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In recent years, the military has made great progress in the assessment and treatment of PTSD and other combat-related psychological disorders. Although once ignored by the military, the mental health needs of todays soldiers and combat veterans are addressed through a variety of psychological services during and after deployment. For instance, upon returning from deployment, combat veterans are assessed for psychological disorders and, if necessary, provided psychological treatment. However, some experts question the value and utility of these procedures given the nature of military culture.In this Discussion, you will analyze the militarys response to the mental health needs of combat veterans and any potential barriers to treatment that might exist.To prepare for this Discussion:Think about how the military screens for and treats combat-related psychological disorders.Consider core actions employed by military mental health personnel following traumatic incidents.Think about the personal and cultural barriers that combat veterans might encounter when seeking and engaging in treatment for combat-related psychological disorders.With these thoughts in mind:By Day 4Post a brief analysis of how the military responds to combat veterans mental health needs during and after deployment. In your analysis, be sure to include brief descriptions of crisis intervention strategies and/or skills used during deployment and assessment strategies and treatment modalities used after deployment. Then, describe at least one barrier that might prevent a combat veteran from seeking or engaging in treatment for a combat-related disorder, and explain why. Be specific.Be sure to support your postings and responses with specific references to the Learning Resources. combat_related_posttraumatic_stress_disorder_.pdf what_is_its_effect_on_stress_in_the_military.pdf deployment_risk_and_resilience_inventory.pdf combat_and_interpersonal_trauma_on_ptsd_.pdf Unformatted Attachment Preview Journal of Psychiatric Research 45 (2011) 1579e1584 Contents lists available at ScienceDirect Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/psychires An examination of the relation between combat experiences and combat-related posttraumatic stress disorder in a sample of Connecticut OEFeOIF Veterans Robert H. Pietrzak a, b, *, Julia M. Whealin c, d, Rebecca L. Stotzer e, Marc B. Goldstein f, Steven M. Southwick a, b a National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, USA Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA National Center for Posttraumatic Stress Disorder, Pacific Islands Division, VA Pacific Island Health Care System, Honolulu, HI, USA d Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA e Myron B. Thompson School of Social Work, University of Hawaii, Honolulu, HI, USA f Department of Psychology, Central Connecticut State University, New Britain, CT, USA b c a r t i c l e i n f o a b s t r a c t Article history: Received 15 April 2011 Received in revised form 9 July 2011 Accepted 14 July 2011 Background: Combat exposure is an important risk factor for posttraumatic stress disorder (PTSD). However, little research has examined specific combat experiences associated with PTSD and confirmatory factor analytically (CFA)-derived re-experiencing, avoidance, dysphoria, and hyperarousal symptom clusters. Methods: A total of 285 predominantly older National Guard/Reservist OEFeOIF Veterans completed an anonymous mail survey that assessed demographics and deployment history, a broad range of combat experiences, PTSD, and unit and postdeployment social support. Results: Personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed (b ¼ 0.22), and being exposed to “friendly” fire (b ¼ 0.14) and land mines/traps (b ¼ 0.13) were the only three combat experiences associated with severity of combat-related PTSD symptoms, after adjustment for age, relationship status, unit support, postdeployment social support, and other combat experiences. Differential patterns of associations were observed for specific combat experiences in relation to CFAderived symptom clusters (e.g., experiencing “friendly” fire was associated with re-experiencing and dysphoria symptoms, but not avoidance and hyperarousal symptoms). Personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed (odds ratio [OR] ¼ 4.34; 95\% confidence interval [CI] ¼ 1.62e11.61) and being exposed to “friendly” fire (OR ¼ 2.94; 95\%CI ¼ 1.16e7.47) emerged as independent predictors of a positive screen for probable PTSD. Conclusions: Results of this study suggest that witnessing someone in one’s unit or ally unit being seriously wounded or killed while in a combat zone and being exposed to “friendly” fire are most strongly associated with combat-related PTSD in this sample of OEF/OIF Veterans. Examination of the relation between specific combat experiences and combat-related PTSD in OEF/OIF Veterans may help inform etiologic models of PTSD, and guide prevention and treatment approaches in this population. Published by Elsevier Ltd. Keywords: Combat Posttraumatic stress disorder Depression Veterans 1. Introduction Posttraumatic stress disorder (PTSD) is one of the most prevalent psychiatric conditions among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEFeOIF), with 13.8\% meeting * Corresponding author. National Center for PTSD, VA Connecticut Healthcare System and Department of Psychiatry, Yale University School of Medicine, 950 Campbell Avenue/151E, West Haven, CT 06516, USA. Tel.: þ1 860 638 7467; fax: þ1 203 937 3481. E-mail address: robert.pietrzak@yale.com (R.H. Pietrzak). 0022-3956/$ e see front matter Published by Elsevier Ltd. doi:10.1016/j.jpsychires.2011.07.010 screening criteria for this condition (Tanielian and Jaycox, 2008). Combat exposure is related to PTSD in a “doseeresponse” manner, with increased frequency and intensity of combat exposure related to greater severity and likelihood of a positive screen for PTSD (Iversen et al., 2008; Phillips et al., 2010; Pietrzak et al., 2009; Rona et al., 2009; Vogt et al., 2008). Emerging research has begun to examine specific combat experiences associated with PTSD in OEFeOIF Veterans (Maguen et al., 2010; Phillips et al., 2010; Rona et al., 2009). For example, a study of active duty service members from the United Kingdom who were deployed to the Iraq war found that while most combat 1580 R.H. Pietrzak et al. / Journal of Psychiatric Research 45 (2011) 1579e1584 experiences assessed were associated with PTSD, coming under small arms fire, discharging a weapon in combat, being in a forward area and in close contact with the enemy, and seeing personnel wounded or killed were particularly strongly associated with PTSD odds ratios [ORs] ¼ 8.9e15.3; (Rona et al., 2009). More recently, a study of U.S. Marine OEFeOIF Veterans found that feeling in great danger of death, being shot or seriously injured, and seeing someone wounded or killed were independently associated with PTSD ORs ¼ 2.5e4.6; (Phillips et al., 2010). Taken together, results of these studies suggest that certain combat experiences may be independently related to PTSD in OEFeOIF Veterans. The purpose of the current study was to examine how 15 different combat experiences were related to overall severity of and a positive screen for combat-related PTSD, as well as confirmatory factor analytically (CFA)-derived PTSD symptom clusters of reexperiencing, avoidance, dysphoria, and hyperarousal (Pietrzak et al., 2010) in a sample comprised predominantly of National Guard and Reservist OEFeOIF Veterans. We hypothesized that experiences associated with killing and life threat (e.g., hostile fire, “friendly” fire, mines/traps), and witnessing serious injury or death would be most strongly related to combat-related PTSD. We further expected that experiences associated with killing and life threat would be related specifically to re-experiencing and hyperarousal symptoms. 2. Method 2.1. Sample Respondents were 285 OEF/OIF Veterans who completed the Connecticut OEF/OIF Veterans Needs Assessment Survey (dates of military service: 01/03 to 03/07). The target population was all Connecticut veterans who served in OIF/OEF since 2003. Potential respondents were identified by inspection of copies of discharge papers (DD214s) that were sent to the Commissioner of Veterans Affairs for the state. Her staff identified eligible veterans and selected the first 1050 (alphabetically by surname) for the target sample. Because DD214 forms were not computerized, assembling a potential sample required a staff member sorting through DD214 forms for all Veterans in the State of Connecticut and selecting only OEF/OIF Veterans. Given that there are in excess of 200,000 DD214s on file, the first 1050 OEF/OIF Veterans identified were selected for potential participation in this study. A total of 1050 surveys were mailed and 285 were returned (27.1\% return rate). A reminder postcard was sent one week after the surveys were mailed. Respondents were older than non-respondents in the sampling frame (33.4 vs. 31.3 years, t ¼ 2.87, p ¼ 0.004). On average, surveys were completed 26.9 months (standard error of the mean [SEM] ¼ 0.7) following return from deployment. Institutional review boards of Yale University, Central Connecticut State University, and the VA Connecticut Healthcare System approved the study. 2.2. Assessments The Combat Experiences Scale (CES) is a 15-item self-report instrument from the Deployment Risk and Resilience Inventory DRRI; (King et al., 2006; Vogt et al., 2008). It was developed over a 4-year period using an item development process that involved review of existing combat literature, focus groups with Veterans, and review by content experts and members of the target population. Psychometric analyses of multiple datasets confirmed the scale’s internal consistency reliability, test-retest reliability, criterion-related validity, as well as convergent and discriminant validity in U.S. Gulf War and Iraq War veterans (King et al., 2006; Vogt et al., 2008). The CES assesses 15 different combat-related experiences, including firing a weapon, being fired on by enemy or friendly fire, and witnessing injury and death (see Table 1). Higher scores indicate greater combat exposure. A previous validation study in OIF veterans found that CES scores correlated positively with PTSD and depression symptoms, and negatively with mental health functioning (Vogt et al., 2008). In this sample, Cronbach’s a on CES items was 0.93. The Posttraumatic Stress Disorder Checklist-Military Version PCL-M; (Weathers et al., 1993) is a 17-item screening instrument based on diagnostic criteria for PTSD. Respondents who scored 50 and who met B, C, and D criteria for PTSD (i.e., “moderate” or greater severity of symptoms) were identified as screening positive for PTSD. This definition provides a conservative estimate of the prevalence of PTSD that corresponds to DSM-IV criteria for PTSD. Cronbach’s a on PCL-M items was 0.96. A total of 284 (99.6\% of sample) Veterans completed the PCL-M. 2.3. Data analysis Bivariate correlations were conducted to examine associations between individual combat experiences and PTSD symptoms, including total PCL-M scores and symptom clusters derived from a confirmatory factor analysis of PCL-M in the current sample of OEFeOIF Veterans (Pietrzak et al., 2010). Greater age (r ¼ 0.22, p < 0.001), not being in a relationship (r ¼ 0.19, p ¼ 0.002), and social support scores on the Unit Support Scale [USS] and Postdeployment Social Support Scale [PSSS] from the DRRI (King et al., 2006; Vogt et al., 2008); r’s ¼ 0.56 and 0.23, respectively, both p’s < 0.001 were significantly associated with total PCL-M scores, but correlations with other demographic and deployment-related characteristics, including nonwhite race (r ¼ 0.05, p ¼ 0.42), college or higher education (r ¼ 0.07, p ¼ 0.26), active duty vs. National Guard/Reservist; (r ¼ 0.04, p ¼ 0.57), and having served more than one deployment (r ¼ 0.10, p ¼ 0.11), were not. Complete data on all study variables entered into regression analyses were available for 272 Veterans. Multiple linear regression analyses were conducted to examine combat experiences associated with total PTSD symptoms and CFA-derived PTSD symptom clusters (Pietrzak et al., 2010). Age, relationship status, and USS and PSSS scores; and combat experiences associated with PTSD symptoms at the p < 0.05 level in bivariate analyses were entered as independent variables; total PTSD and CFA-derived subscale scores were entered as dependent variables in separate analyses. Collinearity diagnostics, including tolerance, variance inflation factor, and condition indices, were generated to evaluate for possible multicollinearity. Tolerance values <0.20, variance inflation factor >4.0, and condition indices >15 were used to indicate possible multicollinearity. A logistic regression analysis was then conducted to examine the relation between combat experiences and a positive screen for combat-related PTSD. In this analysis, age, USS and PSSS scores; and combat experiences associated with a positive screen for PTSD in bivariate analyses were entered as independent variables; and PTSD status (negative vs. positive screen) was entered as the dependent variable. To reduce the number of independent variables entered into this analysis (Vittinghoff and McCulloch, 2007), only those combat experiences associated with PTSD at the p < 0.001 level in bivariate analyses were entered into this analysis. To determine whether specific combat experiences were associated with severity of and positive screen for PTSD above and beyond the frequency of deployments and overall level of combat exposure, two supplementary regression analyses, one for PCL-M scores and one for positive screen for PTSD, were conducted with R.H. Pietrzak et al. / Journal of Psychiatric Research 45 (2011) 1579e1584 number of deployments (one vs. two or more) and CES total scores entered as additional independent variables. 3. Results Table 1 shows demographic, deployment, psychosocial, and combat experience variables by PTSD status. Compared to Veterans without PTSD, Veterans with PTSD were younger and served more deployments; they also scored higher on measures of combat exposure and PTSD symptoms, and lower on measures of unit support and postdeployment social support. c2 analyses revealed that all combat experiences were associated with a positive screen for PTSD. All of the combat experiences assessed correlated significantly with PCL-M scores in bivariate analyses, with magnitudes of these correlations ranging from 0.19 to 0.39. Large r  0.37; (Cohen, 1988) magnitude correlations were observed between personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed, and total PTSD symptoms, and re-experiencing, avoidance, and avoidance symptoms. All other correlations were small-to-moderate in magnitude (i.e., r’s in 0.10e0.36 range). Collinearity diagnostics did not indicate the presence of multicollinearity in any of the regression analyses conducted. Tolerance values ranged from 0.76 to 0.92, variance inflation factors from 1.08 to 1.32, and condition indices from 1.00 to 4.46. Table 2 displays results of regression analyses that examined associations between types of combat experiences and PTSD symptoms; the top part of the table shows the full regression model with total PTSD symptoms as the dependent variable; the bottom part of the table shows 1581 only those combat experiences that were significantly associated with re-experiencing, avoidance, dysphoria, and hyperarousal symptoms. The experience of personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed” was associated with total PTSD symptoms, as well as re-experiencing, avoidance, dysphoria, and hyperarousal symptoms. Receiving “friendly” incoming fire from small arms, artillery, rockets, mortars, or bombs; and encountering land or water mines and/or booby traps was associated with total, re-experiencing, and dysphoria symptoms. Encountering land or water mines and/or booby traps was associated with total and hyperarousal symptoms. Finally, killing or thinking that one killed someone in combat was associated with re-experiencing symptoms; taking part in an invasion was associated with avoidance symptoms; and receiving hostile fire was associated with dysphoria symptoms. Adding number of deployments and total CES scores into this regression analysis revealed that total CES scores (b ¼ 0.24, t ¼ 3.60, p < 0.001) and personally witnessing someone from one’s unit or an ally unit being seriously wounded or killed (b ¼ 0.14, t ¼ 2.09, p ¼ 0.038) were significantly associated with total PTSD symptoms. Two or more deployments (b ¼ 0.07, t ¼ 1.31, p ¼ 0.19); Receiving “friendly” incoming fire from small arms, artillery, rockets, mortars, or bombs (b ¼ 0.09, t ¼ 1.57, p ¼ 0.12); encountering land or water mines and/ or booby traps (b ¼ 0.03, t ¼ 0.48, p ¼ 0.63); and all of the other combat experiences assessed (all p’s > 0.15), were not significant in this analysis. Table 3 shows results of a logistic regression analysis that examined predictors of a positive screen for PTSD. In this analysis, Table 1 Demographic, deployment, psychosocial, and combat experiences variables by PTSD status. N Age* Sex (\% male) Race/ethnicity White Black Hispanic Other Education High school Some college/college graduate Graduate school Married/living w/partner Service duty Active duty National Guard or Reserves Number of deployments* Combat exposure total score*** Posttraumatic stress disorder severity*** Unit support*** Postdeployment social support*** Combat experiences I went on combat patrols or missions** I or members of my unit encountered land or water mines and/or booby traps*** I or members of my unit received hostile incoming fire from small arms, artillery, rockets, mortars, or bombs** I or members of my unit received “friendly” incoming fire from small arms, artillery, rockets, mortars, or bombs*** I was in a vehicle (for example, truck, tank, APC, helicopter, plane, or boat) that was under fire** I or members of my unit were attacked by terrorists or civilians*** I was part of a land or naval artillery unit that fired on the enemy* Assaulted entrenched/fortified positions*** I took part in an invasion that involved naval and/or land forces* My unit engaged in battle in which it suffered casualties*** I personally witnessed someone from my unit or an ally unit being seriously wounded or killed*** I personally witnessed soldiers from enemy troops being seriously wounded or killed*** I was wounded or injured in combat** I fired my weapon at the enemy*** I killed or think I killed someone in combat Note. Significant group difference: *p < 0.05; **p < 0.01; ***p < 0.001. No PTSD PTSD 225 34.0 (0.6) 88.8\% 59 31.1 (1.2) 91.5\% 82.7\% 5.3\% 5.8\% 6.2\% 73.3\% 10.0\% 6.7\% 10.0\% 18.2\% 70.2\% 11.6\% 53.8\% 27.1\% 67.8\% 5.1\% 55.2\% 27.0\% 73.0\% 1.5 (0.1) 3.1 (0.3) 27.8 (0.7) 42.9 (0.8) 57.6 (0.7) 39.6\% 60.4\% 1.9 (0.2) 8.3 (5) 64.3 (1.3) 35.7 (1.5) 47.5 (1.3) 119 (57.5\%) 84 (41.0\%) 148 (71.2\%) 32 (15.4\%) 87 (41.8\%) 97 (47.1\%) 38 (18.3\%) 36 (17.5\%) 40 (19.5\%) 51 (24.6\%) 54 (26.1\%) 62 (29.8\%) 25 (12.1\%) 59 (28.4\%) 31 (15.0\%) 45 40 52 25 38 47 17 25 20 31 42 40 17 34 26 (76.3\%) (67.8\%) (88.1\%) (42.4\%) (64.4\%) (79.7\%) (30.4\%) (43.1\%) (35.1\%) (53.4\%) (72.4\%) (69.0\%) (29.3\%) (58.6\%) (45.6\%) F or c2 p 4.55 0.36 3.17 0.03 0.55 0.37 3.80 0.15 0.04 2.88 0.85 0.09 4.62 87.67 646.96 16.76 49.30 0.032 <0.001 <0.001 <0.001 <0.001 6.85 13.23 7.05 19.94 9.41 19.61 3.91 16.73 6.13 17.60 42.09 29.41 10.09 18.26 24.78 0.009 <0.001 0.008 <0.001 0.002 <0.001 0.048 <0.001 0.013 <0.001 <0.001 <0.001 0.001 <0.001 <0.001 1582 R.H. Pietrzak et al. / Journal of Psychiatric Research 45 (2011) 1579e1584 Table 2 Demographic and psychosocial characteristics, and combat experiences with severity of total PTSD symptoms and confirmatory factor analysis-derived PTSD symptom clusters. Adjusted R2 Total PTSD symptoms 0.39 Demographic and psychosocial variables Age* Married/living with partner Unit support Postdeployment social support*** Combat experiences I went on combat patrols or missions I or members of my unit encountered land or water mines and/or booby traps* I or members of my unit received hostile incoming fire from small arms, artillery, rockets, mortars, or bombs I or members of my unit received “friendly” incoming fire from small arms, artillery, rockets, mortars, or bombs* I was in a vehicle (for example, truck, tank, APC, helicopter, plane, or boat) that was under fire I or members of my unit were attacked by terrorists or civilians I was part of a land or naval artillery unit that fired on the enemy Assaulted entrenched/fortified positions I took part in an invasion that involved naval and/or land forces My unit engaged in battle in which it suffered casualties I personally witnessed someone from my unit or an ally unit being seriously wounded or killed*** I personally witnessed soldiers from enemy troops being seriously wounded or killed I was wounded or injured in combat I fired my weapon at the enemy I killed or think I killed someone in combat Re-experiencing symptoms I personally witnessed someone from my unit or an ally unit being seriously wounded or killed*** I or members of my unit received “friendly” incoming fire from small arms, artillery, ro ... 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