Suicidal ideation among National Guard troops deployed to Iraq: the association with postdeployment readjustment problems.

Despite well-documented postdeployment readjustment problems affecting veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), few studies have explored the possible relationship of readjustment stressors to the recent increase in military suicide. This study examined associations between suicidal ideation and postdeployment readjustment problems using cross-sectional population-based survey data from 1665 National Guard members who recently returned from Iraq. The findings suggested that readjustment problems are widespread, with 45% of veterans endorsing one or more financial or family problems 3 months postdeployment. After adjusting for mental health and combat exposure, veterans with the highest number of readjustment stressors were at 5½ times greater risk of suicidal ideation than those with no stressors. In a psychiatrically impaired subsample, the high stressor group experienced a fourfold risk of suicide ideation compared with those with no stressors. The findings argue for suicide prevention efforts that more directly target readjustment problems in returning OEF/OIF veterans.

Effects of repeated deployment to Iraq and Afghanistan on the health of New Jersey Army National Guard troops: implications for military readiness.

OBJECTIVES: We assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq. METHODS: We analyzed anonymous, self-administered predeployment surveys from 2543 National Guard members deployed to Iraq in 2008. We used bivariate and multivariate analyses to measure the effects of prior service in Afghanistan (Operation Enduring Freedom [OEF]) or Iraq (Operation Iraqi Freedom [OIF]) on mental and physical health. RESULTS: Nearly 25% of respondents reported at least 1 previous OEF or OIF deployment. Previously deployed soldiers were more than 3 times as likely as soldiers with no previous deployments to screen positive for posttraumatic stress disorder (adjusted odds ratio [AOR]=3.69; 95% confidence interval [CI]=2.59, 5.24) and major depression (AOR=3.07; 95% CI=1.81, 5.19), more than twice as likely to report chronic pain (AOR=2.20; 95% CI=1.78, 2.72) and more than 90% more likely to score below the general population norm on physical functioning (AOR=1.94; 95% CI=1.51, 2.48). CONCLUSIONS: Repeated OEF and OIF deployments may adversely affect the military readiness of New Jersey National Guard combat soldiers.

Illness trajectories in the chronic fatigue syndrome: a longitudinal study of improvers versus non-improvers.

The natural progression of chronic fatigue syndrome (CFS) in adults is not well established. The aims of this longitudinal study were to (a) compare CFS Improvers and Non-Improvers; (b) determine whether an initial diagnosis of fibromyalgia (FM) was associated with CFS nonimprovement; and (c) determine whether this effect could be explained by the presence of nonspecific physical symptoms. Consecutive referrals to a tertiary clinic that satisfied case criteria for CFS were invited to enroll in a longitudinal study. After an initial on-site physical examination and psychiatric interview, a total of 94 female care-seekers completed biannual telephone surveys, including the Short Form-36 physical functioning (PF) scale, over a period of 2(1/2) years. There were very few differences between Improvers and Non-Improvers at baseline but at final assessment Improvers had less disability, less fatigue, lower levels of pain, fewer symptoms of depressed mood, and fewer nonspecific physical complaints. Participants with FM at baseline were 3.23 times (p < 0.05) more likely to become Non-Improvers than those without FM. Participants identified initially as Somatizers were 3.33 times (p < 0.05) more likely to become Non-Improvers. Patients with CFS who bear the added burden of FM are at greater risk of a negative outcome than patients with CFS alone. This effect could not be explained by the presence of multiple, nonspecific symptoms.

Chronic fatigue syndrome in male Gulf war veterans and civilians: a further test of the single syndrome hypothesis.

Different modes of fatigue onset in male Gulf War veterans versus male civilians raise the possibility that chronic fatigue syndrome (CFS) may not be a single disease entity. We addressed this issue by comparing 45 male veterans with CFS to 84 male civilians who satisfied identical case criteria. All were evaluated for fibromyalgia (FM), multiple chemical sensitivity and psychiatric comorbidity. CFS was more likely to present in a sudden flu-like manner in civilians than veterans (p < .01) and comorbid FM was more prevalent in civilians (p < .01). These findings question the assumption that all patients with CFS suffer from the same underlying disorder.

Telephone-Based versus In-Person Delivery of Cognitive Behavioral Treatment for Veterans with Chronic Multisymptom Illness: A Controlled, Randomized Trial.

BACKGROUND: The goal of this randomized clinical trial was to examine the efficacy of a cognitive behavioral stress reduction treatment for reducing disability among veterans with chronic multisymptom illness (CMI). METHOD: Veterans (N=128) who endorsed symptoms of CMI were randomized to: usual care (n=43), in-person (n=42) or telephone-delivered cognitive behavioral stress management (n=43). Assessments were conducted at baseline, three months, and twelve months. The primary outcome was limitation in roles at work and home (i.e., 'role physical'). Reductions in catastrophizing cognitions were evaluated as a mechanism of action. RESULTS: Intent-to-treat analyses showed no statistically significant main effect (F(2, 164)=.58, p=.56) or interaction effect (F(4,164)=.94, p=.45) for role physical. Over time, veterans improved in their physical function (F(2,170)=5.34, p<.01; á½´2 partial=.06), PTSD symptoms (F(2,170)=9.39, p<.01; á½´2 partial=.10), depressive symptoms (F(2,170)=10.81, p<.01, á½´2 partial=.11), and physical symptoms (F(2, 172)=12.65, p<.01; á½´2 partial=.13), but these improvements did not differ across study arms over time. Completer analyses yielded similar results. There were no differences in catastrophizing between arms. CONCLUSION: Findings suggest stress reduction may not be the right target for improving disability among veterans with CMI. Veterans with CMI may need intervention that directly impacts medical self-management to improve disability.

Sub-typing CFS patients on the basis of 'minor' symptoms.

The diagnosis of chronic fatigue syndrome (CFS), an illness characterized by medically unexplained fatigue, depends on a clinical case definition representing one or more pathophysiological mechanisms. To prepare for studies of these mechanisms, this study sought to identify subtypes of CFS. In 161 women meeting 1994 criteria for CFS, principal components analysis of the 10 'minor' symptoms of CFS produced three factors interpreted to indicate musculoskeletal, infectious and neurological subtypes. Extreme scores on one or more of these factors characterized about 2/3 of the sample. Those characterized by the neurological factor were at increased risk of reduced scores on cognitive tests requiring attention, working memory, long-term memory or rapid performance. In addition, the neurological subtype was associated with reduced levels of function. Those characterized by the musculoskeletal factor were at increased risk for the diagnosis of fibromyalgia (chronic widespread pain and mechanical allodynia) and reduced physical function. Those characterized by the infectious factor were less likely to evidence co-occurring fibromyalgia, and showed lesser risk of functional impairment. The prevalence of disability was increased in those with the highest scores on any of the subtypes, as well as in those with high scores on multiple factors. Depression and anxiety, while frequently present, were not more prevalent in any particular subtype, and did not increase with the severity of specific symptom reports. Results suggest that subtypes of CFS may be identified from reports of the minor diagnostic symptoms, and that these subtypes demonstrate construct validity.

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis.

OBJECTIVES: According to the trauma hypothesis, women with fibromyalgia syndrome (FMS) are more likely to report a history of sexual and/or physical abuse than women without FMS. In this study, we rely on a community sample to test this hypothesis and the related prediction that women with FMS are more likely to have posttraumatic stress disorder than women without FMS. METHODS: Eligibility for the present study was limited to an existing community sample in which FMS and major depressive disorder were prevalent. The unique composition of the original sample allowed us to recruit women with and without FMS from the community. A total of 52 female participants were enrolled in the present FMS group and 53 in the control (no FMS) group. Sexual and physical abuse were assessed retrospectively using a standardized telephone interview. RESULTS: Except for rape, sexual and physical abuse were reported equally often by women in the FMS and control groups. Women who reported rape were 3.1 times more likely to have FMS than women who did not report rape (P<0.05). There was no evidence of increased childhood abuse in the FMS group. Women with FMS were more likely to have posttraumatic stress disorder symptoms (intrusive thoughts and arousal) as well as posttraumatic stress disorder diagnosis (P<0.01). DISCUSSION: With the exception of rape, no self-reported sexual or physical abuse event was associated with FMS in this community sample. In accord with the trauma hypothesis, however, posttraumatic stress disorder was more prevalent in the FMS group. Chronic stress in the form of posttraumatic stress disorder but not major depressive disorder may mediate the relationship between rape and FMS.

Comorbid illness in women with chronic fatigue syndrome: a test of the single syndrome hypothesis.

OBJECTIVE: Evidence of comorbidity among unexplained illness syndromes raises the possibility that all are variants of a single functional disorder, leading some to suggest that separate case definitions for chronic fatigue syndrome (CFS), fibromyalgia (FM), and multiple chemical sensitivity (MCS) may be unnecessary. Our objective was to determine whether discrete diagnostic labels provide useful information about physical functioning, symptom severity, and risk of psychiatric illness. METHODS: The sample consisted of 163 consecutive female referrals with CFS enrolled at a tertiary clinic. Each participant was retrospectively assigned to one of four groups: CFS only, CFS/FM, CFS/MCS, and CFS/FM/MCS. At enrollment, participants gave their history, underwent a physical examination and a standardized psychiatric interview (Diagnostic Interview Schedule), and answered self-report questionnaires. RESULTS: Additional unexplained syndromes were prevalent: 37% met criteria for FM, and 33% met criteria for MCS. With the exception of FM-related pain and disability, there were few differences between the CFS only and CFS with comorbid illness groups. Patients with additional illness were more likely to have major depression and a higher risk of psychiatric morbidity compared with patients in the CFS only group (p <.01). Rates of lifetime depression increased from 27.4% in the CFS only group to 52.3% in the CFS/FM group, 45.2% in the CFS/MCS group, and 69.2% in the CFS/FM/MCS group. CONCLUSIONS: The prevalence of comorbid illness in the present CFS sample and the failure to find widespread differences in symptom severity can be seen as support for the single syndrome hypothesis. On the other hand, the existence of discrete syndromes could not be ruled out because of reliable differences between CFS and CFS/FM. Increasing comorbidity was associated with a corresponding increase in risk of major depression.

Psychiatric morbidity in the chronic fatigue syndrome: are patients with personality disorder more physically impaired?

OBJECTIVE: The long-term consequences of chronic fatigue syndrome (CFS) include substantial impairment in physical functioning and high levels of work disability. In the absence of a medical explanation for this impairment, some have speculated that it may be due to comorbid psychiatric illness or personality disorder. We addressed this possibility by comparing the functional status of three CFS groups: no psychiatric diagnosis, psychiatric illness only, psychiatric illness and personality disorder. A second aim of the study was to determine whether a continuous measure of psychological distress could provide a better account of impairment than psychiatric diagnosis. METHOD: The study sample consisted of 84 consecutive female referrals with CFS. All participants satisfied the case definition and completed an assessment protocol consisting of: physical examination, psychiatric interview and self-report questionnaires. RESULTS: Psychiatric illness, either alone or in combination with a comorbid personality disorder, was not associated with physical impairment or disability in female participants. A regression model of physical functioning found that psychological distress accounted for 6% and symptom severity for 41% of the variance (P=.06 and <.01, respectively). In the case of disability, the corresponding percentages were 2% and 18% (NS and P<.01, respectively). The modest effects of psychological distress could not be attributed to symptom severity. CONCLUSIONS: Although psychiatric illness and personality disorder was prevalent, neither could explain the effects of CFS on physical functioning and disability. As yet, there is no psychological or medical explanation for the behavioral consequences of CFS.

Medical versus nonmedical mental health referral: clinical decision-making by telephone access center staff.

A database review investigated decisions of clinicians staffing a university-based telephone access center in referring new adult patients to nonpsychiatrists versus psychiatrists for initial ambulatory behavioral health care appointments. Systematically collected demographic and clinical data in a computer log of calls to highly trained care managers at the access center had limited predictive value with respect to their referral decisions. Furthermore, while 28% of the 610 study patients were initially referred to psychiatrists, billing data revealed that in-person therapists soon cross-referred at least 20% more to a psychiatrist. Care managers sent 56% of callers already taking psychotropic medications to nonpsychiatrists, 51% of whom were then cross-referred to psychiatrists. Predictive algorithms showed no potential to enhance efficiency of decisions about referral to a psychiatrist versus a nonpsychiatrist. Efforts to enhance such efficiency may not be cost-effective. It may be more fiscally efficient to assign less-experienced personnel as telephone care managers.

Increased risk of alcohol dependency in a cohort of National Guard troops with PTSD: a longitudinal study.

Studies show high rates of co-morbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) but there is no consensus on the causal direction of the relationship. Some theories suggest AUD develops as a coping mechanism to manage PTSD symptoms and others that AUD is a vulnerability factor for PTSD. A third hypothesis posits independent developmental pathways stemming from a shared etiology, such as the trauma exposure itself. We examined these hypotheses using longitudinal data on 922 National Guard soldiers, representing a subsample (56%) of a larger pre- and post-deployment cross-sectional study of New Jersey National Guard soldiers deployed to Iraq. Measures included the PTSD Checklist (PCL), DSM-IV-based measures of alcohol use/misuse from the National Household Survey of Drug Use and Health and other concurrent mental health, military and demographic measures. Results showed no effect of pre-deployment alcohol status on subsequent positive screens for new onset PTSD. However, in multivariate models, baseline PTSD symptoms significantly increased the risk of screening positive for new onset alcohol dependence (AD), which rose 5% with each unit increase in PCL score (AOR = 1.05; 95% CI = 1.02-1.07). Results also supported the shared etiology hypothesis, with the risk of a positive screen for AD increasing by 9% for every unit increase in combat exposure after controlling for baseline PTSD status (AOR = 1.09; 95% CI = 1.03-1.15) and, in a subsample with PCL scores <34, by 17% for each unit increase in exposure (AOR = 1.17; 95% CI = 1.05-1.31). These findings have implications for prevention, treatment and compensation policies governing co-morbidity in military veterans.

Gender differences in the risk and protective factors associated with PTSD: a prospective study of National Guard troops deployed to Iraq.

This study examines gender differences in post-traumatic stress symptoms (PTSS) and PTSS risk/protective factors among soldiers deployed to Iraq. We pay special attention to two potentially modifiable military factors, military preparedness and unit cohesion, which may buffer the deleterious psychological effects of combat. Longitudinal data were collected on 922 New Jersey National Guard soldiers (91 women) deployed to Iraq in 2008. Anonymous surveys administered at pre- and post-deployment included the PTSD Checklist (PCL), the Unit Support Scale, and a preparedness scale adapted from the Iowa Gulf War Study. Bivariate analyses and hierarchical multiple regression were used to identify predictors of PTSS and their explanatory effects on the relationship between gender and PTSS. Women had a higher prevalence of probable post-deployment PTSD than men (18.7% vs. 8.7%; OR = 2.45; CI [1.37, 4.37]) and significantly higher post-deployment PTSS (33.73 vs. 27.37; p = .001). While there were no gender differences in combat exposure, women scored higher on pre-deployment PTSS (26.9 vs. 23.1; p ≤ .001) and lower on military preparedness (1.65 vs. 2.41; p ≤ .001) and unit cohesion (32.5 vs. 38.1; p ≤ .001). In a multivariate model, controlling for all PTSS risk/resilience factors reduced the gender difference as measured by the unstandardized Beta (B) by 45%, with 18% uniquely attributable to low cohesion and low preparedness. In the fully controlled model, gender remained a significant predictor of PTSS but the effect size was small (d = .26). Modifiable military institutional factors may account for much of the increased vulnerability of women soldiers to PTSD.

A longitudinal study of pain and pain catastrophizing in a cohort of National Guard troops at risk for PTSD.

A recent cross-sectional study of National Guard troops found that pain and pain catastrophizing were prevalent and highly correlated with posttraumatic stress disorder (PTSD). At issue in the present study was whether pain and catastrophizing before military deployment could account for individual differences in PTSD symptoms after deployment. An anonymous survey was administered to a population sample of New Jersey National Guard troops before they were sent overseas and again when they returned home (1 year later). The survey included a validated PTSD screening questionnaire, numerical ratings of pain intensity, and a measure of pain catastrophizing. A cohort of 922 National Guard members completed the survey before and after deployment. An uncontrolled analysis indicated that pain and catastrophizing before deployment were significantly but modestly associated with PTSD symptoms after deployment (accounting for 4.5% and 1.3% of the variance, respectively). A hierarchical regression model that controlled for sex, preexisting PTSD symptoms, and recent combat found that pain but not pain catastrophizing explained variance in postdeployment PTSD. The size of the effect, however, was negligible (0.8%, p<.01). Consistent with previous research, a cross-sectional analysis revealed that postdeployment pain and catastrophizing successfully accounted for unique variance in postdeployment PTSD. The failure of longitudinal predictors in the present study, therefore, cannot be attributed to insensitive screening instruments. These findings offer little or no support for the hypothesis that predeployment pain and catastrophizing can account for individual differences in PTSD after exposure to combat trauma.

Catastrophic appraisal of acute and chronic pain in a population sample of new jersey national guard troops.

OBJECTIVES: Catastrophic appraisal has been implicated as a possible cause of psychiatric morbidity, psychological distress, and physical impairment in individuals with chronic pain. At issue in this study was whether catastrophizing was associated with psychiatric morbidity in a population sample of National Guard members. In addition, we sought to determine whether it could account for individual differences in psychological distress and impaired physical function in the presence of acute and chronic pain. METHODS: We performed a secondary analysis of an existing survey database. The original survey was designed to assess combat readiness in a population sample of 2995 National Guard troops about to deploy overseas. The database included screening instruments for psychiatric illness as well as continuous measures of psychological distress, pain perception, pain catastrophizing, and perceived physical function. RESULTS: Among Guard members reporting a problem with pain, frequent catastrophizing was associated with higher rates of depression, posttraumatic stress, alcohol dependence, and somatization-like illness. Higher rates were also associated with chronic as opposed to acute pain (except for alcohol dependence). Pain-related catastrophizing accounted for substantial variance in measures of psychological distress and physical impairment regardless of pain duration. DISCUSSION: Although catastrophizing beliefs are common in clinical settings, this study suggests that the phenomenon may be prevalent in the population at large and likely to influence the outcome of acute as well as chronic pain.

A test of the symptom amplification hypothesis in patients with asthma.

The present study sought to measure the accuracy of symptom reporting in patients with asthma by calculating the difference between a subjective rating of illness severity and an objective test of lung function (forced expiratory volume in 1 second). At issue was the hypothesis that self-reported "symptom amplification" or sensory awareness accounts for differences in the accuracy of symptom reporting. Spirometric examination was performed, and psychological tests of symptom amplification, emotional distress, and neuroticism were administered. Participants consisted of 42 consecutive patients seeking medical treatment of asthma. The disparity between symptom perception (assessed by a Borg scale) and a corresponding measure of lung capacity allowed us to identify patients who overreported their symptoms (amplifiers) along with those who underreported them (minimizers). After controlling for the effects of sex and psychological distress, a self-report measure of symptom amplification explained 15% of the variability in reporting accuracy. Related constructs such as somatization and neuroticism could not explain differences in reporting ability.

Localization of pain and self-reported rape in a female community sample.

OBJECTIVE: Studies suggest that rape increases risk of medically unexplained pain in women. At present it is not clear whether rape is associated with pain at specific locations or at multiple locations. In this study we tested the hypothesis that rape was associated with a preferential increase in risk of pelvic pain that was not explained by pain at other sites. DESIGN: We relied on an existing community study that oversampled women with fibromyalgia and major depression. Localization was assessed by asking about pain at four sites: pelvic region; jaw/face; headache; and lower back. Three groups were identified using a structured telephone interview: Abuse Only (sexual/physical abuse excluding rape); Rape+Abuse (rape in addition to other sexual/physical abuse); and No Abuse. RESULTS: Compared with the No Abuse group, the Rape+Abuse group was eight times more likely to have pelvic pain and 3.7 times more likely to have jaw/face pain after we controlled for the effect of widespread pain. Rape was not associated with lower back pain or headache. The Abuse Only group did not show a preferential increase in risk of pain at any of the four locations that were assessed. After controlling for pain at other locations, we found that the Rape + Abuse group was 10 times more likely to report pelvic pain than the No Abuse group (P<0.005). DISCUSSION: In accord with the localization hypothesis, self-reported rape was uniquely associated with pelvic pain. Future efforts to account for pain in the aftermath of rape must specify a mechanism that can simultaneously cause widespread pain as well as increase risk of localized pain.

Positive straight-leg raising in lumbar radiculopathy: is documentation affected by insurance coverage?

OBJECTIVE: To evaluate whether differences exist in documentation of straight-leg raising (SLR), based on insurance coverage. DESIGN: Retrospective study. SETTING: Managed care organization (MCO). PARTICIPANTS: Two hundred people with a diagnosis of lumbar radiculopathy or herniated disk were referred to an MCO for authorization of further treatment. Half were self-directed under a personal injury program (PIP) after automobile collisions, and half were covered under a managed care workmen's compensation (WC) program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Documentation of an SLR test, strength, sensation, and/or reflexes were eligible for the study. The results of SLR were coded as 0, 1, or 2, for absent, positive unilateral, and positive bilateral, respectively. Additional information included subject age, sex, date of injury, provider type, and presence of attorney representation RESULTS: A positive (unilateral, bilateral) SLR in women was 7.4 times more likely if they were covered by PIP than by WC (95% confidence interval [CI], 1.4-38.7; P=.018). For men, a positive SLR was 23.5 times more likely if they were covered by a PIP (95% CI, 2.9-189.9; P=.003). The odds of bilateral SLR (radicular pain on both sides) were even more strongly associated with type of reimbursement. For women, bilateral SLR was 105.1 times more likely if they were covered by a PIP than by WC (95% CI, 11.1-992.6; P<.001). For men, bilateral SLR was 38.9 times more likely if covered by a PIP (95% CI, 11.3-133.6; P<.001). CONCLUSIONS: Reasons for reporting higher rates of positive SLR in the PIP group include an added incentive to treat, poor knowledge of proper interpretation of the SLR test, and/or an increased exaggeration of symptoms.

Is childhood abuse a risk factor for chronic pain in adulthood?

Childhood sexual and physical abuse often are viewed as important factors in the development and persistence of chronic pain syndromes in adulthood. Nevertheless, earlier reviews on this issue have reached conflicting conclusions regarding the veracity of the relationship. In this critical review of existing research on childhood abuse and pain in adulthood, surprisingly mixed evidence is found, with significant effects found most consistently in very large cross-sectional studies that rely on self-reported abuse status. The few prospective studies that are available do not support the relationship. When examining the literature from the perspective of epidemiological standards for inferring causation, the authors conclude that the evidence does not demonstrate a causal relationship. It appears that any overall relationship between childhood abuse and pain in adulthood probably is modest in magnitude, if it exists at all. Clinical implications and suggestions for future research directions are discussed.

Functional imaging of pain in patients with primary fibromyalgia.

OBJECTIVE: To examine the function of the nociceptive system in patients with fibromyalgia (FM) using functional magnetic resonance imaging (fMRI). METHODS: Two groups of women, 9 with FM and 9 pain-free, volunteered to participate. In Experiment 1, we assessed psychophysical responses to painful stimuli and prepared participants for fMRI testing. For Experiment 2, subjects underwent fMRI scanning while receiving painful and nonpainful heat stimuli. Conventional and functional MR images were acquired using a 1.5 T MR scanner. Scanning occurred over 5 conditions. Condition 1 served as a practice session (no stimuli). Conditions 2 and 5 consisted of nonpainful warm stimuli. Conditions 3 and 4 consisted of an absolute thermal pain stimulus (47 degrees C) and a perceptually equivalent pain stimulus delivered in counterbalanced order. RESULTS: Experiment 1 indicated that subjects with FM were significantly more sensitive to experimental heat pain than controls (p < 0.001). In Experiment 2, fMRI data indicated that the FM group exhibited greater activity than controls over multiple brain regions in response to both nonpainful and painful stimuli (p < 0.01). Specifically, in response to nonpainful warm stimuli, FM subjects had significantly greater activity than controls in prefrontal, supplemental motor, insular, and anterior cingulate cortices (p < 0.01). In response to painful stimuli, FM subjects had greater activity in the contralateral insular cortex (p < 0.01). Data from the practice session indicated brain activity in pain-relevant areas for the FM group but not for controls. CONCLUSION: Our results provide further evidence for a physiological explanation for FM pain.