ORIGINAL ARTICLE
Posttraumatic Stress Symptoms and Work-Related Accomplishment as Predictors of General Health and Medical Utilization Among Special Operations Forces Personnel Craig J. Bryan, PsyD, ABPP,* James A. Stephenson, PsyD, ABPP,Þ Chad E. Morrow, PsyD, ABPP,þ Mark Staal, PhD, ABPP,§ and Jeremy Haskell, PsyD||
Abstract: Research has established clear links among posttraumatic stress disorder (PTSD), somatic symptoms, and general health among conventional force military personnel. It is possible that the same relationships exist among Special Operations Force (SOF) personnel, but there are very few, if any, studies that examine these relationships. This study investigated correlates of general health and medical visits among SOF personnel and found that the interaction of somatic and PTSD symptoms was associated with worse health and more frequent medical visits. Follow-up analyses indicated that the interaction of avoidance symptoms with somatic symptoms was significantly associated with worse health, whereas the interaction of emotional numbing with somatic symptoms significantly contributed to increased medical visits. In addition, the results suggest that a sense of accomplishment among SOF personnel may serve as a protective factor against poor health. The results suggest developing interactions among SOF personnel that promote a sense of achievement to ultimately improve the health of the force. Key Words: Military, PTSD, health, somatic symptoms, medical utilization, accomplishment (J Nerv Ment Dis 2014;202: 105Y110)
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esearch has established that the incidence and the severity of posttraumatic stress disorder (PTSD) increase subsequent to combat exposure (Castro and McGurk, 2007; Tanielian and Jaycox, 2008), with recent studies suggesting that 5% to 17% of Iraq and Afghanistan veterans have probable PTSD, and up to 25% report psychological problems of some kind (Hoge et al., 2004, 2007, 2005; Milliken et al., 2007; Tanielian and Jaycox, 2008). In addition, military personnel who have deployed are more likely to experience somatic symptoms and complaints relative to those who have not deployed (Hotopf et al., 2006). Research has established clear links among PTSD, somatic symptoms, and general health among military personnel (Asmundson et al., 2002; Hoge et al., 2007), with evidence suggesting that the association is direct (Asmundson et al., 2002). Among US military personnel, for instance, PTSD is associated with poorer health, more severe somatic complaints, more frequent medical visits, higher medical utilization, and more missed workdays (Hoge et al., 2007). Similar findings have been found among UK military personnel, for whom somatic complaints are more severe among those who had deployed as compared with those who have not deployed (Hotopf et al., 2006). Not surprisingly, US military personnel who report
*National Center for Veterans Studies, The University of Utah, Salt Lake City, UT; †Air University, Maxwell Air Force Base, Montgomery, AL; ‡Hurlburt Field, Mary Esther, FL; §Pope Army Air Field, Fayetteville, NC; and ||Nellis Air Force Base, Las Vegas, NV. Send reprint requests to Craig J. Bryan, PsyD, ABPP, National Center for Veterans Studies, 260 S. Central Campus Dr, Room 205, Salt Lake City, UT 84112. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0105 DOI: 10.1097/NMD.0000000000000076
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more severe health problems use medical services more frequently (Elhai et al., 2007; Richardson et al., 2006), but those who also have elevated PTSD symptoms make even more frequent medical visits (Hoge et al., 2007). Hoge et al. (2007) reported, for instance, that 20.5% of US soldiers with severe somatic complaints but without PTSD symptoms made two or more medical visits during the previous month, as compared with 37.6% of soldiers with both severe somatic complaints and PTSD symptoms. A study of Canadian military peacekeeping military personnel similarly found that both PTSD and depression severity were significantly associated with more frequent medical visits, with depression being the stronger predictor (Richardson et al., 2006). Although PTSD, somatic complaints, and other risk factors have been well researched among conventional military personnel, much less attention has been paid to identifying protective factors for general health among military personnel. In addition, much less research has been conducted among military Special Operations Forces (SOF) personnel relative to conventional forces. SOF comprises a unique subpopulation of the military in that personnel are chosen from the larger pool of military personnel on the basis of high standards of physical and psychological selection criteria that are believed to be associated with increased resilience to operational and work-related stressors. Graduates of SOF training, for instance, demonstrate higher levels of psychological hardiness than military personnel who begin but ultimately do not complete SOF training, which might lend improved stress tolerance and successful performance in high-stress situations (Bartone et al., 2008). Indeed, research has suggested that, across nations, SOF personnel demonstrate better physical health, psychological well-being, and job satisfaction than do conventional military forces (Manning & Fullerton, 1988; Osorio et al., 2012a, 2012b), despite greater exposure to traumatic events and combat (Hanwella & de Silva, 2012). Despite these relatively lower rates, PTSD symptoms nonetheless have a significant association with physical health complaints among Portuguese SOF personnel (Osorio et al., 2012a), suggesting that even mild symptoms can have a negative impact on health. The high sense of accomplishment and pride in SOF units, combined with higher than average cohesion, has been posited as a buffer against PTSD and other health problems for SOF personnel (Hanwella & de Silva, 2012; Manning and Fullerton, 1988), although this has yet to be rigorously tested. Evidence from civilian samples also suggests that a stronger sense of work-related accomplishment is correlated with better mental and physical health (Kagan et al., 1995; Lee and Ashforth, 1990), although the applicability of these findings to military personnel is as yet unknown. Furthermore, because most studies of work-related accomplishment do not routinely control for commonly occurring psychiatric conditions such as depression or anxiety, the potential beneficial effects of personal accomplishment on general health above and beyond these emotional states are not well understood. In light of these research gaps, the primary aim of the current study was to identify both risk and protective factors associated with
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general health and medical visits among SOF personnel. The following specific hypotheses were tested: 1. PTSD symptoms will be directly associated with poorer general health and increased number of medical visits beyond the effects of covariates. 2. PTSD symptoms will augment the effects of somatic symptoms on general health and number of medical visits beyond the effects of covariates. 3. Personal accomplishment will be associated with better general health and decreased number of medical visits beyond the effects of covariates.
METHODS Participants Participants included 74 active-duty SOF personnel stationed at three Air Force bases in the South, Southwest, and West United States and one base located in Japan. One hundred percent of the participants were men and had been in the military for a mean of 6.72 years (SD, 4.25), ranging in age from 22 to 43 years (mean, 28.28; SD, 4.78). For racial distribution, 85.3% were white; 2.7%, African-American; 2.7%, Native American; 1.3%, Asian; 1.3%, Hawaiian/Pacific Islander; 4.0%, ‘‘other’’; and 2.7%, unknown. Nine participants (12.0%) additionally endorsed Hispanic/Latino ethnicity. For relationship status, 53.3% were married; 20.0%, in a relationship but not cohabiting; 9.3%, in a relationship and cohabiting; 2.7%, separated or divorced; 13.3%, never married and not currently in a relationship; and 1.3%, unknown. Rank was junior enlisted (E1YE4, 33.3%), noncommissioned officer (E5YE6, 42.7%), senior enlisted (E7YE9, 1.3%), and officer (O1YO4, 21.3%). The participants had deployed a mean of 2.30 times (SD, 1.64) to Iraq and/or Afghanistan. Prior deployments to other regions (e.g., Horn of Africa) were also assessed but were not included as covariates in the current study.
Procedures Investigators collected data via self-report survey packets. A total of 94 operators were invited to participate, of which 74 agreed, for a 78.7% participation rate. In coordination with local commanders, personnel were gathered at each base in a group, at which time study procedures were explained, the informed consent document was reviewed, and questions were answered. Commanders and other senior leaders were not present during this presentation to mitigate coercion. Personnel interested in participating signed the informed consent document and were subsequently provided a survey packet, which was returned to the investigators upon completion. The current study was reviewed and approved by the Wilford Hall Ambulatory Surgical Center’s institutional review board.
Instruments Medical Outcomes Survey Short FormY36 The Medical Outcomes Survey Short FormY36 (SF-36; Ware et al., 1993) is a widely used measure of health-related constructs that are affected by disease and treatment, independent of age, condition, treatment group, or cultural background. For the current study, the general health and bodily pain scales of the SF-36 were used. The general health scale assesses current health, health outlook, and resistance to illness. The bodily pain scale assesses intensity of pain and the effect of pain on normal work both at home and elsewhere. Scale scores are scaled from 1 to 100 on the basis of T-score distributions (i.e., population mean of 50, SD of 10). The two scales have very good internal consistency (0.81Y0.90) and convergence with other health-related variables. 106
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Patient Health Questionnaire Somatic Symptoms Scale The Patient Health Questionnaire Somatic Symptoms Scale (PHQ-15; Kroenke et al., 2002) was used to assess the severity of 15 somatic complaints (e.g., headaches, stomach pain, back pain) using the following scale: 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot). Scores from the 15 items are summed to provide an overall metric of somatic symptom severity ranging from 0 to 30. Internal consistency is very good (90.80), and convergent validity with other health-related outcomes has been established.
Patient Health Questionnaire Depression Symptoms Scale The Patient Health Questionnaire Depression Symptoms Scale (PHQ-9; Kroenke et al., 2001) was used to assess the frequency of depression symptoms during the past 2 weeks on the following scale: 0 (not at all) to 3(nearly every day). Scores from the nine items are summed to provide an overall metric of depressive symptom severity ranging from 0 to 27. Internal consistency is very good (90.86), and convergent validity with other measures of depression has been established.
PTSD Checklist, Military Version The 17-item PTSD Checklist, Military Version (PCL-M; Weathers et al., 1993), was used to assess the severity of PTSD symptoms on a scale of 1 (not at all) to 5 (extremely). Scores from each item are summed to provide an overall metric of PTSD symptom severity ranging from 17 to 85. Internal consistency is excellent (0.97), and the scale has been shown to differentiate individuals with and without a PTSD diagnosis.
Maslach Burnout Inventory The eight-item personal accomplishment scale of the Maslach Burnout Inventory (MBI; Maslach and Jackson, 1981) was used to measure the intensity of feelings of competence and successful achievement in work on a scale of 1 (very mild, barely noticeable) to 7 (very strong, major). The mean score for all items is calculated to obtain an overall indicator of personal accomplishment, with higher scores indicating more accomplishment. Internal consistency for the scale is good (0.77).
Medical Visits The participants were asked to report ‘‘how many times you visited a health care provider of any kind’’ during the past 6 months.
Data Analysis Generalized linear regression modeling with robust estimation was used in three steps to test the associations of predictor variables with general health: number of deployments, bodily pain severity, somatic symptoms, depression symptoms, PTSD symptoms, and sense of accomplishment. Generalized linear regression was used because of nonnormal distribution of variables. General health scores were reverse scored for the purposes of regression analyses, such that higher scores indicated worse health or functioning. In the first step, all predictors were entered separately into a regression model to test their independent associations with outcomes. We next constructed a regression model with all predictors entered simultaneously to test their effects while controlling for all other variables and tested the possible augmenting effect of PTSD on somatic symptoms by including the interaction term of these variables. In the third step, we tested the possible protective effects of accomplishment on other predictors by calculating the interaction terms of accomplishment with each predictor and entering them into the equation. Models were subsequently trimmed to identify the most parsimonious model with best data fit by comparing the Aikaike’s information criterion (AIC) * 2014 Lippincott Williams & Wilkins
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PTSD, Accomplishment, and Health
TABLE 1. Generalized Regression Models Predicting Poor General Health and Number of Medical Visits Poor General Health Model 1
Age Deployments Pain Somatic Depression PTSD Accomplishment PTSD somatic
No. Medical Visits Model 2
Model 1
Model 2
B (SE)
p
B (SE)
p
B (SE)
p
B (SE)
p
0.031 (0.023) V V 0.074 (0.069) 0.049 (0.075) 0.010 (0.029) j0.338 (0.096) V
0.253 V V 0.284 0.514 0.733 G0.001 V
V V V j0.345 (0.188) V j0.019 (0.026) 0.295 (0.080) 0.019 (0.007)
V V V 0.067 V 0.462 G0.001 0.009
0.016 (0.037) V V 0.101 (0.124) j0.060 (0.113) 0.085 (0.041) 0.363 (0.220) V
0.673 V V 0.426 0.593 0.039 0.098 V
V V V j1.217 (0.504) V j0.125 (0.092) V 0.060 (0.023)
V V V 0.016 V 0.173 V 0.01
Because the general health variable was reverse scored, higher scores indicated worse general health. Values in bold are statistically significant at p G 0.05.
values, with smaller values indicating better fit. For the planned twotailed multiple regression analyses for p G 0.05, a total of 74 participants resulted in sufficient power (90.91).
RESULTS Are PTSD Symptoms and Personal Accomplishment Associated With General Health and Increased Number of Medical Visits Among SOF Personnel? In terms of general health, the results of regression analyses predicting general health indicated that older age (B = 0.205; SE, 0.050; p G 0.001), more severe somatic complaints (B = 0.172; SE, 0.034; p G 0.001), depression (B = 0.115; SE, 0.017; p G 0.001), and PTSD (B = 0.062; SE, 0.019; p = 0.001) symptoms were significantly associated with worse general health, but accomplishment was significantly associated with better general health (B = j0.328; SE, 0.074; p G 0.001). Number of deployments (B = 0.118; SE, 0.075; p = 0.116) and pain (B = 0.011; SE, 0.017; p = 0.524) were not significantly associated with general health. We next constructed a regression model with the following predictors entered simultaneously to test their effects while controlling for all other variables: age, somatic symptoms, depression symptoms, PTSD symptoms, and accomplishment. In this model, only accomplishment was significantly associated with better general health (B = j0.338; SE, 0.096; p G 0.001; see Table 1). PTSD symptoms were not significantly associated with general health, however. In terms of medical visits, initial regression analyses indicated that only severity of PTSD symptoms (B = 0.099; SE, 0.045; p = 0.029) was significantly associated with more frequent medical visits. Older age (B = 0.071; SE, 0.039; p = 0.071) and accomplishment (B = 0.353; SE, 0.197; p = 0.073) showed nonsignificant trends toward more medical visits, whereas better general health showed a nonsignificant trend toward fewer medical visits (B = 0.035; SE, 0.020; p = 0.081). Number of deployments (B = 0.123; SE, 0.151; p = 0.416), somatic symptoms (B = 0.216; SE, 0.145; p = 0.135), depression (B = 0.169; SE, 0.156; p = 0.277), and pain severity (B = 0.004; SE, 0.009; p = 0.686) were not associated with number of medical visits. We next constructed a regression model with the following predictors entered simultaneously to test their effects while controlling for all other variables: age, somatic symptoms, depression symptoms, PTSD symptoms, and accomplishment. Only PTSD symptoms were significantly associated with more medical visits (B = 0.085; SE, 0.041; p = 0.039), with accomplishment * 2014 Lippincott Williams & Wilkins
showing a nonsignificant trend toward more medical visits (B = 0.363; SE, 0.220; p = 0.098; see Table 1).
Do PTSD Symptoms Augment the Effects of Somatic Symptoms on General Health and Number of Medical Visits? In terms of general health, the interaction of PTSD with somatic symptoms was calculated and added to the regression model, which resulted in a marginally nonsignificant interaction (B = 0.018; SE, 0.010; p = 0.063). Subsequent trimming of the model via comparison of the AIC values resulted in a more parsimonious model with slightly better data fit. In this final model (see Table 1), accomplishment was significantly associated with better general health (B = j0.295; SE, 0.080; p G 0.001) and the PTSDYsomatic symptoms interaction was significant (B = 0.021; SE, 0.009; p = 0.021), with somatic symptoms being associated with general health only among those personnel with the most severe PTSD symptoms. As can be seen in the plot of the two-way interaction (Figure 1), the
FIGURE 1. Form of the two-way interaction of somatic symptoms with PTSD symptoms on general health, with slopes plotted at high (PCL, 28), mean (PCL, 19.56), and low (PCL, 17) values of PTSD symptom severity and high (2 SD higher than the mean) and low (2 SD lower than the mean) values of somatic symptoms. General health is reverse keyed, such that higher scores indicate worse general health. www.jonmd.com
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personnel with severe PTSD symptoms reported worsening general health as their somatic symptoms increased, but the personnel with low to mean PTSD symptoms did not report worsening health as somatic symptoms increased. We next sought to determine which symptom cluster of PTSD was best accounting for the observed interaction with somatic symptoms. Separate regression models were constructed, with each of the four primary symptom clusters of PTSD (i.e., re-experiencing, avoidance, emotional numbing, and hyperarousal) entered as a main effect and as an interaction term with somatic symptoms. Only avoidance symptoms significantly interacted with somatic symptoms (B = 0.142; SE, 0.033; p G 0.001) in contributing to poorer health, with the form of this interaction being very similar to that displayed in Figure 1. Re-experiencing (B = 0.036; SE, 0.033; p = 0.271), emotional numbing (B = 0.079; SE, 0.049; p = 0.109), and hyperarousal (B = 0.023; SE, 0.020; p = 0.256) symptoms did not interact with somatic symptoms as a predictor of general health. In terms of medical visits, the interaction term of PTSD with somatic symptoms was calculated and added to the regression model, which resulted in a significant effect (B = 0.059; SE, 0.023; p = 0.012). Subsequent trimming of the model via comparison of the AIC values resulted in a more parsimonious model with slightly better data fit. In this final model (see Table 1), the PTSDYsomatic symptoms interaction was significant (B = 0.060; SE, 0.023; p = 0.010), with somatic symptoms being associated with more medical visits only among those personnel with the most severe PTSD symptoms (see Figure 2). This model remained significant even when controlling for general health scores, suggesting a direct association of PTSD and somatic symptoms with number of medical visits that is independent of general perceptions of health. To determine which symptom cluster of PTSD was best accounting for the observed interaction with somatic symptoms, separate regression models were constructed with each of the four primary symptom clusters, entered as both a main effect and an interaction term with somatic symptoms. Only emotional numbing symptoms significantly interacted with somatic symptoms (B = 0.186; SE, 0.059; p = 0.002) to increase the number of medical visits. The form of this interaction was similar to that displayed in Figure 2. Re-experiencing (B = 0.046; SE, 0.090; p = 0.609), avoidance (B = 0.396; SE, 0.235; p = 0.092), and hyperarousal (B = 0.048;
FIGURE 2. Form of the two-way interaction of somatic symptoms with PTSD symptoms on number of medical visits, with slopes plotted at high (PCL, 28), mean (PCL, 19.56), and low (PCL, 17) values of PTSD symptom severity and high (2 SD higher than the mean) and low (2 SD lower than the mean) values of somatic symptoms. 108
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SE, 0.066; p = 0.400) symptoms did not interact with somatic symptoms as a predictor of medical visits.
DISCUSSION In the current study, we found that predictors of general health and medical visits among SOF personnel were similar to findings among conventional military forces. In particular, PTSD symptoms augmented the effects of somatic symptoms on both general health and number of medical visits. These results suggest that avoidance symptoms have an especially strong association with poorer general health among SOF with more severe somatic symptoms. It is possible that this interaction is due to somatic manifestations of emotional distress in a population with markedly pronounced mental health stigma. Somatic complaints might be more acceptable or ‘‘safer’’ among SOF personnel to report and might therefore be a more prominent driver of global health problems among those with higher levels of psychological and physical distress. In contrast, we also found that only numbing symptoms contribute to increased medical utilization among SOF personnel with severe somatic complaints, which aligns with prior studies suggesting that patients with severe somatic complaints and co-occurring depressive symptoms use medical services more frequently and intensively than do patients with lower levels of each (Bao et al., 2003; Greenberg et al., 2003). The results also align with recent international research similarly finding that PTSD symptom severity is associated with somatic symptoms and general health complaints among Portuguese SOF personnel (Osorio et al., 2012a) and research suggesting a 42% to 146% increase in medical service utilization among veterans with mental health disorders, especially PTSD, as compared with those without mental health disorders (Cohen et al., 2009). The current findings suggest that severe somatic complaints and frequent medical visits could potentially serve as an indicator of co-occurring psychological distress among SOF personnel, which converges with research finding increased somatic symptoms among individuals with high levels of both anxiety and mood disturbance (e.g., Haug et al., 2004; Silverstein, 1999), both of which commonly co-occur in PTSD. Health care providers working with SOF personnel might therefore benefit from targeted education focused on the interactive nature of the psychological and physical aspects of health and consider screening for PTSD among those SOF personnel who make frequent medical visits. It is possible that SOF personnel’s perceptions of health might be related more to avoidant coping strategies, whereas seeking out medical care might be related more to mood disruption. Critically, the relationship of PTSD and somatic symptoms with medical visits remained even when controlling for general health scores, suggesting that, among SOF personnel, specific symptom clusters may drive actual medical utilization more than general perceptions about health. Longitudinal research is needed to definitively test this possibility. We also found that a stronger sense of accomplishment is associated with better health. Previous research among health care professionals (Kagan et al., 1995; Lee and Ashforth, 1990) has similarly reported a correlation between occupational accomplishment and physical health, although our findings extend these earlier results by controlling for psychiatric distress and other variables associated with health (e.g., age). It is possible, for instance, that low occupational satisfaction negatively impacts energy levels or adversely influences self-appraisals of health, in which case it might be possible for military leaders to positively impact the physical health of their subordinates by fostering and reinforcing a sense of accomplishment and purpose in their work. Conversely, it is possible that because of the physical demands of SOF work, poorer health interferes with a sense of occupational and professional achievement. Given that one’s sense of accomplishment can be influenced by * 2014 Lippincott Williams & Wilkins
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external sources (e.g., leadership appreciation, societal support), the current study suggests that military leaders may be able to positively impact the mental health of their subordinates by supporting good nutrition, exercise, and other activities that contribute to better overall health. Similarly, expressions of appreciation by society at large could also serve to buffer against general health problems. Unfortunately, the current study is unable to more fully consider why accomplishment and health are related, and future studies using longitudinal designs are needed to better tease out the link between accomplishment and general health. Future studies should also seek to determine whether personal accomplishment buffers against negative life experiences such as trauma exposure and is related to decreased emotional distress in military personnel because such findings could potentially uncover clues for reducing psychiatric morbidity in military personnel. Although this study has some important findings, it also has some limitations that warrant discussion. First, the current sample was composed of a small group of military personnel specifically selected and trained to accomplish unique and highly specialized missions. The results therefore might not generalize to civilian samples or to conventional military forces. Along these same lines, because the SOF career field excludes women, the results might not necessarily be applicable to female military personnel. Future studies should therefore be conducted to replicate these findings across a broader range of samples. Second, although our study suggested greater medical utilization among personnel with high levels of both somatic and psychological symptoms, it was not possible to determine the medical setting (e.g., primary care, specialty care) or medical discipline for these visits. Furthermore, the reasons for these visits are unknown. We are therefore unable to determine whether the SOF personnel were seeking care for complaints and issues that are related to psychosocial etiologies. Future studies that track medical specialty in addition to number of visits would be useful for clarifying these results. The current study is limited by self-report methodology, which could be vulnerable to response bias, especially in a group with pronounced mental health stigma. Additional studies that can use structured interviews and/or objective methods for measuring constructs (e.g., accomplishment measured via military awards/decorations or actual successful combat events) are necessary to strengthen the conclusions drawn from these data. Finally, our cross-sectional design restricts our ability to determine directionality of relationships. Future research using a prospective design will help to answer such questions. Despite the limitations of this study, the current study marks an important first step for understanding factors associated with general health and medical utilization among a subgroup of military personnel who play an everexpanding role within overall military operations.
CONCLUSIONS Avoidance symptoms of PTSD are associated with worse health among SOF personnel with higher levels of somatic complaints, whereas emotional numbing symptoms are associated with a greater number of medical visits among SOF personnel with higher levels of somatic complaints. In contrast, a greater sense of workrelated accomplishment is associated with better health, suggesting that this might serve as a protective factor for general health. ACKNOWLEDGMENTS The authors thank TSgt (Ret) AnnaBelle Bryan for her support and contributions to this project. DISCLOSURES This study was supported by a grant from the Air Force Medical Support Agency (FA8650-12-2-6277). The views expressed in * 2014 Lippincott Williams & Wilkins
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this article are those of the authors and do not necessarily represent the official position or policy of the US Government, the Department of Defense, or the Department of the Air Force. Craig J. Bryan reports grant funding from the Department of the Army (W81XWH-10-0181) and the Department of the Air Force (FA8650-12-2-6277), contract funds from the Department of the Air Force, and an honorarium from CMI Education. James A. Stephenson, Chad E. Morrow, Mark Staal, and Jeremy Haskell declare no conflicts of interest or sources of funding.
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Posttraumatic Stress Symptoms and Work-Related Accomplishment as Predictors of General Health and Medical Utilization Among Special Operations Forces Personnel Craig J. Bryan, PsyD, ABPP,* James A. Stephenson, PsyD, ABPP,Þ Chad E. Morrow, PsyD, ABPP,þ Mark Staal, PhD, ABPP,§ and Jeremy Haskell, PsyD||
Abstract: Research has established clear links among posttraumatic stress disorder (PTSD), somatic symptoms, and general health among conventional force military personnel. It is possible that the same relationships exist among Special Operations Force (SOF) personnel, but there are very few, if any, studies that examine these relationships. This study investigated correlates of general health and medical visits among SOF personnel and found that the interaction of somatic and PTSD symptoms was associated with worse health and more frequent medical visits. Follow-up analyses indicated that the interaction of avoidance symptoms with somatic symptoms was significantly associated with worse health, whereas the interaction of emotional numbing with somatic symptoms significantly contributed to increased medical visits. In addition, the results suggest that a sense of accomplishment among SOF personnel may serve as a protective factor against poor health. The results suggest developing interactions among SOF personnel that promote a sense of achievement to ultimately improve the health of the force. Key Words: Military, PTSD, health, somatic symptoms, medical utilization, accomplishment (J Nerv Ment Dis 2014;202: 105Y110)
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esearch has established that the incidence and the severity of posttraumatic stress disorder (PTSD) increase subsequent to combat exposure (Castro and McGurk, 2007; Tanielian and Jaycox, 2008), with recent studies suggesting that 5% to 17% of Iraq and Afghanistan veterans have probable PTSD, and up to 25% report psychological problems of some kind (Hoge et al., 2004, 2007, 2005; Milliken et al., 2007; Tanielian and Jaycox, 2008). In addition, military personnel who have deployed are more likely to experience somatic symptoms and complaints relative to those who have not deployed (Hotopf et al., 2006). Research has established clear links among PTSD, somatic symptoms, and general health among military personnel (Asmundson et al., 2002; Hoge et al., 2007), with evidence suggesting that the association is direct (Asmundson et al., 2002). Among US military personnel, for instance, PTSD is associated with poorer health, more severe somatic complaints, more frequent medical visits, higher medical utilization, and more missed workdays (Hoge et al., 2007). Similar findings have been found among UK military personnel, for whom somatic complaints are more severe among those who had deployed as compared with those who have not deployed (Hotopf et al., 2006). Not surprisingly, US military personnel who report
*National Center for Veterans Studies, The University of Utah, Salt Lake City, UT; †Air University, Maxwell Air Force Base, Montgomery, AL; ‡Hurlburt Field, Mary Esther, FL; §Pope Army Air Field, Fayetteville, NC; and ||Nellis Air Force Base, Las Vegas, NV. Send reprint requests to Craig J. Bryan, PsyD, ABPP, National Center for Veterans Studies, 260 S. Central Campus Dr, Room 205, Salt Lake City, UT 84112. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0105 DOI: 10.1097/NMD.0000000000000076
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more severe health problems use medical services more frequently (Elhai et al., 2007; Richardson et al., 2006), but those who also have elevated PTSD symptoms make even more frequent medical visits (Hoge et al., 2007). Hoge et al. (2007) reported, for instance, that 20.5% of US soldiers with severe somatic complaints but without PTSD symptoms made two or more medical visits during the previous month, as compared with 37.6% of soldiers with both severe somatic complaints and PTSD symptoms. A study of Canadian military peacekeeping military personnel similarly found that both PTSD and depression severity were significantly associated with more frequent medical visits, with depression being the stronger predictor (Richardson et al., 2006). Although PTSD, somatic complaints, and other risk factors have been well researched among conventional military personnel, much less attention has been paid to identifying protective factors for general health among military personnel. In addition, much less research has been conducted among military Special Operations Forces (SOF) personnel relative to conventional forces. SOF comprises a unique subpopulation of the military in that personnel are chosen from the larger pool of military personnel on the basis of high standards of physical and psychological selection criteria that are believed to be associated with increased resilience to operational and work-related stressors. Graduates of SOF training, for instance, demonstrate higher levels of psychological hardiness than military personnel who begin but ultimately do not complete SOF training, which might lend improved stress tolerance and successful performance in high-stress situations (Bartone et al., 2008). Indeed, research has suggested that, across nations, SOF personnel demonstrate better physical health, psychological well-being, and job satisfaction than do conventional military forces (Manning & Fullerton, 1988; Osorio et al., 2012a, 2012b), despite greater exposure to traumatic events and combat (Hanwella & de Silva, 2012). Despite these relatively lower rates, PTSD symptoms nonetheless have a significant association with physical health complaints among Portuguese SOF personnel (Osorio et al., 2012a), suggesting that even mild symptoms can have a negative impact on health. The high sense of accomplishment and pride in SOF units, combined with higher than average cohesion, has been posited as a buffer against PTSD and other health problems for SOF personnel (Hanwella & de Silva, 2012; Manning and Fullerton, 1988), although this has yet to be rigorously tested. Evidence from civilian samples also suggests that a stronger sense of work-related accomplishment is correlated with better mental and physical health (Kagan et al., 1995; Lee and Ashforth, 1990), although the applicability of these findings to military personnel is as yet unknown. Furthermore, because most studies of work-related accomplishment do not routinely control for commonly occurring psychiatric conditions such as depression or anxiety, the potential beneficial effects of personal accomplishment on general health above and beyond these emotional states are not well understood. In light of these research gaps, the primary aim of the current study was to identify both risk and protective factors associated with
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general health and medical visits among SOF personnel. The following specific hypotheses were tested: 1. PTSD symptoms will be directly associated with poorer general health and increased number of medical visits beyond the effects of covariates. 2. PTSD symptoms will augment the effects of somatic symptoms on general health and number of medical visits beyond the effects of covariates. 3. Personal accomplishment will be associated with better general health and decreased number of medical visits beyond the effects of covariates.
METHODS Participants Participants included 74 active-duty SOF personnel stationed at three Air Force bases in the South, Southwest, and West United States and one base located in Japan. One hundred percent of the participants were men and had been in the military for a mean of 6.72 years (SD, 4.25), ranging in age from 22 to 43 years (mean, 28.28; SD, 4.78). For racial distribution, 85.3% were white; 2.7%, African-American; 2.7%, Native American; 1.3%, Asian; 1.3%, Hawaiian/Pacific Islander; 4.0%, ‘‘other’’; and 2.7%, unknown. Nine participants (12.0%) additionally endorsed Hispanic/Latino ethnicity. For relationship status, 53.3% were married; 20.0%, in a relationship but not cohabiting; 9.3%, in a relationship and cohabiting; 2.7%, separated or divorced; 13.3%, never married and not currently in a relationship; and 1.3%, unknown. Rank was junior enlisted (E1YE4, 33.3%), noncommissioned officer (E5YE6, 42.7%), senior enlisted (E7YE9, 1.3%), and officer (O1YO4, 21.3%). The participants had deployed a mean of 2.30 times (SD, 1.64) to Iraq and/or Afghanistan. Prior deployments to other regions (e.g., Horn of Africa) were also assessed but were not included as covariates in the current study.
Procedures Investigators collected data via self-report survey packets. A total of 94 operators were invited to participate, of which 74 agreed, for a 78.7% participation rate. In coordination with local commanders, personnel were gathered at each base in a group, at which time study procedures were explained, the informed consent document was reviewed, and questions were answered. Commanders and other senior leaders were not present during this presentation to mitigate coercion. Personnel interested in participating signed the informed consent document and were subsequently provided a survey packet, which was returned to the investigators upon completion. The current study was reviewed and approved by the Wilford Hall Ambulatory Surgical Center’s institutional review board.
Instruments Medical Outcomes Survey Short FormY36 The Medical Outcomes Survey Short FormY36 (SF-36; Ware et al., 1993) is a widely used measure of health-related constructs that are affected by disease and treatment, independent of age, condition, treatment group, or cultural background. For the current study, the general health and bodily pain scales of the SF-36 were used. The general health scale assesses current health, health outlook, and resistance to illness. The bodily pain scale assesses intensity of pain and the effect of pain on normal work both at home and elsewhere. Scale scores are scaled from 1 to 100 on the basis of T-score distributions (i.e., population mean of 50, SD of 10). The two scales have very good internal consistency (0.81Y0.90) and convergence with other health-related variables. 106
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Patient Health Questionnaire Somatic Symptoms Scale The Patient Health Questionnaire Somatic Symptoms Scale (PHQ-15; Kroenke et al., 2002) was used to assess the severity of 15 somatic complaints (e.g., headaches, stomach pain, back pain) using the following scale: 0 (not bothered at all), 1 (bothered a little), or 2 (bothered a lot). Scores from the 15 items are summed to provide an overall metric of somatic symptom severity ranging from 0 to 30. Internal consistency is very good (90.80), and convergent validity with other health-related outcomes has been established.
Patient Health Questionnaire Depression Symptoms Scale The Patient Health Questionnaire Depression Symptoms Scale (PHQ-9; Kroenke et al., 2001) was used to assess the frequency of depression symptoms during the past 2 weeks on the following scale: 0 (not at all) to 3(nearly every day). Scores from the nine items are summed to provide an overall metric of depressive symptom severity ranging from 0 to 27. Internal consistency is very good (90.86), and convergent validity with other measures of depression has been established.
PTSD Checklist, Military Version The 17-item PTSD Checklist, Military Version (PCL-M; Weathers et al., 1993), was used to assess the severity of PTSD symptoms on a scale of 1 (not at all) to 5 (extremely). Scores from each item are summed to provide an overall metric of PTSD symptom severity ranging from 17 to 85. Internal consistency is excellent (0.97), and the scale has been shown to differentiate individuals with and without a PTSD diagnosis.
Maslach Burnout Inventory The eight-item personal accomplishment scale of the Maslach Burnout Inventory (MBI; Maslach and Jackson, 1981) was used to measure the intensity of feelings of competence and successful achievement in work on a scale of 1 (very mild, barely noticeable) to 7 (very strong, major). The mean score for all items is calculated to obtain an overall indicator of personal accomplishment, with higher scores indicating more accomplishment. Internal consistency for the scale is good (0.77).
Medical Visits The participants were asked to report ‘‘how many times you visited a health care provider of any kind’’ during the past 6 months.
Data Analysis Generalized linear regression modeling with robust estimation was used in three steps to test the associations of predictor variables with general health: number of deployments, bodily pain severity, somatic symptoms, depression symptoms, PTSD symptoms, and sense of accomplishment. Generalized linear regression was used because of nonnormal distribution of variables. General health scores were reverse scored for the purposes of regression analyses, such that higher scores indicated worse health or functioning. In the first step, all predictors were entered separately into a regression model to test their independent associations with outcomes. We next constructed a regression model with all predictors entered simultaneously to test their effects while controlling for all other variables and tested the possible augmenting effect of PTSD on somatic symptoms by including the interaction term of these variables. In the third step, we tested the possible protective effects of accomplishment on other predictors by calculating the interaction terms of accomplishment with each predictor and entering them into the equation. Models were subsequently trimmed to identify the most parsimonious model with best data fit by comparing the Aikaike’s information criterion (AIC) * 2014 Lippincott Williams & Wilkins
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PTSD, Accomplishment, and Health
TABLE 1. Generalized Regression Models Predicting Poor General Health and Number of Medical Visits Poor General Health Model 1
Age Deployments Pain Somatic Depression PTSD Accomplishment PTSD somatic
No. Medical Visits Model 2
Model 1
Model 2
B (SE)
p
B (SE)
p
B (SE)
p
B (SE)
p
0.031 (0.023) V V 0.074 (0.069) 0.049 (0.075) 0.010 (0.029) j0.338 (0.096) V
0.253 V V 0.284 0.514 0.733 G0.001 V
V V V j0.345 (0.188) V j0.019 (0.026) 0.295 (0.080) 0.019 (0.007)
V V V 0.067 V 0.462 G0.001 0.009
0.016 (0.037) V V 0.101 (0.124) j0.060 (0.113) 0.085 (0.041) 0.363 (0.220) V
0.673 V V 0.426 0.593 0.039 0.098 V
V V V j1.217 (0.504) V j0.125 (0.092) V 0.060 (0.023)
V V V 0.016 V 0.173 V 0.01
Because the general health variable was reverse scored, higher scores indicated worse general health. Values in bold are statistically significant at p G 0.05.
values, with smaller values indicating better fit. For the planned twotailed multiple regression analyses for p G 0.05, a total of 74 participants resulted in sufficient power (90.91).
RESULTS Are PTSD Symptoms and Personal Accomplishment Associated With General Health and Increased Number of Medical Visits Among SOF Personnel? In terms of general health, the results of regression analyses predicting general health indicated that older age (B = 0.205; SE, 0.050; p G 0.001), more severe somatic complaints (B = 0.172; SE, 0.034; p G 0.001), depression (B = 0.115; SE, 0.017; p G 0.001), and PTSD (B = 0.062; SE, 0.019; p = 0.001) symptoms were significantly associated with worse general health, but accomplishment was significantly associated with better general health (B = j0.328; SE, 0.074; p G 0.001). Number of deployments (B = 0.118; SE, 0.075; p = 0.116) and pain (B = 0.011; SE, 0.017; p = 0.524) were not significantly associated with general health. We next constructed a regression model with the following predictors entered simultaneously to test their effects while controlling for all other variables: age, somatic symptoms, depression symptoms, PTSD symptoms, and accomplishment. In this model, only accomplishment was significantly associated with better general health (B = j0.338; SE, 0.096; p G 0.001; see Table 1). PTSD symptoms were not significantly associated with general health, however. In terms of medical visits, initial regression analyses indicated that only severity of PTSD symptoms (B = 0.099; SE, 0.045; p = 0.029) was significantly associated with more frequent medical visits. Older age (B = 0.071; SE, 0.039; p = 0.071) and accomplishment (B = 0.353; SE, 0.197; p = 0.073) showed nonsignificant trends toward more medical visits, whereas better general health showed a nonsignificant trend toward fewer medical visits (B = 0.035; SE, 0.020; p = 0.081). Number of deployments (B = 0.123; SE, 0.151; p = 0.416), somatic symptoms (B = 0.216; SE, 0.145; p = 0.135), depression (B = 0.169; SE, 0.156; p = 0.277), and pain severity (B = 0.004; SE, 0.009; p = 0.686) were not associated with number of medical visits. We next constructed a regression model with the following predictors entered simultaneously to test their effects while controlling for all other variables: age, somatic symptoms, depression symptoms, PTSD symptoms, and accomplishment. Only PTSD symptoms were significantly associated with more medical visits (B = 0.085; SE, 0.041; p = 0.039), with accomplishment * 2014 Lippincott Williams & Wilkins
showing a nonsignificant trend toward more medical visits (B = 0.363; SE, 0.220; p = 0.098; see Table 1).
Do PTSD Symptoms Augment the Effects of Somatic Symptoms on General Health and Number of Medical Visits? In terms of general health, the interaction of PTSD with somatic symptoms was calculated and added to the regression model, which resulted in a marginally nonsignificant interaction (B = 0.018; SE, 0.010; p = 0.063). Subsequent trimming of the model via comparison of the AIC values resulted in a more parsimonious model with slightly better data fit. In this final model (see Table 1), accomplishment was significantly associated with better general health (B = j0.295; SE, 0.080; p G 0.001) and the PTSDYsomatic symptoms interaction was significant (B = 0.021; SE, 0.009; p = 0.021), with somatic symptoms being associated with general health only among those personnel with the most severe PTSD symptoms. As can be seen in the plot of the two-way interaction (Figure 1), the
FIGURE 1. Form of the two-way interaction of somatic symptoms with PTSD symptoms on general health, with slopes plotted at high (PCL, 28), mean (PCL, 19.56), and low (PCL, 17) values of PTSD symptom severity and high (2 SD higher than the mean) and low (2 SD lower than the mean) values of somatic symptoms. General health is reverse keyed, such that higher scores indicate worse general health. www.jonmd.com
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personnel with severe PTSD symptoms reported worsening general health as their somatic symptoms increased, but the personnel with low to mean PTSD symptoms did not report worsening health as somatic symptoms increased. We next sought to determine which symptom cluster of PTSD was best accounting for the observed interaction with somatic symptoms. Separate regression models were constructed, with each of the four primary symptom clusters of PTSD (i.e., re-experiencing, avoidance, emotional numbing, and hyperarousal) entered as a main effect and as an interaction term with somatic symptoms. Only avoidance symptoms significantly interacted with somatic symptoms (B = 0.142; SE, 0.033; p G 0.001) in contributing to poorer health, with the form of this interaction being very similar to that displayed in Figure 1. Re-experiencing (B = 0.036; SE, 0.033; p = 0.271), emotional numbing (B = 0.079; SE, 0.049; p = 0.109), and hyperarousal (B = 0.023; SE, 0.020; p = 0.256) symptoms did not interact with somatic symptoms as a predictor of general health. In terms of medical visits, the interaction term of PTSD with somatic symptoms was calculated and added to the regression model, which resulted in a significant effect (B = 0.059; SE, 0.023; p = 0.012). Subsequent trimming of the model via comparison of the AIC values resulted in a more parsimonious model with slightly better data fit. In this final model (see Table 1), the PTSDYsomatic symptoms interaction was significant (B = 0.060; SE, 0.023; p = 0.010), with somatic symptoms being associated with more medical visits only among those personnel with the most severe PTSD symptoms (see Figure 2). This model remained significant even when controlling for general health scores, suggesting a direct association of PTSD and somatic symptoms with number of medical visits that is independent of general perceptions of health. To determine which symptom cluster of PTSD was best accounting for the observed interaction with somatic symptoms, separate regression models were constructed with each of the four primary symptom clusters, entered as both a main effect and an interaction term with somatic symptoms. Only emotional numbing symptoms significantly interacted with somatic symptoms (B = 0.186; SE, 0.059; p = 0.002) to increase the number of medical visits. The form of this interaction was similar to that displayed in Figure 2. Re-experiencing (B = 0.046; SE, 0.090; p = 0.609), avoidance (B = 0.396; SE, 0.235; p = 0.092), and hyperarousal (B = 0.048;
FIGURE 2. Form of the two-way interaction of somatic symptoms with PTSD symptoms on number of medical visits, with slopes plotted at high (PCL, 28), mean (PCL, 19.56), and low (PCL, 17) values of PTSD symptom severity and high (2 SD higher than the mean) and low (2 SD lower than the mean) values of somatic symptoms. 108
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SE, 0.066; p = 0.400) symptoms did not interact with somatic symptoms as a predictor of medical visits.
DISCUSSION In the current study, we found that predictors of general health and medical visits among SOF personnel were similar to findings among conventional military forces. In particular, PTSD symptoms augmented the effects of somatic symptoms on both general health and number of medical visits. These results suggest that avoidance symptoms have an especially strong association with poorer general health among SOF with more severe somatic symptoms. It is possible that this interaction is due to somatic manifestations of emotional distress in a population with markedly pronounced mental health stigma. Somatic complaints might be more acceptable or ‘‘safer’’ among SOF personnel to report and might therefore be a more prominent driver of global health problems among those with higher levels of psychological and physical distress. In contrast, we also found that only numbing symptoms contribute to increased medical utilization among SOF personnel with severe somatic complaints, which aligns with prior studies suggesting that patients with severe somatic complaints and co-occurring depressive symptoms use medical services more frequently and intensively than do patients with lower levels of each (Bao et al., 2003; Greenberg et al., 2003). The results also align with recent international research similarly finding that PTSD symptom severity is associated with somatic symptoms and general health complaints among Portuguese SOF personnel (Osorio et al., 2012a) and research suggesting a 42% to 146% increase in medical service utilization among veterans with mental health disorders, especially PTSD, as compared with those without mental health disorders (Cohen et al., 2009). The current findings suggest that severe somatic complaints and frequent medical visits could potentially serve as an indicator of co-occurring psychological distress among SOF personnel, which converges with research finding increased somatic symptoms among individuals with high levels of both anxiety and mood disturbance (e.g., Haug et al., 2004; Silverstein, 1999), both of which commonly co-occur in PTSD. Health care providers working with SOF personnel might therefore benefit from targeted education focused on the interactive nature of the psychological and physical aspects of health and consider screening for PTSD among those SOF personnel who make frequent medical visits. It is possible that SOF personnel’s perceptions of health might be related more to avoidant coping strategies, whereas seeking out medical care might be related more to mood disruption. Critically, the relationship of PTSD and somatic symptoms with medical visits remained even when controlling for general health scores, suggesting that, among SOF personnel, specific symptom clusters may drive actual medical utilization more than general perceptions about health. Longitudinal research is needed to definitively test this possibility. We also found that a stronger sense of accomplishment is associated with better health. Previous research among health care professionals (Kagan et al., 1995; Lee and Ashforth, 1990) has similarly reported a correlation between occupational accomplishment and physical health, although our findings extend these earlier results by controlling for psychiatric distress and other variables associated with health (e.g., age). It is possible, for instance, that low occupational satisfaction negatively impacts energy levels or adversely influences self-appraisals of health, in which case it might be possible for military leaders to positively impact the physical health of their subordinates by fostering and reinforcing a sense of accomplishment and purpose in their work. Conversely, it is possible that because of the physical demands of SOF work, poorer health interferes with a sense of occupational and professional achievement. Given that one’s sense of accomplishment can be influenced by * 2014 Lippincott Williams & Wilkins
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external sources (e.g., leadership appreciation, societal support), the current study suggests that military leaders may be able to positively impact the mental health of their subordinates by supporting good nutrition, exercise, and other activities that contribute to better overall health. Similarly, expressions of appreciation by society at large could also serve to buffer against general health problems. Unfortunately, the current study is unable to more fully consider why accomplishment and health are related, and future studies using longitudinal designs are needed to better tease out the link between accomplishment and general health. Future studies should also seek to determine whether personal accomplishment buffers against negative life experiences such as trauma exposure and is related to decreased emotional distress in military personnel because such findings could potentially uncover clues for reducing psychiatric morbidity in military personnel. Although this study has some important findings, it also has some limitations that warrant discussion. First, the current sample was composed of a small group of military personnel specifically selected and trained to accomplish unique and highly specialized missions. The results therefore might not generalize to civilian samples or to conventional military forces. Along these same lines, because the SOF career field excludes women, the results might not necessarily be applicable to female military personnel. Future studies should therefore be conducted to replicate these findings across a broader range of samples. Second, although our study suggested greater medical utilization among personnel with high levels of both somatic and psychological symptoms, it was not possible to determine the medical setting (e.g., primary care, specialty care) or medical discipline for these visits. Furthermore, the reasons for these visits are unknown. We are therefore unable to determine whether the SOF personnel were seeking care for complaints and issues that are related to psychosocial etiologies. Future studies that track medical specialty in addition to number of visits would be useful for clarifying these results. The current study is limited by self-report methodology, which could be vulnerable to response bias, especially in a group with pronounced mental health stigma. Additional studies that can use structured interviews and/or objective methods for measuring constructs (e.g., accomplishment measured via military awards/decorations or actual successful combat events) are necessary to strengthen the conclusions drawn from these data. Finally, our cross-sectional design restricts our ability to determine directionality of relationships. Future research using a prospective design will help to answer such questions. Despite the limitations of this study, the current study marks an important first step for understanding factors associated with general health and medical utilization among a subgroup of military personnel who play an everexpanding role within overall military operations.
CONCLUSIONS Avoidance symptoms of PTSD are associated with worse health among SOF personnel with higher levels of somatic complaints, whereas emotional numbing symptoms are associated with a greater number of medical visits among SOF personnel with higher levels of somatic complaints. In contrast, a greater sense of workrelated accomplishment is associated with better health, suggesting that this might serve as a protective factor for general health. ACKNOWLEDGMENTS The authors thank TSgt (Ret) AnnaBelle Bryan for her support and contributions to this project. DISCLOSURES This study was supported by a grant from the Air Force Medical Support Agency (FA8650-12-2-6277). The views expressed in * 2014 Lippincott Williams & Wilkins
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this article are those of the authors and do not necessarily represent the official position or policy of the US Government, the Department of Defense, or the Department of the Air Force. Craig J. Bryan reports grant funding from the Department of the Army (W81XWH-10-0181) and the Department of the Air Force (FA8650-12-2-6277), contract funds from the Department of the Air Force, and an honorarium from CMI Education. James A. Stephenson, Chad E. Morrow, Mark Staal, and Jeremy Haskell declare no conflicts of interest or sources of funding.
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Osorio C, Greenberg N, Jones N, Goodwin L, Fertout M, Maia A (2012b) Combat exposure and posttraumatic stress disorder among Portuguese Special Operations Forces deployed in Afghanistan. Mil Psychol. 25:70Y81. Richardson JD, Elhai JD, Pedlar DJ (2006) Association of PTSD and depression with medical and specialist care utilization in modern peacekeeping veterans in Canada with health-related disabilities. J Clin Psychiatry. 67: 1240Y1245. Silverstein B (1999) Gender difference in the prevalence of clinical depression: The role played by depression associated with somatic symptoms. Am J Psychiatry. 156:480Y482.
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