Responses to Civilian War Experiences: Predictors of Psychological Functioning and Coping

This study investigated civilian war trauma in Central American refugees, focusing on the diagnosis of posttraumatic stress disorder (PTSD) as related to war experience and demographic characteristics. Sixty eight percent of the refugees met the diagnostic criteria for PTSD. Diagnosis was best predicted by number of war experiences, severity of war trauma and level of anxiety/depression. Higher numbers of war experiences predicted PTSD severity, as did involvement in the legalization process, parenthood, and being a citizen of El Salvador. In examining the PTSD symptom cluster scores, it was found that number of war experiences was a significant predictor in all clusters. These results are helpful in increasing our knowledge about the role of war experiences in civilian PTSD and the unique situation of the Central American refugees.     

Posttraumatic Stress Disorder and Somatic Complaints in a Deployed Cohort of Georgian Military Personnel: Mediating Effect of Depression and Anxiety

Several studies have shown the relationship between symptoms of posttraumatic stress disorder (PTSD), somatic symptoms, and the mediating effect of depression and anxiety. The following study was conducted to investigate the relationship between PTSD symptoms and somatic complaints through underlying symptoms of depression and anxiety. The participants of the study were 2,799 veterans who were examined after a 6‐month deployment. They were assessed using the PTSD Checklist (PCL‐5) and Patient Health Questionnaire (PHQ) for depression, anxiety, and somatic complaints. To check the indirect effect of PTSD on somatic complaints through depression and anxiety, mediation model 4 (parallel mediation) of the SPSS PROCESS macro was used. There was a significant total indirect effect of PTSD through depression and anxiety on somatic complaints, b = 0.14, 95% confidence interval (CI) [0.12, 0.16], from which an indirect effect of PTSD on somatic complaints through depression was b = 0.08, 95% CI [0.06, 0.10], and through anxiety it equaled b = 0.06, 95% CI [0.04, 0.07]. The ratio of indirect to total effect was 0.66, 95% CI [0.59, 0.75]. The present study helps us to understand the role of depression and anxiety symptoms when the symptoms of PTSD and somatic complaints are present. These new findings may have implications for the management as well as treatment of PTSD because they recognize the importance of symptoms of anxiety and depression when somatic complaints are present.     

Prevalence of traumatic events and post-traumatic psychological symptoms in a nonclinical sample of college students

The lifetime prevalence of traumatic events and their psychological impact were assessed in 440 undergraduate students. Eighty-four percent of the subjects reported experiencing at least one event of sufficient intensity potentially to elicit Post-Traumatic Stress Disorder (PTSD). One-third of the sample had experienced four or more traumatic events. Subjects who had experienced trauma reported higher levels of depression, anxiety, and PTSD symptomatology than nontraumatized subjects, and these symptoms were more intense in subjects who experienced multiple traumas. Events that were particularly negative in their impact included unwanted sexual experiences and events that subjects reported were too traumatic to discuss openly. Males and females differed in their probability of experiencing some types of events and in the psychological response to certain events.     

An Examination of Antecedent Traumas and Psychiatric Comorbidity Among Male Inmates with PTSD

Despite substantially higher rates of posttraumatic stress disorder (PTSD) among male inmates than among men in the general population, there is a dearth of research on PTSD among incarcerated men. The current study addresses traumatic events that precede PTSD and psychiatric disorders that are comorbid with PTSD in an inmate sample. Seeing someone seriously injured or killed, being sexually abused, and being physically assaulted were the three most commonly reported antecedent traumas to PTSD. Lifetime and current rates of mood disorders, anxiety disorders, and antisocial personality disorder were elevated among inmates with a diagnosis of PTSD. Two hundred and thirteen inmates participated in the study. Sixty-nine participants (33%) met lifetime DSM–III–R criteria for PTSD, and 45 (21%) met current criteria. The findings are compared with general population samples, and implications of the findings are discussed.     

A Prospective Study of Psychiatric Symptoms Among Adolescents After the Wenchuan Earthquake

Natural disaster exposure is associated with increased risk of mental health problems. This study aimed to investigate the prevalence, course, and risk factors of probable psychiatric disorders among 1,573 adolescents following the May 2008 Wenchuan earthquake in China. Symptoms of posttraumatic stress disorder (PTSD), depression, panic disorder (PD), generalized anxiety disorder (GAD), separation anxiety disorder (SAD), social phobia (SP), conduct disorder (CD), and attention deficit hyperactivity disorder (ADHD) were assessed at 6 and 18 months postearthquake using a battery of standardized measures. Approximately 62.9% and 56.1% of the sample, respectively, had at least one probable psychiatric disorder at 6 and 18 months postearthquake. The most common disorders were PTSD, depression, PD, GAD, and ADHD. With regard to the course of disorders, PTSD, GAD, PD, SAD. and ADHD decreased; SP and CD remained stable; and depression increased. Generalized estimating equations models showed that female sex, older age, having experienced the death or injury of family members, being a direct witness of tragic scenes, low social support, and a high level of negative life events were risk factors for most disorders, odds ratios (ORs) = 1.3–20.8. However, logistic regressions indicated that earthquake exposure variables were specifically related to persistent PTSD, ORs = 2.0–2.5, and negative life events were associated with persistent depression, ORs = 2.4–5.3. Various psychiatric symptoms are pervasive, intense, and persistent among adolescent survivors. Systematic and periodic screening are needed to closely monitor the onset, course, and risk factors of mental health problems after disasters.     

Clinical Manifestations of Trauma Exposure in Fibromyalgia: The Role of Anxiety in the Association Between Posttraumatic Stress Symptoms and Fibromyalgia Status

Little research has investigated how traumatic experiences relate to fibromyalgia (FM). We explored the presence of trauma exposure in a sample of Spanish participants with FM and examined the associations between (a) the number and type of traumatic experiences and posttraumatic stress disorder (PTSD) symptoms and (b) the severity of clinical manifestations in FM, testing for possible mediation models. Participants were 173 FM patients and 53 healthy controls aged 24 to 66 years. Traumatic event type (physical trauma, physical and sexual abuse, psychological trauma), PTSD symptoms, pain intensity, sleep disturbance, anxiety, depression, coping style, and daily functioning were evaluated via self-report. Fibromyalgia patients reported a higher percentage of trauma exposure than controls, more traumatic experiences (mainly emotional and physical trauma), and more PTSD symptoms, Hedges’ gs/Cohen's ds = 0.42–0.76. Most FM patients reported having experienced their most distressing traumatic experience and PTSD symptoms before FM diagnosis. PTSD symptom severity was associated with more pain, sleep disturbances, anxiety, depression, coping style, and functional impairment, rs = .23–.33, ps = .025–.008. A multiple mediation analysis showed a significant indirect effect of anxiety in the association between PTSD symptoms and daily functioning. In a subset of FM patients, PTSD symptoms were associated with major clinical symptoms. The results suggest future research should explore the effectiveness of trauma-focused therapy compared to standard cognitive behavioral therapy for these patients.     

The Impact of Interpersonal and Noninterpersonal Trauma on Psychological Symptoms in Refugees: The Moderating Role of Gender and Trauma Type

Research findings have documented a relationship between the number of types of traumatic events to which refugees were exposed and psychological disorders. It is unclear, however, if gender moderates the impact of trauma on refugee mental health. The participants in this study were 60 male and 31 female refugees and asylum‐seekers resettled in Australia. Participants had a mean age of 34.54 years (SD = 9.70), and were from a variety of countries including Iraq, Iran, and Sri Lanka. We conducted a multigroup path analysis to test if the relationship between psychological outcomes of exposure to trauma (posttraumatic stress disorder [PTSD] symptoms, symptoms of anxiety, and symptoms of depression) was different as a function of the type of traumatic exposure (interpersonal vs. noninterpersonal) or as a function of gender. We found a significant relationship between interpersonal trauma exposure and PTSD symptoms (β = .77) and anxiety symptoms (β = .32) in women, and a significant association between noninterpersonal trauma exposure and PTSD symptoms (β = .59), anxiety (β =.49), and depression symptoms (β = .32) in men. For men, the effect sizes of the relationship between exposure to specific types of noninterpersonal trauma and psychological symptoms ranged from d = 0.14 to 1.01; for exposure to interpersonal trauma, they ranged from d = ?0.53 to 0.43. For women, the effect sizes of the relationship between exposure to specific types of noninterpersonal trauma and psychological symptoms ranged from d = ?0.79 to 0.67; for exposure to interpersonal trauma, they ranged from d = ?0.09 to 1.46. These results suggested supporting refugees in their efforts to overcome the psychological impact of trauma, including the allocation of resources in clinical services to support the psychological recovery of refugees.     

Exposure to potentially morally injurious events,disruption in assumptive world,moral injury symptoms,and psychological distress among Israeli female veterans

Exposure to potentially morally injurious events (PMIEs) during military service is associated with mental health problems. However, knowledge about these associations and possible mechanisms of effect among female combat veterans is sparse. This study examines associations between PMIEs, posttraumatic stress disorder (PTSD), complex PTSD, depression and anxiety symptoms among female veterans, as well as the mediating role of disruption in assumptive world and moral injury (MI) symptoms. A volunteer sample of Israeli female combat veterans (n = 885) and non-combat veterans (n = 728) responded to self-report questionnaires in a cross-sectional design study. Results show that combat veterans reported higher levels of PMIEs, PTSD and MI symptoms, but not CPTSD, depression and anxiety symptoms, as compared to non-combat veterans. Importantly, PMIEs was indirectly associated with PTSD, complex PTSD, depression and anxiety symptoms through serial mediators of disruption in assumptive world and MI symptoms. This study emphasized the exposure to PMIEs and its posttraumatic sequelae among female combat veterans as compared to non-combat veterans. Our findings also suggest that future longitudinal studies should examine the mediating role of disruption in assumptive world and MI symptoms for the deleterious effects of exposure to PMIEs during military service.     

Trauma type,gender, and risk of PTSD in a region within an area of conflict

The relation between trauma type, gender, and risk of posttraumatic stress disorder (PTSD) still remains unclear. The authors investigated the association among gender and trauma type and risk of PTSD among people living within an area of conflict. Traumatic experiences and PTSD symptoms among 708 participants were assessed. It was determined that more men (53%) were exposed to traumatic events than women (44%). They also found no difference in PTSD prevalence according to gender. However, the authors found that there was a different risk of PTSD among men and women who experienced similar traumatic events: the risk of PTSD for those who experienced military conflict was higher among men than it was among women.     

Outcome of Depression and Anxiety After War: A Prospective Epidemiologic Study of Children and Adolescents

Prospective studies of children exposed to war have not investigated disorders other than posttraumatic stress disorder (PTSD) and have methodological limitations. From a stratified random sample of 386 children and adolescents who had been interviewed 3 weeks after war exposure (Phase 1) a random subsample (N = 143) was interviewed a year later (Phase 2). PTSD, major depressive disorder (MDD), separation anxiety disorder (SAD), overanxious disorder (OAD), and psychosocial stressors were assessed using structured interviews administered to both children and adolescents and their parents. The prevalence of disorders among the 143 at Phase 1 was MDD 25.9%, SAD 16.1%, OAD 28.0%, and PTSD 26.0%, with 44.1% having any disorder. At Phase 2 the prevalence was MDD, 5.6%; SAD, 4.2%; OAD, 0%; and PTSD, 1.4%, with 9.2% having any disorder. Occurrence of disorders at Phase 1 was associated with older age, prewar disorders, financial problems, fear of being beaten, and witnessing any war event (ORs ranged from 2.5 to 28.6). Persistence of disorders to Phase 2 was associated with prewar disorders (OR = 6.0) and witnessing any war event (OR = 14.3). There are implications for detection of at‐risk cases following wars by screening for adolescents exposed to family violence, those with prewar disorders, and those who directly witnessed war events to target them for specific interventions.     

Anniversary Reactions in Gulf War Veterans: A Naturalistic Inquiry 2 Years After the Gulf War

The goal of this study was to assess the occurrence of anniversary reactions in Gulf War veterans 2 years after the conclusion of Operation Desert Storm. Subjects were administered questionnaires and asked to identify specific months of best and worst functioning, and months of least or most symptoms of posttraumatic stress disorder (PTSD). Negatively experienced months were compared to documented dates of exposure to traumatic events during the war. Anniversary reactions occurred with a frequency greater than chance and were seen most in individuals exposed to a greater number, and to more severe types, of traumatic events. This suggests that anniversary reactions are etiologically linked to traumatic events and may be a part of the syndrome of PTSD.     

Comparison of DSM‐IV and Proposed ICD‐11 Formulations of PTSD Among Civilian Survivors of War and War Veterans

The World Health Organization recently proposed a reformulation of posttraumatic stress disorder (PTSD) for the 11^th edition of the International Classification of Diseases (ICD‐11), employing only 6 symptoms. The aim of this study was to investigate the impact of this reformulation of PTSD as compared to criteria according to Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM‐IV; American Psychiatric Association, 1994) on the prevalence of current PTSD as well as comorbid major depressive episode and anxiety disorders other than PTSD. Study 1 involved previously collected interviews with 560 Kosovar civilian war survivors; Study 2 employed a previously collected sample of 142 British war veterans. Results revealed no change in the diagnostic status under the criteria proposed for ICD‐11 in 87.5% of civilian war survivors and 91.5% of war veterans. Participants who only met the newly proposed criteria showed lower rates of comorbid major depressive episode than participants who only met DSM‐IV criteria (13.6% vs. 43.8% respectively). Rates of comorbid anxiety disorders did not significantly differ between participants who lost or gained a PTSD diagnosis under the proposed criteria.     

Comorbid Anxiety Disorders in Civilians Seeking Treatment for Posttraumatic Stress Disorder

Research indicates that posttraumatic stress disorder (PTSD) is associated with high rates of comorbid psychiatric diagnoses. Yet, it remains unknown whether PTSD is associated with greater comorbidity relative to patients with other anxiety disorders. This study examined prevalence of comorbid anxiety disorders with PTSD relative to other disorders among a treatment-seeking population. Patients with PTSD (n = 83) evidenced greater overall comorbidity as compared to patients with other anxiety (n = 151) or Axis I (n = 73) disorders. Compared to patients with panic disorder, patients with PTSD were more likely to be diagnosed with depression and social phobia, but not other anxiety disorders. Extent of anxiety disorder comorbidity was not related to PTSD severity. These findings are discussed in terms of their relevance for treatment of PTSD.     

Initial Findings From Project Recover: Overcoming Co‐Occurring Eating Disorders and Posttraumatic Stress Disorder Through Integrated Treatment

This pilot study is the initial investigation of an integrated cognitive behavioral therapy (CBT) for co‐occurring eating disorders (ED) and posttraumatic stress disorder (PTSD). Following a course of intensive hospital‐based ED treatment focused on ED behavioral symptom interruption, 10 individuals with ED‐PTSD received 16 sessions of CBT that focused on maintaining improvements in ED symptoms outside of the hospital environment and integrated cognitive processing therapy for PTSD. We hypothesized that the treatment would be associated with significant improvements in PTSD symptoms, depression, and anxiety, as well as sustained improvements in ED symptomatology. There were statistically significant improvements in clinician‐rated PTSD symptoms (g av = 4.58), depression (g av = 1.37), and anxiety (g av = 1.00). As expected, there was no statistically significant change in ED cognitions (g av = .28). Reliable change analyses revealed that only 1 participant experienced deterioration in ED cognitions over the course of the integrated treatment. Of the 9 participants who were remitted from behavioral ED symptoms at the end of intensive treatment/beginning of the integrated treatment, 8 remained behaviorally remitted at poststudy treatment, which is encouraging given the high rate of rapid relapse following intensive ED treatment. Findings from this study provide preliminary support for the efficacy of an integrated CBT for ED‐PTSD.     

Female dissociative responding to extreme sexual violence in a chronic crisis setting: the case of Eastern Congo

This cross-sectional study aimed to examine relationships between the number of traumatizing events, degree of shutdown dissociation, posttraumatic stress disorder (PTSD), and depression. Fifty-three female survivors of the ongoing war in Congo who sought medical treatment were interviewed. A path-analytic model was created with paths to PTSD via dissociation, and both the number of self-experienced and witnessed traumatizing events. Cumulative exposure and dissociation were associated with increased PTSD severity. Posttraumatic stress disorder and witnessing predicted depression when depression was modeled as a consequence of PTSD. Moreover, PTSD mediated the correlation between dissociation and depression. The findings suggest that shutdown dissociation may have value in predicting PTSD, and there is evidence of differential effects of threat to oneself as opposed to witnessing trauma.     

Trauma-Related Dissociative States and Long-Term Psychopathology in Posttraumatic Stress Disorder

Dissociative responses to trauma have been hypothesized to be associated with long-term increases in psychopathology. The purpose of this study was to examine dissociative responses to premilitary, combat-related and postmilitary traumatic events and long-term psychopathology in Vietnam combat veterans with (n = 34) and without (n = 28) posttraumatic stress disorder (PTSD). PTSD patients reported higher levels of dissociative states at the time of combat-related traumatic events than non-PTSD patients. Higher levels of dissociative states persisted in PTSD patients in the form of higher levels of dissociative states in response to postmilitary traumatic events. In addition, dissociative responses to combat trauma were associated with higher long-term general dissociative symptomatology as measured by scores on the Dissociative Experience Scale, as well as increases in the number of flashbacks since the time of the war. These findings are consistent with previous formulations that dissociation in the face of trauma is a marker of long-term psychopathology.     

Equine‐Assisted Therapy for Anxiety and Posttraumatic Stress Symptoms

We tested the efficacy of the Equine Partnering Naturally^© approach to equine‐assisted therapy for treating anxiety and posttraumatic stress disorder (PTSD) symptoms. Participants were 16 volunteers who had experienced a Criterion A traumatic event, such as a rape or serious accident, and had current PTSD symptoms above 31 on the PTSD Checklist (PCL‐S; Weathers, Litz, Herman, Huska, & Keane, 1993). Participants engaged in tasks with horses for 6 weekly 2‐hour sessions. Immediately following the final session, participants reported significantly reduced posttraumatic stress symptoms, d = 1.21, less severe emotional responses to trauma, d = 0.60, less generalized anxiety, d = 1.01, and fewer symptoms of depression, d = 0.54. As well, participants significantly increased mindfulness strategies, d = 1.28, and decreased alcohol use, d = 0.58. There was no significant effect of the treatment on physical health, proactive coping, self‐efficacy, social support, or life satisfaction. Thus, we found evidence that the Equine Partnering Naturally^© approach to equine‐assisted therapy may be an effective treatment for anxiety and posttraumatic stress symptoms. Future research should include larger groups, random assignment, and longer term follow‐up.     

A 7‐Year Follow‐Up Study on the Mental Health of North Korean Defectors in South Korea

This study was conducted to describe the relationship of past trauma and current stress on the mental health of North Korean (NK) defectors living in South Korea 7 years after a baseline assessment. Of the 200 who participated in the initial study, 106 participated in follow‐up. Previous data regarding past traumatic events experienced in North Korea and during defection, past posttraumatic stress disorder (PTSD), and their current stress levels were correlated with the participants’ current mental health status including depression, anxiety, and PTSD. The rate of PTSD in the sample and the scores on the PTSD symptom scale decreased significantly from the baseline. The participants’ current mental health was negatively related to previous traumatic experiences in North Korea and past symptoms of PTSD, but unrelated to previous trauma experienced during defection. In addition, although current mental health was negatively related to only current culture‐related stress, it was unrelated to the level of current ordinary life stress. The results of this study suggest that PTSD symptoms decreased during the 7 years between assessments, and that current culture‐related stress is the most important variable related to the mental health of NK defectors living in South Korea.     

Associations among psychosis,mood, anxiety,and posttraumatic stress symptoms: A network analysis

The associations among psychotic experiences (i.e., hallucinations and delusions), trauma exposure, and posttraumatic stress symptoms are complex and multidirectional. Using network analysis to understand how psychotic experiences and symptoms of posttraumatic stress disorder (PTSD) relate to one another may identify new interventional targets to treat comorbidity and its underlying pathological processes. This study aimed to use network analysis to examine the associations among psychotic experiences; negative symptoms of psychosis; and symptoms of PTSD, anxiety, and depression. In this population-based cohort study, 4,472 participants (36.7% male) were assessed for psychotic experiences, negative symptoms of psychosis, PTSD, anxiety, and depression at age 23 (M = 23.86 years, SD = 0.520) or 24 years (M = 24.03, SD = 0.848). Associations among symptoms were assessed via network analysis. Exploratory graph analysis identified three clusters of densely connected symptoms within the overall network: psychotic experiences; PTSD symptoms; and depressive and anxiety symptoms and negative symptoms of psychosis. Psychotic experiences had the strongest associations with other symptoms in the network, and symptoms of anxiety played a key role in bridging psychotic experiences, symptoms of PTSD, and depressive symptoms. Consistent with the stress reactivity and affective models for psychotic experiences, the results suggest that symptoms of anxiety and emotional distress (e.g., hyperarousal, panic) may have a key role in the development and maintenance of psychotic experiences and symptoms of PTSD. Targeting these symptoms may ameliorate symptom burden transdiagnostically.     

Friendship in War: Camaraderie and Prevention of Posttraumatic Stress Disorder Prevention

Aspects of social support during combat deployment, such as unit cohesion, have been shown to affect later posttraumatic stress disorder (PTSD) development among veterans. We utilized a longitudinal database to assess how relationship quality with fellow soldiers in World War II (WWII) might be linked with postwar PTSD symptoms. Data were available on 101 men who experienced combat exposure in WWII, documented through postwar assessment. Upon study entry (1939 to 1942), data were collected on the quality of participants’ early childhood relationships and their emotional adjustment during college. Data on WWII experiences were collected in 1946. Relationship quality with fellow soldiers in WWII was examined as a moderator of the link between combat exposure and postwar PTSD symptoms. Prewar emotional adjustment was examined as a mediator between quality of childhood relationships and subsequent quality of relationships quality with fellow soldiers during war. Better quality relationships with fellow soldiers attenuated (i.e., moderated) the link between combat exposure severity and PTSD symptom count, explaining a significant percent of the variance, R ² = .19, p < .001. There was also a significant indirect mediation effect of childhood relationship quality on relationships with soldiers through prewar emotional adjustment, ab = 0.02, 95% BCa CI [0.01, 0.05]. Results suggest that better peer relationship quality during deployment may reduce the likelihood of subsequent PTSD symptom development, and that the quality of early relationships may set the stage for better relationships during stressful contexts such as war. These findings have implications for PTSD risk factor screening prior to deployment, and underscore the importance of interpersonal support among soldiers during deployment.