Combat stress reactions, posttraumatic stress disorder, cumulative life stress, and physical health among Israeli veterans twenty years after exposure to combat

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

ABSTRACT

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

The Link Between Somatization and Dissociation and PTSD Severity in Veterans Who Sought Help From the IDF Combat Stress Reaction Unit

INTRODUCTION

This study aimed to examine the relationships between dissociative and somatic symptoms and how they might contribute to PTSD severity among ex-soldiers who sought help from the IDF Combat Stress Reaction Unit (CSRU).

MATERIALS AND METHODS

This cross-sectional study included 1,305 former compulsory, career, and reserve soldiers, who filled out self-report questionnaires on admission for evaluation at the CSRU. The study's dependent variables included two posttraumatic stress disorder measures (CAPS and PCL-5). The independent variables were the Dissociative Experience Scale and Brief Symptom Inventory. Background and service-related variables were also examined.

RESULTS

Spearman correlation revealed that the higher the level of somatization is, the higher the level of PTSD via PCL and CAPS. A significant positive association was found between somatization and dissociation (r = 0.544; P < 0.001). The higher the somatization level, the more severe the dissociation. A multivariate logistic regression analysis to predict severe PTSD revealed that the longer the time elapsed from the traumatic event (OR = 1.019, P = 0.015), the higher the risk for severe PTSD. The most prominent variables were dissociation (OR = 6.420, P < 0.001) and somatization (OR = 4.792, P < 0.001). The entire model reached 40.8% of the shared variance in the regression.

CONCLUSIONS

While there is direct reference to dissociation in the clinical assessment by PCL or CAPS, there is no such reference to somatization. Highly functioning combatants sometimes express their distress somatically. Our findings suggest regarding severe somatic symptoms as diagnostic criteria for PTSD.

Associations of active-duty mental health trajectories with post-military adjustment: Results from the STARRS Longitudinal Study

BACKGROUND

Many servicemembers experience difficulties transitioning from military to civilian life. We examined whether changes in mental health observed during active duty were associated with indices of post-military adjustment.

METHODS

Survey data from the multi-wave Army STARRS Pre/Post Deployment Study (PPDS; conducted 2012-2014) were linked to follow-up data from wave 1 of the STARRS Longitudinal Study (STARRS-LS1; conducted 2016-2018). Empirical Bayes estimates of intercepts and slopes of posttraumatic stress, problematic anger, and depressive symptoms during the PPDS were extracted from mixed-effects growth models and evaluated as predictors of life stress among 1080 participants who had separated or retired from the Army at STARRS-LS1; and of job satisfaction among 586 veterans who were employed at STARRS-LS1.

RESULTS

Higher average levels and larger increases in posttraumatic stress, anger, and depression over the deployment period were each associated with increased stress and (in the case of anger and depression) reduced job satisfaction. Posttraumatic stress and anger slopes were associated with overall stress (b = 5.60, p < 0.01 and b = 15.64, p = 0.04, respectively) and relationship stress (b = 5.50, p = 0.01 and b = 22.86, p = 0.01, respectively) beyond the average levels of those symptoms.

LIMITATIONS

Some transition-related difficulties may have resolved before outcome assessment; some measures were not previously validated.

CONCLUSIONS

Larger increases in posttraumatic stress and anger over a deployment period were associated with increased stress after leaving the Army, even after controlling for average symptom levels during the same period. Monitoring changes in mental health during active duty may help identify personnel who need additional support to facilitate the military-to-civilian transition.

Long-Term Consequences of War Captivity in Military Veterans

Numerous studies on the health and functioning of veterans and former prisoners of war have shown that the experience of war captivity is one of the most difficult human experiences. Captivity is often characterized by extremely difficult and inhumane conditions, as well as exposure to various forms of both psychological and physical abuse. Such traumatic experiences can lead to serious psychological consequences that can last for years, even decades after release from captivity. The aim of this paper is to present a brief overview of research that points to the specifics of wartime captivity and the long-term psychological consequences in veterans of former camp detainees, as well as the consequences suffered by their families and factors that, apart from the intensity of the trauma, contribute to the emergence and persistence of psychological disorders. From the presented research, it can be concluded that former prisoners of the camp represent an extremely vulnerable group of the social community and require long-term appropriate treatment, while the needs of veterans' families should not be neglected, with the necessity of including spouses and children in psychological and psychosocial treatments.

Quality of Life among Couples with a Fertility Related Diagnosis

Fertility-related stress can negatively impact infertile couples' quality of life (QoL). Most previous studies have concentrated on the effects of stress and infertility on individual persons, especially women, though infertility affects the QoL of both spouses. Our research aimed to investigate the roles of infertility and stress in couples' quality of life as a single unit. The research sample consisted of 202 spouses, i.e., 101 couples, with a mean age of 39.5 years (SD = 4.9 years) undergoing fertility treatment at Athens Naval Hospital-Assisted Reproduction Unit. Data collection was completed via self-administered questionnaires: the FertiQoL International Questionnaire for measuring the quality of life in infertility and The Demographic Information and Medical History Questionnaire. Data collection was conducted between January and November 2022. Quantitative variables are expressed as mean values (standard deviation) and as median interquartile range, and qualitative variables are expressed as absolute and relative frequencies. Pearson's (r) and Spearman's (rho) correlations coefficients were used to explore the association of two continuous variables. Multiple linear regression analysis was used with dependence on the Ferti-QoL's subscales. The regression equation included terms for participants' demographics and information from their medical history. Adjusted regression coefficients (β) with standard errors (SE) were computed from the results of the linear regression analyses. All reported p values are two-tailed. Statistical significance was set to p < 0.05, and analyses were conducted using SPSS statistical software (version 22.0). We found that greater anxiety and depression were significantly associated with worse quality of life. Additionally, quality of life, according to Ferti-QoL, was significantly worse in women, participants with a high level of education, those with greater depressive symptoms, and those with greater state scores. Findings of this study highlight the need for implementing interventions of supportive care methods, counseling, stress reduction methods, and improving the fertility-related quality of life of infertile couples.

Exploring combat stress exposure effects on burn pain in a female rodent model

In the military, constant physiological and psychological stress encountered by Soldiers can lead to development of the combat and operational stress reaction (COSR), which can effect pain management. Similar effects are seen in other populations subjected to high levels of stress. Using a model of COSR, our lab recently showed that four weeks of stress prior to an injury increases pain sensitivity in male rats. With the roles of women in the military expanding and recent studies indicating sex differences in stress and pain processing, this study sought to investigate how different amounts of prior stress exposure affects thermal injury-induced mechanosensitivity in a female rat model of COSR. Adult female Sprague Dawley rats were exposed to the unpredictable combat stress (UPCS) procedure for either 2 or 4 weeks. The UPCS procedure included exposure to one stressor each day for four days. The stressors include: (1) sound stress for 30 min, (2) restraint stress for 4 h, (3) cold stress for 4 h, and (4) forced swim stress for 15 min. The order of stressors was randomized weekly. Mechanical and thermal sensitivity was tested twice weekly. After the UPCS procedure, a sub-set of rats received a thermal injury while under anesthesia. The development of mechanical allodynia and thermal hyperalgesia was examined for 14 days post-burn. UPCS exposure increased mechanosensitivity after two weeks. Interestingly, with more stress exposure, females seemed to habituate to the stress, causing the stress-induced changes in mechanosensitivity to decrease by week three of UPCS. If thermal injury induction occurred during peak stress-induced mechanosensitivity, after two weeks, this resulted in increased mechanical allodynia in the injured hind paw compared to thermal injury alone. This data indicates a susceptibility to increased nociceptive sensitization when injury is sustained at peak stress reactivity. Additionally, this data indicates a sex difference in the timing of peak stress. Post-mortem examination of the prefrontal cortex (PFC) showed altered expression of p-TrkB in 4-week stressed animals given a thermal injury, suggesting a compensatory mechanism. Future work will examine treatment options for preventing stress-induced pain to maintain the effectiveness and readiness of the Warfighter.

Age differences in allostatic load among veterans: The importance of combat exposure

The current study examinedage differences in allostatic load among nonveterans, noncombat veterans, and combat veterans. Participants included 280 individuals from the Midlife Development in the United States (MIDUS) survey, including 164 veterans (n = 48 combat veterans; n = 116 noncombat veterans) and 116 nonveterans. Age differences in allostatic load were similar among nonveterans and noncombat veterans, B = 0.002, SE = .011, p = .878, with older adults showing higher levels of allostatic load than their comparatively younger counterparts. Among combat veterans, however, a different pattern emerged. In this group, levels of allostatic load were similar across age, seemingly due to higher levels of allostatic load among younger combat veterans, B = -0.029, SE = .014, p = .031, ƞ_p ²  =  .022. Results reveal the importance of considering combat exposure when examining health outcomes of military veterans, particularly in the context of age.

Self-Rated Health Among Patients With Severe Traumatic Brain Injury and Their Close Relatives: The Role of Posttraumatic Stress Symptoms

OBJECTIVE

Severe traumatic brain injury (sTBI) is accompanied by significant declines in self-rated health (SRH). Although such deteriorations in SRH are related to various consequences of sTBI, the effect of posttraumatic reactions (i.e., posttraumatic stress [PTS] symptoms) has been tested insufficiently to date, especially among civilians. The present investigation is based on Trajectories of Recovery After Severe Traumatic brain injury-Matters In families (TRAST-MI), a unique study among civilians with sTBI and their families. Previous research revealed that civilian sTBI has effects beyond the injured patient, influencing their close relatives as well. The aim of this study was to assess the association between PTS symptoms and SRH among patients with civilian sTBI and their close relatives.

METHODS

Patients with sTBI (assessed by an Abbreviated Injury Scale of the head region score >3) and their close relatives participated in TRAST-MI. One hundred twenty-six patient-relative dyads were assessed at 3, 6, and 12 months after the injury.

RESULTS

Multilevel modeling revealed that patients' PTS symptoms were associated with consequent SRH (slope = 0.42; p < .001), and relatives' PTS symptoms were associated with their respective SRH (slope = 0.2; p = .012).

CONCLUSIONS

The findings of this study reveal that SRH of both patients with sTBI and their relatives are negatively affected by their own PTS symptoms. These findings underline the understanding that sTBI is not merely a medical trauma but rather a comprehensive psychosocial trauma, which has consequences for the whole family system.

COVID-19-related fear and stress among individuals who experienced child abuse: The mediating effect of complex posttraumatic stress disorder

BACKGROUND

The COVID-19 pandemic exposes individuals not only to health-related risks, but also to psychosocial fear and acute stress. Previous studies reveal that individuals who experienced child abuse (CA), especially those who suffer from complex posttraumatic stress disorder (CPTSD), are at a higher risk of reacting with fear and stress when faced with stressful life-events.

OBJECTIVE

To test whether exposure to CA is implicated in a higher risk of COVID-19-related fear and acute stress, and whether CPTSD intervenes in such processes.

PARTICIPANTS AND SETTINGS

A convenience sample of 837 adults participated in the study during the first peak of COVID-19 in Israel.

METHODS

Participants completed self-report questionnaires, assessing child physical, sexual and emotional abuse, CPTSD (ITQ), COVID-19-related acute stress disorder (COVID-19 ASD; ASDS) and fear of COVID-19.

RESULTS

Bivariate analyses showed that participants who experienced CA were higher than participants who did not experience CA in COVID-19 ASD (p = .032), but not in fear of COVID-19 (p = .65). Mediation analyses demonstrated two significant paths: in the first, CA was associated with elevated fear of COVID-19 (effect = .061, .059; p < 0.05) and COVID-19 ASD (effect = .14, .084; p < 0.05) through the mediation of CPTSD; in the second path, when controlling for the mediation of CPTSD, CA was associated with reduced fear of COVID-19 (effect = -.15; p = 0.001), and COVID-19 ASD (effect = -.12; p = 0.024).

CONCLUSIONS

The findings reveal a complex pattern, indicating that CPTSD may be a risk factor for elevated levels of COVID-19 distress among individuals who experienced CA. However, some CA survivors may express reduced COVID-19 distress.

From the Frontline to the Homefront: The Experience of Israeli Veterans

In 1948, the state of Israel was created as a homeland for the Jewish people after 2,000 years of persecution and deportations in the diaspora. During the past 72 years, its inhabitants have experienced several wars and numerous terrorist attacks. Therefore, the issue of trauma goes beyond academic study, it is part of daily life. These circumstances have, unfortunately, turned Israel into a natural stress laboratory, which has enabled the systematic research of the biopsychosocial effects of traumatic stress on soldiers and civilians. This article reviews the findings of a series of studies that examine (a) the short- and long-term mental health effects of war on combat veterans; (b) the effects of repeated exposure to war on veterans; (c) trajectories of PTSD; and, specifically, (d) reactivation and (e) delayed-onset PTSD. We present the findings of two decades of systematic trauma research, which have followed the ongoing psychopathological effect of war on veterans. In understanding the ripple effects of trauma, it can be seen that veterans do not leave the events of the war behind once they are home; rather, it is with them wherever they go. Consequently, the trauma has a ripple effect that may carry over to veterans' spouses and offspring. The multiple manifestations and trajectories of both acute and chronic trauma will be presented. Clinical ramifications and implications will also be discussed.

Disarming Ex-Combatants' Minds: Toward Situated Reintegration Process in Post-conflict Colombia

Collective violence in the context of armed conflict impacts the economy, health systems, and social stability of affected countries. This is considered a complex phenomenon with interwoven biological, psychological, social, cultural, and political factors. However, most of the research on this topic still lacks suitable established integrative approaches to assess multilevel perspectives. Social, cognitive and affective mental processes (SCAMP) are critical factors that should be considered in multilevel approaches. In this article, we critically discuss some of the classically isolated approaches used in violence research, the absence of successful interventions for ex-combatants reintegration, and the specific neglect of SCAMP in these interventions. We present the case of post-conflict Colombia as a unique opportunity to study the different roots of collective violence, and we call for a more robust and situated approach to understanding of and intervention in this multifaceted phenomenon. In addition, we suggest a two-stage approach for addressing ex-combatants’ reintegration programs, which considers the situated nature of post-conflict scenarios and the urgent need for evidence-based interventions. This approach focuses on the comprehensive scientific assessment of specific factors involved in violence exposure and the subsequent design of successful interventions. The implementation of this approach will contribute to the effective reintegration of individuals who have been exposed to extreme violence for more than 50 years.

The Association of Post-traumatic and Postmigration Stress with Pain and Other Somatic Symptoms: An Explorative Analysis in Traumatized Refugees and Asylum Seekers

Objective

Post-traumatic stress disorder (PTSD) and somatic symptoms, such as pain, are frequently seen in refugees. Their relationship is poorly understood, and the treatment of these comorbid conditions can be very challenging. The current cross-sectional study examined pain and other somatic symptoms and their relationship with trauma history, PTSD symptom clusters, and current living difficulties among treatment-seeking refugees.

Methods

One hundred thirty-four treatment-seeking traumatized refugees (78% male, mean age = 42 years) were assessed regarding lifetime traumatic experiences, symptoms of post-traumatic stress, overall pain and somatic symptoms, and postmigration living difficulties.

Results

An exploratory factor analysis of the 12 somatic symptoms revealed two distinct factors: somatic symptoms related to bodily dysfunction ("weakness") and somatic symptoms related to increased sympathetic activity ("arousal"). DSM-5 PTSD Criteria D "alterations in cognitions and mood" and E "alterations in arousal and reactivity" were primarily related to "weakness," while PTSD Criterion E "alterations in arousal and reactivity" and postmigration living difficulties were associated with "arousal." Overall pain was associated primarily with living difficulties and PTSD Criterion D and Criterion E.

Conclusions

Results indicate that somatic symptoms are of considerable concern among traumatized refugees and that different patterns of somatic symptoms are associated with different clusters of PTSD symptoms. The findings contribute to the better understanding of the symptom presentation of traumatized people who are experiencing somatization and potentially inform treatment directions and highlight the importance of screening for PTSD in refugees presenting with pain and somatic symptoms.

Parental PTSD, health behaviors and successful aging among offspring of Holocaust survivors

Unhealthy behaviors and physical morbidity are more common among trauma survivors, especially those who suffer from posttraumatic stress disorder (PTSD). This study looked at the underexplored relationships between parental PTSD, unhealthy behaviors and aging of trauma survivors' offspring. Dyads of parents (mean age = 82.42) and offspring (mean age = 55.48) reported PTSD symptoms, health behaviors and completed indices of successful aging. Dyads were divided into three groups: Holocaust survivors (HS) with probable PTSD (n = 28 dyads), HS without PTSD (n = 86 dyads) and comparison parents without PTSD (n = 73 dyads). Relative to the other groups, HS parents with probable PTSD and their offspring reported more unhealthy behaviors. Serial mediation models showed that the effect of parental PTSD on offspring successful aging was mediated by both parental and offspring unhealthy behaviors. Findings remained significant after controlling for background characteristics and offspring PTSD. This study provides preliminary evidence that PTSD is related to unhealthy behaviors across generations in HS families. Possible mechanisms for such intergenerational effect and its clinical implication are discussed.

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

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

One 'knows': self-rated health and telomere length among ex-prisoners of war

OBJECTIVE

Ill-health and early mortality are amongst the most significant ramifications of trauma. Furthermore, trauma alters the subjective perception and experience of the body. The aim of this study is to examine the extent to which deteriorations in perceived health among traumatised individuals are associated with cellular health as manifested in telomere length.

METHODS

Specifically, 88 former prisoners of war (ex-POWs) evaluated their health (self-rated health; SRH) at 18 (T1), 35 (T2) and 42 (T3) years after the war, and were assessed for telomere length at T3. Health behaviour, BMI, morbidity and PTSD were also examined at T3.

RESULTS

The findings demonstrated that SRH was cross-sectionally correlated with telomere length. Furthermore, a significant sequential indirect effect was found, in which worse SRH in T1 was associated with shorter telomere length at T3, through worse SRH at T2 and at T3.

CONCLUSIONS

These findings demonstrate that long-term deteriorations in the subjective evaluations of health are implicated in actual cellular health among individuals exposed to trauma.

A network analysis of DSM-5 posttraumatic stress disorder and functional impairment in UK treatment-seeking veterans

Network analysis is a relatively new methodology for studying psychological disorders. It focuses on the associations between individual symptoms which are hypothesized to mutually interact with each other. The current study represents the first network analysis conducted with treatment-seeking military veterans in UK. The study aimed to examine the network structure of posttraumatic stress disorder (PTSD) symptoms and four domains of functional impairment by identifying the most central (i.e., important) symptoms of PTSD and by identifying those symptoms of PTSD that are related to functional impairment. Participants were 331 military veterans with probable PTSD. In the first step, a network of PTSD symptoms based on the PTSD Checklist for DSM-5 was estimated. In the second step, functional impairment items were added to the network. The most central symptoms of PTSD were recurrent thoughts, nightmares, negative emotional state, detachment and exaggerated startle response. Functional impairment was related to a number of different PTSD symptoms. Impairments in close relationships were associated primarily with the negative alterations in cognitions and mood symptoms and impairments in home management were associated primarily with the reexperiencing symptoms. The results are discussed in relation to previous PTSD network studies and include implications for clinical practice.

Torturing personification of chronic pain among torture survivors

BACKGROUND

Consistent with the human tendency to anthropomorphize objects, events, and situations, individuals might ascribe human characteristics to physical symptoms and illnesses. This manuscript presents an examination of chronic pain personification in torture survivors. Specifically, it was hypothesized that torture survivors personify chronic pain as a torturing sensation. It was further hypothesized that PTSD mediates the effect of past torture on torturing pain personification.

METHODS

Fifty-nine Israeli ex-prisoners of war (ex-POWs), who experienced severe torture in captivity, and 44 matched controls completed self-administered questionnaires at 18, 30, and 35years post captivity.

RESULTS

Whereas ex-POWs exhibit higher torturing personification than controls, no differences were found in concrete description of chronic pain. PTSD trajectories were implicated in different levels of torturing personification. Finally, sequential mediation analysis revealed that PTSD at T2 and T3 mediated the association between torture and torturing personification.

CONCLUSIONS

The findings suggest that trauma shapes the way individuals relate to and experience their bodily sensations.

Psychosocial impacts of communal conflicts in a sample of secondary school youths from two conflict communities in south east Nigeria

In Nigeria, communal conflicts arise due to misunderstanding from ownership of land for farming, oil deposits, solid minerals or water for fishing activities. It may also arise in defence of community pride and properties or even in defence of the people involved in the conflict. The General Health Questionnaire (GHQ-12), The Short Screening Scale for Post traumatic stress disorder, The Generalized Anxiety Disorder Scale (GAD-7) and the Beck Depression Inventory (BDI-2) were used to assess psychosocial impacts of communal conflicts among 560 secondary school youths from two communities in south east Nigeria. Result revealed various forms of psychosocial impacts of communal conflicts among the youths.

Explaining the frequency of alcohol consumption in a conflict zone: Jews and Palestinians in Israel

Experiencing stress and exposure to terrorism may have an adverse effect on health risk behaviors. Few studies have examined alcohol use among adults living in Israel under chronic, stressful terrorism-related conditions. In this study, we examined the relationships of demographics, past stressful events, and terrorism exposure to the frequency of alcohol use and the mediating roles of depressive and post-traumatic stress disorder (PTSD) symptoms. We used three waves of data from a 2007-2008 nationally representative sample of Jewish and Palestinian adults in Israel. We assessed past stressful events, in addition to direct and indirect exposures to terrorism. Results indicated that past stressful events and exposure to terrorism were not directly associated with alcohol use, but were indirectly associated and mediated by depressive and PTSD symptomology. Mental health symptoms were differentially associated with alcohol use. More frequent drinking was mediated by higher levels of depression, including for women and Palestinians; however, PTSD symptom severity was related to less frequent drinking. Mental health may play a prominent role in the frequency of alcohol use among adults exposed to terrorism in Israel. Alcohol use, as a coping mechanism, may differ by demographic characteristics (gender and ethnicity) and psychological symptomology for adults living in a conflict zone in Israel.

Aggressive situational cues among Israeli security personnel

The present study enriches our knowledge on the relationship between security personnel and situational cues that may provoke aggression, such as arms and uniforms. The study examined 259 security personnel who completed an aggression questionnaire (AGQ). The study aimed (a) to compare the tendency toward aggression of security personnel who carry or do not carry arms and/or wear a uniform and (b) to compare the tendency toward aggression of men and women security personnel who carry or do not carry arms and/or wear a uniform. The findings indicated no main effect for aggression cueing classification. However, uniformed men had higher scores of physical aggression than women, and women scored significantly higher on anger than men when not carrying any aggressive cues. The findings also revealed that in general, men security personnel reported much higher physical aggression than women, while women showed slightly higher means of verbal aggression than men. The findings are discussed in light of the gender theory and research.

Indirect associations of combat exposure with post-deployment physical symptoms in U.S. soldiers: roles of post-traumatic stress disorder, depression and insomnia

OBJECTIVE

To characterize the indirect associations of combat exposure with post-deployment physical symptoms through shared associations with post-traumatic stress disorder (PTSD), depression and insomnia symptoms.

METHODS

Surveys were administered to a sample of U.S. soldiers (N = 587) three months after a 15-month deployment to Iraq. A multiple indirect effects model was used to characterize direct and indirect associations between combat exposure and physical symptoms.

RESULTS

Despite a zero-order correlation between combat exposure and physical symptoms, the multiple indirect effects analysis did not provide evidence of a direct association between these variables. Evidence for a significant indirect association of combat exposure and physical symptoms was observed through PTSD, depression, and insomnia symptoms. In fact, 92% of the total effect of combat exposure on physical symptoms scores was indirect. These findings were evident even after adjusting for the physical injury and relevant demographics.

CONCLUSION

This is the first empirical study to suggest that PTSD, depression and insomnia collectively and independently contribute to the association between combat exposure and post-deployment physical symptoms. Limitations, future research directions, and potential policy implications are discussed.

An Exploration of Spirituality and the Traumatizing Experiences of Combat

The complex experiences of combat demand significant levels of adaptation and resilience. An individual’s spirituality may be challenged by these experiences, and as a result, he or she may be left both psychologically and spiritually wounded. Incorporating spirituality into the healing process may help mend the wounds of combat soldiers, especially within an integrative treatment framework. In this article, spirituality and the impact of traumatizing combat experiences are discussed from a cultural perspective, using the experiences of an Israeli soldier as an example.

Subjective Age and Health in Later Life: The Role of Posttraumatic Symptoms

OBJECTIVES

We examined: (a) long-term effects of war-related trauma and captivity on posttraumatic stress symptoms (PTSS), physical health, and subjective age; and (b) the moderation effect of PTSS and health on subjective age among ex-prisoners of war (ex-POWs) and war veterans.

METHOD

Israeli veterans of the 1973 Yom Kippur War (mean age 57 years), including 111 ex-POWs and 167 matched veterans were assessed for subjective age, war-related PTSS, and health-related measures (physical symptoms, somatization, health-risk behaviors, and self-rated health).

RESULTS

Controlling for age, ex-POWs endorsed higher subjective age than controls, and ex-POWs with posttraumatic stress disorder (PTSD) endorsed higher subjective age than ex-POWs and controls without PTSD. PTSS and health measures besides health-risk behaviors predicted subjective age. Significant interactions were found between PTSS and each health measure, suggesting that health only predicts subjective age for those reporting high PTSS.

DISCUSSION

PTSS appear to be implicated in the link between health measures and subjective age in later life, pointing to the long-term effect of captivity and war-induced traumatic distress on aging.

Military service, exposure to trauma, and health in older adulthood: an analysis of northern Vietnamese survivors of the Vietnam War

OBJECTIVES

We sought to better understand the association between early life exposure to war and trauma and older adult health status in a developing setting.

METHODS

We analyzed data of 405 Vietnamese men and women in 1 northern Vietnam commune who entered early adulthood during the Vietnam War and who are now entering late adulthood (i.e., ages 55 years and older in 2010).

RESULTS

The toll of war's trauma in the aging northern Vietnamese population was perceptible in the association between exposure to war trauma and various measures of physical health, including negative self-reported health and somatic symptoms. Killing another person and being exposed to toxic substances in warfare was especially detrimental to health in older adulthood. War traumas were likely implicated more strongly as determinants of late adulthood health in men than in women. The weak association between trauma exposure and reported depressive symptoms raised questions about measuring mental health.

CONCLUSIONS

Military service and war trauma were important determinants of older adult health beyond the US context, given the widespread waging of war and concentration of recent armed conflicts within developing societies.

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.

Higher FKBP5, COMT, CHRNA5, and CRHR1 allele burdens are associated with PTSD and interact with trauma exposure: implications for neuropsychiatric research and treatment

OBJECTIVE

The study aim was to assess the cumulative burden of polymorphisms located within four genetic loci previously associated with posttraumatic stress disorder (PTSD) among outpatients at risk for PTSD.

METHODS

Diagnostic interviews were completed and DNA samples collected among 412 pain patients to determine if FKBP5 (rs9470080), COMT (rs4680), CHRNA5 (rs16969968), and CRHR1 (rs110402) single nucleotide polymorphisms were cumulatively associated with increased risk for PTSD.

RESULTS

In bivariate analyses, it was found that a count of specific PTSD risk alleles located within FKBP5, COMT, CHRNA5, and CRHR1 genetic loci (allele range = 0-6, mean count = 2.92, standard deviation = 1.36) was associated with lifetime (t [409] = 3.430, P = 0.001) and early onset PTSD (t [409] = 4.239, P = 0.000028). In logistic regression, controlling for demographic factors, personality traits, and trauma exposures, this risk allele count remained associated with both lifetime (odds ratio = 1.49, P = 0.00158) and early onset PTSD (odds ratio = 2.36, P = 0.000093). Interaction effects were also detected, whereby individuals with higher risk allele counts and higher trauma exposures had an increased risk of lifetime PTSD (allele count × high trauma, P = 0.026) and early onset PTSD (allele count × high trauma, P = 0.016) in these logistic regressions. Those with no or few risk alleles appeared resilient to PTSD, regardless of exposure history.

CONCLUSION

A cumulative risk allele count involving four single nucleotide polymorphisms located within the FKBP5, COMT, CHRNA5, and CRHR1 genes are associated with PTSD. Level of trauma exposure interacts with risk allele count, such that PTSD is increased in those with higher risk allele counts and higher trauma exposures. Since the single nucleotide polymorphisms studied encompass stress circuitry and addiction biology, these findings may have implications for neuropsychiatric research and treatment.

Determinants of changes in self-rated health among Finnish war veterans: results from the Veteran Project 1992 and 2004 surveys

Self-rated health is a strong predictor of mortality, morbidity, future functional capacity and the quality of life. Measures of self-rated health have been collected fairly regularly since the 1980s, but few of them focus on self-rated health among the elderly war veterans. The aim of this study was to examine changes in self-rated health among Finnish war veterans from 1992 to 2004 and to analyze the independent determinants associated with changes in veterans' self-rated health. The study population was 4999 veterans living in Finland, who participated in data collection of both the Veteran Project 1992 and 2004. Logistic regression models were used to identify independent predictors for changes in self-rated health. Analyses were conducted separately for men with and without disability and for women. During the follow-up, self-rated health improved or remained unchanged among 88.8% of the men without disability, 90.5% of the men with disability and 87.9% of the women. Determinants for declined self-rated health were a new cardiovascular disease (CVD) among all veteran groups, increased walking difficulties among men without disability and women, a new neurological disease and institutionalization among men without disability, and a new musculoskeletal disease among men with disability. In conclusion, the majority of veterans rated their health improved or unchanged during the follow-up. The importance of mobility impairments and cardiovascular, musculoskeletal and neurological diseases as the predictors of declined self-rated health were confirmed.

Trajectories of stress reactions and somatization symptoms among war veterans: a 20-year longitudinal study

BACKGROUND

There is considerable evidence that immediate and long-term stress reactions are associated with increased somatic symptomatology. However, because of the scarcity of long-term longitudinal studies, the trend of mutual change of these factors has not been assessed. This study examined the chronological inter-relationships between post-traumatic stress reactions and somatization symptoms among combatants over a 20-year period.

METHOD

Two groups of veterans were assessed 1, 2, 3 and 20 years after their participation in the 1982 Lebanon War: a clinical group of veterans who had been diagnosed with combat stress reaction (CSR) on the battlefield (n=363), and a matched control group of veterans (n=301).

RESULTS

The CSR veterans reported higher initial levels of intrusion and avoidance and a steeper decline in those symptoms over time in comparison to the control group. The former also reported higher initial levels of somatization symptoms than the latter. In addition, over the years, stress reactions were positively associated with somatization symptoms. For both study groups, in the first years after the war, stress reaction symptoms predicted somatization symptoms. However, with time, the trend was reversed and somatization symptoms predicted stress reactions.

CONCLUSIONS

The findings suggest that CSR is a marker for future stress reactions and somatization symptoms, and indicate a long-term role for these symptoms in veterans' psychological distress.

A brief screening tool for assessing psychological trauma in clinical practice: development and validation of the New York PTSD Risk Score

OBJECTIVE

The objective was to develop a brief posttraumatic stress disorder (PTSD) screening instrument that is useful in clinical practice, similar to the Framingham Risk Score used in cardiovascular medicine.

METHODS

We used data collected in New York City after the World Trade Center disaster (WTCD) and other trauma data to develop a new PTSD prediction tool--the New York PTSD Risk Score. We used diagnostic test methods to examine different clinical domains, including PTSD symptoms, trauma exposures, sleep disturbances, suicidal thoughts, depression symptoms, demographic factors and other measures to assess different PTSD prediction models.

RESULTS

Using receiver operating curve (ROC) and bootstrap methods, five prediction domains, including core PTSD symptoms, sleep disturbance, access to care status, depression symptoms and trauma history, and five demographic variables, including gender, age, education, race and ethnicity, were identified. For the best prediction model, the area under the ROC curve (AUC) was 0.880 for the Primary Care PTSD Screen alone (specificity=82.2%, sensitivity=93.7%). Adding care status, sleep disturbance, depression and trauma exposure increased the AUC to 0.943 (specificity=85.7%, sensitivity=93.1%), a significant ROC improvement (P<.0001). Adding demographic variables increased the AUC to 0.945, which was not significant (P=.250). To externally validate these models, we applied the WTCD results to 705 pain patients treated at a multispecialty group practice and to 225 trauma patients treated at a Level I Trauma Center. These results validated those from the original WTCD development and validation samples.

CONCLUSION

The New York PTSD Risk Score is a multifactor prediction tool that includes the Primary Care PTSD Screen, depression symptoms, access to care, sleep disturbance, trauma history and demographic variables and appears to be effective in predicting PTSD among patients seen in healthcare settings. This prediction tool is simple to administer and appears to outperform other screening measures.

A twin study of the association between PTSD symptoms and rheumatoid arthritis

OBJECTIVES

To assess the association between posttraumatic stress disorder (PTSD) and rheumatoid arthritis (RA) and to determine if this was due to PTSD or confounding by environmental and genetic factors.

METHODS

Data were obtained from 3143 twin pairs in the Vietnam Era Twin Registry, which included male twin pairs who served during the Vietnam War era (mean age, 40.6 years; standard deviation, 2.9). Measurements included a PTSD symptom scale, history of physician-diagnosed RA, sociodemographics, and health confounding factors. Co-twin control analytic methods used generalized estimating equation logistic regression to account for the paired twin data and to examine the association between PTSD symptoms and RA in all twins. Separate analyses were conducted within twin pairs.

RESULTS

The prevalence of RA among this population was 1.9% (95% confidence interval, 1.6-2.3) and the mean PTSD symptom level was 25.5 (standard deviation, 9.6). PTSD symptoms were associated with an increased likelihood of adult RA even after adjustment for confounding (p(trend) < .001). Among all twins, those in the highest PTSD symptom quartile were 3.8 times more likely (95% confidence interval, 2.1-6.1) to have RA compared with those in the lowest. These findings also persist when examined within twin pairs (p(trend) < .022).

CONCLUSIONS

PTSD symptoms were associated with adult RA onset. Even after adjustment for familial/genetic factors and other confounders, an association between PTSD symptoms and RA remained. This is one of the first studies to demonstrate a link between PTSD and RA onset among a community-based population sample, independent of familial and genetic factors.

Natural killer cell cytotoxicity and lymphocyte perforin expression in veterans with posttraumatic stress disorder

OBJECTIVE

To examine the effect of posttraumatic stress disorder (PTSD) on the measures of immune function and the hypothalamic-pituitary-adrenal axis components, and to determine whether additional life stressors affect measured variables.

METHODS

We simultaneously examined the natural killer cell cytotoxicity (NKCC), perforin and glucocorticoid receptor (GCR) expression in natural killer (NK) and cytotoxic T (CD8) cells, as well as serum cortisol concentration in a group of Croatian war veterans with chronic, combat-related PTSD (n=29) and a group of healthy, age-matched men (n=13). PTSD patients were divided into two subgroups: compensation-seeking (n=15) and retired or compensation non-seeking (n=14) subjects. The former includes those involved in the process of getting disability-based army retirement as an additional life stressor.

RESULTS

NKCC was decreased in both PTSD groups when compared to controls. Impairment of NKCC could not be attributed to the perforin expression as perforin was not decreased in comparison to controls. Moreover, the increased level of perforin was recorded in NK cells of retired PTSD subjects. Both PTSD groups shared an increased relative quantity of GCR in lymphocytes, whereas no difference between the groups in the baseline levels of serum cortisol was observed.

CONCLUSIONS

Diminished NKCC was not accompanied by perforin insufficiency in PTSD subjects, and other causes should be examined. An additional life stressor does not contribute considerably to either immune or endocrine system related changes.

The long-term costs of traumatic stress: intertwined physical and psychological consequences

The gradual emergence of symptoms following exposure to traumatic events has presented a major conceptual challenge to psychiatry. The mechanism that causes the progressive escalation of symptoms with the passage of time leading to delayed onset post-traumatic stress disorder (PTSD) involves the process of sensitization and kindling. The development of traumatic memories at the time of stress exposure represents a major vulnerability through repeated environmental triggering of the increasing dysregulation of an individual's neurobiology. An increasing body of evidence demonstrates how the increased allostatic load associated with PTSD is associated with a significant body of physical morbidity in the form of chronic musculoskeletal pain, hypertension, hyperlipidaemia, obesity and cardiovascular disease. This increasing body of literature suggests that the effects of traumatic stress need to be considered as a major environmental challenge that places individual's physical and psychological health equally at risk. This broader perspective has important implications for developing treatments that address the underlying dysregulation of cortical arousal and neurohormonal abnormalities following exposure to traumatic stress.

Evaluation of psychological support for victims of sexual violence in a conflict setting: results from Brazzaville, Congo

BACKGROUND

Little is known about the impact of psychological support in war and transcultural contexts and in particular, whether there are lasting benefits. Here, we present an evaluation of the late effect of post-rape psychological support provided to women in Brazzaville, Republic of Congo.

METHODS

Women who attended the Médecins Sans Frontières program for sexual violence in Brazzaville during the conflict were selected to evaluate the psychological consequences of rape and the late effect of post-rape psychological support. A total of 178 patients met the eligibility criteria: 1) Women aged more than 15 years; 2) raped by unknown person(s) wearing military clothes; 3) admitted to the program between the 1/1/2002 and the 30/4/2003; and 4) living in Brazzaville.

RESULTS

The initial diagnosis according to DSM criteria showed a predominance of anxious disorders (54.1%) and acute stress disorders (24.6%). One to two years after the initial psychological care, 64 women were evaluated using the Trauma Screening Questionnaire (TSQ), the Global Assessment of Functioning scale (GAF) and an assessment scale to address medico-psychological care in emergencies (EUMP). Two patients (3.1%) met the needed criteria for PTSD diagnosis from the TSQ. Among the 56 women evaluated using GAF both as pre and post-test, global functioning was significantly improved by initial post-rape support (50 women (89.3%) had extreme or medium impairment at first post-rape evaluation, and 16 (28.6%) after psychological care; p = 0.04). When interviewed one to two years later, the benefit was fully maintained (16 women (28.6%) presenting extreme or medium impairment).

CONCLUSION

We found the benefits of post-rape psychological support to be present and lasting in this conflict situation. However, we were unable to evaluate all women for the long-term impact, underscoring the difficulty of leading evaluation studies in unstable contexts. Future research is needed to validate these findings in other settings.

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.

Coping with life-threatening events was associated with better self-perceived health in a naval cross-sectional study

OBJECTIVE

We studied the relationship between experiencing and coping with life-threatening events and self-perceived health in navy personnel operating mainly under peaceful circumstances.

METHODS

The data were collected in a cross-sectional study from a questionnaire sent by mail at the end of 2002 to all employees in the Royal Norwegian Navy (N=3878) as part of a general health study. Both military and civilian personnel with different types of work on ships and ashore participated in the study. Logistic regression analyses were performed to study the relationship between the number of life-threatening events, occupational status, sex, age, and the extent of putting these events behind. The possible trends between the degree of putting the events behind and each of the eight SF-36 scales were calculated by bivariate correlations.

RESULTS

Military personnel had experienced life-threatening events more often than civilians, but the military personnel appeared 5.5 times more likely to have put such events behind themselves than the civilians. The extent of having put life-threatening events behind oneself was clearly correlated to self-perceived health as measured by the SF-36 subscales bodily pain, general health, vitality, social functioning, role-emotional, and mental health. These associations had linear appearances.

CONCLUSION

Navy personnel who have experienced a life-threatening event and have not been able to put this event behind them are more likely to report a reduced self-perceived health.

Trauma exposure influences cue elicited affective responses among smokers with and without a history of major depression

The current study tested the emotional reactivity of smokers with and without histories of major depression (MDD Hx) and trauma exposure (TE). Four counterbalanced conditions nested negative (e.g., dysphoric) or neutral mood inductions with in vivo versus control smoking paraphernalia cues (Neutral+Control; Neutral+Cigarette; Neg+Control; Neg+Cigarette). Mixed model analysis of covariance (ANCOVA) tested between and within subjects differences in negative affective symptoms pre- to post-exposure across four groups (TE+MDD Hx; TE only; MDD Hx only; no history). Results produced two notable effects. First, TE only individuals endorsed the greatest increase in depressive symptoms across both negative mood induction conditions (regardless of smoking paraphernalia) compared with other groups. Second, dual history participants (TE+MDD Hx) show a potentiated depressive response to the Neg+Cigarette condition compared with the Neg+Control condition. Implications to a depression-specific negative affective vulnerability among TE only smokers that is independent of MDD Hx and greater than smokers with a MDD Hx are discussed.

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.

Collateral gains from the military? A cross-national analysis of the armed forces crime relationship

Research has repeatedly showed that males aged between 16 and 24 years old account for a disproportionately large volume of crime. Armed forces are major employers of young males in their crime-prone ages and thus could play an essential role in crime prevention. The military is a highly structured and regimented total institution in which rigid behavioral norms and very close monitoring are imposed both on soldiers and on officers. Using data from 65 countries for the period of 1995 to 1999, this study assesses the crime-reduction function of the military by testing the influence of the relative size of the armed forces and the existence of conscription on national rates of homicide. The findings show that the size of the military and the existence of conscription are significantly related to homicide rates. Implications for future research are discussed.

The association between childhood abuse, PTSD, and the occurrence of adult health problems: moderation via current life stress

The association between childhood abuse, current life stressors, and the occurrence of adult medical problems was investigated in the National Comorbidity Survey. It was found that after controlling for a number of covariates, current life stressors moderated the relationship between abuse history and medical problems such that health problems were greater for individuals who had been abused in the presence of current stressors. The findings suggest that a history of childhood abuse, even without the presence of posttraumatic stress disorder (PTSD), can influence the occurrence of poor health if current life stressors are present. Future directions and implications are discussed.

Life events and adjustment following myocardial infarction: a longitudinal study

OBJECTIVES

This study examines the implications of both pre-Myocardial Infarction (MI) and post-MI life events on the severity of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) symptomatology.

METHODS

116 MI patients were examined twice. At Time 1, within a week of the MI, severity of ASD and pre-MI life events were assessed, and medical measures were obtained from patients' hospital records. At Time 2, seven months later, severity of PTSD and post-MI life events were assessed.

RESULTS

Although pre-MI life events were associated with both ASD and PTSD symptom severity, the relation between these events and PTSD was mediated by ASD. Post MI stressful life events made an independent contribution to PTSD severity.

DISCUSSION

These findings emphasize the fact that traumatic events do not occur in isolation and that their emotional impact is related to other events that occur both before and after.

Stressful life events and physical health

PURPOSE OF REVIEW

This review summarizes the findings of recent researches from selected empirical and nonempirical publications focused on stressful life events and physical health.

RECENT FINDINGS

The findings can be divided into biological, psychological, and social issues concerning the important relationship between stressful life events and physical health. Growing evidence in the field of psychoneuroimmunology contributes to the understanding of the mechanisms by which stressful events affect physical health. The interactions between behavior, central nervous system, and endocrine system that might cause immunosuppression is the most fascinating finding in modern medicine, and its implications are important for the prevention and treatment of somatic illnesses. Trauma, abuse, and stressful events have been studied extensively, especially among vulnerable groups such as children, women, caregivers, and combatants. Risk factors and resilience were the focus of attention of some authors as well as the behavioral intervention for coping with stressful events.

SUMMARY

The findings support old observations and case reports of a close link between stressful life events and physical health and emphasize the necessity of early recognition and timely management of stress-induced illnesses. Psychosomatic approach, multidimensional diagnostics, and treatment should be sine qua non in the integrated care of affected people and should improve their quality of life.