Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans

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.

Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence

BACKGROUND

Posttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease.

PURPOSE

The purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes.

METHODS

A systematic literature search in the period of 2002-2009 for PTSD, cardiovascular disease, and metabolic disease was conducted.

RESULTS

The literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers.

CONCLUSIONS

Although the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research.

Complicated grief and posttraumatic stress disorder in humans' response to the death of pets/animals

The present exploratory project represents a cross-sectional study designed to determine the percentage of people reporting significant symptoms of complicated grief (CG) and/or posttraumatic stress disorder (PTSD) in response to the death of companion pets/animals. Human participants (N = 106) were sampled from a veterinary clinic. Fifty-two percent of participants had lost one to three pets from natural causes, 60% had never lost a pet to euthanasia, and 37% had lost one to three pets to euthanasia. The study suggests that many people experience significant attachment to their pets/animals and experience significant features of grief reactions (about 20%) after the death of a pet/animal. However, the percentage of people experiencing major pathological disruption is relatively low (<5%-12%). Thus, subclinical levels of grief and sadness are relatively common human responses to the death of companion pets/animals and last 6 months or more for about 30% of those sampled. Severe pathological reactions do occur but are quite rare among human survivors. Implications for mental health clinicians working with affected populations are discussed.

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.

Association of posttraumatic stress disorder with low-grade elevation of C-reactive protein: evidence from the general population

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with several somatic diseases, and low-grade inflammation may be one psychobiological mechanism mediating this relationship. We assessed the association between PTSD and elevated serum levels of C-reactive protein (CRP; >3mg/L) in a large general population sample.

METHODS

About 3049 adults living in the community were included in the present study. CRP, lipoproteins and triglycerides were determined. Participants were also examined with regard to blood pressure, body mass index (BMI), physical activity, comorbid somatic diseases, medication, daily alcohol intake, and depression.

RESULTS

PTSD was diagnosed in 55 participants (1.8%), and low-grade inflammation (i.e. CRP >3mg/L) was found in 701 subjects (23.0%). PTSD positive participants had significantly higher odds for elevated CRP values than those without PTSD (OR=2.27; 95% CI: 1.32-3.93). Even after adjusting for sex, age, other sociodemographic factors, BMI, blood pressure, lipoproteins and triglycerides, physical activity, comorbid somatic diseases, daily alcohol intake, and trauma exposure, there were almost twofold higher odds for elevated CRP levels in participants with PTSD compared to those without PTSD (OR=1.87; 95% CI: 1.05-3.35).

CONCLUSIONS

Our findings suggest a close relationship between PTSD and low-grade inflammation possibly representing one psychobiological pathway from PTSD to poor physical health, particularly with respect to cardiovascular and pulmonary disease as well as diabetes.

Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans

BACKGROUND

Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients' use of non-mental health medical services and the impact of mental disorders on utilization.

OBJECTIVE

To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.

DESIGN AND PARTICIPANTS

National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.

MEASUREMENTS

We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans' first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.

MAIN RESULTS

Veterans with mental disorders had 42-146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71-170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization.

CONCLUSIONS

Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs.

The influence of news events on health after disaster: a longitudinal study in general practice

This study investigates the influence of local and international news events on utilization of health services resources and health complaints as presented by victims of a fireworks depot disaster. It was hypothesized that victims (N = 2,854) will show more utilization and health complaints to their general practitioner (GP) in the week after 11 local news reports of events relating to the specific index trauma and 6 unrelated disasters reported in international print news, than the week before. Health data of victims and matched controls were extracted from electronic medical records, covering 4-years postdisaster. Especially local news events concerning the cause of the disaster were associated in both victims and controls with an increase of GP utilization and health complaints, including medically unexplained physical symptoms, chronic diseases, and psychological problems. No difference between victims and controls were found.

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.

Mental health service utilization after physical trauma: the importance of physician referral

BACKGROUND

Despite the availability of effective treatments for posttraumatic stress reactions after serious physical injuries, many sufferers do not use mental health services. Attempts to understand the factors that facilitate mental health service use have often focused on patient-related factors without assessing provider behavior.

OBJECTIVES

To examine the relative influence of patient-related factors and physician referral on mental health service utilization among patients after a traumatic physical injury.

DESIGN

A fully structured interview was administered prospectively by trained lay persons to Los Angeles Country trauma center injury patients. A total of 677 patients completed an initial interview. Of those who completed an initial interview, 70% (n = 476) completed a 6-month follow-up interview and 68% (n = 462) completed a 12-month interview.

MEASURES

We examined 3 classes of patient characteristics hypothesized to be related to mental health service use: need (eg, posttraumatic stress symptoms), predisposing factors (eg, gender), and enabling resources (eg, health insurance). Additionally, we looked at physician referral to mental health treatment as a provider behavior hypothesized to predict service use.

RESULTS

Age, posttraumatic stress disorder symptom severity, previous mental health treatment, and physician referral were all associated with mental health service use. Physician referral demonstrated the strongest relationship with mental health service utilization. While controlling for other factors, the odds of mental health service use were nearly 8 times higher for those respondents receiving a physician referral than for those without a referral.

CONCLUSIONS

Findings highlight the importance of physician referral in facilitating access to mental health services for trauma injury survivors.

Childhood Emotional Neglect Related to Posttraumatic Stress Disorder Symptoms and Body Mass Index in Adult Women

The relationships among the severity of childhood abuse and neglect, posttraumatic stress disorder (PTSD), and adult obesity were investigated. 207 women ( M age = 26.5 yr., SD = 6.7) completed the Childhood Trauma Questionnaire, Millon Clinician Multiaxial Inventory, and a demographic questionnaire. Analyses of variance indicated that women who reported moderate-to-extreme emotional neglect ( n = 71) had significantly higher PTSD scores and increased BMI compared to women who reported low emotional neglect ( n = 84). Women who reported severe sexual or emotional abuse also had higher PTSD scores, but no relationship was found with BMI when other factors were controlled. Although PTSD scores and self-reported severity of childhood emotional neglect were strongly correlated ( r206 = .61, p < .001), PTSD was not found to be a mediating factor in obesity in women who reported childhood emotional neglect, although depression was.

Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008

OBJECTIVES

We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans.

METHODS

We determined the prevalence and predictors of mental health diagnoses among 289,328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from 2002 to 2008 using national VA data.

RESULTS

Of 289,328 Iraq and Afghanistan veterans, 106,726 (36.9%) received mental health diagnoses; 62,929 (21.8%) were diagnosed with posttraumatic stress disorder (PTSD) and 50 432 (17.4%) with depression. Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD.

CONCLUSIONS

Mental health diagnoses increased substantially after the start of the Iraq War among specific subgroups of returned veterans entering VA health care. Early targeted interventions may prevent chronic mental illness.

Posttraumatic stress disorder and nocturnal blood pressure dipping in young adult African Americans

OBJECTIVE

To evaluate the relationship between posttraumatic stress disorder (PTSD) and nocturnal blood pressure (BP) dipping in young adult African Americans (AAs). PTSD is associated with physical illnesses including cardiovascular conditions. Sleep disturbances related to heightened arousal likely contribute to physical health risk; however, this possibility has not been studied. The studies that have found a relationship between PTSD and hypertension (HTN) have substantial representation of AAs. AAs have elevated rates of HTN and are more likely to exhibit an absence of the normal "dip" of BP at night. Nocturnal BP "nondipping" is an established risk factor for HTN and its cardiovascular complications. Nocturnal BP nondipping and sleep disturbances of PTSD have both been linked to sympathetic nervous system function.

METHODS

Thirty healthy young adult AAs (60% female; mean age = 20.0 years; 17 with lifetime full or subthreshold PTSD, 4 with current symptoms) received 24-hour BP and actigraphy monitoring, filled out sleep diaries, and had structured clinical assessment of PTSD.

RESULTS

There were significant associations of lifetime full and subthreshold PTSD and BP nondipping, and the degree of nocturnal dipping correlated with lifetime and current PTSD severity.

CONCLUSION

Elevated nocturnal BP may be a link between PTSD and cardiovascular morbidity in AAs that can be targeted in prevention.

Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: a pilot study

In an open trial design, adults (n=20) with posttraumatic stress disorder (PTSD) and either schizophrenia or schizoaffective disorder were treated via an 11-week cognitive-behavioral intervention for PTSD that consisted of education, anxiety management therapy, social skills training, and exposure therapy, provided at community mental health centers. Results offer preliminary hope for effective treatment of PTSD among adults with schizophrenia or schizoaffective disorder, especially among treatment completers (n=13). Data showed significant PTSD symptom improvement, maintained at 3-month follow-up. Further, 12 of 13 completers no longer met criteria for PTSD or were considered treatment responders. Clinical outcomes for other targeted domains (e.g., anger, general mental health) also improved and were maintained at 3-month follow-up. Participants evidenced high treatment satisfaction, with no adverse events. Significant improvements were not noted on depression, general anxiety, or physical health status. Future directions include the need for randomized controlled trials and dissemination efforts.

Women with posttraumatic stress disorder have larger decreases in heart rate variability during stress tasks

The relationship between posttraumatic stress disorder (PTSD) and high frequency heart rate variability (HF-HRV) was investigated during a resting baseline period and two 4-minute laboratory speech tasks. Participants were 20 women with PTSD and 20 age- and gender-matched controls. Parasympathetic nervous system (PNS) cardiac control was measured as HF-HRV (0.12-0.40 Hz) using power spectrum analysis. Participants with PTSD had significantly greater reductions in HF-HRV during two speech tasks (trauma recall and mental arithmetic) than control. These results suggest that PTSD is related to the magnitude of decrease in parasympathetic cardiac control during stress in women. Health implications of altered PNS activity associated with PTSD deserve further study.

Post-traumatic stress disorder and health problems among medically ill Canadian peacekeeping veterans

OBJECTIVE

The aim of the present study was to examine the relationship between post-traumatic stress disorder (PTSD) symptom severity and four significant health conditions (gastrointestinal disorders, musculoskeletal problems, headaches, and cardiovascular problems).

METHOD

Participants included 707 Canadian peacekeeping veterans with service-related disabilities, from a random, national Canadian survey, who had been deployed overseas.

RESULTS

PTSD severity was significantly related to gastrointestinal disorders, musculoskeletal problems, and headaches, but not to cardiovascular problems. Controlling for demographic factors did not affect PTSD's relationships with the three significant health conditions.

CONCLUSIONS

The present study supports previous work in finding consistent relations between PTSD severity and specific types of medical problems.

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.

Posttraumatic stress disorder and depression negatively impact general health status after hand injury

PURPOSE

To estimate the prevalence of posttraumatic stress disorder (PTSD) and depression among hand-injured patients and assess the impact of these disorders on general health status.

METHODS

A total of 106 adult hand-injured patients (40 women, 66 men) with a mean age of 42 years (range, 18-79 years) participated. Patients with a chronic mental illness or cognitive impairment were excluded. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD and the Beck Depression Inventory. General health status was evaluated with the Short Form-36 health survey (SF-36). We obtained demographics and injury characteristics from the patient medical records.

RESULTS

Prominent mechanisms of injury included a fall (n = 38), traffic-related injuries (n = 14), machine versus operator (n = 8), gunshot wounds (n = 6), and assault (n = 6). Using the screening questionnaires, 32 persons qualified for PTSD and 19 for depression. Sixteen patients met the criteria for both PTSD and depression. The association between PTSD and depression was significant (p < .01). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role-emotional (p < .01), body pain (p = .013), social function (p = .028), and mental health (p < .01). We found no significant differences between groups for the subscales of role-physical (p = .289), general health (p = .147), vitality (p = .496), and physical functioning (p = .476). Patients who had concurrent PTSD and depression had significantly lower scores than patients who had neither PTSD nor depression on all subscales (p < .05 for all) except role-physical (p = .135). We found significant negative correlations between Beck Depression Inventory scores and all of the SF-36 subscales (p < .05 for all).

CONCLUSIONS

In this study, nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, according to the thresholds of the instruments used to measure these psychological aspects of illness. PTSD and depression had a negative effect on general health status after hand injury. It may be important to consider psychological status when caring for patients with hand injuries.

Hypertension in relation to posttraumatic stress disorder and depression in the US National Comorbidity Survey

The clinical literature increasingly indicates that cardiovascular risk factors and cardiovascular disease (CVD) are more common among individuals with posttraumatic stress disorder (PTSD). Depression also poses a risk for CVD and is often comorbid with PTSD. Research to date has not established whether PTSD is associated with additional CVD risk beyond the risks associated with comorbid depression. The authors examined relationships of lifetime PTSD and depression with high blood pressure in data from the US National Comorbidity Survey. They divided participants into 4 mutually exclusive diagnostic groups: (1) PTSD history and no depression history, (2) PTSD and depression history, (3) depression history and no PTSD history, and (4) no history of mental disorder. Hypertension prevalence was higher for the PTSD, no depression and PTSD plus depression groups compared with the depression only and no mental disorder groups. PTSD appears to be related to hypertension independent of depression. This may partially explain elevated rates of CVD in PTSD patients.

Reflections on the culture of veterans

Veterans, as a cultural group, present unique challenges to health care providers. Veteran culture includes health inequalities and health disparities related to posttraumatic stress disorder, depression, and substance abuse that must be understood in context to provide the best care possible to this population. Veterans are not, however, frequently viewed in terms of culturally competent nursing care. Changes in the approach to this population are necessary to provide effective, comprehensive, and compassionate care.

Reflections on the Culture of Veterans

Veterans, as a cultural group, present unique challenges to health care providers. Veteran culture includes health inequalities and health disparities related to posttraumatic stress disorder, depression, and substance abuse that must be understood in context to provide the best care possible to this population. Veterans are not, however, frequently viewed in terms of culturally competent nursing care. Changes in the approach to this population are necessary to provide effective, comprehensive, and compassionate care.

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.

Measures of endothelial dysfunction in plasma of patients with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) confers an increased cardiovascular risk. In 14 otherwise healthy patients with PTSD and in 14 age- and gender-matched non-PTSD controls, we investigated whether the categorical diagnosis of PTSD and severity of PTSD symptom clusters (i.e. re-experiencing, avoidance, arousal, and overall score) would be associated with plasma concentrations of three markers of endothelial dysfunction [soluble tissue factor (sTF), von Willebrand factor (VWF), and soluble intercellular adhesion molecule (sICAM)-1]. Compared with controls, patients had significantly higher sTF; this difference became nonsignificant when controlling for psychological distress. VWF and sICAM-1 levels were not significantly different between patients and controls. In the entire sample virtually all PTSD symptom clusters correlated significantly and positively with sTF and VWF but not with sICAM-1. The correlation between symptoms of re-experiencing and sTF was significantly different between patients and controls. Controlling for symptoms of anxiety and depression (i.e. psychological distress) rendered most associations between PTSD symptom clusters and sTF nonsignificant, whereas controlling for age retained significance of associations with VWF. Posttraumatic stress showed a continuous relationship with sTF and VWF, with the former relationship being partly affected by psychological distress. This suggests one mechanism by which posttraumatic stress could contribute to atherosclerosis.

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.

Holocaust survivors in old age: the Jerusalem Longitudinal Study

OBJECTIVES

To examine the hypothesis that Holocaust exposure during young adulthood negatively affects physical aging, causing greater morbidity, faster deterioration in health parameters, and shorter survival.

DESIGN

A longitudinal cohort study of the natural history of an age-homogenous representative sample born in 1920/21 and living in Jerusalem.

SETTING

Community-based home assessments.

PARTICIPANTS

Four hundred fifty-eight subjects of European origin aged 70 at baseline and 77 at follow-up.

MEASUREMENTS

Comprehensive assessment of physical, functional, and psychosocial domains; biographical history of concentration camp internment (Camp), exposure to Nazi occupation during World War II (Exposure), or lack thereof (Controls); and 7-year mortality data from the National Death Registry.

RESULTS

Holocaust survivors of the Camp (n=93) and Exposure (n=129) groups were more likely than Controls (n=236) to be male and less educated and have less social support (P=.01), less physical activity (P=.03), greater difficulty in basic activities of daily living (P=.009), poorer self-rated health (P=.04), and greater usage of psychiatric medication (P=.008). No other differences in health parameters or physical illnesses were found. Holocaust survivors had similar rates of deterioration in health and illness parameters over the follow-up period, and 7-year mortality rates were identical. Proportional hazard models showed that being an elderly Holocaust survivor was not predictive of greater 7-year mortality.

CONCLUSION

Fifty years after their Holocaust trauma, survivors still displayed significant psychosocial and functional impairment, although no evidence was found to support the hypothesis that the delayed effects of the trauma of the Holocaust negatively influence physical health, health trajectories, or mortality.

Evidence for low-grade systemic proinflammatory activity in patients with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) may increase cardiovascular risk but the psychophysiological mechanisms involved are elusive. We hypothesized that proinflammatory activity is elevated in patients with PTSD as diagnosed by the Clinician Administered PTSD Scale (CAPS) interview. Plasma levels of proinflammatory C-reactive protein (CRP), interleukin (IL)-1beta, IL-6, and tumor necrosis factor (TNF)-alpha, and of anti-inflammatory IL-4 and IL-10 were measured in 14 otherwise healthy PTSD patients and in 14 age- and gender-matched healthy non-PTSD controls. Levels of TNF-alpha (p=0.038; effect size Cohen's d=0.58) and of IL-1beta (p=0.075, d=0.68) were higher in patients than in controls. CRP (d=0.10), IL-6 (d=0.18), IL-4 (d=0.42), and IL-10 (d=0.37) were not significantly different between groups. Controlling for traditional cardiovascular risk factors, mood, and time since trauma revealed lower IL-4 in patients than in controls (p=0.029) and rendered group differences in TNF-alpha and IL-1beta insignificant. In all subjects, TNF-alpha correlated with total (frequency and intensity) PTSD symptom cluster of re-experiencing (r=0.49, p=0.008), avoidance (r=0.37, p=0.050), and hyperarousal (r=0.42, p=0.026), and with PTSD total symptom score (r=0.37, p=0.054). Controlling for time since trauma attenuated these associations. The correlation between IL-1beta and total avoidance symptoms (r=0.42, p=0.028) became insignificant when controlling for anxiety and depression. IL-4 correlated with total hyperarousal symptoms (r=-0.38, p=0.047), and after controlling for systolic blood pressure and smoking status, with PTSD total symptom score (r=-0.41, p=0.035). PTSD patients showed a low-grade systemic proinflammatory state, which, moreover, was related to PTSD symptom levels suggesting one mechanism by which PTSD could contribute to atherosclerotic disease.

Baroreceptor sensitivity at rest and during stress in women with posttraumatic stress disorder or major depressive disorder

The relationship between posttraumatic stress disorder (PTSD) and parasympathetic nervous system functioning was investigated during a baseline rest period and anger recall speaking task using noninvasive estimates of baroreceptor sensitivity. Participants (N = 124) were women categorized into one of four diagnostic groups: PTSD without major depressive disorder (MDD), PTSD with comorbid MDD, MDD without PTSD, and controls with neither psychiatric diagnosis. Women with PTSD (with or without MDD) exhibited significantly lower resting baroreceptor sensitivity than women not diagnosed with PTSD. Baroreceptor sensitivity decreased during the anger recall task, and the decrease was less among the psychiatric groups. Taken together, these findings suggest that PTSD is associated with reduced parasympathetic nervous system functioning.

Do trauma history and PTSD symptoms influence addiction relapse context?

Exposure to traumatic events is common among individuals with substance use disorders (SUD), although not all go on to develop PTSD. We compared SUD treatment outcomes and relapse features in three groups of male veterans receiving SUD treatment: (1) those without trauma exposure (SUD-only; n=68), (2) those with PTSD (SUD-PTSD; n=32), and (3) those with trauma exposure but no PTSD (SUD-trauma; n=34). Veterans were assessed regarding psychiatric symptoms, substance use, and relapse features quarterly for 1 year. The groups did not differ on length of abstinence, relapse prevalence or severity. SUD-PTSD and SUD-trauma reported more depression, anxiety, PTSD, and total psychiatric symptoms prior to relapse than SUD-only. SUD-PTSD and SUD-trauma also endorsed more PTSD, and total symptoms following relapse than SUD-only. PTSD symptoms were associated with greater risk of relapse in intrapersonal and negative physiological contexts. Understanding relapse contexts for those experiencing PTSD symptoms can help us to understand one mechanism whereby those with both PTSD and SUD have a poorer clinical course.

Disaster-related posttraumatic stress disorder and physical health

OBJECTIVE

To examine the relationship between posttraumatic stress disorder (PTSD) and self-reported as well as physician-recorded physical health in a sample of survivors (n = 896) of a man-made disaster, using a longitudinal design that included predisaster health data. Most studies on the relationship between PTSD and physical health are cross-sectional and use self-reported physical health outcomes.

METHODS

A surveillance using the electronic medical records of survivors' family practitioners (FPs), 1 year predisaster until 4 years postdisaster, was combined with a survey, 3 weeks and 18 months postdisaster. Self-reported PTSD and self-reported physical health were assessed at 18 months postdisaster. FP-recorded physical health problems in the subsequent 2 years were classified according to the International Classification of Primary Care. Multiple regression analyses were used to describe the relationships between PTSD and physical health.

RESULTS

After adjusting for demographics, smoking behavior, and predisaster physical health, PTSD was significantly associated with FP-recorded vascular, musculoskeletal, and dermatological problems, and with all self-reported physical health aspects. Prospectively, PTSD signaled an increased risk of new vascular problems (odds ratio = 1.92; 1.04-3.55).

CONCLUSIONS

This study suggests an effect of PTSD in the development of vascular problems. The results imply that clinicians should be alert that disaster survivors with PTSD can suffer from comorbid medical problems as well.

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

Health problems of substance-dependent veterans with and those without trauma history

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services.

Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms

BACKGROUND

Post-traumatic stress disorder (PTSD) may develop in the aftermath of an acute myocardial infarction (MI). Whether PTSD is a risk factor for cardiovascular disease (CVD) is elusive. The biological mechanisms linking PTSD with atherosclerosis are unclear.

DESIGN

A critical review of 31 studies in the English language pursuing three aims: (i) to estimate the prevalence of PTSD in post-MI patients; (ii) to investigate the association of PTSD with cardiovascular endpoints; and (iii) to search for low-grade systemic inflammatory changes in PTSD pertinent to atherosclerosis.

METHODS

We located studies by PubMed electronic library search and through checking the bibliographies of these sources.

RESULTS

The weighted prevalence of PTSD after MI was 14.7% (range 0-25%; a total of 13 studies and 827 post-MI patients). Two studies reported a prospective association between PTSD and an increased risk of cardiovascular readmission in post-MI patients and of cardiovascular mortality in combat veterans, respectively. In a total of 11 studies, patients with PTSD had increased rates of physician-rated and self-reported cardiovascular diseases. Various cytokines and C-reactive protein were investigated in a total of seven studies suggesting that PTSD confers a pro-inflammatory state.

CONCLUSIONS

Increasing evidence suggests that PTSD specifically related to MI develops considerably frequently in post-MI patients. More research is needed in larger cohorts applying a population design to substantiate findings suggesting PTSD is an atherogenic risk factor and to understand better the suspected behavioural and biological mechanisms involved.

Immune function in PTSD

Disturbed regulation of both the hypothalamic-pituitary-adrenal (HPA) axis and sympathoadrenomedullary system in posttraumatic stress disorder (PTSD) suggests that immune function, which is modulated by these systems, may also be dysregulated. Two dermatologic, in vivo measures of immune function, delayed-type hypersensitivity (DTH) and skin barrier function recovery, were examined in female subjects with PTSD and compared to measures in healthy female comparison subjects. In addition, at the time of DTH test placement, circulating numbers of lymphocyte subtypes were assessed. In separate studies, the effects of acute psychological stress on DTH and skin barrier function recovery were examined in healthy volunteer subjects. Both DTH and barrier function recovery were enhanced in women with PTSD. These findings contrast with the effects of acute stress in healthy control subjects, which was associated with suppression of DTH responses and skin barrier function recovery. There was no difference between subjects with PTSD and healthy control subjects in proportions of circulating lymphocyte subsets or in expression of the lymphocyte markers CD62, CD25, and CD45RO/CD45RA. These results suggest that cell-mediated immune function is enhanced in individuals with PTSD, a condition that imposes chronic physiologic and mental stress on sufferers. These findings contrast with suppression of DTH and skin barrier function recovery in healthy volunteers in response to acute psychological stress.

Associations between psychological trauma and physical illness in primary care

Psychological trauma is associated with poor physical health. We examined whether specific trauma types (assaultive, sexual, any) are associated with specific medical illnesses and whether posttraumatic stress disorder (PTSD) mediated these relationships in 680 primary care patients. For men, trauma history was associated with arthritis and diabetes; PTSD mediated the association between trauma and arthritis but not diabetes. Among women, trauma was associated with digestive diseases and cancer; PTSD did not mediate these relationships. Awareness of the presence of the physical illnesses examined here may help with the identification and treatment of primary care patients with trauma histories.

Health and well being of substance use disorder patients with and without posttraumatic stress disorder

While studies link posttraumatic stress disorder (PTSD) to substance use disorders (SUDs), little is known about the health and functional status of patients with such comorbidity. This study examined the health and well being of SUD patients with and without PTSD. Participants were assessed using structured clinical interviews and self-administered questionnaires assessing chronic physical symptoms, and functional status and well being. PTSD was significantly associated with more cardiovascular, neurological, and total chronic physical symptoms. In addition, PTSD was significantly related to poorer functional status and well being, particularly in the mental health realm of functioning. The association between PTSD and mental health component of functional health and well-being remained significant after controlling for chronic physical symptoms and other comorbid psychopathology.

Altered blood coagulation in patients with posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been associated with an increased cardiovascular risk, though the pathophysiologic mechanisms involved are elusive. A hypercoagulable state before occurrence of coronary thrombosis contributes to atherosclerosis development. We investigated whether PTSD would be associated with increased coagulation activity.

METHODS

We measured resting plasma levels of clotting factor VII activity (FVII:C), FVIII:C, FXII:C, fibrinogen, and D-dimer in 14 otherwise healthy patients with PTSD and in 14 age- and gender-matched, trauma-exposed non-PTSD controls. Categorical and dimensional diagnoses of PTSD were made using the Clinician-Administered PTSD Scale (CAPS) interview. We also investigated to what extent the relationship between PTSD and coagulation measures would be confounded by demographics, cardiovascular risk factors, lifestyle variables, time since trauma, and mood.

RESULTS

Coagulation factor levels did not significantly differ between patients with a categorical diagnosis of PTSD and controls while controlling for covariates. In all subjects, FVIII:C was predicted by hyperarousal severity (beta = 0.46, p = .014) independent of covariates and by overall PTSD symptom severity (beta = 0.38, p = .045); the latter association was of borderline significance when separately controlling for gender, smoking, exercise, and anxiety (p values <.07). In patients, fibrinogen was predicted by hyperarousal severity (beta = 0.70, p = .005) and by overall PTSD symptom severity (beta = 0.61, p = .020), with mood partially affecting these associations. FVII:C, fibrinogen, and D-dimer showed no independent association with PTSD symptoms.

CONCLUSIONS

PTSD may elicit hypercoagulability, even at subthreshold levels, offering one psychobiological pathway by which posttraumatic stress might contribute to atherosclerosis progression and clinical cardiovascular disease.

Posttraumatic stress disorder: clinical features, pathophysiology, and treatment

Posttraumatic stress disorder (PSTD), classified as an anxiety disorder, has become increasingly important because of wars overseas, natural disasters, and domestic violence. After trauma exposes the victim to actual or threatened death or serious injury, 3 dimensions of PTSD unfold: (1) reexperiencing the event with distressing recollections, dreams, flashbacks, and/or psychologic and physical distress; (2) persistent avoidance of stimuli that might invite memories or experiences of the trauma; and (3) increased arousal. Traumatic events sufficient to produce PTSD in susceptible subjects may reach a lifetime prevalence of 50% to 90%. The actual lifetime prevalence of PTSD among US citizens is approximately 8%, with the clinical course driven by pathophysiologic changes in the amygdala and hippocampus. Comorbid depression and other anxiety disorders are common. General principles of treatment include the immediate management of PTSD symptoms and signs; management of any trauma-related comorbid conditions; nonpharmacologic interventions including cognitive behavioral treatment; and psychopharmacologic agents including antidepressants (selective serotonin reuptake inhibitors most commonly), antianxiety medications, mood stabilizing drugs, and antipsychotics. This review of PTSD will provide the reader with a clearer understanding of this condition, an increased capacity to recognize and treat this syndrome, and a greater appreciation for the role of the internist in PTSD.

Posttraumatic stress disorder screening status is associated with increased VA medical and surgical utilization in women

BACKGROUND

Women with posttraumatic stress disorder (PTSD) report poor health, but associations with health care utilization are understudied.

OBJECTIVE

To determine associations between medical/surgical utilization and PTSD in female Veterans Affairs (VA) patients.

DESIGN

Prospective comparison of utilization rates between women screening positive or negative for PTSD on a mailed survey.

SUBJECTS

Women receiving care at an urban VA medical center between October 1996 and January 2000.

MEASUREMENTS

Survey responses, including a validated screen for PTSD (PCL-C), and VA utilization data through September 2002.

RESULTS

Two thousand five hundred and seventy-eight (2,578) women (78% of those eligible) completed the PCL-C; 858 (33%) of them screened positive for PTSD (PTSD+). In unadjusted models, PTSD+ women had higher rates of medical/surgical hospitalizations and surgical inpatient procedures. Among women ages 35 to 49, mean days hospitalized/100 patients/year was 43.4 (95% CI 26 to 61) for PTSD+ women versus 17.0 (16 to 18) for PTSD negative (PTSD-) women. More PTSD+ women underwent surgical procedures (P<.001). Mean annual outpatient visits were significantly higher among PTSD+ women, including: emergency department (ED) (1.1 [1.0 to 1.2] vs 0.6 [0.5 to 0.6]), primary care (3.2 [3.0 to 3.4] vs 2.2 [2.1 to 2.3]), medical/surgical subspecialists (2.1 [1.9 to 2.3] vs 1.5 [1.4 to 1.6]), ancillary services (4.1 [3.7 to 4.5] vs 2.4 [2.2 to 2.6]), and diagnostic tests (5.6 [5.1 to 6.1] vs 3.7 [3.4 to 4.0]). In multivariate models adjusted for demographics, smoking, service access, and medical comorbidities, PTSD+ women had greater likelihood of medical/surgical hospitalization (OR=1.37 [1.04 to 1.79]) and of being among the top quartile of patients for visits to the ED, primary care, ancillary services, and diagnostic testing.

CONCLUSIONS

Female veterans who screen PTSD+ receive more VA medical/surgical services. Appropriateness of that care deserves further study.

Physical and mental health costs of traumatic war experiences among Civil War veterans

BACKGROUND

Hundreds of thousands of soldiers face exposure to combat during wars across the globe. The health effects of traumatic war experiences have not been adequately assessed across the lifetime of these veterans.

OBJECTIVE

To identify the role of traumatic war experiences in predicting postwar nervous and physical disease and mortality using archival data from military and medical records of veterans from the Civil War.

DESIGN

An archival examination of military and medical records of Civil War veterans was conducted. Degree of trauma experienced (prisoner-of-war experience, percentage of company killed, being wounded, and early age at enlistment), signs of lifetime physician-diagnosed disease, and age at death were recorded.

SETTING AND PARTICIPANTS

The US Pension Board surgeons conducted standardized medical examinations of Civil War veterans over their postwar lifetimes. Military records of 17,700 Civil War veterans were matched to postwar medical records.

MAIN OUTCOME MEASURES

Signs of physician-diagnosed disease, including cardiac, gastrointestinal, and nervous disease; number of unique ailments within each disease; and mortality.

RESULTS

Military trauma was related to signs of disease and mortality. A greater percentage of company killed was associated with signs of postwar cardiac and gastrointestinal disease (incidence risk ratio [IRR], 1.34; P < .02), comorbid nervous and physical disease (IRR, 1.51; P < .005), and more unique ailments within each disease (IRR, 1.14; P < .005). Younger soldiers (<18 years), compared with older enlistees (>30 years), showed a higher mortality risk (hazard ratio, 1.52), signs of comorbid nervous and physical disease (IRR, 1.93), and more unique ailments within each disease (IRR, 1.32) (P < .005 for all), controlling for time lived and other covariates.

CONCLUSIONS

Greater exposure to death of military comrades and younger exposure to war trauma were associated with increased signs of physician-diagnosed cardiac, gastrointestinal, and nervous disease and more unique disease ailments across the life of Civil War veterans. Physiological mechanisms by which trauma might result in disease are discussed.

Posttraumatic Stress Disorder and Health Status

This article examines the association between self-reported prevalence of posttraumatic stress disorder (PTSD) and health status in a sample of 2425 male Department of Veterans Affairs (VA) ambulatory care patients who participated in the Veterans Health Study. Participants were recruited at 1 of 4 VA outpatient clinics in the Boston area. They completed self-report measures of PTSD (using the PTSD Checklist and measures of exposure to traumatic events), depression (using the Center for Epidemiologic Studies--Depression scale), and health status (using the Short-Form-36) and a medical history interview assessing 22 conditions and a history of psychiatric treatment. The screening prevalence of PTSD was 20.2% among all patients (24.3% among those exposed to traumatic events); another 15.5% met the criteria for depression but not PTSD. The health status of patients with either PTSD or depression was significantly worse than that of patients with neither disorder, even after controlling for age, education, and number of comorbid medical conditions. Patients with PTSD reported more medical conditions than did other patients. Patients with PTSD currently in mental health treatment had worse health status than did those who reported no treatment; the health status of patients who reported past mental health treatment was generally comparable to that of those with no treatment. The prevalence and comorbidity of PTSD among this sample of VA ambulatory care patients were higher than previously reported among samples of community-residing adults. The association of PTSD with health status was substantial, suggesting that the burden of PTSD is at least comparable to, and may be worse than, that of depression. Mental health treatment alleviated some of this burden. The potential impact of PTSD on health status should be more widely recognized.

Health problems in children and adolescents before and after a man-made disaster

OBJECTIVE

The aims of this study were to examine health problems of children (4-12 years old at the time of the disaster) and adolescents (13-18 years old at the time of the disaster) before and after exposure to a fireworks disaster in the Netherlands (May 2000), to compare these health problems with a control group, and to identify risk factors for postdisaster psychological problems.

METHOD

Because the electronic medical records of family practitioners were used, longitudinal monitoring of health problems from 1 year predisaster until 2 years postdisaster for both victims (N=1,628) and controls (N=2,856) was possible. Health problems were classified according to the International Classification of Primary Care.

RESULTS

Postdisaster increases were significantly larger in victims than in controls for psychological problems, musculoskeletal problems, stress reactions, and symptoms of the extremities. Children 4-12 years old presented larger increases in sleep problems compared with controls, whereas children 13-18 years old showed larger increases in anxiety problems than their controls. Significant predictors for postdisaster psychological problems included being relocated, presenting predisaster psychological problems, and a low to medium socioeconomic status.

CONCLUSIONS

Children and adolescents exposed to a disaster are at risk of long-lasting increases in both psychological and physical health problems. Postdisaster interventions should focus on those who were relocated and presented predisaster psychological problems.

Health problems presented in general practice by survivors before and after a fireworks disaster: associations with mental health care

OBJECTIVE

To study the health problems presented to general practitioners by disaster survivors who received specialized ambulatory mental health care.

DESIGN

(Longitudinal) case-control study based on general practitioners' electronic medical records.

SETTING

General practice and a mental health institution (MHI) in Enschede, the Netherlands.

SUBJECTS

A total of 728 adult disaster survivors who were registered in 30 study practices and had attended a specialized mental health institution (MHI group), and 728 practice-matched controls.

MAIN OUTCOME MEASURES

Attendance rates in general practice before and after the disaster; health problems presented to the GP, classified according to the International Classification of Primary Care.

RESULTS

Disaster survivors in the MHI group reported higher GP attendance rates pre- and post-disaster and more health problems than controls. In the year post-disaster, the MHI group reported an increase in psychological, medically unexplained physical symptoms (MUPS), gastrointestinal and musculoskeletal problems, compared with the year pre-disaster. Controls, survivors themselves, showed also an increase in psychological problems in the year post-disaster compared with the year pre-disaster.

CONCLUSION

General practitioners should be aware of an increase in consultations and health problems among patients who also receive mental health care following a disaster. The services of GP and mental health care professionals should be integrated when supporting disaster victims. Information on severity of exposure to disasters should be included in disaster databases.

Terrorism's psychologic effects and their implications for primary care policy, research, and education

This paper examines primary care physicians' (PCP) roles in helping the nation prepare for, respond to, and recover from the psychologic consequences of chemical, biologic, radiologic, or nuclear (CBRN) terrorism. First, we discuss the psychologic consequences of a CBRN attack and PCPs' roles in responding to these consequences. Second, we analyze these roles in light of the known barriers to delivering high-quality, primary care-based, mental health care. Third, we offer recommendations for mitigating these barriers and preparing PCPs to respond to the psychosocial consequences of a CBRN weapon. Importantly, our recommendations provide dual-use benefits to PCPs faced with the daily concerns of primary care mental health, including improved linkages and electronic connectivity with mental health, information technology, and decision support for providers, and needed education and research.

Posttraumatic stress disorder is associated with attenuated baroreceptor sensitivity among female, but not male, smokers

BACKGROUND

The relationship between posttraumatic stress disorder (PTSD) and parasympathetic nervous system (PNS) functioning was investigated using baroreflex sensitivity (BRS). We hypothesized that individuals with PTSD would exhibit lower BRS than those without PTSD.

METHODS

Participants were 80 PTSD patients and 50 controls aged 18-68 years. All participants were smokers, many were veterans (55%), and 60 were women. Beat-to-beat BP was collected during a 5-min baseline rest periods from which estimates of BRS were derived using the sequence method.

RESULTS

Women with PTSD exhibited lower BRS (M = 10.5, S.D. = 5.1) than women without PTSD (M = 14.6, S.D. = 10.7). For men, PTSD diagnosis was not associated with BRS, p > .05.

CONCLUSIONS

Among women, PTSD was associated with reduced PNS functioning. Men with PTSD did not have attenuated BRS, which may be due to sample characteristics, such as age and combat veteran status. Reduced PNS activity may predispose women with PTSD to poorer cardiovascular health.

Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes

Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics

Although posttraumatic stress disorder (PTSD) is relatively common in community epidemiologic surveys (5-6% for men, 10-12% for women), and psychiatric patients with PTSD are known to have poor functioning and high levels of psychiatric comorbidity, there are no studies that address PTSD prevalence, functioning, and burden in primary care settings. This article reports on (1) the prevalence of PTSD using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria in Veterans Affairs (VA) primary care settings, (2) associated sociodemographic characteristics and comorbidities, (3) functional status related to PTSD, (4) the extent to which PTSD was recognized by providers and (5) health services use patterns (including specialty mental health) of PTSD patients. Patients were randomly selected from those who had an outpatient visit in FY 1999 at one of four VA hospitals; 888 patients consented (74.1% of 1198 contacted); 746 patients (84.0% of consenting patients; 62.3% of contacted patients) were reached for telephone diagnostic interviews. Diagnostic interviews with the Clinician Administered PTSD Scale yielded estimates of current PTSD prevalence of 11.5%. At statistically significant levels, PTSD was positively associated with a variety of comorbid psychiatric disorders, war zone service, age <65 years, not working, less formal education and decreased functioning. Of patients diagnosed with PTSD by study procedures, 12-month medical record review indicated that providers identified only 46.5% and only 47.7% had used mental health specialty services. PTSD-positive [PTSD(+)] patients who used mental health care in the past 12 months were more apt to be identified as having PTSD than nonmental health service users (78.0% vs. 17.8%). Although PTSD(+) patients had more medical record diagnoses than PTSD-negative [PTSD(-)] patients (6.28 vs. 4.95), their use of primary care, urgent care and inpatient care was not different from PTSD(-) patients.