Trauma, PTSD, and physical health: An epidemiological study of Australian Vietnam veterans

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Abstract

Objective

This study aimed to examine the relative contributions to physical health of combat trauma exposure and posttraumatic stress disorder (PTSD), which have both been implicated separately in poorer physical health but whose unconfounded effects have not been teased out.

Methods

Data from an epidemiological study of Australian Vietnam veterans, which used personal interviews and standardized physical and psychiatric health assessments, provided the means to assess the independent and joint effects of psychological trauma exposure and PTSD on a wide range of self-reported measures of physical health. Trauma exposure was measured by published scales of combat exposure and peritraumatic dissociation. Logistic regression modeling was used to assess the relative importance of trauma exposure and PTSD to health while controlling for a set of potential confounders including standardized psychiatric diagnoses.

Results

Greater health service usage and more recent health actions were associated more strongly with PTSD, which was also associated with a range of illness conditions coded by the World Health Organization International Classification of Diseases, 9th Edition (asthma, eczema, arthritis, back and other musculoskeletal disorders, and hypertension) both before and after controlling for potential confounders. In contrast, combat exposure and peritraumatic dissociation were more weakly associated with a limited number of unconfounded physical health outcomes.

Conclusions

This study provided evidence that PTSD, rather than combat exposure and peritraumatic dissociation, is associated with a pattern of physical health outcomes that is consistent with altered inflammatory responsiveness.

Introduction

It is well established from military cohorts that exposure to traumatic stress, particularly combat, is associated with development of posttraumatic stress disorder (PTSD) [1], [2], [3], [4], [5], [6]. It is becoming clearer that physical problems may also be associated with prior traumatic exposures [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], while some studies have suggested that PTSD may itself be associated with physical illness [10], [13], [17], [19], [20], [21], [22], [23]. However, most of these studies have not unraveled the comparative roles of PTSD or traumatic stress exposure in subsequent health, nor has potential confounding by other individual health risks always been controlled. The measurement of traumatic stress exposure, PTSD, and physical health also has been varied, leading to difficulties in specifying the precise nature of the relationships between trauma exposure, physical illness, and PTSD or the conditions that are implicated. For example, measurement of traumatic war exposure has ranged from simple group categorization in terms of “theater” veterans and “nontheater” veterans [3], [5], [9] to measures of individual combat experiences [17], [24]. However, even combat scales merely aggregate the frequency or duration of exposure to a range of events, without assessing individual personal reactions of fear, helplessness, or horror, such as peritraumatic dissociation to individually intense events, as required by the diagnostic criteria. Measures of PTSD have ranged from symptom checklists and psychometric scales such as the Mississippi Scale for Combat-Related PTSD [25] to standardized psychiatric assessment protocols [3], [4], [6], and physical health measures have ranged from global “body systems scores” [18] to individual clinical diagnoses and blood biochemistry [4], [26], [27], [28], [29], [30]. Results also have been inconsistent. For example, conditions that have been associated with either war service or PTSD range from deafness or hearing problems [3], [9], [13], [25], to skin problems [3], [9], [35], to urinary conditions [3], [9], [21], [25], to stomach conditions [3], [9], [13], [21], [25], to hypertension [3], [25], to musculoskeletal conditions [13], [20], [21], to respiratory conditions [14], [21]. However, the opportunity to test whether PTSD or traumatic exposure was the more important factor in subsequent physical health was not taken up by most studies. Few also have controlled for demographics such as age or marital status; socioeconomic status such as education, employment, and income; or health risk factors such as smoking or alcohol use; none has controlled for comorbid psychiatric conditions when assessing the effects of trauma and PTSD on health.

In one study that considered both PTSD and combat exposure [19], a subgroup of 921 men was selected from the U.S. Department of Veterans Affairs Normative Aging Study [17], [19]. While only 17% had had heavy combat exposure and the prevalence of PTSD overall was only 4%, using the SF-36 [31], they found that PTSD was related to all SF-36 endpoints but combat was related only to pain. In a path analysis, combat was not related to physical health except through smoking, but the largest path coefficient was for that from PTSD to physical health. Another study [32] of 2949 U.S. Persian Gulf War (PGW) veterans who were assessed on return and followed up 12–24 months later reported that PTSD was significant in multiple regressions after controlling for combat, demographics, and initial health state. An interesting design [33] selected 2022 PGW veterans from 8603 eligible veterans from Oregon and southwest Washington, of whom 1119 responded to a mail survey. After exclusions, 443 were medically examined and an expert panel classified them into “cases” and controls on the basis of documented but unexplained physical illnesses. Multivariate regression analysis showed that both combat exposure (measured using a 50-item scale) and PTSD symptoms (measured using the Mississippi PTSD scale) were important in the logistic regression comparing cases and controls.

However, no study has controlled for the effect of comorbid psychiatric diagnosis when assessing the relationship between combat trauma exposure and physical health. Thus, despite the findings that combat exposure may lead to poorer physical health and that PTSD itself may be related to poorer physical health, the ability to examine the relationship among these in a single study would provide an opportunity to assess the relative contribution of trauma exposure and PTSD separately on different aspects of physical health. The present study uses data from the Australian Vietnam Veterans Health Study [6], [13], [24] to examine the evidence of the relationship between traumatic exposure, PTSD, and physical health in a cohort of Australian Vietnam veterans while controlling for potential confounding effects of health risk factors and comorbid psychiatric diagnoses.

Section snippets

Methods

The cohort study design is described in detail elsewhere [24]; briefly, a simple random sample of 1000 male Australian Vietnam theater veterans was selected from a computer file held by the Australian Army that contained all postings to Vietnam in the period 1962–1972 (the years of Australian involvement). Of the original 1000 selected, 8 had died in Vietnam and a further 43 were found on death registries to have died postwar. Fieldwork from November 1991 to February 1993 resulted in location

Results

Veterans reported an average of 2.34 recent conditions (range=0–11, S.D.=1.85) and 3.79 chronic conditions (range=0–8, S.D.=2.22), whereas the corresponding means for the Australian population were 1.42 and 1.75, respectively [13]. In comparing the Australian Vietnam veteran cohort with the Australian population [6], [35], it was found that 13 of the 18 recent health actions, 34 of the 36 recent conditions, and 31 of the 37 chronic conditions were significantly in excess of population

Discussion

This epidemiological cohort study of Australian soldiers posted to the Vietnam War, in whom more than one fifth were diagnosed with PTSD, examined the relationship between self-reported combat exposure, peritraumatic dissociation, and PTSD with self-reported medical conditions and health care utilization. An important strength of the present study is that it was able to control for important confounders such as physical exercise, BMI, smoking, and alcohol. Also, this study represents the first

Acknowledgments

The Australian Vietnam Veterans Health Study is an independent investigator-initiated study supported by grants from the Australian National Health and Medical Research Council (NHMRC), the Public Health Research and Development Committee of the NHMRC, and the Australian Vietnam War Veterans Trust Ltd.; by travel grants from the Australian DVA; by a research grant from the Westmead Research Institute; and by a grant-in-aid from the Australian War Memorial. The authors are indebted to the study

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