Effect of Symptom Over-Reporting on Heart Rate Variability in Veterans With Posttraumatic Stress Disorder.

Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.

Repetitive transcranial magnetic stimulation and threat memory: selective reduction of combat threat memory p300 response after right frontal-lobe stimulation.

Using the event-related potential P3a component as a marker, the authors tested the efficacy of repetitive transcranial magnetic stimulation (rTMS) for reducing hyperarousability to specific threat stimuli in one Vietnam veteran with chronic posttraumatic stress disorder (PTSD), who exhibited an exaggerated P3a response to combat-related pictures. Twenty minutes of 1-Hz rTMS to the right prefrontal area effected a reduction in the P3a amplitude, whereas similar rTMS to the left prefrontal area did not. In addition to providing evidence for the effectiveness of right frontal rTMS for an exaggerated response to trauma-related stimuli, this study provides electrophysiological corroboration of subjective reports of PTSD symptoms.

Differentiating between appraisal process and product in cognitive theories of posttraumatic stress.

Biased appraisal is central to cognitive theories of posttraumatic stress, but little research has examined the potentially distinct meanings of the term. The ongoing process of appraising social information and the beliefs that emerge as products of that process can be distinguished conceptually. This study sought to examine whether these 2 meanings are empirically distinct as well, and if so, to begin exploring potential relations between these appraisal constructs and posttraumatic stress symptoms. Soldiers (N = 424) preparing for deployment to Iraq or Afghanistan were administered measures of each construct. Results of confirmatory factor analysis suggest that the appraisal process and the products of that process (i.e., beliefs) are indeed distinct. Structural equation models are consistent with cognitive bias and social information processing literatures, which posit that a biased appraisal process may contribute to the development of dysfunctional beliefs and posttraumatic stress symptoms following trauma. The potential utility of distinctly conceptualizing and measuring the appraisal process in both clinical and research settings is discussed.

Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.

IMPORTANCE: Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments. OBJECTIVE: To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD. DESIGN, SETTING, AND PARTICIPANTS: The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months. INTERVENTIONS: Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations. MAIN OUTCOMES AND MEASURES: The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy. RESULTS: During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (ß = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (ß = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (ß = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months. CONCLUSIONS AND RELEVANCE: Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00821678.

Left prefrontal-repetitive transcranial magnetic stimulation (rTMS) and regional cerebral glucose metabolism in normal volunteers.

Repetitive transcranial magnetic stimulation (rTMS) holds promise as a probe into the pathophysiology and possible treatment of neuropsychiatric disorders. To explore its regional effects, we combined rTMS with positron emission tomography (PET). Fourteen healthy volunteers participated in a baseline 18-fluorodeoxyglucose (FDG) PET scan. During a second FDG infusion on the same day, seven subjects received 30 min of 1 Hz rTMS at 80% of motor threshold to left prefrontal cortex, and seven other subjects received sham rTMS under identical conditions. Global and normalized regional cerebral glucose metabolic rates (rCMRglu) from the active and sham conditions were compared to baseline and then to each other. Sham, but not active 1 Hz rTMS, was associated with significantly increased global CMRglu. Compared to baseline, active rTMS induced normalized decreases in rCMRglu in right prefrontal cortex, bilateral anterior cingulate, basal ganglia (L>R), hypothalamus, midbrain, and cerebellum. Increases in rCMRglu were seen in bilateral posterior temporal and occipital cortices. Sham rTMS compared to baseline resulted in isolated normalized decreases in rCMRglu in left dorsal anterior cingulate and left basal ganglia, and increases in posterior association and occiptal regions. Differences between the 1 Hz active versus sham changes from baseline revealed that active rTMS induced relative decrements in rCMRglu in the left superior frontal gyrus and increases in the cuneus (L>R). One Hertz rTMS at 80% motor threshold over the left prefrontal cortex in healthy subjects compared to sham rTMS in another group (each compared to baseline) induced an area of decreased normalized left prefrontal rCMRglu not directly under the stimulation site, as well as increases in occipital cortex. While these results are in the predicted direction, further studies using other designs and higher intensities and frequencies of rTMS are indicated to better describe the local and distant changes induced by rTMS.

Over-reporting bias and the modified Stroop effect in Operation Enduring and Iraqi Freedom veterans with and without PTSD.

The current study investigated in a sample of Operation Enduring and Iraqi Freedom (OEF/OIF) veterans how a symptom overreporting response style might influence the association between PTSD diagnostic status and color-naming response latency for trauma-related stimuli during the Modified Stroop Task (i.e., the Modified Stroop Task effect, MST effect). It was hypothesized that, if an overreporting response style reflected feigning or exaggerating PTSD symptoms, an attenuated MST effect would be expected in overreporters with PTSD as compared with PTSD-diagnosed veterans without an overreporting style. If, however, overreporting stemmed from high levels of distress, the MST effect might be greater in overreporters compared with those with a neutral response style. The results showed that veterans with PTSD and an overreporting response style demonstrated an augmented MST effect in comparison with those with a more neutral style of response. Overreporters also reported greater levels of psychopathology, including markedly elevated reports of dissociative experiences. We suggest that dissociation-prone overreporters may misattribute emotional distress to combat experiences leading to the enhanced MST effect. Other possible explanations for these results are also discussed.

Veteran perceptions of virtual reality to assess and treat posttraumatic stress disorder.

Implementation of evidence-based treatments (EBT) is necessary to address posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) military service personnel. Because virtual reality (VR) offers a promising tool for delivery of one type of EBT--exposure therapy--this study explored veterans' perceptions of VR as an assessment tool and treatment adjunct. We conducted semi-structured interviews with 14 OEF/OIF veterans being treated for PTSD after viewing two 3 minute VR scenarios as part of a larger research study. Veterans reported a capacity for immersion in VR in both combat and civilian environments, characterized by self-reported physiological reactivity, thoughts/behaviors similar to those experienced in Iraq, and triggered memories. Although participants were generally positive about VR, they expressed concerns about the possibility of negative reactions after viewing VR. Findings are discussed in the context of further development of VR aided interventions in veteran healthcare systems.

Clinician perceptions of virtual reality to assess and treat returning veterans.

OBJECTIVE: Implementation of evidence-based, innovative treatments is necessary to address posttraumatic stress disorder (PTSD) and related mental health problems of Operation Enduring Freedom and Operation Iraqi Freedom (OEF-OIF) military service personnel. The purpose of this study was to characterize mental health clinicians' perceptions of virtual reality as an assessment tool or adjunct to exposure therapy. METHODS: Focus groups were conducted with 18 prescribing and nonprescribing mental health clinicians within the Veterans Health Administration. Group discussion was digitally recorded, downloaded into Ethnograph software, and coded to arrive at primary, secondary, and tertiary themes. RESULTS: Most frequently mentioned barriers pertained to aspects of virtual reality, followed by veteran characteristics. Organizational barriers were more relevant when implementing virtual reality as a treatment adjunct. CONCLUSIONS: Although the study demonstrated that use of virtual reality as a therapy was feasible and acceptable to clinicians, successful implementation of the technology as an assessment and treatment tool will depend on consideration of the facilitators and barriers that were identified.