A longitudinal and retrospective study of PTSD among older prisoners of war

OBJECTIVE: The authors examined the longitudinal changes in posttraumatic stress disorder (PTSD) symptom levels and prevalence rates over a 4-year time period among American former prisoners of war (POWs) from World War II and the Korean War. Retrospective symptom reports by World War II POWs dating back to shortly after repatriation were examined for 1) additional evidence of changing PTSD symptom levels and 2) evidence of PTSD cases with a long-delayed onset. METHOD: PTSD prevalence rates and symptom levels were measured by the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. For the longitudinal portion of the study, participants were 177 community-dwelling World War II and Korean POWs. For the retrospective portion, participants were 244 community-dwelling World War II POWs. RESULTS: PTSD prevalence rates and symptom levels increased significantly over the 4-year measurement interval. Retrospective symptom reports indicated that symptoms were highest shortly after the war, declined for several decades, and increased within the past two decades. Long-delayed onset of PTSD symptoms was rare. Demographic and psychosocial variables were used to characterize participants whose symptoms increased over 4 years and differentiate participants who reported a long-delayed symptom onset. CONCLUSIONS: Both longitudinal and retrospective data support a PTSD symptom pattern of immediate onset and gradual decline, followed by increasing PTSD symptom levels among older survivors of remote trauma.     

Impact of war stress on posttraumatic stress symptoms in hospital personnel

OBJECTIVE: This study examines the relationship between exposure to war stress and posttraumatic symptoms among nurses and physicians in a general hospital targeted by missiles. METHOD: Hospital staff who were exposed to missile attacks and casualties of war, both military and civilians (n=80), were assessed for posttraumatic stress disorder (PTSD) symptoms a month after the war between Lebanon and Israel erupted (during the last days of the war). RESULTS: High levels of PTSD symptoms were found in 10.5% of physicians and 35.7% of nurses. Logistic regression analysis showed that nurses had an increased risk for PTSD in comparison to physicians (odds ratio=5.28). CONCLUSION: These findings show that nurses suffered from more severe posttraumatic symptoms compared to physicians after exposure to prolonged war stress. The gap between physicians and nurses warrants further study.     

Trajectories of PTSD: a 20-year longitudinal study

OBJECTIVE: This study assessed the psychopathological effects of combat in veterans with and without combat stress reaction. METHOD: Veterans (N=214) from the 1982 Lebanon War were assessed in a prospective longitudinal design: 131 suffered from combat stress reaction during the war, and 83 did not. They were evaluated 1, 2, 3, and 20 years after the war. RESULTS: Combat stress reaction is an important vulnerability marker. Veterans with combat stress reaction were 6.6 times more likely to endorse posttraumatic stress disorder (PTSD) at all four measurements, their PTSD was more severe, and they were at increased risk for exacerbation/reactivation. A qualitative analysis of the profile of PTSD symptoms revealed some time-related changes in the symptom configuration of veterans who did not suffer from combat stress reaction. In both groups, the course fluctuated; PTSD rates dropped 3 years postwar and rose again 17 years later; 23% of veterans without combat stress reaction reported delayed PTSD. CONCLUSIONS: These findings suggest that the detrimental effects of combat are deep and enduring and follow a complex course, especially in combat stress reaction casualties. The implications of aging and ongoing terror in impeding recovery from the psychological wounds of war are discussed.     

Phenomenology and course of psychiatric disorders associated with combat-related posttraumatic stress disorder.

OBJECTIVE: Studies indicate that chronic combat-related posttraumatic stress disorder (PTSD) is frequently associated with other psychiatric disorders. Questions regarding the nature and interrelationships of these conditions require clarification. The purpose of this study was to address primary and secondary illness relationships by focusing on the specific phenomenology and course of illness onset of PTSD comorbidity. METHOD: In order to minimize confounding factors, only outpatients without recent substance use disorders were included. Sixty subjects who had been exposed to severe combat stress including veterans of Vietnam and veterans of World War II or Korea, 15 of whom were former prisoners of war, received structured assessments over serial evaluations. RESULTS: PTSD was the most prevalent lifetime disorder followed by major depression, panic disorder, generalized anxiety disorder, and phobic disorder or symptoms. Endogenous-appearing features overlapping other clinical populations were common; however, some specific symptom patterns also were suggestive of traumatic influence. Unlike generalized anxiety disorder and past substance use, the mean onset of phobias, major depression, and panic disorder, respectively, occurred later than PTSD. CONCLUSIONS: These observations suggest that persistent conditions related to PTSD progress toward symptoms that are increasingly autonomous in their pattern of occurrence.     

Fifty years later: the long-term psychological adjustment of ageing World War II survivors

OBJECTIVE: Most studies of the long-term after-effects of war have focused on survivors seeking treatment or financial compensation. The present study examined the current psychological adjustment of a community sample of ageing World War II (WW II) survivors, including survivors of bombardments, persecution, resistance, combat and other violence. METHOD: A community sample of 4057 Dutch WW II survivors answered a 4-page postal questionnaire. Of these, 1461 survivors answered a second follow-up questionnaire. RESULTS: Even 50 years after World War II, a statistically significant but modest relationship was found to exist between exposure to shocking war events and current psychological adjustment in terms of symptoms of post-traumatic stress disorder (PTSD), anxiety and anger. A total of 66 respondents (4.6%) met the criteria for PTSD. The highest level of current PTSD (13%) was found among survivors of persecution. The lowest level of PTSD (4%) was found among civilian war victims and resistance participants, while military veterans had an intermediate score (7%). With regard to absolute numbers, civilian war victims represented the largest proportion of PTSD sufferers. CONCLUSION: In a study of a community sample of WW II survivors, we found that most of these survivors had no severe symptoms of PTSD. Nevertheless, probably tens of thousands of Dutch individuals are still suffering from long-term after-effects from World War II. For these vulnerable survivors, the ageing process will complicate the coping process.     

Interpersonal trauma, war zone exposure, and posttraumatic stress disorder among veterans with schizophrenia

The present study examined the prevalence of war zone exposure, interpersonal trauma and post-traumatic stress disorder (PTSD) in veterans with primary schizophrenia hospitalized on a VA inpatient psychiatric unit. Data were collected on a sample of male veterans (N=165) with a primary diagnosis of schizophrenia or schizoaffective disorder, who were consecutively admitted to a VAMC inpatient psychiatric unit. The prevalence of interpersonal trauma exposure and comorbid PTSD were assessed. Analyses also explored differences between those patients who had been identified with PTSD to those who screened positive but had not been previously identified as having PTSD. Ninety-six percent of the sample endorsed interpersonal trauma or exposure to a war zone. The prevalence of PTSD was 47% (n=78), although only 14% (n=11) of those who screened positive for PTSD had a diagnosis of PTSD in their medical record. Among those screening positive, having a chart diagnosis of PTSD was associated with more severe PTSD symptoms and combat exposure. Results suggest that PTSD is highly prevalent and under-diagnosed among veterans with schizophrenia. Increased assessment of trauma and PTSD in this population is warranted.     

Posttraumatic residues of captivity: a follow-up of Israeli ex-prisoners of war

BACKGROUND: This article examines the long-term impact of wartime captivity. METHOD: One hundred sixty-four prisoners of war (POWs) and 189 matched combatants of the 1973 Yom Kippur War filled out a series of questionnaires that assessed posttraumatic stress disorder (PTSD), general psychiatric symptomatology, and social functioning according to DSM-III-R criteria. RESULTS: Almost 2 decades after the war, ex-POWs exhibited higher rates and greater intensity of posttraumatic stress reactions, more general psychiatric symptomatology, and more severe problems in functioning at home, at work, and in the military than did the control group (Israeli veterans who were not POWs). They were also more likely to obtain official disability recognition and to seek psychological help. Their recovery was slower and professional help less effective. In addition, the veterans with PTSD in both groups had high rates of comorbid general psychiatric symptomatology. CONCLUSION: These findings point to the depth, range, and persistence of the stress residuals of wartime captivity.     

The impact of torture on post-traumatic stress symptoms in war-affected Tamil refugees and immigrants.

The present study examines the effect of torture in generating post-traumatic stress disorder (PTSD) symptoms by comparing its impact with that of other traumas suffered by a war-affected sample of Tamils living in Australia. Traumatic predictors of PTSD were examined among a subsample of 107 Tamils (refugees, asylum seekers, and voluntary immigrants) who had endorsed at least one trauma category on the Harvard Trauma Questionnaire. Principal components analysis (PCA) yielded five trauma factors that were applied to predicting PTSD scores. Tamils exposed to torture returned statistically higher PTSD scores than other war trauma survivors after controlling for overall levels of trauma exposure. The torture factor identified by the PCA was found to be the main predictor of PTSD in a multiple regression analysis. Although limited by sampling constraints and retrospective measurement, the present study provides support for the identification of torture as a particularly traumatic event, even when the impact of other war-related trauma is taken into account.     

Weight loss and PTSD symptom severity in former POWs

To determine the relationship between weight loss suffered by former prisoners of war during captivity during World War II and the Korean Conflict and current posttraumatic stress disorder (PTSD) symptoms, the Clinician-Administered PTSD Symptom Scale, a lifetime stressor checklist, and the Structured Clinical Interview for DSM-IV were administered to 102 former prisoners of war. Preconfinement and postconfinement weights and length of confinement were obtained from military medical records. Percentage of body weight lost during captivity was significantly higher in those subjects with PTSD and correlated with current PTSD symptom severity. Length of confinement was not associated with current PTSD symptoms.     

Trauma and post-traumatic stress symptoms in former German child soldiers of World War II

ABSTRACTBackground: The aim of the study was to determine the amount of trauma impact and significant post-traumatic stress symptoms, which can indicate a possible post-traumatic stress disorder (PTSD), in a sample of former German child soldiers of World War II.Methods: 103 participants were recruited through the press, then administered a modified Post-traumatic Diagnostic Scale (PDS).Results: Subjects reported a high degree of trauma exposure, with 4.9% reporting significant post-traumatic stress symptoms after WW II, and 1.9% reporting that these symptoms persist to the present.Conclusion: In line with other studies on child soldiers in actual conflict settings, our data document a high degree of trauma exposure during war. Surprisingly, the prevalence of significant post-traumatic stress symptoms indicating a possible PTSD was low compared to other groups of aging, long-term survivors of war trauma. Despite some limitations our data highlight the need for further studies to identify resilience and coping factors in traumatized child soldiers.     

A hazardous profession: war,journalists, and psychopathology

OBJECTIVE: War journalists often confront situations of extreme danger in their work. Despite this, information on their psychological well-being is lacking. METHOD: The authors used self-report questionnaires to assess 140 war journalists, who recorded symptoms of posttraumatic stress disorder (PTSD) (with the Impact of Event Scale-Revised), depression (with the Beck Depression Inventory-II), and psychological distress (with the 28-item General Health Questionnaire). To control for stresses generic to all journalism, the authors used the same instruments to assess 107 journalists who had never covered war. A second phase of the study involved interviews with one in five journalists from both groups, using the Structured Clinical Interview for Axis I DSM-IV Disorders. RESULTS: The rates of response to the self-report questionnaires were approximately 80% for both groups. There were no demographic differences between groups. Both male and female war journalists had significantly higher weekly alcohol consumption. The war journalists had higher scores on the Impact of Event Scale and the Beck Depression Inventory. Their lifetime prevalence of PTSD was 28.6%, and the rates were 21.4% for major depression and 14.3% for substance abuse. War journalists were not, however, more likely to receive treatment for these disorders. CONCLUSIONS: War journalists have significantly more psychiatric difficulties than journalists who do not report on war. In particular, the lifetime prevalence of PTSD is similar to rates reported for combat veterans, while the rate of major depression exceeds that of the general population. These results, which need replicating, should alert news organizations that significant psychological distress may occur in many war journalists and often goes untreated.     

Posttraumatic stress in immigrants from Central America and Mexico

International migration has been associated with increased levels of psychological disturbance, particularly among refugees who have fled from war or political unrest. This study examined self-reported symptoms of depression, anxiety, somatization, generalized distress, and posttraumatic stress disorder (PTSD) in a community sample of 258 immigrants from Central America and Mexico and 329 native-born Mexican Americans and Anglo Americans. Immigrants were found to have higher levels of generalized distress than native-born Americans. Fifty-two percent of Central American immigrants who migrated as a result of war or political unrest reported symptoms consistent with a diagnosis of PTSD, compared with 49 percent of Central Americans who migrated for other reasons and 25 percent of Mexican immigrants. The authors call for more research to document the psychosocial aspects of migration.     

Clinical presentation of PTSD in World War II combat veterans.

Clinicians have increasingly recognized posttraumatic stress disorder (PTSD) among Vietnam veterans, but the disorder may be easily overlooked among World War II combat veterans. The authors review recent studies of PTSD in older veterans and describe five cases that illustrate the diverse clinical presentations of PTSD in this population. Symptoms included anxiety, cognitive and somatic complaints, depression, alcohol dependence, and amnestic periods. Despite the varied presentations, a fairly consistent patient profile emerged. Patients avoided reminders of war, showed an exaggerated startle response, and experienced restless sleep and chronic anxiety. Factors associated with exacerbations of symptoms were retirement and reminders of war experiences. Although past studies have emphasized resuppression of the trauma, the authors encourage a flexible approach to treatment, including exploratory techniques.     

Posttraumatic stress symptoms in parentally bereaved children and adolescents

OBJECTIVE: To compare parentally bereaved children with a disaster comparison group and a nontrauma control group on measures of emotional adjustment. METHOD: Children and adolescents who had lost a parent (n = 39), had experienced a tornado disaster (n = 69), or were coping with an ongoing social or academic stressor (n = 118) completed measures of posttraumatic stress disorder (PTSD) symptoms, anxiety, and depression. Risk factors for symptoms among the bereaved children also were evaluated. RESULTS: Parentally bereaved children reported significantly more PTSD symptoms than the disaster and nontrauma control groups. Among the bereaved children, girls, younger children, and children living with a surviving parent who scored high on a measure of posttraumatic stress reported more symptoms. CONCLUSION: Children and adolescents who have lost a parent could be vulnerable to PTSD symptoms.     

Cognitive dysfunctions associated with PTSD: evidence from World War II prisoners of war

The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.     

Trauma exposure, resilience, social support, and PTSD construct validity among former prisoners of war

  Background: The aim of this study was to investigate predictors of persistent symptoms of posttraumatic stress disorder (PTSD) and to examine the construct validity of PTSD in a national sample of 270 World War II and Korean Conflict prisoners of war (POWs). Method: POWs were interviewed at two points in time (1965 and 1990). Predictors included PTSD symptomatology measured in 1965 by items from the Cornell Medical Index (CMI), severity of captivity trauma, resilience factors, and post-trauma social support. The criterion, symptomatology in the early 1990s, was evaluated with the PTSD module of the Structured Clinical Interview for DSM (SCID). Results: The CMI provided only partial coverage of PTSD criteria and appeared to provide only a general index of distress. Clustering of SCID items in two-dimensional space via multidimensional scaling analysis offers some construct validation for the DSM's differentiation of PTSD symptoms into criterion groups, although there was not a perfect match. Trauma severity is best related to PTSD symptomatology experienced in 1990, mitigated in part by greater education level and age at the time of trauma exposure. Surprisingly, 1965 distress added only a modest amount to the prediction of current distress, while post-trauma social support added none. Conclusions: These findings support previous work showing the severe psychological sequelae of POW status 40–50 years after captivity, and indicate that trauma severity during captivity is the best predictor of current PTSD symptomatology. Results also add to our understanding of the conceptual differentiation of PTSD symptoms into separate and distinct symptom clusters. Accepted: 25 August 1999     

Delayed and immediate onset posttraumatic stress disorder

Summary The current study examined the role battle experiences and personal resources play in the development of combat-related posttraumatic stress disorder (PTSD). For this purpose, battle experiences (battle stress, military unit environment) and personal resources (coping styles, causal attribution) were assessed two years after the 1982 Lebanon War in three groups of male Israeli frontline soldiers: 1. soldiers who sought treatment 6 months or more after the war (delayed PTSD); 2. soldiers who sought treatment during the war (immediate PTSD); and 3. control soldiers. Findings indicated that both immediate and delayed PTSD casualties reported similar and higher levels of battle stress than control subjects. In addition, delayed PTSD casualties evinced less personal resouces than control subjects, and immediate PTSD casualties evinced still less personal resources than delayed PTSD casualties. The theoretical implications of the findings were discussed.This study was supported by the U.S. Army Medical Research and Development Command, Grant No.DAMD17-87-G-7002. The views, opinions, and findings contained in this report are those of the authors and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by other documentation.     

Posttraumatic stress disorder among Israeli ex-prisoners of war 18 and 30 years after release

BACKGROUND: The psychological responses to captivity were measured in a sample of former prisoners of war (POWs) 18 and 30 years after release from captivity. METHOD: 209 Israeli veterans of the 1973 Yom Kippur War (103 ex-POWs and 106 controls) who had taken part in a previous study conducted in 1991 participated in the current study conducted in 2003. The study assessed current rates of posttraumatic stress disorder (PTSD), changes in PTSD over time, and the contribution of captivity severity (objective and subjective), sociode-mographic variables, and psychological appraisal and coping with captivity to predicting PTSD using standardized self-report questionnaires. RESULTS: Twenty-three percent of the ex-POWs met PTSD criteria and were 10 times more likely than controls to experience deterioration in their psychological condition in the 12-year interval between the 2 assessments. Almost 20% of ex-POWs who did not meet PTSD criteria in 1991 met criteria in the current assessment, in comparison to almost 1% of the controls. Current PTSD was predicted by younger age at the time of captivity, by loss of emotional control and higher subjective appraisal of suffering in captivity, and by a greater number of PTSD symptoms in the 1991 assessment. CONCLUSION: It is important to follow up and offer treatment to former POWs. Special attention should be paid to those who lost emotional control in captivity and to those who felt that the conditions of their captivity were severe.     

Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury

OBJECTIVE: To assess the ability of acute stress disorder to predict posttraumatic stress disorder (PTSD), the relationship between acute stress disorder and PTSD over the 2 years following mild traumatic brain injury was determined. METHOD: Survivors of motor vehicle accidents who sustained mild traumatic brain injuries were assessed for acute stress disorder within 1 month of the trauma (N=79) and for PTSD at 6 months (N=63) and 2 years (N=50) posttrauma. RESULTS: Acute stress disorder was diagnosed in 14% of the patients. Among the patients who participated in all three assessments, 80% of the subjects who met the criteria for acute stress disorder were diagnosed with PTSD at 2 years. Of the total initial group, 73% of those diagnosed with acute stress disorder had PTSD at 2 years. CONCLUSIONS: This study provides further support for the utility of the acute stress disorder diagnosis as a predictor of PTSD but indicates that the predictive power of the diagnostic criteria can be increased by placing greater emphasis on reexperiencing, avoidance, and arousal symptoms.     

Delayed and immediate onset posttraumatic stress disorder

Delayed PTSD has been the focus of numerous clinical reports. Systematic investigations of this phenomenon are practically nonexistent, however. Utilizing a unique psychiatric register developed by the Israel Defense Forces in the 1982 Lebanon War, this study compared the clinical picture of three groups of veterans: 1. PTSD casualties who sought help at least six months after their exposure to combat; 2. PTSD casualties who sought help during the Lebanon War; and 3. soldiers who emerged from the 1982 war without any diagnosable psychiatric disorder (controls). Significant differences were found in the clinical picture of the study groups. Both treated groups, the delayed and the immediate onset PTSD casualties, showed significantly more trauma-related intrusion and avoidance responses, more severe psychiatric symptomatology, more problems in social functioning, and lower perceived self efficacy in combat than non-PTSD controls. However, the psychological and social adjustment of the PTSD veterans whose treatment was delayed was found to be significantly better than that of the immediate onset PTSD veterans. Implications of these findings and recommendations for further research into the significance of time of onset are discussed.