Valproate in combat-related posttraumatic stress disorder

BACKGROUND: The symptoms of posttraumatic stress disorder (PTSD) suggest sympathetic nervous system hyperarousal and hyperreactivity. Pathophysiology of this condition may include stress-activated limbic kindling. Antikindling agents lithium and carbamazepine have been found effective for PTSD symptoms of intrusive reexperiencing and increased arousal. These facts suggest that valproate, another drug shown to interfere with limbic kindling, could also be effective for treatment of PTSD. METHOD: An open clinical trial of valproate was conducted in 16 Vietnam veterans diagnosed with DSM-III-R combat-related PTSD. RESULTS: Ten of 16 patients showed significant improvement, especially in hyperarousal/hyperreactivity symptoms. CONCLUSIONS: The efficacy of valproate in the treatment of PTSD should be rigorously studied.     

Reactivation of combat-related posttraumatic stress disorder

The authors conducted an exploratory study of the nature and course of reactivation of combat-related posttraumatic stress disorder. Experienced psychiatrists, they each independently assessed 35 men with recurrent combat-related posttraumatic stress disorder. Two major types of reactivated posttraumatic stress disorder, each representing a different degree of pathology, were delineated: uncomplicated reactivation and heightened vulnerability. The second category was further subdivided into specific sensitivity, moderate generalized sensitivity, and severe generalized sensitivity. The authors conclude that reactivation of war-related trauma is a complex phenomenon that may take different forms.     

Neuropsychological findings in combat-related posttraumatic stress disorder

Previous research investigating whether combat-related Posttraumatic Stress Disorder (PTSD) is associated with impaired neuropsychological functioning has yielded inconsistent findings. The present study addressed many methodological limitations of previous research. Neuropsychological measures of intellectual ability, learning, memory, attention, visuospatial ability, executive functioning, language, and psychomotor speed were compared in four groups of early middle-aged community dwelling veterans. The four demographically comparable groups were: (a) those with current PTSD symptoms (n=80); (b) those with a prior history of PTSD but not currently experiencing active PTSD symptoms (n=80); (c) a non-PTSD psychiatrically matched control group (n=80); and (d) a normal control group (n=80). Results indicated that the four groups did not statistically differ on the neuropsychological measures and that veterans with PTSD perform similarly to demographically matched controls. Results further suggested that the cognitive difficulties previously linked to PTSD may actually have been secondary to preexisting individual differences or other clinical conditions coexisting with PTSD.     

Psychotic symptoms in combat-related posttraumatic stress disorder

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

Auditory hallucinations in combat-related chronic posttraumatic stress disorder

Intrusive images have been reported to occur in a broad range of people with posttraumatic stress disorder, but the frequency of intrusive auditory perceptions has rarely been addressed. This study compared five posttraumatic stress disorder veterans experiencing auditory hallucinations with 31 nonhallucinating veterans on demographic, military, postmilitary, and symptom variables. Veterans who reported auditory hallucinations had higher combat exposure and more intense posttraumatic stress disorder symptoms than the other veterans. These veterans also tended to be more refractory to treatment than veterans with no hallucinations. Clinical vignettes of the veterans with auditory hallucinations are given, and the implications of the results for a subgroup of chronic posttraumatic stress disorder veterans are discussed.     

Nature adventure rehabilitation for combat-related posttraumatic chronic stress disorder: A randomized control trial

Chronic combat-related posttraumatic stress disorder (CR-PTSD) is a condition with many treatment barriers. Nature Adventure Rehabilitation (NAR) as a second line or as a supplemental intervention has the potential to overcome some of these barriers and incorporate aspects of successful treatment modalities for PTSD within an experiential learning paradigm. In a pre-post controlled trial, CR-PTSD veterans (n=22) underwent a 1-year NAR intervention compared to a waiting list (WL) control group (n=20). Posttraumatic symptoms (PTS), depression, functional problems, quality of life, perceived control over illness (PCI) and hope were measured by self report measures. PTS, emotional and social quality of life, PCI, hope and functioning improved significantly. Change in PTS was contingent upon change in PCI. The current study is the first to present NAR as a promising supplemental intervention for chronic CR-PTSD. NAR seems to work through a process of behavioral activation, desensitization, gradual exposure to anxiety evoking situations and gaining control over symptomatology.     

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.     

Contemporary group treatment of combat-related posttraumatic stress disorder

The contemporary group treatment of veterans from the Vietnam War to the present who suffer from combat-related PTSD is reviewed in light of the dynamic understanding of combat trauma developed during and since World War II. Both dynamic and cognitive behavioral group therapies are explored. The common features of all group treatments of combat PTSD involve the development of trust and the communalization of trauma within a cohesive group. Further research is needed to increase our understanding of effectiveness, mediating factors, and relationships between childhood experience and combat trauma.     

Plasma testosterone levels in patients with combat-related posttraumatic stress disorder

BACKGROUND: An abnormal level of androgens has been reported in various psychiatric disorders and the important role of androgens in the regulation of human sexuality, aggression, cognition, emotions and personality have been described. Previous studies in the area of stress and the hypothalamic-pituitary-gonadal (HPG) system in humans indicate that circulating testosterone levels are suppressed by physical and psychological stress. However, there is also evidence that plasma levels of testosterone can increase during potentially stressful events and may be elevated in combat-related posttraumatic stress disorder (CR-PTSD) in comparison with normal subjects and major depressive disorder patients. METHODS: The aim of the present study was to examine the possible involvement of the HPG system in chronic untreated CR-PTSD. To this end, we assessed the morning plasma levels of testosterone and cortisol in never-treated chronic CR-PTSD outpatients compared with normal healthy controls. RESULTS: There were no statistically significant differences between the CR-PTSD patients and healthy control subjects in morning plasma testosterone (547.8 +/- 152.2 ng/dl vs. 565.6 +/- 122.4 ng/dl; p = 0.7) and cortisol (19.0 +/- 8.5 microg/dl vs. 15.4 +/- 5.1 microg/dl; p = 0.1) levels. However, a significant correlation between plasma testosterone level and avoidance symptom scores of the Impact of Events Scale (IES) was found in the CR-PTSD patients (r = 0.43, p < 0.05). CONCLUSIONS: The findings of plasma testosterone levels comparable with normal controls in CR-PTSD patients may indicate that the previously described reduction in testosterone levels in normal subjects under stressful conditions may reflect the acute stress response of the HPG axis, in contrast to an adaptation of the HPG axis under chronic psychological stress.     

The effect of combat-related posttraumatic stress disorder on the family

This paper reviews literature on the detrimental effect of combat-related posttraumatic stress disorder on the family. The literature indicates that guilt feelings, emotional withdrawal and elevated levels of aggression in the returning veteran make it difficult, perhaps even impossible, for him to fully resume his former roles of father, husband and breadwinner. Wives and children of veterans show psychiatric symptoms. Despite these hardships, the families are generally reluctant to seek professional help. The clinical implications are discussed and suggestions are made for intervention and outreach.     

Severity of combat-related posttraumatic stress disorder versus noncombat-related posttraumatic stress disorder: a community-based study in American Indian and Hispanic veterans

The goal of the study was to compare severity of combat-related posttraumatic stress disorder (PTSD) versus noncombat-related PTSD in a group known to have high rates of combat-related PTSD. Sample consisted of 255 male American Indian and Hispanic veterans with lifetime PTSD who were contacted in communities in 2 regions of the country. Measures of PTSD severity included current posttraumatic symptoms, remission from lifetime PTSD, lifetime severity of alcohol-drug related problems, and mental health treatment history. Our findings revealed that veterans with combat-related PTSD had more severe posttraumatic symptoms, were less apt to have remitted from PTSD during the last year, and-contrary to expectation-were less apt to have sought mental health treatment since military duty. In conclusion, combat-related PTSD was more severe, as compared with noncombat-related PTSD, in this group, on 2 out of 5 measures. A low rate of mental health treatment since military duty may have contributed to increased symptoms and a lower remission rate.     

Decreased benzodiazepine receptor binding in prefrontal cortex in combat-related posttraumatic stress disorder

OBJECTIVE: Animals exposed to stress exhibit a decrease in benzodiazepine receptor binding in the frontal cortex. No studies have examined central benzodiazepine receptor binding in patients with posttraumatic stress disorder (PTSD). The purpose of this study was to examine measures of benzodiazepine receptor binding in PTSD. METHOD: From 13 patients with Vietnam combat-related PTSD and 13 case-matched healthy comparison subjects, a quantitative measure related to benzodiazepine receptor binding (distribution volume) was obtained with single photon emission computed tomography (SPECT) imaging of [(123)I]iomazenil binding and measurement of radioligand concentration in plasma. Distribution volume image data were analyzed by means of statistical parametric mapping. RESULTS: Lower distribution volumes were found in the prefrontal cortex (Brodmann's area 9) of PTSD patients than in comparison subjects. CONCLUSIONS: These findings of lower values for the benzodiazepine receptor binding measure of distribution volume are consistent with fewer benzodiazepine receptors and/or reduced affinity of receptor binding in the medial prefrontal cortex in patients with PTSD. Alterations in benzodiazepine receptor function in this area may underlie many of the symptoms of PTSD.