Increased PTSD risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events

OBJECTIVE: The aim of the present study was to isolate the unique contribution of physical injury to the subsequent development of posttraumatic stress disorder (PTSD). METHOD: Participants were 60 injured soldiers and a comparison group of 40 soldiers (matched by rank, military role, and length of service) who took part in the same combat situations but were not injured. Current and lifetime diagnoses were determined by using the Structured Clinical Interview for DSM-IV. In addition, an extensive battery of self-report questionnaires was given to assess severity of PTSD, anxiety, depression, and dissociative symptoms. The average time that elapsed between the injury and the interview was 15.5 months (SD=7.3). RESULTS: Ten (16.7%) of the 60 injured survivors but only one (2.5%) of the 40 comparison soldiers met diagnostic criteria for PTSD at the time of the interview (odds ratio=8.6, 95% confidence interval=1.1-394.3). Moreover, wounded participants had significantly higher scores than their noninjured counterparts on all clinical measures. Finally, presence of PTSD was not related to severity of injury or severity of the trauma. CONCLUSIONS: The findings clearly indicate that bodily injury is a major risk factor-rather than a protective one-for PTSD. While supporting the notion that bodily injury contributes to the appraisal of the traumatic event as more dangerous, the data also suggest that this heightened level of perceived threat is not a simple, straightforward function of the severity of injury or of the traumatic event.     

Risk factors for post-deployment posttraumatic stress disorder in national guard/reserve service members

Identification of factors that increase risk for PTSD in military personnel following deployments is critical to early intervention and prevention. The study tested hypothesized main and moderating risk factors for PTSD in National Guard/Reserve members deployed to Iraq or Afghanistan. Members of the National Guard/Reserves (n=238) completed diagnostic interviews and measures of risk factors at a post-deployment assessment conducted an average of four and a half months following return from deployment. Hierarchical multivariate logistic regression analyses were used to test hypotheses. Higher levels of combat exposure, life and family concerns during deployment, and post-deployment social support independently predicted PTSD. Life/family concerns during deployment and perceived adequacy of training and preparation were significant moderators of the association between combat exposure and PTSD. Among those with higher levels of both combat exposure and life and family stress, 27% had PTSD in contrast to 3% of those with high exposure but lower levels of such stress during deployment.     

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans

OBJECTIVE: Studies of soldiers from prior wars conducted many years after combat have shown associations between combat-related posttraumatic stress disorder (PTSD) and physical health problems. The current Iraq war has posed a considerable PTSD risk, but the association with physical health has not been well studied. METHOD: The authors studied 2,863 soldiers using standardized self-administered screening instruments 1 year after their return from combat duty in Iraq. RESULTS: Among all participants, 16.6% met screening criteria for PTSD. PTSD was significantly associated with lower ratings of general health, more sick call visits, more missed workdays, more physical symptoms, and high somatic symptom severity. These results remained significant after control for being wounded or injured. CONCLUSIONS: The high prevalence of PTSD and its strong association with physical health problems among Iraq war veterans have important implications for delivery of medical services. The medical burden of PTSD includes physical health problems; combat veterans with serious somatic concerns should be evaluated for PTSD.     

Post-traumatic stress disorder among wives of Kuwaiti veterans of the first Gulf War

OBJECTIVES: To assess post-traumatic stress disorder (PTSD) among wives of Gulf War Kuwaiti military men, divided into four groups according to degree of combat exposure: the retired, an active-in-the-army group (AIA) (involved in duties at the rear); an in-battle group (IB) (involved in combat); and a prisoners-of-war (POWs) group. To assess the relationship between wives' PTSD and indices of family adjustment, husbands' level of combat exposure, and PTSD status. METHOD: One hundred and seventy-six wives were assessed with the PTSD Checklist for DSM-IV, the family adjustment device, and for anxiety/depression. RESULTS: Fifty (28.4%) fulfilled criteria for probable PTSD. The prevalence was significantly associated with husbands' combat exposure, her presence in Kuwait, but not with husbands' PTSD status. Wives' PTSD was mostly predicted by their depression/anxiety scores. CONCLUSION: The findings support the salience of effective social support, and the need for women empowerment issues in psychosocial intervention for this group.     

Predictors of emotional distress reported by soldiers in the combat zone

Objective

Few studies have examined rates of distress of military personnel during deployment to a war zone. Our study sought to (a) identify rates of self-reported posttraumatic stress disorder (PTSD) and depression symptoms during combat deployment, (b) characterize higher order dimensions of emotional distress experienced by soldiers during deployment, and (c) identify predictors of these dimensions of emotional distress.

Method

Participants were 2677 National Guard soldiers deployed as part of Operation Iraqi Freedom in 2006-07. We performed a principal components factor analysis on items of the PTSD Checklist - Military Version and the Beck Depression Inventory to identify dimensions of emotional distress, followed by multiple regression analyses to identify factors that predicted these dimensions of distress.

Results

Rates of PTSD and depression in our sample were 7% and 9%, respectively. Five dimensions of emotional distress emerged: negative affect/cognitions, trauma-specific re-experiencing and avoidance, vegetative symptoms, loss of interest/numbing symptoms, and arousal/irritability. Two dimensions, trauma-specific symptoms and arousal/irritability, appeared to be more indicative of trauma sequelae, while the other three dimensions were more indicative of depressive symptoms. Demographic factors, combat exposure (including injury and exposure to explosive blast), and attitudinal variables predicted trauma-specific aspects of distress. Symptoms characteristic of depression or generalized distress were predicted by female gender, recent prior deployment, and attitudinal factors but were not predicted by blast exposure or injury.

Conclusions

These findings suggest specific targets for contextual and individual interventions to reduce deployment-related distress and point out the need for longitudinal follow-up to determine long-term implications for post-deployment functioning.     

Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan

ObjectiveAlthough women in the military are exposed to combat and its aftermath, little is known about whether combat as well as pre-deployment risk/protective factors differentially predict post-deployment PTSD symptoms among women compared to men. The current study assesses the influence of combat-related stressors and pre-deployment risk/protective factors on women's risk of developing PTSD symptoms following deployment relative to men's risk.MethodParticipants were 801 US National Guard Soldiers (712 men, 89 women) deployed to Iraq or Afghanistan who completed measures of potential risk/protective factors and PTSD symptoms one month before deployment (Time 1) and measures of deployment-related stressors and PTSD symptoms about 2–3 months after returning from deployment (Time 2).ResultsMen reported greater exposure to combat situations than women, while women reported greater sexual stressors during deployment than men. Exposure to the aftermath of combat (e.g., witnessing injured/dying people) did not differ by gender. At Time 2, women reported more severe PTSD symptoms and higher rates of probable PTSD than did men. Gender remained a predictor of higher PTSD symptoms after accounting for pre-deployment symptoms, prior interpersonal victimization, and combat related stressors. Gender moderated the association between several risk factors (combat-related stressors, prior interpersonal victimization, lack of unit support and pre-deployment concerns about life/family disruptions) and post-deployment PTSD symptoms.ConclusionsElevated PTSD symptoms among female service members were not explained simply by gender differences in pre-deployment or deployment-related risk factors. Combat related stressors, prior interpersonal victimization, and pre-deployment concerns about life and family disruptions during deployment were differentially associated with greater post-deployment PTSD symptoms for women than men.     

Longitudinal relationships of insomnia,nightmares, and PTSD severity in recent combat veterans

Objective

This observational, longitudinal study of veterans with recent combat exposure describes the prevalence, severity and associations of posttraumatic stress disorder (PTSD), insomnia, and nightmares over time.

Methods

Eighty recent combat veterans recruited from Veterans Health Administration primary care settings met inclusion criteria including hazardous alcohol use and at least subthreshold PTSD. Insomnia status and nightmare status were assigned based on the Insomnia Severity Index total score and the PTSD Checklist nightmare item, respectively. Participants were re-assessed six months following their baseline assessment. Analyses of variance compared insomnia and nightmare groups on PTSD, depression, and alcohol use severity. Analyses of covariance (controlling for baseline differences) examined whether insomnia and/or nightmares were associated with the clinical course of PTSD. Persistence of conditions was also examined.

Results

At baseline, 74% presented with insomnia and 61% endorsed distressing nightmares. Insomnia was associated with significantly higher PTSD and depression severity at both baseline and six months. The presence of nightmares was associated with significantly higher PTSD severity at both time points and with depression severity at baseline only. Despite decreases in PTSD and depression severity, insomnia severity was relatively unchanged after six months. The prevalence and severity of nightmare complaints diminished modestly over time.

Conclusion

Among this sample of recent combat veterans, insomnia and nightmares were each strongly associated with the severity of both PTSD and depressive symptoms. Over time, insomnia in particular did not appear to resolve spontaneously and was associated with ongoing PTSD. Addressing insomnia early, therefore, may be a strategy to alter the course of PTSD.     

Posttraumatic stress symptoms across the deployment cycle: A latent transition analysis

Our objective was to examine symptom-level changes in the course in posttraumatic stress disorder (PTSD) across the deployment cycle among combat-exposed Marines, and to determine the degree to which combat exposure and post-deployment stressor exposure predicted PTSD symptom profile transitions. We examined PTSD symptoms in a cohort of U.S. Marines (N = 892) recruited for the Marine Resiliency Study (MRS). Marines deployed as one battalion infantry unit to Afghanistan in 2010 and were assessed pre-deployment and one, five, and eight months post-deployment. We employed latent transition analysis (LTA) to examine Marines' movement across PTSD symptom profiles, determined by latent class analysis (LCA). LCAs revealed a 3-class solution one month pre-deployment, a 4-class solution at five months post-deployment, and a 3-class solution at eight months post-deployment. LTA revealed notable movement between classes over time, which depended chiefly on pre-deployment symptom presentation. Marines who reported few pre-deployment symptoms either maintained these low levels or returned to low levels by eight months. Marines who reported a moderate number of symptoms at pre-deployment had variable outcomes; 50% had reductions by eight months, and those who reported numbing symptoms at five months post-deployment tended to report more symptoms at eight months. Marines who reported more PTSD symptoms prior to deployment retained more symptoms eight months post-deployment. Combat exposure and post-deployment stressor exposure predicted profile transitions. Examining transitions between latent class membership over time revealed prognostic information about Marines' eight-month PTSD outcomes. The extent of pre-deployment PTSD symptoms was particularly informative of likely PTSD outcomes.     

Narcissistic vulnerability and the development of PTSD: a prospective study

This study empirically examined the role of narcissistic traits and narcissistic vulnerability in the development of post-traumatic stress disorder (PTSD). One hundred forty-four survivors of a traumatic event were assessed 1 week, 1 month, and 4 months following the event. In the first-week assessment, patients were administered the Narcissistic Vulnerability Scale and self-reported rating scale to assess event severity and symptoms ensuing from the impact of the traumatic event: depression, intrusions, avoidance, and arousal. In the follow-up assessments, subjects were interviewed on the Clinician-Administered PTSD Scale and were readministered the self-rating symptoms scale. Survivors who developed acute (1 month) and chronic (4 months) PTSD had significantly higher levels of narcissistic vulnerability in the first-week assessment. Narcissistic Vulnerability Scale scores predicted PTSD status with sensitivity of 81.6% and 85.1% and specificity of 40.4% and 38.6% at the 1-month and 4-month assessments, respectively. Narcissistic vulnerabilities contribute to the occurrence of PTSD.     

Posttraumatic stress disorder (PTSD) in the German Armed Forces: a retrospective study in inpatients of a German army hospital

In 2006 and 2007, around 0.4 and 0.7% of all German soldiers involved in missions abroad were registered as suffering from PTSD. The frequency of PTSD in the German Armed Forces was assessed from army records. All soldiers admitted to the German Military Hospital in Hamburg, Germany, with PTSD (n?=?117) in the years 2006 and 2007 were assessed by using questionnaires and structure interviews. Risk factors associated with PTSD were identified. Of the 117 soldiers with PTSD, 39.3% were in missions abroad, and 18.0% had participated in combat situations. Five (4.3%) were wounded in combat, and 4 of them had a serious irreversible injury. In total, 53.8% of the PTSD cases were related to injuries or physical/sexual abuse, while 46.2% were due to psychological traumatization. Among soldiers with PTSD who were not abroad, sexual or physical abuse were the most common traumas. In 35.9% of the patients, there was evidence for psychiatric disorders existing before the traumatic event. The percentage of women among sufferers from PTSD was significantly higher than the proportion of women in the armed forces (30.8% vs. 5.17%). A careful psychiatric screening before recruitment might help to identify persons at risk of PTSD.     

Leadership, cohesion, morale, and the mental health of UK Armed Forces in Afghanistan

UK Armed Forces (AF) personnel deployed to Afghanistan are frequently exposed to intense combat and yet little is known about the short-term mental health consequences of this exposure and the potential mitigating effects of military factors such as cohesion, morale, and leadership. To assess the possible modulating influence of cohesion, morale, and leadership on post-traumatic stress disorder (PTSD) symptoms and common mental disorders resulting from combat exposure among UK AF personnel deployed to Afghanistan, UK AF personnel, during their deployment to Afghanistan in 2010, completed a self-report survey about aspects of their current deployment, including perceived levels of cohesion, morale, leadership, combat exposure, and their mental health status. Outcomes were symptoms of common mental disorder and symptoms of PTSD. Combat exposure was associated with both PTSD symptoms and symptoms of common mental disorder. Of the 1,431 participants, 17.1% reported caseness levels of common mental disorder, and 2.7% were classified as probable PTSD cases. Greater self-reported levels of unit cohesion, morale, and perceived good leadership were all associated with lower levels of common mental disorder and PTSD. Greater levels of unit cohesion, morale, and good leadership may help to modulate the effects of combat exposure and the subsequent development of mental health problems among UK Armed Forces personnel deployed to Afghanistan.     

Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans

This study examined combat and mental health as risk factors of suicidal ideation among 2854 U.S. soldiers returning from deployment in support of Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 2.8% of soldiers reported suicidal ideation. Postdeployment depression symptoms were associated with suicidal thoughts, while postdeployment PTSD symptoms were associated with current desire for self harm. Postdeployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while postdeployment PTSD symptoms mediated the association between killing in combat and desire for self harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans.     

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

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

Gender differences in depression and PTSD symptoms following combat exposure

Background: This research examined gender as a moderator of the association between combat exposure (CE) and depression as well as CE and PTSD symptoms among a nonclinical sample of Soldiers following deployment in support of operations in Afghanistan and Iraq. Methods: Cases included 6,943 (516 women, 6,427 men) active duty Soldiers that were retrospectively analyzed from a pre‐ and post‐deployment screening database at a large Army installation. Results: Gender moderated the association between CE and depressive and PTSD symptoms such that higher levels of CE were more strongly associated with depression and PTSD symptoms in women compared to men. Female Soldiers also reported higher severity of depressive symptoms compared to male Soldiers, whereas men reported higher levels of CE and a greater number of previous deployments compared to women. Conclusions: CE was a stronger predictor of post‐deployment depression and PTSD symptoms for women compared to men. These results provide evidence for gender‐based differences in depression and PTSD risk. Screening for degree of CE in addition to symptoms associated with depression and PTSD can help with the care for service members who are returning from deployments to combat zones. Depression and Anxiety, 2010. Published 2010 Wiley‐Liss, Inc.     

The role of stress sensitization in progression of posttraumatic distress following deployment

Purpose

Military personnel exposed to combat are at risk for experiencing post-traumatic distress that can progress over time following deployment. We hypothesized that progression of post-traumatic distress may be related to enhanced susceptibility to post-deployment stressors. This study aimed at examining the concept of stress sensitization prospectively in a sample of Dutch military personnel deployed in support of the conflicts in Afghanistan.

Method

In a cohort of soldiers (N = 814), symptoms of post-traumatic stress disorder (PTSD) were assessed before deployment as well as 2, 7, 14, and 26 months (N = 433; 53 %) after their return. Data were analyzed using latent growth modeling. Using multiple group analysis, we examined whether high combat stress exposure during deployment moderated the relation between post-deployment stressors and linear change in post-traumatic distress after deployment.

Results

A higher baseline level of post-traumatic distress was associated with more early life stressors (standardized regression coefficient = 0.30, p < 0.001). In addition, a stronger increase in posttraumatic distress during deployment was associated with more deployment stressors (standardized coefficient = 0.21, p < 0.001). A steeper linear increase in posttraumatic distress post-deployment (from 2 to 26 months) was predicted by more post-deployment stressors (standardized coefficient = 0.29, p < 0.001) in high combat stress exposed soldiers, but not in a less combat stress exposed group. The group difference in the predictive effect of post-deployment stressors on progression of post-traumatic distress was significant (χ²(1) = 7.85, p = 0.005).

Conclusions

Progression of post-traumatic distress following combat exposure may be related to sensitization to the effects of post-deployment stressors during the first year following return from deployment.     

The class-dimensional structure of PTSD before and after deployment to Iraq: Evidence from direct comparison of dimensional,categorical, and hybrid models

The assumption of specific etiology in posttraumatic stress disorder (PTSD) differentiates the disorder from most other psychiatric conditions. A ‘risky test’ of the assumption of specific etiology and resultant trauma-related symptom dimensions was conducted through structural modeling of PTSD symptoms in soldiers before (N = 522) and after (n = 423) a combat deployment to Iraq. If PTSD represents a discrete diagnostic entity that emerges after trauma exposure, we hypothesized either the number of latent classes should increase from pre- to post-deployment or symptom dimensions should qualitatively distinguish affected from unaffected classes following trauma exposure. Comparison of latent structural models revealed best fitting hybrid models for PTSD and depression with strong invariance of symptom dimensions across classes both before and after deployment and only quantitative (i.e., severity) differences between classes. These findings suggest PTSD is generally well-conceptualized as a dimensional syndrome worsened but not necessarily elicited by trauma exposure.     

Follow-up of Pentagon employees two years after the terrorist attack of September 11, 2001

OBJECTIVE: This study examined probable posttraumatic stress disorder (PTSD) and probable depression, degree of psychological distress, and rates of mental health treatment in a sample of Pentagon staff two years after the terrorist attack of September 11, 2001. METHODS: Anonymous surveys were administered to staff at one Pentagon work center. Respondents were asked about exposure to the attack; injuries; exposure to dead bodies or families of the deceased; psychological distress; and use of mental health services. Probable PTSD and depression were assessed with the PCL-17 and the PHQ-9. RESULTS: A total of 267 responses were received. Fourteen percent of the sample had probable PTSD, and 7 percent had probable depression. Staff who were at the Pentagon on the day of the attack were more likely to have probable PTSD and probable depression. Exposure through watching television was not associated with a higher frequency of probable PTSD, probable depression, or distress. Injury during the attack was associated with a higher frequency of probable PTSD, probable depression, and distress. Respondents who were exposed to dead bodies or who acted as lay counselors to families of the deceased were more likely to have probable PTSD and depression and to report chronic distress. Of those with probable PTSD, 70 percent made at least one mental health visit during the next two years. Of those with probable depression, 74 percent reported at least one mental health visit. CONCLUSIONS: Direct exposure to the September 11 terrorist attack on the Pentagon, injury during the attack, and exposure to dead bodies or acting as a lay counselor to families of persons who were killed during the attack were all associated with higher frequencies of probable psychiatric illness and higher levels of psychological distress two years after the attack. Among survivors who had probable psychiatric illness, more than two-thirds received mental health treatment after the attack.     

Prediction of the occurrence and intensity of post-traumatic stress disorder in victims 32 months after bomb attack.

INTRODUCTION: Our objective was to identify factors that predict occurrence and severity of post-traumatic stress disorder (PTSD) after a terrorism attack. POPULATION: We evaluated 32 victims of a bomb attack in a Paris subway in December 1996 at 6 and 32 months. METHOD: Sociodemographic characteristics, clinical data and physical injuries were used to predict PTSD occurrence and severity in 32 victims. The Watson's PTSD Inventory (PTSD-I) and the Impact of Event Scale (IES) by Horowitz were used to evaluate occurrence and severity of PTSD, respectively. RESULTS: Thirty-nine percent of participants met PTSD criteria at 6 months, 25% still had PTSD at 32 months. Women had PTSD 32 months after the bomb attack more frequently than men. Employment predicted PTSD severity at 32 months. PTSD scores assessed by PTSD-I at 6 months were significantly and positively associated with IES scores at 32-month follow-up (r = 0.55, P = 0.004). Psychotropic drug use before the bomb attack significantly predicted PTSD occurrence and severity at 6 and 32 months. In a linear regression model, physical injuries, employment status and psychotropic drug use before the bomb attack were independent predictors of severity of PTSD at 32 months. CONCLUSIONS: Bomb attack exposure resulted in persisting PTSD in a significant proportion of victims; the severity was predicted at 32 months by physical injuries and psychotropic drug use before the terrorism attack and by the PTSD score few months after the bomb attack.     

The effects of prior combat experience on the expression of somatic and affective symptoms in deploying soldiers

OBJECTIVE: Deployment to a combat zone is undoubtedly an extremely stressful experience. It was hypothesized that, when faced with an impending wartime deployment, soldiers with prior combat experience would report minimal emotional problems accompanied by high rates of somatic complaints compared with combat-naive soldiers. METHODS: Self-reports of posttraumatic stress disorder (PTSD) and affective and somatic complaints were collected from 2068 U.S. soldiers just prior to combat deployment during Operation Iraqi Freedom. RESULTS: Although the percentage of soldiers scoring positive for PTSD was nearly identical for the experienced and inexperienced groups, scores on the Affective and Somatic scales differed as a function of prior combat history. Previous combat experience was associated with lower affective and greater somatic complaints relative to combat-naive soldiers. CONCLUSIONS: Consistent with theories of stress reaction, repression, and somatic amplification, combat-experienced soldiers reported limited affective complaints but greater somatic complaints relative to soldiers without combat experience.     

Military unit support,postdeployment social support,and PTSD symptoms among active duty and National Guard soldiers deployed to Iraq

Research suggests that military unit support and community postdeployment social support are associated with fewer PTSD symptoms following military deployment. This study extended prior research by examining the associations among predeployment unit support and PTSD symptoms before Iraq deployment as well as unit support, PTSD symptoms, and postdeployment social support after deployment among 835 U.S. Army and 173 National Guard soldiers. Multiple regression analyses indicated that predeployment unit support was not significantly associated with postdeployment PTSD severity in either group of soldiers, whereas higher unit support during deployment was significantly associated with lower postdeployment PTSD severity among active duty soldiers only. Among both groups, higher levels of postdeployment social support were associated with lower levels of postdeployment PTSD symptom severity. These findings suggest that postdeployment social support is a particularly strong buffer against postdeployment PTSD symptoms among both groups of soldiers whereas the effects of unit support may be limited.