Search

Postdoctoral training is increasingly common in the field of psychology. Although many individuals pursue postdoctoral training in psychology, guidelines for research training programs at this level do not exist. The rapid advances in the field, particularly with respect to genetics, neuroimaging, and data analytic approaches, require clinical scientists to possess knowledge and expertise across a broad array of areas. Postdoctoral training is often needed to acquire such a skill set. This paper describes a postdoctoral training program designed for individuals pursuing academic careers in traumatic stress disorders research. In this paper, we describe the structure of our training program, challenges we have faced during the 15 years of its existence, and how we have addressed these challenges. We conclude with a presentation of outcome data for the training program and a discussion of how training programs in other settings might be structured.

A longitudinal life span model of factors contributing to later-life positive adjustment was tested on 567 American repatriated prisoners from the Vietnam War. This model encompassed demographics at time of capture and attributes assessed after return to the United States (reports of torture and mental distress) and approximately three decades later (later-life stressors, perceived social support, positive appraisal of military experiences, and positive adjustment). Age and education at time of capture and physical torture were associated with repatriation mental distress, which directly predicted poorer adjustment 30 years later. Physical torture also had a salutary effect, enhancing later-life positive appraisal of military experiences. Later-life events were directly and indirectly (through concerns about retirement) associated with positive adjustment. Results suggest that the personal resources of older age and more education and early-life adverse experiences can have cascading effects over the life span to impact well-being in both positive and negative ways.

Improved accessibility of effective and efficient evidence-based treatments (EBTs) for military personnel suffering with posttraumatic stress disorder (PTSD) is an urgent need to meet the growing demand for timely care. In addition, a better understanding of the mechanism of action of behavioral therapy can inform the delivery of care to meet accessibility demands. Effective EBTs for PTSD are available, but logistical and stigma-related barriers to accessing behavioral healthcare can deter military personnel from receiving these treatments. Web-based treatments represent an innovative way to overcome these barriers. The efficacy of previously developed web-based treatments for PTSD appears promising; however, they were not developed based on treatment protocols with strong empirical support for their efficacy. No study to date has examined web-based treatment of PTSD using a well-established evidence-based treatment, nor delineated the biological mechanisms through which a web-based treatment exerts its effects. This paper describes the rationale and methods of a randomized controlled trial comparing the efficacy and potential biological mediators of 10 sessions of a web-version of Prolonged Exposure (PE), “Web-PE,” delivered over 8 weeks compared to 10 sessions of in-person Present-Centered Therapy (PCT) delivered over 8 weeks by a therapist in 120 active duty military personnel and veterans with PTSD.

Background Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF; LeardMann et al., 2013). Identification of factors with the greatest contribution to suicide risk among veterans is needed to inform risk assessment and to identify intervention targets. Methods This study examined predictors of suicide attempts among participants in the Veterans After-Discharge Longitudinal Registry; a nationwide cohort of OEF/OIF veterans enrolled in Department of Veterans Affairs (VA) services. Veterans with and without probable posttraumatic stress disorder (PTSD) were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio. Participants (N = 1,649) were assessed at two time points, roughly 2 years apart (M = 28.74 months, SD = 8.72). Results Seventy-four participants (4.49%) attempted suicide during the follow-up period. The strongest predictors of suicide attempts among the full sample were suicidal intent, attempt history, suicide ideation, PTSD symptoms, alcohol use disorder (AUD) symptoms, and depression. Veterans with multiple risk factors were particularly vulnerable; of veterans with 0, ≥1, ≥2, ≥3, or ≥ 4 of these risk factors, 0%, 7.81%, 10.31%, 18.45%, and 20.51% made a suicide attempt, respectively. Conclusions This prospective study identified several strong predictors of suicide attempts among OEF/OIF veterans which may be important targets for suicide prevention efforts. Further, co-occurrence of multiple risk factors was associated with markedly greater risk for suicide attempts; veterans with multiple risk factors appear to be at the highest risk among OEF/OIF veterans enrolled in VA care.

OBJECTIVE: The purpose of the current study was to evaluate the relationship between baseline levels of posttraumatic stress disorder (PTSD), combat exposure, and alcohol outcomes in a sample of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans using a web-based self-management intervention (VetChange) for problem drinking. METHOD: The current study focuses on 523 veterans who participated in a larger randomized clinical trial. Analyses in the current study include (a) multivariable linear regression models to assess the relationship between PTSD, combat exposure, and alcohol variables at baseline, and (b) general linear models accounting for correlated data within subjects to analyze change over time for alcohol outcomes as a function of baseline PTSD symptoms, combat exposure, and covariates. RESULTS: There was a positive association between PTSD symptom severity and alcohol use and alcohol problem severity at baseline. However, participants with higher baseline PTSD symptoms demonstrated a significantly greater reduction in alcohol use during the intervention and a greater reduction in alcohol problems from baseline to 3-month follow-up. Combat exposure severity was positively associated with alcohol problems at baseline. However, veterans with higher exposure demonstrated a greater reduction in average weekly drinking between end of intervention and follow-up, and otherwise showed changes similar to participants with lower exposure. CONCLUSIONS: Higher levels of baseline PTSD symptoms and combat exposure severity did not prevent OEF/OIF veterans from achieving positive alcohol outcomes through participation in a self-management web intervention for problem drinking. (PsycINFO Database Record(c) 2017 APA, all rights reserved). Language: en

The Clinician-Administered PTSD Scale (CAPS) is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder (PTSD). The CAPS was recently revised to correspond with PTSD criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This article describes the development of the CAPS for DSM-5 (CAPS-5) and presents the results of an initial psychometric evaluation of CAPS-5 scores in 2 samples of military veterans (Ns = 165 and 207). CAPS-5 diagnosis demonstrated strong interrater reliability (к = .78 to 1.00, depending on the scoring rule) and test-retest reliability (к = .83), as well as strong correspondence with a diagnosis based on the CAPS for DSM-IV (CAPS-IV; к = .84 when optimally calibrated). CAPS-5 total severity score demonstrated high internal consistency (α = .88) and interrater reliability (ICC = .91) and good test-retest reliability (ICC = .78). It also demonstrated good convergent validity with total severity score on the CAPS-IV (r = .83) and PTSD Checklist for DSM-5 (r = .66) and good discriminant validity with measures of anxiety, depression, somatization, functional impairment, psychopathy, and alcohol abuse (rs = .02 to .54). Overall, these results indicate that the CAPS-5 is a psychometrically sound measure of DSM-5 PTSD diagnosis and symptom severity. Importantly, the CAPS-5 strongly corresponds with the CAPS-IV, which suggests that backward compatibility with the CAPS-IV was maintained and that the CAPS-5 provides continuity in evidence-based assessment of PTSD in the transition from DSM-IV to DSM-5 criteria. (PsycINFO Database Record

The 11th edition of the International Classification of Diseases ( ICD–11) is under development, and current proposals include major changes to trauma-related psychiatric diagnoses, including a heavily restricted definition of posttraumatic stress disorder (PTSD) and the addition of complex PTSD (CPTSD). We aimed to test the postulates of CPTSD in samples of 2,695 community participants and 323 trauma-exposed military veterans. CPTSD prevalence estimates were 0.6% and 13% in the community and veteran samples, respectively; one quarter to one half of those with PTSD met criteria for CPTSD. There were no differences in trauma exposure across diagnoses. A factor mixture model with two latent dimensional variables and four latent classes provided the best fit in both samples: Classes differed by their level of symptom severity but did not differ as a function of the proposed PTSD versus CPTSD diagnoses. These findings should raise concerns about the distinctions between CPTSD and PTSD proposed for ICD–11.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) featured extensive changes to the posttraumatic stress disorder (PTSD) diagnosis. PTSD was moved out of the anxiety disorders into a new class of “trauma- and stressor-related disorders,” and the definition of what constitutes a traumatic experience was revised. Three new symptoms were added, existing ones were modified, and a new four-cluster organization and diagnostic algorithm were introduced. Finally, a new dissociative subtype was added to the diagnosis. We review these changes, discuss some of the controversies surrounding them, and then introduce a new debate involving a radically different conceptualization of PTSD proposed for International Classification of Diseases, 11th edition.

OBJECTIVE Administrative planning and policy decisions frequently rely on diagnostic data extracted from large electronic databases. However, the accuracy of this diagnostic information is uncertain. The present study examined the degree to which various diagnoses of posttraumatic stress disorder (PTSD) within Department of Veterans Affairs (VA) electronic databases were concordant with PTSD diagnostic status determined by standardized diagnostic interview. METHOD We interviewed 1,649 veterans of the Iraq and Afghanistan wars using the PTSD Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed other interview-based and self-report measures of psychopathology and provided consent to access their electronic medical records (EMRs). RESULTS Concordance between database diagnosis and SCID diagnosis was 72.3% for current PTSD and 79.4% for lifetime PTSD. We observed associations between concordance status and combat exposure, PTSD symptom presentation, comorbid anxiety and depression, and psychosocial impairment. Veterans with false-negative PTSD diagnoses in the EMR were more likely to report lower levels of combat exposure, panic, and PTSD avoidance symptoms. Veterans with false-positive PTSD diagnoses in the EMR were more likely to report treatment seeking for emotional problems and less overall functional impairment. CONCLUSIONS Although the majority of participants were concordant for PTSD status, over 25% of EMR diagnoses differed from those obtained in the diagnostic interview, with varying proportions of false positives and false negatives. Overall, those individuals with the most and least severe symptom presentations in the diagnostic interview were more likely to be accurately classified.

Suicide is a prevalent problem among veterans deployed to Iraq and Afghanistan. Traumatic brain injury (TBI) and psychiatric conditions, such as posttraumatic stress disorder (PTSD), are potentially important risk factors for suicide in this population, but the literature is limited by a dearth of research on female veterans and imprecise assessment of TBI and suicidal behavior. This study examined 824 male and 825 female U.S. veterans who were enrolled in the baseline assessment of the Veterans After-Discharge Longitudinal Registry (Project VALOR), an observational registry of veterans with and without PTSD who deployed in support of the wars in Iraq and Afghanistan and were enrolled in the Veterans Affairs healthcare system. RESULTS indicated that current depressive symptoms, PTSD, and history of prior TBI were all significantly associated with current suicidal ideation (Cohen's d = 0.91, Cramers' Vs =.19 and.08, respectively). After adding a number of variables to the model, including psychiatric comorbidity, TBI history was associated with increased risk of current suicidal ideation among male veterans only (RR = 1.55). TBI is an important variable to consider in future research on suicide among veterans of the wars in Iraq and Afghanistan, particularly among male veterans. Language: en

Emerging methodological research suggests that the World Wide Web (“Web”) is an appropriate venue for survey data collection, and a promising area for delivering behavioral intervention. However, the use of the Web for research raises concerns regarding sample validity, particularly when the Web is used for recruitment and enrollment. The purpose of this paper is to describe the challenges experienced in two different Web-based studies in which participant misrepresentation threatened sample validity: a survey study and an online intervention study. The lessons learned from these experiences generated three types of strategies researchers can use to reduce the likelihood of participant misrepresentation for eligibility in Web-based research. Examples of procedural/design strategies, technical/software strategies and data analytic strategies are provided along with the methodological strengths and limitations of specific strategies. The discussion includes a series of considerations to guide researchers in the selection of strategies that may be most appropriate given the aims, resources and target population of their studies. Copyright © 2014 John Wiley & Sons, Ltd.

Research has revealed a significant association between several peritraumatic emotional responses and posttraumatic stress disorder (PTSD). Preliminary research has also linked peritraumatic emotional responses with a diagnosis of major depressive disorder (MDD). The majority of this research has been cross-sectional, thereby making it difficult to determine the extent to which the various peritraumatic emotional responses may increase risk for, or serve as a premorbid marker of, PTSD and MDD. This study examined the longitudinal role of peritraumatic emotional responses on the subsequent development of PTSD and MDD in a sample of US military veterans. Whereas a number of peritraumatic emotional responses were concurrently associated with PTSD, only peritraumatic numbness maintained the association with this diagnosis longitudinally. For MDD, peritraumatic numbness was the only emotional response related to the diagnosis both concurrently and longitudinally. Study findings are a preliminary proof of concept that peritraumatic numbness may serve as a premorbid marker for the development of PTSD and MDD following a traumatic event. Implications of these findings for the diagnosis, assessment, and treatment of both PTSD and MDD are discussed.

OBJECTIVE: Veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) commonly experience alcohol misuse and symptoms of posttraumatic stress disorder (PTSD) following deployment. We conducted a randomized clinical trial to evaluate the efficacy of a newly developed, eight-module, self-management Web intervention (VetChange) based on motivational and cognitive-behavioral principles to reduce alcohol consumption, alcohol-related problems, and PTSD symptoms in returning combat Veterans. METHODS: Six hundred participants, recruited through targeted Facebook ads, were randomized to either an Immediate Intervention Group (IIG, n = 404) or a Delayed Intervention Group (DIG, n =196) that waited eight weeks for access to VetChange. Primary outcome measures were Drinks per Drinking Day, Average Weekly Drinks, Percent Heavy Drinking Days and PTSD symptoms. Intent-to-treat analyses compared changes in outcome measures over time between IIG and DIG, as well as within-group changes. RESULTS: IIG participants demonstrated greater reductions in drinking (p < .001 for each measure) and PTSD symptoms (p = .009) between baseline and end-of-intervention than did DIG participants between baseline and the end of the waiting period. DIG participants showed similar improvements to those in IIG following participation in VetChange. Alcohol problems were also reduced within each group between baseline and three-month follow-up. CONCLUSIONS: Results indicate that VetChange is effective in reducing drinking and PTSD symptoms in OIF/OEF Veterans. Further studies of VetChange are needed to assess Web-based recruitment and retention methods and to determine VetChange’s effectiveness in demographic and clinical sub-populations of returning Veterans.

I’m very happy to share some thoughts about this topic. For a long time I have been following the professional dialogue about posttraumatic stress disorder (PTSD), psychological trauma, domestic violence, interpersonal violence, and then the emergence of a condition called complex trauma. I believe that one of the very first places that Judy Herman discussed complex trauma was in my living room in Brookline, as part of the Harvard Study Group on Trauma. That group comprised 25 to 30 people who consistently attended a monthly meeting in Boston, starting in the mid-1980s and continuing until my sabbatical year in 1993 when, for a variety of reasons, it never picked up again. This group gathered people who were doing some of the foundational work on psychological trauma. It included colleagues in Boston at many of the key academic and clinical institutions, some who were visiting Boston for one reason or another, and some whom we would invite from elsewhere in the country to talk with our group about concepts of psychological trauma. Over time the people who comprised the Harvard Study Group on Trauma and those who presented to that group emerged as some of the leading figures in the field, including some who defined key concepts related to psychological trauma. Initially, the group met at the home of Henry Murray’s1 wife (Nina). Their home was in the shadows of Harvard’s William James Hall–a particularly wonderful place to have a conversation about a disorder that was not well-accepted by mainstream psychology and psychiatry. Bessel van der Kolk also hosted the group at times in his beautiful South End row house. One evening Judy Herman spoke about her concerns about the issues of PTSD and the very different patient population she was seeing at the Victims of Violence program at Cambridge Hospital. Her take on it was that many of the people who were given diagnoses of personality disorders were really people who suffered considerable domestic violence, child physical abuse, child sexual abuse, and neglect in ongoing ways. The nature of the distinction was that these were ongoing psychological traumas–ongoing oppression, ongoing stress associated with living in abusive situations, whether it was the spouse, or the parents, or the uncle, or whomever. It was this ongoing nature of it, the sense that “there is no safety,” “no place where anything is safe,” that I think led her to think a bit differently about what conventionally was called personality disorders (borderline being one, but not the only one). She gave birth to the notion of complex trauma and it received a great deal of attention from lots of people at the time who were seeing patients with this same set of problems. I would characterize the patients being discussed as those with dysregulated emotion, cognition, and behavior. The common thread was the existence of this background of ongoing, abusive environments. Interestingly, the syndrome

This study conducted a meta-analysis of published randomized clinical group trials for adult survivors of trauma to examine the efficacy of the group format. Effect sizes for posttraumatic stress disorder (PTSD) severity outcome were examined. Sixteen studies were included, with a total of 1686 participants. Results of a random effects model meta-analysis indicated that group treatments are associated with significant preto posttreatment reduction in PTSD symptom severity (within treatment d .71, 95% CI [.51, .91]), and result in superior treatment effects relative to a wait list comparison condition (d .56, 95% CI [.31, .82]). However, no significant findings were obtained for group interventions relative to active treatment comparison conditions (d .09, 95% CI [ .03, .22]). Moderator analyses also indicated that gender and type of trauma moderated treatment effects for PTSD outcome, with smaller effect sizes associated with males relative to females and combined gender samples, and smaller effect sizes for combat and child sexual assault trauma samples relative to mixed-trauma sample studies. Taken together, group treatment for trauma symptoms is better than no treatment but not better relative to comparison conditions that control for nonspecific benefits of therapy. Additional work is needed to identify effective group treatments for PTSD, especially for patients with repeated or chronic traumatization.

Posttraumatic stress disorder (PTSD) is one of the fastest growing compensated medical conditions. The present study compared usual disability examiner practices for PTSD with a standardized assessment that incorporates evidence-based assessments. The design was a multicenter, cluster randomized, parallel-group study involving 33 clinical examiners and 384 veterans at 6 Veterans Affairs medical centers. The standardized group incorporated the Clinician Administered PTSD Scale and the World Health Organization Disability Assessment Schedule-II into their assessment interview. The main outcome measures were completeness and accuracy of PTSD diagnosis and completeness of functional assessment. The standardized assessments were 85% complete for diagnosis compared to 30% for nonstandardized assessments (p < .001), and, for functional impairment, 76% versus 3% (p < .001). The findings demonstrate that the quality of PTSD disability examination would be improved by using evidence-based assessment.

Background Posttraumatic stress disorder (PTSD) diagnostic criteria have been criticized for including symptoms that overlap with commonly comorbid disorders, which critics argue undermines the validity of the diagnosis and inflates psychiatric comorbidity rates. In response, the upcoming 11th edition of the International Classification of Diseases (ICD-11) will offer PTSD diagnostic criteria that are intended to promote diagnostic accuracy. However, diagnostic utility analyses have not yet assessed whether these criteria minimize diagnostic errors. The present study examined the diagnostic utility of each PTSD symptom in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for males and females. Methods Participants were 1,347 individuals enrolled in a longitudinal national registry of returning veterans receiving care at a Department of Veterans Affairs (VA) facility. Doctoral level clinicians assessed all participants using the PTSD module of the Structured Clinical Interview for DSM. Results Of the 20 symptoms examined, the majority performed in the fair to poor range on test quality indices. Although a few items did perform in the good (or better) range, only half were ICD-11 symptoms. None of the 20 symptoms demonstrated good quality of efficiency. Results demonstrated few sex differences across indices. There were no differences in the proportion of comorbid psychiatric disorders or functional impairment between DSM-5 and ICD-11 criteria. Conclusions ICD-11 PTSD criteria demonstrate neither greater diagnostic specificity nor reduced rates of comorbidity relative to DSM-5 criteria and, as such, do not perform as intended. Modifications to existing symptoms or new symptoms may improve differential diagnosis.

BackgroundPost-traumatic stress disorder (PTSD) is associated with elevated risk for metabolic syndrome (MetS). However, the direction of this association is not yet established, as most prior studies employed cross-sectional designs. The primary goal of this study was to evaluate bidirectional associations between PTSD and MetS using a longitudinal design.MethodA total of 1355 male and female veterans of the conflicts in Iraq and Afghanistan underwent PTSD diagnostic assessments and their biometric profiles pertaining to MetS were extracted from the electronic medical record at two time points (spanning ~2.5 years, n = 971 at time 2).ResultsThe prevalence of MetS among veterans with PTSD was just under 40% at both time points and was significantly greater than that for veterans without PTSD; the prevalence of MetS among those with PTSD was also elevated relative to age-matched population estimates. Cross-lagged panel models revealed that PTSD severity predicted subsequent increases in MetS severity (β = 0.08, p = 0.002), after controlling for initial MetS severity, but MetS did not predict later PTSD symptoms. Logistic regression results suggested that for every 10 PTSD symptoms endorsed at time 1, the odds of a subsequent MetS diagnosis increased by 56%.ConclusionsResults highlight the substantial cardiometabolic concerns of young veterans with PTSD and raise the possibility that PTSD may predispose individuals to accelerated aging, in part, manifested clinically as MetS. This demonstrates the need to identify those with PTSD at greatest risk for MetS and to develop interventions that improve both conditions.

The World Health Organization's posttraumatic stress disorder (PTSD) work group has published a proposal for the forthcoming edition of the International Classification of Diseases (ICD-11) that would yield a very different diagnosis relative to DSM-5. This study examined the impact of the proposed ICD-11 changes on PTSD prevalence relative to the ICD-10 and DSM-5 definitions and also evaluated the extent to which these changes would accomplish the stated aim of reducing the comorbidity associated with PTSD. Diagnostic prevalence estimates were compared using a U.S. national community sample and two U.S. Department of Veterans Affairs clinical samples. The ICD-11 definition yielded prevalence estimates 10 to 30 percent lower than DSM-5 and 25 and 50 percent lower than ICD-10 with no reduction in the prevalence of common comorbidities. Findings suggest that by constraining the diagnosis to a narrower set of symptoms, the proposed ICD-11 criteria set would substantially reduce the number of individuals with the disorder. These findings raise doubt about the extent to which the ICD-11 proposal would achieve the aim of reducing comorbidity associated with PTSD and highlight the public health and policy implications of such a redefinition.

Group delivery of posttraumatic stress disorder (PTSD) treatment has several advantages, however group research is not comparable to individual trials. This study extends the group literature by improving methodology in examining the efficacy of a 3-module (cognitive, exposure, skills) group treatment for PTSD, establishes a format for the delivery of group exposure therapy, and compares 3 treatment modules within the group.Eighty-six Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) women veterans were randomized to a 16-week, 3-member group treatment (Tx) or a waitlist (WL) condition. The primary (Clinician Administered PTSD Scale [CAPS]) and secondary (Medical Outcomes Study Short Form-36 [SF-36], Quality of Life Inventory [QOLI], and PTSD Checklist [PCL]) outcome measures were administered at baseline, post Tx/WL, and at 3- and 6-months post Tx (PCL additionally at pre/post for each treatment module).PTSD symptoms significantly improved in Tx arm participants (p.001, ES = 1.72; unit of analysis group: n = 14), as did mental and physical life functioning (SF-36; p.001), and quality of life (QOLI; p.001). The WL significantly improved on the SF-36 (mental; p = .04) and QOLI (p = .02). Clinical improvement (CAPS) in the Tx arm reflected a treatment response (≥10-point decrease) in 77% and loss of PTSD diagnosis (45) in 52% of participants, comparable to individual prolonged exposure (PE) treatment. Finally, PCL scores significantly lowered in exposure and cognitive modules.This study supports the use of group format for PTSD with 3 modules using improved methodology, with a novel, 3-member group which allows repeated in-session weekly imaginal exposures. The results suggest future examination of group delivered PE. (PsycINFO Database Record

Inthisreport,drinkingchanges,traumaexposure,and occupational stress were compared among firefighters(N =81) who reported a relapse to cigarette smoking (n =27), a lifetime former history of smoking (n = 27), or nohistory of smoking (n = 27). Mechanisms behind tobaccorelapse occurring after employment in fire service were ex-plored.

This study examined concordance between physiological arousal and subjective distress during a laboratory challenge task. Data were collected during the multisite VA Cooperative Study 334 in the early 1990s examining psychophysiological arousal among combat-exposed Vietnam veterans with (n = 775) and without (n = 369) posttraumatic stress disorder (PTSD). Study participants were presented with 6 standardized neutral scenes and 6 standardized combat scenes. Participants provided a subjective rating of distress after each slide. During the presentation, levels of heart rate (HR) and skin conductance (SC) were recorded. Using linear mixed effects modeling, both HR level and SC level exhibited significant positive associations with subjective distress ratings (pr = .33, p < .001 and pr = .19, p < .001, respectively). Individuals with PTSD demonstrated greater concordance between their distress ratings and SC level during exposure to combat slides than participants without PTSD (pr = .28, p < .001 vs. pr = .18, p < .001). Although a significant association was found between subjective distress and HR reactivity and SC reactivity, these findings were not moderated by PTSD status. The results of these analyses suggest that patients' reports of distress during exposure-based treatments might serve as approximate measures of actual physiological arousal.

In this reply to McNally and Frueh (2012), we offer some additional insight into the studies they use to support their argument that we should be worried about malingering among veterans. We also describe other research on the disability system of the Department of Veterans Affairs and compensation-seeking behavior that challenges their conclusions.

We examined the relationship between trauma exposure and the perpetration of aggression by male Vietnam veterans (N = 1,328) using archival data from a multisite study conducted by the Cooperative Studies Program of the Department of Veteran Affairs (CSP-334) in the early 1990s. Both traumatic events in civilian life and combat exposure were examined as correlates of aggression. Results indicated that pre- and postmilitary traumatic events and combat exposure were all related to perpetration of aggression at the bivariate level; r = .07, r = .20, and r = .13, respectively. When these variables were examined simultaneously, only combat exposure (β = .14, p < .001) and postmilitary traumatic events (β = .20, p < .001) were associated with aggression. No interaction effects were found for civilian traumatic events and combat in relation to aggression. Results highlight the importance of attending to the psychological aftermath of exposure to traumatic events experienced during and following deployment before aggressive patterns develop.

VA National Center for PTSD; VA Boston Healthcare System, Boston, MA; Boston UniversitySchool of MedicineObjective: The commission of wartime atrocities is a phenomenon known to occuramong military personnel deployed to war zones. Although some research hasexamined the psychological sequelae to these events, there is virtually no researchon the causes or correlates of such behavior. The present study examined associ-ations among personality variables, combat exposure, and witnessing or participat-ing in wartime atrocities during the Vietnam War. Method: One thousand onehundred and four Army and Marine veterans of the Vietnam War completedself-report measures that assessed personality, combat exposure, and participationin atrocities. Structural equation modeling was used to test a model in whichcombat exposure mediated the association between personality and participation inatrocities. Results: Combat exposure was strongly associated with self-reportedparticipation in atrocities and fully mediated the association between trait aggres-sion and participation in atrocities. Combat exposure was also shown to partiallymediate the association between trait neuroticism and atrocities but evidenced norelationship with trait disconstraint. Disconstraint showed only a direct associationwith participation in atrocities. Conclusions: Personality and exposure to heavycombat should be considered not only risk factors for physical or mental illness, butalso important risk factors for the commission of atrocities. Longitudinal researchon risk factors for the commission of atrocities is needed, with a focus on thoseservice members tasked with more dangerous assignments. Military commandersmay wish to pay close attention to units under greater combat stress and to continueto devote resources to screening and treatment of members of these units.Keywords

The present study examined reported rates of specific posttraumatic stress disorder (PTSD) symptoms in a veteran sample and the extent to which specific symptoms predicted PTSD diagnostic status. A sample of 1325 unmedicated male Vietnam veterans were interviewed using the Structured Clinical Interview for the Diagnostic and Statistical Manual, 3rd edition revised (DSM–III–R) by doctoral-level clinicians. Of the total sample, 798 met diagnostic criteria for current PTSD, 189 met criteria for a lifetime diagnosis of PTSD, and 338 did not meet criteria for either current or lifetime PTSD. Overall, participants endorsed a median of 9, and a mean of 8.4 (SD 5.4) out of 17 possible PTSD symptoms. The most frequently endorsed symptoms among participants meeting criteria for current PTSD were hypervigilance and detachment from others, followed by intrusive recollections and sleep difficulties. The symptoms with the greatest diagnostic sensitivity in this sample were hypervigilance and detachment from others and those with the greatest diagnostic specificity were flashbacks and nightmares. Intrusive recollections and interpersonal detachment were the overall best predictors of current PTSD diagnostic status. Psychiatric comorbidity was associated with increased overall symptom endorsement rather than the presence of a different pattern of symptom distribution. The finding that hyperarousal and detachment symptoms are more strongly associated with PTSD diagnosis is consistent with reports from other studies conducted with veterans and other trauma-exposed samples. However, certain symptoms were found to occur at higher rates than have been reported in different populations with PTSD.

Although most individuals with posttraumatic stress disorder (PTSD) demonstrate heightened physiological reactivity to trauma-related cues, many of these individuals do not. The presence of comorbid externalizing disorders is a potential explanation for this inconsistency. This study investigated the psychophysiological reactions to both standardized and idiographic trauma-related cues among male Vietnam Veterans with PTSD only, PTSD and a comorbid substance use disorder (PTSD-SUD), PTSD and comorbid antisocial personality disorder (PTSD-ASPD), PTSD and both comorbid ASPD and SUD (PTSD-ASPD/SUD), and healthy controls. Results showed that the heart rate reactivity of the PTSDASPD and PTSD-ASPD/SUD groups failed to exceed that of the No Disorder group during the imagery-based task, and the PTSD-ASPD/SUD group showed less skin conductance reactivity than the other three PTSD groups in response to the standardized trauma cues. These findings implicate ASPD comorbidity in reduced physiological reactivity to trauma reminders in some individuals with PTSD.

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that affects 7-8% of the general U.S. population at some point during their lifetime; however, the prevalence is much higher among certain subgroups, including active duty military personnel and veterans. In this article, we review the empirical literature on the epidemiology and screening of PTSD in military and veteran populations, including the availability of sensitive and reliable screening tools. Although estimates vary across studies, evidence suggests that the prevalence of PTSD in deployed U.S. military personnel may be as high as 14-16%. Prior studies have identified trauma characteristics and pre- and posttrauma factors that increase risk of PTSD among veterans and military personnel. This information may help to inform prevention and screening efforts, as screening programs could be targeted to high-risk populations. Large-scale screening efforts have recently been implemented by the U.S. Departments of Defense and Veterans Affairs. Given the prevalence and potential consequences of PTSD among veterans and active duty military personnel, development and continued evaluation of effective screening methods is an important public health need.

Few studies have investigated the natural history of post-traumatic stress disorder (PTSD). Project VALOR (Veterans' After-discharge Longitudinal Registry) was designed as a longitudinal patient registry assessing the course of combat-related PTSD among 1600 male and female Veterans who served in Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF). Aims of the study include investigating patterns and predictors of progression or remission of PTSD and treatment utilization. The study design was based on recommendations from the Agency for Healthcare Quality and Research for longitudinal disease registries and used a pre-specified theoretical model to select the measurement domains for data collection and interpretation of forthcoming results. The registry will include 1200 male and female Veterans with a recent diagnosis of PTSD in the Department of Veteran Affairs (VA) electronic medical record and a comparison group of 400 Veterans without a medical record-based PTSD diagnosis, to also allow for case-control analyses. Data are collected from administrative databases, electronic medical records, a self-administered questionnaire, and a semi-structured diagnostic telephone interview. Project VALOR is a unique and timely registry study that will evaluate the clinical course of PTSD, psychosocial correlates, and health outcomes in a carefully selected cohort of returning OEF/OIF Veterans.

James C. Jackson, Center for Health Services Research, Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Division of Allergy/Pulmonary/CriticalCare Medicine, Vanderbilt University School of Medicine, and Oliver Zangwill Centre; Patricia L. Sinnott, Health Economics Resource Center, VA Palo Alto Health Care System, and Departmentof Physical Therapy and Rehabilitation Science, University of California, San Francisco; Brian P. Marx, VA National Center for PTSD, VA Boston Healthcare System, and Department of Psychiatry,Boston University School of Medicine; Maureen Murdoch, Center for Chronic Disease Outcomes Research and Section of General Internal Medicine, Minneapolis VA Medical Center, andDepartment of Medicine, University of Minnesota; Nina A. Sayer, Center for Chronic Disease Outcomes Research and Section of General Internal Medicine, Minneapolis VA Medical Center, andDepartment of Psychiatry, University of Minnesota; JoAnn M. Alvarez, and Robert A. Greevy, Department of Biostatistics, Vanderbilt University School of Medicine; Paula P. Schnurr, VA NationalCenter for PTSD, White River Junction VA Medical Center, and Department of Psychiatry, Dartmouth Medical School; Matthew J. Friedman, VA National Center for PTSD, White River JunctionVA Medical Center, and Department of Pharmacology & Toxicology, Dartmouth Medical School; Andrea C. Shane, Health Economics Resource Center, VA Palo Alto Health Care System; RichardR. Owen, VA Mental Health Quality Enhancement Research Initiative (MH QUERI), Central Arkansas VA Healthcare System and Division of Health Services Research, Department of Psychiatry,College of Medicine, University of Arkansas for Medical Sciences; Terence M. Keane, VA National Center for PTSD, VA Boston Healthcare System and Department of Psychiatry, Boston UniversitySchool of Medicine; Theodore Speroff, Center for Health Services Research, Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Department ofBiostatistics, and Division of General Internal Medicine, Department of Medicine, Vanderbilt University School of Medicine.This research was supported by grant number SDP 06-331 from the U. S. Department of Veterans Affairs Quality Enhancement Research Initiative. This material is based upon work supportedby the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development QUERI program. The views expressed inthis article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.Correspondence concerning this article should be addressed to James C. Jackson, 6th Floor MCE, Suite 6100, Division of Allergy/Pulmonary/Critical Care Medicine, Vanderbilt Medical School,Nashville, TN 37232. E-mail: james.c.jackson@vanderbilt.edu.

America's involvement in the wars in Afghanistan and Iraq (i.e., OEF-OIF) is entering its 9th year with casualties exceeding 5,000 American deaths and many times that number with serious physical injuries. Epidemiological surveys and mental health screening concurrent with service and at the point of discharge provide us with important information on the psychological status of those directly involved in the military action. Support to mental health professionals coming primarily from the Department of Defense, the Department of Veterans Affairs, and the National Institutes of Health provided an important catalyst in the development of psychological treatments aimed specifically at the presenting problems of service men and women and their families. This special series highlights the impressive growth in treatments developed for OEF-OIF military and demonstrates the wide-ranging nature of the treatments that are now available for testing and use in assisting those most affected by the war. The creativity of these research teams in addressing the needs of these service men and women inspires continuing work in this area that will undoubtedly enhance mental health services available to the general population in the near term.

The diagnosis of posttraumatic stress disorder (PTSD) is unique in that its criteria are embedded with a presumed causal agent, viz, a traumatic event. This assumption has come under scrutiny as a number of recent studies have suggested that many symptoms of PTSD may not necessarily be the result of trauma and may merely represent general psychiatric symptoms that would have existed even in the absence of a trauma event but are subsequently misattributed to it. The current study tests this hypothesis.A case-control twin study conducted between 1996-2001 examined psychopathologic symptoms in a national convenience sample of 104 identical twin pairs discordant for combat exposure in Vietnam, with (n = 50) or without (n = 54) combat-related PTSD (DSM-IV-diagnosed) in the exposed twin. Psychometric measures used were the Symptom Checklist-90-Revised, the Clinician-Administered PTSD Scale, and the Mississippi Scale for Combat-Related PTSD. If a psychopathologic feature represents a factor that would have existed even without traumatic exposure, then there is a high chance that it would also be found at elevated rates in the non-trauma-exposed, identical cotwins of trauma-exposed twins with PTSD. In contrast, if a psychopathologic feature is acquired as a result of an environmental factor unique to the exposed twin, eg, the traumatic event, their cotwins should not have an increased incidence of the feature.Combat veterans with PTSD demonstrated significantly higher scores (P.0001) on the Symptom Checklist-90-Revised and other psychometric measures of psychopathology than their own combat-unexposed cotwins (and than combat veterans without PTSD and their cotwins).These results support the conclusion that the majority of psychiatric symptoms reported by combat veterans with PTSD would not have been present were it not for their exposure to traumatic events.

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) are the longest sustained ground combat operations involving American forces since the Vietnam era. Our continued involvement in these conflicts has yielded an experienced fighting force; however, to meet the demands of these wars, soldiers are often being asked to complete multiple tours of duty, thus increasing the probability they will experience a combat-related physical injury or experience one or more potentially traumatic events. This article addresses the major psychological issues of concern associated with OEF/OIF deployment and combat. A central aim of this review is to focus on posttraumatic stress disorder, but the authors also address other frequently observed conditions, such as chronic pain, traumatic brain injury, substance abuse, and depression, all of which can have a negative effect on soldiers’ and veterans’ functioning and quality of life. Evidence-based assessment and treatment approaches are reviewed, and relevant resources for health care professionals are identified.

This study examined the degree to which combat-related guilt mediated the relations between exposure to combat-related abusive violence and both Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) in Vietnam Veterans. Methods: Secondary analyses were conducted on data collected from 1,323 male Vietnam Veterans as part of a larger, multisite study. Results: Results revealed that combat-related guilt partially mediated the association between exposure to combat-related abusive violence and PTSD, but completely mediated the association with MDD, with overall combat exposure held constant in the model. Follow-up analyses showed that, when comparing those participants who actually participated in combat-related abusive violence with those who only observed it, combat-related guilt completely mediated the association between participation in abusive violence and both PTSD and MDD. Moreover, when comparing those participants who observed combat-related abusive violence with those who had no exposure at all to it, combat-related guilt completely mediated the association between observation of combat-related abusive violence and MDD, but only partially mediated the association with PTSD. Conclusions: These findings suggest that guilt may be a mechanism through which abusive violence is related to PTSD and MDD among combat-deployed Veterans. These findings also suggest the importance of assessing abusive-violence related guilt among combat-deployed Veterans and implementing relevant interventions for such guilt whenever indicated. Language: en

Objective. The purpose of this article is to describe the development of the first integrated treatment for Veterans with comorbid chronic pain and posttraumatic stress disorder (PTSD). Design. Descriptive, including pre- and posttreatment assessment results from a pilot study of six veterans with comorbid chronic pain and PTSD. Setting. Northeastern Department of Veterans Affairs Medical Center. Interventions. Using components of cognitive processing therapy (CPT) for PTSD and cognitive behavioral therapy (CBT) for chronic pain management, a 12-session integrated treatment for veterans with comorbid chronic pain and PTSD was developed. A therapist manual and patient workbook that included weekly readings and homework assignments were created. Participants received pre- and posttreatment evaluations using measures of pain, PTSD, physical disability, and psychological distress. The treatment development process is reviewed and the benefits and challenges of implementing this integrated treatment are presented. Results. Several themes emerged over the course of implementing the treatment, including the importance of establishing participant trust, regular therapy attendance, and addressing participant avoidance. Of the six participants recruited for the pilot study, three withdrew from the study and three completed the integrated treatment. Participants reported that they generally liked the format of treatment, appreciated learning about the ways that chronic pain and PTSD share some common symptoms, and ways that the two disorders can interact with one another. The assessment results of those who completed treatment suggest that this treatment approach is feasible and may have clinical benefit. Conclusions. Participants appeared to benefit from receiving the integrated treatment for pain and PTSD. A randomized clinical trial is currently being conducted to evaluate the efficacy of this treatment approach.

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment(GCBT) or a minimum contact comparison group (MCC).Compared to the MCC participants (n=16), individuals who completed GCBT (n=17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to31.3% of the MCC participants. Examination of anxiety,depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs.Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.

The psychometric properties of the PTSD Checklist-Civilian version (PCL-C) were calculated for a population of HIV-seropositive individuals, using diagnoses and scores from the Clinician-Administered PTSD Scale (CAPS) as the criterion measure. Results indicated rates of posttraumatic stress disorder (PTSD) higher than that of the general population, with 12.3% of participants meeting criteria for PTSD in the past month. The PCL-C exhibited excellent internal consistency with a Cronbach's alpha of .94 for the whole measure. Receiver Operating Characteristic curve yielded an optimum cut score of 52 to determine the presence of PTSD as measured by the CAPS. This resulted in a sensitivity of .71, a specificity of .84, and a diagnostic efficiency of .82. Although this cut score yielded a slightly higher diagnostic efficiency, the cut score of 50 provided the optimal balance between sensitivity (.86) and specificity (.79)

INTRODUCTION Posttraumatic stress disorder (PTSD) is a major health concern for military war veterans and the Department of Veterans Affairs (VA). Estimates based on the National Vietnam Veterans Readjustment Study (NVVRS) indicate that between 9 and 15 percent of male Vietnam veterans met diagnostic criteria for current PTSD approximately 20 years after the Vietnam war and that between 19 and 31 percent of male veterans had met criteria for the disorder at some point since the Vietnam war [1-2]. More recently, the mental health of veterans of conflicts in Iraq and Afghanistan has become a national priority. In one recent study of troops returning from Iraq, Hoge et al. found that approximately 15 percent met presumptive criteria for PTSD, major depression, and/or generalized anxiety disorder and of those who met criteria for one of these disorders, 75 percent had PTSD [3]. PTSD exacts an enormous and growing cost from American society and the VA. A recent Inspector General's report found that the number of veterans receiving disability awards for PTSD, as well as the size of those awards, is growing [4]. From 1999 to 2004, the total number of PTSD cases increased by 79.5 percent while PTSD benefits payments grew 148.8 percent from $1.7 billion to $4.3 billion. Furthermore, while veterans being compensated for PTSD represented only 8.7 percent of all compensation recipients, this subgroup received 20.5 percent of all compensation payments. The VA Compensation and Pension (CP assessment of trauma exposure, PTSD, and mental status; evaluation of social and occupational function; and assignment of a Global Assessment of Functioning (GAF) score [5]. The latter is a numerical rating of the overall severity of psychiatric disturbance and is assigned by a clinician. In cases in which a GAF score is unavailable, C&P raters may request that an evaluator provide one and the Board of Veterans' Appeal may also require a GAF score as part of a remand of a rating decision [6]. The central role of the GAF score in VA mental health assessment is further evidenced by Veterans Health Administration (VHA) Directive 97-059, which mandated that clinicians record "at least one GAF score reflecting the 'current level of functioning' for each veteran patient seen at any VHA mental health inpatient or outpatient setting" [7]. Despite the VA's adoption of the GAF as a benchmark for the assessment of PTSD-related and other psychiatric impairment, concerns have been raised about the scale's reliability, validity, and suitability for this purpose. Criticisms have focused on the use of one item to measure many different functional areas, limitations due to the origin of the GAF as a measure for the study of affective disorders and schizophrenia, and evidence that the score may have a greater association with psychiatric symptoms than with functional abilities [6,8]. Another concern is that because the assessment of functional impairment is involved in the determination of PTSD severity, both at the individual symptom level and the syndrome level, an inherent overlap, or confound, exists between ratings of GAF and PTSD severity. Estimating the strength of this association (i.e., degree of overlap) in a veteran sample with PTSD was a primary aim of this study. Prior research on the relationship of GAF scores to PTSD severity in such samples is surprisingly limited given its role in VA assessment. One large-scale study by Greenberg and Rosenheck that did examine the utility of the GAF as a VA mental health outcome measure found a moderate association between the PTSD diagnosis and GAF in outpatients [9]. The authors concluded that the GAF was reasonably reliable, discriminated severe illnesses such as schizophrenia and Alzheimer disease from those of lesser severity, and was sensitive to improvement. …

Although needs assessment surveys are carried out after many large natural and man-made disasters, synthesis of findings across these surveys and disaster situations about patterns and correlates of need is hampered by inconsistencies in study designs and measures. Recognizing this problem, the US Substance Abuse and Mental Health Services Administration (SAMHSA) assembled a task force in 2004 to develop a model study design and interview schedule for use in post-disaster needs assessment surveys. The US National Institute of Mental Health subsequently approved a plan to establish a center to implement post-disaster mental health needs assessment surveys in the future using an integrated series of measures and designs of the sort proposed by the SAMHSA task force. A wide range of measurement, design, and analysis issues will arise in developing this center. Given that the least widely discussed of these issues concerns study design, the current report focuses on the most important sampling and design issues proposed for this center based on our experiences with the SAMHSA task force, subsequent Katrina surveys, and earlier work in other disaster situations.

The sexual abuse of children can leave profound emotional and psychological scars that reverberate through the entire lifecycle. In this volume, the sexual abuse of children and adults perpetrated by clergy is considered. The editors have provided a cross section of authors to examine the unique aspect of this form of trauma, with particular emphasis on providing a voice for the survivors of such abuse.

This study assessed adherence to HAART among 67 HIV-infected adults, and the degree to which gender and psychological factors-including depression, drug and alcohol use, quality of life, and medication side effects-influenced adherence. Although overall adherence was greater than rates reported in similar studies, no significant difference in adherence was observed between men and women in the present sample. Medication side effects were a significant predictor of non-adherence in the sample at large and among women in particular, while alcohol dependence was a significant predictor of non-adherence only in women. Possible explanations are explored.