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Traumatic stress reactions (TSRs) exist on a continuum that includes posttraumatic stress disorder (PTSD), highly comorbid psychopathology, and resilience, highlighting the need for comprehensive and integrative approaches capable of capturing the full spectrum of heterogeneous reactions. Here, we used a transdiagnostic and multidimensional method to characterize clinical phenotypes of TSRs in a nationally representative sample of U.S. military veterans. The Middle‐Out Approach was used to evaluate self‐reported PTSD, generalized anxiety, major depressive symptoms, and physical and mental functioning to identify discrete latent classes of TSRs and their demographic, military and trauma history, and psychosocial correlates. Cross‐sectional data were analyzed from 3,727 U.S. veterans who participated in the National Health and Resilience in Veterans Study. Latent class analysis identified five classes of veterans: low TSR (61.3%), anxious/depressive (16.6%), avoidant arousal (9.2%), dysphoric arousal (8.2%), and high TSR (4.7%). Veterans in the dysphoric arousal and high TSR classes demonstrated lower functioning than other classes, which showed similar levels of moderate‐to‐high functioning despite symptom differences. Classes distinguished between resilience to PTSD symptoms versus resilience to all symptoms and functioning domains and were differentially associated with demographic characteristics, trauma and military histories, and psychosocial characteristics. The results suggest that veterans exhibit different clinical phenotypes of TSRs, which may help inform etiology, diagnostic subtypes, and personalized treatment. Further, although most veterans with psychopathology experience functional impairment, a sizable subset demonstrates high functioning despite psychopathology symptoms. [ABSTRACT FROM AUTHOR]

The two widely available evidence‐based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are cognitive processing therapy and prolonged exposure. Although the U.S. Department of Veterans Affairs (VA) has invested in intensive clinical training to provide these first‐line treatments, most military veterans do not receive these therapies. Prior research indicates that patient interest and motivation depend on how patients are educated, and differences in how information is presented shape their decision‐making. To our knowledge, no studies have addressed how clinicians "pitch" EBPs for PTSD and examined whether certain approaches are more effective than others. We recorded and thematically analyzed 25 treatment planning sessions across 10 VA sites in the United States to better understand how providers talk to patients about treatment options. Five themes were identified: using rich description, integrating various forms of questioning to engage the patient, sharing prior patient success stories, using inviting and direct language, and tailoring therapy talk to fit patient needs. Providers learning to offer EBPs can use these strategies to serve as a "menu" of options that will allow them to present EBPs in a way that appeals to a particular patient. [ABSTRACT FROM AUTHOR]

Negative mental health outcomes are prevalent among veterans exposed to military‐related stressors and are associated with social isolation. Limited research exists on resilience following military separation and its impact on social isolation in veterans. We examined resilience against military‐related stressors and 2‐year longitudinal associations with social isolation indicators; gender differences were also explored. U.S. military veterans (N = 351, 70.4% men) who deployed to the wars in and around Iraq and Afghanistan following the September 11, 2001, terrorist attacks (9/11) were recruited as part of a longitudinal assessment study examining predictors of postdeployment adjustment. Using a residualization approach, resilience was approximated as low stressor reactivity (SR), calculated by regressing mental health onto military‐related stressor exposure. Military‐related stressors were significantly associated with posttraumatic stress disorder (PTSD) related to both events during post‐9/11 deployment (deployment event) and outside of post‐9/11 deployment (other event), functional disability, and depression. After correcting for multiple comparisons, only SR derived from depressive symptoms predicted more closeness difficulties in social relationships longitudinally, B = 0.50, q = .023. Women also demonstrated higher SR than men regarding other event‐related PTSD symptoms, B = −0.52, q < .001; functional disability, B = −0.28, q = .028; and depression, B = −0.34, q = .012. Results suggest that veterans with higher depressogenic reactivity to military‐related stressors were more likely to endorse discomfort with closeness than those with lower depressogenic reactivity. Women veterans may also be more impacted by nondeployment traumatic distress, psychosocial dysfunction, and depression in response to military‐related stressors. [ABSTRACT FROM AUTHOR]

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population‐based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma‐related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma‐related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non‐Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement‐based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury. [ABSTRACT FROM AUTHOR]

This pilot randomized clinical trial (RCT) sought to examine the preliminary efficacy of an internet‐based version of written exposure therapy delivered to veterans through an online program supported by peer coaches. Veterans (N = 124) with clinically significant posttraumatic stress disorder (PTSD) symptoms were randomly assigned to imaginal exposure either via writing (written exposure) or verbal recounting (verbal exposure). The online treatment involved four to eight sessions of imaginal exposure preceded and followed by an online chat with a peer coach. Participants completed assessments at baseline, posttreatment, and 3‐month follow‐up. Half of the participants never started treatment; among those who started treatment, the mean number of sessions completed was 4.92. At posttreatment, participants in both conditions reported clinically meaningful improvements in PTSD symptoms, d = 1.35; depressive symptoms, d = 1.10; and functioning, d = 0.39. Although participants in both treatment conditions demonstrated significant improvements in PTSD symptom severity, equivalence results were inconclusive, as the 95% confidence interval of the change score difference exceeded the specified margin and overlapped with 0. Estimated mean change scores demonstrated that both conditions showed significant reductions at posttreatment and follow‐up. Although engagement with the online program was a significant challenge, the findings suggest that written exposure therapy is effective for improving PTSD symptoms, depressive symptoms, and functioning when adapted for internet‐based delivery and facilitated by peer coaches. Using technology to deliver exposure therapy and task‐shifting the role of the therapist to peer coaches are promising strategies to increase access to effective PTSD care. [ABSTRACT FROM AUTHOR]

The current study investigated the associations among probable posttraumatic stress disorder (PTSD), recent Veterans Health Administration (VHA) health care use, and care‐seeking for PTSD in U.S. military veterans. Analyses were conducted among 19,691 active duty military personnel enrolled in the Millennium Cohort Study who separated from the military between 2000 and 2012 and were weighted to the 1,130,103 active duty personnel who separated across this time period. VHA utilization was identified from electronic medical records in the year before survey completion, and PTSD care‐seeking and PTSD symptoms were assessed through self‐report on the 2014–2016 survey; thus, the observation period regarding care‐seeking and VHA use encompassed 2013–2016. Veterans with probable PTSD were more likely to use VHA services than those without probable PTSD, aOR = 1.12, 95% CI [1.01, 1.24], although the strongest association with recent VHA use was a depression diagnosis, aOR = 2.47, 95% CI [2.26, 2.70]. Among veterans with probable PTSD, the strongest predictor of care‐seeking was recent VHA use compared to community care, aOR = 4.01, 95% CI [3.40, 4.74); reporting a diagnosis of depression was the second strongest predictor of PTSD care‐seeking, OR = 2.99, 95% CI [2.53, 3.54]. However, the absolute number of veterans with probable PTSD who were not seeking care was approximately equivalent between veterans using VHA services and those not using VHA services. Additionally, certain groups were identified as being at risk of not seeking care, namely Air Force veterans and veterans with high physical and mental functioning despite substantial PTSD symptoms. [ABSTRACT FROM AUTHOR]

Trauma-informed beliefs often decrease during posttraumatic stress disorder (PTSD) treatment. This may also extend to anxiety sensitivity (AS), defined as a fear of anxiety-related sensations and beliefs that anxiety is dangerous and/or intolerable. However, little is known about how AS changes during exposure-based and psychopharmacological PTSD treatments. Further, high AS may be a risk factor for diminished PTSD symptom improvement and increased treatment dropout. To better understand how AS impacts and is impacted by PTSD treatment, we conducted a secondary analysis of a randomized clinical trial with a sample of 223 veterans (87.0% male, 57.5% White) with PTSD from four U.S. sites. Veterans were randomized to receive prolonged exposure (PE) plus placebo (n = 74), sertraline plus enhanced medication management (n = 74), or PE plus sertraline (n = 75). Veterans answered questions about PTSD symptoms and AS at baseline and 6-, 12-, 24-, 36-, and 52-week follow-ups. High baseline AS was related to high levels of PTSD severity at 24 weeks across all conditions, β = .244, p = .013, but did not predict dropout from exposure-based, β = .077, p = .374, or psychopharmacological therapy, β = .009, p = .893. AS also significantly decreased across all three treatment arms, with no between-group differences; these reductions were maintained at the 52-week follow-up. These findings suggest that high AS is a risk factor for attenuated PTSD treatment response but also provide evidence that AS can be improved by both PE and an enhanced psychopharmacological intervention for PTSD.

Trauma-exposed veterans receiving mental health care may have an elevated risk of experiencing COVID-19-related difficulties. Using data from several ongoing clinical trials (N = 458), this study examined exposure to COVID-19-related stressors and their associations with key sociodemographic factors and mental health outcomes. The results showed that exposure to COVID-19-related stressors was common, higher among veterans who were racial/ethnic minorities d = 0.32, and associated with elevated posttraumatic stress disorder (PTSD), r = .288, and depressive symptom severity, r = .246. Women veterans experienced more difficulty accessing social support, d = 0.31, and higher levels of COVID-19-related distress, d = 0.31, than men. Qualitative data were consistent with survey findings and highlighted the broader societal context in veterans' experience of COVID-19-related distress. These findings may inform future research on the impact of the pandemic on veterans, particularly those who are women and members of minoritized racial/ethnic groups, as well as mental health treatment planning for this population.

Research has sought to identify whether women have an increased risk of developing mental health problems following military trauma compared to men, but the results are mixed. This study examined gender differences in a range of mental health outcomes within three levels of war zone trauma exposure and investigated gender differences in risk and protective factors associated with clinical mental health problems. Using data from a cross‐sectional, postdeployment survey, a sample of Norwegian veterans of recent military operations in Afghanistan (N = 6,205, 8.3% women) were sorted according to reported war zone trauma exposure level (low, medium, high), then assessed for symptoms of posttraumatic stress disorder (PTSD), posttraumatic distress, anxiety, depression, insomnia, and alcohol problems. The findings revealed that men who reported low war zone exposure had lower levels of posttraumatic distress symptoms than women, d = ‐0.20, p =.040, but were more likely to report symptoms of alcohol problems within the low, d = 0.33, p <.001; medium, d = 0.39, p <.001; and high, d = 0.37, p =.049, exposure groups; however, these differences disappeared when all symptom variables were combined into one clinical mental health problem variable. Women with a clinical mental health problem were less likely to report war zone exposure than men, OR = 0.93, 95% CI [0.90, 0.97], p =.001. Findings suggest that although gender differences in mental health symptoms exist, male and female veterans with mental health problems may share more similarities than previously recognized. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic thoughts during (a) prolonged exposure (PE) plus pill placebo (PE+PLB), (b) sertraline plus enhanced medication management (SERT+EMM), and (c) PE plus sertraline (PE+SERT) as part of a randomized clinical trial in a sample of 176 veterans. Lagged regression modeling revealed that change in posttraumatic negative thoughts was associated with PTSD symptom change in the conditions in which participants received sertraline, ds = 0.14-0.25, ps = 0.04-.001). However, contrary to previous research, the models that started with symptom change were also statistically significant, d = 0.23, p

The onset of the COVID-19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in-person to telemental health. In the present study, we explored the impact of the pandemic on individuals' ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the association between the impact of COVID-19 impact on health and financial well-being and psychotherapy participation. Participants (N = 161, 63.2% male, Mage = 42.7 years) were United States military veterans (n = 108), active duty military personnel (n = 12), and civilians (n = 6), who were participating in one of nine PTSD treatment trials. The results indicate a predominately negative COVID-19 impact on therapy participation, although some participants (26.1%) found attending therapy sessions through telehealth to be easier than in-person therapy. Most participants (66.7%) reported that completing in vivo exposure homework became harder during the pandemic. Moreover, the impact of the pandemic on PTSD symptom severity and daily stress were each associated with increased difficulty with aspects of therapy participation. The findings highlight the unique challenges to engaging in PTSD treatment during the pandemic as well as a negative impact on daily stress and PTSD severity, both of which were related to treatment engagement difficulties.

Gulf War illness (GWI) is a chronic multisymptom disorder of unknown etiology that is believed to be caused by neurotoxicant exposure experienced during deployment to the Gulf War. Posttraumatic stress disorder (PTSD) covaries with GWI and is believed to play a role in GWI symptoms. The present study examined the association between self‐reported military exposures and GWI, stratified by PTSD status, in veterans from the Gulf War Era Cohort and Biorepository who were deployed to the Persian Gulf during the war. Participants self‐reported current GWI and PTSD symptoms as well as military exposures (e.g., pyridostigmine [PB] pills, pesticides/insecticides, combat, chemical attacks, and oil well fires) experienced during the Gulf War. Deployed veterans' (N = 921) GWI status was ascertained using the Centers for Disease Control and Prevention definition. Individuals who met the GWI criteria were stratified by PTSD status, yielding three groups: GWI‐, GWI+/PTSD‐, and GWI+/PTSD+. Multivariable logistic regression, adjusted for covariates, was used to examine associations between GWI/PTSD groups and military exposures. Apart from insect bait use, the GWI+/PTSD+ group had higher odds of reporting military exposures than the GWI+/PTSD‐ group, adjusted odds ratio (aOR) = 2.15, 95% CI [1.30, 3.56]–aOR = 6.91, 95% CI [3.39, 14.08]. Except for PB pills, the GWI+/PTSD‐ group had a higher likelihood of reporting military exposures than the GWI‐ group, aOR = 2.03, 95% CI [1.26, 3.26]–aOR = 4.01, 95% CI [1.57, 10.25]. These findings are consistent with roles for both PTSD and military exposures in the etiology of GWI. [ABSTRACT FROM AUTHOR]

One of the central symptoms of posttraumatic stress disorder (PTSD) is a heightened reactivity to trauma cues. The current study used experience sampling to investigate the associations between exposure to combat‐related cues and PTSD symptoms in 93 U.S. veterans who served in support of recent military operations in Afghanistan and Iraq. We also examined the effects of peri‐ and postdeployment factors, including exposure to combat, unit support during deployment, and postdeployment social support on PTSD. Participants completed eight brief random surveys daily for 2 weeks using palmtop computers. The results indicated that more daytime exposure to trauma cues was associated with experiencing more PTSD symptoms at the within‐person level, B = 3.18. At the between‐person level, combat exposure, B = 4.20, was associated with more PTSD symptoms, whereas unit support, B = –0.89, was associated with experiencing fewer symptoms. At the cross‐level interaction, unit support, B = –0.80, moderated the association between trauma cue exposure and PTSD symptom count. Contrary to our hypothesis, postdeployment social support, B = –0.59, was not associated with PTSD symptoms. These findings suggest a functional association between exposure to trauma cues and PTSD symptoms among recent‐era U.S. veterans and underscore the importance of unit support during deployment. [ABSTRACT FROM AUTHOR]

Evidenced‐based posttraumatic stress disorder (PTSD) treatments generally reduce suicidal ideation (SI), and the interpersonal theory of suicide (ITS) may theoretically account for this finding. The ITS posits that SI stems from feeling like a burden (i.e., perceived burdensomeness) and a lack of belonging (i.e., thwarted belongingness). Previous research suggests that change in PTSD severity has a significant indirect effect on change in SI through changes in perceived burdensomeness, but not thwarted belongingness, among patients receiving residential PTSD treatment in a Veterans Affairs (VA) medical center; however, no research has investigated these associations in an outpatient VA setting with fewer confounding factors that might affect ITS constructs. Therefore, the current sample included veterans (N = 126) who completed PTSD treatment and pre‐ and posttreatment assessments in a VA outpatient clinic. Results from parallel models of multiple indirect effects suggest that change in PTSD severity was indirectly associated with change in SI through changes in perceived burdensomeness, B = 0.35, p <.001; β =.36, p <.001, SE =.10, 95% CI [.15,.54], but not thwarted belongingness, B = 0.14, p =.146; β =.14, p =.161, SE =.10, 95% CI [−.05,.33]. Additional models were examined using PTSD cluster scores for exploratory purposes. The results indicate that PTSD treatment reduces the perceived and objective burden of PTSD to decrease SI. Study findings support the importance of access to evidence‐based care to treat PTSD and alleviate burdensomeness for suicide prevention. [ABSTRACT FROM AUTHOR]

The current study examined the prevalence and correlates of employment status in a nationally representative sample of U.S. military veterans with a probable lifetime history of posttraumatic stress disorder. Participants were 4,609 veterans from National Health and Resilience in Veterans Study (NHRVS) Bivariate analyses compared the employment status of veterans with regard to sociodemographic, military, health, and psychiatric characteristics. A multinomial regression analysis was conducted to determine the effect of lifetime PTSD status on employment and identify variables that differentiated employment status among veterans with a history of PTSD. In the total sample, 450 (weighted 12.5%) screened positive for lifetime PTSD. Veterans with PTSD were more than twice as likely to be unemployed, OR = 2.41, and retired, OR = 2.26, and nearly 4 times as likely to be disabled, OR = 3.84, relative to those without PTSD. Among veterans with PTSD, 203 (54.0%) were employed, 178 were retired (28.2%), 31 (7.3%) were unemployed, and 38 (10.5%) were disabled. Relative to employed veterans, retired veterans were older and reported more medical conditions; unemployed veterans were almost 5 times as likely to be female; disabled veterans reported lower income, more medical conditions, and more severe symptoms of current major depressive disorder but less severe symptoms of alcohol use disorder, ORs = 0.88–4.88. This study provides an up‐to‐date characterization of employment status in a nationally representative sample of U.S. military veterans with a history of PTSD. Results may inform efforts to provide sustainable employment in this segment of the population. [ABSTRACT FROM AUTHOR]

Over the past 20 years, U.S. military conflicts in Iraq and Afghanistan have been marked by high rates of combat and wartime killings. Research on Vietnam‐era service members suggests that the type of killing (i.e., killing a combatant vs. noncombatant) is an important predictor of later mental health problems, including posttraumatic stress disorder (PTSD). The present study aimed to update these findings by exploring the impact of type of killing on PTSD symptoms using a sample of postdeployment active duty U.S. Army personnel (N = 875). Using multiple regression analysis, we found that the act of killing a noncombatant was significantly associated with PTSD symptoms, B = 7.50, p <.001, whereas killing a combatant was not, B = ‐0.85, p =.360. This remained significant after controlling for demographic variables, depressive symptoms, and general combat experiences. These findings support the need for thoughtful postdeployment screenings and targeted clinical interventions. [ABSTRACT FROM AUTHOR]

The course of posttraumatic stress disorder (PTSD) symptoms varies among veterans of war zones, but sources of variation in long‐term symptom course remain poorly understood. Modeling of symptom growth trajectories facilitates the understanding of predictors of individual outcomes over time. Although growth mixture modeling (GMM) has been applied to military populations, few studies have incorporated both predeployment and follow‐up measurements over an extended time. In this prospective study, 1,087 U.S. Army soldiers with varying military occupational specialties and geographic locations were assessed before and after deployment to the Iraq war zone, with long‐term follow‐up assessment occurring at least 5 years after return from deployment. The primary outcome variable was the PTSD Checklist–Civilian Version summary score. GMM yielded four latent profiles, characterized as primarily asymptomatic (n = 194, 17.8%); postdeployment worsening symptoms (n = 84, 7.7%); mild symptoms (n = 320, 29.4%); and preexisting, with a chronic postdeployment elevation of symptoms (n = 489, 45.0%). Regression models comparing the primarily asymptomatic class to the symptomatic classes revealed that chronic symptom classes were associated with higher degrees of stress exposure, less predeployment social support, military reservist or veteran status at the most recent assessment, and poorer predeployment visual memory, ORs = 0.98–2.90. PTSD symptom course varies considerably over time after military deployment and is associated with potentially modifiable biopsychosocial factors that occur early in its course in addition to exposures and military status. [ABSTRACT FROM AUTHOR]

Revisions to the posttraumatic stress disorder (PTSD) criteria in the DSM‐5 included a new criterion in the alterations in arousal and reactivity cluster (i.e., engagement in reckless and self‐destructive behaviors; Criterion E2). Despite its clinical significance, little is known about how this symptom corresponds to engagement in specific direct and indirect self‐harm behaviors. We examined associations between E2 and self‐reported recent engagement in direct and indirect self‐harm behaviors, including disordered eating, which is not included in the prototypical E2 symptom scope, in a trauma‐exposed sample of 1,010 recent‐era veterans (61.5% self‐identified women, 38.5% self‐identified men). We also tested whether gender moderated these associations. We repeated analyses in a subsample of participants with clinically elevated PTSD symptoms. Participants self‐reported past‐month PTSD symptoms (PCL‐5) as well as past‐month nonsuicidal self‐injury, suicidal ideation, suicide planning, fasting, purging, binge eating, compulsive exercise, and problematic alcohol and drug use. We found no evidence for moderation by gender for any of the behaviors examined in the main sample. However, after controlling for gender and demographic covariates, weighted logistic regressions showed small, significant associations between E2 score and direct self‐harm behaviors, substance use, purging, and binge eating, aORs = 1.30–1.91. Criterion E2 was linked to behaviors included in the typical symptom scope (self‐directed violence, substance use) and those that are not (disordered eating behaviors). Comprehensive screening for self‐destructive behaviors, including disordered eating, among veteran men and women who endorse Criterion E2 is indicated. [ABSTRACT FROM AUTHOR]

Research documenting differences in mortality risk across the life course between veterans and nonveterans has not accounted for combat status. To address this gap in the literature, the current study examined differences in long‐term mortality among midlife and older‐adult male nonveterans, noncombat veterans, and combat veterans. Data were drawn from Wave 2 (2004/2005) of the Midlife Development in the United States survey and linked to 2020 mortality data (N = 2,024). Based on interpretation of a veteran‐combat status by age interaction term, compared to nonveterans, noncombat veterans experienced a mortality advantage at younger ages, ORmain effect = 0.12, 95% CI [0.03, 0.54], p =.006, and a mortality disadvantage at older ages, ORinteraction term = 1.06, 95% CI [1.01, 1.05], p =.004, with the crossover occurring at 73.4 years. A similar pattern was present among combat veterans, with the mortality advantage at younger ages not reaching significance, ORmain effect = 0.16; 95% CI [0.02, 1.18], p =.072; a mortality advantage at older ages, ORinteraction term = 1.03, 95% CI [1.00, 1.05], p =.040; and the crossover occurring 4.2 years earlier at 69.2 years. The findings suggest that combat status may accelerate the age‐related mortality disadvantage among veterans. Studies of health and mortality outcomes among veterans should, therefore, account for combat status. When data allow, future studies should confirm whether this pattern is present in nationally representative samples. [ABSTRACT FROM AUTHOR]

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.

Posttraumatic stress disorder (PTSD) is associated with inhibitory control dysfunction that extends beyond difficulties inhibiting trauma-related intrusions. Inhibitory learning has been proposed as a potential mechanism of change underlying the effectiveness of extinction-based therapies such as prolonged exposure (PE), a first-line treatment for PTSD. To identify neurocognitive markers of change in inhibitory learning associated with PE, we applied a Bayesian learning model to the analysis of neuroimaging data collected during an inhibitory control task, both before and after PE treatment. Veterans (N = 20) with combat-related PTSD completed a stop-signal task (SST) while undergoing fMRI at time points immediately before and after PE treatment. Participants exhibited a small, significant improvement in performance on the SST, as demonstrated by longer reaction times and improved inhibition accuracy. Amplitude of neural activation associated with a signed prediction error (SPE; i.e., the discrepancy between actual outcome and model-based expectation of needing to stop) in the right caudate decreased from baseline to posttreatment assessment. Change in model-based activation was modulated by performance accuracy, with a decrease in positive SPE activation observed on successful trials, d = 0.79, and a reduction in negative SPE activation on error trials, d = 0.74. The decrease in SPE-related activation on successful stop trials was correlated with PTSD symptom reduction. These results are consistent with the notion that PE may help broadly strengthen inhibitory learning and the development of more accurate model-based predictions, which may thus facilitate change in cognitions in response to trauma-related cues and help reduce PTSD symptoms.

An effectiveness trial found that telemedicine collaborative care for posttraumatic stress disorder (PTSD) significantly increased engagement in trauma‐focused psychotherapy (TFP) and improved PTSD symptoms. However, in a subsequent implementation trial, very few veterans enrolled in collaborative care initiated TFP. We conducted a mixed‐methods evaluation to determine why veterans did not initiate TFP in the implementation trial. After conducting chart reviews of 1,071 veterans with PTSD enrolled in collaborative care, patients were categorized into four mutually exclusive TFP groups: TFP not discussed; TFP discussed, declined; TFP discussed, did not decline; and TFP initiated. We conducted semistructured interviews with 43 unique patients and 58 unique providers (i.e., care managers and mental health specialists). Almost half (48.6%) of the veterans had no documentation of discussing TFP with their care manager; another 28.9% discussed it but declined. Most veterans (77.1%) had an encounter with a mental health specialist, 36.8% of whom never discussed TFP, and 35.7% of whom discussed it but declined. Providers reported that many veterans were not able, willing, or ready to engage in TFP and that non–trauma‐focused therapies were better aligned with their treatment goals. Veterans gave numerous reasons for not initiating TFP, including having bad prior experiences with TFP and wanting to avoid thinking about past traumatic experiences. Commonly cited reasons for noninitiation were providers never discussing TFP with veterans and veterans declining TFP after discussing it with their provider. Interventions, such as shared decision‐making tools, may be needed to engage providers and patients in informed discussions about TFP. [ABSTRACT FROM AUTHOR]

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT‐I&N) and cognitive processing therapy (CPT) for PTSD are first‐line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT‐I&N delivered before CPT, CBT‐I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT‐I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = −0.36; insomnia, d = −0.77; sleep efficiency, d = 0.62; and nightmares, d = −.53. Compared to participants who received CBT‐I&N delivered before CPT, those who received CBT‐I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = −0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) is linked to negative relationship outcomes, but the relational processes that link specific PTSD symptoms to these outcomes over granular periods are not well understood. The current study used a daily diary methodology to investigate the associations between specific PTSD symptoms (i.e., anger, avoidance, reexperiencing, hyperarousal, and numbing) and proximal indices of relationship functioning (i.e., accommodation behaviors, disclosure, intimacy). Participants were members of 64 couples, each comprising a male service member (SM) and female romantic partner (RP), who completed daily assessments of PTSD symptoms and indices of relationship functioning for 2 weeks. The results suggest a somewhat unique role of anger on relationship dynamics: Although mean levels of PTSD symptom clusters were associated with negative relationship outcomes at the bivariate level, daily fluctuations in anger were uniquely related to accommodation behaviors and SM‐ and RP‐reported intimacy in multilevel models, Bs = −0.08–0.50). These findings highlight the importance of considering the differential role of specific PTSD symptoms, like anger, in dyadic interventions for PTSD; several strategies for doing so in the context of contemporary evidence‐based treatments are discussed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Among veterans with posttraumatic stress disorder (PTSD), alcohol use disorders (AUDs) are highly prevalent. Furthermore, PTSD frequently co-occurs with chronic pain (CP), and CP is associated with an increased risk of AUD. Pain-related beliefs and appraisals are significantly associated with poorer pain-related functional status, yet few studies have examined negative trauma-related cognitions and their impact on pain-related functional disability in veterans with co-occurring PTSD and AUD. Accordingly, we examined the association between negative trauma-related cognitions and pain severity and pain disability in 137 veterans seeking treatment for PTSD and AUD. Using hierarchical multiple linear regression, we found that higher levels of negative trauma-related cognitions (e.g., "I am completely incompetent") were associated with a higher level of pain severity, after controlling for PTSD symptom severity and frequency of alcohol use, total R2 = .07, ΔR2 = .06. Additionally, as hypothesized, we found that higher levels of negative trauma-related cognitions were associated with higher levels of pain disability, after controlling for PTSD symptom severity, frequency of alcohol use, and pain severity, total R2 = .46, ΔR2 = .03. Given that negative trauma-related cognitions contributed to pain severity and pain disability, even when controlling for PTSD severity and frequency of alcohol use, future studies should explore the potential impact of interventions that address negative trauma-related cognitions (e.g., prolonged exposure or cognitive processing therapy) on pain severity and disability.

Posttraumatic stress disorder (PTSD) significantly impacts many veterans. Although PTSD has been linked to alterations in the fear brain network, the disorder likely involves alterations in both the fear and anxiety networks. Fear involves responses to imminent, predictable threat and is driven by the amygdala, whereas anxiety involves responses to potential, unpredictable threat and engages the bed nucleus of the stria terminalis (BNST). The BNST has been implicated in PTSD, but the role of the BNST in combat veterans with PTSD has yet to be examined. Identifying alterations in BNST responses to unpredictable threat could provide important new targets for treatment. The current study examined whether veterans with PTSD have altered BNST or amygdala responses (function and connectivity) to unpredictable and predictable threat. The fMRI task involved viewing predictable threat cues followed by threat images, predictable neutral cues followed by neutral images, and unpredictable threat cues followed by either a threat or neutral image. Participants included 32 combat‐exposed veterans with PTSD and 13 combat‐exposed controls without PTSD. Across all conditions, veterans with PTSD had heightened BNST activation and displayed stronger BNST and amygdala connectivity with multiple fear and anxiety regions (hypothalamus, hippocampus, insula, ventromedial prefrontal cortex) relative to controls. In contrast, combat controls showed a pattern of stronger connectivity during neutral conditions (e.g., BNST‐vmPFC), which may suggest a neural signature of resilience to developing PTSD, ηp2 =.087–.527, ps <.001. These findings have implications for understanding fear and anxiety networks that may contribute to the development and maintenance of PTSD. [ABSTRACT FROM AUTHOR]

Group therapy is a frequently used therapy format for posttraumatic stress disorder (PTSD). However, factors contributing to treatment completion remain understudied. The current study examined predictors of treatment completion, defined as having completed 10 out of 14 sessions within 16 weeks, in veterans with PTSD who engaged in a hybrid efficacy–effectiveness randomized controlled trial of group psychotherapy for PTSD. Veterans (N = 198) were randomly assigned to 14 sessions of either group cognitive behavioral treatment (GBCT; n = 98) or group present‐centered treatment (GPCT; n = 100). Four primary domains of predictors were examined, encompassing sociodemographic factors, the severity of PTSD and comorbid conditions, modifiable predictors, and treatment condition. Multilevel binomial logistic regression models following the Fournier analysis approach were used to examine significant predictors within domains, which were then included in a final model. Overall, 70.7% of participants completed treatment (GCBT = 61.6%, GPCT = 79.8%). Participants in the GPCT condition were 2.389 times, 95% CI [1.394, 4.092], more likely to complete treatment than those in the GCBT condition. Older age, a higher income and level of educational attainment, more lifetime and current mental health diagnoses, and higher use of positive reappraisal ER skills predicted treatment completion. Higher levels of depressive symptoms, cumulative trauma burden, and use of positive refocusing ER skills predicted treatment noncompletion. These findings are discussed in the context of current clinical and research practices for examining treatment noncompletion, with attention to the inclusion of translational predictors. [ABSTRACT FROM AUTHOR]

Failures by researchers and clinicians to overcome barriers in veteran health–related research may result in clinical trial (CT) discontinuation and nonpublication. Such outcomes are a waste of limited academic resources. To determine rates of discontinuation and nonpublication among CTs for posttraumatic stress disorder (PTSD) with pharmaceutical interventions specific to the veteran population, we performed a systematic search of registered trials in ClinicalTrials.gov for pharmaceutical interventions for the treatment of PTSD. Extracted study characteristics included sample size, study design, trial status, phase, and funding source. Studies were classified as completed or discontinued based on the status listed in ClinicalTrials.gov. Descriptive statistics of trials were reported, and associations of trial termination and nonpublication were assessed using logistic regression. The final sample included 54 CTs, 15 of which (27.8%) had not been published within the FDA's required timeframe, and 11 (20.4%) were discontinued. The total number of trial participants was 3,463, with a median of 37 (interquartile range: 15–92). Of the 54 trials, 12 (22.2%) were nonrandomized, and 42 (77.8%) were randomized. There were 25 (46.3%) trials that were in either Phase 3 or Phase 4, and 39 (72.2%) were government‐funded. We found high rates of CT discontinuation and nonpublication among PTSD pharmaceutical intervention studies in veterans, as has been shown in other fields of research. [ABSTRACT FROM AUTHOR]

For parents of color, publicized racial violence can heighten concerns about their children's safety. The goal of this study was to test whether this form of race‐related stress exacerbates maternal posttraumatic stress disorder (PTSD) symptoms over a 4‐month period in families of color. Participants included 262 U.S. mothers with a lifetime mental health diagnosis (67.6% non‐Hispanic White, 15.6% African‐American/Black, 16.8% other family of color). Mothers completed online surveys and open‐ended questions, including appraisals of the meaning of the 2020 race‐related events (i.e., George Floyd's death, subsequent protests) in relation to their children's future. Open‐ended responses were quantified using LIWC15 text analysis for emotion word frequency and thematic coding for perceived implications. In ANCOVA, there were significant racial group differences in appraisals, ds = 0.09–0.57. The responses from mothers of Black children included fewer positive and more negative emotion words than mothers of White children; they also included more perceived negative implications than all other mothers but did not vary on perceived positive implications. In regression analyses, there were significant moderating effects of race/ethnicity in the association between appraisals and PTSD symptom course such that negative appraisals predicted a subsequent increase in PTSD symptoms only for mothers of Black children, βs =.26–.37. Variations in event appraisals were unrelated to PTSD symptom course for other mothers. These findings provide longitudinal support for the link between vicarious racism exposure and PTSD symptoms and highlight one potential form of racism‐related stress for parents of Black children. [ABSTRACT FROM AUTHOR]

In the current study, we explored exaggerated physiological startle responses in posttraumatic stress disorder (PTSD) and examined startle reactivity as a biomarker of PTSD in a large veteran sample. We assessed heart rate (HR), skin conductance (SC), and electromyographic (EMG) startle responses to acoustic stimuli under low-, ambiguous-, and high-threat conditions in Gulf War veterans with current (n = 48), past (n = 42), and no history of PTSD (control group; n = 152). We evaluated PTSD status using the Clinician-Administered PTSD Scale and trauma exposure using the Trauma History Questionnaire. Participants with current PTSD had higher HR, ds = 0.28-0.53; SC, d = 0.37; and startle responses than those with past or no history of PTSD. The HR startle response under ambiguous threat best differentiated current PTSD; however, sensitivity and specificity analyses revealed it to be an imprecise indicator of PTSD status, ROC AUC = .66. Participants with high levels of trauma exposure only showed elevated HR and SC startle reactivity if they had current PTSD. Results indicate that startle is particularly elevated in PTSD when safety signals are available but a possibility of danger remains and when trauma exposure is high. However, startle reactivity alone is unlikely to be a sufficient biomarker of PTSD.

Posttraumatic stress disorder (PTSD) is associated with significant individual and relationship impairment for people with PTSD and their romantic partners. Conjoint treatments, such as cognitive behavioral conjoint therapy for PTSD (CBCT), are designed to address individual and relationship factors, yet significant barriers impede accessing in‐person therapy. Couple HOPES (i.e., Helping Overcome PTSD and Enhance Satisfaction) is a coach‐guided, online couple intervention for PTSD based on CBCT that was designed to address these barriers. Previous investigations have found preliminary efficacy of Couple HOPES for improving PTSD symptoms, relationship functioning, and some individual functioning domains for the partner with probable PTSD. However, no study to date has tested individual outcomes for romantic partners, which is needed to fully evaluate the intervention's promise. The current study tested these partner outcomes in a combined, uncontrolled sample of 27 couples. Intent‐to‐intervene analyses found significant improvements at postintervention in four of eight tested outcomes, including ineffective arguing, g = 0.74; anger, g = 0.32; perceived health, g = 0.67; and quality of life, g = 0.56. Depressive symptoms, generalized anxiety, alcohol misuse, and work functioning did not significantly change, gs = 0.17–0.42. Among participants who completed a 1‐month follow‐up assessment, generalized anxiety, g = 0.43, and perceived health, g = 0.73, significantly improved over follow‐up, whereas anger, g = ‐0.48, lost gains previously made. Results were largely consistent in the completer sample. These findings show the potential of Couple HOPES to have broad benefits not only for individuals with probable PTSD but also for their romantic partners. [ABSTRACT FROM AUTHOR]

Exposure to potentially morally injurious events has been shown to be associated with posttraumatic stress disorder (PTSD) and depression symptoms in military personnel. Few studies have examined factors that help to explain how potentially morally injurious events may contribute to the development of trauma-related psychopathology. Negative posttrauma cognitions are thought to play a role in the etiology of PTSD and depression following trauma; however, it is unclear whether more global beliefs about the self, others, and world play a role in the development of PTSD and depression due to morally injurious events. Using structural equation modeling, we tested whether morally injurious experiences were indirectly related to trauma-related psychopathology (PTSD and depression) through negative posttrauma cognitions in a sample of veterans seeking treatment for PTSD. An indirect effects only model best fit the data and showed that morally injurious experiences, specifically perceived transgressions by oneself and perceived betrayal, were indirectly associated with trauma-related psychopathology through negative posttrauma cognitions, β = .17; 95% CI [.04, .31] and β = .25; 95% CI [.11, .41], respectively. Our findings suggest that negative posttrauma cognitions may be an important mechanism linking exposure to morally injurious events and trauma-related psychopathology.

The goal of the present study was to examine associations between posttraumatic stress disorder (PTSD) symptom severity, the number of stressors experienced, and cognitive outcomes in a sample of U.S. Vietnam War Veterans (N = 274). Adults between 60 and 85 years of age completed a Vietnam Veterans Alzheimer's Disease Neuroimaging Initiative Project visit. A modified version of the Life Stressor Checklist‐Revised (LSC‐R) was used to assess the number of stressful experiences participants experienced, current PTSD severity scores were measured via the Clinician‐Administered PTSD Scale for DSM‐IV (CAPS‐IV), and cognition was assessed using the Montreal Cognitive Assessment (MoCA). Linear regressions were conducted to examine the effect of CAPS‐IV and LSC‐R scores on cognitive performance. Higher CAPS‐IV scores were associated with worse cognitive outcomes on the MoCA, ΔF(1, 264) = 12.686, p <.001, R2 =.142. In contrast, the number of reported stressful experiences was not associated with cognitive outcomes. After accounting for multiple comparisons, findings indicated that CAPS‐IV severity scores were significantly associated with the MoCA memory index. In a sample of older Veterans, PTSD symptom severity, but not the number of reported stressors, was associated with poorer performance on a well‐established cognitive function screening tool. Analyses of specific MoCA domains indicated that memory may be driving this association. These findings suggest that highly arousing stressors characteristic of PTSD, rather than stressful experiences more broadly, contribute to this association. Future work can use these findings to explore whether treating PTSD symptoms may help maintain cognitive function during the aging process. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence‐based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military‐affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military‐affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM‐5 (PCL‐5) and the nine‐item Patient Health Questionnaire (PHQ‐9) in a community setting. Participants (N = 502) included military‐affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL‐5, military‐affiliated: d = −0.91, civilian: d = ‐1.18; and PHQ‐9, military‐affiliated: d = ‐0.65, civilian: d = ‐0.88, following treatment. However, military‐affiliated patients demonstrated smaller posttreatment reductions on the PCL‐5, Mdiff= 5.75, p =.003, and PHQ‐9, Mdiff = 1.71, p =.011, compared to civilians. Results demonstrate that military‐affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD. [ABSTRACT FROM AUTHOR]

Transitioning out of the military can be a time of change and challenge. Research indicates that altered threat monitoring in military populations may contribute to the development of psychopathology in veterans, and interventions that adjust threat monitoring in personnel leaving the military may be beneficial. Australian Defence Force personnel (N = 59) transitioning from the military were randomized to receive four weekly sessions of either attention‐control training or a placebo attention training. The primary outcome was symptoms of posttraumatic stress disorder (PTSD), as measured using the PTSD Checklist for DSM‐5 (PCL‐5) at posttreatment. Following training, participants who received attention‐control training reported significantly lower levels of PTSD symptoms, Hedges' g = 0.86, 95% CI [0.37, 1.36], p =.004, and significantly improved work and social functioning, Hedges' g = 0.93, 95% CI [0.46, 1.39], p =.001, relative to those in the placebo condition. Moreover, no participants who received attention‐control training worsened with regard to PTSD symptoms, whereas 23.8% of those who received the placebo attention training experienced an increase in PTSD symptoms. The preliminary findings from this pilot study add to a small body of evidence supporting attention‐control training as a viable indicated early intervention approach for PTSD that is worthy of further research. [ABSTRACT FROM AUTHOR]

Military sexual assault (MSA) is a prevalent issue among military personnel that can have direct implications on postmilitary mental health. Gulf War era U.S. veterans represent the first cohort in which women veterans were integrated into most aspects of military service except for combat. The present study sought to build on prior studies by identifying characteristics associated with the occurrence of MSA and clinical correlates of MSA and examining how these differ between men and women. This study analyzed cross‐sectional survey data from a national sample of treatment‐seeking Gulf War era veterans. Participants (N = 1,153) reported demographic information, clinical outcomes, military background, and history of MSA. MSA was more common among female veterans (n = 100, 41.3%) than male veterans (n = 32, 3.6%). The odds of experiencing MSA were approximately 19 times higher for female veterans relative to their male peers, OR = 18.92, p <.001. Moreover, as expected, MSA was robustly associated with probable current posttraumatic stress disorder, probable current depression, and past‐year suicidal ideation in female veterans, whereas combat exposure was robustly associated with these sequelae in male veterans. The present findings confirm that a large proportion of female veterans from the Gulf War era experienced MSA and highlight the deleterious correlates of MSA on veterans' mental health. Sex differences of correlates of MSA and subsequent clinical associations are highlighted. [ABSTRACT FROM AUTHOR]

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019–2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past‐6‐month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co‐occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4–3.8, or used cannabis less than weekly, ORs = 2.7–3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2–12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7–9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87–0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD. [ABSTRACT FROM AUTHOR]

The present study examined revictimization, defined as sexual or physical assault in adulthood that followed a history of childhood maltreatment. We aimed to identify factors associated with revictimization over time in a group of U.S. military veterans deployed following the September 11, 2001, terrorist attacks (9/11). As revictimization is associated with multiple negative mental health outcomes in the literature, identifying risk and protective factors can aid in the prevention of revictimization and associated poor health outcomes among veterans. In this sample, the proportion of adult revictimization was 2.7% for men, 95% CI [2.0, 3.6] and 22.9% for women, 95% CI [20.5, 25.8]. Using multilevel logistic models, we found that women, β = 2.2, p <.001; Navy veterans, β = 1.5, p <.001; and participants who reported posttraumatic stress symptoms, β = 0.2, p =.028, were at significantly higher risk of revictimization across time compared to nonrevictimized counterparts. Social support while in the military was protective, β = −0.1, p <.001, against revictimization. In addition, childhood abuse experiences combined with characteristics such as female gender were related to an increased risk of revictimization during and following military service. The findings highlight opportunities for intervention and areas of strength within this population; social connection garnered during military service may serve as a protective factor against revictimization. Future research is needed to examine the role of social support in possibly lowering veterans' risk of revictimization over time, particularly for post‐9/11 veterans struggling with transitioning from military to civilian life. [ABSTRACT FROM AUTHOR]

Cross‐sectional work suggests that deployment‐related posttraumatic sequelae are associated with increased disability in U.S. veterans deployed following the September 11, 2001 (9/11), terrorist attacks. However, few studies have examined the psychiatric and somatic variables associated with changes in functional disability over time. A total of 237 post‐9/11 veterans completed comprehensive assessments of psychiatric and cognitive functioning, as well as a disability questionnaire, at baseline and 2‐year follow‐up. At baseline, higher levels of PTSD, depressive, and pain‐related symptoms were associated with baseline global functional disability, semipartial r2 =.036–.044. Changes in symptoms of PTSD, depression, pain, and sleep, but not anxiety or alcohol use, were independently associated with changes in functional disability, semipartial r2 =.017–.068. Baseline symptoms of these conditions were unrelated to changes in disability, and cognitive performance was unrelated to disability at any assessment point. Together, this suggests that changes in psychiatric and somatic symptoms are tightly linked with changes in functional disability and should be frequently monitored, and even subclinical symptoms may be a target of intervention. [ABSTRACT FROM AUTHOR]

Gulf War veterans (GWVs) were exposed to neurotoxicants, including sarin nerve gas, anti–nerve agent pills, pesticides, oil well fires, and fumes from unvented tent heaters, all of which have been associated with subsequent adverse health. Posttraumatic stress disorder (PTSD) symptoms have also been associated with GW deployment; however, associations between exposures and PTSD symptoms have not been investigated. We assessed PTSD symptom trajectories and associations with neurotoxicant exposures in Ft. Devens Cohort (FDC) veterans (N = 259) who endorsed trauma exposure during deployment and completed the PTSD Checklist at three follow‐ups (1992–1993, 1997–1998, 2013–2017). Results indicate that among veterans with more severe initial PTSD symptoms, symptoms remained significantly higher across follow‐ups, Bs = −1.489–1.028, whereas among those with low initial PTSD symptoms, symptom severity increased significantly over time, Bs = 1.043–10.304. Additionally, neurotoxicant exposure was associated with a significant increase in PTSD symptoms, Bs = −1.870–9.003. Significant interactions between time and exposures were observed for PTSD symptom clusters, suggesting that among participants with high initial PTSD symptom, unexposed veterans experienced symptom alleviation, whereas exposed veterans' PTSD symptoms remained high. In GWVs with low initial PTSD symptoms, both unexposed and exposed veterans experienced PTSD symptom exacerbations over time; however, this occurred at a faster rate among exposed veterans. These findings suggest that in the years following deployment, GWVs who were exposed to both traumatic events and neurotoxicants may experience more severe and chronic PTSD symptoms than those without neurotoxicant exposures. [ABSTRACT FROM AUTHOR]

Psychological comorbidity, the co‐occurrence of mental health disorders, is more often the rule than the exception among individuals with posttraumatic stress disorder (PTSD). Research shows that prevalence estimates for specific psychological disorders differ by gender; however, little is known about whether these patterns persist in the presence of a comorbid PTSD diagnosis. This study examined gender differences in prevalence estimates for conditions comorbid with PTSD using medical records for 523,626 active duty U.S. Sailors and Marines who entered the military over an 8‐year period. Using chi‐square tests of independence, we detected statistically significant gender differences for specific comorbid conditions in the subsample of 9,447 service members with a PTSD diagnosis. Women were more likely than men to have PTSD with comorbid adjustment, OR = 1.35; depressive, OR = 1.71; and generalized anxiety or other anxiety disorders, OR = 1.16, with the largest effects for eating, OR = 12.60, and personality disorders, OR = 2.97. In contrast, women were less likely than men to have a diagnosis of PTSD with comorbid alcohol use, OR = 0.69, and drug use disorders, OR = 0.72, with the largest effects for insomnia, OR = 0.42, and traumatic brain injury, OR = 0.17. No significant gender differences emerged for comorbid bipolar, obsessive–compulsive, panic/phobic, psychotic, or somatoform/dissociative disorders, ps =.029–.314. The results show gender differences in conditions comorbid with PTSD generally align with internalizing and externalizing dimensions. Differences in comorbidities with PTSD between women and men could have implications for treatment development and delivery. [ABSTRACT FROM AUTHOR]

Whereas some prior studies have assessed associations between general self‐efficacy, intimate partner violence (IPV) experiences, and posttraumatic stress disorder (PTSD) symptoms cross‐sectionally, there is limited research investigating the potential directions of these effects or the longitudinal effects over multiple assessment points. We investigated the role of general self‐efficacy in experiences of IPV and PTSD symptoms across time among 411 women veterans of the U.S. Armed Forces. Online survey data were collected at baseline (Time 1; T1), 18 months after baseline (Time 2; T2), and 2 years after baseline (Time 3; T3). Structural equation models were used to test hypotheses that T2 general self‐efficacy would mediate reciprocal associations between IPV experiences and PTSD symptoms while controlling for T2 IPV experiences, T1 PTSD symptoms, and demographic and military covariates (i.e., age, military sexual trauma, and combat exposure). Specifically, we hypothesized that T2 general self‐efficacy would mediate the association between (a) T1 IPV experiences and T3 IPV experiences, (b) T1 IPV experiences and T3 PTSD symptoms, (c) T1 PTSD symptoms and T3 IPV experiences, and (d) T1 PTSD symptoms and T3 PTSD symptoms. Findings revealed that T1 PTSD symptoms predicted lower T2 general self‐efficacy, and, in turn, lower T2 general self‐efficacy was associated with higher T3 IPV experiences, 95% CI [0.06, 0.41]; no other hypotheses were supported. The findings speak to the importance of clinical interventions which promote general self‐efficacy as well as assess and treat PTSD symptoms among women who experience IPV. [ABSTRACT FROM AUTHOR]

We sought to determine whether posttraumatic stress disorder (PTSD) was associated with sexual health in returned warzone-deployed veterans from the recent Iraq and Afghanistan conflicts. We studied 1,581 males and females from the Veterans After-Discharge Longitudinal Registry, a gender-balanced U.S. Department of Veterans Affairs registry of health care-seeking veterans with and without PTSD. Approximately one quarter (25.1%) of males (n = 198) and 12.7% of females (n = 101) had a sexual dysfunction diagnosis and/or prescription treatment for sexual dysfunction. Both genders were more likely to have a sexual dysfunction diagnosis and/or prescription treatment if they had PTSD compared with those without PTSD (male: 27.3% vs. 21.1%, p = .054; female: 14.9% vs. 9.4%, p = .022). Among the 1,557 subjects analyzed here, males with PTSD had similar levels of sexual activity compared to those without PTSD (71.2% vs. 75.4%, p = .22), whereas females with PTSD were less likely to be sexually active compared to females without PTSD (58.7% vs. 72.1%, p < .001). Participants with PTSD were also less likely to report sex-life satisfaction (male: 27.6% vs. 46.0%, p < .001; female: 23.0% vs. 45.7%, p < .001) compared with those without PTSD. Although PTSD was not associated with sexual dysfunction after adjusting for confounding factors, it was significantly negatively associated with sex-life satisfaction in female veterans with a prevalence ratio of .71, 95% confidence interval [.57, .90].

Individuals with preexisting psychological difficulties are at risk of further deterioration of their mental well-being during the COVID-19 pandemic. This longitudinal study, conducted during the period between two national lockdowns, aimed to investigate the impact of the COVID-19 pandemic on veterans in the United Kingdom with preexisting mental health difficulties. Treatment-seeking veterans with preexisting mental health difficulties (N = 95) were surveyed in two waves. Wave 1 was conducted at the end of the first lockdown (June 2020-July 2020), andWave 2 took place during the second lockdown (November 2020). Participants completed measures to assess symptoms of posttraumatic stress disorder (PTSD); common mental health difficulties (CMDs), including anxiety and depression; anger; and alcohol use. Initial analyses revealed no significant changes in symptoms of PTSD, CMDs, anger, or alcohol use between the lockdowns, ps = .247-.986. However, veterans who experienced more COVID-19-related stressors were more likely to experience increases in PTSD, odds ratio (OR) = 6.30, p = .002, and CMD symptoms, OR = 4.32, p = .025. Participants with lower levels of social support during the second lockdown were more likely to experience increased anger difficulties, OR = 0.91, p = .025. The findings suggest that although mental health among veterans in the United Kingdom may have remained relatively stable between the two lockdowns, those who reported more COVID-related stressors and lower levels of social support may have been particularly vulnerable to symptom exacerbation. Such findings hold important implications for tailoring support for veterans during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Given the disproportionate rate of alcohol misuse among veterans and related outcomes as compared to the general population, the examination of predictors of alcohol misuse in this population is imperative. Potentially morally injurious events (PMIEs), defined as severe transgressions of a moral code, have been positively associated with alcohol misuse. Exposure to PMIEs may challenge one's religious beliefs, which may, in turn, influence the strength of the association between PMIEs and alcohol misuse among military veterans. The goal of the current study was to examine the potential moderating role of religiosity in the association between PMIEs and alcohol misuse (i.e., alcohol consumption, drinking behaviors, adverse reactions to drinking, and alcohol-related problems). Participants were 496 military veterans in the community (Mage = 37.80 years, SD = 11.42; 70.5% male). The results of moderation analyses indicated that overall religiosity, organizational religiosity, and intrinsic religiosity significantly moderated the association between PMIEs and alcohol misuse such that the positive relation between PMIEs and alcohol misuse was stronger at high versus low levels of religiosity, R²s = .01. Our findings highlight the importance of considering the role of religiosity in relation to alcohol misuse as a moral injury outcome and the potential utility of tailoring treatments for military veterans who have experienced moral injury. [ABSTRACT FROM AUTHOR]

Emotion dysregulation (ED) can be defined as one's inability to effectively respond to andmanage internal experiences and the expression of emotion. ED has been linked to the development and maintenance of posttraumatic stress disorder (PTSD), with recent research suggesting that reductions in ED may predict improved treatment outcomes among both civilian and veteran populations. However, few studies have examined how changes in ED may predict treatment outcomes among veterans with PTSD and whether certain core features of PTSD, such as shame, may act as potential mediators in the association between ED and PTSD symptom reductions. The present study sought to explore facets of ED, feelings of shame, and PTSD symptoms among 43 combat veterans upon their admission and discharge to a residential PTSD program. The results demonstrated that all variables of interest significantly decreased from admission to discharge, ds = 0.75-1.84. Correlations indicated that reductions in ED, R² = .184, and shame, R² = .228, were associated with reductions in PTSD symptoms. However, the association between reductions in ED and PTSD was significantly mediated by reductions in shame. Overall, these results suggest that higher levels of emotion regulation may partially affect PTSD symptoms through reductions in shame. This may explain the efficacy of frontline PTSD treatments, as they explicitly focus on the processing of one's traumatic experience by reducing PTSD symptoms through regulation techniques that target emotional-behavioral cycles, which may include the shame-withdraw cycle. [ABSTRACT FROM AUTHOR]

The current study examinedage differences in allostatic load among nonveterans, noncombat veterans, and combat veterans. Participants included 280 individuals from the Midlife Development in the United States (MIDUS) survey, including 164 veterans (n = 48 combat veterans; n = 116 noncombat veterans) and 116 nonveterans. Age differences in allostatic load were similar among nonveterans and noncombat veterans, B = 0.002, SE = .011, p = .878, with older adults showing higher levels of allostatic load than their comparatively younger counterparts. Among combat veterans, however, a different pattern emerged. In this group, levels of allostatic load were similar across age, seemingly due to higher levels of allostatic load among younger combat veterans, B=-0.029, SE = .014, p = .031, ƞp² = .022. Results reveal the importance of considering combat exposure when examining health outcomes of military veterans, particularly in the context of age. [ABSTRACT FROM AUTHOR]

Posttraumatic stress disorder (PTSD) in military veterans increases the risk of PTSD in their offspring, a concept known as "intergenerational transmission;" however, the mechanism by which this transmission may occur is, as yet, undetermined. The present study included a nonclinical sample of 197 Australian Army veterans of the Vietnam War who were interviewed 17 years before in-person interviews of their adult daughters (n = 163) and sons (n = 120) were conducted. Veterans' PTSD symptoms were assessed using the Mississippi Scale for Combat-Related PTSD. Approximately 17 years later, offspring PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for DSM-IV. In addition, offspring described the family emotional climate during their youth; responses were coded using the Family Affective Attitude Rating Scale (FAARS) to produce scale scores of veterans' negative, positive, and family relationship styles. A path analysis was conducted via structural equation modeling to test for significant path coefficients between veteran PTSD, family emotional climate, and offspring PTSD symptoms. For daughters, significant path coefficients were observed between veteran PTSD scores and FAARS scores, path coefficient = -.268; FAARS scores and offspring CAPS severity scores, path coefficient = -.223; and veteran PTSD scores and daughters' CAPS severity scores, path coefficient = .186. No satisfactory model could be found for sons. The results suggest that a positive emotional climate while growing up may be a significant protective factor against the development of PTSD in veterans' daughters, but other factors remain significant in veteran-to-offspring intergenerational transmission. [ABSTRACT FROM AUTHOR]