Do adverse childhood experiences increase the risk of postdeployment posttraumatic stress disorder in US Marines?

Blood-based DNA methylation and exposure risk scores predict PTSD with high accuracy in military and civilian cohorts

BACKGROUND

Incorporating genomic data into risk prediction has become an increasingly popular approach for rapid identification of individuals most at risk for complex disorders such as PTSD. Our goal was to develop and validate Methylation Risk Scores (MRS) using machine learning to distinguish individuals who have PTSD from those who do not.

METHODS

Elastic Net was used to develop three risk score models using a discovery dataset (n = 1226; 314 cases, 912 controls) comprised of 5 diverse cohorts with available blood-derived DNA methylation (DNAm) measured on the Illumina Epic BeadChip. The first risk score, exposure and methylation risk score (eMRS) used cumulative and childhood trauma exposure and DNAm variables; the second, methylation-only risk score (MoRS) was based solely on DNAm data; the third, methylation-only risk scores with adjusted exposure variables (MoRSAE) utilized DNAm data adjusted for the two exposure variables. The potential of these risk scores to predict future PTSD based on pre-deployment data was also assessed. External validation of risk scores was conducted in four independent cohorts.

RESULTS

The eMRS model showed the highest accuracy (92%), precision (91%), recall (87%), and f1-score (89%) in classifying PTSD using 3730 features. While still highly accurate, the MoRS (accuracy = 89%) using 3728 features and MoRSAE (accuracy = 84%) using 4150 features showed a decline in classification power. eMRS significantly predicted PTSD in one of the four independent cohorts, the BEAR cohort (beta = 0.6839, p=0.006), but not in the remaining three cohorts. Pre-deployment risk scores from all models (eMRS, beta = 1.92; MoRS, beta = 1.99 and MoRSAE, beta = 1.77) displayed a significant (p < 0.001) predictive power for post-deployment PTSD.

CONCLUSION

The inclusion of exposure variables adds to the predictive power of MRS. Classification-based MRS may be useful in predicting risk of future PTSD in populations with anticipated trauma exposure. As more data become available, including additional molecular, environmental, and psychosocial factors in these scores may enhance their accuracy in predicting PTSD and, relatedly, improve their performance in independent cohorts.

The Impact of Adversity on Body Mass Index as Veterans Transition to Civilian Life

INTRODUCTION

The impact of adverse childhood experiences (ACEs), warfare exposure, and mental health symptoms upon changes in body mass index (BMI) were examined in a large U.S. post-9/11 veteran sample to assess gender-specific changes in BMI within the first 2½ years after military service.

MATERIALS AND METHODS

Data were collected with institutional approval in 6 waves between 2016 and 2019 from veterans who (1) separated from active duty component service branches (i.e., Army, Navy, Air Force, and Marine Corps) or National Guard or Reserve or (2) deactivated from active duty status after serving in a National Guard or Reserve component. Veterans self-reported height and weight at separation/deactivation at wave 2, and weight was asked at each subsequent wave. Multilevel growth model analyses estimated the relationship between ACEs, warfare exposure, and mental health symptoms and BMI for males and females. Weighted wave 5 analyses were conducted to ensure the sample was calibrated for nonresponse based on wave 1 and the full sample (n = 48,965) for each cross-classification of the weighting variables of gender, rank, and branch.

RESULTS

Approximately one-third of the veterans reported a normal BMI at separation/deactivation in comparison to being overweight (51%) or obese (20%). Twenty-six percent of male veterans had a normal BMI in contrast to almost half of the female veterans. Male veterans who experienced 3-7 ACEs had a higher BMI (0.74) compared to male veterans without any ACEs, where a BMI increase of 0.08 per year was reported. Female veterans who experienced 1-2 ACEs had a higher BMI (0.89) compared to female veterans without ACEs. Male veterans who engaged in warfare (e.g., combat patrols and firing a weapon at enemy combatants) and experienced corollaries (i.e., consequences of combat) or who experienced corollaries alone (e.g., saw refugees who lost their homes/belongings) had higher BMIs (1.14 and 0.82, respectively) compared to male veterans without warfare exposure. Female veterans who experienced corollaries had a higher BMI (0.94) compared to female veterans with no warfare exposure. Female veterans who experienced warfare (i.e., corollaries and combat) had a higher BMI (0.71) compared to female veterans with no warfare exposure. Male veterans who screened positive for likely post-traumatic stress disorder (PTSD) or depressive symptoms had a higher BMI (1.01 and 0.52, respectively) compared to male veterans who did not screen positive. Male veterans who screened positive for likely PTSD increased their BMI by 0.10 per year. Male veterans who screened positive for both likely PTSD and depressive symptoms had a higher BMI (1.32) compared to male veterans who did not screen positive, and they increased their BMI by 0.21 per year. Female veterans who screened positive for likely PTSD and depressive symptoms had a higher BMI (0.78) and increased their BMI by 0.25 per year compared to female veterans who did not screen positive.

CONCLUSIONS

Boosting veterans' and service members' mental and emotional healing from childhood and warfare adversities through sound health promotion policies and increased access to evidence-informed interventions is imperative for optimal body weight and physical health.

A Baseline Model of PTSD From the ACES Cohort

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a primary military psychiatric condition with complex etiology including strong genetic and/or environmental influences. Environmental influences and demographics can play a role in supporting underlying genetic traits for clinical utility evaluation as risk modifying factors. We are undertaking an IRB approved study to evaluate polygenic scores of PTSD risk in the adverse childhood experience and serotonin (ACES) transporter cohort.

MATERIALS AND METHODS

Baseline demographic characteristics and statistical modeling of 291 active duty service members from ACES cohort were used and excluded individuals with traumatic brain injury-induced loss of consciousness, pre-deployment PTSD or anxiety disorder, and pre-deployment prescription of antidepressants or psychoactive medications. Summary of categorical and numerical variables were evaluated using chi-square and t-test, respectively. We model PTSD risk and associated scores using linear and logistic regressions.

RESULTS

The ACES subset was 79.1% males, multi-ancestry, and mean age of 38.3 years. Most PTSD individuals received behavioral therapy (89.6%) and/or prescribed antidepressants (67%) had higher scores in ACES, combat exposure scales, PTSD checklist military version, neurobehavioral symptom inventory, Pittsburg sleep quality index, insomnia severity index, and composite autonomic symptom score surveys and were less likely to expect future deployment. A positive correlation between age, total months deployed, ACES, CES, PCL-M, and positive-PTSD diagnosis were consistent but not in older individuals, who were more likely and frequently deployed although increasing risk for combat exposure.

CONCLUSION

Demographic characteristics of the ACES cohort fit a coherent model of risk for PTSD to evaluate polygenic scores. Additional research is merited to understand PTSD effects on these confounding factors.

Sex, Adverse Childhood Experiences, and Substance Use Disorders in US Military Veterans: Results From the National Health and Resilience in Veterans Study

OBJECTIVES

US veterans report more adverse childhood experiences (ACEs) than nonveterans, and a greater number of ACEs has been linked to substance use disorders (SUDs). To date, however, no study has examined whether specific ACEs may be linked to SUDs in this population in a sex-related fashion.

METHODS

We analyzed data from the National Health and Resilience in Veterans Study, a nationally representative survey of 4069 US veterans. ACEs, current alcohol use disorder (AUD), and current drug use disorder (DUD) were assessed using validated self-report measures.

RESULTS

Being raised in a household with people with SUDs was independently associated with current AUD. Childhood sexual abuse and having an incarcerated family member were independently associated with current DUD. Sex moderated associations with specific ACEs. Specifically, female veterans who had experienced physical neglect in childhood or were raised with a mentally ill family member in the home were more likely to endorse current AUD and DUD, whereas male veterans who experienced sexual abuse in childhood or who were raised in a home with someone who used substances were more likely to endorse current AUD and DUD.

CONCLUSIONS

Results underscore the importance of targeted and sex-sensitive interventions in addressing potentially unresolved childhood traumas as part of treatment efforts for SUDs in veterans.

A summary of the U.S. Marine Recruit Assessment Program (RAP) procedures and survey from 2003 to 2021

The Recruit Assessment Program (RAP) is a cross-sectional, baseline survey of U.S. Marine recruits administered at Marine Corps Recruit Depot, San Diego. This report presents RAP study procedures and survey content that was administered to 229,015 participants between 2003 and 2021. Self-reported data were collected on recruit demographics, physical and mental health, adverse life experiences, lifestyle and risky behaviors, and substance use. In 2013, the survey was updated to remove questions with other linkable and reliable sources and those with low completion rates and low relevance to Marine health research; the removal of these items allowed for the addition of instrument measures for major depression, post-traumatic stress disorder, anger, and resilience with no significant change to overall survey length. Average completion rates are approximately 95%. Multiple studies have shown the utility of RAP data collected thus far as a robust data repository of pre-service health and behavioral measures.

Blood-based DNA methylation and exposure risk scores predict PTSD with high accuracy in military and civilian cohorts

Background

Incorporating genomic data into risk prediction has become an increasingly useful approach for rapid identification of individuals most at risk for complex disorders such as PTSD. Our goal was to develop and validate Methylation Risk Scores (MRS) using machine learning to distinguish individuals who have PTSD from those who do not.

Methods

Elastic Net was used to develop three risk score models using a discovery dataset (n = 1226; 314 cases, 912 controls) comprised of 5 diverse cohorts with available blood-derived DNA methylation (DNAm) measured on the Illumina Epic BeadChip. The first risk score, exposure and methylation risk score (eMRS) used cumulative and childhood trauma exposure and DNAm variables; the second, methylation-only risk score (MoRS) was based solely on DNAm data; the third, methylation-only risk scores with adjusted exposure variables (MoRSAE) utilized DNAm data adjusted for the two exposure variables. The potential of these risk scores to predict future PTSD based on pre-deployment data was also assessed. External validation of risk scores was conducted in four independent cohorts.

Results

The eMRS model showed the highest accuracy (92%), precision (91%), recall (87%), and f1-score (89%) in classifying PTSD using 3730 features. While still highly accurate, the MoRS (accuracy = 89%) using 3728 features and MoRSAE (accuracy = 84%) using 4150 features showed a decline in classification power. eMRS significantly predicted PTSD in one of the four independent cohorts, the BEAR cohort (beta = 0.6839, p-0.003), but not in the remaining three cohorts. Pre-deployment risk scores from all models (eMRS, beta = 1.92; MoRS, beta = 1.99 and MoRSAE, beta = 1.77) displayed a significant (p < 0.001) predictive power for post-deployment PTSD.

Conclusion

Results, especially those from the eMRS, reinforce earlier findings that methylation and trauma are interconnected and can be leveraged to increase the correct classification of those with vs. without PTSD. Moreover, our models can potentially be a valuable tool in predicting the future risk of developing PTSD. As more data become available, including additional molecular, environmental, and psychosocial factors in these scores may enhance their accuracy in predicting the condition and, relatedly, improve their performance in independent cohorts.

Do Adverse Childhood Experiences Modify the Association Between Disaster-Related Trauma and Cognitive Disability?

Identifying subpopulations that are particularly vulnerable to long-term adverse health consequences of disaster-related trauma is needed. We examined whether adverse childhood experiences (ACEs) potentiate the association between disaster-related trauma and subsequent cognitive disability among older adult disaster survivors. Data were from a prospective cohort study of older adults who survived the 2011 Great East Japan Earthquake. The baseline survey pre-dated the disaster by 7 months. We included participants who completed follow-up surveys (2013 and 2016) and did not have a cognitive disability before the disaster (n = 602). Disaster-related traumas (i.e., home loss, loss of friends or pets) and ACEs were retrospectively assessed in 2013. Cognitive disability levels in 2016 were objectively assessed. After adjusting for pre-disaster characteristics using a machine learning-based estimation approach, home loss (0.19, 95% confidence interval (CI): 0.09, 0.28) was, on average, associated with greater cognitive disability. Among individuals with ACEs, home loss was associated with even higher cognitive disability levels (0.64, 95% CI: 0.24, 1.03). Losses of friends (0.18, 95% CI: 0.05, 0.32) and pets (0.13, 95% CI: 0.02, 0.25) were associated with higher cognitive disability levels only among those with ACEs. Our findings suggest that individuals with a history of ACEs may be particularly vulnerable to adverse health consequences related to disasters.

Chronic Pain and Childhood Adversity Experiences Among U.S. Military Personnel

INTRODUCTION

Chronic pain in a military population is prevalent, is costly, and can limit daily activities and affect soldier readiness. It has been associated with childhood adversity (CA) within the veteran, adult, and pediatric populations. Given the need to maximize soldier resiliency, an examination of the link between CA and chronic pain in an active duty population for a better understanding that informs treatment options is warranted.

MATERIALS AND METHODS

The analytic sample comprised 32 men and 8 women drawn from a retrospective review of 203 intake assessments at an interdisciplinary pain management center. We identified a group (CA) of 20 patients who reported a history of pre-adolescent sexual abuse or living in an "abusive" childhood home and compared it with a control group (no-CA) of 20 patients, matched for age, gender, pain history duration, and pain problem. Validated measures were used to assess pain intensity, interference in functioning and well-being, emotional sequelae of pain as reflected in symptoms of depression and anxiety, and pain-related catastrophic thinking. Data were analyzed using descriptive statistics and independent samples t-test analyses.

RESULTS

Differences in current, worst, and average pain ratings were non-significant between groups. The CA group reported significantly greater effect of pain on mood (mean: 6.20 versus 4.25, P < .02) and showed a trend toward higher pain interference in functioning (mean: 17.70 versus 15.05, P = .053). The CA patients had significantly more serious depression (mean: 12.65 versus 4.50, P < .001) and anxiety symptoms (mean: 10.60 versus 2.35, P < .001) and significantly higher pain catastrophizing tendency (mean: 30.05 versus 20.50, P < .03).

CONCLUSIONS

Overall, the findings suggest that childhood trauma should be considered by providers when treating depression and anxiety in soldiers with chronic pain. Being mindful of trauma-informed care may have implications, perhaps, for cases perceived as treatment resistant.

Trauma-Informed Care: A Missing Link in Addressing Burnout

The Covid-19 pandemic and national movements for health equity have highlighted the impact of trauma on public health as well as on health worker well-being. As burnout rates across healthcare climb, we seek creative and effective solutions. Current anti-burnout strategies focus on much needed systems solutions for employee success; however, they often lack a trauma-informed approach. Trauma is highly prevalent in society at large, and health workers are further exposed to trauma in the course of their professional studies and duties. Common symptoms of burnout may actually be manifestations of traumatic stress. Trauma-informed care (TIC) is a strategic framework and growing social movement for providing quality care to survivors of individual, interpersonal, collective, and structural trauma. Importantly, TIC has practical applications to address our healthcare burnout epidemic. In this perspective piece, an expert describes a trauma-informed lens through which to view burnout solutions using SAMHSA's 4 Rs of a trauma-informed approach: 1) Realize the widespread impact of trauma, 2) Recognize the signs and symptoms in patients and staff, 3) Respond by integrating knowledge about trauma into practice, and actively 4) Resist re-traumatization. Moving forward, key stakeholders must collaborate to build and refurbish efficient systems alongside a trauma-informed organizational model. TIC can transform the healthcare experience for patients and employees alike by fostering community, empowerment, and healing.

The Effects of Adverse Childhood Experiences and Warfare Exposure on Military Sexual Trauma Among Veterans

Military sexual trauma (MST) is a pervasive problem; this study examined the relationship of the precursory traumas of adverse childhood experiences (ACEs) and warfare exposure with MST. Post-9/11 veterans were surveyed at 3 months and at 24 to 30 months post-military separation. Female veterans who experienced at least 1 ACE but no warfare exposure were significantly more likely to receive unwanted sexual attention. Veterans (males and females) experiencing three or more ACEs but no warfare exposure were significantly more likely to receive unwanted sexual attention and contact. Experiencing only warfare exposure was not related to unwanted sexual attention or contact for females; however, a significant interaction was found between combined warfare exposure, ACEs, and MST for males and females. Veterans who reported warfare exposure and one to two or three or more ACEs were more likely to report unwanted sexual attention and/or contact. Exploration of individual ACEs revealed a significant relationship between childhood sexual abuse and unwanted sexual contact. For females, witnessing domestic violence predicted unwanted sexual contact. There was also a significant interaction between childhood sexual abuse and warfare exposure. Females who experienced both childhood sexual abuse and warfare exposure were significantly more likely to receive unwanted sexual attention and unwanted sexual contact. Albeit a small sample, males who experienced both were also significantly more likely to receive unwanted sexual attention. The findings reveal that precursory traumatic experiences in childhood and the interaction of ACEs and warfare exposure during military service can increase the likelihood of unwanted sexual attention and contact. This research further substantiates the need for screening efforts. It also demonstrates the importance of practitioners engaging in trauma-informed care principles and practices to address the residual effects of previous experiences during sexual trauma or mental health treatment efforts.

Modelling the neurodevelopmental pathogenesis in neuropsychiatric disorders. Bioactive kynurenines and their analogues as neuroprotective agents-in celebration of 80th birthday of Professor Peter Riederer

Following introduction of the monoamine oxidase type B inhibitor selegiline for the treatment of Parkinson's disease (PD), discovery of the action mechanism of Alzheimer's disease-modifying agent memantine, the role of iron in PD, and the loss of electron transport chain complex I in PD, and development of the concept of clinical neuroprotection, Peter Riederer launched one of the most challenging research project neurodevelopmental aspects of neuropsychiatric disorders. The neurodevelopmental theory holds that a disruption of normal brain development in utero or during early life underlies the subsequent emergence of neuropsychiatric symptoms during later life. Indeed, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Classification of Diseases, 11th Revision categorize autism spectrum disorder and attention deficit hyperactivity disorder in neurodevelopmental disorders (NDDs). More and more evidence, especially from preclinical studies, is revealing that neurodevelopmental pathology is not limited to the diagnostic class above, but also contributes to the development of other psychiatric disorders such as schizophrenia, bipolar disorder, and obsessive-compulsive disorder as well as neurodegenerative diseases such as PD and Huntington's disease. Preclinical animal research is taking a lead in understanding the pathomechanisms of NDDs, searching for novel targets, and developing new neuroprotective agents against NDDs. This narrative review discusses emerging evidence of the neurodevelopmental etiology of neuropsychiatric disorders, recent advances in modelling neurodevelopmental pathogenesis, potential strategies of clinical neuroprotection using novel kynurenine metabolites and analogues, and future research direction for NDDs.

The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans

Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.

Gender Differences in Childhood Maltreatment: A Comparative Study of Nightmare Sufferers and Non-sufferers

Child maltreatment has been identified as a significant problem, both within India and outside. According to UNICEF, over the last decade, there has been a growing recognition about this, but the problem has remained unresolved largely due to being underreported and undocumented. Previous research in this area has reported inconsistent gender differences across the world. Besides, there are shreds of evidence to suggest that childhood maltreatment would be associated with nightmares later in life, but a handful of studies exist in this context. Moreover, there is a paucity of research concerning the interaction effect of gender and group (nightmare sufferer vs non-sufferer) on childhood maltreatment. Owing to the insufficient research and inconsistent findings, the present study aimed to investigate gender differences in childhood maltreatment among nightmare sufferers as compared to non-sufferers. A total of 120 participants were selected from New Delhi. The results of two-way ANOVA suggest that the nightmares later in life would be associated with the abuse and neglect experienced during childhood as nightmare sufferer group reported having higher rates of child abuse and neglect than non-sufferers. It also suggests that male participants in general experience childhood maltreatment more than females; however, emotional abuse was experienced by males only if they belonged to the nightmare sufferer group.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

Associations Between Adverse Childhood Experiences and Adult Health Outcomes: Exploring Gender Differences

Objectives: This study aimed to (1) understand the associations between Adverse Childhood Experiences (ACEs) and poor adult health outcomes, specifically looking at both physical and mental health indicators, and (2) examine gender differences in ACEs’ impact on adult health outcomes.Methods: Data were obtained from the 2012 Korean General Social Survey. The study sample comprised 1,396 individuals aged ≥ 18 years who answered the ACE questionnaire. Controlling for sociodemographic factors, linear regression models were run to estimate the relationships between ACEs and adult physical (self-rated poor physical health status) and mental health indicators (depressive symptoms). Furthermore, the Chow test was carried out to ascertain whether there were any gender differences in ACEs’ impact on both adult physical and mental health outcomes.Results: Higher numbers of ACEs were significantly and positively associated with worse adult physical and mental health outcomes, such as poorer physical health status and higher levels of depressive symptoms compared with individuals who reported no adversities during childhood. In addition, gender differences were identified in ACEs’ impact on both health indicators, suggesting that females were at a higher risk of depression, while males were more likely to experience poor physical health.Conclusion: Adults reporting multiple adversities during childhood are more likely to experience poorer physical and mental health, demonstrating a strong, graded dose-response relationship between the number of ACEs and a range of negative adult health outcomes. Gender differences also exist in ACEs’ impact on adult physical and mental health, thus suggesting the need for gender-based intervention strategies to address ACEs in the adult population.

Adverse Childhood Experience, Genes, and PTSD Risk in Soldiers: A Methylation Study

INTRODUCTION

Epigenetics can serve as a marker of susceptibility to many known psychiatric diseases. DNA methylation patterns of multiple genes have been studied in both civilian populations and military personnel with post-traumatic stress disorder (PTSD). Many of these genes serve various functions that span the hypothalamic-pituitary-adrenal axis, immune system, and central nervous system (CNS) growth factors and neurotransmission. It is thought that the methylation levels of such genes may be able to identify individuals who are at higher risk of developing PTSD. Our study seeks to establish whether previously reported PTSD genes possess a particular methylation pattern that is predictive of PTSD in active duty military members with combat exposure.

MATERIALS AND METHODS

This is an institutional review board (IRB)-approved, cross-sectional, case control, gene-environment interaction study. About 170 active military members with and without PTSD were recruited. Patients with a history of structural brain damage, traumatic brain injury (TBI) resulting in loss of consciousness, predeployment diagnosis of PTSD or anxiety disorder, and predeployment prescription of an antidepressant or psychoactive medication were excluded. Validated measures of childhood trauma and adversity (adverse childhood experience [ACE] score), PTSD symptoms (PTSD check-list military version [PCL-M]), and combat exposure scales (CES) were measured via validated questionnaires for all subjects. After extracting DNA from peripheral blood provided by the 170 subjects, we determined methylation percentages, via pyrosequencing assays, for nine target areas within the following seven genes: BDNF, NR3C1, MAN2C1, TLR8, SLC6A4, IL-18, and SKA2. These genes are commonly reported in the literature as being highly correlated with PTSD and early-life traumatic experiences.Methylation levels were measured as a percentage at specific sites within the previously mentioned genes. Data were examined with SPSS v 22.0 Statistics and JMP v13.1 software using a general linear model for methylation × trauma (CES scores) split by diagnosis of PTSD or not, methylation versus childhood trauma (ACE scores), and methylation versus PTSD severity (PCL-M score). Two-way ANOVA was performed to control for antidepressant use. A two-tailed Student t-test was performed for PTSD analyses and was correlated with PTSD diagnosis, demographic information as well as ACE score, PCL-M score, and CES scores.

RESULTS

Differentially methylated sites that were highly associated with PTSD diagnosis were found in three of seven candidate genes: BDNF, NR3C1, and MAN2C1. When compared to controls, patients with PTSD diagnosis had significantly lower levels of methylation, even after controlling for antidepressant use. PCL-M, ACE, and CES scores were significantly associated with PTSD diagnosis.

CONCLUSION

Our study suggests that methylation of key genes involved in synaptic plasticity and the hypothalamic-pituitary-adrenal axis is associated with lower levels of methylation in military PTSD subjects exposed to combat when compared to their non-PTSD counterparts. Strengths of this study include controlling for antidepressant use and excluding TBI patients. Similar studies in an active duty population of this size are scarce. What is not clear is whether methylation changes are driving PTSD symptomology or whether they are merely a marker of disease. Future areas of research include prospective studies that measure methylation pre- and postcombat exposure in the same individual.

Vulnerability Factors Associated with Lifetime Posttraumatic Stress Disorder among Veterans 40 Years after War

Vulnerability factors for posttraumatic stress disorder (PTSD) development are still controversial. Our aim was to study the vulnerability factors for the development of war-related PTSD over a period of 40 years after exposure. A cross-sectional, observational study was carried out on 61 male traumatized war veterans, taking into consideration adverse childhood experiences (ACE), attachment orientations, number of non-war-related traumatic events, and war experiences. Lifetime PTSD was assessed by using the Clinician-Administered PTSD Scale. Insecure attachment styles were significantly associated with lifetime PTSD and even after adjustment for war exposure this was still significant. Non-war-related traumatic events were not associated with lifetime PTSD, whereas ACE were associated with lifetime PTSD. War-related experiences were also associated with lifetime PTSD, except for injury or disease. The results for our sample show that, 40 years after war, the intensity of war-related experiences and ACE were significantly and independently associated with the development of lifetime PTSD. Insecure attachment was significantly associated with lifetime PTSD, which, in turn, are both positively associated with war exposure. These findings may have implications for patient care, as they constitute a strong argument that attachment-focused therapies could well be necessary 40 years after trauma.

The Buffering Effect of Relationships on Combat Exposure, Military Performance, and Mental Health of U.S. Military Soldiers: A Vantage Point for CFTs

This study examined the role of cumulative combat experiences with regard to military performance and conduct and mental health among a sample of young soldiers from the Army STARRS dataset (N = 5,283). Higher levels of cumulative combat experiences were directly related to poorer performance and conduct and a greater likelihood of anxiety, depression, and post-traumatic stress disorder (PTSD). Military performance and conduct served as a linking mechanism between combat experiences and mental health. Using moderated mediation structural equation modeling, relationship disruptions were found to exacerbate the adverse effects of combat experiences; conversely, unit cohesion buffered the impact of combat experiences. Implications for military helping professionals include identifying leverage points for intervention, particularly strengthening the social connections of service members within and outside the military.

Longitudinal trajectories of comorbid PTSD and depression symptoms among U.S. service members and veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) often co-occurs with other psychiatric disorders, particularly major depressive disorder (MDD). The current study examined longitudinal trajectories of PTSD and MDD symptoms among service members and veterans with comorbid PTSD/MDD.

METHODS

Eligible participants (n = 1704) for the Millennium Cohort Study included those who screened positive at baseline for both PTSD (PTSD Checklist-Civilian Version) and MDD (Patient Health Questionnaire). Between 2001 and 2016, participants completed a baseline assessment and up to 4 follow-up assessments approximately every 3 years. Mixture modeling simultaneously determined trajectories of comorbid PTSD and MDD symptoms. Multinomial regression determined factors associated with latent class membership.

RESULTS

Four distinct classes (chronic, relapse, gradual recovery, and rapid recovery) described symptom trajectories of PTSD/MDD. Membership in the chronic class was associated with older age, service branch, deployment with combat, anxiety, physical assault, disabling injury/illness, bodily pain, high levels of somatic symptoms, and less social support.

CONCLUSIONS

Comorbid PTSD/MDD symptoms tend to move in tandem, and, although the largest class remitted symptoms, almost 25% of participants reported chronic comorbid symptoms across all time points. Results highlight the need to assess comorbid conditions in the context of PTSD. Future research should further evaluate the chronicity of comorbid symptoms over time.

Childhood adversities and psychopathology among military veterans in the US: The mediating role of social networks

Childhood adversities can impact negatively on psychological health across the lifespan. Many military veterans have a history of adverse childhood experiences, which when combined with deployment related traumas, can lead to high levels of psychopathology. Social networks can however be protective. The current study aimed to identify typologies of childhood adversity in U.S. military veterans (n = 3092) and explore relationships between the adversity typologies and PTSD, mood and anxiety disorders, utilising data from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III). The mediating role of quality and quantity of social networks were examined. Latent class analysis identified four adversity classes; 1) baseline, 2) household dysfunction, 3) maltreatment, and 4) multi-adversity. Individuals in the adversity classes (2-4), especially those who experienced multi-adversity had higher rates of psychopathology. The quality of social networks played an important mediating role, while quantity of networks did not. Those who experienced adversity were less likely to have supportive social networks, therefore adversity had both a direct and indirect impact on psychopathology. The findings highlight the importance of developing and maintaining social networks following military life. Recommendations include interpersonal skills training and programmes which may help them engage back into the community and enhance relationships.

A Review of Epigenetics of PTSD in Comorbid Psychiatric Conditions

Post-traumatic stress disorder (PTSD) is an acquired psychiatric disorder with functionally impairing physiological and psychological symptoms following a traumatic exposure. Genetic, epigenetic, and environmental factors act together to determine both an individual's susceptibility to PTSD and its clinical phenotype. In this literature review, we briefly review the candidate genes that have been implicated in the development and severity of the PTSD phenotype. We discuss the importance of the epigenetic regulation of these candidate genes. We review the general epigenetic mechanisms that are currently understood, with examples of each in the PTSD phenotype. Our focus then turns to studies that have examined PTSD in the context of comorbid psychiatric disorders or associated social and behavioral stressors. We examine the epigenetic variation in cases or models of PTSD with comorbid depressive disorders, anxiety disorders, psychotic disorders, and substance use disorders. We reviewed the literature that has explored epigenetic regulation in PTSD in adverse childhood experiences and suicide phenotypes. Finally, we review some of the information available from studies of the transgenerational transmission of epigenetic variation in maternal cases of PTSD. We discuss areas pertinent for future study to further elucidate the complex interactions between epigenetic modifications and this complex psychiatric disorder.

Adverse childhood experiences, exposure to a natural disaster and posttraumatic stress disorder among survivors of the 2011 Great East Japan earthquake and tsunami

AIMS

To investigate whether adverse childhood experiences (ACEs) modify the impact of exposure to a natural disaster (the 2011 Great East Japan earthquake and tsunami) on the occurrence of posttraumatic stress disorder (PTSD) among older people.

METHODS

Data were collected as part of the Japan Gerontological Evaluation Study (JAGES), which is an on-going epidemiological survey investigating social determinants of health among older people across Japan. Information on PTSD symptoms based on the Screening Questionnaire for Disaster Mental Health, traumatic exposure to the earthquake (i.e., house damage and loss of relatives/friends during the earthquake/tsunami) and ACEs was obtained from 580 participants aged 65 or older living in Iwanuma City, Miyagi Prefecture, which suffered severe damage as a result of the earthquake and the subsequent tsunami in March 2011. Associations were examined using Poisson regression analysis with a robust variance estimator after adjusting for covariates.

RESULTS

The prevalence of PTSD was 9.7% in this population; compared to those with no traumatic experience, the prevalence of PTSD was approximately two times higher among those who experienced the loss of close friends/relatives (PR = 1.84, 95% CI = 1.11-3.03, p = 0.018), or whose house was damaged (PR = 2.15, 95% CI = 1.07-4.34, p = 0.032). ACE was not significantly associated with PTSD. Stratified analyses by the presence of ACE showed that damage due to the earthquake/tsunami was associated with PTSD only among those without ACEs; more specifically, among non-ACE respondents the PR of PTSD associated with house damage was 6.67 (95% CI = 1.66-26.80), while for the loss of a relative or a close friend it was 3.56 (95% CI = 1.18-10.75). In contrast, no statistically significant associations were observed among those with ACEs.

CONCLUSION

Following the Great East Japan earthquake/tsunami in 2011 a higher risk of developing PTSD symptoms was observed in 2013 especially among older individuals without ACEs. This suggests that ACEs might affect how individuals respond to subsequent traumatic events later in life.

The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces

Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

Addressing adverse childhood experiences and health risk behaviors among low-income, Black primary care patients: Testing feasibility of a motivation-based intervention

OBJECTIVE

This pilot study tests the feasibility of implementing a two-session intervention that addresses adverse childhood experiences (ACEs), post-traumatic stress symptoms, and health risk behaviors (HRBs) among Black primary care patients. African Americans are disproportionately exposed to stressful and traumatic events and are at greater risk for PTSD than the general population.

METHOD

A prospective cohort, experimental (pre-post) design with 2 post-intervention assessments were used to evaluate the feasibility of a motivation-based intervention for Black primary care patients with one or more ACEs. Indicators of feasibility implementation outcomes were assessed by participant adherence to treatment; suitability, satisfaction, and acceptability of the intervention; in addition to clinical outcomes of stress, HRBs, and behavioral health referral acceptance.

RESULTS

Out of 40 intervention participants, 36 completed the intervention. Of the patients with one or more ACEs who participated in the intervention, 65% reported 4 or more ACEs and 58% had positive PTSD screens, and nearly two-thirds of those had at least one HRB. Satisfaction with the program was high, with 94% of participants endorsing "moderately" or "extremely" satisfied. The sample showed significant post-intervention improvements in stress, alcohol use, risky sex, and nutrition habits. Although stress reduction continued through 2-month follow-up, unhealthy behaviors rebounded. Almost one-third of participants were connected to behavioral health services.

CONCLUSIONS

Brief motivational treatment for ACEs is feasible in underserved primary care patients and could help individuals develop healthier ways of coping with stress and improve health.

Patterns of Adverse Experiences and Health Outcomes Among Women Veterans

INTRODUCTION

Adverse childhood experiences are associated with poor health outcomes in adulthood, such as depression, suicidal behavior, and post-traumatic stress disorder. Subsequent military service may continue trajectories of childhood adversity and contribute to cumulative disadvantage over the life span. This study examines distinct patterns of adversity from childhood through military service and their relationships with adult health and mental health outcomes.

METHODS

The study used data from a nationally representative survey (conducted in 2012, analysis in 2016) with >6,000 women primary care users in the Veterans Health Administration, and linked to data from electronic medical records. Latent class analysis was used to derive qualitatively distinct patterns of adverse experiences and logistic regression to model odds of past-year health conditions, comparing effect sizes across classes.

RESULTS

Prevalence of both childhood and military adverse events was high. Five meaningful classes of adversity were observed, characterized by low adversity across all events, high adversity across all events, extreme high adversity across all events, adverse family context, and a class characterized primarily by adverse military experiences. Odds of past-year diagnoses of depression, anxiety, post-traumatic stress disorder, substance use disorder, and comorbid mental health and chronic health conditions significantly differed across classes.

CONCLUSIONS

Among women Veterans Health Administration users, examination of qualitatively distinct patterns of adversity yielded more meaningful results than counting the number of adverse events. Given the high incidence of adverse experiences, Veterans Health Administration is positioned to respond with secondary prevention and a universal trauma precautions approach to all care for women Veterans.

The Relationship of Childhood Adversity on Burnout and Depression Among BSN Students

BACKGROUND

Research evidence strongly suggests that Adverse Childhood Experiences (ACEs) predispose individuals to development of an increased sensitivity to stress and negative physical and mental health outcomes in adulthood.

PURPOSE

To determine if there was a relationship between the number of ACEs reported by first semester BSN students and their reported level of Burnout and Depression.

METHODS

211 students enrolled in the first semester of upper division courses of their BSN program completed self-report questionnaires which measured the number of ACEs, the level of Depression and the level of Burnout.

RESULTS

The number of reported ACEs by participants had a significant relationship on the levels of burnout and severity of depressive symptoms. Female students with a higher number of ACEs were more likely to report higher levels of Burnout A (Emotional Exhaustion) and Burnout B (Depersonalization), and higher depression severity scores compared to males.

CONCLUSION

Nursing programs should educate faculty concerning the frequency and range of adverse experiences that students may have had prior to admission to the nursing program, and the possible relationship with Burnout and Depression. Faculty can provide early information on counseling and support services.

Predictors of Posttraumatic Stress Disorder, Anxiety Disorders, Depressive Disorders, and Any Mental Health Condition Among U.S. Soldiers and Marines, 2001-2011

Understanding mental health disorder diagnosis and treatment seeking among active-duty military personnel is a topic with both clinical and policy implications. It has been well documented in military populations that individual-level military experience, including deployment history and combat exposure, influences mental health outcomes, but the impact of unit-level factors is less well understood. In the current study, we used administrative longitudinal data to examine a comprehensive set of unit- and individual-level predictors of posttraumatic stress disorder (PTSD), non-PTSD anxiety disorders, depressive disorders, and overall mental health diagnoses among Army and Marines Corps personnel. Using Cox survival models for time-dependent variables, we analyzed time from military accession (between January 1, 2001 and December 31, 2011) until first mental health diagnosis for 773,359 soldiers and 332,093 Marines. Prior diagnosis of a substance abuse disorder during one's military career, hazard ratios (HRs) = 1.68-3.10, and cumulative time spent deployed, HRs = 1.11-2.04, were the most predictive risk factors for all outcomes. Male sex, HRs = 0.35-0.57, and officer rank, HRs = 0.13-0.23, were the most protective factors. Unit-level rate of high deployment stress was a small but significant predictor of all outcomes after controlling for individual-level deployment history and other predictors, HRs = 1.01-1.05. Findings suggest both unit- and individual-level risk and protective factors of mental health diagnoses associated with treatment seeking. Clinical, including mental health assessment and management, and policy implications related to the military environment and the individual as it relates to mental health disorders are discussed.

Analysis and determinants of Chinese navy personnel health status: a cross-sectional study

BACKGROUND

There have been very few studies analyzing the relationship of physical and mental health status with health behaviors and deployment status in Chinese navy personnel. Thus, we undertook this survey to assess this relationship and identify specific factors affecting the physical and mental health status.

METHODS

The subjects enrolled in this study were selected from four units of the active-duty navy personnel in China, based on a cluster random sampling design. A total of 1200 Chinese navy personnel participated and completed the questionnaire survey that included veteran SF-36 form and a self-designed questionnaire regarding their sociodemographic characteristics, deployment status, self-rated health status and health behaviors. Totally 1200 questionnaires were distributed to different participants, while 1083 valid questionnaires were included in the final analysis. All data were analyzed using SPSS18.0 software.

RESULTS

Based on the information provided by navy personnel, 17.82, 35.09 and 23.08% rated their health as excellent, very good and good, respectively. The mean score of physical component summary (PCS) and mental component summary (MCS) was 50.53 and 41.39, respectively. Length of service, binge drinking, regular drinking and BMI appeared to be associated with PCS score, while household income, binge drinking and BMI affected MCS score. Deployment status and smoking exhibited no significant association with PCS and MCS scores.

CONCLUSIONS

Our study suggested that the sociodemographic factors like length of service and household income, along with behavioral risk factors like binge drinking, regular drinking and body mass index (BMI), seem to affect the physical and mental health status of Chinese navy personnel. However, additional data collection and more detailed analysis would still be required to develop a systematic, comprehensive and corresponding health education program to promote overall health status.

Reduced levels of miRNAs 449 and 34 in sperm of mice and men exposed to early life stress

Exposure of male mice to early life stress alters the levels of specific sperm miRNAs that promote stress-associated behaviors in their offspring. To begin to evaluate whether similar phenomena occur in men, we searched for sperm miRNA changes that occur in both mice and men exposed to early life stressors that have long-lasting effects. For men, we used the Adverse Childhood Experience (ACE) questionnaire. It reveals the degree of abusive and/or dysfunctional family experiences when young, which increases risks of developing future psychological and physical disorders. For male mice, we used adolescent chronic social instability (CSI) stress, which not only enhances sociability defects for >1 year, but also anxiety and defective sociability in female offspring for multiple generations through the male lineage. Here we found a statistically significant inverse correlation between levels of multiple miRNAs of the miR-449/34 family and ACE scores of Caucasian males. Remarkably, we found members of the same sperm miRNA family are also reduced in mice exposed to CSI stress. Thus, future studies should be designed to directly test whether reduced levels of these miRNAs could be used as unbiased indicators of current and/or early life exposure to severe stress. Moreover, after mating stressed male mice, these sperm miRNA reductions persist in both early embryos through at least the morula stage and in sperm of males derived from them, suggesting these miRNA changes contribute to transmission of stress phenotypes across generations. Since offspring of men exposed to early life trauma have elevated risks for psychological disorders, these findings raise the possibility that a portion of this risk may be derived from epigenetic regulation of these sperm miRNAs.

Differences by Veteran/civilian status and gender in associations between childhood adversity and alcohol and drug use disorders

PURPOSE

To examine differences by US military Veteran status and gender in associations between childhood adversity and DSM-5 lifetime alcohol and drug use disorders (AUD/DUD).

METHODS

We analyzed nationally representative data from 3119 Veterans (n = 379 women; n = 2740 men) and 33,182 civilians (n = 20,066 women; n = 13,116 men) as provided by the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). We used weighted multinomial logistic regression, tested interaction terms, and calculated predicted probabilities by Veteran status and gender, controlling for covariates. To test which specific moderation contrasts were statistically significant, we conducted pairwise comparisons.

RESULTS

Among civilians, women had lower AUD and DUD prevalence than men; however, with more childhood adversity, this gender gap narrowed for AUD and widened for DUD. Among Veterans, in contrast, similar proportions of women and men had AUD and DUD; with more childhood adversity, AUD-predicted probability among men surpassed that of women. Childhood adversity elevated AUD probability among civilian women to levels exhibited by Veteran women. Among men, Veterans with more childhood adversity were more likely than civilians to have AUD, and less likely to have DUD.

CONCLUSIONS

Childhood adversity alters the gender gap in AUD and DUD risk, and in ways that are different for Veterans compared with civilians. Department of Defense, Veterans Affairs, and community health centers can prevent and ameliorate the harmful effects of childhood adversity by adapting existing behavioral health efforts to be trauma informed, Veteran sensitive, and gender tailored.

The Stress Acceleration Hypothesis of Nightmares

Adverse childhood experiences can deleteriously affect future physical and mental health, increasing risk for many illnesses, including psychiatric problems, sleep disorders, and, according to the present hypothesis, idiopathic nightmares. Much like post-traumatic nightmares, which are triggered by trauma and lead to recurrent emotional dreaming about the trauma, idiopathic nightmares are hypothesized to originate in early adverse experiences that lead in later life to the expression of early memories and emotions in dream content. Accordingly, the objectives of this paper are to (1) review existing literature on sleep, dreaming and nightmares in relation to early adverse experiences, drawing upon both empirical studies of dreaming and nightmares and books and chapters by recognized nightmare experts and (2) propose a new approach to explaining nightmares that is based upon the Stress Acceleration Hypothesis of mental illness. The latter stipulates that susceptibility to mental illness is increased by adversity occurring during a developmentally sensitive window for emotional maturation—the infantile amnesia period—that ends around age 3½. Early adversity accelerates the neural and behavioral maturation of emotional systems governing the expression, learning, and extinction of fear memories and may afford short-term adaptive value. But it also engenders long-term dysfunctional consequences including an increased risk for nightmares. Two mechanisms are proposed: (1) disruption of infantile amnesia allows normally forgotten early childhood memories to influence later emotions, cognitions and behavior, including the common expression of threats in nightmares; (2) alterations of normal emotion regulation processes of both waking and sleep lead to increased fear sensitivity and less effective fear extinction. These changes influence an affect network previously hypothesized to regulate fear extinction during REM sleep, disruption of which leads to nightmares. This network consists of a fear circuit that includes amygdala, hippocampus, and medial prefrontal cortex and whose substantial overlap with the stress acceleration findings allows the latter to be incorporated into a wider, more developmentally coherent framework.

Social Support, Help-Seeking, and Mental Health Outcomes Among Veterans in Non-VA Facilities: Results from the Veterans' Health Study

Using a stress process model, the authors examined social and psychological resources to better understand mental health outcomes among veterans. For this study, we surveyed 700 U.S. veterans who were outpatients in the Geisinger Health System. Independent variables included demographic factors, stressful and traumatic events, social support measures, and psychosocial factors. Using logistic regression, the authors examined 4 types of social connections: social support, help-seeking support, social capital, and other mental health support to predict mental health outcomes, including posttraumatic stress disorder, depression, suicide ideation, alcohol misuse, mental health service use, and Veterans Affairs service use. Results suggested that help-seeking support since deployment was a risk factor for 5 adverse outcomes, whereas social support was protective for 1 outcome. We concluded that high levels of help-seeking support since deployment among veterans was associated with a higher prevalence of mental health problems. These findings were unexpected and suggest the need for additional social support-related research among veterans.

An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review

IMPORTANCE

Posttraumatic stress disorder (PTSD) is a common psychiatric illness, increasingly in the public spotlight in the United States due its prevalence in the soldiers returning from combat in Iraq and Afghanistan. This educational review presents a contemporary approach for how to incorporate a modern neuroscience perspective into an integrative case formulation. The article is organized around key neuroscience "themes" most relevant for PTSD. Within each theme, the article highlights how seemingly diverse biological, psychological, and social perspectives all intersect with our current understanding of neuroscience.

OBSERVATIONS

Any contemporary neuroscience formulation of PTSD should include an understanding of fear conditioning, dysregulated circuits, memory reconsolidation, epigenetics, and genetic factors. Fear conditioning and other elements of basic learning theory offer a framework for understanding how traumatic events can lead to a range of behaviors associated with PTSD. A circuit dysregulation framework focuses more broadly on aberrant network connectivity, including between the prefrontal cortex and limbic structures. In the process of memory reconsolidation, it is now clear that every time a memory is reactivated it becomes momentarily labile-with implications for the genesis, maintenance, and treatment of PTSD. Epigenetic changes secondary to various experiences, especially early in life, can have long-term effects, including on the regulation of the hypothalamic-pituitary-adrenal axis, thereby affecting an individual's ability to regulate the stress response. Genetic factors are surprisingly relevant: PTSD has been shown to be highly heritable despite being definitionally linked to specific experiences. The relevance of each of these themes to current clinical practice and its potential to transform future care are discussed.

CONCLUSIONS AND RELEVANCE

Together, these perspectives contribute to an integrative, neuroscience-informed approach to case formulation and treatment planning. This may help to bridge the gap between the traditionally distinct viewpoints of clinicians and researchers.

Resilience Mediates Impact of Some Childhood Maltreatment on Post-Traumatic Stress Symptoms in Conscripted Marines in the Republic of Korea

Although it is known that post-traumatic stress symptoms (PTSS) can result from military service, the variance in PTSS unexplained by military service warrants further investigation, and no researchers have investigated South Korean Marines' vulnerability during their 2-year conscripted service as the first line of national defense against threats from North Korea. This study was designed to examine whether resilience mediated the relationship between childhood maltreatment and PTSS in 169 Korean conscripts into the Marine Corps. In a cross-sectional study design, the Childhood Trauma Questionnaire-Short Form was used to measure childhood maltreatment, including abuse and neglect. The Impact of Event Scale-Revised and the Connor-Davidson Resilience Scale were used to measure PTSS and resilience. Structural equation modeling was used for data analysis. Half the conscripts reported at least one type of childhood maltreatment, and 22.3% had high PTSS, even in a short period of service. Childhood abuse was significantly associated with PTSS during military service, a relationship that was not mediated by resilience. However, resilience mediated the relationship between childhood neglect and PTSS during military service. Assessment of childhood maltreatment and resilience prior to military service is crucial for identifying conscripts at increased risk for PTSS during even brief military service. In addition to direct interventions for abuse effects among all Marines, interventions enhancing resilience may benefit conscripts who experienced childhood neglect. © 2016 Wiley Periodicals, Inc.

Resilience: A psychobiological construct for psychiatric disorders

Understanding of psychopathology of mental disorder is evolving, particularly with availability of newer insight from the field of genetics, epigenetics, social, and environmental pathology. It is now becoming clear how biological factors are contributing to development of an illness in the face of a number of psychosocial factors. Resilience is a psychobiological factor which determines individual's response to adverse life events. Resilience is a human capacity to adapt swiftly and successfully to stressful/traumatic events and manage to revert to a positive state. It is fundamental for growth of positive psychology which deals with satisfaction, adaptability, contentment, and optimism in people's life. Of late, there has been a paradigm shift in the understanding of resilience in context of stress risk vulnerability dimension. It is a neurobiological construct with significant neurobehavioral and emotional features which plays important role in deconstructing mechanism of biopsychosocial model of mental disorders. Resilience is a protective factor against development of mental disorder and a risk factor for a number of clinical conditions, e.g. suicide. Available information from scientific studies points out that resilience is modifiable factor which opens up avenues for a number of newer psychosocial as well as biological therapies. Early identification of vulnerable candidates and effectiveness of resilience-based intervention may offer more clarity in possibility of prevention. Future research may be crucial for preventive psychiatry. In this study, we aim to examine whether resilience is a psychopathological construct for mental disorder.

Nursing students' post-traumatic growth, emotional intelligence and psychological resilience

Nursing students in the present sample who have experienced childhood adversity have a certain level of post-traumatic growth. If introduced into nursing curricula, emotional intelligence interventions may increase emotional coping resources and enhance social skills for nurses, which may benefit their long-term occupational health. As researchers consider personal resilience a strategy for responding to workplace adversity in nurses, resilience building should be incorporated into nursing education. This is a preliminary study that may guide future investigations of the curvilinear relationship rather than linear relationship between post-traumatic growth and positive factors in the special sample of nursing students. Resilience, emotional intelligence and post-traumatic growth may benefit nursing students' careers and personal well-being in clinical work. Developing both their emotional intelligence and resilience may assist their individual post-traumatic growth and enhance their ability to cope with clinical stress. To investigate the relationships among post-traumatic growth, emotional intelligence and psychological resilience in vocational school nursing students who have experienced childhood adversities, a cross-sectional research design with anonymous questionnaires was conducted and self-report data were analysed. The Childhood Adversities Checklist (Chinese version), Posttraumatic Growth Inventory, Emotional Intelligence Scale and the 10-item Connor-Davidson Resilience Scale were used. Survey data were collected from 202 Chinese vocational school nursing students during 2011. Post-traumatic growth was associated with emotional intelligence and psychological resilience. Results indicated a curvilinear relationship between emotional intelligence and post-traumatic growth, and between psychological resilience and post-traumatic growth. Moderate-level emotional intelligence and psychological resilience were most associated with the greatest levels of growth. The results imply that moderate resilience and emotional intelligence can help nursing students cope with adversity in their future clinical work. This study first provided preliminary data suggesting the curvilinear relationship rather than linear relationship between post-traumatic growth and positive factors in the sample of nursing students.

A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans

Post-traumatic stress disorder (PTSD), a complex and chronic disorder caused by exposure to a traumatic event, is a common psychological result of current military operations. It causes substantial distress and interferes with personal and social functioning. Consequently, identifying the risk factors that make military personnel and veterans more likely to experience PTSD is of academic, clinical, and social importance. Four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) were used to search for observational studies (cross-sectional, retrospective, and cohort studies) about PTSD after deployment to combat areas. The literature search, study selection, and data extraction were conducted by two of the authors independently. Thirty-two articles were included in this study. Summary estimates were obtained using random-effects models. Subgroup analyses, sensitivity analyses, and publication bias tests were performed. The prevalence of combat-related PTSD ranged from 1.09% to 34.84%. A total of 18 significant predictors of PTSD among military personnel and veterans were found. Risk factors stemming from before the trauma include female gender, ethnic minority status, low education, non-officer ranks, army service, combat specialization, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems. Various aspects of the trauma period also constituted risk factors. These include increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma, and deployment-related stressors. Lastly, lack of post-deployment support during the post-trauma period also increased the risk of PTSD. The current analysis provides evidence of risk factors for combat-related PTSD in military personnel and veterans. More research is needed to determine how these variables interact and how to best protect against susceptibility to PTSD.

Disparities in adverse childhood experiences among individuals with a history of military service

IMPORTANCE

Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data.

OBJECTIVE

To compare the prevalence of ACEs among individuals with and without a history of military service.

DESIGN, SETTING, AND PARTICIPANTS

Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973.

MAIN OUTCOMES AND MEASURES

History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex.

RESULTS

Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras.

CONCLUSIONS AND RELEVANCE

Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.

Childhood maltreatment in adult offspring of Portuguese war veterans with and without PTSD

BACKGROUND

The colonial war that Portugal was involved in between 1961 and 1974 had a significant impact on veterans and their families. However, it is unclear what the consequences of this war are, in particular with regard to levels of childhood maltreatment (CM) in offspring.

OBJECTIVE

Our study aims to analyze the influences of fathers' war exposure and posttraumatic stress disorder (PTSD) on the offspring's CM and simultaneously test the hypothesis of the intergenerational transmission of father-child CM.

METHOD

Cross-sectional data were collected, using the Childhood Trauma Questionnaire-Short Form, from 203 adult children and 117 fathers. Subjects were distributed according to three conditions based on the father's war exposure status: did not participate in war, or non-war-exposed (NW); participated in war, or war-exposed (W); and war-exposed with PTSD diagnosis (WP). The data were examined using correlations, variance/covariance, and regression analyses.

RESULTS

Children of war veterans with PTSD reported more emotional and physical neglect, while their fathers reported increased emotional and physical abuse exposure during their own childhood. Significant father-child CM correlations were found in the war veteran group but less in the war veteran with PTSD group. Father CM predicted 16% of offspring CM of children of war veterans.

CONCLUSIONS

The father's war-related PTSD might be a risk factor for offspring neglect but potentially a protective one for the father-child abuse transmission. War-exposed fathers without PTSD did transmit their own CM experiences more often. Therefore, father's war exposure and father's war PTSD may each be important variables to take into account in the study of intergenerational transmission of CM.

Relationship of early-life stress and resilience to military adjustment in a young adulthood population

PURPOSE

Early-life stress (ELS) may mediate adjustment problems while resilience may protect individuals against adjustment problems during military service. We investigated the relationship of ELS and resilience with adjustment problem factor scores in the Korea Military Personality Test (KMPT) in candidates for the military service.

METHODS

Four hundred and sixty-one candidates participated in this study. Vulnerability traits for military adjustment, ELS, and resilience were assessed using the KMPT, the Korean Early-Life Abuse Experience Questionnaire, and the Resilience Quotient Test, respectively. Data were analyzed using multiple linear regression analyses.

RESULTS

The final model of the multiple linear regression analyses explained 30.2 % of the total variances of the sum of the adjustment problem factor scores of the KMPT. Neglect and exposure to domestic violence had a positive association with the total adjustment problem factor scores of the KMPT, but emotion control, impulse control, and optimism factor scores as well as education and occupational status were inversely associated with the total military adjustment problem score.

CONCLUSIONS

ELS and resilience are important modulating factors in adjusting to military service. We suggest that neglect and exposure to domestic violence during early life may increase problem with adjustment, but capacity to control emotion and impulse as well as optimistic attitude may play protective roles in adjustment to military life. The screening procedures for ELS and the development of psychological interventions may be helpful for young adults to adjust to military service.

Deployment-related insomnia in military personnel and veterans

Insomnia is a prevalent disorder that greatly impacts military personnel, especially those deployed in support of combat efforts. Deployment-related stressors like combat exposure, mild traumatic brain injury (mTBI) irregular sleep-wake schedules, and adjustment to the return home all contribute to insomnia. However, insomnia can also exacerbate the deployment experience and is a risk factor for traumatic stress reactions such as PTSD, depression, and suicide. Military personnel with mTBI are significantly impacted by insomnia; the majority experience sleep disruption and this can impede recovery and rehabilitation. As more service members return home from deployment, treatment is vital to reduce the impact of insomnia. Preliminary outcome data, showing positive results for reduction of sleep disruption, has been found with treatments such as combined cognitive behavioral treatment of insomnia (CBTI) and imagery rehearsal therapy (IRT), preference-based interventions, as well as efforts to broadly disseminate CBTI. The recent literature on the impact and treatment of deployment-related insomnia is reviewed.

Gender differences of postdeployment post-traumatic stress disorder among service members and veterans of the Iraq and Afghanistan conflicts

Despite the marked expansion of roles for women in the US military over the last decade, whether differences by gender exist in regard to the development of mental health conditions postdeployment is unclear. This comprehensive review of the literature (2001-2012) examined whether US servicewomen were more likely than men to experience post-traumatic stress disorder (PTSD) after returning from deployments to the Iraq and Afghanistan conflicts. Findings from 18 studies from 8 unique study populations were reviewed. Seven studies found that women had a higher risk for screening positive for PTSD compared with men, including prospectively designed studies that evaluated new-onset PTSD among members from all service branches. Although results from studies with Veterans Affairs samples found women at decreased risk in 4 analyses, these studies used the same source databases, were conducted in treatment-seeking populations, and were mostly unable to account for combat experience. Seven studies detected no differences by gender. In summary, women appeared to have a moderately higher risk for postdeployment PTSD, although there was a lack of consensus among the studies, and even those with the most rigorous methods were not designed specifically to evaluate potential gender differences. Given the limitations of the published literature, further research should use longitudinal study designs and comprehensive evaluations of deployment experiences while adjusting for predeployment factors to confirm that gender differences exist with regard to postdeployment PTSD.

Early adversity and combat exposure interact to influence anterior cingulate cortex volume in combat veterans

Objective

Childhood and combat trauma have been observed to interact to influence amygdala volume in a sample of U.S. military veterans with and without PTSD. This interaction was assessed in a second, functionally-related fear system component, the pregenual and dorsal anterior cingulate cortex, using the same sample and modeling approach.

Method

Anterior cingulate cortical tissues (gray + white matter) were manually-delineated in 1.5 T MR images in 87 U.S. military veterans of the Vietnam and Persian Gulf wars. Hierarchical multiple regression modeling was used to assess associations between anterior cingulate volume and the following predictors, trauma prior to age 13, combat exposure, the interaction of early trauma and combat exposure, and PTSD diagnosis.

Results

As previously observed in the amygdala, unique variance in anterior cingulate cortical volume was associated with both the diagnosis of PTSD and with the interaction of childhood and combat trauma. The pattern of the latter interaction indicated that veterans with childhood trauma exhibited a significant inverse linear relationship between combat trauma and anterior cingulate volume while those without childhood trauma did not. Such associations were not observed in hippocampal or total cerebral tissue volumes.

Conclusions

In the dorsal anterior cingulate cortex, as in the amygdala, early trauma may confer excess sensitivity to later combat trauma.

•

Childhood and combat trauma may interact to influence anterior cingulate cortex.

•

These findings partially replicate findings in amygdala.

•

Formally similar relations are found in endocrinological and psychometric data.