The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans

Sex differences in post-traumatic stress disorder risk: autonomic control and inflammation

AIM

Over 7 million U.S. adults and about 20% of the military population have post-traumatic stress disorder (PTSD), a debilitating condition that is independently linked to a significantly greater risk of developing cardiovascular disease (CVD). Women have twice the probability of developing PTSD after experiencing a traumatic event compared to men. Existing literatures have reported higher inflammation and autonomic dysfunction including impaired baroreflex sensitivity, increased sympathetic reactivity and decreased parasympathetic activity in PTSD. However, most of these findings stem from studies conducted predominantly in males.

METHODS

We attempt in this narrative review to summarize the mixed literature available on sex differences in autonomic dysfunction and inflammation in PTSD, at rest and in response to stress in PTSD.

RESULTS

This review reveals that there is a paucity of research exploring autonomic function in females with PTSD. Recent studies have included female participants without probing for sex differences. A small number of studies have been conducted exclusively in women. Available data suggest that sympathetic nervous system output tends to be heightened, while parasympathetic activity and arterial baroreflex sensitivity appear more blunted in females with PTSD. Although few studies have investigated sex differences in inflammation in PTSD, data within females suggest chronic increases in inflammation with PTSD. This autonomic dysregulation and inflammation have also been described in males with PTSD.

CONCLUSION

In sum, given the inherent biological differences in CVD clinical presentation and characteristics between men and women, human and animal studies aiming at elucidating sex differences in the pathophysiology of PTSD are needed.

Attention control therapy for acute stress disorder: A randomized controlled trial

BACKGROUND

A subset of people exposed to traumatic events develop acute stress disorder (ASD), and approximately half of people with ASD develop posttraumatic stress disorder (PTSD). This randomized controlled trial examined the efficacy of internet-delivered attention control therapy (ACT), previously shown to reduce PTSD symptoms, as an adjuvant to treatment as usual in the community for patients with ASD.

METHODS

About 119 participants with ASD were randomly assigned to ACT or treatment as usual in the community within the first month following their traumatic event. PTSD symptoms and attention patterns were measured.

RESULTS

A significant reduction in stress-related symptoms was noted across participants with no difference between the two groups. Approximately half of the participants developed PTSD 2 months after the trauma. High attention bias variability was associated with elevated PTSD symptoms. However, attention bias variability did not change due to the therapy sessions.

CONCLUSIONS

Internet-delivered ACT was no more effective in reducing risk for PTSD in participants with ASD than treatment as usual in the community. Although elevated attention bias variability was detected in the patients with ASD, ACT failed to engage this cognitive target. Finally, ACT-based prevention research should proceed with caution given the possibility that this intervention might be associated with symptom worsening as indexed by the Clinical Global Impression scale.

Using Interpretation Bias Modification to Reduce Anger in Veterans with Posttraumatic Stress Disorder: A Pilot Study

Difficulty controlling anger is the most commonly reported reintegration concern among veterans with posttraumatic stress disorder (PTSD). One of the mechanisms associated with problematic anger is a tendency to interpret ambiguous interpersonal situations as hostile, known as the hostile interpretation bias (HIB). A computer-based interpretation bias modification (IBM) intervention has been shown to successfully reduce HIB and anger but has not been tested in veterans with PTSD. The current study was a pilot trial of this IBM intervention modified to address problematic anger among veterans with PTSD. Veterans with PTSD and a high level of anger (N = 7) completed eight sessions of IBM treatment over the course of 4 weeks. Participants completed self-report questionnaires at pre- and posttreatment assessment visits, as well as a treatment acceptability interview at posttreatment. Veterans experienced large reductions in hostile interpretation bias and anger from pre- to posttreatment, ds = 1.03-1.96, although these estimates may be unstable due to the small sample size. The feasibility for recruitment, retention, and treatment completion were high. Questionnaire and interview data demonstrated that most participants were satisfied with the treatment and found it helpful and easy to use. Overall, IBM for anger was feasible and acceptable to veterans with PTSD and was associated with reductions in hostile interpretations and self-reported anger outcomes. Further research examining this approach is warranted.

Individual differences in attentional control explain the differential expression of threat-related attentional bias among those with posttraumatic stress symptomatology and predict symptom maintenance up to one year later

Individual differences in attentional control may explain null findings and inconsistent patterns of threat-related attentional bias (ABT) that are common in the posttraumatic stress disorder (PTSD) literature. At Time 1 (T1), trauma-exposed community participants (N = 89) completed a clinical interview, self-report measures, and an eye-tracking task developed to assess ABT. Participants completed follow-up assessments online 6 (T2) and 12 (T3) months later. Those with higher PTSD symptoms and deficits in attentional control exhibited a pattern of undercontrol, characterized by attention maintenance on threat and increased arousal. In contrast, those with higher PTSD symptoms and relatively better attentional control exhibited a pattern of overcontrol, characterized by threat avoidance and reduced arousal. These effects were specific to threat stimuli. Among PTSD symptom clusters, symptoms of hyperarousal were of central importance to the observed effects. Results from the longitudinal analysis indicate that both of these patterns of ABT are maladaptive, resulting in symptom maintenance at T2 and T3. These results have implications for (a) reconciling tensions between disparate models of ABT (i.e., vigilance-avoidance vs. attention maintenance), (b) precision medicine based approaches to targeting PTSD-related ABT, and (c) understanding the transdiagnostic role that attentional control may play in influencing ABT expression.

Exposure, Relaxation, and Rescripting Therapy for Trauma-Related Nightmares With Psychiatric Inpatients: A Case Series

Research has shown that posttraumatic stress disorder (PTSD) is a highly prevalent diagnosis for psychiatric patients, yet individualized care and treatment is limited in the inpatient acute care sector. Two case studies are presented which examine the use of Exposure, Relaxation, and Rescripting Therapy (ERRT) for chronic trauma-related nightmares, within a private acute care inpatient psychiatric hospital setting. ERRT is empirically supported with efficacy for veteran and civilian populations, however no research to date has been conducted with psychiatric inpatients. Two participants diagnosed with PTSD, suffering distressing trauma-related nightmares, completed ERRT over three sessions during their psychiatric hospital admission, with the aim of reducing the frequency and severity of nightmares and related psychological symptoms. PTSD, depression, sleep quality and quantity, and nightmare frequency and related distress, were measured pre-treatment, during treatment, and follow-up at one, 3 and 6 months. Only one participant reported ongoing nightmares by the third week of the intervention, with both participants reporting an absence of nightmares at the one and 3-month follow-ups, but mixed results by the 6-month follow-up. One participant also reported a reduction in PTSD symptoms and a mild improvement in depression. The results offer some preliminary support for the provision of ERRT for the treatment of trauma-related nightmares for psychiatric inpatients.

Application of Noninvasive Vagal Nerve Stimulation to Stress-Related Psychiatric Disorders

BACKGROUND

Vagal Nerve Stimulation (VNS) has been shown to be efficacious for the treatment of depression, but to date, VNS devices have required surgical implantation, which has limited widespread implementation.

METHODS

New noninvasive VNS (nVNS) devices have been developed which allow external stimulation of the vagus nerve, and their effects on physiology in patients with stress-related psychiatric disorders can be measured with brain imaging, blood biomarkers, and wearable sensing devices. Advantages in terms of cost and convenience may lead to more widespread implementation in psychiatry, as well as facilitate research of the physiology of the vagus nerve in humans. nVNS has effects on autonomic tone, cardiovascular function, inflammatory responses, and central brain areas involved in modulation of emotion, all of which make it particularly applicable to patients with stress-related psychiatric disorders, including posttraumatic stress disorder (PTSD) and depression, since dysregulation of these circuits and systems underlies the symptomatology of these disorders.

RESULTS

This paper reviewed the physiology of the vagus nerve and its relevance to modulating the stress response in the context of application of nVNS to stress-related psychiatric disorders.

CONCLUSIONS

nVNS has a favorable effect on stress physiology that is measurable using brain imaging, blood biomarkers of inflammation, and wearable sensing devices, and shows promise in the prevention and treatment of stress-related psychiatric disorders.

Longitudinal change in self-reported peritraumatic dissociation during and after a course of posttraumatic stress disorder treatment: Contributions of symptom severity and time

Objective: Peritraumatic dissociation, a dissociative reaction that occurs at the time of a traumatic event, has been established as a strong risk factor for posttraumatic stress disorder (PTSD). However, self-reported peritraumatic dissociation is typically assessed months or years after trauma exposure and may be influenced by current distress levels and other factors. Method: We examined the temporal stability of scores on the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) among 126 treatment-seeking adults with PTSD during and after trauma-focused treatment. Participants reported dissociation during the same index event at baseline and 6, 12, 24, 36, and 60 weeks after the first treatment session. Results: There were substantial changes in PDEQ total scores over time, with > 40% of participants experiencing reliable change from baseline at least once during the study. Multilevel modeling revealed an overall decrease in PDEQ scores over time; scores on the Clinician-Administered PTSD Scale for DSM-5, Beck Depression Inventory-II, and PTSD Checklist for DSM-5 were each significantly associated with PDEQ scores. Conclusions: Our findings suggest the PDEQ does not provide temporally stable assessment of peritraumatic dissociation. Accordingly, it is crucial to control for current PTSD symptom levels when examining the degree to which peritraumatic dissociation confers risk for future symptom severity. Without such an accounting, our understanding of the relationship between PTSD and peritraumatic dissociation may be incorrect. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Hair cortisol levels in posttraumatic stress disorder and metabolic syndrome

Individuals with post-traumatic stress disorder (PTSD) evidence increased rates of metabolic syndrome (MetS), and both PTSD and MetS are associated with alterations in hypothalamic-pituitary-adrenal (HPA) axis function. Few investigations have examined the possible role of HPA-axis dysfunction in the co-occurrence of PTSD and MetS. In a case-control study, we aimed to determine whether hair cortisol concentrations (HCC) were associated with (i) PTSD caseness and severity and (ii) PTSD and MetS co-occurrence. We used the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) to determine PTSD diagnoses and severity scores in 216 females of mixed ancestry aged between 20 and 79 years (M = 43.8, SD =13.3). Hair samples, representing a three-month retrospective window of cortisol levels, were obtained and analyzed utilizing liquid chromatography-tandem mass spectrometry. We constructed multivariate linear regression models to evaluate whether PTSD diagnosis, PTSD severity, and MetS comorbidity were associated with HCC, controlling for potential confounders. HCC were significantly higher (adj β = 0.154, p = .033; Cohen's d = 0.44) in PTSD patients (n = 110) than trauma-exposed controls (n = 106) and CAPS severity scores (adj β = 0.207, p = .005) were significantly associated with HCC. MetS was not associated with HCC and there were no significant interactions between PTSD and MetS on HCC. This study provides evidence of a chronically dysregulated neuroendocrine mediated stress response in PTSD, with a clear dose-response relationship. HCC do not, however, appear to have specificity for the comorbidity of PTSD and MetS in this sample.LAY SUMMARYWe found that levels of the stress hormone, cortisol, measured in hair samples were significantly higher in South African women with post-traumatic stress disorder (PTSD) than in women who had also experienced trauma but did not have PTSD. Hair cortisol levels were, however, not associated with metabolic syndrome, a cluster of risk factors for heart disease, in the women studied. We thus show that South African women with PTSD have elevated long-term stress hormone levels and that this effect is related to PTSD and not solely due to trauma exposure.

The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis

BACKGROUND

Globally, the number of refugees and asylum seekers has reached record highs. Past research in refugee mental health has reported wide variation in mental illness prevalence data, partially attributable to methodological limitations. This systematic review aims to summarise the current body of evidence for the prevalence of mental illness in global refugee populations and overcome methodological limitations of individual studies.

METHODS AND FINDINGS

A comprehensive search of electronic databases was undertaken from 1 January 2003 to 4 February 2020 (MEDLINE, MEDLINE In-Process, EBM Reviews, Embase, PsycINFO, CINAHL, PILOTS, Web of Science). Quantitative studies were included if diagnosis of mental illness involved a clinical interview and use of a validated assessment measure and reported at least 50 participants. Study quality was assessed using a descriptive approach based on a template according to study design (modified Newcastle-Ottawa Scale). Random-effects models, based on inverse variance weights, were conducted. Subgroup analyses were performed for sex, sample size, displacement duration, visa status, country of origin, current residence, type of interview (interpreter-assisted or native language), and diagnostic measure. The systematic review was registered with PROSPERO (CRD) 42016046349. The search yielded a result of 21,842 records. Twenty-six studies, which included one randomised controlled trial and 25 observational studies, provided results for 5,143 adult refugees and asylum seekers. Studies were undertaken across 15 countries: Australia (652 refugees), Austria (150), China (65), Germany (1,104), Italy (297), Lebanon (646), Nepal (574), Norway (64), South Korea (200), Sweden (86), Switzerland (164), Turkey (238), Uganda (77), United Kingdom (420), and the United States of America (406). The prevalence of posttraumatic stress disorder (PTSD) was 31.46% (95% CI 24.43-38.5), the prevalence of depression was 31.5% (95% CI 22.64-40.38), the prevalence of anxiety disorders was 11% (95% CI 6.75-15.43), and the prevalence of psychosis was 1.51% (95% CI 0.63-2.40). A limitation of the study is that substantial heterogeneity was present in the prevalence estimates of PTSD, depression, and anxiety, and limited covariates were reported in the included studies.

CONCLUSIONS

This comprehensive review generates current prevalence estimates for not only PTSD but also depression, anxiety, and psychosis. Refugees and asylum seekers have high and persistent rates of PTSD and depression, and the results of this review highlight the need for ongoing, long-term mental health care beyond the initial period of resettlement.

Residual symptoms of PTSD following Sertraline plus enhanced medication management, Sertraline plus PE, and PE plus placebo

Although prolonged exposure (PE) and SSRI antidepressants are effective in treating posttraumatic stress disorder (PTSD), previous studies have shown that some symptoms tend to persist. The current study compared sertraline hydrochloride plus enhanced medication management (EMM), PE plus placebo, or PE plus sertraline hydrochloride in the likelihood of each individual PTSD symptom persisting in veterans with a PTSD diagnosis. We compared the likelihood of individual PTSD symptoms persisting in those with versus without a PTSD diagnosis at posttreatment. We found no significant differences across conditions in which symptoms were likely to persist posttreatment. Among those without a PTSD diagnosis at posttreatment, sleeping difficulties (63.0%), hypervigilance (47.3%), and nightmares (45.0%) were most likely to persist. Findings indicate no consistent differences in residual symptoms between PE and medications, and shared decision making with patients is encouraged in selecting treatments. Gold standard treatments (e.g., CBT-I) may be warranted for residual symptoms like insomnia.

Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content

Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.

Neuroendocrine biomarkers of prolonged exposure treatment response in military-related PTSD

Posttraumatic stress disorder (PTSD) is associated with dysregulation of the neuroendocrine system, including cortisol, allopregnanolone, and pregnanolone. Preliminary evidence from animal models suggests that baseline levels of these biomarkers may predict response to PTSD treatment. We report the change in biomarkers over the course of PTSD treatment. Biomarkers were sampled from individuals participating in (1) a randomized controlled trial comparing a web-version of Prolonged Exposure (Web-PE) therapy to in-person Present-Centered Therapy (PCT) and (2) from individuals participating in a nonrandomized effectiveness study testing PE delivered in-person as part of an intensive outpatient PTSD program. We found that higher cortisol reactivity during script-driven imagery was associated with higher baseline PTSD severity and that baseline allopregnanolone, pregnanolone, and cortisol reactivity were associated with PTSD treatment responder status over the course of intensive outpatient treatment. These findings demonstrate that peripherally assessed biomarkers are associated with PTSD severity and likelihood of successful treatment outcome of PE delivered daily over two weeks. These assessments could be used to determine which patients are likely to respond to treatment and which patients require augmentation to increase the likelihood of optimal response to PTSD treatment.

Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study

Background

Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion.

Method

A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury.

Result

127 participants (66%; 95% CI: 59–72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; p ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt; p = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for DSM-5 = 1.3, 95% CI = −27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = −6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = −2.7, 15.6).

Conclusions

Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months.

ClinicalTrials.gov Identifier

NCT02419131

Clinical effectiveness study of a treatment to prepare for trauma-focused evidence-based psychotherapies at a veterans affairs specialty posttraumatic stress disorder clinic

Posttraumatic stress disorder (PTSD) clinics in the Department of Veterans Affairs (VA) often provide psychoeducational or skill-building groups to prepare veterans for trauma-focused PTSD treatments. However, there has been limited evaluation of the effectiveness of this phase-based approach for treatment engagement and symptom reduction. Participants included 575 veterans seeking treatment for PTSD whose treatment outcomes were assessed in a VA outpatient PTSD clinic staffed by mental health professionals and trainees. Participants completed self-report measures of baseline characteristics and psychiatric symptoms as part of routine PTSD clinic treatment. We tested the association of preparatory group treatment with engagement in and treatment response to subsequent trauma-focused psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE), which are designated by VA as evidence-based psychotherapies (EBP). Following participation in preparatory treatments, 94/391 (24%) of veterans engaged in a subsequent trauma-focused EBP (CPT or PE). Relative to patients who had previously completed a preparatory group, patients initiating a trauma-focused EBP without having first attended preparatory PTSD treatment had similar rates of trauma-focused EBP completion and better treatment response, as measured by decreases on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; PCL-5), F(1, 3009) = 10.89, p = .001, and Patient Health Questionnaire 9 measure of depressive symptoms F(1, 3688) = 6.74, p = .010. Overall, veterans reported greater symptom reduction when engaging in trauma-focused EBP directly, without having previously attended a preparatory group. These data support veteran engagement in trauma-focused EBPs for PTSD without first being encouraged to complete psychoeducational or skill-building groups. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Maintenance of treatment gains up to 12-months following a three-week cognitive processing therapy-based intensive PTSD treatment programme for veterans

BACKGROUND

Intensive treatment programmes (ITPs) have shown promise for reducing PTSD and depression symptoms. It is still unknown whether treatment gains are maintained following completion.

OBJECTIVE

This study examined whether veterans were able to maintain treatment gains for up to 12 months after an ITP for PTSD and whether reductions in negative posttrauma cognitions predicted treatment gain maintenance.

METHODS

209 veterans (62.7% male, mean age = 40.86 years) completed a 3-week, CPT-based ITP for PTSD. Participants' PTSD (PCL-5) and depression (PHQ-9) symptoms were assessed at pre-treatment, post-treatment, and at 3-, 6-, and 12-month follow-up timepoints.

RESULTS

Despite small symptom increases from post-treatment to 3-month follow-up, significant and clinically meaningful reductions in PTSD and depression symptoms were reported from intake to 12 months follow-up (averaging >18 points on the PCL-5 and >6 points on the PHQ-9; d = 1.28, and d = 1.18, respectively). Greater reductions in negative posttrauma cognitions during treatment were associated with lower PTSD (p <.001) and depression (p =.005) severity at follow-up. Most veterans who completed the aftercare survey followed treatment recommendations and reported seeing a mental health provider at 3-, 6-, and 12-months post-treatment. Aftercare treatment did not significantly predict whether veterans maintained treatment gains at follow-up.

CONCLUSIONS

Overall maintenance of treatment gains long-term suggests veterans may be able to apply skills acquired during the ITP following treatment. These findings further support the feasibility and effectiveness of intensive, trauma-focused, evidence-based therapy delivery.

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design

BACKGROUND

Comorbidity between Posttraumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD) is high. There is growing motivation among clinicians to offer PTSD treatments - such as Eye Movement Desensitization and Reprocessing (EMDR) - to patients with PTSD and comorbid BPD. However, a large subgroup with comorbid BPD does not sufficiently respond to PTSD treatment and is more likely to be excluded or to dropout from treatment. Dialectical Behaviour Therapy (DBT) for BPD is well established and although there is some evidence that DBT combined with DBT Prolonged Exposure (DBT + DBT PE) is twice as effective in reducing PTSD symptoms than DBT alone, the comparative efficacy of integrated PTSD-DBT and PTSD-only treatment has not been investigated yet. The current study will therefore evaluate the comparative clinical efficacy and cost-effectiveness of EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD. Moreover, it is not clear yet what treatment works best for which individual patient. The current study will therefore evaluate neurobiological predictors and mediators of the individual response to treatment.

METHOD

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of integrated EMDR-DBT (n = 63) and EMDR-only (n = 63) in treatment-seeking adult patients with PTSD and comorbid (sub)clinical BPD. In addition, neurobiological predictors and mediators of treatment outcome, such as hair cortisol, FKBP5 and BDNF protein levels and FKBP5 and BDNF methylation status, are measured through hair and blood samples.

DISCUSSION

This is the first study to compare the clinical efficacy and cost-effectiveness of integrated EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD, while simultaneously identifying individual predictors and mediators of treatment response. Results will reveal which treatment works best for which individual patient, thereby guiding individual treatment choices and personalizing psychiatry.

TRIAL REGISTRATION

Clinical Trials, NCT03833453 . Retrospectively registered, 15 March 2019.

A multi-centre, double-blind, 12-week, randomized, placebo-controlled trial to assess the efficacy of adjunctive N-Acetylcysteine for treatment-resistant PTSD: a study protocol

BACKGROUND

Most patients with Posttraumatic Stress Disorder (PTSD) suffer residual symptoms following first-line treatment. Oxidative stress has been implicated in the pathophysiology of PTSD. N-acetylcysteine (NAC) is a precursor of the brain's primary antioxidant, glutathione, and may diminish oxidative cellular damage. An 8-week pilot study of NAC in veterans with PTSD found that symptoms were significantly reduced in the NAC group compared to placebo. This study aims to confirm these findings with a larger sample in a double-blind, placebo-controlled trial to further explore the efficacy of NAC as an adjunctive therapy in treatment-resistant PTSD.

METHODS

A multicentre, randomised, double-blind, placebo-controlled trial for adult patients who still meet criteria for PTSD following first-line treatment. The intervention comprises either NAC as a fixed dose regime of 2.7 g/day (900 mg three times daily) administered orally for 12 weeks, or placebo. Standard care for PTSD will continue in addition, including other pharmacotherapies. Detailed clinical data will be collected at randomisation and weeks 4, 8, 12, 16, and 64 post-randomisation, with self-report measures completed weekly from baseline to 16 weeks and at 64 weeks post-randomisation. Blood-based biomarkers will be collected at baseline and 12 weeks to assess the mechanism of effect. The primary outcome measure will be change in Clinician-Administered PTSD Scale for DSM-5 at 12 weeks compared with baseline. Secondary outcomes will be change in quality of life, depression, anxiety, substance use and craving, and somatic symptoms. With 126 completed participants (63 per arm), the study is powered at 80% to detect a true difference in the primary outcome measure using a two-tailed analysis with alpha = 0.05, beta = 0.2.

DISCUSSION

This is the first multicentre, double blind, randomised, placebo-controlled trial of adjunctive NAC for treatment-resistant PTSD. NAC has an established safety profile, is readily available and easy to administer, and has a favourable tolerability profile, therefore making it an attractive adjunctive therapy. Inclusion of blood analyses to assess potential target engagement biomarkers of oxidative stress and neuroinflammation may help gauge the biological mechanisms of effect of NAC.

TRIAL REGISTRATION

ACTRN12618001784202, retrospectively registered 31/10/2018, URL: http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376004 .

Trauma nation: Exposure to traumatic events among South African university students

The current study investigated exposure to past trauma among South African students at a historically disadvantaged institution (HDI). The student population at HDI's are typically from low-income communities that were marginalized by apartheid-era policies and few studies have focused on trauma exposure among this population group. Respondents (N=914) completed the Life Events Checklist and a demographic questionnaire. Logistic regression analysis was conducted to identify gender differences in exposure. 97.6% of the sample reported trauma exposure. The most frequently experienced traumatic events were physical assault (69.3%) and transportation accidents (64.7%). While men were almost twice as likely to report exposure to physical assault (77.2% vs. 67%; β=.53; odds ratio [OR]=1.70; p<.01) and assault with a weapon (59.7% vs. 44.3%; β=.62; OR=1.86; p<.01), women were twice as likely to report unwanted or uncomfortable sexual experiences (32.3% vs. 19.4%; β=-.69; OR=0.50; p<.01) and sexual assault (19.3% vs. 13.1%; β=-.69; OR=0.50; p<.01). It is recommended that psycho-education on trauma be included in orientation programmes and mental health screening and early referrals for psychological services be implemented.

Comparing Exposure- and Coping Skills-Based Treatments on Trauma-Related Guilt in Veterans With Co-Occurring Alcohol Use and Posttraumatic Stress Disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur, and this comorbidity (PTSD-SUD) is associated with more severe symptoms and functional impairment than either disorder alone. Growing evidence indicates that trauma-related guilt, typically concerning negative appraisals of one's actions or inaction during a traumatic event, is associated with PTSD, depression, suicidality, and, possibly, substance use. The present study examined whether integrated treatment for PTSD-SUD was effective in reducing trauma-related guilt as measured by the Trauma-Related Guilt Inventory. Data were drawn from a randomized clinical trial comparing the effectiveness of two integrated therapies on treatment outcomes in a sample of U.S. veterans (N = 119) with comorbid PTSD and SUD. Participants were randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE; n = 63) or Seeking Safety (SS; n = 56). The results indicated that global guilt decreased over time for the whole sample. However, there was a significant Treatment × Time interaction, such that participants in the COPE condition reported lower rates of global guilt, d = 0.940, over time compared to those in the SS condition, d = .498. To our knowledge, this was the first study to examine the effects of integrated PTSD-SUD treatment on trauma-related guilt. The findings highlight that exposure-based, trauma-focused treatment for comorbid PTSD-SUD can be more effective in decreasing trauma-related guilt, with potentially longer-lasting effects, than non-exposure-based treatment, adding evidence that patients with PTSD-SUD should be offered such treatment.

Interaction between catechol-O-methyltransferase polymorphism and childhood trauma in suicidal ideation of patients with post-traumatic stress disorder

INTRODUCTION

Suicidal behavior of post-traumatic stress disorder (PTSD) patients is influenced by genetic and environmental factors. The catechol-O-methyltransferase (COMT) gene has been known to be associated with suicidal ideation. The present study aimed to explore the relationship of COMT polymorphism, childhood trauma, and suicidal ideation in patients with PTSD.

METHODS

Fifty patients with PTSD and 62 healthy controls (HCs) were recruited, and COMT variants rs4680 and rs4633 were genotyped through peripheral blood. Psychological assessments such as the childhood trauma questionnaire (CTQ), the scale for suicidal ideation, the clinician-administered PTSD scale for DSM-5, and a PTSD checklist were administered. A regression analysis, the Johnson-Neyman technique, and a two-way analysis of covariance were conducted.

RESULTS

Interaction of COMT polymorphism (rs4680, rs4633) and childhood emotional abuse (subscale of CTQ) predicted suicidal ideation in patients with PTSD. Patients with the rs4680 Val/Val genotype, compared to Met carriers genotype, showed higher suicidal ideation when childhood emotional abuse was high. Patients with the rs4633 CC genotype, compared to T carriers genotype, showed higher suicidal ideation when childhood emotional abuse was high.

CONCLUSION

Our results suggest that vulnerability to suicide could be increased in the Val/Val genotype of COMT rs4680 and the CC genotype of rs4633 in patients with PTSD. Moreover, PTSD group with high childhood emotional abuse demonstrated a significantly higher suicidal ideation than did those with low childhood emotional abuse.

Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment

Although some studies have demonstrated residual symptoms in patients who have participated in posttraumatic stress disorder (PTSD) treatment, no studies to date have assessed residual PTSD symptoms following treatment for comorbid alcohol use disorder (AUD) and PTSD (PTSD/AUD). We examined residual symptoms of PTSD and AUD in 73 veterans with PTSD/AUD who completed a posttreatment assessment after being randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) or Seeking Safety (SS). We used logistic regression to identify differences (a) in residual PTSD and AUD symptoms among participants randomized to COPE versus SS and (b) among those with versus without a posttreatment PTSD/AUD diagnosis within both treatment conditions. Participants randomized to SS were more likely to report persistent avoidance, inability to experience positive emotions, hypervigilance, difficulty concentrating, and difficulty sleeping, ORs = 3.74-6.21. There were no differences between COPE and SS regarding the likelihood of persistent AUD symptoms. Participants without a posttreatment PTSD diagnosis had lower conditional probabilities of most symptoms, although exaggerated startle, OR = 0.71, and irritability/aggression, OR = 0.58, were most likely to persist. Participants without a posttreatment AUD diagnosis had lower conditional probabilities of most symptoms, although withdrawal, OR = 0.21; unsuccessful quit attempts, OR = 0.04; and higher intake, OR = 0.01, were most likely to persist. Findings indicate hyperarousal may warrant additional intervention following PTSD treatment. Residual AUD symptoms may relate to the enduring nature of some AUD symptoms rather than a lack of treatment efficacy.

Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

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.

Sequence matters: Combining Prolonged Exposure and EMDR therapy for PTSD

OBJECTIVE

Investigating the influence of the sequence in which two evidence-based trauma-focused treatments are offered to PTSD-patients.

METHODS

PTSD-patients were treated using an intensive eight-day treatment program, combining Prolonged Exposure (PE) and EMDR therapy. Forty-four patients received a PE session in the morning and an EMDR session in the afternoon, while 62 patients received the reversed sequence (EMDR followed by PE). Outcome measures were PTSD symptom severity and subjective experiences.

RESULTS

Patients who received PE first and EMDR second showed a significantly greater reduction in PTSD symptoms. Patients preferred this sequence and valued the treatment sessions as significantly more helpful compared to patients in the EMDR-first condition.

CONCLUSION

The results of this explorative study are supportive of the notion that PE and EMDR therapy can be successfully combined, and that sequence matters. First applying PE sessions before EMDR sessions resulted in better treatment outcome, and better subjective patient's evaluations in terms of treatment helpfulness and preference.

Trauma-focused treatment outcome for complex PTSD patients: results of an intensive treatment programme

BACKGROUND

Complex PTSD (CPTSD) has been incorporated in the 11th edition of the International Classification of Diseases (ICD-11) as a mental health condition distinct from PTSD.

OBJECTIVE

The objective of the current study is to determine whether individuals classified as having CPTSD can benefit from an intensive trauma-focused treatment, resulting in decreased PTSD and CPTSD symptoms, and loss of diagnoses.

METHOD

Patients diagnosed with PTSD (N = 308) took part in an intensive 8-day treatment programme combining prolonged exposure, EMDR therapy, psycho-education, and physical activity. The treatment was not phase-based in that it did not contain a stabilization phase or skill training prior to therapy. CPTSD diagnosis was assessed by means of the International Trauma Questionnaire (ITQ) and PTSD diagnosis was assessed with both the ITQ and CAPS-5. Treatment response was measured with the CAPS-5, PCL-5, and ITQ.

RESULTS

Symptoms of both PTSD and CPTSD significantly decreased from pre- to post-treatment resulting in a significant loss of CAPS-5 based PTSD (74.0%) and ITQ-based PTSD and CPTSD diagnoses (85.0% and 87.7%, respectively). No adverse events occurred in terms of suicides, suicide attempts, or hospital admissions.

CONCLUSIONS

The results are supportive of the notion that the majority of patients classified as having CPTSD strongly benefit from an intensive trauma-focused treatment for their PTSD.

Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder?

OBJECTIVE

Patients with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are often not offered exposure therapy for PTSD due to concerns that symptoms may worsen. This study examined whether initiating exposure would cause exacerbation of PTSD, alcohol use, depression, or suicidal ideation (SI) among patients with PTSD/AUD participating in exposure therapy for PTSD.

METHOD

Veterans were randomized to either concurrent treatment of PTSD and substance use disorders using prolonged exposure (COPE) or seeking safety, a nonexposure intervention, and were included in this study if they had data to at least Session 5 available (n = 81). They completed measures of PTSD, alcohol use, and depression/SI symptom severity throughout treatment and posttreatment. The reliable exacerbation method examined the number of participants who demonstrated clinically meaningful symptom exacerbation from Sessions 3 to 5 (capturing the prepost window for the start of exposure in COPE). Hierarchical/logistic regressions examined whether treatment condition predicted exacerbation of symptoms. T tests/chi-square analyses examined whether clinical exacerbation led to worse posttreatment outcomes.

RESULTS

Few participants endorsed exacerbation in symptoms of PTSD (15.8%), alcohol use (5.1%), depression (10.2%), or SI (12.8%). No significant treatment condition differences existed. Participants who experienced symptom exacerbation had higher rates of depression posttreatment compared to those who did not experience symptom exacerbation, but there were no differences in PTSD, alcohol use, or SI.

CONCLUSIONS

Exposure therapy did not lead to more clinical exacerbation than nonexposure therapy during the course of treatment, providing support that exposure therapy should not be withheld from patients with PTSD/AUD. This was a secondary analysis. and future studies that are sufficiently powered may demonstrate different results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Pilot Trial of a Combined Cognitive Processing Therapy and Smoking Cessation Treatment

OBJECTIVE/BACKGROUND

Posttraumatic stress disorder (PTSD) and smoking are often comorbid. Combining PTSD and smoking cessation treatments could increase access to each treatment and could provide improved rates of smoking cessation through reductions in PTSD and depressive symptoms.

PARTICIPANTS

Participants were veterans with current PTSD who smoked cigarettes and were willing to initiate treatment for both problems.

METHOD

We conducted a randomized pilot trial (n = 40) to explore feasibility and estimate effect sizes of a treatment combining trauma-focused Cognitive Processing Therapy (CPT) with smoking cessation counseling and pharmacotherapy, relative to the same smoking cessation treatment without CPT.

RESULTS

Rates of bioverified 7-day point prevalence smoking abstinence at the end of treatment or at 6-month follow-up were similar across treatments. Relative to the comparison, the combined CPT and smoking cessation treatment were associated with moderate-to-large effect sizes at end of treatment for reductions in PTSD symptoms, Cohen's d = 0.718, 95% confidence interval (CI) = 0.078-1.358, that decreased by the 6-month follow-up, Cohen's d = 0.306, 95% CI = -0.334 to 0.946; and large reductions in depressive symptoms that were maintained to the 6-month follow-up, Cohen's d = 1.007, 95% CI = 0.367-1.647.

CONCLUSIONS

This pilot trial did not detect a difference in smoking cessation when combining CPT to smoking cessation treatment, relative to smoking cessation treatment without CPT. However, results suggest that combining CPT and smoking cessation treatment was associated with both reductions of psychiatric symptoms along with smoking abstinence rates similar to previous smoking cessation trials in veterans with PTSD.

Non-invasive vagal nerve stimulation decreases brain activity during trauma scripts

Background:

Traumatic stress can have lasting effects on neurobiology and result in psychiatric conditions such as posttraumatic stress disorder (PTSD). We hypothesize that non-invasive cervical vagal nerve stimulation (nVNS) may alleviate trauma symptoms by reducing stress sympathetic reactivity. This study examined how nVNS alters neural responses to personalized traumatic scripts.

Methods:

Nineteen participants who had experienced trauma but did not have the diagnosis of PTSD completed this double-blind sham-controlled study. In three sequential time blocks, personalized traumatic scripts were presented to participants immediately followed by either sham stimulation (n = 8; 0–14 V, 0.2 Hz, pulse width = 5s) or active nVNS (n = 11; 0–30 V, 25 Hz, pulse width = 40 ms). Brain activity during traumatic scripts was assessed using High Resolution Positron Emission Tomography (HR-PET) with radiolabeled water to measure brain blood flow.

Results:

Traumatic scripts resulted in significant activations within the bilateral medial and orbital prefrontal cortex, premotor cortex, anterior cingulate, thalamus, insula, hippocampus, right amygdala, and right putamen. Greater activation was observed during sham stimulation compared to nVNS within the bilateral prefrontal and orbitofrontal cortex, premotor cortex, temporal lobe, parahippocampal gyrus, insula, and left anterior cingulate. During the first exposure to the trauma scripts, greater activations were found in the motor cortices and ventral visual stream whereas prefrontal cortex and anterior cingulate activations were more predominant with later script presentations for those subjects receiving sham stimulation.

Conclusion:

nVNS decreases neural reactivity to an emotional stressor in limbic and other brain areas involved in stress, with changes over repeated exposures suggesting a shift from scene appraisal to cognitively processing the emotional event.

Posttraumatic Stress and Parenting Behaviors: The Mediating Role of Emotion Regulation

PURPOSE

Maternal trauma has been linked with problematic parenting, including both harsh and permissive behaviors. However, little is known about mechanisms accounting for this association. The current study examined the potential impact of posttraumatic stress disorder (PTSD) and emotion regulation on dysfunctional parenting behaviors in a sample of community mothers. We hypothesized a mediation model wherein PTSD would be associated with dysfunctional parenting (i.e., lax and overreactive behaviors) indirectly through deficits in maternal emotion regulation.

METHOD

Seventy-eight community mothers of 18- to 36-month-old children were administered the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and 19 mothers met criteria for PTSD. Mothers also completed self-report measures of difficulties with emotion regulation and maternal laxness and overreactivity in parenting.

RESULTS

Results revealed that emotion dysregulation fully mediated relations between PTSD status and lax (but not overreactive) parenting behaviors. Compared to mothers without PTSD, those with PTSD reported greater lax parenting behaviors indirectly through greater emotion dysregulation.

CONCLUSIONS

Mothers with PTSD may struggle to parent assertively when trauma symptoms interfere with emotion regulation abilities. The current study highlights the need to design interventions focused on helping trauma-exposed mothers manage distress, ultimately aiming to enhance parenting effectiveness and improve child outcomes.

Negative Affect Mediates the Association between Posttraumatic Cognitions and Craving in Veterans with Posttraumatic Stress Disorder and Alcohol Use Disorder

Objective: The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common. Individuals with PTSD/AUD commonly drink to cope with PTSD symptoms, which maintains PTSD/AUD, and may result in increased craving for alcohol. Negative affect is implicated in negative reinforcement models of craving. Further, Emotional Processing Theory posits that posttraumatic cognitions lead to the experience of negative affect, which may result in increased craving in PTSD/AUD. The current study aims to advance the understanding of craving in PTSD/AUD by evaluating if specific posttraumatic cognitions (e.g., cognitions about the self, world, and self-blame) are associated with increased negative affect, and whether higher negative affect is associated with heightened craving. Methods: Three separate simple mediation models were utilized to test if negative affect mediated the relationship between each specific posttraumatic cognition type and craving among 136 treatment-seeking veterans with PTSD/AUD. Results: We found that negative affect mediated the association between all posttraumatic cognition types and craving. Specifically, viewing oneself as being unable to handle PTSD-related distress, viewing the world as very dangerous, and blaming oneself for one's role in a traumatic event were all associated with increased negative affect, which was related to higher craving. Conclusions: Given that posttraumatic cognitions improve via trauma-focused treatment for PTSD, future work should evaluate whether improvements in posttraumatic cognitions via trauma-focused treatment lead to decreased negative affect and craving in PTSD/AUD.

Impulsivity and Cognitive Flexibility as Neuropsychological Markers for Suicidality: A Multi-Modal Investigation Among Military Veterans with Alcohol Use Disorder and PTSD

To examine relations between self-report and behavioral measures of impulsivity and cognitive flexibility with suicidal ideation and self-harm and suicide attempt history. Methods: Eighty-seven military veterans who met DSM-5 diagnostic criteria for alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) were evaluated for current suicidal ideation and self-harm, suicide attempt history, impulsivity, and cognitive flexibility. Results: Higher levels of self-reported impulsivity were associated with greater suicidal ideation and self-harm and lower behavioral inhibition was associated with greater likelihood of endorsing a suicide attempt. Conclusion: Use of multi-modal assessment of impulsivity and cognitive flexibility may aid in suicide screening and intervention among vulnerable and high-risk populations.

Serum Neurosteroid Levels Are Associated With Cortical Thickness in Individuals Diagnosed With Posttraumatic Stress Disorder and History of Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) co-occurring with mild traumatic brain injury (mTBI) is common in veterans. Worse clinical outcome in those with PTSD has been associated with decreased serum neurosteroid levels. Furthermore, decreased cortical thickness has been associated with both PTSD and mTBI. However, it is not known whether decreased neurosteroids are associated with decreased cortical thickness in PTSD co-occurring with mTBI. This study included 141 individuals divided into the following groups: (a) mTBI group (n = 32 [10 female, 22 male] veterans with a history of mTBI); (b) PTSD + mTBI group (n = 41 [6 female, 35 male] veterans with current PTSD with a history of mTBI); and (c) control group (n = 68 [35 female, 33 male] control participants), which were acquired through the Injury and Traumatic Stress (INTRuST) Clinical Consortium. Subjects underwent clinical assessment, magnetic resonance imaging at 3 T, and serum neurosteroid quantifications of allopregnanolone (ALLO) and pregnenolone (PREGN). Group differences in cortical thickness and associations between serum neurosteroid levels and cortical thickness were investigated. Cortical thickness was decreased in the PTSD + mTBI group compared with the other groups. In the PTSD + mTBI group, decreased cortical thickness was also associated with lower serum ALLO (right superior frontal cortex) and lower serum PREGN (left middle temporal and right orbitofrontal cortex). Cortical thickness in the middle temporal and orbitofrontal cortex was associated with PTSD symptom severity. There were no significant associations between neurosteroids and cortical thickness in the mTBI or control groups. Decreased cortical thickness in individuals with PTSD + mTBI is associated with decreased serum neurosteroid levels and greater PTSD symptom severity. Causality is unclear. However, future studies might investigate whether treatment with neurosteroids could counteract stress-induced neural atrophy in PTSD + mTBI by potentially preserving cortical thickness.

A systematic review of validated screening tools for anxiety disorders and PTSD in low to middle income countries

BACKGROUND

Anxiety and post-traumatic stress disorder (PTSD) contribute significantly to disability adjusted life years in low- to middle-income countries (LMICs). Screening has been proposed to improve identification and management of these disorders, but little is known about the validity of screening tools for these disorders. We conducted a systematic review of validated screening tools for detecting anxiety and PTSD in LMICs.

METHODS

MEDLINE, EMBASE, Global Health and PsychINFO were searched (inception-April 22, 2020). Eligible studies (1) screened for anxiety disorders and/or PTSD; (2) reported sensitivity and specificity for a given cut-off value; (3) were conducted in LMICs; and (4) compared screening results to diagnostic classifications based on a reference standard. Screening tool, cut-off, disorder, region, country, and clinical population were extracted for each study, and we assessed study quality. Accuracy results were organized based on screening tool, cut-off, and specific disorder. Accuracy estimates for the same cut-off for the same screening tool and disorder were combined via meta-analysis.

RESULTS

Of 6322 unique citations identified, 58 articles including 77 screening tools were included. There were 46, 19 and 12 validations for anxiety, PTSD, and combined depression and anxiety, respectively. Continentally, Asia had the most validations (35). Regionally, South Asia (11) had the most validations, followed by South Africa (10) and West Asia (9). The Kessler-10 (7) and the Generalized Anxiety Disorder-7 item scale (GAD-7) (6) were the most commonly validated tools for anxiety disorders, while the Harvard Trauma Questionnaire (3) and Posttraumatic Diagnostic Scale (3) were the most commonly validated tools for PTSD. Most studies (29) had the lowest quality rating (unblinded). Due to incomplete reporting, we could meta-analyze results from only two studies, which involved the GAD-7 (cut-off ≥10, pooled sensitivity = 76%, pooled specificity = 64%).

CONCLUSION

Use of brief screening instruments can bring much needed attention and research opportunities to various at-risk LMIC populations. However, many have been validated in inadequately designed studies, precluding any general recommendation for specific tools in LMICs. Locally validated screening tools for anxiety and PTSD need further evaluation in well-designed studies to assess whether they can improve the detection and management of these common disorders.

TRIAL REGISTRATION

PROSPERO registry number CRD42019121794 .

Efficacy and safety of acupuncture in treating post-traumatic stress disorder: A protocol for systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) acts as a complex mental illness in which individuals are prone to long-lasting mental disorders after suffering traumatic events. PTSD is usually accompanied by some comorbidities, such as depressive disorder and sleep disorder, which seriously threaten patients' life and health. Evidences showed that acupuncture could remarkably relieve the symptoms of PTSD patients. The review aims at assessing the safety and effectiveness exhibited by acupuncture for treating PTSD patients.

METHODS AND ANALYSIS

The literature identified by searching 8 English electronic databases and 5 Chinese electronic databases from their inception to April 20, 2020 will be incorporated into the study. Two researchers will independently take charge of the research selection, the data extraction, as well as the assessment on research quality. The primary outcomes will be total PTSD symptoms, measured by different instruments including interviews and self-report measures. Data analysis will be performed via the RevMan 5 software, and Grading of Recommendations Assessment, Development, and Evaluation will help to assess the evidence level. A heterogeneity x test, the Higgins' I test as well as visually inspecting the forest plot will help to investigate the heterogeneity of data. A sensitivity analysis and subgroup analyses will assist in investigating the sources of heterogeneity.

ETHICS AND DISSEMINATION

The review neither assesses the individual information of patients nor impacts their rights, so it is not necessary for it to be approved by ethical institution. The article will be published in a peer-reviewed journal and present at relevant conferences. OSF REGISTRATION NUMBER:: https://osf.io/dc3js.

Psychometric properties of the German version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in clinical routine settings: study design and protocol of a multitrait-multimethod study

INTRODUCTION

The aim of this study is to investigate the diagnostic accuracy, psychometric properties and clinical utility of the German version of the Clinician-Administered Post-Traumatic Stress Disorder (PTSD) Scale for Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (CAPS-5) in routine clinical settings.

METHODS AND ANALYSIS

This study is a non-interventional, multitrait-multimethod design, multicentre study that will be carried out at German civil and military inpatient and outpatient clinics. A total sample size of n=219 participants who have experienced at least one traumatic event according to criteria as defined in the DSM-5 will be recruited. For the investigation of the diagnostic accuracy and clinical utility of the CAPS-5, participants will be categorised into one of three groups, depending on their traumatic experiences and post-traumatic symptomatology: (1) monotraumatisation with PTSD; (2) multiple traumatisation with PTSD and (3) traumatisation without PTSD. Interviews will be conducted face to face by interviewers in routine clinical settings. All participants will also be asked to complete a comprehensive set of questionnaires in order to investigate different facets of construct validity and clinical utility. First, differences between all three groups in CAPS-5 sum and subscale scores will be investigated. Test-retest reliability and inter-rater reliability will be determined. Internal consistency will be calculated using structural equation modeling (SEM) based internal consistency coefficients. Construct validity will be measured with Spearman's rank correlation analyses and multivariate analyses of variance with Holm-Bonferroni corrected post hoc analysis of variances. In order to test diagnostic accuracy, receiver operating characteristics and sensitivity and specificity analyses will be conducted. The model structure of the German CAPS-5 will be analysed using confirmatory factor analyses.

ETHICS AND DISSEMINATION

The study received ethical approval by the Ethics Committees of the Faculty of Psychology at the Ruhr-Universität Bochum (reference numbers: 331 and 358). The results of the study will be presented nationally and internationally at scientific conferences and will be published in scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00015325.

Feasibility of narrative exposure therapy in an outpatient day treatment programme for refugees: improvement in symptoms and global functioning

BACKGROUND

 Refugees are at high risk for developing post-traumatic stress disorder (PTSD). Narrative exposure therapy (NET) is an evidence-based treatment of PTSD, designed for patients exposed to (multiple) traumatic events and recommended for patients with culturally diverse backgrounds. In clinical practice, adherence to the NET-protocol has been challenged because of psychosocial complexities and comorbid disorders. .

OBJECTIVE

The current study investigated the feasibility of NET embedded in an outpatient day treatment programme for refugees and examined reduction in PTSD symptoms and improvement of global functioning as well as correlates of change. .

METHOD

Participants were patients who consecutively entered an outpatient daytreatment programme from 2013-2017. The majority had a history of prior unsuccessful treatment. PTSD was assessed with the Clinically Administered PTSD Scale (CAPS) before and after finishing NET. Global Assessment of Functioning (GAF) was used to examine changes in functioning. Changes in PTSD scores and functioning were analyzed using paired t-tests and reliable change indices. Patients showing significant improvement were compared to those who did not, on patient and treatment characteristics, including sex, age, region of origin, childhood trauma and treatment duration and dosage of NET. .

RESULTS

Of 97 patients, 76 (78.4%) completed NET. Completers had a longer residency and were more likely to have a partner. Significant reductions in PTSD symptoms and improvements in global functioning were observed. Twenty-eight percent showed reliable improvement with large effect sizes. Four patients did no longer meet the criteria for PTSD. No strong moderators for changes were found. Patients who did not improve more often had a history of childhood trauma.

CONCLUSIONS

NET embedded in an outpatient day treatment programme appears to be feasible. In those who improved, a substantial decline in symptoms and improvement of functioning were observed. The findings suggest that a socially supportive living environment enhances acceptability of trauma-focused treatment in refugees.

Identification of risk for posttraumatic stress disorder symptom clusters early after trauma

The current study examined how the injured trauma survivor screen (ITSS), a hospital-administered screener of posttraumatic stress disorder (PTSD) and depression, differentially predicted PTSD symptom cluster severity. Participants from a Level 1 trauma center (n = 220) completed the ITSS while inpatient and PTSD symptoms were assessed one-month post discharge. Perceived life threat and intentionality of injury were key predictors of avoidance, re-experiencing, and hyperarousal symptom clusters. However, negative alterations in mood and cognition cluster seemed best predicted by mood and cognitive risk factors. Therefore, the ITSS provides utility in differentially predicting symptom clusters and treatment planning after traumatic injury.

Processing of Positive Visual Stimuli Before and After Symptoms Provocation in Posttraumatic Stress Disorder - A Functional Magnetic Resonance Imaging Study of Trauma-Affected Male Refugees

Background

Symptoms of anhedonia are often central to posttraumatic stress disorder (PTSD), but it is unclear how anhedonia is affected by processes induced by reliving past traumatic memories.

Methods

Sixty-nine male refugees (PTSD = 38) were interviewed and scanned with functional magnetic resonance imaging while viewing positive, neutral and Scrambled Pictures after being read personalized scripts evoking an emotionally neutral memory and a traumatic memory. We further measured postprovocation state symptoms, physiological measures and PTSD symptoms. We tested whether neural activity associated with positive picture viewing in participants with PTSD was differentially affected by symptom provocation compared to controls.

Results

For the pictures > scrambled contrast (Positive contrast), PTSD participants had significantly less activity than controls in fusiform gyrus, right inferior temporal gyrus and left middle occipital gyrus. The Positive contrast activity in fusiform gyrus scaled negatively with anhedonia symptoms in PTSD participants after controlling for total PTSD severity. Relative to the emotionally Neutral Script, the Trauma Script decreased positive picture viewing activity in posterior cingulate cortex, precuneus and left calcarine gyrus, but there was no difference between PTSD participants and controls.

Conclusions

We found reduced responsiveness of higher visual processing of emotionally positive pictures in PTSD. The significant correlation found between positive picture viewing activity and anhedonia suggests the reduced responsiveness to be due to the severity of anhedonia.

Validation of Abbreviated Four- and Eight-Item Versions of the PTSD Checklist for DSM-5 in a Traumatically Injured Sample

Rates of posttraumatic stress disorder (PTSD) are three times higher in traumatically injured populations than the general population, yet limited brief, valid measures for assessing PTSD symptom severity exist. The PTSD Checklist for DSM-5 (PCL-5) is a valid, efficient measure of symptom severity, but its completion is time consuming. Subsequently, abbreviated four- and eight-item versions were developed using the Mini-International Neuropsychiatric Interview-7 PTSD module and validated in Veteran samples. This study aimed to validate these abbreviated versions using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD diagnosis, in a traumatically injured civilian population. Participants were 251 traumatically injured adults (M_age = 42.52 years; 69.3% male; 50.2% Caucasian) recruited from a Level 1 trauma center inpatient unit; 32.3% and 17.9% of participants experienced a motor vehicle crash or gunshot wound, respectively. The CAPS-5 and PCL-5 were administered approximately 6.5 months postinjury. We examined whether compared to the full PCL-5, the abbreviated versions would adequately differentiate between participants with and without a CAPS-5 PTSD diagnosis. The abbreviated versions were highly correlated with the total scale and showed good-to-excellent internal consistency. The diagnostic utility of the abbreviated measures was comparable to that of the total scale regarding sensitivity, suggesting they may be useful as abbreviated screening tools; however, the total scale functioned better regarding specificity. The abbreviated versions of the PCL-5 may be useful screening instruments in the long-term care of traumatic injury survivors and may be more likely to be implemented across routine clinical and research contexts.

The Role of Impulsivity in the Association Between Posttraumatic Stress Disorder Symptom Severity and Substance Use in Male Military Veterans

High rates of posttraumatic stress disorder (PTSD) and comorbid substance use disorder (SUD) are prevalent in military veterans. However, few studies have investigated impulsivity as a risk factor for engaging in substance use behavior for individuals who are experiencing PTSD symptoms. The present study evaluated impulsivity as a moderator of the association between PTSD symptoms and alcohol/drug use. Male military veterans (N = 106) completed self-report measures of alcohol use behavior, drug use behavior, and impulsivity. Participants also completed a structured diagnostic interview to assess for PTSD. The findings indicated that impulsivity moderated the relation between total PTSD symptoms and alcohol use, B = 0.01, p = .035, along with associations between alcohol use and two of the symptom clusters: PTSD reexperiencing symptoms, B = 0.01, p = .016; and PTSD avoidance/numbing symptoms, B = 0.01, p = .029. Veterans with high levels of impulsivity were at significantly higher risk of engaging in alcohol use than veterans with low-to-average levels. Impulsivity did not potentiate the relation between PTSD hyperarousal symptoms and alcohol use nor did it moderate the association between any of the PTSD variables and drug use. Impulsivity appears to serve as a significant risk factor for alcohol use, but not drug use, for male veterans experiencing PTSD symptoms. Future studies are necessary to replicate and expand upon these findings, particularly to facilitate the development of integrated evidence-based treatments that target both alcohol use and impulsivity within the context of PTSD.

Non-invasive brain stimulation for posttraumatic stress disorder: a systematic review and meta-analysis

Approximately 7-9% of people develop posttraumatic stress disorder in their lifetime, but standard pharmacological treatment or psychotherapy shows a considerable individual variation in their effectiveness. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) hold promise for the treatment of posttraumatic stress disorder. The objective of this meta-analysis was to summarize the existing evidence on the therapeutic effects of these brain stimulation treatments on posttraumatic core symptoms. We systematically retrieved articles published between 1st January 2000 and 1st January 2020 comparing the effects of active with sham stimulation or no intervention in posttraumatic patients from eight databases. Random-effects model was used for meta-analysis. Meta-regression and subgroup meta-analysis was performed to investigate the influence of stimulation dose and different stimulation protocols, respectively. 20 studies were included in this review, where of 11 randomized controlled trials were subjected to quantitative analysis. Active stimulation demonstrated significant reductions of core posttraumatic symptoms with a large effect size (Hedge's g = -0.975). Subgroup analysis showed that both excitatory and inhibitory rTMS of the right dorsolateral prefrontal cortex led to symptom reductions with a large (Hedges' g = -1.161, 95% CI, -1.823 to -0.499; p = 0.015) and medium effect size (Hedges' g = -0.680, 95% CI: -0.139 to -0.322; p ≤ 0.001) respectively. Results further indicated significant durability of symptom-reducing effects of treatments during a two to four weeks period post stimulation (Hedges' g = -0.909, 95% CI: -1.611 to -0.207; p = 0.011). rTMS of the right dorsolateral prefrontal cortex appears to have a positive effect in reducing core symptoms in patients with posttraumatic stress disorder.

Sacrificing reward to avoid threat: Characterizing PTSD in the context of a trauma-related approach-avoidance conflict task

Posttraumatic stress disorder (PTSD) is characterized by heightened avoidance, cognitive inflexibility, and impaired reward processing. Maladaptive behavior in PTSD may reflect an imbalance between approach and avoidance, but no research has investigated approach-avoidance conflict (AAC) in PTSD. The current study investigated approach-avoidance behavior in PTSD using a trauma-related AAC (trAAC) task in two independent samples. In Study 1, 43 women with a current diagnosis of PTSD and 18 healthy comparison subjects were recruited from the community. In Study 2, 53 women with trauma exposure and a range of PTSD symptoms were recruited from a correctional institution. Trials were separated into two phases: conflict (the option most likely to win points was most likely to show a trauma-related image) and congruent (the option most likely to win points was least likely to show a trauma-related image). In Study 1, reward obtainment varied with the task manipulation (i.e., fewer points earned during conflict compared to congruent Phase) in PTSD but not healthy subjects. These results indicate that when avoidance is advantageous (congruent phase), individuals with PTSD show increased task performance, whereas when avoidance is maladaptive (conflict phase), individuals with PTSD show increased sacrifice of reward. In Study 2, higher PTSD symptoms predicted decreased reward earning during the conflict phase, again indicating a sacrifice of reward when avoidance is maladaptive. Across both studies, PTSD associated with increased AAC and sacrifice of reward in the presence of trauma-related stimuli. These studies shed light on AAC in PTSD and could inform more targeted therapy approaches. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms

BACKGROUND

The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day.

METHODS

Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models.

RESULTS

Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%.

CONCLUSIONS

The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12616000956404.

Abnormal sympathetic neural recruitment patterns and hemodynamic responses to cold pressor test in women with posttraumatic stress disorder

The novel findings of the present study are that women with posttraumatic stress disorder (PTSD) have an augmented pressor response to the sympathoexcitatory stimulus of a cold pressor test (CPT) compared with healthy control subjects. Although integrated muscle sympathetic nerve activity burst responses were not significantly different between groups, total sympathetic action potential discharge in response to the CPT was markedly elevated in women with PTSD exhibiting increased firing of low-threshold axons as well as the recruitment of latent subpopulations of larger-sized axons that are otherwise silent at baseline. Aberrant autonomic circulatory control in response to sympathoexcitatory stimulus may in part explain the propensity toward developing hypertension and cardiovascular disease in this population.

Estradiol Modulates Neural and Behavioral Arousal in Women With Posttraumatic Stress Disorder During a Fear Learning and Extinction Task

BACKGROUND

Fear responding in posttraumatic stress disorder (PTSD) is sexually heterogeneous and varies with hormonal fluctuations throughout the menstrual cycle. While research suggests that estrogen levels affect PTSD symptoms among women, there is a dearth of research on modulatory effects of estrogen on fear responding among women with PTSD, and neural outcome measures are lacking.

METHODS

A sample of 42 women with PTSD underwent 2 consecutive alternating blocks of fear conditioning and extinction training, during which a CS+ conditioned stimulus, but not a CS-, predicted the occurrence of an electric shock in an acquisition context but not in an extinction context. Assayed saliva determined estradiol levels. Skin conductance response and whole-brain voxelwise activity during functional magnetic resonance imaging were outcome variables in linear mixed-effects models, with estradiol level, PTSD severity, and task contrasts as predictors.

RESULTS

Skin conductance response exhibited a significant estradiol × PTSD severity × habituation interaction (t = 3.180, p = .002), such that PTSD severity was correlated with increased arousal responding between training blocks among women with lower estradiol (t = -3.985, p < .001) but not higher estradiol (t = 0.550, p = .583). Voxelwise activity also demonstrated an identical three-way interaction within dorsomedial prefrontal cortex and anterior insula clusters. The skin conductance response and imaging interactions between PTSD severity and estradiol were not specific to conditioned stimulus type or context.

CONCLUSIONS

Estradiol moderated the relationship between PTSD severity and arousal response habituation between fear conditioning and extinction training sessions, such that high estradiol protected against the negative impact of severe PTSD symptoms on fear habituation. These findings suggest that estrogen enhances habituation among women with severe PTSD, potentially influencing the efficacy of extinction-based therapies.

Objective Characterization of Activity, Sleep, and Circadian Rhythm Patterns Using a Wrist-Worn Actigraphy Sensor: Insights Into Posttraumatic Stress Disorder

BACKGROUND

Wearables have been gaining increasing momentum and have enormous potential to provide insights into daily life behaviors and longitudinal health monitoring. However, to date, there is still a lack of principled algorithmic framework to facilitate the analysis of actigraphy and objectively characterize day-by-day data patterns, particularly in cohorts with sleep problems.

OBJECTIVE

This study aimed to propose a principled algorithmic framework for the assessment of activity, sleep, and circadian rhythm patterns in people with posttraumatic stress disorder (PTSD), a mental disorder with long-lasting distressing symptoms such as intrusive memories, avoidance behaviors, and sleep disturbance. In clinical practice, these symptoms are typically assessed using retrospective self-reports that are prone to recall bias. The aim of this study was to develop objective measures from patients' everyday lives, which could potentially considerably enhance the understanding of symptoms, behaviors, and treatment effects.

METHODS

Using a wrist-worn sensor, we recorded actigraphy, light, and temperature data over 7 consecutive days from three groups: 42 people diagnosed with PTSD, 43 traumatized controls, and 30 nontraumatized controls. The participants also completed a daily sleep diary over 7 days and the standardized Pittsburgh Sleep Quality Index questionnaire. We developed a novel approach to automatically determine sleep onset and offset, which can also capture awakenings that are crucial for assessing sleep quality. Moreover, we introduced a new intuitive methodology facilitating actigraphy exploration and characterize day-by-day data across 49 activity, sleep, and circadian rhythm patterns.

RESULTS

We demonstrate that the new sleep detection algorithm closely matches the sleep onset and offset against the participants' sleep diaries consistently outperforming an existing open-access widely used approach. Participants with PTSD exhibited considerably more fragmented sleep patterns (as indicated by greater nocturnal activity, including awakenings) and greater intraday variability compared with traumatized and nontraumatized control groups, showing statistically significant (P<.05) and strong associations (|R|>0.3).

CONCLUSIONS

This study lays the foundation for objective assessment of activity, sleep, and circadian rhythm patterns using passively collected data from a wrist-worn sensor, facilitating large community studies to monitor longitudinally healthy and pathological cohorts under free-living conditions. These findings may be useful in clinical PTSD assessment and could inform therapy and monitoring of treatment effects.

Sequelae of Blast Events in Iraq and Afghanistan War Veterans using the Salisbury Blast Interview: A CENC Study

Objective: To comprehensively characterize blast exposure across the lifespan and relationship to TBI.Participants: Post-deployment veterans and service members (N = 287).Design: Prospective cohort recruitment.Main Measures: Salisbury Blast Interview (SBI).Results: 94.4% of participants reported at least one blast event, 75% reported a pressure gradient during a blast event. Participants reported an average of 337.7 (SD = 984.0) blast events (range 0-4857), 64.8% occurring during combat. Across participants, 19.7% reported experiencing a traumatic brain injury (TBI) during a blast event. Subjective ratings of blast characteristics (wind, debris, ground shaking, pressure, temperature, sound) were significantly higher when TBI was experienced and significantly lower when behind cover. Pressure had the strongest association with resulting TBI (AUC = 0.751). Pressure rating of 3 had the best sensitivity (.54)/specificity (.87) with TBI. Logistic regression demonstrated pressure, temperature and distance were the best predictors of TBI, and pressure was the best predictor of primary blast TBI.Conclusion: Results demonstrate the ubiquitous nature of blast events and provide insight into blast characteristics most associated with resulting TBI (pressure, temperature, distance). The SBI provides comprehensive characterization of blast events across the lifespan including the environment, protective factors, blast characteristics and estimates of distance and munition.