Posttraumatic stress disorder in a community group of former prisoners of war: a normative response to severe trauma

Long-Term Consequences of War Captivity in Military Veterans

Numerous studies on the health and functioning of veterans and former prisoners of war have shown that the experience of war captivity is one of the most difficult human experiences. Captivity is often characterized by extremely difficult and inhumane conditions, as well as exposure to various forms of both psychological and physical abuse. Such traumatic experiences can lead to serious psychological consequences that can last for years, even decades after release from captivity. The aim of this paper is to present a brief overview of research that points to the specifics of wartime captivity and the long-term psychological consequences in veterans of former camp detainees, as well as the consequences suffered by their families and factors that, apart from the intensity of the trauma, contribute to the emergence and persistence of psychological disorders. From the presented research, it can be concluded that former prisoners of the camp represent an extremely vulnerable group of the social community and require long-term appropriate treatment, while the needs of veterans' families should not be neglected, with the necessity of including spouses and children in psychological and psychosocial treatments.

Primary Care Considerations for Elderly U.S. Veterans of World War II and the Korean War: A Narrative Review

Many of the United States' more than 18 million veterans obtain healthcare through the Department of Veterans Affairs' (VA) Veterans Health Administration system; however, recent legislative changes have expanded veterans' access to non-VA care in their communities, particularly for those who do not live near VA medical centers. Veterans are seen by physicians in outpatient practice across the United States and are admitted to non-VA hospitals; this is particularly salient for older veterans, who may require a more frequent and high level of care. We present a review of characteristics of U.S. veterans from two conflicts: World War II (WWII) and the Korean War. While non-VA clinicians are well equipped to provide care for patients of all different ages, veterans of armed conflicts have a unique constellation of exposures and cultural considerations that must be accounted for when providing them care. In this review, we describe characteristics of the generations of American veterans who served in WWII and the Korean War conflicts in a brief historical context. We then note conflict-specific exposures and potential long-term sequelae to watch for during physical examinations and to monitor thereafter, age-specific health and emotional concerns, and best practices for providing care to this cohort of veterans.

Relationship between Socio-Demographic Factors and Posttraumatic Stress Disorder: A Cross Sectional Study among Civilian Participants' Hostilities in Ukraine

Background: Even though there is an extensive body of literature on posttraumatic stress disorder (PTSD) in individuals who have experienced armed conflict, there are still many grey areas, especially in relation to civilian participants in hostilities. This article evaluates how socio-demographic factors and the interactions between them have influenced PTSD among civilians involved in the recent war in Ukraine. Methods: This cross-sectional study included a convenience sample of 314 adults, 74 women, and 235 men. The mean age was 34.08 years. We used the Posttraumatic Stress Disorder (PTSD) Checklist–Civilian Version (PCL-C). Results: Our findings show that predictors of posttraumatic stress are loss of a loved one, place of residence, gender, continuation of education, and health insurance. We demonstrated that PTSD produced by the loss of a loved one as a result of war is determined by participation in the education system, whatever the level of education. The literature emphasises the importance of social support, e.g., from the family. We demonstrated that having children is associated with a risk of more severe PTSD, causing serious mental strain among participants of hostilities. We discovered that material security lowers PTSD, but only among people who have no children. Conclusions: PTSD is the result of not only the violence and damage caused by war but also of other stressful circumstances associated with the social and financial conditions of life. Further research needs to focus on identifying modifiable risk factors and protective factors that could be embraced by intervention strategies. Our findings can inform the goals behind therapeutic support for civilian participants of hostilities, and implications for social work. Social work professionals are encouraged to engage in direct questioning and to maintain a supportive and safe environment for participants in hostilities, e.g., in the area of education. Trauma-affected people need to be given opportunities to build up their strengths and increase their psychological resources towards well-being. Social security (health insurance, savings, material security) should be taken into account when working with people affected by PTSD.

Cognitive treatment of post-traumatic stress disorder in the elderly. A longitudinal study

OBJECTIVE

This article aims to verify whether a cognitive treatment of post-traumatic stress disorder (PTSD) by cognitive behavioural therapy (CBT) adapted to elderly subjects can lead to long-term improvement in symptomatology and quality of life.

METHOD

We present a longitudinal study of 32 subjects over the age of 65 years, with no cognitive impairment or mild impairment, residing in two nursing homes. We compare a target group (n=16) with PTSD treated with 20 CBT sessions and a control group (n=16) with PTSD without symptom treatment. The two groups are compared in four stages: (T1) before treatment of the target group's PTSD, (T2) after treatment of PTSD, (T3) after six months of follow-up and (T4) after 18 months of follow-up. The absence of cognitive impairment is verified with the MMSE. The evolution of PTSD is monitored with the CAPS. The evolution of the quality of life of the subjects in the target group is verified with the ADRQL.

RESULTS

If both groups show elevated PTSD symptoms at the beginning of the study (T1), the signs of PTSD disappear for the target group at the end of treatment (T2) at the same time as quality of life improves (scores more than doubled). These improvements continue for more than 18 months (T4). Conversely, the control group retains high PTSD symptoms, without significant decrease over time.

CONCLUSION

The treatment of PTSD by cognitive-behavioural therapy adapted to elderly people without cognitive impairment, or with mild cognitive or memory disorders, allows for a lasting disappearance of symptoms and an improvement in quality of life.

[Prevalence of anxiety disorders in people over 65 years-old: A systematic review]

Anxiety is an emotional problem that causes discomfort and suffering to those that suffer from it. Anxiety disorders can affect the functioning in different facets of a person's life. Studies on the prevalence of anxiety disorders in people over 65 years show variable results, ranging between 0.1% and 17.2%. Most of these studies include samples of the general population, in which the population of people over 65 years is under-represented. These studies evaluate older people with the same diagnostic tools used to assess anxiety disorders in people under 65 years, and collect data from people between 65 and 75 years old, leaving out people aged 75 and over. A systematic review of the prevalence studies of anxiety disorders in elderly people is presented. It is concluded that when representative samples of people over 65 years are used and evaluated with suitable tools, the prevalence rate of these disorders in the elderly is much higher than previously thought, reaching an annual prevalence rate of 20.8%.

Posttraumatic Stress Disorder, Orientation to Pain, and Pain Perception in Ex-Prisoners of War Who Underwent Torture

OBJECTIVE

Studies suggest that torture survivors often experience long-term chronic pain and increased pain perception. However, it is unclear whether the actual experience of torture or rather the subsequent posttraumatic stress disorder (PTSD) explains these pain problems. Furthermore, although catastrophic and fearful orientations to pain have been suggested to play a significant role in the association between trauma and pain, the underlying mechanisms remain unclear. This study examined whether chronic pain and pain perception among torture survivors are associated with torture experience or PTSD and whether catastrophic and fearful orientations mediate or moderate these associations.

METHODS

Fifty-nine ex-prisoners of war who underwent torture and 44 matched veterans participated in this study. Pain perception was evaluated by assessing pain threshold and reactivity to experimental suprathreshold noxious stimuli. Participants completed self-administered questionnaires assessing PTSD, chronic pain, pain catastrophizing, and fear of pain.

RESULTS

Although chronic pain was associated with PTSD (0.44 < β < 0.49, p < .002), increased pain perception was correlated with torture (0.33 < β < 0.65, p < .05). Pain catastrophizing was found to mediate the association between PTSD and chronic pain (β = 0.18 and 0.19, respectively; p < .05). Fear of pain moderated the association between torture and pain perception (β = 0.41 and 0.42, respectively; p < .017).

CONCLUSIONS

The findings suggest that chronic pain is contingent upon the psychological toll of torture, that is, PTSD. This study also indicates that PTSD exacerbates catastrophic orientation, which in turn may amplify chronic pain. Reactivity to experimental noxious stimuli was related to previous experiences of torture, which enhances perceived pain intensity when interacting with a fearful pain orientation. These findings highlight the significance of orientation to bodily experiences after trauma.

Posttraumatic Stress Disorder 23 Years After the 1988 Spitak Earthquake in Armenia

This population-based longitudinal study examined the rates and predictors of posttraumatic stress disorder (PTSD) among 725 differentially exposed survivors of the 1988 Spitak earthquake in Armenia, 23 years after the event. Participants had been previously evaluated in 1991. Evaluations included assessment of current PTSD (based on DSM-5 criteria), and a variety of potential risk and protective factors. For the whole sample, the rate of PTSD attributed to the earthquake decreased from 48.7% in 1991 to 11.6% in 2012 (p < .001). A "dose of exposure" pattern persisted, and 15.7% of participants who were in Spitak (high exposure) and 6.6% of participants who were in Kirovagan (low exposure) during the earthquake met the criteria for PTSD (p = .003). Additionally, in 2012, another 9.9% of participants met PTSD criteria due to post-earthquake traumas, which is a 5-fold increase from pre- to postearthquake (p < . 001). Factors positively associated with PTSD included earthquake-related job loss, exposure to post-earthquake traumas, depression at baseline, and chronic illness since the earthquake. Factors inversely associated with PTSD included housing assistance within two years after the earthquake, support of family and/or friends, and to a lesser degree, higher education and high living standard. These variables accounted for 23.1% of the variance in current PTSD severity scores. These findings indicate that PTSD rates subside significantly after a catastrophic disaster, although earthquake-related PTSD persists among a subgroup of exposed individuals. Predictors of PTSD identified in this study provide guidance for planning acute and longer-term postdisaster public mental health recovery programs.

Torturing personification of chronic pain among torture survivors

BACKGROUND

Consistent with the human tendency to anthropomorphize objects, events, and situations, individuals might ascribe human characteristics to physical symptoms and illnesses. This manuscript presents an examination of chronic pain personification in torture survivors. Specifically, it was hypothesized that torture survivors personify chronic pain as a torturing sensation. It was further hypothesized that PTSD mediates the effect of past torture on torturing pain personification.

METHODS

Fifty-nine Israeli ex-prisoners of war (ex-POWs), who experienced severe torture in captivity, and 44 matched controls completed self-administered questionnaires at 18, 30, and 35years post captivity.

RESULTS

Whereas ex-POWs exhibit higher torturing personification than controls, no differences were found in concrete description of chronic pain. PTSD trajectories were implicated in different levels of torturing personification. Finally, sequential mediation analysis revealed that PTSD at T2 and T3 mediated the association between torture and torturing personification.

CONCLUSIONS

The findings suggest that trauma shapes the way individuals relate to and experience their bodily sensations.

The implications of war captivity and long-term psychopathology trajectories for telomere length

BACKGROUND

Previous findings have demonstrated the link between trauma, its psychopathological aftermath and cellular aging, as reflected in telomere length. However, as long-term examinations of psychopathology following trauma are scarce, very little is known regarding the repercussions of depression and PTSD trajectories of psychopathology for telomeres. The current study examined the implications of war captivity and depression/PTSD trajectories on telomere length.

METHODS

Ninety-nine former prisoners of war (ex-POWs) from the 1973 Yom Kippur War were evaluated for depression and PTSD at 18, 30, 35 and 42 years after the war. Data on leukocyte telomere length of ex-POWs and 79 controls was collected 42 years after the war.

RESULTS

Ex-POWs had shorter telomeres compared to controls (Cohen's d=.5 indicating intermediate effect). Ex-POWs with chronic depression had shorter telomeres compared to those with delayed onset of depression (Cohen's d=4.89), and resilient ex-POWs (Cohen's d= 3.87), indicating high effect sizes. PTSD trajectories were not implicated in telomere length (Partial eta²=.16 and p=.11).

CONCLUSION

The findings suggest that the detrimental ramifications of war captivity are extensive, involving premature cellular senesces. These findings further point to the wear-and-tear effect of long-term depression, but not PTSD, on telomere length. Explanations for the findings are discussed.

Posttraumatic Growth and Dyadic Adjustment among War Veterans and their Wives

The controversy regarding the nature of posttraumatic growth includes two main competing claims: one which argues that posttraumatic growth reflects authentic positive changes and the other which argues that posttraumatic growth reflects illusory defenses. While the former might suggest that posttraumatic growth enhances intimacy and close relationships, the latter might imply that posttraumatic growth hinders interpersonal relations. The present study aimed to test these claims by investigating the association between posttraumatic growth and dyadic adjustment over time at both the individual and dyadic levels, and the potential role of posttraumatic stress symptoms. Former prisoners of war and comparable war veterans and their wives (n = 229) were assessed twice, 30-31 (T1) and 35-38 (T2) years after the 1973 Yom Kippur War in Israel, with regard to posttraumatic growth, posttraumatic stress symptoms and dyadic adjustment. Results indicated that posttraumatic growth was associated with both elevated posttraumatic stress symptoms and low dyadic adjustment among both husbands and wives. Posttraumatic stress symptoms at T1 and T2 mediated the association between posttraumatic growth and dyadic adjustment. Wives' posttraumatic growth at T1 predicted posttraumatic growth and dyadic adjustment of the husbands at T2. The higher the wives' posttraumatic growth, the higher the posttraumatic growth and the lower the dyadic adjustment of the husbands in the subsequent measure. The findings suggest that posttraumatic growth reflects defensive beliefs which undermine marital relationships and that posttraumatic growth might be transmitted between spouses and implicated in the deterioration of the marital relationship over time.

The longitudinal relationship between post-traumatic stress disorder and perceived social support in survivors of traumatic injury

BACKGROUND

Although perceived social support is thought to be a strong predictor of psychological outcomes following trauma exposure, the temporal relationship between perceived positive and negative social support and post-traumatic stress disorder (PTSD) symptoms has not been empirically established. This study investigated the temporal sequencing of perceived positive social support, perceived negative social support, and PTSD symptoms in the 6 years following trauma exposure among survivors of traumatic injury.

METHOD

Participants were 1132 trauma survivors initially assessed upon admission to one of four Level 1 trauma hospitals in Australia after experiencing a traumatic injury. Participants were followed up at 3 months, 12 months, 24 months, and 6 years after the traumatic event.

RESULTS

Latent difference score analyses revealed that greater severity of PTSD symptoms predicted subsequent increases in perceived negative social support at each time-point. Greater severity of PTSD symptoms predicted subsequent decreases in perceived positive social support between 3 and 12 months. High levels of perceived positive or negative social support did not predict subsequent changes in PTSD symptoms at any time-point.

CONCLUSIONS

Results highlight the impact of PTSD symptoms on subsequent perceived social support, regardless of the type of support provided. The finding that perceived social support does not influence subsequent PTSD symptoms is novel, and indicates that the relationship between PTSD and perceived social support may be unidirectional.

Sleep and mental disorders: A meta-analysis of polysomnographic research

Investigating sleep in mental disorders has the potential to reveal both disorder-specific and transdiagnostic psychophysiological mechanisms. This meta-analysis aimed at determining the polysomnographic (PSG) characteristics of several mental disorders. Relevant studies were searched through standard strategies. Controlled PSG studies evaluating sleep in affective, anxiety, eating, pervasive developmental, borderline and antisocial personality disorders, attention-deficit-hyperactivity disorder (ADHD), and schizophrenia were included. PSG variables of sleep continuity, depth, and architecture, as well as rapid-eye movement (REM) sleep were considered. Calculations were performed with the "Comprehensive Meta-Analysis" and "R" software. Using random effects modeling, for each disorder and each variable, a separate meta-analysis was conducted if at least 3 studies were available for calculation of effect sizes as standardized means (Hedges' g). Sources of variability, that is, sex, age, and mental disorders comorbidity, were evaluated in subgroup analyses. Sleep alterations were evidenced in all disorders, with the exception of ADHD and seasonal affective disorders. Sleep continuity problems were observed in most mental disorders. Sleep depth and REM pressure alterations were associated with affective, anxiety, autism and schizophrenia disorders. Comorbidity was associated with enhanced REM sleep pressure and more inhibition of sleep depth. No sleep parameter was exclusively altered in 1 condition; however, no 2 conditions shared the same PSG profile. Sleep continuity disturbances imply a transdiagnostic imbalance in the arousal system likely representing a basic dimension of mental health. Sleep depth and REM variables might play a key role in psychiatric comorbidity processes. Constellations of sleep alterations may define distinct disorders better than alterations in 1 single variable. (PsycINFO Database Record

Dissociative Subtypes in Posttraumatic Stress Disorders and Hypnosis

Converging evidence suggests that heterogeneity in posttraumatic stress disorder (PTSD) arises from the presence of discrete subtypes of patients, one of which is characterized by elevated dissociative symptoms. A similar dissociative subtype has been observed among individuals displaying high hypnotic suggestibility. Here we highlight important parallels between these subtypes, drawing from research on a history of exposure to stressful life events and pathological symptomatology, cognitive functioning, hypnotic suggestibility, and functional neuroimaging and electrophysiology. Further clarification of these parallels can help elucidate the developmental paths and neurocognitive basis of heterogeneity in PTSD and high hypnotic suggestibility and refine the understanding and treatment of different subtypes of PTSD.

Positive Adjustment Among American Repatriated Prisoners of the Vietnam War: Modeling the Long-Term Effects of Captivity

A longitudinal lifespan model of factors contributing to later-life positive adjustment was tested on 567 American repatriated prisoners from the Vietnam War. This model encompassed demographics at time of capture and attributes assessed after return to the U.S. (reports of torture and mental distress) and approximately 3 decades later (later-life stressors, perceived social support, positive appraisal of military experiences, and positive adjustment). Age and education at time of capture and physical torture were associated with repatriation mental distress, which directly predicted poorer adjustment 30 years later. Physical torture also had a salutary effect, enhancing later-life positive appraisals of military experiences. Later-life events were directly and indirectly (through concerns about retirement) associated with positive adjustment. Results suggest that the personal resources of older age and more education and early-life adverse experiences can have cascading effects over the lifespan to impact well-being in both positive and negative ways.

Risk among Combat Veterans with Post-traumatic Stress Disorder: The Impact of Psychosocial Factors on the Escalation of Suicidal Risk

INTRODUCTION

The purpose of this study was to (a) evaluate the influence of post-traumatic stress disorder (PTSD) and other comorbid disorders on suicidal risk among combat veterans and (b) evaluate the impact of psychosocial factors on the escalation of suicidal risk.

METHODS

Data were gathered from a random and representative sample of 215 Kosovo War veterans. Subjects were assessed for the presence of lifetime and current psychiatric disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision (DSM-IV TR) using the following questionnaires: Harvard Trauma Questionnaire (HTQ), Beck's Depression Inventory (BDI) and Beck's Suicide Intent Scale (BSIS).

RESULTS

Suicidal ideations were observed in 44 (20.5%) of the 215 subjects. High suicide risk was found in 31.8% veterans diagnosed with PTSD and comorbid major depressive disorder. In addition, high suicide risk was also observed in the group of unemployed veterans, veterans dissatisfied with social/economic attainment and veterans dissatisfied with living conditions.

CONCLUSION

Our study showed that socioeconomic factors contributes to the deterioration of symptoms of major depression, PTSD and other comorbid disorders, with a direct impact of worsening suicidal ideations and suicidal behavior among war veterans.

Development of the combat distress scale of the Combat Experiences Questionnaire (CEQ)

BACKGROUND

Military combat exposure can be perceived as a great threat to the integrity of soldiers. However, no available assessment tools evaluate the degree of emotional distress that results from the exposure to various combat scenarios. This paper presents the second independent section of the Combat Exposure Questionnaire, the Combat Distress Scale (CEQ B). This questionnaire assesses Veterans׳ subjective emotional distress that is due to objective and typical military combat scenarios during war.

METHODS

A sample of 708 Portuguese Overseas War Veterans participated. The scale structure of the CEQ B was analyzed with a Rasch Model, and the internal consistency and convergent validity of the scale were studied. The temporal reliability was calculated in a subgroup of 112 participants. Two samples of war Veterans with and without war-related Post-Traumatic Stress Disorder (N=40 and N=47, respectively) were used to explore the scale׳s discriminant validity.

RESULTS

Overall, the CEQ B showed an acceptable fit to the data, excellent internal consistency, high temporal stability, adequate convergent validity and suitable discriminant validity.

LIMITATIONS

This study used a population of male war Veterans that did not equally represent genders or the full adult age span, which may hinder the generalization of the results.

CONCLUSION

The findings indicated that the CEQ B is valid, reliable and supported by convergent and discriminant data. This lends confidence in the use of the measure as an assessment of the subjective emotional distress resulting from exposure to military combat scenarios in clinical and research settings.

Suicide Ideation and Deliberate Self-Harm among Ex-Prisoners of War

The current study aims to assess the relations among war captivity, PTSD, suicidal ideation (SI), and deliberate self-harm (DSH) among former prisoners of war (ex-POWs). Israeli ex-POWs (N = 176) and a matched control group of combat veterans (controls; N = 118) were assessed using self-report measures. Ex-POWs with PTSD reported higher levels of both SI and DSH compared to ex-POWs and comparable veterans without PTSD. Furthermore, captivity-related variables as well as PTSD symptom clusters were positively related to both SI and DSH. However, only loss of emotional control in captivity and posttraumatic intrusion and emotional numbing symptoms, predicted SI. Ex-POWs with PTSD endorse high levels of SI and DSH. Among ex-POWs, both SI and DSH share similar captivity-related and posttraumatic symptoms correlates but only posttraumatic intrusion and emotional numbing symptoms predict SI.

[War trauma and PTSD among German war survivors. A comparison of former soldiers and women of World War II]

Stressful war experiences can cause posttraumatic stress disorder (PTSD) in survivors. To what extent were the soldiers and young women of World War II affected by PTSD symptoms over the course of their lives? Do these men and women differ in the traumatic experiences and PTSD symptom severity? To investigate these questions 52 male and 20 female Germans aged 81-95 years were recruited through newspaper advertisements and notices and interviewed regarding war experiences and PTSD symptoms. Of the men 2% and 7% met the criteria for current and lifetime PTSD diagnoses, respectively, as compared to 10% and 30% of the women, respectively. Using multiple linear regression a dose-response relationship between the number of trauma types experienced and PTSD symptom severity could be demonstrated. The slope of the regression curve was steeper for women than for men. When controlling for the number of different traumatic experiences women reported a significantly higher severity of PTSD symptoms than men. It is presumed that this difference in severity of symptoms can be attributed to qualitative differences in the type of traumatic stress factors during the war. The present study provides evidence that even today people continue to be affected by PTSD symptoms due to events which occurred during World War II; therefore, during patient contact with this age group the war experiences specific to each individual need to be considered as potential moderators of symptoms.

War leaves an enduring legacy in combatants' lives

The memory of combat experience endures in World War II veterans. As veterans age, traumatic memory that previously may have been suppressed in the busyness of family and everyday life can re-emerge. Combat stress may affect not only the veterans, but also those people closely associated with them. Interviews were conducted with World War II veteran aircrew, wives, children, grandchildren, siblings, and friends to examine the impact of combat experience on the veterans and the family across the life course from the perspectives of the various participants. The combat experience significantly affected the life course of most.

THE ROLES OF COMBAT EXPOSURE, PERSONAL VULNERABILITY, AND INVOLVEMENT IN HARM TO CIVILIANS OR PRISONERS IN VIETNAM WAR-RELATED POSTTRAUMATIC STRESS DISORDER

The diagnosis, Posttraumatic Stress Disorder, was introduced in 1980 amidst debate about the psychiatric toll of the Vietnam War. There is controversy, however, about its central assumption that potentially traumatic stressors are more important than personal vulnerability in causing the disorder. We tested this assumption with data from a rigorously diagnosed male subsample (n = 260) from the National Vietnam Veterans Readjustment Study. Combat exposure, pre-war vulnerability, and involvement in harming civilians or prisoners were examined, with only combat exposure proving necessary for disorder onset. While none of the three factors proved sufficient, estimated onset reached 97% for veterans high on all three, with harm to civilians or prisoners showing the largest independent contribution. Severity of combat exposure proved more important than pre-war vulnerability in onset; pre-war vulnerability at least as important in long-term persistence. Implications for the primacy of the stressor assumption, further research, and policy are discussed.

Does Wartime Captivity Affect Late-life Mental Health? A Study of Vietnam-era Repatriated Prisoners of War

Our earlier study of U.S. prisoners of war in Vietnam (King et al., 2011) examined personal and military demographics and aspects of the stressful experience of wartime imprisonment as they related to psychological well-being shortly after homecoming in 1973. Research with repatriated prisoners of war (RPWs) from other military eras suggests that the severity of captivity stressors might predict long-term distress. However, the extent to which effects of the captivity experience persisted for Vietnam-era RPWs is unknown. The present study extended our previous analyses by examining the associations of demographic factors, captivity stressors, and repatriation mental health with subsequent symptoms of posttraumatic stress disorder (PTSD), anxiety, and depressive symptoms (measured nearly 30 years later) in a sample of 292 Vietnam-era RPWs. Results indicated that although most of the men in our sample were within normal limits on anxiety and depressive symptoms, a substantial minority reported experiencing clinically significant levels. Levels of PTSD symptoms were generally low, with only a modest proportion demonstrating elevations. Multiple regression analyses showed that age at capture and posttraumatic stress symptoms at repatriation predicted all three long-term mental health outcomes. In addition, physical torture predicted long-term PTSD symptoms. Findings highlight the potential long-term effects of wartime captivity, and also suggest that most Vietnam-era RPWs demonstrate remarkable resilience to extraordinarily stressful life experiences.

Potentially traumatic events at different points in the life span and mental health: findings from SHARE-Israel

This study addressed the association between adversity cumulated at different points in the life span and present mental health. Data of 1,130 participants aged 50+ were drawn from the Israeli component of the Survey of Health, Ageing and Retirement in Europe (SHARE). Measures included an inventory of potentially traumatic events, mental distress (depressive symptoms), and well-being (quality of life, life satisfaction). Adversity reported to have occurred early in life was positively related to mental health (i.e., to lower distress and higher well-being), whereas adversity reported to occur in late life was negatively related (i.e., to higher distress and lower well-being). Additional analyses showed that the positive association between early-life adversity and mental health was mainly restricted to adversity in which the primary harm was to another person (other-oriented adversity). In contrast, the negative association between late-life adversity and mental health was mainly restricted to adversity in which the primary harm was to the self (self-oriented adversity). This study suggests that the differential association between cumulative adversity and mental health is best captured when accounting for both time of occurrence and adversity type.

Long-term effects of coping with extreme stress: longitudinal study of Vietnam-era repatriated prisoners of war

Captivity stressors and coping strategies were assessed shortly after the repatriation of Vietnam-era prisoners of war, and physical and mental health were assessed almost three decades later. Given research on coping goodness-of-fit, specifically the extent to which coping effects depend on situational controllability, we proposed that endorsement of the usefulness of avoidance-based strategies in captivity would be predictive of better later-life health. Findings indicated that approach-based and avoidance-based coping both moderated the link between physical torture and later physical health functional status, whereas approach-based coping moderated the link between injuries at capture and later mental health. Specifically, greater endorsement of avoidance-based coping was associated with better long-term physical health for prisoners who experienced the most physical torture. Lower endorsement of approach-based coping was associated with better long-term mental health for prisoners who reported the most injuries at the time of capture.

Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF-OIF Veterans

Posttraumatic stress disorder (PTSD) is associated with intrusive trauma-related thoughts and avoidance behaviors that contribute to its severity and chronicity. This study examined thought control and avoidance coping strategies associated with both a probable diagnosis and symptom severity of combat-related PTSD in a sample of 167 treatment-seeking Operations Enduring Freedom and Iraqi Freedom (OEF-OIF) Veterans. Within one year of returning from deployment, Veterans completed a survey containing measures of combat exposure, coping strategies, psychopathology, and postdeployment social support. Veterans with a positive screen for PTSD scored higher than Veterans without a positive screen for PTSD on measures of worry, self-punishment, social control, behavioral distraction, and avoidance coping strategies. Worry and social avoidance coping were positively related to PTSD symptoms, and greater perceptions of understanding from others were negatively related to these symptoms. A structural equation model revealed that scores on a measure of postdeployment social support were negatively associated with scores on measures of maladaptive cognitive coping (i.e., worry, self-punishment) and avoidance coping (social and non-social avoidance coping) strategies, which were positively associated with combat-related PTSD symptoms. These results suggest that maladaptive thought control and avoidance coping may partially mediate the relation between postdeployment social support and combat-related PTSD symptoms in treatment-seeking OEF-OIF Veterans. Consistent with cognitive therapy models, these findings suggest that interventions that target maladaptive coping strategies such as worry, self-punishment, and social avoidance, and that bolster social support, most notably understanding from others, may help reduce combat-related PTSD symptoms in this population.

Trends in probable PTSD in firefighters exposed to the World Trade Center disaster, 2001-2010

OBJECTIVE

We present the longest follow-up, to date, of probable posttraumatic stress disorder (PTSD) after the 2001 terrorist attacks on the World Trade Center (WTC) in New York City firefighters who participated in the rescue/recovery effort.

METHODS

We examined data from 11,006 WTC-exposed firefighters who completed 40,672 questionnaires and reported estimates of probable PTSD by year from serial cross-sectional analyses. In longitudinal analyses, we used separate Cox models with data beginning from October 2, 2001, to identify variables associated with recovery from or delayed onset of probable PTSD.

RESULTS

The prevalence of probable PTSD was 7.4% by September 11, 2010, and continued to be associated with early arrival at the WTC towers during every year of analysis. An increasing number of aerodigestive symptoms (hazard ratio [HR] 0.89 per symptom, 95% confidence interval [CI] 0.86-.93) and reporting a decrease in exercise, whether the result of health (HR 0.56 vs no change in exercise, 95% CI 0.41-.78) or other reasons (HR 0.76 vs no change in exercise, 95% CI 0.63-.92), were associated with a lower likelihood of recovery from probable PTSD. Arriving early at the WTC (HR 1.38 vs later WTC arrival, 95% CI 1.12-1.70), an increasing number of aerodigestive symptoms (HR 1.45 per symptom, 95% CI 1.40-1.51), and reporting an increase in alcohol intake since September 11, 2001 (HR 3.43 vs no increase in alcohol intake, 95% CI 2.67-4.43) were associated with delayed onset of probable PTSD.

CONCLUSIONS

Probable PTSD continues to be associated with early WTC arrival even 9 years after the terrorist attacks. Concurrent conditions and behaviors, such as respiratory symptoms, exercise, and alcohol use also play important roles in contributing to PTSD symptoms.

[How does collective violence shape the health status of its victims? Conceptual model and design of the ISAVIC study]

OBJECTIVES

Epidemiologic research on collective violence (violence exerted by and within groups in pursuit of political, social or economic goals) is very scarce despite its growing recognition as a major public health issue. This paper describes the conceptual model and design of one of the first research studies conducted in Spain aiming to assess the impact of collective violence in the health status of its victims (study known as ISAVIC, based on its Spanish title Impacto en la SAlud de la VIolencia Colectiva).

METHODS

Starting with a comprehensive but non-systematic review of the literature, the authors describe the sequelae likely produced by collective violence and propose a conceptual model to explain the nature of the relationships between collective violence and health status. The conceptual model informed the ISAVIC study design and its measurement instruments.

RESULTS

The possible sequelae of collective violence, in the physical, emotional and social dimensions of health, are described. Also, the review distinguishes the likely impact in primary and secondary victims, as well as the interplay with the social environment. The mixed methodological design of the ISAVIC study supports the coherence of the conceptual model described.

CONCLUSIONS

The ISAVIC study suggests that collective violence may affect the main dimensions of the health status of its victims, in intimate relation to the societal factors where it operates. It is necessary to validate these results with new studies.

Twin studies of posttraumatic stress disorder: differentiating vulnerability factors from sequelae

Posttraumatic stress disorder (PTSD) is defined by one's response to an environmental event. However, genetic factors are important in determining people's response to that event, and even their likelihood of being exposed to particular traumatic events in the first place. Classical twin designs can decompose genetic and environmental sources of variance. Such studies are reviewed extensively elsewhere, and we cover them only briefly in this review. Instead, we focus primarily on the identical co-twin control design. This design makes it possible to resolve the "chicken-egg" dilemma inherent in standard case-control designs, namely, distinguishing risk from sequelae. Abnormalities that are present in both the twin with PTSD and the unaffected co-twin suggest pre-existing vulnerability indicators. These include smaller hippocampal volume, large cavum septum pellucidum, more neurological soft signs, lower general intellectual ability, and poorer performance in the specific cognitive abilities of executive function, attention, declarative memory, and processing of contextual cues. In contrast, abnormalities in a twin with PTSD that are not present in the identical co-twin suggest consequences of PTSD or trauma exposure. These include psychophysiological responding, higher resting anterior cingulate metabolism, event-related potential abnormalities associated with attentional processes, recall intrusions, and possibly some types of chronic pain. Most co-twin control studies of PTSD have been small and come from the same twin registry of middle-aged male veterans. Consequently, there is a great need for replication and extension of the findings, particularly in women and younger individuals. The creation of new twin registries would do much toward accomplishing this goal. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Alexithymia and posttraumatic stress: subscales and symptom clusters

This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difficulty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed.

Comorbidity of PTSD and depression in Korean War veterans: prevalence, predictors, and impairment

BACKGROUND

Rates of PTSD and depression are high in Korean War veterans. The prevalence and impact of the two disorders occurring comorbidly, however, has not been investigated. This paper aims to investigate the extent to which PTSD and depression co-occur in Australian veterans of the Korean War, the symptom severity characteristics of comorbidity, the impact on life satisfaction and quality, and the association with war-related predictors.

METHODS

Veterans (N=5352) completed self-report questionnaires including the Posttraumatic Stress Disorder Checklist, the Hospital Anxiety and Depression Scale, the Life Satisfaction Scale, the brief World Health Organisation Quality of Life questionnaire and the Combat Exposure Scale.

RESULTS

Seventeen percent of veterans met criteria for comorbid PTSD and depression, 15% had PTSD without depression, and a further 6% had depression without PTSD. Compared with either disorder alone, comorbidity was associated with impaired life satisfaction, reduced quality of life, and greater symptom severity. Several war-related factors were associated with comorbidity and with PTSD alone, but not with depression alone.

LIMITATIONS

The reliance on self-reported measures and the necessity for retrospective assessment of some deployment-related factors renders some study data vulnerable to recall bias.

CONCLUSIONS

Comorbid PTSD and depression, and PTSD alone, are prevalent among Korean War veterans, are both associated with war-related factors 50 years after the Korean War, and may represent a single traumatic stress construct. The results have important implications for understanding complex psychopathology following trauma.

[Violence is also a public health issue]

In 1996, the World Health Organization declared violence a major and growing public health problem across the world. In Spain, despite the growing incidence of reports of deaths and abuse due to intimate partners violence; the emergent data on school-based violence among children and adolescents; the persisting political violence and the tragic experience of the 11-M attacks in Madrid; a clear positioning over the role of the public health structures in the study and intervention of violence has not taken place. This article provides a characterization of the impact of violence in the health of its victims, as derived from a non-systematic review of the clinical, psychological and social literature. It also includes some prevalence data from Spanish studies. Special emphasis is given to violence against women, and political violence. The article highlights the scarcity of epidemiological data, which hinders the assessment of the health impact of violence in Spain. It brings, instead, the opinions of a number of public health professionals over the role of the Spanish communities of epidemiology and public health in this matter. The article concludes with a call to public health professionals, including the Spanish scientific societies involved in public health, to facilitate the public debate leading to the definition of the role of the Spanish public health in the understanding and reduction of the impact of violence on the health of its victims.

Psychosocial predictors of military misconduct

The objective of this longitudinal study was to determine psychosocial predictors of military misconduct in a cohort of Marine Corps war veterans. The study included data from 20,746 male Marines who completed a life history questionnaire during initial basic training and were subsequently deployed to a combat zone. Associations between psychosocial variables, psychiatric diagnoses, and subsequent misconduct outcomes were analyzed using Cox proportional hazards regression. The strongest predictors of misconduct outcomes (bad conduct discharges and military demotions) were psychiatric diagnoses and young age at first combat deployment. The results indicate that combat-related psychological disorders may manifest in numerous harmful ways, including impulsive, disruptive, and antisocial behavior. We recommend that the association between misconduct and psychiatric disorders be more explicitly acknowledged in research and treatment efforts involving military war veterans and other trauma victims.

Psychological resilience and postdeployment social support protect against traumatic stress and depressive symptoms in soldiers returning from Operations Enduring Freedom and Iraqi Freedom

BACKGROUND

A number of studies have examined the prevalence and correlates of posttraumatic stress disorder (PTSD), depression, and related psychiatric conditions in soldiers returning from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF), but none have examined whether factors such as psychological resilience and social support may protect against these conditions in this population.

METHODS

A total of 272 predominantly older reserve/National Guard OEF/OIF veterans completed a mail survey assessing traumatic stress and depressive symptoms, resilience, and social support.

RESULTS

Resilience scores in the full sample were comparable to those observed in civilian outpatient primary-care patients. Respondents with PTSD, however, scored significantly lower on this measure and on measures of unit support and postdeployment social support. A hierarchical regression analysis in the full sample suggested that resilience (specifically, increased personal control and positive acceptance of change) and postdeployment social support were negatively associated with traumatic stress and depressive symptoms, even after adjusting for demographic characteristics and combat exposure.

CONCLUSIONS

These results suggest that interventions to bolster psychological resilience and postdeployment social support may help reduce the severity of traumatic stress and depressive symptoms in OEF/OIF veterans.

Ten-year follow-up study of PTSD diagnosis, symptom severity and psychosocial indices in aging holocaust survivors

OBJECTIVE

We performed a longitudinal study of holocaust survivors with and without post-traumatic stress disorder (PTSD) by assessing symptoms and other measures at two intervals, approximately 10 years apart.

METHOD

The original cohort consisted of 63 community-dwelling subjects, of whom 40 were available for follow-up.

RESULTS

There was a general diminution in PTSD symptom severity over time. However, in 10% of the subjects (n=4), new instances of delayed onset PTSD developed between time 1 and time 2. Self-report ratings at both assessments revealed a worsening of trauma-related symptoms over time in persons without PTSD at time 1, but an improvement in those with PTSD at time 1.

CONCLUSION

The findings suggest that a nuanced characterization of PTSD trajectory over time is more reflective of PTSD symptomatology than simple diagnostic status at one time. The possibility of delayed onset trajectory complicates any simplistic overall trajectory summarizing the longitudinal course of PTSD.

The impact of social support: an analogue investigation of the aftermath of trauma exposure

Recent meta-analytic studies suggest that social support plays an important role in regulating the severity of post-traumatic adjustment; however, few studies have manipulated potential underlying mechanisms. This analogue study examined how various social reactions, following trauma exposure, influenced subsequent anxiety, affect, and intrusive thoughts. Ninety-three participants viewed a distressing videotape followed by a portrayal of positive, negative, or neutral social reactions. While negative reactions increased initial negative affect, neutral reactions increased later frequency and severity of intrusive thoughts. Based on this, it was suggested that "neutral" social reactions following trauma exposure may have the potential for being highly invalidating and in some circumstances may actually have more negative later effects than overtly negative ones.

Posttraumatic stress disorder; combat exposure; and nicotine dependence, alcohol dependence, and major depression in male twins

Combat exposure is associated with increased risk of psychiatric and substance use disorders in veterans. However, it is not known whether combat exposure independently increases risk for these disorders or whether this association is accounted for by genetic vulnerability common to posttraumatic stress disorder (PTSD). This article tests competing explanations for the association of combat exposure and PTSD with nicotine dependence (ND), alcohol dependence (AD), and major depression (MD). Data were obtained from 6099 members of the Vietnam Era Twin Registry, a national registry of male-male twin pairs who served in the military during the Vietnam era. Twin models were fit to estimate the genetic and environmental variance common and specific to Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, lifetime diagnoses of PTSD, combat trauma, and 3 comorbid conditions: ND, AD, and MD. Variance specific to ND, AD, and MD was due to genetic factors (48%, 36%, and 12%, respectively) and unique environmental factors (36%, 42%, and 58%, respectively). After accounting for variance common to PTSD, no residual genetic and environmental variance overlapped between combat and ND, combat and AD, and combat and MD. Combat exposure is not independently associated with lifetime ND, AD, and MD. The association of combat exposure with these 3 disorders is due to genetic and unique environmental contributions in common with PTSD. These findings suggest comorbid PTSD may represent a genetically mediated vulnerability to psychopathology after trauma.

Social bonds and posttraumatic stress disorder

Retrospective and prospective studies consistently show that individuals exposed to human-generated traumatic events carry a higher risk of developing Posttraumatic Stress Disorder (PTSD) than those exposed to other kinds of events. These studies also consistently identify perceptions of social support both before and after a traumatic event as an important factor in the determining vulnerability to the development of PTSD. We review the literature on interpersonal traumas, social support and risk for PTSD and integrate findings with recent advances in developmental psychopathology, attachment theory and social neuroscience. We propose and gather evidence for what we term the social ecology of PTSD, a conceptual framework for understanding how both PTSD risk and recovery are highly dependent on social phenomena. We explore clinical implications of this conceptual framework.

Posttraumatic stress disorder and posttraumatic growth among Israeli ex-pows

In this article, the authors present a prospective study that dealt with pathological (posttraumatic stress disorder; PTSD) and salutary (posttraumatic growth; PTG) outcomes of captivity and the correlates of those outcomes among a sample of ex-prisoners of war (POWs) and a control group of combat veterans. Posttraumatic stress disorder and its correlates were assessed in 1991 and 2003, and PTG was assessed in 2003. The results indicate that ex-POWs exhibited higher levels of PTSD and PTG than did the controls. In addition, both linear and quadratic associations between PTSD and PTG were found. The authors discuss some unresolved issues related to assessment of PTG and salutary outcomes, and outline directions for future research.

Anxiety, post-traumatic stress disorder and depression in Korean War veterans 50 years after the war

BACKGROUND

There has been no comprehensive investigation of psychological health in Australia's Korean War veteran population, and few researchers are investigating the health of coalition Korean War veterans into old age.

AIMS

To investigate the association between war service, anxiety, post-traumatic stress disorder (PTSD) and depression in Australia's 7525 surviving male Korean War veterans and a community comparison group.

METHOD

A survey was conducted using a self-report postal questionnaire which included the PTSD Checklist, the Hospital Anxiety and Depression scale and the Combat Exposure Scale.

RESULTS

Post-traumatic stress disorder (OR 6.63, P<0.001), anxiety (OR 5.74, P<0.001) and depression (OR 5.45, P<0.001) were more prevalent in veterans than in the comparison group. These disorders were strongly associated with heavy combat and low rank.

CONCLUSIONS

Effective intervention is necessary to reduce the considerable psychological morbidity experienced by Korean War veterans. Attention to risk factors and early intervention will be necessary to prevent similar long-term psychological morbidity in veterans of more recent conflicts.

The impact of resource loss on Holocaust survivors facing war and terrorism in Israel

We examined the distress level of 102 Holocaust survivors in Israel during a recent period of continuous exposure of the Israeli population to terror and the threat of missile attack. Based on the Conservation of Resources (COR) theory, we explored the contribution of losses suffered during the Holocaust and of current loss of resources due to terror attacks on their distress level. Twenty one percent of the sample had probable PTSD and high psychological distress levels in general. Current loss of psychosocial resources contributed significantly to survivors' current PTSD symptomatology and general psychological distress, above the contribution of the previous Holocaust-related loss. Our findings support COR theory, which states that traumatic events are associated with ongoing and often rapid loss of resources. Resource loss, in turn, is associated with higher distress levels. Moreover, current loss of resources compounds the impact of earlier resource losses incurred during the Holocaust.

Are male disaster workers with Vietnam military service at greater risk for ptsd than peers without combat history?

This study examined whether male disaster workers with Vietnam service histories were at risk for posttraumatic stress disorder when compared with colleagues following duties at Ground Zero. The study compared participants from ongoing psychiatric screening of disaster workers: those with Vietnam service (Vietnam veteran; N = 125), those without trauma history (no trauma; N = 116); and those with childhood physical abuse but no combat history (physical abuse; N = 57). ANOVA indicated the trauma groups differed significantly in clinician-rated posttraumatic stress disorder severity (p < 0.005). However, post hoc analyses revealed the Vietnam veteran group did not differ significantly from the no trauma group; both had significantly lower severity compared with the physical abuse group. It should be noted that veterans in this sample, unlike in many studies, were in the workforce. Research with different veteran groups is warranted to clarify further the relation of combat experience and symptoms in disaster workers.

A comparative study of posttraumatic stress disorder assessment under standard conditions and in the field

Little is known about the performance of clinician-administered structured diagnostic interviews when given under variable levels of examiner training and monitoring. We sought to explore this question. We examined the performance of a self-report questionnaire and a structured clinical interview in the assessment of post-traumatic stress disorder (PTSD) in two community samples of war veterans. One sample was interviewed under standard conditions (N = 372) and the other under unknown and less standardized conditions (N = 420), more closely approximating 'field conditions'. Interview results were used to predict questionnaire-based PTSD status. Kappas, sensitivities, specificities, and positive predictive powers were moderate and of similar magnitude in both samples. Our results suggest that even under uncertain ('field') conditions, clinician-administered structured interviews can produce results comparable to those produced under more tightly controlled conditions.

Evidence of resilience: neuroimaging in former prisoners of war

In this study, single voxel proton magnetic resonance spectroscopic imaging ((1)H-MRS) and volumetric analysis of hippocampal magnetic resonance imaging (MRI) images were used to determine if any differences in hippocampal biochemistry or volume were present between former prisoners of war (POWs) with and without posttraumatic stress disorder (PTSD) and control subjects matched for age and education. This study did not find lower hippocampal concentrations of N-acetylaspartate (NAA), smaller hippocampal volumes, or more impaired memory function in older veterans with PTSD compared with a group matched for traumatic experience or a nontraumatized control group.

Review of assessment and treatment of PTSD among elderly American armed forces veterans

BACKGROUND

The number of elderly combat veterans is steadily increasing in the US and estimates project that a notable percentage of these veterans experience symptoms of posttraumatic stress disorder (PTSD). Limited data exist specifically related to prevalence, assessment, and treatment of PTSD among the elderly veteran population.

OBJECTIVE

This review summarizes the available research related to difficulties in assessment with the elderly American Armed Forces veteran population. In addition, both psychotherapeutic and pharmacological treatment interventions for PTSD are discussed.

METHODS

A literature search was conducted using PsycINFO, Medline, and the National Center for PTSD's PILOTS database.

RESULTS

Evidence suggests that elderly veterans generally present more somatic symptoms of PTSD. Medical and psychological comorbidities, such as depression, substance abuse, or cognitive deficits can further complicate the assessment process. Cut-scores for existing instruments need to be further established with elderly veterans. Use of exposure therapies with the elderly has not been adequately researched and mixed results have been obtained for supportive therapy for treatment of PTSD. Controlled research investigating pharmacological interventions for PTSD with the elderly is also limited.

CONCLUSION

Evidence suggests that some psychotherapeutic and pharmacological interventions already utilized with younger individuals may be useful with the elderly veteran population. However, research indicates that modifications may be required for working with the elderly population and further research in the areas of assessment and treatment are necessary.

Trauma, PTSD, and resilience: a review of the literature

Based on the available literature, this review article investigates the issue of resilience in relation to trauma and posttraumatic stress disorder. Resilient coping to extreme stress and trauma is a multifaceted phenomena characterized as a complex repertoire of behavioral tendencies. An integrative Person x Situation model is developed based on the literature that specifies the nature of interactions among five classes of variables: (a) personality, (b) affect regulation, (c) coping, (d) ego defenses, and (e) the utilization and mobilization of protective factors and resources to aid coping.