Manage Emotions to Reduce Aggression: A Pilot Study of a Brief Treatment to Help Veterans Reduce Impulsive Aggression.

Veterans with posttraumatic stress disorder (PTSD) report more aggression than civilians with PTSD. Because emotion regulation difficulties mediated the relationship between PTSD symptoms and impulsive aggression in veterans, we developed an intervention to increase emotion regulation skills. This pilot study tested the feasibility and acceptability of a three-session treatment, Manage Emotions to Reduce Aggression (MERA), and examined its effectiveness at reducing aggression and emotion dysregulation. Male combat veterans with PTSD and impulsive aggression completed assessments before and 4 weeks after MERA. Overt Aggression Scale measured frequency of aggression; Difficulties in Emotion Regulation Scale assessed emotion dysregulation. Most veterans (95%) who completed MERA and the posttreatment assessment (n = 20) reported MERA was helpful. Veterans in the intent-to-treat sample demonstrated a significant decrease in their frequency of aggression (Cohen's d = -0.55) and emotion dysregulation (Cohen's d = -0.55). MERA may be an innovative treatment that helps veterans reduce aggression.

Video to Home Delivery of Evidence-Based Psychotherapy to Veterans With Posttraumatic Stress Disorder.

Background: The Veterans Health Administration (VHA) has pioneered the implementation of video to home (VTH) technology to increase access to mental health treatments for Veterans facing barriers to receiving in-person care, particularly for posttraumatic stress disorder (PTSD). Randomized controlled trials have established the noninferiority of evidence-based psychotherapies (EBPs) for PTSD delivered through VTH, compared to in-person delivery. Less is known about the use of VTH to deliver EBPs for PTSD in routine clinical practice. Objective: We examined the provision of EBPs for PTSD delivered via VTH at a large Southwestern VHA PTSD outpatient clinic. Methods: Data were obtained from chart review of the electronic medical records of Veterans receiving at least one session of Cognitive Processing Therapy or Prolonged Exposure via VTH in the VHA PTSD clinic during the study time frame. Results: Fourteen providers (including six psychology trainees) delivered EBPs for PTSD via VTH between 2016 and 2018. Providers treated 74 Veterans (33.8% women) from diverse sociocultural backgrounds who ranged in age from 25 to 79. Each provider treated about 3.08 (± 2.18) Veterans using VTH, not including one provider who saw more than 30. A hybrid approach, in which VTH-delivery was coupled with in-person delivery, was used with 70.3% of Veterans across treatment (including sessions completed before initiation and after termination of the EBP). This demonstrates the versatility of VTH for meeting individual patient needs. Most EBP sessions (85.4%) were conducted over VTH. Despite Veterans attending an average of 6.85 (± 4.88) EBP sessions, 50% terminated before session 7. This dropout rate is consistent with national and local EBP completion averages within the VHA. Veterans receiving Cognitive Processing Therapy via VTH were more likely to complete treatment than those receiving Prolonged Exposure. No other patient factors predicted attrition. Conclusions: This study highlights the use of VTH as "tool in the toolbox" that expands the scope of practice for providers and increases opportunities for Veterans to receive EBPs for PTSD. We describe other potential advantages of using VTH to deliver EBPs for PTSD.

Prevention and treatment of secretory diarrhea by the lysophosphatidic acid analog Rx100.

IMPACT STATEMENT: A critical barrier in treating diarrheal disease is easy-to-use effective treatments. Rx100 is a first in class, novel small molecule that has shown efficacy after both subcutaneous and oral administration in a mouse cholera-toxin- and Citrobacter rodentium infection-induced diarrhea models. Our findings indicate that Rx100 a metabolically stable analog of the lipid mediator lysophosphatidic acid blocks activation of CFTR-mediated secretion responsible for fluid discharge in secretory diarrhea. Rx100 represents a new treatment modality which does not directly block CFTR but attenuates its activation by bacterial toxins. Our results provide proof-of-principle that Rx100 can be developed for use as an effective oral or injectable easy-to-use drug for secretory diarrhea which could significantly improve care by eliminating the need for severely ill patients to regularly consume large quantities of oral rehydration therapies and offering options for pediatric patients.

Pilot study comparing telephone to in-person delivery of cognitive-behavioural therapy for trauma-related insomnia for rural veterans.

Introduction It is estimated that 70% of patients with posttraumatic stress disorder (PTSD) have chronic insomnia. A recent meta-analysis examined cognitive-behavioural therapy for insomnia (CBT-I) in veterans with and without PTSD, and suggested that most studies had questionable methodology, but generally supported its effectiveness in this population. Further, while CBT-I via telehealth (i.e. using telecommunication and information technology to deliver health services) has shown effectiveness for primary insomnia, it has not been applied to PTSD-related insomnia. Methods Veterans with insomnia who were diagnosed with PTSD ( n = 12) or having significant subthreshold PTSD symptoms ( n = 6) on the Clinician Administered PTSD Scale were randomly assigned to receive CBT-I in-person ( n = 7) or by telephone ( n = 11), to pilot test the potential effectiveness, acceptability, and feasibility of administering CBT-I in rural veterans. A six-week CBT-I protocol was delivered, and the veteran's insomnia was assessed at post-treatment and follow-up. Results Given the small sample size, Cohen's d was used to detect group differences, finding large effect sizes favouring the in-person delivery, until three-months post-treatment when this difference diminished. Most veterans found the treatment acceptable, regardless of mode of delivery. Based on the results, a larger project is feasible. Feasibility for a larger project is favourable. Discussion In summary, our findings uphold and extend previous research. Specifically, current pilot data suggest that telephone-delivered CBT-I may be able to reduce trauma-related insomnia symptoms. Future trials are needed to assess the effectiveness of CBT-I delivered to rural veterans with posttraumatic insomnia.

Increased utilization of prolonged exposure and cognitive processing therapy over time: A case example from a large Veterans Affairs posttraumatic stress disorder clinic.

Prior single-site and regional studies have documented difficulties in implementing prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) into practice in Veterans Affairs (VA) Medical Centers, estimating that between 6% and 13% of VA patients with PTSD receive PE or CPT (Lu, Plagge, Marsiglio, & Dobscha, 2016; Mott et al., 2014; Shiner et al., 2013). However, these studies examined data from fiscal years 2008-2012, and therefore may not reflect more recent utilization patterns. Beginning in 2007, the VA invested heavily in increasing implementation of PE and CPT, including nationwide training rollouts and consultation. Given the length of time required for successful implementation of new practices, it is important to evaluate use of PE and CPT over time. We examined current use of PE and CPT at 1 VA medical center PTSD specialty clinic and compared this to prior rates for the same clinic. Chart reviews for all patients receiving a PTSD clinic initial evaluation between January 1, 2015, and May 31, 2015, indicated that 52% of patients began a course of PE or CPT within the 1-year follow-up period, representing a 5-fold increase from 2008 to 2012. We discuss changes in clinic structure, processes, training, and clinician support that might account for the successful implementation of PE and CPT in this clinic. We also present data on alternative referrals provided to patients not engaging in PE and CPT, and predictors of engagement in PE and CPT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Delivery of mental health treatment to combat veterans with psychiatric diagnoses and TBI histories.

Traumatic brain injury (TBI) and mental health (MH) disorders are prevalent in combat veterans returning from Afghanistan and/or Iraq (hereafter referred to as returning veterans). Accurate estimates of service utilization for veterans with and without TBI exposure (referred to as TBI history) are imperative in order to provide high quality healthcare to returning veterans. We examined associations between TBI history and MH service utilization in a subsample of returning veterans who were newly diagnosed with posttraumatic stress disorder (PTSD), depression, and/or anxiety in the 2010 fiscal year (N = 55,458). Data were extracted from the Veterans Health Administration (VHA) National Patient Care Database. Veterans with MH diagnoses and TBI histories attended significantly more psychotherapy visits, (M = 8.32 visits, SD = 17.15) and were more likely to attend at least 8 psychotherapy visits, (15.7%) than veterans with MH diagnoses but no TBI history (M = 6.48 visits, SD = 12.12; 10.1% attended at least 8 sessions). PTSD and TBI history, but not depression or anxiety, were associated with a greater number of psychotherapy visits when controlling for demographic and clinical variables. PTSD, anxiety, depression, and TBI history were associated with number of psychotropic medication-management visits. TBI history was related to greater MH service utilization, independent of MH diagnoses. Future research should examine what MH services are being utilized and if these services are helping veterans recover from their disorders.

Single-session emotion regulation skills training to reduce aggression in combat veterans: A clinical innovation case study.

Posttraumatic stress disorder (PTSD) is common among returning veterans, and aggression frequently co-occurs with PTSD. Veterans with PTSD most commonly engage in impulsive aggression, or aggression that is emotionally charged, unplanned, and uncontrolled, rather than premeditated aggression, which is planned and controlled. Previous research demonstrated a variety of emotions can result in aggression, rather than the traditional conceptualization that only anger leads to aggression. In a veteran sample, deficiencies in the ability to regulate emotions (emotion dysregulation) mediated the relationship between PTSD and impulsive aggression. These results suggest that teaching veterans with PTSD and impulsive aggression how to regulate emotions may decrease aggression. The cases presented illustrate the use of an innovative, single-session emotion regulation treatment for combat veterans with PTSD. Two cases are presented to generate hypotheses on who might benefit from this treatment in the future. The two male veterans treated with this protocol differed in how frequently they used the emotion regulation skills after the treatment and in their treatment outcomes. Teaching veterans how to regulate their emotions in a condensed time frame may be beneficial for certain veterans, and further research on this brief treatment is warranted. (PsycINFO Database Record

Childhood trauma and posttraumatic stress disorder in a real-world Veterans Affairs clinic: Examining treatment preferences and dropout.

OBJECTIVE: The Department of Veterans Affairs (VA) has promoted large-scale dissemination efforts of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). In spite of efforts to make gold-standard treatments available to veterans, few veterans with PTSD receive a full course of psychotherapy. It is unclear if type of trauma experienced is related to treatment initiation and completion. This study aimed to identify patient factors, including experiencing childhood trauma that related to treatment preferences and dropout in a real-world VA PTSD clinic. METHOD: A chart review was conducted for veterans who were referred for individual EBPs for PTSD (N = 199). Extracted variables included demographics, PTSD symptoms, treatment preferences, and treatment completion/dropout. RESULTS: Veterans choose to engage in individual EBP (48%), group treatment (11%), nontrauma focused psychotherapy (15%), or no psychotherapy (26%). Slightly over half of the veterans who began individual EBP completed it, with no statistical differences in completion rates for prolonged exposure and cognitive processing therapy. Childhood trauma was the second-most common type of trauma experienced, next to combat exposure. Those who completed EBP had higher rates of combat trauma (88%) than noncompleters (70%), and noncompleters (50%) had higher rates of childhood trauma than completers (29%). Regardless of trauma experienced, those who completed an EBP experienced substantial reductions in PTSD symptoms. CONCLUSIONS: Assessing veterans for childhood trauma and emotion regulation difficulties may be beneficial even in VA clinics where treatment is most often focused on combat trauma. (PsycINFO Database Record

Quinic acid derivative KZ-41 exhibits radiomitigating activity in preclinical models of radiation injury.

Acute radiation syndrome is induced when a significant portion of the body receives high-dose, as well as high-dose rate, radiation. We have previously identified a quinic acid-based derivative, KZ-41, that protects from radiation injury. Further preclinical efficacy studies were conducted to determine the radiomitigating activity of KZ-41. C57BL/6 mice received total body irradiation (TBI-LD80/30, ¹³7Cs; ∼2 min) followed by either normal saline or KZ-41 (100 mg/kg sc ∼26 h post-TBI). KZ-41 increased 30-day survival by approximately 45% compared with vehicle controls (P < 0.05). To further investigate the potential radiomodulating mechanisms of KZ-41, we developed a combined radiation and vascular injury model. C57BL/6 mice surgically fixed with dorsal windows for dermal vasculature imaging received either sham or TBI (¹³7Cs; 6 Gray). Postcapillary venule injury was induced (24, 48, 72, and 96 h post-TBI) followed by imaging at 5 min and 24 h to assess clot formation and blood flow. Impairment in flow (P < 0.05) and clot formation (P < 0.05) were observed as early as 48 and 72 h, respectively. Thus, vascular injury 72 h post-TBI was used to evaluate intervention (KZ-41; 100 mg/kg i.p. at 12, 36, and 60 h post-TBI) on radiation-induced changes in both flow and clot formation. KZ-41, although not improving flow, increased clot formation (P < 0.05). Platelet counts were lower in both irradiated groups compared with sham controls (P < 0.05). In summary, KZ-41 exerts radiomitigating activity in lethally irradiated mice. Imaging results suggest KZ-41 exerts radiomitigating activity through mechanisms involving promotion of initial clot formation and vascular flow restoration. The imaging model described herein is useful for further examination of radiation-induced vascular injury repair mechanisms.

Deletion of apoptosis signal-regulating kinase-1 prevents ventilator-induced lung injury in mice.

Both hyperoxia and mechanical ventilation can independently cause lung injury. In combination, these insults produce accelerated and severe lung injury. We recently reported that pre-exposure to hyperoxia for 12 hours, followed by ventilation with large tidal volumes, induced significant lung injury and epithelial cell apoptosis compared with either stimulus alone. We also reported that such injury and apoptosis are inhibited by antioxidant treatment. In this study, we hypothesized that apoptosis signal-regulating kinase-1 (ASK-1), a redox-sensitive, mitogen-activated protein kinase kinase kinase, plays a role in lung injury and apoptosis in this model. To determine the role of ASK-1 in lung injury, the release of inflammatory mediators and apoptosis, attributable to 12 hours of hyperoxia, were followed by large tidal volume mechanical ventilation with hyperoxia. Wild-type and ASK-1 knockout mice were subjected to hyperoxia (Fi(O(2)) = 0.9) for 12 hours before 4 hours of large tidal mechanical ventilation (tidal volume = 25 µl/g) with hyperoxia, and were compared with nonventilated control mice. Lung injury, apoptosis, and cytokine release were measured. The deletion of ASK-1 significantly inhibited lung injury and apoptosis, but did not affect the release of inflammatory mediators, compared with the wild-type mice. ASK-1 is an important regulator of lung injury and apoptosis in this model. Further study is needed to determine the mechanism of lung injury and apoptosis by ASK-1 and its downstream mediators in the lung.

A couple-based approach to the reduction of PTSD avoidance symptoms: preliminary findings.

This study reports preliminary findings regarding the feasibility and efficacy of a novel couple-based treatment, named Strategic Approach Therapy (SAT), for reducing avoidance symptoms of posttraumatic stress disorder (PTSD). Six male Vietnam combat veterans diagnosed with PTSD and their cohabitating marital partners participated in 10 weeks of SAT treatment. Self-report, clinician ratings, and partner ratings of PTSD symptoms were obtained before the first session and after the tenth session of treatment. Veterans reported statistically significant reductions in self-reported, clinician-rated, and partner-rated effortful avoidance, emotional numbing, and overall PTSD severity. These data indicate that SAT offers promise as an effective treatment for PTSD avoidance symptoms.

Early symptom predictors of chronic distress in Gulf War veterans.

Although there is evidence that specific early hyperarousal, avoidance, and emotional numbing symptoms are associated with later posttraumatic stress disorder (PTSD) symptomatology among veterans, little is known about predictors of later non-PTSD-related psychological symptoms. One and 2 years after serving in the Gulf War, 348 military reservists were assessed for severity of war zone stress, PTSD, psychological distress, and stress-mediated physical complaints. Overall PTSD symptomatology and emotional numbing and hyperarousal symptom clusters increased over time, whereas re-experiencing and avoidance symptoms showed no change. Emotional numbing and hyperarousal symptoms at 1 year predicted generalized distress, depression, anxiety, hostility, and somatic symptoms at 2 years, whereas re-experiencing and avoidance symptoms did not. Findings highlight the importance of targeting early emotional numbing and hyperarousal symptom clusters to reduce longer-term psychological distress.

Assessment of response style in combat veterans seeking compensation for posttraumatic stress disorder.

This study examined response styles of veterans seeking compensation for PTSD (N = 204). Veterans were classified as having a valid or overreporting response style based on their scores on three MMPI-2 validity scales that measure overreporting F, F(p), F-K. Sixteen percent of veterans had valid scores on all three scales. The number of veterans classified as having an overreporting response style differed depending on which scale was used. This finding highlights the importance of using multiple validity scales to measure response style. Veterans who were and were not classified as overreporters were compared on measures of combat exposure, PTSD, and depression.

Differentiating overreporting and extreme distress: MMPI-2 use with compensation-seeking veterans with PTSD.

This purpose of this study was to examine overreporting on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) in compensation-seeking veterans with posttraumatic stress disorder (PTSD). A sample of veterans tested during a V.A. hospital compensation and pension exam were given the MMPI-2 and measures of PTSD, depression, and combat exposure. Veteran's MMPI-2s were only included in the analyses if their profile was extremely exaggerated, as measured by an F scale T score above 80, did not elevate the MMPI-2 VRIN and TRIN scales, and had a primary diagnosis of PTSD (n = 127). Using the Infrequency-Psychopathology, F(p), scale to distinguish overreporting from distress, it was found that 98 veterans elevated profiles due to distress, whereas 29 elevated due to overreporting, F(p) below and above 7, respectively. Differences between groups on MMPI-2 clinical scales and the other measures were assessed. Implications of these findings for assessing veteran response style and using the MMPI-2 with a PTSD population are discussed.