The association between posttraumatic stress disorder symptom severity and distress tolerance in traumatic stress treatment.

Distress tolerance, or the perceived ability to tolerate negative emotional states, is often associated with posttraumatic stress disorder (PTSD) such that higher distress tolerance is generally associated with less severe PTSD symptom levels. As distress tolerance is often considered a risk and maintenance factor in distress disorders, examining the association between changes in distress tolerance and changes in PTSD symptoms may have clinical relevance. The present study examined the associations between PTSD symptom severity and distress tolerance across three assessment points over 12 weeks among 212 patients receiving outpatient psychotherapy services. Using random-intercept cross-lagged panel modeling (RI-CLPM), concurrent and prospective associations between PTSD and distress tolerance were examined. PTSD symptoms at Time 1 and Time 2 significantly predicted distress tolerance at Time 2, ß = -.296, and Time 3, ß = -.395, respectively. Distress tolerance did not predict subsequent PTSD symptom severity. Exploratory analyses examined distress tolerance and four PTSD symptom clusters over time. Patterns of results differed across clusters, though it was consistent that only PTSD symptom clusters predicted subsequent distress tolerance and not vice versa. The results support the interrelationship of changes in psychopathology and emotional distress tolerance and indicate that distress tolerance may be an important factor in symptom remission during PTSD treatment.

Emotion Dysregulation and Substance Use Risk and Protective Factors among Veterans in Residential Treatment.

Background: Substance use disorders (SUDs) are frequent concerns among healthcare providers serving military personnel and Veterans, and SUDs are also associated with high healthcare utilization. Problematic substance use is consistently associated with deficits in emotion regulation, and changes in emotional regulatory processes may be important factors during treatment and recovery. Methods: The present study examined emotion regulation and substance use risk and protective factors among Veterans seeking residential treatment for SUD within the Veterans Health Administration (VHA). Data were collected from 138 Veterans at pre-treatment and post-treatment to examine if changes in emotion regulation were associated with post-treatment outcomes. Results: Results indicated difficulties with emotion dysregulation at discharge predicted substance use risk factors, but not substance use protective factors, after controlling for scores at intake. Emotion regulation significantly improved throughout the course of treatment. Facets of emotion dysregulation at post-treatment, specifically difficulties engaging in goal-directed behavior, lower emotional clarity, lower emotional awareness, and more impulse control difficulties, predicted future admission to withdrawal management services, but not future mental health engagement, mortality, or resumed use (positive urine drug screen). Conclusions: Emotion regulation skills may be valuable treatment components, as they are related to reduced substance use risk factors; however, the results of improved emotion regulation were mixed for other measures of treatment outcome.

A Bifactor Model of General and Specific PTSD Symptom Change During Treatment.

Posttraumatic stress disorder (PTSD) consists of four main components in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5): intrusions (INT), avoidance (AV), negative alterations in cognition and mood (NACM), and arousal and reactivity (AAR); however, studies do not always support this four-factor model. A sample of 348 treatment-seeking adults was assessed for PTSD symptoms at baseline (Time 1) and then 12 weeks later (Time 2). Confirmatory factor analysis (CFA) was used to examine the model fit of the DSM-5 four-factor model of PTSD with and without a general factor at both time points, and structural equation modeling allowed for examination of these associations between time points. The four-factor model did not meet the criteria for excellent model fit, and the bifactor model provided improved model fit. The NACM specific factor did not meet the criteria for unique variance above and beyond the general factor. The bifactor model of PTSD symptoms was reliable over time, and both the general factor and the AAR factor significantly predicted subsequent symptom severity.

Factor structure of the international trauma questionnaire in trauma exposed LGBTQ+ adults: Role of cumulative traumatic events and minority stress heterosexist experiences.

Exposure to prolonged and/or multiple types of psychological trauma and stressors has been shown to be more strongly associated with ICD-11 complex posttraumatic stress disorder (CPTSD) than posttraumatic stress disorder (PTSD). Lesbian, gay, bisexual, trans- and queer adults (LGBTQ+) are at a heightened risk of exposure to traumatic events, and minority stressors including harassment, discrimination, rejection by family, and isolation. OBJECTIVE: To examine the factor structure of the international trauma questionnaire (ITQ), a self-report measure of PTSD and CPTSD, and the associations of cumulative lifetime trauma exposure assessed via the life events checklist and minority stress assessed via the daily heterosexist experiences scale, with CPTSD (three PTSD symptom clusters, three clusters reflecting disturbances in self-organization [DSO]) among LGBTQ + adults. METHOD: Participants comprised 225 LGBTQ + adults (including 74 transgender and gender diverse individuals; age range: 18-60 years; M/SD = 31.35/9.48) residing in Spain. RESULTS: Confirmatory factor analyses indicated that both a first-order six-factor model and a hierarchical two-factor model, comprising PTSD and DSO as second-order factors, fit the data best. Cumulative traumatic events score was associated with PTSD, and cumulative minority stress was associated with PTSD and DSO. Among the minority stress subscales, harassment based on gender expression was positively associated with all symptom clusters of PTSD and DSO. CONCLUSION: This is the first study to examine the role of minority stressors alongside exposure to psychological traumas in ICD-11 PTSD and CPTSD and emphasizes the inclusion of minority stressors in trauma-related assessments. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Effect of Cognitive-Affective Factors on PTSD and Alcohol Use Symptoms: An Investigation on Rumination, Suppression, and Reappraisal.

Background: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are mental health conditions that often co-occur. The complexity of this comorbidity is well-documented, though the role of malleable cognitive-affective factors in PTSD/AUD warrants further study. Specifically, attaining a more comprehensive understanding of the role of malleable cognitive-affective factors in individuals with symptoms of PTSD/AUD may have important implications for future research, such as in treatment-seeking individuals. Extant examinations of cognitive-affective factors have demonstrated unique associations of cognitive reappraisal, expressive suppression, and rumination in PTSD symptom severity, though these effects had yet to be explored in subgroups of comorbid PTSD/AUD.Methods: In a sample of trauma-exposed individuals (n = 334) recruited to participate through an internet labor market, we first empirically examined latent subgroups of PTSD/AUD symptoms using latent profile analysis, then included expressive suppression, cognitive reappraisal, and four dimensions in the model to elucidate their role in specific profile patterns of PTSD/AUD symptom typologies.Results: Our results support a four-class model of PTSD/AUD symptoms, with unique predictive effects of expressive suppression, problem-focused thoughts, repetitive thoughts, and anticipatory thoughts on latent profile status.Conclusions: These findings may have important implications for future research focused on examining cognitive-affective patterns as they apply to intervention techniques in treatment-seeking individuals with symptoms of PTSD/AUD.

Replication and longitudinal measurement invariance of the PTCI-9.

Inflexible negative trauma-related cognitions are a common consequence of trauma exposure and an important indicator of posttraumatic stress disorder. One common measure of trauma-related cognitions is the 36-item Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999). Recently, a nine-item abbreviated version was developed (PTCI-9; Wells et al., 2019), which may be a reliable alternative with improved model fit. The present study examined the latent factor structure of the PTCI and PTCI-9 in a sample of 185 treatment-seeking outpatients with traumatic stress symptoms to replicate and extend initial findings on the psychometric properties of the PTCI-9. Using confirmatory factor analysis, the correlated three-factor model of the PTCI-9 demonstrated excellent model fit at Time 1 and Time 2 (6 weeks later), as well as strong internal and test-retest reliability. It also exhibited configural, metric, and scalar invariance across time. The present study replicated previous findings that the PTCI-9 may be a psychometrically sound alternative for measuring trauma-related cognitions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychometric evaluation of the Brief Experiential Avoidance Questionnaire among treatment-seeking veterans with posttraumatic stress disorder.

Objective: The present study aimed to explore the psychometric properties of the Brief Experiential Avoidance Questionnaire (BEAQ) among veterans seeking treatment for posttraumatic stress disorder (PTSD). Given that experiential avoidance (EA) is implicated in the development and maintenance of PTSD, it appears to be a possible clinical target for change across treatment. Method: The BEAQ was administered among two samples of military veterans seeking outpatient (n = 179) and residential (n = 257) treatment for PTSD at a Veterans Affairs specialty clinic. The BEAQ is a 15-item self-report measure intended to assess EA, and additional information regarding its psychometric properties is warranted. Results: Descriptive results of the BEAQ in veteran samples are presented. Confirmatory factor analyses of the BEAQ found poor fit in both samples, indicating the BEAQ is not a unidimensional construct, as has been proposed. Conclusions: Future research should consider whether the current structure of the BEAQ is appropriate for measuring EA in veteran samples. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The probability of change versus dropout in veterans receiving Cognitive Processing Therapy for posttraumatic stress disorder.

OBJECTIVE: We sought to elucidate the timing of symptom change and treatment dropout in a leading evidence-based psychotherapy for posttraumatic stress disorder, Cognitive Processing Therapy (CPT). Despite its efficacy across numerous populations, treatment nonresponse and premature dropout are common in CPT and other trauma-focused interventions, particularly among military veterans. Advancements are therefore needed to reduce dropout and increase retention. METHOD: Survival analysis was used to identify the temporal probability of symptom amelioration at each session of CPT (with written trauma account; CPT-A) and compare this with the cumulative, session-by-session probability of dropout. Data were obtained from 194 veterans seeking outpatient treatment at a Veterans Affairs specialty clinic. RESULTS: Overall, 49-61% of veterans reported meaningful symptom reduction in the course of CPT-A and 40% dropped out prematurely. The cumulative probability of dropout exceeded the probability of symptom change beginning after session six of therapy. Secondary analyses indicated that this six session rule generalized well across subgroups. CONCLUSIONS: When symptom amelioration is not observed by the midway point in CPT-A, a change in therapeutic approach appears warranted for preempting dropout among veterans and boosting treatment retention.

Assessment of the revised Difficulties in Emotion Regulation Scales among adolescents and adults with severe mental illness.

The Difficulties in Emotion Regulation Scale (DERS) comprising 36 items has been widely used across age, gender, psychopathology, language, and culture. Recently several alternative abridged forms have been introduced, namely, the DERS-16 (Bjureberg et al. 2016), the DERS-SF (Kaufman et al. 2016), and the DERS-18 (Victor and Klonsky, 2016), each composed of 16 or 18 items, to provide researchers and clinicians with a shorter measure of emotion dysregulation. However, no study to date has directly compared the psychometrics of these alternative forms. In the present study, using confirmatory factor analysis we first examined the factor structure of the four models of the DERS in two inpatient samples of 636 adolescents in the age-range of 12-17 years (M = 15.33, SD = 1.43), and 1807 adults in the age-range of 18-76 years (M = 34.86, SD = 14.63) with severe mental illness. Next, measurement invariance was tested comparing the two age groups across the four models of DERS. Only the DERS-SF established metric and scalar measurement invariance. Findings suggest that the factor structure of the original and the abridged models of DERS have acceptable fit, however only DERS-SF had equivalence of factor loadings and item intercepts across adolescents and adults.

Anger as an underlying dimension of posttraumatic stress disorder.

In this study, we examined the underlying role of anger in posttraumatic stress disorder (PTSD). Although anger is currently considered within two symptoms of PTSD (i.e., anger/irritability; and negative emotional state), some research has found that anger is more than just a diagnostic symptom of PTSD. The sample consisted of 375 trauma-exposed individuals that completed the PTSD Checklist-5 and Dimensions of Anger Reactions Scale. Confirmatory factor analysis was used to assess PTSD's factor structure based on the four-factor DSM-5 PTSD model. Subsequently, the model was re-tested, statistically controlling for anger by regressing PTSD's items on an observed anger score. Individual factor loading differences were then compared to determine anger's underlying role. Results indicated that a significant amount of variance in PTSD, at both the item level and factor level, was attributable to an underlying dimension of anger. The largest factor attenuation was for the symptom of irritability/anger and the smallest attenuation was recklessness. The results suggest that anger underlies more of PTSD than the two diagnostic symptom criteria.

General distress is more important than PTSD's cognition and mood alterations factor in accounting for PTSD and depression's comorbidity.

BACKGROUND: Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) are highly comorbid and exhibit strong correlations with each other at both the symptom level and latent factor level. Various theories have attempted to explain this relationship. Results have been inconsistent regarding whether PTSD's negative alterations in cognition and mood factor (NACM) is significantly more related to depression, in contrast to other factors of PTSD. METHODS: Confirmatory factor analysis was used to attempt to address the relationships between PTSD and MDD in a large sample of trauma-exposed combat veterans from the Ohio National Guard as part of a larger longitudinal study. RESULTS: Confirmatory factor analysis was used to test a bifactor model of PTSD symptoms, testing relations between PTSD's factors and a latent depressive factor. After partitioning out the common variance into the bifactor, we found that in contrast to other PTSD factors, PTSD's NACM factor was not significantly more related to depression. Instead, only the general bifactor predicted depressive symptoms. LIMITATIONS: The limitations of the present study include the following: the specific measures of PTSD and MDD used were based on self-report, and the sample consisted of non-clinical, non-treatment seeking veterans. CONCLUSIONS: The present study suggests that the high rate of comorbidity between posttraumatic stress disorder (PTSD) and major depressive disorder is more related to underlying general distress or negative affectivity than the symptom categories of the PTSD diagnostic criteria.

Latent classes of childhood poly-victimization and associations with suicidal behavior among adult trauma victims: Moderating role of anger.

The aims of the present study were first to identify discrete patterns of childhood victimization experiences including crime, child maltreatment, peer/sibling victimization, sexual violence, and witnessing violence among adult trauma victims using latent class analysis; second, to examine the association between class-membership and suicidal behavior, and third to investigate the differential role of dispositional anger on the association between class-membership and suicidal behavior. We hypothesized that those classes with accumulating exposure to different types of childhood victimization (e.g., poly-victimization) would endorse higher suicidal behavior, than the other less severe classes, and those in the most severe class with higher anger trait would have stronger association with suicidal behavior. Respondents were 346 adults (N=346; Mage=35.0years; 55.9% female) who had experienced a lifetime traumatic event. Sixty four percent had experienced poly-victimization (four or more victimization experiences) and 38.8% met the cut-off score for suicidal behavior. Three distinct classes emerged namely, the Least victimization (Class 1), the Predominantly crime and sibling/peer victimization (Class 2), and the Poly-victimization (Class 3) classes. Regression analysis controlling for age and gender indicated that only the main effect of anger was significantly associated with suicidal behavior. The interaction term suggested that those in the Poly-victimization class were higher on suicidal behavior as a result of a stronger association between anger and suicidal behavior in contrast to the association found in Class 2. Clinical implications of findings entail imparting anger management skills to facilitate wellbeing among adult with childhood poly-victimization experiences.

Relations between anger and DSM-5 posttraumatic stress disorder symptoms.

The present study investigated the relationship between posttraumatic stress disorder (PTSD) and anger. Anger co-occurring with PTSD is found to have a severe effect across a wide range of traumatic experiences, making this an important relationship to examine. The present study utilized data regarding dimensions of PTSD symptoms and anger collected from a non-clinical sample of 247 trauma-exposed participants. Confirmatory factor analysis (CFA) was used to determine the underlying factor structure of both PTSD and anger by examining anger in the context of three models of PTSD. Results indicate that a five-factor representation of PTSD and one-factor representation of anger fit the data best. Additionally, anger demonstrated a strong relationship with the dysphoric arousal and negative alterations in cognitions and mood (NACM) factors; and dysphoric arousal was differentially related to anger. Clinical implications include potential need to reevaluate PTSD's diagnostic symptom structure and highlight the potential need to target and treat comorbid anger in individuals with PTSD. In regard to research, these results support the heterogeneity of PTSD.

An investigation of PTSD's core dimensions and relations with anxiety and depression.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is highly comorbid with anxiety and depressive disorders, which is suggestive of shared variance or common underlying dimensions. The purpose of the present study was to examine the relationship between the latent factors of PTSD with the constructs of anxiety and depression in order to increase understanding of the co-occurrence of these disorders. METHOD: Data were collected from a nonclinical sample of 186 trauma-exposed participants using the PTSD Checklist and Hospital Anxiety and Depression Scale. Confirmatory factor analyses were conducted to determine model fit comparing 3 PTSD factor structure models, followed by Wald tests comparing the relationships between PTSD factors and the core dimensions of anxiety and depression. RESULTS: In model comparisons, the 5-factor dysphoric arousal model of PTSD provided the best fit for the data, compared to the emotional numbing and dysphoria models of PTSD. Compared to anxious arousal, the dysphoric arousal and numbing factors of PTSD were more related to depression severity. Numbing, anxious arousal, and dysphoric arousal were not differentially related to the latent anxiety factor. CONCLUSIONS: The underlying factors of PTSD contain aspects of the core dimensions of both anxiety and depression. The heterogeneity of PTSD's associations with anxiety and depressive constructs requires additional empirical exploration because clarification regarding these relationships will impact diagnostic classification as well as clinical practice.

Hispanic ethnicity and Caucasian race: Relations with posttraumatic stress disorder's factor structure in clinic-referred youth.

The severity of posttraumatic stress disorder (PTSD) symptoms is linked to race and ethnicity, albeit with contradictory findings (reviewed in Alcántara, Casement, & Lewis-Fernández, 2013; Pole, Gone, & Kulkarni, 2008). We systematically examined Caucasian (n = 3,767) versus non-Caucasian race (n = 2,824) and Hispanic (n = 2,395) versus non-Hispanic ethnicity (n = 3,853) as candidate moderators of PTSD's 5-factor model structural parameters (Elhai et al., 2013). The sample was drawn from the National Child Traumatic Stress Network's Core Data Set, currently the largest national data set of clinic-referred children and adolescents exposed to potentially traumatic events. Using confirmatory factor analysis, we tested the invariance of PTSD symptom structural parameters by race and ethnicity. Chi-square difference tests and goodness-of-fit values showed statistical equivalence across racial and ethnic groups in the factor structure of PTSD and in mean item-level indicators of PTSD symptom severity. Results support the structural invariance of PTSD's 5-factor model across the compared racial and ethnic groups. Furthermore, results indicated equivalent item-level severity across racial and ethnic groups; this supports the use of item-level comparisons across these groups.