Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans

Associations between lifetime traumatic events and subsequent chronic physical conditions: a cross-national, cross-sectional study

Background

Associations between lifetime traumatic event (LTE) exposures and subsequent physical ill-health are well established but it has remained unclear whether these are explained by PTSD or other mental disorders. This study examined this question and investigated whether associations varied by type and number of LTEs, across physical condition outcomes, or across countries.

Methods

Cross-sectional, face-to-face household surveys of adults (18+) were conducted in 14 countries (n = 38, 051). The Composite International Diagnostic Interview assessed lifetime LTEs and DSM-IV mental disorders. Chronic physical conditions were ascertained by self-report of physician's diagnosis and year of diagnosis or onset. Survival analyses estimated associations between the number and type of LTEs with the subsequent onset of 11 physical conditions, with and without adjustment for mental disorders.

Findings

A dose-response association was found between increasing number of LTEs and odds of any physical condition onset (OR 1.5 [95% CI: 1.4–1.5] for 1 LTE; 2.1 [2.0–2.3] for 5+ LTEs), independent of all mental disorders. Associations did not vary greatly by type of LTE (except for combat and other war experience), nor across countries. A history of 1 LTE was associated with 7/11 of the physical conditions (ORs 1.3 [1.2–1.5] to 1.7 [1.4–2.0]) and a history of 5+ LTEs was associated with 9/11 physical conditions (ORs 1.8 [1.3–2.4] to 3.6 [2.0–6.5]), the exceptions being cancer and stroke.

Conclusions

Traumatic events are associated with adverse downstream effects on physical health, independent of PTSD and other mental disorders. Although the associations are modest they have public health implications due to the high prevalence of traumatic events and the range of common physical conditions affected. The effects of traumatic stress are a concern for all medical professionals and researchers, not just mental health specialists.

Posttraumatic stress disorder and risk for coronary heart disease: a meta-analytic review

OBJECTIVE

The aim of this study was to estimate the association of posttraumatic stress disorder (PTSD) with risk for incident coronary heart disease (CHD).

DESIGN

A systematic review and meta-analysis were used as study designs.

DATA SOURCES

Articles were identified by searching Ovid MEDLINE, PsycINFO, Scopus, Cochrane Library, PILOTS database, and PubMed Related Articles and through a manual search of reference lists (1948-present).

STUDY SELECTION

All studies that assessed PTSD in participants initially free of CHD and subsequently assessed CHD/cardiac-specific mortality were included.

DATA EXTRACTION

Two investigators independently extracted estimates of the association of PTSD with CHD, as well as study characteristics. Odds ratios were converted to hazard ratios (HRs), and a random-effects model was used to pool results. A secondary analysis including only studies that reported estimates adjusted for depression was conducted.

RESULTS

Six studies met our inclusion criteria (N = 402,274); 5 of these included depression as a covariate. The pooled HR for the magnitude of the relationship between PTSD and CHD was 1.55 (95% CI 1.34-1.79) before adjustment for depression. The pooled HR estimate for the 5 depression-adjusted estimates (N = 362,950) was 1.27 (95% CI 1.08-1.49).

CONCLUSION

Posttraumatic stress disorder is independently associated with increased risk for incident CHD, even after adjusting for depression and other covariates. It is common in both military veterans and civilian trauma survivors, and these results suggest that it may be a modifiable risk factor for CHD. Future research should identify the mechanisms of this association and determine whether PTSD treatment offsets CHD risk.

The long-term implications of war captivity for mortality and health

The current study aims to (1) assess the long-term impact of war captivity on mortality and various health aspects and (2) evaluate the potential mediating role of posttraumatic stress disorder (PTSD) and depressive symptoms. Israeli ex-prisoners of war (ex-POWs) (N = 154) and a matched control group of combat veterans (N = 161) were assessed on health conditions and self-rated health 18 years post-war (1991: T1). The whole population of ex-POWs, and the T1 sample of controls were then contacted 35 years after the war (2008: T2), and invited to participate in a second wave of measurement (ex-POWs: N = 171; controls: N = 116) Captivity was implicated in premature mortality, more health-related conditions and worse self-rated health. PTSD and depressive symptoms mediated the relationship between war captivity and self-rated health, and partially mediated the relationship between war captivity and health conditions, and these effects were amplified with age. Aging ex-POWs who develop psychiatric symptomatology should be considered a high-risk group entering a high-risk period in the life cycle. It is important to monitor ex-POWs and provide them with appropriate medical and psychological treatment as they age.

Multiple physical symptoms in a military population: a cross-sectional study

BACKGROUND

Medically unexplained symptoms have been reported among both civilians and military personnel exposed to combat. A large number of military personnel deployed to the Gulf War in 1991 reported non-specific symptoms. These symptoms did not constitute a clearly defined syndrome. Post-traumatic stress disorder (PTSD) and to a lesser degree exposure to combat are associated with physical symptoms.

METHODS

This is a cross-sectional study of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a 1-year period. Multiple physical symptoms were elicited using a checklist of 53 symptoms. Cases were defined as individuals with ten or more symptoms. Symptoms of common mental disorder were identified using the General Health Questionnaire 12 (GHQ-12). PTSD was diagnosed using the 17-item National Centre for PTSD checklist civilian version.

RESULTS

Prevalence of multiple physical symptoms was 10.4% (95% CI 8.11-12.75). Prevalence was significantly less in the Special Forces (5.79%) than in the regular forces (13.35%). The mean number of symptoms reported by those who met the criteria for PTSD was 12.19 (SD 10.58), GHQ caseness 7.87 (SD 7.57) and those without these conditions 2.84 (SD 3.63). After adjusting for socio-demographic and service variables, 'thought I might be killed' , 'coming under small arms fire' , and 'coming under mortar, missile and artillery fire' remained significant. Multiple physical symptoms were associated with functional impairment and poor perceived general health.

CONCLUSIONS

Prevalence of multiple physical symptoms was significantly lower in the Special Forces despite high exposure to potentially traumatic events. More multiple physical symptoms were reported by personnel with PTSD and common mental disorders. Multiple physical symptoms were associated with functional impairment.

Posttraumatic stress symptomatology as a mediator of the relationship between warzone exposure and physical health symptoms in men and women

The mediating role of posttraumatic stress symptomatology (PSS) on the association between warzone exposure and physical health symptoms in 7 bodily systems (cardiovascular, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, and pulmonary) was examined. We also examined if mediation effects varied as a function of sex. A sample of 317 U.S. Gulf war veterans was assessed for warzone exposure, PSS, and physical health symptoms 10 years after deployment. PSS was significantly associated with postdeployment physical health in all symptom categories when accounting for predeployment health (with effect sizes ranging from a 1.27-1.64 increase in the likelihood of postdeployment physical health symptoms with a 1 standard deviation increase in the PSS symptoms). PSS severity mediated the relationship between warzone exposure and postdeployment symptoms in all physical health domains (with percent mediation ranging 44%-75%). A significant Warzone Exposure × PSS interaction emerged for 5 outcomes such that the effect of PSS on physical health was stronger for veterans reporting lower warzone exposure. No significant interactions with sex emerged. These findings suggest the important influence of PSS on physical health symptoms for both men and women.

Posttraumatic stress disorder and impaired autonomic modulation in male twins

BACKGROUND

Posttraumatic stress disorder (PTSD) has been linked to increased morbidity. An inflexibility of the autonomic nervous system might be the underlying mechanism. We aimed to assess whether PTSD and combat trauma exposure are associated with lower heart rate variability (HRV), a measure of autonomic function and a predictor of death.

METHODS

We measured HRV by power spectral analysis on 24-hour ambulatory electrocardiogram in 459 middle-aged veteran male twins. Combat trauma was assessed with the combat exposure scale, and current and remitted PTSD was assessed with the Structured Clinical Interview for Psychiatry Disorders. Mixed-effects regression models were used to test associations of PTSD and HRV between and within twin pairs.

RESULTS

Of all twins, 211 had combat exposure, 31 had current PTSD, and 43 had remitted PTSD. Current PTSD was inversely associated with very-low-frequency and low-frequency HRV both in individual twins and within 20 pairs discordant for current PTSD. Twins with current PTSD had a 49% lower low-frequency HRV than their brothers without PTSD (p<.001). Remitted PTSD was not associated with HRV. Results were robust to adjustment for depression and other risk factors. Combat exposure was inversely associated with most HRV frequencies, but this association mostly diminished after adjustment for current PTSD.

CONCLUSION

In middle-aged veteran men, combat exposure and current PTSD are associated with measures of autonomic inflexibility previously shown to have prognostic significance. The negative health impact of combat exposure on autonomic function is mediated largely through PTSD and might reverse with remission of PTSD.

What pre-deployment and early post-deployment factors predict health function after combat deployment?: a prospective longitudinal study of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) soldiers

Background

Physical and mental function are strong indicators of disability and mortality. OEF/OIF Veterans returning from deployment have been found to have poorer function than soldiers who have not deployed; however the reasons for this are unknown.

Methods

A prospective cohort of 790 soldiers was assessed both pre- and immediately after deployment to determine predictors of physical and mental function after war.

Results

On average, OEF/OIF Veterans showed significant declines in both physical (t=6.65, p<.0001) and mental function (t=7.11, p<.0001). After controlling for pre-deployment function, poorer physical function after deployment was associated with older age, more physical symptoms, blunted systolic blood pressure reactivity and being injured. After controlling for pre-deployment function, poorer mental function after deployment was associated with younger age, lower social desirability, lower social support, greater physical symptoms and greater PTSD symptoms.

Conclusions

Combat deployment was associated with an immediate decline in both mental and physical function. The relationship of combat deployment to function is complex and influenced by demographic, psychosocial, physiological and experiential factors. Social support and physical symptoms emerged as potentially modifiable factors.

Treatment-related reductions in PTSD and changes in physical health symptoms in women

This study examined the relationship between change in posttraumatic stress disorder (PTSD) symptoms over the course of PTSD treatment and the association with changes in general physical health symptoms. Both positive health habits (e.g., exercise) and negative (e.g., smoking), were examined to determine if they accounted for the association between changes in PTSD severity over time and changes in physical health. Participants were 150 women seeking treatment for PTSD. Latent growth curve modeling indicated a substantial relationship (R (2) = 34%) between changes in PTSD and changes in physical health that occurred during and shortly following treatment for PTSD. However, there was no evidence to suggest that changes in health behaviors accounted for this relationship. Thus, PTSD treatment can have beneficial effects on self-reported physical health symptoms, even without direct treatment focus on health per se, and is not accounted for by shifts in health behavior.

Posttraumatic stress disorder, depression, and HIV risk behavior among Ohio Army National Guard Soldiers

We examined the relationship between posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and human immunodeficiency virus (HIV) risk behavior among the Ohio Army National Guard (OHARNG). We analyzed data collected from a sample of OHARNG enlisted between June 2008 and February 2009. Participants completed interviews assessing HIV risk activities defined by the Behavioral Risk Factor Surveillance System, and were screened for PTSD and MDD based on DSM-IV criteria according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994). Logistic regression was used to examine the independent and combined effects of PTSD and MDD on past-year HIV risk behavior. Of 2,259 participants, 142 (6.3%) reported at least 1 past-year HIV risk behavior. In adjusted models, relative to soldiers with neither disorder, screening positive for MDD only was associated with HIV risk behavior (adjusted odds ratio [AOR] = 2.33, 95% CI = [1.15, 4.71]), whereas PTSD was not significant (AOR = 1.60, 95% CI = [0.80, 3.20]). Participants with both PTSD and depression were most likely to report HIV risk behavior (AOR = 2.75, 95% CI = [1.06, 7.11]). Soldiers with PTSD and MDD may be at greater risk for HIV infection due to increased engagement in HIV risk behavior. Integrated interventions to address mental health problems and reduce HIV risk behavior are in need of development and evaluation.

The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review

The present meta-analysis systematically examined associations between physical health and posttraumatic stress disorder (PTSD)/PTSD symptoms (PTSS), as well as moderators of this relationship. Literature searches yielded 62 studies examining the impact of PTSD/PTSS on physical health-related quality of life (HR-QOL), general health symptoms, general medical conditions, musculoskeletal pain, cardio-respiratory (CR) symptoms, and gastrointestinal (GI) health. Sample-specific and methodological moderators were also examined. Results revealed significantly greater general health symptoms, general medical conditions, and poorer HR-QOL for PTSD and high PTSS individuals. PTSD/PTSS was also associated with greater frequency and severity of pain, CR, and GI complaints. Results of moderation analyses were mixed. However, consistent relationships emerged regarding PTSD assessment method, such that effect sizes were largest for self-reported PTSD/PTSS and all but one health outcome. Results highlight the need for prospective longitudinal examination of physical health shortly following trauma, and suggest variables to consider in the design of such studies.

Women Vietnam Veterans: Do PTSD Symptoms Mediate Effects of Warzone Service on Health?

We assessed the impact of warzone stress on the physical and mental health functioning and well-being of 975 female nurse veterans who had been deployed to Vietnam, and examined whether PTSD symptoms at the time of the survey mediated these relations. A questionnaire was mailed to the Women's Vietnam Memorial Project members, approximately 25 - 30 years after their wartime service. We examined current physical and mental health functioning in relation to several measures of warzone stress and PTSD symptoms, adjusting for age, length of military service, and current physical health problems. Using regression models, we evaluated whether current PTSD symptoms mediated the effects of warzone stress on mental and physical health. Findings suggested that PTSD symptoms did mediate the relationship between warzone stress and mental, but not physical, health functioning in later life. These findings suggest that among women nurses deployed to Vietnam, the effects of warzone stress many years earlier on current functioning and well-being are both direct and indirect, mediated by PTSD symptoms. The legacy of wartime deployment remains, although muted in its expression, in military nurses nearly 30 years after their return.

PTSD and depression as predictors of physical health-related quality of life in tobacco-dependent veterans

OBJECTIVE

Smoking, depression and PTSD are related to poor physical health outcomes and health-related quality of life (HRQoL). Previous studies examining the effects of quitting smoking on HRQoL have been mixed. This study aimed to examine the effects of PTSD, depressive symptoms and smoking cessation on HRQoL in a sample receiving treatment for PTSD.

METHOD

This study utilized archival interview and self-report data from a clinical trial (VA Cooperative Study 519) that recruited tobacco dependent veterans with chronic PTSD (N=943).

RESULTS

Analyses were conducted using hierarchical linear modeling and indicated that PTSD and depressive symptoms differentially affected the various physical health status domains. Additionally, quitting smoking was associated with better self-perceived health status and social functioning.

CONCLUSION

Our findings further explain the interrelationships of PTSD, depression, and smoking in the prediction of physical HRQoL and advocate the importance of integrated care.

Cancer and post-traumatic stress disorder: diagnosis, pathogenesis and treatment considerations

OBJECTIVE

The purpose of this article was to review the literature regarding diagnosis, pathogenesis, and treatment of post-traumatic stress disorder (PTSD) associated with cancer.

METHOD

We surveyed studies examining the validity of diagnostic scales commonly used to measure PTSD in patients with cancer. Neurobiological underpinnings of PTSD and cancer, including inflammation as the physiological mechanism linking these comorbidities, were examined. Psychopharmacologic and psychotherapeutic treatment of PTSD symptoms in patients with cancer was reviewed. In addition, potential drug-drug interactions between psychotropic medications commonly used to treat PTSD and anti-cancer agents were reviewed.

RESULTS

Multiple studies demonstrated the validity of the PTSD Checklist Civilian Version (PCL-C) in diagnosing PTSD in patients with cancer. Research has shown that PTSD as defined in DSM-IV appears to be a better model for conceptualizing distress in patients with cancer than a generalized "distress" model. Epidemiologic studies have shown an increased incidence of PTSD associated with cancer; however, literature regarding characteristics of PTSD in patients with cancer is cross-sectional in nature.

SIGNIFICANCE OF RESULTS

Future research focusing on longitudinal, prospective studies to identify patients at risk, determine causal or aggravating factors, and develop preventive interventions is needed. Further study of PTSD in patients with cancer may help increase recognition of this disorder, optimize treatment, and enhance the quality of life of these individuals.

The influence of posttraumatic stress disorder numbing and hyperarousal symptom clusters in the prediction of physical health status in veterans with chronic tobacco dependence and posttraumatic stress disorder

Smoking and PTSD are predictors of poor physical health status. This study examined the unique contribution of PTSD symptoms in the prediction of the SF-36 physical health status subscales accounting for cigarette smoking, chronic medical conditions, alcohol and drug use disorders, and depression. This study examined baseline interview and self-report data from a national tobacco cessation randomized, controlled trial (Veterans Affairs Cooperative Study 519) that enrolled tobacco-dependent veterans with chronic PTSD (N = 943). A series of blockwise multiple regression analyses indicated that PTSD numbing and hyperarousal symptom clusters explained a significant proportion of the variance across all physical health domains except for the Physical Functioning subscale, which measures impairments in specific physical activities. Our findings further explain the impact of PTSD on health status by exploring the way PTSD symptom clusters predict self-perceptions of health, role limitations, pain, and vitality.

Physical health problems after single trauma exposure: when stress takes root in the body

Research has established that chronic stress, including traumatic events, leads to adverse health outcomes. The literature has primarily used two approaches: examining the effect of acute stress in a laboratory setting and examining the link between chronic stress and negative health outcomes. However, the potential health impact of a single or acute traumatic event is less clear. The goal of this literature review is to extend the literature linking both chronic trauma exposure and posttraumatic stress disorder to adverse health outcomes by examining current literature suggesting that a single trauma may also have negative consequences for physical health. The authors review studies on health, including cardiovascular, immune, gastrointestinal, neurohormonal, and musculoskeletal outcomes; describe potential pathways through which single, acute trauma exposure could adversely affect health; and consider research and clinical implications.

Type D personality, temperament, and mental health in military personnel awaiting deployment

Background

The Type D (distressed) personality refers to a general propensity to psychological distress defined by the combination of negative affectivity and social inhibition. Type D personality predicts poor mental and physical health in cardiac patients, but it has been argued that its assessment is affected by the state of illness. Therefore, validation of the Type D construct in healthy adults remains essential.

Purpose

The objectives of this study were (1) to validate Type D personality against temperament and character dimensions in young, healthy adults and (2) to investigate the association between Type D personality and pre-deployment mental health.

Method

Type D personality, temperament, and questionnaires on mental health were filled out by 86 healthy male Dutch military personnel before UN deployment to Afghanistan.

Results

Type D personality was present in 16% of healthy military personnel before deployment. The Type D components social inhibition (α = 0.89) and negative affectivity (α = 0.85) correlated positively with harm avoidant temperament (r = 0.66 and 0.46) and negatively with self-directed character (r = −0.33 and −0.57). In addition, these four traits loaded on the same broad personality dimension. Military men with a Type D personality not only reported significantly less self-directedness and more harm avoidance as compared to non-Type D men (p < 0.001) but also more symptoms of PTSD, general emotional distress, and hostility (all p < 0.012).

Conclusions

Type D personality was associated with harm avoidance, low self-directedness, and increased symptoms of PTSD and hostility in men awaiting deployment. This association was not caused by any somatic confounding in these young, healthy men.

Posttraumatic stress disorder, poor physical health and substance use behaviors in a national trauma-exposed sample

Both experiencing a traumatic event and PTSD are related to physical health problems (e.g., Schnurr and Jankowski, 1999) and health-risk behavior (e.g., Stewart, 1996). Using structural equation modeling analyses, we examined the interrelationships among number of distinct traumatic event exposures, PTSD diagnosis, physical health, and substance use behavior using epidemiological data from the National Comorbidity Survey Replication (NCS-R; Kessler et al., 2004). Results provide some evidence that PTSD mediates the relationship between: (a) number of distinct traumatic event exposures and poor physical health defined by clusters of difficulties with gastrointestinal, musculoskeletal, and/or cardiovascular health, and (b) number of distinct traumatic event exposures and substance use behaviors. However, substance use behaviors did not significantly mediate the relationship between PTSD and poor physical health.

Exposure to trauma and posttraumatic stress disorder symptoms in older veterans attending primary care: comorbid conditions and self-rated health status

OBJECTIVES

Assess the prevalence of posttraumatic stress disorder (PTSD) symptomatology and its association with health characteristics in a geriatric primary care population.

DESIGN

Cross-sectional screening assessments during a multisite trial for the treatment of depression, anxiety, and at-risk drinking.

SETTING

Department of Veterans Affairs (VA)-based primary care clinics across the United States.

PARTICIPANTS

Seventeen thousand two hundred five veterans aged 65 and older.

MEASUREMENTS

Sociodemographic information, the General Health Questionnaire (GHQ-12), questions about death wishes and suicidal ideation, quantity and frequency of alcohol use, smoking, exposure to traumatic events, and PTSD symptom clusters.

RESULTS

Twelve percent (2,041/17,205) of participants screened endorsed PTSD symptoms. Veterans with PTSD symptoms from some (partial PTSD) or each (PTSD all clusters) of the symptom clusters were significantly more likely to report poor general health, currently smoke, be divorced, report little or no social support, and have a higher prevalence of mental distress, death wishes, and suicidal ideation than those with no trauma history or those with trauma but no symptoms. Group differences were most pronounced for mental distress and least for at-risk drinking. Presence of PTSD all clusters was associated with poorer outcomes on all of the above-mentioned health characteristics than partial PTSD.

CONCLUSION

PTSD symptoms are common in a substantial minority of older veterans in primary care, and careful inquiry about these symptoms is important for comprehensive assessment in geriatric populations.

The association of traumatic experiences and posttraumatic stress disorder with physical morbidity in old age: a German population-based study

OBJECTIVE

To examine the relationship of traumatic experiences and posttraumatic stress disorder (PTSD) among a representative population sample of 1456 German elderly (60-85 years). Several studies have suggested that PTSD and traumatic experiences are related to adverse health outcomes. However, many past studies were based on special samples such as combat veterans or survivors of natural disasters.

METHODS

Using self-report data and regression analyses, we investigated the association of traumatic experiences and PTSD with several medical conditions.

RESULTS

Traumatized subjects had a significantly increased risk for all the medical conditions under study compared with those participants without a traumatic exposure, ranging from odds ratio of 1.37 (95% confidence interval [CI] = 1.07-1.75) for hypertension up to 5.12 (95% CI = 2.25-11.6) for cancer. There are significant associations of current PTSD with cardiovascular diseases (angina pectoris/coronary artery disease, congestive heart failure, and peripheral vascular disease) and cardiovascular risk factors (hypertension and elevated cholesterol level; odds ratio of 1.94 [95% CI = 1.14-3.31]) for peripheral vascular disease up to 3.76 [95% CI = 2.11-6.70] for elevated cholesterol level), as well as with asthma, cancer, back pain, hard of hearing, osteoporosis, stomach problems, and thyroid disorders.

CONCLUSIONS

These findings suggest an association between traumatic stress and PTSD with impaired physical health in a general population sample in the German elderly. It underscores the importance of traumatic experiences and PTSD not only for mental health but also for physical health as a long-term consequence.

Prospectively assessed posttraumatic stress disorder and associated physical activity

OBJECTIVES

We examined the association of physical activity with prospectively assessed posttraumatic stress disorder (PTSD) symptoms in a military cohort.

METHODS

Using baseline and follow-up questionnaire data from a large prospective study of U.S. service members, we applied multivariable logistic regression to examine the adjusted odds of new-onset and persistent PTSD symptoms associated with light/moderate physical activity, vigorous physical activity, and strength training at follow-up.

RESULTS

Of the 38,883 participants, 89.4% reported engaging in at least 30 minutes of physical activity per week. At follow-up, those who reported proportionately less physical activity were more likely to screen positive for PTSD. Vigorous physical activity had the most consistent relationship with PTSD. Those who reported at least 20 minutes of vigorous physical activity twice weekly had significantly decreased odds for new-onset (odds ratio [OR] = 0.58, 95% confidence interval [CI] 0.49, 0.70) and persistent (OR = 0.59, 95% CI 0.42, 0.83) PTSD symptoms.

CONCLUSIONS

Engagement in physical activity, especially vigorous activity, is significantly associated with decreased odds of PTSD symptoms among U.S. service members. While further longitudinal research is necessary, a physical activity component may be valuable to PTSD treatment and prevention programs.

Combat exposure and mental health: the long-term effects among US Vietnam and Gulf War veterans

Using a random sample of more than 4000 veterans, we test the effects of combat exposure on mental health. We focus on two cohorts of veterans: those who served in Vietnam (1964-1975) and the Gulf War (1990-1991). Combat exposure differed between these groups in intensity, duration and elapsed time since exposure. We find that combat exposure generally, and exposure to dead, dying, or wounded people, specifically, is a significant predictor of mental health declines as measured by an individual's Mental Component Summary score. Under our general specifications, the negative effects of combat on mental health were larger for Gulf war veterans than for Vietnam veterans as of 2001. These effects persist after controlling for demographic characteristics, insurance coverage, income and assets. Using discrete factor, nonparametric maximum likelihood (DFML) estimation we controlled for unobserved heterogeneity as well as the factors above. In the DFML specifications we find a negative impact of exposure to dead, wounded or dying people for both Gulf and Vietnam veterans, but find no statistically significant effect for combat exposure overall for Vietnam veterans as of 2001. Based on our Gulf war parameters, we estimate that the costs of mental health declines to be between $87 and $318 per year for each soldier with combat service and exposure to dead, dying and wounded people.

War Stress and Late-Life Mortality in World War II Male Civilian Resistance Veterans

The mental and physical health of 146 Dutch males exposed to severe war stress during their young adulthood were examined in 1986–1987 when they were at ages 61 to 66 years. The veterans' data were compared with a randomly selected population-based sample of same-aged males. In 2005, 70% of the war stress veterans had died, and only 35% of the comparison group. The baseline quality of life was significantly poorer in the war stress veterans than in the comparison group. Baseline variables explained 42% of the increased risk of mortality among war stress veterans. Smoking was the largest single contributor to mortality.

The stratification of military service and combat exposure, 1934-1994

Previous research has suggested that men who were exposed to combat during wartime differed from those who were not. Yet little is known about how selection into combat has changed over time. This paper estimates sequential logistic models using data from the Panel Study of Income Dynamics to examine the stratification of military service and combat exposure in the US during the last six decades of the twentieth century. It tests potentially overlapping hypotheses drawn from two competing theories, class bias and dual selection. It also tests a hypothesis, drawn from the life course perspective, that the processes by which people came to see combat have changed historically. The findings show that human capital, institutional screening, and class bias all determined who saw combat. They also show that, net of historical change in the odds of service and combat, the impact of only one background characteristic, race, changed over time.

The Pervasive Role of Rank in the Health of U.S. Veterans

The following article tests the hypothesis that veterans have better health if they were officers when they were in the U.S. military than if they served in the enlisted ranks. It examines this hypothesis by presenting results from logistic regressions that are based on four surveys: the National Survey of Veterans, the Survey of Retired Military, the Panel Study of Income Dynamics, and the Wisconsin Longitudinal Study. In all four of these surveys, the evidence is consistent with the hypothesis that military rank is associated with health, particularly among veterans who served longer. It also suggests that the health gradient by rank is independent of similar gradients by education and income as well as health differences by race. These findings indicate that health may be influenced not just by differences in civilian society but also by those in the military.

The Pervasive Role of Rank in the Health of U.S. Veterans

The following article tests the hypothesis that veterans have better health if they were officers when they were in the U.S. military than if they served in the enlisted ranks. It examines this hypothesis by presenting results from logistic regressions that are based on four surveys: the National Survey of Veterans, the Survey of Retired Military, the Panel Study of Income Dynamics, and the Wisconsin Longitudinal Study. In all four of these surveys, the evidence is consistent with the hypothesis that military rank is associated with health, particularly among veterans who served longer. It also suggests that the health gradient by rank is independent of similar gradients by education and income as well as health differences by race. These findings indicate that health may be influenced not just by differences in civilian society but also by those in the military.

Association between posttraumatic stress disorder and primary care provider-diagnosed disease among Iraq and Afghanistan veterans

OBJECTIVE

To determine if a diagnosis of posttraumatic stress disorder (PTSD) was associated with primary care provider-diagnosed physical disease in the first 5 years post deployment.

METHODS

An examination of medical records of 4416 veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) was conducted. Participants were veterans who served between September 11, 2001 and December 31, 2007, without prior combat exposure, and who utilized primary care services within the VA Healthcare Network of Upstate New York. Primary care provider-diagnosed International Statistical Classification of Diseases and Related Health Problems, Revision 9 (ICD-9) physical diseases were examined.

RESULTS

Adjusting for demographic characteristics and clinical factors (e.g., age, gender, depression, and substance use), PTSD was significantly associated with an almost two-fold increase of developing nervous system (odds ratio [OR], 1.98), musculoskeletal disease (OR, 1.84), and signs and ill-defined conditions of disease (OR, 1.78). A diagnosis of PTSD was significantly associated with increased odds of developing circulatory (OR, 1.29), hypertensive (OR, 1.38), and digestive system disease (OR, 1.34). Survival analyses showed that veterans with PTSD experienced early onset disease compared with veterans without PTSD; hypertensive (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.19-2.04), circulatory, (HR, 1.36; 95% CI, 1.11-1.67), digestive (HR, 1.24; 95% CI, 1.08-1.43), nervous (HR, 1.81; 95% CI, 1.59-2.06), musculoskeletal disease (HR, 1.49; 95% CI, 1.32-1.67), and signs and ill-defined disease (HR, 1.70; 95% CI, 1.51-1.92).

CONCLUSIONS

PTSD is associated with increased prevalence and onset of physical disease among OEF/OIF veterans within the early years post military service. Rising rates of PTSD may foreshadow an increase in lifespan morbidity and healthcare utilization in the coming years among OEF/OIF veterans.

Is post-traumatic stress disorder related to development of heart disease?

It has long been hypothesized that post-traumatic stress disorder (PTSD) increases coronary heart disease (CHD) risk, however, empirical evidence is limited. In the first prospective study to date, individuals with higher PTSD symptom levels had a significantly increased risk for CHD, after controlling for known coronary risk factors. PTSD indicates a chronic stress reaction and is hypothesized to influence CHD either by causing biological alterations that lead to cardiovascular damage, or by leading to adverse health behaviors that increase CHD risk. A key issue is whether PTSD contributes to the development of CHD, if PTSD and CHD share common pathways or if CHD causes PTSD. Research combined across different disciplines suggests that prolonged or chronic stress does influence the development of CHD. A better understanding of the relationship will increase prevention and intervention efforts. Cardiologists may be most effective when they can recognize and manage emotional distress in practice.

The relationship between posttraumatic stress disorder, psychiatric comorbidity, and personality traits among patients with chronic idiopathic urticaria

BACKGROUND

Several studies have highlighted the link between posttraumatic stress disorder (PTSD) and physical illnesses. No empirical studies, however, have investigated the relationship between PTSD and chronic idiopathic urticaria (CIU). The role of personality traits in this relationship was also unknown.

OBJECTIVES

This study aimed to investigate (1) the extent to which patients with CIU fulfilled the PTSD diagnosis resulting from past traumas and (2) whether they developed psychiatric comorbidity, and (3) the relationship between CIU patients' personality traits, PTSD diagnosis, severity of CIU, and psychiatric comorbidity.

METHODS

One hundred patients with CIU and 60 patients with allergy (control) participated in the study. Patients' CIU severity was assessed. Both groups completed the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire-28, the Social Readjustment Rating Scale, the Perceived Stress Scale, and the NEO-Five Factor Inventory.

RESULTS

Thirty-four percent of patients with CIU and 18% of allergy patients met the diagnostic criteria for PTSD. Patients with CIU were 1.89 times more likely to have a current diagnosis of PTSD than the control group. Controlling for life event stress and perceived stress, significant differences were found between groups (CIU PTSD, CIU no PTSD, allergy PTSD, allergy no PTSD) in somatic problems, anxiety, and social dysfunction. Controlling for life event stress and perceived stress, regression analyses showed no significant associations between personality traits, PTSD diagnosis, and the severity of CIU. Posttraumatic stress disorder diagnosis and neuroticism were, however, associated with psychiatric comorbidity.

CONCLUSIONS

Patients with CIU have been shown to have concurrent PTSD resulting from past traumas and developed psychiatric comorbidity. Chronic idiopathic urticaria patients' comorbidity was related to the patients' PTSD diagnosis and their neurotic personality trait.

Testing posttraumatic stress as a mediator of physical, sexual, and psychological intimate partner violence and substance problems among women

This study examined whether posttraumatic stress specifically resulting from intimate partner violence (IPV-related posttraumatic stress) mediated relationships between types of IPV and drug and alcohol problems among 212 women currently experiencing IPV. Six-month prevalence was high for drug use (48%) and alcohol use (59%). Structural equation modeling revealed that the frequency of physical, sexual, and psychological IPV were significantly and positively related to greater IPV-related posttraumatic stress, and IPV-related posttraumatic stress was significantly and positively related to drug problems. Further, IPV-related posttraumatic stress mediated the relationships between physical IPV and drug problems and psychological IPV and drug problems. Findings suggest that prevention and intervention efforts targeting posttraumatic stress among IPV-exposed women may reduce drug problems in this population.

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with significant health risk, illness, and functional impairment, e.g., Green and Kimerling [2004: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association] Kimerling et al. [2000: Trauma and Health: J Trauma Stress 13:115-128].

METHODS

These analyses examined whether negative health perceptions and general social functioning change with treatment of chronic PTSD among women from a randomized controlled study comparing prolonged exposure (PE; n=48) or PE combined with cognitive restructuring (PE/CR; n=40) to waitlist (n=19; Foa et al., 2005: J Consult Clin Psychol 73:953-964].

RESULTS

Self- reported physical health difficulties were significantly reduced in the PE and PE/CR conditions compared to the waitlist condition. These reductions did not demonstrate significant change during the 12 month follow-up period. Self-reported discomfort associated with physical health difficulties did not demonstrate significant change over treatment. No difference was detected between the active treatment and waitlist conditions. Both the PE and PE/CR groups reported improved social functioning at post treatment compared to the waitlist. Additional improvement in general social functioning was found between 3 and 12 month follow-up assessments. Changes in PTSD and depressive symptoms over treatment accounted for 29% of the variance in reduction of reported health problems and 30% of the variance in improvement of general social functioning. Importantly, only changes in PTSD symptoms significantly contribute to the model predicting change in physical health problems with depression associated only at a trend level. However, collinearity between PTSD and depression makes interpretation difficult.

CONCLUSIONS

Negative health perceptions and general social function improve with PE. Changes in depression and PTSD with treatment are related to these changes.

Trauma, posttraumatic stress disorder, and physical illness: findings from the general population

OBJECTIVE

To determine in a general population sample the differential impact on physical health of exposure to traumatic experiences and posttraumatic stress disorder (PTSD). Trauma exposure and PTSD have been associated with physical illness in specific populations, such as veterans.

METHODS

Medical histories including cardiovascular, endocrine, pulmonary, and other chronic diseases were obtained from 3171 adults living in the community. They were administered the PTSD module of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), and were assigned to three groups: no trauma (n = 1440); trauma, but no PTSD (n = 1669); and trauma with subsequent PTSD (n = 62).

RESULTS

After adjustments for sociodemographic factors, smoking, body mass index, blood pressure, depression, and alcohol use disorders, subjects with trauma history had higher odds ratios (ORs) for angina pectoris and heart failure (OR = 1.2; 95% Confidence Interval [CI] = 1.1-1.3), stroke (OR = 1.2; 95 CI = 1.0-1.5), bronchitis, asthma, renal disease, and polyarthritis (ORs between 1.1 and 1.3) compared with nontraumatized participants. The PTSD positive subsample had increased ORs for angina (OR = 2.4; 95% CI = 1.3-4.5), heart failure (OR = 3.4; 95% CI = 1.9-6.0), bronchitis, asthma, liver, and peripheral arterial disease (ORs, range = 2.5-3.1).

CONCLUSIONS

Our findings suggest a strong association between PTSD and cardiovascular and pulmonary diseases. Particular diagnostic and treatment attention should be paid to physical illness in PTSD positive patients in primary care, medical, and mental health settings.

War-related exposure and psychological distress as predictors of health and sleep: a longitudinal study of Kuwaiti children

OBJECTIVES

To determine whether exposure to war-related trauma during childhood predicted posttraumatic stress, self-reported health, sleep, and obesity in adulthood, and whether psychological distress mediated the relationships.

METHODS

We assessed 151 Kuwaiti boys and girls aged 9 to 12 years in 1993 to determine their level of exposure to war-related trauma during the Iraqi occupation and Gulf war, health complaints, and psychological distress. In 2003, 120 (79%) of the initial participants reported on their posttraumatic stress, general health, body mass index (BMI), and sleep quality. We tested a structural model where exposure to war-related trauma predicted psychological distress and health complaints 2 years after the war, and posttraumatic stress, self-reported health, BMI, and sleep quality and duration 10 years later, controlling for intermediary life events. We also tested effects of exposure to war-related trauma on self-reported health and sleep factors mediated by psychological distress.

RESULTS

Results indicated a direct effect of exposure on poor sleep quality and BMI. Exposure also predicted poor sleep quality through its association with concurrent posttraumatic stress. The effect of exposure on self-reported health was mediated by health complaints and psychological distress, which included symptoms of depression, anxiety, and posttraumatic stress.

CONCLUSION

Exposure to war-related events during childhood is associated with posttraumatic stress, poor sleep quality, high BMI, and poor self-reported health in adulthood.

The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder

The long-term health consequences of war service remain unclear, despite burgeoning scientific interest. A longitudinal cohort study of a random sample of Australian Vietnam veterans was designed to assess veterans' postwar physical and mental health 36 years after the war (2005-2006) and to examine its relation to Army service, combat, and post-traumatic stress disorder (PTSD) assessed 14 years previously (1990-1993). Prevalences in veterans (n = 450) were compared with those in the Australian general population. Veterans' Army service and data from the first assessments were evaluated using multivariate logistic regression prediction modeling. Veterans' general health and some health risk factors were poorer and medical consultation rates were higher than Australian population expectations. Of 67 long-term conditions, the prevalences of 47 were higher and the prevalences of 4 were lower when compared with population expectations. Half of all veterans took some form of medication for mental well-being. The prevalence of psychiatric diagnoses exceeded Australian population expectations. Military and war service characteristics and age were the most frequent predictors of physical health endpoints, while PTSD was most strongly associated with psychiatric diagnoses. Draftees had better physical health than regular enlistees but no better mental health. Army service and war-related PTSD are associated with risk of illness in later life among Australian Vietnam veterans.

Pathways linking intimate partner violence and posttraumatic disorder

Intimate partner violence (IPV), which includes physical violence, sexual violence, and psychological or emotional abuse, is a significant public health threat. The Centers for Disease Control and Prevention (CDC) estimate that each year 1.5 million women are physically assaulted and/or raped by an intimate partner. However, because many victims of IPV are repeatedly abused, a more accurate accounting of the extent of violence suggests that approximately 4.8 million intimate partner physical assaults and rapes are perpetrated annually against women in the United States. The article discusses a survey involving 3,429 English-speaking women enrolled in a health maintenance organization (HMO) for 3 or more years. The findings are 46% of participants who were screened reported a lifetime history of any IPV and 14.7% reported a history within the past 5 years, including physical, sexual, and nonphysical types.

Does cognitive-behavioral therapy for PTSD improve perceived health and sleep impairment?

There is a paucity of empirical study about the effects of evidence-based psychotherapy for posttraumatic stress disorder (PTSD) on concurrent health concerns including sleep impairment. This study compares the differential effects of cognitive processing therapy (CPT) and prolonged exposure (PE) on health-related concerns and sleep impairment within a PTSD sample of female, adult rape survivors (N = 108). Results showed that participants in both treatments reported lower health-related concerns over treatment and follow-up, but there were relatively more improvements in the CPT condition. Examination of sleep quality indicated significant improvement in both CPT and PE across treatment and follow-up and no significant differences between treatments. These results are discussed with regard to the different mechanisms thought to underlie the treatments and future innovations in PTSD treatment.

Is posttraumatic stress disorder related to development of heart disease? An update

It has long been hypothesized that posttraumatic stress disorder (PTSD) increases coronary heart disease (CHD) risk; however, empirical evidence is limited. In the first prospective study to date, individuals with higher PTSD symptom levels had a significantly increased risk for CHD, after controlling for known coronary risk factors. PTSD indicates a chronic stress reaction and is hypothesized to influence CHD either by causing biological alterations that lead to cardiovascular damage, or by leading to adverse health behaviors that increase CHD risk. A key issue is whether PTSD contributes to the development of CHD, if PTSD and CHD share common pathways, or if CHD causes PTSD. Research combined across different disciplines suggests that prolonged or chronic stress does influence the development of CHD. A better understanding of the relationship will increase prevention and intervention efforts. Cardiologists may be most effective when they can recognize and manage emotional distress in practice.

Trajectories of self-rated health among veterans: a latent growth curve analysis of the impact of posttraumatic symptoms

OBJECTIVES

To examine the effects of combat stress reaction (CSR) and posttraumatic stress symptoms (PTS) on the level and trajectories of self-rated health (SRH) over 20 years after war exposure.

METHODS

A total of 675 veterans comprising two groups, a CSR group (n = 369) and a matched control group without CSR (n = 306), were assessed in a prospective longitudinal design, 1, 2, 3, and 20 years after their participation in the 1982 Lebanon War. SRH and PTS were assessed repeatedly, at each point of measurement.

RESULTS

The CSR participants showed more impaired initial SRH than the controls. Although the CSR group showed an improvement in SRH over time, its SRH level remained lower than that of the control group in all 4 points in time. Initial levels of PTS were associated with more impaired SRH and lower improvement over time. In addition, increased levels of PTS in the first follow-up period were related to poorer SRH, in comparison to the predicted trajectory on the basis of CSR and initial PTS.

CONCLUSIONS

Stress reaction to war trauma affected the trajectory of SRH over a 20-year period. Although the differences between veterans who had shown acute stress reaction and those who had not persisted over the entire period, there was slow improvement in SRH over time among the more impaired CSR group. PTS in the first years after the war slowed this improvement and thus played a key role in the relationship between war trauma and physical health.

Sexual harassment in the Marines, posttraumatic stress symptoms, and perceived health: evidence for sex differences

Sex differences and pretrauma functioning have been understudied in examinations of posttraumatic stress symptoms (PSS) and health. This study examined relationships between sexual harassment and assault in the military (MST), PSS, and perceived physical health when accounting for pre-MST PSS, pre-MST health, and current depression. Relationships were examined separately in 226 female and 91 male Marines endorsing recent MST (past 6 months). MST predicted increased PSS for women and especially men. For men, higher levels of MST were associated with worse perceived physical health, whereas for women, lower levels of MST were associated with worse perceived health. For men with MST, there was some evidence for the association being partially mediated by PSS, but no mediation was found in women.

Posttraumatic stress disorder and health-related quality of life among a sample of treatment- and pension-seeking deployed Canadian Forces peacekeeping veterans

OBJECTIVES

To examine the health-related quality of life (HRQOL) in deployed Canadian Forces peacekeeping veterans, addressing associations with posttraumatic stress disorder (PTSD), and depression severity.

METHODS

Participants (n = 125) were consecutive male veterans who were referred for a psychiatric assessment. Instruments administered included the Clinician-Administered PTSD Scale, Hamilton Depression Scale, Short-Form-36 Health Survey, and sociodemographic characteristics.

RESULTS

Mental HRQOL was significantly lower for peacekeepers with, than without, PTSD. Using univariate analyses, PTSD and depression severity were each significantly negatively related to mental HRQOL. In sequential regression analyses controlling for age, we found that PTSD and depression severity significantly predicted both mental and physical HRQOL.

CONCLUSIONS

Veterans with PTSD have significant impairments in mental and physical HRQOL. This information is useful for clinicians and Veterans Affairs administrators working with the newer generation of veterans, as it stresses the importance of including measures of quality of life in the psychiatric evaluation of veterans to better address their rehabilitation needs.

posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care

The relationship between posttraumatic stress and physical health functioning was examined in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA care. Iraq and Afghanistan War veterans (N = 108) who presented for treatment to a specialty postdeployment care clinic completed self-report questionnaires that assessed symptoms of posttraumatic stress disorder (PTSD), chemical exposure, combat exposure, and physical health functioning. As predicted, PTSD symptom severity was significantly associated with poorer health functioning, even after accounting for demographic factors, combat and chemical exposure, and health risk behaviors. These results highlight the unique influence of PTSD on the physical health in treatment seeking Iraq and Afghanistan War veterans.

Posttraumatic stress disorder, alcohol use, and physical health concerns

PTSD is a risk factor for alcohol problems and both in turn have been independently associated with increased health problems. However, it is unclear whether alcohol use moderates the relationship between PTSD and health. Participants were battered women (N = 336) recruited from local domestic violence shelters and non-shelter victim-assistance agencies. A 2 (PTSD diagnosis) x 3 (abstainer, infrequent/light, regular/heavy drinking) ANCOVA was conducted, with injuries and length of abuse as covariates and health concerns as the dependent variable. Main effects for PTSD and alcohol use were significant but not the interaction. Women with PTSD reported the greatest number of health concerns. Women who abstained from drinking and those who drank regularly/heavily reported more health concerns than the infrequent/light drinkers. Health concerns associated with PTSD do not appear to be due to problem drinking. In addition, infrequent/light drinking, even for women with PTSD, may be associated with fewer health concerns.

Persisting posttraumatic stress disorder symptoms and their relationship to functioning in Vietnam veterans: a 14-year follow-up

The authors examined the longitudinal association between persisting posttraumatic stress disorder (PTSD) symptoms and multiple domains of life functioning in a community sample of 1,377 American Legionnaire Vietnam veterans first assessed in 1984 and followed-up 14 years later. Almost 30 years after their return from Vietnam, 10% of veterans continued to experience severe PTSD symptoms. At all levels of combat exposure, persisting severe PTSD symptoms were associated with worse family relationships, more smoking, less life satisfaction and happiness, more mental health service use, and more nonspecific health complaints at the 14-year follow-up. Further investigation is needed to determine whether the PTSD-functioning relationship is causal and if successful treatment of PTSD is associated with improvement in functioning.

Trauma, PTSD, and physical health: an epidemiological study of Australian Vietnam veterans

OBJECTIVE

This study aimed to examine the relative contributions to physical health of combat trauma exposure and posttraumatic stress disorder (PTSD), which have both been implicated separately in poorer physical health but whose unconfounded effects have not been teased out.

METHODS

Data from an epidemiological study of Australian Vietnam veterans, which used personal interviews and standardized physical and psychiatric health assessments, provided the means to assess the independent and joint effects of psychological trauma exposure and PTSD on a wide range of self-reported measures of physical health. Trauma exposure was measured by published scales of combat exposure and peritraumatic dissociation. Logistic regression modeling was used to assess the relative importance of trauma exposure and PTSD to health while controlling for a set of potential confounders including standardized psychiatric diagnoses.

RESULTS

Greater health service usage and more recent health actions were associated more strongly with PTSD, which was also associated with a range of illness conditions coded by the World Health Organization International Classification of Diseases, 9th Edition (asthma, eczema, arthritis, back and other musculoskeletal disorders, and hypertension) both before and after controlling for potential confounders. In contrast, combat exposure and peritraumatic dissociation were more weakly associated with a limited number of unconfounded physical health outcomes.

CONCLUSIONS

This study provided evidence that PTSD, rather than combat exposure and peritraumatic dissociation, is associated with a pattern of physical health outcomes that is consistent with altered inflammatory responsiveness.

Posttraumatic stress disorder, gender, and problem profiles in substance dependent patients

Patients with a chronic and severe substance-use disorder who also have a history of posttraumatic stress disorder (PTSD) are thought to have a unique set of problems. The present study assessed psychiatric disorders, psychosocial problems, and traumatic events with structured interviews in 747 men and 693 women enrolling in urban opioid substitution treatment programs from 1995 to 2001. Participants with versus without a history of PTSD were more likely to have a history of many other psychiatric disorders and demonstrated more current and historical medical, employment, family/social, and psychiatric problems. PTSD was generally unrelated to substance-use disorder severity or diagnoses, with the exception of an increased risk of alcohol dependence. Women were more likely than men to have experienced sexual assault, and less likely to have been physically assaulted, although these events precipitated PTSD at equivalent rates across gender. In contrast, witnessing or hearing about the death or injury of others was more likely to precipitate PTSD in women than men. Female gender, exposure to combat, sexual assault, or physical assault, and a history of major mood or anxiety disorder were the best predictors of PTSD in this group. Study limitations are noted.

Screening for posttraumatic stress disorder among Somali ex-combatants: a validation study

Background

In Somalia, a large number of active and former combatants are affected by psychological problems such as Posttraumatic Stress Disorder (PTSD). This disorder impairs their ability to re-integrate into civilian life. However, many screening instruments for Posttraumatic Stress Disorder used in post-conflict settings have limited validity. Here we report on development and validation of a screening tool for PTSD in Somali language with a sample of ex-combatants.

Methods

We adapted the Posttraumatic Diagnostic Scale (PDS) to reflect linguistic and cultural differences within the Somali community so that local interviewers could be trained to administer the scale. For validation purposes, a randomly selected group of 135 Somali ex-combatants was screened by trained local interviewers; 64 of them were then re-assessed by trained clinical psychologists using the Composite International Diagnostic Interview (CIDI) and the Self-Report Questionnaire (SRQ-20).

Results

The screening instrument showed good internal consistency (Cronbach's α = .86), convergent validity with the CIDI (sensitivity = .90; specificity = .90) as well as concurrent validity: positive cases showed higher SRQ-20 scores, higher prevalence of psychotic symptoms, and higher levels of intake of the local stimulant drug khat. Compared to a single cut-off score, the multi-criteria scoring, in keeping with the DSM-IV, produced more diagnostic specificity.

Conclusion

The results provide evidence that our screening instrument is a reliable and valid method to detect PTSD among Somali ex-combatants. A future Disarmament, Demobilization and Reintegration Program in Somalia is recommended to screen for PTSD in order to identify ex-combatants with special psycho-social needs.