Social support and posttraumatic stress disorder in combat veterans in Croatia

Recent studies have shown that greater social support after combat stress is associated with better psychological posttraumatic outcomes. By comparison of a group of veterans (n = 71) who sought psychiatric help and were diagnosed with PTSD (clinical group) and a group of veterans (n = 43) without PTSD (control group) we examined various components of structural and functional social support in war veterans in Croatia. The measures of social support were assessed for two time periods: a) immediately after the war, and b) at the present time. Results of two-way analysis of variance indicate that veterans without PTSD tend to report significantly higher number of persons who provide them different forms of social support than veterans with PTSD. Perceived family and friends support is higher in veterans without PTSD than in veterans with PTSD. Support received from friends and fellow soldiers decreases over time in both groups, whereas for the clinical group support of friends decreases significantly more.     

Childhood adversity during the post-apartheid transition and COVID-19 stress independently predict adult PTSD risk in urban South Africa: A biocultural analysis of the stress sensitization hypothesis

Objectives

The COVID-19 pandemic in South Africa introduced new societal adversities and mental health threats in a country where one in three individuals are expected to develop a psychiatric condition sometime in their life. Scientists have suggested that psychosocial stress and trauma during childhood may increase one's vulnerability to the mental health consequences of future stressors—a process known as stress sensitization. This prospective analysis assessed whether childhood adversity experienced among South African children across the first 18 years of life, coinciding with the post-apartheid transition, exacerbates the mental health impacts of psychosocial stress experienced during the 2019 coronavirus (COVID-19) pandemic (ca. 2020–2021).

Materials and Methods

Data came from 88 adults who participated in a follow-up study of a longitudinal birth cohort study in Soweto, South Africa. Childhood adversity and COVID-19 psychosocial stress were assessed as primary predictors of adult PTSD risk, and an interaction term between childhood adversity and COVID-19 stress was calculated to evaluate the potential effect of stress sensitization.

Results

Fifty-six percent of adults exhibited moderate-to-severe PTSD symptoms. Greater childhood adversity and higher COVID-19 psychosocial stress independently predicted worse post-traumatic stress disorder symptoms in adults. Adults who reported greater childhood adversity exhibited non-significantly worse PTSD symptoms from COVID-19 psychosocial stress.

Discussion

These results highlight the deleterious mental health effects of both childhood trauma and COVID-19 psychosocial stress in our sample and emphasize the need for greater and more accessible mental health support as the pandemic progresses in South Africa.     

The Cultural Construction of Mental Illness in Prison: A Perfect Storm of Pathology

Large numbers of individuals in U.S. prisons meet DSM criteria for severe psychiatric disorder. These individuals also have co-occurring personality and substance abuse disorders, medical conditions, and histories of exposure to social pathologies. Based on nine months of ethnographic fieldwork in a U.S. prison, focusing on staff narratives, I utilize interpretivist and constructivist perspectives to analyze how mental health clinicians construct psychiatric disorder among inmates. Discrete categorization of disorders may be confounded by the clinical co-morbidities of inmates and the prison context. Incarcerated individuals’ responses to the institutional context substantially inform mental health staffs’ illness construction and the prison itself is identified as an etiological agent for disordered behaviors. In addition, diagnostic processes are found to be indeterminate, contested, and shaped by interactions with staff. Analysis of illness construction reveals that what is at stake for clinicians is not only provision of appropriate treatment, but also mandates for the safety and security of the institution. Enmeshed in these mandates, prison mental health becomes a particular local form of psychiatric knowledge. This paper contributes to anthropological approaches to mental disorder by demonstrating how local contexts mediate psychiatric knowledge and contribute to the limited ethnographic record of prisons.     

A Meta-Analysis of Risk Factors for Combat-Related PTSD among Military Personnel and Veterans

Post-traumatic stress disorder (PTSD), a complex and chronic disorder caused by exposure to a traumatic event, is a common psychological result of current military operations. It causes substantial distress and interferes with personal and social functioning. Consequently, identifying the risk factors that make military personnel and veterans more likely to experience PTSD is of academic, clinical, and social importance. Four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) were used to search for observational studies (cross-sectional, retrospective, and cohort studies) about PTSD after deployment to combat areas. The literature search, study selection, and data extraction were conducted by two of the authors independently. Thirty-two articles were included in this study. Summary estimates were obtained using random-effects models. Subgroup analyses, sensitivity analyses, and publication bias tests were performed. The prevalence of combat-related PTSD ranged from 1.09% to 34.84%. A total of 18 significant predictors of PTSD among military personnel and veterans were found. Risk factors stemming from before the trauma include female gender, ethnic minority status, low education, non-officer ranks, army service, combat specialization, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems. Various aspects of the trauma period also constituted risk factors. These include increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma, and deployment-related stressors. Lastly, lack of post-deployment support during the post-trauma period also increased the risk of PTSD. The current analysis provides evidence of risk factors for combat-related PTSD in military personnel and veterans. More research is needed to determine how these variables interact and how to best protect against susceptibility to PTSD.     

Quality of life in families of Croatian veterans 15 years after the war

Exposure to war trauma with its consequences such as post traumatic stress disorder (PTSD) and disability due to combat injuries poses a significant problem for modern Croatian society. However, this is also a public health problem requiring continuous study of effective treatment strategies to achieve an increase in quality of life of most war-affected groups. Aim of this study was to examine the quality of life of population most affected by war - families of Croatian veterans. Present study included 126 female participants, who agreed to complete physical and psychiatric examination organized by the Ministry of Family, War Veterans and Intergenerational Solidarity. Included were participants with status of either wife of war veteran suffering from PTSD, wife who lost her husband in war circumstances or wife of war veteran with physical disabilities resulting from war activities. All three groups were asked to fill out the World Health Organization Quality of Life Questionnaire - short form (WHOQOL-BREF). Results indicate that assumed intensity of secondary trauma is not associated with quality of life. Namely, the highest level of satisfaction was found in wives of the most seriously affected invalids of war (M=3.77; sd=0.741), folowed by the wives of deceased soldiers (M=3.5; sd= 0.697), while the lowest quality of life results were found in wives of veterans suffering from PTSD (M=3.12; sd=0.608). Our results confirm that, nearly 15 years after the war, wives of disabled or killed Croatian soldiers have a (comparatively) satisfactory quality of their everyday lives, compared to the wives of veterans suffering from PTSD.     

Stigmatization in the long-term treatment of psychotic disorders

Stigma is linked to negative prejudices without examining whether there is any justification for such behaviour. Over time, various efforts have been made to reduce prejudice toward people with mental illness. Yet, the World Health Organization (WHO) World Health Report still describes stigma as one of the greatest obstacles to the treatment of mental illness. While schizophrenia, among other mental illnesses, is the most stigmatized even to the point that some want the name of the illness to be hidden or changed, patients with bipolar illness may also be exposed to stigma. The degree of stigmatization has been found to be positively associated with the severity of the mental disorder, and stigma is carried out not only by patients but also by their families in correlation with the severity. Tragically, people with mental illness themselves are as negative in their opinions about mental illness as is the general public, and concerns about stigma adversely affect self-esteem and adaptive social functioning. There are many programmes worldwide for the fight against stigmatization, and there is clear recognition of the fact that stigma can only be successfully eliminated if the programme becomes a normal part of health service rather than of campaigns of limited duration.     

“Nudging Them Back to Reality”: Toward a Growing Public Acceptance of the Role Dogs Fulfill in Ameliorating Contemporary Veterans' PTSD Symptoms

ABSTRACT

There is a long history of service dog usage to assist people with physical disabilities (e. g., dogs for the blind, deaf, and disabled). In comparison, however, relatively little empirical research has been conducted into the use of service or emotional support dogs for people with psychiatric disabilities (e. g., PTSD, bipolar disorder, anxiety disorder and schizophrenia). Given this research shortfall, the present study sought to provide insights into the post-war dog ownership experiences of contemporary veterans from the Iraq and Afghanistan fields of engagement, particularly in relation to the differences adopted dogs have made to the veterans' readjustment back into society. In this regard, reporters' media accounts of the experiences of veterans with PTSD and the general public's social media response comments were subjected to a triangulated three-phase content analysis to explore the role dogs seemingly play in helping contemporary veterans to readjust to civilian life. The core theme to emerge from the study was one of: “‘Nudging them back to reality’: Toward a growing public acceptance of the role dogs fulfill in ameliorating contemporary veterans' PTSD symptoms.” In light of the difficulties of interpreting the accounts of veterans through the filter of media coverage and social commentary, this core finding may prove to provide insights into how contemporary veterans diagnosed with PTSD utilize the assistance of dogs to help deal with their fundamental human needs for safety, affiliation, and succourance. Finally, the difficulties associated with dogs as therapeutic agents are discussed.     

Examining Effects of Anticipated Stigma,Centrality, Salience,Internalization, and Outness on Psychological Distress for People with Concealable Stigmatized Identities

Understanding how stigmatized identities contribute to increased rates of depression and anxiety is critical to stigma reduction and mental health treatment. There has been little research testing multiple aspects of stigmatized identities simultaneously. In the current study, we collected data from a diverse, urban, adult community sample of people with a concealed stigmatized identity (CSI). We targeted 5 specific CSIs – mental illness, substance abuse, experience of domestic violence, experience of sexual assault, and experience of childhood abuse – that have been shown to put people at risk for increased psychological distress. We collected measures of the anticipation of being devalued by others if the identity became known (anticipated stigma), the level of defining oneself by the stigmatized identity (centrality), the frequency of thinking about the identity (salience), the extent of agreement with negative stereotypes about the identity (internalized stigma), and extent to which other people currently know about the identity (outness). Results showed that greater anticipated stigma, greater identity salience, and lower levels of outness each uniquely and significantly predicted variance in increased psychological distress (a composite of depression and anxiety). In examining communalities and differences across the five identities, we found that mean levels of the stigma variables differed across the identities, with people with substance abuse and mental illness reporting greater anticipated and internalized stigma. However, the prediction pattern of the variables for psychological distress was similar across the substance abuse, mental illness, domestic violence, and childhood abuse identities (but not sexual assault). Understanding which components of stigmatized identities predict distress can lead to more effective treatment for people experiencing psychological distress.     

Post‐traumatic stress disorder and beyond: an overview of rodent stress models

Post‐traumatic stress disorder (PTSD) is a psychiatric disorder of high prevalence and major socioeconomic impact. Patients suffering from PTSD typically present intrusion and avoidance symptoms and alterations in arousal, mood and cognition that last for more than 1 month. Animal models are an indispensable tool to investigate underlying pathophysiological pathways and, in particular, the complex interplay of neuroendocrine, genetic and environmental factors that may be responsible for PTSD induction. Since the 1960s, numerous stress paradigms in rodents have been developed, based largely on Seligman's seminal formulation of ‘learned helplessness’ in canines. Rodent stress models make use of physiological or psychological stressors such as foot shock, underwater trauma, social defeat, early life stress or predator‐based stress. Apart from the brief exposure to an acute stressor, chronic stress models combining a succession of different stressors for a period of several weeks have also been developed. Chronic stress models in rats and mice may elicit characteristic PTSD‐like symptoms alongside, more broadly, depressive‐like behaviours. In this review, the major existing rodent models of PTSD are reviewed in terms of validity, advantages and limitations; moreover, significant results and implications for future research—such as the role of FKBP5, a mediator of the glucocorticoid stress response and promising target for therapeutic interventions—are discussed.     

Social Defeat in Recovery-Oriented Supported Housing: Moral Experience, Stigma, and Ideological Resistance

Drawing from ethnographic observations and interview data gathered during 6?months working as a home caregiver at the Pinewood Apartments, a recovery-oriented supported housing community in Texas, I demonstrate how stigma and social defeat were moral and social processes that pervaded life for all involved, including service providers. Yet, because of the extreme power differentials that characterized tenant-staff relationships, the assault of stigma and social defeat was much more frequent, existentially intense, and morally and materially consequential for certain tenants, whose attempts at ideological resistance were delegitimized by service providers, including myself, who were backed by the authority of dominant psychiatric and moralistic discourses concerning the inherent irrationality and irresponsibility of people with severe mental illness. Nevertheless, due to the indeterminate and at times inharmonious nature of moral experience, it is not my intention to portray tenants as wholly defeated. Rather, individual tenants often exhibited defeat and resistance simultaneously.     

Residential Treatment for Combat-Related Posttraumatic Stress Disorder: Identifying Trajectories of Change and Predictors of Treatment Response

Background

Combat-related posttraumatic stress disorder (PTSD) can be a difficult condition to treat and has been associated with serious medical and economic issues among U.S. military veterans. Distinguishing between treatment responders vs. non-responders in this population has become an important public health priority. This study was conducted to identify pre-treatment characteristics of U.S. veterans with combat-related PTSD that might contribute to favorable and unfavorable responses to high value treatments for this condition.

Method

This study focused on 805 patients who completed a VHA PTSD residential program between 2000 and 2007. These patients completed the PTSD Clinical Checklist at pre-treatment, post-treatment, and a four-month follow-up assessment. Latent growth curve analysis (LCGA) was incorporated to determine trajectories of changes in PTSD across these assessments and whether several key clinical concerns for this population were associated with their treatment responses.

Study Findings

LCGA indicated three distinct trajectories in PTSD outcomes and identified several clinical factors that were prospectively linked with changes in veterans'' posttraumatic symptomatology. When compared to a group with high PTSD symptom severity that decreased over the program but relapsed at follow-up (41%), the near half (48.8%) of the sample with an improving trajectory had less combat exposure and superior physical/mental health. However, when compared to a minority (10.2%) with relatively low symptomatology that also remained somewhat stable, patients in the improving group were younger and also reported greater combat exposure, poorer physical/mental health status, and more problems with substance abuse before the start of treatment.

Conclusions

Findings suggest that veterans are most likely to benefit from residential treatment in an intermediate range of symptoms and risk factors, including PTSD symptom severity, history of combat exposure, and comorbid issues with physical/mental health. Addressing these factors in an integrative manner could help to optimize the effectiveness of treatments of combat-related PTSD in many cases.     

An evolutionary theory of moral injury with insight from Turkana warriors

Clinicians in Western, Educated, Industrialized, Rich, and Democratic (WEIRD) societies are rethinking whether Post-traumatic Stress Disorder (PTSD) is caused solely by exposure to life-threatening experiences, or also by moral injury—witnessing or participating in acts that violate moral beliefs. However, while there are evolutionary hypotheses explaining PTSD as a response to physical danger, the evolutionary roots of moral injury lack an explanation. We posit that a subset of symptoms of combat-related PTSD is associated with moral injury and that these symptoms evolved in tandem with human's norm-psychology. We can examine this hypothesis by comparing societies with different moral beliefs about warfare, norm enforcement mechanisms, and spheres of moral concern. To illustrate the utility of this framework, we describe combat trauma, war norms, and norm enforcement among Turkana pastoralist warriors in Kenya who participate in highly lethal raids of neighboring ethnic groups. We previously showed that depressive PTSD symptoms in Turkana warriors are more strongly associated with experiencing moral violations in combat, and that Turkana warriors with comparably high overall PTSD symptom-severity experience lower rates of depressive symptoms than US combat veterans. Here we detail aspects of Turkana warfare, moral beliefs, and post-battle rituals that differ from WEIRD societies, and that may ameliorate the symptoms of moral injury in Turkana warriors. Our findings highlight how further studies of combat trauma outside of WEIRD militaries can help evaluate this theory and illustrate the importance of cross-cultural research for identifying the evolutionary roots of combat stress and best practices for prevention and recovery.     

Excavating the Psyche: A Social History of Soviet Psychiatry in Bulgaria

This article investigates how an imported Soviet psychiatric model affected Bulgarians who experienced psychological crisis by examining therapeutic possibilities that were available and foreclosed in the People’s Republic of Bulgaria. Bulgarians struggling with psychological disorders in the present day experience polar forms of marginalization: non-recognition on one extreme, and chronic medicalization on the other. Both tendencies can be traced to the Communist-period remodeling of mental healthcare, which outlawed private practice and individual-centered therapy, which reified empirically observable, physiological underpinnings of pathology while suppressing therapies that engaged with the existential context of mental illness. I argue that the reproduction of a Soviet psychiatric model instigated a modernization process but failed to anticipate the idiosyncrasy of economic and social conditions within the country. Furthermore, that this model rejected a therapeutic focus on the individual but developed no effective alternative for identifying and treating subjective characteristics of mental illness. Bulgaria’s history of psychiatry has received little scholarly attention beyond Bulgarian psychiatrists who documented the development of their field. This article presents archival, literary and oral history footholds towards the development of a social history of Bulgarian psychiatry—a perspective that is especially and problematically missing.     

Hypodensity of platelet serotonin uptake sites in posttraumatic stress disorder: Associated clinical features

We have previously reported that binding to blood platelets of paroxetine, a selective serotonin (5-HT) reuptake inhibitor which binds to 5-HT uptake sites, is decreased in patients with posttraumatic stress disorder (PTSD). Specifically, we found a lower number of platelet ³H-paroxetine binding sites (B_max) and a lower dissociation constant (K_d) for ³H-paroxetine binding in combat veterans with PTSD compared to normal control subjects. In the current study we assessed the relationship of platelet ³H-paroxetine binding to clinical features in 41 Vietnam combat veterans with SCID-diagnosed PTSD. The results indicated that B_max of platelet ³H-paroxetine binding was negatively correlated with both state and trait anxiety, as well as with depressive and overall PTSD symptoms. However, there was no evidence that platelet ³H-paroxetine binding differed as a function of comorbid psychiatric diagnoses including major depression, other anxiety disorders and substance abuse in these patients.     

An Examination of the Association between 5-HTTLPR,Combat Exposure,and PTSD Diagnosis among U.S. Veterans

Objective

To examine the association between the 5-HTTLPR polymorphism of the serotonin transporter (SLC6A4) gene, combat exposure, and posttraumatic stress disorder (PTSD) diagnosis and among two samples of combat-exposed veterans.

Method

The first sample included 550 non-Hispanic Black (NHB) combat-exposed veterans. The second sample included 555 non-Hispanic White (NHW) combat-exposed veterans. Participants were genotyped for the 5-HTTLPR/rs25531 variants of the SLC6A4 gene. A structured clinical interview was used to diagnose PTSD. Combat and civilian trauma exposure were assessed with validated self-report instruments. Logistic regression was used to test for main effects of 5-HTTLPR on PTSD diagnosis as well as gene x environment (GxE) interactions after adjusting for sex, ancestry proportion scores, civilian trauma exposure, and combat exposure.

Results

Within the NHB sample, a significant additive effect was observed for 5-HTTLPR (OR = 1.502, p = .0025), such that the odds of having a current diagnosis of PTSD increased by 1.502 for each additional S’ allele. No evidence for an association between 5-HTTLPR and PTSD was observed in the NHW sample. In addition, no evidence for combat x 5-HTTLPR effects were observed in either sample.

Conclusion

The present study suggests that there may be an association between 5-HTTLPR genotype and PTSD diagnosis among NHB veterans; however, no evidence for the hypothesized 5-HTTLPR x combat interaction was found.     

Medical Student Attitudes Towards People with Mental Illness in China: A Qualitative Study

Stigma towards people with mental illness is a worldwide concern. A five-nation survey of medical student attitudes towards people with mental illness recently reported far lower levels of social acceptance among Chinese medical students compared to those from the US, Brazil, Ghana, and Nigeria. This qualitative study presented recent Chinese medical school graduates with probes based on questions used in the aforementioned cross-national study to elicit their views of factors underlying the negative attitudes towards social acceptance of people with mental illness. One-hour interviews were conducted with twenty psychiatry residents in June, 2016. Of 241 coded responses concerning negative attitudes, 51.5% were coded as reflecting fear of violent behavior, 22.8% as loss of face (i.e. shame from interpersonal associations), 17.0% lowered social status, 4.98% nonconforming social behavior, and 3.73% the heritability of mental illness. Low levels of social acceptance of individuals with mental illness among medical students in China are largely related to fears of violence of and loss of face. Understanding the attitudes of medical students may inform efforts to reduce stigma through educational initiatives targeted at both medical students and the general public.     

A phenomenological account of users' experiences of assertive community treatment

Assertive community treatment (ACT) is a widely propagated team approach to community mental health care that 'assertively' engages a subgroup of individuals with severe mental illness who continuously disengage from mental health services. It involves a number of interested parties – including clients, carers, clinicians and managers. Each operates according to perceived ethical principles related to their values, mores and principles. ACT condenses a dilemma that is common in psychiatry. ACT proffers social control whilst simultaneously holding therapeutic aspiration. The clients' perspective of this dilemma was studied in interviews with 12 clients using the 'grounded theory' approach. Results suggest that clients' disengagement is as much a historical and cultural phenomenon as a result of lack of insight. Many clients had experienced rejection of early help–seeking behaviour and all had been subject to coercive interventions. These coercive interventions were experienced as an attack on identity. All felt that their voice had not been listened to in previous interactions with psychiatric services. Consequentially the clients had an increased level of arousal around issues of power, which needs to be incorporated when examining the ethics of community psychiatry. Traditional notions of the difference between persuasion and coercion – for example – may need to be adapted for this client group. Results are compared with the provider perspective. We conclude that the perspectives differ on two key dimensions. Such an empirical approach to examining psychiatric ethics may ensure that we incorporate the subjectivities of various interested parties in the clinical decision–making process.     

Association of Trauma-Related Disorders and Dissociation with Four Idioms of Distress Among Latino Psychiatric Outpatients

Past research on idioms of distress among U.S. Latinos has revealed that ataque de nervios and altered perceptions, such as hearing and seeing things when alone, are independent markers of higher morbidity and mental health utilization despite having no one-to-one relationships with any single psychiatric diagnosis. It has been proposed that the idioms exert this effect because they are signs of distressing dissociative capacity associated with traumatic exposure. This study examines the relationships in an ethnically diverse Latino psychiatric outpatient sample (N = 230) among interpersonal trauma, posttraumatic stress disorder (PTSD), major depressive disorder, dissociative capacity and four cultural idioms of distress associated with the popular overall category of nervios. We particularly explore how these relationships change with varied measures of traumatic exposure, including trauma severity and timing or persistence of trauma. A series of adjusted bivariate regressions assessed the matrix of associations between the idioms and the clinical variables. In this highly traumatized population, we identified a strong ‘nexus’ of associations between dissociation and three of the idioms: currently being ill with nerves, ataque de nervios and altered perceptions. These idioms were largely independent from PTSD and depression and were associated with trauma persistence and severity. A fourth idiom, being nervous since childhood, was not associated with any other variable and may represent a personality trait rather than a diagnosable condition. Our results validate the clinical utility of the construct of nervios as a set of specific idioms associated with dissociation that are useful markers of mental health need among Latinos independently of their association with clinical diagnoses.     

Heart Rate Variability (HRV) and Posttraumatic Stress Disorder (PTSD): A Pilot Study

Exposure to combat experiences is associated with increased risk of developing Post Traumatic Stress Disorder. Prolonged exposure therapy and cognitive processing therapy have garnered a significant amount of empirical support for PTSD treatment; however, they are not universally effective with some patients continuing to struggle with residual PTSD symptoms. Heart rate variability (HRV) is a measure of the autonomic nervous system functioning and reflects an individual’s ability to adaptively cope with stress. A pilot study was undertaken to determine if veterans with PTSD (as measured by the Clinician-Administered PTSD Scale and the PTSD Checklist) would show significantly different HRV prior to an intervention at baseline compared to controls; specifically, to determine whether the HRV among veterans with PTSD is more depressed than that among veterans without PTSD. The study also aimed at assessing the feasibility, acceptability, and potential efficacy of providing HRV biofeedback as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. Veterans with combat-related PTSD displayed significantly depressed HRV as compared to subjects without PTSD. When the veterans with PTSD were randomly assigned to receive either HRV biofeedback plus treatment as usual (TAU) or just TAU, the results indicated that HRV biofeedback significantly increased the HRV while reducing symptoms of PTSD. However, the TAU had no significant effect on either HRV or symptom reduction. A larger randomized control trial to validate these findings appears warranted.