Measurement Models of Child Maltreatment and Associations With Suicidal Ideation Endorsement by Youth in Foster Care: A Multiverse Analytic Approach

Youth suicidal ideation is a prevalent experience, particularly among youth exposed to maltreatment, with a variety of indicators such as youth statements of ideation. To better understand suicidal ideation, and the associations with youth mental health outcomes, a fruitful path may be through the study of the dimensions (e.g., severity, frequency) of maltreatment exposure. While there exists extensive work on methods to best operationalize casefile records of maltreatment, such work has not been undertaken for youth self-reports, which are an important indicator of youth functioning following exposure. To address the lack of clarity of how to best operationalize youth self-reports of maltreatment, a multiverse analytic approach was taken to operationalize severity and frequency in a sample of 471 8- to 17-year-old children in foster care. We examined differences across measurement models and the models' associations with caregiver reports of youth suicidal ideation statements. Results indicate that the operationalizations used to define maltreatment resulted in differing measurement models that further differed in their associations with reports of youth suicidal ideation. This study highlights the importance of how researchers operationalize their data and the role dimensions of maltreatment have in further elucidating differential outcomes for youth exposed to maltreatment.

Elucidating behavioral and functional connectivity markers of aberrant threat discrimination in PTSD

BACKGROUND

Patients with posttraumatic stress disorder (PTSD) tend to overgeneralize threat to safe stimuli, potentially reflecting aberrant stimuli discrimination. Yet, it is not clear whether threat overgeneralization reflects general discrimination deficits, or rather a specific bias related to aversive stimuli. Here we tested this question and characterized the neural correlates of threat discrimination.

METHODS

One-hundred and eight participants (33 PTSD; 43 trauma-exposed controls; 32 healthy controls) completed an emotionally neutral complex shape discrimination task involving identifying in 42 similar pairs the previously observed shape; and an emotionally aversive discrimination task, involving providing risk ratings for an aversive conditioned stimulus (CS+), and for several stimuli gradually differing in size from the original CS+. Resting state functional connectivity (rsFC) was collected before completing the tasks.

RESULTS

No group differences emerged on the emotionally neutral task. Conversely, on the emotionally aversive task, individuals with PTSD had steeper linear risk rating slopes as the stimuli more resembled the conditioned stimulus. Finally, lower rsFC of amygdala-default mode network (DMN) and DMN-salience network (SN) were associated with steeper risk slopes, while for hippocampus-SN, lower rsFC was found only among participants with PTSD.

CONCLUSIONS

Individuals with PTSD show deficits in discrimination only when presented with aversive stimuli. Dysregulated discrimination pattern may relate to a lack of input from regulatory brain areas (e.g., DMN/hippocampus) to threat-related brain areas (e.g., SN/amygdala).

Sequential fear generalization and network connectivity in trauma exposed humans with and without psychopathology

While impaired fear generalization is known to underlie a wide range of psychopathology, the extent to which exposure to trauma by itself results in deficient fear generalization and its neural abnormalities is yet to be studied. Similarly, the neural function of intact fear generalization in people who endured trauma and did not develop significant psychopathology is yet to be characterized. Here, we utilize a generalization fMRI task, and a network connectivity approach to clarify putative behavioral and neural markers of trauma and resilience. The generalization task enables longitudinal assessments of threat discrimination learning. Trauma-exposed participants (TE; N = 62), compared to healthy controls (HC; N = 26), show lower activity reduction in salience network (SN) and right executive control network (RECN) across the two sequential generalization stages, and worse discrimination learning in SN measured by linear deviation scores (LDS). Comparison of resilient, trauma-exposed healthy control participants (TEHC; N = 31), trauma exposed individuals presenting with psychopathology (TEPG; N = 31), and HC, reveals a resilience signature of network connectivity differences in the RECN during generalization learning measured by LDS. These findings may indicate a trauma exposure phenotype that has the potential to advance the development of innovative treatments by targeting and engaging specific neural dysfunction among trauma-exposed individuals, across different psychopathologies.

Treatment dropout among veterans and their families: Quantitative and qualitative findings

BACKGROUND

Psychotherapy noncompletion rates for veterans and their families are high. This study sought to (a) measure noncompletion rates of such patients at a university-based treatment center, (b) compare veteran and family member attrition rates, (c) identify dropout predictors, and (d) explore clinicians' perspectives on treatment noncompletion.

METHOD

Using quantitative and qualitative approaches, we analyzed demographic and clinical characteristics of 141 patients (90 military veterans; 51 family members) in a university treatment center. We defined dropout as not completing the time-limited therapy contract. Reviewing semistructured interview data assessing clinicians' perspectives on their patients' dropout, three independent raters agreed on key themes, with interrater coefficient kappa range .74 to 1.

RESULTS

Patient attrition was 24%, not differing significantly between veterans and family members. Diagnosis of major depression (MDD) and exposure-based therapies predicted noncompletion, as did higher baseline Hamilton Depression Rating Scale (HDRS) total scores, severe depression (HDRS > 20), lack of Beck Depression Inventory weekly improvement, and history of military sexual trauma. Clinicians mostly attributed noncompletion to patient difficulties coping with intense emotions, especially in exposure-based therapies.

CONCLUSION

Noncompletion rate at this study appeared relatively low compared to other veteran-based treatment centers, if still unfortunately substantial. Patients with comorbid MDD/PTSD and exposure-based therapies carried greater noncompletion risk due to the MDD component, and this should be considered in treatment planning. Ongoing discussion of dissatisfaction and patient discontinuation, in the context of a strong therapeutic alliance, might reduce noncompletion in this at-risk population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Equine-Assisted Therapy for Posttraumatic Stress Disorder Among Military Veterans: An Open Trial

Objective: As veterans have high rates of posttraumatic stress disorder (PTSD) and historically poor treatment outcomes and high attrition, alternative treatments have gained much popularity despite lack of rigorous research. In this study, a recently developed and manualized 8-session group Equine-Assisted Therapy for PTSD (EAT-PTSD) was tested in an open trial to assess its preliminary feasibility, acceptability, and outcomes for military veterans. Methods: The study was conducted from July 2016 to July 2019. Sixty-three treatment-seeking veterans with PTSD enrolled. PTSD diagnosis was ascertained using the Structured Clinical Interview for DSM-5, Research Version (SCID-5-RV) and confirmed using the Clinician-Administered PTSD Scale (CAPS-5). Mean age was 50 years, and 23 patients (37%) were women. Clinician and self-report measures of PTSD and depression were assessed at pretreatment, midtreatment, and posttreatment and at a 3-month follow-up. An intent-to-treat analysis and a secondary analysis of those who completed all 4 clinical assessments were utilized. Results: Only 5 patients (8%) withdrew from treatment, 4 before midtreatment and 1 afterward. Posttreatment assessment revealed marked reductions in both clinician-rated and self-reported PTSD and depression symptoms, which persisted at 3-month follow-up. Specifically, mean (SD) CAPS-5 scores fell from 38.6 (8.1) to 26.9 (12.4) at termination. Thirty-two patients (50.8%) showed clinically significant change (≥ 30% decrease in CAPS-5 score) at posttreatment and 34 (54.0%) at follow-up. Conclusions: Manualized EAT-PTSD shows promise as a potential new intervention for veterans with PTSD. It appears safe, feasible, and clinically viable. These preliminary results encourage examination of EAT-PTSD in larger, randomized controlled trials. Trial Registration: ClinicalTrials.gov identifier: NCT03068325.

Interpersonal Psychotherapy of Posttraumatic Stress Disorder for Veterans and Family Members: An Open Trial

OBJECTIVE

Military service members and veterans have high rates of posttraumatic stress disorder (PTSD), as do military family members. Exposure-based, cognitive-behavioral approaches have received ample research, but other PTSD therapies require further empirical attention. Interpersonal psychotherapy (IPT) targets affective awareness, life circumstances, and social support. IPT has shown efficacy for civilians with PTSD but awaits rigorous testing among military personnel; only two small military pilot studies and two case reports have been published. Military family members have received minimal attention from clinical outcomes research. Addressing these gaps, this open trial examined IPT for PTSD among veterans, service members, and family members, including a patient subset with comorbid PTSD and depression.

METHODS

Fifty U.S. military service members, veterans, and family members (age ≥18 years) were offered 14 sessions of IPT for PTSD. Individuals with psychosis, bipolar disorder, moderate or severe substance use disorders, or high suicide risk were excluded. PTSD and depressive symptoms were assessed at baseline, midtreatment, posttreatment, and 3-month follow-up.

RESULTS

Clinician-assessed PTSD (Clinician-Administered PTSD Scale) and depression (Hamilton Depression Rating Scale) symptoms decreased over time in the full sample and the comorbid PTSD/depression subset (p<0.05). Service members, veterans, and family members had similar treatment responses.

CONCLUSIONS

Patients receiving IPT showed reductions in PTSD and depressive symptoms. These open trial findings provide preliminary support for the utility of IPT in reducing PTSD symptoms among veterans and family members. This largest IPT trial to date for PTSD in military patients also bolsters the literature on treating military family members.

Separation anxiety in PTSD: A pilot study of mechanisms in patients undergoing IPT

INTRODUCTION

Separation anxiety disorder (SAD) comprises one aspect of attachment dysregulation or insecurity. Although SAD aggravates posttraumatic stress disorder (PTSD) risk, no clinical research has tracked how many patients with PTSD have SAD, its clinical associations, or its response to PTSD treatment. Our open trial of interpersonal psychotherapy (IPT) for veterans with PTSD assessed these SAD domains.

METHODS

Twenty-nine veterans diagnosed with chronic PTSD on the Clinician-Administered PTSD Scale were assessed for SAD using the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and for Symptom-Specific Reflective Function (SSRF), another dysregulated-attachment marker capturing patients' emotional understanding of their symptoms. Patients received 14 IPT sessions for PTSD with assessments at baseline, Week 4 (SCI-SAS and SSRF), and termination for SAD, PTSD, and depression.

RESULTS

At baseline, 69% of patients met SAD criteria. Separation anxiety did not correlate with baseline PTSD severity, depressive severity, or age when traumatized; patients with and without SAD had comparable PTSD and depression severity. Patients with baseline comorbid SAD who completed IPT (N = 17) reported significantly improved adult separation anxiety (p = .009). Adult SAD improvements predicted depressive improvement (p = .049). Patients with SAD showed a stronger relationship between early SSRF gains and subsequent adult SAD improvement (p = .021) compared with patients without SAD.

DISCUSSION

This first exploration of dysregulated/insecure attachment features among patients with PTSD found high SAD comorbidity and adult SAD improvement among patients with SAD following IPT. Highly impaired attachment patients normalized attachment posttreatment: 14-session IPT improved attachment dysregulation. This small study requires replication but begins to broaden clinical understanding of separation anxiety, attachment dysregulation, and PTSD.