MMPI-2 based subgroups of veterans with combat-related PTSD: differential patterns of symptom change after treatment

Personality assessment inventory internalizing and externalizing structure in veterans with posttraumatic stress disorder: associations with aggression

Posttraumatic stress disorder (PTSD) is associated with aggressive behavior in veterans, and difficulty controlling aggressive urges has been identified as a primary postdeployment readjustment concern. Yet only a fraction of veterans with PTSD commit violent acts. The goals of this study were to (1) examine the higher-order factor structure of Personality Assessment Inventory (PAI) scales in a sample of U.S. military veterans seeking treatment for PTSD; and (2) to evaluate the incremental validity of higher-order latent factors of the PAI over PTSD symptom severity in modeling aggression. The study sample included male U.S. Vietnam (n = 433) and Iraq/Afghanistan (n = 165) veterans who were seeking treatment for PTSD at an outpatient Veterans Affairs (VA) clinic. Measures included the Clinician Administered PTSD Scale, the PAI, and the Conflict Tactics Scale. The sample was randomly split into two equal subsamples (n's = 299) to allow for cross-validation of statistically derived factors. Parallel analysis, variable clustering analysis, and confirmatory factor analyses were used to evaluate the factor structure, and regression was used to examine the association of factor scores with self-reports of aggression over the past year. Three factors were identified: internalizing, externalizing, and substance abuse. Externalizing explained unique variance in aggression beyond PTSD symptom severity and demographic factors, while internalizing and substance abuse did not. Service era was unrelated to reports of aggression. The constructs of internalizing versus externalizing dimensions of PTSD may have utility in identifying characteristics of combat veterans in the greatest need of treatment to help manage aggressive urges.

Lasting personality pathology following exposure to catastrophic trauma in adults: systematic review

BACKGROUND

By definition, personality disorders (PDs) are evident in late childhood and adolescence, but evidence for personality pathology occurring after adolescence is unclear.

AIM

We aimed to review extant literature on personality change following exposure to catastrophic trauma in adults in order to identify the prevalence and clinical features of any long-term personality pathology.

METHOD

Relevant studies were identified by searching three bibliographic databases (MEDLINE, EMBASE and PsychINFO) from inception to November 2011 using terms related to personality and trauma.

RESULTS

No prospective studies that investigated long-term personality change following exposure to trauma in adults were found. Two retrospective studies reported the prevalence of enduring personality change of 2.6% and 6% (weighted prevalence 4.6%, 95% confidence interval 3.4-6.3%), and one study reported 20% increase in adult-onset antisocial behaviour following exposure to trauma. Findings from cross-sectional studies that examined the prevalence of PDs in people exposed to catastrophic trauma reported that Cluster C and Cluster A were the most common with avoidant, paranoid and obsessive-compulsive PDs among those most frequently reported.

CONCLUSION

A minority of adults who are exposed to severe trauma appear to go on to develop significant personality pathology. The observed personality disturbance is multifarious and more extensive than the prototype described in ICD-10.

Alcohol problems, aggression, and other externalizing behaviors after return from deployment: understanding the role of combat exposure, internalizing symptoms, and social environment

OBJECTIVES

The study examined whether elevated rates of externalizing behaviors following deployment could be explained by internalizing symptoms (depression, anxiety, and PTSD symptoms), and health of the social environment (unit leadership, organizational support, and stigma/barriers to care).

DESIGN

A model of combat exposure, social environment, internalizing symptoms, and externalizing behaviors was tested in a military unit following a fifteen-month deployment to Iraq. The sample included 1,397 soldiers assessed four month post-deployment; 589 of these soldiers were assessed again nine months post-deployment.

RESULTS

Externalizing behaviors were highly stable over the five-month post-deployment period. Both social environment and internalizing symptoms were significantly associated with level of externalizing behaviors at four months and nine months post-deployment, but combat exposure alone significantly predicted change in externalizing behaviors over the follow-up period.

CONCLUSIONS

Results suggest the need to broaden the scope of interventions targeted to combat veterans and have implications for care providers and military leaders.

Internalizing and externalizing classes in posttraumatic stress disorder: a latent class analysis

Using latent class analysis (LCA) the typology of personality profiles of veterans with posttraumatic stress disorder (PTSD) was examined based on internalizing/externalizing dimensions of psychopathology. Latent class analysis on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Personality Psychopathology-5 (PSY-5) scale data from 299 Australian combat veterans with PTSD supported the model, identifying an optimal 4-class solution, with PTSD externalizing class defined by aggressiveness and disconstraint, high and moderate internalizing classes differentiated on the extent of elevations in introversion and negative emotionality and elevation of psychoticism in the high internalizing class and a simple PTSD class with normal range scores. The model was validated using external self-report and psychiatric-interview-derived diagnoses. A second exploratory LCA using broader comorbidity indicators (MMPI-2 Restructured Clinical scales) demonstrated some support for, although limitations in, using nonpersonality measures to identify these classes directly.

Cortisol metabolic predictors of response to psychotherapy for symptoms of PTSD in survivors of the World Trade Center attacks on September 11, 2001

BACKGROUND

A proportion of subjects with symptoms of posttraumatic stress disorder (PTSD) are unresponsive to specialized psychotherapy, but a biological basis for this has not been described. To observe whether differences in cortisol or its metabolites predict or correlate with response to therapy for PTSD symptoms, cortisol and its metabolites were measured from urine samples at pre-treatment, at the conclusion of psychotherapy, and at 3-month follow-up.

METHODS

28 survivors of the World Trade Center attacks on September 11, 2001 seeking psychological treatment for PTSD symptoms received four sessions of either exposure therapy or supportive counseling, followed by up to 10 sessions of prolonged exposure in a specialized PTSD treatment program at a private hospital serving the New York City metropolitan area. 24-h mean integrated cortisol excretion was assessed by radioimmunoassay (RIA); urinary free cortisol and metabolites cortisone, 5alpha-tetrahydrocortisol (5alpha-THF), 5beta-tetrahydrocortisol, and tetrahydrocortisone were assessed by gas chromatography-mass spectrometry (GC-MS); and indices of enzyme activity for 5alpha- and 5beta-reductase and for the 11beta-hydroxysteroid dehydrogenases were derived from the metabolite and glucocorticoid measures.

RESULTS

5alpha-Reductase activity was significantly lower at pre-treatment among non-responders, whereas there were no significant pre-treatment differences between responders and non-responders in any other hormone or metabolite level. In repeated measures analyses across the three time points, 5alpha-reductase activity, as well as 5alpha-THF and total glucocorticoids, significantly differed between responders and non-responders. For urinary cortisol measured by RIA, there was a significant groupxtime interaction indicating that, although not different at pre-treatment, urinary cortisol levels declined over time in the non-responder group, such that by follow-up, lowered cortisol significantly distinguished non-responders from responders. Indices of 5alpha-reductase activity, including 5alpha-THF and total glucocorticoids, were significantly negatively correlated with avoidance symptom severity at pre-treatment. At follow-up, indices of 5alpha-reductase activity were significantly negatively correlated with severity of all three PTSD symptom clusters and with total PTSD severity scores.

CONCLUSION

Lower 5alpha-reductase activity is associated with avoidance severity and predicts non-responsiveness to psychological treatment for PTSD symptomatology. Relatively diminished 5alpha-reductase activity may mark a state of primary vulnerability, perhaps via attenuated peripheral catabolism of cortisol resulting in the suppression of hypothalamic-pituitary-adrenal axis responsiveness. Lower cortisol levels appear later in the progression to chronic, treatment-resistant PTSD.

The internalizing and externalizing structure of psychiatric comorbidity in combat veterans

This study examined the latent structure of psychiatric disorders in a sample with a high prevalence of PTSD. A series of confirmatory factor analyses tested competing models for the covariation between Structured Clinical Interview for DSM-III-R diagnoses among 1,325 Vietnam veterans. The best-fitting solution was a 3-factor model that included two correlated internalizing factors: anxious-misery, defined by PTSD and major depression, and fear, defined by panic disorder/agoraphobia and obsessive-compulsive disorder. The third factor, externalizing, was defined by antisocial personality disorder, alcohol abuse/dependence, and drug abuse/dependence. Both substance-related disorders also showed significant, albeit smaller, cross-loadings on the anxious-misery factor. These findings shed new light on the structure of psychiatric comorbidity in a treatment-seeking sample characterized by high rates of PTSD.

Treatment for combat-related posttraumatic stress disorder: two-year follow-up

This study reports on outcomes 2 years following completion of specialist veteran posttraumatic stress disorder (PTSD) treatment programs in 2,223 (reduced to 1,508 at 24 months) consecutive admissions. Self-report measures of PTSD, anxiety, depression, anger, alcohol use, and general functioning were obtained at admission, 6, 12, and 24 months after admission. Significant improvements were demonstrated at 6 months, with smaller gains continuing through to 24-month assessment. Within subject effect sizes of around 0.8 were obtained for PTSD and around 0.5 for anxiety and depression. Although lack of a control group limits the extent to which improvements can be attributed to the treatment program, the data suggest that specialized treatment programs for combat-related PTSD continue to be of value.