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The authors describe an overview of the pilot project Taking Charge, a 36-hour comprehensive behavioral intervention involving psychoeducation, personal safety, and self-defense training for 12 female veterans with posttraumatic stress disorder (PTSD) from military sexual trauma. Self-defense training can incorporate the benefits of repeated exposure while teaching proactive cognitive and behavioral responses to the feared stimuli, and thus facilitate emotional and physical rescripting of and mastery over the trauma. Results up to 6 months follow-up indicate significant reductions in behavioral avoidance, PTSD hyperarousal, and depression, with significant increases in interpersonal, activity, and self-defense self-efficacy. The authors propose that this therapeutic self-defense curriculum provides an enhanced exposure therapy paradigm that may be a potent therapeutic tool in the treatment of PTSD. [ABSTRACT FROM AUTHOR]

We assessed perceptions of vulnerability and the desire for personal safety/selfdefense (PS/SD) training among 67 female veterans receiving outpatient mental health treatment, primarily for post-traumatic stress disorder (PTSD) from sexual and/or physical trauma. Consistent with the literature on the impact of such training on nonclinical populations and on individuals with visual impairments, the results of this study indicate that traumatized female veterans believe that PS/SD training would be an effective and powerful addition to more traditional treatments for PTSD. Study participants indicated they believe such training would positively affect their sense of personal safety; promote increased competencein thwarting future assaults; improve their self-esteem, confidence, and assertiveness; and reduce avoidant and agoraphobic behaviors. These pilot results support the development of an adjunct intervention to augment current PTSD treatments for women veterans with histories of sexual and physical trauma. [ABSTRACT FROM AUTHOR]

Background: Nearly 2 million U.S. veterans live with co-occurring alcohol use disorder and posttraumatic stress disorder (AUD/PTSD). Extant AUD/PTSD treatments emphasize symptom reduction, sometimes overlooking psychosocial functioning improvements, and have dropout rates as high as 50 %. Additionally, current approaches to measuring psychosocial functioning are limited to self-report. This study protocol describes a 1:1 parallel, two-arm, pilot randomized controlled trial comparing Behavioral Activation (BA) psychotherapy to Relapse Prevention (RP) psychotherapy for veterans with AUD/PTSD., Methods: Forty-six veterans with AUD/PTSD will be block-randomized to eight weekly, virtual, hour-long individual sessions of BA or RP. Clinical interview, self-report, and geospatial assessments will be administered at pre- and post-treatment. Select outcome and exploratory measures will be administered during treatment. Analyses will focus on trial feasibility, BA acceptability, and preliminary efficacy. Geospatial analyses will explore whether pre- to post-treatment changes in geospatial movement can be used to objectively measure treatment response. The study site and an independent Data and Safety Monitoring Board will monitor trial progress, safety, and quality. De-identified data from consenting participants will be submitted to a sponsor-designated data repository., Conclusion: If successful, this trial could help to provide veterans with AUD/PTSD with a more acceptable treatment option. Positive findings would also lay groundwork for testing BA in civilians with AUD/PTSD. Finally, by incorporating novel geospatial methods and technologies, this study could potentially yield a new approach to objectively measuring AUD/PTSD recovery that could be used in other clinical trials. This study was registered in ClinicalTrials.gov (NCT06249386)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package., Objective: To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries., Design: Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023., Participants: A total of 6653 Veterans (54% response rate) completed the survey., Main Measures: Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region., Key Results: Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery., Conclusions: GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans., Competing Interests: Declarations: Conflict of Interest: The following authors have nothing to disclose: AJ Littman, A Jeon, CL Fort, K Dashtestani, A Korpak, MR Kauth, JC Shipherd, GK Jasuja, HL Wolfe, J Caballero, S Garcia, C Williamson, B Collongues, and TL Simpson. PM Neira received speaker fees or honorariums from the following organizations for presentations related to LGBTQ + or TGD health/healthcare: Elsevier (fee for reviewing textbooks), the Jackson Laboratory, World Professional Association for Transgender Health, APP Oncology Summit, NYLF Speaker Panel, and AORN. Disclaimer: The views expressed within are solely those of the authors, and do not necessarily represent the views of any academic affiliate, the Department of Veterans Affairs or the United States government., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objectives: To examine the associations of two measures of minority stress, non-affirmation minority stress and internalized transphobia, with subjective cognitive decline (SCD) among transgender and gender diverse (TGD) veterans., Method: We administered a cross-sectional survey from September 2022 to July 2023 to TGD veterans. The final analytic sample included 3,152 TGD veterans aged ≥45 years. We used a generalized linear model with quasi-Poisson distribution to calculate prevalence ratios (PR) and 95% confidence intervals (CIs) measuring the relationship between non-affirmation minority stress and internalized transphobia and past-year SCD., Results: The mean age was 61.3 years (SD = 9.7) and the majority (70%) identified as trans women or women. Overall, 27.2% ( n  = 857) reported SCD. Adjusted models revealed that TGD veterans who reported experiencing non-affirmation minority stress or internalized transphobia had greater risk of past-year SCD compared to those who did not report either stressor (aPR: 1.09, 95% CI: 1.04-1.15; aPR: 1.19, 95% CI: 1.12-1.27)., Conclusion: Our findings demonstrate that proximal and distal processes of stigma are associated with SCD among TGD veterans and underscore the need for addressing multiple types of discrimination. Above all, these results indicate the lasting sequelae of transphobia and need for systemic changes to prioritize the safety and welfare of TGD people.

Aims: We conducted a proof-of-concept randomized controlled trial of the mu-opioid receptor antagonist, naltrexone, augmented with the alpha-1 adrenergic receptor antagonist, prazosin, for alcohol use disorder in veterans. We sought a signal that the naltrexone plus prazosin combination regimen would be superior to naltrexone alone., Methods: Thirty-one actively drinking veterans with alcohol use disorder were randomized 1:1:1:1 to naltrexone plus prazosin (NAL-PRAZ [n = 8]), naltrexone plus placebo (NAL-PLAC [n = 7]), prazosin plus placebo (PRAZ-PLAC [n = 7]), or placebo plus placebo (PLAC-PLAC [n = 9]) for 6 weeks. Prazosin was titrated over 2 weeks to a target dose of 4 mg QAM, 4 mg QPM, and 8 mg QHS. Naltrexone was administered at 50 mg QD. Primary outcomes were the Penn Alcohol Craving Scale (PACS), % drinking days (PDD), and % heavy drinking days (PHDD)., Results: In the NAL-PRAZ condition, % reductions from baseline for all three primary outcome measures exceeded 50% and were at least twice as large as % reductions in the NAL-PLAC condition (PACS: 57% vs. 26%; PDD: 51% vs. 22%; PHDD: 69% vs. 15%) and in the other two comparator conditions. Standardized effect sizes between NAL-PRAZ and NAL-PLAC for each primary outcome measure were >0.8. All but one participant assigned to the two prazosin containing conditions achieved the target prazosin dose of 16 mg/day and maintained that dose for the duration of the trial., Conclusion: These results suggest that prazosin augmentation of naltrexone enhances naltrexone benefit for alcohol use disorder. These results strengthen rationale for an adequately powered definitive randomized controlled trial., (Published by Oxford University Press on behalf of Medical Council on Alcohol 2024.)

Purpose: Social support is a treatment target for individuals with post-traumatic stress disorder (PTSD) but is not systematically assessed in clinical care. This review evaluated the quality of patient-reported social support instruments used in PTSD research to identify candidates for measurement-based care (MBC) with this population., Method: A systematic review identified all validated measures of social support used in research with traumatized populations after 1990. Instrument development/validation studies were then evaluated using components of the updated COSMIN guidelines. Instruments were rated for clinical utility and evidence of their psychometric properties in use with traumatized individuals was synthesized., Results: Twenty-nine instruments were identified across 231 studies. Evaluation of development articles found 14 instruments with sufficient evidence of content validity and internal consistency reliability that could be considered for clinical use. Of these, nine had comparable properties in traumatized samples and could be preliminarily included in MBC of social support in the treatment of PTSD. Additional studies on measures' responsiveness and test-retest reliability are needed., Conclusions: Existing measures of social support could improve clinical care of PTSD when used routinely to provide feedback on this critical component of health. MBC of social support may also improve clinical care of other psychiatric conditions., Competing Interests: This work was supported by a grant from United States Department of Veterans Affairs, Health Services Research and Development (CDA 19-208) to SBC. The authors have no relevant financial or non-financial interests to disclose.

Women veterans are exposed to high rates of trauma, including military sexual trauma (MST), and face unique barriers to posttraumatic stress disorder (PTSD) treatment. Telehealth interventions that are tailored to women veterans' unique lived experiences may improve treatment engagement and outcomes. It is important to ascertain how beneficial new telehealth interventions are in the context of different patient characteristics and trauma types, particularly for lower-intensity telehealth interventions (e.g., web-based programs or apps). This secondary analysis of a randomized clinical trial conducted in a sample of 102 women veterans examines predictors of treatment response to a self-management, telehealth intervention for PTSD: Delivery of Self Training and Education for Stressful Situations-Women Veterans (DESTRESS-WV). In the trial, women veterans with PTSD received either an online cognitive behavioral intervention with phone coaching, or phone monitoring alone. We examined associations between baseline patient characteristics (demographics, trauma types, and clinical symptoms) and treatment outcome at post-treatment, 3 months, and 6 months, focusing on the association between treatment outcome and MST. Our primary outcomes were changes in PTSD (PTSD Symptom Checklist, Version 5, PCL-5) and depression (8-item Patient Health Questionnaire, PHQ-8) in the full sample, adjusting for treatment condition. Women veterans who identified MST as the primary trauma for which they were seeking PTSD treatment experienced a nearly nine-point lesser improvement on the PCL-5 than those seeking PTSD treatment for other trauma types (e.g., childhood abuse, combat trauma; p  = .0073). Similar patterns were found for depression symptoms. To our knowledge, this is the first study to examine the association between trauma type and treatment outcomes within the context of a self-management, telehealth treatment for PTSD. While the study was not powered to examine differential treatment response for patient subgroups, our exploratory findings suggest that gaps remain in providing effective PTSD care for women veterans who experienced MST. Trial registration : The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT02917447)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood. Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles. Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought. Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%). Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).

Objective: There is inconclusive evidence regarding sexual identity and race/ethnicity differences in outcomes in evidence-based psychological treatments. Although dialectical behavior therapy (DBT) is well-studied, little is known about the extent to which its efficacy generalizes to sexual minority and racial/ethnic minority people. This study examined sexual identity, race/ethnicity, and their interaction as predictors of treatment outcome and retention in DBT., Method: Data were from five clinical trials conducted in research and community settings with a variety of adult populations ( N = 269) engaged in standard DBT, augmented DBT, or DBT components. Longitudinal mixed-effects models evaluated sexual identity and racial/ethnic differences in clinical outcomes (suicide attempts, nonsuicidal self-injury [NSSI], global functioning, psychiatric hospitalizations) and retention., Results: Sexual identity, race/ethnicity, and their interaction did not predict the average severity or the rate of change in any clinical outcome over time. Sexual minority identity was associated with decreased risk of treatment dropout ( OR = .44, p < .001). However, this effect was moderated by race/ethnicity, such that non-Hispanic White sexual minority participants had the lowest rates of dropout. Exploratory analyses suggested potential differences related to NSSI for certain sexual and racial/ethnic minority subgroups., Conclusions: Findings suggest no significant differences in DBT treatment outcomes when comparing between sexual minority and heterosexual individuals and between non-Hispanic White and racial/ethnic minority individuals. Sexual minority identity interacted with race/ethnicity to predict dropout, such that non-Hispanic sexual minority people were more likely to complete DBT compared to sexual minority people of color and heterosexual individuals. Further research is needed to clarify potential subgroup and intersectional differences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Influential psychological theories hypothesize that people consume alcohol in response to the experience of both negative and positive emotions. Despite two decades of daily diary and ecological momentary assessment research, it remains unclear whether people consume more alcohol on days they experience higher negative and positive affect in everyday life. In this preregistered meta-analysis, we synthesized the evidence for these daily associations between affect and alcohol use. We included individual participant data from 69 studies ( N = 12,394), which used daily and momentary surveys to assess affect and the number of alcoholic drinks consumed. Results indicate that people are not more likely to drink on days they experience high negative affect, but are more likely to drink and drink heavily on days high in positive affect. People self-reporting a motivational tendency to drink-to-cope and drink-to-enhance consumed more alcohol, but not on days they experienced higher negative and positive affect. Results were robust across different operationalizations of affect, study designs, study populations, and individual characteristics. These findings challenge the long-held belief that people drink more alcohol following increases in negative affect. Integrating these findings under different theoretical models and limitations of this field of research, we collectively propose an agenda for future research to explore open questions surrounding affect and alcohol use., Competing Interests: Competing interests: Authors declare that they have no competing interests.

Objective: To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD., Method: Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days., Results: At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days., Conclusion: Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care., Trial Registration: The trial is registered at clinicaltrials.gov (NCT01663337)., Competing Interests: Dr. Kaysen is a co-author of a book on Cognitive Processing Therapy published by Elsevier for which she receives royalties. In addition she has conducted clinical workshops on Cognitive Processing Therapy for which she has received speakers fees, which could constitute a conflict of interest. Dr. Resick is a co-author on the Cognitive Processing Therapy treatment manual for which she receives royalties and she conducts clinical workshops on Cognitive Processing Therapy for which she receives speakers’ fees, which could constitute a conflict of interest. The other co-authors have no conflicts of interest to declare pertinent to this submission. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objective: Posttraumatic stress disorder (PTSD) is associated with high comorbidity rates across the full range of psychiatric disorders. However, little is known about how psychiatric comorbidity manifests among people with PTSD, particularly with regard to concurrent diagnoses., Method: Latent class analysis (LCA) was used to characterize discrete classes of PTSD comorbidity using past year DSM-5 diagnostic standards among a large nationally representative epidemiologic sample of U.S. adults. Follow-up analyses compared participant characteristics across latent classes., Results: The LCA was best characterized by five classes: low comorbidity, distress-fear, distress-externalizing, mania-fear-externalizing, and mania-externalizing. Excluding the low comorbidity class, proportions of borderline and schizotypal personality disorder were high across classes., Conclusion: Participant characteristics across classes of past year PTSD comorbidity are explored through the lens of case conceptualization and treatment planning utility., (© 2022 Wiley Periodicals LLC.)

Goals: Our aim was to describe the prevalence of irritable bowel syndrome (IBS) and other gastrointestinal symptoms in a sample of veterans with posttraumatic stress disorder (PTSD) and to examine the relationship between gastrointestinal symptoms, PTSD severity, depression severity, and number of prior traumatic events reported., Background: IBS and PTSD can co-occur; yet, little research has focused on describing the gastrointestinal symptoms and prevalence of IBS among veterans with PTSD., Materials and Methods: We examined baseline data from a randomized clinical trial of behavioral interventions for veterans with PTSD. Veterans completed questionnaires assessing gastrointestinal symptoms (Gastrointestinal Patient-Reported Outcome Measures Information Systems; PROMIS) and lifetime traumatic events. Multivariable regression analyses were performed to examine associations between gastrointestinal symptoms and the number of prior traumas reported PTSD severity, and depression symptom severity., Results: One hundred eighty-four veterans with a diagnosis of PTSD were included. Twenty-five percent met the Rome III criteria for IBS. Veterans reported gastrointestinal symptoms including abdominal/belly pain (36%), diarrhea (21%), constipation (18%), and bloating/gas (17%). In multivariable analyses, greater PTSD severity was associated with worse constipation ( P =0.008), diarrhea ( P =0.005), and gas/bloating ( P =0.001) when controlling for age and sex. Higher levels of depressive symptoms severity were associated with greater abdominal/belly pain ( P =0.04)., Conclusions: Among a sample of veterans with PTSD, rates of IBS and abdominal/belly pain are greater than general US population reference values. Although levels of constipation and bloating/gas are lower than general US population reference values, increased severity of PTSD was associated with increased gastrointestinal symptoms., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Clinical Relevance: The discovery of an accommodative response to ocular surface stimulation could inform clinicians and patients that optical effects may occur due to ocular discomfort and perhaps an assessment of the accommodative system after carrying out interventions impacting the ocular surface, may be warranted., Background: There have been no previous reports evaluating the effect of noxious stimulation on accommodation. Here, the accommodative response of healthy participants after the application of noxious corneal stimulation is characterised., Methods: A computerised Belmonte pneumatic esthesiometer was used to determine detection thresholds (using ascending method of limits), and to randomly deliver mechanical and chemical stimuli from levels of detection threshold to twice the threshold in 50% steps, to the central cornea of 15 healthy subjects. For each suprathreshold stimulus, accommodative and pupil responses were measured with a validated eccentric infrared photorefractor. Quantitative differences in accommodative/pupil response, stimulus modality/intensity and left/right eye were analysed using repeated measures ANOVA. Tukey HSD tests were used for all post hoc analyses., Results: Accommodation increased from baseline as the corneal apical stimulus intensity increased. This happened regardless of whether mechanical or chemical stimulation occurred (ANOVA, p < 0.05). At 200% threshold, accommodative response was greater than all stimulus intensities (Tukey HSD, all p <  0.05). There was no difference in pupil response between the stimulation intensities (100%, 150% and 200% threshold). There was no difference in accommodative response between the left and right eye for mechanical (ANOVA, p >  0.05) and chemical stimulation (ANOVA, p > 0.05)., Conclusion: Noxious stimulation of the cornea seems to produce a dose-dependent increase in the accommodative response in the eyes but not a dose-dependent pupil response.

Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder (PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision-making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual-level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM-5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients., (© 2022 International Society for Traumatic Stress Studies.)

Objective: Concurrent posttraumatic stress disorder and substance use disorder (PTSD/SUD) in U.S. military veterans represents an urgent public health issue associated with significant clinical challenges. Although previous research has shown that veterans with PTSD/SUD endorse more psychosocial risk factors and fewer protective factors than veterans with neither or only one of these disorders, no study has applied a comprehensive framework to characterize the vocational, financial, and social well-being of veterans with PTSD/SUD. Furthermore, it is not fully known how well-being among veterans with PTSD/SUD compares to that of veterans with posttraumatic stress disorder (PTSD) only, substance use disorder (SUD) only, or neither disorder., Method: This cross-sectional observational study analyzed data from the National Post-Deployment Adjustment Survey, which recruited a random national sample of U.S. veterans who served on/after September 11, 2001. Participants (weighted N = 1,102) self-reported sociodemographic, clinical, and military background information in addition to aspects of their vocational, financial, and social well-being., Results: Veterans with PTSD/SUD were particularly likely to report lifetime experiences of homelessness, violent behavior, suicidal ideation, and suicide attempts. Veterans with PTSD/SUD reported worse social well-being than the PTSD-only, SUD-only, and neither-disorder groups. They also reported worse vocational and financial well-being than veterans with SUD only or with neither disorder but did not significantly differ from the PTSD-only group on vocational or financial well-being., Conclusions: The findings underscore the importance of assessing multiple aspects of well-being in veterans with PTSD and/or SUD. The findings also point to promising treatment targets to improve psychosocial functioning and overall quality of life among veterans with PTSD and/or SUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating illness characterized by exacerbations that require timely intervention. COPD patients often rely on informal caregivers-relatives or friends-for assistance with functioning and support. Caregivers perform roles that may be particularly important during acute exacerbations in monitoring symptoms and seeking medical intervention. However, little is known about caregivers' roles and experiences as they support their patients during exacerbations., Purpose: To explore the experiences, roles in care seeking, and needs of caregivers during COPD exacerbations., Methods: Semi-structured interviews were conducted with 24 caregivers of Veterans with COPD who experienced a recent exacerbation. Interviews were recorded, transcribed, and analyzed using inductive content analysis., Results: Five themes arose: (a) caregivers reported continuously monitoring changes in patients symptom severity to identify exacerbations; (b) caregivers described emotional reactions evoked by exacerbations and constant vigilance; (c) caregivers described disagreements with their patient in interpreting symptoms and determining the need for care seeking; (d) caregivers noted uncertainty regarding their roles and responsibilities in pursuing care and their approaches to promote care varied; and (e) expressed their need for additional information and support. Caregivers of patients with COPD often influence whether and when patients seek care during exacerbations. Discrepancies in symptom evaluations between patients and caregivers paired with the lack of information and support available to caregivers are related to delays in care seeking. Clinical practice should foster self-management support to patient-caregiver dyads to increase caregiver confidence and patient openness to their input during exacerbations., (© Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Patients who receive earlier treatment for acute exacerbations of chronic obstructive pulmonary disease (COPD) have a better prognosis, including earlier symptom resolution and reduced risk of future emergency-department visits (ED) or hospitalizations. However, many patients delay seeking care or do not report worsening symptoms to their healthcare provider. In this study, we aimed to understand how patients perceived their breathing symptoms and identify factors that led to seeking or delaying care for an acute exacerbation of COPD. We conducted semistructured interviews with 60 individuals following a recent COPD exacerbation. Participants were identified from a larger study of outpatients with COPD by purposive sampling by exacerbation type: 15 untreated, 15 treated with prednisone and/or antibiotics in the outpatient setting, 16 treated in an urgent care or ED setting, and 14 hospitalized. Data were analyzed using inductive content analysis. Participants were primarily male (97%) with a mean age of 69.1 ± 6.9 years, mean FEV 1 1.42 (±0.63), and mean mMRC dyspnea of 2.7 (±1.1). We identified 4 primary themes: (i) access and attitudinal barriers contribute to reluctance to seek care, (ii) waiting is a typical response to new exacerbations, (iii) transitioning from waiting to care-seeking: the tipping point, and (iv) learning from and avoiding worse outcomes. Interventions to encourage earlier care-seeking for COPD exacerbations should consider individuals' existing self-management approaches, address attitudinal barriers to seeking care, and consider health-system changes to increase access to non-emergent outpatient treatment for exacerbations.Clinical Trial Registration NCT02725294., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objective: Rates of lifetime substance use disorder (SUD) are high among people with lifetime posttraumatic stress disorder (PTSD). Panic attacks are also prevalent among trauma survivors and people with SUD, yet studies on PTSD/SUD have rarely examined comorbid panic. This potentially creates additional barriers to effective treatment for people with PTSD/SUD, in that panic may be under-diagnosed among people with PTSD/SUD and consequently attenuate treatment outcome. Additionally, research on PTSD/SUD often combines people with alcohol use disorder (AUD) and people with drug use disorders (DUDs) into a single group despite evidence that these two PTSD/SUD subgroups differ along important sociodemographic and clinical variables. This study tested the hypothesis that among adults with lifetime PTSD, panic attacks would be associated with greater lifetime risk for both AUD and DUD. We also explored whether panic attacks were associated with specific DUDs that frequently co-occur with PTSD (cannabis, sedatives/tranquilizers, heroin/opioids, and cocaine). Methods: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a cross-sectional national study. Adults with lifetime PTSD ( N  = 2,230) were classified into one of three groups based on diagnostic interview data: adults with PTSD/AUD (i.e., met criteria for PTSD and AUD but not DUD; n  = 656), adults with PTSD/DUD (i.e., met criteria for PTSD and DUD, regardless of AUD diagnostic status; n  = 643), or adults with PTSD-only (i.e., met criteria for PTSD but not AUD or DUD; n  = 1,031). Results: Weighted logistic regression analyses showed that lifetime risk of PTSD/AUD and PTSD/DUD, each relative to PTSD-only, was greater for adults who were younger at the time of data collection, were male, and had a history of panic attacks. Panic attacks did not predict specific DUD diagnoses comorbid with PTSD in exploratory analyses adjusting for sociodemographic and clinical covariates. Conclusions: Findings highlight the importance of assessing and targeting panic in PTSD/SUD clinics, but suggest panic may not discriminate between specific DUDs that commonly co-occur with PTSD. Study limitations and future directions are discussed.

Over the past 20 years, numerous treatments addressing comorbid Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) have been developed and tested. The current meta-analysis examined the efficacy and acceptability of the two central treatment types- trauma-focused and non-trauma-focused - compared with all comparators and with cognitive-behavioral manualized SUD treatments immediately post-treatment and at longest follow-up. Twenty-eight randomized clinical trials (N = 3247) were included. There were small to large within-group effects for all forms of active treatment (gs = 0.30-1.11). Trauma-focused but not non-trauma-focused treatments outperformed all comparators on PTSD outcomes at post-treatment. Neither trauma-focused nor non-trauma-focused treatment outperformed all comparators on SUD outcomes at post-treatment. Neither trauma- nor non-trauma-focused treatment outperformed manualized SUD treatments on PTSD outcomes at either time point. Manualized SUD treatments outperformed trauma-focused treatments on SUD outcomes at post-treatment and non-trauma-focused treatments on PTSD outcomes at follow-up. Regarding treatment retention, neither trauma-focused nor non-trauma-focused treatments significantly differed from all comparators or from manualized SUD treatments. Between-group results were largely unchanged in trim-and-fill analyses, but were not robust to fail-safe N. Few moderators were detected. Taken together, results suggest that trauma-focused, non-trauma-focused, and manualized SUD interventions are sound options for individuals with comorbid PTSD/SUD., (Published by Elsevier Ltd.)

Purpose: This study evaluates the spectral transmission of photochromic contact lenses., Method: A custom built photochromic filter transmission testing device (ICS photochromic bench) was developed to measure the spectral transmission of light adaptive filters. The spectral properties of seven contact lenses were measured using the ICS photochromic bench at 23⁰C and 35⁰C in their exposed (darkening) state at time points 0 s, 45 s, 90 s, and 15 min. and their unexposed (fading) state at 45 s, 15 min. and 20 min.. Mixed between and within repeated measures ANOVA (MRM-ANOVAs) and generalized additive modeling (GAMs) were used to compare the effects of temperature and solar exposure time on spectral transmittance of photochromic contact lenses., Results: The mean (±SD) transmission of photochromic contact lenses in the exposed state were 94.7 ± 0.2, 39.1 ± 1.4, 27.0 ± 0.7 and 14.7 ± 1.0, and 93.7 ± 0.9, 38.8 ± 2.4, 30.2 ± 1.8, and 26.1 ± 1.0 at times 0 s, 45 s, 90 s, and 15 min. at 23⁰C and 35⁰C respectively. The mean (±SD) transmission of photochromic contact lenses in the unexposed state were 18.3 ± 1.5, 71.3 ± 2.4, and 80.2 ± 2.4, and 39.1 ± 1.0, 90.6 ± 1.0 and 91.1 ± 0.9 at times 45 s, 15 min. and 20 min. at 23⁰C and 35⁰C respectively. There was a significant decrease in light transmission as solar exposure time increased (GAM, MRM-ANOVA, p < 0.05). There was a significant effect of temperature and solar exposure time on the photochromic contact lenses (GAM, MRM-ANOVA, p < 0.05). The differences in the light transmitted by the photochromic contact lenses occurred at time 90 s and 15 min (Tukey HSD, at 90 s and 15 min, p < 0.05), where contact lenses at a temperature of 35⁰C showed greater light transmission than that at 23⁰C. There were differences in spectral transmittance based on the temperature of the contact lens. Contact lenses at 35⁰C transmitted more light than at 23⁰C at all unexposed times (MRM-ANOVA, p < 0.05)., Conclusion: Spectral transmission of photochromic contact lenses were successfully measured with the ICS photochromic bench. Temperature appears to influence both the activation and deactivation of photochromic contact lenses such that the higher the temperature, the greater the light transmission., (Copyright © 2021 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.)

Importance: Additional options are needed for treatment of posttraumatic stress disorder (PTSD) among veterans., Objective: To determine whether group loving-kindness meditation is noninferior to group cognitive processing therapy for treatment of PTSD., Design, Setting, and Participants: This randomized clinical noninferiority trial assessed PTSD and depression at baseline, posttreatment, and 3- and 6-month follow-up. Veterans were recruited from September 24, 2014, to February 5, 2018, from a large Veternas Affairs medical center in Seattle, Washington. A total of 184 veteran volunteers who met Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for PTSD were randomized. Data collection was completed November 28, 2018, and data analyses were conducted from December 10, 2018, to November 5, 2019., Interventions: Each intervention comprised 12 weekly 90-minute group sessions. Loving-kindness meditation (n = 91) involves silent repetition of phrases intended to elicit feelings of kindness for oneself and others. Cognitive processing therapy (n = 93) combines cognitive restructuring with emotional processing of trauma-related content., Main Outcomes and Measures: Co-primary outcomes were change in PTSD and depression scores over 6-month follow-up, assessed by the Clinician-Administered PTSD Scale (CAPS-5; range, 0-80; higher is worse) and Patient-Reported Outcome Measurement Information System (PROMIS; reported as standardized T-score with mean [SD] of 50 [10] points; higher is worse) depression measures. Noninferiority margins were 5 points on the CAPS-5 and 4 points on the PROMIS depression measure., Results: Among the 184 veterans (mean [SD] age, 57.1 [13.1] years; 153 men [83.2%]; 107 White participants [58.2%]) included in the study, 91 (49.5%) were randomized to the loving-kindness group, and 93 (50.5%) were randomized to the cognitive processing group. The mean (SD) baseline CAPS-5 score was 35.5 (11.8) and mean (SD) PROMIS depression score was 60.9 (7.9). A total of 121 veterans (66%) completed 6-month follow-up. At 6 months posttreatment, mean CAPS-5 scores were 28.02 (95% CI, 24.72-31.32) for cognitive processing therapy and 25.92 (95% CI, 22.62-29.23) for loving-kindness meditation (difference, 2.09; 95% CI, -2.59 to 6.78), and mean PROMIS depression scores were 61.22 (95% CI, 59.21-63.23) for cognitive processing therapy and 58.88 (95% CI, 56.86-60.91) for loving-kindness meditation (difference, 2.34; 95% CI, -0.52 to 5.19). In superiority analyses, there were no significant between-group differences in CAPS-5 scores, whereas for PROMIS depression scores, greater reductions were found for loving-kindness meditation vs cognitive processing therapy (for patients attending ≥6 visits, ≥4-point improvement was noted in 24 [39.3%] veterans receiving loving-kindness meditation vs 9 (18.0%) receiving cognitive processing therapy; P = .03)., Conclusions and Relevance: Among veterans with PTSD, loving-kindness meditation resulted in reductions in PTSD symptoms that were noninferior to group cognitive processing therapy. For both interventions, the magnitude of improvement in PTSD symptoms was modest. Change over time in depressive symptoms was greater for loving-kindness meditation than for cognitive processing therapy., Trial Registration: Clinicaltrials.gov Identifier: NCT01962714.

Purpose: Social support is an important correlate of health behaviors and outcomes. Studies suggest that veterans have lower social support than civilians, but interpretation is hindered by methodological limitations. Furthermore, little is known about how sex influences veteran-civilian differences. Therefore, we examined veteran-civilian differences in several dimensions of social support and whether differences varied by sex., Methods: We performed a cross-sectional analysis of the 2012-2013 National Epidemiologic Survey of Alcohol and Related Conditions-III, a nationally representative sample of 34,331 respondents (male veterans = 2569; female veterans = 356). We examined veteran-civilian differences in functional and structural social support using linear regression and variation by sex with interactions. We adjusted for socio-demographics, childhood experiences, and physical and mental health., Results: Compared to civilians, veterans had lower social network diversity scores (difference [diff] = - 0.13, 95% confidence interval [CI] - 0.23, - 0.03). Among women but not men, veterans had smaller social network size (diff = - 2.27, 95% CI - 3.81, - 0.73) than civilians, attributable to differences in religious groups, volunteers, and coworkers. Among men, veterans had lower social network diversity scores than civilians (diff = - 0.13, 95% CI - 0.23, - 0.03); while among women, the difference was similar but did not reach statistical significance (diff = - 0.13, 95% CI - 0.23, 0.09). There was limited evidence of functional social support differences., Conclusion: After accounting for factors that influence military entry and social support, veterans reported significantly lower structural social support, which may be attributable to reintegration challenges and geographic mobility. Findings suggest that veterans could benefit from programs to enhance structural social support and improve health outcomes, with female veterans potentially in greatest need.

Purpose: To evaluate the feasibility of using signal detection theory (SDT) in estimating criterion and detectability indices for corneal pneumatic stimuli and test corneal psychophysical data against linking hypotheses from nonprimate physiology using Bayesian analysis., Methods: Corneal pneumatic stimuli were delivered using the Waterloo Belmonte esthesiometer. Corneal thresholds were estimated in 30 asymptomatic participants and 1.5× threshold stimuli were used as signals (with 0.4 probability). There were 100-trial mechanical and cold stimulus experiments and 50-trial chemical experiments. Trials were demarcated auditorily and "yes" or "no" recorded after each trial. Cold stimulus experiments were conducted with 0.6 signal probability. Criterion ( c ), likelihood ratio (lnβ), and d ' were calculated from the yes-no responses., Results: Average d ' was 0.59 ± 0.1, 1.65 ± 0.37, and 1.14 ± 0.3 units for cold, mechanical, and chemical stimuli, respectively. Bayes factors obtained using Bayesian analysis of variance mildly favored (BF 10 = 1.55) differences between d 's of the stimulus types, with no support for differences in criteria between stimulus types. Multiple comparisons of d ' supported linking hypotheses based on nociception and nerve conductance theories., Conclusions: Our experiments are the first to demonstrate the feasibility of estimating SDT indices and test different hypotheses. The conservative strategy (reporting "no" more often) chosen by participants was anticipated due to relatively large proportion of catch trials., Translational Relevance: SDT when using pneumatic esthesiometry is vital to evaluate bias in responses of participants. Considering the varied forms of inherent noise in the corneal sensory system, SDT is critical to understand the sensory and decisional characteristics., Competing Interests: Disclosure: V. Jayakumar, None; T.L. Simpson, None, (Copyright 2020 The Authors.)

Experiencing a sexual assault can have long-lasting negative consequences including development of posttraumatic stress disorder (PTSD) and alcohol misuse. Intervention provided in the initial weeks following assault can reduce the development of these chronic problems. This study describes the iterative treatment development process for refining a brief intervention targeting PTSD and alcohol misuse for women with recent sexual assault experiences. Experts, treatment providers, and patients provided feedback on the intervention materials and guided the refinement process. Based on principles of cognitive change, the final intervention consists of one in-person session and four coaching calls targeting beliefs about the assault and about drinking behavior. Initial feasibility and acceptability data are presented for patients enrolled in an open trial ( N = 6). The intervention was rated as helpful, not distressing, and interesting by patients and all patients completed the entire treatment protocol. A large decrease in PTSD symptoms pre- to post-intervention was observed. A small effect on decreasing alcohol consequences also emerged, although drinks consumed per week showed a slight increase, not a decrease, over the course of the intervention. Applications of this intervention and next steps for testing efficacy are presented., Competing Interests: The authors declare that there are no conflicts of interest.

Objective: To determine latent classes of treatment receipt among people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) and describe each class by demographics, disease characteristics, and psychiatric diagnoses., Method: Participants were National Epidemiologic Survey on Alcohol and Related Conditions-III respondents with lifetime PTSD and SUD (n = 1,349; mean age 40.3; 62.5% female; 30.9% non-White or Hispanic-White). Cross-sectional data were collected using the DSM-5 Alcohol Use Disorder and Associated Disabilities Interview Schedule. Latent class analysis was used to identify subgroups of participants with different patterns of treatment receipt., Results: Of the patients, 36% received at least 1 SUD treatment while 84% received at least 1 mental health (MH) treatment. Six latent classes were identified: no treatment (17.3%), outpatient MH (34.0%), outpatient + inpatient MH (17.9%), SUD (7.3%), SUD + outpatient MH (15.7%), and SUD + outpatient MH + inpatient MH (7.7%). The SUD treatment classes evidenced greater social instability, had higher alcohol use disorder symptom severity, and used more drug types than the non-SUD classes. Classes receiving inpatient MH treatment had a greater incidence of additional comorbid conditions and suicidal behaviors. Across all 6 classes, most respondents met diagnostic criteria for chronic PTSD (overall: 68.9%) while fewer met diagnostic criteria for chronic SUD (overall: 38.7%)., Conclusions: Most people with lifetime PTSD and SUD have sought either SUD or MH treatment or both, with substantially greater receipt of MH treatment. This comorbid group has complex clinical presentations that differ depending upon treatment subgroup, and for most, their PTSD persisted despite high rates of treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background: Military veterans report high rates of psychiatric and physical health symptoms that may be amenable to mindfulness-based interventions (MBIs). Inconsistent prior findings and questions of fit between MBIs and military culture highlight the need for a systematic evaluation of this literature., Objective: To quantify the efficacy and acceptability of MBIs for military veterans., Data Sources: We searched five databases (MEDLINE/PubMed, CINAHL, Scopus, Web of Science, PsycINFO) from inception to October 16th, 2019., Study Selection: Randomized controlled trials (RCTs) testing MBIs in military veterans., Results: Twenty studies (k = 16 unique comparisons, N = 898) were included. At post-treatment, MBIs were superior to non-specific controls (e.g., waitlist, attentional placebos) on measures of posttraumatic stress disorder (PTSD), depression, general psychological symptoms (i.e., aggregated across symptom domains), quality of life / functioning, and mindfulness (Hedges' gs = 0.32 to 0.80), but not physical health. At follow-up (mean length = 3.19 months), MBIs continued to outperform non-specific controls on general psychological symptoms, but not PTSD. MBIs were superior to specific active controls (i.e., other therapies) at post-treatment on measures of PTSD and general psychological symptoms (gs = 0.19 to 0.25). Participants randomized to MBIs showed higher rates of attrition than those randomized to control interventions (odds ratio = 1.98). Several models were not robust to tests of publication bias. Study quality and risk of bias assessment indicated several areas of concern., Conclusions: MBIs may improve psychological symptoms and quality of life / functioning in veterans. Questionable acceptability and few high-quality studies support the need for rigorous RCTs, potentially adapted to veterans., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To examine the diurnal variation of corneal threshold and suprathreshold sensory processing, symptoms, and tear secretion in symptomatic and asymptomatic contact lens (CL) wearers and controls., Methods: 26 symptomatic and 25 asymptomatic CL wearers and 15 asymptomatic non-CL wearing controls participated. Cooling thresholds, symptoms and tear meniscus height (TMH) were measured on each of 3 measurement days (random order) on the following schedules; Day-1 within 1 h of awakening (Baseline) and 3, 6 and 9 h later, Day-2 baseline and 9 h later (CLs worn in CL group) and Day-3 baseline and 9 h later. Magnitudes estimates for threshold-scaled suprathreshold stimuli were also estimated on Day-3. Data were analyzed using mixed models and repeated measures ANOVA., Results: Cooling thresholds for the symptomatic group were lower and decreased over Day-1 (p < 0.008) and after 8 h of CL wear on Day-2 (p < 0.001) and were paralleled by increased symptoms (all p < 0.001), whereas minimal variations were found in the asymptomatic and control groups. Magnitude estimates for suprathreshold stimuli were higher (p ≤ 0.002) in the symptomatic group but did not differ significantly over the day. TMH varied little over time and was lower in the symptomatic group, but the difference was not statistically significant., Conclusion: Corneal sensitivity and symptoms, but not TMH, increased diurnally irrespective of CL wear in symptomatic CL wearers. These results reveal the essential role of neurosensory abnormalities in CL discomfort and suggest involvement of a central mechanism in the diurnally increased symptoms of these patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

We aimed to evaluate whether military service and access to veteran heath care coverage attenuates racial/ethnic disparities in time to mental health treatment initiation for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder. Results are based on 13,528 civilians and 1392 veterans from NESARC-III. Among civilians, racial/ethnic minorities reported longer time to PTSD and depression treatment initiation than non-Hispanic whites. Among veterans, racial/ethnic minorities did not differ from whites in time to PTSD and depression treatment initiation, and showed shorter time to treatment initiation for alcohol-use disorder treatment. Racial/ethnic minorities with past year veteran health care coverage showed the strongest evidence for attenuated disparities.

Posttraumatic stress disorder (PTSD) is characterized by re-experiencing, avoidance, negative alterations in cognition and mood, and arousal symptoms per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). While numerous symptom combinations are possible to meet diagnostic criteria, simplification of this heterogeneity of symptom presentations may have clinical utility. In a nationally representative sample of American adults with lifetime DSM-5 PTSD diagnoses from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 2,365), we used Latent Class Analysis (LCA) to identify qualitatively distinct PTSD symptom typologies. Subsequently, we used linear and logistic regressions to identify demographic, trauma-related, and psychiatric characteristics associated with membership in each class. In contrast to prior LCAs with DSM-IV-TR diagnostic criteria, fit indices for the present analyses of DSM-5 PTSD revealed a four-class solution to the data: Dysphoric (23.8%), Threat-Reactivity (26.1%), High Symptom (33.7%), and Low Symptom (16.3%). Exploratory analyses revealed distinctions between classes in socioeconomic impairment, trauma exposure, comorbid diagnoses, and demographic characteristics. Although the study is limited by its cross-sectional design (preventing analysis of temporal associations or causal pathways between covariates and latent classes), findings may support efforts to develop personalized medicine approaches to PTSD diagnosis and treatment., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier B.V.)

Purpose: Ocular somatosensory-autonomic reflexes play critical roles in maintaining homeostasis of the eye. The purpose of this study was to investigate the pupil response to nociceptive corneal stimuli., Methods: A Waterloo-Belmonte pneumatic esthesiometer was used to determine detection thresholds and randomly deliver mechanical and chemical stimuli from levels of detection threshold to twice the threshold in 50% steps to the central cornea of 15 healthy subjects. For each stimulus, imaging of the stimulated/unstimulated eye was performed using two modified/calibrated Logitech c920 digital cameras for 4 seconds each, pre/post stimulus capture. The data were processed with a custom segmentation algorithm to help identify the pupils and pupil diameter was measured using ImageJ software. Pupil dilation response differences between the ipsi- and contralateral eye was analyzed using dependent t-tests. The effect of stimulus intensity, modality and sex of subjects were analyzed using repeated measures., Results: In mechanical and chemical stimulation experiments, there was no difference in pupil responses between the stimulated eye and the unstimulated eye, (all dependent T-test p > 0.05). On average, pupil diameter increased from baseline as the corneal stimulus intensity increased. This happened regardless of whether mechanical or chemical stimulation occurred (ANOVA p < 0.05). At 200% threshold, pupil diameter was greater than at all stimulus intensities (Tukey HSD, all p < 0.05). Based on stimulus intensity, females had greater pupil diameters than males at levels of 150% threshold and 200% threshold (ANOVA p < 0.05, all Tukey HSD p < 0.05)., Conclusion: This study serves as a basis for the characterization of the local stimulus-response neural circuitry relating nociceptive stimuli to autonomic responses and in combination with our work on completely separate autonomic circuits of bulbar conjunctival vessel dilation and reflex tearing suggests that the monotonic measurements of redness, tearing and pupils provide accurate, separable responses that reflect painful stimulus intensity., Competing Interests: The authors have declared that no competing interests exist.

Objective: Lack of social support predicts the development, maintenance, and exacerbation of posttraumatic stress disorder (PTSD). Moreover, social dysfunction is associated with recurrent episodes of PTSD care, and detachment/estrangement from others is a strong predictor of suicidal ideation among those with PTSD. Thus, treatments to improve social functioning among those with PTSD are needed., Method: Eighty veterans of recent operations in Iraq and Afghanistan participated in a randomized controlled trial comparing treatment as usual to behavioral activation (BA) for PTSD, a treatment that focuses on reducing avoidance behaviors and increasing engagement in valued goals rather than explicitly confronting trauma memories., Results: Mixed-model regression analyses revealed that, accounting for gender, baseline PTSD, and marital status, participants who received BA experienced greater improvements in the number of social supports from baseline to posttreatment compared with those in treatment as usual (F1,96 = 6.29, p = .014). Gains were not maintained at 3-month follow-up, and significant results were not found for satisfaction with social supports., Conclusions: BA may facilitate an increase in the perceived number of social supports available to veterans with PTSD, but treatment adaptation may be necessary to maintain these gains and to increase satisfaction with social support. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mindfulness-based cognitive therapy (MBCT) appears to be a promising intervention for the prevention of relapse in major depressive disorder, but its efficacy in patients with current depressive symptoms is less clear. Randomized clinical trials of MBCT for adult patients with current depressive symptoms were included ( k = 13, N = 1046). Comparison conditions were coded based on whether they were intended to be therapeutic (specific active controls) or not (non-specific controls). MBCT was superior to non-specific controls at post-treatment ( k = 10, d = 0.71, 95% confidence interval [CI] [0.47, 0.96]), although not at longest follow-up ( k = 2, d = 1.47, [-0.71, 3.65], mean follow-up = 5.70 months across all studies with follow-up). MBCT did not differ from other active therapies at post-treatment ( k = 6, d = 0.002, [-0.43, 0.44]) and longest follow-up ( k = 4, d = 0.26, [-0.24, 0.75]). There was some evidence that studies with higher methodological quality showed smaller effects at post-treatment, but no evidence that effects varied by inclusion criterion. The impact of publication bias appeared minimal. MBCT seems to be efficacious for samples with current depressive symptoms at post-treatment, although a limited number of studies tested the long-term effects of this therapy.

Purpose: To use a human-based model to study the effects of repeated tear film instability on corneal detection thresholds to cold, mechanical, and chemical stimuli., Methods: Twenty-five subjects participated in three study visits. A computer-controlled Belmonte esthesiometer was used to estimate corneal detection thresholds to cold, mechanical, and chemical stimuli before, after, and 30 minutes following 10 consecutive sustained tear exposure (STARE) trials. Subjects turned a pain knob (0-10) to indicate discomfort during STARE trials. The area of tear breakup and thinning in each trial was analyzed. Symptoms were evaluated by the Current Symptom Questionnaire (CSQ)., Results: There was a significant time effect on CSQ symptoms during both visits (Friedman test, P < 0.001), with immediately after repeated STARE and 30 minutes later significantly differing from before STARE (Wilcoxon, P < 0.017). Tear breakup occurred in every trial, ranging from 25% to 88% of the exposed corneal area and all subjects indicated discomfort during trials. There was a significant time effect on mechanical thresholds between before STARE mechanical thresholds and 30 minutes later (repeated measures analysis of variance [ANOVA] P < 0.001), but not cold (P = 0.057) or chemical (P = 0. 565) thresholds., Conclusions: In this study, tear breakup during STARE trials was associated with discomfort, which when repeated, resulted in increased symptoms of ocular discomfort and alterations of mechanical sensory thresholds after 30 minutes. These results suggest that tear film instability, which is thought to occur repeatedly during normal blinking among dry eye patients over the day, can produce neurosensory alterations.

Purpose: To determine the feasibility of using a portable carbon dioxide (CO 2 ) sensor to calibrate a pneumatic esthesiometer and then to calibrate the chemical stimuli., Methods: The chemical stimuli in ocular surface experiments are combinations of medical air and added CO 2 (%CO 2 ). These stimuli were calibrated using a portable CO 2 sensor (COZIR CM-0041) and data logger, delivered for 100 seconds by using the Waterloo Belmonte esthesiometer. The distances between the sensor and esthesiometer tip were 0 (to measure feasibility), 3, 5, and 10 mm. In experiment I, 100% CO 2 was tested using four different flow rates (50, 100, 150, and 200 mL/min) at three working distances. In experiment II, flow rates of 20 to 100 mL/min and concentrations of 20% to 100% CO 2 were tested in 20 steps at 3 working distances., Results: The CO 2 sensor correctly reported the esthesiometer extremes of 0% and 100% CO 2 when placed at the esthesiometer tip. There were progressive, systematic increases in concentrations reaching/reported by the sensor with increasing flow rates and nominal concentrations and progressive decreases in measurements with increases in working distance., Conclusions: CO 2 concentrations in pneumatic esthesiometers can be calibrated and, as expected, vary with flow rate and distance, highlighting the importance of calibration and standardization of CO 2 stimuli in these instruments., Translational Relevance: Calibrated CO 2 , a chemical sensory stimulus in humans, may be used in testing the surface of the eye as well as other membranes within which the CO 2 can be dissolved (e.g., mucous) to produce an acidic stimulus., (Copyright 2019 The Authors.)

Military sexual trauma (MST) is a significant public health issue associated with adverse psychiatric outcomes, including heightened risk for suicide, posttraumatic stress disorder, depression, and substance use disorders. Recently, research has begun exploring gender-linked disparities in mental health outcomes for individuals who experience MST. The current study assessed whether women who screened positive for MST were at disproportionately higher risk for diagnoses of alcohol-use disorder (AUD) or drug-use disorder (DUD) relative to men. Veterans Health Administration (VHA) clinical data were extracted for 435,690 military veterans who separated from the military between 2004 and 2011 and had at least 5 years of follow-up data after their initial VHA visit until the end of fiscal year 2014. Logistic regression models examined the main and interactive effects of gender and screening positively for MST as predictors of AUD and DUD. MST positive screens were associated with increased rates of both AUD and DUD across genders. Although rates of both AUD and DUD were higher among men, the increased rate of diagnosis associated with MST positive screens was proportionally higher for women than men (interaction adjusted odds ratios = 1.43 and 1.17 for AUD and DUD, respectively), indicating the presence of a gender-linked health risk disparity. This disparity was more pronounced for AUD than DUD ( p < .01). The current study adds to previous literature documenting increased risk for women exposed to MST. These findings support efforts to reduce the occurrence of MST and continued use of MST screening measures within the VHA. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose: To investigate the effects of tear film instability (TFI) induced by sustained tear exposure (STARE) on sensory responses to corneal cold, mechanical, and chemical stimuli., Methods: Fifteen normal subjects were enrolled. TFI was induced during 10 repeated trials of STARE. Pneumatic cold, mechanical, and chemical stimuli were delivered using a computer-controlled Belmonte esthesiometer on three separate visits. The magnitude of the sensory responses to threshold and suprathreshold (1.25 and 1.50 times threshold levels) stimuli were assessed for intensity, coolness or warmness, irritation and pain, using a 0 (none) to 100 (very strong) scale, before and after STARE trials. Symptoms of ocular discomfort were evaluated using the Current Symptom Questionnaire (CSQ). Repeated measures ANOVA was used for data analysis., Results: Following STARE trials, the intensity and coolness ratings to cooling stimuli decreased (P = 0.043 and 0.044 for intensity and coolness, respectively), while rated irritation to mechanical stimuli was increased (P = 0.024). The CSQ scores also increased regardless of visits (all P < 0.001). Intensity ratings, coolness to room temperature stimuli and irritation to mechanical and chemical stimuli increased for all suprathreshold stimuli with increasing stimulus levels (P ≤ 0.005)., Conclusions: Repeated TFI induced by STARE affects neurosensory function of the ocular surface. The decrease in reports of cooling and increase in irritation after repeated TFI suggest a complex interaction of neural mechanisms (particularly nonnociceptive cold and nociceptive mechanical) giving rise to ocular surface sensation in humans.

Significance: The conjunctiva is an integral component of the ocular surface, and its vasculature forms a terminal vascular bed of the human internal carotid artery. No research on the response of conjunctival vasculature to ocular surface stimulation exists; however, it is essential to understand the local physiological and pathological responses to such a stimulus., Purpose: The purpose of this study was to characterize the ocular redness levels in healthy participants after the application of noxious corneal stimulation., Methods: A computerized Belmonte pneumatic esthesiometer was used to determine detection thresholds (using ascending method of limits) and to randomly deliver mechanical and chemical stimuli from levels of detection threshold to twice the threshold in 50% steps to the central cornea of 15 healthy subjects. For each suprathreshold stimulus, a spectrophotometer was used to measure ipsilateral and contralateral conjunctival redness before and after delivery of the corneal stimulus. Redness between the stimulated and unstimulated eyes was analyzed using dependent t tests. The effects of stimulus intensity and modality on conjunctival redness were analyzed using repeated-measures analysis of variance (ANOVA). Tukey honestly significant difference tests were used for all post hoc analyses. P ≤ .05 was considered statistically significant., Results: In mechanical and chemical stimulation experiments, the stimulated eye became redder than the unstimulated eye (all t tests, P > .05). On average, redness increased from baseline as the corneal stimulus intensity increased with corneal stimulation (ANOVA, P < .05). Chemical stimulation produced greater conjunctival redness than did mechanical stimulation at all stimulation levels (ANOVA, P < .05; all Tukey honestly significant difference tests, P < .05)., Conclusions: Stimulation of the central cornea by noxious mechanical and chemical stimuli evokes a dose-dependent autonomic conjunctival redness response. Chemical stimulation of the cornea seems to evoke a greater response compared with mechanical stimulation. This study serves as a basis for the characterization of the local stimulus-response neural circuitry relating nociceptive ocular surface stimuli to autonomic responses.

Objective: A significant subset of college students experience PTSD symptoms, and many engage in problematic alcohol use. Some college students with PTSD symptoms may use alcohol and other substances to cope with their symptoms, and those with PTSD experience more negative alcohol and drug consequences than those without PTSD. Mindfulness-Based Interventions (MBIs) have been successfully utilized for individuals with PTSD or substance use disorders. However, to date, no studies have evaluated MBIs for college students with co-occurring PTSD symptoms and problem drinking., Method: This study was a feasibility pilot of a 4-week group loving-kindness meditation (LKM) intervention, a practice of intentionally directing well wishes to oneself and others. LKM was compared to referral to treatment as usual (RTAU) for non-treatment seeking college students ( N =75) with PTSD symptoms and problem drinking., Results: Overall, the LKM group had low to moderate feasibility and acceptability among college students, as recruitment was lower than expected and attendance at LKM groups was modest. Participants' PTSD symptoms, drinking quantity, and negative drinking consequences decreased, and state mindfulness increased over the course of the study, but there were no significant differences between LKM and RTAU on these outcomes. Additionally, higher coping drinking motives predicted greater PTSD symptoms and more drinking consequences over the course of the study., Conclusions: Effective interventions for college students with PTSD symptoms and problematic alcohol use are needed, especially for individuals who drink to cope with their PTSD symptoms. Future research on LKM that addresses the limitations of the current study is warranted., Competing Interests: Conflict of Interest: The authors declare that they have no conflicts of interest.

Aims: To compare individuals with comorbid life-time post-traumatic stress disorder (PTSD) and alcohol use disorders [AUD; i.e. no drug use disorders (DUD)] with those with comorbid PTSD and DUD on past-year prevalence of these disorders, social functioning, life-time psychiatric comorbidities, and treatment receipt. The comorbid groups were also compared with their single diagnosis counterparts., Design and Setting: Cross-sectional cohort study using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC-III)., Participants: The total sample size was 36 309. Six groups were established: PTSD/AUD, PTSD/DUD, AUD, DUD, PTSD, and neither PTSD nor AUD/DUD. Life-time prevalence of AUD among those with PTSD/DUD was 80.2% and among those with DUD was 73.8%., Measurements: The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 version assessed life-time and past-year psychiatric disorders and treatment receipt. Demographics and social stability indicators were queried. Group characteristics were summarized using weighted means. Prevalences and estimates for adjusted differences in means and adjusted odds ratios (aORs) were derived from multiple linear regression and logistic regression models, respectively. Analyses were conducted in R and accounted for the NESARC-III's complex survey design, clustering, and non-response., Findings: Compared with those with life-time PTSD/AUD, those with life-time PTSD/DUD were significantly less likely to have neither disorder in the past year (PTSD/AUD = 16.1%; PTSD/DUD = 8.5%; aOR = 0.54), and were more likely to report worse social and psychiatric functioning, and to have received both addiction and mental health treatment (PTSD/AUD = 18.4%; PTSD/DUD = 43.2%; aOR = 3.88). Compared with their single disorder counterparts, those with PTSD/DUD reported greater impairment than both groups, whereas the comorbid PTSD/AUD group differed more from the AUD than the PTSD group., Conclusions: People with comorbid PTSD and drug use disorder have greater social and psychiatric impairment and may require different types and intensity of intervention than people with comorbid post-traumatic stress disorder and alcohol use disorder., (© 2019 Society for the Study of Addiction.)

Because they provide data on responsiveness to experimental manipulation, clinical trials involving mindfulness-based interventions are a source of evidence for the construct validity of self-report measures of mindfulness. Within-group and between-group changes in mindfulness were examined from randomized clinical trials comparing mindfulness interventions to other bona fide treatment comparison conditions or waitlist control conditions. We also examined changes in clinical outcomes and the magnitude of these changes relative to changes in mindfulness. We included 69 published studies representing 55 unique samples ( n = 4,743). Self-report mindfulness measures showed relatively larger gains in mindfulness intervention conditions vis-à-vis waitlist comparison conditions at both post-treatment (effect size [ES] = 0.52, 95% CI [0.40, 0.64]) and follow-up (ES = 0.52 [0.20, 0.84]), although the effect at follow-up diminished to non-significance in a trim-and-fill analysis intended to account for publication bias (ES = 0.35 [-0.03, 0.72]). Measures of mindfulness also showed relatively larger gains in mindfulness intervention conditions vis-à-vis bona fide comparison conditions, but only at post-treatment (ES = 0.25 [0.11, 0.38], 0.10 [-0.08, 0.28], at post-treatment and follow-up, respectively). All three conditions (mindfulness, bona fide , waitlist) showed relatively larger improvements on measures of clinical outcomes than measures of mindfulness, with the exception of waitlist conditions for which this effect was no longer significant at follow-up. Taken together, findings provide partial support for the unique responsiveness of mindfulness self-report measures to interventions that include promotion of mindfulness meditation practice., Competing Interests: Conflict of Interest: The remaining authors (SG, RT, PG, TS, WH, DK) declare that they have no conflict of interest.

Objective: The study compared delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder among post-9/11 veterans versus pre-9/11 veterans and civilians., Methods: The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of U.S. noninstitutionalized adults, was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, or alcohol use disorder. Cox proportional hazard models, controlling for relevant demographic characteristics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment)., Results: Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (adjusted hazard ratios [AHRs]=0.69 and 0.74, respectively) and civilians (AHRs=0.60 and 0.67, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol use disorder. In an exploratory analysis, post-9/11 veterans with past-year military health care coverage (e.g., Veterans Health Administration) had shorter delays for depression treatment compared with post-9/11 veterans without military coverage, pre-9/11 veterans regardless of health care coverage, and civilians, although past-year coverage did not predict treatment delay for PTSD or alcohol use disorder., Conclusions: Post-9/11 veterans were less likely to delay treatment for some common psychiatric conditions compared with pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol use disorder, highlighting the need for further engagement efforts.

Research suggests the prevalence of suicide ideation and suicide attempts in the transgender veteran community may be upwards of 20 times higher than nontransgender veterans, who are known to be at increased risk than the general US population. This study aimed to understand the potential influence of external and internal minority stress experienced during and after military service on past-year and recent suicide ideation in a sample of 201 transgender veterans. Nonparametric bootstrapping analyses indicated past-year transgender-specific discrimination and rejection (external minority stress) indirectly predicted frequency of both past-year and past 2-week suicide ideation through past-year shame related to gender identity (internal minority stress). This result was significant when controlling for symptoms of depression and demographics. Similar patterns emerged when examining relationships among military external and internal minority stress on suicide outcomes. These results suggest that attempts to reduce both the experience and impact of minority stressors related to gender identity during and after military service may be an important avenue for suicide prevention., (© 2018 The American Association of Suicidology.)