

Attachment organization in Vietnam combat veterans with posttraumatic stress disorder

Attachment organization in a combat-related PTSD sample was investigated and compared with previously published clinical and non-clinical samples. The association between insecure attachment and unresolved mourning classification (U-loss) and between U-loss and PTSD symptoms was investigated. Vietnam combat veterans diagnosed with PTSD and in treatment (N = 48) were administered the Adult Attachment Interview, the SCID-IV, and CAPS. The PTSD sample was like non-clinical samples in the incidence of secure attachment (50%), but were more commonly unresolved. Veterans with insecure attachment organizations were more likely than those with secure attachment to be classified U-loss. U-loss classification was associated with greater likelihood of comorbid anxiety disorders and PTSD avoidance/numbing symptoms. The results suggest that while insecure attachment organization is associated with unresolved mourning in response to loss, it is not differentially associated with combat-related PTSD. The relationship between U-loss and PTSD is discussed in light of current literature.     

Applying posttraumatic stress disorder MMPI subscale to World War II POW veterans

In order to determine whether the MMPI-PTSD subscale has application for assessing DSM-III diagnosed PTSD among populations other than Vietnam veterans, a group of WWII POWs (N = 69) were given the subscale. Results indicated that the use of the PTSD subscale can be generalized to older veterans; in a small sample of Pacific POWs, PTSD is more common among those from the Pacific theater than those from Europe. However, the subscale fails to distinguish between Pacific and European POW veterans. Difficulties in sampling and confounding stressors are discussed, as well as implications for treatment of WWII veterans.     

Key determinants of the MMPI-PTSD subscale: treatment considerations

Seventy-five "in country" Vietnam combat psychiatric inpatients were given a battery of measures upon admission to the medical center. These included the MMPI, VETS Adjustment Scale, State-Trait Anxiety Scale, Rotter Locus of Control, Profile of Mood Scale, and a variation of the Figley Stress Scale that measures current stress. Post-traumatic stress disorder (PTSD) was determined by the MMPI-PTSD subscale. Ten of the battery variables were used as predictors for a multiple regression analysis on the MMPI-PTSD subscale. Results yielded a multiple R of .89 for two predictors, Figley Stress Scale and Rotter Locus of Control (external). Patients with PTSD, therefore, suffer most from perceived and experienced current stressors and a low sense of control. Arguments are made for more present-centered and interpersonal strategies in the treatment of PTSD combat veterans.     

An examination of family adjustment among Operation Desert Storm veterans

This study examined interrelationships among combat exposure, symptoms of posttraumatic stress disorder (PTSD), and family adjustment in a sample of male and female Operation Desert Storm veterans (N = 1,512). In structural equation models for both male and female veterans, higher combat exposure was associated with higher PTSD symptoms, which in turn were associated with poorer family adjustment, although these indirect effects did not reach statistical significance. The model for female veterans evidenced a significant direct negative association between combat exposure and family adjustment when it statistically accounted for PTSD symptoms. When the relative impacts of separate PTSD symptom groupings were examined, those reflecting withdrawal/numbing symptoms and arousal/lack of control symptoms significantly and indirectly accounted for the negative effects of combat exposure on family adjustment. Study findings indicate a number of possible pathways through which war-zone deployments negatively impact military families and suggest several avenues for future research.