Post-traumatic stress disorder in Hispanic Vietnam veterans. Clinical phenomenology and sociocultural characteristics

The complex symptomatology of Hispanic Vietnam veterans receiving treatment for post-traumatic stress disorders (PTSD) was explored with the National Institute of Mental Health Diagnostic Interview Schedule, a structured diagnostic interview that yields current and lifetime operational diagnoses (e.g., DSM-III). Social networks and level of acculturation of these veterans were also examined and compared to those of a "control" group and a sample of veterans with DSM-III schizophrenic disorder (both samples included only Hispanic veterans from the Vietnam and post-Vietnam eras). All subjects reported heavy combat stress and met DSM-III criteria for PTSD. Most were very symptomatic and had significant social impairment. PTSD was rarely seen as a discrete entity but appeared instead mixed with symptom clusters cutting across various DSM-III diagnoses. Social networks of PTSD veterans were intermediate in size, frequency of contact with network members, and network density to those of the comparison groups. A distinctive feature of the PTSD group was the high proportion of negative relationships with close family members, especially spouses. "Highly" symptomatic PTSD veterans reported significantly smaller networks, fewer contacts outside the close family circle, and more negative emotionality directed toward family members than "minimally" symptomatic veterans. While all Hispanic groups studied were not significantly different in level of acculturation, PTSD veterans appeared more alienated from their cultural heritage than the other groups. The severe and polymorphous psychopathology found among these veterans suggests that "rap" groups alone may not constitute an adequate therapeutic approach and that more formal psychiatric therapies should be additionally considered in the management of Vietnam-linked PTSD.     

Suicide and guilt as manifestations of PTSD in Vietnam combat veterans

OBJECTIVE: Although studies have suggested a disproportionate rate of suicide among war veterans, particularly those with postservice psychiatric illness, there has been little systematic examination of the underlying reasons. This study aimed to identify factors predictive of suicide among Vietnam combat veterans with posttraumatic stress disorder (PTSD). METHOD: Of 187 veterans referred to the study through a Veterans Administration hospital, 100 were confirmed by means of a structured questionnaire and five clinical interviews as having had combat experience in Vietnam and as meeting the DSM-III criteria for PTSD. The analysis is based on these 100 cases. RESULTS: Nineteen of the 100 veterans had made a postservice suicide attempt, and 15 more had been preoccupied with suicide since the war. Five factors were significantly related to suicide attempts: guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD. Logistic regression analysis showed that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide. For a significant percentage of the suicidal veterans, such disturbing combat behavior as the killing of women and children took place while they were feeling emotionally out of control because of fear or rage. CONCLUSIONS: In this study, PTSD among Vietnam combat veterans emerged as a psychiatric disorder with considerable risk for suicide, and intensive combat-related guilt was found to be the most significant explanatory factor. These findings point to the need for greater clinical attention to the role of guilt in the evaluation and treatment of suicidal veterans with PTSD.     

The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans

OBJECTIVE: This study explored the emotional and physical health of a group of families of Australian Vietnam veterans suffering posttraumatic stress disorder (PTSD). The aim was to study the impact of PTSD upon the families of the sufferers. METHOD: The families of a random sample of Vietnam veterans receiving treatment at a specialist PTSD Unit were invited to participate in this study. Partners of the veterans and children over the age of 15 years were eligible to participate. Four self-report psychometric inventories were administered assessing psychological distress, social climate within their families, self-esteem, and a range of lifestyle issues, including physical health. A control group, consisting of a sample of volunteers, was also surveyed. RESULTS: The partners of the Vietnam veterans showed significantly higher levels of somatic symptoms, anxiety and insomnia, social dysfunction and depression than the control group. They reported significantly less cohesion and expressiveness in their families and significantly higher levels of conflict. The partners also had significantly lower levels of self-esteem. The children of the veterans reported significantly higher levels of conflict in their families. However, the children showed no significant differences on measures of psychological distress and self-esteem from their matched counterparts. CONCLUSIONS: These findings support overseas studies that indicate that the families of PTSD sufferers are also impacted by the disorder. In this study, the families of Australian Vietnam veterans experienced more conflict and their partners were significantly more psychologically distressed (i.e. somatic symptoms, anxiety, insomnia, social dysfunction, depression and low self-esteem) than a matched control group.     

Attachment style in the prediction of recovery following group treatment of combat veterans with post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) can be difficult to treat, with gains often particularly modest in combat veterans. Although group-based treatments are commonly delivered for veterans, little is known about factors influencing their outcomes. Attachment style is known to be associated with psychopathology after trauma and is critical to group-based interventions, but has not yet been investigated in relation to treatment outcome. A better understanding of factors that influence outcome is critical in optimizing the effectiveness of such interventions. This study investigated attachment style as a predictor of outcome for 103 veterans attending group-based treatment for combat-related PTSD. Measures included the Clinician Administered PTSD Scale, PTSD Checklist, and Relationship Styles Questionnaire. Path analyses indicated preoccupied attachment style strongly negatively predicted outcome following treatment. The preoccupied attachment style impedes recovery in group-based treatment for veterans with PTSD. Potential mechanisms underlying this finding are discussed. The results suggest that greater attention should be paid at initial assessment to attachment style of veterans before entering PTSD treatment, particularly group-based interventions.     

MMPI-2 based subgroups of veterans with combat-related PTSD: differential patterns of symptom change after treatment

Considerable research has focused on the use of the MMPI to assess posttraumatic stress disorder (PTSD) through identification of mean profile configurations and the development of PTSD subscales. Little work, however, has addressed the heterogeneity of profiles evident in PTSD populations. This study investigated the MMPI-2 profiles of 158 Australian treatment-seeking Vietnam veterans with combat-related PTSD to identify distinct subgroups. Three robust subgroups were identified on the basis of their MMPI-2 profile and compared on PTSD and associated symptomatology. These subgroups consisted of a mild PTSD group with subclinical personality pathology, and two severe PTSD groups that differed in levels of personality disturbance and general psychopathology. Most notably, differences between these latter two groups occurred in the areas of externalization, alienation, and propensity for acting out. These groups were labeled as subclinical, trauma profile, and global. The groups demonstrated significant differences in the patterns of recovery after treatment. The subclinical group demonstrated little change after treatment. In contrast, the trauma profile and global groups both improved, although the trauma profile group demonstrated greater PTSD symptom reduction than the global group.     

Posttraumatic stress disorder among Hispanic Vietnam veterans

OBJECTIVE: The purpose of this study was to examine posttraumatic stress disorder (PTSD) among Hispanics who served in the Vietnam War. METHOD: The authors conducted secondary data analyses of the National Vietnam Veterans Readjustment Study, a national epidemiologic study completed in 1988 of a representative sample of veterans who served during the Vietnam era (N=1,195). RESULTS: After adjustment for premilitary and military experiences, the authors found that Hispanic, particularly Puerto Rican, Vietnam veterans had significantly more severe PTSD symptoms and a higher probability of experiencing PTSD than nonminority veterans. However, they had no greater risk for other mental disorders, and their greater risk for PTSD was not explained by acculturation. Despite their more severe symptoms, Hispanic veterans, especially Puerto Rican veterans, showed no greater functional impairment than non-Hispanic white veterans. CONCLUSIONS: Hispanic Vietnam veterans, especially Puerto Rican Vietnam veterans, have a higher risk for PTSD and experience more severe PTSD symptoms than non-Hispanic white Vietnam veterans, and these differences are not explained by exposure to stressors or acculturation. This high level of symptoms was not accompanied by substantial reduction in functioning, suggesting that the observed differences in symptom reporting may reflect features of expressive style rather than different levels of illness.     

Clinical presentations and treatment outcomes of peacekeeper veterans with PTSD: preliminary findings

OBJECTIVE: Despite evidence of potential psychiatric sequelae following peacekeeping operations, no data have appeared on treatment outcome for this population. This study examined intake and treatment outcome data for a group of peacekeepers with posttraumatic stress disorder (PTSD). METHOD: Participants were 63 Australian Vietnam veterans and 66 Australian peacekeepers attending specialized PTSD treatment units. Measures of PTSD, depression, anxiety, alcohol use, and anger were obtained at intake and 3-month follow-up. RESULTS: PTSD scores were more severe for peacekeepers than Vietnam veterans at intake, primarily in reexperiencing symptoms. In terms of comorbidity, only anger was higher among peacekeepers. No differences were apparent in treatment outcome. Initial anger predicted change in PTSD severity for peacekeepers. CONCLUSIONS: The finding of differences between peacekeepers and Vietnam veterans in anger and reexperiencing symptoms, in addition to the attenuating role of anger on treatment outcome, suggests that modification to standard PTSD treatment models may be warranted for peacekeepers.     

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.     

Treatment-seeking veterans of Iraq and Afghanistan: comparison with veterans of previous wars

Differences in the characteristics and mental health needs of veterans of the Iraq/Afghanistan war when compared with those of veterans who served in the Persian Gulf war and in the Vietnam war may have important implications for Veterans Affairs (VA) program and treatment planning. Subjects were drawn from administrative data bases of veterans who sought treatment from specialized VA programs for treatment of posttraumatic stress disorder (PTSD). Current Iraq/Afghanistan veterans were compared with 4 samples of outpatient and inpatient Persian Gulf and Vietnam veterans whose admission to treatment was either contemporaneous or noncontemporaneous with their admission. A series of analyses of covariance was used hierachically to control for program site and age. In analyses of contemporaneous veterans uncontrolled for age, Iraq/Afghanistan veterans differed most notably from Vietnam veterans by being younger, more likely to be female, less likely to be either married or separated/divorced, more often working, less likely to have ever been incarcerated, and less likely to report exposure to atrocities in the military. Regarding clinical status, Iraq/Afghanistan veterans were less often diagnosed with substance abuse disorders, manifested more violent behavior, and had lower rates of VA disability compensation because of PTSD. Differences are more muted in comparisons with Persian Gulf veterans, particularly in those involving noncontemporaneous samples, or those that controlled for age differences. Among recent war veterans with PTSD, social functioning has largely been left intact. There is a window of opportunity, therefore, for developing and focusing on treatment interventions that emphasize the preservation of these social assets.     

Basal and suppressed salivary cortisol in female Vietnam nurse veterans with and without PTSD

It has been suggested that discrepant findings regarding low basal cortisol levels and enhanced suppression of cortisol in response to dexamethasone (DEX) administration in post-traumatic stress disorder (PTSD) may reflect individual differences in gender, trauma type, stage of development at trauma occurrence (e.g., childhood vs. adulthood), early pre-traumatic risk factors, or other individual differences. This study examined salivary cortisol levels at 08.00h and 16.00h as well as cortisol response to 0.50 mg DEX in 40 female Vietnam nurse veterans who had current, chronic PTSD (Current) vs. 43 who never had PTSD (Never). Repeated measures analyses of covariance did not reveal significant group differences in cortisol levels or cortisol suppression. Given that nurses who served in Vietnam had similar exposures, ages at exposure, and duration since exposure to previously studied male Vietnam combat veterans, the present lack of evidence for low cortisol and cortisol hyper-suppression in nurses with PTSD suggests that previous findings of low cortisol and cortisol hyper-suppression in male Vietnam veterans, females sexually abused as children, and other populations may reflect risk factors beyond simply having PTSD.     

Combat-related PTSD and psychosocial adjustment problems among substance abusing veterans

The purpose of this study were the following: a) to determine the prevalence of combat-related posttraumatic stress disorder (PTSD) symptoms among veterans seeking assistance at a Veterans Administration medical center substance abuse treatment facility, b) to examine the relative contribution of Vietnam war zone variables to PTSD symptom development, and c) to study psychosocial adjustment problems associated with Vietnam combat exposure and with PTSD symptoms among help-seeking substance abusing men. Of 489 male veterans presenting for treatment, 10.7% had significant Vietnam combat-related PTSD symptoms as measured by the Mississippi Scale for Combat-Related PTSD. Clinically significant PTSD symptoms occurred among 46% of the subsample of combat-exposed Vietnam veterans with substance abuse problems. Degree of combat exposure was the most important military stressor that distinguished Vietnam veterans with PTSD from those without PTSD, but the groups also differed on age of war zone duty, duration of war zone duty, and whether they were wounded. Veterans who served in Vietnam did not differ from veterans who had no war zone duty on various parameters of psychosocial adjustment. However, the subgroup of Vietnam veterans with PTSD symptoms reported significantly greater psychosocial adjustment problems than their counterparts who did not have PTSD. The deleterious effects associated with combat-related PTSD appeared to be confined to adjunctive psychiatric difficulties and unemployment and did not increase risk of arrests for antisocial conduct beyond that found for veterans without PTSD. Methodological and clinical implications of these findings are discussed.     

Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample.

Research has indicated significant comorbid psychopathology with chronic posttraumatic stress disorder (PTSD) in samples of war veterans. The present paper examines the issue of comorbidity in a disaster sample to learn whether findings from veterans generalized to this event. A total of 193 subjects exposed to the Buffalo Creek dam collapse of 1972 were examined 14 years later using diagnoses derived from the Structured Clinical Interview for DSM-III (SCID). Past and present PTSD was found in a significant portion of the sample. Major depression was the next most common diagnosis and was highly related to PTSD. Anxiety disorders were also common. The overlap with other diagnoses was quite similar to that found in a sample of Vietnam veterans we studied earlier, except that the disaster sample had fewer dysthymic disorders, substance abusers, and antisocial personality disorders. Possible explanations for comorbidity in chronic PTSD were discussed and it was suggested that the morphology of PTSD may be quite stable in at least some other nonveteran trauma populations.     

Attachment Representation and Suicidal Ideation in Vietnam Combat Veterans With Posttraumatic Stress Disorder

Attachment representation has been linked to psychopathology and suicidality. Possible links between attachment representations and suicidal ideation in a PTSD sample were examined. Vietnam combat veterans in treatment for PTSD (N = 48) were assessed for PTSD severity, attachment representation and current and lifetime suicidality. Contrary to expectation individuals with secure attachment representations had higher levels of current suicidal ideation than those with insecure attachment representations, and unresolved/disorganized attachment was associated with lower levels of current suicidal ideation. Secure attachment may not provide protection against high levels of distress and suicidal ideation among combat veterans with PTSD.     

The D2 dopamine receptor (DRD2) gene is associated with co-morbid depression, anxiety and social dysfunction in untreated veterans with post-traumatic stress disorder.

OBJECTIVE: To identify clusters of patients with post-traumatic stress disorder (PTSD) according to symptom profile and to examine the association of the A1 allele of the D2 dopamine receptor (DRD2) gene with these clusters. METHOD: Fifty-seven untreated Caucasian Vietnam veterans with PTSD were administered the General Health Questionnaire-28 (GHQ) and the Mississippi Scale for combat-related PTSD. DRD2 allelic status was determined by PCR. RESULTS: Subjects with the DRD2 Al allele compared to those without this allele had significantly higher scores on GHQ 2 (anxiety/insomnia), GHQ 3 (social dysfunction) and GHQ 4 (depression). Cluster analysis of the GHQ data identified two primary groups. A high psychopathology cluster (cluster 3), featured by high co-morbid levels of somatic concerns, anxiety/insomnia, social dysfunction and depression, and a low psychopathology cluster (cluster 1), manifested by the reverse pattern. Scores in each of the four GHQ groups were significantly higher in cluster 3 than cluster 1, as was Mississippi Scale PTSD score. DRD2 A1 allele veterans compared to those without this allele were significantly more likely to be found in the high than the low psychopathology cluster group. CONCLUSIONS: DRD2 variants are associated with severe co-morbid psychopathology in PTSD subjects.     

Failure to detect fabricated posttraumatic stress disorder with the use of the MMPI in a clinical population

The authors attempted to replicate previous studies that used the Frequency (F) scale and the posttraumatic stress disorder (PTSD) subscale of the MMPI to discriminate Vietnam veterans with PTSD from well-adjusted veterans and mental health professionals who feigned symptoms of PTSD. Profiles of veterans with PTSD were compared to those of veterans with non-PTSD psychiatric disorders and veterans with fabricated PTSD symptoms who sought treatment. Discriminant analysis of F scale and PTSD subscale scores correctly identified only 43.59% of the subjects, thus failing to support use of the MMPI in detecting fabricated symptoms of PTSD in a clinical population.     

Multidimensional assessment of anger in Vietnam veterans with posttraumatic stress disorder.

This study examined the effects of combat exposure and posttraumatic stress disorder (PTSD) on dimensions of anger in Vietnam veterans. Vietnam combat veterans were compared with Vietnam era veterans without war zone duty on the Multidimensional Anger Inventory (MAI). Combat veterans were not significantly more angry than their veteran peers who did not serve in Southeast Asia. Additionally, various parameters of war zone duty were not highly associated with anger scores. However, combat veterans with PTSD scored significantly higher than veterans without PTSD on measures of anger arousal, range of anger-eliciting situations, hostile attitudinal outlook, and tendency to hold anger in. These results suggest that PTSD, rather than war zone duty, is associated with various dimensions of angry affect.     

The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma?

OBJECTIVE: The presence of posttraumatic stress disorder (PTSD) in trauma survivors has been linked with family dysfunction and symptoms in their children, including lower self-esteem, higher disorder rates and symptoms resembling those of the traumatized parent. This study aims to examine the phenomenon of intergenerational transfer of PTSD in an Australian context. METHOD: 50 children (aged 16-30) of 50 male Vietnam veterans, subgrouped according to their fathers' PTSD status, were compared with an age-matched group of 33 civilian peers. Participants completed questionnaires with measures of self-esteem, PTSD symptomatology and family functioning. RESULTS: Contrary to expectations, no significant differences were found between the self-esteem and PTSD symptomatology scores for any offspring groups. Unhealthy family functioning is the area in which the effect of the veteran's PTSD appears to manifest itself, particularly the inability of the family both to experience appropriate emotional responses and to solve problems effectively within and outside the family unit. CONCLUSION: Methodological refinements and further focus on the role of wives/mothers in buffering the impact of veterans' PTSD symptomatology on their children are indicated. Further effort to support families of Veterans with PTSD is also indicated.     

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.     

Posttraumatic stress disorder among black Vietnam veterans

Because of racism in the military and racial and social upheaval in the United States during the Vietnam War years, as well as limited opportunities for blacks in the postwar period, black veterans of the Vietnam War often harbor conflicting feelings about their wartime experiences and have difficulty rationalizing brutality against the Vietnamese. As a result, black veterans suffer from posttraumatic stress disorder (PTSD) at a higher rate than white veterans. Diagnosis and treatment of PTSD in black veterans is complicated by the tendency to misdiagnose black patients, by the varied manifestations of PTSD, and by patients' frequent alcohol and drug abuse and medical, legal, personality, and vocational problems. The author presents his and others' recommendations about ways to treat black veterans with PTSD.     

Race and Incarceration in an Aging Cohort of Vietnam Veterans in Treatment for Post-Traumatic Stress Disorder (PTSD)

Cross sectional studies have addressed the incarceration of Vietnam veterans with post-traumatic stress disorder (PTSD), but no studies have examined changes in incarceration as they age. This study examines patterns of incarceration among Vietnam veterans treated in specialized veterans affairs (VA) intensive PTSD programs over time. Data was drawn from admission data from the initial episode of treatment of Caucasian and African American Vietnam veterans entering VA specialized intensive PTSD programs between 1993 and 2011 (N = 31,707). Bivariate correlations and logistic regression were used to examine associations among race and incarceration over time and the potentially confounding influence of demographic and clinical covariates on this relationship. Rates of reported incarceration declined from 63 to 43 %. Over time, African American veterans were 34 % more likely than Caucasian veterans to have a lifetime history of incarceration while interaction analysis showed steeper declines for Caucasians than African Americans. Rates of incarceration among these Vietnam veterans declined as they aged. Furthermore, African American veterans were substantially more likely than Caucasian veterans to have been incarcerated and showed less decline as the cohort aged. While reduced, needs for clinical PTSD services remain among aging combat veterans.