Gratitude and hedonic and eudaimonic well-being in Vietnam war veterans

Little information exists on the contribution of psychological strengths to well-being in persons with post-traumatic stress disorder (PTSD). Data from other populations suggest that gratitude, defined as the positive experience of thankfulness for being the recipient of personal benefits, may have salutary effects on everyday functioning. We investigated whether dispositional gratitude predicted daily hedonic and eudaimonic well-being in combat veterans with and without PTSD. We also examined associations between daily gratitude and daily well-being across time. Veterans with PTSD, compared to those without PTSD, exhibited significantly lower dispositional gratitude; no differences were found on daily gratitude. Dispositional gratitude predicted greater daily positive affect, percentage of pleasant days over the assessment period, daily intrinsically motivating activity, and daily self-esteem over and above effects attributable to PTSD severity and dispositional negative and positive affect in the PTSD group but not the non-PTSD group. Daily gratitude was uniquely associated with each dimension of daily well-being in both groups. Although preliminary, these results provide support for the further investigation of gratitude in trauma survivors.

Casualties: narrative and images of the war on Iraq

The Iraqi people have endured an excess burden of morbidity and mortality during the past 15 years due to war and sanctions, with the March 2003 Anglo-American assault on and subsequent occupation of Iraq representing the most recent chapter. Children have been disproportionately affected; many have died from infectious disease, malnutrition, and lack of access to health care. There have been significant differences in the availability of narrative accounts and images of this suffering, reflective of the need of those who wage wars and impose sanctions to keep the public uninformed. This article suggests that public health and medical practitioners have a responsibility to seek out such accounts and images. The authors explore possible responses to narrative and images of this suffering, and outline the sorts of responses engendered by three perspectives-charity, development, and social justice. The suffering of the people of Iraq should spur a response from the health community to alleviate the situation and prevent unnecessary suffering.

Australia's Vietnam veterans--a review

BACKGROUND

Vietnam veterans' war experiences have adversely affected their own mental health and that of one in 3 partners and one in 4-6 of their dependents, many of whom are reluctant to seek help.

OBJECTIVE

This article reviews the health problems suffered by families of Australia's Vietnam veterans and discusses what the future might hold for these families, what the implications might be for families of veterans of more recent conflicts, and how general practitioners and divisions of general practice might help.

DISCUSSION

Mental illness of veterans' dependents may increase their risk of cardiovascular and other physical diseases, and their children's risk of psychological problems. Caring for veterans as they age may further strain the mental health of one in 3-4 partners and jeopardise their role as grandparents. General practitioners can help by paying attention to the mental health of veterans and their dependents, working with the families, providing education and support, assessing the need for individual or family counselling, encouraging veterans' dependents to use universal or Department of Veterans' Affairs services, and building dependent's and grandchildren's resilience.

The Management of Trauma Venous Injury: Civilian and Wartime Experiences

The management of venous trauma continues to be debated. Historically, ligation of injured veins is the most common modality of surgical treatment. In the past half-century, additional techniques have been used, including primary repair, interposition graft, and occasionally endovascular techniques. Venous repair, whether in the acute or chronic setting, is believed to prevent or ameliorate the complications of pain, edema, and phlegmasia. Venous repair in civilian trauma and in wartime is commonplace; however, overall treatment strategies remain largely unchanged since the Vietnam War.

Reconciling disparate prevalence rates of PTSD in large samples of US male Vietnam veterans and their controls

BACKGROUND

Two large independent studies funded by the US government have assessed the impact of the Vietnam War on the prevalence of PTSD in US veterans. The National Vietnam Veterans Readjustment Study (NVVRS) estimated the current PTSD prevalence to be 15.2% while the Vietnam Experience Study (VES) estimated the prevalence to be 2.2%. We compared alternative criteria for estimating the prevalence of PTSD using the NVVRS and VES public use data sets collected more than 10 years after the United States withdrew troops from Vietnam.

METHODS

We applied uniform diagnostic procedures to the male veterans from the NVVRS and VES to estimate PTSD prevalences based on varying criteria including one-month and lifetime prevalence estimates, combat and non-combat prevalence estimates, and prevalence estimates using both single and multiple indicator models.

RESULTS

Using a narrow and specific set of criteria, we derived current prevalence estimates for combat-related PTSD of 2.5% and 2.9% for the VES and the NVVRS, respectively. Using a more broad and sensitive set of criteria, we derived current prevalence estimates for combat-related PTSD of 12.2% and 15.8% for the VES and NVVRS, respectively.

CONCLUSION

When comparable methods were applied to available data we reconciled disparate results and estimated similar current prevalences for both narrow and broad definitions of combat-related diagnoses of PTSD.

Analysis of a hepatitis C screening programme for US veterans

This study analyses a screening programme for hepatitis C virus (HCV) infection among US veterans in a suburban Veterans Affairs Medical Center, in New York. This is the first study examining all 11 potential risk factors listed in the 2001 National U.S. Veterans Health Administration Screening Guidelines. A retrospective study was conducted of 5400 veterans 'at risk' of HCV, identified through a questionnaire in this institution's primary-care outpatient departments between 1 October 2001 and 31 December 2003. Multivariate logistic regression models were built to identify independent predictors of infection. Of 2282 veterans tested for HCV, 4.6% were confirmed by HCV PCR to be HCV infected. In the multivariate model developed, injection drug use, blood transfusion before 1992, service during the Vietnam era, tattoo, and a history of abnormal liver function tests were independent predictors of HCV infection. Our data support considering a more targeted screening approach that includes five of the 11 risk factors.

Symptom patterns associated with chronic PTSD in male veterans: new findings from the National Vietnam Veterans Readjustment Study

A subsample of 255 male Vietnam veterans from the National Vietnam Veterans Readjustment Study received in-depth psychiatric diagnostic interviews. This paper focuses on the 88 veterans with a war-related onset of PTSD. Among these veterans, the avoidance cluster, especially its symptoms of numbing, was most strongly associated with chronic PTSD; less strongly but also significantly associated was the hyperarousal cluster. Further analyses show that these associations are not artifacts of the relationship of symptom patterns to prewar demographic factors (race/ethnicity, socioeconomic status, age at entry into Vietnam), comorbidity, treatment and compensation seeking, or probable severity of war-related trauma. We conclude that certain symptom profiles may predict enduring pathological responses to trauma and therefore provide targets for intervention efforts.

Decreased anterior cingulate volume in combat-related PTSD

BACKGROUND

Neuroanatomical data point to functional relationships between the anterior cingulate cortex (ACC) and subcortical centers regulating fear, in particular, the amygdala. Functional brain imaging has disclosed divergent patterns of ACC activation in persons with posttraumatic stress disorder (PTSD). In addition, two preliminary structural imaging studies have found evidence of smaller ACC volume in PTSD. We explored associations between PTSD and ACC volume in a relatively large sample of adult combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed.

METHODS

Subjects were US military combat veterans of the Vietnam and Gulf Wars recruited from two metropolitan areas served by allied Department of Veterans Affairs PTSD treatment/research centers. Anterior cingulate cortex volume was analyzed as a function of grouping factors with and without adjustment for body size.

RESULTS

Posttraumatic stress disorder was associated with smaller anterior cingulate cortex volume. This effect persisted in subjects without histories of alcoholism, did not interact with cohort effects, and was not modified by adjustment for body size.

CONCLUSIONS

Anterior cingulate cortex volume is substantially smaller in association with combat-related PTSD, a finding broadly consistent with cingulate hypofunctionality in that disorder.

Agent Orange, Dioxins, and Other Chemicals of Concern in Vietnam: Update 2006

OBJECTIVE

The objective of this study was to find sites in Vietnam where there was human exposure from Agent Orange herbicide sprayed between 1962 and 1971, as determined by congener-specific measurement of dioxins, including 2,3,7,8-tetrachlorodibenzodioxin (TCDD), the dioxin that contaminated Agent Orange, in blood.

METHODS

Blood was collected from residents of eight heavily sprayed regions in the south of Vietnam and analyzed for TCDD and in some cases the dioxin-like dibenzofurans and dioxin-like PCBs.

RESULTS

Six of the eight newly studied sites did not show substantial or any elevated TCDD in blood. Marked elevation of TCDD in Vietnamese blood was found in one new location with a suggestion of slightly elevated TCDD in a second location.

CONCLUSIONS

In newly studied locations in Vietnam, we found some persons with elevation of TCDD consistent with exposure to dioxin from Agent Orange. In our previous studies, we found PCBs, PCDDs, and PCDFs as well as pesticides in human milk, blood, or in food. Health effects from Agent Orange need to be differentiated from effects caused by chemicals other than TCDD from Agent Orange.

Hippocampal volume, PTSD, and alcoholism in combat veterans

Studies imposing rigorous control over lifetime alcohol intake have usually not found smaller hippocampal volumes in persons with posttraumatic stress disorder. Because the majority of negative studies have used adolescent samples, it has been suggested that chronicity is a necessary condition for such findings. To test the hypothesis that a smaller hippocampus in PTSD is unrelated to comorbid alcoholism or to chronicity, this study estimated hippocampal volume in a relatively large group (N=99) of combat veterans in which PTSD, lifetime alcohol abuse/dependence, and Vietnam versus Gulf War service were crossed. In subjects with histories of alcoholism, unadjusted hippocampal volume was 9% smaller in persons with PTSD than in those without PTSD. In nonalcoholic subjects, the PTSD-related difference in hippocampal volume was 3%. The failure to observe a strong association between PTSD and hippocampal volume in nonalcoholic subjects was not ascribable to younger age, reduced PTSD chronicity, or lower PTSD symptom severity. The possibility that smaller hippocampal volume is limited to groups in which PTSD is compounded by comorbid alcoholism is not necessarily incompatible with results suggesting a smaller hippocampus is predispositional to PTSD. Further examination of the role of alcoholism and other comorbid conditions in studies of brain structure and function in PTSD appears warranted.

Vietnam military service history and prostate cancer

Background

Three decades after US and Australian forces withdrew from Vietnam, there has been much public interest in the health consequences of service in Vietnam. One controversial question is whether the risk of prostate cancer amongst Vietnam veterans is increased. This paper examines relationships between military history, family history and risk of prostate cancer in a population-based case control study.

Methods

Cases were selected from the Cancer Registry of Western Australia as incident cases of histologically-confirmed prostate cancer, and controls were age-matched and selected from the Western Australian electoral roll. Study participants were asked to report any military service history and details about that service.

Results

Between January 2001 and September 2002, 606 cases and 471 controls aged between 40–75 years were recruited. An increased prostate cancer risk was observed in men reporting they were deployed in Vietnam although this was not statistically significant (OR = 2.12; 95% CI 0.88–5.06). An increased risk was also observed in men reporting prostate cancer in fathers (OR = 1.90; 95% CI 1.20–3.00) or brothers (OR = 2.05; 95% CI 1.20–3.50) diagnosed with prostate cancer.

Conclusion

These findings support a positive association between prostate cancer and military service history in the Vietnam war and a first degree relative family history of prostate cancer.

Prevalence of Tension Pneumothorax in Fatally Wounded Combat Casualties

BACKGROUND

Tension pneumothorax is a potential cause of death in victims of penetrating chest trauma, but little is known about its actual prevalence.

METHODS

Data that are part of the Vietnam Wound Data and Munitions Effectiveness Team study were analyzed to address this question. Radiographs of 978 casualties were examined for evidence of tension pneumothorax using standard radiologic criteria such as pleural separation, displacement of the mediastinum and diaphragm, trachea deviation, and compression of the contralateral lung.

RESULTS

Some or all of the radiographic changes were found in 198 casualties. Autopsy evidence indicated that 79 of these casualties died solely due to a chest wound. The fatal chest injury involved only the lungs in 55 casualties and caused a tension pneumothorax in 26. Fifteen of the 26 lived long enough to receive first aid from a medic or corpsman.

CONCLUSION

Tension pneumothorax was the cause of death in 3 to 4% of fatally wounded combat casualties. Some may be temporarily helped by battlefield thoracentesis.

Understanding Combat Casualty Care Statistics

Maintaining good hospital records during military conflicts can provide medical personnel and researchers with feedback to rapidly adjust treatment strategies and improve outcomes. But to convert the resulting raw data into meaningful conclusions requires clear terminology and well thought out equations, utilizing consistent numerators and denominators. Our objective was to arrive at terminology and equations that would produce the best insight into the effectiveness of care at different stages of treatment, either pre or post medical treatment facility care. We first clarified three essential terms: 1) the case fatality rate (CFR) as percentage of fatalities among all wounded; 2) killed in action (KIA) as percentage of immediate deaths among all seriously injured (not returning to duty); and 3) died of wounds (DOW) as percentage of deaths following admission to a medical treatment facility among all seriously injured (not returning to duty). These equations were then applied consistently across data from the WWII, Vietnam and the current Global War on Terrorism. Using this clear set of definitions we used the equations to ask two basic questions: What is the overall lethality of the battlefield? How effective is combat casualty care? To answer these questions with current data, the three services have collaboratively created a joint theater trauma registry (JTTR), cataloging all the serious injuries, procedures, and outcomes for the current war. These definitions and equations, consistently applied to the JTTR, will allow meaningful comparisons and help direct future research and appropriate application of personnel.

Resolution of small-scale commingling: A case report from the Vietnam War

A case is reported that involves the commingled skeletal remains of two individuals who died in a helicopter crash in 1969 during the Vietnam War. The incomplete portions of two bodies were initially recovered soon after the crash. These portions were identified by personnel at a U.S. Army Mortuary in Saigon and were returned to the next-of-kin. While searching for scrap metal in 2002, a Vietnamese citizen unexpectedly discovered human remains and personal effects interspersed with buried aircraft wreckage. The personal effects correlated with the individuals who died in the 1969 incident. These newly discovered remains and artifacts were subsequently received at the U.S. Army Central Identification Laboratory, Hawaii (CILHI) for analysis. As part of the CILHI analysis it was necessary to segregate the commingled remains into specific individuals for identification purposes. Details regarding various sorting techniques are described that provide a solid framework for systematically dealing with small-scale commingling. The sorting techniques used in the resolution of this case consist of visual pair-matching, articulation, process of elimination, osteometric comparison, and taphonomy. These techniques, when used in conjunction with each other, provided a solid basis for the individualization of most skeletal elements.

A twin registry study of the relationship between posttraumatic stress disorder and nicotine dependence in men

CONTEXT

Recent studies indicate a strong association between posttraumatic stress disorder (PTSD) and nicotine dependence (ND). However, the explanation for the association remains unclear.

OBJECTIVE

To test competing explanations for the association between PTSD and ND.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of data on 6744 members of the Vietnam Era Twin Registry, a national registry of all male-male twin pairs who served in the military during the Vietnam era interviewed in 1991-1992.

MAIN OUTCOME MEASURES

Risk of PTSD and ND using the Diagnostic Interview Schedule for the DSM-III-R.

RESULTS

The prevalence of ND was elevated among trauma-exposed individuals (52.0%) and those with PTSD (71.7%) compared with unexposed individuals (40.5%). This association was significant for ND and for trauma without PTSD (odds ratio, 1.31; 95% confidence interval [CI], 1.18-1.45) and for PTSD (odds ratio, 2.34; 95% CI, 1.92-2.84) and was not entirely explained by shared risk factors. Shared genetic effects explained 63% of the PTSD-ND association; the remaining covariance was explained by individual-specific environmental effects. Using survival analysis with time-dependent covariates, ND was associated with a substantially increased risk of PTSD among trauma-exposed men (hazard ratio, 1.98; 95% CI, 1.61-2.42). Trauma (hazard ratio, 1.49; 95% CI, 1.35-1.64) and PTSD (hazard ratio, 1.36; 95% CI, 1.14-1.61) were less strongly but significantly associated with increased risk of ND onset after controlling for shared risk factors.

CONCLUSIONS

Most of the PTSD-ND association is explained by shared genetic effects. However, there is a substantial, robust PTSD-ND association not explained by shared risk factors. Multiple explanations for the association were supported; however, the strongest association was consistent with preexisting ND increasing the risk of PTSD onset. These data suggest that male veterans with a history of ND may be at increased risk for PTSD. Further research on the biological mechanisms underlying PTSD-ND comorbidity is needed.

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

OBJECTIVE

Despite evidence of potential psychiatric sequelae following peacekeeping operations, no data have appeared on treatment outcome for this population. This study examined intake and treatment outcome data for a group of peacekeepers with posttraumatic stress disorder (PTSD).

METHOD

Participants were 63 Australian Vietnam veterans and 66 Australian peacekeepers attending specialized PTSD treatment units. Measures of PTSD, depression, anxiety, alcohol use, and anger were obtained at intake and 3-month follow-up.

RESULTS

PTSD scores were more severe for peacekeepers than Vietnam veterans at intake, primarily in reexperiencing symptoms. In terms of comorbidity, only anger was higher among peacekeepers. No differences were apparent in treatment outcome. Initial anger predicted change in PTSD severity for peacekeepers.

CONCLUSIONS

The finding of differences between peacekeepers and Vietnam veterans in anger and reexperiencing symptoms, in addition to the attenuating role of anger on treatment outcome, suggests that modification to standard PTSD treatment models may be warranted for peacekeepers.

Relationship of in vivo medial temporal lobe magnetic resonance spectroscopy to documented combat exposure in veterans with chronic posttraumatic stress disorder

Veterans diagnosed with combat-related posttraumatic stress disorder (PTSD) and comparison subjects underwent single voxel proton magnetic resonance spectroscopy (1H-MRS) of the medial temporal lobe (MTL). PTSD subjects were divided into combat and non-combat groups based on military records. Combat PTSD subjects did not have lower MTL levels of N-acetylaspartate compared with non-combat PTSD subjects.

Employment outcomes and PTSD symptom severity

A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.

A taxometric investigation of dissociation in Vietnam veterans

There is long-standing debate about whether elevated dissociative symptoms are common in posttraumatic stress disorder (PTSD) or whether there is a distinct subtype of cases with elevated dissociation. The current investigation examined the latent structure of dissociative symptoms in a sample of 316 male, trauma-exposed Vietnam veterans, 76 of whom were diagnosed with current PTSD. Three taxometric procedures (MAMBAC, MAXEIG, and MAXCOV) were performed on three indicator sets drawn from the Dissociative Experiences Scale. Taxometric analyses consistently revealed a taxon (subtype) of highly dissociative individuals. The taxon members had significantly more severe posttraumatic symptoms and were more often diagnosed with current PTSD than were non-taxon members. Among participants with a current PTSD diagnoses, only 32% belonged to the dissociative taxon, suggesting that there is a subtype of severe PTSD with elevated dissociation.

Risk, psychiatry and the military

The relationship between combat and psychiatric breakdown has been well recognised for decades. The change to smaller, professional armed forces has reduced the risk of large-scale acute psychiatric casualties, and should have led to a corresponding decrease in long-term ill health, but this expected reduction seems not to have happened. Likewise, attempts at preventing psychiatric injury, by screening before deployment or debriefing after, have been disappointing. Three reasons for this are proposed: a rethinking of the relationship between trauma and long-term outcome, catalysed by the attempts of US society to come to terms with the Vietnam conflict; a broadening of the scope of psychiatric injury as it moved to the civilian sector; and the increased prominence of unexplained syndromes and contested diagnoses such as Gulf War syndrome. Traditional psychiatric injury is predictable, proportionate and can, in theory, be managed. These newer forms of injury are in contrast unanticipated, paradoxical, ill understood and hard to manage. Traditional approaches to risk management by reducing exposure have not been successful, and may increase risk aversion and reduce resilience. However, the experiences of civilians in wartime or the military show that people are not intrinsically risk-averse, provided they can see purpose in accepting risk.

The mobile Army surgical hospital (MASH): a military and surgical legacy

Operation Iraqi Freedom was perhaps the last military campaign that will ever utilize the services of a mobile Army surgical hospital (MASH). The Army has now essentially replaced the MASH with combat surgical hospitals (CSH) and forward surgical teams (FST). MASH units were designed as mobile, flexible, forward-deployed military hospitals, providing care for the wounded near the frontlines of the battlefield. These hospitals not only saved thousands of lives during war but also greatly influenced the delivery of trauma and critical care in civilian hospitals. The MASH was made popular by the television series of the 1970s, depicting the 4077th during the Korean War. Although a comical series, these television episodes provided viewers with a glimpse of life in a MASH during time of war. This article chronicles the history of the MASH from its inception during World War II to recent experiences in Operation Iraqi Freedom.

Postservice Mortality of Air Force Veterans Occupationally Exposed to Herbicides during the Vietnam War: 20-Year Follow-Up Results

Since 1982, the Air Force Health Study has continued to assess the mortality for veterans of Operation Ranch Hand, the unit responsible for aerially spraying herbicides in Vietnam. The mortality for 1,262 Ranch Hand veterans to December 31, 1999 was contrasted with that for 19,078 comparison veterans. The relative risk (RR) for all-cause death was borderline significantly increased (RR, 1.15; 95% confidence interval, 1.0-1.3; p = 0.06). The risk of death caused by cancer was not increased (RR = 1.0), but the risk of death caused by circulatory system diseases was significantly increased among enlisted ground crew workers (RR = 1.7; 95% confidence interval, 1.2-2.4; p = 0.001). Results for Ranch Hand all-cause death differed from previous reports, with the RR now exceeding 1.0. The risk of death attributable to circulatory system diseases continues to be increased, especially for enlisted ground crew, a subgroup with relatively high skin exposure to herbicides.

Glucocorticoid receptor polymorphisms and post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is reported in some studies to be associated with increased glucocorticoid (GC) sensitivity. Two common glucocorticoid receptor (GR) polymorphisms (N363S and BclI) appear to contribute to the population variance in GC sensitivity. There is some evidence that there may be a genetic predisposition to PTSD. Hence we studied 118 Vietnam war veterans with PTSD for (i) GR polymorphisms, particularly the N363S and the BclI polymorphisms which are thought to be GC sensitising, and (ii) two measures of GC sensitivity, the low-dose 0.25 mg dexamethasone suppression test (LD-DST) and the dermal vasoconstrictor assay (DVVA). The DST and GR polymorphisms were also performed in 42 combat exposed Vietnam war veterans without PTSD. Basal plasma cortisol levels were not significantly different in PTSD (399.5+/-19.2 nmol/L, N=75) and controls (348.6+/-23.0 nmol/L, N=33) and the LD-DST resulted in similar cortisol suppression in both groups (45.6+/-3.2 vs. 40.8+/-4.1%). The cortisol suppression in PTSD patients does not correlate with Clinician Administered PTSD Scores (CAPS), however there was a significant association between the BclI GG genotype and low basal cortisol levels in PTSD (P=0.048). The response to the DVVA was similar to controls (945+/-122, N=106 vs. 730+/-236, N=28, P=0.42). PTSD patients with the GG genotype, however, tended to be more responsive to DVVA and in this group the DVVA correlated with higher CAPS scores. The only exon 2 GR polymorphisms detected were the R23K and N363S. Heterozygosity for the N363S variant in PTSD, at 5.1% was not more prevalent than in other population studies of the N363S polymorphism in Caucasians (6.0-14.8%). The GG genotype of the BclI polymorphism found to be associated with increased GC sensitivity in many studies showed a tendency towards increased response with DVVA and correlated with higher CAPS scores. In conclusion, the N363S and BclI GR polymorphisms were not more frequent in PTSD patients than controls and reported population frequencies. Our PTSD group did not display GC hypersensitivity, as measured by the LD-DST and DVVA. In a subset of PTSD patients with the BclI GG genotype, CAPS scores and basal cortisol levels were negatively correlated.

The legacy of agent orange: empirical evidence from central Vietnam

This paper seeks to provide a socio-economic impact assessment for Vietnamese victims of the principal US military herbicide, Agent Orange, used during the Vietnam War in the period 1961-71. The study is based on a field survey of 30 affected and 30 unaffected households in Quang Tri province. With this assessment, the paper attempts to address the broader issues of compensation currently available to victims. The coverage and composition of current benefits are deemed inadequate as an effective redress. In view of this, revision of current compensation, the mobilization of an international donor fund and spurred non-governmental support is strongly recommended.

The role of war-zone trauma and PTSD in the etiology of antisocial behavior

Historically, successful reintegration of war veterans into civilized society has been an enduring concern of nations. Data from the National Vietnam Veterans Readjustment Study were used to develop and evaluate an etiological model of postwar antisocial behavior. Two initial models specified causal paths among five sets of variables, ordered according to their historical occurrence: (a) premilitary risk factors, (b) military traumas and disciplinary actions, (c) the homecoming reception, (d) postmilitary PTSD and substance abuse, and (e) postmilitary antisocial behavior. PTSD and substance abuse were omitted in one model and included in the other. The initial models were refined and then cross-validated, leading to the specification of replicated models with highly satisfactory fit and parsimony. Comparison of the two models suggested that (1) premilitary experiences and behavior exert the largest effects on postmilitary antisocial behavior, and that (2) PTSD plays a necessary mediational role for the effects of war-zone traumatic exposure on postmilitary antisocial behavior.

Lessons learned and advice from Vietnam war nurses: a qualitative study

AIM

The aim of this paper is to describe guidance for nurses today from the lessons learned by nurses who served in the Vietnam War.

BACKGROUND

There is little research focusing on nurses' experiences in the Vietnam War. Lessons learned and subsequent advice from nurses who served in Vietnam may be helpful to those serving in current and future wars.

METHODS

A Husserlian phenomenological approach was taken, using interviews with a purposive sample of Registered Nurses who were female, and had served in the United States of America armed forces in Vietnam during the war.

FINDINGS

Seven theme clusters described the lesson learned and guidance offered by the Vietnam War nurses: advice about journaling, training, caring for yourself, use of support systems, talking about your experiences, understanding the mission, and lack of preparation for war.

CONCLUSIONS

Much can be learned from the lessons learned and advice given by Vietnam War nurses. These lessons stress that nurses need to take a pro-active role in preparing themselves for deployment to a war zone, and that institutional training for war needs to be intensive and realistic. The environmental, cultural, technological, clinical and psychosocial demands of war nursing need to be comprehensively addressed before nurses deploy to a war.

Postservice mortality in Vietnam veterans: 30-year follow-up

BACKGROUND

During the 1980s, the postservice mortality component of the Vietnam Experience Study was conducted to examine the health effects of the Vietnam experience. This study was limited by the relatively short follow-up and the young age of the veterans. Thus, a follow-up mortality investigation on this cohort was undertaken to further assess the impact of the Vietnam experience on chronic conditions.

METHODS

Vital status and underlying cause-of-death data on the Vietnam Experience Study cohort (18 313 male US Army veterans) were retrospectively ascertained from the end of the original study through 2000. Cox proportional hazards regression was used to calculate crude and adjusted rate ratios (RRs) for all-cause and cause-specific mortality, comparing Vietnam and non-Vietnam veterans.

RESULTS

All-cause mortality was 7% higher in Vietnam vs non-Vietnam veterans during 30-year follow-up (95% confidence interval [CI], 0.97-1.18). The excess mortality among Vietnam veterans was isolated to the first 5 years after discharge from active duty and resulted from an increase in external causes of death (RR, 1.62; 95% CI, 1.16-2.26). Cause-specific analyses revealed no difference in disease-related mortality. Vietnam veterans, however, experienced excess unintentional poisoning (RR, 2.26; 95% CI, 1.12-4.57) and drug-related (RR, 1.70; 95% CI, 1.01-2.86) deaths throughout follow-up.

CONCLUSIONS

Vietnam veterans continued to experience higher mortality than non-Vietnam veterans from unintentional poisonings and drug-related causes. Death rates from disease-related chronic conditions, including cancers and circulatory system diseases, did not differ between Vietnam veterans and their peers, despite the increasing age of the cohort (mean age, 53 years) and the longer follow-up (average, 30 years).

Lifetime and 12-month prevalence of psychiatric disorders in 8,169 male Vietnam War era veterans

OBJECTIVE

This study reports the prevalence of psychiatric disorders among a nationally distributed sample of Vietnam Era veterans assessed using standardized psychiatric interviewing methods.

METHODS

In 1992, the National Institute of Mental Health Diagnostic Interview Schedule was administered by telephone to 8,169 middle-aged males who served in the military during the Vietnam era (1965-1975).

RESULTS

Approximately 72% of respondents reported a lifetime history and 36% reported a 12-month history of at least one psychiatric disorder. The most prevalent psychiatric disorders included alcohol abuse and/or dependence (54% lifetime, 17% 12 month), nicotine dependence (48% lifetime, 22% 12 month), and posttraumatic stress disorder (10% lifetime, 4.5% 12 month).

CONCLUSIONS

Because of possible participation bias, these results likely represent conservative estimates of psychiatric disorder prevalences among the more than eight million Vietnam Era veterans and reinforces the major public health challenge of preventing, identifying, and treating psychiatric illness in American veterans.

Juvenile conduct disorder as a risk factor for trauma exposure and posttraumatic stress disorder

Juvenile conduct disorder (CD) is a well-documented risk factor for posttraumatic stress disorder (PTSD). This study examines the mechanisms underlying this relationship by using data from 3,315 twin pairs in the Vietnam Era Twin Registry. Results indicate the number of conduct disorder symptoms increased risk of trauma exposure and PTSD in a dose-response fashion. This increased risk was mediated in part by the positive association between CD and lifestyle factors and was not due to confounding by shared genetic or familial vulnerability. The findings suggest CD increases risk for trauma exposure and PTSD among male veterans through direct and indirect mechanisms. Veterans who have a history of CD are at high risk for trauma exposure and development of PTSD.

Variations in health communication needs among combat veterans

In this cross-sectional study of US military combat veterans, we assessed the helpfulness of different media for providing health risk communication messages. We have provided preliminary results from a postal survey of 5000 veterans sampled because of their deployment to Vietnam, the Persian Gulf, or Bosnia-Kosovo. Respondents endorsed the primary care provider as the most helpful source of health information. Access to the Internet and use of this medium for seeking health information differed by race, age, and cohort.

Suicide in Vietnam veterans: The Suicide Wall

Although official data have reported an average number of suicides in the veterans of the Vietnam War, the veterans themselves estimate that the death toll from suicide may be 8 to 10 times the official toll. Attention is drawn to a website honoring those veterans of the war who have committed suicide: www.suicidewall.com

Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use

This study examines the roles of post-traumatic stress disorder (PTSD) and drug dependence in non-fatal suicidality, i.e., suicidal ideation and suicide attempt, among Vietnam veterans in their adult years. The sample includes male veterans deployed to Vietnam, including an oversample of those who tested positive for opiates at their return (n = 642). PTSD, substance abuse, suicidality, and other psychopathology are analyzed using three waves of survey and military data covering the time period from early adolescence to middle adulthood. Measures include the onset and recency of each of the lifetime DSM-IV PTSD symptom criteria, and yearly symptom measures of DSM-IV dependence for alcohol and eight classes of psychoactive substances. Survival and hazard models are applied to assess the effects of drug dependence, PTSD, and other psychopathology on the duration of suicidality. Longitudinal models estimate the casual relationships among PTSD, drug dependence, and suicidality over a 25-year period. Results show evidence of strong continuity of PTSD, drug dependence, and suicidality over time. The causal role of drug dependence on PTSD and suicidality is limited to young adulthood. Evidence is stronger for self-medication in later adulthood. The results indicate that a life course perspective is needed for the combined treatment of PTSD and drug dependence for severely traumatized populations.

[Posttraumatic stress disorder (PTSD)]

The diagnosis of posttraumatic stress disorder (PTSD) has been introduced in 1980. The diagnosis, as construct raises several political, moral, legal, and compensation issues. PTSD is considered as a multisystemic dysregulation, involving the hypothalamic- pituitary - adrenal axis, adrenergic hypersensibility, and serotonergic dysfunction. The prevalence of PTSD is 1-9% in the general population, but substantially higher among victims of traumatic events: 19-70%. Placebo controlled studies provide a body of evidence concerning efficacy of selective serotonin reuptake inhibitors in the treatment of PTSD both in the acute and maintenance treatments. Studies with balanced male-female ratio suggest no gender-related differences in the clinical response, furthermore both civilians and veterans improved significantly for selective serotonin reuptake inhibitor treatment.

Shame, Guilt, Self-Hatred and Remorse in the Psychotherapy of Vietnam Combat Veterans Who Committed Atrocities

The soldiers who perpetrated atrocities during the Vietnam War are a group much less studied than the victims of violence during peacetime. These soldiers were catalyzed by war to express a darker side of their humanity, a side that our society often chosses to ignore. At some level their experiences relate to us all. In the future more young men and, probably young women, will be sent to war. Once they have been transformed by military training and the hellish conditions of war, society tends to forget them--to leave them wandering in a no man's land of their own tortured thoughts and feelings. We need to understand more about how such transformations of the self beset our returning soldiers. And, once this has happened, we need to know how to help them reintegrate into society and reconnect with others in a meaningful way. A psychotherpy that embraces the patient's need to express remorse is necessary in order to help these patients work through their guilt and self-hatred. These are the main objectives of treatment.

Neurology in the Vietnam War: CPT Carr's Patients

CPT Andrew C. Carr was the second neurologist to be assigned to Vietnam during the early years of the war. Soon after his return, he prepared a commentary on the practice of neurology under field conditions, providing a vivid account of the practice of good neurology under bad conditions.

Specter orange

Nearly 30 years after the Vietnam War, a chemical weapon used by U.S. troops is still exacting a hideous toll on each new generation in Vietnam. The dioxin (TCCD) that contaminated the herbicide Agent Orange is one of the most toxic molecules known to science. The contaminant persists in the soil. The United States has done nothing to combat the medical and environmental catastrophe that is overwhelming the country.

Persistence and change of PTSD symptomatology--a longitudinal co-twin control analysis of the Vietnam Era Twin Registry

INTRODUCTION

Previous twin studies have demonstrated a strong association between the degree of combat exposure and PTSD, and the continued presence of PTSD, almost two decades after combat. Independent genetic effects have also been demonstrated for both combat exposure and PTSD vulnerability in Vietnam veterans. The current study, involving a subset of male-male twin pairs discordant for service in Southeast Asia (SEA), is a follow-up to an earlier study conducted in 1987. The purpose of this study is to examine the changes in the combat exposure-PTSD relationship over an additional decade of time.

METHODS

The Mississippi Scale for Combat-Related or Civilian PTSD was administered by telephone in 1997 during a follow-up survey of the Vietnam Era Twin Registry. Only twins discordant for service in Southeast Asia who originally participated in the 1987 study were included. Results of this scale and the original 1987 PTSD symptom scale were separately standardized using z-score transformations and used as dependent variables in a random effects regression model with zygosity, time and combat exposure as independent variables. Main effects and interactions were estimated to address whether there were differential effects of combat on PTSD over time, and whether there was evidence of genetic covariation between combat exposure and PTSD in 1987 that persisted to 1997.

RESULTS

Combat exposure was strongly associated with PTSD in both 1987 and 1997. Although still highly significant, the effect sharply diminished over time. There is little evidence for a shared genetic vulnerability between combat and PTSD in either 1987 or 1997.

CONCLUSION

This analysis documents the continuing role of combat exposure (i. e., trauma severity) on the persistence and chronicity of PTSD. Nearly 25 years after the end of hostilities, PTSD symptoms continue to be elevated in those exposed to the highest levels of combat. There is no evidence that genetic influences on exposure to combat are shared with those inducing a genetic vulnerability to PTSD. Clinicians need to be aware of the persistent and long-term residual effects of trauma exposure.

Blood pressure and cerebrospinal fluid norepinephrine in combat-related posttraumatic stress disorder

OBJECTIVE

Central nervous system norepinephrine (NE) is normally involved in blood pressure regulation, but it is pathophysiologically elevated in posttraumatic stress disorder (PTSD).

METHODS

We monitored blood pressure while performing serial cerebrospinal fluid (CSF) sampling for 6 hours to determine CSF NE concentrations in men with combat-related PTSD (n = 11) and in healthy men (n = 8).

RESULTS

CSF NE concentrations strongly and positively correlated with mean diastolic blood pressure in the healthy men (R = 0.93, p <.002) but not in the patients (R = 0.10, p =.77). Within individuals, mean arterial pressure, systolic blood pressure, diastolic blood pressure and pulse pressure were poorly correlated over time in patients with PTSD but highly correlated over time in the healthy men, indicating that measurement of these hemodynamic parameters are poorly prognostic of subsequent measurements of the same parameter in patients with PTSD.

CONCLUSION

These data demonstrate the loss of the normal direct relationship between CSF NE and blood pressure in combat veterans with PTSD. Whether this dysynchrony mechanistically relates to the hemodynamic abnormalities in PTSD or, like some of the psychobehavioral symptoms, can be corrected with anti-noradrenergic pharmacotherapy remains to be determined.