Documented combat exposure of US veterans seeking treatment for combat-related post-traumatic stress disorder

A Theoretical and Theological Reframing of Trauma

Racism, eco-violence, and myriad sociopolitical and interpersonal injustices continuously injure individuals, communities, and the globe, thereby challenging the human capacity to endure. The prevailing biomedical model of trauma, with its emphasis on pathology, fails to acknowledge the traumatic nature of these diffuse and pervasive injuries. The disciplines of spiritual and pastoral psychology are uniquely poised to reconceptualize trauma and reframe it as part of a stress-trauma continuum, given the way trauma can engender great suffering as well as resistance and the possibility of transformation. This perspective eschews the sentiment, ubiquitous in popular culture, that everything stressful is traumatic as well as the notion that "true" trauma is delimited by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This article posits a strength-based approach to trauma that contextualizes our societal negativity bias within spiritual values of hope, (post-traumatic) growth, and (possibly) resilience while not diminishing the very real suffering, even despair, that emerge from trauma of all kinds.

Detecting Negative Response Bias Within the Trauma Symptom Inventory–2 (TSI-2): a Review of the Literature

This systematic review was performed to summarize existing research on the symptom validity scales within the Trauma Symptom Inventory–Second Edition (TSI-2), a relatively new self-report measure designed to assess the psychological sequelae of trauma. The TSI-2 has built-in symptom validity scales to monitor response bias and alert the assessor of non-credible symptom profiles. The Atypical Response scale (ATR) was designed to identify symptom exaggeration or fabrication. Proposed cutoffs on the ATR vary from ≥ 7 to ≥ 15, depending on the assessment context. The limited evidence available suggests that ATR has the potential to serve as measure of symptom validity, although its classification accuracy is generally inferior compared to well-established scales. While the ATR seems sufficiently sensitive to symptom over-reporting, significant concerns about its specificity persist. Therefore, it is proposed that the TSI-2 should not be used in isolation to determine the validity of the symptom presentation. More research is needed for development of evidence-based guidelines about the interpretation of ATR scores.

Depression in post-traumatic stress disorder

Major depressive disorder (MDD) symptoms commonly occur after trauma-exposure, both alone and in combination with post-traumatic stress disorder (PTSD). This article reviews recent research on comorbidity between these disorders, including its implications for symptom severity and response to treatment. Despite considerable symptom overlap, the two disorders represent distinct constructs and depend, at least in part, on separate biological mechanisms. Both, however, are also clearly related to stress psychopathology. We recommend that more research focus specifically on the study of individual differences in symptom expression in order to identify distinct subgroups of individuals and develop targeted treatments. However, a barrier to this line of inquiry is the trend of excluding particular patients from clinical trials of new interventions based on symptom severity or comorbidity. Another obstacle is the overreliance on self-report measures in human research. We argue that developing computer-based behavioral measures in order to supplement self-report can help address this challenge. Furthermore, we propose that these measures can help tie findings from human and non-human animal research. A number of paradigms have been used to model MDD-and PTSD-like behavior in animals. These models remain valuable for understanding the biological basis of these disorders in humans and for identifying potential interventions, but they have been underused for the study of comorbidity. Although the interpretation of animal behavior remains a concern, we propose that this can also be overcome through the development of close human analogs to animal paradigms.

Coronavirus syndrome: COVID-19 psychotrauma

The authors propose term "coronavirus syndrome" for the mental disorder that is a psychical response to the global problem of COVID-19 pandemic. This syndrome will affect up to 10% of the population and we could already observe acute stress reactions to the spread of the infection and changes in people's ordinary lifestyle. However, the most severe response will be seen later, in this case the catastrophe is similar to the clinical picture of post-traumatic stress disorder. The problem is that coronavirus syndrome will affect the working capacity of population at the period, when economical recovery is essential. The risk groups are health caregivers who worked in COVID departments; patients recovered from a severe form of the disease; people who have lost their loved ones; and those who have suffered significant financial losses or lost their jobs. Adequate prophylaxis of coronavirus syndrome especially in high-risk groups are important for maintaining global mental health and economy.

Psychometric Performance of the Miller Forensic Assessment of Symptoms Test (M-FAST) in Veteran PTSD Assessment

This study examined the psychometric properties of a widely used measure of symptom exaggeration, the Miller Forensic Assessment of Symptoms Test (M-FAST, Miller, 2001), in a sample of 209 (83.7% male) trauma-exposed veterans (57.9% probable current posttraumatic stress disorder; PTSD). M-FAST total scores evidenced acceptable internal consistency, but several subscales showed poor internal consistency. Factor analytic and item-response theory analyses identified seven poorly performing items. Comparisons with other measures of psychopathology and response validity (including subscales from the Minnesota Multiphasic Personality Inventory-2 Restructured Form) revealed that M-FAST scores were highly correlated with indices of psychopathology while less strongly associated with measures of symptom over-reporting. Empirically and clinically-derived (using a follow-up testing-the-limits procedure) revised M-FAST scores failed to improve the measure's psychometric performance. Results raise concerns about the validity of the M-FAST for identifying malingering in veterans with PTSD and carry implications for access to care and forensic evaluations in this population.

The Impacts of Service Related Exposures on Trajectories of Mental Health Among Aging Veterans

Objectives

Drawing on life-course perspective and cumulative advantage theory, we examined whether service related exposures (SREs)-combat and exposure to death-have lasting impacts on depressive symptom and psychiatric problem trajectories of aging veterans.

Methods

The Health and Retirement Study and linked 2013 Veterans Mail Survey were used to examine SREs and mental health among older veterans between 2002 and 2012 (N = 1,662). Latent growth curves were used to measure how individuals vary from average mental health trajectories based on SREs and other important covariates.

Results

Exposure to death had a significant and lasting effect on depressive symptoms for veterans in late life but was reduced to nonsignificance when physical health trajectories were included. Combat and exposure to death had independent and robust impacts on psychiatric problems, which were robust in final models.

Discussion

SREs presented varied and significant impacts, suggesting that combat does not work alone in driving poor mental health trajectories, and that exposure to death is a more robust risk marker for later outcomes.

Terrorism and post-traumatic stress disorder: a historical review

Terror is a psychological state. Historically, most studies of terrorism focused on its societal purpose and structural consequences rather than mental health effects. That emphasis began to change shortly before the Sept 11, 2001, terrorist attacks. A vast expansion of research into post-traumatic stress disorder accompanied revisions to the classification of mental health disorders. The effect of terrorist incidents on those people now deemed vulnerable, both directly and indirectly, was actively sought. However, a review of more than 400 research articles (mostly published after Sept 11) on the association between terrorism and mental health reached the largely overlooked conclusion that terrorism is not terrorising-at least not in a way that causes a greater than expected frequency of post-traumatic stress disorder than other traumatic events. This conclusion is surprising given the emphasis on the psychological effects of terrorism in political discourse, media commentary, contemporary culture, and academic inquiry. Authorities might prefer to encourage an interpretation of terrorist incidents that highlights fortitude and courage rather than psychological vulnerability.

White Matter Associations With Performance Validity Testing in Veterans With Mild Traumatic Brain Injury: The Utility of Biomarkers in Complicated Assessment

OBJECTIVE

Failure on performance validity tests (PVTs) is common in Veterans with histories of mild traumatic brain injury (mTBI), leading to questionable validity of clinical presentations.

PARTICIPANTS

Using diffusion tensor imaging, we investigated white matter (WM) integrity and cognition in 79 Veterans with history of mTBI who passed PVTs (n = 43; traumatic brain injury [TBI]-passed), history of mTBI who failed at least 1 PVT (n = 13; TBI-failed), and military controls (n = 23; MCs) with no history of TBI.

RESULTS

The TBI-failed group demonstrated significantly lower cognitive scores relative to MCs and the TBI-passed group; however, no such differences were observed between MCs and the TBI-passed group. On a global measure of WM integrity (ie, WM burden), the TBI-failed group showed more overall WM abnormalities than the other groups. However, no differences were observed between the MCs and TBI-passed group on WM burden. Interestingly, regional WM analyses revealed abnormalities in the anterior internal capsule and cingulum of both TBI subgroups relative to MCs. Moreover, compared with the TBI-passed group, the TBI-failed group demonstrated significantly decreased WM integrity in the corpus callosum.

CONCLUSIONS

Findings revealed that, within our sample, WM abnormalities are evident in those who fail PVTs. This study adds to the burgeoning PVT literature by suggesting that poor PVT performance does not negate the possibility of underlying WM abnormalities in military personnel with history of mTBI.

UK extended Medical Assessment Programme for ex-service personnel: the first 150 individuals seen

Aims and method

To describe an interim service set up to examine the breadth of UK ex-service personnel's concerns in relation to their mental health and military service and provide a record of the first 150 individuals assessed following conformation of military service and examination of all available military and civilian medical records.

Results

The majority of attendees were White male ex-soldiers. Average age, service and time to assessment were 44.5, 15.8 and 11.7 years respectively. Two-thirds were receiving help from the National Health Service and ex-service nongovernmental organisations. Rates of post-traumatic stress disorder were similar to previous UK studies. Obsessional symptoms were of relevance to the clinical presentation in a third. Fabrication and/or exaggeration occurred in about 10%.

Clinical implications

The spread of diagnoses and delay in help-seeking are similar to civilians. The link between mental disorders and military service is seldom straightforward and fabrication or exaggeration is difficult for civilians to recognise. Verification and contextualisation of service using contemporaneous service medical records is important given the possible occupational origin of mental health conditions.

Targets for the Treatment of Insomnia in Veterans With Serious Mental Illness

STUDY OBJECTIVES

Insomnia is pervasive among people with serious mental illnesses (SMI) and has a profound negative impact on their psychiatric symptom management and recovery. However, little is known about the factors that affect severity of insomnia in those with SMI. In addition, very few studies have explored whether evidence-based interventions developed for those without SMI are appropriate for or applicable to individuals with SMI. The purpose of this study was to test the role of arousal, dysfunctional cognitions about sleep, and sleep-related behaviors in predicting severity of insomnia in a sample of 60 Veterans who were receiving care in Veterans Health Administration mental health and psychosocial rehabilitation programs and who reported subjective insomnia. In addition, information was collected regarding the types of insomnia treatments provided to these Veterans.

METHODS

Participants completed assessments of insomnia severity and sleep-related arousal, behaviors, and cognitions. Medical records were reviewed to determine whether participants had been screened/assessed for insomnia and whether treatments for insomnia were provided before the date of referral to the study. Multiple regression was used to predict insomnia severity on the basis of these factors.

RESULTS

Most participants (81.7%) reported moderate to severe insomnia, although only 3.3% had a diagnosis of insomnia in their medical records. Worry and helplessness about sleep were predictive of insomnia severity; better self-reported sleep hygiene and higher levels of arousal were also associated with greater severity of insomnia. Education about sleep hygiene and medication were the only types of insomnia treatment received.

CONCLUSIONS

Similar to insomnia among individuals without SMI, insomnia in Veterans with SMI is associated with dysfunctional sleep-related behaviors and cognitions. Many of the Veterans also lacked access to settings and resources conducive to healthy sleep. Veterans with SMI should be regularly assessed for insomnia. Research is needed concerning optimal evidence-based insomnia interventions for addressing behaviors and cognitions in this population in the context of these challenges.

The Role of Patient Characteristics in the Concordance of Daily and Retrospective Reports of PTSD

Research has documented discrepancies between daily and retrospective reports of psychological symptoms in a variety of conditions. A limited number of studies have assessed these discrepancies in samples of individuals with posttraumatic stress disorder (PTSD), with even less research addressing potential covariates that may influence such discrepancies. In the current study, 65 individuals with co-occurring PTSD and alcohol use disorder (AUD) completed daily assessments of their PTSD symptoms for 1 month, followed by a standard retrospective report of PTSD over the same month. Initial analyses explored the mean levels of daily and retrospective PTSD symptoms, while multilevel models assessed the level of agreement between daily and retrospective reports and the role of demographic variables and comorbid psychopathology (e.g., depression) or substance use (e.g., alcohol use) in moderating the association of daily and retrospective reports. Results showed that retrospective reports of arousal and avoidance symptoms were weakly related to daily reports of these symptoms, while reports of reexperiencing and numbing symptoms showed better agreement. Intra-individual alcohol consumption also moderated associations of reexperiencing and avoidance symptoms, such that on days individuals drank more, their daily reports resembled their retrospective reports less well. Future research should explore the degree to which these results generalize to nondually diagnosed samples, as well as the role such reporting discrepancies may play in PTSD treatment.

PTSD in Court III: Malingering, assessment, and the law

This journal's third article on PTSD in Court focuses especially on the topic's "court" component. It first considers the topic of malingering, including in terms of its definition, certainties, and uncertainties. As with other areas of the study of psychological injury and law, generally, and PTSD (posttraumatic stress disorder), specifically, malingering is a contentious area not only definitionally but also empirically, in terms of establishing its base rate in the index populations assessed in the field. Both current research and re-analysis of past research indicates that the malingering prevalence rate at issue is more like 15±15% as opposed to 40±10%. As for psychological tests used to assess PTSD, some of the better ones include the TSI-2 (Trauma Symptom Inventory, Second Edition; Briere, 2011), the MMPI-2-RF (Minnesota Multiphasic Personality Inventory, Second Edition, Restructured Form; Ben-Porath & Tellegen, 2008/2011), and the CAPS-5 (The Clinician-Administered PTSD Scale for DSM-5; Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane, 2013b). Assessors need to know their own possible biases, the applicable laws (e.g., the Daubert trilogy), and how to write court-admissible reports. Overall conclusions reflect a moderate approach that navigates the territory between the extreme plaintiff or defense allegiances one frequently encounters in this area of forensic practice.

Consistency of Self-Reported Neurocognitive Symptoms, Post-Traumatic Stress Disorder Symptoms, and Concussive Events From End of First Deployment to Veteran Health Administration Comprehensive Traumatic Brain Injury Evaluation by Operations Enduring Freedom/Iraqi Freedom/New Dawn Veterans

Objective

This study examined the consistency of self-reported symptoms and concussive events in combat veterans who reported experiencing concussive events.

Method

One hundred and forty, single deployed, Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn combat veterans with Veteran Health Administration (VHA) Comprehensive Traumatic Brain Injury Evaluations (CTBIE) and no post-deployment head injury were examined to assess consistency of self-reported (a) traumatic brain injury (TBI)-related symptoms, (b) post-traumatic stress disorder (PTSD)-related symptoms, and (c) TBI-related concussive events from soon after deployment to time of VHA CTBIE.

Results

Compared to their self-report of symptoms and traumatic events at the time of their Post-Deployment Health Assessment, at the time of their comprehensive VHA evaluation, subjects reported significantly greater impairment in concentration, decision making, memory, headache, and sleep. In addition, although half the subjects denied any PTSD symptoms post-deployment, approximately three quarters reported experiencing all four PTSD screening symptoms near the time of the VHA CTBIEs. At the latter time, subjects also reported significantly more TBI-related concussive events, as well as more post-concussive sequelae such as loss of consciousness immediately following these concussive events. Finally, although 84% reported a level of impairment so severe as to render all but the simplest activity doable, the vast majority simultaneously reported working and/or attending college.

Conclusions

These findings raise questions regarding the accuracy of veteran self-report of both near and distant traumatic events, and argue for the inclusion of contemporaneous Department of Defense (DOD) records in veteran assessment and treatment planning.

A Daily Diary Study of Posttraumatic Stress Symptoms and Romantic Partner Accommodation

Little is known about the role of romantic partner symptom accommodation in PTSD symptom maintenance. To explore the bidirectional associations of posttraumatic stress disorder (PTSD) symptoms and romantic partner symptom accommodation over time, military servicemen (n=64) with symptoms of PTSD and their cohabiting heterosexual civilian romantic partners (n=64) completed a 2-week daily diary study. Cross-lagged, autoregressive models assessed the stability of men's PTSD symptoms and partners' accommodation, as well as the prospective associations of earlier PTSD symptoms with later accommodation and vice versa. Analyses used Bayesian estimation to provide point estimates (b) and Credible Intervals (CIs). In all models, PTSD symptoms (total and individual clusters) were highly stable (b=0.91; CI: 0.88-0.95), and accommodation was moderately stable (b=0.48; CI: 0.40-0.54). In all models, earlier PTSD symptoms (total and clusters) were significantly, positively associated with later accommodation (b=0.04; CI: 0.02-0.07). In contrast, earlier accommodation was significantly associated only with later situational avoidance (b=0.02; CI: 0.00-0.07). Thus, PTSD symptoms may lead to subsequent accommodating behaviors in romantic partners, but partner accommodation seems to contribute only to survivors' future situational avoidance symptoms. The findings reinforce the notion that PTSD symptoms have an impact on relationship behaviors, and that accommodation from partners may sustain avoidant behaviors in particular. Clinicians should attend to romantic partners' accommodating behaviors when working with survivors.

Forensic implications of changes in DSM-5 criteria for responses to trauma and stress

DSM-5 significantly changed the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) relative to DSM-IV/DSM-IV-TR. These changes do not alter its basic approach to diagnosing mental disorders, which treats each disorder as a separate category. This article analyzes the strengths and weaknesses of the categorical approach, and reviews empirical evidence regarding the impact of changes within it on the ease or difficulty of receiving the PTSD diagnosis. It especially analyzes the impact of newly included symptoms that are meant to identify cases in which trauma exposure was associated with changes in more serious PTSD cases, known as Complex PTSD (C-PTSD). It proposes some effects that the changes could have on psychological injury claims. Many changes could support plaintiffs' claims while others could support defense claims. Some changes could support either. Overall, DSM-5 PTSD diagnosis is more responsive to individual differences in symptom presentations and appears able to diagnose some C-PTSD cases. The thesis throughout the article is that PTSD diagnostic accuracy could be improved further, especially for C-PTSD cases, by complementing its current exclusive reliance on behavioral symptoms that are characteristic of victims in general with assessment of the meaning that the symptoms have for individual victims. The article proposes some principles to guide interpretation of the individualized meaning of victims' symptoms, which help make the reasoning behind the interpretations explicit.

DSM-5 Criteria and Its Implications for Diagnosing PTSD in Military Service Members and Veterans

This review addresses how changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 posttraumatic stress disorder (PTSD) criteria has the potential to affect the care and careers of those who have served in the military, where the diagnosis often determines fitness for duty and veterans' benefits. PTSD criteria changes were intended to integrate new knowledge acquired since previous DSM editions. Many believe the changes will improve diagnosis and treatment, but some worry these could have negative clinical, occupational, and legal consequences. We analyze the changes in classification, trauma definition, symptoms, symptom clusters, and subtypes and possible impacts on the military (e.g., over- and under-diagnosis, "drone" video exposure, subthreshold PTSD, and secondary PTSD). We also discuss critiques and proposals for future changes. Our objectives are to improve the screening, diagnosis, and treatment of those service members who have survived trauma and to improve policies related to the military mental healthcare and disability systems.

Combat-related PTSD in military court: a diagnosis in search of a defense

As more veterans return from Iraq and Afghanistan, Posttraumatic Stress Disorder (PTSD) often returns with them. As a result, PTSD has quickly become the most prevalent mental disorder diagnosis among active duty United States (U.S.) military. Although numerous studies have not only validated PTSD but have chronicled its negative behavioral impact, it remains a controversial diagnosis. It is widely diagnosed by all types of mental health professionals for even minimal trauma, and DSM-IV PTSD criteria have wide overlap with other mood and anxiety disorders. This, however, has not stopped PTSD from being used in civilian courts in the U.S. as a mental disorder to establish grounds for mental status defenses, such as insanity, diminished capacity, and self-defense, or as a basis for sentencing mitigation. Not surprisingly, PTSD has recently found its way into military courts, where some defense attorneys are eager to draw upon its understandable and linear etiology to craft some type of mental incapacity defense for their clients. As in the civilian sphere, this has met with mixed success due to relevance considerations. A recent court-martial, U.S. v. Lawrence Hutchins III, has effectively combined all the elemental nuances of PTSD in military court.

The Effectiveness of the Personality Assessment Inventory With Feigned PTSD: An Initial Investigation of Resnick's Model of Malingering

Malingered posttraumatic stress disorder (PTSD) poses a formidable clinical challenge because of the apparent ease in feigning PTSD. As an additional confound, some patients with genuine PTSD produce elevated profiles on feigning indicators that are difficult to distinguish from feigned PTSD. The current study utilized 109 inpatients from a trauma unit to examine whether the Personality Assessment Inventory and the Detailed Assessment of Posttraumatic Stress can effectively differentiate between genuine and feigned PTSD. As a primary focus, Resnick's model of malingered PTSD was evaluated with its three subtypes: pure malingering, partial malingering, and false imputation. They were tested on their ability to (a) effectively simulate PTSD and (b) avoid being classified as feigning. The partial malingering group proved to be the best feigning group in achieving these two goals. Overall, the Personality Assessment Inventory Malingering Index and Negative Distortion Scale were the most effective at identifying feigning.

Etiology of depression comorbidity in combat-related PTSD: a review of the literature

Posttraumatic stress disorder is often diagnosed with other mental health problems, particularly depression. Although PTSD comorbidity has been associated with more severe and chronic symptomology, relationships among commonly co-occurring disorders are not well understood. The purpose of this study was to review the literature regarding the development of depression comorbid with combat-related PTSD among military personnel. We summarize results of commonly tested hypotheses about the etiology of PTSD and depression comorbidity, including (1) causal hypotheses, (2) common factor hypotheses, and (3) potential confounds. Evidence suggests that PTSD may be a causal risk factor for subsequent depression; however, associations are likely complex, involving bidirectional causality, common risk factors, and common vulnerabilities. The unique nature of PTSD-depression comorbidity in the context of military deployment and combat exposure is emphasized. Implications of our results for clinical practice and future research are discussed.

Over-reporting bias and the modified Stroop effect in Operation Enduring and Iraqi Freedom veterans with and without PTSD

The current study investigated in a sample of Operation Enduring and Iraqi Freedom (OEF/OIF) veterans how a symptom overreporting response style might influence the association between PTSD diagnostic status and color-naming response latency for trauma-related stimuli during the Modified Stroop Task (i.e., the Modified Stroop Task effect, MST effect). It was hypothesized that, if an overreporting response style reflected feigning or exaggerating PTSD symptoms, an attenuated MST effect would be expected in overreporters with PTSD as compared with PTSD-diagnosed veterans without an overreporting style. If, however, overreporting stemmed from high levels of distress, the MST effect might be greater in overreporters compared with those with a neutral response style. The results showed that veterans with PTSD and an overreporting response style demonstrated an augmented MST effect in comparison with those with a more neutral style of response. Overreporters also reported greater levels of psychopathology, including markedly elevated reports of dissociative experiences. We suggest that dissociation-prone overreporters may misattribute emotional distress to combat experiences leading to the enhanced MST effect. Other possible explanations for these results are also discussed.

Why are Iraq and Afghanistan War veterans seeking PTSD disability compensation at unprecedented rates?

The wars in Iraq and Afghanistan have produced historically low rates of fatalities, injuries, and posttraumatic stress disorder (PTSD) among U.S. combatants. Yet they have also produced historically unprecedented rates of PTSD disability compensation seeking from the U.S. Department of Veterans Affairs. The purpose of this article is to consider hypotheses that might potentially resolve this paradox, including high rates of PTSD, delayed onset PTSD, malingered PTSD, and economic variables.

Lessons from the 2004 Asian tsunami: epidemiological and nosological debates in the diagnosis of post-traumatic stress disorder in non-Western post-disaster communities

BACKGROUND

The nosological validity of post-traumatic stress disorder (PTSD) remains controversial in non-Western communities. After natural disasters, epidemiological studies often overlook these conceptual debates and assess post-traumatic stress symptoms (PTSS) by short screening instruments. Such PTSS estimates are reported as inflated prevalence rates of PTSD in post-disaster settings.

AIMS

To discuss the prevalence and determinants of PTSS within the context of pertinent epidemiological and nosological debates.

METHODS

We assessed PTSS and grief symptoms of 643 survivors from five Indian villages struck by the Asian tsunami using the Impact of Events Scale - Revised and Complicated Grief Assessment Scale. We adopted a case control design and employed complex sample multiple logistic regression statistics to study the determinants of PTSS.

RESULTS

The prevalence of PTSS was 15.1% (95% CI 12.3%-17.9%). PTSS was significantly associated with traumatic grief, female gender, physical injury, death of children and financial losses, but not with functional disability (p = .91).

CONCLUSIONS

Although PTSS were common in this population, elevating them to a psychiatric construct of PTSD is questionable, when functional impairment and avoidance behaviours were absent. Grief reactions, socio-economic burden, and poor support systems contribute towards PTSS. We highlight the important issues regarding the nosological validity and epidemiology of PTSD in non-Western communities.

Diagnostic and statistical manual-5: Position paper of the Indian Psychiatric Society

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Psychiatric disorder and suicide in the military, then and now: commentary on Frueh and Smith

Consulting archival medical data from the American Civil War, Frueh and Smith found little evidence of mental disorders, no evidence of reexperiencing symptoms suggestive of posttraumatic stress disorder, but a notable rate of suicide. In this commentary, I suggest reasons why the archives contain so few traces of combat-related disorders despite the massive trauma experienced by soldiers in the Civil War, and I draw implications for military personnel returning from the wars in Iraq and Afghanistan.

Suicide, alcoholism, and psychiatric illness among union forces during the U.S. Civil War

Little is known about post-combat psychological reactions of warriors prior to the Twentieth Century. We estimated rates of suicide, alcohol abuse, and probable psychiatric illness among Union Forces during the U.S. Civil War via examination of data compiled by the Union Army. White active-duty military personnel suicide rates ranged from 8.74 to 14.54 per 100,000 during the war, and surged to 30.4 the year after the war. For blacks, rates ranged from 17.7 in the first year of their entry into the war (1863), to 0 in their second year, and 1.8 in the year after the war. Rates for most other relevant domains, including chronic alcoholism, "nostalgia," and insanity, were extremely low (<1.0%) by modern day standards. Data provide contextual information on suicide and psychiatric variables for combatants during the U.S. Civil War, a brutal modern war with vastly higher casualty rates than recent wars in Iraq and Afghanistan.

Why we should worry about malingering in the VA system: comment on Jackson et al. (2011)

In a recent survey, Jackson et al. (2011) found that clinicians who evaluate veterans for service-connected disability pensions rarely use recommended best practices to assess for posttraumatic stress disorder (PTSD) within the Department of Veterans Affairs (VA). We share their dismay, and we hope that their article will help foster evidence-based assessments for diagnosing PTSD in veterans. Jackson et al. briefly discussed scholarship on malingering among applicants for service-connected disability compensation for PTSD, concluding that concerns about malingering are largely unfounded. The data they adduce, however, in support of this conclusion actually provide reasons for concern as we document in this article. We cite recent work by labor economists in support of our argument.

Trajectories of trauma symptoms and resilience in deployed U.S. military service members: prospective cohort study

BACKGROUND

Most previous attempts to determine the psychological cost of military deployment have been limited by reliance on convenience samples, lack of pre-deployment data or confidentiality and cross-sectional designs.

AIMS

This study addressed these limitations using a population-based, prospective cohort of U.S. military personnel deployed in support of the operations in Iraq and Afghanistan.

METHOD

The sample consisted of U.S. military service members in all branches including active duty, reserve and national guard who deployed once (n = 3393) or multiple times (n = 4394). Self-reported symptoms of post-traumatic stress were obtained prior to deployment and at two follow-ups spaced 3 years apart. Data were examined for longitudinal trajectories using latent growth mixture modelling.

RESULTS

Each analysis revealed remarkably similar post-traumatic stress trajectories across time. The most common pattern was low-stable post-traumatic stress or resilience (83.1% single deployers, 84.9% multiple deployers), moderate-improving (8.0%, 8.5%), then worsening-chronic post-traumatic stress (6.7%, 4.5%), high-stable (2.2% single deployers only) and high-improving (2.2% multiple deployers only). Covariates associated with each trajectory were identified.

CONCLUSIONS

The final models exhibited similar types of trajectories for single and multiple deployers; most notably, the stable trajectory of low post-traumatic stress preto post-deployment, or resilience, was exceptionally high. Several factors predicting trajectories were identified, which we hope will assist in future research aimed at decreasing the risk of post-traumatic stress disorder among deployers.

Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans

One hundred thirty-eight Veterans Affairs mental health professionals completed a 128-item Posttraumatic Stress Disorder (PTSD) Practice Inventory that asked about their practices and attitudes related to disability assessment of PTSD. Results indicate strikingly wide variation in the attitudes and practices of clinicians conducting disability assessments for PTSD. In a high percentage of cases, these attitudes and practices conflict with best-practice guidelines. Specifically, 59% of clinicians reported rarely or never using testing, and only 17% indicated routinely using standardized clinical interviews. Less than 1% of respondents reported using functional assessment scales.

The Things They Carry: Combat, Disability and Unemployment among US Men

Sociologists have long recognized that historical events, such as wars, depressions, and natural disasters, can affect the trajectories of people's lives and can reproduce or alter social structure. The following paper examines the effect of a type of event, war, on a facet of people's lives, their ability to work. It uses data from the Panel Study of Income Dynamics to test three accounts regarding how wars affect men's lives. The direct cumulative disadvantage account sees wars as negatively affecting the service-men who see combat regardless of their pre-combat characteristics. The moderated cumulative disadvantage account suggests that combat most negatively affects those who, before they fought, had lower status. The turning point account suggests the reverse: combat most negatively affects those who, before they fought, had greater status. The evidence suggests that, with regard to disability and unemployment, the effects of combat are most consistent with the direct cumulative disadvantage account.

What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study

BACKGROUND

Concerns have been raised about the psychological effect of continued combat exposure and of repeated deployments. We examined the consequences of deployment to Iraq and Afghanistan on the mental health of UK armed forces from 2003 to 2009, the effect of multiple deployments, and time since return from deployment.

METHODS

We reassessed the prevalence of probable mental disorders in participants of our previous study (2003-05). We also studied two new randomly chosen samples: those with recent deployment to Afghanistan, and those who had joined the UK armed forces since April, 2003, to ensure that the final sample continued to be representative of the UK armed forces. Between November, 2007, and September, 2009, participants completed a questionnaire about their deployment experiences and health outcomes.

FINDINGS

9990 (56%) participants completed the study questionnaire (8278 regulars, 1712 reservists). The prevalence of probable post-traumatic stress disorder was 4.0% (95% CI 3.5-4.5; n=376), 19.7% (18.7-20.6; n=1908) for symptoms of common mental disorders, and 13.0% (12.2-13.8; n=1323) for alcohol misuse. Deployment to Iraq or Afghanistan was significantly associated with alcohol misuse for regulars (odds ratio 1.22, 95% CI 1.02-1.46) and with probable post-traumatic stress disorder for reservists (2.83, 1.23-6.51). Regular personnel in combat roles were more likely than were those in support roles to report probable post-traumatic stress disorder (1.87, 1.26-2.78). There was no association with number of deployments for any outcome. There was some evidence for a small increase in the reporting of probable post-traumatic stress disorder with time since return from deployment in regulars (1.13, 1.03-1.24).

INTERPRETATION

Symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders in UK armed forces personnel, whereas the prevalence of probable post-traumatic stress disorder was low. These findings show the importance of continued health surveillance of UK military personnel.

FUNDING

UK Ministry of Defence.

Prevalence Estimates of Combat-Related PTSD: A Critical Review

The aim of the present study was to provide a critical review of prevalence estimates of combat-related post-traumatic stress disorder (PTSD) among military personnel and veterans, and of the relevant factors that may account for the variability of estimates within and across cohorts, including methodological and conceptual factors accounting for differences in prevalence rates across nations, conflicts/wars, and studies. MEDLINE and PsycINFO databases were examined for literature on combat-related PTSD. The following terms were used independently and in combinations in this search: PTSD, combat, veterans, military, epidemiology, prevalence. The point prevalence of combat-related PTSD in US military veterans since the Vietnam War ranged from approximately 2% to 17%. Studies of recent conflicts suggest that combat-related PTSD afflicts between 4% and 17% of US Iraq War veterans, but only 3-6% of returning UK Iraq War veterans. Thus, the prevalence range is narrower and tends to have a lower ceiling among combat veterans of non-US Western nations. Variability in prevalence is likely due to differences in sampling strategies; measurement strategies; inclusion and measurement of the DSM-IV clinically significant impairment criterion; timing and latency of assessment and potential for recall bias; and combat experiences. Prevalence rates are also likely affected by issues related to PTSD course, chronicity, and comorbidity; symptom overlap with other psychiatric disorders; and sociopolitical and cultural factors that may vary over time and by nation. The disorder represents a significant and costly illness to veterans, their families, and society as a whole. Further carefully conceptualized research, however, is needed to advance our understanding of disorder prevalence, as well as associated information on course, phenomenology, protective factors, treatment, and economic costs.

Kamikaze Attack Survivors: How Accurate are Their PTSD Reports?

12 survivors of the USS Emmons ( M age = 81.3 yr., SD = 3.26), which was sunk by kamikaze attacks during World War II, were given an adapted form of the Posttraumatic Stress Disorder Checklist-Civilian. Five of their wives ( M age = 78.8 yr., SD = 3.42) and 16 of their children ( M age = 50.2 yr., SD = 5.37) estimated the veterans' checklist scores. The combined wives' and children's mean score estimate was nearly identical to the veterans' mean checklist score. Analysis using the Wilcoxon signed rank test comparing the veterans' self-reports and their family members' estimated reports of them was statistically insignificant. The findings suggest that Emmons survivors' PTSD reports are reliable.