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To treat the impact of trauma, most current evidence supports the use of trauma-focused psychotherapy as the first line approach. However, millions of individuals exposed to trauma worldwide seek Complementary and Integrative Health (CIH) therapies in hopes of achieving wellness above and beyond reducing symptoms. But what is the evidence for CIH interventions? What are potential pitfalls? Given the growing popularity of and strong interest in CIH, EJPT is featuring research on these approaches in this special issue. The papers range from common interventions such as mindfulness to the use of service dogs and scuba diving to alleviate trauma related symptoms. A featured editorial highlights the importance of defining when, where, and how placebo responses work. Nonspecific elements of treatment such as positive expectations, therapeutic rituals, healing symbols, and social interactions are identified as factors influencing treatment response and scientists looking to add to the CIH evidence base are encouraged to consider the impact and methodological challenges these elements present. CIH interventions more specifically recognize and harness some of these factors in addition to intervention-specific factors such as attention or emotion regulation along with focus on overall wellbeing. The body of work in this special issue supports the emerging evidence for meditative and relaxation-based interventions and illustrates a creative but nascent state of the field. Cross-intervention mechanisms that may play a role in achieving wellness, such as arousal reduction, emotion regulation, posttraumatic growth, and positive affect are highlighted. The trauma field would benefit from accumulation of evidence for promising CIH interventions, evaluation of potential mechanisms, and examination of health and wellbeing outcomes. With the paucity of high-quality trials, it would be premature to recommend CIH interventions as first-line treatments. However, the emerging literature on CIH continues to advance our understanding of what works and how these interventions exert their effects. Complementary and Integrative Health (CIH) interventions for trauma that target holistic wellness above and beyond symptom reduction are increasingly used in the real world, though the evidence base lags. Papers in this issue support the emerging evidence for efficacy of mindfulness or other meditative or relaxation-based interventions. This special issue illustrates creative approaches but also the need for continued research establishing efficacy, evaluating more inclusive outcomes (e.g. a sense of wellbeing or ability to pursue valued life goals), and identifying potential mechanisms. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To systematically review outcomes from randomized controlled trials (RCTs) of mind–body treatments for PTSD. Methods: Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches. Results: Twenty‐two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between‐group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between‐group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within‐group symptom improvements in the relaxation condition for the majority of studies. Conclusions: Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind–body trials are offered. [ABSTRACT FROM AUTHOR]

Many of the 700,000 American military personnel deployed to the Persian Gulf region in 1990 and 1991 have since reported health symptoms of unknown etiology. This cluster of symptoms has been labeled Gulf War Illness and include chronic musculoskeletal pain, fatigue, headaches, memory and attention difficulties, gastrointestinal complaints, skin abnormalities, breathing problems, and mood and sleep problems [ 1 , 2 ]. There have been few high-quality intervention trials and no strong evidence to support available treatments [ 3 ]. Tai Chi is an ancient Chinese martial art with benefits that include enhancing physical and mental health and improving quality of life for those with chronic conditions. In this randomized controlled trial, GW Veterans are randomly assigned to either Tai Chi or a Wellness control condition, with both remotely delivered intervention groups meeting twice a week for 12 weeks. The primary aim is to examine if Tai Chi is associated with greater improvements in GWI symptoms in Veterans with GWI compared to a Wellness intervention. Participants will receive assessments at baseline, 12 weeks (post-intervention), and follow-up assessments 3- and 9-months post-intervention. The primary outcome measure is the Brief Pain Inventory that examines pain intensity and pain interference. This trial will produce valuable results that can have a meaningful impact on healthcare practices for GWI. If proven as a helpful treatment for individuals with GWI, it would support the implementation of remotely delivered Tai Chi classes that Veterans can access from their own homes. • There is a need for high-quality intervention trials for Gulf War Illness. • Tai Chi shows promise to address pain and improve functioning in Gulf War Illness. • Using telehealth therapies for Gulf War Veterans can improve access to care. [ABSTRACT FROM AUTHOR]

The present study examined fluctuation over time in symptoms of posttraumatic stress disorder (PTSD) among 34 combat veterans (28 with diagnosed PTSD, 6 with subclinical symptoms) assessed every 2 weeks for up to 2 years (range of assessments = 13-52). Temporal relationships were examined among four PTSD symptom clusters (reexperiencing, avoidance, emotional numbing, and hyperarousal) with particular attention to the influence of hyperarousal. Multilevel cross-lagged random coefficients autoregression for intensive time series data analyses were used to model symptom fluctuation decades after combat experiences. As anticipated, hyperarousal predicted subsequent fluctuations in the 3 other PTSD symptom clusters (reexperiencing, avoidance, emotional numbing) at subsequent 2-week intervals (rs = .45, .36, and .40, respectively). Additionally, emotional numbing influenced later reexperiencing and avoidance, and reexperiencing influenced later hyperarousal (rs = .44, .40, and .34, respectively). These findings underscore the important influence of hyperarousal. Furthermore, results indicate a bidirectional relationship between hyperarousal and reexperiencing as well as a possible chaining of symptoms (hyperarousal → emotional numbing → reexperiencing → hyperarousal) and establish potential internal, intrapersonal mechanisms for the maintenance of persistent PTSD symptoms. Results suggested that clinical interventions targeting hyperarousal and emotional numbing symptoms may hold promise for PTSD of long duration. [ABSTRACT FROM AUTHOR]

Objective This study explored possible mechanisms through which symptoms of posttraumatic stress disorder (PTSD) were reduced in a randomized controlled trial comparing the effect of a yoga intervention with an assessment control. Method We examined whether changes in psychological flexibility, mindfulness, and emotion regulation strategies (expressive suppression and reappraisal) were associated with posttreatment PTSD symptoms for 38 women with Diagnostic and Statistical Manual of Mental Disorders Fourth Edition full or subthreshold PTSD. Results Hierarchical linear regression models revealed that expressive suppression significantly decreased for the yoga group relative to the assessment control. Psychological flexibility increased significantly for the control but not yoga group. However, increases in psychological flexibility were associated with decreases in PTSD symptoms for the yoga but not control group. Conclusion Preliminary findings suggest that yoga may reduce expressive suppression and may improve PTSD symptoms by increasing psychological flexibility. More research is needed to replicate and extend these findings. [ABSTRACT FROM AUTHOR]

How might a practice that has its roots in contemplative traditions, seeking heightened awareness through meditation, apply to trauma-related mental health struggles among military veterans? In recent years, clinicians and researchers have observed the increasing presence of mindfulness in Western mental health treatment programs. Mindfulness is about bringing an attitude of curiosity and compassion to present experience. This review addresses the above question in a detailed manner with an emphasis on the treatment of military veterans suffering from posttraumatic stress disorder (PTSD) and related psychopathology. In addition, the integration of mindfulness with current empirically supported treatments for PTSD is discussed with specific attention to directions for future research in this area. [ABSTRACT FROM AUTHOR]

Abstract: Mindfulness is increasingly conceptualized in terms of its regulatory function with research suggesting that mindfulness may have a salutary effect on psychological well-being. The present cross-sectional study of 514 college students (84% Caucasian and 62% females), using self-report questionnaires, tested a proposed model for understanding the relationship between dispositional mindfulness and depressive symptoms through three types of affect regulation: emotion regulation, mood regulation and self-regulation, as measured by positive emotions, mood regulation expectancies (i.e., perceived mood repair ability), and self-acceptance, respectively. Structural equation modeling revealed that the model fit the data well, with the relationship between mindfulness, as measured by the Freiburg Mindfulness Inventory, and depressive symptoms, as measured by the Center for Epidemiological Studies-Depression Scale, fully mediated by the proposed regulatory processes. Higher levels of dispositional mindfulness were associated with higher levels of positive emotions, mood regulation expectancies, and self-acceptance, which in turn, were all inversely related to depressive symptoms. Self-acceptance emerged as the strongest mediator of mindfulness and depressive symptoms. Our findings suggest that mindfulness might serve a regulatory function by targeting low positive emotionality, poor mood regulation, and negative self-concept, risk factors implicated in the onset, development, and maintenance of depressive symptoms. [Copyright &y& Elsevier]

Identifying and treating depression has been a major focus in primary care over the last decade. Unfortunately, treatments have not been as successful as originally hoped. The current study investigated factors that may contribute to poor outcomes in a sample of VA primary care patients. Results indicate that 15.5% of the patients in this investigation had significant symptoms of depression. The vast majority (89.6%) of these patients also had significant symptoms of at least one additional comorbid psychiatric condition. Furthermore, an association between depression and unhealthy behaviors (smoking, not exercising) was demonstrated. Finally, sexual dysfunction and chronic pain were more frequently observed in individuals with depressive symptoms. These findings illustrate that depression is only one of many problems for most primary care patients identified with depression. A multidisciplinary team in primary care is recommended to provide a coordinated approach to the treatment of depression and its associated problems. [ABSTRACT FROM AUTHOR]

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope. [ABSTRACT FROM AUTHOR]

Background: The unified protocol (UP) is a promising transdisgnostic treatment for emotional disorders; limited data exists with trauma‐exposed populations. This study compared effectiveness of the UP, presented centered therapy (PCT), and treatment as usual (TAU) in trauma‐exposed veterans presenting to routine care. Method: Trauma‐exposed veterans with one or more emotional disorder diagnoses participated in a pilot hybrid‐1 effectiveness/preimplementation study. Thirty‐seven male and female veterans were randomized to one of three conditions. Results: Multilevel growth curve modeling demonstrated improvement over time across conditions with large effect sizes (range: −2.15 to −3.32), with the UP demonstrating the greatest change. The between group effect sizes for reductions in number of comorbid diagnoses were medium to small and statistically significant (TAU and UP, d = 0.49, p =.056; TAU and PCT d = 0.18, p =.166, UP and PCT d = 0.31, p =.229). Only the UP led to a decrease in the number of comorbid diagnoses (d = −0.71). Psychosocial functioning varied by group, with slight increases in impairment in PCT and TAU, and medium effect size reduction in the UP. Only the UP exhibited significant decreases in self‐reported anxiety and depression. Between group differences for UP and PCT were medium to large and statistically significant for depression across two measures (d = −0.72 to d = −1.40). Conclusions: This represents the first trial examining effectiveness of the UP, PCT, and TAU in trauma‐exposed veterans. Despite a small sample, large effect size differences demonstrated promising advantages for the UP. Trial Registration Number: NCT02944994. [ABSTRACT FROM AUTHOR]

Objective The goal of this study was to explore sleep quality as a potential mediator between depression symptoms and diabetes quality of life (DQOL), and anxiety symptoms and DQOL. Method Participants were 83 male and 3 female veterans with type 2 diabetes ( Mage = 62.4). Self-report measures were completed during the baseline assessment of a larger intervention study conducted at the VA Boston Healthcare System. Results Depression symptoms, anxiety symptoms, and sleep quality were all associated with DQOL. Additionally, sleep quality had a partial indirect effect on the relationships between depression symptoms and DQOL, and between anxiety symptoms and DQOL. Conclusions These findings suggest that sleep quality may have an important role in the way that psychological distress affects diabetes quality of life. [ABSTRACT FROM AUTHOR]

The psychometric properties of the PTSD Checklist (PCL) were investigated in a sample of treatment-seeking and community-dwelling male veterans. In conjunction with previous reports, results from the present study indicate that the PCL possesses strong, robust psychometric properties. The current investigation suggests a cutoff score of 60-higher than previous investigations-related to posttraumatic stress disorder (PTSD) diagnosis derived from the Clinician-Administered PTSD Scale. This research supports the use of the PCL as a brief self-report measure of PTSD symptomatology. [ABSTRACT FROM AUTHOR]

Despite the prevalence of psychiatric disorders in medical settings, mental health problems often go undetected and patients do not receive appropriate treatment. The main goal of this study is to provide additional information about the Beck Anxiety Inventory — Primary Care (BAI—PC), a brief instrument that screens for patients with anxiety. This study provides information on the performance of the BAI—PC as a screening instrument for depression and PTSD in addition to its original purpose as a screening instrument for anxiety. This efficient tool can identify patients who can benefit from effective psychological treatments and facilitate referrals to psychologists working in medical settings. [ABSTRACT FROM AUTHOR]

There is growing interest in expanding mental health treatment options for individuals suffering from posttraumatic stress disorder (PTSD), and mindfulness interventions encompass a family of approaches that are gaining popularity and empirical support. "Mindfulness interventions" is a broad umbrella term used in this article to encompass a diverse range of psychological and mind-body interventions that incorporate mindfulness practice as a core component. In this article, our primary aims are to (a) briefly define mindfulness and mindfulness interventions, (b) summarize recent randomized control trials on mindfulness interventions for PTSD, (c) highlight hypothesized mechanisms of these interventions (i.e., improved interoceptive awareness and arousal regulation, acceptance, and attentional control), and (d) offer clinical tips for practitioners aiming to incorporate or implement diverse mindfulness interventions with their clients. Throughout, we include clinical examples and applications from our work implementing mindfulness interventions with survivors of trauma experiencing PTSD. We conclude this article by offering potential directions for future research. Public Significance Statement: This narrative review discusses recent randomized control trial literature on mindfulness interventions for posttraumatic stress disorder (PTSD) and highlights strategies for practitioners implementing these interventions. Additionally, it offers potential directions for future research to better understand the impact and mechanisms of mindfulness interventions for PTSD. [ABSTRACT FROM AUTHOR]

Veterans with posttraumatic stress disorder (PTSD) report more aggression than civilians with PTSD. Because emotion regulation difficulties mediated the relationship between PTSD symptoms and impulsive aggression in veterans, we developed an intervention to increase emotion regulation skills. This pilot study tested the feasibility and acceptability of a three-session treatment, Manage Emotions to Reduce Aggression (MERA), and examined its effectiveness at reducing aggression and emotion dysregulation. Male combat veterans with PTSD and impulsive aggression completed assessments before and 4 weeks after MERA. Overt Aggression Scale measured frequency of aggression; Difficulties in Emotion Regulation Scale assessed emotion dysregulation. Most veterans (95%) who completed MERA and the posttreatment assessment (n = 20) reported MERA was helpful. Veterans in the intent-to-treat sample demonstrated a significant decrease in their frequency of aggression (Cohen's d = -0.55) and emotion dysregulation (Cohen's d = -0.55). MERA may be an innovative treatment that helps veterans reduce aggression. [ABSTRACT FROM AUTHOR]

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD. [ABSTRACT FROM AUTHOR]

The authors examined initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. Onehundred and 78 male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive-behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or noninterpersonal) impacted initial levels of alliance or change in alliance over time. Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a noninterpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05) but did not have significantly different initial alliance ratings. The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) is a debilitating condition that affects approximately 10% of women in the United States. Although effective psychotherapeutic treatments for PTSD exist, clients with PTSD report additional benefits of complementary and alternative approaches such as yoga. In particular, yoga may downregulate the stress response and positively impact PTSD and comorbid depression and anxiety symptoms. We conducted a pilot study of a randomized controlled trial comparing a 12-session Kripalu-based yoga intervention with an assessment control group. Participants included 38 women with current full or subthreshold PTSD symptoms. During the intervention, yoga participants showed decreases in reexperiencing and hyperarousal symptoms. The assessment control group, however, showed decreases in reexperiencing and anxiety symptoms as well, which may be a result of the positive effect of self-monitoring on PTSD and associated symptoms. Between-groups effect sizes were small to moderate (0.08-0.31). Although more research is needed, yoga may be an effective adjunctive treatment for PTSD. Participants responded positively to the intervention, suggesting that it was tolerable for this sample. Findings underscore the need for future research investigating mechanisms by which yoga may impact mental health symptoms, gender comparisons, and the long-term effects of yoga practice. [ABSTRACT FROM AUTHOR]

The primary objective of this pilot study was to develop and implement a telephone intervention for veterans with diabetes and posttraumatic stress symptoms (PTSS). Additional objectives were to evaluate study feasibility and to conduct exploratory analyses of the influence of the intervention on diabetic self-care, quality of life, treatment adherence, and mental health functioning. Twenty-three veterans with PTSS and diabetes enrolled in the study and received an initial assessment interview and intervention session. Twenty participants completed the study protocol in its entirety and also received 7 weekly motivational telephone calls with a clinician and a final assessment. Results revealed high levels of compliance with telephone calls. Participants reported satisfaction with and benefit from the intervention that occurred during weekly telephone calls. Participants reported a statistically significant increase in exercise behaviors and healthy eating from pre- to postintervention. Results also revealed a decrease in psychological distress. Although these data are preliminary, they speak to the feasibility and benefits of a brief telephone intervention to address self-care behaviors critical to the management of diabetes for individuals with PTSS. [ABSTRACT FROM AUTHOR]

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators. [ABSTRACT FROM AUTHOR]

Prior research has revealed heightened aggressive behavior among veterans with PTSD. This study tested a model examining the interrelationships among combat exposure, posttraumatic stress disorder (PTSD) symptoms, dysphoric symptoms, and anxiety symptoms in predicting aggressive behavior in a sample of 265 male combat veterans seeking diagnostic assessment of PTSD. Combat exposure was indirectly associated with aggression primarily through its relationship with PTSD symptoms. Symptoms of PTSD were directly related to aggression, and indirectly related to aggression through dysphoric symptoms. Results highlight the role of PTSD symptoms and dysphoric symptoms with respect to aggressive behavior among this population, and suggest the relevance of aggression theory to the study of combat veterans. [ABSTRACT FROM AUTHOR]