Is acute stress reaction a risk factor for early mortality?

OBJECTIVE: This study aimed to examine the role of combat stress reaction (CSR) in predicting all-cause mortality over a 33-year period following the end of the war. METHOD: Two groups of male veterans from the 1982 Lebanon War participated in this study in 1983 (T1) and 2016 (T2): the CSR group (n = 375) and a matched comparison group (n = 305) consisting of combatants who had participated in combat in the same units as the CSR group but were not identified as having CSR. Participants were assessed for posttraumatic stress disorder symptoms and depressive symptoms in T1 and mortality in T2. RESULTS: The distribution of mortality rates was significantly different between the 2 groups and higher among the CSR group (n = 32, 8.5%) as compared to the comparison group (n = 12, 3.9%; χ2 = 5.89, p = .01). Both posttraumatic stress disorder symptoms and depressive symptoms were controlled for because they have been shown to be risk factors for all-cause mortality. The mortality curve of the CSR group increased steeply around the age of 40 years, whereas in the comparison group, the increase was less substantial. CONCLUSIONS: CSR was found to be a significant predictor of all-cause mortality. The risk for mortality was higher and earlier among the CSR group compared with the comparison group. The findings of this study call attention to the importance of immediately identifying CSR to better care for the individual and minimize long-term negative effects. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Specialized Palliative and Hospice Care and the Importance of Mourning Our Nation's Veterans.

One aspect of palliative medicine that has been underexplored is the perspective of veterans either facing critical life-limiting illness or at the end of life. The needs of veterans differ not only because military culture affects how veterans cope with their illness but also because exposure-related factors (combat and environmental) differ between military branches. In this paper, we describe two cases involving end-of-life care for veterans with combat trauma and describe individualized approaches to their care.

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data.

INTRODUCTION: Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations. METHODS: The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ2 and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05. RESULTS: We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%). CONCLUSION: Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

Mortality of first world war military personnel: comparison of two military cohorts.

OBJECTIVE: To identify the impact of the first world war on the lifespan of participating military personnel (including in veterans who survived the war). DESIGN: Comparison of two cohorts of military personnel, followed to death. SETTING: Military personnel leaving New Zealand to participate in the first world war. PARTICIPANTS: From a dataset of the New Zealand Expeditionary Forces, we randomly selected participants who embarked on troopships in 1914 and a comparison non-combat cohort who departed on troopships in late 1918 (350 in each group). MAIN OUTCOME MEASURES: Lifespan based on dates of birth and death from a range of sources (such as individual military files and an official database of birth and death records). RESULTS: A quarter of the 1914 cohort died during the war, with deaths from injury predominating (94%) over deaths from disease (6%). This cohort had a significantly shorter lifespan than the late 1918 "non-combat" cohort, with median ages of death being 65.9 versus 74.2, respectively (a difference of 8.3 years shown also in Kaplan-Meier survival curves, log rank P<0.001). The difference for the lifespan of veterans in the postwar period was more modest, with median ages of death being 72.6 versus 74.3, respectively (a difference of 1.7 years, log rank P=0.043). There was no evidence for differences between the cohorts in terms of occupational class, based on occupation at enlistment. CONCLUSIONS: Military personnel going to the first world war in 1914 from New Zealand lost around eight years of life (relative to a comparable military cohort). In the postwar period they continued to have an increased risk of premature death.

Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army's increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.

Freud y la Gran Guerra / Freud and the Great War

En el corazón de este trabajo hay una viñeta clínica de una paciente neurótica, menos defendida y con más capacidad de recordar. Otra paciente más difícil, límite, está presa de una historia traumática en la que busca una salida repitiendo. Nuestro maestro Freud elaboró un breve y brillante escrito técnico titulado Recordar, repetir y reelaborar en el año del comienzo de la Gran Guerra. Esos acontecimientos dejaron honda huella en él, como en tantos europeos civilizados. El trabajo de Lear presentado en el Congreso de Berlín me ayuda a pensar el difícil problema de la elaboración de los cambios culturales desestructurantes. Trabajar en la formación de símbolos es una de las principales tareas del analista. Freud y Winnicott así lo hicieron y por tener una construcción simbólica de la realidad psíquica distinta, Freud y Jung no se entendieron (AU)

At the heart of this work is a clinical vignette of a less-defended neurotic patient, with more capacity far remembering. Another more difficult, borderline patient is prisoner to a traumatic history in which she seeks a way out by repeating. Freud, our great teacher, formulated a brief and brilliant work on technique entitled Remembering, repeating and working through in the year of the start of the Great War. Those events would leave a profound mark on him, as on so many civilized Europeans. Lear's paper, presented at the Berlin Congress, helps us to consider the difficult problem of working through destructuring cultural changes. Working on symbol formation is one of the principal tasks of the analyst. This Freud and Winnicott did, while Freud and Jung, through their differing symbolic construction of psychic reality, carne to be at loggerheads (AU)

Respuesta a Freud y la Gran Guerra / No disponible

No disponible

The association between substance use disorders and mortality among a cohort of Veterans with posttraumatic stress disorder: variation by age cohort and mortality type.

BACKGROUND: Prior studies of Veterans have linked posttraumatic stress disorder (PTSD) with an increased risk of mortality. Other studies of Veterans have found that substance use disorders (SUDs) are associated with an excess risk of mortality among those with psychiatric disorders. It is not known whether having an SUD increases the risk of mortality among Veterans with PTSD, and whether the association differs by mortality type or varies by age cohort. METHODS: A cohort of patients who received Veterans Health Administration services during fiscal year (FY) 2004 and diagnosed with PTSD (n=272,509) were followed from FY 2005 through FY 2007 for the main outcomes of mortality and cause of death. RESULTS: SUD was positively associated with mortality during follow-up (adjusted hazards ratio: 1.70; 95% confidence interval: 1.64, 1.77). SUD was a stronger predictor of non-injury-related mortality for the <45 years group compared with the 45-64 or ≥65 group. SUD predicted injury-related mortality for all age groups. CONCLUSIONS: Among Veterans with PTSD, the association between SUD and mortality was most pronounced for the youngest age group, which included Iraq/Afghanistan Veterans. For older age groups, which included Vietnam-era Veterans, SUD was a greater predictor of injury-related mortality. The findings could be useful for identifying PTSD patients at excess risk of mortality.

War stress and late-life mortality in World War II male civilian resistance veterans.

The mental and physical health of 146 Dutch males exposed to severe war stress during their young adulthood were examined in 1986-1987 when they were at ages 61 to 66 years. The veterans' data were compared with a randomly selected population-based sample of same-aged males. In 2005, 70% of the war stress veterans had died, and only 35% of the comparison group. The baseline quality of life was significantly poorer in the war stress veterans than in the comparison group. Baseline variables explained 42% of the increased risk of mortality among war stress veterans. Smoking was the largest single contributor to mortality.

Reduced hippocampal and amygdala activity predicts memory distortions for trauma reminders in combat-related PTSD.

Neurobiological models of posttraumatic stress disorder (PTSD) suggest that altered activity in the medial temporal lobes (MTL) during encoding of traumatic memories contribute to the development and maintenance of the disorder. However, there is little direct evidence in the PTSD literature to support these models. The goal of the present study was to examine MTL activity during trauma encoding in combat veterans using the subsequent memory paradigm. Fifteen combat veterans diagnosed with PTSD and 14 trauma-exposed control participants viewed trauma-related and neutral pictures while undergoing event-related fMRI. Participants returned one week after scanning for a recognition memory test. Region-of-interest (ROI) and voxel-wise whole brain analyses were conducted to examine the neural correlates of successful memory encoding. Patients with PTSD showed greater false alarm rates for novel lures than the trauma-exposed control group, suggesting reliance on gist-based representations in lieu of encoding contextual details. Imaging analyses revealed reduced activity in the amygdala and hippocampus in PTSD patients during successful encoding of trauma-related stimuli. Reduction in left hippocampal activity was associated with high arousal symptoms on the Clinician-Administered PTSD Scale (CAPS). The behavioral false alarm rate for traumatic stimuli co-varied with activity in the bilateral precuneus. These results support neurobiological theories positing reduced hippocampal activity under conditions of high stress and arousal. Reduction in MTL activity for successfully encoded stimuli and increased precuneus activity may underlie reduced stimulus-specific encoding and greater gist memory in patients with PTSD, leading to maintenance of the disorder.

War-related stress exposure and mortality: a meta-analysis.

BACKGROUND: Domestic and international wars continue to be pervasive in the 21st century. This study summarizes the effects of war-related stress on all-cause mortality using meta-analyses and meta-regressions. METHODS: A keyword search was performed, supplemented by extensive iterative hand-searches for observational studies of war-related stress and mortality. Two hundred and twenty mortality risk estimates from 30 studies were extracted, providing data on more than 9 million persons. RESULTS: The mean hazard ratio (HR) was 1.05 [95% confidence interval (CI) 0.98-1.13] among HRs adjusted for age and additional covariates. The mean effect for men was 1.14 (CI 1.00-1.31), and for women it was 0.92 (CI 0.66-1.28). No differences were found for various follow-up durations or for various types of war stress. Neither civilians nor military personnel had an elevated mortality risk. Those exposed to a combat zone during the Vietnam War had a slightly higher chance of death (HR 1.11; 95% CI 1.00-1.23). CONCLUSIONS: The results show that, over all, exposure to war-stress did not increase the risk of death when studies were well controlled. Effects were small when found. This lack of substantial effect may be the result of selection processes, developed resiliency and/or institutional support.

Prospective study of externalizing and internalizing subtypes of posttraumatic stress disorder and their relationship to mortality among Vietnam veterans.

Posttraumatic stress disorder (PTSD) can be a complex disorder, and some studies have found that samples of individuals with PTSD contain subtypes that may relate to health outcomes. The goals were to replicate previously identified PTSD subtypes and examine how subtype membership relates to mortality. Data from the Vietnam Experience Study and a clinical sample of Vietnam veterans were combined (n = 5248) to address these research questions. Consistent with previous studies, 3 PTSD subtypes emerged: externalizers (n = 317), internalizers (n = 579), and low pathology (n = 280). Posttraumatic stress disorder diagnosis was associated with increased risk of all-cause and behavioral-cause (eg, homicide, suicide) mortality. Both externalizing and internalizing subtypes had higher mortality and were more likely to die from cardiovascular causes than those without PTSD. Externalizers were more likely to die from substance-related causes than those without PTSD. The value of considering possible PTSD subtypes is significant in that it may contribute to identifying more specific targets for treatment and rehabilitation in veterans with PTSD.

Predicting mortality in veterans with posttraumatic stress disorder thirty years after Vietnam.

Previous research has demonstrated elevated mortality rates among Vietnam-era veterans with posttraumatic stress disorder, especially deaths resulting from nonmedical causes. However, information on the relative contribution of particular risk factors to increased mortality is limited. We used receiver operating characteristics methodology to identify patient-level characteristics that predicted 7-year mortality in 79,551 middle-aged, male, posttraumatic stress disorder-diagnosed outpatients seeking mental health treatment within the Veterans Affairs Health Care System between April 1, 1998 and September 30, 1998. Receiver operating characteristics models indicated that the strongest predictor of mortality was a recent history of medical hospitalization, followed by severity of medical diagnoses and presence of a substance disorder. Results highlight the importance of addressing comorbid medical illnesses and addictive disorders when caring for this population.

Psychobiologic predictors of disease mortality after psychological trauma: implications for research and clinical surveillance.

Research has suggested that exposure to traumatic events can result in adverse health outcomes. However, the reasons for this are unclear. We examined psychobiologic factors associated with disease mortality among a community-based sample of 4462 male veterans 30 years after military service, including posttraumatic stress disorder (PTSD), erythrocyte sedimentation rate (ESR), white blood cell (WBC) count, and cortisol/dehydroepiandrosterone-sulfate (cortisol/DHEA-s) ratio. In the study, 56% (n = 2490) were theater veterans who served in Vietnam and 44% (n = 1972) era veterans who served elsewhere. During baseline in 1985, 10.2% of theater and 3.4% of era veterans had current PTSD. At follow-up in 2000, 13.6% of men with current baseline PTSD were deceased, compared with 5% without PTSD. Analyses suggested that having PTSD, a high ESR, a high WBC count, and a high cortisol/DHEA-s ratio at baseline were associated with all-cause disease mortality at follow-up. With the exception of cortisol/DHEA-s ratio, these factors also predicted cardiovascular mortality. Depression was not consistently associated with mortality, once other factors were controlled. Noteworthy was that having PTSD had an impact on mortality nearly comparable to common indicators of disease in medicine, such as an ESR >65 mm/h and a WBC count >11,000 mm(3). This study suggests that the morbidity associated with PTSD may be comparable to laboratory measures of disease pathology in common use and warrants further investigation and surveillance among at risk populations.

Wartime stressors and mental health symptoms as predictors of late-life mortality in World War II survivors.

BACKGROUND: Pathways through which wartime stress leads to excess mortality have not been examined so far. The current study examines wartime stress in relation to late-life mortality among 1448 World War II survivors, and potential mediating effects of mental health symptoms that were assessed in 1992. METHODS: In 1992, a community survey was held. In 2002, vital status was checked. RESULTS: The highest hazard rates of mortality were found among military veterans and war survivors who had been seriously wounded. Posttraumatic stress disorder, suicidal thoughts, and, particularly, depression were associated with a higher hazard rate. Depression, anxiety, and somatic complaints appeared to act as mediators between the wartime stressor 'permanent disability or illness' and survival time. LIMITATIONS: The results may not be generalizable to all World War II survivors since the sample was restricted to those who survived until 1992. In addition, there was a considerable level of non-response, and the study used self-report data on wartime exposure and psychological symptoms. CONCLUSIONS: Exposure to wartime stress as well as mental health symptoms in the long-term aftermath of war and violence are significant predictors of late-life mortality. Wounded survivors and those with a permanent disability or illness are particularly vulnerable.

External-cause mortality after psychologic trauma: the effects of stress exposure and predisposition.

Research suggests that exposure to psychologic trauma is associated with mortality from external causes, including homicide, suicide, drug overdoses, and unintended injury. However, the etiology of this association is unclear. We examined the survival time and cause of death among a national sample of 15288 US Army veterans by posttraumatic stress disorder (PTSD) status 30 years after military service. In these analyses, we included demographic (age, race, marital status, service entry age, and birthplace), predisposing (army volunteer status, discharge status, history of drug abuse, early-age alcohol use, and intelligence), and combat exposure variables. After adjusting for demographic and predisposing factors, all-cause mortality was associated with PTSD for all veterans combined (hazards ratio [HR] = 2.1, P < .001), as well as for era veterans without Vietnam service (HR = 2.0, P = .001) and theater veterans with Vietnam service (HR = 2.1, P < .001). For theater veterans, PTSD remained significant for all-cause mortality, even after controlling for demographic, predisposition, and combat exposure measures (HR = 2.1, P < .001). For external mortality, the adjusted results indicated that PTSD was associated with death for all veterans combined (HR = 2.3, P < .001) and for theater veterans separately (HR = 2.2, P = .002). For era veterans, the adjusted external mortality results also approached statistical significance (HR = 2.2, P = .068). Among theater veterans, PTSD remained significant for external mortality, even after controlling for all variables and combat exposure (HR = 2.2, P = .002). Combat exposure was not associated with external mortality once all variables were controlled. In addition, theater veterans who volunteered for Vietnam and those with dishonorable discharges were at increased risk for external-cause mortality.

Long-term course of treatment-seeking Vietnam veterans with posttraumatic stress disorder: mortality, clinical condition, and life satisfaction.

This study is a 6-year longitudinal study of 51 treatment-seeking male veterans with combat-related posttraumatic stress disorder. Measures of PTSD and psychiatric symptomatology, social functioning, and program impact were assessed at admission to an inpatient treatment program, at 18 months, and 6 years later. Previous studies had shown that the treatment program's impact on course of illness had been negligible. The sample showed an extremely high mortality rate of 17% over 6 years. The remaining veterans showed improvement in violence and alcohol and drug use, but an increase in hyperarousal symptoms and social isolation. Nearly three-fourths had had an inpatient hospitalization. Veterans' self-ratings, in contrast, indicated significant improvement in all areas of functioning except employment, as well as an overall positive view of the impact of the program on their lives. Results indicate that the majority of the veteran sample had experienced some improvement in their ability to cope with their chronic illness, decreasing their use of violence and substance abuse but still were experiencing high levels of symptomatology. The extremely high mortality rate, however, provides a somber reminder of the seriousness of this disorder.

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.