Combat stress reactions, posttraumatic stress disorder, and social adjustment. A study of Israeli veterans

This study assessed social functioning among three groups of Israeli soldiers: a) front-line soldiers who had been treated for combat stress reaction during the 1982 Lebanon war (N = 382); b) matched control front-line soldiers who did not sustain combat stress reaction (N = 334); and c) combat-ready soldiers who did not participate in the 1982 war (N = 88). Subjects were screened 1 year after the war for posttraumatic stress disorder and social functioning. Results indicated that participation in combat per se did not have adverse effects on postwar social functioning. However, combat stress reactions and posttraumatic stress disorder were found to be associated with a decline in postwar social functioning. The practical and theoretical implications of these findings were discussed.     

The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon War

The authors examined the effectiveness of the prevailing treatment doctrine stressing the principles of proximity, immediacy, and expectancy for combat stress reaction among Israeli soldiers in the Lebanon War. Two treatment outcomes were measured: return to military unit and presence of posttraumatic stress disorder. All three treatment principles were associated with a higher rate of return to the military unit. The beneficial effect of frontline treatment was also evidenced by lower rates of posttraumatic stress disorder. The authors suggest that these principles can also be effective in treating other forms of posttraumatic stress disorder.     

Psychological sequelae of war. A 3-year prospective study of Israeli combat stress reaction casualties

The long-term psychological sequelae of combat were assessed employing the Impact of Event Scale (IES) 1, 2, and 3 years after the 1982 Lebanon War. The following groups of Israeli veterans participated: combat stress reaction casualties (N = 213) and comparable controls (N = 116). For the purpose of the study, the subjects in each group were screened and further divided according to whether they did or did not suffer from posttraumatic stress disorder (PTSD). Results showed that elevated rates of distress were reported by both combat stress reaction and PTSD casualties at all three points in time. In both study groups the level of distress declined with time. Theoretical and methodological implications were discussed.     

PTSD and social functioning

This longitudinal study assessed long term social functioning among two groups of Israeli soldiers: (a) front line soldiers who had been treated for combat stress reaction (CSR) during the 1982 Lebanon war (n = 213); and (b) matched controls who were front line soldiers participating in the same battles, but did not sustain a CSR (n = 116). Subjects were screened one, two, and three years after the war for PTSD and social functioning. Results indicated that CSR and PTSD casualties reported more problems in social functioning than controls. The link between PTSD and social functioning was stronger among PTSD veterans who had suffered an antecedent CSR episode. Time had a differential effect on the social functioning of CSR and control subjects.     

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 frontline soldiers with combat stress reaction: the 1982 Israeli experience

One year after the 1982 Lebanon War, the authors assessed the prevalence, type, and severity of posttraumatic stress disorder in a large representative sample of Israeli soldiers who had been treated for combat stress reactions. Comparisons were made with a group of soldiers who had fought in the same battles but had not been treated for this reaction. A dramatically higher percentage of soldiers with combat stress reaction (59%) than of soldiers without combat stress reaction (16%) developed posttraumatic stress disorder. Age was significantly associated with posttraumatic stress disorder. The authors discuss the differential quality of posttraumatic stress disorder among both groups as well as the factors facilitating recovery.     

Reactions to combat stress in Israeli veterans twenty years after the 1982 Lebanon war

During the war or shortly thereafter, the most common manifestation of combat induced psychopathology is combat stress reaction (CSR). The long-term consequences of CSR have so far received little scientific attention. The aim of this study was to examine whether CSR is a marker for long-term PTSD and other psychiatric comorbidities. Two groups of veterans from the 1982 Lebanon war were assessed 20 years after the war: one comprised 286 CSR casualties and the other comprised 218 matched non-CSR soldiers. Participants were assessed for PTSD, psychiatric symptomatology, social functioning, physical health, and postwar life events. Twenty years after the war, veterans with antecedent CSR reported more PTSD, psychiatric symptomatology and distress, social dysfunction, and health problems than did non-CSR veterans. We conclude that CSR should be seen as a marker for long-term psychiatric distress and impairment. In addition, the implications of combat-related trauma are broad and varied, and go beyond the narrow scope of PTSD.     

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.     

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.     

Combat-related posttraumatic stress disorder among second-generation Holocaust survivors: preliminary findings

The authors assessed the impact of the Nazi Holocaust on the course and symptoms of posttraumatic stress disorder (PTSD) among Israeli combat stress reaction casualties. They examined a sample of 96 such casualties of the 1982 Lebanon War whose parents had gone through the Nazi Holocaust and compared them to casualties who did not have such family history for 3 consecutive years beginning 1 year after their participation in the war. Results showed that 2 and 3 years after their participation in the 1982 Lebanon War, the children of Holocaust survivors, i.e., "second-generation" casualties, had higher rates of PTSD than did the control subjects, as well as a somewhat different clinical picture. Clinical and methodological implications of the findings are discussed.     

Psychological sequelae of war. A 2-year follow-up study of Israeli combat stress reaction casualties

The relationships of two stress-related intrapsychic manifestations--intrusion and avoidance--to combat stress reaction and posttraumatic stress disorder were assessed 1 and 2 years after the 1982 Lebanon War. The sample consisted of 285 combat stress reaction Israeli casualties and 198 comparable control subjects. Results showed that higher rates of intrusion and avoidance were reported by both combat stress reaction and posttraumatic stress disorder casualties at the two points in time. In addition, the level of intrusion tendencies declined with time. Theoretical and methodological implications are discussed.     

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

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

Combat stress reactions, post traumatic stress disorder and somatic complaints among Israeli soldiers

This study examined the effect of combat stress on somatic health in a sample of 804 Israeli soldiers. Three groups of subjects were assessed: combatants who did not participate in the Lebanon War, combatants who fought and suffered from combat stress reactions, and combatants who participated in the Lebanon War but did not sustain psychiatric injury. One year following the war subjects were asked to report somatic complaints and were screened for post-traumatic stress disorder. Results indicated that participation in combat per se did not have pathogenic effects. However, combat stress reactions and post-traumatic stress disorder were found to be associated with somatic complaints. The practical and theoretical implications of these findings are discussed.     

Psychiatric disorders among United States Marines wounded in action in Vietnam

Although the posttraumatic stress disorders of Vietnam veterans have been well documented, the psychological and environmental factors that gave rise to these and other psychiatric disorders remain to be clearly identified. The object of this study is to determine if United States Marines who were wounded in action in Vietnam were also at risk for an impatient admission with a psychiatric disorder. We also wish to examine the effect of the practice of returning psychiatric patients to duty upon completion of treatment on the relationship between combat exposure and psychiatric distress. Records of all hospital admissions for active-duty Marines for the period 1965 to 1972 were examined and personnel having a combat-related wound or injury and/or a psychiatric hospitalization were identified. Rates of first hospitalization were calculated and standardized incidence ratios were used to obtain measures of risk. Results indicated that, compared with Marines not wounded in Vietnam, Marines wounded in Vietnam were at significant risk for having a psychiatric hospitalization. Most of the psychiatric first hospitalizations occurred before being wounded in action, however, and psychiatric patients who were treated and then returned to duty had a significantly greater than expected risk of being subsequently wounded. This risk differed with respect to psychiatric diagnosis due to variations in the practice of returning psychiatric patients to duty on the basis of primary diagnosis. Variations in the probability of being returned to duty also accounted for variations in the relative risk of psychiatric first hospitalizations among wounded Marines by diagnostic category. These results cell into question the validity of using ratios of psychiatric casualties to numbers of wounded personnel as measures of the relationship between combat exposure and psychological distress.     

Combat exposure, posttraumatic stress symptoms and risk-taking behavior in veterans of the Second Lebanon War

Prior research has revealed heightened risk-taking behavior among veterans with posttraumatic stress disorder (PTSD). This study examined whether the risktaking behavior is a direct outcome of the traumatic exposure or whether this relationship is mediated by posttraumatic stress symptoms. The sample was comprised of 180 traumatized Israeli reserve soldiers, who sought treatment in the wake of the Second Lebanon War. Combat exposure was indirectly associated with risk-taking behavior primarily through its relationship with posttraumatic stress symptoms. Results of the multivariate analyses depict the implication of posttraumatic stress symptoms in risk taking behavior, and the role of self-medication and of aggression in traumatized veterans.     

Age differences in posttraumatic stress disorder, psychiatric disorders, and healthcare service use among veterans in Veterans Affairs primary care clinics.

OBJECTIVE: To expand our understanding of posttraumatic stress disorder (PTSD) prevalence, its psychiatric characteristics, and service use among elderly veterans in Veterans Affairs (VA) primary care clinics. METHODS: A cross-sectional, epidemiological design (N = 745) incorporating self-report measures, structured interviews, and chart reviews was used to obtain relevant information for analyses. RESULTS: The oldest group of veterans (>or=65 years; N = 318) had lower prevalence of most psychiatric diagnoses than the youngest (18-44 years; N = 69) and middle-aged (45-64 years; N = 358) groups. Despite having higher rates of combat exposure, veterans in the oldest group (6.3%) had one-third the prevalence of PTSD than those in the middle-aged group (18.6%). A similar pattern was found across other psychiatric diagnoses. For example, those in the oldest group (7.5%) had one-third the prevalence of major depression as those in the two younger groups (21.7% and 22.9%). These differences were maintained after controlling for relevant demographic covariates (race, sex). Results from examination of VA health care service use across the three groups were consistent with the findings that the oldest veteran group is functioning significantly better across mental health domains. CONCLUSION: Elderly veterans who use VA primary care services evidence lower rates of PTSD and other psychiatric disorders, and they use significantly less VA mental health services. They also do not appear to show evidence of worse physical health functioning or use VA health care services or disability benefits at a meaningfully higher rate than their younger counterparts.     

Epidemiology of psychiatric disorders sustained by a U.S. Army brigade combat team during the Iraq War

Objective

This study was designed to describe the epidemiology of psychiatric illnesses experienced by soldiers in a combat environment, which has been previously underreported.

Methods

A U.S. Army brigade combat team deployed to Iraq during the Iraq War “Troop Surge" was followed by reviewing unit casualty rosters and electronic medical records for psychiatric diagnoses made by treating providers. The main outcome was the incidence rates of psychiatric disease and nonbattle injury (DNBI).

Results

Of the 4122 soldiers deployed, there were 308 psychiatric DNBI casualties (59.8 per 1000 soldier combat-years), which represented 23% of all DNBIs and was second only to musculoskeletal injuries (50% of all DNBI). Most psychiatric DNBI (88%) were treated in theater and returned to duty, 11% were medically evacuated and 1% died. Junior enlisted soldiers, compared with junior officers, and women, compared with men, were at a significantly increased risk for becoming a psychiatric DNBI casualty (77.3 vs. 32.2 per 1000 combat-years, P<.002 and 110.8 vs. 55.4 per 1000 combat-years P<.05, respectively).

Conclusions

Psychiatric diagnoses are second only to musculoskeletal injuries as a cause for DNBIs sustained in the current combat environment. Most can be treated in theater and permit soldiers to return to duty.     

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

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

Belief in exposure to chemical and biological agents in Persian Gulf War soldiers

This is the first longitudinal cohort study of Persian Gulf War US soldiers to examine belief in exposure to chemical and biological weapons before and shortly after combat. A longitudinal sample of n = 1250 male Persian Gulf War US Army soldiers were surveyed 3 to 4 months before and 6 to 10 months after the 1991 War. Six to 10 months after combat, 4.6% of the cohort believed they had been exposed to chemical and biological weapons. Adjusting for demographics only, those who reported a greater number of combat exposures (odds ratio, OR: 18.8), or higher combat stress (OR: 12.27) were more likely to believe they were exposed. Adjusting for all variables soldiers who reported higher combat stress continued to be most likely (OR: 6.58) to believe they had been exposed to chemical and biological weapons. Individuals reporting higher combat stress are at substantially greater risk of reporting they have been exposed to chemical or biological weapons.     

The Conflict for the News Editor in Desegregation Disturbances

Background: Little is known about longer term military work outcomes in UK military personnel who develop mental health problems when operationally deployed. Deployed Field Mental Health Teams (FMHTs) who support them follow the principles of “Forward Psychiatry,” aiming to treat psychiatric casualties close to the front line to maximize operational effectiveness and occupational retention. Aim: To examine the short- and long-term military work outcomes in soldiers deployed to Iraq between 2003 and 2007 who were referred to the FMHT. Method: FMHT clinical records were linked to occupational records with 825 resulting matches. Results: 71.6% of the referred soldiers with a documented short-term military work outcome returned to their operational unit, and 73.5% of those who had a documented long-term military work outcome served on for a period in excess of two years. Adjusting for potential confounders, a shorter service length and removal from the operational theatre were both strongly associated with premature discharge; however, it was not possible to determine the severity of the presenting mental health problem and assess whether this impacted outcome. Conclusions: The results of this study support the use of the Forward Psychiatry principles in achieving good short-term military work outcomes. Utilizing these principles, three-quarters of those referred to the FMHT were returned to their deployed unit and approximately three-quarters of those assessed by the FMHT remained in service two years after referral. We suggest that these are positive work outcomes; however, being evacuated out of the operational environment and having a short service length were both associated with premature discharge, though we were unable to examine the role of illness severity.