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.

The impact of item order on the factor structure of the PTSD Checklist for DSM-5.

The PTSD Checklist for DSM-5 (PCL-5) is the most widely used self-report measure of posttraumatic stress disorder (PTSD) and is frequently modeled as having four correlated factors consistent with the DSM-5 symptom structure. Some researchers have argued that item order may influence factor structure. Although two studies have examined this, they were both based on DSM-IV criteria, and neither utilized a randomized design. Thus, this study aimed to determine whether item order impacts the factor structure of the PCL-5, using two independent samples of community participants (N = 347, 67.7% female, 85.3% White) and veterans (N = 409, 83.6% male, 61.9% Black/African American). Approximately half of each sample was randomized to receive the PCL-5 in the original fixed order, whereas the other half received a uniquely randomized version. We compared the DSM-5 four-factor model to several theoretically relevant models and found improved model fit in the seven-factor hybrid model, community sample: ∆χ2 = 153.87, p < .001; veterans: ∆χ2 = 152.61, p < . 001. Consequently, the DSM-5 four-factor and seven-factor hybrid models were retained for invariance testing. Across both samples, measurement invariance was examined between the randomized and fixed-order groups. Configural invariance, partial metric invariance, and partial scalar invariance were achieved in both samples, ps = .054-.822, suggesting that the fit of the DSM-5 four-factor structure and the seven-factor hybrid model, as measured using the PCL-5, are not due to order effects. These findings support the continued use of the PCL-5 in a fixed fashion.

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.

Anxiety sensitivity and posttraumatic stress symptoms: Associations among female Veterans with a history of military sexual trauma.

Anxiety sensitivity (AS), the degree to which individuals fear bodily sensations associated with anxious arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite this well-established link, AS has yet to be examined among women who experience military sexual trauma (MST). This is particularly important as research has shown that rates of AS and PTSD are higher among females compared to males. Thus, the purpose of the current investigation was to examine the association between AS and overall PTSD symptom and cluster severity using a sample of female Veterans with a history of MST. The sample included 50 women Veterans presenting for psychological services to a MST specialty clinic at a large southeastern Veterans Affairs hospital. Results revealed a significant positive association between AS and overall PTSD symptom severity, even after controlling for levels of depression, which appeared to be driven by the relationship between AS and negative alterations in cognitions and mood and arousal and reactivity clusters. These findings provide initial support for the association between AS and PTSD symptoms among female Veterans with a history of MST. Given the malleable nature of AS, future research should examine the extent to which targeting this cognitive-behavioral construct reduces PTSD symptoms among such samples.

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.

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.

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.

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.

Defining Subthreshold PTSD in the DSM-IV Literature: A Look Toward DSM-5.

Subthreshold posttraumatic stress disorder (PTSD), whether due to absence of symptom development or partial remission, is the subject of research and clinical work despite being absent from the DSM. A problem with the literature is that subthreshold definitions are inconsistent across studies and therefore aggregating results is difficult. This study compared the diagnostic hit rates and validity of commonly used definitions of Subthreshold PTSD in a single sample. Three definitions of Subthreshold PTSD were extracted from the literature and two were formed, including a model of DSM-5 PTSD-criterion sets, and a definition that requires six or more PTSD symptoms, but no particular criterion set. Participants (N = 654) with a criterion A stressor, but without full PTSD diagnosis, were included. Most individuals did not meet any definition of Subthreshold PTSD. Findings are discussed in light of previous research and need for increased understanding of the diagnostic implications of Subthreshold PTSD.

Psychometric properties of the PTSD checklist for DSM-5 in treatment-seeking Black veterans.

OBJECTIVE: Despite widespread use of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-fifth edition (PCL-5) across various trauma-exposed populations, little is known about the psychometric properties of the instrument in certain ethnic minority groups with increased risk of trauma exposure, including Black veterans. To this end, the current study examined the internal consistency of the PCL-5, convergent validity using correlations between the PCL-5 and another measure of PTSD, and discriminant validity using correlations between the PCL-5 and other commonly occurring psychiatric symptoms, including depression as well as alcohol and substance misuse. METHOD: The sample was composed of 327 Black veterans (84% male, Mage = 51.87, SD = 13.72) presenting to a PTSD specialty clinic at a large Veterans Affairs hospital in the Midwest United States to receive psychological services. In addition to a diagnostic interview, veterans were asked to complete a brief battery of self-report questionnaires to assist with diagnostic clarification and treatment planning. RESULTS: The PCL-5 demonstrated excellent internal consistency. Furthermore, the PCL-5 was significantly and positively correlated with PTSD diagnostic status, suggesting evidence of convergent validity. Finally, the PCL-5 was strongly correlated with symptoms of depression and moderately correlated with alcohol and substance misuse. CONCLUSIONS: Findings suggest that the PCL-5 is a psychometrically sound measure to assess PTSD symptoms among Black veterans. Considering the brevity of PCL-5 administration, clinicians should consider utilizing this and other psychometric tests in clinical care to reduce disparities in health equity among Black patients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Bifactor Evaluation of Self-Report and Clinician-Administered Measures of PTSD in Veterans.

The PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) are two of the most widely used and well-validated PTSD measures providing total and subscale scores that correspond with DSM-5 PTSD symptoms. However, there is little information about the utility of subscale scores above and beyond the total score for either measure. The current study compared the proposed DSM-5 four-factor model to a bifactor model across both measures using a sample of veterans (N = 1,240) presenting to a Veterans Affairs (VA) PTSD specialty clinic. The correlated factors and bifactor models for both measures evidenced marginal-to-acceptable fit and were retained for further evaluation. Bifactor specific indices suggested that both measures exhibited a strong general factor but weak lower-order factors. Structural regressions revealed that most of the lower-order factors provided little utility in predicting relevant outcomes. Although additional research is needed to make definitive statements about the utility of PCL-5 and CAPS-5 subscales, study findings point to numerous weaknesses. As such, caution should be exercised when using or interpreting subscale scores in future research.

Examining the unique and interactive associations of gender and race on PTSD symptom severity among military sexual trauma survivors.

OBJECTIVE: Despite a robust association between military sexual trauma (MST) and posttraumatic stress disorder (PTSD), few studies have examined factors that are associated with increased symptom severity. To this end, the current study was designed to examine the unique and interactive effects of gender and race on PTSD symptoms using a sample of MST survivors. METHOD: The sample included 126 veterans (71% Women, 29% Men; 70% Black/African American and 30% White/Caucasian) presenting for psychological services to a MST specialty clinic at a large Southeastern Veterans Affairs (VA) hospital. As part of their intake evaluation, veterans completed a diagnostic interview and battery of self-report questionnaires. RESULTS: Results revealed a main effect of gender and race such that veteran men and Black/African American veterans were found to have increased PTSD symptom severity. However, there was not a significant gender by race interaction. CONCLUSION: Findings are discussed with regard to previous research and treatment implications. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Pain and posttraumatic stress: Associations among women veterans with a history of military sexual trauma.

OBJECTIVE: Chronic pain and posttraumatic stress disorder (PTSD) are two highly prevaxlent and comorbid conditions common within veteran populations. Notably, those with comorbid pain and PTSD tend to have more severe presentations and poorer quality of life than those with either disorder alone. Despite this well-established relationship, limited research has examined the association between pain and PTSD symptom severity among women veterans with a history of military sexual trauma (MST). METHOD: The current study included 107 women veterans presenting for psychological services to an MST specialty clinic at a large southeastern Veterans Affairs (VA) hospital in the United States. RESULTS: Findings indicated a significant relationship between pain and overall PTSD symptom severity, as well as the intrusions and arousal and reactivity symptom clusters. Contrary to prediction, there was not a significant relationship between pain interference and PTSD symptom or cluster severity. CONCLUSION: Results highlight the importance of inquiring about pain when working with women veterans with a history of MST. Future research aimed at disentangling the casual relationship between pain and PTSD symptoms is crucial to enhance our understanding of these constructs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Coping in crisis: The role of psychologists in response to a pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on the world. In the United States, healthcare systems have been taxed, medical supplies depleted, and healthcare providers overburdened by the increased need. Although psychologists cannot provide medical services, we possess a unique skillset that can alleviate some of the stress placed on healthcare providers, answer important questions about how this disease impacts patients, and support the growing mental health needs of providers and patients alike. The following commentary outlines the ways in which psychologists and mental health workers at one facility, the Southeast Louisiana Veterans Health Care System, supported the medical system and cared for patient and staff mental health in response to the COVID-19 pandemic. Lessons learned from this experience as well as important future steps are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Correlates of death among SARS-CoV-2 positive veterans: The contribution of lifetime tobacco use.

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.

An initial investigation of the association between distress intolerance and posttraumatic stress within military sexual trauma survivors.

OBJECTIVE: Researchers have recently found several links between distress intolerance (DI), the perceived inability to withstand aversive emotional and somatic states, and posttraumatic stress disorder (PTSD) symptoms. Despite this well-established relationship, DI has yet to be examined among victims of military sexual trauma (MST), a population known to have increased rates of PTSD. Thus, the purpose of the current study was to examine overall rates of DI, as well as the relationship between DI and PTSD symptom and cluster severity using an outpatient sample of MST survivors. METHOD: The sample included 103 veterans presenting for psychological services to an MST specialty clinic at a large southeastern Veterans Affairs hospital. As part of their intake evaluation, veterans completed a brief battery of self-report questionnaires to assist with diagnostic clarification and treatment planning. RESULTS: Results revealed that DI was significantly associated with PTSD symptom severity above and beyond depression symptoms. Further, DI was significantly associated with the PTSD intrusion, negative alterations in cognitions and mood, and arousal and reactivity clusters. DISCUSSION: These findings provide initial evidence for a relationship between DI and PTSD symptoms within MST patients. Pending further research, investigators should determine the extent to which targeting this cognitive-behavioral construct reduces PTSD symptoms among MST samples. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

PTSD networks of veterans with combat versus non-combat types of index trauma.

BACKGROUND: Network analysis has become popular among PTSD researchers for studying causal structure or interrelationships among symptoms. However, some have noted that results do not seem to be consistent across studies. Preliminary evidence suggests that trauma type may be one source of variability. METHODS: The current study sought to examine the PTSD networks of veterans with combat versus non-combat index trauma. Participants included 944 veterans who completed the PTSD Checklist for DSM-5 at intake at two VA PTSD clinics. RESULTS: There were many similarities between the combat and non-combat trauma networks, including strong edges between symptoms that were theoretically related or similar (e.g., avoidance) and negative emotion being a highly central symptom. However, correlations of edge weights (0.509) and node centrality (0.418) across networks suggested moderate correspondence, and there appeared to be some differences associated with certain symptoms. Detachment was relatively more central and the connections of negative emotion with blame and lack of positive emotion with reckless behavior were stronger for veterans with combat-related index trauma. LIMITATIONS: The data were cross-sectional, which limits the ability to infer directional relationships between symptoms. In addition, the sample was likely not large enough to directly test for differences between networks via network comparison tests. CONCLUSIONS: Although there were many similarities, results also suggested some variability in PTSD networks associated with combat versus non-combat index trauma that could have implications for conceptualizing and treating PTSD among veterans.

Correlates of Suicidal Ideation and Behaviors Among Former Military Personnel Not Enrolled in the Veterans Health Administration.

The current study sought to explore suicidal concomitants, both demographic and psychological, among former military personal. The sample included 645 veterans who are at increased risk for suicide but have not yet pursued Veterans Health Administration (VHA) services. Descriptive statistics revealed that these veterans are primarily young Caucasian males who served in the U.S. Army. In terms of psychological characteristics, the current sample reported clinically significant levels of depression, post-traumatic stress, and insomnia. Furthermore, respondents acknowledged use of various substances and high levels of perceived burdensomeness and thwarted belongingness. The demographic and psychological makeup of our sample was somewhat similar to that of VHA-connected veterans except that our sample was slightly more educated and reported less physical pain.

The overlap between OCD and PTSD: Examining self-reported symptom differentiation.

The role of stressful precipitating events has long been recognized in the genesis of obsessive-compulsive disorder (OCD). Posttraumatic stress disorder (PTSD) also necessitates the experience of a traumatic event (PTSD criterion A). Research has demonstrated a high degree of comorbidity between these two conditions. However, few studies have examined symptom overlap as a potential cause for this co-occurrence. Thus, the purpose of the present study was to examine symptom endorsement and overlap between OCD and PTSD using a sample of trauma exposed veterans. Veterans were administered self-report assessments, including the Dimensional Obsessive-Compulsive Scale (DOCS) and the PTSD Checklist for DSM-5 (PCL-5), as part of a routine clinical care at a Veteran's Administration hospital. Based on self-report assessment of clinical cut scores, 81% of participants met for probable PTSD and 74% for probable OCD. In addition, a series of chi square analyses revealed frequent overlap of endorsement across items with similar content. There is significant overlap between PTSD and OCD symptoms, and patients may find it difficult to differentiate between them on self-report measures. As such, caution should be used when using self-report solely to assess PTSD and OCD, particularly in traumatized samples.