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.     

Group psychotherapy for children of fathers with PTSD: Evidence of psychopathology emerging in the group process

Growing awareness of the high incidence of PTSD, particularly among Vietnam veterans, has been associated with increasing interest in the impact that PTSD has on the families and children of these patients. The present report describes a psychotherapy group conducted with latency aged children of Vietnam veterans concurrently receiving outpatient treatment for PTSD. During the course of the group significant levels of psychopathology became evident in many of the members, particularly in the areas of modulation of aggressive impulses, ability to relate to peers and siblings in an age appropriate fashion, ability to obtain help from adult caregivers in coping with stress, and ability to cope with psychosocial stress without severe regression. The need for further research to determine what types of psychopathology that children of parents with PTSD may be at increased risk of developing, and what the optimal treatment strategies are for this population, is discussed.     

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.     

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.     

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.     

Suicidality in Australian Vietnam veterans and their partners

Lifetime suicidality was assessed in a cohort of 448 ageing Australian Vietnam veterans and 237 female partners during in-person structured psychiatric interviews that permitted direct comparison with age-sex matched Australian population statistics. Relative risks for suicidal ideation, planning and attempts were 7.9, 9.7 and 13.8 times higher for veterans compared with the Australian population and for partners were 6.2, 3.5 and 6.0 times higher. Odds ratios between psychiatric diagnoses and suicidality were computed using multivariate logistic regression, and suicidality severity scores were assigned from ideation, planning and attempt, and analysed using ordinal regression. PTSD, depression alcohol disorders, phobia and agoraphobia were prominent predictors of ideation, attempts and suicidal severity among veterans, while depression, PTSD, social phobia and panic disorder were prominent predictors among partners. For veterans and their partners, PTSD is a risk factor for suicidality even in the presence of other psychiatric disorders, and is stronger in Vietnam veterans than their partners.     

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.     

Incidence of Postconcussion Symptoms in Psychiatric Diagnostic Groups,Mild Traumatic Brain Injury,and Comorbid Conditions

The constellation of physical, cognitive, and emotional symptoms, collectively known as postconcussion syndrome (PCS), is not uniquely associated with concussion, making the etiology of chronic postconcussion symptoms controversial. The current study compared percentages of individuals meeting symptom-based criteria for PCS in a population-based sample of veterans composed of subgroups with various psychiatric diagnoses, a history of mild traumatic brain injury (MTBI), and healthy controls. Participants were identified from 4462 randomly sampled male U.S. Army veterans who served during the Vietnam era. Only 32% of veterans with a history of MTBI met DSM-IV symptom criteria for PCS as compared to 40% of those diagnosed with post-traumatic stress disorder (PTSD), 50% with generalized anxiety disorder (GAD), 57% with major depressive disorder (MDD), and 91% with somatization disorder. Results were consistent with existing literature showing that the PCS symptoms are not unique to concussion, and also provide important base-rate information for neuropsychologists practicing in both clinical and personal injury forensic settings.     

Nefazodone in patients with treatment-refractory posttraumatic stress disorder

BACKGROUND: Posttraumatic stress disorder (PTSD) is a highly prevalent and often chronic disorder among combat veterans, persisting in as many as 15% of Vietnam veterans for at least 20 years. Treatment response in veterans with combat-related PTSD has been disappointing. Although anxiolytics, anticonvulsants, antipsychotics, and antidepressants have been tried, none has been consistently associated with improvement in all primary symptom domains (i.e., intrusive recollections, avoidance/numbing, and hyperarousal). This open-label study evaluated the use of nefazodone in a group of Vietnam veterans with chronic, treatment-refractory symptoms of PTSD. METHOD: Male outpatients with DSM-IV PTSD who had failed a minimum of 3 previous medication trials were eligible for the study. Nineteen Vietnam combat veterans entered the study and were treated with nefazodone, 100-600 mg/day, for 12 weeks. PTSD symptoms, anxiety, depression, sleep, sexual functioning, and adverse events were assessed weekly. RESULTS: Severity of depression lessened, as did PTSD symptoms of intrusive recollections, avoidance, and hyperarousal. Depressive symptom severity as measured by the Beck Depression Inventory decreased by a mean of 30%. Similarly, there was an overall drop in the intensity of PTSD symptoms as measured by the Clinician Administered PTSD Scale of 32% with a 26% improvement for symptoms of intrusion, 33% for avoidance, and 28% for arousal. In addition, improvements in sleep and sexual functioning were reported. The mean daily dose of nefazodone after 12 weeks was 430 mg (range, 200-600 mg/day). The most frequently reported side effects were headaches (53%), dry mouth (42%), and diarrhea (42%), but side effects tended to be mild and transient. CONCLUSION: In this group of Vietnam veterans with chronic treatment-refractory PTSD and multiple comorbid Axis I psychiatric disorders, nefazodone was well tolerated and effective. Larger, controlled studies are warranted.     

Single-voxel proton MR spectroscopy of right versus left hippocampi in PTSD

Previous magnetic resonance (MR) volume imaging and proton MR spectroscopy studies have suggested a reduction in the hippocampal size and/or neuronal/axonal density in posttraumatic stress disorder (PTSD). The lack of agreement on the laterality of the hippocampal dysfunction prompted this study. A total of 20 veterans (18 men and two women) and one female non-veteran participated in this study conducted in accordance with approved human study protocols. Six of the male veterans and the female non-veteran were without PTSD. Vietnam veterans formed a large subset of the study subjects. Single-voxel proton MR spectra were obtained from the hippocampal region bilaterally on a clinical MR scanner operating at 1.5 T. Analysis of the proton MR spectra showed a decrease in hippocampal NAA/creatine ratio in PTSD subjects significantly higher on the left than the right for the entire study group, as well as for the Vietnam subset. It was concluded that the hippocampal dysfunction in PTSD is lateralized with the left side being more impaired than the right.     

Pedigrees, functioning, and psychopathology in families of school phobic children

Family pedigrees of six children with severe school phobia compared with those of a matched group of families of five children with psychiatric disorders showed a clustering of affective and anxiety disorders. Blind and independent family histories and structured interviews of parents and siblings demonstrated higher rates of depressive and anxiety disorders in first-degree relatives of children with school phobia. Parents of children with school phobia described more disturbance in family functioning on the Family Assessment Measure than did parents in the comparison group in the areas of role performance, communication, affective expression, and control.     

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.     

Posttraumatic stress disorder among Hispanic Vietnam veterans

OBJECTIVE: The purpose of this study was to examine posttraumatic stress disorder (PTSD) among Hispanics who served in the Vietnam War. METHOD: The authors conducted secondary data analyses of the National Vietnam Veterans Readjustment Study, a national epidemiologic study completed in 1988 of a representative sample of veterans who served during the Vietnam era (N=1,195). RESULTS: After adjustment for premilitary and military experiences, the authors found that Hispanic, particularly Puerto Rican, Vietnam veterans had significantly more severe PTSD symptoms and a higher probability of experiencing PTSD than nonminority veterans. However, they had no greater risk for other mental disorders, and their greater risk for PTSD was not explained by acculturation. Despite their more severe symptoms, Hispanic veterans, especially Puerto Rican veterans, showed no greater functional impairment than non-Hispanic white veterans. CONCLUSIONS: Hispanic Vietnam veterans, especially Puerto Rican Vietnam veterans, have a higher risk for PTSD and experience more severe PTSD symptoms than non-Hispanic white Vietnam veterans, and these differences are not explained by exposure to stressors or acculturation. This high level of symptoms was not accompanied by substantial reduction in functioning, suggesting that the observed differences in symptom reporting may reflect features of expressive style rather than different levels of illness.     

The D2 dopamine receptor (DRD2) gene is associated with co-morbid depression, anxiety and social dysfunction in untreated veterans with post-traumatic stress disorder.

OBJECTIVE: To identify clusters of patients with post-traumatic stress disorder (PTSD) according to symptom profile and to examine the association of the A1 allele of the D2 dopamine receptor (DRD2) gene with these clusters. METHOD: Fifty-seven untreated Caucasian Vietnam veterans with PTSD were administered the General Health Questionnaire-28 (GHQ) and the Mississippi Scale for combat-related PTSD. DRD2 allelic status was determined by PCR. RESULTS: Subjects with the DRD2 Al allele compared to those without this allele had significantly higher scores on GHQ 2 (anxiety/insomnia), GHQ 3 (social dysfunction) and GHQ 4 (depression). Cluster analysis of the GHQ data identified two primary groups. A high psychopathology cluster (cluster 3), featured by high co-morbid levels of somatic concerns, anxiety/insomnia, social dysfunction and depression, and a low psychopathology cluster (cluster 1), manifested by the reverse pattern. Scores in each of the four GHQ groups were significantly higher in cluster 3 than cluster 1, as was Mississippi Scale PTSD score. DRD2 A1 allele veterans compared to those without this allele were significantly more likely to be found in the high than the low psychopathology cluster group. CONCLUSIONS: DRD2 variants are associated with severe co-morbid psychopathology in PTSD subjects.     

Traumatic events and posttraumatic stress disorder in an urban population of young adults

To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population.     

Selective processing of trauma-relevant words in posttraumatic stress disorder

This study investigated Stroop color-naming of trauma-related words in male Vietnam combat veterans with (n = 42) and without (n = 15) posttraumatic stress disorder (PTSD). The anxiety connotations of the words were either very specific to the Vietnam experience (point, lead), general but still Vietnam-related (medevac, bodybags), or general and not specifically related to Vietnam (crash, grief). All three categories of words slowed color-naming compared to neutral control words. This was true for all subjects, but the effect was more pronounced in veterans with PTSD. The generally negative but still Vietnam-related words caused more interference in colornaming than did the other categories of words, which was attributed to their ability to access Vietnam combat memories more efficiently. There was a free recall and recognition memory advantage for the emotion words, suggesting that the Stroop interference effect was mediated by an attentional bias towards the anxiety-related material rather than avoidance of it. Veterans with PTSD were slower in color-naming overall, an effect that could not be attributed to group differences in psychiatric medication, depression, or anxiety.     

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.     

The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma?

OBJECTIVE: The presence of posttraumatic stress disorder (PTSD) in trauma survivors has been linked with family dysfunction and symptoms in their children, including lower self-esteem, higher disorder rates and symptoms resembling those of the traumatized parent. This study aims to examine the phenomenon of intergenerational transfer of PTSD in an Australian context. METHOD: 50 children (aged 16-30) of 50 male Vietnam veterans, subgrouped according to their fathers' PTSD status, were compared with an age-matched group of 33 civilian peers. Participants completed questionnaires with measures of self-esteem, PTSD symptomatology and family functioning. RESULTS: Contrary to expectations, no significant differences were found between the self-esteem and PTSD symptomatology scores for any offspring groups. Unhealthy family functioning is the area in which the effect of the veteran's PTSD appears to manifest itself, particularly the inability of the family both to experience appropriate emotional responses and to solve problems effectively within and outside the family unit. CONCLUSION: Methodological refinements and further focus on the role of wives/mothers in buffering the impact of veterans' PTSD symptomatology on their children are indicated. Further effort to support families of Veterans with PTSD is also indicated.     

Concurrent posttraumatic stress disorder in psychogeriatric patients

Despite the fact that there are over 11 million World War II veterans in the United States, recent research on combat-related trauma has focused primarily on symptoms of posttraumatic stress disorder (PTSD) in Vietnam veterans. Several studies have found that the majority of Vietnam veterans who meet the Diagnostic and Statistical Manual of Mental Disorders, ed 3 (DSM-III) criteria for PTSD have an additional major psychiatric diagnosis. This study explores the presence of the diagnosis of PTSD in an inpatient sample of 42 World War II veterans with an admission diagnosis other than PTSD. Following a structured diagnostic interview, a second examiner, blind to the patients' combat history, interviewed the subjects to obtain information regarding the past and current impact of the "most stressful experience" of their lives. Subjects were instructed not to reveal the nature of the stressor until completion of the study. Fifty-four percent of the combat-exposed veterans (14 of 26) spontaneously listed combat as the most significant stressor in their life. Furthermore, 54% of the combat-exposed veterans met DSM-III criteria for past PTSD and 27% met criteria for current PTSD in addition to another axis I diagnosis. These preliminary findings underscore the need for clinicians to assess the long-term effects of combat trauma in psychogeriatric patients.     

Comparison of outcome between homogeneous and heterogeneous treatment environments in combat-related posttraumatic stress disorder

This study compared treatment outcome at discharge, and 4, 8, and 12 month follow-up between an inpatient program consisting of a mixture of Vietnam combat veterans with posttraumatic stress disorder (PTSD) and general psychiatric patients (N = 42), and the same program at a later period, consisting of only Vietnam combat veterans with PTSD (N = 33). Veterans rated the homogeneous environment higher in satisfaction, support, order, clarity, and amount of discussion of combat, and lower in hostility, than the heterogeneous condition. However, veterans showed no improvement in condition at 12 month follow-up, with the exception of decreased violence, replicating earlier studies. No differences in outcome were found between homogeneous or heterogeneous treatment environments. This study underscores the enduring nature of chronic posttraumatic stress disorder in the veteran population.