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Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen's d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.

Background Posttraumatic stress disorder (PTSD) has been associated with exaggerated threat processing and deficits in emotion modulation circuitry. It remains unknown how neural circuits are associated with response to evidence-based treatments for PTSD. Method We examined associations between PTSD symptoms and indicators of neural response in key emotion processing and modulation regions. Fifty-six military Veterans with PTSD were randomly assigned to one of three evidence-based treatments (prolonged exposure, sertraline, and PE plus sertraline) in a randomized clinical trial ("PROGrESS"; 2018, Contemp Clin Trials, 64, 128-138). Twenty-seven combat-exposed controls (CCs) served as a comparison group at pretreatment. Before and after PTSD treatment, functional magnetic resonance imaging was used to assess brain activation and connectivity during the validated Shifted Attention Emotion Appraisal Task (2003, J Neurosci, 23, 5627-5633; 2013, Biol Psychiatry, 73, 1045-1053). Results Greater activation in emotion processing (anterior insula) and modulation (prefrontal cortex) regions and increased connectivity between attentional control (dorsolateral prefrontal cortex and superior parietal cortex) and emotion processing (amygdala) regions, at pretreatment, were associated with subsequent PTSD symptom improvement. Conclusions This study is one of the first to examine task-based activation and functional connectivity in a PTSD treatment trial, and provides evidence to suggest that activation in and connectivity between emotion processing and modulation regions are important predictors of treatment response.

There is limited study of suicidal behaviors among veterans identifying as sexual and gender minorities (SGMs), despite previous research indicating rates of suicide attempts are high within civilian SGM populations. Further, some research incorporating military service members suggests those identifying as SGMs are disproportionately exposed to military sexual trauma (MST), an additional risk factor for negative psychiatric sequelae. To address health care research disparities among minority veterans (i.e., women, those endorsing MST, SGMs), we examined presentations of veterans (N = 277) who attended initial consultation appointments for MST-related treatment and completed a semistructured clinical interview including demographic characteristics, history of suicide attempts (HSA), and a diagnostic evaluation. Twenty-eight (10.1%) veterans identified as SGMs. SGM/non-SGM groups were contrasted on suicidal and psychiatric morbidity outcomes. Overall, endorsement of HSA was high (30.7%). Despite similar clinical profiles, 53.6% of veterans who identified as SGM endorsed HSA in contrast with 28.1% of peers identifying as heterosexual and nontransgender, a significant effect of small-to-moderate size. Findings suggest assessment and clinical management of suicidality is of critical importance for clinicians providing services to veterans pursuing recovery from MST, generally, and may be especially so when delivering care to SGM. Further, results underscore the need for culturally competent delivery of trauma-focused interventions. (PsycINFO Database Record

This study examined whether specific combat experiences and trauma-related beliefs were differentially related to anger among 869 treatment-seeking veterans. Total combat and specific types of comb...

Mild traumatic brain injury (mTBI) is commonly reported in recent combat Veterans. While the majority resolve, some Veterans develop postconcussive symptoms (PCS). Previous research suggests these symptoms are not specific to head injury and are often associated with psychiatric symptoms. The current study examines the relative contributions of posttraumatic stress, depressive symptoms, and TBI on postconcussive symptoms, and explores whether the relationship remains after controlling for symptom overlap. Two hundred eighteen combat Veterans from Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) provided the data for this study as part of a baseline evaluation for inclusion into larger treatment study for posttraumatic stress disorder (PTSD). Participants completed the Brief Traumatic Brain Injury Screen (BTBIS), Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Stressor Version (PCL-S), Beck Depression Inventory-II (BDI-II). Significant differences in NSI total score between individuals with and without history of TBI were not found. A series of regression analyses demonstrated that Depression and PTSD were significant predictors of NSI score even after removal of NSI symptoms that overlap with PTSD or depression. TBI status was also a significant predictor of PCS in most models, but its relative contribution was much smaller than that of depression and PTSD. Within PTSD symptoms, hyperarousal cluster was a significant predictor of NSI scores. Findings demonstrate that depression and PTSD are related to PCS beyond similarities in construct. Further, within a primarily PTSD treatment-seeking population, these psychiatric symptoms appear to be a stronger contributor than TBI.

The aim of this study was to evaluate the psychometric properties of the Posttraumatic Diagnostic Scale for DSM–5 (PDS–5), a self-report measure of posttraumatic stress disorder (PTSD) based on diagnostic criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Par

Changes to the diagnostic criteria for posttraumatic stress disorder (PTSD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) create a need for valid and reliable updated assessment tools. This study examined key psychometric properties (e.g., internal consistency, test-retest reliability, interrater reliability, and convergent and discriminant validity) of the PTSD Symptom Scale Interview for DSM-5 (PSSI-5), a modified version of the PSS-I (PTSD Symptom Scale)-Interview Version for the DSM-IV. Participants were 242 urban community residents, veterans, and college undergraduates, recruited from 3 study sites, who had experienced a DSM-5 Criterion A traumatic event. The PSSI-5 demonstrated good internal consistency (α = .89) and test-retest reliability (r = .87), as well as excellent interrater reliability for the total severity score (intraclass correlation = .98) and interrater agreement for PTSD diagnosis (κ = .84). The PSSI-5 also demonstrated convergent validity with 3 measures of PTSD (i.e., Clinician-Administered PTSD Scale for DSM-5, Posttraumatic Diagnostic Scale for DSM-5, and PTSD Checklist-Specific Version; all rs > .72) and discriminant validity with the Beck Depression Inventory-II and the State-Trait Anxiety Inventory-Trait scale. Receiver operating characteristic analysis yielded a cutoff score of 23 for identifying a probable PTSD diagnosis. Together, these findings indicate that the PSSI-5 is a valid and reliable instrument for assessing PTSD diagnosis and severity. (PsycINFO Database Record

Objective. Posttraumatic stress disorder (PTSD) and pain are frequently comorbid conditions that can result in bidirectional exacerbations. Initial research suggests physical activity may prevent PTSD symptoms or assist with recovery. Unfortunately, Veterans with PTSD are less likely to engage in physical activity, often citing pain as a primary reason. The current study examines the potential role of physical activity as a moderator of the pain and PTSD relationship. Design. Data were collected from 239 Veterans who were seeking PTSD treatment at a Veterans Affairs (VA) hospital between 2006 and 2013. Veterans completed the Clinician-Administered PTSD Scale (CAPS) to measure PTSD severity and self-report inventories to measure pain and physical activity. Multiple moderated linear regressions were used to examine the influence of physical activity on the relationship between pain and PTSD symptoms. Results. Pain severity and interference were associated with more severe PTSD. Physical activity did not have main effects on PTSD severity. However, it did moderate the relationship between PTSD and pain, such that those who were active, despite high levels of pain severity or pain interference, had fewer PTSD symptoms. Conclusions. For Veterans seeking treatment for PTSD, physical activity was particularly salient for those reporting high levels of pain severity and intensity. While assessment of pain is recommended with all Veterans, it may also be beneficial to evaluate physical activity in those with prominent pain complaints. Further examination of the role of exercise in integrated care for pain and PTSD is warranted.

Posttraumatic Stress Disorder (PTSD) is a debilitating condition often associated with difficulty in emotion regulation, including reappraising negative emotions. This study assessed neural mechanisms associated with emotion regulation in veterans prior to and following treatment for PTSD. Participants with PTSD and combat exposed controls (CC) completed diagnostic evaluation and underwent fMRI scanning while completing Emotion Regulation Task (ERT) and Emotional Faces Assessment Task (EFAT). Participants with PTSD were randomly assigned to Prolonged Exposure plus placebo (PE+PLB), Sertraline plus enhanced medication management (SERT+EMM), or PE plus SERT (PE+SERT) and repeated diagnostic evaluation and MRI scanning following treatment. The amygdala, dmPFC, and dlPFC were examined as regions of interest. On ERT, veterans with PTSD showed significantly less dmPFC activation than CCs during reappraisal vs emotional maintenance. Within the PTSD group, results demonstrated a significant association between less activation in the dmPFC during emotion reappraisal vs maintenance trials before treatment and greater reductions in symptoms from pre- to post-treatment. During the EFAT, there were no group differences between participants with PTSD and CCs in brain activation, and no relationships between brain function and PTSD symptoms. These findings suggest that less emotional reactivity might potentially reflect less need for recruitment of prefrontal regions when reappraising negative emotion, and is an individual factor associated with better treatment outcome.

INTRODUCTION: Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships. MATERIALS AND METHODS: Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses. RESULTS: For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of post-concussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094–0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075–0.0471). CONCLUSIONS: These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.

Previous research has consistently demonstrated that Prolonged Exposure (PE) therapy is an effective treatment for posttraumatic stress disorder (PTSD). Traditionally, PE has been studied and delivered on an individual basis. However, the growing number of Veterans in need of PTSD treatment has led to increased interest in group therapies as an efficient way to provide access to care. The current study examined a group and individual hybrid treatment that was developed based on PE principles. Treatment was 12 weeks in length and consisted of 12 one-hour group sessions focused on in vivo exposures, and an average of approximately five-hour long individual imaginal exposure sessions. Data for this study were derived from 67 veterans who participated in 12 cohorts of the Group PE. Significant reductions in PTSD and depression symptoms were found in both completers and intent-to-treat sample analyses. The clinical implications of these findings are discussed.

Trauma related guilt, a distressing emotion associated with negative cognitions regarding one's actions or inaction during a traumatic event, is common among individuals with posttraumatic stress disorder (PTSD). We hypothesized that trauma related guilt cognitions would partially explain the relationship between PTSD symptom severity and functioning. The sample consisted of 254 combat veterans or active duty military personnel who served in Operation Enduring Freedom, Operation Iraqi Freedom or Operation New Dawn (OEF/OIF/OND) who consented to participate in a larger PTSD treatment study. Results revealed a significant relationship between PTSD severity and guilt cognitions (standardized β = 0.40), as well as PTSD and overall functioning (β = 0.49). Guilt cognitions (β's = 0.13 to 0.32) were significantly associated with nearly all domains of functioning, including overall functioning (β = 0.27), and partially explained the relationship between PTSD and functioning. This study lends support to the addition of guilt as a symptom of PTSD in the DSM-5 as it contributes significantly to functional impairment even when accounting for other symptoms of PTSD, although co-occurring mental health problems may also contribute to functional impairments associated with PTSD. Future studies are needed to investigate whether reductions in traumatic guilt are related to improved functional outcomes in PTSD treatments.

Sleep disturbances (SD) are pronounced in Veterans with posttraumatic stress disorder (PTSD). In clinical trials, SD have been shown to limit the effectiveness of evidence-based treatments for non-PTSD disorders. The purpose of this study was to investigate the relationships between pretreatment SD and the effectiveness of Prolonged Exposure (PE) therapy for Veterans with PTSD. Twenty-one Veterans completed the Pittsburgh Sleep Quality Index (PSQI) and the Clinician Administered PTSD Scale upon presenting to a PTSD specialty clinic. Veterans completed the PTSD Symptom Checklist-Civilian (PCL-C) at the initiation of PE and biweekly thereafter for the duration of treatment (96 total assessments). Correlations and hierarchical linear modeling were utilized to examine the potential impact of baseline sleep variables on the slope and magnitude of treatment outcomes. Higher PSQI total scores, and higher sleep latency and sleep medication use subscale scores were associated with higher PCL-C scores at baseline. Veterans evidenced significant reductions in PTSD symptoms during the course of the treatment study. Total PSQI scores and composites were not associated with reduced effectiveness of PE treatment or the slope of PTSD symptom changes. Sleep disturbances do not preclude Veterans from benefits derived from engagement in this gold standard PTSD intervention.

Adoption of a standard depression measures across clinics and populations is advantageous for continuity of care and facilitation of research. This study provides information on the comparative utility of a commonly used perinatal-specific depression instrument (the Edinburgh Postnatal Depression Scale-EPDS) with a general depression screener (Patient Health Questionnaire-9-PHQ-9) in a sample of perinatal women seeking psychiatry services within a large health care system. Electronic medical records (which included PHQ-9 and EDPS) were abstracted for a final sample of 81 pregnant and 104 postpartum patients (n=185). Psychometric properties were examined among women who met the criteria for Major Depressive Disorder (MDD) based on clinician diagnoses, as compared to women without any mood disorder diagnosis. Using commonly recommended cut-off scores, both measures had comparable sensitivity, specificity, PPV and NPV for both pregnant and postpartum women. Comparative AUC for ROC contrasts were not significantly different between the two measures. Thus, this study found few significant differences in the performance of the PHQ-9 and EPDS in detecting clinician-diagnosed MDD in a psychiatry outpatient sample of pregnant and postpartum women.

To replicate and expand upon the relationship of somatic symptoms and posttraumatic stress disorder (PTSD) by comparing symptoms among service eras in US Veterans.Data were collected from 226 Vietnam and 132 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who were referred to a Veterans Affairs (VA) hospital PTSD outpatient clinic between 2005 and 2013. Veterans were administered self-report inventories and a clinical interview to measure somatic symptoms and PTSD severity. A subset of Veterans (n=185) screening positive for PTSD were administered the Clinician Administered PTSD Scale (CAPS) to measure PTSD severity. Multiple moderated linear regressions were used to examine the influence of service era on the relationship between somatic and PTSD symptoms.There were no significant differences between service eras in pain severity, pain interference, and total somatic symptoms reported. Vietnam Veterans were more likely to report limb/join pain (p.05), fainting (p.01), and shortness of breath (p.001), whereas OIF/OEF Veterans were more likely to complain of headaches (p.001). A significant interaction effect occurred between service era and dizziness (p.05) and chest pain (p.01), with OIF/OEF Veterans reporting higher levels of these symptoms significantly more likely than Vietnam Veterans to also experience more severe PTSD.Findings are consistent with previous research demonstrating the relationship of somatic symptoms and PTSD across service eras but provide additional data concerning similarities and differences of somatic symptoms between eras. Potential explanations for observed service era differences in somatic symptoms are discussed.

Previous research demonstrates a history of sexual assault is a substantial risk factor for future sexual assaults [1, 2]. Several studies suggest differences in risk detection may contribute to this pattern [e.g., 3]. The purpose of this study was to investigate if sexual victimization impacts perception and response in dating scenarios; and assessed if differences existed between the perceived risk and benefits of remaining in risky interpersonal situations as a function of sexual assault history. One hundred and eleven female college students viewed and responded to two videos depicting dating vignettes. Results indicated participants did not differ in their perception of risk as a function of sexual assault history; however, those with a sexual assault history indicated they would stay in the situation longer in some instances. Additionally, when asked to predict what would happen if the scenario continued, participants with a history of sexual assault were significantly more likely to predict the characters would have consensual sex if the female remained and negative social consequences if she chose to leave. The potential clinical implications of these findings are discussed.

Objective Previous research has demonstrated a significant relationship between posttraumatic stress disorder (PTSD) and pain. While several models attempt to explain this relationship, significant questions remain regarding factors that may play a role in this interaction. The purpose of this study was to determine whether posttraumatic cognitions mediate the relationship between PTSD and pain. Design The sample comprised 136 veterans who presented to the VA Ann Arbor Health Care System seeking evaluation and treatment in the PTSD clinic. Participants completed the Clinician-Administered PTSD Scale, the Posttraumatic Cognitions Inventory, and Brief Pain Inventory-Short Form, along with other assessments as part of their evaluation. Results This study showed that the majority of patients (86.8%) reported some problems with pain. Further, the findings indicate that there is a significant relationship between PTSD severity and pain severity. Posttraumatic cognitions were not related to the level of pain experienced, but they were related to pain interference in this population. Conclusions In particular, negative cognitions regarding the self were associated with the level of pain-related interference, and partially mediated the relationship between PTSD and pain. The clinical implications of these findings are discussed.

The current proposal aims to directly compare the psychotherapy and medication treatments for PTSD considered to have the most evidence for effectiveness. While both SSRI and PE have demonstrated efficacy, there are significant individual differences in clinical responses to both treatments. To achieve best clinical outcomes and to utilize available treatment most effectively, it is critical to examine how PTSD and related psychopathology and functional impairment change with these treatments alone and in combination. Further, in order to inform clinical practice, we plan to examine psychological and neurobiological predictors of response to treatment and mechanisms of change during treatment (pre to post treatment change) based on previously identified predictors, including emotion regulation and processing with fMRI in response to emotional challenge tasks, DNA and mRNA (pre and post treatment), and cortisol response to awakening. The primary activity and focus this year has been on recruitment and retention. We obtained funding to expand to 2 new CBOCs that are under the coverage of current IRBs. We were also approved for a 1-year no cost extension. Completion of study research and treatment protocol is our primary focus for the coming year. As of 12/21/15, we have recruited and randomized 203 Veterans and 92 Veterans have completed the Week 52 final study assessment visit.

Prior research suggests that dissociation and anger are risk factors for the development of posttraumatic stress disorder (PTSD). Research found that trauma survivors with higher levels of anger also report more severe PTSD overall. Studies also support a relationship between PTSD severity and dissociation. Only one prior study of sexual assault survivors by Feeny, Zoellner, and Foa (2000) examined the relationships among dissociation, anger, and PTSD. While Veterans have been found to report high levels of anger and dissociation, the relationship between these factors and PTSD has not been examined among Veterans. This paper examines the relationship among anger, dissociation, and PTSD in treatment-seeking Veterans who presented for evaluation at the PTSD Clinic in the VA Ann Arbor Healthcare System during a four year period. Anger and dissociation predicted PTSD, hyperarousal, and avoidance/numbing severity while dissociation predicted intrusive severity. The implications of these results for clinical practice are discussed.