Service utilization among adolescents seeking trauma-related care: Differences by risk for suicide and ethnoracial background.

Adolescents from ethnoracially minoritized backgrounds increasingly report high rates of attempted suicide, trauma exposure, and limited access to mental healthcare services. However, less is known regarding their use of services across different youth-serving systems. This study examines the associations and interactions between self-injurious thoughts and behaviors (SITBs), race/ethnicity, and service sector utilization (mental healthcare, general healthcare, school, and social services) among a sample of trauma-exposed and treatment-seeking adolescents. Participants were treatment-seeking adolescents (N = 4406) ages 12-17 from the National Child Traumatic Stress Network Core Data Set who had available data for SITBs, race/ethnicity, services utilized, and other key variables. Mixed effects logistic regression was used to examine main and interactive effects for whether adolescents' race/ethnicity and SITBs were associated with service utilization in each of the identified service sectors. SITBs were associated with adolescents' utilization of mental healthcare (OR = 1.38 p < 0.001), general healthcare (OR = 2.30; p < 0.001), and school services (OR = 1.38 p < 0.001). NH Black adolescents reporting SITBs were less likely to use mental health services than other NH Black youths (OR = 0.53; p = 0.004). Hispanic adolescents reporting SITBs were more likely to utilize healthcare services than other Hispanic youths (OR = 1.51; p = 0.039). Trauma-exposed adolescents reporting SITBs are more likely to utilize mental healthcare, general healthcare, and school-based services than other trauma-exposed adolescents. However, NH Black adolescents experiencing SITBs may face additional barriers to utilizing mental healthcare services. Findings can be used to develop nursing practices and policies to address barriers faced by adolescents reporting SITBs.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders.

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Toward an empirically based Developmental Trauma Disorder diagnosis and semi-structured interview for children: The DTD field trial replication.

OBJECTIVE: Developmental trauma disorder (DTD) is a childhood psychiatric syndrome designed to include sequelae of trauma exposure not fully captured by PTSD. This study aimed to determine whether the assessment of DTD with an independent sample of children in mental health treatment will replicate results from an initial validation study. METHODS: The DTD semi-structured interview (DTD-SI) was administered to a convenience sample in six sites in the United States (N = 271 children in mental health care, 8-18 years old, 47% female, 41% Black or Latinx) with measures of trauma history, DSM-IV PTSD, probable DSM-IV psychiatric diagnoses, emotion regulation/dysregulation, internalizing/externalizing problems, and quality of life. Confirmatory factor (CFA) and item response theory (IRT) analyses tested DTD's structure and DTD-SI's information value. Bivariate and multivariate analyses tested DTD's criterion and convergent validity. RESULTS: A three-factor solution (i.e., emotion/somatic, attentional/behavioral, and self/relational dysregulation) best fit the data (CFI = 0.91; TLI = 0.89; BIC = 357.17; RMSEA = 0.06; SRMR = 0.05). DTD-SI items were informative across race/ethnicity, gender, and age with three exceptions. Emotion dysregulation was the most informative item at low levels of DTD severity. Non-suicidal self-injury was rare but discriminative in identifying children with high levels of DTD severity. Results supported the criterion and convergent validity of the DTD construct. CONCLUSION: This replication provides empirical support for DTD as a construct and potential psychiatric syndrome, and the DTD-SI's validity as a clinical research tool.

Childhood trauma, attachment orientation, and complex PTSD (CPTSD) symptoms in a clinical sample: Implications for treatment.

Although there has been significant work on the association between posttraumatic stress disorder (PTSD) and attachment orientation, this is less the case for complex PTSD (CPTSD). The primary aim of this paper was to assess the strength of the association between the four adult attachment styles (i.e., secure, dismissing, preoccupied, and fearful) and severity of CPTSD symptoms (i.e., symptoms of PTSD and disturbances in self-organization [DSO]). We hypothesized that attachment orientation would be more strongly associated with DSO symptoms compared to PTSD symptoms. A trauma exposed clinical sample (N = 331) completed self-report measures of traumatic life events, CPTSD symptoms, and attachment orientation. It was found that secure attachment and fearful attachment were significantly associated with DSO symptoms but not with PTSD symptoms. Dismissing attachment style was significantly associated with PTSD and DSO symptoms. Preoccupied attachment was not significantly associated with CPTSD symptoms. Treatment implications for CPTSD using an attachment framework are discussed.

Temporal trends in health worker social media communication during the COVID-19 pandemic.

During the COVID-19 pandemic, healthcare professionals are exposed to extreme hazards and workplace stressors. Social media postings by physicians and nurses related to COVID-19 from January 21 to June 1, 2020 were obtained from the Reddit website. Topic modeling via Latent Dirichlet Allocation (LDA) using a machine-learning approach was performed on 1723 documents, each posted in a unique Reddit discussion. We selected the optimal number of topics using a heuristic approach based on examination of the rate of perplexity change (RPC) across LDA models. A two-step multiple linear regression was done to identify differences across time and between nurses versus physicians. Prevalent topics included excessive workload, positive emotional expression and collegial support, anger and frustration, testing positive for COVID-19 and treatment, use of personal protective equipment, impacts on healthcare jobs, disruption of medical procedures, and general healthcare issues. Nurses' posts initially reflected concern about workload, personal danger, safety precautions, and emotional support to their colleagues. Physicians posted initially more often than nurses about technical aspects of the coronavirus disease, medical equipment, and treatment. Differences narrowed over time: nurses increasingly made technical posts, while physicians' posts increasingly were in the personal domain, suggesting a convergence of the professions over time.

The psychometric properties of the adolescent dissociative experiences scale (A-DES) in a sample of Portuguese at-risk adolescents.

Dissociation is a process that often occurs as a sequela of psychological trauma, and it is interrelated with psychological and behavioral problems. In the at-risk adolescent population, dissociation is often underdiagnosed and undertreated. Having reliable measures to assess this phenomenon can help in identifying adolescents at-risk and improve treatment outcomes. This study assessed the psychometric properties of the Adolescent Dissociative Experiences Scale (A-DES) with a sample of 402 Portuguese adolescents recruited from three at-risk populations. Participants completed self-report measures of trauma exposure, posttraumatic symptoms, psychological and behavioral problems, and the A-DES. A subset of the sample also completed test-retest measures. Confirmatory factor analyses revealed a best-fitting 3-factor model. Analyses revealed good internal consistencies and good agreement test-retest reliability for the scale overall and the factor-based sub-scales. Construct and predictive validity was supported with results showing that A-DES discriminates between youth reporting high versus low levels of cumulative trauma exposure and youth who meet or do not meet criteria for a probable PTSD diagnosis. Study findings replicate prior research supporting a 3-factor model of dissociation and the usefulness of A-DES to identify adolescents with dissociative symptoms. Clinical and research implications are discussed.

Introduction to the Special Issue: Disproportionate trauma, stress, and adversities as a pathway to health disparities among disenfranchised groups globally.

Globally, individuals and communities that are marginalized based on their identities are at heightened risk for exposure to traumatic stress and socioeconomic hardship. Marginalization and disproportionate risk for many types of adversities correspond with disparities in physical health, mental health, and overall well-being. Together, the 12 empirical studies, one systematic review, and commentary in this special issue of the Journal of Traumatic Stress highlight the impact of discrimination and disproportionate adversity among groups marginalized based on race, ethnicity, nativity, caste, gender identity, sexual orientation, economic status, and medical status. Although most studies in this issue focus on the United States, the articles that focus on disparities and risk factors in India, El Salvador, Uganda, and Burundi provides a multicontinent global perspective. The global perspective, including the impact of the global pandemic, invites further examination of how disproportionate exposure to traumatic stress and adversity are associated with inequitable burden and health disparities worldwide. This special issue further highlights the developmental and multigenerational burden of systemic marginalization by including studies of children, young adults, adults, and parent-child dyads. Pathways for change and intervention are illustrated through a liberatory consciousness perspective, with one study utilizing liberatory media skills (e.g., positive media images and messages) to mitigate the adverse effects of trauma exposure on at-risk young adults of color. Worldwide, research on the effects of trauma, stress, and adversities must examine contextual factors (e.g., economic hardship), marginalization (e.g., discrimination, identity factors), and the differential impact on health among individuals and communities.

Developmental Trauma Disorder: A Legacy of Attachment Trauma in Victimized Children.

Developmental trauma disorder (DTD) and posttraumatic stress disorder (PTSD) have been found to have both shared and unique traumatic antecedents. The present study was an independent replication, with the DTD Structured Interview and the Traumatic Events Screening Instrument administered to 271 children in mental health treatment in six U.S. sites. On an unadjusted basis, DTD (27.3% prevalence, N = 74) and PTSD (40.2% prevalence, N = 109) both were associated with traumatic physical assault or abuse, family violence, emotional abuse, caregiver separation or impairment, and polyvictimization. After controlling for PTSD, DTD was associated emotional abuse, OR = 2.9, 95% CI [1.19, 6.95], and traumatic separation from a primary caregiver, OR = 2.2, 95% CI [1.04. 4.60], both of which also were associated with caregiver impairment, physical assault/abuse, and witnessing family/community violence. Three traumatic antecedents associated with PTSD were not associated with DTD: noninterpersonal trauma, sexual trauma, and traumatic loss. Children exposed to both traumatic victimization and attachment trauma (36.2%) or attachment trauma alone (32.5%) were more likely than children exposed only to victimization (17.5%) or those with no history of victimization or attachment trauma (8.1%) to meet the symptom criteria for DTD, χ²(3, N = 271) = 17.68, p < .001. Study findings replicate and extend prior DTD field trial study results, showing that, although PTSD and DTD share traumatic antecedents, DTD is uniquely associated with traumatic emotional abuse and caregiver separation. Further research is needed to examine how specific trauma types contribute to the risk, course, and severity of DTD.

Interpersonal Trauma Exposure and Interpersonal Problems in Adolescent Posttraumatic Stress Disorder.

Traumatic experiences have been differentiated as interpersonal (i.e., the direct result of actions by other people) or noninterpersonal (i.e., other life-threatening events, such as severe accidents). Interpersonal trauma exposure generally has been shown to be associated with more severe posttraumatic stress disorder (PTSD) symptoms than noninterpersonal trauma exposure. Interpersonal problems also tend to be associated with trauma exposure and PTSD symptoms, but it is unclear whether a mediating association exists between trauma type, interpersonal problems, and PTSD symptoms. A clinical sample of 4,275 adolescents (age range: 12-18 years) from the National Child Traumatic Stress Network Core Data Set were classified as having experienced interpersonal trauma, noninterpersonal trauma, or both. Interpersonal problems were operationalized by social problem behaviors (e.g., immature and dependent behaviors) and aggressive behaviors on the Child Behavior Checklist. The results of path analyses showed that cumulative interpersonal trauma exposure was both directly and indirectly associated with PTSD symptoms via social problem behaviors but not aggressive behaviors, total effect ß = .20, 95% CI [.17, .23]. In a second model, path analyses showed that cumulative interpersonal trauma exposure was associated directly and indirectly via PTSD symptoms with social problem behaviors, total effect ß = .15, 95% CI [.11, .18], and aggressive behaviors, total effect ß = .13, 95% CI [.09, .17]. These findings suggest that during adolescence, interpersonal problems play an important role in the association between interpersonal trauma exposure and PTSD symptoms.

Factor Structure, Reliability, and Validity of the Daily Self-Report Measure for Trauma-Related Sequelae (DSR-TRS).

The structure and psychometrics of daily self-report measures have only rarely been empirically tested. We developed the Daily Self-Report of Trauma-Related Sequelae (DSR-TRS), comprised of items assessing, in the past day: (1) posttraumatic stress disorder (PTSD) symptoms: (2) symptoms of affective-, behavioral-, relational-, somatic-, dissociative-, and self-dysregulation; and (3) stressors, mood, coping strategies, and drug and alcohol use. Psychometric analyses were conducted with data from 141 women who participated in a randomized clinical trial of two present-centered therapies for PTSD or a wait-list condition and completed at least one DSR-TRS during two 30-day periods at baseline and posttreatment/wait-list. Five DSR-TRS subscales were created based on a series of exploratory, confirmatory, and multilevel factor analyses: Positive Affect, Negative Affect, Self-Regulation, Dysregulation, and PTSD symptoms. DSR-TRS subscales had acceptable within-person and between-person reliability. Convergent and discriminant validity were supported at baseline and posttest in relation to questionnaire and interview assessment measures. Implications for research on daily self-report measures such as the DSR-TRS with trauma survivors are discussed.

Commentary on the Special Section on Complex PTSD: Still Going Strong After All These Years.

Posttraumatic stress disorder (PTSD) is inherently complex, yet a growing evidence base indicates that a complex variant (CPTSD) can be distinguished from classic PTSD based on evidence of clinically significant affect, interpersonal, and self/identity dysregulation. This Commentary to the Journal of Traumatic Stress special section on CPTSD reviews the results of four new studies that empirically tested the structure, traumatic stressor antecedents, and construct validity of CPTSD in relation to PTSD and borderline personality disorder (BPD). Based on these and prior empirical findings, a reconceptualization of PTSD, CPTSD, and BPD as posttraumatic threat, betrayal, and rejection disorders, respectively, is proposed. Implications for treatment of trauma survivors are discussed in relation to articles in this special section, which describe a modular framework for CPTSD treatment and an innovative attachment and self-regulation focused on the redesign of a traditional outpatient mental health clinic.

Relationships Between Maltreatment, Posttraumatic Symptomatology, and the Dissociative Subtype of PTSD Among Adolescents.

The purpose of this study was to explore relationships between maltreatment, posttraumatic stress disorder, and the dissociative subtype of posttraumatic stress disorder among adolescents. This descriptive study used secondary data from the National Child Traumatic Stress Network Core Data Set. A clinical sample of adolescents exposed to potentially traumatizing events ages 12 to 16 was selected (N = 3081) to explore associations between trauma history characteristics, sociodemographic factors, posttraumatic stress disorder, and the dissociative subtype of PTSD which includes depersonalization and derealization. More than half of adolescents who met criteria for posttraumatic stress disorder also met criteria for the posttraumatic stress disorder dissociative subtype with significant depersonalization/derealization symptoms. No particular maltreatment type was associated with increased odds of posttraumatic stress disorder, with or without the dissociative subtype. All posttraumatic stress disorder-affected adolescents, with or without the dissociative subtype, experienced more overall potentially traumatizing events and maltreatment events than those without a posttraumatic stress disorder diagnosis. Girls and adolescents in residential treatment were more likely to have posttraumatic stress disorder with the dissociative subtype. This study provides evidence about the dissociative subtype of posttraumatic stress disorder among adolescents and provides new directions for research on trauma and dissociation. Future research studies should explore the co-occurrence of posttraumatic stress disorder and dissociation with broader range of dissociative symptoms than only depersonalization/derealization to further understand how to diagnose and treat traumatic stress disorders among adolescents.

Trauma Memory Processing in Posttraumatic Stress Disorder Psychotherapy: A Unifying Framework.

Trauma memory processing (TMP) is an empirically supported approach to psychotherapy for posttraumatic stress disorder (PTSD). However, TMP is not a single, uniform intervention but instead a paradigm that can be operationalized through a variety of component procedures that have not been systematically elucidated and formally tested. Based on findings from phenomenological/structural and neuroimaging research, a central feature of PTSD is theorized to be the involuntary immersion in trauma memories with diminished awareness or negative appraisals of self and current context. Such intrusive reexperiencing-which is epitomized by, but not limited to, flashbacks-is postulated to underlie PTSD's avoidance, altered emotions and cognitions, dissociative, and hyperarousal/hypervigilance symptoms; it is thus a logical target for TMP. The varied approaches to TMP for PTSD are conceptualized as having the common goal of activation of the neural networks in the brain that underlie two key capacities disrupted by intrusive reexperiencing in PTSD: intentional self-referential retrieval of memories and suppression of memory retrieval. Therefore, TMP is postulated to involve two core functions (purposeful reflective remembering and memory awareness in situ) and three essential types (in vivo, imaginal, and cognitive reappraisal). Several implications of this framework for clinical practice and research on TMP for PTSD are discussed.

When Nowhere Is Safe: Interpersonal Trauma and Attachment Adversity as Antecedents of Posttraumatic Stress Disorder and Developmental Trauma Disorder.

Developmental trauma disorder (DTD) has been proposed as clinical framework for the sequelae of complex trauma exposure in children. In this study, we investigated whether DTD is associated with different traumatic antecedents than posttraumatic stress disorder (PTSD). In a multisite sample of 236 children referred from pediatric or mental health treatment, DTD was assessed using the DTD Structured Interview. Trauma history was assessed using the Traumatic Events Screening Instrument (TESI). On an unadjusted basis, both DTD, odds ratios (ORs) = 2.0-3.8, 95% CI [1.17, 7.19]; and PTSD, ORs = 1.8-3.0, 95% CI [1.04, 6.27], were associated with past physical assault and/or abuse, family violence, emotional abuse, neglect, and impaired caregivers; and DTD was associated community violence, OR = 2.7, 95% CI [1.35, 5.43]. On a multivariate basis after controlling for the effects of PTSD, DTD was associated with family and community violence and impaired caregivers, ORs = 2.0-2.5, 95% CI [1.09, 5.97], whereas PTSD was only associated with physical assault and/or abuse after controlling for the effects of DTD, OR = 2.4, 95% CI [1.07, 4.99]. Exposure to both interpersonal trauma and attachment adversity was associated with the highest DTD symptom count, controlling for the PTSD symptom count. Although childhood PTSD and DTD share several traumatic antecedents, DTD may be uniquely associated with pervasive exposure to violent environments and impaired caregiving. Therefore, DTD warrants further investigation as a framework for the assessment and treatment of children with histories of interpersonal victimization and attachment adversity.

Randomized clinical trial pilot study of prolonged exposure versus present centred affect regulation therapy for PTSD and anger problems with male military combat veterans.

A randomized controlled trial pilot study (www.ClinicalTrials.org; NCT01228539) with N = 31 U.S. male military recent combat veterans with PTSD and severe anger problems was conducted comparing 10-session individual therapy versions of Trauma Affect Regulation: Guide for Education and Therapy (TARGET) versus prolonged exposure (PE). TARGET had fewer drop-outs than PE (i.e., 29% vs. 64%). At post-test, improvements were found for both interventions in increased emotion regulation and hope, and reduced PTSD symptoms, hostility, experiential avoidance, and mental health problems. At a four-month follow-up, comparable proportions (approximately 40%) of recipients in each therapy maintained clinically significant gains. Self-rated expectancy of therapeutic outcome and working alliance was comparable for both PE and TARGET early in therapy, at mid-treatment, and at the end of treatment. While preliminary, these results suggest that TARGET may be a viable therapeutic option for male military veterans with PTSD and anger problems.

Polyvictimization in childhood and its adverse impacts across the lifespan: Introduction to the special issue.

Although much empirical work has focused on the adverse impact of specific types of childhood victimization (e.g., sexual, physical, or emotional abuse), researchers and clinicians increasingly are recognizing the prevalence of polyvictimization, or exposure to multiple types of victimization. Polyvictimization during formative developmental periods may have detrimental and potentially lifelong biopsychosocial impacts over and above the effects of exposure to specific types of adversity. In this guest editorial, we summarize the key questions and findings for six empirical studies on polyvictimization included in this Special Issue of the Journal of Trauma & Dissociation. These empirical studies further our understanding of the nature, consequences, and assessment of polyvictimization. We conclude with recommendations for continued scientific research and clinical inquiry on polyvictimization.

PTSD and dissociation symptoms as mediators of the relationship between polyvictimization and psychosocial and behavioral problems among justice-involved adolescents.

Polyvictimization (PV) has been shown to be associated with psychosocial and behavioral impairment in community and high risk populations, including youth involved in juvenile justice. However, the mechanisms accounting for these adverse outcomes have not been empirically delineated. Symptoms of posttraumatic stress disorder (PTSD) and dissociation are documented sequelae of PV and are associated with a wide range of behavioral/emotional problems. This study used a cross-sectional research design and bootstrapped multiple mediation analyses with self-report measures completed by a large sample of justice-involved youth (N = 809, ages 12-19 years old, 27% female, 46.5% youth of color) to test the hypothesis that PTSD and dissociation symptoms mediate the relationship between PV and problems with anger, depression/anxiety, alcohol/drug use, and somatic complaints after controlling for the effects of exposure to violence and adversities related to juvenile justice involvement. As hypothesized, PTSD symptoms mediated the relationship of PV with all outcomes except alcohol/drug use problems (which had an unmediated direct association with PV). Partially supporting study hypotheses, dissociation symptoms mediated the relationship between PV and internalizing problems (i.e., depression anxiety; suicide ideation). Implications are discussed for prospective research demarcating the mechanisms linking PV and adverse outcomes in juvenile justice and other high risk populations.