Post-traumatic stress disorder in Hispanic Vietnam veterans. Clinical phenomenology and sociocultural characteristics

The complex symptomatology of Hispanic Vietnam veterans receiving treatment for post-traumatic stress disorders (PTSD) was explored with the National Institute of Mental Health Diagnostic Interview Schedule, a structured diagnostic interview that yields current and lifetime operational diagnoses (e.g., DSM-III). Social networks and level of acculturation of these veterans were also examined and compared to those of a "control" group and a sample of veterans with DSM-III schizophrenic disorder (both samples included only Hispanic veterans from the Vietnam and post-Vietnam eras). All subjects reported heavy combat stress and met DSM-III criteria for PTSD. Most were very symptomatic and had significant social impairment. PTSD was rarely seen as a discrete entity but appeared instead mixed with symptom clusters cutting across various DSM-III diagnoses. Social networks of PTSD veterans were intermediate in size, frequency of contact with network members, and network density to those of the comparison groups. A distinctive feature of the PTSD group was the high proportion of negative relationships with close family members, especially spouses. "Highly" symptomatic PTSD veterans reported significantly smaller networks, fewer contacts outside the close family circle, and more negative emotionality directed toward family members than "minimally" symptomatic veterans. While all Hispanic groups studied were not significantly different in level of acculturation, PTSD veterans appeared more alienated from their cultural heritage than the other groups. The severe and polymorphous psychopathology found among these veterans suggests that "rap" groups alone may not constitute an adequate therapeutic approach and that more formal psychiatric therapies should be additionally considered in the management of Vietnam-linked PTSD.     

Functional somatic symptoms: a cross-ethnic comparison.

Type, distribution, and comorbidity of functional somatic symptoms were examined in four community samples, three Hispanic and one non-Hispanic white. Important intergroup and intragroup differences between Hispanic and non-Hispanic white groups were identified. Of the four groups, Puerto Rican respondents reported the highest level of somatic symptoms; this finding was apparently independent of sociodemographic factors.     

Ethnic and racial differences in clinically relevant symptoms in active duty military personnel with posttraumatic stress disorder

Previous research has shown racial/ethnic differences in Vietnam veterans on symptoms related to posttraumatic stress disorder (PTSD). The current study explored racial/ethnic differences in PTSD symptoms and clinically relevant symptoms. Resilience and social support were tested as potential moderators of racial/ethnic differences in symptoms. The sample included 303 active duty male service members seeking treatment for PTSD. After controlling for age, education, military grade, and combat exposure, Hispanic/Latino and African American service members reported greater PTSD symptoms compared to non-Hispanic White service members. Higher alcohol consumption was endorsed by Hispanic/Latino service members compared to non-Hispanic White or African American service members, even after controlling for PTSD symptom severity. No racial/ethnic differences were found with regard to other variables. These results suggest that care should be made to thoroughly assess PTSD patients, especially those belonging to minority groups, for concurrent substance use problems that may impede treatment utilization or adherence.     

Psychotic symptoms in combat-related posttraumatic stress disorder

BACKGROUND: Posttraumatic stress disorder (PTSD) is known often to be comorbid with other anxiety, mood, and substance use disorders. Psychotic symptoms have also been noted in PTSD and have been reported to be more common in Hispanic veterans. However, the occurrence of psychotic symptoms, including the degree to which they are accounted for by comorbid disorders, have received limited systematic investigation. Our study objectives were to assess psychotic symptoms according to DSM-III-R criteria in patients with a primary diagnosis of combat-related PTSD and determine the associations of those symptoms with psychiatric comorbidity and ethnicity. METHOD: Fifty-three male combat veterans consecutively admitted to a PTSD rehabilitation unit were assessed for psychotic symptoms and Axis I disorders. Ninety-one percent were Vietnam veterans; 72% were white, 17% were Hispanic, and 11% were black. Associations between psychotic symptoms and comorbid depression, substance use disorders, and minority status were compared by chi-square analyses; associations between psychotic symptoms and both PTSD and dissociative symptom severity were compared by t test analysis. RESULTS: Forty percent of patients reported a psychotic symptom or symptoms in the preceding 6 months. These symptoms featured auditory hallucinations in all but 1 case. The psychotic symptoms typically reflected combat-themes and guilt, were nonbizarre, and were not usually associated with formal thought disorder or flat or inappropriate affect. Psychotic symptoms were significantly associated with current major depression (p < .02), but not with alcohol or drug abuse or with self-rated PTSD and dissociation severity. Psychotic symptoms and current major depression were more common in minority (black and Hispanic) than white veterans (p < .002). CONCLUSION: Psychotic symptoms can be a feature of combat-related PTSD and appear to be associated with major depression. The association with minority status may be a function of comorbidity.     

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.     

Clinical presentations and treatment outcomes of peacekeeper veterans with PTSD: preliminary findings

OBJECTIVE: Despite evidence of potential psychiatric sequelae following peacekeeping operations, no data have appeared on treatment outcome for this population. This study examined intake and treatment outcome data for a group of peacekeepers with posttraumatic stress disorder (PTSD). METHOD: Participants were 63 Australian Vietnam veterans and 66 Australian peacekeepers attending specialized PTSD treatment units. Measures of PTSD, depression, anxiety, alcohol use, and anger were obtained at intake and 3-month follow-up. RESULTS: PTSD scores were more severe for peacekeepers than Vietnam veterans at intake, primarily in reexperiencing symptoms. In terms of comorbidity, only anger was higher among peacekeepers. No differences were apparent in treatment outcome. Initial anger predicted change in PTSD severity for peacekeepers. CONCLUSIONS: The finding of differences between peacekeepers and Vietnam veterans in anger and reexperiencing symptoms, in addition to the attenuating role of anger on treatment outcome, suggests that modification to standard PTSD treatment models may be warranted for peacekeepers.     

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.     

Physiological evidence of exaggerated startle response in a subgroup of Vietnam veterans with combat-related PTSD

One of the diagnostic criteria for posttraumatic stress disorder (PTSD) is an exaggerated startle response; however, this phenomenon has not been verified empirically. The authors compared 20 Vietnam combat veterans with PTSD and 18 combat veterans without PTSD on the eyeblink reflex electromyographic response of the startle reaction. Subjects in both groups who failed to show an eyeblink response to the startle stimuli were eliminated from further analyses. Among the remaining subjects, the 13 with PTSD had a significantly greater startle response amplitude than the 12 control subjects at intermediate intensities of acoustic stimuli. The relationship between startle responsivity and both negative and positive symptoms was also investigated.     

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.     

Symptom responses of female Vietnam veterans to Operation Desert Storm.

OBJECTIVE: This study examined the status of symptoms of posttraumatic stress disorder (PTSD) in a cohort of women after the onset of Operation Desert Storm. METHOD: Seventy-six non-treatment-seeking Vietnam veterans were obtained from lists of those who recently had participated in other research projects conducted at the National Center for Post-Traumatic Stress Disorder. Before the onset of Operation Desert Storm, subjects had completed a set of psychometrically valid instruments measuring general psychological symptoms and PTSD symptoms (e.g., SCL-90-R, Mississippi Scale for Combat-Related Posttraumatic Stress Disorder). On the basis of the latter scale, subjects were divided into groups with and without PTSD symptoms. At the height of the military conflict, subjects were recontacted and asked to complete the SCL-90-R and the Veterans Update Form, a measure assessing changes in PTSD symptoms. RESULTS: Multivariate analyses indicated that while most female Vietnam veterans experienced some intensification of stress-related symptoms during Operation Desert Storm, those who had previously reported high levels of PTSD were significantly more susceptible to greater distress. CONCLUSIONS: Results of this survey indicate that female Vietnam veterans with prior wartime exposure are an at-risk population for the intensification of stress symptoms after the recurrence of a military conflict.     

PTSD and utilization of medical treatment services among male Vietnam veterans

This study investigated the effect of posttraumatic stress disorder (PTSD) on help-seeking for physical problems. Merging two large data sets resulted in a sample of 1773 male Vietnam veterans from white, black, Hispanic, Native Hawaiian, and Japanese American ethnic groups. Predictors of utilization included PTSD, other axis I disorders, and substance abuse. In analyses that adjusted only for age, PTSD was related to greater utilization of recent and lifetime VA medical services, and with recent inpatient care from all sources. Further analysis showed that the increased utilization associated with PTSD was not merely due to the high comorbidity between PTSD and other axis I disorders. The uniqueness of the association between PTSD and medical utilization is discussed in terms of somatization and physical illness.     

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.     

Failure to detect fabricated posttraumatic stress disorder with the use of the MMPI in a clinical population

The authors attempted to replicate previous studies that used the Frequency (F) scale and the posttraumatic stress disorder (PTSD) subscale of the MMPI to discriminate Vietnam veterans with PTSD from well-adjusted veterans and mental health professionals who feigned symptoms of PTSD. Profiles of veterans with PTSD were compared to those of veterans with non-PTSD psychiatric disorders and veterans with fabricated PTSD symptoms who sought treatment. Discriminant analysis of F scale and PTSD subscale scores correctly identified only 43.59% of the subjects, thus failing to support use of the MMPI in detecting fabricated symptoms of PTSD in a clinical population.     

Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics

Between 1981 and 1995, approximately 5 million people from either Mexico, Cuba, Central America, or South America immigrated to the United States. Some regional studies have suggested that as Hispanic immigrants become acculturated to American society, their risk of mental illness increases sharply. This study examined the lifetime risk of psychiatric and substance use disorders among U.S. Hispanic subgroups and the specific role of nativity, parental nativity, language preferences, and other sociodemographic characteristics as risk factors for these disorders. The study used the National Comorbidity Survey (NCS), a national probability sample of 8098 U.S. adults aged 15 to 54. Selected DSM-III-R psychiatric diagnoses were collapsed into eight categories. When compared with non-Hispanic whites, Mexican-Americans were less likely to have any psychiatric disorder. After multivariate adjustment, acculturation items predicted greater risk of having any DSM-III-R disorders for Mexican-Americans and "other" Hispanics and greater risk of having a substance abuse disorder for Puerto Ricans, among other significant relationships. The results suggest that there is likely to be an increasing prevalence of psychiatric and substance use disorders among Hispanics that may be attributable to increasing levels of acculturation among the more than 5 million recent immigrants from Latin America.     

Post-september 11 admission symptoms and treatment response among veterans with posttraumatic stress disorder

OBJECTIVE: Evidence has been found of significant psychological distress after the terrorist attacks of September 11, 2001, even in communities that were not directly affected. Persons with preexisting posttraumatic stress disorder (PTSD) may be especially vulnerable to such distress. The authors examined clinical data on veterans who had a diagnosis of PTSD to determine whether the attacks exacerbated their symptoms. METHOD:S: Outcome-monitoring data were analyzed from a national sample of more than 9,000 veterans who were treated in specialized intensive PTSD programs of the Department of Veterans Affairs (VA) from March 11, 1999, to March 11, 2002. Analysis of variance was used to compare symptom levels at admission and clinical improvement during the six months before and six months after September 11 and in comparison with the same periods in 1999 and 2000. RESULTS: Veterans who were admitted after September 11, 2001, had less severe symptoms than those admitted before September 11, a pattern that was significantly different from previous years. Veterans who were followed up after September 11 showed significantly more improvement in PTSD symptoms than those who were followed up before then, which also represented a significant difference from previous years. CONCLUSION:S: VA patients with preexisting PTSD were, unexpectedly, less symptomatic at admission after September 11 than veterans admitted before September 11, and patients who had follow-up assessments after September 11 showed more improvement. It is possible that these veterans benefited from the shared feelings of national unity, pride, and patriotism in the months after September 11 as well as from the normalization of PTSD-like reactions by the news media and a sense of mastery at having past experience in coping with trauma.     

Basal and suppressed salivary cortisol in female Vietnam nurse veterans with and without PTSD

It has been suggested that discrepant findings regarding low basal cortisol levels and enhanced suppression of cortisol in response to dexamethasone (DEX) administration in post-traumatic stress disorder (PTSD) may reflect individual differences in gender, trauma type, stage of development at trauma occurrence (e.g., childhood vs. adulthood), early pre-traumatic risk factors, or other individual differences. This study examined salivary cortisol levels at 08.00h and 16.00h as well as cortisol response to 0.50 mg DEX in 40 female Vietnam nurse veterans who had current, chronic PTSD (Current) vs. 43 who never had PTSD (Never). Repeated measures analyses of covariance did not reveal significant group differences in cortisol levels or cortisol suppression. Given that nurses who served in Vietnam had similar exposures, ages at exposure, and duration since exposure to previously studied male Vietnam combat veterans, the present lack of evidence for low cortisol and cortisol hyper-suppression in nurses with PTSD suggests that previous findings of low cortisol and cortisol hyper-suppression in male Vietnam veterans, females sexually abused as children, and other populations may reflect risk factors beyond simply having PTSD.     

Familial psychiatric illness in chronic posttraumatic stress disorder

One hundred and eight veterans with posttraumatic stress disorder (PTSD) were compared with 60 age-matched controls with regard to family history of psychiatric illness. Depressed controls had a higher morbidity risk (MR) for depression and generalized anxiety in siblings/parents and children, respectively. Patients with PTSD did not differ from alcoholics or nonpsychiatric controls on the basis of family history. PTSD was associated with greater familial anxiety when compared with controls who had experienced combat. When World War II and Vietnam veterans with PTSD were compared, a higher MR for alcohol and drug abuse was found in siblings/parents of Vietnam veterans, and a higher MR was found for other chronic psychiatric disorders in the children of Vietnam veterans.     

Social anxiety,depression, and PTSD in Vietnam veterans

Many Vietnam veterans with PTSD report a high level of social anxiety and avoidance. Many traumatized individuals also suffer from symptoms of depression, which is often associated with significant problems in social functioning. In order to explore the relationship between social anxiety, depression, and PTSD, we recruited a group of Vietnam veterans with PTSD (n = 27), veterans with other mental disorders (n = 20), and veterans with no mental disorders (n = 35). Participants were administered diagnostic interviews and some of the most commonly used social anxiety instruments. Although the groups did not differ in their rates of social phobia, veterans with PTSD scored highest in most social anxiety measures. Veterans with PTSD were also more likely to be clinically depressed than veterans without PTSD at the time of the assessment. When controlling for the level of depression, the three groups no longer differed in any of the social anxiety measures. Furthermore, level of depression was the best predictor for group membership. These findings suggest that social anxiety in Vietnam combat veterans with PTSD is closely associated with mood disturbance, social withdrawal, and isolation associated with depression.     

The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans

OBJECTIVE: This study explored the emotional and physical health of a group of families of Australian Vietnam veterans suffering posttraumatic stress disorder (PTSD). The aim was to study the impact of PTSD upon the families of the sufferers. METHOD: The families of a random sample of Vietnam veterans receiving treatment at a specialist PTSD Unit were invited to participate in this study. Partners of the veterans and children over the age of 15 years were eligible to participate. Four self-report psychometric inventories were administered assessing psychological distress, social climate within their families, self-esteem, and a range of lifestyle issues, including physical health. A control group, consisting of a sample of volunteers, was also surveyed. RESULTS: The partners of the Vietnam veterans showed significantly higher levels of somatic symptoms, anxiety and insomnia, social dysfunction and depression than the control group. They reported significantly less cohesion and expressiveness in their families and significantly higher levels of conflict. The partners also had significantly lower levels of self-esteem. The children of the veterans reported significantly higher levels of conflict in their families. However, the children showed no significant differences on measures of psychological distress and self-esteem from their matched counterparts. CONCLUSIONS: These findings support overseas studies that indicate that the families of PTSD sufferers are also impacted by the disorder. In this study, the families of Australian Vietnam veterans experienced more conflict and their partners were significantly more psychologically distressed (i.e. somatic symptoms, anxiety, insomnia, social dysfunction, depression and low self-esteem) than a matched control group.     

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.