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French LM, Brickell TA, Lippa SM, Rogers AA, Cristaudo KE, Walker TT, Higgins M, Bailie JM, Kennedy J, Hungerford L, Lange RT. Clinical relevance of subthreshold PTSD versus full criteria PTSD following traumatic brain injury in U.S. service members and veterans. J Affect Disord 2024; 358:408-415. [PMID: 38705525 DOI: 10.1016/j.jad.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/22/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND The purpose of this cross-sectional study was to examine the influence of subthreshold posttraumatic stress disorder (PTSD) and full PTSD on quality of life following mild traumatic brain injury (mTBI). METHODS Participants were 734 service members and veterans (SMV) classified into two injury groups: uncomplicated mild TBI (MTBI; n = 596) and injured controls (IC, n = 139). Participants completed a battery of neurobehavioral measures, 12-or-more months post-injury, that included the PTSD Checklist Civilian version, Neurobehavioral Symptom Inventory, and select scales from the TBI-QOL and MPAI. The MTBI group was divided into three PTSD subgroups: No-PTSD (n = 266), Subthreshold PTSD (n = 139), and Full-PTSD (n = 190). RESULTS There was a linear relationship between PTSD severity and neurobehavioral functioning/quality of life in the MTBI sample. As PTSD severity increased, significantly worse scores were found on 11 of the 12 measures (i.e. , MTBI Full-PTSD > Sub-PTSD > No-PTSD). When considering the number of clinically elevated scores, a linear relationship between PTSD severity and neurobehavioral functioning/quality of life was again observed in the MTBI sample (e.g., 3-or-more elevated scores: Full-PTSD = 92.1 %, Sub-PTSD = 61.9 %, No-PTSD = 19.9 %). LIMITATIONS Limitations included the use of a self-report measure to determine diagnostic status that may under/overcount or mischaracterize individuals. CONCLUSION PTSD symptoms, whether at the level of diagnosable PTSD, or falling short of that because of the intensity or characterization of symptoms, have a significant negative impact on one's quality of life following MTBI. Clinicians' treatment targets should focus on the symptoms that are most troubling for an individual and the individual's perception of quality of life, regardless of the diagnosis itself.
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Affiliation(s)
- Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; Contractor, General Dynamics Information Technology, Silver Spring, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sara M Lippa
- Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alicia A Rogers
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; CICONIX, Annapolis, MD, USA
| | - Kendal E Cristaudo
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; CICONIX, Annapolis, MD, USA
| | - Thomas T Walker
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; CICONIX, Annapolis, MD, USA
| | - Molly Higgins
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; University of Colorado, Colorado Springs, CO, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Contractor, General Dynamics Information Technology, Silver Spring, MD, USA; 33 Area Branch Clinic Camp Pendleton, CA, USA
| | - Jan Kennedy
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Contractor, General Dynamics Information Technology, Silver Spring, MD, USA; Brooke Army Medical Center, Joint Base San Antonio, TX, USA
| | - Lars Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Contractor, General Dynamics Information Technology, Silver Spring, MD, USA; Naval Medical Center San Diego, CA, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA; Walter Reed National Military Medical Center, Bethesda, MD, USA; National Intrepid Center of Excellence, Bethesda, MD, USA; Contractor, General Dynamics Information Technology, Silver Spring, MD, USA; University of British Columbia, Vancouver, BC, Canada; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Wadham B, Andrewartha L, Lawn S, Onur I, Edney LC. A Scoping Review of Interventions Targeting the Mental Health of Australian Veterans. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:796. [PMID: 38929042 PMCID: PMC11204173 DOI: 10.3390/ijerph21060796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/16/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
Serving in the military can have significant impacts on the mental health of veterans and their families. Military personnel can be exposed to a range of physical stressors, psychological trauma, risky lifestyle factors, a regimented military culture, and inadequate support when transitioning out of service. This article reviews research on interventions designed to improve the mental health of Australian military veterans in order to synthesise current knowledge and identify gaps in the literature. Our scoping review followed PRISMA recommendations and comprised peer-reviewed literature published since 2000. The review demonstrates a dominance of psychologically driven research paradigms and interventions and a neglect of the importance of social factors in shaping veteran mental health. There is a wide range of interventions available; however, the literature is narrow and limited. We found little evidence that the lived experience of veterans had been harnessed in program design or delivery. We argue the need for a holistic approach that moves beyond psychological and biological understandings of health and wellbeing to incorporate social and cultural determinants. Future research could adopt a stronger multidisciplinary approach, increased socio-cultural understanding, and greater consideration of the lived experience of veterans and their families.
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Affiliation(s)
- Ben Wadham
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA 5000, Australia;
| | - Lisa Andrewartha
- School of Education, La Trobe University, Melbourne, VIC 3000, Australia;
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5000, Australia
| | - Ilke Onur
- College of Business, Government and Law, Flinders University, Adelaide, SA 5000, Australia;
| | - Laura Catherine Edney
- Flinders University Institute of Mental Health and Wellbeing, Flinders University, Adelaide, SA 5000, Australia;
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Lu W, Mueser KT, Yanos PT, Jia Y, Siriram A, Bullock D, Wang K, Silverstein SM, Gottlieb J, Rogers K, Aftab PG, Rosenberg SD. Factor structure of posttraumatic stress disorder (PTSD) in persons with serious mental illness. J Ment Health 2024; 33:366-375. [PMID: 38804258 PMCID: PMC11373362 DOI: 10.1080/09638237.2024.2332809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Trauma and posttraumatic stress disorder (PTSD) are common among individuals with serious mental illness (SMI; e.g., schizophrenia, schizoaffective disorder, bipolar disorder, treatment refractory major depressive disorder), with resultant functional impairment. Previous studies have not evaluated the factor structure of the PTSD Checklist (PCL) among persons with SMI. AIMS This study evaluated the factor structure of the PCL in two large SMI samples from public mental health treatment sectors screened for PTSD using the PCL. METHODS Four different models of PTSD were tested using confirmatory factor analyses. RESULTS Results indicated that the DSM-5 4-factor model (intrusion, avoidance, numbing, and hyperarousal) had the best fit. Further, the DSM-5 4-factor model demonstrated measurement invariance. CONCLUSIONS Results supported the suitability of the DSM-5 4-factor model of PTSD among people with SMI.
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Affiliation(s)
- Weili Lu
- Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, New Brunswick, New Jersey, USA
| | - Kim T Mueser
- Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts, USA
| | - Philip T Yanos
- Psychology Department, City University of New York, New York, New York, USA
| | - Yuane Jia
- Department of Interdisciplinary Studies, Rutgers University, New Brunswick, New Jersey, USA
| | - Amanda Siriram
- Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, New Brunswick, New Jersey, USA
| | - Deanna Bullock
- Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, New Brunswick, New Jersey, USA
| | - Ke Wang
- Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, New Brunswick, New Jersey, USA
| | - Steven M Silverstein
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Jennifer Gottlieb
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Krista Rogers
- Psychology Department, City University of New York, New York, New York, USA
| | - Pouya G Aftab
- Department of Psychiatric Rehabilitation and Counseling Professions, Rutgers University, New Brunswick, New Jersey, USA
| | - Stanley D Rosenberg
- Department of Psychiatry, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
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Campos B, Vinder V, Passos RBF, Coutinho ESF, Vieira NCP, Leal KB, Mendlowicz MV, Figueira I, Luz MP, Marques-Portela C, Vilete LMP, Berger W. To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis. J Psychopharmacol 2022; 36:449-459. [PMID: 35437077 DOI: 10.1177/02698811221080464] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD). METHODS We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170). RESULTS The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I2 = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79). CONCLUSION The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.
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Affiliation(s)
- Bruna Campos
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Vitor Vinder
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | - Evandro Silva Freire Coutinho
- National School of Public Health, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil.,Institute of Social Medicine, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Norma Cavalcanti Pontilhão Vieira
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Katherine Branco Leal
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Mauro Vitor Mendlowicz
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.,Department of Psychiatry and Mental Health, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Ivan Figueira
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Mariana Pires Luz
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Carla Marques-Portela
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Liliane Maria Pereira Vilete
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - William Berger
- Department of Psychiatry and Legal Medicine, Institute of Psychiatry (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Stevens ES, Bourassa KJ, Norr AM, Reger GM. Posttraumatic Stress Disorder Symptom Cluster Structure in Prolonged Exposure Therapy and Virtual Reality Exposure. J Trauma Stress 2021; 34:287-297. [PMID: 33128806 PMCID: PMC8035142 DOI: 10.1002/jts.22602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/01/2020] [Accepted: 07/15/2020] [Indexed: 11/12/2022]
Abstract
The emotional processing theory of posttraumatic stress disorder (PTSD) posits that avoidance is central to PTSD development and maintenance. Prolonged exposure (PE) therapy, which clinically focuses on avoidance reduction, has strong empirical support as a PTSD treatment. Virtual reality exposure (VRE) has been utilized to accelerate avoidance reduction by increasing multisensory engagement. Although some exposure therapy studies have found associations between avoidance and PTSD symptoms, others have indicated that reexperiencing or hyperarousal symptoms drive symptom trajectories. Using a cross-lagged panel design, the present secondary data analysis examined temporal associations between clinician-assessed PTSD symptom clusters during treatment with PE, VRE, or a waitlist control condition. There were no significant differences between PE and VRE regarding symptom clusters at any assessment. Compared to the waitlist condition, individuals who received VRE or PE exhibited earlier reductions in avoidance/numbing symptoms, β = -.19, 95% CI [-.33, -.05], followed by reductions in hyperarousal symptoms, β = -.21, 95% CI [-.33, -.09]. Hyperarousal symptoms predicted changes in later avoidance/numbing and reexperiencing outcomes across treatment: pretreatment to midtreatment, β = .29, 95% CI [.17, .42]; midtreatment to posttreatment, β = .23, 95% CI [.07, .39]. Reexperiencing symptoms predicted changes in hyperarousal outcomes earlier in treatment, β = .22, 95% CI [.02, .37], whereas avoidance/numbing symptoms predicted changes in hyperarousal outcomes later in treatment, β = .18, 95% CI [.04, .32]. These findings support the efficacy of exposure therapy in addressing avoidance/numbing symptoms and highlight the potential importance of hyperarousal symptoms in relation to other symptom clusters.
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Affiliation(s)
- Elizabeth S. Stevens
- VA Puget Sound Healthcare System, Seattle, Washington, USA,Department of Psychology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kyle J. Bourassa
- VA Puget Sound Healthcare System, Seattle, Washington, USA,Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, USA
| | - Aaron M. Norr
- VA Northwest Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Seattle, Washington, USA,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Greg M. Reger
- VA Puget Sound Healthcare System, Seattle, Washington, USA,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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Bar-Haim Y, Stein MB, Bryant RA, Bliese PD, Yehuda AB, Kringelbach ML, Jain S, Dan O, Lazarov A, Wald I, Levi O, Neria Y, Pine DS. Intrusive Traumatic Reexperiencing: Pathognomonic of the Psychological Response to Traumatic Stress. Am J Psychiatry 2021; 178:119-122. [PMID: 33517759 PMCID: PMC9074400 DOI: 10.1176/appi.ajp.2020.19121231] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yair Bar-Haim
- School of Psychological Sciences, Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Murray B. Stein
- Department of Psychiatry, University of California, San Diego, La Jolla,Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - Richard A. Bryant
- School of Psychology, University of New South Wales, Kensington, Australia
| | - Paul D. Bliese
- Department of Management, Darla Moore School of Business, University of South Carolina, Columbia
| | - Ariel Ben Yehuda
- Department of Mental Health, Medical Corps, Israel Defense Forces, Ramat Gan, Israel
| | | | - Sonia Jain
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - Orrie Dan
- Department of Psychology, Max Stern Yezreel Valley College, Emek Yezreel, Israel
| | - Amit Lazarov
- School of Psychological Sciences, Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Wald
- School of Psychological Sciences, Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Ofir Levi
- School of Social Work, Tel Aviv University, Tel Aviv, Israel
| | - Yuval Neria
- Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York
| | - Daniel S. Pine
- Section on Development and Affective Neuroscience, NIMH, Bethesda, Md
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Relationship between change in in-vivo exposure distress and PTSD symptoms during exposure therapy for active duty soldiers. J Psychiatr Res 2019; 116:133-137. [PMID: 31233896 DOI: 10.1016/j.jpsychires.2019.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/23/2019] [Accepted: 06/17/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The current study sought to examine the relationship between changes in distress for items on in-vivo exposure hierarchies and posttraumatic stress disorder (PTSD) symptom change over the course of exposure therapy. METHODS Active duty army soldiers (N = 108) were recruited from a military base in the U.S. and were enrolled in a randomized clinical trial comparing Prolonged Exposure (PE), Virtual Reality Exposure (VRE), and a wait-list control for the treatment of PTSD stemming from deployments to Iraq or Afghanistan. PTSD diagnosis followed DSM-IV-TR criteria. Outcome measures were assessed via self-report and clinician interview. The relationships between in-vivo exposure distress, imaginal exposure distress, and PTSD symptoms, were examined in a factor of curves model for participants in the treatment conditions. RESULTS Analyses revealed that, when controlling for one another, changes in in-vivo exposure distress were significantly associated with changes in PTSD symptoms (β = 0.75, 95% CI [0.60, 0.90]), while changes in imaginal exposure distress were not (β = 0.03, 95% CI [-0.27, 0.33]). The model also revealed that after accounting for the shared variation in trajectories of change, symptom clusters did not have unique variation, meaning that symptom clusters did not change independently. CONCLUSION Results suggest the possibility that in-vivo exposures are more closely tied to changes in overall PTSD symptoms than imaginal exposures during exposure therapy. Furture research should incorporate more frequent measurement of in-vivo exposure distress to better elucidate these relations over the course of treatment.
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