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Vietnam and madness: dreams of schizophrenic veterans.

1. Vietnam veterans who still suffer from post-traumatic stress and delayed-stress disorders may respond to psychotherapy. Dreams that have recurred as often as every night for 8 to 15 years may be depotentiated. 2. In the records of the Vietnam veterans whom I have seen on my ward, almost without exception there has been no documentation of the contents, frequency and nature of their dreams and nightmares, and no precise record of their military experience in Vietnam. 3. By creating special group therapy, a Dream Seminar, and by individual analytical psychotherapy, a way has been found to work with these dreams as part of the post-traumatic stress disorder. 4. Three case histories have been presented to highlight the nature of these dreams and how they may respond to therapy. 5. In a larger perspective, the dreams of Vietnam offer a unique record of the unconscious history of Vietnam, uncontaminated by the waking ego, by conscious motivations or distortions. There cases have led to an extensive in-depth study of 125 randomly selected Vietnam combat veterans, which will be reported later. 6. Combat dreams recurring in identical form for years may change and evolve in a therapeutic drama.

Adult↗

Self-critical depressive experience in posttraumatic stress disorder.

Consistent with prior research, 73 hospitalized male Vietnam veterans with combat-related Posttraumatic Stress Disorder (PTSD) reported high scores on Self-criticism as measured by the Depressive Experiences Questionnaire. Self-criticism scores predicted greater severity of PTSD (Mississippi scale) after controlling for symptomatic depression (MMPI-D scale), suggesting that the nature of depression in Posttraumatic Stress Disorder differs from that in major depressive disorder.

Adult↗

Assessment of long-term psychosocial sequelae among POW survivors of the Korean Conflict.

Psychological and psychiatric assessments were performed among 20 prisoner-of-war (POW) Korean-Conflict survivors. Results revealed extraordinary biological and psychological abuse with weight losses exceeding 35% of preservice weights and long-term cognitive, emotional, and behavioral sequelae. The full range of posttraumatic stress disorder symptoms was seen in 90% to 100% of the cases with high prevalence of co-morbidity, specifically mood (75%), other anxiety (45%), and alcohol abuse (20%) disorders. Documented by clinical investigators at POW release and now more than 30 years later, symptoms of apprehensiveness, confusion, detachment, and depression reflect the persistence of psychiatric morbidity over time.

Adaptation, Psychological↗

Suicidal behavior among patients in the VA health care system.

A total of 167 Department of Veterans Affairs medical centers responded to a survey that sought information on suicidal behavior during a one-year period among patients in inpatient or outpatient treatment. Of 248 completed suicides during the period, about 60 percent occurred among patients in outpatient mental health treatment. The incidence of anxiety disorder diagnoses (17.7 percent), particularly posttraumatic stress disorder, among patients who completed suicide was much higher than that reported for persons who completed suicide in the general population. Many patients with psychiatric diagnoses who completed suicide had comorbid substance abuse diagnoses.

Adult↗

MMPI-2 as a predictor of change in PTSD symptom clusters: a further analysis of the Forbes et al. (2002) data set.

In this study, we reanalyzed the Forbes et al. (2002) data set to examine the Minnesota Multiphasic Personality Inventory (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) as a differential predictor of change across posttraumatic stress disorder symptom clusters following treatment in 141 Vietnam veterans. A series of partial correlation and linear multivariate regression analyses, controlling for initial symptom severity, identified several scales predictive of symptom change. None of the MMPI-2 scales, however, emerged as predictors of change in reexperiencing symptoms. Social alienation and marital distress were the most potent predictors for avoidance symptoms. Anger, alcohol use, and hypomania were the most potent predictors for the hyperarousal symptoms. Of the personality disorders, borderline personality was the strongest predictor of change in the avoidance and hyperarousal clusters. Further replication of the findings of this article and those reported by Forbes et al. (2002) is required.

Adaptation, Psychological↗

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample.

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Aged↗

Psychiatric diagnoses in Gulf War veterans with fatiguing illness.

The purpose of this study was to determine whether Gulf War Illness (GWI) can be explained by the presence of psychiatric disorders as assessed by DSM-III-R. To reduce the heterogeneity amongst Persian Gulf War veterans with GWI (PGV-F), only those were studied who presented with severe fatigue as a major complaint and also fulfilled clinical case definitions for Chronic Fatigue Syndrome, Idiopathic Chronic Fatigue, and/or Multiple Chemical Sensitivity. A total of 95 Registry PGVs were examined; 53 presented with GWI and 42 did not report any post-war health problems (PGV-H). All subjects were assessed for the presence of DSM-III-R Axis I psychiatric disorders. Compared to PGV-Hs, 49% of PGV-Fs had similar post-war psychiatric profiles: either no, or only one, psychiatric disorder was diagnosed. Psychiatric profiles of the remaining 51% of PGV-Fs were significantly different from PGV-Hs in that most of these veterans suffered from multiple post-war psychiatric diagnoses. The presence of psychiatric disorders as assessed by DSM-III-R criteria cannot explain symptoms of Gulf War Illness among all Persian Gulf veterans with severe fatiguing illness.

Adult↗

Oklahoma City bombing: exacerbation of symptoms in veterans with PTSD.

Posttraumatic stress disorder (PTSD) develops following exposure to an extremely traumatic stressor and consists of reexperiencing, avoidance, and hyperarousal symptoms. Exposure to stimuli reminiscent of the original trauma often causes an exacerbation of symptoms. Models attempting to explain this phenomenon include classical conditioning, emotional network imagery, and memory consolidation. The recent bombing in Oklahoma City caused an exacerbation of symptoms in veterans from World War II, the Korean War, and Vietnam, ranging from images of combat to memories of being called "baby-killer." These various responses to identical stimuli might help to explain the importance of attached meaning to traumatic events.

Combat Disorders↗

Sleep respiratory concomitants of comorbid panic and nightmare complaint in post-traumatic stress disorder.

Posttraumatic stress disorder (PTSD) patients with comorbid panic disorder (PD) may express additive symptoms of central fear system disturbance. They endorse elevated levels of sleep and nightmare disturbance [Leskin GA, et al., J Psychiatr Res 2002;36:449-452], and demonstrate movement suppression during laboratory sleep [Woodward SH, et al., Sleep 2002;25:681-688]. We estimated respiratory rate and rate variability separately for rapid-eye movement (REM) and non-rapid-eye movement (NREM) sleep. Subjects were 49 Vietnam combat-related PTSD inpatients (11 with comorbid PD and 38 without) and 15 controls. Computer-based estimates of respiratory rate and variability were derived from 10 to 18 hr of baseline sleep collected over two or three nights. Neither rate nor rate variability distinguished PTSD patients with comorbid PD from those without, or PTSD patients from controls; however, PTSD patients failed to exhibit the expected differences between REM and NREM respiratory rates. Moreover, the difference between REM and NREM respiratory rate was inversely related to a continuous measure of PTSD severity. PTSD patients with trauma-related nightmare complaint exhibited higher sleep respiration rates over both REM and NREM sleep. Conversely, in addition to slowed respiration, nightmare-free patients exhibited reduced respiratory rate variability in REM relative to NREM sleep, which was a reversal of the normal pattern. These finding are discussed in light of known telencephalic regulatory influences upon respiration rate.

Adult↗

Integrative treatment in persons with intellectual disability and mental health problems.

BACKGROUND: Clinical experience has proven thus far that a monodisciplinary treatment approach to behavioural and psychiatric problems in persons with intellectual disability (ID), such as psychotropic medication or behaviour modification programmes, has yielded limited success. It is clear that the complexity of behavioural and psychiatric problems in this population calls for a treatment approach from different perspectives. METHODS: A multidimensional treatment approach to the persons with ID who suffer from behaviour problems and psychiatric disorders is described. RESULTS: Four dimensions - biological, psychological, social and developmental - are represented as well in an integrative diagnosis as in an integrative treatment, embodied by cooperation of different professionals, such as a psychiatrist, psychologist, pedagogues, social worker, nurse and, where possible, the person's caretakers. The developmental dimension receives a salient attention of assessors. By introducing the developmental dimension in diagnostics and treatment, the bio-psycho-social dimensions are set in a new context, more appropriate for persons with ID. CONCLUSION: The integrative treatment should not be primarily directed towards the symptoms of the disorder but towards restoring a person's mental well-being. The disorder is combated through treatment of the underlying processes that have led to its onset. Different treatment methods from different perspectives may be applied. Strategy and methodological procedures of an integrative treatment are discussed by way of case presentations.

Adult↗

Posttraumatic stress disorder and substance abuse. Clinical issues.

A review of clinical issues relevant to the treatment of individuals with a combination of posttraumatic stress disorder and substance abuse disorder is presented. There are several issues that these two disorders share, including the need for heightened awareness on the part of clinicians, the ability to make the diagnoses, the conceptualization of etiological factors, and the issues of therapeutic attitudes and countertransference problems. In addition, a brief review of relevant therapeutic approaches is presented and treatment priorities discussed.

Alcoholism↗

The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans.

OBJECTIVE: This study explored the emotional and physical health of a group of families of Australian Vietnam veterans suffering posttraumatic stress disorder (PTSD). The aim was to study the impact of PTSD upon the families of the sufferers. METHOD: The families of a random sample of Vietnam veterans receiving treatment at a specialist PTSD Unit were invited to participate in this study. Partners of the veterans and children over the age of 15 years were eligible to participate. Four self-report psychometric inventories were administered assessing psychological distress, social climate within their families, self-esteem, and a range of lifestyle issues, including physical health. A control group, consisting of a sample of volunteers, was also surveyed. RESULTS: The partners of the Vietnam veterans showed significantly higher levels of somatic symptoms, anxiety and insomnia, social dysfunction and depression than the control group. They reported significantly less cohesion and expressiveness in their families and significantly higher levels of conflict. The partners also had significantly lower levels of self-esteem. The children of the veterans reported significantly higher levels of conflict in their families. However, the children showed no significant differences on measures of psychological distress and self-esteem from their matched counterparts. CONCLUSIONS: These findings support overseas studies that indicate that the families of PTSD sufferers are also impacted by the disorder. In this study, the families of Australian Vietnam veterans experienced more conflict and their partners were significantly more psychologically distressed (i.e. somatic symptoms, anxiety, insomnia, social dysfunction, depression and low self-esteem) than a matched control group.

Adaptation, Psychological↗

Evaluation of the HEDIS measure of behavioral health care quality. Health Plan Employer Data and Information Set.

OBJECTIVE: The Health Plan Employer Data and Information Set (HEDIS) is the most widely used "report card" system comparing health care plans across different dimensions of performance. HEDIS uses only one measure of the quality of behavioral health care-the rate of follow-up after hospitalization for major affective disorder. This study used data from a national Veterans Affairs database to evaluate the generalizability of the HEDIS behavioral health quality measure. METHODS: Using administrative data from a nationwide sample of 114 VA hospitals, the HEDIS (version 2.5) quality measure was compared with several related performance measures including readmission rates and outpatient follow-up rates for other psychiatric disorders and for substance use disorders. The magnitude and statistical significance of Pearson's r value for correlation between measures was calculated. RESULTS: The HEDIS measure was moderately correlated with 30-day follow-up after hospitalization for other psychiatric disorders and with other performance measures of outpatient care. However, it was poorly correlated with follow-up for substance use disorders, inpatient measures including readmission rates, and several other measures of quality. CONCLUSIONS: Caution is needed in drawing conclusions about the quality of behavioral health plans based on the single measure used in HEDIS, version 2.5. Inclusion of other performance measures may be warranted.

Adult↗

Clinical detection, diagnosis, and differential diagnosis of post-traumatic stress disorder.

This article has reviewed the detection, diagnosis, and differential diagnosis of PTSD. Recognition of particular effects of traumatic stress on patients' communications and adjustments in interviewing technique facilitate the expression and detection of PTSD when it is present. The phenomenologic boundaries between PTSD and a number of clinical syndromes and disorders are explored in detail. Delineation of PTSD from other disorders even when they co-occur with PTSD is almost always possible with effective rapport and knowledge from clinical research. An understanding of the role of traumatic stress in the origin of several disorders aside from PTSD assists in differential diagnosis, particularly when PTSD is present along with another trauma disorder. To avoid an undue, misleading proliferation of diagnoses (illusory comorbidity), the clinician should move beyond simply a cross-sectional enumeration of symptoms, to conduct a careful exploration of the patient's longitudinal history and thus understand fully which features are secondary to traumatic stress.

Adaptation, Psychological↗

Adult trauma survivors and post-traumatic stress sequelae: an analysis of reexperiencing, avoidance, and arousal criteria.

The relationship of traumatic events to DSM-III criteria symptoms for post-traumatic stress disorder was examined in a randomized community survey (N = 2,364) of Los Angeles residents. Multivariate analysis of covariance revealed that both demographic factors and the type of traumatic event influenced respondents' reports of reexperiencing, avoidance, and arousal symptoms after the event.

Adaptation, Psychological↗

Post-Vietnam stress disorder: a metaphor for current and past life events.

Delayed posttraumatic stress reactions are often triggered by events that echo the original trauma. It is not uncommon, however, for these delayed reactions to represent a metaphor for other current or past life events. A case is presented that illustrates the diagnostic and therapeutic significance of understanding these reactions as a metaphor.

Adaptation, Psychological↗

Correspondence between MMPI PTSD measures and clinical diagnosis.

Correspondence of the Minnesota Multiphasic Personality Inventory (MMPI) posttraumatic stress disorder (PTSD) subscale and the clinical scale decision rules reported by Keane, Malloy, and Fairbank (1984) with clinical diagnoses of PTSD was measured on a sample of 595 veterans. The measures demonstrated good sensitivity and selectivity, but the false-positive rate was high. It is suggested the MMPI measures be used to rule out, but not to establish, the diagnosis of PTSD. The construct validity of the PTSD subscale was supported by the finding of a higher mean score in combat than noncombat veterans.

Combat Disorders↗

Treatment of post-traumatic stress disorders: an applied rear-echelon approach.

This paper presents an applied innovative rear-echelon approach for the treatment of recalcitrant soldiers suffering from post-traumatic stress disorder in the 1982 Lebanon-Israel War. This was used as an alternative to psychiatric hospitalization. Use was made of a short-term, goal-directed, multidisciplinary treatment approach within the confines of a clear military setting. Reintegration into military and civilian life was an integral part of the program. Results indicated that at discharge, all soldiers showed a markedly improved clinical picture. Follow-up results 2.5 years later indicated that the percentage of regulars who returned to combat units doubled, whereas the reservists showed a slight tendency toward deterioration. Follow-up 6 years later showed the continuation of the same tendency. Ramifications of our findings are extensively discussed.

Adolescent↗