February 2017 - Volume 205 - Issue 2

  • John A. Talbott, MD
  • 0022-3018
  • 1539-736X
  • 12 issues / year
  • 1.836

ORIGINAL ARTICLES

Longitudinal Study of Posttraumatic Stress Disorder in the Community: Risk and Recovery Factors
Bojana Pejuskovic, MD, PhD, Dusica Lecic-Tosevski, MD, PhD, Oliver Toskovic, PhD

Our study aimed to examine potential risk and recovery factors of PTSD in the general adult population at a 1-year follow-up period. The sample consisted of 640 subjects in the initial phase, chosen by random walk technique in five regions of the country, and 100 in the follow-up. Older age, low education, and lower monthly income are potential risk factors for current PTSD, as well as decreased quality of life, psychiatric comorbidity, and higher personal distress. Urban population, higher quality of life, smaller number of stressors, and lower personal distress contributed to recovery of PTSD.

Gender and Age Differences in Trauma and PTSD Among Dutch Treatment-Seeking Police Officers
Christianne A.I. van der Meer, MSc, Anne Bakker, PhD, Annika S. Smit, PhD, Susanne van Buschbach, MSc, Melissa den Dekker, MSc, Gré J. Westerveld, MSc, Renée C. Hutter, MSc, Berthold P.R. Gersons, PhD, Miranda Olff, PhD

In this study, we examined 967 diagnostic files of police officers seeking treatment for PTSD. Six hundred twelve (63%) of the referred police officers were diagnosed with PTSD (n = 560) or partial PTSD (n = 52). Police officers reported on average 19.5 different types of traumatic events (range 1–43). Also, women reported more often direct life-threatening or private events as their index trauma than men, and suffered from more PTSD symptoms than their male colleagues. Results indicate that police officers experience a considerable number of different traumatic events, which is significantly associated with PTSD symptoms.

Posttraumatic Stress and Physical Health Functioning: Moderating Effects of Deployment and Postdeployment Social Support in OEF/OIF/OND Veterans
Matthew T. Luciano, MS and Meghan E. McDevitt-Murphy, PhD

The present analysis explores how Veteran-specific social support (during military deployment and postdeployment) may moderate the relationship between PTSD and physical health functioning. Participants were recruited from a VA Medical Center. Self-report data were analyzed from 63 Veterans (17.46% female; 42.86% white) who had been deployed in support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND). Data indicate that military deployment social support moderated the relationship between PTSD and pain (β = 0.02, p = 0.02), whereas postdeployment social support moderated the relationship between PTSD and general health perceptions (β = 0.03, p = 0.01).

Social Support and Relationship Satisfaction as Moderators of the Stress-Mood-Alcohol Link Association in U.S. Navy Members
Michelle L. Kelley, PhD, Robert J. Milletich, MS, Brittany F. Hollis, MS, Anna Veprinsky, MS, Allison T. Robbins, BA, Alicia K. Snell, BS

Participants were 108 U.S. Navy members assigned to an Arleigh Burke–class destroyer anticipating an 8-month deployment after Operational Enduring Freedom/Operation Iraqi Freedom. Stress was indirectly related to problematic alcohol use, such that higher levels of stress were associated with higher levels of depressive symptoms and were further associated with higher levels of alcohol use. The indirect effect of stress to problematic alcohol use via depressive symptoms was tested at different levels of social support and relationship satisfaction. At higher levels of social support and relationship satisfaction, the association between stress and problematic alcohol use via depressive symptoms decreased.

Negative Consequences of Family Caregiving for Veterans With PTSD and Dementia
Caitlin M. Pinciotti, MA, David M. Bass, PhD, Catherine A. McCarthy, Katherine S. Judge, PhD, Nancy L. Wilson, MSW, Robert O. Morgan, PhD, A. Lynn Snow, PhD, Mark E. Kunik, MD, MPH

Using the Stress Process Model, the current investigation explored the similarities and differences in psychosocial, health, and service use outcomes among caregivers assisting veterans with PTSD and dementia compared with caregivers assisting veterans with dementia only. Caregivers of veterans with PTSD and dementia indicated that their relative exhibited more difficult behavior symptoms and used more community services. These caregivers also reported more difficulties understanding veterans' memory problems and more physical strain. Together, results suggested caregivers of veterans with both PTSD and dementia were at greater risk of negative caregiving consequences.

Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder
Mark A. Greenbaum, MS, MA, Thomas C. Neylan, MD, Craig S. Rosen, PhD

This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.

An Investigation of Treatment Engagement Among Returning Veterans With Problematic Anger
Kirsten H. Dillon, PhD, Eric F. Crawford, PhD, Harold Kudler, MD, Kristy A. Straits-Troster, PhD, Eric B. Elbogen, PhD, Patrick S. Calhoun, PhD

Anger is a commonly reported problem among returning veterans, yet little attention has been devoted to studying treatment engagement among veterans who report anger problems but do not have posttraumatic stress disorder (PTSD). This study compares Iraq-Afghanistan veterans with anger/no PTSD (n = 159) to others reporting significant PTSD symptoms (n = 285) and those reporting neither anger nor PTSD (n = 716) on rates of treatment utilization, perceived barriers to treatment, and preferences for care. Relative to the PTSD group, the anger/no-PTSD group was significantly less likely to have received mental health treatment in the last year, despite endorsing barriers to treatment at a lower rate. Furthermore, the anger/no-PTSD group endorsed fewer preferences than the PTSD group. Results suggest that the anger/no-PTSD group is a unique subgroup that may be less likely to identify a need for treatment.

Group Psychotherapeutic Factors and Perceived Social Support Among Veterans With PTSD Symptoms
Daniel W. Cox, PhD, Jess J. Owen, MA, John S. Ogrodniczuk, PhD

We investigated which interpersonal therapeutic factors were related to changes in social support, beyond posttraumatic stress disorder (PTSD) symptom reduction. Participants were 117 veterans in a multimodal outpatient group psychotherapy treatment designed to reduce PTSD symptoms and interpersonal difficulties. Generally, therapeutic factors were related to improvements in social support from baseline to posttreatment beyond the effects of PTSD symptom reduction. Specifically, social learning was associated with changes in appraisal support, secure emotional expression was associated with changes in tangible support, and neither was associated with changes in belonging support.

Combat-Related Multifaceted Trauma-Focused Group Therapy: A Pilot Study
Ofir Levi, PhD, Ilan Wald, PhD, Vlad Svetlitsky, PhD, Sergei Zusmanovitz, MSW, Eli Parasha, MSW, Yael Shoval-Zuckerman, PhD, Gal Afik, MA, Gal Haikin, MA, Eyal Fruchter, MD

The efficacy of combat-related trauma-focused group therapy (TFGT) was tested using a unique technique that combines principles from prolonged exposure, cognitive processing therapy, and art therapy. Eighty Israeli male veterans exposed to traumatic events participated in the study. They were divided into eight therapeutic groups, led by four pairs of trained therapists. Posttraumatic stress disorder and depression symptoms and levels of functioning were taken at pretherapy, end of therapy, and 6 months posttherapy. Analyses found that therapy helped in reducing posttraumatic and depressive symptoms at the end of therapy and at 6 months follow-up. It also showed that patients' functioning had significantly improved by the end of therapy and at 6 months followup. A significant clinical change in each parameter over time was also observed. In conclusion, the study provides preliminary evidence that combat-related TFGT may be efficacious in reducing psychological suffering and enhancing actual functioning.

Patient, Therapist, and System Factors Influencing the Effectiveness of Prolonged Exposure for Veterans With Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury
Eric Floyd Crawford, PhD, Gregory K. Wolf, PsyD, Tracy Kretzmer, PhD, Kirsten H. Dillon, PhD, Christina Thors, PhD, Rodney D. Vanderploeg, PhD

In contrast to concerns that cognitive limitations and neurobehavioral symptoms (NBS) associated with traumatic brain injury (TBI) may inhibit treatment effectiveness, a recent study found prolonged exposure (PE) led to large reductions in posttraumatic stress disorder (PTSD) symptoms among Iraq/Afghanistan veterans with a range of TBI severity. We further examined this sample of 69 veterans to determine whether system, veteran, and therapist factors predicted clinically significant responses. Results of hierarchical, logistic regressions revealed that therapist training in PE and lower service connection were associated with increased odds of large decreases in PTSD symptoms after adjusting for the robust effect of PE sessions completed. Other patient-level factors including age, time since injury, and baseline NBS were unrelated to significant improvements. Findings emphasized the impact of PE dosage, indicated greater mastery of the protocol was beneficial, and showed that service connection could impede self-reported, clinically significant change during PE in this important cohort.

Pilot Study of a Telehealth-Delivered Medication-Augmented Exposure Therapy Protocol for PTSD
Megan Olden, PhD, Katarzyna Wyka, PhD, Judith Cukor, PhD, Melissa Peskin, PhD, Margaret Altemus, MD, Francis S. Lee, MD, PhD, Lucy Finkelstein-Fox, BA, Terry Rabinowitz, MD, JoAnn Difede, PhD

This study aimed to investigate the feasibility of conducting a research trial with exposure therapy delivered via videoconferencing. Eleven adults working in occupations at risk with PTSD enrolled and seven completed 12 to 15 sessions. Individuals were randomized to receive the cognitive enhancer D-cycloserine or placebo, and participants provided saliva samples for genetic analysis. Treatment completers demonstrated decreases in PTSD and depressive symptomatology. Participants reported high therapeutic alliance, treatment satisfaction, and telehealth satisfaction. There were no significant technical, medication, or safety issues, and no clinical emergencies. The results suggest that it may be feasible to conduct clinical research using telehealth for PTSD and to use telehealth to increase access to care.

Implementing Effective Policy in a National Mental Health Reengagement Program for Veterans
Shawna N. Smith, PhD, Zongshan Lai, MS, Daniel Almirall, PhD, David E. Goodrich, PhD, Kristen M. Abraham, PhD, Kristina M. Nord, MSW, Amy M. Kilbourne, PhD

This article used validated measures of organizational resources, culture, and climate to predict uptake of a nationwide Veteran's Health Administration (VA) policy aimed at implementing Re-Engage, a brief care management program that reestablishes contact with veterans with serious mental illness lost to care. Patient care databases were used to identify 2738 veterans lost to care. Local recovery coordinators (LRCs) were to update disposition for 2738 veterans at 158 VA facilities and, as appropriate, facilitate a return to care. Multivariable regression was used to assess organizational culture and climate as predictors of early policy compliance (via LRC presence) and uptake at 6 months. Higher composite climate and culture scores were associated with higher odds of having a designated LRC but were not predictive of higher uptake. Sites with LRCs had significantly higher rates of updated documentation than sites without LRCs.http://journals.lww.com/jonmd/Fulltext/2017/02000/Gender_and_Age_Differences_in_Trauma_and_PTSD.4.aspx

BRIEF REPORT

The Impact of Trauma Type or Number of Traumatic Events on PTSD Diagnosis and Symptom Severity in Treatment Seeking Veterans​
Jeanne M.D. Jakob, PhD, Kristen Lamp, PhD, Sheila A.M. Rauch, PhD, Erin R. Smith, PhD, Katherine R. Buchholz, PhD

This study assessed trauma type and exposure history, diagnostic impressions, and PTSD severity in a large clinical dataset (n = 2463) of veterans presenting for PTSD evaluation between the years 2006 and 2013. The degree of lifetime trauma exposure was pronounced, with approximately 76% of the sample reporting exposure to at least four traumatic events. Higher numbers of lifetime trauma and higher levels of combat exposure were associated with more severe PTSD symptoms. Sexual trauma and combat trauma were more predictive of PTSD than other trauma types. Sexual trauma was associated with more severe PTSD than combat and other trauma.

CLINICAL CONTROVERSIES

Rationale for Spiritually Oriented Cognitive Processing Therapy for Moral Injury in Active Duty Military and Veterans With Posttraumatic Stress Disorder​
Harold G. Koenig, MD, Nathan A. Boucher, DrPH, PA-C, MS, MPA, CPHQ, Rev. John P. Oliver, DMin, BCC, Nagy Youssef, MD, Scott R. Mooney, PhD, ABPP, DAC, Joseph M. Currier, PhD, Michelle Pearce, PhD, BCC

"Moral injury" (MI) (also sometimes called "inner conflict") is the term used to capture this emotional, cognitive, and behavioral state. In this article, we provide rationale for developing and testing Spiritually Oriented Cognitive Processing Therapy, a version of standard cognitive processing therapy for the treatment of MI in active duty and veteran service members (SMs) with posttraumatic stress disorder symptoms who are spiritual or religious (S/R). Many SMs have S/R beliefs that could increase vulnerability to MI. Because the injury is to deeply held moral standards and ethical values and often adversely affects spiritual beliefs and worldview, we believe that those who are S/R will respond more favorably to a therapy that directly targets this injury from a spiritually oriented perspective.


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