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de Souza Junior S, Monteiro Fabricio Gama C, Menezes Gonçalves R, Lorrany Campos Guerra T, Volchan E, Erthal FS, Mocaiber I, de Paula Antunes David I, Catarina Lima Portugal L, Mendlowicz MV, Berger W, de Oliveira L, Garcia Pereira M. Tonic immobility triggered by COVID-19-related trauma is associated with long-term PTSD symptoms. J Anxiety Disord 2024; 105:102894. [PMID: 38959538 DOI: 10.1016/j.janxdis.2024.102894] [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: 12/14/2023] [Revised: 05/01/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024]
Abstract
During the COVID-19 pandemic healthcare workers were repeatedly exposed to traumatic experiences. Facing life-threatening events and repeated exposure to traumatic duty-related situations may cause posttraumatic stress disorder (PTSD). While tonic immobility has been considered a key vulnerability factor for PTSD, little is known about this relationship in the long term. In this study, we aimed to determine whether peritraumatic tonic immobility triggered by COVID-19-related trauma predicts PTSD symptom severity six to twelve months later. We conducted an online longitudinal survey using the PTSD Checklist for the DSM-5 (PCL-5) and the Tonic Immobility Scale to assess PTSD symptoms and the tonic immobility response, respectively. Multivariate regression models revealed a significant association between tonic immobility and PTSD symptoms. Each one-unit increase in the tonic immobility score was associated with a 1.5 % increase in the average PTSD symptom score six to twelve months after the traumatic event that triggered the tonic immobility. Furthermore, participants who showed significant or extreme levels of tonic immobility were 3.5 times or 7.3 times more likely to have a probable PTSD diagnosis, respectively. Hence, peritraumatic tonic immobility seems to have a lasting deleterious effect on mental health. Psychological treatment for health care professionals is urgent, and psychoeducation about the involuntary, biological nature of tonic immobility is essential to reduce suffering.
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Affiliation(s)
- Sérgio de Souza Junior
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil
| | - Camila Monteiro Fabricio Gama
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil
| | - Raquel Menezes Gonçalves
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil
| | - Thayssa Lorrany Campos Guerra
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil
| | - Eliane Volchan
- Laboratório de Neurobiologia, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho 373, Cidade Universitária, Rio de Janeiro, RJ 21941-902, Brazil; Instituto de Psiquiatria da UFRJ, Departamento de Psiquiatria e Saúde Mental, Universidade Federal do Rio de Janeiro, Avenida Venceslau Brás, 71, Fundos, Botafogo, Rio de Janeiro, RJ 22290140, Brazil
| | - Fátima Smith Erthal
- Laboratório de Neurobiologia, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho 373, Cidade Universitária, Rio de Janeiro, RJ 21941-902, Brazil; Instituto de Psiquiatria da UFRJ, Departamento de Psiquiatria e Saúde Mental, Universidade Federal do Rio de Janeiro, Avenida Venceslau Brás, 71, Fundos, Botafogo, Rio de Janeiro, RJ 22290140, Brazil
| | - Izabela Mocaiber
- Laboratório de Psicofisiologia Cognitiva, Departamento de Ciências da Natureza, Instituto de Humanidades e Saúde, Universidade Federal Fluminense, Rua Recife s/nº, Jardim Bela Vista, Rio das Ostras, RJ 28890-000, Brazil; Programa de pós-graduação em Medicina (Neurologia/Neurociências), Universidade Federal Fluminense, Niterói, Brasil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil
| | - Isabel de Paula Antunes David
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil
| | - Liana Catarina Lima Portugal
- Departamento de Ciências Fisiológicas, Instituto de Biologia Roberto Alcantara Gomes, Centro Biomédico, Universidade do Estado do Rio de Janeiro, Avenida Professor Manuel de Abreu 444, 5º Andar, Vila Isabel, Rio de Janeiro, RJ 20550-170, Brazil
| | - Mauro Vitor Mendlowicz
- Instituto de Psiquiatria da UFRJ, Departamento de Psiquiatria e Saúde Mental, Universidade Federal do Rio de Janeiro, Avenida Venceslau Brás, 71, Fundos, Botafogo, Rio de Janeiro, RJ 22290140, Brazil
| | - William Berger
- Instituto de Psiquiatria da UFRJ, Departamento de Psiquiatria e Saúde Mental, Universidade Federal do Rio de Janeiro, Avenida Venceslau Brás, 71, Fundos, Botafogo, Rio de Janeiro, RJ 22290140, Brazil
| | - Leticia de Oliveira
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil.
| | - Mirtes Garcia Pereira
- Departamento de Fisiologia e Farmacologia, Instituto Biomédico, Universidade Federal Fluminense, Rua Hernani Pires de Mello, 101, São Domingos, Niterói, RJ 24210-130, Brazil; Programa de pós-graduação em Medicina (Neurologia/Neurociências), Universidade Federal Fluminense, Niterói, Brasil; Programa de Pós-graduação em Ciências Biomédicas (Fisiologia e Farmacologia), Universidade Federal Fluminense, Niterói, RJ Brazil.
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Van Voorhees EE, Dillon KH, Crombach A, Beaver T, Kelton K, Wortmann JH, Visn-Mid-Atlantic Mirecc Workgroup, Nieuwsma J. Enjoying the violence of war: Association with posttraumatic symptomatology in U.S. combat veterans. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2024; 16:618-625. [PMID: 37384480 PMCID: PMC10755059 DOI: 10.1037/tra0001530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Engaging in war-related violence can have a devastating impact on military personnel, with research suggesting that injuring or killing others can contribute to posttraumatic stress disorder (PTSD), depression, and moral injury. However, there is also evidence that perpetrating violence in war can become pleasurable to a substantial number of combatants and that developing this "appetitive" form of aggression can diminish PTSD severity. Secondary analyses were conducted on data from a study of moral injury in U.S., Iraq, and Afghanistan combat veterans, to examine the impact of recognizing that one enjoyed war-related violence on outcomes of PTSD, depression, and trauma-related guilt. METHOD Three multiple regression models evaluated the impact of endorsing the item, "I came to realize during the war that I enjoyed violence" on PTSD, depression, and trauma-related guilt, after controlling for age, gender, and combat exposure. RESULTS Results indicated that enjoying violence was positively associated with PTSD, β (SE) = 15.86 (3.02), p < .001, depression, β (SE) = 5.41 (0.98), p < .001, and guilt, β (SE) = 0.20 (0.08), p < .05. Enjoying violence moderated the relationship between combat exposure and PTSD symptoms, β (SE) = -0.28 (0.15), p < .05, such that there was a decrease in the strength of the relationship between combat exposure and PTSD in the presence of endorsing having enjoyed violence. CONCLUSIONS Implications for understanding the impact of combat experiences on postdeployment adjustment, and for applying this understanding to effectively treating posttraumatic symptomatology, are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | - Jennifer H Wortmann
- Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC)
| | | | - Jason Nieuwsma
- Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC)
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McCann JP, Tipsword JM, Brake CA, Badour CL. Trauma-Related Shame and Guilt as Prospective Predictors of Daily Mental Contamination and PTSD Symptoms in Survivors of Sexual Trauma. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:11117-11137. [PMID: 37386852 PMCID: PMC10602615 DOI: 10.1177/08862605231179721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Mental contamination (MC), the experience of dirtiness in the absence of a physical contaminant, has established links with posttraumatic stress disorder (PTSD). Shame and guilt have well-documented relationships with symptoms of PTSD and may play a role in the development and maintenance of MC. The present study examined whether trauma-related shame and guilt prospectively predicted daily MC and symptoms of PTSD among 41 women with a history of sexual trauma. Women completed baseline and twice-daily assessments of MC and symptoms of PTSD over a 2-week period and baseline measures of trauma-related shame and guilt. Two sets of hierarchical mixed linear regression models examined individual and combined fixed effects of baseline trauma-related guilt (guilt cognitions and global guilt) and shame in predicting daily trauma-related MC and symptoms of PTSD. Trauma-related shame positively predicted both daily MC and PTSD. This association remained robust even when accounting for the experience of trauma-related guilt. Neither trauma-related guilt cognitions nor global guilt predicted daily MC or PTSD. While other studies have addressed shame related to sexual assault, this is the first study to demonstrate a positive prospective relationship between shame and trauma-related MC. Findings regarding PTSD and shame are consistent with a growing literature. Further research is needed to better understand the temporal relationships between trauma-related shame, MC, and symptoms of PTSD, including how these variables interact and change over the course of PTSD treatment. A better understanding of the factors influencing the development and maintenance of MC can inform efforts to more easily target and improve MC, and subsequently PTSD.
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Affiliation(s)
| | | | - C. Alex Brake
- Department of Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University
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Meque AGM, Hussain N, Sidorov G, Gelbukh A. Machine learning-based guilt detection in text. Sci Rep 2023; 13:11441. [PMID: 37454207 PMCID: PMC10349868 DOI: 10.1038/s41598-023-38171-0] [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: 02/23/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
We introduce a novel Natural Language Processing (NLP) task called guilt detection, which focuses on detecting guilt in text. We identify guilt as a complex and vital emotion that has not been previously studied in NLP, and we aim to provide a more fine-grained analysis of it. To address the lack of publicly available corpora for guilt detection, we created VIC, a dataset containing 4622 texts from three existing emotion detection datasets that we binarized into guilt and no-guilt classes. We experimented with traditional machine learning methods using bag-of-words and term frequency-inverse document frequency features, achieving a 72% f1 score with the highest-performing model. Our study provides a first step towards understanding guilt in text and opens the door for future research in this area.
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Affiliation(s)
- Abdul Gafar Manuel Meque
- Instituto Politécnico Nacional (IPN), Centro de Investigación en Computación (CIC), Mexico City, Mexico
- Faculdade de Economia e Gestao, Catholic University of Mozambique, Beira, 2100, Mozambique
| | - Nisar Hussain
- Instituto Politécnico Nacional (IPN), Centro de Investigación en Computación (CIC), Mexico City, Mexico
| | - Grigori Sidorov
- Instituto Politécnico Nacional (IPN), Centro de Investigación en Computación (CIC), Mexico City, Mexico.
| | - Alexander Gelbukh
- Instituto Politécnico Nacional (IPN), Centro de Investigación en Computación (CIC), Mexico City, Mexico
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Szeto EH, Ammendola E, Starkey A, Hay J, McClung JG, Bryan CJ. Differences in Guilt, Shame, Self-Anger, and Suicide Cognitions Based on Recent Suicide Ideation and Lifetime Suicide Attempt History. J Nerv Ment Dis 2023; 211:226-232. [PMID: 36166283 DOI: 10.1097/nmd.0000000000001592] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Suicide risk factors such as hopelessness and psychiatric disorders can predict suicide ideation (SI) but cannot distinguish between those with SI and those who attempt suicide (SA). The fluid vulnerability theory of suicide posits that a person's activation of the suicidal mode is predicated on one's predisposition, triggers, and baseline/acute risks. This study compared guilt, shame, self-anger, and suicidal beliefs based on recent SI and lifetime SA. In a total of 2222 primary care patients in this cross-sectional, observational study reported no recent SI or lifetime SA (SI-SA-), 161 reported recent SI only (SI-SA+), 145 reported lifetime SA only (SI+SA-), and 56 reported both recent SI and lifetime SA (SI+SA+). Kruskal-Wallis test showed that the four risk factors were the highest for SI+SA+, followed by SI+SA-, then SI-SA+, and lastly SI-SA-. The study shows that risk factors may be worse in those with recent SI than those with SA history.
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Affiliation(s)
- Edwin H Szeto
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Houle SA, Inhaber J, Jetly R, Ashbaugh AR. Negative cognition in the context of suicidality after exposure to military-related potentially morally injurious events. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
LAY SUMMARY Moral injury (MI) refers to the psycho-spiritual consequences of events that deeply transgress a person’s core moral beliefs and values. Such events are reportedly common in the military context, and strong associations have been demonstrated between exposure to potentially morally injurious events (PMIEs) and suicidality. This study explored differences in negative cognitions between treatment-seeking Canadian Armed Forces members and Veterans with and without current suicidal thoughts and behaviours (STBs), all of whom reported current distress in response to a PMIE. Those exhibiting STBs reported stronger negative beliefs about the self. Scores for event-related guilt cognitions and self-blame were similar across individuals with and without STBs. Individuals reporting STBs also displayed higher depression and symptoms of posttraumatic stress disorder. The results suggest that severity of mental health symptoms and negative self-evaluations may be most pertinent in their association with suicidality in the MI context. Results remain preliminary, however, and additional research is needed to properly examine how event and self-related evaluations affect suicidality after PMIEs.
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Affiliation(s)
| | - Joseph Inhaber
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Rakesh Jetly
- The Royal’s Institute of Mental Health Research, Ottawa, Ontario, Canada
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Kelley ML, Strowger M, Chentsova VO, Bravo AJ, Gaylord SA, Burgin EE, Vinci C, Ayers KL, Agha E. Mindfulness to Manage Moral Injury: Rationale and development of a live online 7-week group intervention for veterans with moral injury. Contemp Clin Trials Commun 2022; 30:101011. [PMID: 36340697 PMCID: PMC9626875 DOI: 10.1016/j.conctc.2022.101011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 10/01/2022] [Indexed: 11/14/2022] Open
Abstract
Background Military service puts service members at risk for moral injury. Moral injury is an array of symptoms (e.g., guilt, shame, anger) that develop from events that violate or transgress one's moral code. Objective We describe adaption of in-person mindfulness training program, Mindfulness to Manage Chronic Pain (MMCP), to address symptoms of moral injury to be delivered live via the web. We discuss how we will assess benchmarks (i.e., recruitment, credibility and acceptability, completion rates, and adherence) of the Mindfulness to Manage Moral Injury (MMMI) program. Methods Aim 1: To develop and then adapt the MMCP program based on feedback from experts and veterans who took part in Study 1. Aim 2: To develop an equally intensive facilitator-led online Educational Support (ES) program to serve as a comparison intervention and conduct a run-through of each program with 20 veterans (10 MMMI; 10 ES). Aim 3: To conduct a small-scale randomized controlled trial (N = 42 veterans; 21 MMMI; 21 ES) in which we will collect pre-post-test and weekly benchmark data for both refined intervention arms. Results Study 1 and 2 are completed. Data collection for Study 3 will be completed in 2022. Conclusion MMMI is designed to provide a live facilitated mindfulness program to address symptoms of moral injury. If Study 3 demonstrates good benchmarks, with additional large-scale testing, MMMI may be a promising treatment that can reach veterans who may not seek traditional VAMC care and/or who prefer a web-based program.
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Affiliation(s)
- Michelle L. Kelley
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
- Corresponding author. Department of Psychology, Old Dominion University, 250 Mills Godwin Building, Norfolk, VA, 23529, USA.
| | - Megan Strowger
- Old Dominion University, Old Dominion University, Norfolk, VA, USA
| | | | - Adrian J. Bravo
- Department of Psychological Sciences, William & Mary, Williamsburg, VA, USA
| | - Susan A. Gaylord
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth E. Burgin
- School Psychology and Counselor Education, William & Mary, Williamsburg, VA, USA
| | - Christine Vinci
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
| | - Kenneth L. Ayers
- Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
| | - Erum Agha
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Allard CB, Norman SB, Straus E, Kim HM, Stein MB, Simon NM, Rauch SAM. Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression. J Behav Ther Exp Psychiatry 2021; 73:101666. [PMID: 34147766 DOI: 10.1016/j.jbtep.2021.101666] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 04/27/2021] [Accepted: 05/28/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear. METHODS Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed. RESULTS The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function. LIMITATIONS Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt. CONCLUSIONS PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.
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Affiliation(s)
- Carolyn B Allard
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; California School of Professional Psychology, Alliant International University, Daley Hall, 10455 Pomerado Rd, San Diego, CA, 92131, USA.
| | - Sonya B Norman
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; National Center for PTSD, VA Medical Center, 215 North Main st, White River Junction, VT, 05009, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA; VA Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, MC116B, San Diego, CA, 92161, USA.
| | - Elizabeth Straus
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - H Myra Kim
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109, USA.
| | - Murray B Stein
- VA San Diego Healthcare System, 3350 Villa La Jolla Drive, San Diego, CA, 92161, USA; University of California, San Diego, School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - Naomi M Simon
- Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA, 02114, USA; New York University Grossman School of Medicine, Department of Psychiatry, One Park Avenue 8th Floor, New York, NY, 10016, USA.
| | - Sheila A M Rauch
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Emory University School of Medicine, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
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9
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Rugo-Cook KF, Kerig PK, Crowell SE, Bryan CJ. Fluid vulnerability theory as a framework for understanding the association between posttraumatic stress disorder and suicide: A narrative review. J Trauma Stress 2021; 34:1080-1098. [PMID: 34881461 DOI: 10.1002/jts.22782] [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: 03/18/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
Suicide is a persistent issue in the United States and across the globe. A large body of published research shows that posttraumatic stress disorder (PTSD) increases the risk of suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (e.g., psychology, nursing) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were to (a) provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the association between PTSD and suicide and (b) organize that knowledge according to a specified theoretical framework. The framework guiding this review is "fluid vulnerability theory," a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of the findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.
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Affiliation(s)
- Kelsi F Rugo-Cook
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Patricia K Kerig
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Sheila E Crowell
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
| | - Craig J Bryan
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, New York, USA
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10
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Guo H, Zhong S, Yue Y, Gou N, Sun Q, Liang X, Wang F, Lu J, Li Q, Zhou J, Wang X. Self-Harm History, Anxiety-Depression, Severity of Disease, and Insight Are Significantly Associated With Suicide Risk in Forensic Psychiatric Inpatients of China. Front Psychiatry 2021; 12:706416. [PMID: 34630175 PMCID: PMC8497710 DOI: 10.3389/fpsyt.2021.706416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Forensic psychiatric patients have higher suicide risk than the general population. This study aimed to evaluate the extent of suicide risk and to explore the associated factors in forensic psychiatric inpatients in China. Methods: We conducted a cross-sectional study from 1st November, 2018 to 30th January, 2019 in the Forensic Psychiatric Hospital of Hunan Province, China. Patient's information on socio-demographic, clinical, and criminological characteristics was collected. The suicidality subscale of the MINI-International Neuropsychiatric Interview (M.I.N.I.), the Brief Psychiatric Rating Scale (BPRS), and the Severity of Illness of Clinical Global Impressions Scale (CGI-SI) were used to measure present suicide risks, psychiatric symptoms, and the severity of the patient's disease, respectively. Binary logistic regression models were used to examine factors associated with suicide risk. Results: Twenty-one percent (84/408) of the forensic psychiatric inpatients reported suicide risk. Logistic regression analysis suggested that self-harm history (OR:3.47, 95% confidence interval CI: 1.45-8.33), symptoms of anxiety-depression (OR:1.15, 95% CI:1.04-1.27), and more severe mental disorder (OR:1.42, 95% CI:1.08-1.87) were associated with elevated suicide risk, while insight disorder (OR:0.81, 95% CI:0.65-0.99) was related to decreasing suicide risk. Conclusion: The study supplied useful clinical information to recognize high suicide risk in forensic psychiatric inpatients and may aid the development of valuable strategies for preventing and reducing suicide events.
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Affiliation(s)
- Huijuan Guo
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shaoling Zhong
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yuchen Yue
- Department of Psychiatry at the Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Ningzhi Gou
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qiaoling Sun
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaoxi Liang
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Fanglan Wang
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Juntao Lu
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qiguang Li
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiansong Zhou
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaoping Wang
- National Clinical Research Center for Mental Disorders, and Department of Psychiatry, The Second Xiangya Hospital of Central South University, Changsha, China
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11
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A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events. COGNITIVE BEHAVIOUR THERAPIST 2021. [DOI: 10.1017/s1754470x21000192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving.
Key learning aims
(1)
To understand why feelings of guilt may arise following experiences of trauma or adversity.
(2)
To be able to assess and formulate feelings of guilt.
(3)
To be able to choose an appropriate cognitive technique, based on the reason for the feeling of guilt/responsibility, and work through this with a client.
(4)
To be able to use imagery techniques to support cognitive interventions with feelings of guilt.
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12
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Cunningham KC, Aunon FM, Patel TA, Mann AJ, DeBeer BB, Meyer EC, Morissette SB, Silvia PJ, Gratz KL, Calhoun PS, Beckham JC, Kimbrel NA. Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders. J Affect Disord 2021; 287:276-281. [PMID: 33799048 PMCID: PMC9004586 DOI: 10.1016/j.jad.2021.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans. METHODS Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts. RESULTS BPD, Χ2=11.1, p<0.001, and NSSID, Χ2=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001. LIMITATIONS Causality cannot be determined from cross-sectional analyses. CONCLUSION These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.
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Affiliation(s)
| | | | - Tapan A. Patel
- Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Adam J. Mann
- Durham Veterans Affairs Health Care System, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bryann B. DeBeer
- VA Rocky Mountain Mental Illness, Research, Education, and Clinical Center, Aurora, CO,Department of Physical Medicine and Rehabilitation, Anschutz Medical Campus, University of Colorado
| | - Eric C. Meyer
- Department of Rehabilitation Science and Technology, University of Pittsburgh
| | - Sandra B. Morissette
- VISN 17 Center of Excellence for Research on Returning War Veterans at Central Texas Veterans Health Care System, Waco, TX, USA,Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Paul J. Silvia
- Department of Psychology, University of North Carolina at Greensboro, NC, USA
| | - Kim L. Gratz
- Department of Psychology, University of Toledo, OH, USA
| | - Patrick S. Calhoun
- Durham Veterans Affairs Health Care System, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA,VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Jean C. Beckham
- Durham Veterans Affairs Health Care System, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
| | - Nathan A. Kimbrel
- Durham Veterans Affairs Health Care System, Durham, NC, USA,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA,VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA,Corresponding author at: Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), Durham Veterans Affairs Health Care System, 3022 Croasdaile Drive, Durham, NC, 27705. (N.A. Kimbrel)
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13
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Kealy D, Treeby MS, Rice SM. Shame, guilt, and suicidal thoughts: The interaction matters. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 60:414-423. [PMID: 33836103 DOI: 10.1111/bjc.12291] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/01/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study examined associations between generalized shame and guilt, and suicidal ideation. METHODS Individuals attending outpatient mental health services (N = 100) completed study measures at a single time point. Correlation and regression analyses examined associations between recent suicidal ideation and generalized shame and guilt, both concurrently and interacting, controlling for depressive symptoms and history of previous suicide attempt. RESULTS When examined concurrently, guilt - but not shame - remained significantly associated with suicidal ideation, after accounting for effects of depressive symptoms and past suicide attempt. A significant shame × guilt interaction revealed the association between guilt and suicidal ideation intensified with higher shame. CONCLUSIONS Findings emphasize consideration of generalized shame and guilt - and their interaction - when working with patients exhibiting suicidal thoughts. PRACTITIONER POINTS Shame and guilt are self-conscious emotions that, when generalized and excessive, may confer risk for suicidal ideation Generalized guilt may be uniquely linked with suicidal ideation, yet this association may also amplified by shame Both shame and guilt - and their interaction - are important to consider when working with patients exhibiting suicidal thoughts.
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Affiliation(s)
- David Kealy
- Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matt S Treeby
- School of Psychology and Public Health, LaTrobe University, Bundoora, Victoria, Australia
| | - Simon M Rice
- Orygen, Parkville, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia
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14
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Fontanesi L, Marchetti D, Limoncin E, Rossi R, Nimbi FM, Mollaioli D, Sansone A, Colonnello E, Simonelli C, Di Lorenzo G, Jannini EA, Ciocca G. Hypersexuality and Trauma: a mediation and moderation model from psychopathology to problematic sexual behavior. J Affect Disord 2021; 281:631-637. [PMID: 33229025 DOI: 10.1016/j.jad.2020.11.100] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION . Hypersexuality is a clinical condition regarding the psychopathology of sexual behavior. In this study, we aimed to investigate the role of trauma, through the post-traumatic stress-disorder (PTSD), depression, shame and guilt on the hypersexual behavior. METHODS . Through an online platform, a convenience sample of 1025 subjects was recruited (females: n=731; 71.3%; males: 294; 28.7%; age: 29.62±10.90). Recruited subjects compiled a psychometric protocol composed by the Hypersexual Behavior Inventory (HBI) to assess hypersexuality, the International Trauma Questionnaire (ITQ) for PTSD, the Patient Health Questionnaire (PHQ-9) to evaluate depression and the State Shame and Guilt Scale (SSGS) for shame and guilt. Then a mediation/moderation model was performed for the data analysis. RESULTS . There was a statistically significant direct effect of post-traumatic symptoms (ITQTotal) on hypersexual behavior (HBTotal). Furthermore, indirect effects were also statistically significant, providing support to the hypothesis that depression and guilt would be serial mediators of trauma-hypersexual behavior relations. The paths through depression and guilt have been found to be the most significant with moderate and high indirect effects on hypersexuality. Moreover, male gender, as covariate variable, is a relevant risk factor for hypersexual behavior. CONCLUSION . We found the relationship between hypersexuality and trauma describing a possible etiological pathway mainly involving depression, shame and guilt. Hypersexuality can be considered as a reactive form of a major affective psychopathology representing a tip of the iceberg hiding the real issues of a suffering personality. Clinicians and researchers should therefore consider hypersexual behavior in the light of a symptomatic manifestation of a major psychopathology involving the affective aspects of personality.
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Affiliation(s)
- Lilybeth Fontanesi
- Department of Psychological, Health and Territorial Sciences, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Daniela Marchetti
- Department of Psychological, Health and Territorial Sciences, University G. D'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Erika Limoncin
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Rodolfo Rossi
- Chair of Psychiatry Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Filippo M Nimbi
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Daniele Mollaioli
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Sansone
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Elena Colonnello
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Chiara Simonelli
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Emmanuele A Jannini
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giacomo Ciocca
- Chair of Endocrinology & Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy.
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15
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Capone C, Tripp JC, Trim RS, Davis BC, Haller M, Norman SB. Comparing Exposure- and Coping Skills-Based Treatments on Trauma-Related Guilt in Veterans With Co-Occurring Alcohol Use and Posttraumatic Stress Disorders. J Trauma Stress 2020; 33:603-609. [PMID: 32521096 DOI: 10.1002/jts.22538] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/30/2019] [Accepted: 01/17/2020] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Christy Capone
- Providence VA Medical Center, Providence, Rhode Island, USA.,Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jessica C Tripp
- VA San Diego Healthcare System, San Diego, California, USA.,School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Ryan S Trim
- VA San Diego Healthcare System, San Diego, California, USA.,School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Brittany C Davis
- James A Haley Veterans Hospital, Tampa, Florida, USA.,Department of Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, Florida, USA
| | - Moira Haller
- VA San Diego Healthcare System, San Diego, California, USA.,School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, California, USA.,School of Medicine, University of California, San Diego, La Jolla, California, USA.,National Center for PTSD, White River Junction, Vermont, USA.,Center of Excellence for Stress and Mental Health, San Diego, California, USA
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16
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Hagenaars MA, Hagenaars JAP. Tonic immobility predicts poorer recovery from posttraumatic stress disorder. J Affect Disord 2020; 264:365-369. [PMID: 32056773 DOI: 10.1016/j.jad.2019.11.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 06/07/2019] [Accepted: 11/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tonic immobility (TI; a state of motor arrest during threat) and has been found to be associated with the development of psychopathology. It also hindered recovery from posttraumatic stress disorder (PTSD) after pharmacological treatment. The present study investigated the role of TI in recovery from PTSD in a large representative community sample with mixed traumas outside an exclusive treatment context. METHODS Participants with PTSD from the panel for Longitudinal Internet Studies for the Social Sciences (LISS) completed measures for trauma, PTSD symptoms, and peritraumatic responses (fear, dissociation, and TI) in two subsequent years. Traumatized participants with PTSD were selected for the analyses (N = 262). RESULTS TI was a relevant predictor for increased PTSD symptoms in year 2 after controlling for peritraumatic fear, peritraumatic dissociation, and PTSD symptoms in year 1, especially in abuse victims. Peritraumatic fear and dissociation no longer predicted PTSD in year 2 after entering TI in the model. CONCLUSIONS Our results indicate that TI may indeed hinder recovery from PTSD. TI may thus be a relevant factor to take into account after trauma and in treatment. The effects of TI may be especially negative for abuse victims.
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Affiliation(s)
- Muriel A Hagenaars
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands.
| | - Jacques A P Hagenaars
- Department of Methodology and Statistics, Tilburg University, Tilburg, the Netherlands
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17
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Hoopsick RA, Homish DL, Bartone PT, Homish GG. Developing a Measure to Assess Emotions Associated with Never Being Deployed. Mil Med 2019; 183:e509-e517. [PMID: 29547934 DOI: 10.1093/milmed/usy005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/06/2017] [Accepted: 01/05/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Much research has focused on stress related to deployments; however, a substantial proportion of soldiers never deploy. In a study of 1.3 million veterans, suicide risk was higher among veterans who had never deployed. Thus, not being deployed may have an impact on soldiers' well-being; however, no measures exist to assess emotions regarding non-deployment. We aimed to develop and test an original measure of non-deployment emotions. METHODS We examined the Non-Deployment Emotions (NDE) questionnaire, a novel four-item measure of guilt, unit value, unit camaraderie, and unit connectedness in a sample of never-deployed male and female US Army Reserve/National Guard (USAR/NG) soldiers (N = 174). Data are from Operation: SAFETY (Soldiers and Families Excelling Through the Years), an ongoing survey-based study examining the health of USAR/NG soldiers and their partners. The protocol was approved by the Institutional Review Board at the State University of New York at Buffalo. The relationship between each of the items was examined by calculating correlation and alpha coefficients. Latent class analyses tested for the existence of distinct levels of negative emotions related to non-deployment. Negative binomial regression models examined the cross-sectional associations between NDE summary score and each of the following outcomes, separately: anger, anxiety, depression, and post-traumatic stress. FINDINGS More than half of never-deployed USAR/NG soldiers expressed negative emotions for having not been deployed. "Guilt," "value," "camaraderie," and "connectedness" were each positively correlated with each other (p < 0.001) and the internal consistency reliability was high (male soldier α = 0.90, female soldier α = 0.93). Latent class analyses revealed a superior three-class model with well-delineated class membership (entropy = 0.93): "Class 1" (low NDE; 47.6%), "Class 2" (moderate NDE; 33.8%), and "Class 3" (high NDE; 18.6%). Regression models demonstrated that greater non-deployment emotions were independently associated with more severe anger (RR = 1.02, 95% CI: 1.01, 1.03, p < 0.001), anxiety (RR = 1.06, 95% CI: 1.01, 1.11, p < 0.05), depression (RR = 1.06, 95% CI: 1.01, 1.11, p < 0.05), and PTSD (RR = 1.10, 95% CI: 1.04, 1.16, p < 0.01). DISCUSSION Findings demonstrate that negative emotions regarding non-deployment are prevalent among never-deployed USAR/NG soldiers and that these emotions are related to a mental health. The NDE provides a measure of "guilt," "value," "camaraderie," and "connectedness" specific to non-deployed soldiers and is able to well discriminate between soldiers that have low, moderately, and highly negative non-deployment emotions. These findings suggest that all military personnel, regardless of deployment status, could be at risk for negative outcomes. As with any survey-based study, there is a potential for response bias; however, given the range of responses collected with the NDE, social desirability is unlikely. Further work is needed to confirm our findings in other components of the military and to examine soldiers in the rear detachment.
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Affiliation(s)
- Rachel A Hoopsick
- Department of Community Health and Health Behavior, State University of New York at Buffalo, 3435 Main Street, Buffalo, NY
| | - D Lynn Homish
- Department of Community Health and Health Behavior, State University of New York at Buffalo, 3435 Main Street, Buffalo, NY
| | - Paul T Bartone
- Center for Technology & National Security Policy, Institute for National Strategic Studies, National Defense University, 300 5th Avenue SW, Building 62, Fort Lesley J. McNair, Washington, DC
| | - Gregory G Homish
- Department of Community Health and Health Behavior, State University of New York at Buffalo, 3435 Main Street, Buffalo, NY
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18
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Koenig HG, Youssef NA, Pearce M. Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review. Front Psychiatry 2019; 10:443. [PMID: 31316405 PMCID: PMC6611155 DOI: 10.3389/fpsyt.2019.00443] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Moral injury (MI) involves distress over having transgressed or violated core moral boundaries, accompanied by feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. MI is often found in Veterans and Active Duty Military personnel with posttraumatic stress disorder (PTSD). MI is widespread among those with PTSD symptoms, adversely affects mental health, and may increase risk of suicide; however, MI is often ignored and neglected by mental health professionals who focus their attention on PTSD only. Methods: A review of the literature between 1980 and 2018 conducted in 2018 is presented here to identify scales used to assess MI. Databases used in this review were PsychInfo, PubMed (Medline), and Google Scholar. Search terms were "moral injury," "measuring," "screening," "Veterans," and "Active Duty Military." Inclusion criteria were quantitative measurement of MI and health outcomes, Veteran or Active Duty Military status, and peer-review publication. Excluded were literature reviews, dissertations, book chapters, case reports, and qualitative studies. Results: Of the 730 studies identified, most did not meet eligibility criteria, leaving 118 full text articles that were reviewed, of which 42 did not meet eligibility criteria. Of the remaining 76 studies, 34 were duplicates leaving 42 studies, most published in 2013 or later. Of 22 studies that assessed MI, five used scales assessing multiple dimensions, and 17 assessed only one or two aspects (e.g., guilt, shame, or forgiveness). The remaining 20 studies used one of the scales reported in the first 22. Of the five scales assessing multiple dimensions of MI, two assess both morally injurious events and symptoms and the remaining three assess symptoms only. All studies were cross-sectional, except three that tested interventions. Conclusions: MI in the military setting is widespread and associated with PTSD symptom severity, anxiety, depression, and risk of suicide in current or former military personnel. Numerous measures exist to assess various dimensions of MI, including five multidimensional scales, although future research is needed to identify cutoff scores and clinically significant change scores. Three multidimensional measures assess MI symptoms alone (not events) and may be useful for determining if treatments directed at MI may both reduce symptoms and impact other mental health outcomes including PTSD.
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Affiliation(s)
- Harold G Koenig
- Duke University Medical Center, Durham, NC, United States.,King Abdulaziz University, Jeddah, Saudi Arabia.,Ningxia Medical University, Yinchuan, China
| | - Nagy A Youssef
- Medical College of Georgia, Augusta University, Charlie Norwood VA Medical Center, Augusta, GA, United States
| | - Michelle Pearce
- Department of Family and Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
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19
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Dillon KH, Cunningham KC, Neal JM, Wilson SM, Dedert EA, Elbogen EB, Calhoun PS, Beckham JC, Kimbrel NA. Examination of the indirect effects of combat exposure on suicidal behavior in veterans. J Affect Disord 2018; 235:407-413. [PMID: 29677605 PMCID: PMC8954689 DOI: 10.1016/j.jad.2018.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/06/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Researchers have theorized that increased rates of suicide in the military are associated with combat exposure; however, this hypothesis has received inconsistent support in the literature, potentially because combat exposure may be indirectly related to suicide risk through its influence on posttraumatic stress disorder (PTSD) and depressive symptoms. The current study tested the hypothesis that combat exposure has a significant indirect effect on suicidal behavior among Iraq/Afghanistan-era veterans through its effects on PTSD-depressive symptomatology. METHODS Iraq/Afghanistan-era veterans (N = 3,238) participated in a cross-sectional, multi-site study of post-deployment mental health consisting of clinical interviews and self-report questionnaires. Structural equation modeling (SEM) was used to examine direct and indirect relationships between three latent variables: combat exposure, PTSD-depression, and suicidal behavior (past attempts and current ideation, intent, and preparation). RESULTS A partial mediation model was the best-fitting model for the data. Combat exposure was significantly associated with PTSD-depression (β = 0.50, p < .001), which was in turn associated with suicidal behavior (β = 0.62, p < .001). As expected, the indirect effect between combat exposure and suicidal behavior was statistically significant, β = 0.31, p < .001. LIMITATIONS Data were cross-sectional, and suicidal behavior was measured via self-report. CONCLUSIONS Results indicated that combat exposure was indirectly related to suicidal behavior via PTSD-depressive symptomatology. Findings lend support for a higher-order combined PTSD-depression latent factor and suggest that Iraq/Afghanistan-era veterans with high levels of PTSD-depressive symptoms are at increased risk for suicidal behavior.
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Affiliation(s)
- Kirsten H. Dillon
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Katherine C. Cunningham
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Julia M. Neal
- Duke University Medical Center, Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sarah M. Wilson
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,VA Center for Health Services Research in Primary Care, Durham, NC, USA
| | - Eric A. Dedert
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Eric B. Elbogen
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Patrick S. Calhoun
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,VA Center for Health Services Research in Primary Care, Durham, NC, USA
| | - Jean C. Beckham
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | - Nathan A. Kimbrel
- Duke University Medical Center, Durham, NC, USA,VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center; Durham, NC, USA,Durham Veterans Affairs Medical Center, Durham, NC, USA,Correspondence concerning this article should be sent to: Dr. Nathan A. Kimbrel, VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, 3022 Croasdaile Drive, Durham, NC, 27705,
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