Anxiety Disorders: Veterans Health System

Daggett V, Bakas T, Habermann B. · National VA Stroke QUERI, Health Services, Research & Development, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA. · J Neurosci Nurs. · Pubmed #19361122 No free full text.

Abstract: Health-related quality of life (HRQOL) research in traumatic brain injury (TBI) populations is beginning to emerge in the literature. Because rehabilitation and reintegration issues are complex with TBI, especially with new combat veterans, it is critical that future HRQOL research be designed to consider these issues. Utilizing explicit definitions and a conceptual model of HRQOL can provide researchers with a holistic base on which to build interventions for successful patient outcomes. The conceptual model of HRQOL of C.E. Ferrans, J.J. Zerwic, J.E. Wilbur, and J.L. Larson (2005) is an exemplar model that presents clear definitions and encompasses domains of HRQOL relevant to TBI survivors and their families. This review was organized utilizing the model of HRQOL of Ferrans et al. The objective of this review was to identify gaps in current knowledge of HRQOL and TBI. These findings were then used to develop recommendations for future research with combat veterans who have sustained a TBI.

Elder GA, Cristian A. · James J Peters Department of Veterans Affairs Medical Center, Rehabilitation Medicine Service, Bronx, NY, USA. · Mt Sinai J Med. · Pubmed #19306373 No free full text.

Abstract: Mild traumatic brain injury has been called the signature injury of the wars in Iraq and Afghanistan. In both theaters of operation, traumatic brain injury has been a significant cause of mortality and morbidity, with blast-related injury the most common cause. Improvised explosive devices have been the major cause of blast injuries. It is estimated that 10% to 20% of veterans returning from these operations have suffered a traumatic brain injury, and there is concern that blast-related injury may produce adverse long-term health affects and affect the resilience and in-theater performance of troops. Blast-related injury occurs through several mechanisms related to the nature of the blast overpressure wave itself as well as secondary and tertiary injuries. Animal studies clearly show that blast overpressure waves are transmitted to the brain and can cause changes that neuropathologically are most similar to diffuse axonal injury. One striking feature of the mild traumatic brain injury cases being seen in veterans of the wars in Iraq and Afghanistan is the high association of mild traumatic brain injury with posttraumatic stress disorder. The overlap in symptoms between the disorders has made distinguishing them clinically challenging. The high rates of mild traumatic brain injury and posttraumatic stress disorder in the current operations are of significant concern for the long-term health of US veterans with associated economic implications.

North CS, Suris AM, Davis M, Smith RP. · Program in Trauma and Disaster, Dallas VAMC, 4500 S. Lancaster Rd., Dallas, TX 75216, USA. · Am J Psychiatry. · Pubmed #19047323 No free full text.

Abstract: Unlike most psychiatric diagnoses, posttraumatic stress disorder (PTSD) is defined in relation to a potentially etiologic event (the traumatic "stressor criterion") that is fundamental to its conceptualization. The diagnosis of PTSD thus inherently depends on two separate but confounded processes: exposure to trauma and development of a specific pattern of symptoms that appear following the trauma. Attempts to define the range of trauma exposure inherent in the diagnosis of PTSD have generated controversy, as reflected in successive revisions of the criterion from DSM-III onward. It is still not established whether or not there are specific types of traumatic events and levels of exposure to them that are associated with a syndrome that is cohesive in clinical characteristics, biological correlates, familial patterns, and longitudinal diagnostic stability. On the other hand, the symptomatic description of PTSD is becoming more clear. Of three categories of symptoms associated with PTSD--intrusive memories, avoidance and numbing, and hyperarousal--avoidance and numbing appear to be the most specific for identification of PTSD. Research is now poised to answer questions about the relevance of traumatic events based on their relationship to symptomatic outcome. The authors recommend that future research begin with existing diagnostic criteria, testing and further refining them in accordance with the classic Robins and Guze strategy for validation of psychiatric diagnoses. In this process, diligent adherence to the criteria under examination is paramount to successful PTSD research, and changes in criteria are driven by empirical data rather than theory. Collaborations among trauma research biologists, epidemiologists, and nosologists to map the correspondence between the clinical and biological indicators of psychopathology are necessary to advance validation and further understanding of PTSD.

Graham DP, Cardon AL. · Houston Center for Quality of Care and Utilization Studies, Health Services Research, Houston, TX 77030, USA. · Ann N Y Acad Sci. · Pubmed #18991956 No free full text.

Abstract: Traumatic brain injury (TBI) is a leading cause of mortality and morbidity among young adults. Substance abusers constitute a disproportionate percentage of these patients. A history of substance abuse predicts increased disability, poorer prognosis, and delayed recovery. While consensus in the literature indicates that substance-abuse rates decline following injury, conflicting literature shows a significant history of brain injury in addicts. We reviewed the literature on substance abuse after TBI to explore the state of knowledge on TBI as a risk factor for substance abuse. While recent reviews regarding substance abuse in TBI patients concur that substance-abuse rates decline even after mild TBI, an emerging literature suggests mild TBI may cause subtle impairments in cognitive, executive, and decision-making functions that are often poorly recognized in early diagnosis and treatment. When combined with difficulties in psychosocial adjustment and coping skills, these impairments may increase the risk for chronic substance abuse in a subset of TBI patients. Preliminary results from veterans indicate these patterns hold in a combat-related post-traumatic stress disorder population with TBI. This increasingly prevalent combination presents a specific challenge in rehabilitation. While this comorbidity presents a challenge for the successful treatment and rehabilitation of both disorders, there is sparse evidence to recommend any specific treatment strategy for these individuals. Mild TBI and substance abuse are bidirectionally related both for risks and treatment. Further understanding the neuropsychiatric pathology and different effects of different types of injuries will likely improve the implementation of effective treatments for each of these two conditions.

Suris A, Lind L. · Department of Veterans Affairs, North Texas Health Care System, Dallas, USA. · Trauma Violence Abuse. · Pubmed #18936282 No free full text.

Abstract: This article reviews the literature documenting the prevalence of military sexual trauma (MST) and its associated mental and physical health consequences. Existing research indicates that prevalence rates of MST vary depending on method of assessment, definition of MST used, and type of sample. Risk factors for MST have been identified as including age, enlisted rank, negative home life, and previous assault history. MST has been associated with increased screening rates of depression and alcohol abuse, in addition to significantly increased odds of meeting criteria for post-traumatic stress disorder. In addition, MST has been associated with reporting increased number of current physical symptoms, impaired health status, and more chronic health problems in veterans. Available research on health care utilization and MST is also discussed. Researchers are encouraged to utilize standardized definitions of MST, employ standardized assessment methodology, and utilize more male veterans in future research. Policy and practice implications are discussed.

Beshai JA. · Veteran Affairs Medical Center, Lebanon, Pennsylvania 17042, USA. · Omega (Westport). · Pubmed #18837176 No free full text.

Abstract: Cross-cultural comparisons of norms derived from research on Death Anxiety are valid as long as they provide existential validity. Existential validity is not empirically derived like construct validity. It is an understanding of being human unto death. It is the realization that death is imminent. It is the inner sense that provides a responder to death anxiety scales with a valid expression of his or her sense about the prospect of dying. It can be articulated in a life review by a disclosure of one's ontology. This article calls upon psychologists who develop death anxiety scales to disclose their presuppositions about death before administering a questionnaire. By disclosing his or her ontology a psychologist provides a means of disclosing his or her intentionality in responding to the items. This humanistic paradigm allows for an interactive participation between investigator and subject. Lester, Templer, and Abdel-Khalek (2006-2007) enriched psychology with significant empirical data on several correlates of death anxiety. But all scientists, especially psychologists, will always have alternative interpretations of the same empirical fact pattern. Empirical data is limited by the affirmation of the consequent limitation. A phenomenology of language and communication makes existential validity a necessary step for a broader understanding of the meaning of death anxiety.

Beaudreau SA, O'Hara R. · Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Clinical Center (MIRECC), Palo Alto, CA 94304, USA. · Am J Geriatr Psychiatry. · Pubmed #18827225 No free full text.

Abstract: Emerging research implicates a consistent reciprocal relationship between late-life anxiety and cognition. Understanding this relationship may clarify pathophysiological substrates of cognitive impairment and why co-occurring anxiety and cognitive impairment relates to poorer treatment prognosis for both conditions. This article critically reviews evidence of more prevalent anxiety in cognitively impaired older adults, elevated anxiety related to poorer cognitive performance, and more severe anxiety symptoms predicting future cognitive decline. It considers pathophysiologic mediators and moderators, and the influence of comorbid depression or medical illness in anxiety. Identified directions for future research includes use of in-depth anxiety assessment comparing normal and mild cognitively impaired older adults and use of challenging neuropsychological tests to determine if specific cognitive domains suffer in anxious older adults.

Khouzam HR. · Chemical Dependency Treatment Program, Veterans Affairs Central California Health Care System, Fresno, CA 93703, USA. · Postgrad Med. · Pubmed #18824831 No free full text.

Abstract: The evidence base on effective treatments for posttraumatic stress disorder (PTSD) in the elderly population is scarce. The assessment and treatment of PTSD could pose a challenge for primary care providers and residents in training involved in treating PTSD in older adults. This article will review the epidemiology, the morbidity, the mortality, the biological perspective, the prognosis, and the psychosocial and pharmacological treatment options, in addition to the spiritual dimensions of PTSD and aging.

Rumpler CH. · VA Medical Center, Cincinnati, OH, USA. · Rehabil Nurs. · Pubmed #18767399 No free full text.

This publication has no abstract.

Culberson JW, Ziska M. · Department of Medicine, Section of Geriatrics, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, USA. · Geriatrics. · Pubmed #18763848 No free full text.

Abstract: One quarter of the prescription drugs sold in the United States are used by the elderly, often for problems such as chronic pain, insomnia, and anxiety. The prevalence of abuse may be as high as 11 percent with female gender, social isolation, depression, and history of substance abuse increasing risk. Screening instruments for prescription drug abuse have not been validated in the geriatric population. Benzodiazepines, opiate analgesics, and some skeletal muscle relaxants may result in physical dependence; however, tolerance, withdrawal syndrome, and dose escalation may be less common in the older patient. Lower doses may decrease the risk of abuse and dependence; however, fear of abuse often results in a failure to adequately treat symptoms such as anxiety, pain, and insomnia.

Nampiaparampil DE. · Department of Internal Medicine, Veterans Affairs Central California Healthcare System, Fresno, CA 93703, USA. · JAMA. · Pubmed #18698069 links to  free full text

Abstract: CONTEXT: The Centers for Disease Control and Prevention estimates that approximately 1.4 million US individuals sustain traumatic brain injuries (TBIs) per year. Previous reports suggest an association between TBI and chronic pain syndromes (eg, headache) thought to be more common in patients with mild TBI and in those who have sustained brain injury from violent rather than unintentional trauma. Comorbid psychiatric disorders such as posttraumatic stress disorder (PTSD) may also mediate chronic pain symptoms. OBJECTIVES: To determine the prevalence of chronic pain as an underdiagnosed consequence of TBI and to review the interaction between chronic pain and severity of TBI as well as the characteristics of pain after TBI among civilians and combatants. EVIDENCE ACQUISITION: The Ovid/MEDLINE database was searched for articles published between 1951 and February 2008 using any combination of the terms brain injury, pain, headache, blast injury, and combat (combat disorders, war, military medicine, wounds and injuries, military personnel, veterans). The PubMed and MD Consult databases were searched in a similar fashion. The Cochrane Collaboration, National Institutes of Health Clinical Trials Database, Meta-Register of Current Controlled Trials, and CRISP databases were searched using the keyword brain injury. All articles in peer-reviewed journals reporting original data on pain syndromes in adult patients with TBI with regard to pain prevalence, pain category, risk factors, pathogenesis, and clinical course were selected, and manual searches were performed of their reference lists. The data were pooled and prevalence rates calculated. EVIDENCE SYNTHESIS: Twenty-three studies (15 cross-sectional, 5 prospective, and 3 retrospective) including 4206 patients were identified. Twelve studies assessed headache pain in 1670 patients. Of these, 966 complained of chronic headache, yielding a prevalence of 57.8% (95% confidence interval [CI], 55.5%-60.2%). Among civilians, the prevalence of chronic pain was greater in patients with mild TBI (75.3% [95% CI, 72.7%-77.9%]) compared with moderate or severe TBI (32.1% [95% CI, 29.3%-34.9%]). Twenty studies including 3289 civilian patients with TBI yielded a chronic pain prevalence of 51.5% (95% CI, 49.8%-53.2%). Three studies assessed TBI among 917 veterans and yielded a pain prevalence of 43.1% (95% CI, 39.9%-46.3%). PTSD may mediate chronic pain, but brain injury appears to have an independent correlation with chronic pain. CONCLUSIONS: Chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain.

Kudler H, Straits-Tröster K. · Department of Veterans Affairs Mid-Atlantic Mental Illness Research, Education, 508 Fulton Street, Durham, NC 27705, USA. · N C Med J. · Pubmed #18429565 No free full text.

This publication has no abstract.

York KM, Hassan M, Sheps DS. · VAMC, Psychology Service (116b), North Florida/South Georgia VA Healthcare System, 1601 SW Archer Rd, Gainesville, FL 32608, USA. · Heart Fail Rev. · Pubmed #18368481 No free full text.

Abstract: Heart failure affects millions of Americans and new diagnosis rates are expected to almost triple over the next 30 years as our population ages. Affective disorders including clinical depression and anxiety are common in patients with congestive heart failure. Furthermore, the presence of these disorders significantly impacts quality of life, medical outcomes, and healthcare service utilization. In recent years, the literature has attempted to describe potential pathophysiologic mechanisms relating affective disorders and psychosocial stress to heart failure. Several potential mechanisms have been proposed including autonomic nervous system dysfunction, inflammation, cardiac arrhythmias, and altered platelet function. These mechanisms are reviewed in this article. Additional novel mechanisms such as mental stress-induced myocardial ischemia are also discussed.

Morel KR, Shepherd BE. · Neuropsychology Laboratory, Psychology Service 116B, Department of Veterans Affairs Tennessee Valley Health Care System, 1310 24th Avenue South, Nashville, TN 37212-2637, United States. · J Anxiety Disord. · Pubmed #18295444 No free full text.

Abstract: The past decade has witnessed a significant increase in research on the detection of malingered Posttraumatic Stress Disorder (PTSD) in civil litigation, other disability pension contexts, and in forensic cases. This article reviews the basic principles and statistical procedures that can be used to design and develop a Symptom Validity Test (SVT) for PTSD. We demonstrate how the practical application of the binomial distribution can detect response bias in specific psychiatric disorders such as PTSD and can provide empirically grounded probabilistic evidence of malingering. We cite the Morel Emotional Numbing Test for Posttraumatic Stress Disorder (MENT) as an example.

Antai-Otong D. · Fort Worth Outpatient Clinic, Department of Veterans Affairs in Fort Worth, TX, USA. · Perspect Psychiatr Care. · Pubmed #18177278 No free full text.

This publication has no abstract.

Yehuda R, Bierer LM. · The Traumatic Stress Studies Program, Department of Psychiatry, Mount Sinai School of Medicine and Bronx Veterans Affairs, James J Peters VAMC, 116-A, OOMH-PTSD, Bronx, NY 10468, USA. · Prog Brain Res. · Pubmed #18037011 No free full text.

Abstract: Parental posttraumatic stress disorder (PTSD) appears to be a relevant risk factor for the development of PTSD, as evidenced by a greater prevalence of PTSD, but not trauma exposure, in adult offspring of Holocaust survivors with PTSD, compared to children of Holocaust-exposed parents without PTSD. This paper summarizes recent neuroendocrine studies in offspring of parents with PTSD. Offspring of trauma survivors with PTSD show significantly lower 24-h mean urinary cortisol excretion and salivary cortisol levels as well as enhanced plasma cortisol suppression in response to low dose dexamethasone administration than offspring of survivors without PTSD. In all cases, neuroendocrine measures were negatively correlated with severity of parental PTSD symptoms, even after controlling for PTSD and even other symptoms in offspring. Though the majority of our work has focused on adult offspring of Holocaust survivors, recent observations in infants born to mothers who were pregnant on 9/11 demonstrate that low cortisol in relation to parental PTSD appears to be present early in the course of development and may be influenced by in utero factors such as glucocorticoid programming. Since low cortisol levels are particularly associated with the presence of maternal PTSD the findings suggest the involvement of epigenetic mechanisms.

Maguen S, Papa A, Litz BT. · San Francisco VA Medical Center, University of California at San Francisco, CA, USA. · Anxiety Stress Coping. · Pubmed #18027122 No free full text.

Abstract: Terrorism creates a ripple of fear and uncertainty. Although most individuals are resilient and recover over time, a minority remains functionally and psychologically impaired. In this paper, we examine research on coping strategies employed in the aftermath of terrorist events, theories and empirical findings related to appraisal processes that influence individuals' primary attributions of risk, and normative processes that shape secondary appraisals, which predict specific coping behaviors. We also describe individual diatheses and factors promoting resilience that may influence coping and functioning in the face of terrorism. Finally, we offer suggestions for future research.

Fu SS, McFall M, Saxon AJ, Beckham JC, Carmody TP, Baker DG, Joseph AM. · Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, and Department of Medicine, University of Minnesota, Minneapolis, MN, USA. · Nicotine Tob Res. · Pubmed #17978982 No free full text.

Abstract: We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Yehuda R, LeDoux J. · Division of Traumatic Stress Studies, Mount Sinai School of Medicine, James J Peters Veteran Affairs, New York, NY 10468, USA. · Neuron. · Pubmed #17920012 No free full text.

Abstract: Exposure to traumatic stress is a requirement for the development of posttraumatic stress disorder (PTSD). However, because the majority of trauma-exposed persons do not develop PTSD, examination of the typical effects of a stressor will not identify the critical components of PTSD risk or pathogenesis. Rather, PTSD represents a specific phenotype associated with a failure to recover from the normal effects of trauma. Thus, research must focus on identifying pre- and posttraumatic risk factors that explain the development of the disorder and the failure to reinstate physiological homeostasis. In this review, we summarize what is known about the clinical and biological characteristics of PTSD and articulate some of the gaps in knowledge that can be addressed by basic neuroscience research. We emphasize how knowledge about individual differences related to genetic and epigenetic factors in behavioral and brain responses to stress offers the hope of a deeper understanding of PTSD.

Southwick SM, Vythilingam M, Charney DS. · Yale University School of Medicine, National Center for Post-Traumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, Connecticut 06516, USA. · Annu Rev Clin Psychol. · Pubmed #17716089 No free full text.

Abstract: This review discusses neurobiological and psychosocial factors associated with stress-induced depression and compares these factors with those believed to characterize stress resilience. Neurobiological factors that are discussed and contrasted include serotonin, the 5-HT1A receptor, polymorphisms of the 5-HT transporter gene, norepinephrine, alpha-2 adrenergic receptors, neuropeptide Y, polymorphisms of the alpha-2 adrenergic gene, dopamine, corticotropin-releasing hormone (CRH), dehydroepiandrosterone (DHEA), cortisol, and CRH receptors. These factors are described in the context of brain regions believed to be involved in stress, depression, and resilience to stress. Psychosocial factors associated with depression and/or stress resilience include positive emotions and optimism, humor, cognitive flexibility, cognitive explanatory style and reappraisal, acceptance, religion/spirituality, altruism, social support, role models, coping style, exercise, capacity to recover from negative events, and stress inoculation. The review concludes with potential psychological, social, spiritual, and neurobiological approaches to enhancing stress resilience, decreasing the likelihood of developing stress-induced depression/anxiety, and treating stress-induced psychopathology.

Reeves RR. · Chief of Mental Health, G.V. (Sonny) Montgomery VA Medical Center (11M), 1500 E Woodrow Wilson Dr, Jackson, MS 39216-5116, USA. · J Am Osteopath Assoc. · Pubmed #17596586 links to  free full text

Abstract: As the conflict in Iraq continues, public health authorities in the United States anticipate that many returning soldiers will suffer from posttraumatic stress disorder (PTSD). Initially, most of these veterans are likely to consult their primary care physicians about health problems. However, the diagnosis of PTSD is often missed in primary care settings. The author encourages physicians to become better prepared to recognize this disorder in their patients and initiate proper treatment or appropriate referral. Current diagnostic approaches and treatment modalities for combat-related PTSD are reviewed-with an emphasis on clinical procedures for the primary care physician.

Kraus CA, Kunik ME, Stanley MA. · Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center (152) (MEDVAMC 152), Houston, Tex, USA. · Geriatrics. · Pubmed #17547480 No free full text.

Abstract: With prevalence rates approaching 10% for anxiety disorders and 6% for major depression, anxiety and depression have a significant impact on adults in later life. Cognitive behavioral therapy (CBT) is a psychosocial intervention for anxiety and depression that can serve as a useful alternative or adjunct to pharmacologic intervention for older adults.

Laramie JA. · Veterans' Affairs Medical Center, Washington, DC, USA. · Home Healthc Nurse. · Pubmed #17495556 No free full text.

This publication has no abstract.

Bracha HS, Vega EM, Vega CB. · National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs, Pacific Islands Health Care System, Spark M. Matsunaga Medical Center, Honolulu, Hawaii, USA. · Hawaii Dent J. · Pubmed #17152624 No free full text.

Abstract: In this brief review article, we suggest that the term "dental phobia" may be a misnomer. The problem with using the term "phobia" in a dental-care context is as follows: by definition, phobias involve a fear that is "excessive or unreasonable," which the individual recognizes as such, and in which the anxiety, panic attacks and phobic avoidance are not better accounted for by another disorder, including posttraumatic stress disorder (PTSD). In our experience, most individuals with dental "phobia" do not recognize their symptoms as "excessive or unreasonable" and in that sense, resemble individuals with PTSD. Our review of the dental-care literature suggests that true (innate) dental phobias (akin to unreasonable fear at the sight of blood or a syringe) probably account for a smaller percentage of cases, and that the vast majority of dental-care anxiety (DA) cases stem from aversive dental experiences. Research has documented that individuals who reported having experienced painful dental treatments and perceived a lack of control in the dental situation were approximately 14 times more likely to also report higher dental fear, and approximately 16 times more likely to report being less willing to return to the dental treatment. Therefore, we propose that this psychological condition should be conceptualized as Posttraumatic Dental-Care Anxiety (PTDA), and should be classified as part of the Posttraumatic Stress Disorder (PTSD) spectrum in the forthcoming Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V).

Hurley RA, Fisher R, Taber KH. · Hefner VA Medical Center, 1601 Brenner Ave., Salisbury, NC 28144, USA. · J Neuropsychiatry Clin Neurosci. · Pubmed #17135371 links to  free full text

This publication has no abstract.