The Nature of Combat Stress Development During Military Operations and Psychotherapy in Extreme Situations

ABSTRACT

The purpose of the research work is the theoretical and empirical analysis of the study of the nature of combat stress in military personnel and the assessment of psychotherapeutic methods of providing psychological assistance in extreme situations. The authors used the following methods to achieve this goal: method of analysis and synthesis, hermeneutic method, testing method, comparative method, and generalization method. The results of the research work have revealed the meaning of traumatic stress, psychological trauma, and combat mental trauma, and explained the concept of combat stress and the dynamics of its growth. The findings identified the factors of posttraumatic stress syndrome and its prevalence, tracked down the dynamics of psychoemotional disorders, and revealed the importance of military psychological selection and determination of combat readiness. The authors established the main tasks of a staff psychologist in working with military personnel, conducted an empirical study of the nature of combat stress in the military, observed main psychotherapeutic tools for the prevention of negative mental states in combat conditions, and investigated self-regulation techniques of emotional, physical, and mental health. The practical significance of the scientific work lies in the modern coverage of the phenomenon of combat stress and the classification of effective psychotherapeutic methods that will ensure the sustainable psychological preparation of the soldiers for extreme situations.

The Psychological Consequences of Combat Injury Among U.S. Navy Health Care Personnel

INTRODUCTION

Military health care personnel face numerous risks to mental health, including those associated with combat injury, although no study has described combat injuries within this subgroup or assessed their impact on mental health outcomes.

MATERIALS AND METHODS

Male U.S. Navy-enlisted health care personnel, or corpsmen, with combat injury were identified from clinical records. Noninjured corpsmen were matched to injured corpsmen with a 4:1 ratio on year of deployment end or injury and location (Iraq or Afghanistan). The final study population included 2,025 corpsmen (405 injured and 1,620 noninjured). Mental health disorders assessed included posttraumatic stress disorder (PTSD), anxiety, adjustment, mood, and substance abuse disorders. Stratified Cox models were used for analysis while controlling for additional covariates, and injury severity was evaluated as a predictor.

RESULTS

Injuries primarily involved the head/neck (73.8%) and extremities (45.7%), and overall injury severity was mostly mild-to-moderate (85.9%). Injured relative to noninjured corpsmen had greater risk of PTSD (risk ratio [RR] 2.45, 95% confidence interval [CI] 2.05 to 2.94), anxiety disorder (RR 1.61, 95% CI 1.32 to 1.96), adjustment disorder (RR 1.88, 95% CI 1.55 to 2.27), mood disorder (RR 1.44, 95% CI 1.16 to 1.79), and substance abuse (RR 1.48, 95% CI 1.14 to 1.91). More severe injuries yielded stronger associations with PTSD (RR 3.57, 95% CI 2.48 to 5.14), anxiety disorder (RR 2.53, 95% CI 1.74 to 3.69), and adjustment disorder (RR 2.17, 95% CI 1.44 to 3.27).

CONCLUSIONS

U.S. Navy corpsmen are at risk of combat injury and associated mental health disorders. Injured corpsmen should be screened for mental health problems in the acute phase postinjury, during their remaining time in theater, and after returning home. Future research should address how combat injury compares with other stressors that health care personnel experience and whether the psychological consequences of these injuries (e.g., PTSD) negatively impact work performance and increase risk of burnout.

Exposure to combat experiences: PTSD, somatization and aggression amongst combat and non-combat veterans

To this date, the prevalence of posttraumatic stress disorder (PTSD) and associated psychological symptom profiles amongst non-combatant community-based veterans in Israel has not been studied. Data were analysed from a web-based survey of veterans via a market research platform during September 2021 and included 522 non-combat (e.g. intelligence, office-based or education corps) veterans and 534 combat (e.g. front-line infantry) veterans. The survey assessed PTSD, depression, anxiety and somatic symptoms in addition to the prevalence of self-reported aggression. A two-way multivariate analysis of covariance indicated that higher PTSD and somatic symptoms were prevalent for those exposed to combat experiences even when not in a combatant role. A logistic regression indicated that of those who did not self-define as aggressive prior to service, those exposed to combat were three times more likely to be aggressive following their service than veterans not exposed to combat. This effect was not demonstrated for combat soldiers compared to non-combat soldiers. Results indicate that mental health outreach would be better targeted towards those who have been exposed to combat-type experiences during their service even in non-combat units. The current study highlights the effect of combat exposure on secondary PTSD symptoms; aggression and somatization.

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.

Is avoidance the only issue? A case study of "self-triggering" in combat-related posttraumatic stress disorder

OBJECTIVE

We explore the emerging concept of "self-triggering" through a case illustration of a Vietnam veteran with posttraumatic stress disorder (PTSD) who engaged in self-triggering for 50 years after his index trauma. He reduced the frequency of self-triggering upon receiving a combination of cognitive processing therapy and behavioral exposure treatment.

METHOD

This article provides a brief overview of the emerging literature on self-triggering, proposes theory for its function, and discusses how self-triggering affected the treatment of this veteran's chronic PTSD.

RESULTS

Through clinical intervention that focused on what to approach (i.e., real-world experiences) and what to avoid (i.e., online triggering videos), the veteran stopped one kind of self-triggering but not another. The veteran attributed much of his positive behavior change to desire to honor the life of a young boy whose likely death he witnessed in Vietnam.

CONCLUSIONS

Though people with PTSD often go to great lengths to avoid reminders of their trauma, there is a subset who seek reminders that trigger distressing reexperiencing symptoms. Such puzzling self-triggering behavior in those with PTSD is seldom studied and poorly understood. The details of this veteran's experience present a compelling case for self-triggering as an attempt to search for meaning in one's trauma, gain control of symptoms, and punish oneself. Implications for research and clinical practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Post-traumatic growth amongst UK armed forces personnel who were deployed to Afghanistan and the role of combat injury, mental health and pain: the ADVANCE cohort study

BACKGROUND

Post-traumatic growth (PTG) is a positive psychological consequence of trauma. The aims of this study were to investigate whether combat injury was associated with deployment-related PTG in a cohort of UK military personnel who were deployed to Afghanistan, and whether post-traumatic stress disorder (PTSD), depression and pain mediate this relationship.

METHODS

521 physically injured (n = 138 amputation; n = 383 non-amputation injury) and 514 frequency-matched uninjured personnel completed questionnaires including the deployment-related Post-Traumatic Growth Inventory (DPTGI). DPTGI scores were categorised into tertiles of: no/low (score 0-20), moderate (score 21-34) or a large (35-63) degree of deployment-related PTG. Analysis was completed using generalised structural equation modelling.

RESULTS

A large degree of PTG was reported by 28.0% (n = 140) of the uninjured group, 36.9% (n = 196) of the overall injured group, 45.4% (n = 62) of amputee and 34.1% (n = 134) of the non-amputee injured subgroups. Combat injury had a direct effect on reporting a large degree of PTG [Relative risk ratio (RRR) 1.59 (95% confidence interval (CI) 1.17-2.17)] compared to sustaining no injury. Amputation injuries also had a significant direct effect [RRR 2.18 (95% CI 1.24-3.75)], but non-amputation injuries did not [RRR 1.35 (95% CI 0.92-1.93)]. PTSD, depression and pain partially mediate this relationship, though mediation differed depending on the injury subtype. PTSD had a curvilinear relationship with PTG, whilst depression had a negative association and pain had a positive association.

CONCLUSIONS

Combat injury, in particular injury resulting in traumatic amputation, is associated with reporting a large degree of PTG.

Limitations of benefit finding as a coping mechanism for combat-related PTSD symptoms

Benefit finding has been identified as a buffer of the combat exposure-PTSD symptom link in soldiers. However, benefit finding may have a limited buffering capacity on the combat-PTSD symptom link over the course of a soldier's post-deployment recovery period. In the present study, soldiers returning from Operation Iraqi Freedom (OIF) were surveyed at two different time periods post-deployment: Time 1 was 4 months post-deployment (n = 1,510), and Time 2 was at 9 months post-deployment (n = 783). The surveys assessed benefit finding, PTSD symptoms, and combat exposure. Benefit finding was a successful buffer of the cross-sectional relationship between combat exposure and PTSD reexperiencing symptoms at Time 1, but not at Time 2. In addition, the benefit finding by combat interaction at time 1 revealed that greater benefit finding was associated with higher symptoms under high combat exposure at Time 2 after controlling for PTSD arousal symptoms at Time 1. The results of the present study indicate that benefit finding may have a buffering capacity in the immediate months following a combat deployment, but also indicates that more time than is allotted during the post-deployment adjustment period is needed to enable recovery from PTSD. Theoretical implications are discussed.

Emotion regulation and combat severity differentiates PTSD diagnostic status among veterans

OBJECTIVE

This study examined whether posttraumatic stress disorder (PTSD) diagnostic groups in veterans were differentiated by combat severity and specific avoidance and approach-related emotion regulation (ER) strategies.

METHOD

In a cohort study, 725 participants (Mage = 58.39, SD = 11.27, 94.5% male, 58.2% White) recruited from VHA facilities completed the Clinician Administered PTSD Scale (CAPS), Combat Exposure Scale (CES), and Emotion Regulation Questionnaire (ERQ). Participants were categorized into three PTSD groups: Current, Remitted, and Never.

RESULTS

Multinomial logistic regressions adjusting for age, sex, and race, showed combat severity significantly differentiated all groups from each other (ps < .001). Specifically, combat severity was significantly associated with increased odds of Current PTSD versus Remitted (OR: 1.02, 95% CI [1.01, 1.05]) and Never PTSD (OR: 1.14, [1.12, 1.17]) and odds of Remitted compared with Never PTSD (OR: 1.11, [1.09, 1.14]). Suppression, but not reappraisal, was significantly associated with increased odds of Current PTSD compared with Remitted (OR: 1.15, [1.06, 1.24]) and Never PTSD (OR: 1.14, [1.06, 1.22]; ps < .001). Lower reappraisal was only significantly associated with the likelihood of Remitted PTSD compared with Never PTSD (OR: 0.93, [0.88, 0.99], p = .03).

CONCLUSIONS

Increasing levels of combat severity differentiated veterans with current, remitted, and no history of PTSD, suggesting screening for severity of combat may be helpful. Greater habitual suppression distinguished current versus non-current PTSD status, whereas only less reappraisal distinguished non-current groups from each other. Lower suppression may be an important treatment target for veterans with moderate and high combat severity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Does Prior Civilian Trauma Moderate the Relationship Between Combat Trauma and Post-deployment Mental Health Symptoms?

In addition to combat trauma, childhood and adult non-military, interpersonal trauma exposures have been linked to a range of psychiatric symptoms (e.g., alcohol use problems, posttraumatic stress disorder [PTSD], depression symptoms) in veterans. However, few studies simultaneously explore the associations between these civilian and combat trauma types and mental health outcomes. Using a sample of combat-exposed veterans who were previously deployed to Iraq and Afghanistan (N = 302), this study sought to (a) understand the independent associations of civilian interpersonal trauma (i.e., childhood trauma and non-military adult trauma) and combat-related trauma with post-deployment alcohol use, PTSD symptoms, and depressive symptoms, respectively and (b) to examine the interactive effects of trauma type to test whether childhood and non-military adult trauma moderate the association of combat trauma with these outcomes. A path analytic framework was used to allow for the simultaneous prediction of these associations. In the final model non-military adult trauma and combat trauma were found to be significantly associated with PTSD symptoms and depression symptoms, but not average amount of drinks consumed per drinking day. Childhood trauma was not associated with any outcomes (i.e., PTSD symptoms, depression symptoms, average amount of drinks consumed per day). Only combat trauma was significantly associated with average amount of drinks consumed per day. Results underscore the importance of assessing multiple trauma types and considering trauma as a non-specific risk factor, as different trauma types may differentially predict various mental health outcomes other than PTSD. Further, results highlight the noteworthiness of considering co-occurring outcomes within the veteran community. Limitations, future directions, and implications of diversity are discussed.

Characteristics of Posttraumatic Nightmares and Their Relationship to PTSD Severity Among Combat Veterans With PTSD and Hazardous Alcohol Use

ABSTRACT

Although nightmares are known to predict the clinical course of posttraumatic stress disorder (PTSD), research on the relationship between specific nightmare characteristics and PTSD severity is sparse. This study conducted a secondary analysis to explore how five nightmare characteristics are cross-sectionally related to PTSD severity in 76 combat veterans with PTSD and at-risk alcohol use. Consistent with emotional processing theory, we hypothesized that more replicative, threatening, realistic, and easily recalled nightmares would be associated with more severe PTSD, whereas those with greater symbolism would predict lower PTSD severity. Nightmares narratives were audio-recorded and rated by multiple coders. Multiple analyses of variance explored the relationship between nightmare characteristics and PTSD clinical indicators. Most nightmares were realistic, easily recalled, and involved significant threat. Greater realism and replication were associated with greater PTSD severity. Realistic and replicative nightmares may be markers of more severe PTSD and may indicate that less emotional processing of the trauma has occurred.

Posttraumatic stress disorder: from gene discovery to disease biology

Posttraumatic stress disorder (PTSD) is a complex mental disorder afflicting approximately 7% of the population. The diverse number of traumatic events and the wide array of symptom combinations leading to PTSD diagnosis contribute substantial heterogeneity to studies of the disorder. Genomic and complimentary-omic investigations have rapidly increased our understanding of the heritable risk for PTSD. In this review, we emphasize the contributions of genome-wide association, epigenome-wide association, transcriptomic, and neuroimaging studies to our understanding of PTSD etiology. We also discuss the shared risk between PTSD and other complex traits derived from studies of causal inference, co-expression, and brain morphological similarities. The investigations completed so far converge on stark contrasts in PTSD risk between sexes, partially attributed to sex-specific prevalence of traumatic experiences with high conditional risk of PTSD. To further understand PTSD biology, future studies should focus on detecting risk for PTSD while accounting for substantial cohort-level heterogeneity (e.g. civilian v. combat-exposed PTSD cases or PTSD risk among cases exposed to specific traumas), expanding ancestral diversity among study cohorts, and remaining cognizant of how these data influence social stigma associated with certain traumatic events among underrepresented minorities and/or high-risk populations.

Remote exposure to traumatic events and PTSD symptoms among U.S. Air Force intelligence personnel: Moderating effects of morally injurious experiences

OBJECTIVES

U.S. Air Force (USAF) intelligence, surveillance, and reconnaissance (ISR) personnel continuously view high-resolution, real-time imagery and video feeds that include intermittent exposure to graphic events. This brief report examined whether cumulative exposure (still imagery, video, and audio) to graphic events was associated with posttraumatic stress disorder (PTSD) symptoms among USAF ISR personnel. We also examined whether morally injurious experiences (MIEs)-as well as three MIE subtypes: (a) personal moral transgressions, (b) transgressions by others, and (c) feelings of betrayal by others-moderated the association between ISR work-related traumatic exposure and PTSD symptoms.

METHOD

Participants were 277 USAF ISR personnel assigned to intelligence units.

RESULTS

We found two significant moderation effects. First, we found that the association between ISR remote graphic media exposure and PTSD symptoms was strongest for participants with higher levels of MIE exposure. Second, we found that the ISR remote graphic media exposure-PTSD symptoms association was strongest among participants who reported higher levels of MIEs that were self-directed; that is, they reported being troubled with believing they had violated their own morals, values, or principles.

CONCLUSIONS

Findings emphasize the importance of moral injury in understanding PTSD symptoms in ISR personnel. Specifically, because MIEs and PTSD are possible in remote combat agents, prevention and intervention efforts for ISR actors should directly target this special population with recognition that (a) remote combat exposure can be traumatic and (b) perceived violations of moral beliefs or values may be central to any posttraumatic psychopathology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Initial Validation of the Mid-Atlantic Mental Illness Research, Education, and Clinical Center Assessment of Traumatic Brain Injury

With the increasing prevalence of traumatic brain injury (TBI), the need for reliable and valid methods to evaluate TBI has also increased. The purpose of this study was to establish the validity and reliability of a new comprehensive assessment of TBI, the Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Assessment of TBI (MMA-TBI). The participants in this study were post-deployment, combat exposed veterans. First, MMA-TBI outcomes were compared with those of independently conducted clinical TBI assessments. Next, MMA-TBI outcomes were compared with those of a different validated TBI measure (the Ohio State University TBI Identification method [OSU-TBI-ID]). Next, four TBI subject matter experts independently evaluated 64 potential TBI events based on both clinical judgment and Veterans Administration/Department of Defense (VA/DoD) Clinical Practice Guidelines. Results of the MMA-TBI algorithm (based on VA/DoD clinical guideline) were compared with those of the subject matter experts. Diagnostic correspondence with independently conducted expert clinical evaluation was 96% for lifetime TBI and 92% for deployment-acquired TBI. Consistency between the MMA-TBI and the OSU-TBI-ID was high (κ = 0.90; Kendall Tau = 0.94). Comparison of MMA-TBI algorithm results with those of subject matter experts was high (κ = 0.97-1.00). The MMA-TBI is the first TBI interview to be validated against an independently conducted clinical TBI assessment. Overall, results demonstrate the MMA-TBI is a highly valid and reliable instrument for determining TBI based on VA/DoD clinical guidelines. These results support the need for application of standardized TBI criteria across all diagnostic contexts.

Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder

BACKGROUND

Tetris has been proposed as a preventative intervention to reduce intrusive memories of a traumatic event. However, no neuroimaging study has assessed Tetris in patients with existing posttraumatic stress disorder (PTSD) or explored how playing Tetris may affect brain structure.

METHODS

We recruited patients with combat-related PTSD before psychotherapy and randomly assigned them to an experimental Tetris and therapy group (n = 20) or to a therapy-only control group (n = 20). In the control group, participants completed therapy as usual: eye movement desensitization and reprocessing (EMDR) psychotherapy. In the Tetris group, in addition to EMDR, participants also played 60 minutes of Tetris every day from onset to completion of therapy, approximately 6 weeks later. Participants completed structural MRI and psychological questionnaires before and after therapy, and we collected psychological questionnaire data at follow-up, approximately 6 months later. We hypothesized that the Tetris group would show increases in hippocampal volume and reductions in symptoms, both directly after completion of therapy and at follow-up.

RESULTS

Following therapy, hippocampal volume increased in the Tetris group, but not the control group. As well, hippocampal increases were correlated with reductions in symptoms of PTSD, depression and anxiety between completion of therapy and follow-up in the Tetris group, but not the control group.

LIMITATIONS

Playing Tetris may act as a cognitive interference task and as a brain-training intervention, but it was not possible to distinguish between these 2 potential mechanisms.

CONCLUSION

Tetris may be useful as an adjunct therapeutic intervention for PTSD. Tetris-related increases in hippocampal volume may ensure that therapeutic gains are maintained after completion of therapy.

Changes in the dynamic network structure of PTSD symptoms pre-to-post combat

BACKGROUND

Combat exposure is associated with elevated risk for post-traumatic stress disorder (PTSD). Despite considerable research on PTSD symptom clustering, it remains unknown how symptoms of PTSD re-organize following combat. Network analysis provides a powerful tool to examine such changes.

METHODS

A network analysis approach was taken to examine how symptom networks change from pre- to post-combat using longitudinal prospective data from a cohort of infantry male soldiers (Mage = 18.8 years). PTSD symptoms measured using the PTSD Checklist (PCL) were assessed after 6 months of combat training but before deployment and again after 6 months of combat (Ns = 910 and 725 at pre-deployment and post-combat, respectively).

RESULTS

Stronger connectivity between PTSD symptoms was observed post-combat relative to pre-deployment (global strength values of the networks were 7.54 pre v. 7.92 post; S = .38, p < 0.05). Both the re-experiencing symptoms cluster (1.92 v. 2.12; S = .20, p < 0.03) and the avoidance symptoms cluster (2.61 v. 2.96; S = .35, p < 0.005) became more strongly inter-correlated post-combat. Centrality estimation analyses revealed that psychological reaction to triggers was central and linked the intrusion and avoidance sub-clusters at post-combat. The strength of associations between the arousal and reactivity symptoms cluster remained stable over time (1.85 v. 1.83; S = .02, p = .92).

CONCLUSIONS

Following combat, PTSD symptoms and particularly the re-experiencing and avoidance clusters become more strongly inter-correlated, indicating high centrality of trigger-reactivity symptoms.

Blast concussion and posttraumatic stress as predictors of postcombat neuropsychological functioning in OEF/OIF/OND veterans

OBJECTIVES

Many combat veterans exhibit cognitive limitations of uncertain origin. In this study, we examined factors that predict cognitive functioning by considering effects of blast-related concussion (BRC), non-blast-related concussion (NBRC), and posttraumatic stress disorder (PTSD) symptoms. Analyses specifically tested whether (a) BRC and NBRC were distinct in their prediction of cognitive performance; (b) a dose-response relationship existed between recurrent concussion (BRC and NBRC) and cognitive impairment; and (c) PTSD symptoms mediated the relationship between BRC and cognitive performance.

METHOD

Two hundred eighty veterans with combat zone deployment histories completed semistructured clinical interviews to define BRC and NBRC histories, current and past mental health disorders, and dimensional ratings of PTSD symptomatology. Participants were also administered a number of neuropsychological measures to appraise cognitive functioning.

RESULTS

A structural equation model (SEM) suggested that BRC and NBRC were not distinct in their prediction of cognitive performance, and there was no evidence that recurrent concussion (blast or nonblast) was directly associated with cognitive performance. BRC was significantly associated with PTSD symptoms (r = .24), PTSD symptoms were significantly associated with cognitive performance in the SEM (r = -.27), and PTSD symptoms significantly mediated the link between BRC and cognitive performance (p = .03).

CONCLUSIONS

These results suggest that concussion history fails to directly contribute to cognitive performance, regardless of mechanism (blast or nonblast) and recurrence. BRC is nonetheless unique in its contribution to PTSD and PTSD-related cognitive deficits. Results support interventions specific to PTSD management in the interest of promoting neuropsychological functioning among war veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Psychophysiological Intervention to Improve Preparedness in Military Special Operations Forces

BACKGROUND: Actual studies in military training support the use of new methodological approaches such as high intensity interval training and inverse periodization training rather than conventional approaches. However, the application and analysis of success of these new methodologies are as yet unknown.METHODS: The military adapted the civil reverse periodization training system, composed of 6 wk and five sessions per week. For the first 3 wk soldiers performed two sessions with the objective of increasing the maximal strength of the upper and lower body muscles, and three sessions of short high-intensity interval training (HIIT). In the following 3 wk they combined two endurance HIIT and two resistance HIIT sessions with military equipment while conducting a military task.RESULTS: After the training a significant body mass index decrease was found, along with an increase in lower limb muscular strength, aerobic and anaerobic performance, resilience, stress tolerance, and psychological flexibility. Regarding the ratio of acceptance there was an increased ratio compared to previous years of 7%. In addition, married soldiers with children presented greater resilience, stress tolerance, psychological flexibility, and a higher ratio of success.DISCUSSION: Accepted soldiers presented greater psychological status and stress tolerance, highlighting the importance of the work of the unit psychologists to reinforce and monitor the psychometric profile of the soldiers as well as their intrinsic characteristics of personality and emotionality. The greater baseline physical condition and higher performance in all physical tests proves how reverse periodization training models are a great stimuli and training approach in soldiers.Tornero-Aguilera JF, Gregório Pelarigo J, Clemente-Suarez VJ. Psychophysiological intervention to improve preparedness in military Special Operations forces. Aerosp Med Hum Perform. 2019; 90(11):953-958.

Moral decision making, religious strain, and the experience of moral injury

OBJECTIVE

Moral injury is the lasting psychological, spiritual, and behavioral effects of having perpetrated acts that transgress moral boundaries. Contemporary models of moral injury in military veterans examine the role of transgressive acts, moral appraisals of these acts, and the symptoms of moral injury. However, little research has examined potential pathways between these elements. The current study examined appraisals of one's acts and religious strain as potential mediators of the link between transgressive acts and symptoms of moral injury. Further, given the inherent importance of moral cognitions in the appraisal process, we tested whether the acts to appraisals link was moderated by altruism in military veterans.

METHOD

An online survey, distributed using crowdsourcing software, was completed by military veterans. The survey included measures of transgressive acts, appraisals of these acts, religious strain, altruism, and self- and other-directed symptoms of moral injury. Mediation and moderated serial mediation were used to test the hypotheses.

RESULTS

Our results indicated appraisals and religious strain significantly mediated the acts to symptoms pathway for both self- and other-directed aspects of moral injury. This pathway was significantly moderated by altruism such that a stronger link exists between acts and appraisals at higher levels of altruism.

CONCLUSION

Overall, these findings suggest that religious functioning and moral decision making are important aspects of the experience of moral injury and are worthy of future study. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Psychiatric Care of the Post-September 11 Combat Veteran: A Review

BACKGROUND

Post-September 11, 2001 combat veterans represent a growing cohort of patients with unique mental health needs, particularly around post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). The United States (US) remains engaged in conflicts around the globe, so this patient cohort will continue to grow in number. With around 40% of American combat veterans from Iraq and Afghanistan seeking mental health care outside of the Veterans Affairs, understanding the psychiatric needs of the post-September 11 combat veteran is an important goal for all psychiatrists. These patients are relevant to consultation-liaison (C-L) psychiatrists because of their high comorbidity of conditions such as TBI, obstructive sleep apnea, insomnia, and chronic pain. This article reviews the current literature on mental health care for the post-September 11 combat veteran, emphasizing PTSD and TBI treatment, and culling evidence-based recommendations from randomized controlled trials of combat veterans. Emphasis is also placed on the Veterans Affairs/Department of Defense Clinical Practice Guidelines. The authors also bring unique clinical expertise of having served on active duty as psychiatrists for the US Army, including in a combat zone, and both currently work in a Veterans Affairs Iraq and Afghanistan combat veteran mental health clinic.

OBJECTIVE

This review outlines useful treatment approaches for PTSD and TBI and briefly covers the comorbid conditions of major depression, chronic pain, and substance use disorders. This review will prepare C-L psychiatrists to care for this challenging patient cohort.

Post-traumatic growth in (ex-) military personnel: review and qualitative synthesis

BACKGROUND

Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development.

AIMS

To qualitatively examine the experience of (PTG) in military and ex-military personnel.

METHODS

A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel.

RESULTS

Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society.

CONCLUSIONS

The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

Religion, Combat Casualty Exposure, and Sleep Disturbance in the US Military

Does religious involvement (i.e., attendance and salience) mitigate the association between combat casualty exposure and sleep disturbance among US military veterans? To address this question, we analyze cross-sectional survey data from the public-use version of the 2011 Health Related Behaviors Survey of Active Military Personnel. Results from multivariate regression models indicate: (1) Combat casualty exposure was positively associated with sleep disturbance; (2) religious salience both offset and moderated (i.e., buffered) the above association; and (3) religious attendance offset but did not moderate the above association. We discuss study implications and limitations, as well as some avenues for future research.

Locus of control in US combat veterans: Unique associations with posttraumatic stress disorder 5-factor model symptom clusters

Given elevated rates of posttraumatic stress disorder (PTSD) among US military veterans, identifying correlates of PTSD and specific PTSD symptom clusters that best represent PTSD in veterans (i.e., the five-factor Dysphoric Arousal model) is critical to prevention and intervention efforts. One potential correlate is locus of control (i.e., the extent to which individuals believe they have control over events in their lives). The aim of this study was to examine the relations between locus of control and five-factor model PTSD symptom clusters (i.e., re-experiencing, avoidance, numbing, dysphoric arousal, anxious arousal) among combat veterans. Eighty-nine combat exposed veterans completed self-report measures of demographics, locus of control, PTSD symptoms, and combat exposure. Bivariate correlations indicated relations between locus of control and overall PTSD symptoms, avoidance symptoms, and numbing symptoms. When controlling for sex and combat exposure in regression analyses, only avoidance remained a significant correlate of locus of control. Among veterans with the most extreme scores (n = 26), external locus of control predicted overall PTSD symptoms and avoidance symptoms. External locus of control is uniquely associated with avoidance symptoms, and represents a potentially modifiable factor to address in trauma-focused treatments.

Neural correlates of response bias: Larger hippocampal volume correlates with symptom aggravation in combat-related posttraumatic stress disorder

The diagnosis of posttraumatic stress disorder (PTSD) is vulnerable to the simulation or exaggeration of symptoms as it depends on the individual's self-report of symptoms. The use of symptom validity tests is recommended to detect malingering in PTSD. However, in neuroimaging research, PTSD diagnosis is often taken at face validity. To date, no neuroimaging study has compared credible PTSD patients with those identified as malingering, and the potential impacts of including malingerers along with credible patients on results is unclear. We classified male patients with combat-related PTSD as either credible (n = 37) or malingerers (n = 9) based on the Morel Emotional Numbing Test and compared structural neuroimaging and psychological questionnaire data. Patients identified as malingerers had larger gray matter volumes in the hippocampus, right inferior frontal gyrus and thalamus, and reported higher PTSD symptoms than credible PTSD patients. This is the first structural neuroimaging study to compare credible PTSD patients and malingerers. We find evidence of structural differences between these groups, in regions implicated in PTSD, inhibition and deception. These results emphasize the need for the inclusion of SVTs in neuroimaging studies of PTSD to ensure future findings are not confounded by an unknown mix of valid PTSD patients and malingerers.

Real-time fMRI amygdala neurofeedback positive emotional training normalized resting-state functional connectivity in combat veterans with and without PTSD: a connectome-wide investigation

Self-regulation of brain activation using real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) is an emerging approach for treating mood and anxiety disorders. The effect of neurofeedback training on resting-state functional connectivity warrants investigation as changes in spontaneous brain activation could reflect the association between sustained symptom relief and brain alteration. We investigated the effect of amygdala-focused rtfMRI-nf training on resting-state functional connectivity in combat veterans with and without posttraumatic stress disorder (PTSD) who were trained to increase a feedback signal reflecting left amygdala activity while recalling positive autobiographical memories (Zotev et al., 2018). The analysis was performed in three stages: i) first, we investigated the connectivity in the left amygdala region; ii) next, we focused on the abnormal resting-state functional connectivity identified in our previous analysis of this data (Misaki et al., 2018); and iii) finally, we performed a novel data-driven longitudinal connectome-wide analysis. We introduced a longitudinal multivariate distance matrix regression (MDMR) analysis to comprehensively examine neurofeedback training effects beyond those associated with abnormal baseline connectivity.

These comprehensive exploratory analyses suggested that abnormal resting-state connectivity for combat veterans with PTSD was partly normalized after the training. This included hypoconnectivities between the left amygdala and the left ventrolateral prefrontal cortex (vlPFC) and between the supplementary motor area (SMA) and the dorsal anterior cingulate cortex (dACC). The increase of SMA-dACC connectivity was associated with PTSD symptom reduction. Longitudinal MDMR analysis found a connectivity change between the precuneus and the left superior frontal cortex. The connectivity increase was associated with a decrease in hyperarousal symptoms. The abnormal connectivity for combat veterans without PTSD - such as hypoconnectivity in the precuneus with a superior frontal region and hyperconnectivity in the posterior insula with several regions - could also be normalized after the training. These results suggested that the rtfMRI-nf training effect was not limited to a feedback target region and symptom relief could be mediated by brain modulation in several regions other than in a feedback target area. While further confirmatory research is needed, the results may provide valuable insight into treatment effects on the whole brain resting-state connectivity.

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fMRI neurofeedback training effect on resting-state connectivity was examined

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Left amygdala activity was trained to increase with positive memory

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Neurofeedback normalized altered connectivity in veterans with and without PTSD

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PTSD symptom reductions were significant but not specific to group (exp/ctrl)

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Connectivity-symptom association was seen in mPFC and precuneus

Race/ethnicity, psychological resilience, and social support among OEF/OIF combat veterans

This study examined the relationship between race/ethnicity and psychological resilience, and the moderating role of social support in this relationship among non-Hispanic White (n = 605), Hispanic (n = 107), African American (n = 141), and Asian American (n = 97) Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans. Veterans were primarily male (88%) with a mean age of 31.4 years (SD = 8.35). An analysis of covariance showed that Asian American veterans reported significantly lower psychological resilience than non-Hispanic White veterans. The interaction of race/ethnicity and social support with psychological resilience was examined via linear regression. We found that the relationship between psychological resilience and social support significantly differed by race/ethnicity such that social support was positively associated with psychological resilience among non-Hispanic White veterans, but not among other racial/ethnic groups. Our findings are consistent with previous studies that show Asian American veterans report lower psychological resilience than non-Hispanic White veterans. Cultural differences in how and why individuals use social support may underlie racial/ethnic differences in the relationship between social support and psychological resilience. Future qualitative and quantitative research is encouraged to better understand how social support relates to psychological resilience among minority OEF/OIF combat veterans.

Sleep disturbances after deployment: National Guard soldiers' experiences and strategies

Sleep deprivation and sleep disturbance are pervasive among military personnel during and after combat deployment. However, occupational and other constraints often influence military workers to decline behavioral health services and prescription pharmaceutical sleep aids. This article, drawing on ethnographic interviews with National Guard veterans of combat deployment, demonstrates that soldiers with sleep disturbance frequently manage symptoms without medical supervision and by using ad hoc methods including alcohol use. Findings suggest the potential significance of further research into the sleep management practices of military populations, who face both high risk for sleep disturbance and occupational and cultural constraints in effectively managing these serious health concerns.

What drives the relationship between combat and alcohol problems in soldiers? The roles of perception and marriage

BACKGROUND

While the relationship between combat exposure and alcohol problems is well-established, the role of perceptions of trauma is less understood. The goal of this study was to explore associations between National Guard (NG) and reserve soldiers' perceptions of combat experiences as traumatic and alcohol problems, and to examine marital satisfaction as a possible protective factor.

METHODS

The Operation: SAFETY study recruited US Army Reserve and NG soldiers and their partners to complete a questionnaire covering many physical and mental health, military service, and substance use topics. Negative binomial regression models examined the impact of perceived trauma of combat experiences on alcohol problems (N = 198). The potential role of marital satisfaction as a resiliency factor was also examined.

RESULTS

The perception of combat experiences as traumatic was associated with increased risk of alcohol problems (risk ratio [RR] = 1.06, 95% confidence interval [CI] 1.01, 1.12; p = 0.024). Combat exposure itself showed no relationship. Marital satisfaction had a significant interaction with perceived combat trauma on alcohol problems (RR = 0.90, 95% CI 0.81, 0.99, p = 0.046), such that soldiers who perceived combat exposure as moderately-highly traumatic were less likely to have alcohol problems when they rated their marital satisfaction highly.

CONCLUSIONS

Our results demonstrate that the perception of combat experiences as traumatic may be a greater contributor to adverse outcomes, such as alcohol problems, than mere combat exposure. They also demonstrate the importance of marital satisfaction as a resiliency factor, particularly at the highest levels of trauma.

Influence of military component and deployment-related experiences on mental disorders among Canadian military personnel who deployed to Afghanistan: a cross-sectional survey

OBJECTIVE

The primary objective was to explore differences in mental health problems (MHP) between serving Canadian Armed Forces (CAF) components (Regular Force (RegF); Reserve Force (ResF)) with an Afghanistan deployment and to assess the contribution of both component and deployment experiences to MHP using covariate-adjusted prevalence difference estimates. Additionally, mental health services use (MHSU) was descriptively assessed among those with a mental disorder.

DESIGN

Data came from the 2013 CAF Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were limited to those with an Afghanistan deployment (population n=35 311; sampled n=4854). Logistic regression compared MHP between RegF and ResF members. Covariate-adjusted prevalence differences were computed.

PRIMARY OUTCOME MEASURE

The primary outcomes were MHP, past-year mental disorders, identified using the WHO's Composite International Diagnostic Interview, and past-year suicide ideation.

RESULTS

ResF personnel were less likely to be identified with a past-year anxiety disorder (adjusted OR (AOR)=0.72 (95% CI 0.58 to 0.90)), specifically both generalised anxiety disorder and panic disorder, but more likely to be identified with a past-year alcohol abuse disorder (AOR=1.63 (95% CI 1.04 to 2.58)). The magnitude of the covariate-adjusted disorder prevalence differences for component was highest for the any anxiety disorder outcome, 2.8% (95% CI 1.0 to 4.6); lower for ResF. All but one deployment-related experience variable had some association with MHP. The 'ever felt responsible for the death of a Canadian or ally personnel' experience had the strongest association with MHP; its estimated covariate-adjusted disorder prevalence difference was highest for the any (of the six measured) mental disorder outcome (11.2% (95% CI 6.6 to 15.9)). Additionally, ResF reported less past-year MHSU and more past-year civilian MHSU.

CONCLUSIONS

Past-year MHP differences were identified between components. Our findings suggest that although deployment-related experiences were highly associated with MHP, these only partially accounted for MHP differences between components. Additional research is needed to further investigate MHSU differences between components.

Beyond Pathologizing Harm: Understanding PTSD in the Context of War Experience

An alternative to objectifying approaches to understanding Post-traumatic Stress Disorder (PTSD) grounded in hermeneutic phenomenology is presented. Nurses who provided care for soldiers injured in the Iraq and Afghanistan wars, and sixty-seven wounded male servicemen in the rehabilitation phase of their recovery were interviewed. PTSD is the one major psychiatric diagnosis where social causation is established, yet PTSD is predominantly viewed in terms of the usual neuro-physiological causal models with traumatic social events viewed as pathogens with dose related effects. Biologic models of causation are applied reductively to both predisposing personal vulnerabilities and strengths that prevent PTSD, such as resiliency. However, framing PTSD as an objective disease state separates it from narrative historical details of the trauma. Personal stories and cultural meanings of the traumatic events are seen as epiphenomenal, unrelated to the understanding of, and ultimately, the therapeutic treatment of PTSD. Most wounded service members described classic symptoms of PTSD: flashbacks, insomnia, anxiety etc. All experienced disturbance in their sense of time and place. Rather than see the occurrence of these symptoms as decontextualized mechanistic reverberations of war, we consider how these symptoms meaningfully reflect actual war experiences and sense of displacement experienced by service members.

Edgar Adrian (1889-1977) and Shell Shock Electrotherapy: A Forgotten History?

The English electrophysiologist Edgar Adrian (1889-1977) was the recipient of the Nobel Prize for physiology in 1932 for his research on the functions of neurons. During World War I, at Queen Square in London, he devised an intensive electrotherapeutic treatment for shell-shocked soldiers. The procedure, developed with Lewis Yealland (1884-1954), was similar to "torpillage," the faradic psychotherapy used in France. Adrian and Yealland considered that the pain accompanying the use of faradic current was necessary for both therapeutic and disciplinary reasons, especially because of the suspicion of malingering. According to Adrian, this controversial electric treatment was only able to remove motor or sensitive symptoms. After the war, he finally admitted that war hysteria was a complex and difficult phenomenon.

Deployment Status and Child Neglect Types in the U.S. Army

Increases in combat deployments have been associated with rises in rates of child neglect in U.S. military families. Although various types of child neglect have been described in military families, it is unknown whether deployment status is associated with specific types of child neglect and whether other factors, such as substance misuse, play a role. To determine the contribution of service member deployment status to the risk of specific child neglect types, data were collected from 390 substantiated U.S. Army child neglect case files. The contributions of deployment status at the time of the neglect incident and parental alcohol or drug-related misuse to risk of neglect types were examined controlling for military family rank and child age. Compared to never deployed families, families with a service member concurrently deployed at the time of the neglect incident were at higher risk for failure to provide physical needs, lack of supervision, and educational neglect, but at lower risk for emotional neglect. Being previously deployed incurred risk for moral-legal neglect. Substance misuse added risk for moral-legal and educational neglect. Findings indicate the need for tailored prevention strategies to target different periods within the deployment cycle.

Attention training modulates resting-state neurophysiological abnormalities in posttraumatic stress disorder

Recent research indicates the relative benefits of computerized attention control treatment (ACT) and attention bias modification treatment (ABMT) for posttraumatic stress disorder (PTSD); however, neural changes underlying these therapeutic effects remain unknown. This study examines how these two types of attention training modulate neurological dysfunction in veterans with PTSD. A community sample of 46 combat veterans with PTSD participated in a randomized double-blinded clinical trial of ACT versus ABMT and 32 of those veterans also agreed to undergo resting-state magnetoencephalography (MEG) recordings. Twenty-four veterans completed psychological and MEG assessments at pre- and post-training to evaluate treatment effects. MEG data were imaged using an advanced Bayesian reconstruction method and examined using statistical parametric mapping. In this report, we focus on the neural correlates and the differential treatment effects observed using MEG; the results of the full clinical trial have been described elsewhere. Our results indicated that ACT modulated occipital and ABMT modulated medial temporal activity more strongly than the comparative treatment. PTSD symptoms decreased significantly from pre- to post-test. These initial neurophysiological outcome data suggest that ACT modulates visual pathways, while ABMT modulates threat-processing regions, but that both are associated with normalizing aberrant neural activity in veterans with PTSD.

U.S. reserve soldiers' combat exposure and intimate partner violence: Not more common but it is more violent

Combat exposure's influence on intimate partner violence (IPV) in reserve soldiers is not well understood. This work examines combat exposure's influence on IPV in U.S. Army Reserve/National Guard soldiers and partners. Data are from Operation: SAFETY, a longitudinal study of U.S. Army Reserve/National Guard soldiers and partners. Logistic regression models examined odds of sexual aggression, physical aggression, and physical injury with combat exposure, controlling for posttraumatic stress disorder symptoms, marital satisfaction, and age. Combat exposure was associated with greater physical injury, despite no association between combat exposure and physical aggression. This was significant for male soldier to female partner, as well as female partner to male soldier injury. In addition, female partners were more likely to be sexually aggressive against their male soldiers. Female soldiers' combat exposure was not associated with IPV or injury. Although men's combat exposure did not increase the likelihood of physical aggression, it increased the likelihood of IPV resulting in injury for both husband to wife and wife to husband aggression. Results indicate postdeployment programming should focus on conflict resolution and communication for both partners.

Reduced lateral prefrontal cortical volume is associated with performance on the modified Iowa Gambling Task: A surface based morphometric analysis of previously deployed veterans

Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are two of the most common consequences of combat deployment. Estimates of comorbidity of PTSD and mTBI are as high as 42% in combat exposed Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn (OEF/OIF/OND) Veterans. Combat deployed Veterans with PTSD and/or mTBI exhibit deficits in classic executive function (EF) tasks. Similarly, the extant neuroimaging literature consistently indicates abnormalities of the ventromedial prefrontal cortex (vmPFC) and amygdala/hippocampal complex in these individuals. While studies examining deficits in classical EF constructs and aberrant neural circuitry have been widely replicated, it is surprising that little research examining reward processing and decision-making has been conducted in these individuals, specifically, because the vmPFC has long been implicated in underlying such processes. Therefore, the current study employed the modified Iowa Gambling Task (mIGT) and structural neuroimaging to assess whether behavioral measures related to reward processing and decision-making were compromised and related to cortical morphometric features of OEF/OIF/OND Veterans with PTSD, mTBI, or co-occurring PTSD/mTBI. Results indicated that gray matter morphometry in the lateral prefrontal cortex (lPFC) predicted performance on the mIGT among all three groups and was significantly reduced, as compared to the control group.

Pathways Between Combat Stress and Physical Health Among Portuguese War Veterans

In this study, I explored the experience of both physical and psychological chronic illnesses among a sample of Portuguese war veterans. Twenty suffered from chronic posttraumatic stress disorder (PTSD; unrecovered) and 20 had remission from PTSD (recovered), and all participants suffered from a chronic physician-diagnosed medical disorder. Two semistructured interviews were conducted. Analysis of the interviews was conducted using the Thematic and Categorical Analysis. Unrecovered participants reported higher moral injury, discrepancy between pre- and postwar identity, medication side effects, and lower repertoire of coping strategies, and verbalized that treatment care plan triggers posttraumatic symptoms. Recovered participants reported stronger moral repair, sense of continuity between pre- and postwar identity, and wider repertoire of coping strategies, well-being. Veterans' adjustment to chronic physician-diagnosed medical disorders is related to the accommodation of war traumatic experiences within existing self-schemas to restore a sense of continuity between veterans' pre- and postwar identity.

Heart rate variability of chronic posttraumatic stress disorder in the Korean veterans

Patients with post-traumatic stress disorder (PTSD) have lower heart rate variability (HRV) than the general population, but findings in this area have been inconsistent. This study was conducted to investigate the characteristics of HRV in patients with PTSD and to evaluate associations between PTSD symptoms and HRV indices. Sixty-eight patients with PTSD and 73 controls without PTSD were evaluated. HRV was measured in all subjects after they completed self-reported questionnaires. Patients with PTSD had significantly more depressed moods, anxiety, and poorer sleep quality than individuals in the non-PTSD group. Standard deviations of NN intervals (SDNN), the square root of the mean squared differences of successive NN intervals (RMSSD), and log high-frequency (LNHF) were significantly lower in the PTSD group than in the non-PTSD group. Comparisons of HRV indices among four sub-groups according to presence/absence of PTSD and experiences of combat-related or other trauma indicated that individuals in the PTSD group who had experienced combat-related trauma had the lowest HRV indices. These indices included SDNN, RMSSD, and LNHF. Further, SDNN, RMSSD, and HF power were significantly associated with symptoms of hyperarousal. HRV measures might be useful physiological parameters in assessing and monitoring sympathovagal function in patients with PTSD.

Deployment and Alcohol Use in a Military Cohort: Use of Combined Methods to Account for Exposure-Related Covariates and Heterogeneous Response to Exposure

Studies have shown that combat-area deployment is associated with increases in alcohol use; however, studying the influence of deployment on alcohol use faces 2 complications. First, the military considers a confluence of factors before determining whether to deploy a service member, creating a nonignorable exposure and unbalanced comparison groups that inevitably complicate inference about the role of deployment itself. Second, regression analysis assumes that a single effect estimate can approximate the population's change in postdeployment alcohol use, which ignores previous studies that have documented that respondents tend to exhibit heterogeneous postdeployment drinking behaviors. Therefore, we used propensity score matching to balance baseline covariates for the 2 comparison groups (deployed and nondeployed), followed by a variable-oriented difference-in-differences approach to account for the confounding and a person-oriented approach using a latent growth mixture model to account for the heterogeneous response to deployment in this prospective cohort study of the US Army National Guard (2009-2014). We observed a nonsignificant increase in estimated monthly drinks in the first year after deployment that regressed to predeployment drinking levels 2 years after deployment. We found a 4-class model that fit these data best, suggesting that common regression analyses likely conceal substantial interindividual heterogeneity in postdeployment alcohol-use behaviors.

Recurring Vivid Dreams in an Older Hmong Man With Complex Trauma Experience and Cognitive Impairment

INTRODUCTION

Health care workers need to consider the culture and ethnic preferences prevalent in the Hmong community in order to provide optimal care. We describe an older Hmong man to illustrate the challenges faced and competencies needed by primary care.

CASE PRESENTATION

An 80-year-old non-English speaking Hmong man with diabetes, nerve sheath tumor, and hypertension presented to the outpatient clinic with his grandson complaining of sleep problems. He had had 2 vivid recurring dreams during the previous few months. Memory assessment was significant for dementia.

DISCUSSION

This case addresses the complexity in taking care of a non-English speaking Hmong older man who has memory loss, trauma in adulthood, multiple caregivers, and sleep problems.

CONCLUSIONS

A careful history from patient and family to get to know their cultural preferences and attitudes was helpful. Identification of the primary caregiver was critical in providing care.

Circulating miRNA associated with posttraumatic stress disorder in a cohort of military combat veterans

Posttraumatic stress disorder (PTSD) affects many returning combat veterans, but underlying biological mechanisms remain unclear. In order to compare circulating micro RNA (miRNA) of combat veterans with and without PTSD, peripheral blood from 24 subjects was collected following deployment, and isolated miRNA was sequenced. PTSD was associated with 8 differentially expressed miRNA. Pathway analysis shows that PTSD is related to the axon guidance and Wnt signaling pathways, which work together to support neuronal development through regulation of growth cones. PTSD is associated with miRNAs that regulate biological functions including neuronal activities, suggesting that they play a role in PTSD symptomatology.

Anticonvulsant Medication Use in Veterans With Posttraumatic Stress Disorder

OBJECTIVE

Anticonvulsants have been studied for many indications, including posttraumatic stress disorder (PTSD). The limited efficacy research on anticonvulsants for PTSD is mixed. However, anticonvulsants are prescribed widely to veterans with PTSD. Our objective was to measure trends and factors associated with anticonvulsant prescriptions among veterans with PTSD.

METHODS

We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the US Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those who received anticonvulsants during the year following their initial clinical PTSD diagnosis and examined common indications for anticonvulsant use, patient characteristics, and service use characteristics. Using logistic regression, we determined the predictors of anticonvulsant initiation among those without an indication.

RESULTS

Although 24.9% of patients in the cohort received an anticonvulsant during their initial year of PTSD treatment, 94.6% had an indication unrelated to PTSD and 51.2% initiated anticonvulsant use before their PTSD diagnosis. While there was growth in anticonvulsant initiation over the 10-year period, this was explained both by growth in indications unrelated to PTSD and by increased use of anticonvulsants for these indications. The rate of anticonvulsant initiation without an indication was stable at approximately 5% throughout the period, with patient and service use characteristics driving the selection of individual agents.

CONCLUSIONS

A large and increasing proportion of veterans with PTSD receives anticonvulsant prescriptions. However, this may be appropriate use driven by increased prevalence of comorbid conditions that may be an indication for anticonvulsant use, including pain and headache disorders.

Comorbid Depression and Suicide Ideation in Patients with Combat-Related PTSD: The Role of Temperament, Character, and Trait Impulsivity

BACKGROUND

War veterans with PTSD have a high chance of developing major depressive disorder (MDD) at some point, while they can also exhibit increased suicidal tendencies. The primary goal of this research was to investigate whether personality dimensions, including temperament, character, and trait impulsivity, were associated with comorbid MDD, as well as with suicidal ideation in psychiatric patients suffering from combat-related PTSD.

SUBJECTS AND METHODS

The sample consisted of 148 Croatian male war veterans (mean age 49.53 years) treated for PTSD at the National Center for Psychotrauma, Department of Psychiatry, University Hospital Center Zagreb. Fifty-one (34%) of them met ICD-10 diagnostic criteria for current or lifetime MDD, while 97 (66%) were diagnosed with PTSD alone. All the participants were assessed with the M.I.N.I. diagnostic interview and they completed the following battery of self-report instruments: the Beck Depression Inventory-Second Edition (BDI-II), the Suicidal Behaviors Questionnaire-Revised (SBQ-R), the Temperament and Character Inventory-Revised (TCI-R), and the Barratt Impulsiveness Scale-11 (BIS-11).

RESULTS

Comparisons between the two clinical groups showed that PTSD+MDD patients were more suicidal and differed with regard to temperament dimensions Harm Avoidance, Reward Dependence and Persistence, character dimension Self-Directedness, and trait impulsivity. In three multivariate regression analyses, it was revealed that character dimension Cooperativeness as well as trait impulsivity were unique predictors of suicidal ideation, while controlling for the influence of sociodemographics, length of treatment and comorbid depression.

CONCLUSIONS

Combat-related PTSD patients with comorbid depression exhibit increased suicide thoughts and different personality profiles in comparison with those suffering from PTSD alone. Character dimension Cooperativeness and trait impulsivity seem to be uniquely predictive of suicide ideation in this population. Elucidation of individual psychological factors that increase the risk of MDD and suicidal tendencies in war veterans with PTSD may facilitate more effective prevention and treatment methods.

Using reinforcement sensitivity to understand longitudinal links between PTSD and relationship adjustment

There is limited research testing longitudinal models of how posttraumatic stress disorder (PTSD) severity leads to impaired relationship adjustment. The present study evaluated 2 potential mechanisms among a longitudinal sample of National Guard soldiers deployed to the Iraq War: (1) sensitivity to cues associated with punishment within intimate relationships and (2) sensitivity to cues associated with incentives in intimate relationships. Participants were surveyed by mail 1 year after an extended 16-month combat deployment and again 2 years later. Using a cross-lagged panel analysis with 2 mediators (relationship-specific threat and incentive sensitivity), findings indicated Time 1 PTSD symptom severity significantly eroded relationship adjustment over time through greater sensitivity to cues of relationship-related punishment, but not through incentive sensitivity. Additionally, findings indicated sensitivity to cues of relationship-related threats maintains symptoms of PTSD while sensitivity to cues of relationship-related incentives maintains relationship adjustment. Finally, PTSD symptoms significantly predicted erosion of relationship adjustment over time; however, associations from relationship adjustment to changes in PTSD severity over time were nonsignificant. Findings are discussed within the context of reinforcement sensitivity theory and emotional processing theory of PTSD. (PsycINFO Database Record

Is the war really over? A 20-year longitudinal study on trajectories of suicidal ideation and posttraumatic stress symptoms following combat

Combat stress reaction (CSR) has widespread long-term consequences, including profound psychopathology in the form of posttraumatic stress disorder (PTSD). Studies have established the link between combat, PTSD, and suicidality. However, little is known about the temporal course of suicidal ideation (SI) in general, specifically among war veterans. We aimed to trace the trajectories of SI in the aftermath of war and to explore the role of CSR and PTSD in SI trajectories. Israeli veterans with CSR (n=164) and a matched control group (NCSR, n=111) were assessed, using self-report measures at three points over the course of 20 years. Veterans with CSR reported significantly higher levels of SI, compared to the NCSR group at all measurement points. Among veterans with CSR, SI increased 2 years after the war and then decreased 20 years following the war. This pattern was particularly characteristic of veterans with chronic PTSD. The results indicate that CSR is a strong predictor of subsequent PTSD and suicidality. These findings highlight the importance of prevention and treatment efforts for these traumatized veterans, who are at risk for suicide even 20 years after the end of the war.

War and remembrance: Combat exposure in young adulthood and memory function sixty years later

OBJECTIVE

Identifying adaptive ways to cope with extreme stress is essential to promoting long-term health. Memory systems are highly sensitive to stress, and combat exposure during war has been shown to have deleterious effects on cognitive processes, such as memory, decades later. No studies have examined coping styles used by combat veterans and associations with later-life cognitive functioning. Defenses are coping mechanisms that manage difficult memories and feelings, with some more closely related to memory processes (e.g., suppression, repression). Utilizing a longitudinal database, we assessed how reliance on certain defense mechanisms after World War II combat exposure could affect cognitive health 60years later.

METHOD

Data spanning 75years were available on 71 men who had post-war assessment of combat exposure, defense mechanism ratings (ages 19-50), and late-life neuropsychological testing. Interaction models of combat exposure with defenses predicting late-life memory were examined.

RESULTS

In bivariate analyses, greater reliance on suppression correlated with worse memory performance (r=-0.30, p=.01), but greater reliance on repression did not. Greater reliance on suppression strengthened the link between combat exposure and worse memory in late life (R²=0.24, p<.001). In contrast, greater reliance on repression attenuated the link between combat exposure and poorer late-life memory (R²=0.19, p<.001).

CONCLUSIONS

Results suggest that coping styles may affect the relationship between early-adult stress and late-life cognition. Findings highlight the importance of understanding how coping styles may impact cognitive functioning as people move through adult life.

A Novel Animal Model Simulating the Beginning of Combat Exposure

OBJECTIVE

Predator stress, social defeat stress, and fear conditioning animal models have been applied to investigate combat-related posttraumatic stress disorder (PTSD). However, no animal model psychopharmacological studies have investigated prevention of somatization of increased mental stress and fatigue at the beginning of combat exposure. This study utilized a novel animal model simulating the beginning of combat exposure that aided specification of a set of biomarkers.

METHODS

Psychological stress was induced by both inescapable electric foot shock and noise stimuli. Physical fatigue was induced by sleep deprivation and forced exercise in a rotating cage. A new device reflecting simultaneous psychological stress and physical fatigue was constructed. The protocol simulating combat exposure was set as 3 rounds of 24-h exposure in a 2-week period, which was specified as intermittent unpredictable stress (IUS).

RESULTS

Mice exposed to IUS (IUS mice) had significantly higher serum corticosterone levels (p < 0.05), excessive locomotive activity (p < 0.001), and anxiety-like behavior (p < 0.02) compared to control mice. IUS mice also had significantly higher IFN-γ (p < 0.001) and TNF-α (p < 0.05) levels in the supernatant of splenic T-cell culture compared to control mice. Brain-derived neurotropic factor levels were significantly decreased (p < 0.04) after IUS exposure.

CONCLUSION

The proposed animal model of combat exposure reflected cognitive function impairment, behavior disturbance, and altered neuroimmune interactions without any apparent histopathological changes, and this animal model may be more applicable to protective research on war syndrome than combat-related PTSD after war because the hypothalamic-pituitary-adrenal axis has not been blunted.

Growth mixture modeling of post-combat aggression: Application to soldiers deployed to Iraq

Prior research has found substantial heterogeneity in the course of key post-deployment outcomes, such as PTSD. The current paper employs growth mixture modeling to identify differential trajectories of change in the course of post-combat aggression. A Brigade Combat Team completed surveys within 72h of return from an Iraq deployment, 4 months later, and at 12 months after return. Based on model fit indices, analyses yielded four latent aggression trajectories: "low-stable", "delayed", "recovery", and "chronic". In addition, most individuals aligned with a "low-stable" trajectory indicative of minimal aggression in the first year following return from a combat deployment. A conditional model showed that lower posttraumatic stress and lower combat exposure characterized individuals aligned with the "low-stable" aggression trajectory relative to individuals aligned with "chronic" and "delayed" aggression trajectories. Implications for targeted intervention and future research are discussed.

Longitudinal Examination of Posttraumatic Stress Disorder as a Long-Term Outcome of Iraq War Deployment

The mental health toll of the Iraq and Afghanistan Wars on military veterans has been considerable, yet little is known about the persistence of these adverse outcomes, especially relative to predeployment status. We prospectively examined posttraumatic stress disorder (PTSD) as a long-term consequence of warzone deployment, integrating data collected from 2003-2014. In the Neurocognition Deployment Health Study, we measured PTSD symptoms in US Army soldiers before and shortly after Iraq War deployment. We used the PTSD Checklist-Civilian Version and a structured clinical interview (i.e., Clinician-Administered PTSD Scale) to reassess PTSD in 598 service members and military veterans a median of 7.9 years (interquartile range, 7.2-8.5 years) after an index Iraq deployment. At long-term follow-up, 24.7% (95% confidence interval (CI): 21.5, 28.4) of participants met the case definition for PTSD, which was an absolute increase of 14.2% from the percentage assessed postdeployment (10.5%; 95% CI: 7.8, 13.7) and of 17.3% from the percentage assessed predeployment (7.4%; 95% CI: 5.5, 9.8). These findings highlight that PTSD is an enduring consequence of warzone participation among contemporary military personnel and veterans. The largest increase in PTSD cases occurred between the postdeployment and long-term follow-up assessments, which suggests that adverse stress reactions cannot necessarily be expected to dissipate over time and actually may increase.