Richard K. Herrell

Posttraumatic stress disorder associated with combat service in Iraq or Afghanistan: reconciling prevalence differences between studies.

Abstract Studies of posttraumatic stress disorder (PTSD) prevalence associated with deployment to Iraq or Afghanistan report wide variability, making interpretation and projection for research and public health purposes difficult. This article placed this literature within a military context. Studies were categorized according to deployment time-frame, screening case definition, and study group (operational infantry units exposed to direct combat versus population samples with a high proportion of support personnel). Precision weighted averages were calculated using a fixed-effects meta-analysis. Using a specific case definition, the weighted postdeployment PTSD prevalence was 5.5% (95% CI, 5.4–5.6) in population samples and 13.2% (12.8–13.7) in operational infantry units. Both population-level and unit-specific studies provided valuable and unique information for public health purposes; understanding the military context is essential for interpreting prevalence studies.

Mild Traumatic Brain Injury (Concussion), Posttraumatic Stress Disorder, and Depression in U.S. Soldiers Involved in Combat Deployments: Association With Postdeployment Symptoms

Objectives Several studies have examined the relationship between concussion/mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), depression, and postdeployment symptoms. These studies indicate that the multiple factors involved in postdeployment symptoms are not accounted for in the screening processes of the Department of Defense/Veteran’s Affairs months after concussion injuries. This study examined the associations of single and multiple deployment-related mTBIs on postdeployment health. Methods A total of 1502 U.S. Army soldiers were administered anonymous surveys 4 to 6 months after returning from deployment to Iraq or Afghanistan assessing history of deployment-related concussions, current PTSD, depression, and presence of postdeployment physical and neurocognitive symptoms. Results Of these soldiers, 17% reported an mTBI during their previous deployment. Of these, 59% reported having more than one. After adjustment for PTSD, depression, and other factors, loss of consciousness was significantly associated with three postconcussive symptoms, including headaches (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.1–2.3). However, these symptoms were more strongly associated with PTSD and depression than with a history of mTBI. Multiple mTBIs with loss of consciousness increased the risk of headache (OR = 4.0, 95% CI = 2.4–6.8) compared with a single occurrence, although depression (OR = 4.2, 95% CI = 2.6–6.8) remained as strong a predictor. Conclusions These data indicate that current screening tools for mTBI being used by the Department of Defense/Veteran’s Affairs do not optimally distinguish persistent postdeployment symptoms attributed to mTBI from other causes such as PTSD and depression. Accumulating evidence strongly supports the need for multidisciplinary collaborative care models of treatment in primary care to collectively address the full spectrum of postwar physical and neurocognitive health concerns. Abbreviations TBI = traumatic brain injury; mTBI = mild traumatic brain injury; LOC = loss of consciousness; AOC = alteration of consciousness; DOD = U.S. Department of Defense; VA = U.S. Department of Veterans Affairs; PTSD = posttraumatic stress disorder; PCS = postconcussive symptom(s); PHQ-15 = 15-item Patient Health Questionnaire; PCL = PTSD Checklist; CES = Combat Exposure Scale

A twin study of chronic fatigue.

Objective The etiology of chronic fatigue syndrome is unknown, but genetic influences may be important in its expression. Our objective was to assess the role of genetic and environmental factors in unexplained chronic fatigue. Methods A classic twin study was conducted using 146 female-female twin pairs, of whom at least one member reported ≥6 months of fatigue. After completing questionnaires on symptoms, zygosity, physical health, and a psychiatric interview, twins were classified using three increasingly stringent definitions: 1) chronic fatigue for ≥6 months, 2) chronic fatigue not explained by exclusionary medical conditions, and 3) idiopathic chronic fatigue not explained by medical or psychiatric exclusionary criteria of the chronic fatigue syndrome case definition. Concordance rates in monozygotic and dizygotic twins were calculated for each fatigue definition along with estimates of the relative magnitude of genetic and environmental influences on chronic fatigue. Results The concordance rate was higher in monozygotic than dizygotic twins for each definition of chronic fatigue. For idiopathic chronic fatigue, the concordance rates were 55% in monozygotic and 19% in dizygotic twins (p = .042). The estimated heritability in liability was 19% (95% confidence interval = 0–56) for chronic fatigue ≥6 months, 30% (95% confidence interval = 0–81) for chronic fatigue not explained by medical conditions, and 51% (95% confidence interval = 7–96) for idiopathic chronic fatigue. Conclusions These results provide evidence supporting the familial aggregation of fatigue and suggest that genes may play a role in the etiology of chronic fatigue syndrome.

Comorbid Clinical Conditions in Chronic Fatigue

OBJECTIVES: Chronically fatiguing illness, defined as fatigue for at least 6 months, has been associated with various physical health conditions. Our objective was to determine whether there is a significant relationship between chronically fatiguing illness and 10 clinical conditions that frequently appear to be associated with fatigue, adjusting for the potentially confounding effects of psychiatric illness.DESIGN: A co-twin control study controlling for genetic and many environmental factors by comparing chronically fatigued twins with their nonfatigued co-twins.SETTING: A nationally distributed volunteer twin registry.PARTICIPANTS: The study included 127 twin pairs in which one member of the pair experienced fatigue of at least 6 months’ duration and the co-twin was healthy and denied chronic fatigue. Fatigued twins were classified into three levels using increasingly stringent diagnostic criteria.MEASUREMENTS AND MAIN RESULTS: Twins reported on a history of fibromyalgia, irritable bowel syndrome, multiple chemical sensitivities, temporomandibular disorder, interstitial cystitis, postconcussion syndrome, tension headache, chronic low back pain, chronic pelvic pain (women), and chronic nonbacterial prostatitis (men). The prevalence of these comorbid clinical conditions was significantly higher in the fatigued twins compared to their nonfatigued co-twins. Most notably, compared to their nonfatigued co-twins, the chronically fatigued twins had higher rates of fibromyalgia (> 70% vs <10%) and irritable bowel syndrome (>50% vs <5%). The strongest associations were observed between chronic fatigue and fibromyalgia (odds ratios >20), irritable bowel syndrome, chronic pelvic pain, multiple chemical sensitivities, and temporomandibular disorder (all with odds ratios ≥4). Regression analysis suggested that the number of comorbid clinical conditions associated with chronic fatigue could not be attributed solely to psychiatric illness.CONCLUSIONS: Chronically fatiguing illnesses were associated with high rates of many other clinical conditions. Thus, patients with chronic fatigue may present a complex clinical picture that poses diagnostic and management challenges. Nonetheless, clinicians should assess such patients for the presence of comorbid clinical conditions. Future research should provide a better understanding of the temporal relationship of the onset of fatigue and these conditions, and develop strategies for early intervention.

Chronic fatigue and chronic fatigue syndrome: A co-twin control study of functional status

Chronic fatigue syndrome (CFS) and the symptom of chronic fatigue may be accompanied by substantial functional disability. A volunteer sample of twins discordant for fatigue was identified from throughout the US. Fatigued twins were classified using three increasingly stringent definitions: (1) ≥6 months of fatigue (119 pairs); (2) CFS-like illness based on self-report of the Centers for Disease Control and Prevention CFS research definition criteria (74 pairs); and (3) CFS assessed by clinical examination (22 pairs). Twins with chronic fatigue were compared with their unaffected co-twins on the eight standard scales and two physical and mental component summary scales from the medical outcomes study short-form health survey (SF-36). Substantial impairment was observed for fatigued twins across all levels of fatigue, while scores in the healthy twins were similar to US population values. Mean scores among fatigued twins on the physical and mental component summary scales were below 97 and 77%, respectively, of the US population scores. Diminished functional status was found across increasingly stringent classifications of fatigue and was associated with a dramatic decrement in physical functioning. The symptom of fatigue has a pronounced impact on functional status, especially in the domain of physical functioning.

Use of Evidence-Based Treatment for Posttraumatic Stress Disorder in Army Behavioral Healthcare

Objective: To identify the extent to which evidence-based psychotherapy (EBP) and psychopharmacologic treatments for posttraumatic stress disorder (PTSD) are provided to U.S. service members in routine practice, and the degree to which they are consistent with evidence-based treatment guidelines. Method: We surveyed the majority of Army behavioral health providers (n = 2,310); surveys were obtained from 543 (26%). These clinicians reported clinical data on a total sample of 399 service member patients. Of these patients, 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses. Results: Army providers reported 86% of patients with PTSD received evidence-based psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased, reported use of EBPs significantly increased. Although EBPs for PTSD were reported to be widely used, clinicians who deliver EBP frequently reported not adhering to all core procedures recommended in treatment manuals; less than half reported using all the manualized core EBP techniques. Conclusions: Further research is necessary to understand why clinicians modify EBP treatments, and what impact this has on treatment outcomes. More data regarding the implications for treatment effectiveness and the role of clinical context, patient preferences, and clinical decision-making in adapting EBPs could help inform training efforts and the ways that these treatments may be better adapted for the military.

Coping strategies in twins with chronic fatigue and chronic fatigue syndrome

OBJECTIVES Individuals with chronic fatigue and chronic fatigue syndrome (CFS) face debilitating symptoms as well as stressful life situations that may result from their condition. The goal of this study was to examine the coping strategies used by fatigue-discordant twin pairs. METHODS We utilized a co-twin design to assess how twin pairs discordant for chronic fatigue and CFS cope with stress. All twin pairs were administered the Revised Ways of Coping Checklist. RESULTS Overall, the pattern of coping strategies was similar for fatigued and non-fatigued twins. However, twins with chronic fatigue or CFS utilized more avoidance strategies than their non-fatigued counterparts; those with chronic fatigue also used more avoidance relative to problem-focused coping than their co-twins. CONCLUSIONS These results suggest that while fatigue-discordant twins generally exhibit similar behavior patterns in order to cope with stress, there may be an association between fatigue and avoidance coping. Future research should focus on the role of avoidance and its relationship to fatiguing illnesses.

Use of alternative treatments by Chronic Fatigue Syndrome discordant twins

Background: Patients with chronic fatigue syndrome (CFS) have been faced with difficulties in diagnosis and lack of effective treatments. Anecdotal evidence suggests that use of alternative treatments may be common in these patients. Our primary objective was to compare the prevalence and patterns of alternative medicine use among twins who met the Centers for Disease Control and Prevention (CDC) CFS criteria to that of their non-CFS co-twins. Secondary goals were to assess how often alternative medicine use was discussed with physicians and the perceived benefit of these therapies. Methods: Sixty-three twin pairs discordant for CFS completed a survey about their use of 22 alternative therapies. Matched pair odds ratios and 95% confidence intervals were used to examine differences in the use between CFS twins and their non-CFS co-twins. Results: 91% of twins with CFS and 71% of non-CFS twins had used at least 1 alternative treatment in their lifetime. Twins with CFS were more likely to use homeopathy, mega-vitamins, herbal therapies, biofeedback, relaxation/meditation, guided imagery, massage therapy, energy healing, religious healing by others, and self-help groups than their non-CFS counterparts. A large proportion of all twins found alternative therapies helpful; however, only 42% of those with CFS and 23% of those without CFS discussed their use of alternative medicine with a physician. Conclusions: Individuals with CFS frequently used alternative medical treatments yet rarely communicated this use to their medical doctor. Future research should ascertain the usefulness of alternative practices in the management of CFS.

Assessing functional impairment in a working military population: the Walter Reed functional impairment scale.

Measurement of functional impairment is a priority for the military and other professional work groups routinely exposed to stressful traumatic events as part of their occupation. Standard measures of impairment used in general or chronically ill populations contain many items not suitable for these populations, and include mental health symptoms items that are not true measures of functioning. We created a new, 14-item scale-the Walter Reed Functional Impairment Scale-to assess functioning in 4 domains (physical, occupational, social, and personal). We asked 3,380 soldiers how much difficulty they currently have in each of the 4 domains on a 5-point scale. Behaviorally based psychosocial and occupational performance measures and general health questions were used to validate the scale. The utility of the scale was assessed against clinical measures of psychopathology and physical health (depression, posttraumatic stress disorder [PTSD], general health, generalized physical symptoms). We utilized Cronbachs alpha, item response theory, and the score test for trend to establish consistency of items and the validity of the scale. The scale exhibited excellent reliability (Cronbachs α= 0.92) and validity. The individual items and quartiles of sum scores were strongly correlated with negative occupational and social performance, and the utility of the scale was demonstrated by strong correlations with depression, PTSD, and high levels of generalized physical symptoms. This scale exhibits excellent psychometric properties in this sample of U.S. soldiers and, pending future research, is likely to have utility for other healthy occupational groups.

Sin, sickness, crime: Queer desire and the American state

Analysts of American life have long argued that local social life is central to normative participation in the affairs of the nation. Three of these areas of social life— religious association, family life, and local politics—are critical sites at which Americans are deemed “good citizens” and at which civic virtue is evidenced. These are also the three sites at which the homosexuals sin before God, sickness in the family, and crime are formulated and allocated. The emergence of gay and lesbian communities in Americas cities and in national organizations represents negotiations with American culture about what it means to be gay or lesbian at the sites where the meanings of being a congregant, a family member, a citizen, etc., are made and unmade, and demonstrates the way remade social identities make possible the active exercise of civil rights.