Posttraumatic stress disorder in incarcerated women: A call for evidence-based treatment.

The majority of women who enter the criminal justice system, most of whom are poor and women of color, have suffered from significant lifetime trauma exposure that can lead to posttraumatic stress disorder (PTSD). It is essential to identify the prevalence of PTSD among this population in order to identify treatment needs. Most studies on PTSD among incarcerated women have focused on PTSD in jailed populations, including women awaiting trial. Using a cross-sectional study design, we estimated the prevalence of PTSD and comorbid physical and mental health conditions in 387 incarcerated women sentenced to a maximum-security prison in the United States. Almost half (44%) of our sample met the diagnostic criteria for PTSD. Women with moderate to severe PTSD symptoms were more likely to report several comorbid physical and mental health conditions than were women without PTSD. Women with the most severe symptoms were most likely to report receiving mental health treatment in prison; women with moderate to severe symptoms were less likely to report receiving similar mental health care. Our findings add support to the link between PTSD and comorbid physical and mental health conditions and suggest that many women with PTSD are not receiving mental health treatment that is likely to benefit them. Because prison has become the mental health safety net for some of the nation's most vulnerable women, it is imperative that prisons provide evidence-based PTSD treatment during incarceration.

Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure.

OBJECTIVE: The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD). Emotional processing theory of PTSD proposes that disconfirmation of erroneous cognitions associated with PTSD is a central mechanism in PTSD symptom reduction; but to date, the causal relationship between change in pathological cognitions and change in PTSD severity has not been established. METHOD: Female sexual or nonsexual assault survivors (N = 64) with a primary diagnosis of PTSD received 10 weekly sessions of PE. Self-reported PTSD symptoms, depression symptoms, and PTSD-related cognitions were assessed at pretreatment, each of the 10 PE treatment sessions, and posttreatment. RESULTS: Lagged mixed-effect regression models indicated that session-to-session reductions in PTSD-related cognitions drove successive reductions in PTSD symptoms. By contrast, the reverse effect of PTSD symptom change on change in cognitions was smaller and did not reach statistical significance. Similarly, reductions in PTSD-related cognitions drove successive reductions in depression symptoms, whereas the reverse effect of depression symptoms on subsequent cognition change was smaller and not significant. Notably, the relationships between changes in cognitions and PTSD symptoms were stronger than the relationships between changes in cognitions and depression symptoms. CONCLUSIONS: To our knowledge, this is the 1st study to establish change in PTSD-related cognitions as a central mechanism of PE treatment. These findings are consistent with emotional processing theory and have important clinical implications for the effective implementation of PE.

Serotonin transporter genotype modulates functional connectivity between amygdala and PCC/PCu during mood recovery.

The short (S) allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) has been associated with increased susceptibility to depression. Previous neuroimaging studies have consistently showed increased amygdala activity during the presentation of negative stimuli or regulation of negative emotion in the homozygous short allele carriers, suggesting the key role of amygdala response in mediating increased risk for depression. The brain default mode network (DMN) has also been shown to modulate amygdala activity. However, it remains unclear whether 5-HTTLPR genetic variation modulates functional connectivity (FC) between the amygdala and regions of DMN. In this study, we re-analyzed our previous imaging dataset and examined the effects of 5-HTTLPR genetic variation on amygdala connectivity. A total of 15 homozygous short (S/S) and 15 homozygous long individuals (L/L) were scanned in functional magnetic resonance imaging (fMRI) during four blocks: baseline, sad mood, mood recovery, and return to baseline. The S/S and L/L groups showed a similar pattern of FC and no differences were found between the two groups during baseline and sad mood scans. However, during mood recovery, the S/S group showed significantly reduced anti-correlation between amygdala and posterior cingulate cortex/precuneus (PCC/PCu) compared to the L/L group. Moreover, PCC/PCu-amygdala connectivity correlated with amygdala activity in the S/S group but not the L/L group. These results suggest that 5-HTTLPR genetic variation modulates amygdala connectivity which subsequently affects its activity during mood regulation, providing an additional mechanism by which the S allele confers depression risk.

The relationship between posttraumatic and depressive symptoms during prolonged exposure with and without cognitive restructuring for the treatment of posttraumatic stress disorder.

OBJECTIVE: In the present study, we examined the relationship between posttraumatic and depressive symptoms during prolonged exposure (PE) treatment with and without cognitive restructuring (CR) for the treatment of posttraumatic stress disorder (PTSD). METHOD: Female assault survivors (N = 153) with PTSD were randomized to either PE alone or PE with added CR (PE/CR). During treatment, bi-weekly self-report measures of posttraumatic and depressive symptoms were administered. RESULTS: Multilevel mediational analyses indicated that during PE, changes in posttraumatic symptoms accounted for 80.3% of changes in depressive symptoms, whereas changes in depressive symptoms accounted for 45.0% of changes in posttraumatic symptoms. During PE/CR, changes in posttraumatic symptoms accounted for 59.6% of changes in depressive symptoms, and changes in depressive symptoms accounted for 50.7% of changes in posttraumatic symptoms. CONCLUSIONS: This pattern of results suggests that PE primarily affects posttraumatic symptoms, which in turn affect depressive symptoms. In contrast, PE/CR results in a more reciprocal relationship between posttraumatic and depressive symptoms.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD.

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

The Child PTSD Symptom Scale: psychometric properties in female adolescent sexual assault survivors.

Traumatic experiences are common among youths and can lead to posttraumatic stress disorder (PTSD). In order to identify traumatized children who need PTSD treatment, instruments that can accurately and efficiently evaluate pediatric PTSD are needed. One such measure is the Child PTSD Symptom Scale (CPSS), which has been found to be a reliable and valid measure of PTSD symptom severity in school-age children exposed to natural disasters (Foa, Johnson, Feeny, & Treadwell, 2001). However, the psychometric properties of the CPSS are not known in youths who have experienced other types of trauma. The current study aims to fill this gap by examining the psychometric properties of the interview (CPSS-I) and self-report (CPSS-SR) administrations of the CPSS in a sample of 91 female youths with sexual abuse-related PTSD, a population that is targeted in many treatment studies. Scores on both the CPSS-I and CPSS-SR demonstrated good to excellent internal consistency. One-week test-retest reliability assessed for CPSS-SR scores was excellent (r=.86); interrater reliability of CPSS-I scores was also excellent (r=.87). Symptom-based diagnostic agreement between the CPSS-SR and CPSS-I was excellent at 85.5%; scores on both the CPSS-SR and CPSS-I also demonstrated good convergent validity (74.5-76.5% agreement) with the PTSD module of The Schedule of Affective Disorders and Schizophrenia for School-Age Children--Revised for DSM--IV (K-SADS; Kaufman, Birmaher, Brent, & Rao, 1997). The strong psychometric properties of the CPSS render it a valuable instrument for PTSD screening as well as for assessing symptom severity.

Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD.

Obsessive-compulsive disorder (OCD) is a highly debilitating disorder. Fortunately there are treatments that help the majority of OCD sufferers. The behavioral treatment with the most empirical support for its efficacy is exposure and response prevention (EX/RP). Over the years in our supervision meetings and in our clinical practice we have noted a number of relatively common therapist pitfalls that decrease the effectiveness of EX/RP. These pitfalls include not encouraging patients to approach the most distressing situations, doing imaginal exposure when in vivo is called for (and vice versa), encouraging distraction during exposure, providing reassurance, failing to address the core fear, ineffective handling of mental compulsions, and difficulty working with close others in the patient's life. In the current article we describe these common pitfalls and how to avoid them.

Reliability and validity of the PDS and PSS-I among participants with PTSD and alcohol dependence.

The prevalence of alcohol use disorder (e.g., alcohol dependence; AD) among individuals with posttraumatic stress disorder (PTSD) is quite high, with estimates of 52% for men and 30% for women (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). There are several interviews and self-report measures of PTSD with good published psychometric properties, and they are routinely used with comorbid AD and PTSD. However, none of these instruments was validated with this population. The current study fills this gap by examining the psychometric properties of the PTSD Symptom Scale-Interview (PSS-I) and the self-report PTSD Diagnostic Scale (PDS) in individuals diagnosed with current PTSD and AD. Both scales comprised of 17 items provide diagnostic and symptom severity information according to DSM-IV-TR criteria. Participants were 167 individuals who were diagnosed with AD and chronic PTSD and were enrolled in a randomized controlled treatment study. Results revealed excellent internal consistency of both the PSS-I and the PDS, good test-retest reliability over a 1-month period, and good convergent validity with the SCID. The specificity of the PSS-I diagnosis of PTSD was better than the PDS diagnosis, the latter exhibiting a greater percentage of false positives. In sum, the results showed that the PSS-I and PDS performed well in this population and can be used with confidence to assess PTSD diagnosis and symptom severity.

The Puzzle of Neuroimaging and Psychiatric Diagnosis: Technology and Nosology in an Evolving Discipline.

Brain imaging provides ever more sensitive measures of structure and function relevant to human psychology and has revealed correlates for virtually every psychiatric disorder. Yet it plays no accepted role in psychiatric diagnosis beyond ruling out medical factors such as tumors or traumatic brain injuries. Why is brain imaging not used in the diagnosis of primary psychiatric disorders, such as depression, bipolar disease, schizophrenia, and ADHD? The present article addresses this question. It reviews the state of the art in psychiatric imaging, including diagnostic and other applications, and explains the nonutility of diagnostic imaging in terms of aspects of both the current state of imaging and the current nature of psychiatric nosology. The likely future path by which imaging-based diagnoses will be incorporated into psychiatry is also discussed. By reviewing one well-known attempt to use SPECT-scanning in psychiatric diagnosis, the article examines a real-world practice that illustrates several related points: the appeal of the idea of image-assisted diagnosis for physicians, patients and families, despite a lack of proven effectiveness, and the mismatch between the categories and dimensions of current nosology and those suggested by imaging.

Serotonin transporter genotype modulates the association between depressive symptoms and amygdala activity among psychiatrically healthy adults.

Recent attempts to understand the biological bases of depression vulnerability have revealed that both the short allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) and activity in the amygdala are associated with depression. Other studies have reported amygdala hyperactivity associated with the 5-HTTLPR short allele, linking the genetic and neuroimaging lines of research and suggesting a mechanism whereby the short allele confers depression risk. However, fewer investigations have examined the associations among depression, 5-HTTLPR variability, and amygdala activation in a single study. The current study thus investigated whether 5-HTTLPR genotype modulates the association between depressive symptoms and amygdala activity among psychiatrically healthy adults. Regional cerebral blood flow was measured with perfusion fMRI during a task-free scan. We hypothesized differential associations between depressive symptoms and amygdala activity among individuals homozygous for the short allele and individuals homozygous for the long allele. Both whole brain analyses and region-of-interest analyses confirmed this prediction, revealing a significant negative association among the long allele group and a trend of positive association among the short allele group. These results complement existing reports of short allele related amygdala hyperactivity and suggest an additional neurobiological mechanism whereby the 5-HTTLPR is associated with psychiatric outcomes.

The effect of anxiety sensitivity on alcohol consumption among individuals with comorbid alcohol dependence and posttraumatic stress disorder.

Existing research has shown that anxiety sensitivity (AS) is positively associated with alcohol use, and that individuals with high AS use alcohol to avoid or escape negative affect associated with aversive stimuli. The current study investigated the associations between AS and drinking behavior among individuals with comorbid alcohol dependence and posttraumatic stress disorder (PTSD). We assessed baseline PTSD symptoms, AS, and drinking behavior among 151 participants enrolled in a randomized clinical trial for alcohol dependence. We hypothesized that AS would moderate the association between PTSD symptoms and drinking behavior, with PTSD symptoms being more strongly associated with drinking behavior among individuals with high AS. Results showed that AS was strongly associated with PTSD (r = .48) and moderately associated with drinking behavior (r = .18). As predicted, the interaction of AS with severity of PTSD symptoms was associated with frequency of drinking; however, contrary to our hypothesis, PTSD symptoms were more strongly associated with drinking behavior among individuals with relatively low AS. The implication of the present results for treatment of both PTSD and alcohol dependence are discussed.

Should we expect "neural signatures" for DSM diagnoses?

Contemporary researchers in psychiatry have sought to develop a nosology based on empirical observation, in line with the principles spelled out by Drs Eli Robins and Samuel B. Guze in 1970. For more than 2 decades, psychiatrists using neuroimaging have aspired to provide one form of "laboratory study" that Robins and Guze said would have to be in place for a psychiatric diagnosis to be valid: researchers have sought "neural signatures" of psychiatric disorders. Our objective was to examine the feasibility of this endeavor. To this end, we examine whether current psychiatric nosology as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) lends itself to the identification of neural signatures for psychiatric diagnoses. Because neuroimaging largely is used only to detect average activation or structural differences between groups of individuals with the same diagnosis and groups of individuals with no diagnosis, it is unlikely that it will be possible to use neuroimaging technologies to determine which psychiatric diagnosis a given individual warrants. In addition, the heterogeneity of psychiatric disorder categories as defined in the DSM reveals that these diagnoses do not reflect neurologically discrete phenomena. Finally, neural correlates of psychopathology generally are not unique to specific diagnoses. Although it is unrealistic to hope that neuroimaging will be used to make psychiatric diagnoses as they are currently conceived, neuroimaging is already being used to make headway in 2 other arenas of psychiatric investigation that we briefly review.

Contrasting roles for lateral and ventromedial prefrontal cortex in transient and dispositional affective experience.

Prefrontal cortex (PFC) has been implicated in the experience and regulation of emotional states. Emotional experience is a complex construct, encompassing a range of more specific processes. This exploratory study aimed to delineate which (if any) aspects of emotional experience rely critically on either the ventromedial frontal (VMF) or lateral frontal (LF) lobes. The affective experience of individuals with damage to these regions was surveyed in detail using several measures and compared with that of control participants. Dependent measures included subjective and observer ratings of both dispositional affect and transient responses to laboratory mood inductions. VMF damage was associated with greater negative dispositional affect relative to controls and to individuals with LF damage; however, transient responses to emotional stimuli were largely normal. In contrast, LF damage was associated with an exaggerated subjective reactivity to sad emotional stimuli relative to control participants, but normal dispositional affect. Interestingly, neither form of PFC damage affected spontaneous emotion recovery following the mood inductions. These findings suggest a role for VMF in modulating dispositional negative affect; in contrast, LF areas appear to be critical in regulating transient emotional responses while emotional stimuli are present. This study also illustrates the dissociability of different aspects of emotional experience in patients with focal brain injury.

Neural Substrates Associated with Weather-Induced Mood Variability: An Exploratory Study Using ASL Perfusion fMRI.

Daily variations in weather are known to be associated with variations in mood. However, little is known about the specific brain regions that instantiate weather-related mood changes. We used a data-driven approach and ASL perfusion fMRI to assess the neural substrates associated with weather-induced mood variability. The data-driven approach was conducted with mood ratings under various weather conditions (N = 464). Forward stepwise regression was conducted to develop a statistical model of mood as a function of weather conditions. The model results were used to calculate the mood-relevant weather index which served as the covariate in the regression analysis of the resting CBF (N = 42) measured by ASL perfusion fMRI under various weather conditions. The resting CBF activities in the left insula-prefrontal cortex and left superior parietal lobe were negatively correlated (corrected p<0.05) with the weather index, indicating that better mood-relevant weather conditions were associated with lower CBF in these regions within the brain's emotional network. The present study represents a first step toward the investigation of the effect of natural environment on baseline human brain function, and suggests the feasibility of ASL perfusion fMRI for such study.

Treatment of posttraumatic stress disorder in U.S. combat veterans: a meta-analytic review.

Among U.S. veterans who have been exposed to combat-related trauma, significantly elevated rates of posttraumatic stress disorder (PTSD) are reported. Veterans with PTSD are treated for the disorder at Veterans Affairs (VA) hospitals through a variety of psychotherapeutic interventions. Given the significant impairment associated with PTSD, it is imperative to assess the typical treatment response associated with these interventions. 24 studies with a total sample size of 1742 participants were quantitatively reviewed. Overall, analyses showed a medium between-groups effect size for active treatments compared to control conditions. Thus, the average VA-treated patient fared better than 66% of patients in control conditions. VA treatments incorporating exposure-based interventions showed the highest within-group effect size. Effect sizes were not moderated by treatment dose, sample size, or publication year. Findings are encouraging for treatment seekers for combat-related PTSD in VA settings.

A meta-analytic review of prolonged exposure for posttraumatic stress disorder.

Two decades of research demonstrate the efficacy of exposure therapy for posttraumatic stress disorder (PTSD). The efficacy of prolonged exposure (PE), a specific exposure therapy program for PTSD that has been disseminated throughout the world, has been established in many controlled studies using different trauma populations. However, a meta-analysis of the effectiveness of PE for PTSD has not been conducted to date. The purpose of the current paper is to estimate the overall efficacy of PE for PTSD relative to adequate controls. We included all published randomized controlled trials of PE vs. control (wait-list or psychological placebo) for the treatment of PTSD in adolescents or adults. Treatments were classified as PE if they included multiple sessions of imaginal and in vivo exposure and were based on the manualized treatment developed by Foa, Rothbaum, Riggs, and Murdock (1991). Thirteen studies with a total sample size of 675 participants met the final inclusion criteria. The primary analyses showed a large effect for PE versus control on both primary (Hedges's g=1.08) and secondary (Hedges's g=0.77) outcome measures. Analyses also revealed medium to large effect sizes for PE at follow-up, both for primary (Hedges's g=0.68) and secondary (Hedges's g=0.41) outcome measures. There was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT). Effect sizes were not moderated by time since trauma, publication year, dose, study quality, or type of trauma. The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures. PE is a highly effective treatment for PTSD, resulting in substantial treatment gains that are maintained over time.

Serotonin transporter genotype modulates amygdala activity during mood regulation.

Recent studies have implicated the short allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) in depression vulnerability, particularly in the context of stress. Several neuroimaging studies have shown that 5-HTTLPR genotype predicts amygdala reactivity to negatively valenced stimuli, suggesting a mechanism whereby the short allele confers depression risk. The current study investigated whether 5-HTTLPR genotype similarly affects neural activity during an induced sad mood and during recovery from sad mood. Participants were 15 homozygous short (S) and 15 homozygous long (L) individuals. Regional cerebral blood flow was measured with perfusion functional magnetic resonance imaging during four scanning blocks: baseline, sad mood, mood recovery and following return to baseline. Comparing mood recovery to baseline, both whole brain analyses and template-based region-of-interest analyses revealed greater amygdala activity for the S vs the L-group. There were no significant amygdala differences found during the induced sad mood. These results demonstrate the effect of the S allele on amygdala activity during intentional mood regulation and suggest that amygdala hyperactivity during recovery from a sad mood may be one mechanism by which the S allele confers depression risk.

Ventromedial frontal lobe plays a critical role in facial emotion recognition.

The ventromedial prefrontal cortex has been implicated in a variety of emotion processes. However, findings regarding the role of this region specifically in emotion recognition have been mixed. We used a sensitive facial emotion recognition task to compare the emotion recognition performance of 7 subjects with lesions confined to ventromedial prefrontal regions, 8 subjects with lesions elsewhere in prefrontal cortex, and 16 healthy control subjects. We found that emotion recognition was impaired following ventromedial, but not dorsal or lateral, prefrontal damage. This impairment appeared to be quite general, with lower overall ratings or more confusion between all six emotions examined. We also explored the relationship between emotion recognition performance and the ability of the same patients to experience transient happiness and sadness during a laboratory mood induction. We found some support for a relationship between sadness recognition and experience. Taken together, our results indicate that the ventromedial frontal lobe plays a crucial role in facial emotion recognition, and suggest that this deficit may be related to the subjective experience of emotion.

Association between serotonin transporter genotype and extraversion.

Despite the long-standing recognition that extraversion is partially heritable, few specific genes have been found to be associated significantly with this personality trait. The purpose of this study was to examine the association between a functional genetic polymorphism of the serotonin transporter promoter region (5-HTTLPR) and extraversion. Caucasian participants (N=183) were genotyped for the 5-HTTLPR; extraversion scores for participants homozygous for the short allele (s/s) were compared with those participants carrying at least one long allele (s/l and l/l). An s/s genotype at 5-HTTLPR was significantly associated with self ratings of reduced extraversion (P=0.012); presence versus absence of the long allele explained 3.4% of the variance in extraversion. These findings provide support for the effect of the 5-HTTLPR, and for the serotonergic system more broadly, on behaviors related to extraversion.