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.     

The effect of nefazodone on subjective and objective sleep quality in posttraumatic stress disorder

BACKGROUND: This study assesses the efficacy of nefazodone treatment (target dose of 400-600 mg/day) on objective and subjective sleep quality in Vietnam combat veterans with chronic DSM-IV posttraumatic stress disorder (PTSD). METHOD: Medically healthy male Vietnam theater combat veterans with DSM-IV PTSD (N = 10) completed a 12-week open-label trial. Two nights of ambulatory polysomnography were obtained at baseline and at the end of the trial. PTSD and depressive symptoms and subjective sleep quality were assessed at baseline and after 12 weeks. Data were collected in 1999 and 2000. RESULTS: Nefazodone treatment led to a significant decrease in PTSD and depressive symptoms (p <.05), an improvement in global subjective sleep quality, and a reduction in nightmares. Nefazodone also resulted in a substantial improvement in objective measures of sleep quality, particularly increased total sleep time, sleep maintenance, and delta sleep as measured by period amplitude analysis. CONCLUSION: Nefazodone therapy results in an improvement of both subjective and objective sleep quality in subjects with combat-related PTSD.     

Five-year follow-up study of eye movement desensitization and reprocessing therapy for combat-related posttraumatic stress disorder

This study reports the results of a 5-year follow-up evaluation of 13 Vietnam combat veterans with chronic posttraumatic stress disorder (PTSD) who participated in a study of eye movement desensitization and reprocessing (EMDR) therapy previously reported in this journal. Pretreatment and follow-up psychometric outcome measures were compared with those of a demographically matched control group of 14 combat veterans with chronic PTSD who did not receive EMDR. Analysis of variance showed that the modest to moderate therapeutic benefits that were manifest immediately following EMDR were lost at the 5-year follow-up evaluation, and there was an overall worsening of PTSD symptomatology over the 5-year period in both EMDR-treated and nontreated control subjects.     

Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder

BACKGROUND: Virtual reality (VR) integrates real-time computer graphics, body-tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). METHOD: This report presents the results of an open clinical trial using VRE to treat Vietnam combat veterans who have DSM-IV PTSD. In 8 to 16 sessions, 10 male patients were exposed to 2 virtual environments: a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. RESULTS: Clinician-rated PTSD symptoms as measured by the Clinician Administered PTSD Scale, the primary outcome measure, at 6-month follow-up indicated an overall statistically significant reduction from baseline (p = .0021) in symptoms associated with specific reported traumatic experiences. All 8 participants interviewed at the 6-month follow-up reported reductions in PTSD symptoms ranging from 15% to 67%. Significant decreases were seen in all 3 symptom clusters (p < .02). Patient self-reported intrusion symptoms as measured by the Impact of Event Scale were significantly lower (p < .05) at 3 months than at baseline but not at 6 months, although there was a clear trend toward fewer intrusive thoughts and somewhat less avoidance. CONCLUSION: Virtual reality exposure therapy holds promise for treating PTSD in Vietnam veterans.     

Predictors of treatment response in Canadian combat and peacekeeping veterans with military-related posttraumatic stress disorder

Military-related posttraumatic stress disorder (PTSD) is a significant psychiatric condition associated with severe psychosocial dysfunction. This study examined the predictors of treatment outcome in a group of veterans with military-related PTSD. Participants were 102 Canadian combat and peacekeeping veterans who received treatment at a specialized outpatient clinic for veterans with psychiatric disorders resulting from military operation. Analysis demonstrated a significant decrease in PTSD severity during the 1-year period (Yuan-Bentler χ [86, N = 99] = 282.45, p < 0.001). We did not find chronicity, alcohol use, and anxiety or depression severity as significant predictors for PTSD symptom decline. However, initial depression significantly predicted anxiety symptom decline, and initial anxiety predicted depression symptom decline. This study demonstrated that, despite considerable comorbidity, significant treatment gains, including remission of PTSD, can be achieved in an outpatient setting in veterans with chronic military-related PTSD.     

Comparison of successful, unsuccessful, and relapsed Vietnam veterans treated for posttraumatic stress disorder

The present study investigated the differences between veterans who benefited from intensive treatment for posttraumatic stress disorder (PTSD) and those who either relapsed or showed no improvement following treatment. Data from 45 combat veterans with PTSD completing at least 6 weeks of treatment in a partial hospitalization program were utilized. Veterans who had improved following treatment and had maintained a positive adjustment 18 months following treatment were found to have had lower rates of alcohol consumption and greater program participation than those who were unimproved or relapsed. These veterans also obtained lower scores on the MMPI-PTSD subscale, the global indices of the SCL-90-R, and seven of nine individual symptom scales of the SCL-90-R. These results were consistent with other recent reports concerning the existence and characteristics of Vietnam veteran symptom overreporters in studies using the MMPI, and suggest possible treatment outcome predictors for these groups.     

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.     

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.     

Peritraumatic dissociation and physiological response to trauma-relevant stimuli in Vietnam combat veterans with posttraumatic stress disorder

A recent study found that female rape victims with acute posttraumatic stress disorder (PTSD) who received a high score on the Peritraumatic Dissociative Experiences Questionnaire exhibited suppression of physiological responses during exposure to trauma-related stimuli. The goal of our present study was to test whether the same relationship holds true for male Vietnam combat veterans with chronic PTSD, using secondary analyses applied to data derived from a Veteran's Affairs Cooperative Study. Vietnam combat veterans (N = 1238) completed measures to establish combat-related PTSD diagnostic status, extent of PTSD-related symptomatic distress, and presence of dissociative symptoms during their most stressful combat-related experiences. Extreme subgroups of veterans with current PTSD were classified as either low dissociators (N = 118) or high dissociators (N = 256) based on an abbreviated version of the Peritraumatic Dissociative Experiences Questionnaire. Dependent variables reflected subjective distress along with heart rate, skin conductance, electromyographic, and blood pressure data when responding to neutral and trauma-related audiovisual and imagery presentations. Veterans in the current PTSD group had significantly higher dissociation scores than did veterans in the lifetime and never PTSD groups. Among veterans with current PTSD, high dissociators reported greater PTSD-related symptomatic distress than did low dissociators, but the groups did not differ with respect to physiological reactivity to the trauma-related laboratory presentations. Our results replicate the previously reported relationship between peritraumatic dissociation and PTSD status in Vietnam combat veterans. However, we found no association between peritraumatic dissociation and the extent of physiological responding to trauma-relevant cues in male veterans with chronic combat-related PTSD.     

Negative parenting behavior, combat exposure, and PTSD symptom severity. Test of a person-event interaction model.

The "personal characteristics" and "extreme event" hypotheses have been proposed as alternative explanations for the development of posttraumatic stress disorder (PTSD) among combat veterans. The person-event interaction model attempts to integrate both perspectives by hypothesizing that premilitary individual vulnerability characteristics play a greater role in influencing risk of PTSD or PTSD symptom severity at lower than at higher levels of exposure to traumatic combat stressors. Focusing on a sample of 57 Vietnam veterans undergoing inpatient treatment for diagnosed PTSD, we assessed this model by examining interactions between negative parenting behaviors in childhood (e.g., inconsistent love) and degree of combat exposure in predicting PTSD symptom severity. Hierarchical regression analyses supported the model, indicating that the father's negative parenting behaviors were more predictive of PTSD symptom severity at relatively lower levels of combat exposure. Implications of the findings for further research on multivariate, interactional models of PTSD etiology among Vietnam combat veterans are discussed.     

posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care

The relationship between posttraumatic stress and physical health functioning was examined in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA care. Iraq and Afghanistan War veterans (N = 108) who presented for treatment to a specialty postdeployment care clinic completed self-report questionnaires that assessed symptoms of posttraumatic stress disorder (PTSD), chemical exposure, combat exposure, and physical health functioning. As predicted, PTSD symptom severity was significantly associated with poorer health functioning, even after accounting for demographic factors, combat and chemical exposure, and health risk behaviors. These results highlight the unique influence of PTSD on the physical health in treatment seeking Iraq and Afghanistan War veterans.     

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.     

Naloxone-reversible analgesic response to combat-related stimuli in posttraumatic stress disorder. A pilot study

We tested the hypothesis that exposure to a stimulus resembling the original traumatic event would induce naloxone-reversible analgesia in patients with posttraumatic stress disorder (PTSD). Eight medication-free Vietnam veterans with PTSD and eight veterans without PTSD, matched for age and combat severity, viewed a 15-minute videotape of dramatized combat under naloxone hydrochloride and placebo conditions in a randomized double-blind crossover design. In the placebo condition, the subjects with PTSD showed a 30% decrease in reported pain intensity ratings of standardized heat stimuli after the combat videotape. No decrease in pain ratings occurred in the subjects with PTSD in the naloxone condition. The subjects without PTSD did not show a decrease in pain ratings in either condition. The results are consistent with the induction of opioid-mediated stress-induced analgesia in the patients with PTSD.     

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.     

Pre-Vietnam contents of posttraumatic stress disorder veterans' service medical and personnel records.

We reviewed the pre-Vietnam contents of the service medical and personnel records of 250 Vietnam combat veterans, in an attempt to identify factors predisposing to the development of posttraumatic stress disorder (PTSD). PTSD and non-PTSD veterans did not differ significantly on self-reported medical history items, sick call visits, or military efficiency and conduct ratings. There were trends for PTSD veterans to have lower arithmetic aptitude, more self-reported school difficulties, and (paradoxically) lower pulse rate at military induction.     

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.     

Medial frontal cortex involvement in PTSD symptoms: a SPECT study.

The regional cerebral blood flow (rCBF) responses to a combat stress-related auditory stimulus was examined in Vietnam veterans diagnosed with posttraumatic stress disorder (PTSD). Based on prior data in healthy subjects, we hypothesized that the medial prefrontal cortex may be involved in the processing of stress responses. Twelve male veterans diagnosed with PTSD, 11 age-matched, combat-exposed subjects without PTSD, and 12 healthy control subjects were studied with single-photon emission tomography and the blood flow tracer [99mTc]-HMPAO. Subjects were studied twice, while listening to combat sounds or white noise. Significant increases in the blood flow to the medial prefrontal cortex were observed in PTSD patients, but not in the control groups, which correlated at trend levels with psychophysical measures of stress response. These data support the involvement of the medial prefrontal cortex in the pathophysiology of PTSD, possibly mediating some of its symptoms.     

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.     

An intensive treatment program for chronic posttraumatic stress disorder: 2-year outcome data

OBJECTIVE: The present study evaluates the efficacy of a closed-cohort treatment program for chronic posttraumatic stress disorder (PTSD). METHOD: The treatment orientation was a combined approach involving cognitive behaviour therapy and pharmacotherapy. Treatment involved an inpatient phase of 4 weeks, with group and individual follow-up sessions of at least 6-month duration. The treatment population consisted largely of Australian Vietnam veterans. Standardised psychometric measures were obtained pre-treatment, on completion of the residential phase; and at 6, 12 and 24 months post discharge from the residential program. RESULTS: The results obtained from 64 patients demonstrate significant reductions in depression, anxiety and PTSD symptoms, maintained at 2 years post discharge from the residential phase of the treatment program. CONCLUSIONS: This paper presents encouraging findings for treatment with this troubled population.     

Clinical symptomatology of posttraumatic stress disorder-diagnosed Australian and United States Vietnam combat veterans: an MMPI-2 comparison

The authors compared MMPI-2 scores of 95 Australian and 96 US Vietnam combat veterans diagnosed with posttraumatic stress disorder (PTSD) from structured PTSD clinical interviews. Groups were strikingly similar on the MMPI-2 clinical and validity scales but were different on two content scales, with higher scores on FRS (fears) and BIZ (bizarre mentation) for the US sample. Employment status was included as a factor, because it too discriminated groups, but it did not interact with the veteran group variable to produce scale differences. The roles of employment status and disability payments are considered in accounting for differences in the psychiatric presentations of the groups. Results suggest that American and Australian Vietnam combat PTSD samples are very similar to each other, with implications for the treatment outcome literature.