This case control study included 1,558 subjects living in central Dalmatia in the region of Split-Dalmatia County. The test group consists of male combat veterans, 36 to 65 years of age, diagnosed with PTSD resulting from the combat experience after the Homeland war in Croatia, who were in outpatient treatment. The group was formed from a sample of all combat veterans who were diagnosed and/or treated at the Regional Center for Psychotrauma, Split Clinical Hospital Center, from May 2010 to May 2011. A total of 1,023 veterans were examined, of whom 759 were diagnosed with PTSD and 501 agreed to participate in the study. The remaining 258 were excluded from the study due to various reasons; 108 of them did not accepted to participate in the study, with the other 150 questionnaires were not properly filled, (49 of them Mississippi scale was not properly filled, and in 101 the data were insufficient). The diagnosis of PTSD was established according to the diagnostic criteria for PTSD based on the ICD-10 criteria (World Health Organization, 1992), but also with a Structured Clinical Interview (SCID) for DSM-IV (First, Spitzer, Gibbon, & Williams, 2000). All participants were assessed systematically. Particular symptoms were evaluated using the self-report questionnaire of the Mississippi Scale for Combat Related Posttraumatic Stress Disorder (M-PTSD) (Keane, Cadell, & Taylor, 1988). PTSD assessed based on combat/military traumas only. This questionnaire is a 35-item self-report measure that assesses combat-related PTSD in veteran populations. This measure has demonstrated good test-retest reliability (r=.97, 1-week interval), internal consistency (alpha= .94) and diagnostic accuracy (90% diagnostic efficiency) in a sample of Vietnam combat veterans (Kulka et al., 1991). Selected symptoms were collected and diagnoses established by three psychiatrists and two psychologists with an extensive experience in war related psychopathologies who were working with veterans with PTSD. Comorbid diagnoses were established using the ICD-10 and SCID according to DSM-IV.

The average age of the participants was 47.5±6.6 years. Most of them (n=384) had a secondary school education (10–12 years of school). The majority (n=384) were married, 78 were single, 37 were divorced and two were widowed. The largest number (n=358) were retired, while 63 of them were unemployed and 80 veterans were employed. Most of the participants (n=202) had spent more than three years on the battlefield, 104 between 2 and 3 years and 130 between 1 and 2 years. Of the total number, 47 had been wounded.

Control group. The total patient populations of three family medical practices in three different cities were examined, which included persons from urban, rural and island milieus, which were not exposed to war activities. There were a total of 5,000 subjects, of whom 2,389 were men and 825 met the criteria for participation in the study. The inclusion criteria were male gender between 36 and 65 years of age. The exclusion criteria were the existence of psychological problems or psychiatric treatment (all codes from F-01 to F-09, according to the ICD-10) and combat duty in the Homeland war. From all patient population, 913 were younger than 35 or older than 65 years, 561 subjects were involved in acts of war. From the subjects examined, 204 showed psychological problems, of which 114 as a result of participation in the war. Assessment of physical diseases was conducted by systematic examination of the medical records, medical examination by three experienced family physicians who received equivalent training, but unfortunately without rater-interrater reliability. Assessment of psychiatric disorders in the control group was conducted by a family physician, who found no criterion for the diagnosis of disorders of the F 00-F 99 ICD-10. In addition, inspection in the whole life medical records for each of the control respondents did not reveal presence of any psychiatric disorders. Average age of the control group was 46.9±7.9 years. Out of 825 included control subjects, most of the participants (n=607) had a secondary school education (10–12 years of school). The majority (n=643) were married, 157 were single and 25 were divorced or widowed. The largest number were employed (n=591), 148 were retired with pensions and 86 were unemployed.

Data were collected by three psychiatrists, two psychologists and four family physicians using a questionnaire especially designed for this purpose. The questionnaire collected data on socio-demographic status (marital status, education, employment status, presence/absence at war and for the group of veterans the length combat duty and wounds). The data on physical illness were divided into gastrointestinal, cardiovascular, dermatological, neurological, metabolic, pulmonary, musculoskeletal systems, tumors, and other disease groups. Information on diseases was obtained from interviews with the subjects, medical examination and inspection of their medical records.

The resulting data described the sociodemographic data, data on the diseases in both groups (veterans and the general population) and differences in diseases, the length of combat duty during the war and wounds incurred, which represented predictors of individual physical illnesses. In the second analysis, the frequencies of physical illnesses in veterans with and without psychiatric comorbidity were compared.

Univariate logistic regression was performed in order to determine the odds ratio for a specific diagnosis in cases and controls. For this purpose, all the variables of a specific diagnose (including Diseases of the Gastrointestinal Tract, Cardiological Diseases, Dermatological Diseases, Diseases of the Locomotor Apparatus, Neurological Diseases, Metabolic Diseases, Pulmonary Diseases, Malignant Diseases and Other) were recoded into variables with two levels (YES= is diagnosed with the specific disease; NO= is not diagnosed with the specific disease). All the binary logistic regression analysis were performed with the inclusion of recoded variables in the model. The adjusted odds ratios were calculated after the inclusion of the following possible confounding factors in the multiple binary logistic regression model: age, education, marital status and employment status. Along with the adjusted odds ratios for a specific disease, Chi squares and a p value of a specific model including the possible confounding factors were reported. The variables were evaluated descriptively (presented as means and standard deviation), and analyzed using binary logistic regression. For a subsequent comparison between the groups, the Student's t-test and χ2 test were used. The software program SPSS 12.0 for Windows (Chicago, IL: SPSS Inc., 2003) was used for data analysis, with the significance level set at .05.

The study was approved by the Ethics Committee of the University of Split Hospital Center. All the subjects were familiarized with the study and gave their written informed consent.

There was no significant difference in age of the veterans and control group (t =1.36 p=.174). However, significant difference was detected in marital status (χ2 (2)=16.77; p=.0005) and employment status (χ2 (2)=426.13; p=.0005). In the control group, there was a marginally higher number of unmarried men and a lower number of divorced men and widowers. Regarding employment status, the veterans were more frequently retired and subjects in the control group were more frequently employed (Table 1).

The difference in the overall prevalence of physical illnesses between these two groups was significant (χ2 (1)=8.67; p=.003) in the morbidity from gastrointestinal, cardiac, dermatological, musculoskeletal, respiratory and metabolic diseases (Table 2). With the exception of gastrointestinal illnesses, all other somatic diseases were more prevalent among the combat veterans suffering from PTSD compared to control group. In the group of subjects with gastrointestinal illnesses, ulcer disease was more common in the general population, while gastritis and ulcerative colitis were more prevalent among the combat veterans (Table 2). Although total cardiovascular diseases were significantly more common among the combat veterans, arterial hypertension was more common in the control group, while myocardial infarction, arrhythmia and other illnesses were more common in the group of combat veterans. Out of dermatological diseases, psoriasis was more common in the control population, but allergies, alopecia and other diseases were more frequent in the group of veterans (χ2 (4)=51.14; p=.001). All diseases of the musculoskeletal system were more frequent in combat veterans (χ2 (4)=104.69; p<.001), which include spinal disorders, arthritis and rheumatoid arthritis, compared to control subjects. All neurological diseases were more common in the group of combat veterans (χ2 (4)=66.36; p=.001), with the most common consisting of headache, epilepsy and cerebrovascular insult(s). Metabolic diseases were more common in combat veterans (χ2 (2)=24.432; p<.001), such as diabetes mellitus and thyroid disease, than in control subjects. There were no differences in the frequencies of malignant and other diseases between these two groups (Table 2). All stated differences are statistically significant also when the influence on length of time spent in combat is controlled, and it means that differences in more often physical illnesses in veterans are mainly results of PTSD rather than duration of trauma exposure (Table 3).

The results of the binary logistic regression confirmed that the patients with PTSD were statistically significantly more likely to be diagnosed with cardiological, dermatological, neurological, metabolic diseases and diseases of the locomotor apparatus (Table 4). When adjusted for possible confounding factors among the cases and controls, including age, education, marital status and employment status, the adjusted odds ratios were still statistically significant in all variables that proved significant in the univariate regression model. After the adjustment, PTSD patients were almost 4 times more likely to be diagnosed with neurological diseases (odds ratio 3.856; 2.381-6.246; p<.001), and two times more likely to be diagnosed with diseases of the locomotor apparatus (odds ratio 2.141; 1.602-2.862; p<.001) and dermatological diseases (odds ratio 2.021; 1.185-3.445; p=.010). Odds ratio for metabolic (odds ratio 1.779; 1.089-2.907; p=.021) and cardiological diseases (odds ratio 1.423; 1.016-1.993; p=.040) were somewhat smaller, but still statistically significant after the adjustment.

In the group of veterans suffering from PTSD, the predictors of the incidence of physical illness were age (B=-0.067, p=.005), the length of time spent on the battlefield (B=0.182, p=.063), and whether they were wounded. Higher age was significant predictor of cardiovascular (B=-0.071, p<.005), musculoskeletal (B=-0.047, p=.002) metabolic (B=-0.078, p=.001) and malignant (B=-0.231, p=.003) diseases. Secondary or higher education was a predictor of gastrointestinal diseases (B=0.701, p=.035) (Table 4). A predictor of cardiovascular (B=0.221, p=.026), musculoskeletal (B=0.254, p=.004), neurological (B=0.264, p=.018) and pulmonary (B=-0.475, p=.013) diseases was the length of time spent on musculoskeletal (B=-0.582, p=.073) and malignant (B=-1.972, p=.038) diseases.

In the control group, age was a predictor of the occurrence of total physical diseases (B=-0.068, p<.005) but also gastrointestinal (B=-0.034, p=.012), cardiovascular (B=-0.113, p<.005) and malignant (B=-0.088, p=.019) diseases, as well as the prediction limit for musculoskeletal diseases (B=-0.022, p=.057). Higher education was a predictor of musculoskeletal diseases and cancer, while being single was a predictor of gastrointestinal diseases. Being employed was a predictor of general physical diseases, particularly regarding dermatological (psoriasis) and neurological (headache) diseases (Table 5).

All veterans examined were PTSD diagnosed. Psychiatric comorbidity was present in 62% of the subjects, most commonly Enduring Personality Change After Catastrophic Experience (EPCACE) (F62.0), detected in over half of the subjects, followed by depressive disorder in 38%, and less frequently, anxiety depressive disorder and addictions.

Sociodemographic data were similar between the two groups. However, veterans with psychiatric comorbidities spent a significantly longer period of time on the battlefield than veterans without comorbidities (χ2 (3)=12.44; p=.006). Significantly more frequent cardiovascular diseases (hypertension and myocardial infarction) occurred in veterans without comorbidities (χ2 (4)=14.49; p=.006), while arrhythmias were somewhat more frequent in veterans with comorbidities (Table 6). There were no significant differences in the incidence of other diseases between veterans with or without psychiatric comorbidities.

As presented in Table 7, PTSD patients with psychiatric comorbidity were statistically significantly less likely to be diagnosed with cardiological (odds ratio 0.537; 0.361-0.800; p=.002) and dermatological (odds ratio 0.487; 0.270-0.877; p=.016) diseases, in comparison with PTSD patients without psychiatric comorbidity, even after the adjustment for confounding sociodemographic variables (Table 7).