Session-level effects of cognitive processing therapy and prolonged exposure on individual symptoms of posttraumatic stress disorder among U.S. veterans.

OBJECTIVE: To compare the course of change in individual posttraumatic stress disorder (PTSD) symptoms during prolonged exposure therapy (PE) and cognitive processing therapy (CPT). METHOD: We analyzed data from a previously published randomized clinical trial comparing PE and CPT among male and female U.S. military veterans with PTSD (Schnurr et al., 2022). Using data from a self-rated PTSD symptom measure administered before each therapy session, we evaluated individual symptom change from pretreatment to final therapy session (N = 802). Then, using network intervention analysis, we modeled session-by-session PTSD symptom networks that included treatment allocation (CPT vs. PE) as a node in the networks, allowing us to compare individual symptom change following each session in each treatment. RESULTS: Relative to CPT, PE was associated with greater reduction in 10 PTSD symptoms from first to final session of therapy. Numerous treatment-specific effects on individual symptoms emerged during the treatment period; these session-level effects occurred only in symptoms relatively specific to the diagnosis of PTSD (e.g., avoidance, hypervigilance). PE was associated with greater reduction in avoidance following the introduction and early weeks of imaginal exposure. The treatments yielded comparable effects on trauma-related blame and negative beliefs from pretreatment to final therapy session. However, there were differences in session-level change in these symptoms that may reflect differential timing of interventions that reduce distorted cognitions within each treatment. CONCLUSIONS: Findings may facilitate the shared decision-making process for patients choosing between CPT and PE. Session-level results provide direction for future research on the specific intervention components of CPT and PE. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of screening positive for hazardous alcohol use on the diagnostic accuracy of the PTSD Checklist for DSM-5 among veterans.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used self-report measure of PTSD symptoms that has demonstrated strong psychometric properties across settings and samples. Co-occurring hazardous alcohol use and PTSD are prevalent among veterans, and the effects of alcohol use may impact the performance of the PCL-5. However, this possibility is untested. In this study, we evaluated the PCL-5 diagnostic accuracy for veterans who did and did not screen positive for hazardous alcohol use according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Participants were 385 veterans recruited from Veterans Affairs primary care clinics. Results indicated that PCL-5 performance, AUC = .904, 95% CI [.870, .937], did not differ as a product of hazardous alcohol use. PCL-5 diagnostic utility was comparably high for veterans with, AUC = .904; 95% CI [.846, .962], and without, AUC = .904 95% CI [.861, .946], positive AUDIT-C screens. Although optimally efficient cutoff scores for veterans who screened positive were higher (i.e., 34-36) than for those with negative screens (i.e., 30), neither were significantly different from the overall PCL-5 cutoff score (i.e., 32), suggesting that neither veterans with nor without positive AUDIT-C screens require differential PCL-5 cutoff scores. The results do underscore the importance of using PCL-5 cutoff scores in concert with clinical judgment when establishing a provisional PTSD diagnosis and highlight the need for additional study of the impact of comorbidities on PCL-5 diagnostic accuracy and cutoff scores.

An empirical investigation of definitions of subthreshold posttraumatic stress disorder.

Subthreshold posttraumatic stress disorder (PTSD) has long been recognized as an important construct that identifies a subgroup of individuals who report significant PTSD symptoms and associated disability but do not endorse enough symptoms to meet the criteria for a full PTSD diagnosis. Different investigators have defined subthreshold PTSD in various ways, making it difficult to interpret findings across studies. To address this problem, we systematically compared individuals who met criteria for nine different subthreshold PTSD definitions with individuals diagnosed with either full PTSD or no PTSD (i.e., failed to meet the criteria for a subthreshold definition) with respect to prevalence and associated clinical outcomes of interest. Participants were 1,082 veterans enrolled in the Veterans After Discharge Longitudinal Registry. PTSD and subthreshold PTSD diagnostic status were determined using the Structured Clinical Interview for DSM-5 (SCID-5) and validated self-report instruments were used to assess clinical outcomes. Across outcomes, subthreshold definitions generally identified a group of participants that was distinguishable from participants in both the PTSD and no PTSD groups, rs = .02-.47. We discuss the benefits and drawbacks of various subthreshold definitions and highlight the need for additional work evaluating these definitions across additional outcomes and samples. In the interim, we propose a working case definition of subthreshold PTSD as meeting any three of the four DSM-5 symptom criteria (i.e., Criteria B, C, D, and E) along with Criterion A and Criteria F-H. The results suggest subthreshold PTSD is a clinically meaningful construct.

An Item Response Theory Analysis of the Clinician-Administered PTSD Scale for DSM-5 Among Veterans.

We used item response theory (IRT) analysis to examine Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) item performance using data from three large samples of veterans (total N = 808) using both binary and ordinal rating methods. Relative to binary ratings, ordinal ratings provided good coverage from well below to well above average within each symptom cluster. However, coverage varied by cluster, and item difficulties were unevenly distributed within each cluster, with numerous instances of redundancy. For both binary and ordinal scores, flashbacks, dissociative amnesia, and self-destructive behavior items showed a pattern of high difficulty but relatively poor discrimination. Results indicate that CAPS-5 ordinal ratings provide good severity coverage and that most items accurately differentiated between participants by severity. Observed uneven distribution and redundancy in item difficulty suggest there is opportunity to create an abbreviated version of the CAPS-5 for determining PTSD symptom severity, but not DSM-5 PTSD diagnosis, without sacrificing precision.

A Systematic Review of the Department of Veterans Affairs Mental Health-Care Access Interventions for Veterans With PTSD.

INTRODUCTION: Access to mental health care has been a priority area for the U.S. Department of Veterans Affairs (DVA) for decades. Access for veterans with PTSD is essential because untreated PTSD is associated with numerous adverse outcomes. Although interventions have been developed to improve access to DVA mental health care, the impact of these interventions on access for veterans with untreated PTSD has not been examined comprehensively, limiting guidance on appropriate implementation. MATERIALS AND METHODS: We conducted a systematic review of PubMed and PTSDpubs between May 2019 and January 2022 to identify DVA access interventions for veterans with PTSD not engaged in DVA mental health care. We identified 17 interventions and 29 manuscripts reporting quantitative access outcomes. We categorized interventions into four major categories: Primary care mental health integration, other national initiatives, telemental health, and direct outreach. We evaluated five outcome domains: Binary attendance, number of sessions attended, wait time, number of patients seen, and care initiation. We assessed the risk of bias using the Cochrane Collaboration criteria. RESULTS: Across articles, binary attendance generally improved, whereas the impact on the number of sessions attended was equivocal. Overall, the number of patients seen increased compared to control participants and retrospective data. The few articles that examined care initiation had mixed results. Only one article examined the impact on wait time. CONCLUSIONS: Access interventions for veterans with PTSD demonstrated varied success across interventions and outcomes. The national initiatives-particularly primary care mental health integration -were successful across several outcomes; telemental health demonstrated promise in improving access; and the success of direct outreach varied across interventions. Confidence in these findings is tempered by potential bias among studies. Limited literature on how these interventions impact relevant preattendance barriers, along with incomplete data on how many perform nationally, suggests that additional work is needed to ensure that these interventions increase access for veterans with PTSD nationwide.

Comparing the Prevalence of Probable DSM-IV and DSM-5 Posttraumatic Stress Disorder in a Sample of U.S. Military Veterans Using the PTSD Checklist.

Posttraumatic stress disorder (PTSD) changed substantially when Diagnostic and Statistical Manual of Mental Disorders transitioned from fourth (DSM-IV) to fifth (DSM-5) edition. Hoge et al. found that although diagnostic prevalence remained consistent across nomenclatures, diagnostic concordance was low (55%). Study goals were to examine both the generalizability of these findings and whether either diagnosis systematically excluded patients. U.S. veterans (N = 1,171) who completed the PTSD Checklist for DSM-IV (PCL-S) and DSM-5 (PCL-5) were classified as: probable PTSD on both measures; probable PTSD on PCL-S only; probable PTSD on PCL-5 only; or no PTSD on either measure. Diagnostic prevalence was equivalent. Unlike Hoge et al.'s findings, diagnostic concordance was high (91.3%). Furthermore, observed demographic and severity differences were driven by disparities between veterans in the no PTSD versus the probable PTSD groups, not diagnostic changes. Findings suggest translatability across measures and that diagnostic changes do not systematically exclude patients.

"Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF)": Correction.

Reports an error in "Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF)" by Michelle J. Bovin, Aaron Schneiderman, Paul A. Bernhard, Shira Maguen, Claire A. Hoffmire, John R. Blosnich, Brian N. Smith, Richard Kulka and Dawne Vogt (Psychological Trauma: Theory, Research, Practice, and Policy, Advanced Online Publication, Jun 02, 2022, np). In the original article, the following acknowledgment of funding was missing from the title page author note: "This material was based upon work supported by the United States Department of Veterans Affairs (VA), Veterans Health Administration, Patient Care Services, Health Outcomes Military Exposures Epidemiology Program as well as two VA Health Services Research and Development Service Grants "Validation of Modified DRRI Scales in a National Sample of OEF/OIF Veterans" (Project DHI 09-086, Dawne Vogt, Principal Investigator) and "Work and Family Functioning in Women Veterans: Implications for VA Service Use" (Project IIR 12-345, Dawne Vogt and Brian N. Smith, Principal Investigators)." All versions of this article have been corrected. (The following abstract of the original article appeared in record 2022-66811-001). OBJECTIVE: It is important to assess warfare experiences beyond direct combat exposure, as these exposures can negatively impact military veterans' health. Although two validated scales from the Deployment Risk and Resilience Inventory-2 [DRRI-2] together capture a broad range of stressful warfare experiences, the length of this combined measure (30 items) is prohibitively long for some settings. Therefore, the goal of this project was to develop and validate a short form Warfare Exposure measure (DRRI-2-WE-SF). METHOD: U.S. veterans deployed for the wars in Iraq and Afghanistan completed questionnaires across 2 studies (study 1, N = 1046; study 2, N = 7141) to develop and validate the DRRI-2 WE-SF. RESULTS: Study 1 involved developing the DRRI-2 WE-SF, a 9-item self-report instrument with strong internal consistency (α = .86) and large correlations with the full Warfare Exposure measure (r = .97). In study 2, the DRRI-2 WE-SF again demonstrated high levels of reliability and validity and evidenced high levels of classification accuracy (89.7% correct classification) and significant time savings (all ts > 39; all ps < .05) in comparison to the full measure. CONCLUSIONS: The DRRI-2 WE-SF is a psychometrically sound measure of direct exposures to warfare and its consequences. This measure of proximal warfare exposure retains the strong properties of the full measure while significantly reducing completion time. These properties make the DRRI-2 WE-SF a useful tool for efficiently evaluating proximal warfare exposure among individuals who have served in both combat and noncombat roles. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Does screening for PTSD lead to VA mental health care? Identifying the spectrum of initial VA screening actions.

Despite the active posttraumatic stress disorder (PTSD) screening program in Department of Veterans Affairs (VA) primary care clinics and the availability of empirically supported treatments for PTSD at VA, many veterans for whom screening suggests treatment may be indicated do not gain access to VA-based mental health care. To determine where we may be losing veterans to follow-up, we need to begin by identifying the initial action taken in response to a positive PTSD screen in primary care. Using VA administrative data and chart review, we identified the spectrum of initial actions taken after veterans screened positive for PTSD in VA primary care clinics nationwide between October 2017 and September 2018 (N = 41,570). We collapsed actions into those that could lead to VA-based mental health care (e.g., consult placed to a VA mental health clinic) versus not (e.g., veteran declined care), and then examined the association between these categories of actions and contextual- and individual-level variables. More than 61% of veterans with positive PTSD screens had evidence that an initial action toward VA-based mental health care was taken. Urban-dwelling and female veterans were significantly more likely to have evidence of these initial actions, whereas White and Vietnam-era veterans were significantly less likely to have this evidence. Our findings suggest that most veterans screening positive for PTSD in VA primary care clinics have evidence of initial actions taken toward VA-based mental health care; however, a substantial minority do not, making them unlikely to receive follow-up care. Findings highlight the potential benefit of targeted primary care-based access interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and validation of a brief warfare exposure measure among U.S. Iraq and Afghanistan war veterans: The Deployment Risk and Resilience Inventory-2 Warfare Exposure-Short Form (DRRI-2 WE-SF).

[Correction Notice: An Erratum for this article was reported online in Psychological Trauma: Theory, Research, Practice, and Policy on Jun 30 2022 (see record 2022-76274-001). In the original article, the following acknowledgment of funding was missing from the title page author note: "This material was based upon work supported by the United States Department of Veterans Affairs (VA), Veterans Health Administration, Patient Care Services, Health Outcomes Military Exposures Epidemiology Program as well as two VA Health Services Research and Development Service Grants "Validation of Modified DRRI Scales in a National Sample of OEF/OIF Veterans" (Project DHI 09-086, Dawne Vogt, Principal Investigator) and "Work and Family Functioning in Women Veterans: Implications for VA Service Use" (Project IIR 12-345, Dawne Vogt and Brian N. Smith, Principal Investigators)." All versions of this article have been corrected.] Objective: It is important to assess warfare experiences beyond direct combat exposure, as these exposures can negatively impact military veterans' health. Although two validated scales from the Deployment Risk and Resilience Inventory-2 [DRRI-2] together capture a broad range of stressful warfare experiences, the length of this combined measure (30 items) is prohibitively long for some settings. Therefore, the goal of this project was to develop and validate a short form Warfare Exposure measure (DRRI-2-WE-SF). METHOD: U.S. veterans deployed for the wars in Iraq and Afghanistan completed questionnaires across 2 studies (study 1, N = 1046; study 2, N = 7141) to develop and validate the DRRI-2 WE-SF. RESULTS: Study 1 involved developing the DRRI-2 WE-SF, a 9-item self-report instrument with strong internal consistency (α = .86) and large correlations with the full Warfare Exposure measure (r = .97). In study 2, the DRRI-2 WE-SF again demonstrated high levels of reliability and validity and evidenced high levels of classification accuracy (89.7% correct classification) and significant time savings (all ts > 39; all ps < .05) in comparison to the full measure. CONCLUSIONS: The DRRI-2 WE-SF is a psychometrically sound measure of direct exposures to warfare and its consequences. This measure of proximal warfare exposure retains the strong properties of the full measure while significantly reducing completion time. These properties make the DRRI-2 WE-SF a useful tool for efficiently evaluating proximal warfare exposure among individuals who have served in both combat and noncombat roles. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

The impact of deployment-related stressors on the development of PTSD and depression among sexual minority and heterosexual female veterans.

OBJECTIVE: Sexual minority female (SMF) veterans experience unique stressors apart from their service in the military. In this study, we compared SMF and heterosexual female (HF) veterans' rates of deployment-related stressors (i.e., military sexual assault, combat exposure, and harassment), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) and their association with one another. METHOD: Participants were 699 female veterans who provided self-report data on exposure to deployment-related stressors and were assessed for MDD and PTSD by trained diagnosticians. RESULTS: SMF and HF veterans had similar rates of PTSD, MDD, and deployment-related stressors. However, deployment-related stressors were less likely to be associated with diagnosis or symptoms of either PTSD or MDD among SMF veterans. CONCLUSION: SMF veterans may have unique stressors driving their development of MDD and PTSD. Understanding how different military stressors may confer risk for SMF veterans versus HF veterans is necessary to provide informed and sensitive clinical care to SMF veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Discrepancies between electronic records and clinical interview diagnosis of PTSD: Differences in mental health care utilization.

Prior research suggests that a significant number of veterans with posttraumatic stress disorder (PTSD) do not have this diagnosis recognized in the electronic health record (EHR). Unfortunately, such diagnostic errors can lead to improper allocation of already scarce health care services and resources. In this study, we examined concordance between PTSD diagnoses in the Veterans Affairs (VA) EHR and PTSD diagnoses based on a semistructured diagnostic interview and mental health service use in a sample of veterans (N = 1,299) enrolled in VA healthcare. Results from negative binomial regressions showed that veterans with PTSD based on the diagnostic interview and the EHR (true positives) used the most mental health care services. There were no significant differences between those without PTSD based on the interview and the EHR (true negatives) and those with PTSD based on interview that was not recognized in the EHR (false negatives) on total nonemergent outpatient mental health visits. However, veterans in the false negative group had more mental health-related emergent care visits (i.e., emergency room, urgent care, hospitalization) than veterans in the true negative group. Our findings suggest that veterans with PTSD who are not coded as such in the EHR may not be utilizing needed outpatient care but are seeking and receiving costly emergent care. Thus, accurate recognition of PTSD in the EHR is essential for connecting patients to outpatient mental health services. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Reliable and clinically significant change in the clinician-administered PTSD Scale for DSM-5 and PTSD Checklist for DSM-5 among male veterans.

We calculated the reliable change index (RCI) and clinically significant change (CSC) values for two widely used measures of posttraumatic stress disorder (PTSD): The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) and examined how symptom changes at these thresholds related to improvements in psychosocial functioning. We used data from three independent samples of male military veterans, including two randomized controlled trials for PTSD (N = 198 for Sample 1 and N = 102 for Sample 2) and a cross-sectional study of primary care patients (N = 228). For Sample 1, within-person change in CAPS-5 and PCL-5 scores of ≥ 13 and 15, respectively, was indicative of reliable change. For Sample 2, within-person change in CAPS-5 and PCL-5 scores of ≥ 12 and 18, respectively, was indicative of reliable change. Scores of ≤ 8 and 28 on the CAPS-5 and PCL-5, respectively, indicated a participant is more likely to belong to the non-PTSD population than the PTSD population (i.e., clinically significant change) in both Samples 1 and 2. Participants who exhibited reliable or CSC reported significantly better psychosocial functioning at all posttreatment assessments than those who did not. Results provide thresholds for identifying clinically meaningful PTSD symptom change using these measures. Care should be taken to interpret these values appropriately and relative to numerous other definitions for meaningful symptom change. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans.

Importance: Posttraumatic stress disorder (PTSD) is a serious mental health disorder that can be effectively treated with empirically based practices. PTSD screening is essential for identifying undetected cases and providing patients with appropriate care. Objective: To determine whether the Primary Care PTSD screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PC-PTSD-5) is a diagnostically accurate and acceptable measure for use in Veterans Affairs (VA) primary care clinics. Design, Setting, and Participants: This cross-sectional, diagnostic accuracy study enrolled participants from May 19, 2017, to September 26, 2018. Participants were recruited from primary care clinics across 2 VA Medical Centers. Session 1 was conducted in person, and session 2 was completed within 30 days via telephone. A consecutive sample of 1594 veterans, aged 18 years or older, who were scheduled for a primary care visit was recruited. Data analysis was performed from March 2019 to August 2020. Exposures: In session 1, participants completed a battery of questionnaires. In session 2, a research assistant administered the PC-PTSD-5 to participants, and then a clinician assessor blind to PC-PTSD-5 results conducted a structured diagnostic interview for PTSD. Main Outcomes and Measures: The range of PC-PTSD-5 cut points overall and across gender was assessed, and diagnostic performance was evaluated by calculating weighted κ values. Results: In total, 495 of 1594 veterans (31%) participated, and 396 completed all measures and were included in the analyses. Participants were demographically similar to the VA primary care population (mean [SD] age, 61.4 [15.5] years; age range, 21-93 years) and were predominantly male (333 participants [84.1%]) and White (296 of 394 participants [75.1%]). The PC-PTSD-5 had high levels of diagnostic accuracy for the overall sample (area under the receiver operating characteristic curve [AUC], 0.927; 95% CI, 0.896-0.959), men (AUC, 0.932; 95% CI, 0.894-0.969), and women (AUC, 0.899, 95% CI, 0.824-0.974). A cut point of 4 ideally balanced false negatives and false positives for the overall sample and for men. However, for women, this cut point resulted in high numbers of false negatives (6 veterans [33.3%]). A cut point of 3 fit better for women, despite increasing the number of false positives. Participants rated the PC-PTSD-5 as highly acceptable. Conclusions and Relevance: The PC-PTSD-5 is an accurate and acceptable screening tool for use in VA primary care settings. Because performance parameters will change according to sample, clinicians should consider sample characteristics and screening purposes when selecting a cut point.

The Role of Negative Affect in Differentiating Posttraumatic Stress Disorder, Depression, and Their Comorbidity Among United States Veterans.

Following trauma exposure, two frequently co-occurring forms of psychopathology include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Although these diagnoses have been identified as distinct constructs, the proper classification of these disorders remains a challenge due to overlapping symptoms. Instead, systematically establishing higher- and lower-order personality traits associated with each diagnosis may avoid this confound and improve differential diagnosis. In the present study, we examined how higher-order negative affect and its lower-order facets (i.e., anxiousness, emotional lability, and separation insecurity) may be associated with a diagnosis of PTSD only, MDD only, both diagnoses, or neither diagnosis. Participants were 1,175 veterans enrolled in the Veterans After Discharge Longitudinal Registry. Higher- and lower-order negative affect were assessed using the Personality Inventory for DSM-5 (PID-5), and PTSD and MDD diagnoses were based on the Structured Clinical Interview for DSM-5 (SCID-5). Multinomial logistic regressions were used to model the association between higher- and lower-order negative affect and diagnostic status, after controlling for potential covariates. Diagnostic utility analyses were conducted to examine the degree to which higher- and lower-order negative affect classified participants across groups. Higher-order negative affect and lower-order anxiousness differentiated diagnostic groups, ORs = 1.76-4.66, and had strong specificity and negative predictive value for individuals with PTSD and MDD and those with MDD only. These findings help explain the role of higher-order negative affect and lower-order anxiousness in differentiating PTSD from MDD and comorbid PTSD and MDD and may have implications for assessment, differential diagnosis, and treatment planning.

The 20-year course of posttraumatic stress disorder symptoms among veterans.

Although numerous longitudinal studies have examined heterogeneity in posttraumatic stress disorder (PTSD) symptom course, the long-term course of the disorder remains poorly understood. This study sought to understand and predict long-term PTSD symptom course among a nationwide sample of Operations Enduring Freedom and Iraqi Freedom veterans enrolled in Veterans Health Administration services. We assessed PTSD symptoms at 4 time points over approximately 4.5 years (M = 55.11 months, SD = 6.89). Participants (N = 1,353) with and without probable PTSD were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio to fully explore the heterogeneity of PTSD symptom course and the effect of sex on symptom course. By coding time as years since index trauma, we estimated the course of PTSD symptoms over 20 years. Results indicate symptom course is most appropriately characterized by substantial heterogeneity. On average, veterans experienced initial PTSD symptom severity above the diagnostic threshold following trauma exposure, which was initially stable over time and later began to gradually improve. Although results indicate symptoms eventually began to decline, this effect was gradual; most participants continued to meet or exceed the PTSD provisional diagnostic threshold long after trauma exposure. We identified several predictors and correlates of symptom course, including Hispanic ethnicity, postdeployment social support, and co-occurring psychopathology. Results highlight the heterogeneous nature of PTSD symptom course following trauma exposure and the urgency of the need to ensure access to evidence-based care and to improve available treatments. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychometric properties of the German version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in clinical routine settings: study design and protocol of a multitrait-multimethod study.

INTRODUCTION: The aim of this study is to investigate the diagnostic accuracy, psychometric properties and clinical utility of the German version of the Clinician-Administered Post-Traumatic Stress Disorder (PTSD) Scale for Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (CAPS-5) in routine clinical settings. METHODS AND ANALYSIS: This study is a non-interventional, multitrait-multimethod design, multicentre study that will be carried out at German civil and military inpatient and outpatient clinics. A total sample size of n=219 participants who have experienced at least one traumatic event according to criteria as defined in the DSM-5 will be recruited. For the investigation of the diagnostic accuracy and clinical utility of the CAPS-5, participants will be categorised into one of three groups, depending on their traumatic experiences and post-traumatic symptomatology: (1) monotraumatisation with PTSD; (2) multiple traumatisation with PTSD and (3) traumatisation without PTSD. Interviews will be conducted face to face by interviewers in routine clinical settings. All participants will also be asked to complete a comprehensive set of questionnaires in order to investigate different facets of construct validity and clinical utility. First, differences between all three groups in CAPS-5 sum and subscale scores will be investigated. Test-retest reliability and inter-rater reliability will be determined. Internal consistency will be calculated using structural equation modeling (SEM) based internal consistency coefficients. Construct validity will be measured with Spearman's rank correlation analyses and multivariate analyses of variance with Holm-Bonferroni corrected post hoc analysis of variances. In order to test diagnostic accuracy, receiver operating characteristics and sensitivity and specificity analyses will be conducted. The model structure of the German CAPS-5 will be analysed using confirmatory factor analyses. ETHICS AND DISSEMINATION: The study received ethical approval by the Ethics Committees of the Faculty of Psychology at the Ruhr-Universität Bochum (reference numbers: 331 and 358). The results of the study will be presented nationally and internationally at scientific conferences and will be published in scientific journals. TRIAL REGISTRATION NUMBER: DRKS00015325.

Psychometric properties of a brief measure of posttraumatic stress disorder-related impairment: The Brief Inventory of Psychosocial Functioning.

This study validated the Brief Inventory of Psychosocial Functioning (B-IPF), an abridged version of the 80-item Inventory of Psychosocial Functioning (IPF; Bovin et al., 2018). The B-IPF-a 7-item self-report questionnaire that assesses posttraumatic stress disorder (PTSD)-related psychosocial functional impairment-was developed for use in settings in which the full IPF would be too time intensive to administer. In this study, we examined the psychometric properties of the B-IPF among a sample of 362 veterans recruited from 2 Veterans Affairs hospitals. The B-IPF demonstrated high internal consistency (Cronbach's alpha = .84) and adequate test-retest reliability (r = .65, p < .001). The B-IPF was strongly correlated with the IPF (r = .71, p < .01) and had higher correlations with measures of mental health impairment and quality of life (all rs > ∥.50∥; all ps < .001) than with a measure of physical health impairment (i.e., the Physical Component Summary; r = -.34; p < .001), which demonstrated strong construct validity. In addition, the B-IPF displayed strong criterion-related validity, with higher correlations with a PTSD symptom measure, (r = .63, p < .05), and measures of other internalizing disorders (all rs > .44; all ps < .05) and a lower correlation with a measure of an externalizing disorder (r = .14; p < .05). These results indicate that the B-IPF is a reliable and valid instrument for assessing PTSD-related impairment. The strong psychometric properties of the instrument, in addition to its length, make it ideal for settings in which time is a factor. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Posttraumatic Stress Disorder Severity and Insomnia-Related Sleep Disturbances: Longitudinal Associations in a Large, Gender-Balanced Cohort of Combat-Exposed Veterans.

Few studies have investigated the range and severity of insomnia-related sleep complaints among veterans with posttraumatic stress disorder (PTSD), and the temporal association between insomnia and PTSD severity has yet to be examined. To examine these associations, a large, gender-balanced cohort of veterans (N = 1,649) of the Iraq and Afghanistan conflicts participated in longitudinal assessments of PTSD and insomnia-related symptoms over a period of 2.5 years following enrollment (range: 2-4 years). Data were obtained from multiple sources, including interviews, self-report assessments, and electronic medical record data. Three-fourths (74.0%) of veterans with PTSD diagnoses at Time 1 (T1) reported insomnia-related sleep difficulties on at least half the nights during the past 30 days, and one-third of participants had received a prescription for a sedative-hypnotic drug in the past year. Veterans without PTSD had fewer sleep problems overall, although the prevalence of sleep problems was high among all study participants. In longitudinal, cross-lagged panel models, the frequency of sleep problems at T1 independently predicted increases in PTSD severity at Time 2 (T2), B = 0.27, p < .001, after controlling for gender and relevant comorbidities. Conversely, T1 PTSD severity was associated with increasing sleep complaints at T2 but to a lesser degree, B = 0.04, p < .001. Moderately high rates of sedative-hypnotic use were seen in veterans with PTSD, with more frequent use in women compared to men (40.4% vs. 35.0%). Sleep complaints were highly prevalent overall and highlight the need for increased clinical focus on this area.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Gravedad del TEPT y Trastornos del Sueño Relacionados con el Insomnio: Asociaciones Longitudinales en una gran Cohorte, Balanceados por Género. de Veteranos Expuestos al Combate SUEÑO, INSOMNIO Y SEVERIDAD DE TEPT Pocos estudios han investigado el rango y la gravedad de las quejas del sueño relacionadas con el insomnio entre veteranos con trastorno de estrés postraumático (TEPT) y la asociación temporal entre el insomnio y la severidad del TEPT aún no se han examinado. Para examinar estas asociaciones, una gran cohorte de veteranos (N = 1,649) de los conflictos de Irak y Afganistán, balanceados por género, participaron en evaluaciones longitudinales de TEPT y síntomas relacionados con el insomnio durante un período de 2.5 años posteriores a la inscripción (rango: 2-4 años). Los datos se obtuvieron de múltiples fuentes, incluyendo entrevistas, autoevaluaciones y datos de registros médicos electrónicos. Tres cuartos (74.0%) de los veteranos con diagnóstico de TEPT en el tiempo 1 (T1) informaron dificultades de sueño relacionadas con el insomnio en al menos la mitad de las noches durante los últimos 30 días, y un tercio de los participantes habían recibido una prescripción de un fármaco sedante-hipnótico en el último año. Los veteranos sin TEPT tenían menos problemas de sueño en general, aunque la prevalencia de problemas de sueño fue alta entre todos los participantes del estudio. En los modelos longitudinales de panel con retardo cruzado, la frecuencia de los problemas de sueño en T1 predijeron independientemente aumentos en la severidad del TEPT en el Tiempo 2 (T2), B = 0.27, p <.001, después controlar por género y comorbilidades relevantes. Por el contrario, la gravedad del TEPT en T1 se asoció con un aumento de las quejas de sueño en T2 pero en menor grado, B = 0.04, p <.001. Se observaron tasas moderadamente altas de uso de hipnóticos-sedativos en veteranos con TEPT, con un uso más frecuente en mujeres comparadas con hombres (40.4% vs. 35.0%). En general las quejas de sueño fueron altamente prevalentes y destacan la necesidad de una mayor focalización clínica en esta área.

An Empirical Crosswalk for the PTSD Checklist: Translating DSM-IV to DSM-5 Using a Veteran Sample.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced numerous revisions to the fourth edition's (DSM-IV) criteria for posttraumatic stress disorder (PTSD), posing a challenge to clinicians and researchers who wish to assess PTSD symptoms continuously over time. The aim of this study was to develop a crosswalk between the DSM-IV and DSM-5 versions of the PTSD Checklist (PCL), a widely used self-rated measure of PTSD symptom severity. Participants were 1,003 U.S. veterans (58.7% with PTSD) who completed the PCL for DSM-IV (the PCL-C) and DSM-5 (the PCL-5) during their participation in an ongoing longitudinal registry study. In a randomly selected training sample (n = 800), we used equipercentile equating with loglinear smoothing to compute a "crosswalk" between PCL-C and PCL-5 scores. We evaluated the correspondence between the crosswalk-determined predicted scores and observed PCL-5 scores in the remaining validation sample (n = 203). The results showed strong correspondence between crosswalk-predicted PCL-5 scores and observed PCL-5 scores in the validation sample, ICC = .96. Predicted PCL-5 scores performed comparably to observed PCL-5 scores when examining their agreement with PTSD diagnosis ascertained by clinical interview: predicted PCL-5, κ = 0.57; observed PCL-5, κ = 0.59. Subsample comparisons indicated that the crosswalk's accuracy did not differ across characteristics including gender, age, racial minority status, and PTSD status. The results support the validity of this newly developed PCL-C to PCL-5 crosswalk in a veteran sample, providing a tool with which to interpret and translate scores across the two measures.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Un cruce empírico para la lista de verificación de TEPT: traducción de DSM-IV a DSM-5 utilizando una muestra de veteranos CRUCE PARA LA LISTA DE VERIFICACIÓN DEL TEPT La quinta edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-5) introdujo numerosas revisiones a los criterios de la cuarta edición (DSM-IV) para el trastorno de estrés postraumático (TEPT), lo que representa un desafío para los médicos e investigadores que desean evaluar los síntomas de TEPT de manera continua a través del tiempo. El objetivo de este estudio fue desarrollar un cruce entre las versiones DSM-IV y DSM-5 de la Lista de verificación de TEPT (PCL en su sigla en inglés), una medida autoevaluada ampliamente utilizada de la gravedad de los síntomas de TEPT. Los participantes fueron 1.003 veteranos estadounidenses (58.7% con TEPT) que completaron el PCL para DSM-IV (PCL-C) y DSM-5 (PCL-5) durante su participación en un estudio de registro longitudinal en curso. En una muestra de entrenamiento seleccionada al azar (n = 800), utilizamos equipercentil equiparado con suavizado loglineal para calcular un "cruce" entre las puntuaciones PCL-C y PCL-5. Evaluamos la correspondencia entre las puntuaciones pronosticadas determinadas por el cruce y las puntuaciones PCL-5 observadas en la muestra de validación restante (n = 203). Los resultados mostraron una fuerte correspondencia entre los puntajes PCL-5 pronosticados para el cruce y los puntajes PCL-5 observados en la muestra de validación, ICC = .96. Los puntajes de PCL-5 pronosticados se compararon con los puntajes de PCL-5 observados al examinar su acuerdo con el diagnóstico de TEPT determinado por entrevista clínica: PCL-5 predicho, κ = 0.57; PCL-5 observado, κ = 0,59. Las comparaciones de submuestras indicaron que la precisión del cruce no difirió entre las características, incluidos el género, la edad, el estado de minoría racial y el estado de TEPT. Los resultados respaldan la validez de este paso de cruce recién desarrollado de PCL-C a PCL-5 en una muestra de veteranos, proporcionando una herramienta con la que interpretar y traducir las puntuaciones en las dos medidas.