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Y .". n It A on u: u n Y . “Eng: Mgr III . e I I v. 1" I'- r '- .. ~ WI - WW ' .Jgfi— ~3~o¢a~ rF—g -qv.- ”qt-v ulna" 'IW 'z‘. fip—fl u— «an '35? £1?" .p.~. . ' .5"; .m- Cur-.- ~— .rr .. m ‘u o .. . ”flu—'1. (231(90ng lullll’l'llnu’”will“luluImmummm midi???“ 3 1293 00575 2708 Unive 't r“ m y This is to certify that the dissertation entitled Posttraumatic Stress Disorder: An Assessment of Hostility and Anger in the Vietnam Veteran. presented by Lawrence Joseph Ledesma has been accepted towards fulfillment of the requirements for Ph.D. degree in Psychology data M Norman Aheles; Ph‘D. Major professor Date f 0[ HQ?— MSU is an Affirmative Action/Equal Opportunity Institution 0-12771 PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE “‘7'“ M49230]. __ [W09 W5 RENE W "time—.2901 II AWE, MSU Is An Affinnetive Action/Equal Opportunity Institution POSTTRAUMATIC STRESS DISORDER: AN ASSESSMENT OF HOSTILITY AND ANGER IN THE_VIETNAM VETERAN By Lawrence Joseph Ledesma A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1988 ABSTRACT POSSTTRAUMATIC STRESS DISORDER: AN ASSESSMENT OF HOSTILITY AND ANGER IN THE VIETNAM VETERAN BY Lawrence Joseph Ledesma The purpose of this study was to examine the direction, focus, and intensity of the anger and hostility currently being experienced by Vietnam combat veterans: with a diagnosis of Posttraumatic Stress Disorder, It was. hypothesized that those with a diagnosis of Posttraumatic Stress Disorder would report more angry and hostile feelings than those with other clinical diagnoses. In addition, it was hypothesized that depression would be a significant symptom associated with Vietnam combat veterans. This study sought to clarify differences between an inpatient and outpatient population of Vietnam combat veterans. It was hypothesized that inpatients would be experiencing a greater degree of psychological dysfunction than the oupatient population. The sample was drawn from a population of veterans who had some form of Veterans Administration contact. Subjects were Vietnam-era veterans having served in the armed forces between 1964 and 1975. They were volunteers randomly drawn from either an inpatient or an outpatient population. Volunteers completed the Minnesota Multiphasic Personality Inventory, the Beck Depression Inventory, the Buss-Durkee Hostility Inventory, the Problem Checklist, and a short demographic form. A total of 120 veterans participated in the study. Results supported the hypotheses presented. Overall, the combat group with a PTSD diagnosis reported significantly higher degrees of anger and hostility. They also reported having current difficulties with depression, guilt, anxiety, suspiciousness, and social isolation. Employment related problems and criminal justice contact were also concerns of veterans experiencing PTSD symptoms. Differences between inpatients and outpatients with a diagnosis of PTSD were less clear. In general, inpatients and outpatients reported experiencing similar life difficulties, but as predicted the inpatient group was experiencing greater degrees of difficulty. The problems of generalizability of results and accuracy of self-report questionnaires were addressed. Copyright by LAWRENCE JOSEPH LEDESMA 1988 ACKNOWLEDGMENTS I would like to thank the members of my committee for their assistance in the completion of this dissertation and their contributions to my graduate career. To Dr. Norm Abeles, who challenged me to think and provided a supportive and open environment in which to do so. To Dr. Ralph Levine, who has made statistics understandable and benign. To Dr. Bert Karon, whose lectures were always captivating, stirring, and motivating. To Dr. Gil DeRath, who opened his home and family to a student far from home and who became my mentor. my friend, and my supporter throughout my graduate career. I am especially indebted to those staff and patients at the various Veterans Administration Medical Centers who provided the utmost cooperation and assistance to me during the collection phase of this research. And finally but most importantly, I would like to extend my deepest gratitude to my wife, Susan. I had a dream as a teenager that one day I would become a psychologist. a therapist. My dream has become a reality due to her encouragement, support, understanding and faith. TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . CHAPTER I. II. III. IV. INTRODUCTION . . . . . . . . LITERATURE REVIEW. . . . . . . Theories of Etiology . . . . . Feelings of Anger and Hostility In the Vietnam Veteran . . . . Depression and Its Relation To Hostility and Depression . . . Problems in Assessing Anger and Hostility . . . . . . . Diagnostic and Research Difficulties Assessment of Posttraumatic Stress Disorder. . . . Hypotheses and Data Analysis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis mmlprH o o o o o o o o o o o o o o o o o o 0 METHOD . Subjects. . Measures. . Procedure . Inpatients . Outpatients. RESULTS . Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis Hypothesis 0 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O anbwthH vi .viii 43 56 50 56 51 51 52 52 54 54 55 58 58 59 60 63 64 70 73 85 V. DISCUSSION . . . . . . . . . . Overview . . . . . . . . . . Assessment of Hostility and Anger . . The MMPI Profile . . . . . . . . Cross Validation . . . . . . . . Inpatient and Outpatient PTSD Groups . Limitations of the Study . . . . . Summary and Conclusion . . . . . . APPENDIX A. BUSS-DURKEE HOSTILITY INVENTORY . . . B. PROBLEM CHECKLIST. . . . . . . . C. DEMOGRAPHIC FORM . . . . . . . . D 0 CONSENT FORM 0 o o o o o o o o E. N, MEANS, AND STANDARD DEVIATIONS OF RAW MMPI SUBSCALE SCORES FOR GROUP 1 (PTSD) VS. GROUP 2 (NON-PTSD) . . . F. N, MEANS, AND STANDARDE DEVIATIONS OF RAW MMPI SUBSCALE SCORES FOR GROUP 1 (INPATIENT) VS. GROUP 2 (OUTPATIENT). G. FACTORS OF THE BUSS-DURKEE HOSTILITY INVENTORY C O O O O O O O O O H. FACTORS OF THE PROBLEM CHECKLIST. . . I. FACTOR ANALYSIS STATISTICS FOR THE PC AND THE BDHI. . . . . . . . LIST OF REFERENCES . . . . . . . . . . . vii 94 94 99 100 102 107 11% 113 117 121 124 125 126 128 130 135 160 LIST OF TABLES Demographic Statistics for the PTSD and Non-PTSD Groups 61 N, Means, and Standard Deviations of T-Scores on the MMPI Subscales for Group I (PTSD) vs. Group 2 (non-PTSD) Multivariate and Univariate Analysis of Variance of the Raw Scores of the MMPI Scales Comparing Combat vs. non-Combat Groups . . . . . . . Means, Standard Deviations, T Values, and l-tail Probabilities Comparing Group 1 (non-PTSD) vs. Group 2 (PTSD) on the modified-BDHI. N, Means, Standard Deviations, and l-tail Probabilities for T Values, the Beck Depression Inventory . Means, Standard Deviations. T Values, and l-tail Probabilities Comparing Group 1 (non-PTSD) vs. Group 2 (PTSD) on the Problem Checklist. . Variable. Wilks' Lambda, F. and Significance Level. . . . Actual Group, Number of Cases. for the Eight Scales . . . Variable, Wilks' Lambda. F, and Significance Level for Scales PTSD, BDI.Anger/Depression, and He viii Predicted Group Membership and Percent of ”Grouped" Cases Correctly Classified 69 71 73 75 76 77 Actual Group, Number of Cases, Predicted Group Membership, and Percent of "Grouped“ Cases Correctly Classified Employing the Scales PTSD, BDI, Anger/Depression, and Hc . . . . Actual Group. Number of Cases, Predicted Group Membership, and Percent of “Grouped" Cases Correctly Classified. and Statistics Employing the MMPI Subscale PTSD. . . . . . . Actual Group. Number of Cases, Predicted Group Membership, and Percent of "Grouped" Cases Correctly Classified, and Statistics Employing the Beck Depression Inventory . . . . Actual Group, Number of Cases, Predicted Group Membership, and Percent of "Grouped" Cases Correctly Classified, and Statistics Employing the Anger/Depression Scale of the Problem Checklist . . . . . . . Actual Group. Number of Cases, Predicted Group Membership, and Percent of "Grouped“ Cases Correctly Classified, and Statistics Employing the BC Subscale of the MMPI . . . . . N, Means, and Standard Deviations of T-Scores on the Subscales of the MMPI for Group 1 (Inpatient) vs. Group 2 (Outpatient) . . . . . . Univariate and Multivariate Analysis of Variance of Raw Scores of the MMPI Comparing Inpatient PTSD vs. Outpatient PTSD Groups . . N, Means, Standard Deviations, T Values, and l-tail Probabilities Comparing Group 1 (Inpatient) vs. Group 2 (Outpatient) on the Subscales of the modified-BDHI . . . . . . . ix 18. Means, Standard Deviations, T Values and 1-tail Probabilities Comparing Group 1 (Inpatient) vs. Group 2 (Outpatient) on the BDI and PC Subscales. . . . . . . . . . . 92 19. Scale, Item, Phi Coefficient, X2, and Significance Level of the Items That Reached Significance on the modified-BDHI. the Problem Checklist and the PTSD Subscale. . . . . . . 93 Chapter I INTRODUCTION The Vietnam War was the longest and costliest war in United States history. Approximately nine million Americans were in the armed forces during the course of the war. Four million Americans were stationed in Indochina and about two million were assigned to the combat zone. It is these two million soldiers, and other military personnel, who are at very high risk for developing combat related Posttraumatic Stress Disorder (PTSD) (Lipkin et al., 1982). Yesavage (1983) estimated that the prevalence of PTSD and other related serious psychological disturbances in Vietnam veterans to be anywhere from 29% to 60%. Walker (1981) believed that the correct figure for those with symptoms of PTSD to be at least 1.5 million and that in the next few years reported cases would increase. In fact, this is what has occurred. Posttraumatic Stress Disorder was included as a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III, 1989). According to the recently revised version, the Diagnostic and Statistical Manual of Mental Disorders, DSM-III—R 1 (DSM-III-R, 1987), any traumatic event that is out of the realm of ordinary human experience such as natural disasters, rape, robbery, and war can cause PTSD symptoms. The disorder requires the following four criteria in order to be diagnosed: (1) the historical antedecent of a traumatic event; (2) a re-experiencing of the event through intrusive memories, dreams, or associations; (3) a decline in involvement with the environment by loss of interest in significant activities, distancing from others, or reduced affect: and (4) two other symptoms that were not present before the trauma including difficulty falling or staying asleep, irritability, difficulty concentrating, hypervigilance, exaggerated startle response, and re-experiencing of the event upon exposure to events that symbolize or resemble the traumatic event (DSM-III-R, 1987). Even though there have been books and articles on the subject, many researchers (Blum et a1., 1984; Lewis, 1975; Silver & Iacono, 1984: Strayer & Ellenhorn, 1975) believe that the hostile and angry feelings of the Vietnam combat veteran’still need to be adequately addressed in the diagnosis, treatment, and understanding of PTSD. Research has pointed towards these symptoms as being important with the veteran population, as well as with other trauma victims. Even though there are many theories and case histories that try to explain the anger of the Vietnam combat veteran, there have not been any well controlled nor psychometrically based studies which specifically address this most important issue. In order for the veteran to recover from the horrors of war, it is deemed important for all their symptoms to be adequately addressed in diagnosis and treatment. The main purpose of this research was, therefore, to assess in Vietnam combat veterans the nature, extent, and severity of angry and hostile feelings. The relationship of these feelings to other symptoms of PTSD were assessed. Vietnam-era veterans with and without a diagnosis of PTSD were included in this study. These veterans completed the following questionnaires: the Minnesota Multiphasic Personality Inventory (MMPI), the Beck Depression Inventory (BDI), the Buss-Durkee Hostility Inventory (BDHI), and the Problem Checklist (PC). It was hypothesized that veterans with a diagnosis of PTSD would report, on the above mentioned questionnaires, significantly more PTSD symptoms, depression, and anxiety than veterans not so diagnosed. It was also hypothesized that those with a diagnosis of PTSD would report more angry and hostile feelings than those without a diagnosis of PTSD on the PC, the BDHI. and the Hostility (HOS), the Overcontrolled hostility (O-H), and the Hostility Control (Hc) scales of the MMPI. And finally, it was also expected to find that the angry and hostile feelings that were reported on the PC, the BDHI, the HOS, the Hc, and the O-H would be significantly related to the symptoms of depression, guilt, and anxiety in both groups, but significantly more in the PTSD group. The veterans were drawn from both an inpatient and outpatient population. Past research has dealt with either an inpatient, an outpatient or a combined inpatient and oupatient population of veterans. It has also combined both populations indiscriminately. Part of this study, therefore, was to clarify any possible differences that may exist between the two groups. It was hypothesized that there would be significant overall differences, on the previously mentioned scales, between the inpatient and outpatient PTSD groups. However, it was hypothesized that the outpatient PTSD population would report, on the hostility scales mentioned above, more specific targets for their angry and hostile feelings than the inpatient PTSD group. It was also hypothesized that the inpatient PTSD group would have more inwardly directed hostile feelings than the outpatient PTSD group. Chapter II LITERATURE REVIEW As mentioned in the introduction, over 1 million combat veterans of the Vietnam War may have symptoms of PTSD. Initially it was believed that Vietnam veterans had a lower incidence of psychiatric symptoms (1.2%) (Bourne, 1969) than among World War II veterans (23%) (Goodwin, 1980). This was partially due to symptoms related to PTSD developing in many veterans several years after their discharge from the service. In fact, reported cases of PTSD did not increase until the late 1970's and early 1988's. Theories of Etiology Many theories have been proposed as to why the disorder is so distinctive and pervasive among Vietnam veterans. Brende (1983) believed that part of the problem could be attributed to the :v::~~cAAnli ‘ t age 3 of the Vietnam veteran (19.6 years) as compared to the average age of the World War II veteran (26 years). Brende reported that the separation from home, and the traumatic events which followed, disrupted the normal path oprsychoiogic l development”in the young‘and'immetume AmeriCan soldier. This was in contrast to the World War 5/” II soldier who was much more psychologically mature when confronted with separation, violence, and death. According to Brende, this maturity served to protect the World War II veteran from longterm psychological difficulties. Others pointed to the abrupt andwindividuelisticsway the.Viatnanmuahanannuns.tnainad-andhdiaaha£ged (Frye & Stockton, 1982). Oftentimes the veteran was not transported to Vietnam with the unit of men with which he trained. In fact, many were shipped individually to Vietnam aboard commercial jets. Walker and Cavenar (1982) felt that this secultedaLghfirlackwofuunit“morale andeidantification. This method also led to lonely and vulnerable feelings. Developing a sense of belonging took many months and when that bond developed between soldiers, it was time to leave for home. Walker and Cavenar also reported that this procedure resulted in the goal of the soldier to be one of survival rather than one of winning. When his enlistment ended, hewusuallyuretunnod to. civilianulifeinithin 1 week. Manywrcport being back at home withinméortyweight henna» This can be contrasted to WoridWWarmIIwwetonaas who both trained and served in units. When they were released from combat duty they spent“weeks,‘sometime5'months,'in'declasSifiCatibn together before being back in civilian clothes. In Vietnam, soldiers were transported from a land of violence and uncertainty to home with family and friends. There was little opportunity to develop a support system within the community or with other vets. Many veterans report being shunned by other veterans and veteran organizations such as the Veterans Of Foreign Wars (VFW). Becausesof their abruptmnetnnnwtowtheir-communities.-theyvetaran.hadrlittle timestoediscusswwithwotherusoldiers.thei; experiences and fisséinSS- Many veterans report being asked by civilians about the war. Many Vietnam veterans felt that civilians couldn't understand the war and so avoided discussing their experiences. sincewtherewwere~nomorganizations for themrt0“discusswtheir«difficulties.wthayaharboredwtheir feelingswuntil~theyueeuldan LQQSQF 99 89. According to Blum et a1. (1984), anothatwcontributing fECtor to the current high rate of PTSD wgsfltflgiLejection andmostracism experienced after returning home. Many of the men who entered the service were outgoing, mature, and trusting individuals (Lewis, 1975). It has been reported that during their time in Vietnam, the American soldier bore up very well psychologically as compared to American soldiers in other wars. The~Vietnamwveteran-assumed that when“they returned from war, 'they would be accepted and ”praised for their contributions to freedom and the American way of life. This did not occur. Lewis (1975) thought their unrealistic expectations often led them to distrust and feel angry towards the civilian population. Many veterans felt extreme alienation on their return stateside (Strayer & Ellenhorn, 1975). The divided sentiment at home was very confusing to the returning veteran (Figley and Leventman, 1980). The veteran returned to a country rejecting his war and his sacrifices. He had no way to justify his part in the war. There were no cheering crowds as there were for veterans of other wars. As one veteran commented (in Strayer & Ellenhorn, 1975): EiUnderstand me, man, I went in as GI Joe, hot i to save America from the Communists. I spent 5 11 months in Nam and got the Bronze Star. Now é I'm back and I find I've been had. I've got . no job and I'm nobody's hero. Sure I'm bitter. Shouldn't I be?" (p.81) The type of warfare and the way it was strategically” conducted by superiors has also been hypothesized to be leading causes of the high rate of PTSD in Vietnam veterans. VietnammwaSWalmost totally a guerrilla war, with the enemy frequently going unseen. :Due to the ever present dangers of guerrilla warfare. the soldier became hypesalaxt. In addition, many veterans felt that they could not trust the Vietnamese people nor their Vietnamese allies in arms. Even children were not to be trusted. Sleep was reduced to a bare minimum. Land was captured from the enemy, only to be abandoned and then recaptured at some later time. Mgnxhggrefilgstmfightingwfor~the same tsggeie. mimwmsantumd and-ft“ * ‘ ‘u Many Vietnam veterans expressed dissatisfaction with their immediate superiors and with the way the war was handled in general (Williams, 1980). These factors, plus thgmgxpgriaaoomofwkillingsotherwhununxbeingss«or: witnessingreomrade3”and~civilians being killed or mutilated,-were“extremeiyattenuatic. Postservice Difficulties Whatever the cause or causes of PTSD, it is a very devastating and debilitating disorder. According to Lipkin et a1. (1982), Elagwproduoes the following alterations in the course of the veteran's life: (1) chronicwanderachieyingsanduinstabilityrinpoducatioaiOr workrwthe veteran findswhimseif~settlingmforwtessvwfor~the duTIhess”that‘he for sd”long“desiredtthIE‘in‘combat, (2) awwaaderingwlifestylechmgoing*fromwjobWtOMjobiwschool.to sehooi7~driftingfwithout‘prOgreSsingwtoward~anyhgoalwuand (3)«ansantisocial~criminalmatting'outrthat'13‘primarily“ a result”not“df”preéexi§ting criminality; but of therstrESs experienced1~v’ The Vietnam combat veteran's interpersonal relationships have also been affected. The percentage of divorces among veterans is higher than in the general 10 population. This may be due to their difficulties in achieving intimacy with a significant other (Lipkin et al., 1982). According to Lipkin et al., they also have trouble relating to their own or other children. These authors stated that this has been traced to the veteran's hearing, seeing, or even personally hurting or killing Vietnamese children. The incidence of substance abuse among Vietnam veterans has also been reported to be higher than the general population (Brende & Parson, 1985; Nace et al., 1978: Penk et al., 1981). Even before the veteran returned home from combat there were many concerns regarding the reported high use of drugs overseas. An 'early report by Postel (1968) reported that fifty-six per cent of his psychiatric population used marijuana in Vietnam. Heroin and alcohol abuse has also been mentioned as problems (Baker, 1971; Nace et al., 1978; Brende & Parson, 1985). There were fears that as the veteran returned home these addictions would continue. Robins (1974) and Nace et a1. (1978) found evidence to the contrary. A review of their articles indicates a continued dependence on substances only by those veterans who were suffering negative affects from the war. At first when this high substance abuse rate was being reported, various explanations were proposed. One explanation was that there was an endless supply of highly ll purified and inexpensive heroin (Baker, 1971). This was reported to be true of various types of drugs. This endless supply theory coupled with the relatively young age of the American soldier far from home were argued as being the major causes for the epidemic proportions of soldiers abusing drugs. Others pointed towards personality characteristics as being the reason for substance abuse. Bey and Zecchinelli (1971) bafiieuadrthat the soldier that was abusing drugs was doing so to cope with identity diffusion, low self- esteem, ego weakness, and shallow object relationships. They disregarded the high levels of stress, life threatening situations, death, bereavement, etc., as being possible contributory factors. 7 , r 1 t It was only until several years later that mental health workers and researchers began to realize that veterans have used substances in futile attempts at self- medication. Lacoursiere, Godfrey, and Ruby (1980) stated that "The acute administration of alcohol relieves many of the symptoms of classical traumatic neurosis" (p.966). Some persons suffering from PTSD have realized that alcohol, and other drugs such as minor tranquilizers, marijuana, and barbituates, relax them and help them to sleep at night. (This use of drugs to alleviate symptoms only leads to a vicious cycle with increased tolerance and dependence on the drug of choice. Chronic 12' use of substances only leads to the exacerbation of the symptoms (Brende & Parson, 1985; Lacoursiere, Godfrey, and Ruby, 1980; Penk et al., 1981). Brende and Parson found that veterans who used alcohol as self-medication reported more problems with intrusive images and unpleasant memories than those who didn't. The authors also noted aggressive outbursts were also more common with those who used alcohol. Drug abuse, therefore, remains a problem for many veterans which eventually effects their personal, social, and employment situations. Veterans report being very disenchanted.and suspicious of any agency that is connected withIthe government they felt betrayed them (Williams, 1988). vMany currently feel that they were not given the help needed at the_time they required it.and so they are against receiving.such help today. Blum and associates (1984) reported that Vietnam veterans were disenchanted with the Veteransvhdministration (VA). One of the most common complaints by the veterans that Blum et al. interviewed was that the MAwuas insensitive to the needs of the “Vietnam veteran. {The veteran, in general, feels alienated and detached from the natural processes of adulthood such as marriage, children, career, and social and political affiliations. This disruption of the maturation process eventually leads , to a loss of social and vocational effectiveness} Brende 13 and Lipkin et a1. noted that the veteran who abused drugs seemed "stuck" at the age they were when they were in the service. For many veterans trying to cope with the horrors of war, the use of drugs for self-medication purposes has been detrimental to their attempt at resocialization. QQEParison of Vietnam Veterans to Those of Previous Wars As stated above, the Vietnam conflict was regarded as a unique war. However, there have been attempts at comparing and contrasting the Vietnam experience with other wars the United States has been involved with in the past. In this section, an attempt will be made to discuss the major findings in this area. Egmparison with World War II veterans. Greenson (1945) described three types of neuroses in World War II veterans resulting from traumatic war experiences which are similar to PTSD in Vietnam veterans. The first he termed a‘fianger-anxiety type, the symptoms of which included startle reactions, nervous trembling, insomnia, and recurrent battle dreams. The second type had symptoms of apathy, submissiveness, and resignation. The final type that Greenson discussed is a guilt laden type. These were the veterans who were very aggressive both during and following combat. Greenson theorized that their aggressiveness”wasiawmeans.—ofreevering-theirwunderlying guilt feelings. l4 Menninger (1946) described the same type of identity change occurring in the World War II soldier as was descibed above with the Vietnam soldier. Menninger reported that the soldier had to give up his identity as an individual and become the member of a team. According to Menninger, this team unity, with the leaders serving as father figures, served to give them permission to kill their enemies. This killing behavior, which was so antithetical in their preservice life, became condoned by the father figure and their society as a whole. According to Menninger, the resultant guilt was shared by the group. This gave the World War II soldier, who was usually in the battle field longer than the Vietnam soldier, a psychological protection which enabled them to goflon performing their~duty. Ironically, this supposed shared guilt and condoning of killing may have ledwto greaterwpsychologioal~damage to the World War II soldier thanmshouldmhavenbeenwallowed. Menninger theorized that posttraumatic stress disorder was due to a combination of traumatic events, varying degrees of soldier predisposition, the peculiar psychological setting of the armed services, and the occurrence of a particular event which precipitates the incapacitating results. Menninger reported that the majority of men who developed posttraumatic symptoms were relatively normal, healthy individuals who were 15 placed in situations of abnormal stress. However, he couldn't quite relinquish the predisposition hypothesis when he stated that "these soldiers must have some predisposition" to developing the disorder (Menninger, 1946, p.203). Blum et a1. (1984) compared Vietnam veterans to World War II and Korean War veterans. Of the 1056 questionnaires mailed, 486 were included in their data base. They~reportedwthat the stress symptoms reported by Vietnamwveteransuwsre_significantly more severe than either of the other two groups. When external adjustment was assessed, such as problems with family, friends, and employment, no significant differences between groups were found. Therefore, Vietnam veterans reported more symptoms, but did not appear to be suffering any social difficulties as a result of these symptoms. Blum and associates reported that a problem with this study was the relatively leng«timo~since the earlier'wars and the difference in a99§vbetwe98 the veterans. Another possible explanation for this difference was that World War II and Korean War veterans come from a different era where the revealing of personal psychological problems was less likely to occur. ngparison with Korean War veterans. Thienes-Hontos and associates (1982) took exception to seeing Vietnam veterans and the Vietnam War as unique. In order to test their theory, these researchers compared the frequency of 16 stress-disorder symptoms reported by Vietnam and Korean veterans in hospital files. The reseachers recognized that there may have been differences in how records were kept. Therefore, the differences in frequencies of a set of non-stress-disorder "control" symptoms was compared to the frequency of stress-disorder symptoms. Twenty-nine veterans from the Korean War and 29 from the Vietnam War were included in the study. The findings were that both groups reported virtually the same amount of stress-disorder symptoms. In addition, the same percentage of Korean War and Vietnam War veterans reported symptoms that fell into the stress-disorder category. The symptoms of constricted affect, memory impairment, and diminished interests were reported significantly more by the Korean War group than the Vietnam group. The Vietnam veterans reported more recurrent dreams. Thearesearchers concluded that the two groups were very similar in the prevalence and nature of the stress symptoms experienced. There appear to be some problems with this study such as: a) using chart reviews, bJ-record'keeping, c) no psychOmetric measures given or assessed, and d) few veterans diagnosed with PTSD (11 Korean War and 7'Vietnam War veterans). The Experience of Tragmatic Events in Other Populations Of course combat veterans are not the only group that can develop PTSD. Anyone who experiences a traumatic life 17 event may do so. In an early article by Warner (1972), an elucidation of the term “traumatic“ syndrome was attempted. Warner identified the common denominators of traumatic experiences to be: (1) Risk of attack or injury, (2) Danger of death and a sense of vulnerability, (3) Family separation and loss, (4) Deprivation, fatigue, hunger, exposure to the elements, torture, and economic social chaos. He further theorized that the premorbid personality, secondary gains, the presence of serious risk to self-preservation, and a reinforcing environment are all factors in the development of symptom severity. He further theorized that the defense mechanisms of wish- fulfilling hallucinations, psychic numbing or closing off, depersonalization, derealization, regression, denial, and identification guilt may be employed by the traumatized individual. One of the earlier studies of the psychological effects on disaster victims was conducted by Raker, Wallace, and Rayner (1956). They found that victims. became less efficient at home and work. Tyhurst (1957) was among the first to categorize the reactions to a disaster into the following stages: impact, recoil, and the posttraumatic period. In a review of the literature, Krupnick and Horowitz (1981) assessed the frequency of ten themes associated with those experiencing a trauma in the case material of 18 30 patients with PTSD. The themes that they assessed were the following: (1) Rage at the Source; (2) Sadness Over Loss: (3) Discomfort Over Vulnerability: (4) Discomfort Over Aggressive Impulses; (5) Fear of Loss of Control Over Aggressive Impulses: (6) Guilt Over Responsibility: (7) Fear of Similarity to the Victim; (8) Rage at Those Exempted: (9) Fear of Repetition: and (18) Survivor Guilt. The patients were either those who suffered a personal loss or personal injury. The authors found that for the bereavement cases, 80% reported Rage at the Source. This was the third most frequent theme cited. The first two were Sadness Over Loss (93%) and Discomfort Over Vulnerability (87%). In the personal injury group, Fear of Repetition and Guilt Over Responsibility were 1 and 2 while Rage at the Source was again the third most frequent theme. The authors were surprised at how frequent the theme of rage was reported in comparison to the themes of fear, sadness, and shame. The authors had expected the latter three themes to be more frequently reported in this population. Wilson, Smith, and Johnson (1985) compared the symptoms of persons involved in rape, combat in Vietnam, serious life-threatening events, divorce, the death of a significant other, near fatal illness, family trauma, multiple traumatic events, and a control group. In order to assess the severity of the symptoms, the Impact of 19‘ Events Scale, the Beck Depression Inventory, the Stress Assessment Scale for PTSD from the Vietnam Era Stress Inventory, and the Sensation Seeking Scale were administered. The researchers sought to assess the effects of stress on the following dimensions of personality: (1) psychosocial development (Erikson, 1982) (2) psychoformative processes (Lifton, 1979); (3) learned helplessness (Seligman & Garber, 1980); and (4) cognitive processing of trauma (Horowitz, 1979). They reported that Vietnam veterans manifest the most PTSD symptoms. The next highest level of PTSD symptoms was exhibited by rape victims. The rape victim had similar scores to the veterans on the Impact of Events Scale. However, their scores on the other scales were somewhat lower. Wilson, Smith, and Johnson concluded that "the severity of PTSD is, in part, a function of the severity of life-threat and bereavement" (1985, p.25). A further finding was that the more loss experienced, the more severe were the symptoms. A four year follow-up of the children from Chowchilla, California who were kidnapped while on their school-bus was conducted by Terr (1983). Terr (1981) had originally studied the children immediately following the traumatic event. The children reported symptoms similar to those mentioned by Horowitz (1979) (i.e. feelings of vulnerability, unusual fears, and intrusive thoughts). 20 Terr found that four years later, the children still exhibited symptoms of PTSD. Even though these other life events are traumatic, the experience of war trauma must be considered an especially severe and unique event (Pearce et al., 1985; Warner, 1972: Wilson, Smith, & Johnson, 1985). DSM-III-R acknowledges that “the symptoms are more severe and are longer lasting" (DSM-III-R, p.248) when the event is man- made, as in the case of war, as opposed to a natural disaster of some kind. Warner (1972) stated that a civilian trauma doesn‘t lead to the total transformation of personality and life style as does a war trauma. As reported in another section of this dissertation, veterans who experienced war related traumatic events reported more current symptoms than those veterans who experienced a non-war trauma (Pearce et al., 1985). Wilson et al. (1985), found that Vietnam veterans had significantly more symptoms than other victims of traumatic events. The Vietnam veteran was exposed daily, and for many months, to very high levels of life threat. The veteran, even though prewarned about becoming attached to other soldiers, felt many instances of loss and bereavement. He was also at times agent and victim of the trauma. He was placed in a situation of high moral conflict. All of these factors, plus the ones mentioned previously as causes of PTSD (e.g. guerrilla warfare, lack 21’ of support upon return, confusion as to reasons for war, being perceived as failures, etc.), serve to explain the high incidence and distinctiveness from other trauma victims. Feelings of Anger and Hostility in the Vietnam Veteran Many reports suggested that one of the major difficulties Vietnam veterans expressed having was in CQDtLolling.their-ang y.fselin s and hostile impulses (Figley, 1978; Hyer et al., 1986: Levy, 1970; Shatan, 1978). Figley noted that rage was one of the six most common themes of the Vietnam veteran. He attributed this rage to feelings of betrayal and manipulation. He also reported that combat veterans were involved in more verbal altercations and had more frequent violent fantasies and daydreams than noncombat veterans. This was a surprising finding to Figley in that the population he assessed was composed of relatively well adjusted, affluent, and educated veterans who had returned to college. Shatan (1978) commented that in his groups rage, and other violent impulses, was one topic of six that repeatedly surfaced. Brende and Parson (1985) noted that many veterans equate interpersonal or socially directed anger, and mental and physical violence with destroying and killing. Many secretly feared losing self-control. This may have led to a self-imposed exile in order to avoid situations where they might have become angry and 22' possibly acted on their service training of attacking perceived aggressors. Brende and Parsons reported that 66% suffer from aggressive outbursts, emotional detachment, and risk-taking behaviors. This same group used substances to control these symptoms. Of these, 33% used marijuana to control their aggressive outbursts. Shatan believed that the veterans indiscriminate rageful impulses were related to the type of training received and warfare experienced. Lifton (1973) identified three different patterns of rage and violence that are related to Shatan's concept. The first of these was a habit of violence. The veteran, who was a young and impressionable young man during his enlistment in the service, had learned that violence was a quick and easy solution. The second was a pervasive feeling of betrayal. As does Figley, Shatan (1978) and Bourne (1969) theorized that their rage was not only tied to feelings of betrayal, but to feelings of manipulation. The veteran was put in a position of killing and suffering many hardships and then ignored on his return stateside. Their rage was expressed in what has been termed a “victims rage”. The last pattern identified was a rage at opening oneself up to family, friends, and acquaintances and then being rebuked. Many veterans reported people asking them naively and callously ”How was it to kill someone?" One veteran reported being sent a box of dog 23 biscuits with a note inside calling him an animal. Others were considered murderers by family and friends. The veteran, on the other hand, feels that he was just doing his job, his duty to his country. In a study by Strayer and Ellenhorn (1975), 40 recently discharged army veterans were assessed using a structured interview, the California F Scale, the Internal-External (I-E) Control Scale, and a sentence completion test. They found that hostility, depression, and guilt were cardinal features of those veterans experiencing severe adjustment problems. Over 49% of the veterans evaluated themselves as strongly hostile while others expressed being more angry and hostile since their combat experiences. Strayer and Ellenhorn reported that their hostility was significantly associated with the intensity of combat the veteran experienced. In their concluding remarks, however, the intensity of the veterans angry and hostile feelings were not addressed. In a more recent study, Silver and Iacono (1984) attempted to assess the criteria for PTSD. In the first part of their two-part study, subjects were all Vietnam combat veterans. There was no control group and subjects were not assessed as to whether or not they met the criteria for PTSD. All subjects filled out a 29 item Likert scaled questionnaire. The questionnaire was then factor analyzed. One of the four factors extracted was 24 termed “Detachment and Anger". The items included in this factor were of a very general nature. In the second part of their study, the researchers compared Vietnam veterans to non-Vietnam veterans using the same scale minus four items that particularly mentioned Vietnam or war experiences. A factor analysis of this data was then computed. The resulting factors this time were termed Depression, Re-experiencing the Trauma, Anger, and Detachment. However, there were only three items included in the Anger category. They were: (1) losing temper easily, (2) having arguments with others, and (3) feeling angry or irritable. The researchers recognized that angry feelings and concerns over loss of impulse control were of major concern to the veteran. In attempting to support the validity of the DSM- III diagnostic criteria, Pearce and associates (1985) also found the symptoms of anger to be a primary concern to veterans. Ninety Vietnam-era veterans were divided into three groups: war-related trauma (e.g. shot at, seeing a friend hit by a grenade), non-war related trauma (e.g. car accident, mugging, large fire) or no trauma. Subjects, however, were not divided into PTSD versus non-PTSD groups. One of the instruments used was a 51 item questionnaire entitled the Problem Checklist. It lists problems characteristic of the diagnostic criteria for PTSD. The 51 items of the questionnaire were factor 25 analyzed. One of the nine factors differentiated was termed Anger/Depression. The results revealed significant differences between groups, with the war-trauma group experiencing significantly more anger/depression than the other two groups. The authors concluded that the: “group of veterans who experienced a war related traumatic event reported currently experiencing more problems than the group who experienced non-war related traumatic events on subscales that assessed mainly affective problems." (p.13) Theories of Etiology Several authors have tried to theorize as to why Vietnam veterans may be experiencing so much anger and hostility as compared to the population in general or as compared to veterans of other wars. Brende (1983) discussed the role of “pathological killer-victim identifications” as one possible cause. According to Brende, the veteran came to identify with the aggressor and the victim. This identity developed through his training and experiences in Vietnam. Aggressiveness and developing a killer personality was idealized in the service (Brende & Benedict, 1988). This identity was intimately tied with the concept of “being a man". The vulnerable combat soldier was very likely to be consumed by the killer identity. Humane feelings were systematically stamped out of the individual during boot 26’“ camp, so that by the time they were sent to Vietnam, they were trained to be unfeeling killers. Shatan (1974) reported that: "when the induction phase of counterguerrilla training succeeds, the soldier patterns himself after his persecutors (his officers)[who encouraged emotional anesthesia by humiliation and maltreatment in basic combat training] and undergoes a psychological regression during which his character is restructured into a combat personality.."(p.9-lfl) Soldiers who did not identify with the aggressor persona had to desensitize themselves to the killing in order to survive. It is only later, when they were able to let themselves recall events, that their angry, hostile, and guilt feelings surfaced. Horowitz and Solomon (1975) believed that this exposure to, and personal acts of violence caused problems in present day reality situations. Combat veterans, as opposed to those with other disorders, know their past history of violence and therefore realize that they are capable of such violence. This, according to the authors, is different from those who merely have fantasized about committing, or witnessing, a violent act. The “obsessional" patient realizes the difference between reality and fantasy and usually has the ability to prevent 27 acting out such fantasies. Horowitz and Solomon believed that this was not so with many of the combat veterans. Howowitz and Solomon stated that: "Some Vietnam veterans may have the damaging knowledge that they have acted violently in the past and this leads to a blurred distinction between what is current fantasy, past reality, or current and future possibility. In other words, there has been a shortening of the conceptual distance between impulse and act, fantasy and reality so that conditioned inhibitions to destructive behavior have been reduced and are difficult to reimpose.“ (p.73) A strong victim identification also developed in many veterans (Brende, 1983). Brende used this concept to account for the physical symptoms and suicidal ideations of many veterans. Brende cited Freud (1917) and Menninger (1946) who believed that a blending of the aggressor/victim identities could occur within the same individual. Brende (1983) and Shatan (1974) believed this was what happened to the Vietnam veteran. Lewis (1975) theorized that veterans were easily stirred to anger with themselves and others in situations which were reminiscent of the extremely vulnerable situations that they experienced in combat. Lipkin et a1. (1982) theorized that due to the relative youth of the 28 veteran, the extreme conditions of combat resulted in the veteran becoming less flexible, anxiety ridden, and overwhelmed by angry, hostile impulses. Levin and associates reported that many of these individuals may come to be overwhelmed by "self-punishing or aggressive urges" (Levin et al., 1975, p.912). In a study which attempted to assess those who did not develop PTSD, Hendin and Haas (1984) sought to define the personal characteristics of veterans which served to insulate them from developing the disorder. They conducted an analysis of 10 veterans whom they believed to be dealing with civilian life without evidence of PTSD symptoms. The studies results were provided through five session clinical evaluations (interview assessments). The authors found that the 16 veterans displayed one or more of the following combat adaptations: (1) Ability to function calmly under pressure, (2) Belief in understanding and judgment, (3) Acceptance of fear in self and others, (4) Lack of excessive violence, and (5) absence of guilt. The authors theorized that this cluster of traits were uniquely suitable to preserving sanity in an unstructured, unstable, and unpredictable environment. Depression and Its Relationship to Hostility and PTSD Many researchers have investigated the relationship between hostility and depression (Aarons, 1969: Freidman, 1970; Weisman et al., 1971). Before researchers attempted 29 to scientifically study this relationship, Freud (1917) and Abraham (1924) theorized about it. Freud basically believed that due to the loss of a significant person, the hostile part of the persons feelings of ambivalence towards that person manifests itself in hatred, sadism, self-reproachment, and self-vilification. Abraham theorized that depression was the result of repressed violent and sadistic impulses.’ Becker and Lesiak (1977) researched the relationships among hostility, personal control, and depression in 58 clinic outpatients. The subjects completed the Rotter Internal-External Control scale, the Beck Depression Inventory, and the Buss-Durkee Hostility Inventory. Becker and Lesiak found that unlike the previous findings of Aarons (1969) and Weisman and Ricks (1966), depressed subjects did not exhibit self-directed aggression. The depressed group reported expressing covert hostility to a greater degree than the non- depressed group. The authors concluded that the less- direct types of hostility are used more readily by those who are depressed. A major problem with this study is that subjects, prior to inclusion, were not diagnosed as being clinically depressed. Schless and associates (1974) attempted to clarify how depressed patients expressed their hostility, whether the hostility was directed internally or externally, and 30 the relationship between hostility and depression. The researchers administered to 27 inpatients diagnosed as depressed the Symptom Check List, the Beck Depression Inventory (BDI), the Buss—Durkee Hostility Inventory (BDHI), the MMPI, and the Osgood Semantic Differential Test. A factor analysis was performed on the data and the following four patterns emerged: a) anxious, guilt ridden, inward turning of hostility wth resentment; b) verbal hostility with negativism; c) anxious, suspicious, resentful, control of hostile feelings: and d) assaultive, verbally abusive outward expression of hostility. In one group of depressed subjects which expressed inward hostility, there was a significant correlation between the degree to which hostility was turned inward and the severity of depression. The group of depressed patients that expressed outward hostility was associated with possessing hystrionic features and resentment. The hostility detected in the depressed group was one of resentment towards an object identified as the cause Of the depression. These results demonstrated to Schless et a1. (1974) that severely depressed patients may exhibit both inwardly and outwardly directed hostility. These authors felt that their results contradicted classic psychoanalytic theories in this area and instead theorized that hostility is a secondary defense to depression. A more recent study by Fava et a1. (1982) reported 31 that the relationship between loss, hostility, and depression was complicated. In patients who had not reported a loss, there was found to be a significant positive correlation between hostility, depression, and paranoid symptoms. A significant positive correlation between those same variables was not found for those who had reported a loss. The incidence of depression has long been known to correlate with combat exposure (Nace et al., 1978; Robins, 1974; Sonnenberg et al., 1985; Strange & Brown, 1970). Sonnenberg, Blank, and Talbott (1985) consider depression and hostility to be integral parts of PTSD even though DSM-III recognized depression only as an associated feature. Nace et a1. (1977) interviewed 202 veterans 8 to 12 months after their return stateside. This subject population was drawn from a sample of over 10,000 soldiers admitted to the two drug treatment centers in Vietnam. Of these 202 subjects, approximately one third were identified by the researchers as clinically depressed. In this study, however, the authors only found a trend between depression and combat exposure. Extent, intensity, and type of combat experience was not assessed. The important issue of loss and bereavement was also not addressed in this study. Helzer, Robins, and Davis (1976) interviewed a random 32 sample of 467 enlisted men returning to this country from Vietnam in 1971. In addition to the interviews, the enlistment records of ninety-nine per cent of the subjects were obtained. The semi-structured interview was composed of a wide range of topics including personal and family history, preservice adjustment, use of illicit drugs, psychiatric symtomatology, and combat experiences. The authors found that significantly more veterans who saw combat, or who lost friends in combat, were experiencing a depressive episode than those men who did not. They also found that 80 per cent of those suffering from a depressive disorder began experiencing the depression before, or shortly upon, their return to the States. This finding, according to the authors, "suggests that depression typically began prior to experiencing difficulties in post-Vietnam readjustment and so increases our suspicions that the combat experience itself was often responsible“ (p.182). Helzer et al. also pointed out that their study was conducted 8 to 12 months after the return of the veterans from Vietnam and thus implied that depression may be a pervasive aspect of PTSD. Helzer, Robins, Wish, and Hesselbrock (1979) conducted a three year follow up study to the Helzer et al. study noted above (Helzer et al., 1976). In this study they were able to compare the veteran group, who were not subjects in the original study, with a matched 33 control group. The control group were men who were eligible to serve but did not do so for a variety of reasons. vThe index group in this study were veterans who served in Vietnam after 1969 and who lived in well populated states. The veterans in this, as in the previous Helzer et a1. study, were not diagnosed with combat fatique or any variation of that disorder. In order to assess the relationship between combat and depression the authors defined combat as: "positive responses to two or more of the three following interview items regarding combat experiences : 1) Did you go on combat patrols or have other very dangerous duty? 2) Were you ever under enemy fire? 3) Were you ever surrounded by the enemy?"(p.527) Helzer et al. found that of the nonwounded combat veterans 14% reported depressive symptoms at some time during the follow up period. In comparing all combat veterans to noncombatants, an 18% to 10% difference was found. This was significant at p < .02. They also found a significant relationship between the number of combat events experienced and the proportion of veterans reporting depressive syndromes. However, they also found that certain preservice factors also played a part in later depression. Rosenheck (1985) reported on what he described as 34 Malignant Post-Vietnam Stress Syndrome (Malignant PVSS). ‘Malignant PVSS has four general features. The features are 1) dramatic violent behavior, 2) social isolation, 3) intense self-loathing, and 4) reexperiencing of the war trauma in extreme physical manners. According to Rosenheck, Malignant PVSS was described as chronic PTSD compounded by ongoing life events that were both stressful and life-threatening. A majority of these individuals eventually seek treatment within the Veterans Administration system. Their treatment, the author contends, is "particularly stormy" (p.167) and endures for some time. The veteran often being transfered from hospital to hospital. The dramatic violent behavior of the veteran is both dramatic and dangerous in nature. It is a behavior fostered by the violence experienced in combat. Many of these veterans violent behavior, according to the author, is associated with flashback experiences. In describing social isolation and intense self-loathing, the author described an individual who was extremely depressed, hopeless, and isolated. The author contended that all four of these signal features were seen together and escalated simultaneously. The author believed that these features were intimately linked and worked in a circular manner. Individuals with Malignant PVSS also meet the 35 criteria for Major Depressive Disorder and Borderline Personality Disorder. Other disorders which were related to PVSS in this article were SchizoPhrenia, Antisocial Personality, Alcoholism, and Somatization Disorder. Rosenheck identified several causes for the development of Malignant PVSS. He reported that the following are the crucial causes for this disorder: 1) a high degree of death immersion in Vietnam, 2) a family and social background in which affective experience was poorly contained and characterictically discharged, and 3) difficulties adjusting to civilian life. Problems in Assessing Anger and Hostility Biaggio and Maiuro (1985) stated that the major problem in this area was that systematic and comprehensive definitions of the terms have not been developed. Spielberger, Russell, and Crane (1983) stated that definitions of the construct of anger and hostility "are ambiguous and sometimes contradictory" (p.161). Early research in this area used projective techniques (e.g. the Rorschach Inkblot Test and the Thematic Aperception Test), clinical interviews, and behavioral observations. Spielberger (1983) believed that the use of projectives in assessing anger was still relatively unreliable and of limited validity. As for behavioral observations, Biaggio and Maiuro reported that not all people responded to the same 36 “ stimuli in the same manner. They also reported that there were problems in interpreting physiological arousal. Emotions can be masked, feigned, or misinterpreted. Furthermore, angry or hostile feelings may not be acknowleded or may be interpreted as fear or repulsion. Biaggio and Maiuro reported that researchers have not been able to find a set of physiological indicators that consistently accompany a certain emotion. Biaggio and Maiuro agreed with Eysenck (1975) that verbal reports are the single most valid and accurate measure of emotional experiences. Biaggio and Maiuro (1983) offered definitions of anger, hostility, and aggression which will be employed in this study. According to these authors, anger is defined as: "a strong emotion or experiential state that occurs in response to a real or imagined frustration, threat,or injustice and is accompanied by cognitions related to the desire to terminate the negative stimulus“. (p.103) It will also be recognized that anger can vary in intensity from a mild irritation to an intense rage (Spielberger, 1983). Hostility will be defined as "a psychological trait characterized by an enduring attitude of anger and/or resentment and a behavioral predisposition to act out aggression" (Biaggio & Maiuro, 1983, p.103). 37 Diagnostic and Research Difficulties Even though this disorder is prevalent in Vietnam veterans and there is clear criteria presented in DSM-III- R, PTSD is still difficult to accurrately diagnose and research. Atkinson et al. (1982) clearly deliniates several problem areas, in part discussed by others, for psychologists trying to work with symptoms of PTSD. These problems could lead to misdiagnosis, overdiagnosis, or confounding of research endeavors. Professional bias against the diagnosis. Atkinson et a1. (1982) reported that a certain number of psychiatrists doubted the validity of PTSD and instead believed that current problems were caused by pre-enlistment difficulties. This belief in a pre-enlistment disposition to the disorder originated in early psychoanalytic concepts of trauma and neurosis. As psychoanalysis grew in popularity, its concepts began to be applied to soldiers returning from World War I. This belief in a predisposition continued through the end of World War II (Boulanger, 1985). As pointed out by Atkinson and associates, however, some psychologists still firmly believe in a predisposition to PTSD. According to Figley (1978), the following factors were more significant than any pre-service characteristics: (1) the nature, quantity, and timing of the trauma, (2) combat cohesion and moral, (3) combat 38 effectiveness, (4) personality factors, (5) the short- and long-term post-trauma environment of the stressed individual, and (6) conveying expectancy of recovery to the affected soldier. Frye (1982) found the following five factors, of which only the last one in any way resembles a “predisposition“ character, that can adequately identify those who were more likely to develop PTSD: (1) Negative perception of family helpfulness upon return to the United States and less talking to family members about Vietnam: (2) Higher level of combat in Vietnam; (3) An external locus of control (post-service); (4) A more immediate discharge from active duty after the war: and (5) A more positive attitude toward the Vietnam War before entering the service. Many other researchers have reported that pre- enlistment characteristics did not play a role in the development of PTSD and should not be the focus of treatment (Boulanger, 1985; Hyer et a1, 1986; Penk et a1, 1981: Solkoff et al., 1986). There has been, according to Atkinson et al., a professional resistence to DSM-III criteria. This problem does not seem to be directly related to DSM-III criteria, but to the requirement by the Department of 39 Veterans Benefits that all of the criteria be met before any compensation can be dispensed. This seems to be less of a present day problem because of increased familiarity with the diagostic criteria. Many professionals, however, still disagree with the criteria stated in DSM-III—R. On the other side of this problem, many examiners are moved to diagnose PTSD even though all the criteria are not met (Atkinson et al., 1982). This can lead to overdiagnosis. PTSD, according to Atkinson et al., has also been misdiagnosed as personality disorder, neurosis, or psychosis. The possibility that PTSD may become complicated by another disorder such as depression, anxiety, substance abuse disorders, or psychosis also exists. Adverse interactional style in claimants and staff. Vietnam veterans usually are extremely sensitive to government agency attitudes and feel that they are treated insensitively by staff members. Atkinson and associates reported that agency staff members should be sensitive to the needs of this population. They suggested that the following efforts be made to mimimize negative reactions: (1) asking national service organization representatives and social workers to tell claimants what to expect in the evaluation and procedural requirements, (2) training clerical and professional personnel, and (3) selecting more flexible staff to make contact with this group. 40 A related problem is what Atkinson et a1. term the "silent" claimant. Because of the veterans sensitivity and deep feelings surrounding their war experience, it is difficult for them to reveal the depth of their combat experiences, or related difficulties, during the usually short hospital intake interviews (Atkinson et al., 1982). Not only must the feelings and concerns of the veteran be addressed, but what also must be acknowledged and dealt with is the impact on the examiner caused by the relaying of this very disturbing material (Atkinson et al., 1982). Atkinson and associates suggested that the issues of the examiner should not go unnoticed. The issues they noted were guilt if they had not served in the war, overempathizing with the veteran, and not wanting to appear part of "the system" that alienated the veteran. Lack of corroborative data. As in many retrOSpective studies of this kind, there is difficulty in acquiring pre-trauma and trauma-related data. This places an overreliance on the veterans self-report. There is a problem with credibility in this area. It has also proved difficult when trying to garner information from the family and friends of veterans. Attempting to elicit information from family members is usually very time consuming and unreliable when doing any subject history studies. As with any other group, this is true in the case of veterans and their families. 41 Exaggeration and falsification of data is also a concern (Atkinson et al., 1982). Many veterans and unenlisted personnel have been exposed to information regarding the Vietnam War. The symptoms of PTSD have been extensively reported in journals, books, and by the media. A novel entitled "A Rumor of War" by Phillip Caputo (1977) provides detailed accounts of the war. These factors may have led to a recent increase of factitious complaints being reported by mental health professionals (Sparr & Pankratz, 1983). A case report by Lynn and Belza (1984) of a Vietnam veteran who was finally diagnosed as Chronic Factitious Disorder with Physical Symptoms may best illustrate this disorder. They reported the case of a 32 year old umemployed man who claimed to be a Vietnam veteran. He presented himself as a paraplegic confined to a wheelchair. He complained of nightmares and flashbacks. He reported that he had a head injury from being shot out of a tree by a sniper. While in the hospital, he underwent one surgical procedure consisting of irrigation and drainage of one of several abscesses of his buttocks. During his stay at the hospital, many inconsistencies came to the attention of the staff regarding his experiences during and subsequent to his military service. When they received a copy of his discharge papers it became clear that he had never been in Vietnam. 42 Confronted with this new evidence, he admitted to fabricating his story. It was later diScovered that due to other fabrications, he had been discharged from the Coast Guard after two months. They reported that he also admitted to having 21 previous hospitalizations at different VA Medical Centers across America. This patient learned to mimic the symptoms of PTSD while at these different VA Medical Centers. Lynn and Belza report that his fabrications were perfect. He had at one time convinced a VA outreach program to hire him as a counselor. Even though a nationwide alert had been issued following his discharge from their hospital, the authors report that he had at least twice more been admitted to VA hospitals. Idiosyncratic disorders. There have been cases of veterans who were not directly involved in combat, but who experienced torturing or provided medical care to wounded soldiers in relative personal safety. These stressors are not life threatening, but nevertheless may cause a delayed stress reaction. When assessing PTSD, Atkinson and associates believed that a wider understanding of what constitutes a traumatic event may be necessary to assist in diagnosis and treatment. Intercurrent civilian stress. Many years have passed since U. S. involvement in Vietnam ended. Because of the delayed stress reaction observed in veterans (sometimes 43 several years passed before the veteran began complaining of symptoms), it is difficult to distinguish between stressful events caused by PTSD or events (e.g. divorce, drug addiction, suicide) that would have occurred irregardless of the combat experience (Atkinson et al., 1982). Assessment of Posttraumatic Stress Disorder Most attempts at assessing the disorder and its symptoms have used self-report questionaires, structured interviews, and more recently, physiological assessments such as EEG's, heart rates, and skin resistence. Rigley (1978) used the Vietnam Veterans Interpersonal Adjustment Questionnaire (VIA) which asks pre- and post-service history. Blum et al. (1984) developed their own needs- assessment questionnaire to measure the occurrence of PTSD, adjustment, and personal attitudes towards the Veterans Administration. Frye and Stockton (1982) designed a 24 item PTSD symptom checklist utilizing a 4- point Lickert scale. Pearce et a1. (1985) used a 51 item questionnaire called the Problem Checklist which lists symptoms characteristics of PTSD. Van der Kolk et a1. (1984) subjected their participants to a 3-5 hour stuctured interview followed by having them fill out the MMPI, the Cornell Medical Index, and the Rorschach. In the same study by van der Kolk and associates, sleep EEG‘s on 2 patients were recorded. They found that 44 traumatic nightmares in PTSD subjects occurred late in the sleep cycle and that the contents of their reported dreams were different in content from longtime nightmare sufferers. PTSD subjects reported nightmares that were connected with events that occurred in Vietnam, while lifelong nightmare sufferers had various dreams of isolation, destruction, and death. Malloy, Fairbank, and Keane (1983) exposed subjects to mild visual and auditory cues of combat while behavioral, cognitive, and physiological measures were being recorded. This tripartite method correctly classified 100% of veterans diagnosed with having symptoms of PTSD from well adjusted veterans and veterans with active psychiatric disorders. This study did not, however, include subjects who may have been faking. Even though these previous studies have been relatively successful in assessing PTSD, many of the assessment methods were developed using small homogenous populations. In many instances these studies were either pilot studies or have not been replicated using a larger population. In other cases, such as the EEG studies and physiological response studies, the procedures are long and costly. Spielberger and Butcher (1985) noted that there are problems with using physiological measures to assess affects experienced. They believed that the technology was not sophisticated enough to eliminate 45 possible subject, environment, and equipment/technique artifacts. Emotional and physiological reactions can be faked, exaggerated, or repressed. In addition, even though there may be a physiological reaction to a stimulus, it is difficult, if not impossible, to ascertain what emotion was being experienced without asking the subject directly. These problems make the application of these methods impractical and of questionable heuristic value. Using the MMPI to Diagnose PTSD It has only been in the past half decade that the MMPI has been consistently used for diagnosing PTSD. In fact, early research (Penk et al., 1981) was negative. In (addition to administering the MMPI, Penk and associates compared 87 combat and 120 non-combat veterans on demographic, family, and military variables. The researchers concluded that the MMPI was not able to adequately differentiate between combat and non-combat groups. This finding was contrary to their initial hypothesis. They felt that the MMPI was not suitable for differential diagnosis when comparing two clinical inpatient groups. Penk et a1. reasoned that any two maladjusted groups can appear equally disturbed on the MMPI. They hypothesized that the MMPI may not be sufficiently sensitive or specific enough to differentiate PTSD frOm other kinds of diagnostic classifications. 46 In 1983, Fairbank, Keane, and Malloy compared the MMPI protocals of three different groups of Vietnam veterans. There were 12 subjects in each group. The groups were: (1) veterans with a reliable diagnosis of PTSD, (2) well-adjusted veterans, and (3) veterans with psychological problems other than PTSD. They found that those in group 1 had an 8-2 profile with significantly higher elevations on all clinical scales (except on scale 5) as compared to group 2. They were also different on scales 1, 3, and 7 from the psychiatric group. As for the validity scales, the PTSD group had an elevated F (M = 75 T) as contrasted with the normal group (M = 53 T) and the psychiatric group (M'= 69 T). The F of the PTSD group was significantly greater than group 2, but not group 3. Keane, Malloy, and Fairbank (1984) sought to replicate and extend their earlier study using a larger subject population. They compared the responses of 100 veterans with a confirmed diagnosis of PTSD to a comparable group of 100 veterans with a disorder other than PTSD. Keane, Malloy, and Fairbank intended on developing cutoff scores and decision rules for making the diagnosis of PTSD using the MMPI. It was also their intention to empirically construct a subscale of items that could discriminate between those with and without PTSD. The subjects were 200 male veterans who were referred 47 for diagnostic assessment. The 100 PTSD subjects were assessed using a structural interview, which in addition to reviewing symptoms of PTSD, reviews military, social, and psychiatric history. In order to attain the 100 PTSD group, over 300 veterans were assessed. The 100 subjects in the control group were diagnosed by psychiatrists and psychologists using DSM-III criteria. The control group consisted of 30 affective disorders, 29 anxiety disorders, 19 personality disorders, and 22 psychotic disordered. The results of their analysis revealed that both groups had similar profiles. The groups peaked on scale 8 (Schizophrenia) and 2 (Depression). The authors stated that the PTSD group, however, produced markedly higher elevations on all clinical scales except scale 5 (Masculinity-Femininity). The PTSD group also scored significantly higher on scale F and lower on scale K. This same group scored significantly higher (M = 37) than did the control subjects (M = 20) on the 49 item PTSD subscale. This subscale was developed by submitting the MMPI responses of both groups to chi-square analysis to determine which items were differentially endorsed. This procedure resulted in the finding of 49 items that produced chi-squares with p values less than .001. A subsequent frequency analysis revealed that the optimal cutting score which separated the PTSD from the control group was 30. Using this cutting score, the subscale was 48 able to correctly classify 82% of both samples. Using a higher cutoff score than the original 30 used in this sample would have resulted in a higher probability of patients displaying PTSD symptoms. According to the authors, scores above 40 would produce a 90% probability of this diagnosis. The authors suggested that higher cutoff scores on the PTSD subscale could be used in the future due to the increased costs and benefits of diagnosing PTSD. In a more recent study, Burke and Mayer (1985) compared 30 Vietnam veterans with PTSD to 30 veterans without PTSD. All subjects were men in their middle thirties. Both groups were newly admitted psychiatric inpatients at the VA Medical Center in East Orange, New Jersey. Burke and Mayer's findings were similar to the Keane et a1. study discussed above. They found that the mean profiles for the two groups were practically identical. Both groups had profiles consistent with a diagnosis of schizophrenia. As in the Keane et a1. study, both the PTSD and the psychiatric patients scored highest on scales 8 and 2 of the MMPI. The PTSD group was described as angry, tense, anxious, worried, grossly confused, alienated, projecting blame, and significantly depressed. On the negative side of this tOpic of consideration is the increased reporting of malingering as reported 49 above. The subjective nature of the criteria used and the widespread proliferation of information on the war lends itself to this increase. The major factors for this increase are the compensations and treatments made available by the government to those who can prove combat related PTSD. Another reason for this increase is the use of PTSD as a defense in seeking acquittals and reduced sentences (Walker, 1981) or as an insanity defense (Sparr & Atkinson, 1986). Walker estimated that 29,000 Vietnam veterans are in state or federal prisons, 37,500 on parole, 250,000 on probation, and 87,000 awaiting trial. A percentage of these may profess having PTSD in order to avoid incarceration. The most effective means for detecting malingering with the MMPI appears to be the Ds scale (Anthony, 1971; Greene, 1980). Other effective scales are the F and F-K -index. Most researchers report the most effective cutoff score using the F scale is an F > 90. This is especially true if L and K scores are less than 50. Greene and Graham reported that an F-K > 9 is indicative of malingering. Using a veteran population, Fairbank and associates reported that an F > 88 and PTSD > 40 was a sign of malingering. Even though their results were significant, the small subject p0pulation and lack of minority subjects serves to limit the generalizability of the results. The MMPI, used in conjunction with other psychometric 50 instruments and an extensive service history, should be proficient at detecting malingering. Despite there being an increase of those trying to “fake" PTSD, most of those seeking treatment are sincere and should be treated with compassion and integrity. Hypotheses and Data Analysis Hypothesis 1. The null hypothesis was assumed in regards to demographic characteristics. Past research has indicated that there are no significant differences on relevant pre-service variables (Emery, 1987; Figley 1978). Therefore, it was expected that there would be no significant differences between the PTSD subjects and the Comparison subjects on the information provided on the demographic information sheet. Hypothesis 2. Past research has shown that veterans with PTSD symptoms score significantly higher on the MMPI clinical scales (Burke & Mayer, 1985; Fairbank, Keane, & Malloy, 1983: Keane, Malloy, & Fairbank, 1984) than veterans without PTSD symptoms. It has also been shown that veterans with PTSD symptoms score significantly higher on the PTSD subscale of the MMPI than veterans without PTSD symptoms. Hypothesis 2, therefore, was the following: that veterans with a PTSD diagnosis (both inpatient and outpatient) would score significantly higher than veterans with another diagnosis (both inpatient and outpatient) on the clinical scales of the MMPI. In 51 addition, those with PTSD (both inpatients and outpatients) would score significantly higher than those without PTSD (both inpatients and outpatients) on the PTSD subscale of the MMPI. A MANOVA and ANOVA was used to test for significance. Hypothesis 3. Past research with veteran (Pearce et al., 1985; Shatan, 1978; Silver & Iacono, 1984: Strayer & Ellenhorn, 1975) and non-veteran populations (Becker & Lesiak, 1977: Fava et al., 1982; Schless et al., 1974) has indicated that individuals with symptoms similar to veterans with PTSD, report difficulty in controlling angry and hostile feelings. Hypothesis 3 was that veterans with a PTSD diagnosis (both inpatient and outpatient) would score significantly higher than veterans with a diagnosis other than PTSD (both inpatient and outpatient) on the Hostility (HOS), the Hostility Control (Ho), and the Overcontrolled hostility (O-H) scales of the MMPI, and on the 7 hostility scales of the BDHI. These three scales were analyzed as part of the Hypothesis 2 MANOVA. gatests were used to test for significance of the BDHI subscales. Hypothesis 4. According to DSM—III-R, depression is an associated feature of PTSD. Several studies have shown that the Vietnam veteran reports a significant degree of depression (Burke & Mayer, 1985; Fairbank, Keane, & Malloy, 1983: Wilson, Smith, a Johnson, 1985). Hypothesis 4 was the following: veterans with a diagnosis of 52 PTSD (both inpatient and outpatient) would report significantly more depression than veterans with other diagnoses (both inpatient and outpatient) on the Beck Depression Inventory. A Tetest was used to test for significance. Hypothesis 5. According to DSM-III-R, the effects of a traumatic event extend to all areas of a traumatized individuals life. Lipkin et a1. (1982) and Pearce et a1. (1985) have shown this to be especially true in the case of a war-related trauma. Hypothesis 5, then, was the following: veterans with a diagnosis of PTSD (both inpatient and outpatient) would report currently experiencing more problems than veterans with other diagnoses (both inpatient and outpatient) on subscales 1, 2, 4, 5, 6, 7, 8, and 9 of the Problem Checklist. Tetests were used to test for significance. Hypothesis 6. Previous research with veterans has not attempted to differentiate between outpatient and inpatient populations. In general, outpatients are considered to be more functional than inpatients with symptoms being less severe. Hypothesis 6 predicted that the same would be true when comparing this veteran population on the above mentioned scales (MMPI, BDI, BDHI, and PC). Appropriate comparisons of the two populations, inpatients with a diagnosis of PTSD and outpatients with a diagnosis of PTSD, were conducted. It was hypothesized 53 that outpatients with a diagnosis of PTSD, would endorse significantly more items that identify specific targets for their angry and hostile feelings than the inpatient PTSD group. It was expected to find that inpatients would also endorse significantly more items that identify inwardly directed hostile thoughts and feelings. A MANOVA and ANOVA was conducted on the clinical and special scales of the MMPI. T—tests were conducted on the BDHI, BDI, and PC. A Phi-Coefficient and x2 was then conducted on the items of the BDHI, the PC, and PTSD subscale. In addition to the above hypotheses and statistics, a series of discriminant analyses were conducted on the data in order to determine which variable, or variables, could best be utilized to identify subjects with PTSD. A factor analysis was conducted on the BDHI and the PC data. It was hypothesized that the major factors found would support the DSM-III-R criteria. Chapter III METHOD Subjects The sample was drawn from a pOpulation of veterans served by several Veterans Administration Medical Centers. Subjects were all Vietnam-era veterans having served in one of the branches of the armed forces between 1964 and 1975. Participants were both inpatients and outpatients currently receiving psychiatric services. All subjects were volunteers who were asked by the staff, their therapist, or by the Principal or Co-Investigator, if they would like to participate in a study. They were informed that their participation would not affect their treatment in any way nor would their identities ever be revealed. They were also informed that their results would remain anonymous and that a subject code number would be the only identifier once they returned the forms. ‘ There were a total of 120 veterans who participated in the study. Of that total 60 were veterans with a diagnosis of PTSD and 60 had been diagnosed with some other disorder. Of the 60 subjects in each group, 30 were currently inpatients and 30 were being seen on an outpatient basis. Subjects in the PTSD Vietnam-era 54 55 .. veteran's group were individuals, both inpatient and outpatient, who currently carried a PTSD diagnosis. Subjects in the PTSD group had all seen active combat in the military during the Vietnam War. Combat being defined in this study as firing a weapon at an enemy, seen or unseen, being fired upon, witnessing or perpetrating the death or injuring of another individual or some other related trauma of warfare. Subjects in the non-PTSD Vietnam-era veteran's group were individuals, both inpatient and outpatient, who were recently assessed with a diagnosis other than PTSD. Veterans in the comparison group were Vietnam-era veterans stationed outside the area of combat. No comparison group subject ever fired a weapon on an enemy, seen or unseen, nor was fired upon, nor witnessed recently wounded or dead individuals or any other trauma of warfare. Individuals with a diagnosis of schizophrenia and/or organic brain disorder were ineligible for inclusion into the study. All diagnoses were made using DSM-III-R criteria. Measures All individuals who agreed to participate were given the Minnesota Multiphasic Personality Inventory, the Beck Depression Inventory (Beck et al., 1961), the Buss-Durkee Hostility Inventory (Buss & Durkee, 1957), and the Problem Checklist (Pearce et al., 1985). The Beck Depression Inventory, the Buss-Durkee Hostility 56 " Inventory, and the Problem Checklist are reviewed below. The Beck Depression Inventory is a 21-item self- report questionnaire which assesses the severity of depression. The 21 items are composed of four self- evaluative statements scored from 0 to 3, with the higher number indicating greater severity of depression. A score is arrived at by simply summing the scores. There are four general levels of depression used. They are the following: 0-9 indicating a normal nondepression state, 10-15 indicating a mild depression, 16-23 a moderate depression, and 24-63 a severe depression. Shaw, Vallis, and McCabe (1985) report the split-half reliability to range from .58 to .93. They also report item-total correlations of .22 to .86, with the average being .68. Shaw et a1. (1985) report concurrent validity of the BDI with clinician's ratings of depth of depression in the range of .62 to .77. The Buss-Durkee Hostility Inventory (Appendix A) is a 75-item true/false self—report questionnaire that attempts to assess various types of hostility. The developers of this inventory believed that other hostility inventories were of limited clinical utility due to their describing only global estimates of hostility. Buss and Durkee (1957) hypothesized that there are many forms of hostility and classified them into the following areas: (1) Assault, (2) Indirect Hostility, (3) Irritability, (4) Negatism, 57" (5) Resentment, (6) Suspicion, and (7) Verbal Hostility. A Guilt variable was added because of the authors interest in it in relation to the 7 hostility areas. An original scale of 105 items was administered to college students. Of these 105 items, only those that met frequency and internal consistency were retained. Only 60 items remained from the original version. Items then were added and some reworded. Another administration of the scale was conducted. An item analysis was computed and the present 75-item scale was finalized. The Problem Checklist (Pearce et al., 1985) is a 51 item self-report questionnaire which lists psychological problems characteristic of the diagnostic criteria of PTSD. The PC (Appendix B) was developed by having the subjects in the study check off the items on the questionnaire that applied to them. A component analysis was performed on the 51 items. The PC was divided into the following nine different factors: (1) anger/depression, (2) emotional numbness/withdrawal, (3) problems related to combat experiences, (4) anxiety/cognitive problems, (5) interpersonal difficulties, (6) schizoid tendencies, (7) job problems, (8) drug abuse/money management problems, and (9) criminal behavior. The scale is scored by summing the items checked under each factor. A conversation with the developers of the scale, who are at the Veterans 58 Administration Medical Center in Topeka, Kansas, revealed that current assessment of the reliability and validity of the scale is very promising. In addition to the questionnaires, a short Demographic Form (Appendix C) was completed. The information requested on the demographic form was obtained from either the patient themselves, the patients' file, or from the assistance of the patients' primary therapist. The questions on the form ranged from pre- service psychiatric history to current marital status. Procedure Inpatients. Inpatients were assessed by the staff psychiatrist, psychologist, or social worker upon admission to a ward. The average length of inpatient stay at the Veterans Administrations utilized was approximately 4-6 weeks. Patients who met the above stated inclusion criteria were asked by the principal, co-prinicipal or research assistant if they would agree to volunteer for this study. They were informed that the study was an effort to understand the present difficulties that Vietnam veterans were facing. They were also told that their results would be anonymous, but that they could request results of the questionnaires if they so desired. If the patient agreed to participate, they first completed a standard consent form (Appendix D) and then were given the above mentioned questionnaires to complete. The average 59 time spent completing the forms was two and one-half to three hours. Patients were able to ask for assistance in completing the forms at all times. Outpatients Outpatients who met the above mentioned criteria were acquired in a manner equal to inpatients. After being given the name of a potential subject by the patients primary therapist, outpatients were contacted by telephone, letter, or in person. As with inpatients, they were briefly informed of the study and informed of their rights. If they agreed to participate, they completed the identical forms as the inpatients. These subjects were outpatients from several Veterans Administration outpatient clinics. Oupatients were clients who were in outpatient treatment for at least the previous 2 months. The length and consistency of therapy contact varied as well as the variety of psychotherapy intervention employed. Some veterans were in individual therapy, others in group therapy, several were in family therapy, with still others in some combination of the above. Chapter IV RESULTS Hypothesis 1 The null hypothesis was assumed for the demographic information. An analysis of the demographic information revealed that there were few significant differences between the PTSD and non-PTSD groups. Table 1 presents the demographic information. As Table 1 indicates, there were no significant differences between PTSD and non-PTSD veterans on the majority of demographic variables. Insert Table 1 about here Six items showed significant differences between the PTSD and non-PTSD groups. The item “Age of Entry Into Service" (t(118) = 2.55, p < .01), with the PTSD group having begun their service at an earlier age (M = 18.4) than the comparison group (M = 19.4), had a significant difference. Significantly more PTSD subjects (75%) were service connected than non-PTSD subjects (x2(1, M = 120) = 24.3, E < .001). Non-PTSD subjects (50%) were diagnosed with a Mood Disorder significantly more than PTSD (6.7%) subjects 60 Table l 61 Demographic Statistics for the PTSD and Non-PTSD Groups PTSD S's Non-PTSD S's Variable N=60 N=60 Diagnosis Alcoholism 28.3 28.3 Substance Abuse 8.3 5.0 Personality Disorder 25.0 36.7* Mood Disorder 6.7 50.0 Anxiety Disorder 1.7 1.7 Marital Status * Single 5.0 26.7 Married 46.7 30.0 Separated 8.3 8.3 Divorced 35.0 36.7 Widowed 0.0 3.0 Ethnic Origin Asian 0.0 0.0 Black 10.0 16.7 Hispanic 1.7 1.7 Native American 0.0 1.7 White 86.7 81.7 Other 0.0 0.0 Highest Grade Completed (Mean) 12.7 14.8 * Age While In Service (Mean) 18.4 19.4 Dates of Service (Mean) From '65.6 '66.7 End '70.6 '70.2 Honorable Discharge 100.0 100.0 Service Connected * Disability 75.0 28.3 Presently on Medication Yes 61.4 60.0 No 38.3 40.0 62 Table l (cont'd) If yes, What type Major Tranquilizor Minor Tranquilizor Antidepressant Antabuse Past Medication Use Yes NO If yes, What type Major Tranquilizor Minor Tranquilizor Antidepressant Antabuse Psych. Hosp. Previous To Service Psych. Hosp. During Service Psych. Hosp. After Service Outpatient Treatment Previous to Service Outpatient Treatment During Service Outpatient Treatment After Service Family History for Psychiatric Illness Criminal Record Before Service Criminal Record After Service Pending Court Date 10.0 15.0 35.0 1.7 53.3 46.7 11.7 11.7 30.0 0.0 0.0 10.0 60.0 5.0 16.7 66.7 11.9 0.0 45.8 8.3 16.9 51.7 10.2 16.9 78.0 6.8 Note. Results are presented as percentages unless * otherwise indicated. B < .05 63 (x2(1, g = 120) = 25.6, B < .001). Non-PTSD subjects (32.2%) also reported more psychiatric histories in the families (x2(l, g = 118) = 5.97, B < .05), than the PTSD group (11.9%). In response to the question "Criminal Record After the Service“, more PTSD veterans (45.8%) responded in the affirmative than the non-PTSD group (15.3%) (x2(1, g = 118) = 11.6, 2.‘ .001). Significantly more of the comparison group (26.7%) reported being single (x2(1, g = 120) = 13.1. E.‘ .01) than PTSD subjects (5.0%). Table 1 presents the material as percentages unless otherwise indicated. Some of the percentages in a category had a sum greater than 100% due to a "yes" response in more than one subcategory. Hypothesis.2 Hypothesis 2 predicted that veterans with a diagnosis of PTSD (both inpatient and outpatient) would score significantly higher than veterans with other diagnoses (both inpatient and outpatient) on the clinical scales of the MMPI. In addition, it was predicted that those with a PTSD diagnosis (both inpatient and outpatient) would score significantly higher than veterans without PTSD (both inpatient and outpatient) on the PTSD subscale of the MMPI. In order to test this hypothesis, a multivariate analysis of variance and univariate analysis of variance were computed. Results supported the hypotheses 64 with only two exceptions. Table 2 presents the T-score Insert Table 2 about here means and standard deviations. Table 3 presents the results of the MANOVA and ANOVA. There were no significant Insert Table 3 about here differences found between the groups on scales 5 (Masculinity-Femininity) and 9 (Hypomania). Raw score means and standard deviations for the validity scales as well as the clinical scales and special scales can be found in Appendix E. Hypothesis 3 Hypothesis 3 predicted that veterans with a PTSD diagnosis (both inpatient and outpatient) would score significantly higher than veterans with other diagnoses on the Hostility Control (Hc), the Manifest Hostility (HOS), and the Overcontrolled hostility (O-H) scales of the MMPI. The same was predicted for the 8 scales of the Buss-Durkee Hostility Inventory (BDHI). Two different statistical analysis were conducted on the data in order to evaluate this hypothesis. The variables Hc, HOS, and O-H were analyzed as part of the multivariate analysis of variance executed for Hypothesis 65 Table 2 N, Means, and Standard Deviations of T-Scores on the MMPI Subscales for Group 1 (PTSD) vs. Group 2 (non-PTSD) Group 1 vs. Group 2 Variable N Mean Standard Dev. L Group 1 57 48.79 6.30 Group 2 60 49.28 6.48 F Group 1 57 88.14 19.97 Group 2 60 71.18 16.69 K Group 1 57 45.11 7.37 Group 2 60 51.22 9.49 Hs Group 1 57 80.84 16.51 Group 2 60 69.48 17.29 D Group 1 57 93.86 17.47 Group 2 60 80.13 19.64 Hy Group 1 57 74.53 9.92 Group 2 60 69.98 11.76 Pd Group 1 57 84.51 11.14 Group 2 60 77.78 12.79 Mf Group 1 57 64.65 9.77 Group 2 60 68.17 12.16 Pa Group 1 57 80.70 14.91 Pt Group 1 57 (86.70 15.46 Group 2 60 77.85 16.20 Sc Group 1 57 101.66 21,97 Group 2 60 82.35 23.83 Ma Group 1 57 70.32 11.25 Group 2 60 64.93 13.12 Si Group 1 57 68.44 10.93 Group 2 60 60.45 13.68 Table 2 (cont'd) PTSD Group HOS Group Group Group Group Group KJH KJH NH 57 60 57 60 57 60 60.39 46.98 58.91 53.20 49.39 53.20 14.01 13.61 12.58 9.41 12.06 9.41 67 Table 3 Multivariate and Univariate Analysis of Variance of the Raw Scores of the MMPI Scales Comparing Combat vs. non- Combat Groups Univariate Analysis of Variance Variable Hyp. 88 Error SS Hyp. MS Error MS F F Sig. L 2.65 557.83 2.65 4.85 0.55 .462 F 1792.83 8806.86 1792.83 76.58 23.41 .001 K 271.91 2158.85 271.91 18.77 14.48 .001 HS 637.06 5227.86 637.06 45.46 14.01 .001 D 842.15 6554.63 842.15 56.99 14.77 .001 Hy 249.86 3961.06 249.86 34.44 7.25 .008 Pd 245.09 3108.88 245.09 27.03 9.07 .003 Mf 93.33 3751.90 93.33 32.63 2.86 .093 Pa 400.55 2801.93 400.55 24.36 16.44 .001 Pt 644.02 7613.12 644.02 66.20 9.73 .002 Sc 3220.00 17305.81 3220.00 150.49 21.40 .001 Ma 64.16 4232.91 64.16 36.81 1.74 .189 Si 1456.82 16141.81 1456.82 140.36 10.38 .002 PTSD 3871.08 12515.23 3871.08 108.83 35.57 .001 HOS 539.82 5584.49 539.82 48.56 11.12 .001 O-H 0.02 2095.97 0.02 18.23 0.00 .999 HC 685.84 4081.41 685.84 35.50 19.32 .001 WSGX'EEQE'EQ;"'52132"§£§22'§~"§§ET'§"E2;T'BEméig. Wilks 0.670 2.868 17.00 99.00 68 2. The eight scales of the Buss-Durkee Hostility Inventory were analyzed using Estests. The results of the analyses supported Hypothesis 3. Table 3 indicates that there was a significant difference on the variables HOS and Ho with the index group scoring significantly higher than the comparison group. There was no significant difference found between groups on the variable O-H. Due to its relatively infrequent use, a reliability analysis was first conducted on the BDHI. It was found that several items were negatively correlated with other subscale items. In order to make the scales as reliable and valid as possible, those items that were negatively correlated with the other items within a scale were eliminated. The following are the items that were eliminated from further statistical analyses: 1, 10, 17, 21, 27, 28, 39, 67, 71, and 72. The questionnaire with the remaining 65 items will be referred to as the modified-BDHI for the rest of the text. The Estest results of the modified-BDHI are presented in Table 4. .There was a significant difference in the expected direction on scales Assault, Irritability, Insert Table 4 about here Resentment, Suspicion, Verbal Hostility, and Guilt of the modified-BDHI. 69 Table 4 Means, Standard Deviations, T Values, and 1-tail Probabilities Comparing Group 1 (non-PTSD) vs. Group 2 (PTSD) on the modified-BDHI I—tests Variable Mean St. Dev. T Value 1-tail_prob. Assault Group 1 3.77 1.98 -5.79 0.001 Group 2 5.80 1.87 Indirect Hostility Group 1 4.80 1.66 0.12 0.454 Group 2 5.65. 1.53 Irritability Group 1 5.22 2.35 -5.62 0.001 Group 2 7.35 1.76 Negativism Group 1 1.88 1.42 -1.08 0.145 Group 2 2.17 1.45 Resentment Group 1 3.68 2.30 -2.06 0.021 Group 2 4.48 1.94 Suspicion Group 2 5.65 2.06 Verbal Hostility Group 1 6.27 2.88 -3.09 0.001 Group 2 7.80 2.54 ' Guilt Group 1 5.03 2.48 -1.98 0.025 Group 2 5.92 2.41 Note. Group 1: M = 60; Group 2: M = 60. 70 Hypothesis 4 It was predicted by this hypothesis that those veterans with a diagnosis of PTSD (both inpatient and outpatient) would report significantly more depression than veterans with other diagnoses (both inpatient and outpatient) on the Beck Depression Inventory. A E-test was conducted in order to test this hypothesis. Results of the Estest are shown in Table 5. As the table indicates, the mean score of the PTSD group (M = 33.07) was significantly higher than the mean score of the Comparison group (M = 19.63), (5(118) = -5.09, p < .001). Hypothesis 4 was thus supported by the results. Insert Table 5 about here Hypothesis 5 It was expected to find that due to the generalized after-affects of combat, combat veterans would experience significantly more life difficulties as measured by the Problem Checklist. Therefore, Hypothesis 5 predicted that combat veterans would report significantly more problems on subscales 1, 2, 4, 5, 6, 7, 8, and 9 of the Problem Checklist. Estests were conducted on these variables to test for significance. As predicted, the combat group reported significantly more problems than the non-combat comparison group as 71 Table 5 N, Means, Standard Deviations, T Values, and l-tail Probabilities for the Beck Depression Inventory Group 1 (non-PTSD) vs. Group 2 (PTSD) Variable N Mean St. Dev. T Value 1-tail Prob. Beck Group 1 60 19.63 14.58 -5.09 0.001 Group 2 60 33.07 14.31 72 measured by the Problem Checklist. Subscales 5 (Interpersonal Problems) and 8 (Drug Abuse/Money Management Problems) were the two lone exceptions. Table 6 presents the means, standard deviations, T Values and 1-tail probabilities of the eight subscales for the two groups. Insert Table 6 about here In order to ascertain the most effective means for differentiating between the PTSD and non-PTSD groups, a stepwise discriminant analysis was conducted. Scales that were found to have significant differences between the PTSD and the Comparison groups were employed. The following scales were initially utilized: 1) Hypochondriasis (Hs), 2) Depression (D), 3) Paranoia (Pa), 4) Schizophrenia (Sc), 5) PTSD, 6) Manifest Hostility (HOS), 7) Hostility control (Hc), 8) Beck Depression Inventory (BDI) 9) Assault, 10) Irritability, 11) Suspicion, 12) Verbal Hostility, 13) Anger/Depression, l4) Emotional Numbness/Withdrawal, and 15) Schizoid Tendencies. Of these variables, scales 9, 5, 7, 1, 10, 3, 2, and 6 accounted for most of the discriminatory ability of the analysis. According to the stepwise method further analysis was completed with these eight variables. 73 Table 6 Means, Standard Deviations, T Values, and 1-tai1 Probabilities Comparing Group 1 (non-PTSD) vs. Group 2 (PTSD) on the Problem Checklist z-tests Variable Mean St. Dev. T Value 1-tail prob. Anger/Depression Group 2 8.45 2.84 Emotional Numbness Group 1 3.80 2.37 -5.00 0.001 Group 2 5.65 1.61 Anxiety/Cog Prob. Group 1 4.40 2.23 -2.36 0.010 Group 2 5.30 1.93 Interpers. Diff. Group 2 3.13 1.52 Schizoid Tendencies Group 1 1.65 1.29 -3.92 0.001 Group 2 2.52 1.13 Job Problems Group 1 1.28 1.14 -1.76 0.040 Group 2 1.65 1.18 Drug Abuse/ Money Problems Group 2 1.73 1.40 Criminal Behavior Group 1 0.50 0.85 -2.90 0.002 Group 2 1.00 1.03 Note. Group 1: M = 60; Group 2: M = 60. 74 Table 7 presents the results of the discriminant analysis. As the table indicates, the variables employed Insert Table 7 about here had relatively high Wilks' Lambda, high F's and levels of significance less than p < .01. Table 8 presents the classification results. As the table indicates, the eight scales correctly classified 76.07% of the cases. It also shows that 82.5% of the Insert Table 8 about here Combat group were correctly classified using these scales. However, only 70% of the Noncombat group were correctly classified. It was next decided that further discriminant analyses would be conducted on the scales which directly addressed the PTSD symptomology focused on in this study. Scales PTSD, BDI, Anger/Depression, and Ho were thus) analyzed. The scale, Wilks' Lambda, F, and significance levels are presented in Table 9. Insert Table 9 about here Table 7 75 Variable, Wilks' Lambda, F, and Significance Level Discriminant Analysis Variable Wilks' Lambda F Significance Coefficient Assault 0.762 35.92 0.001 0.79 PTSD 0.764 35.57 0.001 0.77 Anger/De. 0.798 29.10 0.001 0.64 Irritability 0.795 29.60 0.001 0.60 BDI 0.816 25.89 0.001 0.58 So 0.843 21.40 0.001 0.58 Hc 0.856 19.32 0.001 0.57 D 0.886 14.78 0.001 0.56 Emo. Numbness 0.828 23.92 0.001 0.55 HOS 0.912 11.12 0.001 0.54 Suspicion 0.858 18.98 0.001 0.52 Hs 0.891 14.01 0.001 0.48 Verbal Host. 0.922 9.66 0.002 0.44 Pa 0.875 16.44 0.001 0.42 Schizoid Tend. 0.868 11.52 0.001 0.41 76 Table 8 Actual Group, Number of Cases, Predicted Group Membership and Percent of "Grouped" Cases Correctly Classified for the Eight Scales Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 42 18 70.0% 30.0% Combat 57 10 47 17.5% 82.5% Percent of "Grouped“ Cases Correctly Classified: 76.07% 77 Table 9 Variable, Wilks' Lambda, F, and Significance Level for Scales PTSD, BDI, Anger/Depression, and Hc Discriminant Analysis Variable Wilks' Lambda F Significance Coefficient PTSD 0.764 35.57 0.001 0.90 Anger/De. 0.798 29.10 0.001 0.81 BDI 0.816 25.89 0.001 0.77 Hc 0.856 19.32 0.001 0.66 78 Using these four variables to discriminate between groups, a slightly smaller percentage (74.36%) of subjects were correctly classified. Table 10 presents the Insert Table 10 about here classification results. In addition, a slightly smaller percentage of Combat cases were correctly classified. Individual discriminant analyses were performed on the scales PTSD, BDI, Anger/Depression, and Hc. Using the MMPI subscale PTSD, 70.94% of the cases were correctly classified. The classification results are presented in Table 11 as well as the Wilks' Lambda, F, and significance levels. Insert Table 11 about here The Beck Depression Inventory was then analyzed. As Table 12 presents, by using the BDI alone less cases Insert Table 12 about here were correctly classified. Only 68.3% of the Combat group and 66.7% of the Noncombat group were correctly classified using the BDI. Table 13 presents the discriminant analysis of 79 Table 10 Actual Group, Number of Cases, Predicted Group Membership, and Percent of "Grouped" Cases Correctly Classified Employing the Scales PTSD, BDI, Anger/Depression, and Hc Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 41 19 68.3% 31.7% Combat 57 11 46 19.3% 80.7% Percent of "Grouped" Cases Correctly Classified: 74.36% 80 Table 11 Actual Group, Number of Cases, Predicted Group Membershipy Percent of "Grouped" Cases Correctly Classified, and Statistics Employing the MMPI Subscale PTSD Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 39 21 65.0% 35.0% Combat 57 13 44 22.8% 77.2% Percent of "Grouped" Cases Correctly Classified: 70.94% Wilks' Lambda F Significance 81 Table 12 Actual Group, Number of Cases, Predicted Group Membership, Percent of “Grouped" Cases Correctly Classified, and Statistics Employing the Beck Depression Inventory Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 40 20 66.7% 33.3% Combat 60 19 41 31.7% 68.3% Percent of "Grouped“ Cases Correctly Classified: 67.50% 82 the Anger/Depression Scale of the Problem Checklist. As the table indicates, 70.83% of the cases were correctly Insert Table 13 about here classified. A high percentage of Combat cases (76.7%) were correctly classified. The final discriminant analysis performed was on the Ho subscale of the MMPI. The results were similar to previously reported results in this study. The percent of the total cases correctly classified was 66.67%. Table 14 presents the results of the analysis. Insert Table 14 about here. A factor analysis was conducted on the BDHI and the PC. It was hypothesized that the major factors found would be similar to the original factors and would assist in the description of the population studied. A total of 22 factors were found for the BDHI. Most of the variance was accounted for by the first four factors. These four factors of the BDHI are presented in Appendix F. As for the PC, a total of 10 factors were found. As with the BDHI, most of the variance was accounted for by the first four factors. The four factors generated are presented in Appendix G. 83 Table 13 Actual Group, Number of Cases, Predicted Group Membership, Percent of "Grouped" Cases Correctly Classified, and Statistics Employing the Anger/Depression Scale of the Problem Checklist Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 ' 39 21 65.0% 35.0% Combat 60 14 46 23.3% 76.7% Percent of "Grouped" Cases Correctly Classified: 70.83% 84 Table 14 Actual Group, Number of Cases, Predicted Group Membership, Percent of "Grouped" Cases Correctly Classified, and Statistics Employing the Ho Subscale of the MMPI Classification Results Actual Group No. of Cases Predicted Group Membership Noncombat Combat Noncombat 60 36 24 60.0% 40.0% Combat 60 16 44 26.7% 73.3% Percent of "Grouped" Cases Correctly Classified: 66.67% Wilks' Lambda F Significance 85 Hypothesis 6 Hypothesis 6 predicted that outpatients with a diagnosis of PTSD would present as less pathological on the questionnaires than inpatients with a diagnosis of PTSD. Thus the outpatient population was predicted to score in the less pathological direction on the scales mentioned in the previous four hypotheses. It was also hypothesized that outpatients with a diagnosis of PTSD would endorse significantly more items that identify specific targets for their angry and hostile feelings than inpatients with a diagnosis of PTSD. It was further predicted that inpatients with a diagnosis of PTSD would endorse significantly more items that identified inwardly directed hostile thoughts and feelings. A MANOVA and ANOVA were conducted on the MMPI data. The T-score means and standard deviations are presented in Insert Table 15 about here Table 15. The results of the univariate and multivariate analysis of variance that was executed in order to analyze the clinical scales of the MMPI, and the MMPI subscales PTSD, O-H, HOS, and the Ho are presented in Table 16. The results of the MANOVA showed a significance level of only py< .137. The only significant differences between groups were found on scale 7 (Psychasthenia) and 0 86 Table 15 N, Means, and Standard Deviations of T-Scores on the Subscales of the MMPI for Group 1 (Inpatient) vs. Group 2 (Outpatient) Group 1 vs. Group 2 Variable N Mean Standard Dev. L Group 1 30 49.66 7.22 Group 2 27 47.81 5.03 F Group 1 30 89.23 17.88 Group 2 27 86.93 22.34 K Group 1 30 43.90 6.39 Group 2 27 46.44 8.24 Hs Group 1 30 79.07 13.71 Group 2 27 82.81 19.34 D Group 1 30 97.77 12.52 Group 2 27 89.52 21.10 Hy Group 1 30 73.80 9.33 Group 2 27 75.33 10.66 Pd Group 1 30 85.47 10.38 Group 2 27 83.44 12.04 Mf Group 1 30 65.77 9.35 Group 2 27 63.41 10.26 Pa Group 1 30 81.90 13.65- Group 2 27 79.37 16.36 Pt Group 1 30 90.73 11.53 Group 2 27 82.22 18.08 Sc Group 1 30 105.77 16.97 Group 2 27 97.11 26.02 Ma Group 1 30 70.10 11.12 Group 2 27 70.55 11.60 Table 15 (cont'd) Si PTSD HOS Hc Group Group Group Group Group Group Group Group Group Group NH NH NH NH NH 30 27 30 27 30 27 30 27 30 30 87 71.73 64.78 64.97 55.29 61.50 56.04 51.50 47.04 18.97 15.63 8.27 12.43 6.54 17.99 8.40 15.68 10.49 13.41 3.93 8.39 Table 16 88 Univariate and Multivariate Analysis of Variance of Raw Scores of the MMPI Comparing Inpatient PTSD vs. Outpatient PTSD Groups Univariate Analysis of Variance Variable tup. SS Error SS Hyp. MS Error MS F F Sig, L 3.99 194.99 3.99 3.55 1.12 .294 F 20.46 5247.46 28.46 95.41 8.21 .645 K 25.48 839.26 25.40 15.26 1.66 .282 Hs 28.38 2328.97 28.30 42.28 8.67 .416 D ~151.99 2785.88 151.99 49.18 3.89 .884 Hy 8.84 1698.83 8.84 30.87 8.29 .595 Pd 9.52 1238.37 9.52 22.37 8.43 .517 Mf 28.59 1483.13 28.59 25.51 8.81 .373 Pa 6.96 1366.97 6.96 24.85 8.28 .599 Pt 242.34 2981.88 242.34 54.21 4.47 .839 Sc 383.12 7865.44 303.12 128.46 2.36 .138 Ma 8.61 1136.65 8.61 28.66 8.83 .864 Si 808.84 5468.83 888.84 99.42 8.14 .886 stn 318.38 5217.87 318.38 94.87 3.36 .872 HOS 12.68 4112.83 12.68 74.78 8.17 .682 on 9.26 1531.72 9.26 27.85 8.33 .566 HC 36.21 1675.26 36.21 38.46 1.19 .288 83.333212;212;:'3.113;"E;;ZZ’£~";§ET'BE"E;;T'BIT};. Wilks 8.681 1.524 17.00 39.88 .137 89 (Social Introversion). Raw score means and standard deviations of the scales utilized are presented in Appendix H. Insert Table 16 about here Results of the modified-BDHI are presented in Table 17. The significant differences between the inpatient and outpatient PTSD groups were less than expected. Only subscales Irritability (p < .083) and Suspicion (p < .075) were close to significance. Insert Table 17 about here There were no significant differences between groups on the BDI (t(58) = 0.79, p’< 0.22)., Several significant differences between groups on the Problem Checklist were found. Table 18 presents the results of these analyses. Insert Table 18 about here The table indicates that six of the nine scales analyzed were significant beyond the p < .05 level. In order to analyze whether or not the inpatient PTSD group endorsed items that indicated inwardly directed hostile thoughts and feelings and a more generalized 90 2 was conducted on all the anger, a phi coefficient and x items of the BDHI, the items on the Problem Checklist, and the items on the PTSD subscale. Table 19 presents the Insert Table 19 about here item number, phi coefficient, and x2 results of the significant results found. There were 186 items analyzed. Of the 186 items analyzed, only 12 items reached a significance level of p_< .05. Table 17 N, Means, Standard Deviations, 91 T Values, and 1-tai1 Probabilities Comparing Group 1 (Inpatient) vs. Group 2 (Outpatient) on the Subscales of the modified-BDHI T - tests Variable N Mean St. Dev. T Value l-tail Prob. Assault Group 1 30 5.86 1.87 0.27 0.348 Group 2 30 5.73 1.89 Indirect Hostility Group 1 30 4.60 1.50 -0.89 0.190 Group 2 30 4.93 1.41 Irritability Group 1 30 7.66 1.24 1.40 0.083 Group 2 30 7.03 2.14 Negativism - Group 1 30 2.10 1.35 -0.35 0.343 Group 2 30 2.23 1.57 Resentment Group 1 30 4.53 1.59 0.20 0.422 Group 2 30 4.43 2.27 Suspicion Group 1 30 6.03 1.67 1.46 0.075 Group 2 30 5.27 2.35 Verbal Hostility Group 1 30 7.80 2.43 0.00 1.000 Group 2 30 7.80 2.70 Guilt Group 1 30 6.03 2.31 0.37 0.355 Group 2 30 5.80 2.54 92 Table 18 Means, Standard Deviations, T Values and l-tail Probabilities Comparing Group 1 (Inpatient) vs. Group 2 (Outpatient) on the BDI and PC Subscales Inpatient Vs. Outpatient Variable N Mean St. Dev. T Value l-tail Prob. BDI Group 1 30 34.53 12.68 0.79 0.216 Group 2 30 31.60 15.86 Anger/Depression Group 1 30 9.12 1.93 2.00 0.025 Group 2 30 7.73 3.41 Emotional Numbness Group 1 30 6.10 0.92 2.23 0.015 Group 2 30 5.20 2.01 Anxiety/Cognitive Problems Group 1 30 6.10 1.40 2.15 0.018 Group 2 30 5.13 2.03 Interpersonal‘Difficulties Group 1 30 3.63 1.33 2.67 0.005 Group 2 30 2.63 1.56 Schizoid Tendencies Group 1 30 2.77 0.97 1.75 0.043 Group 2 30 2.27 1.23 Job Problems Group 1 30 1.73 1.23 0.56 0.578 Group 2 30 . 1.57 1.07 Drug Abuse/Money Problems Group 1 30 2.03 1.52 1.68 0.048 Group 2 30 1.43 1.22 Criminal Behavior Group 1 30 1.13 1.01 1.01 0.159 Group 2 30 0.87 1.04 93 Table 19 Scale, Item, Phi Coefficient, X2, and Significance Level of the Items That Reached Significance on the modified- BDHI, the Problem Checklist, and the PTSD Subscale Inpatient Vs. Outpatient Scale Item Phi Coefficient X2 Significance BDHI 18 0.268 4.32 .04 26 0.268 4.32 .04 58 0.258 4.02 .04 66 0.294 5.19 .02 PC 1 0.283 4.81 .03 10 0.294 5.19 .02 48 0.352. 7.17 .01 PTSD 22 0.343 6.70 .01 152 0.337 6.49 .01 241 0.301 5.18 .02 336 0.275 4.31 .04 338 0.264 3.96 .05 Chapter V’/ DISCUSSION Overview The results of the study supported, with few exceptions, the hypotheses presented. Those Vietnam combat veterans with Posttraumaic Stress remain very troubled individuals. In addition, there are clear distinctions between those seeking treatment for Posttraumatic Stress Disorder symptoms and those with other psychological difficulties. Information gathered from this study revealed that the PTSD group and the comparison group were very similar on demographic characteristics. There were few significant differences found between them. Most of the subjects were Caucasion and had at least a high school education. The next most populous ethnic group was Black, with 10.0% of combat and 16.7% of the non-combat . respondents falling into this category. The percentage of minority groups in this study was lower than the national average (Boyle et al., 1987). This could be due to the geographic areas in which subjects were drawn or that many minority groups do not seek treatment (Allen, 1986: Escobar et al., 1983). 94 95 On average, both groups began their military careers around 1965-66 and ended them between 1970 and 1971. Many of the veterans were currently married (PTSD, 46.7%: non- PTSD, 30.0%). However, significantly more non-PTSD veterans were currently single (PTSD, 5.0%: non-PTSD, 26.7%). A high percentage of both groups also reported being divorced (PTSD, 35.0%, non-PTSD, 36.7%). All veterans in the study had honorable discharges. Almost two-thirds of all participants were currently on medication, with antidepressants being the most frequently prescibed. Alcoholism and/or Personality Disorder was frequently an additional diagnosis. Mood Disorder for the non-PTSD group accounted for fifty percent of diagnoses given. Significantly more non-PTSD subjects were diagnosed with a Mood Disorder than the PTSD group. This is most likely a reflection of some variant of a Mood Disorder diagnosis frequently given to those admitted to inpatient psychiatric hospitals. A finding of the study which may be important in determining which veterans would later develop PTSD symptoms was the item concerned with age of entry into military service. As mentioned in the introduction, the average age of beginning service for Vietnam combat veterans was 19.6 years. The PTSD veterans in this study reported a mean age of 18.4 at the start of service. Theorists have discussed the fact that the average age for 96” Vietnam veterans was younger than veterans of other wars that America has fought (Wilson, 1978: Brende, 1983). These theorists believed that one of the main factors in the development of PTSD was the fact that the Vietnam veteran was much younger than his World War II and Korean War counterpart. The results of this study, although not directly addressing this factor as well as some others such as frequency and intensity of combat and loss of a close friend (Card, 1987: Fox, 1974; Friedman et al., 1986: Solkoff et al., 1986), adds credence to the theory that age was a critical factor in the development of PTSD. Subjects in both groups responded similarly when giving past psychiatric histories. Few subjects reported psychiatric hospitalizations during the service. Many reported that the current hospitalization or outpatient treatment was not their first contact with a mental health agency. Sixty percent of the PTSD group reported previous hospitalizations while 51.7% of the comparison group had at least one hospitalization. As for outpatient treatment, two-thirds of the index group reported previous outpatient contact while the comparison group reported a rate of 78%. Only five percent of the combat group reported outpatient psychiatric treatment prior to enlistment. None of the combat group reported an inpatient psychiatric history or a criminal record prior to the 97- service. The figures for the comparison group on these items were 10.2%, 5.1%, and 3.4%, respectively. There were no significant differences found between the two groups on these items. These findings, as well as most of the other responses reported on the Demographic Form, supported previous studies which have shown that the pre- service histories of those who develop PTSD are not any different from the general veteran population (Boulanger, 1985: Emery, 1987: Figley, 1978: Foy & Card, 1987: Foy et al., 1984). Almost half of the combat veterans responded in the affirmative to the question "Criminal Record After Service" while none reported a criminal record before the service. The comparison group reported significantly less problems with the law after the service and few difficulties before. Walker (1981) reported a high incidence of legal difficulties experienced by Vietnam veterans. This incidence may be higher than any other select group. A study by Boyle (1987) also found the incidence of criminal court contact by Vietnam veterans to be high. The responses to the questions concerning criminal contact, therefore, in this study are consistent with past research and government statistics. This consistency with previous studies would appear to validate the voracity of the volunteers. Significantly more of the comparison group admitted 98 to a family history for psychiatric illness than did the PTSD group (32.2% to 11.9% respectively). This could be accurate or it could be seen as another way of combat veterans minimizing pre-service variables and focusing on service experiences as being the root of their current distress. Charts were reviewed to check reliability of patient reports and they were found to be consistent with self-reports. There is always potential for some form of secondary gain when dealing with any psychiatric population. In this case, the fact that 75% of the combat group had some form of service connected disability may have been an uncontrolled factor affecting the results. It is possible that some veterans in the study exaggerated their symptoms in a false belief that appearing emotionally unstable on the questionnaires would maintain their disability compensation. As several researchers have cautioned (Fairbank, 1985; Fleming, 1985: Sparr and Pankratz, 1983), therapists and researchers must be aware that malingering is a possibility. It is possible that some subjects were overstating their symptoms for some unknown secondary gain. However, their self-reports were consistent with their psychiatric histories and the data overall reflects, quite consistently, past research in this area. It was assumed in this study, therefore, that the data gathered was as reliable and valid and the 99'” subject selection was as random as could be expected. It is apparent from these results that those who are suffering from the symptoms of PTSD have a relatively high frequency of mental health agency and criminal court contact. In addition to seeking services at different VAMC's, many of the veterans reported having had contact with private agencies as well as community mental health centers over the past fifteen years. Assessment of Hostility and Anger The major focus of this study, that issues of hostility and anger remain a major difficulty for combat veterans, was supported by the data. Those veterans with a diagnosis of PTSD reported significantly more problems with many different types of hostility and anger than the non-PTSD group. On the modified-BDHI, PTSD subjects reported significantly higher mean scores on the following scales: 1) Assault, 2) Irritability, 3) Resentment, 4) Suspicion, 5) Verbal Hostility, and 6) Guilt. They also had significantly higher HOS and He scores. According to Buss and Durkee (1957), the PTSD group could be described as experiencing themselves as violent towards others at times, quick tempered and easily provoked, with a “feeling of anger at the world over real or imagined fantasied mistreatment“ (Buss & Durkee, 1957, p. 343). Suspicion and mistrust as to others' motives was also found to be a significant problem amongst this sample 100 of Vietnam veterans. Results also indicated that Vietnam veterans perceived themselves as argumentative and verbally aggressive both in style and content of speech. As to the factor of Guilt, which Buss and Durkee related to hostility, the PTSD group again scored significantly higher than the comparison group. Theorists have related guilt feelings to symptoms of PTSD for many years (Green, 1985: Levin et al., 1975: Shatan, 1974). Significantly high scores on the Guilt scale for the PTSD group also supported the MMPI profile results. Those Vietnam combat veterans who are in treatment, therefore, could be described as continuing to experience much survivor guilt. The slightly elevated HOS and Hc scales further supported the hypotheses presented. Those who score high on the Manifest Hostility Scale (HOS) are described as harboring intense hostile and aggressive impulses (Graham, 1982). They are also seen as resentful, argumentative, with many interpersonal difficulties. The Hc scale is more an indicator of indirect hostility expressed without the full awareness of the individual (Schultz, 1954). These results further showed that combat veterans are experiencing difficulty with angry and hostile feelings. The MMPI Profile The MMPI results were consistent with past research. Fairbank, Keane, and Malloy (1983) reported an 8-2 profile 101 for their PTSD group. This profile was also found to be characteristic of the PTSD group in this study. Scale 5 was not different between groups for their study and neither was it for the present one. Similar results were found by Keane et a1. (1984) and Burke and Mayer (1985). For the present study, the MMPI profiles of the "PTSD group indicated severe depression, anxiety, and hypervigilance. This group could be characterized as withdrawn, guilt-ridden, and self-accusatory (Lachar, 1981). They also could be described as irritable and resentful with a fear of loss of control (Graham, 1982). In addition, suspiciousness has been attributed to those who have 8-2—7 profiles. The profile of the comparison group was similar to that of the PTSD group. This group could thus be described as experiencing similar symptoms as the PTSD group. The difference being that on 8 of 10 clinical subscales, the PTSD group scored higher. The index group scored significantly higher on eleven of the fourteen. subscales evaluated. This finding was also similar to past research with the MMPI (Burke & Mayer, 1985: Fairbank et al., 1983: Keane et al., 1984). Therefore, the comparison group could be described in generally the same terms as the PTSD group, but as not experiencing the same intensity of psychological distress. 102 It is important when reviewing any MMPI protocal to review the validity scales. The mean F scale T—score was 88 for the PTSD group. This was two T scale points lower than Graham's (1982) suggested cutoff. The mean F-K index was 10.6. This difference is acceptable by some (Fairbank et al., 1983, Gendreau et al., 1973) and not by others (Graham, 1982; Green, 1980). When dealing with a trauma group, such as combat veterans, the F-K index difference as found in this study is in the acceptable range and indeed appears to be the norm (Burke & Mayer, 1985: Fairbank et a1, 1983: Malloy et a1, 1983). Cross Validation The other instruments used in this study cross validated the MMPI findings and painted a more complete picture of the Vietnam combat veteran. The Beck Depression Inventory results clearly indicated severe depression (Beck et al., 1961) in the PTSD group (M333). Past research has used the Beck with positive results (Fairbank et a1, 1983: Helzer et a1, 1976: Hyer et al., 1986). It would appear from present results that the BDI was an accurate gauge of current depressive states of the Vietnam combat veteran. Results of this study showed that the comparison group, with fifty percent diagnosed with some type of Mood Disorder, had a mean BDI score of 19.63. This mean fell into the “moderate depression” range (Beck et al., 1961). 103 In contrast, the PTSD group had a mean BDI score of 33.07 which falls into the ”severe depression" range (Beck et al., 1961). The BDI indicated that a Vietnam veteran suffering from the trauma of combat would be expected to be experiencing extreme degrees of depression. The topic of suicide must also be kept in mind when dealing with any individual scoring in the severe depression range. The elevated BDI scores indicated that Vietnam veterans with a diagnosis of PTSD may need to be questioned about suicidal ideation or intent. Other studies have indicated similar results. Nace et a1. (1978) assessed Vietnam veterans with the Beck Depression Inventory. Although exact figures were not mentioned, they reported that most of the depressed veterans scored within the moderate and severe range on the BDI. Mueser and Butler (1987) did not utilize the BDI, but assessed the PTSD groups depression in relation to other symptoms. The authors reported a high incidence of depression among their study group. Sonnenberg, Blank, and Talbott (1985) also addressed the importance of . depression when dealing with combat-related trauma. Over a decade ago Helzer, Robins, and Davis (1976) reported the incidence of depressive disorders to be significantly more common to those veterans who experienced combat. In that study, the incidence of depression correlated highly with the loss of a friend in 104’ combat. The authors stated that they were unable to predict how long the symptoms of depression would last. It appears that the experience of depressive symptoms has lasted longer than anyone would have imagined. The results of this study clearly demonstrated that those veterans who have a current diagnosis of combat related PTSD are experiencing extreme degrees of depression. The relegation of depression to an associated feature in DSM- III-R, therefore, has to be questioned. The current study utilized the Problem Checklist. The Problem Checklist was developed in part to validate the criteria stipulated in DSM-III (Schauer et al., 1985). The results they reported were similar to the findings of the current study. However, means on the subscales for this study were slightly higher than those reported by Schauer et a1. (1985). In this study, veterans suffering from PTSD reported experiencing anger and depression with isolative behavior. An emotional withdrawing from others was indicative of these individuals. Anxiousness, an inability to - concentrate, and a significant lack of trust were reported as major concerns. The PTSD subjects also reported current problems with substance abuse and past criminal behavior. These results, therefore, support Schauer et a1. (1985) and, in general, the DSM-III-R description of PTSD symptomatology. 105 It appears from the results of this research that the best manner for discriminating between veterans with a diagnosis of PTSD and veterans with other clinical diagnoses was by using the eight subscale method. Of the fifteen subscales initially employed, the following accounted for the most discriminatory ability: 1) Assault, 2) PTSD, 3) Hc, 4) Hs, 5) Irritability, 6) Pa, 7) D, and 8) HOS. These eight subscales produced a moderate degree of separation (Wilks' lambda of 0.652). These eight subscales appear to cover a wide range of PTSD symptoms. By that method, 82.5% of the PTSD cases were correctly classified. An overall percentage of 76.07% of cases were correctly classified. Discriminating between groups using the variables PTSD, BDI, Ho, and Anger/Depression, also produced relatively reliable results. Using these four scales an 80.7% correct classification rate was found for PTSD subjects and an overall rate of 74.36%. The differences between classification rates were small, but it would appear that by using the eight subscale method a larger percentage of individuals could be more accurately classified. Therefore, it may benefit a clinician to use the eight subscales utilized in this study when attempting to assess an individual presenting with PTSD symptoms. As for using the PTSD subscale to differentiate 106 between groups, the results of this study were similar to those reported by Hyer et a1. (1986) and Keane et a1. (1985). Hyer et al. reported a correct classification rate for all groups assessed to be 69% and for the PTSD group a true positive rate of 73%. The present study found an overall correct classification rate of 70.94% and a PTSD group rate of 77.2%. Both of these results are lower than Keane et al.'s overall correct classification rate of 82%. One possible reason for this difference was the Keane et a1. study was the only one which included a comparison group consisting of subjects with a schizophrenic diagnosis. According to the present study, the standard clinical MMPI subscales and the subscales PTSD, H08, and Hc would appear to be valid assessment tools for identifying patients who are suspected of experiencing Posttraumatic Stress Disorder symptoms. In addition, clinicians should be aware of the elevated profiles and high F-K Indexes of combat veterans. The factors generated by the factor analysis proved to be of questionable utility. The factor analysis of the BDHI (Appendix I) stipulated 22 factors. This is almost three times the number of original factors. Only the first four factors appeared to be of any utility. The main difficulty with generalizability of results with this analysis was the fact that there were less than two 107 observations per case. This would seem to make the factor analysis confusing and meaningless (Thorndike, 1982, p. 286). It appeared more useful, therefore, to use the original eight scales as presented by Buss and Durkee. That is what was done in this study in order to describe the subject population. Almost the same can be said to be true with the Problem Checklist factor analysis (Appendix I). In that case, there was more than a two to one ratio of observations to cases. A total of ten factors were generated, but as in the BDHI analysis only the first four were considered useful. Many of the new factors were similar to the originals. Both had factors related to worry or anxiety, war related problems, anger management problems, drug and criminal problems, interpersonal difficulties, and employment difficulties. The new factors that were somewhat different were those related to self-perceptions or self-image and family problems. These two factors may assist, to a small degree, in stating that those with PTSD symptoms appear to have a poor self-image and that they believe there are family problems which need to be addressed in treatment. Inpatient and Outpatient PTSD Groups Some of the hypothesized differences between inpatient and outpatient PTSD groups were substantiated. It was hypothesized that the outpatient PTSD subjects 108 would score less pathological on personality measures than the inpatient PTSD subjects. This was proven to be the case. On almost all of the subscales analyzed, the outpatient PTSD population scored in the less pathological direction when compared to the inpatient PTSD population. On the MMPI, the only significant differences were on scales 7 (Psychasthenia) and 0 (Social Introversion) with the inpatient group scoring in the more pathological direction. These results would indicate that outpatients admitted to experiencing less anxiety, tenseness, and social withdrawal than the inpatient counterpart. Scores were elevated for both groups on these scales but the inpatient group had significantly higher scores on both scales mentioned above. There were no significant differences found between groups on the PTSD, the O-H, the H08, and the Ho MMPI scales. The PTSD scale was the closest to reaching significance. The outpatient PTSD groups overall mean score (M’= 29.3) was slightly less than the cutoff score of 30 prescribed by Keane (1984). Outpatients, therefore, may have borderline low PTSD scores. This would appear to be an important factor to be cognizant of if one is evaluating an individual in an outpatient situation. Other indicators of the disorder, such as a high HOS, Hc, or an elevated MMPI profile, would have to be assessed if the PTSD score of an individual did not reach the 109w suggested 30 point cutoff score. Although their BDI scores were less than the inpatient group, feelings of depression continued to be a concern for outpatient subjects; Symptoms of depression and concerns about suicide may need to be evaluated by any clinician working with either inpatient or outpatient combat veterans. Most of the significant differences between the inpatient and outpatient PTSD groups were found on the Problem Checklist. According to the scale that addresses anger and depression, the inpatient group reported significantly more difficulties managing angry or depressive feelings. The statements related to depression addressed an overwhelming feeling of depression and sadness, and a feeling of hopelessness and gloom. In addition, the outpatient pOpulation in this study reported significantly less anxiety, less interpersonal difficulties and less isolative behavior, less drug abuse and financial problems, with a better ability to concentrate. A major concern for the outpatient group, as well as the inpatient group, appears to be job related difficulties. It would appear from this study that assisting the combat veteran in areas related to employment is a necessary ingredient for a successful therapeutic treatment plan. The hypothesis that outpatients would indicate more 110 specific targets of their angry thoughts and that inpatients would indicate inwardly directed hostile thoughts and feelings was not supported by the data. An analysis of 186 items were analyzed in order to test this hypothesis. Of these items only 12 reached significance. This number is only about three items more than would be expected by chance. Both groups reported having difficulty modulating the expression of their angry feelings. Outpatients did not identify specific targets of anger any more than inpatients. Both inpatients and outpatients reported difficulty with the external expression of anger such as picking items up and breaking them or slamming doors when angered. Inpatients were no more likely to express difficulties with inwardly directed hostile thoughts and feelings than outpatients. The items "Most nights I go to sleep without thoughts or idea bothering me" and "I dream frequently about things that are best kept to myself" of the MMPI were endorsed in the pathological direction more frequently by inpatients than outpatients. This would indicate that inpatients may be experiencing more nightmares or intrusive thoughts than outpatients. Limitations of the Study A major limitation of the generalizability of results for this study was the population employed. This study utilized subjects that had some form of Veterans 111” Administration contact. Results, therefore, may not be indicative of the Vietnam veteran population en masse. There are many veterans who seek out private or community mental health agencies through their own work related insurance coverage. Others, due to their mistrust and disappointment towards the VA system (Atkinson, 1982), may contact any non-government affiliated mental health source. This study was directed solely towards increasing the understanding of the Vietnam combat veteran and thus may be limited to combat-related trauma similar to that experienced by Vietnam veterans. Other populations that ~may have similar experiences are Israeli soldiers in occupied territory (Solomon et al., 1987) and policeman in high crime rate areas (Martin, McKean, & Veltkamp, 1986). All measures utilized in the present study were of the self-report nature. It was difficult to substantiate much of the demographic information provided. A check of the patients History and Physical and Social Assessment was done whenever possible. Any further investigative analysis, other than the verification of the patients official discharge sheet (DD214), was not undertaken. Therefore, as mentioned previously the combat veteran could have been overstating his current problems or underreporting pre-service difficultes in order to blame the war for much of his current emotional distress. Other 112'” possible reasons for this behavior could be to retain his service connected disability, or to deny early or current traumatic events as being the cause of his emotional difficulties. Facts which highly contradict these possibilities are that the results are very similar to other studies of this nature. Vietnam veterans consistently score higher on many different psychological measures. It would be very difficult to believe that hundreds, if not thousands, of veterans have been lying about their turmoil for the past twenty years. Another factor which must be kept in mind was that all subjects were volunteers with absolutely no compensation given other than the results of their tests being reviewed with them by their primary therapist. Subjects were informed that they could receive results of their tests if they so desired. Only a handful of veterans requested results be provided. In any event, the fact that they were volunteers must be kept in mind when evaluating the results. One reason for the overall few significant results in the comparison of inpatient versus outpatient combat veterans could have been the different time periods of therapy contact that the outpatients had in treatment. Therapy contact ranged from several months to several years. Another difference in the outpatient group that 113' could not be avoided was the consistency of therapeutic attendance. Again, this factor had a range that might have affected the outcome. Finally, the outpatient population was involved in a variety of therapeutic experiences. Some were in individual therapy, some in group therapy, others in couples counseling and others were in some combination of the above. This discrepancy was impossible to overcome given the time and scope of the research project. Summary and Conclusion Overall, the data supported the hypotheses presented. Results of this study indicated that Vietnam veterans in treatment are continuing to experience severe symptoms of Posttraumatic Stress Disorder. Criteria as presented in DSM-III-R are supported by these findings. The inclusion of symptoms of hostility and anger as essential features of PTSD in DSM-III-R was an improvement over DSM-III. Results of this study give statistical support to that inclusion which was previously unsubstantiated by any in- depth research endeavor. . The one shortcoming of DSM-III-R could be in the area of depression. Depressive symptoms as reported in this study appear to be a major concern for those suffering from combat-related PTSD. Issues of loss of a part of one's youth, loss of a friend, or loss of part of one's body or of some body function (for those who have been 114 wounded or lost a limb) must be addressed in treatment. Guilt and its relation to depressive symptoms continue to be reported by Vietnam veterans. The use of the MMPI as a diagnostic tool in the assessment of PTSD was also supported by this study. The MMPI profile of the Vietnam vet across studies has been remarkably consistent. An 8-2-7 profile, with an F-K Index reaching the upper limits of acceptance, is indicative of the Vietnam veteran. Indeed, extremely elevated scores have been the norm rather than the exception when using the MMPI with this population. The hostility scales of the MMPI employed in this study and the Buss-Durkee Hostility Inventory were 'extremely useful in describing the characteristics of those suffering from PTSD. The Vietnam combat veteran continues to have difficulty modulating and managing angry and hostile impulses. Their anger ranges from verbal hostility and resentment to physical aggression. Involvment with the criminal justice system was also shown to be a significant problem. Joblessness and interpersonal difficulties were also a concern of the veteran. The similarity of demographic data between groups must be seen as indicating that the etiology of combat-related Posttraumatic Stess Disorder was the trauma of combat. This is not to deny that pre-service 115 personality characteristics and histories would not affect the symptom presentation. Many of the veterans of this study had secondary diagnoses and/or Axis II diagnoses. The relationship between combat related PTSD, pre—service histories, and secondary diagnoses may need to be addressed in future research. Another area for future research could be how present stressors relate to PTSD symptoms or to evoked combat memories. Card (1987) presented the example of how difficulties at work caused by PTSD exacerbated PTSD symptoms. Work related stressors may evoke memories of failure or guilt related to combat. Another example could be separation from a significant other in the present may precipitate feelings of loss initially experienced as the loss of a friend in Vietnam. Issues related to past combat experiences and how they continue as life themes in the present could be an area for future research. The overall picture of the Vietnam veteran and his current psychological state is much clearer. This study has substantiated the difficulty combat veterans continue to have with anger, hostility, depression, and guilt. Future research in the area of combat-related Posttraumatic Stress Disorder should address the effects of different forms of therapy, or combinations of therapies, on the reduction of PTSD symptoms. 116 The effects of the trauma of war cannot be denied any longer. The disorder has been shown to effect veterans from all socioeconomic backgrounds. It would appear from this study, that those veterans suffering from severe symptoms of PTSD are in great need of psychotherapy, resocialization. and retraining in order to become part of the American dream. ~ APPENDICES Appendix A Buss-Durkee Hostility Inventory This inventory consists of numbered statements. Read each statement and decide whether it is true as applied to you or false as applied to you. If the statement is true as appIch to you, then circle the T. If7thc statement is false as applied to you, then circle the M. Remembér to give your own opinion of yourself. Do not leave any blank spaces if you can avoid it. Be sure that your' answer' agrees ‘JIEh the- number' of’IEfic statement. 1. I seldom strike back, even if someone hits me first. T F 2. I sometimes spread gossip about people I don't like. T F 3. Unless somebody asks me in a nice way, I won't do what they want. . F 4. I lose my temper easily but get over it quickly. T F S. I don't seem to get what's coming to me. T F 6. I know that people tend to talk about me behind my back. T F 7. When I disapprove of my friends' behavior, I let them know it. T F 8. The few times I have cheated, I have suffered unbearable feelings of remorse. T F 9. Once in a while I cannot control my urge to harm others. T F 13. I never get mad enough to throw things. T F 11. When someone makes a rule I don't like I am tempted to break it. ' . F 12. Sometimes people bother me just by being around. T F 13. Other people always seem to get the breaks. T F 14. I tend to be on my guard with people who are somewhat more friendly than I expected. T F 15. I often find myself disagreeing with people. T F 16. I sometimes have bad thoughts which make me feel ashamed of myself. T F 17. I can think of no good reason for ever hitting anyone. T F 13. When I am angry, I sometimes sulk. T F 19. When someone is bossy, I do the opposite of what he asks. T F 117 23. 24. 25. 26. 27. 28. 29. 33. 31. 32. 33. 34. 35. 36. 42. 43. 118 I am irritated a great deal more than people are aware of. I don't know any people that I downright hate. There are a number of people who seem to dislike me very much. I can't help getting into arguments when people disagree with me. People who shirk on the job must feel very guilty. If somebody hits me first, I let him have it. when I am mad, I sometimes slam doors. I am always patient with others. Occasionally when I am mad at someone I will give him the “silent treatment." When I look back on what's happened to me, I can't help feeling mildly resentful. There are a number of people who seem to be jealous of me. I demand that people respect my rights. It depresses me that I did not do more for my parents. Whoever insults me or my family is asking for a fight. I never play practical jokes. t makes my blood boil to have somebody make fun of me. When people are bossy, I take my time just to show them. Almost every week I see someone I dislike. I sometimes have the feeling that others are laughing at me. Even when my anger is aroused, I don't use "strong language. I am concerned about being forgiven for my sins. People who continually pester you are asking for a punch in the nose. I sometimes pout when I don't get my own way. If somebody annoys me, I am apt to tell him what I think of him. *3 r3 r3 '3 *3 ti p—l >3 *3 P38 tit-3 F] '-3 v-i *3 r3 'D'U'YJ'U'U "J 44. 45. 46. 47. 48. 49. SO. 54. SS. 56. 57. 58. 59. 60. 61. 62. 63. 64. ;119 I often feel like a powder keg ready to explode. Although I don't show it, I am sometimes eaten up with jealousy. My motto is "Never trust strangers.“ When people yell at me, I yell back. I do many things that make me feel remorseful afterward. When I really lose my temper, I am capable of slapping someone. Since the age of ten, I have never had a temper tantrum. when I get mad, I say nasty things. I sometimes carry a chip on my shoulder. I If I let people see the way I feel, I'd be considered a hard person to get along with. I commonly wonder what hidden reason another person may have for doing something nice for me. I could not put someone in his place, even if he needed it. Failure gives me a feeling of remorse. I get into fights about as often as the next person. I can remember being so angry that I picked up the nearest thing and broke it. I often make threats I don't really mean to carry out. I can't help being a little rude to people I don't like. At times I feel I get a raw real out of life. I used to think that most people told the truth but now I know otherwise. I generally cover up my poor opinion of others. When I do wrong, my conscience punishes me severely. If I have to resort to physical violence to defend my rights, I will. If someone doesn't treat me right, I don't let it annoy me. I have no enemies who really wish to harm me. 0'! *3 v3 ’3 '3 t3 O-iv-Jd *3 *3 "1 "I "1 "J "1 "J '1’) "1 "1 "J '71 "I"! "J ’1) 129 68. When arguing, I tend to raise my voice. 69. I often feel that I have not lived the right kind of life. 79. I have known people who pushed me so to blows. 71. I don't let a lot of unimportant things 72. I seldom feel that people are trying to 73. Lately, I have been kind of grouchy. 74. I would rather concede a point than get about it. 75. I sometimes show my anger by banging on 5 far that we'came irritate me., anger or insult me. into an argument the table. *1 *3 r3 *3 Appendix B Problem Checklist Please read each statement and decide if it is currently a problem for ou. If it currently is a problem for you, circle currently is not a problem for you, circle the F. spaces. 1. Controlling your temper. 2. Improving relationships with your family. 3. Reacting to stress as you did when you were in combat. 4. s. 10. 11. 12. .13. 14. 15. 16. 17. 18. 19. 20. Learning to worry less. Getting along with people. Getting rid of strange thoughts. Finding or holding a job. Overcoming your dependence on alcohol. Learning how to control your behavior to avoid future with the police. Getting rid of angry feelings. Feeling numb and unemotional about everything. Feelings of guilt that you survived in combat while of your buddies did not. Learning to worry less. Maintaining a better personal appearance. Getting rid of imaginary voices or visions. Getting into school or job training. Overcoming your dependence on drugs. trouble some Learning how to avoid behavior that hurts others physically. Feelings of depression, sadness, crying. Being unable to express feelings as you once did. Being easily startled and over-alert to noises. Feeling more cheerful and optimistic. Using your leisure time better. 121 the T. Do not leave any blank Hat-368 "36*! .3 ~a a *3 a r] P) 0-3 0'! v-3 8*! If it "1"1") "1"! "I "1 "1'1! "I'fl'll'fl "I "I "1 "1'71'3 24. 25. 26. 27. 28. 29. 30. 3l. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 122 Overcoming problems with sexual functioning. Applying for financial assistance or welfare. Learning how to manage your money. Avoiding behavior that violates the property rights of others. for example. burglary or forging checks. Feelings of anger or controlling your temper. Loss of interest in work and social activities. Avoiding things that bring back combat memories. Feeling better physically. Learning how to make and keep friends. Being unable to sleep well. Avoiding the company of alcohol or drug abusing friends. Fantasies of getting revenge and destroying others. Not being able to be close to others (wife, parents). or having no close friends or buddies. Thoughts. dreams. nightmares and pictures of combat. Feeling more self-confident. Increasing your self-respect. Being cynical and distrustful of the government or people in authority (police, boss. physicians. etc.) Being emotionally distant from your parents. spouse, children or others close to you. Being overly concerned about justice for yourself and other veterans of the war. Feelings of anxiety or controlling your shakes. Feeling alone and separated from other people. Fear of losing others who are close and important. Being unable to talk about your war experiences. not being able to remember like you used to do. tit-3 0-1 r] 6 *3 F! *3 "l *3 r3"! r-J *3 HI F] '3 eaeaea "1 "Jeanne: "3'31"! "1 'n m ~1"u m 48. 49. so. 51. 123 Having mostly negative thoughts or feelings about yourself and your future. Working with people in authority (bosses, parents. medical staff. etc.) Fears that you will hurt someone in a fit of rage. Suicidal wishes, thoughts, and feelings. '1 r] '3 Appendix C Demographic Form Subject Code Number: Dx Code: IP OP CO NC Marital Status: Single Married Separated Divorced Widowed Ethnic Origin: Asian Black Hispanic Native American White Other Highest Grade Completed: Age While in Service: Dates of Service: From l9___ To l9___ If Vietnam Combat Veteran. total number of months in Vietnam: Type of Discharge: Service Connected Disability: yes Presently on medication: yes If yes. what type: Past medication use: yes If yes. what type: Psychiatric Hospitalization Previous to Enlistment: yes Psychiatric Hospitalization During Enlistment: yes Psychiatric Hospitalization After Enlistment: yes Outpatient Treatment Previous to Enlistment: yes Outpatient Treatment During Enlistment: yes Outpatient Treatment After Enlistment: yes Family History for Psychiatric Illness: yes Criminal Record Prior to Service: yes Criminal Record After Service: yes Pending Court Date: yes 124 ['10 no no no DO no no no DO no 110 no no Appendix D Consent Form 0‘?! PART I-AGREEIENT TO PARTICIPATE IN RESEARCH BY OR UNDER THE DIRECTION OF THE VETERANS ADIINISTRATION Isoluntanly consent to participate as a submt If,” at mt wheel's "-0 in the investteauon entitled . Title or smfll '2. I have started one or more information sheets with this title to show that I have read the description including the purpose and nature of the n-emntion. the phat'dun'» to bo- used. "to nslts .nt'nnwmun- vs. «do effects and benefits to be exhorted. as well as other courses election open to me and my right to Withdraw from .Iw mr nation at any time. Each of [hi-SP itvms has been explulnt‘d to me by the :nvntiaator lfl thi- prcy-nci- u! a Witness. The investiutor has answered my questions COflCEfl‘Ilfl' the investigation and I believe I understand what is intended. .1. I understand that no zuarantces or assurances have been even me {incr- the results and nslts of an investigation are not always known batorehand. I have hm it told that this investigation has been tareluuy planned. that the plan has been renewed by knowledgeable people. and that every reasonable precaution will be taken to protect my well-being. 4. In the event I sustain physical injury as a result 0! putimpatton in this investtntion. it I am eliobla (or medical care a a mean. all net-essay and appropnata care will be prowded. I! I am not eligible for medical care as a veteran. humanitarian rmncy cars will nevertheless be prondad. 5. I realize I have not released this institution from liability for negligence. Compensation may or may not be payable. in the event of physical injury arising from such research. under applicable federal laws. is. I understand that J" vnt'ormstiun obtained about me during the course of this study will be made available only to doctors who are taking care of me and to qualified tnt’t‘slmalOfl and their assistants where their access to this information ts appro mate and authorized. They will be bound by the «true rvqiurcmc-nt- to Ittuintain my prism-y and .tn-inyrntty as apply to all medical personnel within the \eterans Administration. 7. I (unhi r understand that. wherenra‘utred by law. the appropriate federal olfttwr or aaeni y will have free access to information obtained in the study Generaly shOUId ll become netessary. may expect the same respect for my privacy and anonymity from these agencies a is allordad by the Veterans Administration and its employees. The protrusions o! the Privacy Act apply toall agencies 3. In the event that research in which I participate involves certain new drues. informmon concermna my response to the drums) will be supplied to the ~ponsonna pharmaceutical houselsl that made the drum available. This tnlormation will be even to than: in suuh a way that [cannot be identified. I NAME OF VOLUNTEER HAVE READ THIS CONSENT FORM ALL MY QUESTIONS HAVE BEEN ANSWERED. .AND I FREELY AND \OLLRNTARILY CHOOSE TO PARTICIPATE. I LNDERSTAND THAT MY RIGHTS AND PRIVACY WILL BE \I \INTAINED. I AGREE TO PARTICIPATE .AS A VOLUNTEER IN THIS PROGRAM. 9 Ymrthelm. I wish to limit my oamcrpatton In the investigation as follows: va aaciurv suafiEr‘s no...qu Wu. Auo aooaass rpm: or type) arrears sonata-a ikvlsricarcl s was: PIN" or type) mVISViGATOO'S ucusrufit signed mtormauoa signed mlormattos 0 sheets attached. D sheets available at- L — . tquICT'I toswrilica now ".0. plan or an acne - last. hrsl. mule) ICIJCT 8 L0. ~o. sane AGREEMENT To PARTICIPATE IN RESEARCH BY OR UNDER THE DIRECTION OF THE VETERANS ADAINISTRATION SuOIflIOIS vs Iowa tong. " 'm . m ,uw is". mac-s GILL snot es “I "’0 '0' ~“squ- 125 Appendix E N, Means, and Standard Deviations of Raw MMPI Subscale Scores for Group 1 (PTSD) vs. Group 2 (Non-PTSD) Group 1 vs. Group 2 Variable N Mean Standard Dev. L Group 1 57 3.65 1.89 Group 2 66 3.95 2.47 F Group 1 57 26.36 9.76 Group 2 66 12.47 7.75 K Group 1 57 9.67 3.93 Group 2 66 12.72 4.68 Hs Group 1 57 23.37 6.47 Group 2 66 18.76 6.99 D Group 1 57 35.62 7.14 Group 2 66 29.65 7.92 Hy Group 1 57 36.14 5.52 Group 2 66 27.22 6.18 Pd Group 1 57 33.58 4.71 Group 2 66 36.68 5.63 Mf Group 1 57 27.93 5.64 Group 2 66 29.72 6.28 Pa Group 1 57 18.76 4.95 Group 2 66 15.66 4.92 Pt Group 1 57 46.88 7.59 Group 2 66 36.18 8.63 Sc Group 1 57 49.25 11.47 Group 2 66 38.75 12.98 Ma Group 1 57 24.63 4.51 Group 2 66 23.15 7.24 Si Group 1 57 42.19 16.59 Group 2 66 35.13 12.93 126 PTSD Group Group HOS Group Group O-H Group Group Hc Group Group NH NH NH NH 57 66 57 66 S7 66 66 66 127 31.82 26.32 15.61 11.32 12.98 12.98 17.36 13.37 9.94 16.88 15.61 4.97 5.25 3.67 6.71 6.34 Appendix F N, Means, and Standard Deviations of Raw MMPI Subscale Scores for Group 1 (Inpatient) vs. Group 2 (Outpatient) Group 1 vs. Group 2 Variable N Mean Standard Dev. L Group 1 36 3.96 2.16 Group 2 27 3.37 1.52 F Group 1 36 26.87 8.61 Group 2 27 19.67 16.92 K Group 1 36 9.63 3.38 Group 2 27 16.37 4.42 Hs Group 1 36 22.76 5.39 Group 2 27 24.11 7.54 D Group 1 36 36.57 5.21 Group 2 27 33.36 8.59 Hy Group 1 36 29.77 5.36 Group 2 27 36.56 5.83 .Pd Group 1 36 33.97 4.39 Group 2 27 33.15 5.68 Mf Group 1 36 28.56 4.83 Group 2 27 28.36 5.28 Pa Group 1 36 19.63 4.69 Group 2 27 18.33 5.36 Pt Group 1 36 42.83 5.71 Group 2 27 38.76 8.85 Sc Group 1 36 51.43 8.88 Group 2 27 46.81 13.56 Ma Group 1 36 24.53 4.46 Group 2 27 24.74 4.64 Si Group 1 36 45.77 7.96 Group 2 27 38.22 11.82 128 PTSD Group Group HOS Group ' Group O-H Group Group He Group Group NH NH NH MI" 36 27 36 27 36 27 36 36 129 34.67 29.33 15.17 16.11 12.66 13.41 18.97 15.63 6.23 12.55 4.16 11.78 2.99 7.66 3.93 8.39 Appendix G Factors of the Buss-Durkee Hostility Inventory -Factor Item (1) General Hostility 4. 5. 6. 9. 11. 12. 13. 14. 15. 19. 26. 23. 25. 26. 29. 36. 31. 33. 35. 36. 37. 38. 41. 44. 46. 48. 49. 51. 52. 53. I lose my temper easily but get over it quickly. I don't seem to get what's coming to me. I know that people tend to talk about me behind my back. Once in a while I cannot control my urge to harm others. When someone makes a rule I don't like I am tempted to break it. Sometimes people bother me just by being around. Other people always seem to get the breaks. I tend to be on my guard with people who are somewhat more friendly than I expected. I often find myself disagreeing with people. When someone is bossy, I do the opposite of what he asks. I am irritated a great deal more than people are aware of. I can't help getting into arguments when people disagree with me. If somebody hits me first. I let them have it. When I am mad, I sometimes slam doors. When I look back on what's happened to me, I can't help feeling mildly resentful. There are a number of people who seem to be jealous of me. I demand that people respect my rights. Whoever insults me or my family is asking for a fight. It makes my blood boil to have somebody make fun of me. When people are bossy, I take my time just to show them. Almost every week I see someone I dislike. I sometimes spread gossip about peOple I don't like. People who continuously pester you are asking for a punch in the nose. I often feel like a powder keg ready to explode. My motto is "Never trust strangers". I do many things that make me feel remorseful afterward. When I really lose my temper, I am capable of slapping someone. When I get mad. I say nasty things. I sometimes carry a chip on my shoulder. If I let people see the way I feel, I'd be considered a hard person to get along with. 136 54. 58. 59. 66. 61. 62. 65. 68. 69. 76. 73. 75. 131 I commonly wonder what hidden reason another person may have for doing something nice for me. I can remember being so angry that I picked up the nearest thing and broke it. I often make threats that I don't really mean to carry out . I can't help being a little rude to people I don't like. At times I feel I get a raw deal out of life. I used to think that most people told the truth but now I know otherwise. If I have to resort to physical violence to defend my rights, I will. When arguing, I tend to raise my voice. I often feel that I have not lived the right kind of life. I have known people who pushed me so far that we came to blows. Lately, I have been kind of grouchy. I sometimes show my anger by banging on the table. (2) Verbal Hostility 1. 2. 8. 16. .17. 18. 21. 24. 27. 28. 32. 39. 46. 42. 45. 55. 56. 63. 64. 74. I seldom strike back, even if someone hits me first. I sometimes spread gossip about people I don't like. The few times I have cheated. I have suffered unbearable feelings of remorse. I never get mad enough to throw things. I can think of no good reason for ever hitting anyone. When I am angry, I sometimes sulk. I don't know any people that I downright hate.‘ People who shirk on the job must feel very guilty. I am always patient with others. Occassionally when I am mad at someone I will give him the “silent treatment“. It depresses me that I didn't do more for my parents. Even when my anger is aroused, I don't use ”strong language". I am concerned about being forgiven for my sins. I sometimes pout when I don't get my way. Although I don't show it, I am sometimes eaten up with jealousy. ' I could not put someone in his place, even if he needed it. ‘ Failure gives me a feeling of remorse. I generally cover up my poor opinion of others. When I do wrong, my conscience punishes me severely. I would rather concede a point than get into an argument. 132 (3) Passive/Aggressive 7. 43. 57. 66. 67. 71. 72. When I disapprove of my friends' behavior, I let them know it. If somebody annoys me, I am apt to tell him what I think of him. When people yell at me, I yell back. If someone doesn't treat me right. I don't let it annoy me. I have no enemies who really wish to harm me. I don't let a lot of unimportant things irritate me. I seldom feel that pe0ple are trying to anger or insult me. (4) Indirect/Negative 3. 34. 56. Unless somebody asks me in a nice way, I won't do what they want. I never play practical jokes. Since the age of ten, I have never had a temper tantrum. Appendix H Factors of the Problem Checklist Factor Item (1) General Problems 1. 2. 5. 6. 16. ll. 14. 15. 19. 26. 21. 24. 25. 27. 28. 29. 36. 31. 32. 33. 34. 35. 36. 37. 46. 41. 42. 43. 44. 45. 46. 48. 49. 56. 51. Controlling your anger. Improving your relations with your family. Getting along with people. Getting rid of strange thoughts. Getting rid of angry feelings. Feeling numb and unemotional about everything. Maintaining a better personal appearance. Getting rid of imaginary voices or visions. Feelings of depression, sadness, or crying. Being unable to express feelings as you once did. Being easily startled and overalert to noises. Overcoming problems with sexual functioning. Applying for financial assistance or welfare. Avoiding behavior that violates the property rights of other, for example, burglary or forging checks. Feelings of anger or controlling your temper. Loss of interest in work and social activities. Avoiding things that bring back memories of the war. Feeling better physically. Learning to make and keep friends. Being unable to sleep well. Avoiding the company of alcohol or drug abusing friends. Fantasies of getting revenge and destroying others. Not being able to be close to others (wife, parents) or having no close friends or buddies. Thoughts, dreams, nightmares and pictures of combat. Being cynical and distrustful of the government or people in authority (polic, boss, physicians, etc.) Being emotionally distant from your parents, spouse, children or others close to you. Being overly concerned for justice for youself and other veterans of the war. Feelings of anxiety or controlling your shakes. Feeling alone and separated form other people. Fear of losing others who are close and important. Being unable to talk about your war experiences. Having mostly negative thoughts or feelings about yourself and your future. WOrking with people in authority (bosses, parents, medical staff, etc.) Fears that you will hurt someone in a fit of rage. Suicidal wishes, thoughts, and feelings. (2) Job/Self Image 7. 23. 26. Finding or holding a job. Using your leisure time better. Learning how to manage your money. 133 38. 39. 134 Feeling more self-confident. Increasing your self-respect. (3) Worry/Guilt 3. 4. 12. 13. 22. Reacting to stress as you did when you were in combat. Learning to worry less. Feelings of guilt that you survived in combat while one of your buddies did not. Learning to worry less. Feeling more cheerful and optimistic. (4) Drug Problems/Criminal Activity 8. 9. 16. 17. 18. Overcoming your dependence on alcohol. Learning how to control your behavior to avoid future trouble with the law. Getting into school or job training. Overcoming your dependence on drugs. Learning how to avoid behaviours that hurt others physically. Appendix I Factor Analysis Statistics for the PC and the BDHI ANALYSIS NUMBER 1 LISTUISE OELETION 0F CASES UITH MISSING VALUES EXTRACTION 1 FOR ANALYSIS 1. PRINCIPAL'COMPONENTS ANALYSIS (PC) INITIAL STATISTICS: VARIABLE COMMUNALITY O FACTOR EIGENVALUE PCT 0F VAR CUM PCT P01 1.00000 O 1 19.09994 37.5 37.5 P02 1.00000 O 2 3.49910 6.9 44.3 P03 1.00000 O 3 2.36649 4.6 49.0 P04 1.00000 O 4 2.04045 4.0 53.0 P05 1.00000 O 5 1.86836 3.7 56.6 P06 1.00000 O 6 1.56979 3.1 59.7 P07 1.00000 O 7 1.36041 2.7 62.4 P08 1.00000 O 8 1.27536 2.5 64.9 P09 1.00000 O 9 1.19096 2.3 67.2 P010 1.00000 O 10 1.01583 2.0 69.2 P011 1.00000 O 11 .97544 1.9 71.1 P012 1.00000 O 12 .85193 1.7 72.8 P013 1.00000 O 13 .82219 1.6 74.4 P014 1.00000 O 14 .81332 1.6 76.0 P015 1.00000 O 15 .76512 1.5 77.5 P016 1.00000 O 16 .75790 1.5 79.0 PC17 1.00000 O 17 .71816 1.4 80.4 PC18 1.00000 O 18 .70177 1.4 81.8 P019 1.00000 O 19 .64806 1.3 83.0 P020 1.00000 O 20 .63615 1.2 84.3 P021 1.00000 O 21 .61014 1.2 85.5 P022 1.00000 O 22 .55266 1.1 86.5 P023 1.00000 O 23 .51527 1.0 87.6 P024 1.00000 O 24 .50216 1.0 88.5 P025 1.00000 O 25 .44948 .9 89.4 P026 1.00000 O 26 .43649 .9 90.3 P027 1.00000 O 27 .41342 .8 91.1 P028 1.00000 O 28 .38709 .8 91.8 P029 1.00000 O 29 .36329 .7 92.6 P030 1.00000 O 30 .35179 .7 93.3 P031 1.00000 O 31 .33575 .7 93.9 P032 1.00000 O 32 .31388 .6 94.5 P033 1.00000 O 33 .27539 .5 95.1 P034 1.00000 O 34 .26623 .5 95.6 P035 1.00000 O 35 .25662 .5 96.1 P036 1.00000 O 36 .21124 .4 96.5 P037 1.00000 O 37 .20763 .4 96.9 P038 1.00000 O 38 .20032 .4 97.3 P039 1.00000 O 39 .18913 .4 97.7 P040 1.00000 O 40 .17639 .3 98.0 P041 1.00000 O 41 .16149 .3 98.3 P042 1.00000 O 42 .14409 .3 98.6 P043 1.00000 . 43 .13088 .3 98.9 P044 1.00000 O 44 .12253 .2 99.1 P045 1.00000 O 45 .10909 .2 99.3 P046 1.00000 O 46 .07955 .2 99.5 P047 1.00000 O 47 .06905 .1 99.6 P048 1.00000 O 48 .06462 .1 99.7 P049 1.00000 O 49 .05307 .1 99.9 P050 1.00000 O 50 .0388) .1 99.9 P051 1.00000 O 51 .03572 .1 100.0 P0 EXTRACTEO 10 FACTORS. 135 136 N05NN.. 00.50.. .0n.0.- v00«0.- 05Q.0. 0'00.. 50vv0. 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PRINCIPAL°COMPONENTS ANALYSIS (PC) FACTOR ODQOUOUM-o EIGENVALUE 15. 5. .70010 .99795 .67763 .27601 .13092 .99457 .83237 .70914 .58617 .53453 .45688 .41237 .39616 .35798 .24886 .21439 .15101 .10471 .04813 .01567 .94934 .93493 .87400 .85726 .78693 .75719 .75324 .70451 .67147 .65832 .60856 .58502 . 54744 d“-n“d‘dc§d“-””””u 83770 48002 PCT 0F VAR N §bbbbbbbbLb§bLLbbbaomooo-quaoaoou- CUM PCT 21.1 28.4 33.4 37.4 40.9 44.0 46.8 49.5 51.9 54.2 56.3 58.3 60.3 62.2 64.0 65.8 67.5 69.1 70.7 72.1 73.5 74.9 76.2 77.4 78.6 79.7 80.8 81.8 82.8 83.7 84.6 85.5 86.3 87.1 87.8 VAR H36 H37 H38 H39 H40 H41 H42 H43 H44 H45 H46 H47 H48 H49 H50 H51 H52 H53 H54 H55 H56 H57 H53 H59 H60 H61 H62 H63 H64 H65 H66 H67 H68 H69 H70 H71 H72 H73 H74 H75 TABLE COINUNALITY - 1.00000 1 1.00000 0 1.00000 - 1.00000 - 1.00000 - 1.00000 - 1.00000 - 1.00000 0 1.00000 - 1.00000 - 1.00000 - 1.00000 0 1.00000 - 1.00000 1 1.00000 - 1.00000 - 1.00000 0 1.00000 0 1.00000 - 1.00000 . 1.00000 - 1.00000 0 1.00000 . 1.00000 0 1.00000 - 1.00000 0 1.00000 - 1.00000 - 1.00000 - 1.00000 - 1.00000 ' 1.00000 0 1.00000 - 1.00000 . 1.00000 ¢ 1.00000 - 1.00000 - 1.00000 - 1.00000 - 1.00000 ' PC EXTRACTED 22 FACTORS. FACTOR EIGENVALUE 36 .53989 37 .50050 38 .48485 39 .47060 40 .42390 41 .40670 42 .39711 43 .38787 44 .36670 45 .34094 46 .32529 47 .32086 48 .30468 49 .29806 50 .27520 51 .26685 52 .25225 53 .23899 54 .22847 55 .21557 56 .20964 57 .20278 58 .18269 59 .17245 60 .16536 61 .14634 62 .13078 63 .12268 64 .10670 65 .10147 66 .08532 67 .07673 68 .07022 69 .06854 70 .06393 71 .05356 72 .04601 73 .04169 74 .03456 75 .02182 145 PCT OF VAR I 0 CU“ PCT 88.5 89.2 89.8 90.5 91.0 91 6 92.1 92.6 93.1 93.6 94.0 94.4 94.8 95.2 95.6 95.9 96.3 96.6 96.9 97.2 97.5 97.7 98.0 98.2 98.4 98.6 98.8 99.0 99.1 99.3 99.4 99.5 99.6 99.7 99.7 99.8 99.9 99.9 100.0 100.0 146 mam~0.- nmwno- 65.50. coOmn.. @wm.u- mOnO—- 600m5. .n.0v. 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Ewen 2.20. - 32o. - 2.2.... .20.... 31.. .. .32". 33'. 2: secs: . 2:...” n8... 2...... 2:5. «an; v2.9 933. 22.0. - .32... 0'03. - 230. 2.: 0325.. 92:9. 2.33:. 2500‘ 33.... 3.: c. :28. 8'2. - Eon. . :3. .- 099‘..- I... ooooo . .32.” 33'. 32.6. - .nnso. . 32h . 92:0. 32.0. n33. 3'3. 0..: .532. . 3.3a. 3.98 . '33; no.5". 3.9... 92.0. 093.. .93. co: .1:fo. v.zxc.. G's-O. anon". anon.. ono«.. o.vo.. what". no: .xxxx9. macs“. on.mo. «cane. @0.n.. smn.o.- scam..- pm: 3.59. . «:96. 2am. . n39 . 2.12.0 . anon“. - 3: uh: uh: Oh: act :6: kw: $61 aw: '01 MW! «0: .01 LIST OF REFERENCES LIST OF REFERENCES Aarons, R. (1969). Expectancy for internal versus external control of reinforcement and the experiencing of fear, hostility, and depression. Doctoral Dissertation, Columbia University, Ann Arbor, Michigan: University Microfilms. Abraham, K. (1924). A short study of the development of the libido. In K. Abraham (Ed.) Selected Papers on Psychoanalysis. London: Hogarth Press. Allen, I. (1986). 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