Hostname: page-component-cd9895bd7-mkpzs Total loading time: 0 Render date: 2024-12-23T00:46:30.934Z Has data issue: false hasContentIssue false
  • English
  • Français

Risk factors for post-traumatic stress disorder among UK Armed Forces personnel

Published online by Cambridge University Press:  29 January 2008

A. C. Iversen ,
N. T. Fear ,
A. Ehlers ,
J. Hacker Hughes ,
L. Hull ,
M. Earnshaw ,
N. Greenberg ,
R. Rona ,
S. Wessely  and
M. Hotopf
A. C. Iversen*
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
N. T. Fear
Affiliation:
Academic Centre for Defence Mental Health, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
A. Ehlers
Affiliation:
Department of Psychology, Institute of Psychiatry, King's College London, UK
J. Hacker Hughes
Affiliation:
Academic Centre for Defence Mental Health, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
L. Hull
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
M. Earnshaw
Affiliation:
Academic Centre for Defence Mental Health, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
N. Greenberg
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
R. Rona
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
S. Wessely
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
M. Hotopf
Affiliation:
King's Centre for Military Health Research, King's College London, Department of Psychological Medicine, Institute of Psychiatry, London, UK
*
*Address for correspondence: A. C. Iversen, MRCP, MRCPsych, Department of Psychological Medicine, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

There is considerable interest in understanding further the factors that increase the risk of post-traumatic stress disorder (PTSD) for military personnel. This study aimed to investigate the relative contribution of demographic variables; childhood adversity; the nature of exposure to traumatic events during deployment; appraisal of these experiences; and home-coming experiences in relation to the prevalence of PTSD ‘caseness’ as measured by a score of ⩾50 on the PTSD Checklist (PCL) in UK Armed Forces personnel who have been deployed in Iraq since 2003.

Method

Data were drawn from the first stage of a retrospective cohort study comparing UK military personnel who were deployed to the 2003 Iraq War with personnel serving in the UK Armed Forces on 31 March 2003 but who were not deployed to the initial phase of war fighting. Participants were randomly selected and invited to participate. The response rate was 61%. We have limited these analyses to 4762 regular service individuals who responded to the survey and who have been deployed in Iraq since 2003.

Results

Post-traumatic stress symptoms were associated with lower rank, being unmarried, having low educational attainment and a history of childhood adversity. Exposure to potentially traumatizing events, in particular being deployed to a ‘forward’ area in close contact with the enemy, was associated with post-traumatic stress symptoms. Appraisals of the experience as involving threat to one's own life and a perception that work in theatre was above an individual's trade and experience were strongly associated with post-traumatic stress symptoms. Low morale and poor social support within the unit and non-receipt of a home-coming brief (psycho-education) were associated with greater risk of post-traumatic stress symptoms.

Conclusions

Personal appraisal of threat to life during the trauma emerged as the most important predictor of post-traumatic stress symptoms. These results also raise the possibility that there are important modifiable occupational factors such as unit morale, leadership, preparing combatants for their role in theatre which may influence an individual's risk of post-traumatic stress symptoms. Therefore interventions focused on systematic preparation of personnel for the extreme stress of combat may help to lessen the psychological impact of deployment.

Keywords

Armed Forcescombatmilitarypost-traumatic stress disorder
Type
Original Articles
Information
Psychological Medicine , Volume 38 , Issue 4 , April 2008 , pp. 511 - 522
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Adler, AB, Huffman, AH, Bliese, PD, Castro, CA (2005). The impact of deployment length and experience on the well-being of male and female soldiers. Journal of Occupational Health Psychology 10, 121–137.CrossRefGoogle ScholarPubMed
APA (1980). Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. American Psychiatric Association: Washington, DC.Google Scholar
Basoglu, M, Kilic, C, Salcioglu, E, Livanou, M (2004). Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: an epidemiological study. Journal of Traumatic Stress 17, 133–141.CrossRefGoogle ScholarPubMed
Basoglu, M, Livanou, M, Crnobaric, C (2007). Torture versus other cruel, inhuman, and degrading treatment: is the distinction real or apparent? Archives of General Psychiatry 64, 277–285.CrossRefGoogle ScholarPubMed
Basoglu, M, Livanou, M, Crnobaric, C, Franciskovic, T, Suljic, E, Duric, D, Vranesic, M (2005). Psychiatric and cognitive effects of war in former Yugoslavia: association of lack of redress for trauma and posttraumatic stress reactions. Journal of the American Medical Association 294, 580–590.CrossRefGoogle ScholarPubMed
Basoglu, M, Mineka, S, Paker, M, Aker, T, Livanou, M, Gok, S (1997). Psychological preparedness for trauma as a protective factor in survivors of torture. Psychological Medicine 27, 1421–1433.CrossRefGoogle ScholarPubMed
Basoglu, M, Salcioglu, E, Livanou, M (2002). Traumatic stress responses in earthquake survivors in Turkey. Journal of Traumatic Stress 15, 269–276.CrossRefGoogle ScholarPubMed
Baum, A, Cohen, L, Hall, M (1993). Control and intrusive memories as possible determinants of chronic stress. Psychosomatic Medicine 55, 274–286.CrossRefGoogle ScholarPubMed
Blanchard, EB, Jones, A, Buckley, T, Forneros, C (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 74, 669–673.CrossRefGoogle Scholar
Bremner, J, Southwick, S, Johnson, D, Yehuda, R, Charney, D (1993). Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry 150, 235–239.Google ScholarPubMed
Brewin, CR, Andrews, B, Valentine, JD (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical Psychology 68, 748–766.CrossRefGoogle ScholarPubMed
Britt, TW, Davison, J, Bliese, PD, Castro, CA (2004). How leaders can influence the impact that stressors have on soldiers. Military Medicine 169, 541–545.CrossRefGoogle ScholarPubMed
Browne, T, Hull, L, Horn, O, Murphy, D, Fear, N, Greenberg, N, French, C, Rona, R, Wessely, S, Hotopf, M (2006). Explanations for the increase in mental health problems in UK Reserve Forces who have served in Iraq. British Journal of Psychiatry 190, 484–489.CrossRefGoogle Scholar
Cabrera, OA, Hoge, CW, Bliese, P, Castro, CA, Messer, SC (2007). Childhood adversity and combat: effects on depression and post traumatic stress. American Journal of Preventative Medicine 33, 77–82.CrossRefGoogle Scholar
Carlier, IV, Lamberts, RD, Gersons, BP (1997). Risk factors for posttraumatic stress symptomatology in police officers: a prospective analysis. Journal of Nervous and Mental Disease 185, 498–506.CrossRefGoogle ScholarPubMed
Cobb, S (1976). Social support as a moderator of life stress. Psychosomatic Medicine 38, 300–314.CrossRefGoogle ScholarPubMed
Cohen, S, Willis, TA (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin 98, 310–357.CrossRefGoogle ScholarPubMed
De Bellis, MD, Baum, AS, Birmaher, B, Keshavan, MS, Eccard, CH, Boring, AM, Jenkins, FJ, Ryan, ND (1999). A.E. Bennett Research Award. Developmental traumatology. Part I: Biological stress systems. Biological Psychiatry 45, 1259–1270.CrossRefGoogle ScholarPubMed
Dunmore, E, Clark, DM, Ehlers, A (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behaviour Research and Therapy 37, 809–829.CrossRefGoogle ScholarPubMed
Eaker, S, Bergstron, R, Bergstrom, A, Adami, H, Nyren, O (1998). Response rate to mailed epidemiologic questionnaires: a population-based randomized trial of variations in design and mailing routines. American Journal of Epidemiology 147, 74–82.CrossRefGoogle ScholarPubMed
Ehlers, A, Clark, DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38, 319–345.CrossRefGoogle ScholarPubMed
Ehlers, A, Maercker, A, Boos, A (2000). Posttraumatic stress disorder following political imprisonment: the role of mental defeat, alienation, and perceived permanent change. Journal of Abnormal Psychology 109, 45–55.CrossRefGoogle ScholarPubMed
French, C, Dandeker, C (2005). UK military families and the deployments to Iraq: preliminary findings from a pre-, during-, and post-deployment study of the British Army. Paper presented at the Inter-University Seminar on Armed Forces and Society, Chicago, USA, October 2005.Google Scholar
Green, B, Grace, M, Lindy, J, Gleser, G, Leonard, A (1990). Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. American Journal of Psychiatry 147, 729–733.Google Scholar
Green, MA, Berlin, MA (1987). Five psychosocial variables related to the existence of post-traumatic stress disorder symptoms. Journal of Clinical Psychology 66, 507–512.Google Scholar
Hacker Hughes, J, Cameron, F, Eldridge, R, Devon, M, Wessely, S, Greenberg, N (2005). Going to war does not have to hurt: preliminary findings from the British deployment to Iraq. British Journal of Psychiatry 186, 536–537.CrossRefGoogle Scholar
Halligan, SL, Michael, T, Clark, DM, Ehlers, A (2003). Posttraumatic stress disorder following assault: the role of cognitive processing, trauma memory, and appraisals. Journal of Consulting and Clinical Psychology 71, 419–431.CrossRefGoogle ScholarPubMed
Hoge, CW, Auchterlonie, JL, Milliken, CS (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295, 1023–1032.CrossRefGoogle ScholarPubMed
Hoge, CW, Castro, CA, Messer, SC, McGurk, D, Cotting, DI, Koffman, RL (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351, 13–22.CrossRefGoogle ScholarPubMed
Hotopf, M, Hull, L, Fear, NT, Browne, T, Horn, O, Iversen, A, Jones, M, Murphy, D, Bland, D, Earnshaw, M, Greenberg, N, Hacker Hughes, J, Tate, AR, Dandeker, C, Rona, R, Wessely, S (2006). The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 367, 1731–1741.CrossRefGoogle Scholar
Iversen, A, Fear, NT, Hull, L, Greenberg, N, Jones, M, Browne, T, Murphy, D, Hotopf, M, Rona, R, Wessely, S (2007). Pre-enlistment vulnerability factors and their influence on health outcomes amongst UK Military Personnel. British Journal of Psychiatry 191, 506–511.CrossRefGoogle Scholar
Iversen, A, Liddell, K, Fear, N, Hotopf, M, Wessely, S (2006). Consent, confidentiality, and the Data Protection Act. British Medical Journal 332, 165–169.CrossRefGoogle ScholarPubMed
Jex, SM, Bliese, PD, Buzzell, S, Primeau, J (2001). The impact of self-efficacy on stressor-strain relations: coping style as an explanatory mechanism. Journal of Applied Psychology 86, 401–409.CrossRefGoogle ScholarPubMed
Kessler, RC (2000). Posttraumatic stress disorder: the burden to the individual and to society. Journal of Clinical Psychiatry 61 (Suppl 5), 4–12; discussion 13–14.Google Scholar
King, DW, King, LA, Foy, DW, Gudanowski, DM (1996). Prewar factors in combat-related posttraumatic stress disorder: structural equation modeling with a national sample of female and male Vietnam veterans. Journal of Consulting and Clinical Psychology 64, 520–531.CrossRefGoogle ScholarPubMed
King, LA, King, DW, Fairbank, JA, Keane, TM, Adams, GA (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology 74, 420–434.CrossRefGoogle ScholarPubMed
Koenen, KC, Lyons, MJ, Goldberg, J, Simpson, J, Williams, WM, Toomey, R, Eisen, SA, True, WR, Cloitre, M, Wolfe, J, Tsuang, MT (2003). A high risk twin study of combat-related PTSD comorbidity. Twin Research 6, 218–226.CrossRefGoogle ScholarPubMed
Koenen, KC, Moffitt, TE, Poulton, R, Martin, J, Caspi, A (2007). Early childhood factors associated with the development of post-traumatic stress disorder: results from a longitudinal birth cohort. Psychological Medicine 37, 181–192.CrossRefGoogle ScholarPubMed
Kulka, R, Schlenger, W, Fairbank, J, Hough, R, Jordan, BK, Marmar, C, Weiss, D (1990). Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. Brunner/Mazel: New York, NY.Google Scholar
Lee, K, Vaillant, G, Torrey, W, Elder, G (1995). A 50-year prospective study of the psychological sequelae of World War II combat. American Journal of Psychiatry 152, 516–522.Google ScholarPubMed
Livanou, M, Basoglu, M, Marks, IM, De Silva, P, Noshirvani, H, Lovell, K, Thrasher, S (2002). Beliefs, sense of control and treatment outcome in post-traumatic stress disorder. Psychological Medicine 32, 157–165.CrossRefGoogle ScholarPubMed
Neria, Y, Solomon, Z, Dekel, R (1998). An eighteen-year follow-up study of Israeli prisoners of war and combat veterans. Journal of Nervous and Mental Disease 186, 174–182.CrossRefGoogle ScholarPubMed
Ozer, EJ, Best, SR, Lipsey, TL, Weiss, DS (2003). Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychological Bulletin 129, 52–73.CrossRefGoogle ScholarPubMed
Riddle, JR, Smith, TC, Smith, B, Corbeil, TE, Engel, CC, Wells, TS, Hoge, CW, Adkins, J, Zamorski, M, Blazer, D (2007). Millennium cohort: the 2001–2003 baseline prevalence of mental disorders in the U.S. military. Journal of Clinical Epidemiology 60, 192–201.CrossRefGoogle ScholarPubMed
Rona, RJ, Fear, NT, Hull, L, Wessely, S (2007). Women in novel occupational roles: mental health trends in the UK Armed Forces. International Journal of Epidemiology 36, 319–326.CrossRefGoogle ScholarPubMed
Salcioglu, E, Basoglu, M, Livanou, M (2007). Post-traumatic stress disorder and comorbid depression among survivors of the 1999 earthquake in Turkey. Disasters 31, 115–129.CrossRefGoogle ScholarPubMed
Solomon, Z, Margalit, C, Waysman, M, Bleich, A (1991). In the shadow of the Gulf War: psychological distress, social support and coping among Israeli soldiers in a high risk area. Israeli Journal of Medical Sciences 27, 687–695.Google Scholar
Solomon, Z, Mikulincer, M, Avitzur, E (1988). Coping, locus of control, social support, and combat-related post-traumatic stress disorder. Journal of Personality and Social Psychology 55, 279–285.CrossRefGoogle Scholar
Solomon, Z, Mikulincer, M, Habershaim, N (1990). Life-events, coping strategies, social resources, and somatic complaints among combat stress reaction casualties. British Journal of Medical Psychology 63 (Pt 2), 137–148.CrossRefGoogle ScholarPubMed
Sutker, PB, Davis, JM, Uddo, M, Ditta, SR (1995). Assessment of psychological distress in Persian Gulf troops: ethnicity and gender. Journal of Personality Assessment 64, 415–427.CrossRefGoogle ScholarPubMed
Tate, AR, Jones, M, Hull, L, Fear, NT, Rona, R, Wessely, S, Hotopf, M (2007). How many mailouts: could attempts to increase the response rate in the Iraq cohort study be counter-productive? BMC Medical Research Methodology 7, 51.CrossRefGoogle Scholar
Weathers, FW, Litz, BT, Herman, DS, Huska, JA, Keane, TM (1993). The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX, 1993.Google Scholar
Wessely, S, Unwin, C, Hotopf, M, Hull, L, Ismail, K, Nicolaou, V, David, A (2003). Stability of recall of military hazards over time. Evidence from the Persian Gulf War of 1991. British Journal of Psychiatry 183, 314–322.CrossRefGoogle ScholarPubMed
Zatzick, DF, Marmar, CR, Weiss, DS, Browner, WS, Metzler, TJ, Golding, JM, Stewart, A, Schlenger, WE, Wells, KB (1997). Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry 154, 1690–1695.CrossRefGoogle Scholar