Serotonin Transporter (SLC6A4) and FK506-Binding Protein 5 (FKBP5) Genotype and Methylation Relationships with Response to Meditation in Veterans with PTSD.

Meditation-based interventions are novel and effective non-pharmacologic treatments for veterans with PTSD. We examined relationships between treatment response, early life trauma exposure, DNA polymorphisms, and methylation in the serotonin transporter (SLC6A4) and FK506-binding protein 5 (FKBP5) genes. DNA samples and clinical outcomes were examined in 72 veterans with PTSD who received meditation-based therapy in two separate studies of mindfulness-based stress reduction (MBSR) and Transcendental Meditation (TM). The PTSD Checklist was administered to assess symptoms at baseline and after 9 weeks of meditation intervention. We examined the SLC6A4 promoter (5HTTLPR_L/S insertion/deletion + rs25531_A/G) polymorphisms according to previously defined gene expression groups, and the FKBP5 variant rs1360780 previously associated with PTSD disease risk. Methylation for CpG sites of SLC6A4 (28 sites) and FKBP5 (45 sites) genes was quantified in DNA samples collected before and after treatment. The 5HTTLPR LALA high expression genotype was associated with greater symptom improvement in participants exposed to early life trauma (p = 0.015). Separately, pre to post-treatment change of DNA methylation in a group of nine FKBP5 CpG sites was associated with greater symptom improvement (OR = 2.8, 95% CI 1.1-7.1, p = 0.027). These findings build on a wealth of existing knowledge regarding epigenetic and genetic relationships with PTSD disease risk to highlight the potential importance of SLC6A4 and FKBP5 for treatment mechanisms and as biomarkers of symptom improvement.

A dynamic, multilevel approach to conceptualising and designing resilience research in the context of military stress.

Challenges in conceptualising resilience have impeded advancements in resilience science. In response, the National Institutes of Health (NIH) developed a general framework for harmonising the conceptualisation of resilience as a dynamic process determined by multiple systems and levels of analysis. Consistent with the NIH Resilience Framework, this paper presents a conceptual model of resilience applied to military service members. This model encompasses four core components necessary for resilience research: (1) the presence of significant challenge, (2) successful adaptation in response to the challenge, (3) the capacity for resilience (i.e., protective factors), and (4) the processes (i.e., mechanisms) by which protective factors exert positive effects on an individual's response. Guided by this conceptual model, we outline key methodological recommendations to advance resilience research and illustrate each using the Advancing Research on Mechanisms of Resilience study as an exemplar. We emphasise the need for future research to examine resilience as a dynamic process and apply a multilevel approach. We hope to provide a basic road map to those interested in improving the rigour of future research on resilience in a military context, the results of which can inform the development of interventions.

Footwear limitations in women prosthesis users relate to more than preference.

BACKGROUND: The option to wear desired footwear may be an important part of community reintegration after lower-limb amputation. OBJECTIVES: This study explored outcomes related to footwear, health, and participation in women Veterans with lower-limb amputation. METHODS: A cross-sectional questionnaire was mailed to all women Veterans age 18-82 years with major lower-limb amputation(s) who had received prosthetics services in the US Department of Veterans Affairs (N = 538). The questionnaire assessed Perceived Challenges (including clothing limitations, prosthetic foot limitations [width, height, and shape], and shoe avoidance for safety concerns), type of footwear used and preference, and included subscales from the Patient-Reported Outcome Measurement Information System, Amputee Body Image Scale Prosthetic Limb Users' Survey of Mobility, Community Participation Index, Activities-Specific Balance Confidence Scale, and Prosthesis Evaluation Questionnaire. Bivariate correlations examined relationships between a composite measure of Perceived Challenges and patient-reported outcomes. RESULTS: One hundred questionnaires were returned (18.6% response rate; 3 excluded for limited prosthesis use). The Perceived Challenges score was significantly correlated with scores for the Amputee Body Image Scale-Revised (r = 0.24, p = 0.019), Patient-Reported Outcome Measurement Information System (ability to participate: r = -0.25, p = 0.014), Prosthesis Evaluation Questionnaire (utility: r = -0.32, p = 0.001, appearance: r = -0.48, p < 0.001), Activities-Specific Balance Confidence Scale (r = -0.20, p = 0.046), and Prosthetic Limb Users' Survey of Mobility (r = -0.21, p = 0.036), but not depression or anxiety. CONCLUSIONS: Women who have greater issues with how their prosthesis affects the shoes and clothing they can wear also have poorer body image, reduced functional capabilities, and lower reported participation in activities. Improved prosthetic foot design may help to improve social participation and other important outcomes for women prosthesis users.

Internet-based family training with telephone coaching to promote mental health treatment initiation among veterans with posttraumatic stress disorder: A pilot study.

Posttraumatic stress disorder (PTSD) is common among military veterans, yet many affected veterans do not seek treatment. Family members of these veterans often experience compromised well-being and a desire for the veteran to receive mental health care. The Veterans Affairs (VA)-Community Reinforcement and Family Training (VA-CRAFT) for PTSD is an internet-based intervention intended to teach veterans' family members skills to encourage veterans to initiate mental health care. This study assessed the feasibility, acceptability, and potential efficacy of VA-CRAFT with telephone coaching in a sample of 12 spouses and intimate partners of veterans with PTSD. Participants completed the intervention over 12 weeks and were assessed pre- and posttreatment. For feasibility, 75.0% (n = 9) of participants completed the intervention and reported few difficulties and ease of use. Supporting acceptability, all nine completers had mostly favorable impressions of the intervention and perceived it as helpful. Finally, six (50.0%) participants got the PTSD-affected veteran to engage in mental health care; however, aside from potentially increasing treatment talk frequency, outcome expectancy, and self-efficacy, ds = 0.60-1.08, no apparent improvements were observed for any well-being outcomes, ds = 0.01-0.40. Although the findings are promising, given the study limitations, future research is required to evaluate this approach in a full-scale randomized controlled trial.

Evaluating resilience in response to COVID-19 pandemic stressors among veteran mental health outpatients.

There is a public health need to understand mental health vulnerabilities to COVID-19 pandemic-related stressors and promote resilience among high-risk populations with preexisting psychiatric conditions. Recent cross-sectional studies suggest increases in mental health distress (e.g., depression and anxiety) during the pandemic. The present study expands upon these emerging findings using longitudinal latent modeling and hierarchical linear regressions. Consistent with the developmental psychopathology literature on resilience, we distinguished between promotive or risk (i.e., main effect), and protective or vulnerability (i.e., moderation) effects on mental health during the pandemic. At a large medical center, 398 veterans receiving outpatient mental health care provided prepandemic (Time 1) and during pandemic (Time 2) assessments of mental and physical health-related distress. Additional Time 2 questionnaires assessed pandemic-related stressors and positive behavioral adaptations in the summer of 2020. As expected, total stressor scores predicted longitudinal worsening of self-reported mental (ß = -.205) and physical health (ß = -.217). Positive behavioral adaptations enacted during the pandemic moderated and protected against stressor effects on mental health (ß = .160). In addition, the presence of substance use disorders moderated and conferred vulnerability to stressor effects on physical health (ß = -.158). Thus, higher COVID-19 pandemic stressor exposure may have exacerbated mental and physical health distress among veterans with common forms of psychopathology. Nevertheless, behavioral activation, purposeful maintenance of social connections, and focused treatment for substance misuse may be important intervention targets for reducing the longitudinal impact of pandemic stressors and enhancing resilience among people with mental illness. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The role of the MMPI-2-Restructured Form (MMPI-2-RF) in predicting and better understanding engagement in posttraumatic stress disorder treatment.

The ability of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008/2011) scores to predict treatment engagement in veterans referred for empirically supported treatments for symptoms of Posttraumatic Stress Disorder (PTSD) was examined. Early withdrawal from treatment and process factors, such as adherence and therapy session attendance, were examined in 100 veterans seeking treatment for trauma-related symptoms who were referred to a Veterans Health Administration medical center's tertiary care clinic for Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT). Veterans who scored higher on MMPI-2-RF scales associated with emotional/internalizing problems were more likely to be referred to PE or CPT, but individuals with the highest scores on those scales were also more likely to withdraw before completing treatment. These findings suggest Harkness and Lilienfeld's (1997) call to use personality assessment to guide treatment planning holds promise to better understand treatment engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists.

OBJECTIVE: Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. METHOD: Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. RESULTS: Therapists relied on stereotypes of poor adherence to understand veterans' experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans' needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists' interviews. CONCLUSIONS: Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Amputation-specific and generic correlates of participation among Veterans with lower limb amputation.

Participation in valued interpersonal and community activities is a key component of rehabilitation for Veterans with amputation. The purpose of this study was to identify specific factors that promote or inhibit participation to inform development of interventions that may facilitate participation in desired life activities. A convenience sample of 408 Veterans with at least one lower limb amputation and who had received outpatient care from the Regional Amputation Center (RAC) completed a mailed survey. Participation was measured using the Community Participation Indicators (CPI) Importance, Control, and Frequency scales and the Patient Reported Outcome Measurement Information System (PROMIS) Ability to Participate in Social Roles and Satisfaction with Social Participation scales. Multiple imputation procedures were used to address missing data. Correlates of participation were examined through multiple linear regression. A total of 235 participants completed the survey, a response rate of 58%. Levels of participation, measured with the PROMIS instruments, were 43.2 (SD = 8.1) for Ability and 46.4 (SD = 8.6) for Satisfaction. Regression analyses found robust amputation-specific correlates for participation, including body image and balance confidence. Generic (non-amputation specific) correlates for participation included depression and pain interference. Development of treatment approaches and devices that can address body image, balance confidence, pain, and mental health concerns such as depression have the potential to enhance the participation and rehabilitation of Veterans with lower limb amputation.

Inconsistent Reporting of Adverse Life Events Is Predicted by Current Internalizing Distress Among Military Service Members.

INTRODUCTION: Accurate measurement of adverse life events is critical for understanding the effects of stressors on health outcomes. However, much of this research uses cross-sectional designs and self-report years after the events take place. The reliability of this retrospective reporting and the individual difference factors associated with inconsistent recall over time are not frequently addressed, especially among military service members. MATERIALS AND METHODS: A longitudinal cohort of National Guard service members (n = 801) completed the Deployment Risk and Resilience Inventory-2 Prior Stressors scale and several measures of general well-being, including anxious depressive symptomatology, personal functioning, perceived social support, and overall health at two time points (before and after completion of basic combat training; median 11-month interval). RESULTS: Consistency in reporting the life event items ranged from 69.5% to 99.7%, with an overall Cohen's kappa coefficient of 0.215 for the scale, indicating minimal agreement. Lower well-being scores at Time 1 independently predicted yes-to-no changes in responding, whereas lower well-being scores at Time 2 independently predicted no-to-yes changes in responding. Follow-up mediations were conducted using study measures available only at Time 2. For all study measures, Time 2 well-being independently predicted changes from no-to-yes responding by way of indirect effects through self-reported non-specific internalizing distress and arousal. CONCLUSIONS: These findings highlight the confounding effects of fluctuations in current emotional distress on past stressor recall. There is a need for additional caution regarding the use of retrospective self-report of adverse life events in research and clinical practice and greater consideration of current psychological distress at the time of measurement completion.

Neurocognitive effects of repeated ketamine infusions in comorbid posttraumatic stress disorder and major depressive disorder.

BACKGROUND: The glutamate N-methyl-d-aspartate (NMDA) receptor antagonist ketamine rapidly ameliorates posttraumatic stress disorder (PTSD) and depression symptoms in individuals with comorbid PTSD and major depressive disorder (MDD). However, concerns over ketamine's potential neurocognitive side effects have yet to be assessed in this population. The current study investigated 1) changes in neurocognitive performance after a repeated ketamine dosing regimen and 2) baseline neurocognitive performance as a predictor of ketamine treatment effect. METHOD: Veterans with comorbid PTSD and MDD (N = 15) received six infusions of 0.5 mg/kg ketamine over a 12-day period. Neurocognitive and clinical outcomes assessments occurred at baseline and within 7 days of infusion-series completion using the CogState battery. RESULTS: Repeated ketamine infusions did not significantly worsen any measures of cognition. Rather, significant improvement was observed in working memory following completion of the infusion series. In addition, greater improvements in PTSD and MDD symptoms were associated with lower working memory, slower processing speed and faster set shifting at baseline. Lower verbal learning was also predictive of improvement in depression. LIMITATIONS: This study applied an open-label design without a placebo control. As such, it is not known to what extent the correlations or improvement in neurocognitive performance may have occurred under placebo conditions. CONCLUSION: This is the first study to examine the neurocognitive effects of repeated ketamine in participants with comorbid PTSD and MDD. Our findings suggest potential baseline neurocognitive predictors of ketamine response for comorbid PTSD and MDD symptoms.

Transgender and gender diverse veterans' access to gender-related health care services: The role of minority stress.

Although Veterans Affairs (VA) directives and initiatives have sought to ensure an affirmative environment for transgender and gender diverse (TGD) veterans, barriers to care persist, including enacted/anticipated stigma as well as providers' lack of knowledge regarding specific health concerns of the TGD community. These barriers are significant in light of prior research, which has demonstrated a relationship between fears of transphobic discrimination and avoiding or delaying health care engagement. The present study seeks to explore the relationship between perceptions of providers' competence with TGD patients, veterans' minority stress, and veterans' treatment engagement in gender-related services. To this end, analyses were performed on data collected from 42 TGD veterans. Results suggest that perceptions of providers' competence are positively correlated with engagement in gender-related services. Global gender minority stress was not related to engagement, but the discrimination subscale was significantly correlated with engagement. When entered into a simultaneous regression, both the discrimination subscale and provider competence significantly predicted engagement. Results require replication in larger, more diverse samples, but suggest improving provider competence may bolster engagement for TGD veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Enhancing Discovery of Genetic Variants for Posttraumatic Stress Disorder Through Integration of Quantitative Phenotypes and Trauma Exposure Information.

BACKGROUND: Posttraumatic stress disorder (PTSD) is heritable and a potential consequence of exposure to traumatic stress. Evidence suggests that a quantitative approach to PTSD phenotype measurement and incorporation of lifetime trauma exposure (LTE) information could enhance the discovery power of PTSD genome-wide association studies (GWASs). METHODS: A GWAS on PTSD symptoms was performed in 51 cohorts followed by a fixed-effects meta-analysis (N = 182,199 European ancestry participants). A GWAS of LTE burden was performed in the UK Biobank cohort (N = 132,988). Genetic correlations were evaluated with linkage disequilibrium score regression. Multivariate analysis was performed using Multi-Trait Analysis of GWAS. Functional mapping and annotation of leading loci was performed with FUMA. Replication was evaluated using the Million Veteran Program GWAS of PTSD total symptoms. RESULTS: GWASs of PTSD symptoms and LTE burden identified 5 and 6 independent genome-wide significant loci, respectively. There was a 72% genetic correlation between PTSD and LTE. PTSD and LTE showed largely similar patterns of genetic correlation with other traits, albeit with some distinctions. Adjusting PTSD for LTE reduced PTSD heritability by 31%. Multivariate analysis of PTSD and LTE increased the effective sample size of the PTSD GWAS by 20% and identified 4 additional loci. Four of these 9 PTSD loci were independently replicated in the Million Veteran Program. CONCLUSIONS: Through using a quantitative trait measure of PTSD, we identified novel risk loci not previously identified using prior case-control analyses. PTSD and LTE have a high genetic overlap that can be leveraged to increase discovery power through multivariate methods.

Advancing Research on Mechanisms of Resilience (ARMOR) Longitudinal Cohort Study of New Military Recruits: Results from a Feasibility Pilot Study.

Psychological resilience as a longitudinal process is highly relevant for understanding the functioning outcomes of military populations. Here, we review the extant literature on resilience among military service members, focusing on National Guard Soldiers. Our specific project (Advancing Research on Mechanisms of Resilience, "ARMOR") aims to develop a comprehensive model of resilience using a multilevel perspective. We report results from our prospective pilot study (n = 103) conducted in preparation for our large-scale longitudinal cohort study of Basic Combat Training (BCT) and its impact on military recruits' wellbeing. Results support feasibility of the larger study, evidence for a new measure of BCT stressor exposure, and demonstrate preliminary associations with BCT-related stressors and longitudinal changes in adaptive functioning. Future directions for our larger study will utilize data from survey responses, structured clinical interviews, neurobehavioral tasks, and neurobiological measures (functional and structural MRI and electroencephalography [EEG]) to examine individual differences in self-regulation as a predictor of resilience-related processes. ARMOR is well positioned to elucidate mechanisms that could be targeted for promoting wellbeing, preventing psychopathology, and facilitating long-term recovery.

Pre-deployment personality traits predict prescription opioid receipt over 2-year post-deployment period in a longitudinal cohort of deployed National Guard soldiers.

BACKGROUND: While military service members are at risk forpain conditions, receipt of prescribed opioids is associated with a range of serious adverse outcomes. The goal of this study is to examine the association between pre-deployment personality traits and receipt of prescription opioids after return from deployment. METHOD: Data were drawn from the Readiness and Resilience in National Guard Soldiers (RINGS) cohort study, an ongoing study of post-deployment health. Participants (N = 522) completed baseline assessments one month prior to deploying to Iraq (2006-2007). At baseline, we assessed personality traits using abbreviated versions of the Personality Psychopathology Five scales from the Minnesota Multiphasic Personality Inventory-2. Follow-up assessments were conducted three months, one year, and two years post-deployment. The primary outcome was total amount of prescribed opioids dispensed from Department of Veterans Affairs outpatient pharmacies in the two-year period following soldiers' return from deployment. Unadjusted and adjusted negative binomial regression models examined the relationships of pre-deployment personality traits, demographics (age, gender, and rank), baseline trauma symptoms, deployment related risk factors (difficult living/working environment, deployment injury, combat exposure), and post-deployment trauma symptoms with post-deployment opioid prescribing. RESULTS: Disconstraint, negative emotionality, and introversion/low positive emotionality were associated with receipt of more prescribed opioids over the two years after return from deployment. Personality traits measured at baseline remained statistically significantly after adjusting for all eight baseline and deployment risk factors of interest. CONCLUSIONS: Understanding how pre-deployment personality traits contribute to post-deployment prescription opioid use could inform efforts to improve veterans' health.

Corrigendum: Methylation of FKBP5 and SLC6A4 in Relation to Treatment Response to Mindfulness Based Stress Reduction for Posttraumatic Stress Disorder.

[This corrects the article DOI: 10.3389/fpsyt.2018.00418.].

The Association Between Smoking Abstinence and Pain Trajectory Among Veterans Engaged in U.S. Department of Veterans Affairs Mental Health Care.

OBJECTIVE: To prospectively examine associations between smoking and nicotine abstinence and pain trajectory over 12 months among smokers with low, moderate, and severe pain and to assess whether these associations differ over time. DESIGN: A secondary analysis of the "Proactive Outreach for Smokers in VA Mental Health" study, a randomized controlled trial of proactive outreach for veteran smokers engaged in U.S. Department of Veterans Affairs (VA) mental health care. METHODS: Participants were categorized into "low" (n = 616), "moderate" (n = 479), and "severe" pain (n = 656) groups according to baseline pain score. Associations between self-reported abstinence from smoking and nicotine at 6 and 12 months and pain trajectory, measured via the PEG scale (Pain intensity, Enjoyment of life, General activity) composite score, were assessed through the use of general linear mixed models. Interaction tests assessed whether these associations differed at 6 and 12 months. Analyses were conducted within the overall sample and within the separate pain groups. RESULTS: There were significant interactions in the overall sample and the low and moderate pain groups, such that 7-day point prevalence smoking abstinence was associated with lower pain scores at 6 but not 12 months. In the severe pain group, 7-day abstinence from both smoking and nicotine was associated with lower pain scores across both time points. Six-month prolonged abstinence was not associated with pain scores. CONCLUSIONS: In this prospective analysis conducted among veteran smokers engaged in mental health services, 7-day abstinence from smoking and nicotine was associated with significantly lower levels of pain. Education efforts could help better inform smokers on the relationship between smoking and pain.

Assessing the Clinical Utility of the MMPI-2-RF in Detecting Suicidal Ideation in a High Acuity, Partially-Hospitalized Veteran Sample.

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008/2011) has demonstrated utility in suicide risk assessment. Limited research with the MMPI-2-RF in higher acuity populations exists, particularly regarding the impact of possible underreporting on prediction of suicide risk. The current study serves to extend previous findings of the utility of clinically indicated MMPI-2-RF scales and proxy indices in 293 veterans (83.62% White, 85.32% male, and 74.40% with past-week suicide ideation) enrolled in a Veterans Affairs Medical Center partial psychiatric hospitalization program. Differences in self-report indicators and MMPI-2-RF scales and proxy indices relevant in assessing suicide ideation between veterans indicated as possibly underreporting and those who were not and the ability of the scales and proxy indices to predict current suicide ideation were examined. These indicators, scales, and proxy indices, with the exception of SUI, were significantly impacted by underreporting, and none of the examined scales or proxy indices (or their interaction) were consistently associated with self-reported suicide ideation after accounting for SUI. However, SUI was consistently associated with suicide ideation and was less influenced by under-reporting. In acutely ill psychiatric patients, SUI may be the most robust indicator of current suicide ideation.

A Theory of Planned Behavior Scale for Adherence to Trauma-Focused Posttraumatic Stress Disorder Treatments.

Evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy and prolonged exposure (CPT/PE), greatly reduce suffering for veterans, but many veterans fail to complete treatment. Developing a theory-based understanding of adherence is necessary to inform interventions to improve treatment retention. We developed and tested a series of scales applying the theory of planned behavior (TPB) to CPT/PE adherence. The scales were administered in mailed surveys as part of a larger mixed-methods study of veteran adherence to PE/CPT. Surveys were sent to 379 veterans who were initiating CPT/PE across four U.S. Veterans Affairs (VA) hospitals and 207 of their loved ones. Subsequent session attendance and homework compliance were coded via a review of electronic medical records. We examined item-level characteristics, factor structure, and the convergent and discriminant validity of the resultant scales. The findings support four subscales: two related to attitudes (i.e., Treatment Makes Sense and Treatment Fits Needs), one related to perceived behavioral control over participation (i.e., Participation Control), and one related to perceived family attitudes about CPT/PE participation (i.e., Subjective Norms). Scale validity was supported through significant associations with theoretically relevant constructs, including intentions to persist in CPT/PE, rs = .19-.38; treatment completion, rs = .21-.25; practical treatment barriers, rs = -.19 to -.24; and therapeutic alliance, rs = .39-.57.

Adult Emergence Agitation: A Veteran-Focused Narrative Review.

Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.