Ketamine-enhanced prolonged exposure therapy in veterans with PTSD: A randomized controlled trial protocol.

BACKGROUND: The 2023 VA/DoD Clinical Practice Guideline for the Management of PTSD recommends individual, manualized trauma-focused such as Prolonged Exposure (PE) over pharmacologic interventions for the primary treatment of PTSD. Unfortunately, clinical trials of trauma-based therapies in the military and veteran population showed that 30% to 50% of patients did not demonstrate clinically meaningful symptom change. Ketamine, an FDA-approved anesthetic with potent non-competitive glutamatergic N-methyl-d-aspartate antagonistic properties, has demonstrated to enhance the recall of extinction learning and decrease fear renewal without interference of extinction training in preclinical studies. METHODS: We plan to conduct a single site RCT comparing three ketamine treatment vs. active placebo (midazolam) adjunct to PE therapy among Veterans with PTSD. Pharmacological phase will start simultaneously with PE session 1. Infusions will be administered 24 h. prior to PE session for the first 3 weeks. After PE is completed (session 10), patients will be assessed during a 3-month follow-up period at various time points. We estimate that out of 100 veterans, 80 will reach time point for primary outcome measure and will be considered for primary analysis. Secondary outcomes include severity of depression and anxiety scores, safety and tolerability of ketamine-enhanced PE therapy, cognitive performance during treatment and early improvement during PE related to the rate of dropouts during PE therapy. DISCUSSION: Results of the proposed RCT could provide scientific foundation to distinguish the essential components of this approach, enhance the methodology, elucidate the mechanisms involved, and identify sub-PTSD populations that most likely benefit from this intervention.

Treating Veterans With PTSD and Borderline Personality Symptoms in a 12-Week Intensive Outpatient Setting: Findings From a Pilot Program.

Rates of comorbidity between borderline personality disorder and posttraumatic stress disorder (PTSD) are high in veteran populations, and clinicians are hesitant to treat PTSD given high rates of suicidality. Given promising early work integrating dialectical behavior therapy (DBT) and prolonged exposure (PE) therapy, we created a 12-week intensive outpatient program combining these two treatments. PE and DBT were provided concurrently to 33 veterans with PTSD symptoms and BPD symptoms at a large, midwestern Veteran Affairs medical center. Approximately half of the participants were male, with the majority identifying as Caucasian. Participants' ages ranged from 23 to 58 years, with a mean age of 43.21 years. The full-model of DBT was provided; PE was provided twice weekly for approximately 6 weeks of the program. Of participants, 22 veterans successfully completed the program with no dropout during PE. Large pre- to posttreatment effect sizes were found for decreases in PTSD symptoms (d = 1.61) and dysfunctional coping styles (d = 1.55), and an increase in the use of DBT skills (d = 1.02). A moderate effect size was found in the decrease of suicidal ideation (d = 0.64). The results of this pilot program suggest that PTSD can be safely and effectively treated among veterans with comorbid symptoms of borderline personality disorder through the combination of concurrent intensive DBT and PE.

Self-efficacy, male rape myth acceptance, and devaluation of emotions in sexual trauma sequelae: Findings from a sample of male veterans.

Sexual trauma is an understudied but regrettably significant problem among male Veterans. As in women, sexual trauma often results in serious mental health consequences for men. Therefore, to guide potential future interventions in this important group, we investigated associations among self-efficacy, male rape myth acceptance, devaluation of emotions, and psychiatric symptom severity after male sexual victimization. We collected data from 1,872 Gulf War era Veterans who applied for posttraumatic stress disorder (PTSD) disability benefits using standard mailed survey methods. The survey asked about history of childhood sexual abuse, sexual assault during the time of Gulf War I, and past-year sexual assault as well as Veterans' perceived self-efficacy, male rape myth acceptance, devaluation of emotions, PTSD, and depression symptoms. Structural equation modeling revealed that self-efficacy partially mediated the association between participants' sexual trauma history and psychiatric symptoms. Greater male rape myth acceptance and greater devaluation of emotions were directly associated with lower self-efficacy, but these beliefs did not moderate associations between sexual trauma and self-efficacy. In this population, sexual trauma, male rape myth acceptance, and devaluation of emotions were associated with lowered self-efficacy, which in turn was associated with more severe psychiatric symptoms. Implications for specific, trauma-focused treatment are discussed.

Sexual assault during the time of Gulf War I: a cross-sectional survey of U.S. service men who later applied for Department of Veterans Affairs PTSD disability benefits.

OBJECTIVES: To estimate the cumulative incidence of sexual assault during the time of Gulf War I among male Gulf War I Veterans who later applied for Department of Veterans Affairs (VA) post-traumatic stress disorder disability benefits and to identify potential risk and protective factors for sexual assault within the population. METHOD: Mailed, national, cross-sectional survey supplemented with VA administrative and clinical data. RESULTS: Of 2,415 Veterans sampled, 1,700 (70%) responded. After adjusting for nonignorable missing data, the cumulative incidence of sexual assault during Gulf War I in this population ranged from 18% [95% confidence intervals (CI): 5.0%-51.9%] to 21% (95% CI: 20.0-22.0). Deployment was not associated with sexual assault [Odds Ratio (OR), 0.96; 95% CI: 0.75-1.23], but combat exposure was (OR, 1.80; 95% CI: 1.52-2.10). Other correlates of sexual assault within the population included working in a unit with greater tolerance of sexual harassment (OR, 1.80; 95% CI: 1.52-2.10) and being exposed to more sexual identity challenges (OR, 1.76; 95% CI: 1.55-2.00). CONCLUSIONS: The 9-month cumulative incidence of sexual assault in this particular population exceeded the lifetime cumulative incidence of sexual assault in U.S. civilian women. Although Persian Gulf deployment was not associated with sexual assault in this population, combat exposure was.

An exploratory examination of risk-taking behavior and PTSD symptom severity in a veteran sample.

The present study conducted an exploratory examination of the relationship between self-reported symptoms of post-traumatic stress disorder and an expanded definition of risk-taking behaviors among 395 veterans at a large Midwestern Veterans Affairs Medical Center. Post-traumatic stress disorder symptoms were associated with elevated rates of substance use, thrill seeking, aggression, risky sexual practices, and firearm possession. Results indicated that suicidal ideation and aggressive driving behavior were among the most frequently reported. The present findings hold significant public health implications and highlight the need to attend to risk-taking behaviors in treatment planning.

Prevalence and consequences of adult sexual assault of men: review of empirical findings and state of the literature.

Male victims of adult sexual assault (ASA) are understudied as compared with female victims. Further, commonly-held myths about sexual assault suggest that men cannot be victims or that, if men are victims, they are relatively physically and emotionally unharmed by sexual assault. The goal of this paper was to systematically review the empirical literature on ASA among men to evaluate the veracity of these myths. This paper also sought to examine the methodological quality of the body of research in this area, identify limitations and gaps in the current literature, and suggest directions for future research. Eighty-seven relevant studies were identified through a systematic review of the literature. The reported prevalence of men's sexual aggression varied widely depending on the methods used and the population studied; some populations (e.g., veterans, prison inmates, and gay and bisexual men) reported higher rates of ASA than men in the general population. Few studies have systematically examined the consequences of male ASA; however, those that have suggest that ASA can have notable adverse physical and psychological consequences for some men.

Sexual assault and rape perpetration by college men: the role of the big five personality traits.

A sample of 521 college men completed the Revised NEO Personality Inventory and an expanded version of the Sexual Experiences Survey to examine whether variation in the Big Five personality traits in a normal, college population provides any insight into the nature of sexual assault and rape perpetrators. Rape perpetrators reported lower levels of Agreeableness and Conscientiousness when compared to both sexual assault perpetrators and nonperpetrators, and lower levels of Extraversion when compared to nonperpetrators. Rape perpetrators also endorsed lower levels of tendermindedness, excitement-seeking, warmth, positive emotions, feelings, altruism, competence, and dutifulness, and higher levels of vulnerability. Contrary to expectation, overall personality profiles followed remarkably comparable patterns for sexual assault and nonperpetrators, suggesting that sexual assault perpetrators were more similar to nonperpetrators than to rape perpetrators. Findings suggest that individuals who perpetrate sexual offenses, particularly rape, differ from nonperpetrators on dimensions of normal personality. Clinical and research implications are discussed.

Attraction to sexual violence towards women, sexual abuse of children, and non-sexual criminal behavior: testing the specialist vs. generalist models in male college students.

A sample of 492 college men anonymously completed an expanded version of the Sexual Experiences Survey, the revised Attraction to Sexual Aggression Scale, and the Marlowe-Crowne Social Desirability Scale Short Form to investigate the relations among perpetration of sexual violence (including rape and sexual assault), attraction to sexual violence, attraction to childhood sexual abuse, and attraction towards other crimes while controlling for the impact of social desirability. Analyses indicated that attractions towards sexual violence, general criminality, and childhood sexual abuse were all significantly interrelated. In addition, sexual assault perpetrators reported higher levels of all three types of attraction as compared to nonperpetrators whereas rape perpetrators reported higher levels of attraction to sexual aggression and criminality. Clinical and research implications are discussed.