Journal of Psychosomatic Research, Vol. 20, pp. 151 to 158. Pergamon Press, 1976. Printed in Great Britain
PROGNOSIS FOR PSYCHOPHYSIQLOGIC DISORDERS IN THE NAVAL SERVICE* JOHN
G.
JERRYM. GOFFMANZ) and E. K. ERIC GUNDERSON~
LOONEY,~
(Received 12 August 1975) a few studies have examined treatment outcomes for specific disease entities such as ulcerative colitis, peptic ulcer, eczema, neurodermatitis, asthma, migraine, and tension headache [l-25]. A wide assortment of psychological interventions were used in these studies, including individual psychotherapy, group psychotherapy, hypnosis, counter-conditioning, and biofeedback techniques, but, unfortunately, these studies generally involved small samples, and no reports are available of largescale investigations of post-treatment outcomes for psychophysiologic disorders. Furthermore, there have been no studies of differential outcomes among patients with psychophysiologic reactions involving specific organ systems.
ONLY
Prognostic studies can be effectively conducted on a large scale in the U.S. Navy because naval medical facilities provide standardized record-keeping and readily available hospitalization and follow-up data. Utilizing such sources of information, the relationships of demography, military status, clinical variables, and affected organ system to hospital disposition decisions and posthospital adjustment of patients returned to duty will be examined. Favorable and unfavorable prognostic indicators will be identified. METHOD Subjects were 879 male Navy enlisted personnel discharged from naval medical facilities with diagnoses of Psychophysiologic Disorder during calendar years 19661969. Diagnoses for this sample were established with reference to the Department of Defense Disease and Injury Codes, July 1963 [26]; diagnostic criteria were comparable to those specified in the American Psychiatric Association Diagnostic and Statistical Manual: Mental Disorders (DSM-I), and are very similar to those provided in the Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (DSM-II) [271currently in use. For cases with more than one admission during the period of study data from the first admission were used, and for cases in which transfers from one hospital to another occurred, data from the last hospital were used. Outcome studies were conducted only on patients returned to duty. This sample consisted of 633 patients. Individual records for all psychiatric hospitalizations in naval service are received at the Bureau of Medicine and Surgery Data Services Center, Bethesda, Maryland. These records are forwarded to the Naval Health Research Center, San Diego, California. where they are extensivelv edited and maintained in computer files for epidemiological and clinical’research. _ The records contain the following information: age, years of service, pay grade (rank), occupational speciality, sex, race, marital status, duty assignment, admitting facility, hospital transfers, length of hospitalization, the existence of the illness prior to entry into service (EPTE), primary and secondary *Report Number 75-54, supported by the Bureau of Medicine and Surgery, Department of the Navy, under Research Work Unit MF51.524.022~0001. Ouinions exnressed are those of the authors and are not to be construed as necessarily reflecting the official view orendorsement of the Department of the Navy. TLCDR, MC, USNR, Head, Health Care Systems Branch, Naval Health Research Center, San Diego, California 92152, and Clinical Assistant Professor of Psychiatry, University of California, San Diego. tHead, Psychiatric Effectiveness Branch, Naval Health Research Center, San Diego, California 92152. SHead, Environmental and Social Medicine Division, Naval Health Research Center, San Diego, California 92152, and Adjunct Professor of Psychiatry, University of California, San Diego. 151
152
JOHN
G.
LOONEY, JERRY M. GOFFMAN
and E. K. ERIC GUNDER~ON
diagnoses, and disposition from the hospital. General Classification Test (GCT) scores were obtained from Bureau of Naval Personnel files. The GCT is a measure of verbal aptitudes with a minimum score of 22 and a maximum score of 74. Criterion data pertaining to adjustment after return to duty were obtained from two sources: Bureau of Medicine and Surgery files provided rehospitalization data and Bureau of Naval Personnel computer tapes provided information as to date and type of discharge from service and recommendation for reenlistment. The effectiveness criterion, then, was based upon completion of at least six months on active duty after hospitalization and, if separated from service after six months, completion of current enlistment with a favorable discharge and a positive recommendation for reenlistment; rehospitalization for a psychiatric condition or receiving an unfavorable discharge (such as Unsuitability or Bad Conduct) or a negative recommendation with respect to reenlistment were the bases for classifying an individual as ineffective. Patients returned to duty were followed for approximately four years. The first phase of the analysis was concerned with factors associated with decisions to return men to duty. Patients in the six diagnostic subgroups-gastrointestinal reactions, respiratory reactions, musculoskeletal reactions, cardiovascular reactions, nervous system reactions, and a combined group consisting of infrequently occurring reactions-were divided into groups returned to duty (RTD) and not returned to duty (NRTD). The latter grouu was released from service throuah administrative or medical channels. RTD and NRTD groups-were compared on demographic and clinical variables, and correlations between these variables and the RTD criterion were computed. The second portion of the analysis was concerned with prediction of post-hospital adjustment (rehospitalization or military ineffectiveness) for men returned to duty. In this phase, correlations were computed to identify factors predictive of post-hospital outcomes. Specific diagnostic subcategories were compared on demographic, clinical, and outcome variables. RESULTS Gastrointestinal, musculoskeletal, and respiratory reactions were the most prevalent of the psychophysiologic disorders and represented 36 %, 21x, and 20 %, respectively, of the total sample. Nervous system reactions (5 %) and cardiovascular reactions (4 %) made up relatively small proportions of the total. Other categories-genitourinary reaction, skin reaction, hemic and lymphatic reaction, endocrine reaction, organs of special sense reaction, and other or unclassified reactions-individually comprised small portions (11 ‘A) of the total and were grouped for purposes of analysis. The proportion of non-Caucasians in the total sample was slightly less than that for the Navy enlisted population as a whole or for Navy psychiatric patients generally. The average score for the patient sample (52.6) on the General Classification Test (GCT) was slightly below that of the total Navy population (approx. 55). A high proportion of psychophysiologic disorder patients (72%) was returned to duty after hospitalization. Groups returned to duty and not returned to duty are compared on demographic and clinical variables in Table 1. The RTD group is older, has longer service, and has achieved higher pay grades (job levels) than the NRTD group. At the same time those returned to duty have lower GCT scores than those not returned to duty. This relationship is partly explained by the fact that cases diagnosed respiratory reaction have a very high return to duty rate but have a relatively low average GCT score (see Table 4). Length of hospitalization for the RTD group was less than one-half that of the NRTD group. Part of this difference can be attributed to delays in administrative processing of those released from service; however, a real difference in severity of illness is indicated by the fact that length of hospitalization correlates positively with other unfavorable prognostic indicators: EPTE (an indication of chronicity of illness) and limited duty assignment (an indication of guarded prognosis). Correlations between selected demographic and clinical variables and the return to duty criterion are shown in Table 2. Existence of the condition prior to enlistment is the most important correlate of disposition decisions, and length of hospitalization is the next most important. These two clinical variables, presumably reflecting chronicity and severity of illness, respectively, would be expected to correlate with disposition decisions (prognostic evaluations) in this manner. Demographic factors, that is, age, length of service, pay grade, and marital status, appeared to play a minor role in disposition decisions. There was a tendency for men with lower GCT scores to be returned to duty-a result contrary to expectations if one assumes that verbal abilities are positively associated with coping skills-but, as previously noted, this effect was largely explained by the low GCT scores of the respiratory reaction group. Demographic and clinical correlates of post-hospital effectiveness are shown in Table 2. Pay grade, or job level, was most highly correlated with effectiveness. Age, length of service, and being married also were positively correlated with effectiveness. These results suggest that maturity, stable inter-
Prognosis forpsychophysiologic disorders in the naval service TABLE
1.-DEMOGRAPHIC
AND
CLINICAL CHARACTERISTICS DISPOSITION
OF
153
PSYCHOPHYSIOLOGIC
DISORDERS
BY
NRTD*
-RTD" Xean
S.D.
Mean
S.D.
???
23.9
6.7
21.8
4.8
c .OOl
Length of service
4.6
6.0
2.8
4.4
< .OOl
Pay grade
3.4
1.9
2.9
1.4
< .OOl
General ClassificationTest (GCT)
52.1
10.5
53.9
8.4
< .05
Days hospitalized
23.7
34.6
48.8
49.0
< .OOl
Variable
A@
Number of cases
"RTD-
Returned to Duty; NRTD - Not Returnedto Duty.
tprobabilitythat differencesbetween mean values are significant. personal relationships, and good work adjustment are significant predictors of outcome. The positive correlation of GCT score with effectiveness is consistent with the expectation that verbal aptitudes contribute to coping or adjustment skills. The existence of the condition prior to enlistment and assignment to limited duty, indicators of chronicity and severity of illness, respectively, correlated significantly (negatively) with effectiveness, but these clinical variables were less important than pay grade. Specific diagnostic subcategories differed in RTD rates as shown in Table 3. The respiratory reaction group, despite being much younger in average age than other diagnostic groups (see Table 4), has a higher RTD rate than other groups. The musculoskeletal reaction patients, on the other hand, despite being the oldest group, had a lower RTD rate than other groups. It seems clear that prognostic evaluations, as reflected in disposition decisions, generally were favorable for respiratory conditions and gastrointestinal conditions but unfavorable for musculoskeletal reactions. Differences in effectiveness rates by diagnostic subcategory are presented in Table 3. It should be noted in Table 3 that the Other and Unclassified group has the highest effectiveness rate. This result is particularly striking in view of the fact that the mean age for patients returning to duty in this group was lower (23.9 yr) than that for either the gastrointestinal or musculoskeletal groups. Demographic, clinical, and outcome data for the three largest groups, gastrointestinal reaction, respiratory reaction, and musculoskeletal reaction, are shown in Table 4. Comparison of the major diagnostic subcategories in Table 4 reveals that the respiratory reaction group has a relatively favorable outcome (63 ‘A effective), despite the fact that this group was younger, less experienced, and held lower job levels than other groups. This diagnostic subcategory also has the shortest period of hospitalization. The gastrointestinal reaction group also has a favorable outcome (68 % effective). This group has intermediate values for length of hospitalization, % RTD, and % rehospitalized. The musculoskeletal reaction group has the lowest effectiveness rate (59%). The long period of hospitalization, low % RTD, and relatively high rate of rehospitalization for this group were consistent with the poor outcome. DISCUSSION
A substantial portion (72%) of this sample of patients was returned to military duty. Men with psychophysiologic disorders were returned to duty with a frequency second only to patients with Acute Situational Maladjustment diagnoses (90 % RTD)
154
JOHNG.LOONEY,JERRY
M.GOFFMAN~~~
E.K.ERIc
GUNDERSON
TABLET.----CORRELATIONSBEAVEENDEMOGRAPHICAND CLINICALVAR~ABLESANDTHERETURNTODUTY AND EFFZCTIVENESSCRITERIA
Predictor Existed
Hospital Disposition (RTD vs NRTD)
Variable
prior
to
enlistment
Days hospitalized
(EPTE)
Post-Hospital Effectiveness
-36 *
-12 *
-2r3*
-07
Pay grade
12”
23*
&a
15*
16*
15”
15”
-08 +
15*
07 +
11*
Length
of service
GGT score Marital
status
Limited
duty
Number
(married)
-08+
of cases
879
633
*P < .Ol +P c.05
’
Decimals
are
omitted.
[28]. Thus, clinicians evaluated these disorders as relatively benign when compared with the neuroses, psychoses, affective disorders, and personality disorders. The relatively high rate of effective post-hospital adjustment for the psychophysiologic disorders (66 %) indicates that clinicians’ decisions were generally sound. Positive predictors of return to duty decisions-age, length of service, and pay grade-reflect previous successful adjustment to the military milieu. Negative predictors-existence of the disorder prior to entry into military service and length of hospitalization-appear to be clear indicators of chronicity and severity of illness, respectively. Clinicians in the civilian community would evaluate chronicity, severity, and prior work achievement similarly in making prognostic determinations. Measures of prior work achievement and lack of chronicity also are related to post-hospital effectiveness in these disorders. In addition, being married and having good verbal abilities (GCT scores) are positively related to outcome. Differential outcomes are apparent for the various subcategories of psychophysiologic disorders. Men with musculoskeletal disorders have the poorest prospects with regard to both return to duty and post-hospital effectiveness. Men with gastrointestinal disorders fare well in both respects. Men with respiratory disorders have
Prognosis for psychophysiologic TABLE 3.-RETURN
disorders in the naval service
155
TO DUTY AND EFFECTIVENESS RATES BY DIAGNOSTIC SUBCATEGORIES
Diagnosis
Total No. of Cases
Percent Returned to Duty
Gastrointestinal Reaction+
316
73
68
Musculoskeletal Reaction
189
57
59
RespiratoryReaction
179
87
63
Nervous System Reaction
4s
67
70
CardiovascularReaction*
35
64
64
115
74
73
Other and UnclassifiedReactionsl
Percent Effective?
*Percent effectiveis based upon the number of cases returnedto duty. Criteriafor being classifiedeffectiveincludedcompletionof six months on active duty, no rehospitalization , and favorabledischargefrom serviceand recommendationfor reenlistmentif separated. TIncludesMucous Colitis,Irritabilityof Colon, GastricNeuroses,and Other DigestiveManifestations. ZIncludesNeurocirculatory Asthenia,Other Heart Manifestations,and Other CirculatoryManifestations. IIncludes GenitourinaryReaction,Skin Reaction,Hemic and LymphaticReaction, EndocrineReaction,and Organs of SpecialSense Reactionin additionto the categoryOther and UnclassifiedPsychophysiologic Reactions.
the highestrateof returnto duty but have a lower rate of effectiveness than men with gastrointestinal disorders, although part of this difference in effectiveness can be accounted for by the lesser military experience and lower job levels characteristic of the respiratory reaction group. The Other and Unclassified group actually had the highest effectiveness rate of any group. The numbers of cases diagnosed genitourinary, skin, hemic and lymphatic, endocrine, and organs of special sense reactions were too few to investigate as distinct groups, so these cases were combined with the Other and Unclassified category. The organ systems involved in cases diagnosed “Other and Unclassified” are unknown, but such cases often may be individuals suffering from psychogenic pain. Further study of the medical and psychiatric histories of these patients is needed to interpret the present findings. The poor prognosis for the musculoskeletal group is striking. Anecdotal and clinical experience would suggest that musculoskeletal psychophysiologic reactions are often precipitated by some specific injury such as acute back strain, “whiplash” injury to the cervical region, traumatic bursitis, etc. For traumatized patients who ultimately receive a diagnosis of psychophysiologic reaction, the site of initial injury apparently becomes the focus of psychic conflict, and dysfunction is often prolonged, Such
JOHNG. LOONEY,JERRYM. GOFFMAN and E. K. ERICGUNLIERSON
156
TABLE 4.-DEMOGRAPHIC, CLINICAL, AND OUTCOMECHARACTERISTICS OF PATIENTSRETURNEDTO DUTY FOR MAJORSUFJCATEGORIES OF PSYCHOPHYSIOLOGIC DISORDERS Gastrointestinal Demographic Variables
:
Mean -A
S.D
Respiratory Mean -A
Musculoskeletal
S.D
Mean -f
S.D
25.2
1.2
20.9
4.3
25.4
7.3
Length of service
6.0
6.7
2.0
4.3
6.0
6.4
Pay grade
3.9
1.9
2.2
1.7
3.7
1.6
GCT score
52.9
9.9
50.8
10.4
51.4
9.9
23.8
25.1
13.5
26.0
40.3
57.3
Age
Clinical
and Outcome Variables:
Days hospitalized
Percent
Percent
Percent
Returned to duty*
73
87
57
Rehospitalized
2.5
11
31
Effective
68
63
59
232
156
108
Number of cases
*Based upon total cases: N = 316 for Gastrointestinal, a>d N = 1X9 for Musculoskeletal.
patients
may
be extremely
refractory
N = 179 for
to rehabilitative
Respiratory,
efforts.
Further
research
involving intensive study of the medical histories of patients diagnosed musculoskeletal psychophysiologic reaction will be carried out to determine factors associated with poor prognosis.
A diagnostic and classification problem encountered in the study was the lack of clarity as to the specific symptoms represented by the various psychophysiologic reactions. Present coding systems require only that the affected organ system be specified. Psychophysiologic respiratory reaction presumably could encompass a variety of disorders, including recurrent dyspnea, asthma, or hyperventilation [29]. Research now in progress attempts to clarify this issue. The need for better diagnostic criteria has been demonstrated in the present study. Despite this difficulty, the study documented a relatively good prognosis for Navy men with psychophysiologic disorders. The results indicated that demographic variables, clinical data, and job achievement were related to positive outcomes, and differential prognosis was demonstrated for major psychophysiologic
reactions.
SUMMARY Demographic, military status, and clinical variables were related to hospital discharge disposition decisions and post-hospital adjustment in large samples of U.S. Navy enlisted men with diagnoses of psychophysiologic reaction. Patients returned to Navy duty were followed for approximately four years. Decisions to return men to duty were positively correlated with length of military service, age, and job level; these decisions were negatively correlated with a history of existence of the disorder prior to enlistment and long periods of hospitalization. Post-hospital adjustment was positively correlated with job level, age, length of service, verbal aptitude, and being married. It was negatively
Prognosis for psychophysiologic
disorders in the naval service
157
correlated with a history of existence of the disorder prior to enlistment. Differential outcomes among the various psychophysiologic disorders were determined; patients with musculoskeletal reactions had the poorest prognosis.
REFERENCES 1. FREEDMANA. M., KAPLAN H. I. and SADOCKB. J. (Eds.) Modern Synopsis of Comprehensive Textbook ofPsvchiutrv. D. 13. Williams & Wilkins. Baltimore (1972). 2. ALEXANDERF.- Psychosomatic Medicine: Its Principles and Applications. W. W. Norton, New
York (1950). 3. DUNBARF. Emotions and Bodily Changes. Columbia University Press, New York (1954). 4. WOLF S. and WOLFFH. G. Human Gastric Function. Oxford University Press, New York (1943). 5. HINKLE L. E., JR., PINSKYR. H., BROKEI. D. J. and PLUMMERN. The distribution of sickness disability in a homogeneous group of “healthy adult men”. Am. J. Hyg. 64,220 (1956). 6. COBBS. and ROSER. M. Hypertension, peptic ulcer and diabetes in air traffic controllers. J. Am. Med. Ass. 224,489-492
(1973).
7. CAFFREYB. A. A multivariate analysis of sociopsychological factors in monks with myocardial infarctions. Am. J. Public Hlth. 60, 452-458 (1970). 8. GUNDER~ONE. K. E. Health and adjustment of men at sea. Report No. 75-19, Naval Health Research Center, San Diego, California (1975). 9. GUNDERSONE. K. E. and RAHE R. H. (Eds.) Life Stress and IIlness. Charles C. Thomas, Springfield, Ill. (1974). 10. RAHE R. H. Subjects’ recent life changes and their near-future illness reports. Ann. C/in. Rex 4, 250-265
(1972).
11. WEINERH., THALERM., REISERM. F. and MIR~KYI. A. Etiology of duodenal ulcer: (1) Relation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom. Med. 19, l-10 (1957). 12. Diagnostic and Statistical Manual: Mental Disorders, p. 29. American Psychiatric Association (Special Printing), Washington, DC. (1965). 13. LEIGHTONA. H. My Name is Legion, Foundations for a Theory of Man in Relation to Culture, Vol. 1 of the Stirling County Study of Psychiatric Disorder and Sociocultural Environment. Basic Books, New York (1959). 14. SROLEL., LANGNERT. S., MICHAELS. T., OPLERM. K. and RENNIET. A. C. Mental Health in the h4etropolis: The Midtown Manhatfan Study. McGraw-Hill, New York (1962). 15. CROMBIED. L. The procrustean bed of medical nomenclature. Luncet 1, 1205-1209 (1963). 16. KAPLAN H. S. The concept of psychogenicity in medicine. In Comprehensive Textbook of Psychiatry (Eds. KAPLANA. M. and KAPLANH. I.), p. 1120. Williams & Wilkins, Baltimore (1967). 17. GRACE W. J., PINSKYR. H. and WOLFF H. G. The treatment of ulcerative colitis: II. Gastroenterorogy
26,462-468
(1954).
18. BERLEB. B., PINSKYR. H., WOLF S. and WOLFF H. G. Appraisal of the results of treatment in stress disorders. Res. Pub. Ass. Nerv. Ment. Dis. 31, 167-177 (1953). 19. O’CONNORJ. F., DANIEL G., FLOOD C., KARUSHA., MOSESL. and STERNL. 0. An evaluation of the effectiveness of psychotherapy in the treatment of ulcerative colitis. Ann. Intern. Med. 60, 587-602
(1964).
T. I. Group psychological training in some organic conditions. 20. CHAPPELLM. N. and STEVENSON Ment. Hyg. 20, 588-597
(1936).
21. ZHUKOVI. A. Hypnotherapy of dermatoses in resort treatment. In Psychotherapy in the Soviet Union (Ed. WINN R. B.), pp. 178-181. Philosophical Library, New York (1961). 22. MAHE&LOUGHNONG. P.; MACDONALDN., MASONA. A. and FRY L. Controlled trial of hypnosis in the svmotomatic treatment of asthma. Br. Med. J. 2. 371-376 (1962). in the treatment of asthma. 23. KAHN A. U.,-ST~ERK M. and BONK C. Role of counter-conditioning J. Psychosom. Res. 18, 89-92 (1974). 24. SARGENTJ. D., GREEN E. E. and WALTERSE. D. Preliminary report on the use of autogenic feedback training in the treatment of migraine and tension headaches. Psychosom. Med. 35, 129-135 (1973). 25. B~DZYNSKIT. H., STOYVAJ. M., ADLERC. S. and MULLANEYD. J. EMG biofeedback and tension headache: A controlled outcome study. Psychosom. Med. 35, 484-496 (1973). 26. Department of Defense Disease and Injury Codes, Part I: Diagnosis Nomenclature-Statistical Classification. Department of the Navy, NAVMED P-5082, Washington, D.C., July 1 (1963). 2nd Edition. American Psychiatric Manual of Mental Disorders: 27. Diagnostic and Statistical Association, Washington, D.C. (1968).
158
JOHN G. LOONEY.JERRYM. GOFFMANand E. K. ERIC GUNDERSON
28. GOFFMANJ. M., GUNDERSONE. K. E. and LOONEYJ. G. Prognosis for acute situational maladjustment (transient situational disturbances) in the naval service. Report No. 75-34, Naval Health Research Center, San Diego, California (1975). 29. Eighth Revision International Classification of Diseases, Adapted for Use in the United States. Public Health Service, Publication No. 1693. U.S. Government Printing Office, Washington, D.C. (1968).
PROGNOSIS FOR PSYCHOPHYSIQLOGIC DISORDERS IN THE NAVAL SERVICE* JOHN
G.
JERRYM. GOFFMANZ) and E. K. ERIC GUNDERSON~
LOONEY,~
(Received 12 August 1975) a few studies have examined treatment outcomes for specific disease entities such as ulcerative colitis, peptic ulcer, eczema, neurodermatitis, asthma, migraine, and tension headache [l-25]. A wide assortment of psychological interventions were used in these studies, including individual psychotherapy, group psychotherapy, hypnosis, counter-conditioning, and biofeedback techniques, but, unfortunately, these studies generally involved small samples, and no reports are available of largescale investigations of post-treatment outcomes for psychophysiologic disorders. Furthermore, there have been no studies of differential outcomes among patients with psychophysiologic reactions involving specific organ systems.
ONLY
Prognostic studies can be effectively conducted on a large scale in the U.S. Navy because naval medical facilities provide standardized record-keeping and readily available hospitalization and follow-up data. Utilizing such sources of information, the relationships of demography, military status, clinical variables, and affected organ system to hospital disposition decisions and posthospital adjustment of patients returned to duty will be examined. Favorable and unfavorable prognostic indicators will be identified. METHOD Subjects were 879 male Navy enlisted personnel discharged from naval medical facilities with diagnoses of Psychophysiologic Disorder during calendar years 19661969. Diagnoses for this sample were established with reference to the Department of Defense Disease and Injury Codes, July 1963 [26]; diagnostic criteria were comparable to those specified in the American Psychiatric Association Diagnostic and Statistical Manual: Mental Disorders (DSM-I), and are very similar to those provided in the Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition (DSM-II) [271currently in use. For cases with more than one admission during the period of study data from the first admission were used, and for cases in which transfers from one hospital to another occurred, data from the last hospital were used. Outcome studies were conducted only on patients returned to duty. This sample consisted of 633 patients. Individual records for all psychiatric hospitalizations in naval service are received at the Bureau of Medicine and Surgery Data Services Center, Bethesda, Maryland. These records are forwarded to the Naval Health Research Center, San Diego, California. where they are extensivelv edited and maintained in computer files for epidemiological and clinical’research. _ The records contain the following information: age, years of service, pay grade (rank), occupational speciality, sex, race, marital status, duty assignment, admitting facility, hospital transfers, length of hospitalization, the existence of the illness prior to entry into service (EPTE), primary and secondary *Report Number 75-54, supported by the Bureau of Medicine and Surgery, Department of the Navy, under Research Work Unit MF51.524.022~0001. Ouinions exnressed are those of the authors and are not to be construed as necessarily reflecting the official view orendorsement of the Department of the Navy. TLCDR, MC, USNR, Head, Health Care Systems Branch, Naval Health Research Center, San Diego, California 92152, and Clinical Assistant Professor of Psychiatry, University of California, San Diego. tHead, Psychiatric Effectiveness Branch, Naval Health Research Center, San Diego, California 92152. SHead, Environmental and Social Medicine Division, Naval Health Research Center, San Diego, California 92152, and Adjunct Professor of Psychiatry, University of California, San Diego. 151
152
JOHN
G.
LOONEY, JERRY M. GOFFMAN
and E. K. ERIC GUNDER~ON
diagnoses, and disposition from the hospital. General Classification Test (GCT) scores were obtained from Bureau of Naval Personnel files. The GCT is a measure of verbal aptitudes with a minimum score of 22 and a maximum score of 74. Criterion data pertaining to adjustment after return to duty were obtained from two sources: Bureau of Medicine and Surgery files provided rehospitalization data and Bureau of Naval Personnel computer tapes provided information as to date and type of discharge from service and recommendation for reenlistment. The effectiveness criterion, then, was based upon completion of at least six months on active duty after hospitalization and, if separated from service after six months, completion of current enlistment with a favorable discharge and a positive recommendation for reenlistment; rehospitalization for a psychiatric condition or receiving an unfavorable discharge (such as Unsuitability or Bad Conduct) or a negative recommendation with respect to reenlistment were the bases for classifying an individual as ineffective. Patients returned to duty were followed for approximately four years. The first phase of the analysis was concerned with factors associated with decisions to return men to duty. Patients in the six diagnostic subgroups-gastrointestinal reactions, respiratory reactions, musculoskeletal reactions, cardiovascular reactions, nervous system reactions, and a combined group consisting of infrequently occurring reactions-were divided into groups returned to duty (RTD) and not returned to duty (NRTD). The latter grouu was released from service throuah administrative or medical channels. RTD and NRTD groups-were compared on demographic and clinical variables, and correlations between these variables and the RTD criterion were computed. The second portion of the analysis was concerned with prediction of post-hospital adjustment (rehospitalization or military ineffectiveness) for men returned to duty. In this phase, correlations were computed to identify factors predictive of post-hospital outcomes. Specific diagnostic subcategories were compared on demographic, clinical, and outcome variables. RESULTS Gastrointestinal, musculoskeletal, and respiratory reactions were the most prevalent of the psychophysiologic disorders and represented 36 %, 21x, and 20 %, respectively, of the total sample. Nervous system reactions (5 %) and cardiovascular reactions (4 %) made up relatively small proportions of the total. Other categories-genitourinary reaction, skin reaction, hemic and lymphatic reaction, endocrine reaction, organs of special sense reaction, and other or unclassified reactions-individually comprised small portions (11 ‘A) of the total and were grouped for purposes of analysis. The proportion of non-Caucasians in the total sample was slightly less than that for the Navy enlisted population as a whole or for Navy psychiatric patients generally. The average score for the patient sample (52.6) on the General Classification Test (GCT) was slightly below that of the total Navy population (approx. 55). A high proportion of psychophysiologic disorder patients (72%) was returned to duty after hospitalization. Groups returned to duty and not returned to duty are compared on demographic and clinical variables in Table 1. The RTD group is older, has longer service, and has achieved higher pay grades (job levels) than the NRTD group. At the same time those returned to duty have lower GCT scores than those not returned to duty. This relationship is partly explained by the fact that cases diagnosed respiratory reaction have a very high return to duty rate but have a relatively low average GCT score (see Table 4). Length of hospitalization for the RTD group was less than one-half that of the NRTD group. Part of this difference can be attributed to delays in administrative processing of those released from service; however, a real difference in severity of illness is indicated by the fact that length of hospitalization correlates positively with other unfavorable prognostic indicators: EPTE (an indication of chronicity of illness) and limited duty assignment (an indication of guarded prognosis). Correlations between selected demographic and clinical variables and the return to duty criterion are shown in Table 2. Existence of the condition prior to enlistment is the most important correlate of disposition decisions, and length of hospitalization is the next most important. These two clinical variables, presumably reflecting chronicity and severity of illness, respectively, would be expected to correlate with disposition decisions (prognostic evaluations) in this manner. Demographic factors, that is, age, length of service, pay grade, and marital status, appeared to play a minor role in disposition decisions. There was a tendency for men with lower GCT scores to be returned to duty-a result contrary to expectations if one assumes that verbal abilities are positively associated with coping skills-but, as previously noted, this effect was largely explained by the low GCT scores of the respiratory reaction group. Demographic and clinical correlates of post-hospital effectiveness are shown in Table 2. Pay grade, or job level, was most highly correlated with effectiveness. Age, length of service, and being married also were positively correlated with effectiveness. These results suggest that maturity, stable inter-
Prognosis forpsychophysiologic disorders in the naval service TABLE
1.-DEMOGRAPHIC
AND
CLINICAL CHARACTERISTICS DISPOSITION
OF
153
PSYCHOPHYSIOLOGIC
DISORDERS
BY
NRTD*
-RTD" Xean
S.D.
Mean
S.D.
???
23.9
6.7
21.8
4.8
c .OOl
Length of service
4.6
6.0
2.8
4.4
< .OOl
Pay grade
3.4
1.9
2.9
1.4
< .OOl
General ClassificationTest (GCT)
52.1
10.5
53.9
8.4
< .05
Days hospitalized
23.7
34.6
48.8
49.0
< .OOl
Variable
A@
Number of cases
"RTD-
Returned to Duty; NRTD - Not Returnedto Duty.
tprobabilitythat differencesbetween mean values are significant. personal relationships, and good work adjustment are significant predictors of outcome. The positive correlation of GCT score with effectiveness is consistent with the expectation that verbal aptitudes contribute to coping or adjustment skills. The existence of the condition prior to enlistment and assignment to limited duty, indicators of chronicity and severity of illness, respectively, correlated significantly (negatively) with effectiveness, but these clinical variables were less important than pay grade. Specific diagnostic subcategories differed in RTD rates as shown in Table 3. The respiratory reaction group, despite being much younger in average age than other diagnostic groups (see Table 4), has a higher RTD rate than other groups. The musculoskeletal reaction patients, on the other hand, despite being the oldest group, had a lower RTD rate than other groups. It seems clear that prognostic evaluations, as reflected in disposition decisions, generally were favorable for respiratory conditions and gastrointestinal conditions but unfavorable for musculoskeletal reactions. Differences in effectiveness rates by diagnostic subcategory are presented in Table 3. It should be noted in Table 3 that the Other and Unclassified group has the highest effectiveness rate. This result is particularly striking in view of the fact that the mean age for patients returning to duty in this group was lower (23.9 yr) than that for either the gastrointestinal or musculoskeletal groups. Demographic, clinical, and outcome data for the three largest groups, gastrointestinal reaction, respiratory reaction, and musculoskeletal reaction, are shown in Table 4. Comparison of the major diagnostic subcategories in Table 4 reveals that the respiratory reaction group has a relatively favorable outcome (63 ‘A effective), despite the fact that this group was younger, less experienced, and held lower job levels than other groups. This diagnostic subcategory also has the shortest period of hospitalization. The gastrointestinal reaction group also has a favorable outcome (68 % effective). This group has intermediate values for length of hospitalization, % RTD, and % rehospitalized. The musculoskeletal reaction group has the lowest effectiveness rate (59%). The long period of hospitalization, low % RTD, and relatively high rate of rehospitalization for this group were consistent with the poor outcome. DISCUSSION
A substantial portion (72%) of this sample of patients was returned to military duty. Men with psychophysiologic disorders were returned to duty with a frequency second only to patients with Acute Situational Maladjustment diagnoses (90 % RTD)
154
JOHNG.LOONEY,JERRY
M.GOFFMAN~~~
E.K.ERIc
GUNDERSON
TABLET.----CORRELATIONSBEAVEENDEMOGRAPHICAND CLINICALVAR~ABLESANDTHERETURNTODUTY AND EFFZCTIVENESSCRITERIA
Predictor Existed
Hospital Disposition (RTD vs NRTD)
Variable
prior
to
enlistment
Days hospitalized
(EPTE)
Post-Hospital Effectiveness
-36 *
-12 *
-2r3*
-07
Pay grade
12”
23*
&a
15*
16*
15”
15”
-08 +
15*
07 +
11*
Length
of service
GGT score Marital
status
Limited
duty
Number
(married)
-08+
of cases
879
633
*P < .Ol +P c.05
’
Decimals
are
omitted.
[28]. Thus, clinicians evaluated these disorders as relatively benign when compared with the neuroses, psychoses, affective disorders, and personality disorders. The relatively high rate of effective post-hospital adjustment for the psychophysiologic disorders (66 %) indicates that clinicians’ decisions were generally sound. Positive predictors of return to duty decisions-age, length of service, and pay grade-reflect previous successful adjustment to the military milieu. Negative predictors-existence of the disorder prior to entry into military service and length of hospitalization-appear to be clear indicators of chronicity and severity of illness, respectively. Clinicians in the civilian community would evaluate chronicity, severity, and prior work achievement similarly in making prognostic determinations. Measures of prior work achievement and lack of chronicity also are related to post-hospital effectiveness in these disorders. In addition, being married and having good verbal abilities (GCT scores) are positively related to outcome. Differential outcomes are apparent for the various subcategories of psychophysiologic disorders. Men with musculoskeletal disorders have the poorest prospects with regard to both return to duty and post-hospital effectiveness. Men with gastrointestinal disorders fare well in both respects. Men with respiratory disorders have
Prognosis for psychophysiologic TABLE 3.-RETURN
disorders in the naval service
155
TO DUTY AND EFFECTIVENESS RATES BY DIAGNOSTIC SUBCATEGORIES
Diagnosis
Total No. of Cases
Percent Returned to Duty
Gastrointestinal Reaction+
316
73
68
Musculoskeletal Reaction
189
57
59
RespiratoryReaction
179
87
63
Nervous System Reaction
4s
67
70
CardiovascularReaction*
35
64
64
115
74
73
Other and UnclassifiedReactionsl
Percent Effective?
*Percent effectiveis based upon the number of cases returnedto duty. Criteriafor being classifiedeffectiveincludedcompletionof six months on active duty, no rehospitalization , and favorabledischargefrom serviceand recommendationfor reenlistmentif separated. TIncludesMucous Colitis,Irritabilityof Colon, GastricNeuroses,and Other DigestiveManifestations. ZIncludesNeurocirculatory Asthenia,Other Heart Manifestations,and Other CirculatoryManifestations. IIncludes GenitourinaryReaction,Skin Reaction,Hemic and LymphaticReaction, EndocrineReaction,and Organs of SpecialSense Reactionin additionto the categoryOther and UnclassifiedPsychophysiologic Reactions.
the highestrateof returnto duty but have a lower rate of effectiveness than men with gastrointestinal disorders, although part of this difference in effectiveness can be accounted for by the lesser military experience and lower job levels characteristic of the respiratory reaction group. The Other and Unclassified group actually had the highest effectiveness rate of any group. The numbers of cases diagnosed genitourinary, skin, hemic and lymphatic, endocrine, and organs of special sense reactions were too few to investigate as distinct groups, so these cases were combined with the Other and Unclassified category. The organ systems involved in cases diagnosed “Other and Unclassified” are unknown, but such cases often may be individuals suffering from psychogenic pain. Further study of the medical and psychiatric histories of these patients is needed to interpret the present findings. The poor prognosis for the musculoskeletal group is striking. Anecdotal and clinical experience would suggest that musculoskeletal psychophysiologic reactions are often precipitated by some specific injury such as acute back strain, “whiplash” injury to the cervical region, traumatic bursitis, etc. For traumatized patients who ultimately receive a diagnosis of psychophysiologic reaction, the site of initial injury apparently becomes the focus of psychic conflict, and dysfunction is often prolonged, Such
JOHNG. LOONEY,JERRYM. GOFFMAN and E. K. ERICGUNLIERSON
156
TABLE 4.-DEMOGRAPHIC, CLINICAL, AND OUTCOMECHARACTERISTICS OF PATIENTSRETURNEDTO DUTY FOR MAJORSUFJCATEGORIES OF PSYCHOPHYSIOLOGIC DISORDERS Gastrointestinal Demographic Variables
:
Mean -A
S.D
Respiratory Mean -A
Musculoskeletal
S.D
Mean -f
S.D
25.2
1.2
20.9
4.3
25.4
7.3
Length of service
6.0
6.7
2.0
4.3
6.0
6.4
Pay grade
3.9
1.9
2.2
1.7
3.7
1.6
GCT score
52.9
9.9
50.8
10.4
51.4
9.9
23.8
25.1
13.5
26.0
40.3
57.3
Age
Clinical
and Outcome Variables:
Days hospitalized
Percent
Percent
Percent
Returned to duty*
73
87
57
Rehospitalized
2.5
11
31
Effective
68
63
59
232
156
108
Number of cases
*Based upon total cases: N = 316 for Gastrointestinal, a>d N = 1X9 for Musculoskeletal.
patients
may
be extremely
refractory
N = 179 for
to rehabilitative
Respiratory,
efforts.
Further
research
involving intensive study of the medical histories of patients diagnosed musculoskeletal psychophysiologic reaction will be carried out to determine factors associated with poor prognosis.
A diagnostic and classification problem encountered in the study was the lack of clarity as to the specific symptoms represented by the various psychophysiologic reactions. Present coding systems require only that the affected organ system be specified. Psychophysiologic respiratory reaction presumably could encompass a variety of disorders, including recurrent dyspnea, asthma, or hyperventilation [29]. Research now in progress attempts to clarify this issue. The need for better diagnostic criteria has been demonstrated in the present study. Despite this difficulty, the study documented a relatively good prognosis for Navy men with psychophysiologic disorders. The results indicated that demographic variables, clinical data, and job achievement were related to positive outcomes, and differential prognosis was demonstrated for major psychophysiologic
reactions.
SUMMARY Demographic, military status, and clinical variables were related to hospital discharge disposition decisions and post-hospital adjustment in large samples of U.S. Navy enlisted men with diagnoses of psychophysiologic reaction. Patients returned to Navy duty were followed for approximately four years. Decisions to return men to duty were positively correlated with length of military service, age, and job level; these decisions were negatively correlated with a history of existence of the disorder prior to enlistment and long periods of hospitalization. Post-hospital adjustment was positively correlated with job level, age, length of service, verbal aptitude, and being married. It was negatively
Prognosis for psychophysiologic
disorders in the naval service
157
correlated with a history of existence of the disorder prior to enlistment. Differential outcomes among the various psychophysiologic disorders were determined; patients with musculoskeletal reactions had the poorest prognosis.
REFERENCES 1. FREEDMANA. M., KAPLAN H. I. and SADOCKB. J. (Eds.) Modern Synopsis of Comprehensive Textbook ofPsvchiutrv. D. 13. Williams & Wilkins. Baltimore (1972). 2. ALEXANDERF.- Psychosomatic Medicine: Its Principles and Applications. W. W. Norton, New
York (1950). 3. DUNBARF. Emotions and Bodily Changes. Columbia University Press, New York (1954). 4. WOLF S. and WOLFFH. G. Human Gastric Function. Oxford University Press, New York (1943). 5. HINKLE L. E., JR., PINSKYR. H., BROKEI. D. J. and PLUMMERN. The distribution of sickness disability in a homogeneous group of “healthy adult men”. Am. J. Hyg. 64,220 (1956). 6. COBBS. and ROSER. M. Hypertension, peptic ulcer and diabetes in air traffic controllers. J. Am. Med. Ass. 224,489-492
(1973).
7. CAFFREYB. A. A multivariate analysis of sociopsychological factors in monks with myocardial infarctions. Am. J. Public Hlth. 60, 452-458 (1970). 8. GUNDER~ONE. K. E. Health and adjustment of men at sea. Report No. 75-19, Naval Health Research Center, San Diego, California (1975). 9. GUNDERSONE. K. E. and RAHE R. H. (Eds.) Life Stress and IIlness. Charles C. Thomas, Springfield, Ill. (1974). 10. RAHE R. H. Subjects’ recent life changes and their near-future illness reports. Ann. C/in. Rex 4, 250-265
(1972).
11. WEINERH., THALERM., REISERM. F. and MIR~KYI. A. Etiology of duodenal ulcer: (1) Relation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom. Med. 19, l-10 (1957). 12. Diagnostic and Statistical Manual: Mental Disorders, p. 29. American Psychiatric Association (Special Printing), Washington, DC. (1965). 13. LEIGHTONA. H. My Name is Legion, Foundations for a Theory of Man in Relation to Culture, Vol. 1 of the Stirling County Study of Psychiatric Disorder and Sociocultural Environment. Basic Books, New York (1959). 14. SROLEL., LANGNERT. S., MICHAELS. T., OPLERM. K. and RENNIET. A. C. Mental Health in the h4etropolis: The Midtown Manhatfan Study. McGraw-Hill, New York (1962). 15. CROMBIED. L. The procrustean bed of medical nomenclature. Luncet 1, 1205-1209 (1963). 16. KAPLAN H. S. The concept of psychogenicity in medicine. In Comprehensive Textbook of Psychiatry (Eds. KAPLANA. M. and KAPLANH. I.), p. 1120. Williams & Wilkins, Baltimore (1967). 17. GRACE W. J., PINSKYR. H. and WOLFF H. G. The treatment of ulcerative colitis: II. Gastroenterorogy
26,462-468
(1954).
18. BERLEB. B., PINSKYR. H., WOLF S. and WOLFF H. G. Appraisal of the results of treatment in stress disorders. Res. Pub. Ass. Nerv. Ment. Dis. 31, 167-177 (1953). 19. O’CONNORJ. F., DANIEL G., FLOOD C., KARUSHA., MOSESL. and STERNL. 0. An evaluation of the effectiveness of psychotherapy in the treatment of ulcerative colitis. Ann. Intern. Med. 60, 587-602
(1964).
T. I. Group psychological training in some organic conditions. 20. CHAPPELLM. N. and STEVENSON Ment. Hyg. 20, 588-597
(1936).
21. ZHUKOVI. A. Hypnotherapy of dermatoses in resort treatment. In Psychotherapy in the Soviet Union (Ed. WINN R. B.), pp. 178-181. Philosophical Library, New York (1961). 22. MAHE&LOUGHNONG. P.; MACDONALDN., MASONA. A. and FRY L. Controlled trial of hypnosis in the svmotomatic treatment of asthma. Br. Med. J. 2. 371-376 (1962). in the treatment of asthma. 23. KAHN A. U.,-ST~ERK M. and BONK C. Role of counter-conditioning J. Psychosom. Res. 18, 89-92 (1974). 24. SARGENTJ. D., GREEN E. E. and WALTERSE. D. Preliminary report on the use of autogenic feedback training in the treatment of migraine and tension headaches. Psychosom. Med. 35, 129-135 (1973). 25. B~DZYNSKIT. H., STOYVAJ. M., ADLERC. S. and MULLANEYD. J. EMG biofeedback and tension headache: A controlled outcome study. Psychosom. Med. 35, 484-496 (1973). 26. Department of Defense Disease and Injury Codes, Part I: Diagnosis Nomenclature-Statistical Classification. Department of the Navy, NAVMED P-5082, Washington, D.C., July 1 (1963). 2nd Edition. American Psychiatric Manual of Mental Disorders: 27. Diagnostic and Statistical Association, Washington, D.C. (1968).
158
JOHN G. LOONEY.JERRYM. GOFFMANand E. K. ERIC GUNDERSON
28. GOFFMANJ. M., GUNDERSONE. K. E. and LOONEYJ. G. Prognosis for acute situational maladjustment (transient situational disturbances) in the naval service. Report No. 75-34, Naval Health Research Center, San Diego, California (1975). 29. Eighth Revision International Classification of Diseases, Adapted for Use in the United States. Public Health Service, Publication No. 1693. U.S. Government Printing Office, Washington, D.C. (1968).
