Personality Disorders in Veterans with Posttraumatic Stress Disorder and Depression

Little is known about the frequency of the full-range of personality disorders in outpatients with concurrent posttraumatic stress disorder (PTSD) and depression, a common and oftentimes treatment-resistant combination in clinical practice. In a group therapy outcome study, Axis I and II diagnoses were assessed with the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale to select 115 male combat veterans with PTSD and depressive disorder. Within this sample, 52 (45.2%) had one or more personality disorders--most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)--and 19 (16.5%) had two or more. Documenting a substantial frequency of personality disorders is a first step in devising appropriate interventions for this treatment-resistant combination of disorders.     

Military Combat,Posttraumatic Stress Disorder,and the Course of Alcohol Use Disorders in a Cohort of Australian Vietnam War Veterans

The present study examined the course of diagnosed alcohol use disorders (AUDs) in a cohort of Australian veterans of the Vietnam War (N = 388) who were assessed 22 and 36 years after returning home. Standardized interviews provided data on AUDs, posttraumatic stress disorder (PTSD), other psychiatric diagnoses, and combat exposure. Overall, 148 veterans (38.1%) had no history of alcohol-related diagnoses, 151 veterans (38.9%) had a past AUD diagnosis that was not current at the second assessment point, and 89 veterans (22.9%) had a current AUD diagnosis at the second assessment. Less education, lower intelligence test scores, and misconduct were individual risk factors for AUDs, as were first-interview diagnoses of PTSD, antisocial personality disorder, generalized anxiety, and dysthymia, but not depression; these variables were all nonsignificant after controlling for combat exposure and PTSD. Multinomial regression was used to assess the relative contributions of combat exposure and PTSD to the course of AUDs. Combat exposure and PTSD had different patterns of association with AUDs whereby combat exposure, but not PTSD, was associated with a history of AUDs, odds ratio (OR) = 1.02, but not with current AUDs, whereas PTSD, but not combat exposure, was associated with current AUDs, OR = 3.37. Current numbing and avoidance symptoms were associated with current AUDs, OR = 4.48. The results do not support a mutual maintenance model of PTSD and AUDs but are consistent with a self-medication model, which suggests treatment for PTSD may have beneficial effects on AUDs.     

Incidence and correlates of depersonalization following head trauma

Using the criteria of the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D), we assessed the incidence of feelings of unreality among a sample of 70 persons who had sustained head injuries. Among those whose head trauma could be classfied as mild, more than 60% complained of a depersonalization syndrome. Among those with a significant period of unconsciousness, only 11% had similar complaints. There was a high comorbidity with post-traumatic stress disorder and vertigo. Feelings of unreality were not associated with cognitive impairment or elevated personality test scores, nor were there significant relationships with gender or involvement in litigation. A conservative estimate of incidence of depersonalization among persons with minor head trauma is 13%, while, at the upper end, as many as 67% of persons who sustain mild head injury may experience feelings of unreality.     

The internalizing and externalizing structure of psychiatric comorbidity in combat veterans

This study examined the latent structure of psychiatric disorders in a sample with a high prevalence of PTSD. A series of confirmatory factor analyses tested competing models for the covariation between Structured Clinical Interview for DSM-III-R diagnoses among 1,325 Vietnam veterans. The best-fitting solution was a 3-factor model that included two correlated internalizing factors: anxious-misery, defined by PTSD and major depression, and fear, defined by panic disorder/agoraphobia and obsessive-compulsive disorder. The third factor, externalizing, was defined by antisocial personality disorder, alcohol abuse/dependence, and drug abuse/dependence. Both substance-related disorders also showed significant, albeit smaller, cross-loadings on the anxious-misery factor. These findings shed new light on the structure of psychiatric comorbidity in a treatment-seeking sample characterized by high rates of PTSD.     

Chronic peritoneal dialysis patients diagnosed with clinical depression: results of pharmacologic therapy

Depression has been documented as the most frequently encountered psychological problem in end-stage renal disease (ESRD) patients and has been correlated with both mortality and morbidity in these patients. Previous work by our group has shown that clinical depression is treatable with psychotropic medications in these patients, but that only a limited number of ESRD patients with depression will successfully complete a course of pharmacologic therapy. From July 1997 to October 2002, all chronic peritoneal dialysis (PD) patients in our facility were encouraged to be screened for depression utilizing the self-administered Beck Depression Inventory (BDI) questionnaire. Based on previous work, a score > or =11 on this questionnaire was used to indicate a possible diagnosis of clinical depression; patients with BDI scores > or =11 were encouraged to complete a more formal evaluation for the presence of clinical depression. A total of 320 BDI questionnaires were completed during the study period: 134 patients. (42%) scored > or =11 on the BDI, 69 of the 134 patients (51%) with BDI scores > or =11 agreed to further evaluation. Sixty of these 69 patients (87%) were diagnosed with clinical depression based on scores > or =18 on the Hamilton Depression Scale and standard Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. Forty-four patients with clinical depression agreed to pharmacologic treatment. However, only 23 of the 44 patients (52%) successfully completed a 12-week course of drug therapy. Two unit social work reviewers systematically reviewed the records of these 21 patients who did not complete therapy and assessed the reasons for their inability to complete treatment. Reasons identified included eight patients who experienced acute medical problems, three who were active substance abusers, and two who reported medication side effects. The remaining eight patients who did not complete the 12 weeks of therapy were examined by applying the axis 1 and axis 2 DSM-IV criteria. Axis 1 is used to diagnose clinical disorders and axis 2 is used to diagnose personality disorders. While all these patients met the DSM-IV axis 1 criteria for clinical depression, eight of these patients met axis 2 criteria for personality disorders; five patients had borderline personality disorders, one had a narcissistic personality disorder, one had a factitious disorder, and one had features of avoidant personality disorder. While some chronic PD patients can be successfully treated for clinical depression with psychotropic medication prescribed by the dialysis medical team, not all patients will agree to be evaluated for clinical depression and accept pharmacologic treatment. Others cannot or will not complete treatment when additional psychiatric disorders exist. These patients may require additional intervention when diagnosed with clinical depression and a personality disorder. Further trials are warranted.     

Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non‐PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.     

Heart Rate and Blood Pressure Resting Levels and Responses to Generic Stressors in Vietnam Veterans with Posttraumatic Stress Disorder

Resting heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBF) were measured on 3 successive mornings in the homes of drug-free Vietnam combat veterans, classified on the basis of DSM-III-R criteria into current posttraumatic stress disorder (PTSD; n = 20) or non-PTSD (n = 15). Responses to three generic stressor challenges (orthostatic, mental arithmetic, and cold pressor) were also measured. In the orthostatic stressor condition, DBP increased over time in the non-PTSD, but not in the PTSD, veterans, suggesting a paradoxically reduced autonomic response in PTSD. There were no other significant group differences in resting levels or responses to any of the challenges for any measure.     

Olfactory Identification in Combat-Related Posttraumatic Stress Disorder

Recent neuropsychological conceptualizations of posttraumatic stress disorder (PTSD) implicate dysfunction of the fronto-limbic system, a brain system thought to be involved in the mediation of emotion. However, few studies have examined fronto-limbic subregions, such as the orbitofrontal cortex, in PTSD. As a measure of orbitofrontal integrity, olfactory identification was assessed in 26 Vietnam War veterans with PTSD, 25 Vietnam War veterans without mental disorders, and 17 Vietnam-era, non-war-zone veterans without mental disorders. Relative to veterans without PTSD, those diagnosed with PTSD were less proficient in odor identification and verbal learning but not on other cognitive tests sensitive to dorsolateral prefrontal and mesial temporal functioning. Results bolster prior research indicating fronto-limbic dysfunction in PTSD, and suggest involvement of the orbitofrontal region.     

Assessment of older combat veterans with the Clinician-Administered PTSD Scale

A study of the posttraumatic stress disorder (PTSD) among older combat veterans of World War II and the Korean Conflict was conducted. The Clinician-Administered PTSD Scale (CAPS) was given to 125 older combat veterans, along with a computerized variant of the Structured Clinical Interview for DSM-III-R for PTSD, the SCID-DTREE. (The SCID-DTREE was itself validated against the full SCID). Results showed the CAPS to be a good discriminator of PTSD: Out of the 125 cases, only 9 were misclassified using the SCID-DTREE as the base measure, a 93% efficiency. An alpha on the full CAPS was .95. This suggests that the CAPS is an appropriate scale for use with older combat veterans.     

Psychiatric disorders and health-related quality of life after severe traumatic brain injury: a prospective study

Traumatic brain injury (TBI) is a major cause of death and disability and impairs health-related quality of life (HRQOL). Psychiatric disorders have been recognized as major components of TBI morbidity, yet few studies have addressed the relationship between these outcomes. Sample size, selection bias, and retrospective design, are methodological limitations for TBI-related psychiatric studies. For this study, 33 patients with severe TBI were evaluated prospectively regarding demographic, clinical, radiological, neurosurgical, laboratory, and psychosocial characteristics, as well as psychiatric manifestations and HRQOL, 18 months after hospitalization. Psychiatric manifestations were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Hospital Anxiety and Depression Scale (HADS), the Brief Psychiatric Rating Scale (BPRS), and the Apathy Evaluation Scale (AES). HRQOL was determined using the Medical Outcomes Study's 36-item Short-Form Health Survey (SF-36). Following TBI, a significant increase in the prevalence of major depressive disorder (MDD) and generalized anxiety disorder (p=0.02), and a significant decrease in the prevalence of alcohol and cannabinoid abuse (p=0.001) were observed. The most frequent psychiatric disorders following severe TBI were found to be MDD (30.3%), and personality changes (33.3%). In comparison to patients without personality changes, patients with personality changes experienced a decline in general health and impairments in physical and social functioning. Patients with MDD showed impairment in all SF-36 domains compared to non-depressed patients. This prospective TBI-related psychiatric study is the first to demonstrate a significant association between MDD, personality changes, and HRQOL, following severe TBI in a well-defined sample of patients.     

Modes of long-term coping with trauma memories: Relative use and associations with personality among vietnam veterans with chronic PTSD

Little is known about how individuals who develop chronic posttraumatic stress disorder (PTSD) cope with recurring trauma memories, or how enduring personality characteristics influence such coping. Focusing on 110 hospitalized Vietnam combat veterans with chronic PTSD, this exploratory study assessed the relative frequency of using eight ways of coping with war memories, and associations between relative use of these strategies and eight dysfunctional personality styles. As a secondary issue, associations between coping strategies, combat exposure, and PTSD severity were also examined. Consistent with prior findings, these veterans predominantly used emotion-focused and avoidant strategies to cope with war memories. Differing personality styles and relative use or nonuse of particular coping strategies were also associated in psychologically coherent ways. These preliminary findings are discussed in relation to methodologic and future research issues.     

Odor-induced EEG changes in PTSD Vietnam veterans

Electroencephalogram (EEG) changes in response to trauma and non-traumarelated odors were examined in five Vietnam veterans with a DSM-III-R diagnosis of Post-traumatic Stress Disorder (PTSD) and in five Vietnam veterans with adjustment-related problems (non-PTSD). Period analysis of the EEG indicated that the odors differentially affected the PTSD group's theta and alpha activity compared to the non-PTSD group. The greatest EEG and self-report odor and PTSD effects were found in response to a trauma odor which simulated burning flesh. These findings have important implications in the detection of veterans who attempt to feign deliberately the psychophysiological response pattern associated with PTSD.     

Comparing Outcomes of Women‐Only and Mixed‐Gender Intensive Posttraumatic Stress Disorder Treatment for Female Veterans

Although most female veterans treated in specialized intensive Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) programs receive services in settings in which over 95% of participants are men, two programs include only women. Whether outcomes for women with PTSD are superior in women‐only programs has not been evaluated. National program evaluation data on 1,357 women veterans from 57 sites were collected at program entry and 4 months after discharge. With adjustment for differences in baseline characteristics, outcomes of women in two women‐only programs (n = 469) were compared with those from 55 mixed‐gender programs (n = 888), using mixed models with random effect for site. The primary outcome was total PTSD symptom level, with supplementary information on PTSD assessment subscales, substance use, and other outcomes. At program entry, female veterans in women‐only programs had lower scores on measures of total PTSD symptoms, p = .013, d = ?0.24, and on several subscales. Adjusting for these differences, there were no significant differences between program types in terms of PTSD total score or scores on secondary measures. In women‐only programs, veterans had longer lengths of stay and were rated by their clinicians to have a higher level of commitment to therapy at discharge. Thus, women‐only programs did not show superior outcomes; however, compared to participants in mixed‐gender programs, those in women‐only programs had longer lengths of stay, higher levels of commitment to therapy, and were more likely to participate in posttreatment outcome assessments following discharge.     

Mental disorders among acute burn patients

Objective

To investigate mental disorders among acute hospitalized burn patients.

Method

Consecutive acute adult burn patients (n = 107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

Results

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q = 6.40, df = 1, p = 0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q = 13.00, df = 1, p < 0.001) in acute care.

Conclusions

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.     

A Systematic Review of Dropout From Psychotherapy for Posttraumatic Stress Disorder Among Iraq and Afghanistan Combat Veterans

A significant number of veterans of the conflicts in Iraq and Afghanistan have posttraumatic stress disorder (PTSD), yet underutilization of mental health treatment remains a significant problem. The purpose of this review was to summarize rates of dropout from outpatient, psychosocial PTSD interventions provided to U.S. Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) veterans with combat‐related PTSD. There were 788 articles that were identified which yielded 20 studies involving 1,191 individuals eligible for the review. The dropout rates in individual studies ranged from 5.0% to 78.2%, and the overall pooled dropout rate was 36%, 95% CI [26.20, 43.90]. The dropout rate differed marginally by study type (routine clinical care settings had higher dropout rates than clinical trials) and treatment format (group treatment had higher dropout rates than individual treatment), but not by whether comorbid substance dependence was excluded, by treatment modality (telemedicine vs. in‐person treatment), or treatment type (exposure therapy vs. nonexposure therapy). Dropout is a critical aspect of the problem of underutilization of care among OEF/OIF/OND veterans with combat‐related PTSD. Innovative strategies to enhance treatment retention are needed.     

Post-traumatic stress disorder in Vietnam veterans: An experimental validation of the DSM-III diagnostic criteria

The DSM-III criteria for post-traumatic stress disorder (PTSD) were derived clinically and have been substantiated in the literature only by self-report data while evaluation of these same criteria with more objective measures has been overlooked. This study provided a laboratory-based evaluation of the DSM-III criterion symptoms of PTSD with six symptoms of the disorder which were operationalized as cognitive, behavioral and psychophysiological measures. The responses of 16 Vietnam combat veterans who met the criteria for a PTSD diagnosis were compared to those of 16 well-adjusted combat veterans without PTSD. Dependent measures were obtained twice, following exposure to first control and then combat auditory stimuli. Results showed that five of the six measures were effective in differentiating the two combat veteran groups. These findings provided experimental support and construct validity for five DSM-III criteria of PTSD. The implications of these findings for the DSM-III-R PTSD diagnostic criteria are discussed.This article was accepted for publication under the Editorship of Charles R. Figley.     

The Effect of Sleep Disorders,Sedating Medications,and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis

Cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) is an effortful process requiring engagement in cognitive restructuring. Sleep disorders may lead to avoidance of effortful tasks and cognitive performance deficits. We explored whether sleep disorders, as assessed by polysomnography, were consistently associated with treatment response in combination with other factors. This study included 32 U.S. veterans who were examined both before and after CPT for combat‐related PTSD. We employed a novel, case‐comparative technique, fuzzy set qualitative comparative analysis (fsQCA), to identify combinations of fuzzy and crisp factors (recipes) that achieve a clinically significant outcome. Approximately one‐quarter of cases experiencing clinically significant change were either (a) Vietnam era veterans without sedating medications, moderate sleep disordered breathing, and severe depression; or (b) non–Vietnam era veterans with sedating medications and without severe periodic limb movements (or significant periodic limb movement arousals). Recipes involving the absence of the relevant sleep disorder were associated with the highest coverage values. These results using fsQCA (a) provide valuable information about the heterogeneity of CPT response and (b) suggest that sleep disorders are important factors to consider in theoretical discussions of who responds to CPT for PTSD.     

Causes of Death Among Male Veterans Who Received Residential Treatment for PTSD

Previous studies have shown elevated mortality among psychiatric and substance abusing patients, including veterans with PTSD. Although early studies showed elevated deaths from external causes among Vietnam veterans in the early postwar years, more recent studies have also shown increased health problems among veterans with PTSD. This study compared mortality due to behavioral causes versus other diseases among 1,866 male veterans treated for PTSD. Death certificates obtained for 110 veterans indicated behavioral causes accounted for 62.4% of deaths, standardized mortality ratio = 3.4-5.5, including accidents (29.4%), chronic substance abuse (14.7%), and intentional death by suicide, homicide, or police (13.8%). Results suggest possible opportunities to improve outcomes of this at-risk patient population through harm reduction interventions and improved continuity of care.     

Carotid endarterectomy in octogenarian veterans: does age affect outcome? A single-center experience

BACKGROUND: The efficacy of carotid endarterectomy (CEA) in octogenarians is controversial. Recent reports have examined this question in the general population, but little data exist on veterans. With the emergence of carotid artery stenting, we need to evaluate the role of CEA in treating elderly veterans with carotid stenosis. METHODS: Retrospective chart review of all CEAs performed between January 1995 and December 2004. RESULTS: A total of 286 procedures were performed in 239 patients; 39 procedures were performed in 33 octogenarians, and 247 procedures were performed in 206 younger veterans. Both groups had similar preoperative comorbidities. There were no statistically significant differences between octogenarians and younger veterans for postoperative stroke (2% vs. 1%), death (0% vs. 1%), myocardial infarction (5% vs. 2%), length of stay (7 +/- 19 vs. 3 +/- 8 days), or 4-year survival (53% vs. 57%). CONCLUSIONS: CEA can be safely performed in octogenarian veterans with outcomes similar to younger veterans.     

Examining comorbidity and posttraumatic stress disorder in a vietnam veteran population using the MMPI-2

Examined the discriminant validity of the MMPI-2 in assessing comorbidity in a posttraumatic stress disorder (PTSD) Vietnam veteran population. The Structured Clinical Interview for the DSM-III-R (SCID) was used to diagnose veterans and to classify them into four groups: PTSD Only, PTSD with mood disorders, PTSD with other anxiety disorders, and PTSD with mood and anxiety disorders. All groups had clinical elevations on scales F, 1, 2, 3, 4, 6, 7, 8, 0, PK, and PS, with peak elevations on scales 8, 7, and 2. The PTSD Only group's MMPI-2 scores were not significantly lower than other groups' scores. The PTSD+Mood/Anxiety group was significantly more elevated on scales 2 and 7 than the PTSD Only and PTSD+Anxiety group but did not otherwise show significantly higher scale elevations than other groups. No significant differences existed between groups on scales F, L, K, PK, and PS. Implications of these results for PTSD and the current diagnostic system are explored.