External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition

The impact of repression, hostility, and post-traumatic stress disorder on all-cause mortality: a prospective 16-year follow-up study

A common assumption is that repression of traumatic memories is harmful to health. To assess this, we examined all-cause mortality among a national random sample of 4462 male US Army veterans evaluated in 1985 and followed up in 2000. Our hypothesis was that repression on the Welsh R scale would be associated with increased future mortality. We also expected to find a repression x post-traumatic stress disorder (PTSD) interaction effect. Multivariate Cox regression results for all veterans and for theater veterans (Vietnam service) and era veterans (no Vietnam service) separately, revealed that while PTSD was significant in all models, no main or interaction effect was found for repression. In addition, for era veterans, higher repression symptoms were protective for future mortality (HR = 0.95, p = 0.03). For hostility symptoms, although no interaction effect was found by PTSD, a positive main effect was detected for hostility, but only for theater veterans (HR = 1.04, p = 0.034). Disease-specific results were nonsignificant. Similar to a recent study, we also found that repression symptoms were negatively correlated with PTSD symptoms (r = -0.109, p < 0.001), suggesting repression might be protective. Our study found no evidence that repression had an adverse health impact on men exposed to psychological trauma.

Posttraumatic stress: a concept analysis

The purpose of this article is to examine the phenomenon of "posttraumatic stress" using the process of concept analysis as outlined in L. O. Walker and K. C. Avant's (2005) Strategies for Theory Construction in Nursing. Epidemiological studies estimate that approximately 15% to 24% of adults in America experience posttraumatic stress disorder (PTSD) at some point in their lives. Therefore, it is critical for mental health care professionals to understand its historical evolution, the origins of its name, defining attributes, antecedents and consequences, model cases, and empirical referents. In doing so, a more thorough understanding of the underlying attributes of PTSD will be explicated along with related taxonomies.

Generalized anxiety disorder, major depressive disorder, and their comorbidity as predictors of all-cause and cardiovascular mortality: the Vietnam experience study

OBJECTIVE

To examine whether the 1-year prevalence of major depressive disorder (MDD), generalized anxiety disorder (GAD), and their comorbidity were associated with subsequent all-cause and cardiovascular disease (CVD) mortality during 15 years in Vietnam veterans.

METHODS

Participants (N = 4256) were from the Vietnam Experience Study. Service, sociodemographic, and health data were collected from service files, telephone interviews, and a medical examination. One-year prevalence of MDD and GAD was determined through a diagnostic interview schedule based on the Diagnostic and Statistical Manual of Mental Disorders (version IV) criteria. Mortality over the subsequent 15 years was gathered from US army records.

RESULTS

MDD and GAD were positively and significantly associated with all-cause and CVD mortality. The relationships between MDD and GAD and CVD mortality were no longer significant after adjustment for sociodemograhics, health status at entry, health behaviors, and other risk markers. Income was the covariate with the strongest impact on this association. In analyses comparing comorbidity and GAD and MDD alone, with neither diagnosis, comorbidity proved to be the strongest predictor of both all-cause and CVD mortality.

CONCLUSION

GAD and MDD predict all-cause mortality in a veteran population after adjusting for a range of covariates. However, those with both GAD and MDD were at greatest risk of subsequent death, and it would seem that these disorders may interact synergistically to affect mortality. Future research on mental disorders and health outcomes, as well as future clinical interventions, should pay more attention to comorbidity.

PTSD in the combat veteran: using Roy's Adaptation Model to examine the combat veteran as a human adaptive system

Posttraumatic stress disorder (PTSD) is the most prevalent mental disorder arising from combat and is poised to be a considerable health risk for our military veterans. To date, there is a paucity of nursing research that examines PTSD in this vulnerable population. The purpose of this article is to demonstrate how Roy's Adaptation Model can be an effective framework for nurses to understand the phenomenon of posttraumatic stress disorder in the combat veteran population. Current research conducted on PTSD across other disciplines is highlighted within the context of Roy's model to elucidate the idea of the combat veteran as a human adaptive system and to identify gaps for future nursing research.

Predicting mortality in veterans with posttraumatic stress disorder thirty years after Vietnam

Previous research has demonstrated elevated mortality rates among Vietnam-era veterans with posttraumatic stress disorder, especially deaths resulting from nonmedical causes. However, information on the relative contribution of particular risk factors to increased mortality is limited. We used receiver operating characteristics methodology to identify patient-level characteristics that predicted 7-year mortality in 79,551 middle-aged, male, posttraumatic stress disorder-diagnosed outpatients seeking mental health treatment within the Veterans Affairs Health Care System between April 1, 1998 and September 30, 1998. Receiver operating characteristics models indicated that the strongest predictor of mortality was a recent history of medical hospitalization, followed by severity of medical diagnoses and presence of a substance disorder. Results highlight the importance of addressing comorbid medical illnesses and addictive disorders when caring for this population.

A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention

OBJECTIVE

To examine prospectively early-age heart disease (HD) among a national random sample of 4328 male Vietnam veterans, who did not have HD at baseline in 1985. Studies have suggested that posttraumatic stress disorder (PTSD) may result in cardiovascular disease. However, many past studies had important methodological limitations to their designs.

METHOD

Using Cox regressions, we assessed PTSD, age, race, intelligence, family history, obesity, smoking, alcohol abuse, antisocial personality, and depression in predicting HD mortality at follow-up in December 31, 2000. The men were <65 years old at follow-up.

RESULTS

Using two PTSD measures, a Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) measure (D-PTSD) and one developed by Keane (K-PTSD), we found that among Vietnam theater and era veterans combined (era veterans had no Vietnam service), having PTSD was associated with HD mortality for D-PTSD (hazard ratio (HR) = 2.25, p = .045) and approached significance for K-PTSD (HR = 2.16, p = .066). However, having higher PTSD symptoms on either scale was associated with mortality, with a 5-point increase associated with approximately 20% increase in mortality risk (all p < .05). Controlling for lifetime depression only slightly altered the results. The effects for theater veterans alone were stronger (D-PTSD: HR = 2.58, p = .025; K-PTSD: HR = 2.73, p = .022). Among theater veterans, controlling for lifetime depression or combat exposure made little difference.

CONCLUSION

PTSD was prospectively associated with HD mortality among veterans free of HD at baseline. This study suggests that early-age HD may be an outcome after military service among PTSD-positive veterans.

Psychobiologic predictors of disease mortality after psychological trauma: implications for research and clinical surveillance

Research has suggested that exposure to traumatic events can result in adverse health outcomes. However, the reasons for this are unclear. We examined psychobiologic factors associated with disease mortality among a community-based sample of 4462 male veterans 30 years after military service, including posttraumatic stress disorder (PTSD), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and cortisol/dehydroepiandrosterone-sulfate (cortisol/DHEA-s) ratio. In the study, 56% (n = 2490) were theater veterans who served in Vietnam and 44% (n = 1972) era veterans who served elsewhere. During baseline in 1985, 10.2% of theater and 3.4% of era veterans had current PTSD. At follow-up in 2000, 13.6% of men with current baseline PTSD were deceased, compared with 5% without PTSD. Analyses suggested that having PTSD, a high ESR, a high WBC count, and a high cortisol/DHEA-s ratio at baseline were associated with all-cause disease mortality at follow-up. With the exception of cortisol/DHEA-s ratio, these factors also predicted cardiovascular mortality. Depression was not consistently associated with mortality, once other factors were controlled. Noteworthy was that having PTSD had an impact on mortality nearly comparable to common indicators of disease in medicine, such as an ESR >65 mm/h and a WBC count >11,000 mm(3). This study suggests that the morbidity associated with PTSD may be comparable to laboratory measures of disease pathology in common use and warrants further investigation and surveillance among at risk populations.

Consistent association between mixed lateral preference and PTSD: confirmation among a national study of 2490 US Army Vietnam veterans

OBJECTIVE

To evaluate the research-based association between mixed lateral preference for handedness and risk for posttraumatic stress disorder (PTSD) in a large-scale sample of US Army Vietnam veterans exposed to war zone stressors.

METHOD

We used a national sample of 2490 male US Army veterans, who completed the Edinburgh Handedness Inventory (EHI), a measure ranging from -100 (pure left-handedness) to +100 (pure right-handedness). We developed several classifications representing levels of mixed laterality: a) an EHI -70 to +70 (EHI 70, moderate mixed); b) an EHI -50 to +50 (EHI 50, consistent mixed); and c) an EHI 0, plus reports of using either hand on > or =50% of the tasks assessed (EHI 0+, extreme mixed). We controlled for intelligence, race, Army entry age, and Army volunteer status, and we assessed the impact of combat exposure.

RESULTS

Although all three handedness measures were associated with current PTSD in bivariate analyses, only Edinburgh 0+ was associated with PTSD in the multivariate model (odds ratio (OR) = 2.1; p = .021). However, when we classified handedness by high combat exposure, all three measures were associated with PTSD, with ORs = 2.5, 2.8, and 4.7 for EHI 70, EHI 50, and EHI 0+, respectively (all p < .001). Veterans with mixed laterality and high combat exposure also had significantly increased PTSD symptoms (all p < .001).

CONCLUSION

Our study confirmed findings reported among mostly smaller clinical samples and suggested that mixed lateral preference was associated with PTSD, especially among those individuals exposed to more severe psychological trauma.