Treatment of anger problems in previously deployed post-911 veterans: A randomized controlled trial.

BACKGROUND: Problems with anger and aggression affect many veterans who have deployed to a warzone, resulting in serious impairment in multiple aspects of functioning. Controlled studies are needed to improve treatment options for these veterans. This randomized controlled trial compared an individually delivered cognitive behavioral therapy adapted from Novaco's Anger Control Therapy to a manualized supportive therapy to control for common therapeutic factors. METHODS: Ninety-two post-911 veterans deployed during Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or Operation New Dawn (OND) with moderate to severe anger problems were randomized to receive the cognitive behavioral intervention (CBI) or the supportive intervention (SI). Anger, aggression, multiple areas of functioning and quality of life were assessed at multiple time points inclu\ding 3- and 6-month follow-up. RESULTS: Hierarchical linear modeling (HLM) analyses showed significant treatment effects favoring CBI for anger severity, social and interpersonal functioning, and quality of life. The presence of a PTSD diagnosis did not affect outcomes. CONCLUSIONS: CBI is an effective treatment for OEF/OIF/OND veterans with anger problems following deployment, regardless of PTSD diagnosis.

Preliminary efficacy and mediators of interpersonal psychotherapy for reducing posttraumatic stress symptoms in an incarcerated population.

AbstractObjective: Incarcerated individuals have high rates of trauma exposure. IPT reduces posttraumatic stress disorder (PTSD) symptoms in non-incarcerated adults, but has not been examined in prison populations. Moreover, little is known about the mechanisms through which IPT reduces PTSD symptoms. The current study investigated the direct and indirect effects of IPT on PTSD symptoms. We hypothesized that IPT would decrease PTSD symptoms by enhancing social support and decreasing loneliness (theorized IPT mechanisms). Method: A sub-sample of trauma-exposed participants (n = 168) were drawn from a larger randomized trial (n = 181) of IPT for major depressive disorder among prisoners. We examined a series of mediation models using non-parametric bootstrapping procedures to evaluate the indirect effect of IPT on PTSD symptoms. Results: Contrary to hypotheses, the relation between IPT and PTSD symptoms was significantly mediated through improvements in hopelessness and depressive symptoms (mechanisms of cognitive behavioral interventions), rather than through social support and loneliness. Increased social support and decreased loneliness were associated with decreased PTSD symptoms, but IPT did not predict changes in social support or loneliness. Conclusions: IPT may reduce PTSD symptoms in depressed prisoners by reducing hopelessness and depression. (ClinicalTrials.gov number NCT01685294).

Phosphatidylethanol Levels Among Incarcerated Women: The Influence of Pre-incarceration Alcohol Consumption and Length of Abstinence.

BACKGROUND: Phosphatidylethanol (PEth) is a direct biomarker for alcohol that is formed shortly after alcohol use and may remain detectable in blood for weeks after alcohol consumption. There is little research on alcohol use factors that influence PEth elimination, especially among women. METHODS: Data were collected from 116 alcohol use-disordered women who were recently incarcerated. We used a 2-part model with logistic and linear components to examine whether alcohol consumption in the 2 weeks prior to incarceration and days since last alcoholic drink (operationalized as abstinence days prior to incarceration + days incarcerated) were associated with PEth detectability (>8 ng/ml) and level (ng/ml) in blood. RESULTS: Participants reported drinking an average of 10 drinks per day in the 2 weeks prior to incarceration. Days since last drink was negatively associated with PEth level (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.93; 0.99) and being PEth detectable (OR = 0.96, 95% CI = 0.91; 0.99). Quantity of alcohol consumed prior to jail admission was associated with PEth detection (OR = 1.08; 95% CI = 1.03; 1.16), but not PEth level. CONCLUSIONS: Days since last alcoholic drink and drinks per day both influenced PEth detectability, but only days since last drink predicted PEth level among a large sample of women with alcohol use disorder in the criminal justice system.

Bipolar I disorder with comorbid PTSD: Demographic and clinical correlates in a sample of hospitalized patients.

BACKGROUND: According to data from epidemiological and clinical samples, there are elevated rates of posttraumatic stress disorder (PTSD) among patients with bipolar disorder (BD). However, little is known about the clinical correlates that may distinguish patients with BD and comorbid PTSD from those without comorbid PTSD. The present study sought to elucidate those differences and examine factors, such as psychosis, history of suicide attempts, and comorbid personality disorders, which may predict comorbid PTSD in patients with BD-I. METHODS: We conducted a retrospective chart review of 230 psychiatric inpatients with BD-I. RESULTS: Patients with BD-I and comorbid PTSD were significantly more likely to be female, to be depressed (vs. manic), to have a comorbid personality disorder, and to have a history of suicide attempt. Also, BD-I patients with PTSD were significantly less likely to present for their inpatient hospital stay with psychosis. These effects remained significant after controlling for mood episode polarity, suggesting that findings were not fully explained by the higher incidence of depression in the comorbid PTSD group. CONCLUSIONS: Patients with BD-I and comorbid PTSD appear to be a high risk population with need for enhanced monitoring of suicidality. Clinical implications of these findings are discussed.

Posttraumatic Stress and Distress Tolerance: Associations With Suicidality in Acute-Care Psychiatric Inpatients.

Trauma and posttraumatic stress disorder (PTSD) symptomatology have been associated with suicidality, including ideation and behavior. The current investigation evaluated, in acute-care psychiatric inpatients, the mediating role of perceived (self-reported) distress tolerance in the association between PTSD symptom severity and suicidality, defined as a) suicidal ideation, intent, or behavior leading to current psychiatric hospitalization; b) self-reported severity of suicidal desire; and c) percentage of days of suicidality during current hospitalization. Participants were composed of 105 adults (55.2% women; mean age, 33.9; SD, 10.9) admitted to a public psychiatric acute-care inpatient hospital in a large metropolitan area; 52.3% of the participants were hospitalized for suicidality. Results indicated that PTSD symptom severity (and severity of each PTSD symptom cluster) may exert an indirect effect on suicidality, specifically suicidality as a basis for current hospital admission and self-reported severity of suicidal desire, through perceived distress tolerance. Effects were documented after controlling for theoretically relevant covariates.

Mostly Smokers: Identifying Subtypes of Emerging Adult Substance Users.

BACKGROUND: The concurrent use of marijuana and other substances among emerging adults (ages 18-25) is a major public health problem. This study examined if there are distinct subtypes of emerging adult marijuana users and if these are associated with demographic and substance use variables. METHODS: The design was a cross-sectional interview with a community sample of 1,503 emerging adults in the northeastern U.S. who reported last month marijuana use. We used latent class analysis (LCA) to identify distinct subtypes of emerging adults who used additional substances and examined predictors of the latent classes. RESULTS: We identified three distinct classes of emerging adults who use substances: "mostly smokers" (those who primarily use marijuana and nicotine), "moderate users" (those who primarily use marijuana and/or heavy episodic alcohol), and "polysubstance users." Polysubstance users had higher probabilities of use of all assessed substances (e.g. cocaine, opiates, sleep medications, stimulants, synthetic marijuana, and inhalants) than the other two groups. Not being currently enrolled in school and male gender were associated with mostly smokers and polysubstance users group status. CONCLUSIONS: We identified a distinct group of emerging adult marijuana users who primarily smoke marijuana and cigarettes, suggesting that there could be a shared vulnerability for risk of co-occurrence.

Emotional dysregulation and risky sex among incarcerated women with a history of interpersonal violence.

Incarcerated women, in comparison to nonincarcerated women, are at high risk for sexually transmitted infections (STIs) and many have experienced interpersonal violence. The psychological construct of emotional dysregulation-which includes heightened intensity of emotions, poor understanding of emotions, negative reactivity to emotion state, inability to control behaviors when experiencing emotional distress, and maladaptive emotion management responses-is a possible pathway to explain the link between interpersonal violence exposure and STI risk. The present study examined maladaptive emotion management responses for emotional dysregulation (i.e., avoidance and numbing, and dissociation) occurring in the context of risky sexual behavior. We collected qualitative data from 4 focus groups with a sample of n = 21 incarcerated women (aged 18+ years) from urban facilities in New England. Qualitative data were analyzed using a thematic analysis approach. Findings indicated that incarcerated women reported engaging in a variety of maladaptive responses for emotion management during sexual encounters. These maladaptive responses for emotion management appear to increase sexual risk behaviors and alter women's ability to implement STI protective behaviors, such as sexual negotiation and condom use. Preventive interventions to reduce sexual risk behaviors should incorporate strategies to promote emotional regulation among incarcerated women with histories of interpersonal violence.

Posttraumatic stress symptoms among adults caring for orphaned children in HIV-endemic South Africa.

There is growing evidence that mental health is a significant issue among families affected by AIDS-related parental deaths. The current study examined posttraumatic stress symptoms and identified risk factors among adults caring for AIDS-orphaned and other-orphaned children in an HIV-endemic South African community. A representative community sample of adults caring for children (N = 1,599) was recruited from Umlazi Township. Of the 116 participants who reported that a traumatic event was still bothering them, 19 % reported clinically significant posttraumatic stress symptoms. Of the 116 participants, caregivers of AIDS-orphaned and other-orphaned children were significantly more likely to meet threshold criteria for PTSD (28 %) compared to caregivers of non-orphaned children (10 %). Household receipt of an old age pension was identified as a possible protective factor for PTSD symptoms among caregivers of orphaned children. Services are needed to address PTSD symptoms among caregivers of orphaned children.

Trauma-related correlates of alcohol use in recently deployed OEF/OIF veterans.

The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma-related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in-person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co-occurring PTSD and AUD among veterans postdeployment.

Evaluation of Posttraumatic Stress Disorder and Acute Stress Disorder VA/DoD Clinical Practice Guidelines Training.

INTRODUCTION: This study evaluated the use of an online learning platform [Joint Knowledge Online (JKO)] for dissemination of the Veterans Affairs and Department of Defense Clinical Practice Guidelines for Management of Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD). User satisfaction with the training program was assessed, users were asked to estimate their knowledge base about PTSD and ASD, and users provided comments about how they might use the course material in their clinical practice. MATERIALS AND METHODS: A total of 4,442 users took at least one of three courses offered via JKO related to the PTSD Clinical Practice Guidelines (CPG) between July 1, 2019 and June 25, 2020. A total of 1,663 users took the post-test after the JKO courses and 235 applied to a second website (J7) which granted Continuing Education (CE) credits. Data were gathered from the JKO post-course survey, as well as the J7 course survey, which also asked for respondents' written comments. RESULTS: User satisfaction was analyzed using the JKO survey Likert scale data for each course, and results found most users rated the courses as "good" or "great." Users were also asked to evaluate their knowledge about PTSD management before and after the course. Results from all three courses showed a statistically significant change in pre-post knowledge with a medium effect size. Thematic analysis was performed on the write-in comments from each course. Comments indicated participants found the assessment tools provided in the courses to be of particular value. CONCLUSIONS: The VA/DoD's online learning platform (JKO) was a user-friendly, effective tool for training users on PTSD and ASD clinical practice guidelines. Users were satisfied with their experience of the trainings on JKO and improved their knowledge base about the CPG. This study did not evaluate patient data for CPG compliance, but the future study may benefit from these outcomes to demonstrate provider adherence to the guidelines.

Military behavioral health technicians: Multiple relationship dilemmas and recommendations for supervision.

Enlisted behavioral health technicians (BHTs) in the military provide behavioral health care to service members worldwide under the supervision of licensed providers. Given their paraprofessional role, BHTs serve in close social and personal proximity to their patient population and may be at risk for engaging in multiple relationships. In order to guide supervision of BHTs, a framework should be leveraged that examines power differentials, the duration of treatment, the nature of termination, the compatibility of multiple roles, supervisor consultation, and informed consent. Several illustrative scenarios are provided to demonstrate the utilization of this model in a manner that is sensitive to the unique nature of BHTs serving in the military cultural setting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

College women's perceived risk to experience sexual victimization: a prospective analysis.

This study implemented a prospective design to explore college women's perceived risk to experience sexual victimization over a 2-month interim (N = 143). Compared to women without such histories, women with a history of unwanted sexual contact via arguments/ pressure, or a history of unwanted sexual intercourse via administration of alcohol/drugs reported higher perceived risk to subsequently experience these forms of victimization. Compared to women who were not victimized, women who subsequently experienced unwanted sexual intercourse via administration of alcohol/drugs or arguments/pressure reported higher levels of risk to experience these forms of victimization. Controlling for victimization history, higher levels of risk to experience sexual intercourse over the interim via arguments predicted this form of victimization over the follow-up. Implications are discussed.

A review of research-supported group treatments for drug use disorders.

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

Advances in repetitive transcranial magnetic stimulation for posttraumatic stress disorder: A systematic review.

Repetitive transcranial magnetic stimulation (rTMS) as a treatment for posttraumatic stress disorder (PTSD) has gained interest over the past two decades. However, it has yet to be recommended in major treatment guidelines. We conducted a systematic review of randomized controlled trials to examine the efficacy of rTMS for PTSD. Thirteen studies with 549 participants were included in this review. We compared the effects of (1) rTMS versus sham, and (2) high-frequency (HF) versus low-frequency (LF) rTMS, on posttreatment PTSD scores and other secondary outcomes. We calculated the standardized mean differences (SMD) to determine the direction of effects, and unstandardized mean differences to estimate the magnitude of efficacy. At post-treatment, rTMS was superior to sham comparison in reducing PTSD (SMD = -1.13, 95% CI: -2.10 to -0.15) and depression severity (SMD = -0.83, 95% CI: -1.30 to -0.36). The quality of evidence, however, was rated very low due to small samples sizes, treatment heterogeneity, inconsistent results, and an imprecise pooled effect. HF rTMS was associated with slightly improved, albeit imprecise, outcomes compared to LF rTMS on PTSD (SMD = -0.19, 95% CI: -1.39 to 1.00) and depression (SMD = -1.09, 95% CI: -1.65 to -0.52) severity. Further research is required to advance the evidence on this treatment.

Sex differences in the factor structure of a modified Sexual Experiences Questionnaire.

Sexual harassment has long been a problem in educational, employment, and military populations. It is unclear whether existing questionnaires used to measure sexual harassment in the U.S. military--particularly, derivatives of the Sexual Experiences Questionnaire--perform similarly in men and women. Using exploratory factor analyses in a mixed sample of active duty troops and veterans (289 men, 181 women), sex differences were found in one version's factor structure. Implications and suggestions for improving the validity of the questionnaire for men are offered.

Assessing Autism Spectrum Disorder in Intellectually Able Adults with the Personality Assessment Inventory: Normative Data and a Novel Supplemental Indicator.

Differential diagnosis of autism spectrum disorder (ASD) among intellectually-able adults often presents a clinical challenge, particularly when individuals present in crisis without diagnostic history. The Personality Assessment Inventory (PAI) is a multiscale personality and psychopathology instrument utilized across clinical settings, but to date there are no published normative data for use of the PAI with adults with ASD. This study provides normative PAI data for adults diagnosed with ASD, with effect size comparisons to the PAI clinical standardization sample and an inpatient sample. Additionally, a discriminant function was developed and cross-validated for identification of ASD-like symptomatology in a clinical population, which demonstrates promise as a screening tool to aid in the identification of individuals in need of specialized ASD assessment.

Impact of prior Operation Enduring Freedom/Operation Iraqi Freedom combat duty on mental health in a predeployment cohort of National Guard soldiers.

OBJECTIVES: The goal was to examine the impact of prior Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat deployment on reported psychiatric and somatic symptoms among National Guard/Reserve (NGR) soldiers 1 month before deployment to Iraq. METHOD: 522 NGR soldiers completed a survey assessing predeployment risk and resilience factors as well as current levels of PTSD, depressive, and somatic symptoms. RESULTS: Overall, soldiers reported few psychiatric symptoms present before deployment to Iraq. However, compared to soldiers preparing for their first deployment to Iraq, soldiers previously deployed to OEF/OIF reported more PTSD, depressive, and somatic symptoms. Previously OEF/OIF deployed soldiers reported lower perceptions of unit social support, but reported no differences in perceptions of preparedness or concerns about family disruptions. Implications for interventions and training with military personnel before deployment as well as future longitudinal research directions are discussed.

On counterbalancing of symptom-reporting in trauma surveys.

Some traumatic stress research surveys are potentially subject to context effects, such as priming, because they include questions about traumatic experiences and trauma-related symptoms within the same survey. In this study, asking about traumatic experiences before or after asking about PTSD influenced symptom reporting was investigated in a sample of 424 National Guard soldiers. Results indicate ordering of symptom measures immediately before or after reports of combat experiences did not influence reports of PTSD symptoms. Implications of results are discussed.

Childhood maltreatment and post-deployment psychological distress: The indirect role of emotional numbing.

OBJECTIVE: Childhood maltreatment is an increasingly established predictor of psychological problems. However, limited research addresses pathways though which childhood maltreatment influences the mental health of military personnel following deployment. The current study investigated the direct, and indirect through emotional numbing, relations between childhood maltreatment and psychological distress of recently deployed veterans. METHOD: For a sample of 131 predominantly White, male Operation Iraqi Freedom/Operation Enduring Freedom members of U.S. Army National Guard and Reserve units, a path model was used to test the direct and indirect (through numbing) roles of childhood maltreatment on distress. RESULTS: Results showed that childhood maltreatment was not significantly directly associated with psychological distress one-year post-deployment but was indirectly related to distress by way of emotional numbing symptoms. CONCLUSIONS: Our findings suggest that childhood maltreatment may serve to influence returning veterans' experiences of psychological distress indirectly through increased emotional numbing following deployment. The importance of attending to emotional numbing symptoms among veterans with experiences of childhood maltreatment after deployment is highlighted. (PsycINFO Database Record

Treatment of trauma related anger in operation enduring freedom, operation Iraqi freedom, and operation New Dawn veterans: Rationale and study protocol.

BACKGROUND: Problems with anger and aggression are highly prevalent in Veterans of multiple war eras, including the most recent conflicts in Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF). The consequences of these problems, such as increased rates of divorce, domestic violence, occupational instability, arrests and incarceration, are often devastating. Despite the seriousness of these problems, relatively little is known about effective treatments for anger in Veterans. METHOD AND DESIGN: This paper describes the rationale and study protocol of a randomized controlled trial comparing an adapted cognitive behavioral intervention (CBI) with an active control condition (supportive intervention, SI) for the treatment of anger problems in OEF/OIF Veterans. The sample includes 92 OEF/OIF Veterans, randomized to CBI or SI. Both treatments include 12 weekly, 75-min individual sessions. Participants are assessed at baseline, after sessions 4 and 8, at post-treatment, and at 3 and 6 months post-treatment. Primary outcomes are reduction in anger and aggression; secondary outcomes are improved functioning and quality of life. We hypothesize that CBI will be associated with significantly more improvement than SI on primary and secondary measures. DISCUSSION: Findings from this study will help to address the gap in evidence for effective treatments for anger in Veterans. The use of an active control condition will provide a stringent test of the effects of CBI beyond that of common factors of psychotherapy such as therapeutic relationship, mobilization of hope, and support. Findings have the potential to improve treatment outcomes for Veterans struggling with post-deployment anger problems.