Heterogeneity of posttraumatic stress disorder symptoms in Croatian war veterans: retrospective study

Aim

To determine the relationship between the intensity of combat-related posttraumatic stress disorder (PTSD) and the intensity of predominating symptoms.

Method

The study included 151 veterans from 1992-1995 war in Croatia with PTSD, aged 38.3 ± 7.3 years (mean ± standard deviation). The veterans were psychologically tested with the Mississippi Scale for Combat-related PTSD (M-PTSD), Questionnaire on Traumatic Combat and War Experiences (USTBI-M), and Minnesota Multiphasic Personality Inventory-version 201 (MMPI-201).

Results

The discriminative analysis of the data revealed that the group with lower PTSD intensity had the highest scores on MMPI scales D (depression, T-score 95.7 ± 5.6), Hs (hypochondriasis, 87.6 ± 5.1), and Hy (hysteria, 85.6 ± 4.9), whereas the group with higher PTSD intensity, besides these three scales (D = 98.3 ± 5.3; Hs = 90.1 ± 4.3; Hy = 89.5 ± 4.7), also had clinically significantly elevated Pt (psychastenia, 80.6 ± 5.6), Sc (schizophrenia, 79.6 ± 4.8), and Pa (paranoia, 85.6 ± 5.4) scales, with the highest Pa scale.

Conclusion

It was possible to differentiate study participants with different PTSD intensity on the basis of their MMPI profile. More intense PTSD was associated with externalized symptoms, such as aggression, acting-out, hostility, and mistrust, whereas less intensive PTSD was associated with mostly depressive symptoms. Our study showed that different intensity of PTSD has different symptom patterns.A person’s reaction to trauma depends on the traumatic situation itself, personality characteristics of the person exposed to trauma, and posttraumatic social environment. Most people develop some form of acute stress reaction to traumatic event, but in the majority of cases the stress-related difficulties spontaneously withdraw once the person is removed from the situation (1). Fewer people will develop chronic disorders which may evolve into a clinical picture of posttraumatic stress disorder (PTSD) (2). Symptoms that characterize PTSD include repeated re-experiencing of the trauma, emotional numbing, detachment, lack of affect, anhedonia, and avoidance of activities and situations reminiscent of the traumatic event (3).PTSD is often comorbid with other psychiatric disorders (4-7). Patients with PTSD often complain of psychosomatic disturbances, ranging from anxiety accompanied with tremor and restlessness to depressive problems with predominant cognitive aspects of depression (dark thoughts, shame, guilt, and suicidal thoughts and intentions) and to vegetative symptoms (insomnia and loss of appetite) (8). Comorbidity of PTSD with anxiety or depressive disorders is diagnosed in cases where anxiety or depressive symptoms are prevalent. Due to these psychiatric problems, patients with PTSD often resort to alcohol or drug abuse (4). Memory and concentration impairment, often present in PTSD, may seriously interfere with everyday functioning of these patients (9).Because PTSD symptoms are so heterogeneous, many researchers presume that there are different subtypes of the disorder. Previous attempts to determine different types of PTSD used different methodologic approaches (10-12). Some studies analyzed characteristics of PTSD with respect to predominant symptomatology (6,8), whereas others tried to associate PTSD symptoms with different types of stressors (12,13). Electrophysiological indicators of PTSD as well as the possibility to determine different types of PTSD on the basis of specific electrophysiological indicators were investigated (14,15).Further attempts to discern among different types of PTSD were based on personality tests, primarily Minnesota Multiphasic Personality Inventory (MMPI) (16), response to specific pharmacotherapy (17), and existing aggressive behavior (18-20). Recently, intensity of PTSD has been investigated as a factor that determines the type of the disorder (21-23).The aim of the present study was to determine the relationship between the intensity of PTSD and predominating symptoms in a sample of Croatian 1991-1995 war veterans.     

Sexual functioning in war veterans with posttraumatic stress disorder

Aim

To assess the sexual dysfunction among Croatian war veterans with combat-related posttraumatic stress disorder (PTSD).

Method

The study included two groups – 101 war veterans with PTSD and 55 healthy control volunteers receiving outpatient general health care in several outpatient clinics in Split. tructured interviews on different aspects of sexual functioning were conducted from April to October 2007 by trained interviewers.

Results

Respondents with PTSD reported significantly less sexual activity during the previous month than controls (sexual fantasies 2.5 ± 1.6 vs 3.7 ± 1.7, P<0.001; foreplay 2.4 ± 1.6 vs 3.5 ± 1.6, P<0.001; oral sex 1.6 ± 1.2 vs 2.6 ± 1.5, P<0.001; and sexual intercourse 2.4 ± 1.6 vs 3.8 ± 1.5, P<0.001) on a 7-point Likert type scale (from 1 – not a single time to 7 – more times a day). As reasons for reduced sexual activities, respondents with PTSD more frequently than controls reported their own health problems (3.2 ± 1.2 vs 1.5 ± 0.8; P<0.001) or health problems of their partner (2.4 ± 1.1 vs 1.9 ± 1.1; P = 0.004), whereas controls more frequently reported overwork than respondents with PTSD (2.6 ± 1.1 vs 2.1 ± 1.0; P = 0.007) on a 5-point Likert type scale (from 1 – not a single time to 5 – always). Respondents with PTSD reported antidepressant (n = 52, 51%) or anxyolitics use (n = 73, 72.3%). In a subgroup analysis, respondents with PTSD who were taking antidepressants masturbated less frequently than those who were not taking them (1.9 ± 1.3 vs 2.5 ± 1.6; P = 0.039), whereas premature ejaculation was more often experienced by respondents with PTSD who were not taking antidepressants than by those who were taking them (3.5 ± 1.8 vs 2.7 ± 1.5; P<0.049) both on a 7-point Likert type scale (from1 – not a single time to 7 – more times a day).

Conclusion

War veterans with PTSD had less sexual activity, hypoactive sexual desire, and erectile difficulties. Antidepressant therapy in veterans with PTSD may be associated with hypoactive sexual desire.Posttraumatic stress disorder (PTSD) is a complex phenomenon that develops as a response to a psychological trauma and affects several levels of personality, causing changes in both mental and physical functioning (1-3). It is often associated with problems in interpersonal relationships and difficulties with attachment, intimacy, and sexuality (1,2). Problems in the realm of sexuality arise from the individual’s inability to establish an adequate emotional-physical relationship with the partner, as well as from the disturbances in mental and physical health (4). Several studies found that the prevalence of sexual dysfunctions among patients with PTSD was higher than in general population (5-7). Dysfunctions can occur in almost all domains of sexuality – activity, desire, arousal, orgasm, and satisfaction with sexual life (5). The most frequent difficulties are erectile dysfunction and premature ejaculation (6,7). Antidepressant therapy is an additional factor that can aggravate difficulties in sexual functioning (8).Sexual dysfunctions in Croatia have rarely been explored (4,9). A national study that explored the prevalence and risk factors of erectile and ejaculatory difficulties pointed out the role of anxiety and stress in the occurrence of premature ejaculation (4). The significance of sexuality for one’s perception of quality of life, a high prevalence of PTSD in a post-war society such as Croatia, and a lack of relevant studies all point to the importance of studying this domain of veterans’ life (10,11). Our aim was to assess the impact of PTSD on the occurrence of sexual dysfunctions.     

Short-term memory in Croatian war veterans with posttraumatic stress disorder

Aim

To assess short-term memory impairment in war veterans with combat-related posttraumatic stress disorder (PTSD).

Method

The study included 20 war veterans diagnosed with PTSD and 21 control subjects matched for age, sex, and education level. Both groups were tested with the Rey-Osterrieth Complex Figure Test (ROCFT), consisting of Copy, Immediate Recall, and Delayed Recall steps, and Benton Visual Retention Test (BVRT). Subjects with visuoperceptive and visuoconstructional deficits, as indicated by their ROCFT Copy scores were excluded from the analysis, because this type of cognitive deficit could interfere with the results of the next two ROCFT steps measuring short-term memory.

Results

Subjects with PTSD scored significantly lower than control subjects on both Immediate Recall (mean ± standard deviation [SD], 16.3 ± 6.4 vs 26.7 ± 4.5, respectively; P<0.001, t test for independent samples) and Delayed Recall tests (15.7 ± 6.1 vs 26.3 ± 4.6, respectively; P<0.001, t test for independent samples) on ROCFT test. Intragroup comparison showed that both groups scored significantly lower on Immediate Recall test in comparison with Copy test (19.3 ± 6.4 for veterans and 8.9 ± 4.5 for controls; P<0.001 for both, t test for dependent samples), whereas no significant score difference was found between Immediate and Delayed Recall scores in either group (0.7 ± 2.4 for veterans, P = 0.239, t test for dependent samples; and 0.5 ± 1.8 for controls, P = 0.248, t test for dependent samples), which indicated greater difficulties with acquiring new information than with recalling already memorized information. Subjects with PTSD made significantly more errors on the BVRT for visuoperceptive and visuoconstructional abilities than control subjects (7.8 ± 2.9 for veterans; 4.0 ± 1.88 for controls; P<0.001, t test for independent samples).

Conclusion

War veterans with PTSD had impaired short-term memory and visual retention, but these cognitive deficits could not be related to traumatic experiences with certainty.Chronic posttraumatic stress disorder (PTSD) is accompanied with pathophysiological and biological changes in the brain structures such as hippocampus, amygdale, cortex, nucleus accumbens, striatum, and midbrain (1). These changes may be caused by traumatic experience and responsible for the appearance of PTSD symptoms (1). According to the modern concept of PTSD, it is a psychobiological phenomenon that includes neurobiological dysregulation and psychological dysfunction (2). Studies using sophisticated methods for brain imaging found the dysfunction of the frontal-limbic system as the biological correlate of PTSD (3). Magnetic resonance imaging studies showed that in chronic PTSD patients the volume of the hippocampus was reduced, which affects the learning and memory processes (3-5). The hippocampus atrophy is suspected to result from oversensitivity of the glucocorticoid receptors and increased concentration of glucocorticoids in persons exposed to stress (3,5). However, these changes in hippocampus are not caused by the traumatic experience alone. The trauma is constantly reexperienced through flashbacks and dreams, which are characteristic elements of the clinical picture of PTSD (3). In many PTSD patients, other cognitive dysfunctions are also present, such as intellectual deterioration (3,6), impaired executive functions (3), decreased concentration (7-9), memory deficits (7-9), and forgetfulness (9,10).Due to the high prevalence of PTSD among veterans from 1991-1995 war in Croatia, the degree of PTSD symptoms in this population is frequently assessed (11). Improving our knowledge about memory deficits in PTSD patients would facilitate the severity assessment of the disorder for the purposes of work fitness evaluations and therapy planning (12,13).The aim of this study was to determine the short-term memory deficit in Croatian war veterans with PTSD by comparing their immediate and delayed recall and visual retention abilities with those of healthy controls.     

Secondary traumatization of wives of war veterans with posttraumatic stress disorder

Aim

To determine the symptoms of secondary traumatic stress and possible influences of demographic and socioeconomic factors on the occurrence of secondary traumatic stress in wives of war veterans with posttraumatic stress disorder (PTSD).

Method

The study included 56 wives of war veterans diagnosed with PTSD and treated at the Center for Psychotrauma in Rijeka, Croatia. A short structured interview was conducted with each woman to collect demographic and socioeconomic data. The women independently completed an adapted 16-item version of Indirect Traumatization Questionnaire to determine the presence of secondary traumatic stress symptoms, which corresponded with PTSD symptoms as defined by the fourth edition of the Diagnostic and Statistical Manual for Mental Disorders.

Results

Out of 56 veterans’ wives included in the study, 32 had six or more symptoms of secondary traumatic stress, whereas only 3 had none of the symptoms. Twenty-two women met the diagnostic criteria for secondary traumatic stress. Women with secondary traumatic stress were married longer than those without it (mean ± standard deviation, 19.1 ± 9.1 vs 13.2 ± 7.8 years, respectively; P = 0.016). Eleven of 22 women with secondary traumatic stress and 8 of 34 women without secondary traumatic stress were unemployed (P = 0.05).

Conclusion

As more than a third of war veterans wives met the criteria for secondary traumatic stress, any treatment offered to veterans with PTSD must address the traumatization of their family.The Croatian 1991-1995 war caused a wide range of psychological and psychosocial difficulties in war veterans (1). Many of them were diagnosed with posttraumatic stress disorder (PTSD), which has considerably disrupted their social and emotional functioning (2,3). The veteran’s difficulties in everyday life mostly affect his family, while the family is expected to provide all the support that he needs (2). The wife and children witness his sleepless nights, restless dreams, and absentmindedness that sometimes lasts for hours or even days, and avoid upsetting him as much as possible (2,4-6). His low frustration threshold, lack of patience with children, inability to carry on with his family role, great expectations, and verbal and physical aggressiveness heavily influence the relationship with his spouse, children, parents, and the rest of the family (4,7-10).Previous research showed that close and long-term contact with an emotionally disturbed person may cause chronic stress, which in time in persons providing help leads to various emotional problems, such as higher levels of depressive symptoms and anxiety, problems in concentration, emotional exhaustion, pain syndromes, and sleeping problems (2,3,6). One third of wives of Croatian veterans treated for PTSD met the criteria for secondary traumatization (2). In case of posttraumatic disorders, Figley (10,11) believes that empathy toward the traumatized person may induce significant emotional agitation in other family members and calls this phenomenon the secondary stress reaction to catastrophe. Other authors used different terms for this phenomenon, such as compassion fatigue, secondary traumatic stress, and vicarious trauma (11-13). However, the mechanism of transmission of posttraumatic stress onto persons who witnessed or learned about the trauma exposure of the close ones is still rather unknown (11).Secondary traumatic stress is defined as natural emotional reaction to the traumatic experience of a significant other (10,14). Secondary traumatization is the stress caused by providing help, or wishing to help, and offering emotional support to a traumatized person. Secondary stress disorder as a syndrome is almost identical to PTSD except that indirect exposure to the traumatic event through close contact with the primary victim of trauma becomes the criterion A (10). The symptoms of secondary traumatization are similar to those present in directly traumatized persons: nightmares about the person who was directly traumatized, insomnia, loss of interest, irritability, chronic fatigue, and changes in self-perception, perception of one''s own life, and of other people (10). Physical symptoms may also be present, including headaches, indigestion, susceptibility to infections, and increased use of alcohol, drugs, or tobacco (2,12).A few studies investigated the effects that PTSD in war veterans had on their spouses (5,15,16). Dekel et al (5) in their qualitative study on the marital perceptions of 9 wives of veterans with PTSD found that being employed and having known their husbands before the war was very important to the wives of PTSD-diagnosed veterans. Various demographic variables, such as age, ethnicity, education level, or social support, were not found to influence the perceived burden and psychological distress in partners of veterans with PTSD (16). Apart from qualitative study by Dekel et al (5), our literature search of the PILOTS and EPNET bibliographical databases with the key words secondary traumatization, wives, PTSD, war trauma, sociodemographics, socio economics, education level, employment, income, and several others did not find any studies that specifically investigated the relationship between the socioeconomic status and the level of secondary traumatization symptoms or the association between the duration of marriage and the occurrence of secondary traumatization in veterans’ wives.Due to the exposure to stress, caused by the husband’s PTSD symptoms or other psychiatric and health conditions, often combined with his insufficient social and emotional support and increased demands, the veterans’ wives are at an increased risk of specific mental problems related to the life with mentally disturbed husband (3,17-19). Given the recent war in Croatia and relatively high percentage of war veterans with combat-related PTSD, we expected secondary traumatic stress in their wives and female partners to be relatively frequent and that the duration of their life together, number of children, economic situation, and (un)employment would influence the occurrence of secondary traumatic stress.The aim of this study was to determine whether the wives of war veterans with PTSD had symptoms of secondary traumatic stress and to evaluate the possible influence of demographic and socioeconomic factors on the occurrence of secondary trauma stress in these women.     

Long-term dynamic-oriented group psychotherapy of posttraumatic stress disorder in war veterans: prospective study of five-year treatment

Aim

To assess the effectiveness of the long-term group psychotherapy in the treatment of posttraumatic stress disorder (PTSD) in war veterans on the basis of clinical picture of PTSD, associated neurotic symptoms, and adopted models of psychological defense mechanisms.

Methods

Prospective cohort study involved 59 war veterans who participated in dynamic-oriented supportive group psychotherapy for five years. The groups met once a week for 90 minutes. Forty-two veterans finished the program. The Clinician-Administered PTSD Scale structured interview was used to assess the intensity of PTSD. Crown-Crisp Index was used to evaluate other neurotic symptoms, and Life Style Questionnaire was used to assess the defense mechanisms. The assessments were done at the beginning of psychotherapy, after the second, and after the fifth year of treatment. Comorbid diagnoses, hospitalizations, and outpatient clinic treatments were also recorded.

Results

Long-term group psychotherapy reduced the intensity of PTSD symptoms in our patients (the difference between Clinician-Administered PTSD Scale score at the beginning and the end of treatment, F = 9.103, P = 0.001). Other neurotic symptoms and the characteristic profile of defense mechanisms did not change significantly during the course of treatment. Predominant defense mechanisms were projection (M = 82.0 ± 14.4) and displacement (M = 69.0 ± 16.8). None of the symptoms or defense mechanisms present at the beginning of the treatment changed significantly after two or five years of treatment. The number of diagnosed major depressive episodes, which increased after the second year of psychotherapy, decreased by the end of treatment.

Conclusion

Psychotherapy can reduce the intensity of PTSD symptoms, but the changes in the personality of veterans with PTSD are deeply rooted. Traumatic experiences lead to the formation of rigid defense mechanisms, which cannot be significantly changed by long-term group psychotherapy.A traumatic experience greatly changes the perception of inner and outer world in a patient with posttraumatic stress disorder (PTSD) (1). Feelings of deep isolation, alienation, helplessness, and distrust, together with interpersonal problems and socially dysfunctional behavior, are the main psychological components of PTSD (1). Group psychotherapy, therefore, has the central role in the integrated psychiatric treatment of patients with PTSD (2).Since 1980, when the term “posttraumatic stress disorder” was introduced in psychiatric nomenclature, numerous studies have been conducted to establish the most appropriate psychotherapeutic methods for treating this disorder (3). Although recent guidelines recommend cognitive-behavioral approach, it seems that this type of therapy cannot be successfully applied in all war veterans, especially not in those with chronic PTSD (2-5). Deeply rooted changes in personality, which disturb biological, psychological, and social equilibrium, require long-term therapy. The corrective emotional experience and the feeling of security in a therapeutic group setting strengthen the healthy parts of the self, and neutralize and reintegrate the destructive ones (6). Dynamic-oriented group therapy is commonly used because the number of patients who need psychological help is relatively high, the availability of group therapists is limited, and the range of indications for this type of therapy is broad (2).After the 1991-1995 war in Croatia, the number of war veterans asking for psychiatric help has been increasing. In the first encounters with these patients, psychiatrists prescribed psychopharmaceuticals more often than short psychotherapeutic interventions. However, they soon realized that PTSD symptoms were recurring after an initial improvement and that the disorder had a strong and lasting impact on the patients'' professional, social, and family life. It was obvious that initially applied treatment methods could not successfully meet veterans’ needs for continuous and accessible mental health care. A more comprehensive and effective psychotherapeutic approach had to be adopted (6,7).Our aim was to assess the effectiveness of long-term group psychotherapy in the treatment of war veterans with PTSD by evaluating the clinical picture of PTSD, associated neurotic symptoms, and adopted models of psychological defense mechanisms after two and five years of treatment.     

Psychological problems in children of war veterans with posttraumatic stress disorder in Bosnia and Herzegovina: cross-sectional study

Aim

To assess psychological problems in children as reported by their veteran fathers with war-related posttraumatic stress disorder (PTSD).

Method

The study group consisted of 154 veterans with war-related PTSD who were treated at the Mostar University Hospital. The control group consisted of 77 veterans without war-related PTSD who were selected from veteran associations by the snowball method. General Demographic Questionnaire, the first and fourth module of the Harvard Trauma Questionnaire–Bosnia and Herzegovina version, and the Questionnaire on Developmental, Emotional, and Behavioral Problems in Children, created specifically for the needs of this study, were used to collect data on veterans’ perception of psychological problems in their children.

Results

In comparison with veterans without PTSD, veterans with PTSD reported significantly more developmental (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.51-3.73), behavioral (OR, 3.92; 95% CI, 1.53-10.03), and emotional problems (OR, 17.74; 95% CI, 2.40-131.10) in their children.

Conclusion

Veterans with war-related PTSD more often reported developmental problems in their children. Father’s PTSD may have long-term and long-lasting consequences on the child’s personality.Posttraumatic stress disorder (PTSD) in one family member can negatively influence other family members and affect entire family dynamics (1-3). For many reasons, children in such families are especially vulnerable (4).Many studies have established that, in comparison with children of combat veterans without PTSD, the children of combat veterans with PTSD have more frequent and more serious developmental, behavioral, and emotional problems (2,5-10). Some of them also have specific psychiatric problems (11).Interviews with spouses and partners of combat veterans revealed that children of veterans with PTSD have more behavioral problems (5) and more frequent problems with authority, depression, anger, hyperactivity, and personal relationships (6-10) than children of veterans without PTSD. They are also more aggressive, use opiate drugs more often (6), and have learning difficulties and problems with diadic relations and emotional regulation (8). However, Harkness (8,12) did not find a significant association between the intensity of PTSD symptoms in veteran fathers and behavior of their children. On the other hand, it seems that the children of Vietnam War veterans did have behavioral problems, with veterans’ PTSD being a possible indirect factor in this association (13). It is assumed that direct war experience may disrupt the later capability of veterans to function as parents, leading to difficulties in the development and behavior of their children (12,13).With respect to the degree of individual and social traumatization caused by war trauma and post-war social situation in Bosnia and Herzegovina (BH), we assumed that war-related PTSD in veterans would have noticeable effect on the development of their children and that children of veterans with PTSD would have more psychological problems than children of veterans without PTSD.The aim of our study was to determine developmental, behavioral, and emotional problems of children in BH as reported by their veteran fathers with combat-related PTSD.     

Disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans with posttraumatic stress disorder: case-control study

Aim

To determine the presence of disorder of extreme stress not otherwise specified (DESNOS) in Croatian war veterans who suffer from combat-related posttraumatic stress disorder (PTSD).

Methods

The research included 247 veterans of the 1991-1995 war in Croatia who suffered from PTSD and were psychiatrically examined at four clinical centers in Croatia during a month in 2008. It was based on the following self-assessment instruments: The Harvard Trauma Questionnaire (HTQ): Croatian Version, the Structured Interview for Disorder of Extreme Stress (SIDES-SR), and the Mini International Neuropsychiatric Interview (MINI)

Results

Based on the SIDES-SR results, we formed two groups of participants: the group with PTSD (N = 140) and the group with both PTSD and DESNOS (N = 107). Forty three percent of participants met the criteria for DESNOS. There was a significant difference in the intensity of posttraumatic symptoms between the group with both PTSD and DESNOS and the group with PTSD only (U = 3733.5, P = 0.001). Respondents who suffered from both PTSD and DESNOS also reported a significantly larger number of comorbid mental disorders (U = 1123.5, P = 0.049) and twice more frequently reported comorbid depression with melancholic features (OR = 2.109, P = 0.043), social phobia (OR = 2.137, P = 0.036), or panic disorder (OR = 2.208, P = 0.015).

Conclusion

Our results demonstrate that PTSD and DESNOS can occur in comorbidity, which is in contrast with the ICD-10 criteria. A greater intensity of symptoms and a more frequent comorbidity with other psychiatric disorders, especially depression, panic disorder, and social phobia require additional therapy interventions in the treatment processes.Posttraumatic stress disorder (PTSD) is a common, but not the only disorder that develops as an effect of a traumatic experience. The prevalence of PTSD in general population is 1 to 14% (1-4). In case of war veterans, the rate ranges from 15 to 57% (3,5,6). As much as 79% of persons suffering from PTSD suffer from another mental disorder and 44% suffer from three or more mental disorders. This means that in case of a large number of traumatized persons, PTSD diagnosis covers only a few mental disturbances (7-11).Chronic or complex PTSD and DES or DESNOS (disorder of extreme stress not otherwise specified) have been investigated since the 1990s (12-15). DESNOS is defined and viewed as a group of symptoms within associated features of PTSD, and as such it may be included in future classifications (2,9). On the other hand, the ICD-10 introduced a diagnostic category of Enduring Personality Change After Catastrophic Events (F62.0), which includes features such as hostility and mistrustful attitude toward the world, social isolation, a feeling of emptiness and hopelessness, irritability, and estrangement. The diagnosis can be given only after two years of the illness duration and it excludes the diagnosis of concurrent PTSD because the enduring change is seen only as an adverse outcome of a long-lasting PTSD, not as a separate entity that can exist in comorbidity with PTSD (1). After its full development, enduring personality change cannot be treated that easily. The ICD-10 classification does not allow diagnosing the comorbidity of PTSD and Enduring Personality Change After Catastrophic Experience or DESNOS as a corresponding diagnostic category proposed by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification (2).The correlation of DESNOS and PTSD is still not completely clear. It is not specified whether DESNOS is a separate clinical entity or a complication of PTSD. Potential factors are severity of traumatic experience, correlation with the severity of PTSD, comorbidity in Axes I and II of the DSM-IV classification system, and a range of personal and social factors that add to the development of the disorder (9,16,17). In spite of clinical experience and results speaking in favor of the presence of the entity that can be developed as an effect of trauma independently of PTSD or in comorbidity with PTSD, the DSM IV classification has not included this category (2,16-19).However, over the past 15 years a number of studies have discussed the possible inclusion of DESNOS in the DSM-V classification (16-19), many criteria have been defined, and even a specific questionnaire, Structured Interview for Disorder of Extreme Stress (SIDES), has been formed (9). Six clusters of symptoms have been proposed for establishing the DESNOS diagnosis: 1) alterations in regulation of affect and impulses (eg, extreme and unmodulated emotional states); 2) alterations in attention or consciousness (eg, dissociation); 3) alterations in self-perception (eg, image of self as fundamentally damaged); 4) alterations in interpersonal relations (eg, impaired relational boundaries); 5) alterations in biological self-regulation (eg, somatization), and 6) alterations in sustaining beliefs (eg, spiritual alienation) (18).[REMOVED HYPERLINK FIELD]DESNOS mostly occurs as a separate disorder, but also in comorbidity with PTSD. The prevalence of DESNOS is 1% in female student population (19), 2% in civil population exposed to war (18), and up to 57% in war veterans, 31% in comorbidity with PTSD and 26% as a separate diagnostic category (16). Furthermore, the prevalence of PTSD is the same in the general population and treatment-seeking population (17). Nearly a half of the treatment-seeking population meets the criteria for DESNOS, which suggests that symptoms of DESNOS, more likely than symptoms of PTSD, are the ones prompting patients to seek help (17).Clinical experience in working with war veterans in Croatia shows that there are patients suffering from chronic PTSD who report a range of symptoms meeting the criteria proposed for DESNOS (9). However, possible comorbidity of DESNOS and PTSD has not been assessed, probably to conform to the existing ICD classification (1). It may be assumed that DESNOS affects patients with severe clinical features of PTSD and that it also occurs in cases of Axis I comorbidity. These assumptions were the subject of our investigation.     

Platelet 5-HT concentration and comorbid depression in war veterans with and without posttraumatic stress disorder

BACKGROUND: The serotonergic system is implicated in the pathophysiology of posttraumatic stress disorder (PTSD) and depression. The present study focused on platelet serotonin (5-HT) concentration and symptoms of comorbid depression in war veterans with or without PTSD. METHODS: PTSD and depression were evaluated using Clinician Administered PTSD Scale, Davidson Trauma Scale, Montgomery-Asberg Depression Rating Scale and Hamilton Anxiety Scale. Sixty-five male drug-free war veterans (48 with PTSD and 17 without PTSD) and 65 age- and sex-matched healthy controls were studied. RESULTS: Comorbid depression occurred in 54 and 31% of war veterans with PTSD and without PTSD, respectively. Platelet 5-HT concentration was similar in the groups of depressed and nondepressed war veterans with or without PTSD and healthy controls. Platelet 5-HT concentration was found to differ between war veterans with various degrees of appetite loss. A positive correlation was observed between platelet 5-HT concentration and severity of appetite loss in veterans with PTSD. There was no relationship between platelet 5-HT concentration and severity of other symptoms of PTSD or depression. LIMITATIONS: War veterans included in the study were outpatients. CONCLUSIONS: War veterans with PTSD had a high incidence of comorbid depression, that was not related to platelet 5-HT concentration. The marked relationship between platelet 5-HT concentration and severity of appetite loss, suggested that 5-HT system is involved in the regulation of appetite, at least in depressed war veterans with PTSD.     

Treating comorbid panic disorder in veterans with posttraumatic stress disorder

This study compares the effectiveness of panic control treatment (PCT) with that of a psychoeducational supportive treatment (PE-SUP) in treating panic disorder among a veteran sample with a primary diagnosis of chronic posttraumatic stress disorder (PTSD). Thirty-five patients randomized to receive 10 individual sessions of either PCT or PE-SUP underwent assessments at pretreatment, at 1-week posttreatment, and at a 3-month follow-up. Intent-to-treat analyses of covariance showed that PCT participants significantly improved on panic severity at posttreatment and panic fear at the 3-month follow-up. The PCT group also showed significant reductions in anxiety sensitivity at posttreatment and follow-up compared with that of the PE-SUP group. A significantly higher proportion of persons (63%) in the PCT group was panic free by the follow-up period compared with that of the PE-SUP group (19%). Patient self-report and clinician ratings showed no changes in general anxiety, depression, and PTSD symptoms in either group. These findings indicated that PCT was superior to an active control therapy in reducing the frequency, severity, and distress associated with panic disorder and suggested that brief cognitive-behavioral therapy for panic is effective for persons with chronic PTSD.     

Association between total serum cholesterol and depression,aggression, and suicidal ideations in war veterans with posttraumatic stress disorder: a cross-sectional study

Aim

To investigate the relationship between total serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with posttraumatic stress disorder (PTSD) without psychiatric comorbidity.

Methods

A total of 203 male PTSD outpatients were assessed for the presence of depression, aggression, and suicidality using the 17-item Hamilton Depression Rating Scale (HAM-D₁₇), Corrigan Agitated Behavior Scale (CABS), and Scale for Suicide Ideation (SSI), respectively, followed by plasma lipid parameters determination (total cholesterol, high density lipoprotein [HDL]-cholesterol, low density lipoprotein [LDL]-cholesterol, and triglycerides). PTSD severity was assessed using the Clinician-Administered PTSD Scale for DSM-IV, Current and Lifetime Diagnostic Version (CAPS-DX) and the Clinical Global Impressions of Severity Scale (CGI-S), before which Mini-International Neuropsychiatric Interview (MINI) was administered to exclude psychiatric comorbidity and premorbidity.

Results

After adjustments for PTSD severity, age, body mass index, marital status, educational level, employment status, use of particular antidepressants, and other lipid parameters (LDL- and HDL- cholesterol and triglycerides), higher total cholesterol was significantly associated with lower odds for having higher suicidal ideation (SSI≥20) (odds ratio [OR] 0.09; 95% confidence interval [CI] 0.03-0.23], clinically significant aggression (CABS≥22) (OR 0.28; 95% CI 0.14-0.59), and at least moderate depressive symptoms (HAM-D₁₇≥17) (OR 0.20; 95% CI 0.08-0.48). Association of total cholesterol and HAM-D₁₇ scores was significantly moderated by the severity of PTSD symptoms (P < 0.001).

Conclusion

Our results indicate that higher total serum cholesterol is associated with lower scores on HAM-D₁₇, CABS, and SSI in patients with chronic PTSD.Posttraumatic stress disorder (PTSD) is one of the few mental disorders with a clearly identifiable cause. It is an anxiety disorder caused by exposure to a traumatic event that presented a threat to the physical integrity of persons themselves or other people in their surroundings (1). Key neurochemical PTSD features include altered catecholamines regulation, alterations in serotonergic system, and alterations in systems of aminoacids, peptides, and opioid neurotransmitters (2).Associations between serum lipids and various psychiatric disorders and some behavioral aspects (like aggressive behavior) and/or suicidality have been widely explored. Lower total cholesterol levels were predominantly found in patients with major depressive disorder (MDD) (3-9). Significantly higher high-density lipoprotein cholesterol (HDL-cholesterol) levels were found in depressive patients than in controls (7). Some studies found significantly lower HDL-cholesterol levels (10) and a lower HDL-cholesterol/total cholesterol ratio (5) in patients with MDD than in controls.A negative correlation (11-13) between serum cholesterol level and aggressive behavior was also found, confirming the cholesterol-serotonergic hypothesis of aggression (14,15). Inadequate cholesterol intake could lead to decreased central serotonin activity, which is associated with an increased risk for impulsive-aggressive behavior (14-18). Depression (19-21) and aggression are well-known suicidality risk factors (15,22).The correlation between hypocholesterolemia, decreased central serotonin activity, increased depressive potential, and increased suicidality risk (23-27) was confirmed, implicating that hypocholesterolemia might be indirectly, ie, through decreased central serotonin activity and increased depression potential (20,25,28), associated with an increased suicidality risk (15,19-24,26,27). In patients with anxiety disorders other than PTSD, like panic disorder (PD), lower HDL-cholesterol and higher very low density lipoprotein cholesterol (VLDL-cholesterol) levels were found to be associated with higher suicide ideations/risk (29). Significantly lower serum total cholesterol and LDL cholesterol levels were found in suicidal patients with PD than in control subjects (30).Hypercholesterolemia was found to be associated with chronic, war-related PTSD (31-34). In a study from Bosnia and Herzegovina, not only hypercholesterolemia but also increased VLDL- and HDL-cholesterol levels were found in war veterans with PTSD in comparison with war veterans without psychiatric disorders (35). A Croatian study found no significant differences in the total serum cholesterol level, LDL-, and HDL-cholesterol between war veterans with PTSD, war veterans without PTSD, and healthy volunteers (36).The aim of this study was to investigate the relationship between serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with PTSD free of other psychiatric premorbidity and comorbidity.     

A self-rating scale for the assessment of posttraumatic stress disorder in dutch resistance veterans of world war II

The present study reports on the development of a Dutch PTSD scale based on the DSM-III criteria for PTSD. Test-retest reliability was.91. The scale showed an internal consistency with a coefficient alpha of.88. Factor analysis on a large sample of Resistance veterans (N = 967) yielded six factors, which represent intrusive thoughts, physiological reactions, detachment, rage, active confrontation, and guilt.     

Attachment organization in Vietnam combat veterans with posttraumatic stress disorder

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

Clinical presentations in combat veterans diagnosed with posttraumatic stress disorder

This article investigated subtypes of symptom patterns among male combat veterans diagnosed with posttraumatic stress disorder (PTSD) through a cluster analysis of their Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Graham, Ben-Porath, Tellegen, Dahlstrom, & Kaemmer, 2001) clinical and validity scales. Participants were 126 veterans seeking outpatient treatment for combat-related PTSD at a Veterans Affairs Medical Center. Two well-fitting MMPI-2 cluster solutions (a four-cluster solution and a three-cluster solution) were evaluated with several statistical methods. A four-cluster solution was determined to best fit the data. Follow-up analyses demonstrated between-cluster differences on MMPI-2 "fake bad" scales and content scales, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), Mississippi Combat PTSD scale (M-PTSD; Keane, Caddall, & Taylor, 1988), and Clinician-Administered PTSD Scale (CAPS-1; Blake et al., 1990). Clusters also were different in disability-seeking status, employment status, and income. Implications for research and clinical practice using the MMPI-2 with combat veterans presenting with PTSD are briefly addressed.     

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

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

Positive airway pressure adherence in veterans with posttraumatic stress disorder

Study Objectives:

To determine the short-term positive airway pressure (PAP) adherence rates and to identify non–mask-related risk factors associated with 30-day nonadherence to PAP in a population of veterans with obstructive sleep apnea (OSA) and posttraumatic stress disorder (PTSD).

Design:

A retrospective study.

Settings:

A Veterans Affairs hospital.

Patients:

One hundred forty-eight PTSD veterans newly diagnosed with OSA and a control group of OSA without PTSD matched for age, gender, BMI, and severity of OSA.

Interventions:

N/A

Measurements and Results:

At 30-day follow-up, adherence to PAP was significantly lower in the PTSD group compared to the control group (41% versus 70%, respectively; P < 0.001). Veterans with adequate PAP adherence were more likely to experience sleepiness at baseline compared to nonadherent subjects (ESS 14.4 ± 5.3 versus 12.3 ± 5.9, respectively; P = 0.04). Nightmares were more frequently reported in those who were PAP nonadherent (P = 0.002). Mask discomfort, claustrophobia, and air hunger were the reported reasons for PAP nonadherence in the PTSD group.

Conclusion:

PAP usage and adherence were lower in PTSD veterans with OSA than veterans without PTSD. Excessive sleepiness predicted PAP adherence while frequent nightmares were correlated with poor adherence to PAP therapy.

Citation:

El-Solh AA; Ayyar L; Akinnusi M; Relia S; Akinnusi O. Positive airway pressure adherence in veterans with posttraumatic stress disorder. SLEEP 2010;33(11):1495-1500.     

Attachment organization in Vietnam combat veterans with posttraumatic stress disorder

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

Circulating lymphocyte subsets, natural killer cell cytotoxicity, and components of hypothalamic-pituitary-adrenal axis in Croatian war veterans with posttraumatic stress disorder: cross-sectional study

Aim

To determine peripheral blood lymphocyte subsets – T cells, helper T cells, cytotoxic T cells, B cells, and natural killer cells, natural killer cell cytotoxicity, serum cortisol concentration, and lymphocyte glucocorticoid receptor expression in Croatian combat veterans diagnosed with chronic posttraumatic stress disorder (PTSD); and to examine the relationship between the assessed parameters and the time passed since the traumatic experience.

Methods

Well-characterized group of 38 PTSD patients was compared to a group of 24 healthy civilians. Simultaneous determination of lymphocyte subsets and the expression of intracellular glucocorticoid receptor was performed using three-color flow cytometry. Natural killer cell cytotoxicity was measured by ⁵¹Cr-release assay and the serum cortisol concentration was determined by radioimmunoassay.

Results

We found higher lymphocyte counts in PTSD patients than in healthy controls (2294.7 ± 678.0/μL vs 1817.2 ± 637.0/μL, P = 0.007) and a positive correlation between lymphocyte glucocorticoid receptor expression and the number of years that passed from the traumatic experience (r_s = 0.43, P = 0.008). Lymphocyte glucocorticoid receptor expression positively correlated with serum cortisol concentration both in PTSD patients (r = 0.46, P = 0.006) and healthy controls (r = 0.46, P = 0.035).

Conclusion

This study confirmed that the immune system was affected in the course of chronic PTSD. Our findings also indicated that the hypothalamic-pituitary-adrenal axis profile in PTSD was associated with the duration of the disorder. Due to the lack of power, greater sample sizes are needed to confirm the results of this study.Prolonged or frequently repeated stress response during symptomatic episodes in chronic posttraumatic stress disorder (PTSD) can result in neuroendocrine and immune alterations, posing serious threat to mental and physical health (1,2). Evidence suggests that PTSD is related to increased medical morbidity, particularly from cardiovascular and autoimmune diseases (3). With controversial findings when neurobiology of PTSD is concerned, the patophysiological mechanisms underlying increased susceptibility to disease are not clear (4,5). However, it has been implicated that the sympathetic-adrenal-medullary (SAM) and the hypothalamic-pituitary-adrenal axes are the key mediators in this process (6,7).The immune system interacts with the hypothalamic-pituitary-adrenal axis in a bidirectional fashion to maintain homeostasis. Being the primary effector of the stress response, cortisol modifies the complex cytokine network and, consequently, leukocyte function and recirculation (8). These effects are achieved through its interaction with the specific intracellular glucocorticoid receptors (9).Studies of the leukocyte recirculation (10,11), immune cells function (12), and hypothalamic-pituitary-adrenal axis activity (5) in PTSD yielded controversial results. Overall findings support the hypothesis that immune activation in PTSD may be associated with Th2 cytokine shift and alterations in the proinflammatory cytokine system (4). Besides, it is believed that PTSD is linked with low plasma cortisol levels and higher glucocorticoid receptor expression, suggesting enhanced feedback sensitivity to cortisol (13). In contrast to these findings, Gotovac et al (14) showed that Croatian combat veterans with PTSD, approximately 6 years after traumatic event, had lower expression of glucocorticoid receptor in lymphocyte subsets, with higher serum cortisol concentration than healthy subjects. Majority of other studies did not take into account the time passed since the trauma and their samples mainly included Vietnam veterans (15) or Holocaust survivors (16), who had greater time gap since the traumatic experience than Croatian war veterans.Considering the strong discrepancies in the results published to date, we performed a cross-sectional study to evaluate the correlation between PTSD in Croatian combat war veterans and the percentages of circulating lymphocyte subsets, natural killer cell cytotoxicity as a measure of immune function, and the serum cortisol concentration with lymphocyte glucocorticoid receptor expression as components of hypothalamic-pituitary-adrenal axis. The emphasis was put on the relationship between the assessed parameters and the time passed since the traumatic experience.     

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

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