The Impact of Hostility on Quality of Life, Functioning, and Suicidal Ideation Among Male Veterans with Posttraumatic Stress Disorder.

Veterans with posttraumatic stress disorder (PTSD) often experience high levels of hostility. Although studies have found that PTSD is associated with poorer quality of life (QoL), increased functional impairment, lower levels of social support, and increased suicidal ideation, it is unclear if hostility impacts these domains in veterans with PTSD above and beyond the impact from PTSD and depressive symptoms. The present study aimed to examine whether hostility is related to several indices of poorer QoL and functioning after controlling for demographic characteristics, PTSD symptoms, and depressive symptoms. Participants (N = 641) were male U.S. veterans seeking PTSD treatment through a specialty clinic in the Veterans Affairs Healthcare System. Veterans completed the Davidson Trauma Scale for DSM-IV (DTS), Personality Assessment Inventory (PAI), Quality of Life Inventory, and the Sheehan Disability Scale. Hierarchical regressions were conducted to examine the impact of PAI measures of hostility on QoL, functioning, social support, and suicidal ideation beyond DTS, depression, race, and age. After covarying for DTS total score, depression symptoms, age, and race, higher levels of hostility were significantly associated with higher degrees of functional impairment and lower degrees of social support, ΔR2 = .01 and ΔR2 = .02, respectively. Higher levels of hostility were significantly related to diminished functioning and lower social support beyond PTSD and depressive symptoms in veterans seeking treatment for PTSD. These findings highlight the importance of assessing and treating hostility in veterans with PTSD.

The Personality Assessment Inventory Alcohol Scale in Veterans With PTSD: Convergent and Discriminant Relations With the Alcohol Use Disorders Identification Test.

In this study, we examined the validity of the Personality Assessment Inventory Alcohol (ALC) scale in 736 male veterans presenting for formal evaluation of posttraumatic stress disorder (PTSD). The ALC scale exhibited convergence with other measures of alcohol problems, and this convergence was similar for veterans with and without formal PTSD diagnosis. When predicting alcohol consumption via the Alcohol Use Disorders Identification Test (AUDIT), the ALC scale also displayed substantial incremental validity over the effects of demographics and MMPI-2 MacAndrew Alcohol Scale. Using a standard alcohol consumption cut score on the AUDIT, the ALC scale displayed good specificity and (generally) good sensitivity across three common cut scores. PTSD severity did not significantly affect the association between the ALC composite and alcohol consumption via the AUDIT. Taken together, results suggested that the ALC can provide valid assessment of alcohol use among treatment seeking veterans.

Nonsuicidal Self-Injury and Borderline Personality Features as Risk Factors for Suicidal Ideation Among Male Veterans With Posttraumatic Stress Disorder.

U.S. veterans are at increased risk for suicide compared to their civilian counterparts and account for approximately 20% of all deaths by suicide. Posttraumatic stress disorder (PTSD) and borderline personality features (BPF) have each been associated with increased suicide risk. Additionally, emerging research suggests that nonsuicidal self-injury (NSSI) may be a unique risk factor for suicidal behavior. Archival data from 728 male veterans with a PTSD diagnosis who were receiving care through an outpatient Veterans Health Administration (VHA) specialty PTSD clinic were analyzed. Diagnosis of PTSD was based on a structured clinical interview administered by trained clinicians. A subscale of the Personality Assessment Inventory was used to assess BPF, and NSSI and suicidal ideation (SI) were assessed by self-report. Findings revealed that NSSI (58.8%) and BPF (23.5%) were both relatively common in this sample of male veterans with PTSD. As expected, each condition was associated with significantly increased odds of experiencing SI compared to PTSD alone, odds ratios (ORs) = 1.2-2.6. Moreover, co-occurring PTSD, NSSI, and BPF were associated with significantly increased odds of experiencing SI compared with PTSD, OR = 5.68; comorbid PTSD and NSSI, OR = 2.57; and comorbid PTSD and BPF, OR = 2.13. The present findings provide new insight into the rates of NSSI and BPF among male veterans with PTSD and highlight the potential importance of these factors in suicide risk.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Autoagresiones no suicidas y características del Trastorno de Personalidad Limítrofe como Factores de Riesgo para Ideación Suicida entre Veteranos varones con Trastorno de Estrés Postraumático ALNS, TPL E IS ENTRE VETERANOS VARONES CON TEPT Los veteranos estadounidenses tienen un riesgo de suicidio mayor que su contraparte civil, dando cuenta de aproximadamente el 20% de las muertes por suicidio. El Trastorno de Estrés Postraumático (TEPT) y los síntomas del Trastorno de Personalidad Limítrofe (TPL) han sido asociados individualmente con un aumento del riesgo suicida. Adicionalmente, la investigación emergente sugiere que las autolesiones no suicidas (ALNS) pueden ser un factor de riesgo único para la conducta suicida. Se analizaron datos de archivo de 728 veteranos varones con diagnóstico de TEPT que estaban recibiendo atención a través de una clínica ambulatoria especializada en TEPT de la Administración de Salud de Veteranos (VHA, por sus siglas en inglés). El diagnóstico de TEPT se basó en una entrevista clínica estructurada administrada por clínicos entrenados. Se usó una subescala del Inventario de Evaluación de la Personalidad para evaluar TPL, y las ALNS e Ideación Suicida (IS) fueron evaluadas por auto-reporte. Los hallazgos revelaron que las ALNS (58.8%) y las características de TPL (23.5%) fueron ambas relativamente comunes en esta muestra de varones veteranos con TEPT. Como era esperado, cada condición se asoció con una probabilidad significativamente aumentada de experimentar IS comparado al TEPT solo, odds ratio (ORs) = 1.2-2.6. Más aún, la co-ocurrencia de TEPT, ALNS y TPL se asoció a una probabilidad significativamente mayor de experimentar IS comparado con TEPT, OR = 5.68; TEPT y ALNS comórbidos, OR=2.57; y TEPT comórbido con TPL, OR=2.13. Los presentes hallazgos proveen una nueva visión en las tasas de ALNS y características de TPL entre los varones veteranos con TEPT y destacan la potencial importancia de estos factores en el riesgo de suicidio.

Shame as a mediator between posttraumatic stress disorder symptoms and suicidal ideation among veterans.

BACKGROUND: Suicidal ideation is a problem that disproportionately affects veterans. Moreover, veterans with posttraumatic stress disorder (PTSD) appear to be at particularly high risk for suicide. OBJECTIVE: The purpose of the present research was to examine whether shame mediates the association between PTSD and suicidal ideation. METHODS: Secondary analyses were conducted in a sample of 201 veterans with PTSD seeking care through an outpatient Veterans Affairs specialty PTSD clinic. RESULTS: Path analysis revealed that shame fully accounted for the effects of PTSD on suicidal ideation, suggesting that shame may represent a key link between PTSD and suicidal ideation among veterans. LIMITATIONS: Although the reverse mediation effect was also examined, the present sample was cross-sectional and predominantly male. CONCLUSIONS: The present findings suggest that shame may be an effective point of treatment intervention to reduce suicidal ideation among veterans with PTSD; however, additional prospective research is still needed to delineate the precise nature of these associations over time.

Wall/Object Punching: An Important but Under-Recognized Form of Nonsuicidal Self-Injury.

The present research investigated wall/object punching as a form of nonsuicidal self-injury (NSSI) among 1,143 veterans seeking treatment for posttraumatic stress disorder (PTSD). Wall/object punching was remarkably common in this sample (43%), and its inclusion in the definition of NSSI increased estimated prevalence of recent NSSI by 14%. As expected, wall/object punching was strongly associated with other traditional forms of NSSI, post-NSSI relief, and suicide ideation. Male veterans and veterans with PTSD were significantly more likely to engage in wall/object punching than female veterans and veterans without PTSD. More research on this important but under-recognized form of NSSI is needed.

A model comparison approach to trauma-related guilt as a mediator of the relationship between PTSD symptoms and suicidal ideation among veterans.

BACKGROUND: Suicidal ideation (SI) is a serious issue affecting U.S. veterans, and those with posttraumatic stress disorder (PTSD) are at an especially high risk of SI. Guilt has been associated with both PTSD and SI and may therefore be an important link between these constructs. METHODS: The present study compared models of trauma-related guilt and used path analysis to examine the direct and indirect effects of PTSD and trauma-related guilt on SI among a sample of 988 veterans receiving outpatient PTSD treatment at a Veterans Affairs (VA) specialty clinic. RESULTS: Results showed that a model of trauma-related guilt including guilt-cognitions and global guilt (but not distress) provided the best model fit for the data. PTSD and trauma-related guilt had direct effects on SI, and PTSD exhibited indirect effects on SI via trauma-related guilt. LIMITATIONS: The use of cross-sectional data limits the ability to make causal inferences. A treatment-seeking sample composed primarily of Vietnam veterans limits generalizability to other populations. CONCLUSIONS: Trauma-related guilt, particularly guilt cognitions, may be an effective point of intervention to help reduce SI among veterans with PTSD. This is an important area of inquiry, and suggestions for future research are discussed.

Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder.

Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.

An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD.

OBJECTIVE: This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD). METHODS: In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months. RESULTS: Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ2=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance. CONCLUSIONS: TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

Prevalence and correlates of cannabis use in an outpatient VA posttraumatic stress disorder clinic.

Recent research has documented high rates of comorbidity between cannabis use disorders and posttraumatic stress disorder (PTSD) in veterans. However, despite possible links between PTSD and cannabis use, relatively little is known about cannabis use in veterans who present for PTSD treatment, particularly among samples not diagnosed with a substance use disorder. This study examined the prevalence of cannabis use and the psychological and functional correlates of cannabis use among a large sample of veterans seeking treatment at a Veterans Affairs (VA) PTSD specialty clinic. Male veterans (N = 719) who presented at a VA specialty outpatient PTSD clinic completed measures of demographic variables, combat exposure, alcohol, cannabis and other drug use, and PTSD and depressive symptoms. The associations among demographic, psychological, and functional variables were estimated using logistic regressions. Overall, 14.6% of participants reported using cannabis in the past 6 months. After controlling for age, race, service era, and combat exposure, past 6-month cannabis use was associated with unmarried status, use of tobacco products, other drug use, hazardous alcohol use, PTSD severity, depressive symptom severity, and suicidality. The present findings show that cannabis use is quite prevalent among veterans seeking PTSD specialty treatment and is associated with poorer mental health and use of other substances. It may be possible to identify and treat individuals who use cannabis in specialty clinics (e.g., PTSD clinics) where they are likely to present for treatment of associated mental health issues. (PsycINFO Database Record

Personality assessment inventory internalizing and externalizing structure in veterans with posttraumatic stress disorder: associations with aggression.

Posttraumatic stress disorder (PTSD) is associated with aggressive behavior in veterans, and difficulty controlling aggressive urges has been identified as a primary postdeployment readjustment concern. Yet only a fraction of veterans with PTSD commit violent acts. The goals of this study were to (1) examine the higher-order factor structure of Personality Assessment Inventory (PAI) scales in a sample of U.S. military veterans seeking treatment for PTSD; and (2) to evaluate the incremental validity of higher-order latent factors of the PAI over PTSD symptom severity in modeling aggression. The study sample included male U.S. Vietnam (n = 433) and Iraq/Afghanistan (n = 165) veterans who were seeking treatment for PTSD at an outpatient Veterans Affairs (VA) clinic. Measures included the Clinician Administered PTSD Scale, the PAI, and the Conflict Tactics Scale. The sample was randomly split into two equal subsamples (n's = 299) to allow for cross-validation of statistically derived factors. Parallel analysis, variable clustering analysis, and confirmatory factor analyses were used to evaluate the factor structure, and regression was used to examine the association of factor scores with self-reports of aggression over the past year. Three factors were identified: internalizing, externalizing, and substance abuse. Externalizing explained unique variance in aggression beyond PTSD symptom severity and demographic factors, while internalizing and substance abuse did not. Service era was unrelated to reports of aggression. The constructs of internalizing versus externalizing dimensions of PTSD may have utility in identifying characteristics of combat veterans in the greatest need of treatment to help manage aggressive urges.

Effect of elective surgery on subjective health in veterans with chronic posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common, is often chronic, and has been associated with greater risk of postoperative mortality in veterans. The purpose of this study was to determine if elective outpatient surgery had a persistent effect on the physical or mental health of veterans with chronic PTSD. A longitudinal, quasi-experimental study was conducted that followed up 60 veterans with chronic PTSD over 12 weeks. Self-reported physical and mental health, depressive symptom severity, and posttraumatic symptom severity were measured in 29 veterans undergoing outpatient elective surgery and 31 veterans not having elective surgery (controls). Data collection was performed at baseline and repeated 1, 4, and 12 weeks after surgery or enrollment. At baseline, both surgical and control subjects reported poor physical and mental subjective health status. After surgery, surgical group subjects reported mean age- and gender-adjusted reductions of 3.9 points on the Physical Component Summary score and 2.9 points on the Mental Component Summary score of the Veterans Rand 36-item Health Survey, which resolved by 4 weeks after surgery. These findings suggest that veterans with PTSD were at greater risk of mortality because of poor baseline health, but did not demonstrate persistent decline in health following common elective surgical procedures.

Deliberate self-harm and suicidal ideation among male Iraq/Afghanistan-era veterans seeking treatment for PTSD.

The objectives of the present research were to examine the prevalence of deliberate self-harm (DSH) among 214 U.S. male Iraq/Afghanistan-era veterans seeking treatment for posttraumatic stress disorder (PTSD) and to evaluate the relationship between DSH and suicidal ideation within this population. Approximately 56.5% (n = 121) reported engaging in DSH during their lifetime; 45.3% (n = 97) reported engaging in DSH during the previous 2 weeks. As hypothesized, DSH was a significant correlate of suicidal ideation among male Iraq/Afghanistan-era veterans, OR = 3.88, p < .001, along with PTSD symptom severity, OR = 1.03, p < .001, and combat exposure, OR = 0.96, p = .040. A follow-up analysis identified burning oneself, OR = 17.14, p = .017, and hitting oneself, OR = 7.93, p < .001, as the specific DSH behaviors most strongly associated with suicidal ideation. Taken together, these findings suggest that DSH is quite prevalent among male Iraq/Afghanistan-era veterans seeking treatment for PTSD and is associated with increased risk for suicidal ideation within this population. Routine assessment of DSH is recommended when working with male Iraq/Afghanistan veterans seeking treatment for PTSD.

Suicide attempts in veterans with bipolar disorder during treatment with lithium, divalproex, and atypical antipsychotics.

Suicide attempt rates were assessed in 1306 subjects in this 6 year retrospective study of Bipolar disorder. Participants were Veterans from 5 different Veterans Administration Hospitals who met criteria for bipolar type 1 or 2 and who had at least one prescription for lithium or divalproex or both during the study period. This study focused on the impact of atypical antipsychotics on the suicide attempt rate when used in addition to or in place of lithium or divalproex. Medication exposure was calculated using computerized pharmacy records. Suicide attempts were established through chart review including emergency room records, inpatient records, and outpatient records. There were a total of 117 suicide attempts and 2 suicide completions during the study period. Most attempts (59%) occurred when patients were on no medications. Nearly 90% of subjects spent an average of 45 months during the 6 year period on none of the aforementioned medications. The lowest percentage of suicide attempts (15%) occurred while on lithium, 21% while on divalproex and 24% while on atypical antipsychotics. When total months of exposure were taken into account, the lowest attempt rate occurred on lithium plus divalproex (6.3 attempts per 10,000 months of exposure), followed by divalproex alone (7.0 attempts/10,000 months of exposure), and lithium alone (7.7 attempts per 10,000 months of exposure). Patients on atypical antipsychotics alone had an attempt rate of 26.1 attempts per 10,000 months of exposure. In this study, lithium and divalproex provided protection against suicide attempts. Results need to be replicated in future prospective studies and clearly strategies for improving medication compliance among veterans are warranted.

The influence of depressive symptoms on suicidal ideation among U.S. Vietnam-era and Afghanistan/Iraq-era veterans with posttraumatic stress disorder.

Major depressive disorder (MDD) co-occurs frequently with posttraumatic stress disorder (PTSD), and both disorders are linked to suicidal ideation. An emergent literature examines suicidal ideation in U.S. Afghanistan/Iraq-era veterans. Little research, however, has studied the role of PTSD and comorbid MDD on suicidal ideation across service eras. Therefore, this study aimed to examine the impact of depression on suicidal ideation in Afghanistan/Iraq-era and Vietnam-era veterans with PTSD. The sample included 164 Vietnam and 98 Afghanistan/Iraq veterans diagnosed with PTSD at a VA outpatient PTSD Clinic. Using structured interviews, 63% of the Vietnam sample and 45% of the Afghanistan/Iraq sample were diagnosed with comorbid current MDD. Measures included self-report assessments of PTSD and depressive symptoms and the Personality Assessment Inventory. Results of analyses suggested that in veterans of both eras, PTSD, MDD, and their interaction were significantly related to suicidal ideation (PTSD: η(2) = .01; MDD: η(2) = .10; PTSD × MDD: η(2) = .02). For veterans reporting greater depressive symptoms, there was a stronger relationship between PTSD symptoms and suicidal ideation. These results suggest that veterans from both eras display a similar clinical presentation and highlight the need to consider depressive symptoms when assessing veterans with PTSD. Future research should examine suicidal ideation and behaviors as they change over time in these two cohorts.

An open-label pilot study of aripiprazole for male and female veterans with chronic post-traumatic stress disorder who respond suboptimally to antidepressants.

Emerging data suggest that second-generation antipsychotics such as aripiprazole may be effective in the treatment of post-traumatic stress disorder (PTSD). However, few clinical trials have used aripiprazole in PTSD, and data are limited on its use in Veterans with PTSD. The objective of this pilot trial was to investigate the safety and efficacy of aripiprazole in Veterans with PTSD. Ten individuals (five men and five women) meeting the Diagnostic and statistical manual of mental disorders, 4th ed., PTSD criteria participated in this 12-week, open-label, flexibly dosed monotherapy trial. The dose range of aripiprazole was 5-30 mg/day, titrated to tolerability and clinical response. The primary outcome measure was the Clinician-Administered PTSD Scale. Additional outcomes included the Short PTSD Rating Interview, the Treatment Outcome PTSD Scale (Top-8), the Davidson Trauma Scale, the Positive and Negative Syndrome Scale, the Beck Depression Inventory-Fast Screen, and Clinical Global Impressions-Improvement. Eight participants completed the study, and aripiprazole was generally well tolerated and associated with a significant improvement in PTSD symptoms, as measured by the Clinician-Administered PTSD Scale (primary outcome measure) and by the Short PTSD Rating Interview, the Treatment Outcome PTSD Scale, and the Davidson Trauma Scale. An improvement was also observed on all three Positive and Negative Syndrome Scale subscales and the Beck Depression Inventory-Fast Screen, and the average Clinical Global Impressions-Improvement ratings indicated that patients were 'much improved'. These promising initial results merit further investigation in a larger, randomized-controlled trial.

The perioperative implications of posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops after exposure to a traumatic event and is characterized by symptoms of reexperiencing, emotional numbing, persistent arousal, and avoidance. Approximately 6.8% of the people in the United States will be diagnosed with PTSD at some point in their lives. The presence of PTSD in a surgical patient can be important because PTSD is associated with the use of psychoactive medications, risky health behaviors, cardiovascular comorbidities, depression, chronic pain, and cognitive dysfunction, all of which may influence the risk of perioperative morbidity and mortality. In addition, patients with PTSD are anxious around unfamiliar people and in unfamiliar environments. The purposes of this journal course are to provide anesthetists with a working knowledge of the symptoms, treatments, and comorbidities associated with PTSD and to suggest ways of interacting with patients with the disorder that increase trust and decrease the risk of evoking posttraumatic symptoms in the perioperative environment.

Self-mutilative behaviors in male veterans with posttraumatic stress disorder.

Self-mutilative behaviors (SMB) were examined in a sample of male veterans with posttraumatic stress disorder (PTSD). The primary objective was to determine the prevalence of SMB and any physical, cognitive, or affective antecedents and correlates for these behaviors. Participants included 509 male veterans with PTSD and levels of PTSD, depression, alcohol use, hostility, and impulsivity were evaluated to determine if these variables were related to SMB. Antecedents and sequelae of SMB were also examined to generate hypotheses regarding the functions of these behaviors. A second type of habit behavior, body-focused repetitive behaviors (BFRB), was also examined as part of the study. Findings indicated that veterans who engaged in either type of habit behavior were younger than those who did not engage in SMB or BFRB. Veterans reporting SMB also reported higher levels of PTSD, depression, hostility, and impulsivity compared to the BFRB and no-habit groups. Examination of habit antecedents and sequelae showed support for the automatic-positive reinforcement function of SMB. These findings are discussed in the context of research and treatment involving male veterans with PTSD who engage in SMB.

A placebo-controlled trial of bupropion SR in the treatment of chronic posttraumatic stress disorder.

OBJECTIVE: Although selective serotonin reuptake inhibitors have been the most empirically studied pharmacotherapy for posttraumatic stress disorder (PTSD), a need remains for the investigation of additional pharmacological agents in the treatment of PTSD. The present study examined the use of bupropion sustained release (SR) as compared with placebo for symptom reduction in patients with PTSD: approximately half who were already prescribed an selective serotonin reuptake inhibitor and half who were not. METHOD: Thirty patients (mean age, 50 years) with civilian- or military-related PTSD enrolled in an 8-week evaluation of bupropion SR versus placebo assigned in a 2:1 ratio in addition to their usual pharmacological care. Statistical tests included analyzing both study completers and using an intent-to-treat analysis, as well as post hoc examination of responders versus nonresponders. RESULTS: Although no between-group differences were detected, both groups reported a reduction in PTSD symptoms. In a hypothesis-generating post hoc analysis of responders versus nonresponders in the bupropion SR condition (defined as a Clinician Global Improvement score of at least minimally improved), it seemed that younger patients not currently on another antidepressant were more likely to benefit from bupropion. CONCLUSIONS: Bupropion SR in the treatment of PTSD had no significant effect in the current sample. Factors contributing to the absence of an effect need further study. Our analysis points to the inclusion of age and concomitant antidepressant treatment as important variables in any future larger-scale study.

Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology.

OBJECTIVE: This study examined whether trauma exposure before, during, and/or after military service contributed to current levels of post-traumatic stress disorder (PTSD) and adjustment. Further, we investigated whether trauma exposure before military service was mediated or moderated by military trauma in its effects on current PTSD and adjustment. METHOD: In this retrospective study, archival data from the medical records of 422 male veterans diagnosed with PTSD between December 2001 and July 2004 at a Veterans Administration Medical Center PTSD clinic were analyzed. Measures included the Clinician-Administered PTSD Scale interview as well as self-report measures assessing trauma history, health problems, and general psychopathology (including PTSD). RESULTS: Findings indicated that nonmilitary-related trauma was prevalent in this sample (90%). Regression analyses for PTSD symptom severity revealed that age, greater combat exposure, and a history of physical assault after military service were significantly associated with more severe PTSD symptoms. Childhood physical abuse, adult sexual trauma, and a history of being physically assaulted during military service were also significantly associated with PTSD symptom severity. Mediational analyses indicated that childhood trauma was associated with both adult trauma and increased symptomatology on various outcome measures. Moderational analyses indicated that adult trauma exposure moderated the effect of childhood trauma exposure on health complaints. CONCLUSIONS: Results suggest that several variables, including age, greater combat exposure, and premilitary and postmilitary traumas, are associated with increased PTSD symptomatology. This finding underscores the importance of conducting a thorough assessment of trauma when diagnosing PTSD.

Maintenance therapy with fluoxetine in posttraumatic stress disorder: a placebo-controlled discontinuation study.

The effect of fluoxetine (FLU) in posttraumatic stress disorder was studied in a one-year trial. Subjects received open-label treatment for 6 months, followed by double-blind randomized treatment with FLU or placebo (PBO) for 6 months. Rates of relapse were compared using the Clinical Global Impressions of Improvement. One hundred twenty-three subjects entered open-label treatment, of whom 114 returned at least once. Sixty-two subjects were randomized to receive FLU or PBO, of whom 57 returned at least once and were analyzed. The dose of FLU ranged from 10 to 60 mg/d; at randomization, mean doses were 48.6 and 42.1 mg for FLU and PBO groups. Rates of relapse were 22% for FLU versus 50% for PBO (P = 0.02), and time to relapse on FLU was longer than for PBO (P = 0.02, log-rank statistic). The odds ratio for relapse on PBO relative to FLU was 3.50. No significant differences were found on other measures. Fluoxetine was well tolerated during double-blind treatment.