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Biomedical subjects

M J Friedman

Publications and source records attributed to M J Friedman.

At least 19 recordsLinked to original sources
PubMed1997

Posttraumatic stress disorder.

This article reviews concepts that help synthesize the data on posttraumatic stress disorder (PTSD), a very complex condition in terms of its etiology, psychobiology, epidemiology, comorbidity, and treatment. At least four neurobiologic systems are involved in PTSD: the catecholamine, the hypothalamic-pituitary-adrenocortical, the thyroid, and the endogenous opioid systems. Six other systems are probably or possibly implicated as well. The avoidance and hyperarousal of PTSD distort the patient's appraisal of the world. The symptoms of PTSD can be understood through models of learning and memory, which form the basis of behavioral treatments. The concepts of tonic and phasic alteration and of allostasis versus homeostasis also shed light on PTSD. In addition to PTSD, there may be other identifiable posttraumatic syndromes that might be diagnosed separately, such as "complex" PTSD. Cross-cultural issues may also affect clinical phenomenology and thereby confuse the diagnosis. Comorbid disorders may actually be clues to subtypes of PTSD. The fact that victims of PTSD are also more vulnerable to medical illnesses makes a closer relationship with primary care providers and other specialists mandatory. New approaches to prevention, treatment of chronic PTSD, psychotherapy, pharmacotherapy, and research hold promise of an improved prognosis for patients with PTSD.

Cognitive Behavioral Therapy↗
PubMed1996

Sleep and depression in combat-related PTSD inpatients.

The sleep of 27 unmedicated Vietnam combat-related posttraumatic stress disorder (PTSD) inpatients was monitored for 3 nights. Depressive comorbidity was considered both as a diagnostic category using DMS-III-R criteria, and as a continuous variable using the Beck Depression Inventory (BDI). Data collected included sleep architecture features that have discriminated unipolar depressives from controls in many prior studies, rapid eye movement (REM) sleep latency, and slow-wave sleep time, as well as two additional indices that have sometimes discriminated depressives from controls in waking studies-baseline heart rate and facial electromyography. Structured Clinical Interview for the DSM-III-R (SCID)-diagnosed PTSD+major depressive disorder (MDD) patients failed to exhibit shorter REM latencies, greater REM percents of sleep, or greater REM densities than PTSD-MDD patients, but did exhibit less slow wave sleep. PTSD+MDD patients also exhibited less facial (mentalis) electromyographic activity. REM densities and baseline heart rates were equivocal. REM density, baseline heart rate, and mentalis electromyography all correlated with the BDI, the former two positively, the last, negatively. In summary, SCID-diagnosed PTSD+MDD patients failed to exhibit the classic REM sleep architectural modifications associated with unipolar depression, despite the fact that several other psychophysiologic indices of dysphoria were detectable in their sleep.

Adult↗
PubMed1996

Subjective versus objective sleep in Vietnam combat veterans hospitalized for PTSD.

Twenty-five Vietnam combat veterans with chronic severe posttraumatic stress disorder (PTSD) completed a sleep self-report questionnaire on admission to an inpatient treatment program. Between 1 and 2 months later each spent 3 or more nights in the sleep laboratory. When self-report and laboratory findings were compared, significant relationships were observed between sleep schedule items such as time-to-bed/time-out-of-bed and polysomnographic measures of sleep. In contrast, global ratings of sleep quality were generally unrelated to polysomnographic measures. These findings may have implications for survey research assessing sleep quality in traumatized populations.

Chronic Disease↗
PubMed1996

PTSD diagnosis and treatment for mental health clinicians.

This article focuses on four issues: PTSD assessment, treatment approaches, therapist issues, and current controversies. Important assessment issues include the trauma history, comorbid disorders, and chronicity of PTSD. Effective intervention for acute trauma usually requires a variant of critical incident stress debriefing. Available treatments for chronic PTSD include group, cognitive-behavioral, psychodynamic, and pharmacological therapy. Therapist self-care is essential when working with PTSD patients since this work may be functionally disruptive and psychologically destabilizing. Current controversies include advocacy vs. therapeutic neutrality, eye movement desensitization and reprocessing (EMDR), the so-called false memory syndrome, and the legitimacy of complex PTSD as a unique diagnostic entity.

Attitude of Health Personnel↗
PubMed1996

First night effects in post-traumatic stress disorder inpatients.

Recent data have suggested that first night effects are attenuated in inpatient depressive subjects. We examined first night effects in 80 inpatients hospitalized for post-traumatic stress disorder (PTSD) as well as non-hospitalized PTSD sufferers and non-ill control subjects. PTSD inpatients exhibited attenuated first night effects compared to non-hospitalized PTSD sufferers and non-trauma-exposed controls. Non-ill combat-exposed subjects also exhibited small first night effects. Within the inpatient sample, severity indices of PTSD, depression and anxiety failed to account for variance in first night effects. These data demonstrate attenuation of first night effects in a new inpatient population and suggest their statistical independence vis-a-vis a range of relevant symptoms. Both the attenuation of first night effects in PTSD inpatients and their accentuation in PTSD outpatients may be indicative of enhanced sensitivity to the sleep environment. Conversely, the trend to small first night effects in non-ill combat-exposed subjects may reflect a dimension of their apparent resistance to traumatic stress.

Depressive Disorder↗
PubMed1996

Post-traumatic stress disorder among World War II mustard gas test participants.

Open-minded and structured interviews were conducted to assess post-traumatic stress disorder (PTSD) and other psychosocial outcomes among 24 men who had participated in the military's mustard gas testing program during World War II. Most men had volunteered (92%) and had participated in chamber tests (96%). During the tests, few (22%) understood the danger involved. The majority (67%) were ordered to refrain from discussing their participation with anyone. Most men (83%) experienced physical symptoms subsequent to the test. At present, the men were less psychologically and physically healthy than expected for men of similar age. The current prevalence of PTSD due to the mustard gas was 17%. The current prevalence of subdiagnostic mustard-gas-related PTSD was 25%. Lifetime estimates for full and subdiagnostic PTSD was 17 and 33%, respectively. The only mustard gas experience that predicted lifetime full or subdiagnostic PTSD was the number of exposures to the gas.

Aged↗
PubMed1994

Post-traumatic stress disorder in the military veteran.

1. Military personnel exposed to war-zone trauma are at risk for developing PTSD. Those at greatest risk are those exposed to the highest levels of war-zone stress, those wounded in action, those incarcerated as prisoners of war, and those who manifest acute war-zone reactions, such as CSR. 2. In addition to problems directly attributable to PTSD symptoms per se, individuals with this disorder frequently suffer from other comorbid psychiatric disorders, such as depression, other anxiety disorders, and alcohol or substance abuse/dependence. The resulting constellation of psychiatric symptoms frequently impairs marital, vocational, and social function. 3. The likelihood of developing chronic PTSD depends on premilitary and postmilitary factors in addition to features of the trauma itself. Premilitary factors include negative environmental factors in childhood, economic deprivation, family psychiatric history, age of entry into the military, premilitary educational attainment, and personality characteristics. Postmilitary factors include social support and the veteran's coping skills. 4. Among American military personnel, there are three populations at risk for unique problems that may amplify the psychological impact of war-zone stress. They are women whose war-zone experiences may be complicated by sexual assault and harassment; nonwhite ethnic minority individuals whose premilitary, postmilitary, and military experience is affected by the many manifestations of racism; and those with war-related physical disabilities, whose PTSD and medical problems often exacerbate each other. 5. The longitudinal course of PTSD is quite variable. Some trauma survivors may achieve complete recovery, whereas others may develop a persistent mental disorder in which they are severely and chronically incapacitated. Other patterns include delayed, chronic, and intermittent PTSD. 6. Theoretically primary preventive measures might include prevention of war or screening out vulnerable military recruits. In practice, primary preventive measures have included psychoeducational and inoculation approaches. Secondary prevention has been attempted through critical incident stress debriefing administered according to the principles of proximity, immediacy, expectancy, and simplicity. Tertiary prevention has included psychotherapy, pharmacotherapy, dual diagnosis approaches, peer counseling, and inpatient treatment. Few treatments have been rigorously evaluated. 7. There are both theoretical reasons and empirical findings to suggest that military veterans with PTSD are at greater risk for more physical health problems, poorer health status, and more medical service usage. Much more research is needed on this matter. 8. Despite the potential adverse impact of war-zone exposure on mental and physical health, there is also evidence that trauma can sometimes have salutary effects on personality and overall function.

Chronic Disease↗
PubMed1994

Veterans' psychiatric benefits: enter courts and attorneys.

In 1988, the Veterans Judicial Review Act (VJRA) was signed into law, ending more than a century of Congressional measures that kept veterans' benefits claims completely out of the appellate court system. Before this new law, any decision made by the Department of Veterans' Affairs (VA) about a veteran's claim was final, and there was no recourse for independent judgment of an appeal. The legislation modified the existing Board of Veterans Appeals (BVA) to enhance its independence from the Veterans' Administration and established a new Court of Veterans Appeals (CVA) with jurisdiction to review BVA decisions. Veterans' benefits proceedings have not only been insulated from the courts, they also have been undesirable to private attorneys, because since 1864 Congress has prohibited attorneys from charging more than $10 to advocate a VA disability claim. The new law allows attorneys to represent veterans before the CVA and receive appropriate remuneration. In 1991, the number of veterans was estimated at 26,897,000, and VA disability compensation programs spent $9.6 billion. Currently, there are about 2,179,000 veterans receiving service-connected monetary compensation; approximately 13.5 percent (293,200) have a primary psychiatric disability. The CVA is a specialized Article I court that has seven justices and sits in Washington, D.C. In its formative years, the Court has reached decisions that have had an impact on the veterans' psychiatric benefits examination process. Now more than ever, non-VA psychiatrists may be asked to offer probative opinions in veterans' benefits proceedings. The authors review VA psychiatric disability procedures and, using case examples, discuss both precedent decisions involving VA psychiatric claimants and the evolving standards of judicial review.

Combat Disorders↗
PubMed1993

Alcoholism and drug abuse in patients with PTSD.

The combination of PTSD and substance abuse is both common and problematic. In this chapter we review the following questions: 1) What is the relationship between PTSD, Alcoholism, and Drug Abuse? 2) Can the general "dual diagnosis" literature be of help? 3) Is the phenomenology of PTSD combined with alcoholism and/or drug abuse either unique or specific? 4) Does current pathophysiologic data allow conceptualization of a neurobiological model of PTSD, alcoholism, and drug abuse? 5) Drawing on these ideas, on the limited treatment literature, and the "dual diagnosis" literature, can we develop rational assessment and treatment approaches? Available literature suggests that diagnoses can be validly applied to these patients; that the illnesses must be treated simultaneously as co-primary illnesses; that extreme psychological symptoms reduce the efficacy of alcoholism or drug abuse treatment; and that effective control of these symptoms improves treatment outcome.

Alcoholism↗
PubMed1993

Change in MMPI scores from college to adulthood as a function of military service.

We examined changes in Minnesota Multiphasic Personality Inventory scores from adolescence to adulthood in a longitudinal study of 540 men who attended college during the Vietnam War. Using change scores that were adjusted for initial values, we compared civilians to veterans who were grouped according to combat exposure: none, peripheral, or direct. In cross-sectional analyses, the groups differed only as adults. Groups were similar in relative stability but differed by multivariate analysis in absolute change on the clinical scales. Only veterans with peripheral exposure differed from civilians in multivariate contrasts, even after controlling for premilitary variables. Effect sizes were small. Results suggest that combat exposure does not produce uniformly negative outcomes and may have positive effects in select populations.

Adult↗
PubMed1993

Premilitary MMPI scores as predictors of combat-related PTSD symptoms.

OBJECTIVE: The authors used data collected before military service to assess predictors of combat-related lifetime symptoms of posttraumatic stress disorder (PTSD). METHOD: The subjects were 131 male Vietnam and Vietnam-era veterans who had taken the MMPI in college and who were interviewed as adults with the Structured Clinical Interview for DSM-III-R. Scores on the basic MMPI scales were used to predict combat exposure, lifetime history of any PTSD symptoms given exposure, and lifetime PTSD classification (symptoms only, subthreshold PTSD, or full PTSD). RESULTS: Group means on the MMPI scales were within the normal range. No scale predicted combat exposure. Hypochondriasis, psychopathic deviate, masculinity-femininity, and paranoia scales predicted PTSD symptoms. Depression, hypomania, and social introversion predicted diagnostic classification among subjects with PTSD symptoms. The effects persisted when amount of combat exposure was controlled for. CONCLUSIONS: Pre-military personality can affect vulnerability to lifetime PTSD symptoms in men exposed to combat.

Adult↗
PubMed1993

Pharmacotherapy for recently evacuated military casualties.

In late 1990 during the massive Operation Desert Shield/Storm (ODS) deployment of United Nations troops, the VA/DoD Joint Contingency Plan was activated. Worst case scenarios projected tens of thousands of medical evacuees from the Persian Gulf and predicted that U.S. Military Communication Zone and CONUS bed capacity would quickly be saturated. As a result, a massive educational program was rapidly implemented to prepare 80 VA hospitals to receive ODS personnel within 1-3 weeks of their evacuation from battalion aid stations or other front-echelon medical facilities. This article was written as part of this educational effort. Noting that there were no published articles on pharmacotherapy for recently evacuated military casualties, the authors wrote the present manuscript for inclusion in the ODS Clinical Packet prepared by the VA's National Center for PTSD and circulated to VA mental health professionals. Since the published literature still lacks an article on this subject and since we believe that our comments on pharmacotherapy apply to survivors of most acute traumatic events, we present our observations and recommendations with the hope that they may be useful to military, VA, and civilian practitioners.

Clinical Protocols↗