Salivary Cortisol and Alpha-Amylase in Posttraumatic Stress Disorder and Their Potential Role in the Evaluation of Cognitive Behavioral Treatment Outcomes.

Alterations in HPA-axis and autonomic nervous system activity have been associated with posttraumatic stress disorder (PTSD) development and maintenance and are potentially associated with trauma-focused cognitive behavioral therapy (TF-CBT) outcomes. We examined the role of salivary cortisol (sCort) and alpha-amylase (sAA) in PTSD and TF-CBT outcomes in German Armed Forces service members (N = 100). Participants categorized as PTSD patients (n = 39), previously deployed healthy controls (n = 33), and nondeployed healthy controls (n = 28) provided diurnal profiles of sCort and sAA; PTSD patients provided samples before, immediately after, and 3 months after an internet-based TF-CBT intervention. No group differences emerged regarding total daily sCort and sAA output or daily slopes, ps = .224-.897, fs = 0.05-0.24. Participants with PTSD demonstrated a significantly attenuated sCort awakening response compared to deployed, p = .021, d = 0.59, but not nondeployed controls, p = .918, d = 0.08. Moreover, a significantly steeper sAA awakening response emerged in PTSD patients, p = .034, d = 0.67, and deployed controls, p = .014, d = 0.80, compared to nondeployed controls. From pretreatment to posttreatment (n = 21) and posttreatment to follow-up (n = 14), stable sCort, ps = .282-.628, fs = 0.34-0.49, and sAA concentrations, ps = .068-.758, fs = 0.24-1.13 paralleled a nonsignificant treatment effect. Both PTSD and trauma exposure were associated with alterations in awakening responses, but further investigation is needed to determine whether the observed correspondence remains when PTSD symptoms significantly decline.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms.

BACKGROUND: The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day. METHODS: Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models. RESULTS: Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%. CONCLUSIONS: The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12616000956404.

[Mental Health Stigma: An Influencing Factor in Healthcare Utilization by Veterans of the German Armed Forces]. / "Treffer im Kopf" ­ Stigma psychischer Erkrankungen als Einflussfaktor auf die Inanspruchnahme von Hilfsangeboten durch VeteranInnen der Bundeswehr.

THEORETICAL BACKGROUND AND OBJECTIVE OF THE STUDY: Mental illness stigma is a barrier to healthcare utilization. This study is the first to research the connection between mental illness stigma and the use of healthcare by veterans of the German Armed Forces. An overview of perceived stigma components in this sample is provided that should help understand how these factors influence healthcare utilization. METHODS: 43 interviews with veterans of the German Armed Forces were conducted. The resulting data were analyzed in several coding steps. It was investigated whether the stigma experience of veterans of the German Armed Forces could be well illustrated by the theory-based stigmatization model of Link and Phelan. A set of hypotheses on stigma and healthcare utilization based on the data were developed. RESULTS: All stigma components according to the model of Link and Phelan were found in the sample. Internalized stigma, perceived public stigmatization, vocational disadvantage and social exclusion as well as feared misunderstanding of the military past in the civilian sector were reported as main stigma-relevant barriers to the use of healthcare. CONCLUSIONS: Recommendations for interventions are given to decrease mental illness stigma in this specific group of former soldiers.

[Diagnostics of posttraumatic stress disorder according to DSM-5 and ICD-11]. / Diagnostik der PTBS im Spannungsfeld von DSM-5 und ICD-11.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11, Version 2018) differ with respect to the diagnostic criteria of posttraumatic stress disorder (PTSD). The present study investigated the implications of these differences for the classification of PTSD within a sample of German survivors of various traumatic events. PATIENTS AND METHODS: A total of 341 trauma survivors who participated in a multicenter study were classified according to DSM-5 and ICD-11 and the results were compared. The PTSD checklist for DSM-5 (PCL-5) was used to diagnose PTSD. The ICD-11 PTSD cases were identified using a "restrictive" and a "wide" operationalization of re-experiencing symptoms (i. e. with and without intrusive memories). Depression and the level of trauma-related impairment were also assessed. RESULTS: The diagnosis rate using ICD-11 was significantly lower than under DSM-5 (DSM-5 64.5%, ICD-11 54.0%, p < 0.001) using a restrictive operationalization of re-experiencing symptoms but differences disappeared when using a wide operationalization. Rates of comorbidity with depression were reduced under ICD-11. Individuals with high and low levels of trauma-related impairment were equally likely to receive a PTSD diagnosis under ICD-11. DISCUSSION: Differences in the diagnosis rates between ICD-11 and DSM-5 depend on the operationalization of the specific ICD-11 re-experiencing requirements. Precise diagnostic guidelines are necessary to avoid inconsistent diagnoses.

The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility.

BACKGROUND: The Posttraumatic Stress Disorder (PTSD) Checklist (PCL, now PCL-5) has recently been revised to reflect the new diagnostic criteria of the disorder. METHODS: A clinical sample of trauma-exposed individuals (N = 352) was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PCL-5. Internal consistencies and test-retest reliability were computed. To investigate diagnostic accuracy, we calculated receiver operating curves. Confirmatory factor analyses (CFA) were performed to analyze the structural validity. RESULTS: Results showed high internal consistency (α = .95), high test-retest reliability (r = .91) and a high correlation with the total severity score of the CAPS-5, r = .77. In addition, the recommended cutoff of 33 on the PCL-5 showed high diagnostic accuracy when compared to the diagnosis established by the CAPS-5. CFAs comparing the DSM-5 model with alternative models (the three-factor solution, the dysphoria, anhedonia, externalizing behavior and hybrid model) to account for the structural validity of the PCL-5 remained inconclusive. CONCLUSIONS: Overall, the findings show that the German PCL-5 is a reliable instrument with good diagnostic accuracy. However, more research evaluating the underlying factor structure is needed.

Assessing complex PTSD and PTSD: validation of the German version of the International Trauma Interview (ITI).

Background: With the introduction of the ICD-11 into clinical practice, the reliable distinction between Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD) becomes paramount. The semi-structured clinician-administered International Trauma Interview (ITI) aims to close this gap in clinical and research settings.Objective: This study investigated the psychometric properties of the German version of the ITI among trauma-exposed clinical samples from Switzerland and Germany.Method: Participants were 143 civilian and 100 military participants, aged M = 40.3 years, of whom 53.5% were male. Indicators of reliability and validity (latent structure, internal reliability, inter-rater agreement, convergent and discriminant validity) were evaluated. Confirmatory factor analysis (CFA) and partial correlation analysis were conducted separately for civilian and military participants.Results: Prevalence of PTSD was 30% (civilian) and 33% (military) and prevalence of CPTSD was 53% (civilians) and 21% (military). Satisfactory internal consistency and inter-rater agreement were found. In the military sample, a parsimonious first-order six-factor model was preferred over a second-order two-factor CFA model of ITI PTSD and Disturbances in Self-Organization (DSO). Model fit was excellent among military participants but no solution was supported among civilian participants. Overall, convergent validity was supported by positive correlations of ITI PTSD and DSO with DSM-5 PTSD. Discriminant validity for PTSD symptoms was confirmed among civilians but low in the military sample.Conclusions: The German ITI has shown potential as a clinician-administered diagnostic tool for assessing ICD-11 PTSD and CPTSD in primary care. However, further exploration of its latent structure and discriminant validity are indicated.

This study validated the German International Trauma Interview (ITI), a semi-structured clinician-administered diagnostic interview for ICD-11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder.Internal reliability, inter-rater agreement, latent structure, and convergent validity were explored in trauma-exposed clinical and military samples from five different in- and outpatient centres in Germany and German-speaking Switzerland.The findings supported the German ITI's reliability, inter-rater agreement, convergent validity and usefulness from a patient perspective. Future research should explore its factor structure and discriminant validity, for which differences between the samples were found.

Traumatized German soldiers with moral injury - value-based cognitive-behavioral group therapy to treat war-related shame.

Introduction: During deployment, soldiers are confronted with potentially morally injurious events. In many cases, these events violate their personal values and belief systems, resulting in feelings of anger, alienation, guilt, and shame. The psychological distress caused by such transgressions is defined as moral injury. It remains unclear to date, which therapeutic interventions are most appropriate for addressing this specific psychological condition. This study examines the effectiveness of value-based cognitive-behavioral group therapy combining elements of cognitive-behavioral therapy, acceptance and commitment therapy, spiritual care, and adaptive disclosure therapy. Materials and methods: This controlled study uses the Compass of Shame Scale to assess symptom severity among participants both before and after a three-week inpatient group therapy regimen for moral injury. An intervention group (n = 45) was compared to a waiting-list control group (n = 40). A one-way between subjects ANOVA was conducted to determine the differences between the two measurement points in the intervention group compared to the control group. A positive ethics vote from the Humboldt University Berlin (Charité) was available (No.EA1/092/15). Results: A significant difference was found on the shame-associated maladaptive strategies subscales of attack self (F (1, 83) = 5.942, p = 0.017, Cohen's f = 0,27), withdrawal (F (1, 83) = 8.263, p = 0.005, Cohen's f = 0,32), and attack others (F (1, 83) = 10.552, p = 0.002, Cohen's f = 0,36) of the Compass of Shame Scale between the intervention group and the control group at the p < 0.05 level in the pre- and post-treatment (t1-t2) comparison. Conclusion: This study suggests that the special therapeutic focus in cognitive-behavioral group therapy can alter shame-based maladaptive coping behaviors in response to war-related moral injury. This study provides further evidence that therapeutic approaches - through fostering a reconciliatory, compassionate, and forgiving approach toward oneself and others - target the underlying mechanisms of moral injury. Therefore, value-based cognitive-behavioral interventions should be considered as a standard element of trauma care in a military setting. Future studies should further examine such interventions in randomized control trials. It would also be particularly valuable for future studies to include a follow-up time point.

The dissociative subtype of PTSD in trauma-exposed individuals: a latent class analysis and examination of clinical covariates.

Background: A dissociative subtype of posttraumatic stress disorder (D-PTSD) was introduced into the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) but latent profiles and clinical correlates of D-PTSD remain controversial. Objective: The aims of our study were to identify subgroups of individuals with distinct patterns of PTSD symptoms, including dissociative symptoms, by means of latent class analyses (LCA), to compare these results with the categorization of D-PTSD vs. PTSD without dissociative features according to the CAPS-5 interview, and to explore whether D-PTSD is associated with higher PTSD severity, difficulties in emotion regulation, and depressive symptoms. Method: A German sample of treatment-seeking individuals was investigated (N = 352). We conducted an LCA on the basis of symptoms of PTSD and dissociation as assessed by the CAPS-5. Moreover, severity of PTSD (PCL-5), difficulties in emotion regulation (DERS), and depressive symptoms (BDI-II) were compared between patients with D-PTSD according to the CAPS-5 interview and patients without dissociative symptoms. Results: LCA results suggested a 5-class model with one subgroup showing the highest probability to fulfill criteria for the dissociative subtype and high scores on both BDI and DERS. Significantly higher scores on the DERS, BDI and PCL-5 were found in the D-PTSD group diagnosed with the CAPS-5 (n = 75; 35.7%). Sexual trauma was also reported more often by this subgroup. When comparing the dissociative subtype to the LCA results, only a partial overlap could be found. Conclusions: Our findings suggest that patients with D-PTSD have significantly more problems with emotion regulation, more depressive symptoms, and more severe PTSD-symptoms. Given the results of our LCA, we conclude that the dissociative subtype seems to be more complex than D-PTSD as diagnosed by means of the CAPS-5.

Antecedentes: Un subtipo disociativo del trastorno de estrés postraumático (TEPT-D) fue introducido en la 5ª edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-5), pero los perfiles latentes y los correlatos clínicos del TEPT-D siguen siendo controversiales. Objetivo Los objetivos de nuestro estudio fueron identificar subgrupos de individuos con distintos patrones de síntomas de TEPT, incluyendo síntomas disociativos, mediante análisis de clases latentes (LCA, por sus siglas en inglés), comparar estos resultados con la categorización de TEPT-D vs. TEPT sin rasgos disociativos según la entrevista CAPS-5, y explorar si el TEPT-D se asocia con una mayor gravedad del TEPT, dificultades en la regulación de las emociones y síntomas depresivos.Método: Se investigó una muestra alemana de individuos que buscaban tratamiento (N = 352). Se realizó un LCA sobre la base de los síntomas de TEPT y disociación evaluados por el CAPS-5. Además, se comparó la gravedad del TEPT (PCL-5), las dificultades en la regulación de las emociones (DERS) y los síntomas depresivos (BDI-II) entre los pacientes con TEPT según la entrevista CAPS-5 y los pacientes sin síntomas disociativos.Resultados: Los resultados del LCA sugirieron un modelo de 5 clases con un subgrupo que mostraba la mayor probabilidad de cumplir los criterios del subtipo disociativo y altas puntuaciones tanto en el BDI como en el DERS. Se encontraron puntuaciones significativamente más altas en el DERS, el BDI y el PCL-5 en el grupo de TEPT-D diagnosticado con el CAPS-5 (n = 75; 35,7%). Este subgrupo también informó con más frecuencia de traumas sexuales. Al comparar el subtipo disociativo con los resultados del LCA, sólo se pudo encontrar una superposición parcial. Conclusiones Nuestros resultados sugieren que los pacientes con TEPT-D tienen significativamente más problemas con la regulación emocional, más síntomas depresivos y síntomas de TEPT más graves. Dados los resultados de nuestro LCA, concluimos que el subtipo disociativo parece ser más complejo que el TEPT-D diagnosticado mediante el CAPS-5.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale (CAPS-5) based on DSM-5 vs. ICD-11 criteria.

Introduction: Many studies have investigated the latent structure of the DSM-5 criteria for posttraumatic stress disorder (PTSD). However, most research on this topic was based on self-report data. We aimed to investigate the latent structure of PTSD based on a clinical interview, the Clinician-Administered PTSD Scale (CAPS-5). Method: A clinical sample of 345 participants took part in this multi-centre study. Participants were assessed with the CAPS-5 and the Posttraumatic Stress Disorder Checklist (PCL-5). We evaluated eight competing models of DSM-5 PTSD symptoms and three competing models of ICD-11 PTSD symptoms. Results: The internal consistency of the CAPS-5 was replicated. In CFAs, the Anhedonia model emerged as the best fitting model within all tested DSM-5 models. However, when compared with the Anhedonia model, the non-nested ICD-11 model as a less complex three-factor solution showed better model fit indices. Discussion: We discuss the findings in the context of earlier empirical findings as well as theoretical models of PTSD.

Introducción: Muchos estudios han investigado la estructura latente de los criterios DSM-5 para el trastorno de estrés postraumático (TEPT). Sin embargo, la mayoría de la investigación en este tema estuvo basada en datos de auto-reporte. Nuestro objetivo fue investigar la estructura latente del TEPT basado en una entrevista clínica, la Escala de TEPT administrada por el Clínico (CAPS-5 por su sigla en inglés).Método: En este estudio multicéntrico participó una muestra clínica de 345 personas. Los participantes fueron evaluados con la CAPS-5 y la Lista de Chequeo de Trastorno de Estrés Postraumático (PCL-5, por su sigla en inglés). Evaluamos ocho modelos competitivos de síntomas de TEPT del DSM-5 y tres modelos competitivos de síntomas de TEPT de la CIE-11.Resultados: La consistencia interna de la CAPS-5 fue replicada. En los AFC el modelo de anhedonia emergió como el de mejor ajuste entre todos los modelos del DSM-5 evaluados. Sin embargo, cuando se comparó con el modelo de anhedonia, el modelo no anidado de CIE-11 como una solución menos compleja de tres factores mostró mejores índices de ajuste de modelo.Discusión: Discutimos los hallazgos en el contexto de los resultados empíricos previos y de los modelos teóricos del TEPT.

Attentional bias in German Armed Forces veterans with and without posttraumatic stress symptoms - An eye-tracking investigation and group comparison.

BACKGROUND AND OBJECTIVES: Most eye tracking based paradigms evidence patterns of sustained attention on threat coupled with low evidence for vigilance to or avoidance of threat in posttraumatic stress symptoms (PTSS). Still, eye tracking data on attention bias is particularly limited for military population. This eye tracking study investigated attentional bias in PTSS in a sample of German Armed Forces veterans. METHODS: Veterans with deployment-related PTSS (N = 24), veterans with deployment-related traumatization without PTSS (N = 28), and never-deployed healthy veterans (N = 18) were presented with pairs of combat and neutral pictures, pairs of general threat and neutral pictures, and pairs of emotional and neutral faces. Their eye gazes were tracked during a free viewing task. 3 x 3 x 2 mixed general linear model analyses were conducted. Internal consistency of attention bias indicators was calculated for the entire sample and within groups. RESULTS: Veterans with PTSS dwelled longer on general threat AOIs in contrast to non-exposed controls and shorter on general threat and combat associated neutral AOIs in contrast to both control groups. Veterans with PTSS entered faster to general threat AOIs than non-exposed controls. Veterans with PTSS showed circumscribed higher attention fluctuation in contrast to controls. Internal consistency varied across attention bias indicators. LIMITATIONS: Statistical power was reduced due to recruitment difficulties. CONCLUSIONS: Evidence is provided for the maintenance hypothesis in PTSS. No robust evidence is provided for hypervigilant behavior in PTSS. Findings on attention bias variability remain unclear, calling for more investigations in this field.

Trauma-related but not PTSD-related increases in hair cortisol concentrations in military personnel.

Dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning has been associated with posttraumatic stress disorder (PTSD). The current literature is inconsistent regarding this association, possibly due to confounding influences. Hair cortisol concentrations (HCC) allow for retrospective assessment of cumulative HPA axis secretion over several weeks and are considered a trait-like marker of HPA axis activity. Three groups of active and former German Armed Forces service members, comprising PTSD patients (n = 19), healthy controls with deployment-related trauma exposure (n = 10), and non-deployed healthy controls (n = 10) provided samples for HCC analysis. We observed significantly higher HCC in the PTSD and the deployed compared to the non-deployed group. HCC was neither significantly correlated with perceived chronic stress, nor with PTSD severity within patients. The results suggest a differential impact of trauma exposure on HPA axis activity and highlight the notion of cumulative, retrospective cortisol secretion as a psychobiological indicator of trauma exposure. TRIAL REGISTRATION: Australian Clinical Trials Registry (ACTRN12616000956404).

Comparing PTSD symptom networks in type I vs. type II trauma survivors.

Background: Network analysis has gained increasing attention as a new framework to study complex associations between symptoms of post-traumatic stress disorder (PTSD). A number of studies have been published to investigate symptom networks on different sets of symptoms in different populations, and the findings have been inconsistent. Objective: We aimed to extend previous research by testing whether differences in PTSD symptom networks can be found in survivors of type I (single event; sudden and unexpected, high levels of acute threat) vs. type II (repeated and/or protracted; anticipated) trauma (with regard to their index trauma). Method: Participants were trauma-exposed individuals with elevated levels of PTSD symptomatology, most of whom (94%) were undergoing assessment in preparation for PTSD treatment in several treatment centres in Germany and Switzerland (n = 286 with type I and n = 187 with type II trauma). We estimated Bayesian Gaussian graphical models for each trauma group and explored group differences in the symptom network. Results: First, for both trauma types, our analyses identified the edges that were repeatedly reported in previous network studies. Second, there was decisive evidence that the two networks were generated from different multivariate normal distributions, i.e. the networks differed on a global level. Third, explorative edge-wise comparisons showed moderate or strong evidence for specific 12 edges. Edges which emerged as especially important in distinguishing the networks were between intrusions and flashbacks, highlighting the stronger positive association in the group of type II trauma survivors compared to type I survivors. Flashbacks showed a similar pattern of results in the associations with detachment and sleep problems (type II > type I). Conclusion: Our findings suggest that trauma type contributes to the heterogeneity in the symptom network. Future research on PTSD symptom networks should include this variable in the analyses to reduce heterogeneity.

Antecedentes: El análisis de redes ha ganado cada vez más atención como un nuevo marco para estudiar asociaciones complejas entre síntomas del Trastorno de Estrés Postraumático (TEPT). Se han publicado una cantidad de estudios para investigar las redes de síntomas en diferentes conjuntos de síntomas en distintas poblaciones, y los hallazgos han sido inconsistentes.Objetivos: Nuestro objetivo fue ampliar la investigación previa probando si se pueden encontrar diferencias entre las redes de síntomas del TEPT en sobrevivientes de trauma de tipo 1 (evento único; súbito e inesperado, niveles elevados de amenaza aguda) versus los de tipo 2 (eventos repetidos y/o prolongados; anticipados) (con respecto a su trauma índice).Métodos: Los participantes eran individuos expuestos al trauma con niveles elevados de sintomatología de TEPT, la mayoría de los cuales (94%) se sometían a una evaluación en preparación para el tratamiento del TEPT en varios centros de Alemania y Suiza (n = 286 con tipo 1 y n = 187 con tipo 2 de trauma). Estimamos modelos gráficos Bayesianos Gaussianos para cada tipo de grupo de trauma y exploramos las diferencias entre los grupos en la red de síntomas.Resultados: En primer lugar, para ambos tipos de trauma, nuestros análisis identificaron los bordes que se reportaron repetidamente en estudios de redes anteriores. En segundo lugar, hubo evidencia decisiva que las dos redes fueron generadas de diferentes distribuciones normales multivariadas, es decir, las redes diferían a nivel global. En tercer lugar, las comparaciones exploratorias de los bordes mostraron una evidencia de moderada a fuerte para 12 bordes específicos. Los bordes que surgieron como especialmente importantes para distinguir las redes fueron las intrusiones y flashbacks, destacando la asociación fuertemente positiva entre los grupos de tipo 2 en comparación con los sobrevivientes de trauma del grupo de tipo 1. Los flashbacks mostraron un patrón similar de resultados en las asociaciones con desapego y problemas de sueño (tipo 2 > tipo 1).Conclusiones: Nuestros resultados sugieren que el tipo de trauma contribuye a la heterogeneidad en los síntomas de red. La investigación futura sobre las redes de los síntomas de TEPT debería incluir esta variable en los análisis para reducir la heterogeneidad.

Associations between oxytocin and vasopressin concentrations, traumatic event exposure and posttraumatic stress disorder symptoms: group comparisons, correlations, and courses during an internet-based cognitive-behavioural treatment.

Background: Posttraumatic stress disorder (PTSD) is characterized by impairments in extinction learning and social behaviour, which are targeted by trauma-focused cognitive behavioural treatment (TF-CBT). The biological underpinnings of TF-CBT can be better understood by adding biomarkers to the clinical evaluation of interventions. Due to their involvement in social functioning and fear processing, oxytocin and arginine vasopressin might be informative biomarkers for TF-CBT, but to date, this has never been tested. Objective: To differentiate the impact of traumatic event exposure and PTSD symptoms on blood oxytocin and vasopressin concentrations. Further, to describe courses of PTSD symptoms, oxytocin and vasopressin during an internet-based TF-CBT and explore interactions between these parameters. Method: We compared oxytocin and vasopressin between three groups of active and former male service members of the German Armed Forces (n = 100): PTSD patients (n = 39), deployed healthy controls who experienced a deployment-related traumatic event (n = 33) and non-deployed healthy controls who never experienced a traumatic event (n = 28). PTSD patients underwent a 5-week internet-based TF-CBT. We correlated PTSD symptoms with oxytocin and vasopressin before treatment onset. Further, we analysed courses of PTSD symptoms, oxytocin and vasopressin from pre- to post-treatment and 3 months follow-up, as well as interactions between the three parameters. Results: Oxytocin and vasopressin did not differ between the groups and were unrelated to PTSD symptoms. PTSD symptoms were highly stable over time, whereas the endocrine parameters were not, and they also did not change in mean. Oxytocin and vasopressin were not associated with PTSD symptoms longitudinally. Conclusions: Mainly due to their insufficient intraindividual stability, single measurements of endogenous oxytocin and vasopressin concentrations are not informative biomarkers for TF-CBT. We discuss how the stability of these biomarkers might be increased and how they could be better related to the specific impairments targeted by TF-CBT.

Antecedentes: El trastorno de estrés postraumático (TEPT) se caracteriza por deficiencias en el aprendizaje de extinción y el comportamiento social, que son el objetivo del tratamiento cognitivo conductual centrado en el trauma (TF-CBT). Los fundamentos biológicos de TF-CBT se pueden entender mejor agregando biomarcadores a la evaluación clínica de las intervenciones. Debido a su participación en el funcionamiento social y el procesamiento del miedo, la oxitocina y la arginina vasopresina podrían ser biomarcadores informativos para la TF-CBT, pero hasta la fecha, esto nunca se ha probado.Objetivo: Diferenciar el impacto de la exposición a un evento traumático y los síntomas del TEPT en las concentraciones de oxitocina y vasopresina en la sangre. Además, para describir la evolución de los síntomas del TEPT, la oxitocina y la vasopresina durante una TF-CBT basada en Internet y explorar las interacciones entre estos parámetros.Método: Comparamos la oxitocina y la vasopresina entre tres grupos de militares activos y ex militares de las Fuerzas Armadas Alemanas (n = 100): pacientes con TEPT (n = 39), controles sanos desplegados que experimentaron un evento traumático relacionado con el despliegue (n = 33) y controles sanos no desplegados que nunca experimentaron un evento traumático (n = 28). Los pacientes con TEPT se sometieron a una TF-CBT basada en Internet durante 5 semanas. Correlacionamos los síntomas del TEPT con la oxitocina y la vasopresina antes del inicio del tratamiento. Además, analizamos la evolución de los síntomas del TEPT, la oxitocina y la vasopresina antes y después del tratamiento y el seguimiento de 3 meses, así como las interacciones entre los tres parámetros.Resultados: La oxitocina y la vasopresina no difirieron entre los grupos y no se relacionaron con los síntomas del TEPT. Los síntomas del TEPT fueron muy estables en el tiempo, mientras que los parámetros endocrinos no lo fueron, y tampoco cambiaron en la media. La oxitocina y la vasopresina no se asociaron con los síntomas del TEPT de forma longitudinal.Conclusiones: Principalmente debido a su estabilidad intraindividual insuficiente, las mediciones únicas de las concentraciones de oxitocina y vasopresina endógenas no son biomarcadores informativos para TF-CBT. Discutimos cómo podría aumentarse la estabilidad de estos biomarcadores y cómo podrían relacionarse mejor con las deficiencias específicas a las que se dirige TF-CBT.

Fighter, Corpsman, Partisan an Attempt to Typify Former Soldiers Based on their Coping and Defense Mechanisms.

This work strives to develop a typological classification of the use of conscious and unconscious defense and coping mechanisms based on methodically and structurally collected data from a qualitative survey of 43 former soldiers in Germany. Seven coping and defense types were identified: the Fighter, the Comrade, the Corpsman, the Strategist, the Partisan, the Self-Protector and the Infantryman. The types identified differed with regard to the accumulation, combination, and use of their conscious and unconscious defense and coping mechanisms in the superordinate areas of behaviour, relationships, emotions, reflexivity and time focus. The typological classification could offer psychotherapeutic interventions tailored to individuals and their defense and coping mechanisms, which could lead to improved therapy use and compliance.

Associations Between Difficulties in Emotion Regulation and Post-Traumatic Stress Disorder in Deployed Service Members of the German Armed Forces.

BACKGROUND: Experiencing a traumatic event can lead to post-traumatic stress disorder (PTSD), but not every traumatized person develops PTSD. Several protective and risk factors have been identified in civilians and veterans to explain why some individuals develop PTSD and others do not. However, no research has confirmed the relationship between emotion regulation and PTSD in deployed German Armed Forces service members after a foreign assignment. Previous studies have identified some protective factors, such as social support, social acknowledgment, specific personal values, and posttraumatic growth, as well as risk factors, like moral injury and emotion regulation. Thus, the aim of the present study is to confirm the relationship between emotion regulation and PTSD and to test for factors that are associated with higher severity of PTSD symptoms in such a sample. METHODS: A post-hoc secondary analysis was conducted on data collected in a randomized controlled trial. Participants (N = 72) were male active and former military service members that have returned from deployment and were recruited from the German Armed Forces. These participants were separated into two groups according to PTSD diagnosis based on the results of a structured diagnostic interview. Data from evaluation questionnaires administered upon entry into the study were subjected to a cross-sectional analysis. The measures included the severity of PTSD symptoms, clusters of PTSD symptoms, clinical measures, and several measures assessing PTSD-related constructs. Analyses included the Spearman rank correlation coefficient, X2 tests for nominal data, Mann-Whitney U-tests for non-parametric data, and a mediation analysis. RESULTS: The results of the mediation analysis revealed that difficulties in emotion regulation were significantly associated with the severity of PTSD symptoms, which was mediated by social acknowledgment and experimental avoidance but not by moral injury. The analyses showed that the severity of PTSD symptoms and all clusters of PTSD symptoms were significantly associated with most of the measured constructs in expectable directions. Participants in the PTSD group showed significantly higher mean scores on questionnaires measuring constructs that have been associated with PTSD, like emotion regulation and moral injury. They also showed lower mean scores in questionnaires for social support and social acknowledgment as a victim or survivor than participants in the non-PTSD group. CONCLUSION: The present results show that difficulties in emotion regulation are directly associated with the severity of PTSD symptoms in service members of the German Armed Forces. This association is mediated by social acknowledgment and experimental avoidance, but not by moral injury. Thus, future studies should investigate these potentially crucial factors for better understanding of the development and maintenance of PTSD in service members of the German Armed Forces after deployment to create possible treatment adaptions. CLINICAL TRIAL REGISTRATION: Australian Clinical Trials Registry, identifier ACTRN 12616000956404 http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370924.

Psychometric properties of the German version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in clinical routine settings: study design and protocol of a multitrait-multimethod study.

INTRODUCTION: The aim of this study is to investigate the diagnostic accuracy, psychometric properties and clinical utility of the German version of the Clinician-Administered Post-Traumatic Stress Disorder (PTSD) Scale for Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (CAPS-5) in routine clinical settings. METHODS AND ANALYSIS: This study is a non-interventional, multitrait-multimethod design, multicentre study that will be carried out at German civil and military inpatient and outpatient clinics. A total sample size of n=219 participants who have experienced at least one traumatic event according to criteria as defined in the DSM-5 will be recruited. For the investigation of the diagnostic accuracy and clinical utility of the CAPS-5, participants will be categorised into one of three groups, depending on their traumatic experiences and post-traumatic symptomatology: (1) monotraumatisation with PTSD; (2) multiple traumatisation with PTSD and (3) traumatisation without PTSD. Interviews will be conducted face to face by interviewers in routine clinical settings. All participants will also be asked to complete a comprehensive set of questionnaires in order to investigate different facets of construct validity and clinical utility. First, differences between all three groups in CAPS-5 sum and subscale scores will be investigated. Test-retest reliability and inter-rater reliability will be determined. Internal consistency will be calculated using structural equation modeling (SEM) based internal consistency coefficients. Construct validity will be measured with Spearman's rank correlation analyses and multivariate analyses of variance with Holm-Bonferroni corrected post hoc analysis of variances. In order to test diagnostic accuracy, receiver operating characteristics and sensitivity and specificity analyses will be conducted. The model structure of the German CAPS-5 will be analysed using confirmatory factor analyses. ETHICS AND DISSEMINATION: The study received ethical approval by the Ethics Committees of the Faculty of Psychology at the Ruhr-Universität Bochum (reference numbers: 331 and 358). The results of the study will be presented nationally and internationally at scientific conferences and will be published in scientific journals. TRIAL REGISTRATION NUMBER: DRKS00015325.

Work disability in soldiers with posttraumatic stress disorder, posttraumatic embitterment disorder, and not-event-related common mental disorders.

OBJECTIVE: Posttraumatic mental disorders may occur with different affect qualities. Best known is posttraumatic stress disorder (PTSD), a conditioned anxiety reaction with intrusions. Another event-related mental disorder is posttraumatic embitterment (PTED), characterized by affect of embitterment and thoughts of revenge, occurring after an event deeply hurting basic beliefs. Knowing about associated disability is important for treatment and sociomedical decisions. This is the first study to explore work-disability in patients with PTSD, PTED, and not-event-related common mental disorder (CMD). METHOD: In this observational study, 101 soldiers (85% men, 31 years, 50% experienced expedition abroad) with different mental disorders were investigated concerning common mental disorders (MINI) and accompanying work capacity impairment (Mini-ICF-APP). Interviews were conducted by a state-licensed psychotherapist with expertise in sociomedical description of (work) capacity impairment. Patients with PTSD, PTED, and other CMD were compared concerning their degrees and pattern of work capacity impairment. RESULTS: PTSD patients (n = 23) were more strongly impaired in mobility as compared to patients with other CMD (n = 64) or PTED. Patients with PTED (n = 14) were more impaired in interactional capacities (contacts with others, group integration) as compared to patients with other CMD or PTSD. CONCLUSIONS: PTSD patients need support to improve mobility in (work-relevant) traffic situations. Apart from this, they are not specifically more or less impaired than patients with other CMD. PTED patients should get attention concerning their interactional problems as these may disturb esprit de corps, which is an essential requirement for service in the armed forces. (PsycINFO Database Record

Understanding health care avoidance and initial help-seeking behavior in German veterans: a theory of planned behavior.

OBJECTIVE: To gain initial insights into salient beliefs of former German soldiers (veterans) about the use of mental health services. DATA SOURCE: Narrative interviews with former German soldiers (veterans) were conducted in 2016. DATA COLLECTION/EXTRACTION METHOD: Forty-three interviews were transcribed and analyzed thematically based on the theoretical framework of the theory of planned behavior. From within the behavorial, normative, and control beliefs, the salient beliefs were identified. PRINCIPAL FINDINGS: Four groups of salient beliefs were identified, described, and named: "Autarky", "Ineffectiveness", "Heteronomy", and "Incapacity". CONCLUSION: Interventions and campaigns addressing these four specific groups of beliefs may lead to higher health service use rates. However, as a result of methodological limitations of the study design, the conclusion remains tentative.

Testing the ICD-11 proposal for complex PTSD in trauma-exposed adults: factor structure and symptom profiles.

Background: The proposed ICD-11 criteria for trauma-related disorders define posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (cPTSD) as separate disorders. Results of previous studies support the validity of this concept. However, due to limitations of existing studies (e.g. homogeneity of the samples), the present study aimed to test the construct validity and factor structure of cPTSD and its distinction from PTSD using a heterogeneous trauma-exposed sample. Method: Confirmatory factor analyses (CFAs) were conducted to explore the factor structure of the proposed ICD-11 cPTSD diagnosis in a sample of 341 trauma-exposed adults (n = 191 female, M = 37.42 years, SD = 12.04). In a next step, latent profile analyses (LPAs) were employed to evaluate predominant symptom profiles of cPTSD symptoms. Results: The results of the CFA showed that a six-factor structure (i.e. symptoms of intrusion, avoidance, hyperarousal and symptoms of affective dysregulation, negative self-concept, and interpersonal problems) fits the data best. According to LPA, a four-class solution optimally characterizes the data. Class 1 represents moderate PTSD and low symptoms in the specific cPTSD clusters (PTSD group, 30.4%). Class 2 showed low symptom severity in all six clusters (low symptoms group, 24.1%). Classes 3 and 4 both exhibited cPTSD symptoms but differed with respect to the symptom severity (Class 3: cPTSD, 34.9% and Class 4: severe cPTSD, 10.6%). Conclusions: The findings replicate previous studies supporting the proposed factor structure of cPTSD in ICD-11. Additionally, the results support the validity and usefulness of conceptualizing PTSD and cPTSD as discrete mental disorders.

Antecedentes: Los criterios propuestos por la CIE-11 para los trastornos relacionados con trauma, define el trastorno de estrés postraumático (TEPT) y el trastorno de estrés postraumático complejo (TEPTc) como dos trastornos separados. Los resultados de estudios previos apoyan la validez de este concepto. Sin embargo, debido a las limitaciones de los estudios existentes (ej. Homogeneidad de las muestras), el presente estudio tuvo como objetivo probar la validez de constructo y la estructura factorial del TEPTc y su distinción del TEPT utilizando una muestra heterogénea expuesta a trauma. Metodo: Se realizaron análisis de factores confirmatorios (AFCs) para explorar la estructura de los factores del diagnóstico propuesto de TEPTc por la CIE-11 en una muestra de 341 adultos expuestos al trauma (n = 191 mujeres, M = 37.42 años, SD = 12.04). En un siguiente paso, se emplearon análisis de perfil latente (APL) para evaluar los perfiles de síntomas predominantes de los síntomas de TEPTc. Resultados: Los resultados de la AFC mostraron que una estructura de seis factores (es decir, síntomas de intrusión, evitación, hiperalerta y síntomas de desregulación afectiva, autoconcepto negativo y problemas interpersonales) se ajusta mejor a los datos. Según los APL, una solución de cuatro clases caracteriza de manera óptima los datos. La clase 1 representa un trastorno de estrés postraumático moderado y síntomas bajos en los grupos de específicos de TEPTc (grupo de trastorno de estrés postraumático, 30.4%). La clase 2 mostró una baja gravedad de los síntomas en los seis conglomerados (grupo de síntomas bajos, 24.1%). Las clases 3 y 4 mostraron síntomas de TEPTc, pero difirieron con respecto a la gravedad de los síntomas (clase 3: TEPTc, 34.9% y clase 4: TEPTc grave, 10.6%). Conclusiones: Los hallazgos replican estudios previos que respaldan la estructura de factores propuesta del TEPTc en la CIE-11. Además, los resultados respaldan la validez y la utilidad de conceptualizar el TEPT y el TEPTc como trastornos mentales distintos.

Stigma and its impact on the families of former soldiers of the German Armed Forces: an exploratory study.

BACKGROUND: Military families who have a family member with a mental illness see themselves confronted with many demands. Stigmatization is one of these challenges. Stigmatization affects not only the individual who suffers from a mental illness but also other family members via stigma by association and vicarious stigma. Stigma by association occurs when mental illness stigma spills over to individuals associated with an individual with a mental illness. Vicarious stigma describes the suffering of family members when they note the impact of stigma on their relative with mental illness. As a societal phenomenon, stigma plays out in social interactions and might therefore influence the social networks of families. It is also associated with healthcare utilization. METHOD: Narrative interviews were conducted with 15 family members (partners, spouses, parents and children) of former soldiers of the German Armed Forces with a service-induced mental illness. The transcribed interview data were analyzed using a thematic analysis approach, in which codes were formed and emerging themes were systemized. Relationships between stigma, the families' reactions to it, its effects on their social relationships and its interference with their healthcare utilization were analyzed. RESULTS: This study provides a detailed description of how relatives of former German soldiers with mental health problems experience stigma by association and vicarious stigma. Their perceptions are shown in a model that describes stigma-related attitudes, reactions to them and their effects on the social relationships of former soldiers' families. These families felt stigmatized because of the former soldiers' mental illness (mental illness stigma) and the military context in which it occurred (former soldier stigma). They reacted with nondisclosure, anger, acceptance and self-blame. Stigma was associated with smaller and weaker social networks that were characterized by social exclusion, self-segregation and conflicts with extended family, friends and colleagues. Stigma also affected the families' healthcare utilization. CONCLUSIONS: Urgently needed anti-stigma campaigns, particularly in the civilian context, should address the stigmatization of both mental illness and the military participation of the families affected. They should consider the needs of both former soldiers with a mental illness and their families.