Occupational differences in US Army suicide rates

BACKGROUND

Civilian suicide rates vary by occupation in ways related to occupational stress exposure. Comparable military research finds suicide rates elevated in combat arms occupations. However, no research has evaluated variation in this pattern by deployment history, the indicator of occupation stress widely considered responsible for the recent rise in the military suicide rate.

METHOD

The joint associations of Army occupation and deployment history in predicting suicides were analysed in an administrative dataset for the 729 337 male enlisted Regular Army soldiers in the US Army between 2004 and 2009.

RESULTS

There were 496 suicides over the study period (22.4/100 000 person-years). Only two occupational categories, both in combat arms, had significantly elevated suicide rates: infantrymen (37.2/100 000 person-years) and combat engineers (38.2/100 000 person-years). However, the suicide rates in these two categories were significantly lower when currently deployed (30.6/100 000 person-years) than never deployed or previously deployed (41.2-39.1/100 000 person-years), whereas the suicide rate of other soldiers was significantly higher when currently deployed and previously deployed (20.2-22.4/100 000 person-years) than never deployed (14.5/100 000 person-years), resulting in the adjusted suicide rate of infantrymen and combat engineers being most elevated when never deployed [odds ratio (OR) 2.9, 95% confidence interval (CI) 2.1-4.1], less so when previously deployed (OR 1.6, 95% CI 1.1-2.1), and not at all when currently deployed (OR 1.2, 95% CI 0.8-1.8). Adjustment for a differential 'healthy warrior effect' cannot explain this variation in the relative suicide rates of never-deployed infantrymen and combat engineers by deployment status.

CONCLUSIONS

Efforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.

Mitochondria-focused gene expression profile reveals common pathways and CPT1B dysregulation in both rodent stress model and human subjects with PTSD

Posttraumatic stress disorder (PTSD), a trauma-related mental disorder, is associated with mitochondrial dysfunction in the brain. However, the biologic approach to identifying the mitochondria-focused genes underlying the pathogenesis of PTSD is still in its infancy. Previous research, using a human mitochondria-focused cDNA microarray (hMitChip3) found dysregulated mitochondria-focused genes present in postmortem brains of PTSD patients, indicating that those genes might be PTSD-related biomarkers. To further test this idea, this research examines profiles of mitochondria-focused gene expression in the stressed-rodent model (inescapable tail shock in rats), which shows characteristics of PTSD-like behaviors and also in the blood of subjects with PTSD. This study found that 34 mitochondria-focused genes being upregulated in stressed-rat amygdala. Ten common pathways, including fatty acid metabolism and peroxisome proliferator-activated receptors (PPAR) pathways were dysregulated in the amygdala of the stressed rats. Carnitine palmitoyltransferase 1B (CPT1B), an enzyme in the fatty acid metabolism and PPAR pathways, was significantly over-expressed in the amygdala (P < 0.007) and in the blood (P < 0.01) of stressed rats compared with non-stressed controls. In human subjects with (n = 28) or without PTSD (n = 31), significant over-expression of CPT1B in PTSD was also observed in the two common dysregulated pathways: fatty acid metabolism (P = 0.0027, false discovery rate (FDR) = 0.043) and PPAR (P = 0.006, FDR = 0.08). Quantitative real-time polymerase chain reaction validated the microarray findings and the CPT1B result. These findings indicate that blood can be used as a specimen in the search for PTSD biomarkers in fatty acid metabolism and PPAR pathways, and, in addition, that CPT1B may contribute to the pathology of PTSD.

Understanding the elevated suicide risk of female soldiers during deployments

BACKGROUND

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment.

METHOD

Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders.

RESULTS

The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables.

CONCLUSIONS

These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.

Sociodemographic and career history predictors of suicide mortality in the United States Army 2004-2009

BACKGROUND

The US Army suicide rate has increased sharply in recent years. Identifying significant predictors of Army suicides in Army and Department of Defense (DoD) administrative records might help focus prevention efforts and guide intervention content. Previous studies of administrative data, although documenting significant predictors, were based on limited samples and models. A career history perspective is used here to develop more textured models.

METHOD

The analysis was carried out as part of the Historical Administrative Data Study (HADS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). De-identified data were combined across numerous Army and DoD administrative data systems for all Regular Army soldiers on active duty in 2004-2009. Multivariate associations of sociodemographics and Army career variables with suicide were examined in subgroups defined by time in service, rank and deployment history.

RESULTS

Several novel results were found that could have intervention implications. The most notable of these were significantly elevated suicide rates (69.6-80.0 suicides per 100 000 person-years compared with 18.5 suicides per 100 000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank; a substantially greater rise in suicide among women than men during deployment; and a protective effect of marriage against suicide only during deployment.

CONCLUSIONS

A career history approach produces several actionable insights missed in less textured analyses of administrative data predictors. Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.

p11 is up-regulated in the forebrain of stressed rats by glucocorticoid acting via two specific glucocorticoid response elements in the p11 promoter

Posttraumatic stress disorder (PTSD) is one of the most common psychiatric disorders. Despite the extensive study of the neurobiological correlates of this disorder, the underlying mechanisms of PTSD are still poorly understood. Recently, a study demonstrated that dexamethasone (Dex), a synthetic glucocorticoid, can up-regulate p11, known as S100A10-protein which is down-regulated in patients with depression, (Yao et al., 1999; Huang et al., 2003) a common comorbid disorder in PTSD. These observations led to our hypothesis that traumatic stress may alter expression of p11 mediated through a glucocorticoid receptor. Here, we demonstrate that inescapable tail shock increased both prefrontal cortical p11 mRNA levels and plasma corticosterone levels in rats. We also found that Dex up-regulated p11 expression in SH-SY5Y cells through glucocorticoid response elements (GREs) within the p11 promoter. This response was attenuated by either RU486, a glucocorticoid receptor (GR) antagonist or mutating two of three glucocorticoid response elements (GRE2 and GRE3) in the p11 promoter. Finally, we showed that p11 mRNA levels were increased in postmortem prefrontal cortical tissue (area 46) of patients with PTSD. The data obtained from our work in a rat model of inescapable tail shock, a p11-transfected cell line and postmortem brain tissue from PTSD patients outline a possible mechanism by which p11 is regulated by glucocorticoids elevated by traumatic stress.

Gender differences in posttraumatic stress disorder after motor vehicle accidents

OBJECTIVE

Women have higher rates of posttraumatic stress disorder (PTSD) than men. The authors examined prior trauma, PTSD, major depression, anxiety disorder not including PTSD, and peritraumatic dissociation; current peritraumatic dissociation; and passenger injury as possible explanations for the different rates of acute PTSD in women and men after a serious motor vehicle accident.

METHOD

Subjects age 18-65 years who had been in a serious motor vehicle accident (N=122) were assessed with the Structured Clinical Interview for DSM-III-R and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version 1 month after the accident.

RESULTS

Women did not differ from men in meeting the overall reexperiencing criterion for a diagnosis of PTSD (criterion B), but women were at greater risk for the specific reexperiencing symptoms of intense feelings of distress in situations similar to the motor vehicle accident and physical reactivity to memories of the motor vehicle accident. Women were 4.7 times more likely than men to meet the overall avoidance/numbing criterion (criterion C) and 3.8 times more likely to meet the overall arousal criterion (criterion D). Women were more likely than men to report the criterion C symptoms of avoiding thoughts and situations associated with the accident, loss of interest in significant activities, and a sense of foreshortened future and the criterion D symptoms of trouble sleeping, difficulty concentrating, and exaggerated startle response. Multiple logistic regression analysis indicated that the gender differences in acute PTSD were not associated with prior trauma, PTSD, peritraumatic dissociation, major depression, or anxiety disorder not including PTSD or with passenger injury. However, peritraumatic dissociative symptoms at the time of the accident were associated with a significantly higher risk for acute PTSD in women than in men.

CONCLUSIONS

Gender differences in peritraumatic dissociation may help explain differences in risk for PTSD and for some PTSD symptoms in women and men.

Predictors of posttraumatic stress among victims of motor vehicle accidents

OBJECTIVE

This study identified factors that predict individual vulnerability to psychological trauma by examining the relationships among situation and person variables and symptoms of posttraumatic stress disorder (PTSD) 1, 6, and 12 months after a serious motor vehicle accident (MVA).

METHODS

Background characteristics, exposure variables (ie, injury severity and accident characteristics), and psychosocial variables (ie, perceived loss of control, social support, and coping) were used to predict symptoms of PTSD and recovery in 115 injured MVA victims. All participants were injured during the MVA and provided data prospectively over the course of a year after their accidents.

RESULTS

Along with background and exposure variables, use of wishful thinking coping distinguished between victims with and without symptoms of PTSD.

CONCLUSIONS

Psychosocial variables such as wishful thinking coping can be used to identify MVA victims who are at risk of developing chronic posttraumatic stress and warrant further investigation.

Factors associated with depression on a hospital ship deployed during the Persian Gulf War

Investigators surveyed health care providers (N = 250) deployed to the Persian Gulf on the USNS Comfort hospital ship days before the beginning of the Persian Gulf War in 1990. In this article, we identify factors associated with the development of depression during deployment. Age, gender, negative life events, stress from trauma-related work demands, and occupational experience with the dying and the dead were significant predictors of depression. Military training, although not associated with the experience of depression, was negatively correlated with concern about injury.

Effects of exposure to death in a war mortuary on posttraumatic stress disorder symptoms of intrusion and avoidance

Exposure to the dead has been an important subject for traumatic stress research, considering that such exposure is a risk factor for posttraumatic stress disorder (PTSD). Individuals required to handle the dead from war are exposed to multiple stressors. No previous studies, however, have examined pre- and post-responses to traumatic death. We studied the pre-post responses of 352 military men and women who worked in the mortuary that received the dead from the Persian Gulf War (Operation Desert Storm) in 1990 to 1991. The respondents were volunteers and nonvolunteers for assignment to the mortuary; some had prior experience in handling the dead and some did not. Symptoms of intrusion and avoidance were measured before and after exposure. Four groups were examined based on the degree of exposure to remains. Age, sex, volunteer status, and prior experience handling remains were statistically controlled. Post-exposure intrusion symptoms increased significantly for all groups exposed to the dead. Increased post-exposure avoidance symptoms were present in the two groups with the greatest exposure to remains. There were no significant increases in intrusion or avoidance in the unexposed group.

Spouse abuse recidivism in the U.S. Army by gender and military status

Recidivism by spouse abusers was investigated using records of offenders in the U.S. Army Central Registry. Recidivism by gender and military status (active-duty or civilian spouse) was compared over a 70-month period. Between fiscal years 1989-1997, 48,330 offenders were identified in initial and recidivist incidents. Recidivism was analyzed by means of a Cox proportional hazard rate model, controlling for age, race, number of dependents, education, and substance abuse. Two different sets of survival curves were obtained: (a) Men were much more likely than women to have a recurrence and (b) within gender, civilians were more likely to have a recurrence than were active-duty military personnel. At 70 months, 30% of the male civilian offenders and 27% of the male active-duty offenders had committed a subsequent spouse abuse incident compared with 20% of the female civilian offenders and 18% of the female active-duty offenders, controlling for other variables.

Peritraumatic dissociation following motor vehicle accidents: relationship to prior trauma and prior major depression

Individuals who dissociate at the time of a traumatic event (peritraumatic dissociation) are more likely to develop acute and chronic posttraumatic stress disorder (PTSD). However, little is known about who is at risk of peritraumatic dissociation. Motor vehicle accident subjects (N = 122) were systematically recruited and followed over 12 months. We used the Structured Clinical Interview for DSM-III-R (SCID) and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version (PDEQ-RV). Younger subjects were more likely to experience peritraumatic dissociation as were white versus nonwhites, and single versus married subjects. Younger subjects reported a greater number of peritraumatic dissociative symptoms as did subjects with an injured passenger. After adjusting for age and passenger injury, prior major depression was significantly related to more peritraumatic dissociative symptoms. An interaction of age and prior major depression indicated that those who were younger and reported a history of major depression had the greatest number of peritraumatic dissociative symptoms.

Debriefing following trauma

In this paper we address three areas. First we review the literature on clinical intervention using debriefing, second we examine who attends debriefings by looking at a study of the 1989 plane crash at Ramstein, Germany and lastly we examine the effect of natural debriefing, i.e., talking to family and friends on psychiatric outcome in disaster workers by looking at a study of the Sioux City, Iowa United plane crash, 1989. Our data suggest that those with high exposure and females were more likely to attend a debriefing. People most likely to talk about the disaster with spouse/significant other, coworker and/or another person were: those with acute PTSD, higher total and intrusive Impact of Event symptoms, older, married, those with higher levels of education and higher levels of disaster exposure. Better understanding of who attends formal debriefings will help identify potential high-risk groups. Similarly, whether talking about the disaster is associated with fewer or greater psychological symptoms is important to understanding the outcome, mechanisms, and risks of debriefing.

Deployment and the probability of spousal aggression by U.S. Army soldiers

OBJECTIVE

To determine the relationship between length of soldier deployment and self-reports of moderate and severe spousal violence.

METHODS

The Conflict Tactics Scale was used to measure self-reports of behaviors exhibited in marital conflict. Surveys were administered to a 15% random sample of 26,835 deployed and nondeployed married active duty U.S. Army men and women in the 50 United States during the period 1990 to 1994. Multinomial logistic regression and ordered probit analysis were used to estimate the probabilities of moderate and severe violence by length of deployment.

RESULTS

After controlling for demographic variables, the probability of severe aggression was significantly greater for soldiers who had deployed in the past year compared with soldiers who had not deployed.

CONCLUSIONS

Deployment contributes a significant but small increase to the probability of self-reported spousal aggression during a 1-year period. Although deployment is a military operation, similar effects may be observed in certain civilian occupations.

Disaster psychiatry: principles and practice

Increasingly, trauma and disasters are part of everyday life. Psychiatrists can play an important role in assisting individuals and communities to recover. They bring a unique set of skills and experiences that can be invaluable in minimizing morbidity and facilitating recovery. This paper discusses psychological, physiological, behavioral, and community responses encountered in the aftermath of a disaster. A preventive medicine model of understanding disaster response is discussed in which the psychiatrist delineates traumatic stressors and high-risk populations. The importance of psychiatric participation in disaster preparedness is emphasized. Psychiatric interventions targeted at the various longitudinal phases of disaster response are reviewed.

Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents

OBJECTIVE

This study examined the relation between peritraumatic dissociation and posttraumatic stress disorder (PTSD) in victims of motor vehicle accidents.

METHOD

Victims of serious motor vehicle accidents (N = 122) were assessed for peritraumatic dissociation with the Peritraumatic Dissociative Experiences Questionnaire-Rater Version and followed longitudinally to assess acute and chronic PTSD (1 month and 3 months after the accident) with the Structured Clinical Interview for DSM-III-R.

RESULTS

The most common peritraumatic dissociative symptom was time distortion (56.6%). Subjects with peritraumatic dissociation were 4.12 times more likely than those without to have acute PTSD and 4.86 times more likely to develop chronic PTSD. The risk was independent of risk associated with the presence of PTSD before the accident.

CONCLUSIONS

Peritraumatic dissociation is common following motor vehicle accidents and is a risk factor for acute and chronic PTSD, independent of risk associated with prior PTSD.

Life events in health care providers before and during Persian Gulf War deployment: the USNS Comfort

Just before the onset of Operation Desert Storm, health care personnel (N = 250) onboard the USNS Comfort reported the occurrence of life events for the preceding year, including before deployment and during the Persian Gulf War. Study participants noted both total and negative life events. The mean number of negative life events during the preceding year was 1.44; a sizable proportion of participants (38%) reported no negative life events during this time. There were no differences in the mean number of total or negative life events by gender, although women checked significantly more life event items related to interpersonal factors and men noted more life events concerning financial issues. Women, nurses, the childless, and lower ranking officers noted significantly greater negative life events during predeployment than deployment. Negative life events were moderately related to anxiety, depression, and post-traumatic stress disorder symptoms. Both research and policy implications are discussed.

Trends in child maltreatment in the US Army, 1975-1997

OBJECTIVE

To examine trends by year in reports of victims of child maltreatment in the US Army Central Registry (ACR) during the period 1975-97. We report the rates/1,000 children of Army families of initial substantiated cases from 1988-97 and the number of cases of maltreatment as a percentage of total victims for each year from 1975-97. Army data are compared to published reports from military service child abuse registries.

METHODS

Numbers of cases of child maltreatment for each year were obtained from the ACR for major, minor, and total physical abuse, sexual abuse, emotional abuse, and neglect. Population figures for numbers of children were obtained from the Defense Manpower Data Center.

RESULTS

The rates/1,000 for neglect have decreased by 24% from 1991-97, although the decrease has not been steady. The rates/1,000 of minor physical abuse declined 28% from 1993-97. The rates/1,000 of major physical abuse were basically unchanged from 1988-96, although the highest rate was recorded in 1997. The rates/1,000 of sexual abuse were also basically unchanged with the exception of increases in 1992-94 after which time the rates/1,000 returned to the pre-1992 levels. The rates/1,000 of emotional abuse cases more than doubled from 1988-97.

CONCLUSIONS

While minor physical abuse and neglect have shown decreases over the past decade, major physical abuse has remained virtually unchanged and sexual and emotional abuse have shown fluctuations. All these forms of maltreatment are challenges to the Army Family Advocacy Program.

Disaster-related bereavement: acute symptoms and subsequent depression

Despite the large body of literature on bereavement, gaps remain in our current understanding of disaster-related bereavement. We examined acute (1 wk post-disaster) and subsequent (2 mo) bereavement in 71 members of an Air Force community after the loss of 7 crewmembers and 1 passenger in a plane crash. Relative to a comparison group, the subjects had higher levels of acute intrusive and avoidant symptoms, and higher levels of depressive symptoms at 2 mo. High acute intrusive and avoidant symptoms were associated with higher levels of depressive symptoms at 2 mo. Single subjects with significant others had higher intrusive, avoidant, and depressive symptoms at 2 mo than singles without significant others and married subjects. Closer community ties (less transience) predicted higher acute intrusive and avoidant symptoms, and approached significance for depressive symptoms. After controlling for initial symptoms, the best predictors of depression at 2 mo were: low hardiness, being single, and low perceived support from friends.

Measurement of depression in a military sample

Using the responses of 250 Navy health care providers, we considered the sensitivity and specificity of the SCL-90-R Depression subscale and the Global Severity Index in predicting mild, moderate, and severe depression in a deployed military sample. Using the 90th percentile norms to identify caseness for both measures, each performs with 100% certainty in ascertaining severe depression and with less certainty in pinpointing a nonevent (specificity). Results are further considered by sex.

Acute and chronic posttraumatic stress disorder in motor vehicle accident victims

OBJECTIVE

This study reports the rates of acute and chronic posttraumatic stress disorder (PTSD) in a suburban community study group of 122 victims of serious motor vehicle accidents and a comparison group of 42 (who had been involved in minor, non-motor-vehicle accidents) followed over 12 months.

METHOD

Motor vehicle accident victims were systematically recruited and examined with comparison subjects at 1, 3, 6, 9, and 12 months after the accident. The authors used the Structured Clinical Interview for DSM-III-R to assess DSM-III-R axis I disorders including PTSD.

RESULTS

One month after the accident, 34.4% of the motor vehicle accident victims met criteria for PTSD (versus 2.4% of the comparison subjects). Similarly, at 3 and 6 months, rates of PTSD were higher (25.2% and 18.2%) in the motor vehicle accident victims than in the comparison group. Female victims were 4.64 times more likely than male victims to have PTSD at 1 month. Victims with a history of PTSD were 8.02 times more likely at 1 month and 6.81 times more likely at 3 months to have PTSD than those without a history of PTSD. Having an axis II disorder increased the risk for PTSD at 6 months. After adjustment for a history of PTSD and potentially confounding variables, women were 4.39 times more likely than men to develop PTSD at 1 month but did not have a higher risk for chronic PTSD; at 6 months, those with an axis II disorder were at greater risk of PTSD.

CONCLUSIONS

Rates of PTSD are high in victims of serious motor vehicle accidents and remain high 9 months later. Female victims have an increased risk of acute but not chronic PTSD. Individuals with a history of PTSD are at risk of acute and chronic PTSD. An axis II disorder increases the risk for chronic but not acute PTSD.

Stress and coping in male and female health care providers during the Persian Gulf War: the USNS Comfort hospital ship

The development of the USNS Comfort hospital ship during the Persian Gulf War provided an opportunity to examine the relationship of gender to stress and coping in health care providers exposed to wartime stressors. Just before the outbreak of Operation Desert Storm, medical personnel (N = 250) rated the stressfulness of current wartime experiences and the helpfulness of stress-reducing resources onboard ship in a combat theater. The responses of men and women were compared; to identify the dimensions of these responses, a principal factor analysis (orthogonal rotation) was performed. Generally, men and women ranked stressors and stress reducers similarly; women scored higher on the stress ratings. Two factors, similar for men and women, were identified in the stress ratings: fear of injury and trauma-related work demands. The dimensions of the stress reducers, however, were different for men and women. The findings support retrospective studies and suggest that different mechanisms of stress reduction may be operative even though men and women are performing the same activity.

Posttraumatic stress disorder and identification in disaster workers

OBJECTIVE

Disaster workers who work with deceased victims are at increased risk of posttraumatic stress disorder (PTSD). Identification with the deceased has been proposed as one of the mechanisms in this stress-illness relationship. To examine this hypothesis, this study investigated three types of identification with the dead in a group of disaster workers: identification with the deceased as oneself, identification with the deceased as a friend, and identification with the deceased as a family member.

METHOD

Fifty-four volunteer disaster workers who worked with the dead following an explosion on the USS Iowa naval ship were assessed 1, 4, and 13 months after the disaster. PTSD symptoms (measured with the DSMPTSD-IV scale), intrusive and avoidant disaster-related symptoms (measured with the Impact of Event Scale), somatization and general distress (measured with the SCL-90-R), and health care utilization were assessed.

RESULTS

Disaster workers who reported identification with the deceased as a friend were more likely than those who did not to have PTSD, more intrusive and avoidant symptoms, and greater levels of other posttraumatic symptoms including somatization. Disaster workers who reported identification with the deceased as a family member had greater intrusive symptoms 1 month after the disaster than those who did not. There were no differences between those who did and did not identify with the deceased as self. Health care utilization was not associated with identification.

CONCLUSIONS

Identification with the deceased is a risk factor for PTSD and posttraumatic symptoms in disaster workers exposed to the dead. Identification with the dead as a friend is specifically associated with higher risk for these workers.

Reports of spouse abuse in the U.S. Army Central Registry (1989-1997)

OBJECTIVE

To report the distributions and characteristics of spouse abuse victims and offenders in the U.S. Army Central Registry from 1989 to 1997.

METHOD

Case and population data were tabulated using SAS procedures.

RESULTS

There were 61,827 initial substantiated cases, 5,772 subsequent incidents, and 3,921 reopened cases. Victim rates varied between 8 and 10.5 per 1,000 married persons. About 82% of victims and offenders were between the ages of 18 and 31 years. The racial distribution of married active duty white and black victims and offenders was greatly different from that of the married active duty population. The proportion of female victims increased from initial (67%) to subsequent (71%) to reopened cases (75%).

CONCLUSIONS

U.S. military populations provide unique opportunities to study family violence because of the socioeconomic "floor" under service members and their families. Comparisons between military and civil populations on precipitating circumstances, case assessment and definition, and treatment efficacy would be fruitful areas for research.

Posttraumatic stress disorder: cerebellar regulation of psychological, interpersonal, and biological responses to trauma?

Alteration in the sense of time is the most commonly reported peritraumatic dissociative symptom. A case report of a trauma victim illustrates the posttraumatic alteration in the sense of time as well as loss of spatial memory. Recent studies of cerebellar function indicate the cerebellum may be critical to both spatial memory and the sense of time. Identifying regulators of psychological, interpersonal, and biological responses to traumatic events is important in advancing our understanding of the effects of trauma. The cerebellum may be part of the initial posttraumatic response.

Posttraumatic stress disorder following an air disaster: a prospective study

OBJECTIVE

The purpose of this study was to determine predictors of posttraumatic stress disorder (PTSD) in health care workers exposed to a disaster, in order to facilitate early case identification and prevention of subsequent morbidity.

METHOD

Following an air disaster, 355 military medical health care workers were studied over an 18-month follow-up period. Measures included assessment of peritraumatic reactions associated with the disaster, the frequency of other stressful events after the disaster, and standard PTSD rating scales at 6, 12, and 18 months.

RESULTS

Multivariate logistic regression of data on health care workers who cared for victims of the air disaster showed that PTSD was more likely to develop in those who had not completed college, those who had worked with burn victims, those who had experienced more stressful life events in a period of approximately 6 months following the disaster, and those who experienced emotional numbness immediately after the disaster.

CONCLUSIONS

Results suggest that lower levels of education, exposure to grotesque burn injuries, stressful life events following exposure, and feelings of numbness following exposure are useful predictors of subsequent development of PTSD.

Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents

In this study on the effects of attributions of responsibility for traumatic events, stress, coping, and symptoms of posttraumatic stress disorder (PTSD) were measured, including intrusive thoughts among 130 victims of serious motor vehicle accidents (MVAs) 14-21 days and 3, 6, and 12 months after their accident. MVA victims and 43 control participants were categorized by accident and attribution of responsibility for their accidents (self-responsible, other-responsible, and control). Although initially all MVA victims reported higher levels of intrusive thoughts and were more likely to meet criteria for PTSD diagnoses, only other-responsible participants continued to demonstrate increased distress 6 and 12 months postaccident. Self-responsible participants used more self-blame coping than other-responsible participants, although within the self-responsible group, use of self-blame was associated with more distress.

The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences

The microbial world is mysterious, threatening, and frightening to most people. The stressors associated with a biological terrorist attack could create high numbers of acute and potentially chronic psychiatric casualties who must be recognized, diagnosed, and treated to facilitate triage and medical care. Media communications, planning for quarantine and decontamination, and the role of community leaders are important to the mitigation of psychological consequences. Physicians will need to accurately diagnose anxiety, depression, bereavement, and organic brain syndromes to provide treatment, reassurance, and the relief of pain.

Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents

In this study on the effects of attributions of responsibility for traumatic events, stress, coping, and symptoms of posttraumatic stress disorder (PTSD) were measured, including intrusive thoughts among 130 victims of serious motor vehicle accidents (MVAs) 14-21 days and 3, 6, and 12 months after their accident. MVA victims and 43 control participants were categorized by accident and attribution of responsibility for their accidents (self-responsible, other-responsible, and control). Although initially all MVA victims reported higher levels of intrusive thoughts and were more likely to meet criteria for PTSD diagnoses, only other-responsible participants continued to demonstrate increased distress 6 and 12 months postaccident. Self-responsible participants used more self-blame coping than other-responsible participants, although within the self-responsible group, use of self-blame was associated with more distress.

Psychiatric morbidity in medical and surgical patients evacuated from the Persian Gulf War

Acute treatment records of all medical and surgical patients evacuated to Walter Reed Army Medical Center in Washington, D.C., from the Persian Gulf theater (N = 161) were examined to better understand the relationship of injury to psychiatric symptoms. A total of 110 (68 percent) sustained a traumatic injury. They were significantly more likely to have an axis I disorder or psychiatric symptoms of concern than participants in the Persian Gulf War who did not sustain traumatic injuries but who were evacuated for medical conditions. The results indicate that traumatically injured veterans are at greater risk of psychiatric symptoms than veterans who are not injured and that they should be referred for psychiatric evaluation.

Posttraumatic stress symptoms following forensic dental identification: Mt. Carmel, Waco, Texas

OBJECTIVE

This study was conducted to determine risk factors for posttraumatic stress in medical care professionals who perform postmortem identifications.

METHOD

Thirty-one dentists (29 men and two women) who had identified the dead from the fire at the Branch Davidian compound in April 1993 were compared to 47 dentists (45 men and two women) who lived in the area but had not identified any of these remains. Posttraumatic symptoms in both groups were measured by using the Impact of Event Scale and the Brief Symptom Inventory. For the remains handlers only, the subjective distress of handling remains and the social support received during the procedure were reported.

RESULTS

Higher scores on the Impact of Event Scale intrusion subscale, the overall Impact of Event Scale, and the obsessive-compulsive subscale of the Brief Symptom Inventory were found for the remains handlers than for the comparison group. Within the remains handler group, distress was significantly related to the hours of exposure to the remains, prior experience handling remains, age, and the support received from spouses and co-workers during the identifications.

CONCLUSIONS

Posttraumatic stress symptoms can be expected in some health professionals who perform postmortem identifications. Prior experience and social support may mitigate some of these responses.

Acute stress disorder, subsequent posttraumatic stress disorder and depression after a series of typhoons

From August to November 1992, five typhoons struck the U.S. Pacific island territory of Guam. Three hundred and twenty subjects exposed to all five typhoons participated in a population survey measuring their acute stress symptoms and subsequent diagnoses of posttraumatic stress disorder (PTSD) and depression. A 23-item scale approximating the new DSM-IV diagnosis of acute stress disorder (ASD) was used to classify subjects into three groups based on their symptoms one week after the first typhoon: (1) probable ASD, (2) an early traumatic stress response (ETSR) of fear, intrusion, avoidance, and arousal, without dissociation, and (3) no acute diagnosis. A multi-dimensional measure of PTSD and the Zung Self-Rating Depression Scale were used to assess PTSD and depression 8 months after the first storm. The point prevalence of ASD at one week was 7.2%. An additional 15% of subjects had ETSR. Subjects with probable ASD at one week had significantly increased rates of PTSD and somewhat higher rates of depression at 8 months than those without ASD. In contrast, subjects with ETSR at one week did not have a poorer outcome than those with no acute diagnosis. These findings suggest that ASD is prognostically important, but also indicate that all acute stress symptoms do not have the same discriminative value. In this study, the acute dissociative symptoms of emotional numbing and derealization differentiated highly symptomatic subjects at risk for subsequent psychopathology (ASD) from others who were highly symptomatic at one week, but then had a more benign, posttraumatic course (ETSR).

Anticipatory stress of handling human remains from the Persian Gulf War. Predictors of intrusion and avoidance

High levels of distress were found in military mortuary workers prior to the arrival of the human remains from the Persian Gulf War of 1991. To better understand the stress of anticipating the handling of remains, we performed stepwise multiple regression analyses to identify the best predictors of intrusive thoughts and avoidant thoughts and behavior, two of the primary symptoms of posttraumatic stress disorder. After volunteer status and sex were controlled, fear and discomfort with mutilation and the grotesque, as measured by the Mutilation Questionnaire, and defensiveness or denial, as measured by the Marlowe-Crowne Scale, were significant predictors of intrusion and avoidance in the inexperienced group. In the experienced group, only the Mutilation Questionnaire predicted intrusion and avoidance. Results have implications for selection, training, and interventions for mortuary workers and other disaster workers whose job includes exposure to human remains.

Psychiatric dimensions of disaster: patient care, community consultation, and preventive medicine

The majority of persons exposed to a disaster do well and have only mild, transitory symptoms. However, some individuals develop psychiatric illness postdisaster. Such illnesses include those that are secondary to physical injury and sickenss as well as specific trauma-related psychiatric disorders such as acute stress disorder. The extent of the psychiatric morbidity and mortality that develops in individuals in the community depends on the type of disaster, the degree of injury sustained, the amount of life threat, and the duration of community disruption. In this paper we examine the posttraumatic responses of direct concern to psychiatrists working in a community exposed to a disaster. We review the epidemiology of posttraumatic responses, the interface of psychiatry and traumatic stress, the psychiatric disorders associated with trauma, and psychiatric consultation to the disaster community. Overall, psychiatric intervention after a disaster is based on the principles of preventive medicine and includes community consultation and outreach programs with the goals of identifying high-risk groups, promoting community recovery, and minimizing social disruption.

Symptoms of PTSD following recovery of war dead: 13-15-month follow-up

OBJECTIVE

The authors explored whether individuals who participated in the recovery of war dead were more likely to experience later symptoms of posttraumatic stress disorder (PTSD) than were individuals who were not involved in the recovery of war dead.

METHOD

PTSD symptoms were assessed by questionnaire in men and women who had or had not handled human remains during the Persian Gulf War: 116 men and women who had and 118 who had not handled human remains participated in the study 3-5 months after returning from the war; 55 of the subjects who had and 56 of those who had not handled human remains participated in a follow-up assessment 13-15 months after their return.

RESULTS

Subjects who had been involved in the recovery of war dead had significantly higher symptom levels than comparison subjects at both time points.

CONCLUSIONS

After more than 1 year, individuals who had handled human remains during wartime were at higher risk for PTSD symptoms than those who had not.

Gruesomeness, emotional attachment, and personal threat: dimensions of the anticipated stress of body recovery

Previous research has shown that exposure to grotesque death has been associated with posttraumatic stress disorder and higher levels of stress have been associated with mortuary workers who anticipated handling remains than those who did not. Additional research is presented here to further clarify the nature of the anticipated stress of handling the dead. Anticipated stress of handling human remains was rated for 13 different situations by 479 persons (384 men and 95 women) without such experience, but whose job was likely to require it. Factor analysis of their ratings revealed three psychological dimensions: the gruesomeness of the remains, an emotional link between the viewer and the remains, and personal threats to the remains handler. Suggestions for preventive measures, training, and interventions for those who may handle remains are made.

Longitudinal assessment of posttraumatic stress disorder and depression after exposure to traumatic death

Little is known of the specific effects of exposure to traumatic death, an important dimension of many disasters. This study examined acute and long-term intrusive and avoidant symptoms, depression, and posttraumatic stress disorder (PTSD) in disaster workers exposed to traumatic death after the USS Iowa gun turret explosion. Fifty-four volunteer body handlers were assessed at 1, 4, and 13 months. They were compared with 11 non-body handler disaster worker volunteers. The Impact of Events Scale, Zung Depression Scale, Symptom Checklist-90-Revised, and a multi-method assessment of PTSD were used. Intrusive and avoidant symptoms were elevated at 1, 4, and 13 months, and decreased over time. Probable PTSD was present in 11% at 1 month, 10% at 4 months, and 2% at 13 months. The frequency of depression was not increased. Single body handler disaster workers reported more avoidance (times 1 and 2) and somatization (time 1) than did married workers. Body handlers reported more intrusion, avoidance, hostility, and somatization at 1 month than did non-body handler volunteers. These results indicate that exposure to traumatic death increases intrusive and avoidant symptoms, hostility, somatization, and the risk of PTSD and that symptoms can persist for months.

Factor analysis of the General Health Questionnaire

We present the factor structure of the General Health Questionnaire-60 as derived from a population of 2115 Army soldiers. An eight-factor principal components analysis provided the most clinically relevant solution and explained 58.0% of the variance. We distinguished two types of depressive symptomatology, suggesting the questionnaire may be useful in differentiating shame-ridden dysphoria from anergic disinterest.

Health care delivery in the high-stress environment of chemical and biological warfare

Understanding health care delivery in high-stress environments, such as the chemical and biological warfare (CBW) environment, is important to developing better procedures for providing health care to individuals and groups exposed to this and other traumas and disasters. Little is known about the behavioral and psychological responses affecting health and performance in the CBW environment. In this paper, we report preliminary observations of the behavioral and psychological responses of a health care delivery exercise occurring over 1 week in a simulated CBW environment. Results suggest that responses to the CBW environment will include: claustrophobia, difficulties with masks, overheating, feelings of having failed, increased risk associated with dedication to the group, dehydration secondary to alcohol use, failure to recognize danger, and anxiety.

Symptoms of posttraumatic stress disorder following recovery of war dead

Persons who handled human remains in Operation Desert Storm (N = 116) were compared with those who did not handle remains (N = 118) on symptoms of posttraumatic stress disorder. Subjects who handled remains reported more intrusive and avoidant symptoms than other subjects. Subjects who were inexperienced at handling remains had more symptoms than those who were experienced. Within the experienced group, there was a significant correlation between the number of remains handled and level of symptoms reported.

Anticipation of handling the dead: effects of gender and experience

In addition to the direct psychological effects of disaster stressors, anticipation of stress can itself be debilitating. We examined the relationship between the anticipated stress of handling the dead and gender and experience. Experienced persons had lower anticipated stress than inexperienced persons. Inexperienced, females had higher anticipated stress than inexperienced males; experienced males and females did not differ. Results provide support for an 'inoculation' theory of stress buffering in disaster workers.

Traumatic stress of a wartime mortuary. Anticipation of exposure to mass death

Exposure to traumatic death is a risk factor for posttraumatic stress disorder. For some groups, anticipation of such exposure may contribute to traumatic stress. We studied the anticipated stress of working in the Operation Desert Storm mortuary in two groups prior to the arrival of the dead. We examined those who would handle remains (mortuary workers, N = 386, 330 men and 56 women) and those who would not (support workers, N = 87, 67 men and 20 women). These two groups were a mixture of volunteers and nonvolunteers as well as persons with and without experience in handling the dead. The mortuary workers had higher levels of preexposure distress than support workers; nonvolunteer mortuary workers had higher levels of distress than volunteers. Female mortuary workers had higher levels of distress than males, although this effect was modest. Experienced mortuary workers reported fewer intrusive and avoidant symptoms than did inexperienced workers. Those persons at highest risk for generalized distress as well as intrusive and avoidant symptoms were inexperienced nonvolunteer mortuary workers.

Handling bodies after violent death: strategies for coping

Interviews with and observations of experienced and inexperienced personnel were conducted to determine their coping strategies before, during, and after their work with the bodies of people who had died violently. Avoidance, denial, and social support from the work group and spouse appeared to facilitate coping. The implications of these findings for therapeutic intervention are discussed.

Behavioral and psychological responses to chemical and biological warfare

Understanding the behavioral and psychological responses in a chemical environment is critical to individual health and unit functioning. Reports of incidents of acute nerve agent and other organophosphate exposures and of repeated low-dose toxic exposures can provide information about psychiatric symptomatology, performance disruption, and recovery. This paper presents a review of the literature on the longer term consequences of acute and chronic exposure to nerve agents and other organophosphates. In addition, reports on psychological responses during chemical warfare training are reanalyzed to identify behavioral and psychological casualties attributed to the unique stressors of the CBW environment.

Grandparent deaths and severe maternal reaction in the etiology of adolescent psychopathology

Relationships between the extent of psychopathology and the occurrence of 21 major life events during five developmental periods (prebirth, infancy, childhood, latency, and adolescence) were examined with multiple regression and X2 analyses for 114 hospitalized male and female adolescents. Psychopathology was assessed with the Global Assessment Scale (GAS) at admission to long-term residential treatment in a private psychiatric hospital. Data on deaths, physical illnesses, psychological disturbances, and socioenvironmental events experienced by patients before admission were gleaned from interviews and institutional records. Life events and GAS were scored independently. Only deaths and socioenvironmental events were significantly associated with psychopathology. Specifically, deaths of grandparents during infancy corresponded to lower functioning at admission. Additional analyses showed that severe reactions of patients' mothers to grandparent deaths had been more common among those adolescents who were most disturbed at the time they were admitted to the hospital. These findings were largely serendipitous, however, and need replication.

Birth order, psychological well-being, and social supports in young adults

Enduring aspects of childhood family structure that reflect emotional and interpersonal ties throughout development are assumed to affect the psychological well-being and social relatedness of the mature individual. This study examined one facet of family structure--birth order--and its effects on psychological well-being (PWB) and social networks in young adult high school graduates 17 to 23 years old (N = 2886; male = 76%, female = 24%). PWB was measured as an overall score with positive feelings and negative feelings subscores. First-born males scored greater on the negative feelings subscale of PWB, and male later borns had higher total psychological well-being. No differences were found for females. First borns and later borns did not differ in positive feelings or social relatedness. Further study is needed on the relationship of birth order and social relatedness in young adults, particularly females.