Massed written exposure therapy delivered to veterans with posttraumatic stress symptoms on an acute inpatient mental health unit.

Written exposure therapy (WET) is a brief, manualized trauma-focused treatment typically delivered in five individual weekly sessions. Given the brevity and effectiveness of WET, researchers have begun to focus on its delivery in a massed format. However, only one case study examining massed delivery has been published to date. As such, the objective of the current study was to examine the acceptability, feasibility, and preliminary effectiveness of massed WET among veterans with a trauma- and stressor-related disorder receiving care on an acute inpatient mental health unit. Veterans (N = 26) were assessed prior to, immediately after, and 1 month following massed WET. Most veterans found massed WET to be useful and acceptable. Recruitment and retention rates suggested that the treatment was feasible. Notably, the results revealed statistically significant reductions in overall posttraumatic stress symptoms, ηp 2 = .81, p < .001; depressive symptoms, ηp 2 = .71, p < .001; and functional impairment, ηp 2 = .42, p = .002. These findings add to a growing body of literature highlighting the preliminary effectiveness of WET across various settings, populations, and delivery formats. Limitations include the small sample size and uncontrolled design.

Acceptability, feasibility, and utility of a safety aid reduction treatment in underserved veterans: a pilot investigation.

Access to mental health services, particularly for veterans residing in underserved communities, remain scarce. One approach to addressing availability barriers is through the use of group-based transdiagnostic or unified treatment protocols. One such protocol, Safety Aid Reduction Treatment (START), previously termed False Safety Behavior Elimination Treatment (FSET), has received increasing empirical support. However, prior research has only examined this treatment among civilians with a primary anxiety diagnosis. Thus, the purpose of the current study was to replicate and extend prior research by examining the acceptability, feasibility, and utility of START among veterans, particularly those living in underserved communities, and across a wider array of diagnoses. Veterans (n = 22) were assessed prior to, immediately after, and one month following the 8-week treatment. The majority of veterans found START useful and acceptable. Additionally, recruitment and retention rates suggest that the treatment was feasible. Notably, results revealed reductions in overall anxiety, depression, and safety aid usage, which were maintained throughout the brief follow-up period. These findings add to a growing body of literature highlighting the utility of transdiagnostic approaches in the amelioration of various anxiety and related disorders. Limitations include the small sample size and uncontrolled design.

Posttraumatic stress and substance use among military veterans: Associations with distress intolerance and anxiety sensitivity.

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is highly prevalent among military veterans and represents a difficult-to-treat comorbidity. Distress intolerance (DI; i.e., the perceived inability to tolerate negative emotional states) and anxiety sensitivity (AS, i.e., the fear of anxiety-related sensations) are two promising targetable mechanisms with potential to predict and improve treatment outcomes for veterans with PTSD/SUD. We hypothesized that PTSD symptom severity would be related to (a) alcohol use severity and (b) drug use severity through DI and AS, evaluated concurrently. Participants included 120 military veterans (98.3% male; Mage = 41.41, SD = 10.77) presenting for psychological services at a Veterans Affairs PTSD/SUD clinic. Results indicated that PTSD symptom severity was related to alcohol use severity through AS, but not DI; and PTSD symptom severity was related to drug use severity through DI, but not AS. Clinical and research implications are discussed.

Anxiety sensitivity and substance use: Differential levels across individuals primarily using opioids, cannabis, or stimulants.

BACKGROUND: The purpose of the current study was to compare levels of anxiety sensitivity (AS) across a treatment-seeking sample of individuals primarily using opioids, stimulants, or cannabis. Consistent with the idea that individuals high in AS may be motivated to use substances with real or perceived anxiolytic properties, it was hypothesized that individuals primarily using opioids or cannabis would evidence higher levels of AS compared to individuals primarily using stimulants. METHODS: The sample consisted of 110 veterans (including 29 individuals primarily using opioids, 42 primarily using cannabis, and 39 primarily using stimulants) presenting for psychological services to a Posttraumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD) specialty clinic at a large southeastern Veteran Affairs (VA) hospital. RESULTS: AS levels varied by group with individuals primarily using stimulants evidencing the highest levels followed by those primarily using opioids and then those primarily using cannabis. Individuals primarily using stimulants had statistically significantly higher levels of AS physical concerns compared to individuals primarily using cannabis but not those primarily using opioids. Further, individuals who primarily use opioids did not differ from those primarily using cannabis. CONCLUSIONS: Taken together, these findings call into question the notion that AS may be negatively related to the use of substances that have anxiogenic properties.

Intolerance of uncertainty and DSM-5 PTSD symptoms: Associations among a treatment seeking veteran sample.

Intolerance of uncertainty (IU), defined as an inability to tolerate the unpleasant response triggered by the observed absence of information, has received increased empirical attention in recent years. The contribution of this cognitive behavioral construct to the etiology and maintenance of various anxiety disorders has become increasingly recognized. However, the relationship between IU and other affective disorders, including posttraumatic stress disorder (PTSD), remains largely unexplored. The current study sought to examine the relationship between IU and overall PTSD symptom and cluster severity using an outpatient sample of veterans (N = 116) assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) PTSD symptom structure. Results revealed that IU was significantly associated with overall PTSD symptom severity, above and beyond relevant covariates. Further, IU was significantly associated with the PTSD avoidance and hyperarousal clusters. Prospective IU, rather than inhibitory IU, accounted for these unique associations. These findings add to a growing body of literature establishing IU as a transdiagnostic risk factor and point to the importance of future research on the role of IU in contributing to and/or maintaining PTSD symptoms.

Using a Clinician-Administered Interview to Examine the Overlap in Posttraumatic Stress Disorder Criteria D and E.

Although the diagnosis of posttraumatic stress disorder (PTSD) is often criticized for including symptoms that overlap with one another, only one study has explored the impact of symptom reporting. Using a clinician-rated interview for PTSD (N = 558), the current study examined overlap between PTSD criteria D1, D2, and D3 ("target D symptoms") and criterion E symptoms of similar content (i.e., E1 and E3). Furthermore, their impact on meeting criterion and disorder cutoffs was examined. Results revealed that target symptoms were endorsed in conjunction more than half the time. Criteria D and E also were often coded together. Removal of target D symptoms resulted in 24.7% of participants no longer meeting criterion D, but no reduction in the diagnosis of PTSD. This article is one of the first to report the functioning of the new criterion D symptoms, and the results have diagnostic implications for research and clinical work.

Examining various subthreshold definitions of PTSD using the Clinician Administered PTSD Scale for DSM-5.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) includes Other- and Unspecified- Trauma and Stressor-Related Disorders to capture subthreshold Posttraumatic Stress Disorder (PTSD) symptoms. However, the DSM-5 does not specify the number or type of symptoms needed to assign them. The purpose of the current study was to extend our understanding of subthreshold PTSD by comparing four commonly used definitions adapted to the DSM-5 PTSD criteria in an outpatient treatment-seeking sample. METHODS: Veterans (N = 193) presenting to PTSD clinics were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Participants reported a criterion A traumatic event, but did not meet criteria for threshold-PTSD. We hypothesized that the number of veterans captured would be highest when fewer specific criterion sets were required by the subthreshold definition. RESULTS: Our hypothesis was upheld in that the more criteria required by the subthreshold PTSD definition, the lower the number of veterans counted within the group. LIMITATIONS: The study consisted primarily of trauma treatment-seeking male veterans, with chronic PTSD symptoms. In addition, the sample size was small and was collected as part of routine clinical care. CONCLUSIONS: These results support previous contentions around careful decision making when defining what constitutes subthreshold PTSD in research and clinical work. It also points to the need for continued research to better understand the diagnostic and treatment implications of subthreshold PTSD.

27 ways to meet PTSD: Using the PTSD-checklist for DSM-5 to examine PTSD core criteria.

Posttraumatic stress disorder (PTSD) has been criticized for including symptoms that substantially overlap with other depression and anxiety disorders. To address this concern, Brewin et al. (2009) reformulated the diagnosis around a core symptom set. Although several studies have examined the utility of the core criteria in predicting diagnostic status, none have done so using a self-report screening instrument. The sample included 617 veterans presenting for outpatient psychological services. As a part of the intake process, veterans completed the PTSD Checklist for DSM-5 (PCL-5) and were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Veterans meeting core criteria on the PCL-5 were over 22 times more likely to meet PCL-5 diagnosed PTSD than veterans who met the core criteria on the PCL-5 but did not meet PCL-5 diagnosed PTSD (OR = 22.94; CI [12.76, 41.25]). Further, veterans who met core criteria on the PCL-5 were over 2 times more likely (OR = 2.34; 95.0% CI [1.53, 3.59]) to meet CAPS-5 diagnosed PTSD than veterans who met the core criteria on the PCL-5 but did not meet CAPS-5 diagnosed PTSD. Findings from the current study have implications for the assessment and classification of PTSD.

The relationship between DSM-5 PTSD symptom clusters and alcohol misuse among military veterans.

BACKGROUND AND OBJECTIVES: Prior research has revealed a strong relationship between Posttraumatic Stress Disorder (PTSD) and alcohol misuse. However, previous attempts to understand nuanced associations between PTSD symptom clusters and alcohol misuse within military veteran samples have produced mixed results. In an attempt to better understand the associations between PTSD and alcohol misuse, the current study examined the unique relationships between the newly classified Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) PTSD symptom clusters and alcohol misuse in an outpatient sample of military veterans seeking treatment for PTSD and Substance Use Disorders. METHODS: Veterans (N = 100) were administered a brief battery of self-report questionnaires prior to receiving psychological services to aid in diagnostic assessment and treatment planning. RESULTS: Hierarchical regression analyses revealed that PTSD intrusions (cluster B), negative alterations in cognition and mood (cluster D), and arousal/reactivity (cluster E) symptoms were associated with alcohol misuse. DISCUSSION AND CONCLUSIONS: The positive association between alcohol misuse and PTSD symptom severity is consistent with a broader body of literature demonstrating the co-occurrence of these disorders, particularly in military samples. SCIENTIFIC SIGNIFICANCE: Increased alcohol consumption may interfere with current front-line treatments for PTSD, which encourages patients to experience a full range of emotions. As such, future research should explore the impact of substance use on the effectiveness of trauma focused treatments in the alleviation of DSM-5 PTSD symptoms. (Am J Addict 2018;27:23-28).

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.

Posttraumatic stress disorder and suicidal ideation, plans, and impulses: The mediating role of anxiety sensitivity cognitive concerns among veterans.

BACKGROUND: Although the relationship between posttraumatic stress disorder (PTSD) and suicide has been firmly established, research on underlying mechanisms has been disproportionately low. The cognitive concerns subscale of anxiety sensitivity (AS), which reflects fears of cognitive dyscontrol, has been linked to both PTSD and suicide and thus may serve as an explanatory mechanism between these constructs. METHODS: The sample consisted of 60 male veterans presenting to an outpatient Veteran Affairs (VA) clinic for psychological services. Upon intake, veterans completed a diagnostic interview and brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. RESULTS: Results revealed a significant association between PTSD symptom severity and higher suicidality (i.e., ideation, plans, and impulses), even after accounting for relevant demographic and psychological constructs. Moreover, AS cognitive concerns mediated this association. LIMITATIONS: Limitations include the small sample size and cross-sectional nature of the current study. CONCLUSIONS: These findings add considerably to a growing body of literature examining underlying mechanisms that may help to explain the robust associations between PTSD and suicide. Considering the malleable nature of AS cognitive concerns, research is needed to determine the extent to which reductions in this cognitive risk factor are associated with reductions in suicide among at risk samples, such as those included in the present investigation.

Sometimes Less is More: Establishing the Core Symptoms of PTSD.

Historically, the symptoms of posttraumatic stress disorder (PTSD) have garnered attention and controversy due to symptom overlap with other disorders. To improve diagnostic specificity, researchers have proposed to reformulate PTSD symptoms into a parsimonious set of core criteria. The core symptoms consisted of recurrent distressing dreams or flashbacks; internal or external avoidance; and hypervigilance or exaggerated startle. The purpose of this study was to examine a previously proposed set of "core" PTSD criteria in identifying cases of PTSD within a veteran sample. Veterans (N = 383) presenting to a Veterans Affairs (VA) Medical Center PTSD clinic for psychological services were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). A logistic regression analysis revealed that the core criteria accurately identified 79% of veterans with PTSD (OR = 11.57). Findings support a parsimonious set of core criteria in the assessment and diagnosis of PTSD. Future studies should replicate these findings in diverse, nonveteran samples.

Face to face but not in the same place: A pilot study of prolonged exposure therapy.

This pilot study examined use of smartphone technology to deliver prolonged exposure (PE) therapy to patients with posttraumatic stress disorder (PTSD) with geographic limitations hindering in-person therapy. The primary goal was to examine the feasibility and acceptability of using video teleconferencing (i.e., computer-based and iPhone 4 streaming technology), with a secondary goal of examining clinical outcomes of PE delivered via teleconferencing compared with treatment as usual (TAU) on PTSD and depressive/anxious symptom reduction. Rural veterans (N = 27) were randomized to receive PE by computer teleconferencing at a Veterans Administration community clinic, PE by an iPhone issued for the duration of the study, or TAU provided by a referring clinician. To examine the research goals, we collected data on the number of referrals to the study, number of patients entering the study, and number completing psychotherapy and documented pragmatic and technical issues interfering with the ability to use teleconferencing to deliver PE; results are discussed. In addition, measures of symptom change examined clinical outcomes. Results indicated decreases in PTSD symptoms in veterans who completed PE therapy via teleconferencing; however, there was significantly more attrition in these groups than in the TAU group.

Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms.

Anxiety sensitivity (AS), a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite these associations, little research has examined the relations between AS subfactors (eg physical, cognitive, and social) and PTSD symptoms and none have examined these associations in the context of DSM-5 (Diagnostic Statistical Manual of Mental Disorders, Fifth Edition) PTSD clusters (ie intrusion, avoidance, negative alterations in cognitions/mood, and arousal). Participants included 50 veterans presenting to an outpatient Veteran Affairs Clinic for psychological services. Upon intake, veterans completed a brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. Results revealed unique associations between lower order AS dimensions, in particular the cognitive concerns dimension, and all four DSM-5 PTSD symptom clusters. Given the malleable nature of AS cognitive concerns, as well as the growing number of veterans in need of care, future research should determine the extent to which targeting this cognitive risk factor reduces PTSD symptom severity among veterans.

Spiritual struggles and suicide in veterans seeking PTSD treatment.

OBJECTIVE: Research indicates that trauma can precipitate a loss of faith and struggles in the spiritual domain, leading to increased suicide risk. However, little is known about the specific types of spiritual struggles that may confer risk. This brief report examines the utility of a newly developed measure, the Religious and Spiritual Struggles Scale in gauging suicide risk in veterans. METHOD: As part of their initial assessment, 52 veterans presenting to an outpatient posttraumatic stress disorder and substance use clinic were administered self-report symptom measures. RESULTS: Multiple regression analyses revealed that divine struggles and struggles with the ultimate meaning were significantly and positively associated with increased suicide risk, even after controlling for relevant demographic (e.g., being male and Caucasian) and psychological variables (e.g., posttraumatic stress disorder symptoms as well as alcohol and substance use symptoms). CONCLUSIONS: Results provide preliminary support for use of the Religious and Spiritual Struggles Scale with veterans and highlight the potential utility in assessing for spiritual struggles when assessing suicide risk. (PsycINFO Database Record

Examining potential overlap of DSM-5 PTSD criteria D and E.

The Diagnostic and Statistical Manual, Fifth Edition-5 (DSM-5) has adopted a four-factor symptom model for Posttraumatic Stress Disorder (PTSD) that includes new symptom additions in criterion D (D2, D3, D4), negative alterations in cognition and mood. This article examines potential overlapping endorsement of these symptoms amongst one another and with the behavioral symptoms within PTSD criterion E (E1 and E3; alterations in arousal and reactivity), through the lenses of cognitive-behavioral theory. Responses of veteran participants (N=320) completing the PTSD Checklist-5 were used to determine overlap in symptom reporting. We conducted a series of direct logistic regressions to determine the predictive ability of meeting the criterion D or E symptoms based on endorsement of the target D symptoms (D2, D3, D4). Results suggest that the new cognitive and emotional symptoms of criterion D have significant overlapping content, and that thought-related symptoms are often endorsed in conjunction with their behavioral counterpoint (D2/E3; D4/E1). Our results suggest that DSM-5 criterion D symptoms may not be central to the diagnostic structure of PTSD. These symptoms add complexity and difficulty to diagnosing PTSD without adding much unique content.