Self-report versus observer ratings of distress and pathology in Vietnam veterans with PTSD

Few efforts have been made to examine the relationship between standard self-report measures and observer ratings of distress in veterans suffering from post-traumatic stress disorder (PTSD). In the present study correlations between self-report (verbal ratings and scores on the Brief Symptom Inventory) and observer ratings (scores on the Brief Hopkins Psychiatric Rating Scale) of pathology and distress were analyzed for 40 Vietnam combat veterans participating in a weekly outpatient PTSD therapy program. The relationship of these measures to the Mississippi PTSD scale and measures of combat exposure and duration was also examined. Results suggested that the self report and observer measures of distress were significantly correlated for this group. While written self report and observer ratings were correlated with scores on the Mississippi Scale, verbal self reports of distress were not. However, the verbal self reports of distress were most strongly related to reported combat exposure.     

The Keane PTSD Scale extracted from the MMPI: Sensitivity and specificity with Vietnam veterans

A study was conducted to further investigate whether the Keane Posttraumatic Stress Disorder (PTSD) Scale of the Minnesota Multiphasic Personality Inventory (MMPI) can be employed as a separate instrument administered outside the context of the full MMPI. A group of Vietnam combat veterans with diagnosed PTSD and two comparison groups of veterans without PTSD (Vietnam combat and era veterans) were diagnosed by clinical interviews. Over 84% of the 64 veterans in the study were accurately classified by the Keane PTSD Scale into their original diagnostic groups. Excellent test sensitivity was demonstrated, with 90% of combat veterans with PTSD being properly classified by the Keane PTSD Scale when the recommended cutoff score of 30 was utilized. The clinical and research implications are discussed.     

Social phobia and PTSD in vietnam veterans

Posttraumatic stress disorder (PTSD) is the most prevalent psychological disorder experienced by Vietnam veterans. However, there are many other disorders and problems of adjustment, like social anxiety and social phobia, that have not been fully investigated in this population. This study examined the prevalence of social phobia and the comorbidity of social phobia and PTSD, and tested out a theory of the etiology of social anxiety in trauma victims. Forty one Vietnam combat veterans were interviewed and completed self-report measures assessing PTSD and social phobia. Adversity of homecoming was also assessed. Using a conservative multi-method assessment approach, 32% of the sample were found to be positive for both social phobia and PTSD. Veterans with PTSD were significantly more likely to carry an additional diagnosis of social phobia as compared to veterans without PTSD. Adversity of homecoming and shame about one's experience in Vietnam were significant predictors of current level of social anxiety over and above the effects of pre-military anxiety and severity of combat exposure. These observations suggest that social anxiety and social phobia may be significant problems among individuals with PTSD. Further, these findings offer preliminary support for the theory that posttrauma environment may impact upon the later development of social anxiety.     

Differentiating intervention strategies for primary and secondary trauma in post-traumatic stress disorder: The example of Vietnam veterans

A model of treatment of PTSD is presented. Two central psychological issues are addressed: (1) the conflict between ego forces oriented toward recalling and assimilating the traumatic material (thereby achieving ego integration) versus ego forces oriented toward repressing and avoiding the reexperience of the trauma (thereby defending against ego disintegration); and (2) the loss of self-cohesion which results from the breakdown between the trauma survivor's self and his social milieu. Clinicians are advised to use two different theoretical orientations (ego psychological and self psychological) in treating these two basic issues. The concepts of primary and secondary trauma refer to the initial traumatic experience and the subsequent breakdown in the relationship between the survivor and his social environment and are offered as tools for distinguishing which issue is uppermost in the patient's material at any given time.     

Analysis of Violent Behavior in Vietnam Combat Veteran Psychiatric Inpatients with Posttraumatic Stress Disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric Inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatients with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.     

A three tier evaluation of PTSD among Vietnam combat veterans

A three tier evaluation procedure for chronic Post-traumatic Stress Disorder victims from Vietnam was presented. This evaluation attempts to disaggregate clinical data on a chronic population for purposes of treatment. One hundred veterans with PTSD took personality inventories (MCMI and MMPI), were included in a life style analysis procedure (including early recollections and irrational beliefs), and were evaluated on symptoms. Tier 1 consisted of a life style analysis. This procedure was described and selected data on early recollections and irrational beliefs were presented. Results reflected negative or trauma themes and an excessive amount of irrational beliefs. Tier 2 involved the use of the MCMI. A typology was developed based on a traumatic personality (Passive Aggressive and Avoidant) and three variants. Tier 3 involved symptoms, psychosocial and trauma. Results showed multiple psychosocial symptoms and emphasized the need to contextualize these within the personality (and life style). Also, traumatic memories were collected and four questions were developed to address these in therapy. A case history was presented on the use of this evaluation method.     

An analysis of criteria used by VA clinicians to diagnose combat-related PTSD

The diagnostic criteria for post-traumatic stress disorder (PTSD) were consensually derived from the expert opinions of a small group of DSM-III-R Task Force and advisory committee members. In this study, 448 psychiatrists and psychologists were surveyed to assess their opinions of the criteria they utilize to assign a diagnosis of PTSD to veterans of war. The various DSM-III-R criteria for PTSD were perceived by clinicians as being differentially useful in making diagnostic judgments. Evidence of exposure to traumatic stress and symptoms of reexperiencing the trauma were consistently rated as more influential than criteria of avoidance/numbing and increased arousal. Moreover, symptoms that are directly ascribed to the traumatic event were rated more influential than those not directly referenced to the traumatic experience. Clinicians report they utilize supplemental information that extends beyond the DSM-III-R criteria to diagnose PTSD, and that this information is as important as many official DSM-III-R symptom criteria.     

Male-perpetrated violence among Vietnam veteran couples: relationships with veteran's early life characteristics,trauma history,and PTSD symptomatology

Using structural equation modeling, we examined the impact of early-life stressors, war-zone stressors, and PTSD symptom severity on partner's reports of recent male-perpetrated intimate partner violence (IPV) among 376 Vietnam veteran couples. Results indicated that several variables demonstrated direct relationships with IPV, including relationship quality with mother, war-zone stressor variables, and PTSD symptom severity. Importantly, retrospective reports of a stressful early family life, childhood antisocial behavior, and war-zone stressors were indirectly associated with IPV via PTSD. One of our 2 war-zone stressor variables, perceived threat, had both direct and indirect (through PTSD) relationships with IPV. Experiencing PTSD symptoms as a result of previous trauma appears to increase an individual's risk for perpetrating IPV. Implications for research and treatment are discussed.     

PTSD among vietnam veterans: An early look at treatment outcome using direct therapeutic exposure

Vietnam combat veteran inpatients were evaluated after being treated in a PTSD special treatment unit. Selected pretreatment measures that included mental and physical problems, combat variables, PTSD symptoms, and the standard MMPI scales found no clinically meaningful differences between a group that was found to be successes and another group found to be failures, based on predetermined cutoff scores on the VETS scale, a reliable outcome measure for veteran patients. At 3 months post-therapy, a significantly greater number of subjects treated with Direct Therapeutic Exposure (DTE) (flooding therapy) as compared to another group treated with a more conventional individual therapy, were identified as successes as opposed to failures, based on the VETs scale. Also, the number of failures was greater for those treated with the more conventional therapy and the number of successess was greater for those treated with DTE, when compared to all other subjects in the sample. These preliminary results were interpreted as indicating that DTE, when offered as part of an inpatient milieu, shows promise as an effective treatment for chronic/severe combat veteran PTSD sufferers.     

Combat, Dissociation, and Posttraumatic Stress Disorder in Australian Vietnam Veterans

The specificity of various wartime stressors for different posttraumatic stress disorder (PTSD) symptoms is inconsistently reported in the literature. Combat, wounding, and peritraumatic dissociation have not been assessed together in their effects on each of the various PTSD symptom clusters. This cohort study of a random sample of male Australian Army Vietnam veterans yielded psychiatric assessments of 641 subjects. PTSD measures comprised symptom criteria for reexperiencing, numbing and avoidance, hyperarousal, and PTSD diagnosis both lifetime and current within the past month. Logistic regression is used to examine the effects of combat, wounding, and peritraumatic dissociation together on PTSD. Combat experiences comprised four components derived from a principal components analysis of combat experiences: direct combat exposure, exposure to death and injury, exposure to civilian death and injury, and exposure to mutilation. Each was differentially related to reexperiencing, avoidance, hyperarousal, and PTSD diagnosis. Being wounded was not related to lifetime or current PTSD and peritraumatic dissociation was related to all diagnostic components of PTSD in the presence of other variables.     

A causal model of the etiology of war-related PTSD

Structural equation modeling is used to evaluate a network of causal hypotheses concerning the relationships of premilitary vulnerabilities, military entry conditions, war zone experiences, and dissociative reactions with current symptoms of PTSD and general psychiatric distress. The analyses are directed toward resolving three general issues: (1) the relative contributions of premilitary vulnerabilities and exposure to traumatic events to the development of PTSD, (2) the features of the causal network that are distinctive to the development of PTSD as compared to general psychiatric symptoms, and (3) the major pathways mediating causation among the variables in the model. 381 Vietnam theater veterans who sought treatment from VA's new PTSD Clinical Teams Program and who provided complete data constituted the sample for the study. War zone experiences were the variables that contributed most strongly to the development of both PTSD and general psychiatric symptoms. Combat exposure, however, contributed directly to PTSD symptoms but not to general psychiatric symptoms. The overall fit of the model to the data proved to be quite satisfactory for both PTSD and general psychiatric symptoms, accounting for 59% and 60% of the variance, respectively.An earlier version of this paper was presented at the 7th Annual Meeting of the International Society for Traumatic Stress Studies, October 25, 1991, Washington, D.C.     

Dissociative Processes and Symptoms of Posttraumatic Stress in Vietnam Veterans

The diagnostic taxonomy of posttraumatic stress disorder (PTSD) is a contentious issue. Commentators are divided as to whether PTSD should remain grouped with the anxiety disorders or conceptualized as a dissociative disorder. This study sought to clarify the issue by investigating the extent to which anxiety and dissociative processes differentially predict the severity of each of the three symptom clusters in PTSD. Seventy-four Australian veterans of the Vietnam War were assessed on measures of dissociation, trait anxiety, and posttraumatic stress symptomatology. Multiple regression analyses showed that all three symptoms clusters were predicted by anxiety, but the clusters differed in the pattern of their relationship with dissociation variables. The failure of pathological dissociation to predict PTSD symptoms prompts a reconsideration of the point at which dissociative mechanisms may impact on this disorder. The findings are consistent with current classification of combat-related PTSD as an anxiety disorder.     

MMPI-2 Data for Australian Vietnam Veterans with Combat-Related PTSD

Considerable attention has been devoted to the MM PI in the assessment of combat-related PTSD. To date, published data have focused almost exclusively on American Vietnam veterans. This study investigated MMPI-2 profiles of 100 Australian Vietnam veterans admitted to an intensive PTSD treatment program. Comparisons with United States (U.S.) data suggested strong similarities between the American and Australian populations in terms of F-scale elevations and typical 3-point code types (8-7-2). However, the American samples showed relatively higher elevations of Scales 4 and 6, suggesting social alienation and a tendency to externalize, while a subgroup of Australian veterans showed a greater propensity for somatization (Scale 1). The results provide overall support for the generalizability of American MMPI data to an alternative cultural group of combat veterans.     

Partners' Ratings of Combat Veterans' PTSD Symptomatology

The current study examined the concordance of combat veterans' scores on the Mississippi Scale for Combat-Related PTSD, with scores on a parallel version of that instrument completed by partners to assess veterans' symptoms. Further, the study examined the impact of quality of the marital relationship on score concordance. Bivariate and multiple regression were used with a sample of 466 veteran-partner dyads obtained from the National Vietnam Veterans Readjustment Study. There was moderate agreement in symptom reporting between veterans and their partners and little evidence to suggest that the quality of the relationship impacted upon the association between partner and veteran scores.     

Outcome of treatment for post-traumatic stress disorder in a primary care unit serving vietnam veterans

Veterans diagnosed with PTSD (PTSD in-treatment,N=39), newly admitted to a comprehensive 90-day inpatient treatment program, were tracked at 4-week intervals from admission to discharge. Two control groups were also tracked over 12-week periods — one of previously PTSD diagnosed and treated veterans (PTSD out-of-treatment,N=26), and a second that combined non-PTSD Vietnam era veterans (N=17) and non-veterans (N=16) (non-PTSD nontreatment). As measured by the Penn Inventory for PTSD, 48% of those who completed treatment showed some or substantial gains, 39% showed no gain, and 13% reported some increase in symptoms at the time of discharge. Several patterns were observed on other assessment measures. One year follow-up for those who completed treatment showed a return to pretreatment levels on the PTSD symptom measures employed in this study. These results are discussed in relation to other treatment program outcome studies as a baseline for further research.     

Vietnam veterans in the general hospital: Seven years later

Vietnam era veterans who were originally part of a sample of 300, were surveyed in 1982 and again in 1989. There were significant increases in symptom scores in 5 of 20 questions for the combat veteran subgroup from 1982 to 1989. The avoidance group of symptoms had the highest scores in 1989. Combat veterans continued to be more symptomatic than their non-combat contemporaries. Vietnam veterans estimate of combat activity differed with the passage of time.     

Race-related PTSD: The Asian American Vietnam veteran

This article presents a conceptual framework by which to understand race-related post-traumatic stress disorder (PTSD) for the Asian American Vietnam veteran. The framework draws from cognitive schema theory, social behaviorism, the notion of cumulative racism as trauma, and the assumption that bifurcation and negation of one's bicultural identity is injurious. Classifications of race-related stress or trauma that may be experienced by Asian American Vietnam veterans, with exemplifying clinical case material, are presented. These types of stressors include being mistaken for Vietnamese, verbal and physical assaults that are race-related, death and near-death experiences that are race-related, racial stigmatization, dissociation from one's Asian identity, and marginalization. As studies of combat trauma and sexual assault forced the psychological stresses attendant to war and sexist oppression into public consciousness, so this article addresses psychological stress and trauma attendant to racism.     

The concept of the second generation program in the treatment of post-traumatic stress disorder among vietnam veterans

The concepts of First and Second Generation treatment programs for Vietnam veterans with post-traumatic stress disorder are presented, based on a developmental theoretical model of adaptation. First Generation programs focus on accessing and then working through the effects of the war trauma and aim to diminish the intensity of core PTSD symptoms. Second Generation programs focus on reintegrating veterans into the social context of family and work, and aim to improve their ability to function in society. Both types of treatment may be required in order to help veterans resume their psychological and social development. The need to develop sophisticated models of comprehensive inpatient treatment in order to support scholarly discourse and outcome research is emphasized.     

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

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

Virtual Reality Exposure Therapy for PTSD Vietnam Veterans: A Case Study

Virtual reality (VR) integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). This report presents the results of the first Vietnam combat veteran with PTSD to have been treated with VRE. The patient was exposed to two virtual environments, a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. The patient experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at 6-month follow-up.