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.     

Shame, guilt, self-hatred and remorse in the psychotherapy of Vietnam combat veterans who committed atrocities

The soldiers who perpetrated atrocities during the Vietnam War are a group much less studied than the victims of violence during peacetime. These soldiers were catalyzed by war to express a darker side of their humanity, a side that our society often chosses to ignore. At some level their experiences relate to us all. In the future more young men and, probably young women, will be sent to war. Once they have been transformed by military training and the hellish conditions of war, society tends to forget them--to leave them wandering in a no man's land of their own tortured thoughts and feelings. We need to understand more about how such transformations of the self beset our returning soldiers. And, once this has happened, we need to know how to help them reintegrate into society and reconnect with others in a meaningful way. A psychotherpy that embraces the patient's need to express remorse is necessary in order to help these patients work through their guilt and self-hatred. These are the main objectives of treatment.     

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.     

État des lieux et horizon du soin psychique des blessés de guerre

ObjectivesThe changing nature of armed conflicts lead the defence community to confront new challenges. Deployed in either internal or external missions, soldiers are subjects to many constraints which test their mental and physical limits, and are exposed to unsafe situations which can become potentially traumatic. This psychological impact is a constant concern for Army's Health Service as well as for Commandment. Mental health specialists’ intervention in military environment had to adapt to soldiers and battle group's needs in accordance with the evolution of conflicts themselves.Patients or materials and methodsLessons learned from armed conflicts participated in structuring of medical and psychological support, forming part of a continuum before, during and after the mission. In that context, battlefield psychiatric care's doctrine has been developed around the following founding principles: immediacy, proximity, simplicity, expectative, and non-obligation to return to battle. Classically, immediate phase is time for first aid, which is the only possible on the full forward war zone. Then, when fighting time is over and soldiers are in a secure space, the defusing, literally “psychological shock treatment”, engages in first dialogue after an experience which can be assimilated to a subjective disaster. This dialogue can re-establish a link of humanity with persons whose world perception might have been devastated. À few days after the potentially traumatic event, the post-immediate phase urges the caregivers in identifying disorders to provide a more structured care. It's the time of medico-psychological debriefing which can be either individual or collective. Beyond this phase, care is organized according to a coherent healthcare system, from the operational theatre to mainland, based on a network of mental health actors.ResultsIn this way, psychiatrists on mission provide an approachable and receptive presence which allows soldiers to express their pain in an individual or collective address, and therefore permit engagement on battlefield. The main risk for soldiers is to be injured, whether physically or psychologically, and justify a constant attention from health-care providers towards them.ConclusionsIndeed, we can see that battle wound has an influence on relationships between an individual and his environment which highlights one of the main challenges in mental healthcare, that in addition to the identification of postraumatic suffering involves in therapeutic continuity of the relationship with individual. Finally, consistency of care is organized around a multidisciplinary which requires an institutional work of rehabilitation fully participating in supporting injured persons.     

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.     

Combat stress reactions, posttraumatic stress disorder, and social adjustment. A study of Israeli veterans

This study assessed social functioning among three groups of Israeli soldiers: a) front-line soldiers who had been treated for combat stress reaction during the 1982 Lebanon war (N = 382); b) matched control front-line soldiers who did not sustain combat stress reaction (N = 334); and c) combat-ready soldiers who did not participate in the 1982 war (N = 88). Subjects were screened 1 year after the war for posttraumatic stress disorder and social functioning. Results indicated that participation in combat per se did not have adverse effects on postwar social functioning. However, combat stress reactions and posttraumatic stress disorder were found to be associated with a decline in postwar social functioning. The practical and theoretical implications of these findings were discussed.     

An assessment of beliefs about mental health care among veterans who served in Iraq

OBJECTIVE: This study assessed beliefs about mental health treatment in a group of soldiers newly returning from the war in Iraq. METHODS: Participants were 20 National Guard soldiers who had served in Operation Iraqi Freedom. Soldiers who in phone interviews screened positive for a mental disorder were asked about advantages and disadvantages of seeking treatment, who would or would not support treatment seeking, and facilitators and barriers to treatment seeking. RESULTS: Stigma was portrayed as a major disadvantage to treatment seeking. Yet most participants indicated that people would be supportive of treatment seeking. Reducing symptoms was a major advantage of care. Barriers, especially those viewed as "self-induced," such as pride, not being able to ask for help, and not being able to admit to having a problem, were considered major impediments. CONCLUSIONS: The findings suggest that interventions developed to engage veterans in care must be directed toward cognitive factors that motivate treatment seeking.     

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.     

Les thérapies par l’hypnose dans les armées,quelques jalons dans l’histoire

About 1790, the three Puységur brothers, officers in the French Army, treated soldiers by magnetism or artificial somnambulism. Later, about 1880, Bernheim and Charcot explored under hypnosis soldiers shocked by combat. In 1885, when applying hypnosis to the soldier Louis V., the two navy psychiatrists Bourru and Burot were the first to discover the pathogenic part of the traumatic memories buried in the unconscious. Later, during the two mondial wars, hypnosis was used for the treatment of war neuroses. In present time, hypnosis and para-hypnotic relaxation are sometimes used for treating war traumas.     

Plasma neuropeptide-Y concentrations in humans exposed to military survival training.

BACKGROUND: Neuropeptide-Y (NPY) is present in extensive neuronal systems of the brain and is present in high concentrations in cell bodies and terminals in the amygdala. Preclinical studies have shown that injections of NPY into the central nucleus of the amygdala function as a central anxiolytic and buffer against the effects of stress. The objective of this study was to assess plasma NPY immunoreactivity in healthy soldiers participating in high intensity military training at the U.S. Army survival school. The Army survival school provides a means of observing individuals under high levels of physical, environmental, and psychological stress, and consequently is considered a reasonable analogue to stress incurred as a result of war or other catastrophic experiences. METHODS: Plasma levels of NPY were assessed at baseline (prior to initiation of training), and 24 hours after the conclusion of survival training in 49 subjects, and at baseline and during the Prisoner of War (P.O.W.) experience (immediately after exposure to a military interrogation) in 21 additional subjects. RESULTS: Plasma NPY levels were significantly increased compared to baseline following interrogations and were significantly higher in Special Forces soldiers, compared to non-Special Forces soldiers. NPY elicited by interrogation stress was significantly correlated to the subjects' behavior during interrogations and tended to be negatively correlated to symptoms of reported dissociation. Twenty-four hours after the conclusion of survival training, NPY had returned to baseline in Special Forces soldiers, but remained significantly lower than baseline values in non-Special Forces soldiers. NPY was positively correlated with both cortisol and behavioral performance under stress. NPY was negatively related to psychological symptoms of dissociation. CONCLUSIONS: These results provide evidence that uncontrollable stress significantly increases plasma NPY in humans, and when extended, produces a significant depletion of plasma NPY. Stress-induced alterations of plasma NPY were significantly different in Special Forces soldiers compared to non-Special Forces soldiers. These data support the idea that NPY may be involved in the enhanced stress resilience seen in humans.     

Mental health outcome of unilateral lower limb amputee soldiers in two districts of Sri Lanka

BACKGROUND: Thousands of armed forces personnel in Sri Lanka have undergone lower limb amputations due to war injuries. AIMS: The aims were to describe the mental health outcome of unilateral lower limb amputee male soldiers of the Sri Lanka Army in comparison with nonamputee males and to identify factors affecting the mental health outcome. METHODOLOGY: Selected amputee soldiers (n = 461) and controls (n = 461) were evaluated for psychological distress using self-administered versions of GHQ-30 and BSI. Alcohol and drug consumption patterns were compared. Probable addiction to alcohol and drugs were assessed using the CAGE questionnaire. RESULTS: A majority were below-knee amputees (413, 89.6%). Among amputee soldiers 36% were found to be psychologically distressed according to GHQ-30 while 13.4% were found to be psychologically distressed using BSI. Psychological distress was greater among amputee soldiers compared to controls (p < 0.001). Alcohol consumption and substance abuse were more common among amputees (p < 0.05), as was probable addiction to alcohol (p < 0.001). Being less than 30 years of age (OR =1.6, 95% CI (1.12-2.26)) was a factor influencing presence of psychological distress, characterized by psychological symptoms. Employment in the army adversely influenced psychological distress, characterized by psychological symptoms (OR = 2.35, 95% CI (2.0-3.64)) and by somatic symptoms (OR = 1.8, 95% CI (1.23-3.14)). CONCLUSIONS: The study concluded that amputees have a comparatively poor mental health outcome, which could be improved by modifying some associated factors.     

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.     

The psychosocial consequences for children of mass violence, terrorism and disasters

Children and families are now in the front line of war, conflict and terrorism as a consequence of the paradigm shift in the nature of warfare and the growth of terror as a weapon. They are as vulnerable as are adults to the traumatizing effects of violence and mass violence. Furthermore, employing children as soldiers is not new, but it is continuing and young people are also perpetrators of other forms of violence. This paper summarizes a selection of the literature showing the direct and indirect psychosocial impacts on minors of their exposure to single incident (event) and recurrent or repetitive (process) violence. Additionally, children's psychosocial and physical development may be affected by their engagement with violence as victims or perpetrators. Several studies point to positive learning from certain experiences in particular communities while many others show the potential for lasting negative effects that may result in children being more vulnerable as adults. The spectrum of response is very wide. This paper focuses on resilience but also provides access to several frameworks for planning, delivering and assuring the quality of community and family-orientated and culture-sensitive responses to people's psychosocial needs in the aftermath of disasters of all kinds including those in which children and young people have been involved in mass violence.     

The prognosis of psychiatric treatment in military service

Summary The author discusses the outcome of psychiatric treatment in the Military. He served as a military psychiatrist in Norway for one year. During this time he personally examined and treated 215 soldiers with psychiatric disorders. The diagnostic composition of the patient group and the treatment given are described. The patient material was again examined at the end of the military service period, when one-third of the patients had been found unfit for service. The remainder were still fit for service. The patients did not differ from soldiers in general from a disciplinary point of view. However, they did not achieve as good grades in personal conduct and military efficiency as the other soldiers. The patients' clinical picture at the follow-up examination had improved when compared to the initial psychiatric examination. The author concludes that psychiatric treatment in the Military is both possible and desirable.     

Trauma and post-traumatic stress symptoms in former German child soldiers of World War II

ABSTRACTBackground: The aim of the study was to determine the amount of trauma impact and significant post-traumatic stress symptoms, which can indicate a possible post-traumatic stress disorder (PTSD), in a sample of former German child soldiers of World War II.Methods: 103 participants were recruited through the press, then administered a modified Post-traumatic Diagnostic Scale (PDS).Results: Subjects reported a high degree of trauma exposure, with 4.9% reporting significant post-traumatic stress symptoms after WW II, and 1.9% reporting that these symptoms persist to the present.Conclusion: In line with other studies on child soldiers in actual conflict settings, our data document a high degree of trauma exposure during war. Surprisingly, the prevalence of significant post-traumatic stress symptoms indicating a possible PTSD was low compared to other groups of aging, long-term survivors of war trauma. Despite some limitations our data highlight the need for further studies to identify resilience and coping factors in traumatized child soldiers.     

驻舰艇军人心理状况与人格特征的相关研究

目的:探讨驻舰艇军人心理健康状态及相关因素。方法:采用症状自评量表(SCL-90)、艾森克人格问卷(EPQ)评估海军某水面舰艇200名驻舰航行(长航)前后的心理健康状况。结果:长航前,除人际关系因子外,驻舰军人SCL-90总分及其他因子分均较男性军人常模显著低(P<0.01)。长航后SCL-90总分及各因子分均有所提高,其中总分、躯体化、焦虑、恐惧及精神病性因子分变化有统计学意义(P<0.05或P<0.01)。驻舰军人EPQ各分量表得分与男性常模比较差异均无显著性(P均>0.05)。SCL-90各因子分与EPQ精神质、神经质呈显著正相关(P<0.01),与掩饰性呈显著负相关(P<0.01);而人际关系、抑郁、恐惧因子分与内外向呈负相关(P<0.05或P<0.01)。结论:驻舰军人心理健康水平较好。人格特征与应激状态下心理健康水平关系密切。     

Représentations de la Seconde Guerre mondiale dans le cinéma japonais (de Kon Ichikawa)

“If psychiatry had not existed, the movies would have had to invent it. And in a sense they did”, wrote Irving Schneider in the foreword to the excellent book by Krin and Glen Gabbard, Psychiatry and the Cinema. For this session of the Société Médico-Psychologique focusing on Cinema and Psychiatry, opportunistically “delocalized” at the misfit theatre called Le Brady, we wanted to present two masterpieces of the Japanese director Kon Ichikawa. These two powerful war stories, The Burmese Harp and Fires on the Plain illustrate the fascinating dialogue between movies and psychiatry, specifically in this case around war trauma and its consequences. “While Ozu depicted the consequences of war on contemporary 1950 Japan, Ichikawa remained stuck on the last weeks of agony of 1945… Ozu's films begin where those of Ichikawa end”, wrote Serge Kaganski in the Inrocks in 1994, when the Parisian public was able to discover Kon Ichikawa's movies. Of course, we could have chosen to rather “psycho”-analyze Godzilla, this terrible monster awaken from his deep prehistoric sleep by the Bikini atomic explosions and appearing for the first time on Japanese screens in 1954 as a metaphor of the horror of Hiroshima and Nagasaki, and as a subtle criticism of the US presence in Japan, nine years after the end of the war. We should not forget that King Kong against Godzilla (1962) directed by Inoshiro Honda was part of the Brady unconventional program. Kon Ichikawa was discovered by the majority of the Occidental public in 1960, when he received in Cannes the Jury's Prize for his film Kagi (The strange obsession) together with Antonioni for L’Avventura while the Palme d’Or was awarded to Fellini for La Dolce Vita. Kon Ichikawa, Japanese filmmaker (1915–2008) began his career as a cartoonist. Considered as the tenant of a rather commercial school, Ichikawa directed numerous films, more than fifty, not all always well received by the critics. However, we concur with Max Tessier who in his book Images of the Japanese cinema, states “to see several of his films, you realize that there is in some of his movies a true Ichikawa's ‘eye’, mix of black humor and cinematographic entomology” (indeed Ichikawa depicts some of his main characters as helpless insects), and a very recognizable aesthetic, especially in his films in cinemascope. His first films were satirical comedies, scratching the moral conventions of the Japanese cinema. Then came more drama and deep movies, especially three masterpieces, two great war films, The Burmese Harp in 1956, Fires on the Plain in 1959 and Kagi (The strange obsession) presented and awarded at the Cannes festival in 1960. The characters painted by Ichikawa are not the typical “heros” but individuals lost in a quest of an absurd goal, often isolated, like the two soldiers of his two war films, The Burmese Harp and Fires on the Plain. In Les Carabiniers, Jean-Luc Godard reminds us the true nature of war: (in war…) “there is no victory, there are only flags and men falling”. In these two war films, Ichikawa is far from lecturing us, and far from an alleged exaltation of the values of feudal Japan like what was reproached to his first film by the US censorship. Kon Ichikawa personal aesthetic develops on screen an almost clinical vision of the traumatic destinies of two Japanese soldiers, caught in chaos, lost in the middle a disorganized mass of soldiers. Interestingly, we would suggest to watch these two movies in a row, as they are at the same time so similar and so different, like a kind of construct in mirror, the second prolonging the first in a vertiginous horror. They are quite similar in the sense that they are both depicting the destiny of an anti-hero, a Japanese soldier defeated at the end of the Second World War. But they differ totally aesthetically, to the classical academic format of Buddhist meditation of The Burmese Harp, responds the crude cinemascope format of the Fires on the Plain, using the black and white to emphasize the horror, the unspeakable, the unbearable, making in my opinion Fires on the Plain one of the greatest war movies. This cinematographic artwork reflects the true creative qualities of Kon Ichikawa i.e. the Ichikawa's eye… The Burmese Harp is his last work before switching to cinemascope, which was introduced relatively late in Japan, only in 1957. The classic cinematographic format throughout the film instils a slow pace that drives Mizushima the musician soldier in his journey towards Buddhism. Taken prisoner with what remains of his company, Mizushima is sent by his commanding officer, at the request of the British allied forces, to convince a few soldiers isolated in a cave of the futility of their resistance in front of the British guns. Mizushima manages to reach these survivors but they consider him a traitor, honor ordering them to die in battle but not surrender. Mizushima will only be saved from their violence by the British bombs. Only survivor to rise, he finally collapsed under the Burmese sun. This is his first step of his initiatory journey to Buddhism, that has somewhat been announced by Ichikawa portraying the soldier Mizushima with unusual artistic qualities. The second step is the encounter with a monk who will help him to survive and heal. Finally, Mizushima, considered dead by his comrades, becomes a monk to save the souls of his fellow soldiers, and decides to stay in Burma to give burial to all the dead Japanese soldiers whose bodies cover the beaches and woodland of Burma, and thus to cleanse the shame of the war. In contrast to this Buddhist fable, Fires on the Plain also shows defeated Japanese soldiers exiled this time in the Philippines, and again, through an anti-hero, the soldier Tamura, expelled from his unit because of his tuberculosis, but not sick enough to be admitted to the military hospital, and finally isolated in a mass of wandering soldiers with no goal. By adapting one of the masterpieces of the literature of war, the Fires (Nobi) of Shôhei Ooka, Ichikawa subtly uses the cinemascope to depict with absolute darkness the horror, the deprivation, the degradation, and the unspeakable. In Fires on the Plain, rain and mud, light and shadow exhibit an incredible cinematographic beauty, even when the horror is such that it could become gore, especially when Tamura discovers the true nature of monkey meat that his comrades pretend eating, or when the same Tamura witnesses the murder of a tyrannical sergeant by the young soldier forced to kill “monkeys”, murder followed by strange cannibalistic ritual by this young soldier on the body of his commanding officer. We will not make any psychopathological analysis of the two soldiers depicted by Ichikawa, but we recommend you to see The Burmese Harp and Fires on the Plain, to let you choose to be either a psychiatrist or an entomologist to analyze the destinies of Mizushima, the soldier/bonze and Tamura, cannibal against his will. Let's conclude with Samuel Fuller, who served in the First US Infantry Division during World War II, the famous Big Red One (and who actually directed the eponymous film): “War is barbarous, cannibalistic, barbaric as The Burmese Harp and cannibalistic as Fires on the Plain…”     

The psychosocial consequences for children of mass violence,terrorism and disasters

Children and families are now in the front line of war, conflict and terrorism as a consequence of the paradigm shift in the nature of warfare and the growth of terror as a weapon. They are as vulnerable as are adults to the traumatizing effects of violence and mass violence. Furthermore, employing children as soldiers is not new, but it is continuing and young people are also perpetrators of other forms of violence. This paper summarizes a selection of the literature showing the direct and indirect psychosocial impacts on minors of their exposure to single incident (event) and recurrent or repetitive (process) violence. Additionally, children's psychosocial and physical development may be affected by their engagement with violence as victims or perpetrators. Several studies point to positive learning from certain experiences in particular communities while many others show the potential for lasting negative effects that may result in children being more vulnerable as adults. The spectrum of response is very wide. This paper focuses on resilience but also provides access to several frameworks for planning, delivering and assuring the quality of community and family-orientated and culture-sensitive responses to people's psychosocial needs in the aftermath of disasters of all kinds including those in which children and young people have been involved in mass violence.     

Themes of mistrust and the posttraumatic stress disorder in Vietnam veterans

The attitude of mistrust can frequently be observed in survivors of massive trauma, and is particularly pronounced in Vietnam combat veterans. Three interrelated factors that lead to mistrust are described. They are: the harsh realities of fighting in this guerrilla war, society's negative responses to the men after their return, and the psychosocial development of late-adolescent soldiers. When the attitude of cynicism predominates, the psychotherapeutic treatment more clearly focuses on adolescent themes of idealization and disillusionment. Two case studies with pronounced attitudes of mistrust are presented. The first case highlights the special difficulties of working with the veteran who is also profoundly cynical. The second case describes the defensive function that mistrust can serve by keeping out of awareness the images the veteran had of himself prior to the war. The data obtained from the veterans' respective dreams were especially useful in the diagnosis and treatment.