Problems in families of male Vietnam veterans with posttraumatic stress disorder

Trauma, adversity, and biological aging: behavioral mechanisms relevant to treatment and theory

Although stress and adversity are largely universal experiences, people exposed to greater hardship are at increased risk for negative health consequences. Recent studies identify accelerated biological aging as a mechanism that could explain how trauma and adversity gives rise to poor health, and advances in this area of study coincide with technological innovations in the measurement of biological aging, particularly epigenetic profiles consistent with accelerated aging derived from DNA methylation. In this review, we provide an overview of the current literature examining how adversity might accelerate biological aging, with a specific focus on social and health behaviors. The most extensive evidence in this area suggests that health-compromising behaviors, particularly smoking, may partially explain the association between adversity and accelerated aging. Although there is relatively less published support for the role of social behaviors, emerging evidence points to the importance of social connection as a mechanism for future study. Our review highlights the need to determine the extent to which the associations from adversity to accelerated aging are consistent with causal processes. As we consider these questions, the review emphasizes methodological approaches from the causal inference literature that can help deepen our understanding of how stress and trauma might result in poor health. The use of these methodologies will help provide evidence as to which behavioral interventions might slow aging and improve health, particularly among populations that more often experience adversity and trauma.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Long-Term Consequences of War Captivity in Military Veterans

Numerous studies on the health and functioning of veterans and former prisoners of war have shown that the experience of war captivity is one of the most difficult human experiences. Captivity is often characterized by extremely difficult and inhumane conditions, as well as exposure to various forms of both psychological and physical abuse. Such traumatic experiences can lead to serious psychological consequences that can last for years, even decades after release from captivity. The aim of this paper is to present a brief overview of research that points to the specifics of wartime captivity and the long-term psychological consequences in veterans of former camp detainees, as well as the consequences suffered by their families and factors that, apart from the intensity of the trauma, contribute to the emergence and persistence of psychological disorders. From the presented research, it can be concluded that former prisoners of the camp represent an extremely vulnerable group of the social community and require long-term appropriate treatment, while the needs of veterans' families should not be neglected, with the necessity of including spouses and children in psychological and psychosocial treatments.

Experiences and perceptions of family members of emergency first responders with post-traumatic stress disorder: a qualitative systematic review

OBJECTIVE

The objective of this review was to examine the perceptions and experiences of family members of emergency first responders (EFRs) with post-traumatic stress disorder (PTSD).

INTRODUCTION

Research indicates that rates of PTSD in EFRs are approximately double civilian rates; however, little is known about the resultant effects on their family members. This review identifies the qualitative literature and data examining the perceptions and experiences of families with a current or former EFR family member with diagnosed or undiagnosed PTSD.

INCLUSION CRITERIA

This review included all relevant articles, books, reports, and doctoral theses in English, globally, with no time limits, examining the experiences of family members of current or former EFRs family with diagnosed or undiagnosed PTSD. All possible familial configurations and family members were considered, including nuclear, separated, and blended families, of an EFR. There were no age restrictions on EFRs or their family members, or limitations on recency of service. EFRs included police, ambulance/paramedics, firefighters, and rescue personnel.

METHODS

The databases searched included MEDLINE (PubMed), PsycINFO (Ovid), Embase, CINAHL (EBSCOhost), and Scopus. Hand-searching of relevant journals was conducted across Australian Paramedic , Australasian Journal of Paramedicine , British Paramedic Journal , International Paramedic Practice , Irish Journal of Paramedicine , Journal of Paramedic Practice , Prehospital and Disaster Medicine , and Prehospital Emergency Care . Sources of unpublished studies and gray literature, such as dissertations, were searched via PTSDpubs (ProQuest) and OpenGrey (DANS EASY Data Archive). The search was updated in October 2021. Titles, abstracts, and full texts were screened by 2 independent reviewers against the inclusion criteria, and any conflicting views were resolved by discussion. Results were critically appraised for methodological quality. Post-data extraction results were synthesized and evaluated for credibility and dependability in accordance with the a priori protocol.

RESULTS

The search yielded 1264 records and 48 were deemed eligible for full-text review. Seven studies were critically appraised, and 5 studies were agreed upon for inclusion in the synthesis. From these 5 studies, 53 findings were extracted with associated illustrations and synthesized into 9 categories. Following meta-aggregation, 4 broad synthesized findings were developed: i) Changed family member roles, spousal relationships difficulties, and family functioning when living with an EFR with PTSD; ii) Spouses of an EFR with PTSD may experience vicarious trauma, secondary trauma, and/or overburden as a consequence of protecting the family unit; iii) Children of an EFR parent with PTSD may experience secondary trauma, vicarious trauma, and/or separation anxiety; and iv) Spouses' help-seeking and support needs for their EFR partners with PTSD, their children, and themselves. The first 3 findings received a low ConQual score due to low dependability and moderate credibility. The final finding received a moderate ConQual score due to low dependability and high credibility.

CONCLUSIONS

The findings of the 5 qualitative studies included in the review showed significant mental health and functional impacts for family members of EFR with PTSD. Most studies focused on spouses, with some limited data on children. Two of the 5 studies focused on the 9/11 World Trade Center terrorist attacks in the United States. The findings also indicate the need for targeted psychological and social services for EFR family members. Recommendations derived from the synthesized findings of this review include the need for further qualitative research, not only to deepen the understanding about the impacts and needs of EFR with PTSD on family members, but also to inform the design and provision of support services.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020196605.

Evaluation of the relationship between theory of mind relating to cognitive performance and post-traumatic stress disorder in Syrian refugee amputees living in Turkey

BACKGROUND

According to the available literature, studies examining the relationship between theory of mind (ToM) and post-traumatic stress disorder (PTSD) have a small sample size and are few in number.

AIMS

This study aims to investigate the relationship between the potential presence of PTSD in Syrian refugee amputees living in Turkey, ToM skills measured by Reading the Mind in the Eyes Test (RMET), and variables related to amputation.

METHOD

Our 69 follow-up amputee patients answered a socio-demographic and amputation data form, and the RMET, PTSD checklist for DSM-5 (PCL-5), and Beck Depression Inventory-II (BDI-II) completed a ToM task.

RESULTS

Those with potential PTSD were significantly less educated than those without (p = .017). Prosthesis usage time (p = .002) and duration of post-amputation (p = .033) were significantly shorter in those with potential PTSD compared to those without. The RMET neutral valence (p = .035) and RMET total (p = .017) accuracy scores were significantly lower in patients with potential PTSD. Those with potential PTSD were higher significantly more depressed (p < .001). In our regression analyses, lower education level (p < .05), shorter prosthesis usage time (p = .008), and lower RMET neutral valence (p = .006) / RMET total (p = .032) accuracy scores predicted the presence of potential PTSD.

CONCLUSIONS

Lower education level, prosthesis use for a shorter period, and poor mind-reading skills from neutral and total eye expressions were predictive of the potential presence of PTSD in amputees, even though they were largely exposed to similar traumas. Our findings suggest that treatment and follow-up of PTSD should also target deficits in cognitive and emotional abilities.

Pooled analysis of the association between mental health and violence against women: evidence from five settings in the Global South

OBJECTIVES

To describe associations between men's poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women's mental health and their experiences of IPV and NPSV in five settings in the Global South.

DESIGN

A pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations.

SETTING

Three sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories.

PARTICIPANTS

7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys.

MAIN OUTCOME MEASURES

All studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women's health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women.

FINDINGS

Overall men's poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not.

CONCLUSIONS

Interventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women's experience.

The military spouse experience of living alongside their serving/veteran partner with a mental health issue: A systematic review and narrative synthesis

INTRODUCTION

Military healthcare studies have reported a wide range of mental health issues amongst military personnel. Globally, mental health issues are one of the main causes of ill health. Military personnel have a greater prevalence of mental health issues than that of the general population. The impact of mental health issues can be wide and far reaching for family and carers. This systematic narrative review explores the military spouse experience of living alongside their serving or veteran partner with a mental health issue.

METHODS

The systematic review performed was based on the PRISMA guide for searching, screening, selecting papers for data extraction and evaluation. Studies were identified from CINHAL, ASSIA, Proquest Psychology, Proquest Nursing & Allied Health source, Proquest Dissertations & Theses, ETHOS, PsychArticles, Hospital collection, Medline, Science Direct Freedom Collection and hand searching of citations and reference lists.

RESULTS

Twenty-seven studies were included in the narrative synthesis. Five overarching themes from the experiences of military spouses' living alongside their serving/veteran partners mental health issue were identified: caregiver burden, intimate relationships, psychological/psychosocial effects on the spouse, mental health service provision and spouse's knowledge and management of symptoms.

CONCLUSIONS

The systematic review and narrative synthesis identified that the majority of studies focused on spouses of veterans, very few were specific to serving military personnel, but similarities were noted. Findings suggest that care burden and a negative impact on the intimate relationship is evident, therefore highlight a need to support and protect the military spouse and their serving partner. Likewise, there is a need for greater knowledge, access and inclusion of the military spouse, in the care and treatment provision of their serving partner's mental health issue.

The Role of Social Support in Coping with Psychological Trauma: An Integrated Biopsychosocial Model for Posttraumatic Stress Recovery

This theoretical review proposes an integrated biopsychosocial model for stress recovery, highlighting the interconnectedness of intra- and interpersonal coping processes. The proposed model is conceptually derived from prior research examining interpersonal dynamics in the context of stressor-related disorders, and it highlights interconnections between relational partner dynamics, perceived self-efficacy, self-discovery, and biological stress responsivity during posttraumatic recovery. Intra- and interpersonal processes are discussed in the context of pre-, peri-, and post-trauma stress vulnerability as ongoing transactions occurring within the individual and between the individual and their environment. The importance of adopting an integrated model for future traumatic stress research is discussed. Potential applications of the model to behavioral interventions are also reviewed, noting the need for more detailed assessments of relational dynamics and therapeutic change mechanisms to determine how relational partners can most effectively contribute to stress recovery.

Family Involvement in PTSD Treatment: Perspectives from a Nationwide Sample of Veterans Health Administration Clinicians

Social support is bidirectionally linked to symptoms of posttraumatic stress disorder (PTSD). Evidence suggests that family involvement in veterans' mental health treatment is desired by both veterans and family members, and that such involvement has the potential to improve treatment outcomes. However, rates of family involvement are low in the Veterans Health Administration (VHA). We sought to understand VHA clinicians' perspectives on family involvement in PTSD treatment by conducting qualitative interviews with 31 providers at 10 VHA facilities across the U.S. The i-PARIHS framework was used to guide the interviews and analysis, and several major themes were identified. All clinicians reported that they at least occasionally offered family-inclusive sessions, and they frequently referenced both the influence of family behaviors or attitudes on veterans' functioning, and also how veterans' symptoms could cause tremendous disruption in the family. Clinicians' past experience with supervised family- or couple-based work strongly influenced their current comfort with family-inclusive sessions. Multiple potential avenues exist to support increased family involvement in PTSD treatment in VHA.

Ventral tegmental area dopaminergic action in music therapy for post-traumatic stress disorder: A literature review

Post-traumatic stress disorder (PTSD) is a debilitating sequela of extraordinary traumatic sufferings that threaten personal health and dramatically attenuate the patient's quality of life. Accumulating lines of evidence suggest that functional disorders in the ventral tegmental area (VTA) dopaminergic system contribute substantially to PTSD symptomatology. Notably, music therapy has been shown to greatly ameliorate PTSD symptoms. In this literature review, we focused on whether music improved PTSD symptoms, based on VTA dopaminergic action, including the effects of music on dopamine (DA)-related gene expression, the promotion of DA release and metabolism, and the activation of VTA functional activities. In addition, the strengths and limitations of the studies concerning the results of music therapy on PTSD are discussed. Collectively, music therapy is an effective approach for PTSD intervention, in which the VTA dopaminergic system may hold an important position.

The Aftermath of Trauma and Abuse and the Impact on Family: A Narrative Literature Review

The present narrative review examined quantitative and qualitative research on family members who support survivors of trauma or abuse. Studies included in the present review were found in peer-reviewed journal articles, available in English, published between 1980 and 2019, and focused specifically on the experiences of adult familial supporters of adult trauma and abuse survivors. A search of PsychInfo and Google Scholar identified 136 relevant articles, and analysis of their content generated the following categories: individual-level impacts (i.e., quality of psychological health, burden, secondary traumatic stress, quality of physical health, and positive impacts), interpersonal and environmental level impacts (i.e., quality of relationships with survivors, navigating environment, maltreatment and safety, and social impacts), and other experiences (i.e., social roles, needs, coping strategies, and sociocultural context). Findings indicate that the majority of existing studies examined the experiences of family members of adult survivors of military trauma. Results of the review suggest that family supporters of adult trauma and abuse survivors generally experience physical, emotional, cognitive, behavioral, social, safety, and relational impacts. Implications of review findings and directions for future research are discussed.

The Dynamics of Implicit Intergroup Biases of Victims and Ex-combatants in Post-conflict Scenarios

Strong group identities arise in intergroup conflict scenarios and perpetuate sectarian violence even in post-conflict scenarios. In particular, out-group negative implicit associations are predictors of decreased intergroup forgiveness, as well as increased distrust and aggression against the out-group. Thus, the presence of implicit intergroup (i.e., ex-combatants and victims) biases seems to be a relevant factor in post-conflict scenarios. Here, we aimed to explore whether negative biases toward the out-group are boosted by (a) previous exposure to conflict violence or (b) identification with an armed violent group. One hundred and twenty-eight participants, 65 ex-combatants from Colombian guerrillas and 63 victims of the armed conflict, were assessed with a modified version of the implicit association test (IAT). Our results revealed that the victim group showed a significant negative bias against ex-combatants. However, no bias toward the out-group (i.e., victims) or in-group favoritism was observed in the ex-combatant group. Similarly, we found that IAT scores were not associated with sociodemographical variables (i.e., sex, years of education, or type of dwelling), the levels of combat exposure, victimization armed-conflict-related experiences, or child abuse antecedents. Our results showed an unexpected lack of in-group bias in ex-combatants, potentially triggered by the effect of current demobilization and reintegration processes. Thus, negative associations with the out-group will persist in the framework of societal condemnation of the out-group. In contrast, these negative biases will tend to be abolished when entering in conflict with larger societal reintegration processes. The results reinforce the idea that reintegration may benefit from interventions at the societal level, including all actors of the conflict. In addition, our findings highlight the importance of implementing victim interventions aimed at reducing stigma and revengeful actions in spaces of collective disarmament.

Relationship between Socio-Demographic Factors and Posttraumatic Stress Disorder: A Cross Sectional Study among Civilian Participants' Hostilities in Ukraine

Background: Even though there is an extensive body of literature on posttraumatic stress disorder (PTSD) in individuals who have experienced armed conflict, there are still many grey areas, especially in relation to civilian participants in hostilities. This article evaluates how socio-demographic factors and the interactions between them have influenced PTSD among civilians involved in the recent war in Ukraine. Methods: This cross-sectional study included a convenience sample of 314 adults, 74 women, and 235 men. The mean age was 34.08 years. We used the Posttraumatic Stress Disorder (PTSD) Checklist–Civilian Version (PCL-C). Results: Our findings show that predictors of posttraumatic stress are loss of a loved one, place of residence, gender, continuation of education, and health insurance. We demonstrated that PTSD produced by the loss of a loved one as a result of war is determined by participation in the education system, whatever the level of education. The literature emphasises the importance of social support, e.g., from the family. We demonstrated that having children is associated with a risk of more severe PTSD, causing serious mental strain among participants of hostilities. We discovered that material security lowers PTSD, but only among people who have no children. Conclusions: PTSD is the result of not only the violence and damage caused by war but also of other stressful circumstances associated with the social and financial conditions of life. Further research needs to focus on identifying modifiable risk factors and protective factors that could be embraced by intervention strategies. Our findings can inform the goals behind therapeutic support for civilian participants of hostilities, and implications for social work. Social work professionals are encouraged to engage in direct questioning and to maintain a supportive and safe environment for participants in hostilities, e.g., in the area of education. Trauma-affected people need to be given opportunities to build up their strengths and increase their psychological resources towards well-being. Social security (health insurance, savings, material security) should be taken into account when working with people affected by PTSD.

Intergenerational Transmission of Posttraumatic Stress Disorder in Australian Vietnam Veterans' Daughters and Sons: The Effect of Family Emotional Climate While Growing Up

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

The long shadow of the Kargil War: The effect of early-life stress on education

The paper examines the long-term impact of the India-Pakistan war of 1999 on the educational attainment of children born to families of soldiers who survived the war. Based on the assumption that military families faced higher levels of psychological stress than civilian families during the war period, the paper uses a difference-in-difference methodology with household fixed effects to show that the education of military children exposed to the war during their formative years suffered significantly. An examination of the consumption expenditure pattern of military and civilian households suggests that the effect was unlikely to be via resource-related channels. The improbability of other direct pathways through which the war could affect these families suggests that the negative effect might have resulted from the psychological stress that the war generated for the affected families.

Intimate Partner Violence in Adolescence: Associations With Perpetration Trauma, Rumination, and Posttraumatic Stress

Engagement in intimate partner violence (IPV) is related to a host of negative outcomes for youth, including posttraumatic stress symptoms (PTSS). Moreover, research indicates that the perpetration of violence may constitute a traumatic experience, termed perpetration trauma (PT), which, in turn, is related to elevated levels of PTSS. Little research to date, however, has illuminated the underlying processes that may link IPV perpetration, PT, and PTSS. One potential contributor to this association is rumination on negative emotions. In particular, for youth who report PT and rumination, engaging in IPV may be associated with elevations in PTSS. To investigate this hypothesis, data were gathered from a sample of 235 justice-involved youth (184 boys, 51 girls) who completed self-report measures of IPV perpetration and victimization, PT, sadness and anger rumination, and PTSS. Results of moderated mediational analyses indicated that IPV perpetration was related to PTSS through sadness rumination, and that these effects were stronger when youth endorsed PT. In turn, IPV perpetration was related to PTSS through anger rumination only when youth did not endorse PT. In addition, tests of alternative models indicated that these results were specific to IPV perpetration, given that IPV victimization was not related to PTSS through anger or sadness rumination when youth endorsed PT. These results suggest that the combination of rumination on sadness and endorsement of PT may put youth who perpetrate IPV at the greatest risk of PTSS. Therefore, interventions seeking to interrupt the cycle of IPV perpetration may benefit from targeting perpetrators' sadness rumination, PT, and PTSS.

The association between type of trauma, level of exposure and addiction

Exposure to trauma is considered a risk factor for the development of addictive disorders. Currently, there is a knowledge gap concerning specific links between types and levels of exposure to traumatic events and addiction.In this study we explored the associations between interpersonal trauma and risk of addictive behaviors, stratified by type of trauma (physical, weapon, sexual assault, and combat) and level of exposure (direct/indirect), focusing on a wide range of substances and behaviors. Data from an online representative sample of 4025 respondents were collected, including the Life Events Checklist (LEC-5), substance use disorders and behavioral addictions metrics, and sociodemographic data. Substantial differences were found between specific types of trauma and risk of addiction. Among those exposed to sexual assault, the risk of alcohol use disorder was found to 15.4%, 95%CI[14.4-16.4%], compared to 12.1%,95%CI[11.3-12.8] among those exposed to combat-related trauma. Both direct and indirect exposure to trauma were found to be significantly related with risk of addiction. While direct exposure was most highly associated with addictions across several types of trauma, in the case of combat-related trauma, indirect exposure was more highly associated with alcohol and pornography addiction (14.5%,95%CI[13.2-15.8%] and 10.0%, 95%CI[6.3-15.0%], respectively) compared to direct exposure (10.7%,95%CI[9.9-11.6%] and 7.4%, 95%CI[4.7-11.6%], respectively). Our findings emphasize the strong association between all types of trauma and the risk of several specific substance and behavioral addictions. Specifically, the role of indirect exposure to trauma is highlighted.

Experiences and perceptions of family members of emergency first responders with post-traumatic stress disorder: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to understand the perceptions and experiences of family members of emergency first responders with post-traumatic stress disorder.

INTRODUCTION

Research indicates that rates of post-traumatic stress disorder in emergency first responders are approximately double civilian rates; however, little is known about the effects of post-traumatic stress disorder on family members. This review seeks to identify qualitative research on families' experiences and perceptions.

INCLUSION CRITERIA

This review will consider all studies of family members of current or former emergency first responders with diagnosed or undiagnosed post-traumatic stress disorder of any level of severity. All possible familial configurations and family members will be considered, including nuclear, separated, and blended families, of a current or former emergency first responder. There will be no age restrictions on emergency first responders or their family members, or limitations on recency of service. Emergency first responders may include police, ambulance workers, paramedics, firefighters, or rescue personnel, with no restriction on geographic location.

METHODS

The databases to be searched will include PubMed, PsycINFO, Embase, CINAHL, PTSDpubs, and Scopus, as well as handsearching of relevant journals. Unpublished studies and gray literature will be searched via PTSDpubs and OpenGrey. The search will aim to find English-language publications with no time limits. Titles and abstracts will be reviewed and then full texts, all screened by two independent reviewers against the inclusion criteria. Any conflicting views will be resolved by discussion or a third reviewer. Results will be critically appraised for methodological quality. Data extraction results will be synthesized and evaluated for credibility and dependability.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020196605.

Development and initial testing of a brief adjunctive intervention for family members of veterans in individual PTSD treatment

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans' individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol's efficacy and effectiveness.

Prolonged Exposure Therapy in the Time of COVID-19: Modifying PTSD Treatment for a Military Sexual Trauma Survivor Who Contracted COVID-19 Mid-Treatment

Prolonged exposure (PE) therapy is a gold-standard treatment for posttraumatic stress disorder (PTSD) that can be effectively delivered via telehealth modalities. The following case report describes a course of PE delivered to a veteran seeking PTSD treatment for military sexual trauma (MST), who contracted COVID-19 mid-treatment. Considerations for selecting PE as a treatment modality; modifications made due to the COVID-19 pandemic and transition to telehealth more broadly, and following the veteran contracting COVID-19 more specifically; strategies to increase treatment engagement; and assessment of progress over time, are discussed. In particular, treatment considerations during a global pandemic are explored at the patient-, provider-, and systems level, to inform treatment delivery for other providers during this ongoing pandemic. Although there were numerous technological, environmental, and pandemic-related difficulties, the veteran described here persisted through a course of PE and experienced clinically significant reductions in symptoms of PTSD and a great degree of functional recovery.

Intergenerational Trauma among Families in El Salvador: an Exploratory Study

Adverse childhood events have been shown to impact individuals through adulthood, particularly the impact on relationships. This study aimed to examine intergenerational trauma exposure among a sample of parents living in a semi-urban Salvadoran community and the relationship between child trauma exposure with maternal perceived discrimination, internal strengths and external support. Survey data was collected from 49 mothers residing in El Salvador. Bivariate analyses and multivariate linear regression analyses were used to examine the relationship between children's exposure to adverse childhood events and parents' exposure to adverse childhood events, while controlling for discrimination. The results of the regression analysis indicate that the maternal number of adverse childhood events and experience of discrimination as an adult explained 52.9% of the variance (R ²  = 0.59, F(6, 43) = 10.18, p < .0001). The number of adverse childhood events was significantly predicted by maternal number of adverse events (B = 0.32, 95% CI = 0.17-0.48, p < .0001) and experience of discrimination as adults (B = 5.79, 95% CI = 3.51-8.07, p < .0001). Results suggest that parent exposure to adverse childhood events and parent experience with discrimination are related to the exposure to adverse childhood events of their children. Further research in this area is warranted to better understand the experiences of parents who have been exposed to childhood trauma and the day-to-day parenting challenges. Greater understanding of the impact of childhood trauma also encourages service providers to explore intergenerational interventions.

Impact of low arousal threshold on treatment of obstructive sleep apnea in patients with post-traumatic stress disorder

PURPOSE

We sought to determine the prevalence of low arousal threshold (LAT) in veterans with post-traumatic stress disorder (PTSD) and whether or not LAT is associated with decreased use of continuous positive airway pressure (CPAP).

METHODS

We conducted a retrospective study of all veterans with documented PTSD who had an apnea hypopnea index > 5/h over a 27-month period. Demographic, clinical characteristics, and CPAP usage were extracted from the medical records. A multivariate analysis was conducted to assess predictors of CPAP use at 3 months in patients with LAT after adjusting for severity of PTSD.

RESULTS

LAT was identified in 55% of 119 patients with PTSD and newly diagnosed OSA. LAT was associated with younger age (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.86-0.95), lower BMI (OR 0.82; 95% CI 0.73-0.91), presence of insomnia (OR 1.34; 95% CI 1.19-1.81), and use of antidepressant (OR 1.14; 95% CI 1.09-2.01). PTSD severity, REM rebound, and the presence of baseline comorbid insomnia were each associated with CPAP use at 3 months. Neither daytime sleepiness, body mass index (BMI), nor LAT endotype was correlated with CPAP utilization. Insomnia was the only factor associated with decreased CPAP use in patients with PTSD and LAT (P = 0.04).

CONCLUSION

The LAT endotype is common among veterans with PTSD. An improved understanding of how insomnia in this population affects CPAP utilization would be instrumental in designing targeted therapy to improve sleep quality.

Prevalence of Self-Reported Intimate Partner Violence Victimization Among Military Personnel: A Systematic Review and Meta-Analysis

BACKGROUND

Research on intimate partner violence (IPV) in the military has tended to focus on military personnel as perpetrators and civilian partners/spouses as victims. However, studies have found high levels of IPV victimization among military personnel. This article systematically reviews studies of the prevalence of self-reported IPV victimization among military populations.

METHODS

Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Meta-analyses of the available data were performed, where possible, using the random effects model.

RESULTS

This review included 28 studies with a combined sample of 69,808 military participants. Overall, similar or higher prevalence rates of physical IPV victimization were found among males compared to females and this was supported by a meta-analytic subgroup analysis: pooled prevalence of 21% (95% confidence interval [CI] = [17.4, 24.6]) among males and 13.6% among females (95% CI [9.5, 17.7]). Psychological IPV was the most prevalent type of abuse, in keeping with findings from the general population. There were no studies on sexual IPV victimization among male personnel. Evidence for the impact of military factors, such as deployment or rank, on IPV victimization was conflicting.

DISCUSSION

Prevalence rates varied widely, influenced by methodological variation among studies. The review highlighted the lack of research into male IPV victimization in the military and the relative absence of research into impact of IPV. It is recommended that future research disaggregates results by gender and considers the impact of IPV, in order that gender differences can be uncovered.

Finding meaning in times of family stress: A mixed methods study of benefits and challenges amongst home-front parents in military families

Family stress theory explains how demands placed on the family system interact with capabilities to influence family adaptation. One capability that some military families may use naturalistically is that of benefit-finding, the recognition of value and benefit after a stressful or traumatic experience. In this mixed methods study, authors explore the perception of benefits associated with military service amongst 26 home-front mothers. Methods incorporate a self-report questionnaire adapted for this population and a qualitative interview aimed at understanding challenges and benefits associated with these women's experiences as members of a military family. Results revealed that more women than not endorsed meaningful changes that they have experienced as a result of their family's military service, despite a wide range of challenges and negative experiences. Four themes of benefits emerged from analyses: (a) financial, educational and career benefits; (b) cultivating strength; (c) friendships and community; and (d) pride. These findings illuminate the diverse ways in which women find meaning in their family's military service and upon replication and elaboration of these results, have clinical implications for the development of future prevention and intervention work with military families.

The Role of Perceived Authenticity in Psychological Recovery from Collective Trauma

Introduction: Previous research demonstrates that perceived authenticity is positively associated with psychological health and security in the face of threats. The current research extends this work by testing whether perceived authenticity promotes recovery from the negative mental health consequences of collective trauma (e.g., a natural disaster).

Methods: We recruited a sample of undergraduates (N = 570), many of whom reported direct or indirect exposure to Hurricane Harvey, to complete surveys at two time points. We assessed exposure to the disaster, acute stress, post-traumatic stress, coping, and authenticity twice, once approximately 1 month after Hurricane Harvey (Time 1) and again approximately 9 weeks after Hurricane Harvey (Time 2).

Results: We employed multilevel modelling to explore whether authenticity would aid in recovery from collective trauma. Results showed that perceived authentic living at Time 1 predicted a variety of indicators of stress related to the hurricane at Time 2. Specifically, those participants who reported low authentic living at Time 1 reported greater levels of stress at Time 2, compared to individuals who reported higher levels of authentic living. Importantly, these effects remained even when controlling for known predictors of stress (e.g., levels of stress at Time 1 and coping strategies).

Discussion: Findings provide preliminary insight into authenticity as a part of a likely larger network of interrelated psychosocial qualities that have the potential to help one navigate recovery from trauma.

Mental disorders and medical conditions associated with causing injury or death: A population-based study

The aim of the present study is to examine mental disorders and medical conditions associated with causing harm to another person in the general adult population. The sample (n=22,138) was drawn from a cross-sectional survey designed to characterize mental health needs in France. Twelve-month DSM-IV axis I mental disorders and medical conditions, and lifetime occurrence of potentially traumatic events were assessed with the Composite International Diagnostic Interview-SF Overall, 2% (n=430) of the sample reported having injured or killed someone. Causing harm was associated with male gender, lower education level, and being unemployed. The great majority (85%) of those who caused harm had experienced two or more additional potentially traumatic events. When adjusting for gender, employment status, education and number of events experienced, causing harm was associated with certain anxiety disorders, drug dependence and lifetime suicide attempt but not with major depression or post-traumatic stress disorder. Furthermore, causing harm was not associated with medical conditions in multivariate analyses. These results highlight the need for clinicians to be particularly attentive to the psychological burden that may be experienced by those who have harmed or killed someone.

Principal Diagnoses in Psychiatric Outpatients With Posttraumatic Stress Disorder: Implications for Screening Recommendations

In this study, we examined the prevalence of posttraumatic stress disorder (PTSD) in 3800 psychiatric outpatients with different principal diagnoses. For all disorders identified as a principal diagnosis, we compared patients' odds ratios of PTSD to all other patients in the sample. Approximately one-sixth of the sample (n = 663, 17.4%) was diagnosed with PTSD, including 417 patients with current PTSD and 246 with PTSD in partial remission. Patients with principal bipolar disorder and major depressive disorder (MDD) demonstrated higher rates of PTSD compared with those without principal bipolar and MDD. For most psychiatric outpatients with PTSD, the principal diagnosis for which they seek treatment is not PTSD, but rather a mood disorder. This highlights the importance of screening for PTSD, particularly in patients with a principal diagnosis for which the prevalence of PTSD is relatively high, namely, MDD, bipolar disorder, panic disorder, and borderline personality disorder.

Combat Experience and Posttraumatic Stress Symptoms among Military-Serving Parents: a Meta-Analytic Examination of Associated Offspring and Family Outcomes

In this meta-analysis, we review findings on the relationships between parental combat exposure and PTSD/PTSS in military-serving families and (1) parenting problems, (2) family maladjustment, and (3) offspring problems. We systematically searched for studies in PsycInfo, PsychArticles, Psychology and Behavior Sciences Collection, Published International Literature on Traumatic Stress (PILOTS), and PubMed/Medline as well as conducted manual searches. Search procedures identified 22 eligible studies, including 20 studies examining relationships between parental PTSD/PTSS and parenting, family, and/or offspring outcomes and 8 studies examining relationships between parental combat exposure and parenting, family, and/or offspring outcomes. Random effects meta-analytic models estimated omnibus associations between parental combat exposure/PTSD and pooled Family Difficulties, as well as individual relationships between parental combat exposure and PTSD/PTSS and parenting, family adjustment, and offspring outcomes. Small-to-moderate effect sizes were observed in the omnibus meta-analysis examining relationships between parental PTSD/PTSS and pooled Family Difficulties, and in the meta-analysis examining relationships between parental PTSD/PTSS and parenting problems, between parental PTSD/PTSS and poor family functioning, and between parental PTSD/PTSS and offspring problems. Associations between parental combat exposure and pooled Family Difficulties, as well as between parental combat exposure and parenting problems were smaller in magnitude. PTSD/PTSS among military-serving parents is associated with increased problems in the family environment, including parenting problems, family maladjustment, and offspring problems, whereas combat exposure alone is not as strongly associated with such family difficulties. Moderator analyses are presented and discussed as well. When military-serving parents show psychological symptoms, professionals should consider allocating resources to target broader family issues.

The intergenerational sequelae of war captivity: the impact of a self-amplifying cycle of PTSD and attachment insecurities on offspring's attachment orientations

Background: War captivity is one of the most severe human-made traumatic events which lead to self-amplifying cycle of post-traumatic stress disorder (PTSD) symptoms and attachment insecurities. Solid evidence in the literature pointed out on the intergenerational transmission of PTSD symptoms. However, no research has been conducted on the intergenerational transmission of attachment insecurities and the effect of the self-amplifying cycle among former prisoners of war (ex-POWs) and their offspring attachment insecurities. Objective: This research aims to explore the intergenerational impact of a self-amplifying cycle of PTSD and attachment insecurities among ex-POWs on their offspring's attachment orientations. Method: We sampled dyads of Israeli ex-POWs of the Yom Kippur war and their adult offspring (ex-POW group) (n = 80) as well as dyads of Israeli veterans who fought in the Yom Kippur war, but were never held captive, and their adult offspring (control group) (n = 40). Veterans reported on PTSD severity and attachment orientations (anxiety, avoidance). Offspring reported on attachment orientations. We conducted (a) hierarchical regressions to predict offspring attachment orientations as a function of veterans' attachment orientations, and (b) moderated mediation analyses examining the role of veterans' PTSD in the intergenerational transmission of attachment orientations. Results: Ex-POWs' attachment anxiety was associated with offspring's reports of higher attachment anxiety and avoidance, and this intergenerational transmission of attachment was mediated by ex-POWs' PTSD severity. These effects were not significant in the control group. Conclusions: Decades after the war end, the intergenerational sequelae of war captivity are evident by the impact of the self-amplifying cycle of PTSD and attachment insecurities among ex-POWs and their offspring's attachment insecurities. Therefore, it is imperative for clinicians to recognize the intergenerational transmission and to focus not only on the trauma but also on the traumatized person's attachment injuries and the shattering of core beliefs about the world, self, and others, in the context of attachment-based therapies.

Regions of white matter abnormalities in the arcuate fasciculus in veterans with anger and aggression problems

Aggression after military deployment is a common occurrence in veterans. Neurobiological research has shown that aggression is associated with a dysfunction in a network connecting brain regions implicated in threat processing and emotion regulation. However, aggression may also be related to deficits in networks underlying communication and social cognition. The uncinate and arcuate fasciculi are integral to these networks, thus studying potential abnormalities in these white matter connections can further our understanding of anger and aggression problems in military veterans. Here, we use diffusion tensor imaging tractography to investigate white matter microstructural properties of the uncinate fasciculus and the arcuate fasciculus in veterans with and without anger and aggression problems. A control tract, the parahippocampal cingulum was also included in the analyses. More specifically, fractional anisotropy (FA) estimates are derived along the trajectory from all fiber pathways and compared between both groups. No between-group FA differences are observed for the uncinate fasciculus and the cingulum, however parts of the arcuate fasciculus show a significantly lower FA in the group of veterans with aggression and anger problems. Our data suggest that abnormalities in arcuate fasciculus white matter connectivity that are related to self-regulation may play an important role in the etiology of anger and aggression in military veterans.

Couple and family therapies for post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD.

OBJECTIVES

The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings.

SEARCH METHODS

We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures.

MAIN RESULTS

We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses.

AUTHORS' CONCLUSIONS

There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.

Parenting and discipline in post-conflict Sierra Leone

BACKGROUND

While the literature on physical punishment concludes that it has negative effects on children, the practice remains common in many countries. In post-conflict countries with nongovernmental organizations (NGO) operating in child protection, traditional disciplinary practices may conflict with international child rights agendas. The country of Sierra Leone has a unique history of conflict, abject poverty, low literacy, and weak governance - often, NGO agents are responsible for providing social services that the government is unable to consistently provide.

OBJECTIVE

We examined how Sierra Leonean caregivers think about appropriate discipline for children, and whether they perceived any changes in their attitudes toward disciplinary practices since the end of the war.

PARTICIPANTS AND SETTING

We collected data from parents and caregivers in urban, peri-urban, and rural areas of Sierra Leone's four districts.

METHODS

We used focus groups (12 groups, n = 92) and individual interviews (n = 21) to collect data in 2013. Focus groups and interviews were conducted by research assistants fluent in Krio and English. We used a thematic content analysis approach.

RESULTS

We found that physical discipline-"beating"-was widely acceptable and common. A few parents mentioned other means of discipline, such as withholding food. Parents widely agreed that parenting had changed since the war, and reported that child rights movements supported by NGOs had made it more difficult to discipline their children in traditional ways.

CONCLUSIONS

Discipline was seen a central component of child-rearing and a means of ensuring safe and proper development. This may be a protective mechanism in the precarious, high poverty environment of post-war Sierra Leone. The negative responses of parents to NGO efforts to reduce physical punishment and other forms of child abuse suggest that grassroots approaches are needed to address this pervasive problem.

Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents

Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology. Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as "aggression," "aggressive behavio(u)r," "maladaptive aggression," "juvenile," and "developmental trajectory." These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019. Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed. Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.

Design of a randomized superiority trial of a brief couple treatment for PTSD

Interpersonal difficulties are common among veterans with posttraumatic stress disorder (PTSD) and are associated with poorer treatment response. Treatment outcomes for PTSD, including relationship functioning, improve when partners are included and engaged in the therapy process. Cognitive-behavioral conjoint therapy for PTSD (CBCT) is a manualized 15-session intervention designed for couples in which one partner has PTSD. CBCT was developed specifically to treat PTSD, engage a partner in treatment, and improve interpersonal functioning. However, recent research suggests that an abbreviated CBCT protocol may lead to sufficient gains in PTSD and relationship functioning, and yield lower dropout rates. Likewise, many veterans report a preference for receiving psychological treatments through clinical videoteleconferencing (CVT) rather than traditional face-to-face modalities that require travel to VA clinics. This manuscript describes the development and implementation of a novel randomized controlled trial (RCT) that examines the efficacy of an abbreviated 8-session version of CBCT ("brief CBCT," or B-CBCT), and compares the efficacy of this intervention delivered via CVT to traditional in-person platforms. Veterans and their partners were randomized to receive B-CBCT in a traditional Veterans Affairs office-based setting (B-CBCT-Office), CBCT through CVT with the veteran and partner at home (B-CBCT-Home), or an in office-delivered, couple-based psychoeducation control condition (PTSD Family Education). This study is the first RCT designed to investigate the delivery of B-CBCT specifically to veterans with PTSD and their partners, as well as to examine the delivery of B-CBCT over a CVT modality; findings could increase access to care to veterans with PTSD and their partners.

Standardized Assessment of Relationship Functioning in Iraq and Afghanistan Veterans with PTSD

Posttraumatic Stress Disorder (PTSD) is associated with difficulties in intimate relationships, with most prior research examining associations with continuous, single-dimension, and often-unstandardized measures of general relationship quality or aggression. Standardized, well-normed assessments that include multiple couple problem areas could provide more precise information about the presence and specific nature of clinically significant concerns in patient care settings. This investigation aimed to replicate findings regarding increased difficulties in relationship functioning among Operations Enduring and Iraqi Freedom Veterans with PTSD and their romantic partners, specifically using a standardized assessment that permits identification of cases of clinically significant general couple distress and difficulties across multiple problem areas. We compared 32 male Veterans with PTSD and 33 without PTSD, and their romantic partners on reports of several problem areas using the revised Marital Satisfaction Inventory (MSI-R). All participants underwent structured diagnostic interviewing. PTSD couples reported clinically significant levels of relationship distress several times more frequently than comparison couples, both for general distress and across all specific problem areas (e.g., aggressive behavior, quality of leisure time together, sexual functioning, conflicts about finances and child rearing). The most notable problem areas for PTSD couples were affective and problem-solving communication. These results replicate associations of PTSD with general couple discord and multiple specific areas of couple difficulties and extend them by documenting the clinical severity of these problems. Mental health providers may consider incorporating standardized couple assessments into their evaluations of Veterans' functioning. Couples therapies may consider using such measures to prioritize targets for treatment.

The impact of negative attributions on the link between observed partner social support and posttraumatic stress disorder symptom severity

Lack of perceived social support is one of the strongest correlates of the development and maintenance of posttraumatic stress disorder (PTSD). However, little is known about observed social support and PTSD. The stress buffering effect of social support may be partly determined by the subjective experience of support, which is created by attributions regarding support behaviors. We examined negative attributions about partner-provided support as a moderator of the expected relation between observed support during couple discussions and PTSD symptom severity. Participants included 128 individuals from 64 heterosexual married or cohabitating couples. Per clinician-administered interview, 72 (56%) participants met subthreshold or diagnostic criteria for PTSD. Receipt of relatively more partner support was modestly associated with lower PTSD symptom severity. Negative causal attributions about partner support were not associated with the amount of support received, but were associated with higher PTSD severity. Additionally, the frequency and quality of received partner support was associated with lower PTSD symptom severity only among those who did not make strong negative causal attributions about partner support. Thus, negative causal attributions may dampen the positive effects of social support on PTSD symptoms. PTSD treatments may more effectively facilitate recovery from trauma by decreasing negative support attributions.

The mental health of sons and daughters of Australian Vietnam veterans

Background

War service increases the risk of post-traumatic stress disorder (PTSD) to combatants, and has been shown to increase the risk of PTSD in their offspring. The extent to which there is an excess compared with the general population is not yet established, nor whether PTSD increases the risk of other psychiatric problems.

Methods

A national sample of 133 sons and 182 daughters of a cohort of 179 Australian Vietnam veterans' families were assessed in person, using structured psychiatric interviews. The prevalence of trauma exposures, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) diagnoses and suicidality were compared with the Australian Bureau of Statistics' 2007 National Survey of Mental Health and Wellbeing data matched for age and sex. The risk of mental health problems potentially attributable to PTSD was also assessed.

Results

Sons and daughters were more likely than population expectations to report exposures to natural disasters, fire or explosions and transport accidents, and sons more likely to report exposure to toxic chemicals whereas daughters were more likely to report sexual assault. Sons and daughters had higher prevalences of alcohol and other substance dependence, depression and anxiety, and PTSD, and children's PTSD was associated with substance dependence, depression and suicidal ideation. There were strong associations between children's PTSD and comorbid conditions of substance use disorders, depression and anxiety.

Conclusions

Higher rates of mental health problems in veterans' families, together with comorbidity with PTSD and the link between veterans' and children's PTSD, suggest that the effects of trauma may continue into subsequent generations.

Post-Traumatic Stress, Quality of Life and Alcohol Use Problems among Out-of-School Youth

OBJECTIVE

Post-traumatic stress symptoms (PTSS) in out-of-school youths (OSYs) may be influenced by alcohol use, but there is a lack of evidence explaining how PTSS affect alcohol use problems in OSYs. The present study aimed to investigate the relationships among PTSS, quality of life, and alcohol use in OSYs.

METHODS

In total, 125 OSYs (46.4% male) in South Korea completed the Korean Version of the Child Report of Post-Traumatic Symptoms (CROPS), the KIDSCREEN-27 Quality of Life Measure for Children and Adolescents, and the Alcohol Use Disorders Identification Test-Consumption.

RESULTS

Mean CROPS score was 18.7 (SD=11.6); 37.6% were problem drinkers. Quality of life in the domain of parent relations and autonomy significantly mediated the relationship between PTSS and alcohol use problems. OSYs with high parental satisfaction and autonomy were less likely to have alcohol use problems even with PTSS.

CONCLUSION

Family assessments and therapeutic approaches are needed for OSYs with both PTSS and alcohol use problems.

Male psychosexual therapy in the UK military

Military personnel can experience psychosexual difficulties for a variety of reasons. Problems can arise because of psychological trauma, physical injury, consequences arising from pharmacological and surgical complications and social or emotional concerns relating to intrapersonal and interpersonal relationship dynamics. Such individuals might seek to minimise or avoid resolving their pertinent difficulties, while others can experience cultural, personal or organisational barriers to accessing professional help. This paper offers an overview of the development of a national specialist psychosexual therapy service (PST), commenting specifically on the service delivery for male military personnel. It will also consider factors which may support progress in treatment and reflect upon the importance of considering psychosexual functioning in relationships as part of the broader service-life context, which is especially relevant to military personnel.

Intergenerational transmission of war-related trauma assessed 40 years after exposure

BACKGROUND

The intergenerational transmission of posttraumatic stress disorder (PTSD) from parent to offspring has been suggested in the literature, but this is highly controversial. We aimed to study the association between veterans' war exposure and lifetime PTSD and the psychological characteristics of their respective offspring, 40 years after war-related trauma.

METHODS

Forty-four adult offspring of veterans with PTSD and 29 offspring of veterans without PTSD were included in the study, from a total of 46 veterans. War exposure intensity, lifetime PTSD, and the general psychopathology (with Brief Symptom Inventory-BSI) of the veterans were studied, as were childhood trauma, attachment, and the general psychopathology (with BSI) of their offspring.

RESULTS

Veterans' war exposure was associated with BSI in the offspring with regard to somatisation (β = 0.025; CI 0.001, 0.050), phobic anxiety (β = 0.014; CI: 0.000, 0.027), Global Severity Index (GSI) (β = 0.022; CI 0.005, 0.038), and Positive Symptom Distress Index (β = 0.020; CI 0.006, 0.033). The fathers' GSI mediated only 18% of the effect of the veterans' total war exposure on offspring's GSI. Fathers' war exposure was associated with offspring's physical neglect as a childhood adversity, although non-significantly (p = 0.063). None of the other variables was associated with veterans' war exposure, and veterans' lifetime PTSD was not associated with any of the variables studied.

CONCLUSIONS

The offspring of war veterans showed increased psychological suffering as a function of their fathers' war exposure intensity, but not of their fathers' lifetime PTSD. These results could be used to suggest that mental health support for veterans' offspring should consider the war exposure intensity of their fathers, and not just psychopathology. This could spare offspring's suffering if this mental health support could be delivered early on, after veterans return from war.

Assessment of Moral Injury in Veterans and Active Duty Military Personnel With PTSD: A Review

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.

Music-instruction intervention for treatment of post-traumatic stress disorder: a randomized pilot study

Background

Post-traumatic Stress Disorder (PTSD) is a common sequelae of severe combat-related emotional trauma that is often associated with significantly reduced quality of life in afflicted veterans. To date, no published study has examined the effect of an active, music-instruction intervention as a complementary strategy to improve the psychological well-being of veterans with PTSD. The purpose of this study was to examine the feasibility and potential effectiveness of an active, music-instruction intervention in improving psychological health and social functioning among Veterans suffering from moderate to severe PTSD.

Methods

The study was designed as a prospective, delayed-entry randomized pilot trial. Regression-adjusted difference in means were used to examine the intervention’s effectiveness with respect to PTSD symptomatology (primary outcome) as well as depression, perceptions of cognitive failures, social functioning and isolation, and health-related quality of life (secondary outcomes).

Results

Of the 68 Veterans who were self- or provider-referred to the program, 25 (36.7%) were ineligible due to (i) absence of a PTSD diagnosis (n = 3); participation in ongoing intense psychotherapy (n = 4) or inpatient substance abuse program (n = 2); current resident of the Domiciliary (n = 8) and inability to participate due to distance of residence from the VA (n = 8). Only 3 (4.4%) Veterans declined participation due to lack of interest. The mean age of enrolled subjects was 51 years old [range: 22 to 76]. The majority was male (90%). One-quarter were African American or Black. While 30% report working full or part time, 45% were retired due to disability. Slightly over one-quarter were veterans of the OEF/OIF wars. Estimates from regression-adjusted treatment effects indicate that the average PTSD severity score was reduced by 9.7 points (p = 0.01), or 14.3% from pre- to post-intervention. Similarly, adjusted depressive symptoms were reduced by 20.4% (− 6.3 points, p = 0.02). There were no statistically significant regression-adjusted effects on other outcomes, although the direction of change was consistent with improvements.

Conclusions

Our findings suggest that the active, music-instruction program holds promise as a complementary means of ameliorating PTSD and depressive symptoms among this population.

Trial registration

Trial registered at ClinicalTrials.gov with protocol number Medical College of Wisconsin PRO00019269 on 11/29/2018 (Retrospectively registered).

Mental Health of Children of Deployed and Nondeployed US Military Service Members: The Millennium Cohort Family Study

OBJECTIVE

Families experience multiple stressors as a result of military service. The purpose of this study was to investigate the associations among service member deployment experiences, family and military factors, and children's mental health using baseline data from the Millennium Cohort Family Study, a study designed to evaluate the health and mental health effects of military service on families, including children.

METHOD

This study examined administrative data on deployment status (combat, noncombat, and no deployments), as well as service member- and spouse-reported data on deployment experiences and family functioning in relation to the mental health of children in the family who were aged 9 to 17 years.

RESULTS

Most children were not reported to have mental health, emotional, or behavioral difficulties regardless of parental deployment status. For an important minority of children, however, parental deployments with combat, compared with those with no deployment, were associated with a parental report of attention-deficit disorder/attention-deficit hyperactivity disorder and depression as diagnosed by a clinical provider, after accounting for demographics, psychosocial context, and military factors. Children's odds of a parental report of depression were significantly higher in both the combat and the noncombat deployment groups than in the no deployment group.

CONCLUSION

These findings extend our understanding of the association between parental deployments and children's mental health, with implications for services and training mental health providers serving military families.

Associations of Army Fathers' PTSD Symptoms and Child Functioning: Within- and Between-Family Effects

This study examined the within-family and between-family associations between fathers' military-related PTSD symptoms and parent ratings of children's behavioral and emotional problems. The sample included married couples (N = 419) with children composed of a civilian wife and an active-duty husband serving in the U.S. Army. Results indicate that changes in fathers' PTSD symptoms over time were associated with corresponding changes in both mothers' and fathers' reports of child behavioral and emotional problems. These within-family findings were independent from between-family effects, which showed that higher average PTSD symptomatology was associated with more overall behavioral and emotional problems for children. This study uses advances in statistical methodologies to increase knowledge about how PTSD symptoms and child problems are related, both across different families and over time within families.

Growing up with a father with PTSD: The family emotional climate of the children of Australian Vietnam veterans

A non-clinical sample of male Australian Vietnam veterans, their wives, and adult offspring were interviewed in-person in a national epidemiological study to assess the relationship between the mental ill-health of veterans and the emotional climate of the family while the children were growing up. Veterans were assessed 17 years before their children using standardised psychiatric diagnostic interviews. Family emotional climate was assessed using offspring ratings of parental attachment, and codings of positive and negative family relationship styles based on five minute speech samples provided by the offspring. Sons and daughters had different views of their mothers and fathers, and were less positive towards their fathers particularly if he had posttraumatic stress disorder (PTSD). Veteran PTSD and depression significantly negatively impacted the family emotional climate, while mothers' mental health was not related. Veteran PTSD symptoms were lowest in secure attachment to the veteran and highest in inconsistent attachment for both sons and daughters, but were not related to attachment to the mother. Veteran PTSD was related to daughters' but not sons' perceptions of family emotional climate. The impact of veterans' PTSD on their families' emotional climate is more marked for daughters than sons.

Prevalence of psychiatric morbidity in United States military spouses: The Millennium Cohort Family Study

BACKGROUND

Approximately half of US service members are married, equating to 1.1 million military spouses, yet the prevalence of psychiatric morbidity among military spouses remains understudied. We assessed the prevalence and correlates of eight mental health conditions in spouses of service members with 2-5 years of service.

METHOD

We employed baseline data from the Millennium Cohort Family Study, a 21-year longitudinal survey following 9,872 military-affiliated married couples representing all US service branches and active duty, Reserve, and National Guard components. Couples were surveyed between 2011 and 2013, a period of high military operational activity associated with Operation Iraqi Freedom and Operation Enduring Freedom. Primary outcomes included depression, anxiety, posttraumatic stress disorder (PTSD), panic, alcohol misuse, insomnia, somatization, and binge eating, all assessed with validated self-report questionnaires.

RESULTS

A total of 35.90% of military spouses met criteria for at least one psychiatric condition. The most commonly endorsed conditions were moderate-to-severe somatization symptoms (17.63%) and moderate-to-severe insomnia (15.65%). PTSD, anxiety, depression, panic, alcohol misuse, and binge eating were endorsed by 9.20%, 6.65%, 6.05%, 7.07%, 8.16%, and 5.23% of spouses, respectively. Having a partner who deployed with combat resulted in higher prevalence of anxiety, insomnia, and somatization. Spouses had lower prevalence of PTSD, alcohol misuse, and insomnia but higher rates of panic and binge eating than service members. Both members of a couple rarely endorsed having the same psychiatric problem.

CONCLUSIONS

One third of junior military spouses screened positive for one or more psychiatric conditions, underscoring the need for high-quality prevention and treatment services.