Delayed and immediate onset posttraumatic stress disorder

Summary The current study examined the role battle experiences and personal resources play in the development of combat-related posttraumatic stress disorder (PTSD). For this purpose, battle experiences (battle stress, military unit environment) and personal resources (coping styles, causal attribution) were assessed two years after the 1982 Lebanon War in three groups of male Israeli frontline soldiers: 1. soldiers who sought treatment 6 months or more after the war (delayed PTSD); 2. soldiers who sought treatment during the war (immediate PTSD); and 3. control soldiers. Findings indicated that both immediate and delayed PTSD casualties reported similar and higher levels of battle stress than control subjects. In addition, delayed PTSD casualties evinced less personal resouces than control subjects, and immediate PTSD casualties evinced still less personal resources than delayed PTSD casualties. The theoretical implications of the findings were discussed.This study was supported by the U.S. Army Medical Research and Development Command, Grant No.DAMD17-87-G-7002. The views, opinions, and findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by other documentation.     

Trajectories of PTSD: a 20-year longitudinal study

OBJECTIVE: This study assessed the psychopathological effects of combat in veterans with and without combat stress reaction. METHOD: Veterans (N=214) from the 1982 Lebanon War were assessed in a prospective longitudinal design: 131 suffered from combat stress reaction during the war, and 83 did not. They were evaluated 1, 2, 3, and 20 years after the war. RESULTS: Combat stress reaction is an important vulnerability marker. Veterans with combat stress reaction were 6.6 times more likely to endorse posttraumatic stress disorder (PTSD) at all four measurements, their PTSD was more severe, and they were at increased risk for exacerbation/reactivation. A qualitative analysis of the profile of PTSD symptoms revealed some time-related changes in the symptom configuration of veterans who did not suffer from combat stress reaction. In both groups, the course fluctuated; PTSD rates dropped 3 years postwar and rose again 17 years later; 23% of veterans without combat stress reaction reported delayed PTSD. CONCLUSIONS: These findings suggest that the detrimental effects of combat are deep and enduring and follow a complex course, especially in combat stress reaction casualties. The implications of aging and ongoing terror in impeding recovery from the psychological wounds of war are discussed.     

Psychological sequelae of war. A 3-year prospective study of Israeli combat stress reaction casualties

The long-term psychological sequelae of combat were assessed employing the Impact of Event Scale (IES) 1, 2, and 3 years after the 1982 Lebanon War. The following groups of Israeli veterans participated: combat stress reaction casualties (N = 213) and comparable controls (N = 116). For the purpose of the study, the subjects in each group were screened and further divided according to whether they did or did not suffer from posttraumatic stress disorder (PTSD). Results showed that elevated rates of distress were reported by both combat stress reaction and PTSD casualties at all three points in time. In both study groups the level of distress declined with time. Theoretical and methodological implications were discussed.     

Combat-related posttraumatic stress disorder among second-generation Holocaust survivors: preliminary findings

The authors assessed the impact of the Nazi Holocaust on the course and symptoms of posttraumatic stress disorder (PTSD) among Israeli combat stress reaction casualties. They examined a sample of 96 such casualties of the 1982 Lebanon War whose parents had gone through the Nazi Holocaust and compared them to casualties who did not have such family history for 3 consecutive years beginning 1 year after their participation in the war. Results showed that 2 and 3 years after their participation in the 1982 Lebanon War, the children of Holocaust survivors, i.e., "second-generation" casualties, had higher rates of PTSD than did the control subjects, as well as a somewhat different clinical picture. Clinical and methodological implications of the findings are discussed.     

Reactions to combat stress in Israeli veterans twenty years after the 1982 Lebanon war

During the war or shortly thereafter, the most common manifestation of combat induced psychopathology is combat stress reaction (CSR). The long-term consequences of CSR have so far received little scientific attention. The aim of this study was to examine whether CSR is a marker for long-term PTSD and other psychiatric comorbidities. Two groups of veterans from the 1982 Lebanon war were assessed 20 years after the war: one comprised 286 CSR casualties and the other comprised 218 matched non-CSR soldiers. Participants were assessed for PTSD, psychiatric symptomatology, social functioning, physical health, and postwar life events. Twenty years after the war, veterans with antecedent CSR reported more PTSD, psychiatric symptomatology and distress, social dysfunction, and health problems than did non-CSR veterans. We conclude that CSR should be seen as a marker for long-term psychiatric distress and impairment. In addition, the implications of combat-related trauma are broad and varied, and go beyond the narrow scope of PTSD.     

Delayed onset PTSD among Israeli veterans of the 1982 Lebanon War

This is an exploratory study of the nature, course and rates of delayed post-traumatic stress disorder (PTSD). We reviewed 150 medical files of Israeli soldiers who sought help between 6 months and 5 years after the 1982 Lebanon War. Results indicated that only 10% of the cases were truly examples of delayed PTSD; in a large proportion of the cases, help-seeking rather than onset was delayed.     

PTSD and social functioning

This longitudinal study assessed long term social functioning among two groups of Israeli soldiers: (a) front line soldiers who had been treated for combat stress reaction (CSR) during the 1982 Lebanon war (n = 213); and (b) matched controls who were front line soldiers participating in the same battles, but did not sustain a CSR (n = 116). Subjects were screened one, two, and three years after the war for PTSD and social functioning. Results indicated that CSR and PTSD casualties reported more problems in social functioning than controls. The link between PTSD and social functioning was stronger among PTSD veterans who had suffered an antecedent CSR episode. Time had a differential effect on the social functioning of CSR and control subjects.     

Adjustment profiles of Yom Kippur war veterans seeking delayed help from the IDF

Abstract

The most common stress reactions following combat are post-traumatic stress reactions. These responses have a great impact on quality-of-life and can damage victims’ personal, familial, and social functioning. However, of the people who develop PTSD, only a few request psychological help. The first aim of the research was, therefore, to examine the long-term adjustment patterns of Yom Kippur War veterans who sought help only after a period of more than 30?years. The second aim was to classify the participants according to a common symptom profile. The participant sample consisted of 195 Yom Kippur War veterans who went through a process of assessment and evaluation via intake interviews conducted between 2006 and 2012, when they came to the Combat Stress Reaction (CSR) unit. Data were collected from the participants’ files. The findings indicated that, by the time they arrived at the CSR Unit, 90.8% of the participants were experiencing PTSD. The findings support the argument that delayed onset of PTSD without a background history of symptoms is rare, and indicate that most people who seek help report that their low-level symptoms intensified over the years until these symptoms developed into clinically meaningful PTSD.     

Familial psychiatric illness in chronic posttraumatic stress disorder

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

Smaller head of the hippocampus in Gulf War-related posttraumatic stress disorder

Reductions in hippocampal volume and impairment in short-term verbal memory have been reported in Vietnam combat veterans with posttraumatic stress disorder (PTSD) and in women with abuse-related PTSD. The present investigation evaluated hippocampal volume and memory in Gulf War veterans. This research is timely given the ongoing war in Iraq and the anticipated high rates of PTSD among returning combat soldiers. Fourteen veterans with PTSD related to traumatic experiences during the Gulf War (1990-1991), 23 deployed veterans without PTSD, 22 non-deployed reservists and 29 healthy civilians were studied. Volumes of the hippocampus, temporal lobe, and whole brain were measured on coronal MRI scans, and hippocampal mediated memory function was evaluated. The head of the hippocampus was the only subregion that was significantly smaller in Gulf War veterans with PTSD than in healthy civilians. Deployed veterans with PTSD, deployed veterans without PTSD, and non-deployed reservists had significantly smaller whole hippocampal volume and lower scores on immediate and delayed verbal and visual retrieval compared with healthy civilians.     

A two year follow-up of somatic complaints among Israeli combat stress reaction casualties

The relationships of somatic complaints and health related habits to combat stress reaction and post-traumatic stress disorder were assessed one and two years after the 1982 Lebanon War. The sample consisted of 285 combat stress reaction Israeli casualties and 198 comparable controls. Results showed that higher rates of somatic complaints were reported by both combat stress reaction and post-traumatic stress disorder casualties at the two points in time. Theoretical and methodological implications were discussed.     

Frontline treatment of combat stress reaction: a 20-year longitudinal evaluation study

OBJECTIVE: The purpose of the study was to evaluate the long-term (20-year) effectiveness of frontline treatment provided to combat stress reaction casualties. METHOD: A longitudinal quasi-experimental design was employed. Participants were combat stress reaction casualties of the 1982 Lebanon War who received frontline treatment (N=79), comparable combat stress reaction casualties who did not receive frontline treatment (N=156), and matched soldiers who did not experience combat stress reaction (N=194). Subjects were asked which of the frontline treatment principles (proximity, immediacy, expectancy) were applied in their treatment, whether or not they returned to their unit after frontline treatment, and if so, whether they returned before or after they felt completely recovered. Outcome assessments included measures of posttraumatic and psychiatric symptoms and of social functioning. RESULTS: Twenty years after the war, traumatized soldiers who received frontline treatment had lower rates of posttraumatic and psychiatric symptoms, experienced less loneliness, and reported better social functioning than similarly traumatized soldiers who did not receive frontline treatment. In addition, a cumulative effect of application of frontline treatment principles was documented: the more principles applied, the stronger the effect on psychiatric outcomes. CONCLUSIONS: Frontline treatment is associated with improved outcomes even two decades after its application. This treatment may also be effective for nonmilitary precursors of posttraumatic stress disorder.     

Delayed onset of posttraumatic stress disorder among male combat veterans: a case series.

OBJECTIVE: Authors investigated the nature of delayed-onset posttraumatic stress disorder (PTSD) among combat veterans. METHODS: PTSD, along with cognitive and emotional functioning, was assessed in a case series of elderly Australian war veterans. RESULTS: Fifteen elderly male subjects consecutively referred to an outpatient psychiatric clinic were identified as having PTSD with significantly delayed onset. In most cases, the onset of PTSD symptoms was associated with unrelated medical complaints, psychosocial stress, and/or mild cognitive impairment. CONCLUSION: Environmental stressors, coupled with age-related neurodegeneration, may potentially contribute to the late-life recrudescence or emergence of PTSD symptoms in veterans exposed to combat-related trauma.     

Disability compensation seeking among veterans evaluated for posttraumatic stress disorder

OBJECTIVE: This study sought to further examine the relationship between compensation-seeking status and reporting of symptoms among combat veterans who were evaluated for posttraumatic stress disorder (PTSD). METHODS: Archival data were drawn for 320 adult male combat veterans who were consecutively evaluated at a Department of Veterans Affairs (VA) PTSD outpatient clinic from 1995 to 1999. The veterans were compared on variables from their clinical evaluation, including diagnostic status and self-report measures such as the Minnesota Multiphasic Personality Inventory-2, which includes scales designed to detect feigned or exaggerated psychopathology. RESULTS: Compensation-seeking veterans reported significantly more distress across domains of psychopathology, even after the effects of income had been controlled for and despite an absence of differences in PTSD diagnoses between groups. However, compensation-seeking veterans also were much more likely to overreport or exaggerate their symptoms than were non-compensation-seeking veterans. CONCLUSIONS: This study provided further evidence that VA disability compensation incentives influence the way some veterans report their symptoms when they are being evaluated for PTSD. These data suggest that current VA disability policies have problematic implications for the delivery of clinical care, evaluation of treatment outcome, and rehabilitation efforts within the VA.     

Current combat-related disorders in the absence of PTSD among Australian Vietnam veterans

The research literature on the psychiatric consequences of the Vietnam War focuses primarily on the construct of Posttraumatic Stress Disorder (PTSD), after an initial focus in the 1970s on depression and alcohol and substance abuse. The present paper examines the hypothesis that among men without current PTSD, those with higher combat in Vietnam will be more likely to have current DSM-III-R illnesses. The Australian Vietnam Veterans' Health Study (AVVHS) collected a broad range of interview data on 641 Vietnam veterans throughout 1990–1993. Measures of combat exposure, age at embarkation to Vietnam, enlistment IQ and pre-Army personality problems were drawn from Army records of the era. Retrospective measures of combat were obtained at interview. The interview also involved the administration by trained lay interviewers of the DSM-III-R based Diagnostic Interview Schedule (DIS). This epidemiological instrument provides current psychiatric diagnoses as well as temporal (retrospective) symptom and diagnosis onset data. The results of this study show that current disorders (without PTSD comorbidity) with onsets within 5 years of embarkation to Vietnam are more likely among men who saw higher combat, as indexed by combat-exposure measures drawn from Army records of the era as well as retrospective self-report. This combat relatedness remains when age at embarkation, IQ at enlistment and pre-Army personality measures are used as covariates. No more than 11.4% of sampled Vietnam veterans currently meet DSM-III-R diagnostic criteria for PTSD, while a further 7.8% do not have current PTSD but do have some other current DIS diagnosis with onset in the 5-year period following (first) emabarkation to Vietnam. Our data support the hypothesis that the current illnesses of many of these men without PTSD are combat-related DSM-III-R illnesses. Accepted: 11 September 1997     

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.     

Personality in chronic post-traumatic stress disorder: : A study of the eysenck inventory

Personality variables were assessed in 30 patients with chronic post-traumatic stress disorder (PTSD). World War II/Korean War (WWII/K) veterans with PTSD were significantly more introverted and neurotic than age-matched non-psychiatric controls, whether or not the controls had been in combat. WWII/ K patients scored significantly higher than Vietnam War patients on both intro-version and denial (lie) scales. Eysenck measures did not change during treatment in PTSD patients; PTSD patients were significantly more neurotic than were major depressives.     

Psychological sequelae of war. A 2-year follow-up study of Israeli combat stress reaction casualties

The relationships of two stress-related intrapsychic manifestations--intrusion and avoidance--to combat stress reaction and posttraumatic stress disorder were assessed 1 and 2 years after the 1982 Lebanon War. The sample consisted of 285 combat stress reaction Israeli casualties and 198 comparable control subjects. Results showed that higher rates of intrusion and avoidance were reported by both combat stress reaction and posttraumatic stress disorder casualties at the two points in time. In addition, the level of intrusion tendencies declined with time. Theoretical and methodological implications are discussed.     

Phenomenology and course of psychiatric disorders associated with combat-related posttraumatic stress disorder.

OBJECTIVE: Studies indicate that chronic combat-related posttraumatic stress disorder (PTSD) is frequently associated with other psychiatric disorders. Questions regarding the nature and interrelationships of these conditions require clarification. The purpose of this study was to address primary and secondary illness relationships by focusing on the specific phenomenology and course of illness onset of PTSD comorbidity. METHOD: In order to minimize confounding factors, only outpatients without recent substance use disorders were included. Sixty subjects who had been exposed to severe combat stress including veterans of Vietnam and veterans of World War II or Korea, 15 of whom were former prisoners of war, received structured assessments over serial evaluations. RESULTS: PTSD was the most prevalent lifetime disorder followed by major depression, panic disorder, generalized anxiety disorder, and phobic disorder or symptoms. Endogenous-appearing features overlapping other clinical populations were common; however, some specific symptom patterns also were suggestive of traumatic influence. Unlike generalized anxiety disorder and past substance use, the mean onset of phobias, major depression, and panic disorder, respectively, occurred later than PTSD. CONCLUSIONS: These observations suggest that persistent conditions related to PTSD progress toward symptoms that are increasingly autonomous in their pattern of occurrence.     

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.