Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans

This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD (κ(.5) = .58). Overall, the findings suggest that the PCL-5 is a psychometrically sound instrument that can be used effectively with veterans. Further, by determining a valid cutoff score using the CAPS-5, the PCL-5 can now be used to identify veterans with probable PTSD. However, findings also suggest the need for research to evaluate cluster structure of DSM-5. (PsycINFO Database Record

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans

The Clinician-Administered PTSD Scale (CAPS) is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder (PTSD). The CAPS was recently revised to correspond with PTSD criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This article describes the development of the CAPS for DSM-5 (CAPS-5) and presents the results of an initial psychometric evaluation of CAPS-5 scores in 2 samples of military veterans (Ns = 165 and 207). CAPS-5 diagnosis demonstrated strong interrater reliability (к = .78 to 1.00, depending on the scoring rule) and test-retest reliability (к = .83), as well as strong correspondence with a diagnosis based on the CAPS for DSM-IV (CAPS-IV; к = .84 when optimally calibrated). CAPS-5 total severity score demonstrated high internal consistency (α = .88) and interrater reliability (ICC = .91) and good test-retest reliability (ICC = .78). It also demonstrated good convergent validity with total severity score on the CAPS-IV (r = .83) and PTSD Checklist for DSM-5 (r = .66) and good discriminant validity with measures of anxiety, depression, somatization, functional impairment, psychopathy, and alcohol abuse (rs = .02 to .54). Overall, these results indicate that the CAPS-5 is a psychometrically sound measure of DSM-5 PTSD diagnosis and symptom severity. Importantly, the CAPS-5 strongly corresponds with the CAPS-IV, which suggests that backward compatibility with the CAPS-IV was maintained and that the CAPS-5 provides continuity in evidence-based assessment of PTSD in the transition from DSM-IV to DSM-5 criteria. (PsycINFO Database Record

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common.

OBJECTIVE

The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure.

DESIGN

We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5.

PARTICIPANTS

A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White.

MEASURES

The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences.

KEY RESULTS

The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 % C.I.: 0.912- 0.969). Whereas a cut score of 3 maximized sensitivity (κ[1]) = 0.93; SE = .041; 95 % C.I.: 0.849-1.00), a cut score of 4 maximized efficiency (κ[0.5] = 0.63; SE = 0.052; 95 % C.I.: 0.527-0.731), and a cut score of 5 maximized specificity (κ[0] = 0.70; SE = 0.077; 95 % C.I.: 0.550-0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report.

CONCLUSIONS

The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.

Risk factors for adolescent substance abuse and dependence: data from a national sample

A national household probability sample of 4,023 adolescents aged 12 to 17 years was interviewed by telephone about substance use, victimization experiences, familial substance use, and posttraumatic reactions to identify risk factors for Diagnostic and Statistical Manual of Mental Disorders--(4th ed.; American Psychiatric Association, 1994) defined substance abuse/dependence. Age and ethnicity data were available for 3,907 participants. Major findings were (a) adolescents who had been physically assaulted, who had been sexually assaulted, who had witnessed violence, or who had family members with alcohol or drug use problems had increased risk for current substance abuse/dependence; (b) posttraumatic stress disorder independently increased risk of marijuana and hard drug abuse/dependence; and (c) when effects of other variables were controlled, African Americans, but not Hispanics or Native Americans, were at approximately 1/3 the risk of substance abuse/dependence as Caucasians.

Meta-analysis of the efficacy of treatments for posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD.

DATA SOURCES

PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: post-traumatic stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic.

STUDY SELECTION

Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies.

RESULTS

Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons.

CONCLUSIONS

Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective.

Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial

CONTEXT

The prevalence of posttraumatic stress disorder (PTSD) is elevated among women who have served in the military, but no prior study has evaluated treatment for PTSD in this population. Prior research suggests that cognitive behavioral therapy is a particularly effective treatment for PTSD.

OBJECTIVE

To compare prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial of female veterans (n=277) and active-duty personnel (n=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through October 2005.

INTERVENTION

Participants were randomly assigned to receive prolonged exposure (n = 141) or present-centered therapy (n = 143), delivered according to standard protocols in 10 weekly 90-minute sessions.

MAIN OUTCOME MEASURES

Posttraumatic stress disorder symptom severity was the primary outcome. Comorbid symptoms, functioning, and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up.

RESULTS

Women who received prolonged exposure experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment.

CONCLUSIONS

Prolonged exposure is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00032617.

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.

Change in posttraumatic stress disorder symptoms: do clinicians and patients agree?

This study assessed the longitudinal association between clinician and patient ratings of posttraumatic stress disorder (PTSD) symptoms over the course of 2 different randomized clinical trials of veterans with chronic PTSD. One trial, the Department of Veterans Affairs Cooperative Study 420 (CSP 420; N = 360) compared trauma-focused and present-centered group therapies, and the 2nd trial compared cognitive processing theory and a waitlist control condition (N = 60). Linear mixed effects modeling revealed significant associations between clinician ratings (Clinician-Administered PTSD Scale; CAPS; D. D. Blake et al., 1990) and patient ratings (Posttraumatic Stress Disorder Checklist; PCL; F. W. Weathers, B. T. Litz, J. A. Herman, J. A. Huska, & T. M. Keane, 1993) in total and symptom clusters of PTSD. Contrary to hypothesis, the amount of change on the CAPS ranged from .75 to .82 standard deviations for every 1 standard deviation change on the PCL. The CAPS and PCL were more closely associated in the trauma-focused vs. present-centered treatment condition in CSP 420, and especially regarding hyperarousal symptoms. When comparing categorization of clinically significant change on the CAPS and PCL, the authors found no differences in the percentages of agreement between clinicians and patients in improvement and exacerbation. The value of multimodal assessment of PTSD treatment outcomes is discussed.

Randomized trial of trauma-focused group therapy for posttraumatic stress disorder: results from a department of veterans affairs cooperative study

BACKGROUND

Department of Veterans Affairs Cooperative Study 420 is a randomized clinical trial of 2 methods of group psychotherapy for treating posttraumatic stress disorder (PTSD) in male Vietnam veterans.

METHODS

Vietnam veterans (360 men) were randomly assigned to receive trauma-focused group psychotherapy or a present-centered comparison treatment that avoided trauma focus. Treatment was provided weekly to groups of 6 members for 30 weeks, followed by 5 monthly booster sessions. Severity of PTSD was the primary outcome. Additional measures were other psychiatric symptoms, functional status, quality of life, physical health, and service utilization. Follow-up assessments were conducted at the end of treatment (7 months) and at the end of the booster sessions (12 months); 325 individuals participated in 1 or both assessments. Additional follow-up for PTSD severity was performed in a subset of participants at 18 and 24 months.

RESULTS

Although posttreatment assessments of PTSD severity and other measures were significantly improved from baseline, intention-to-treat analyses found no overall differences between therapy groups on any outcome. Analyses of data from participants who received an adequate dose of treatment suggested that trauma-focused group therapy reduced avoidance and numbing and, possibly, PTSD symptoms. Dropout from treatment was higher in trauma-focused group treatment. Average improvement was modest in both treatments, although approximately 40% of participants showed clinically significant change.

CONCLUSIONS

This study did not find a treatment effect for trauma-focused group therapy. The difference between the effectiveness and adequate dose findings suggests the possible value of methods to enhance the delivery of cognitive-behavioral treatments in clinical practice settings.

Randomized Trial of Cognitive-Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse

The authors conducted a randomized clinical trial of individual psychotherapy for women with posttraumatic stress disorder (PTSD) related to childhood sexual abuse (n = 74), comparing cognitive-behavioral therapy (CBT) with a problem-solving therapy (present-centered therapy; PCT) and to a wait-list (WL). The authors hypothesized that CBT would be more effective than PCT and WL in decreasing PTSD and related symptoms. CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments. CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction in this sample.

Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans

The association between physician-diagnosed medical disorders and combat-related posttraumatic stress disorder (PTSD) symptoms was examined in 605 male combat veterans of World War II and the Korean conflict. Physician exams were performed at periodic intervals beginning in the 1960s. PTSD symptoms were assessed in 1990. Cox regression was used to examine the onset of each of 12 disorder categories as a function of PTSD symptoms, controlling for age, smoking, alcohol use, and body weight at study entry. Even with control for these factors, PTSD symptoms were associated with increased onset of arterial, lower gastrointestinal, dermatologic, and musculoskeletal disorders. There was only weak evidence that PTSD mediated the effects of combat exposure on morbidity. Possible mediators of the relationship between combat exposure, PTSD, and physical morbidity are discussed.

Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments.

OBJECTIVE

To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD.

DESIGN, SETTING, AND PARTICIPANTS

The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months.

INTERVENTIONS

Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy.

RESULTS

During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (β = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (β = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (β = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months.

CONCLUSIONS AND RELEVANCE

Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00821678.

Risk factors for the development versus maintenance of posttraumatic stress disorder

This study examined risk factors for posttraumatic stress disorder (PTSD) in Vietnam veterans: 68 women and 414 men of whom 88 were White, 63 Black, 80 Hispanic, 90 Native Hawaiian, and 93 Japanese American. Continuation ratio logistic regression was used to compare the predictive power of risk factors for the development versus maintenance of full or partial PTSD. The development of PTSD was related to premilitary, military, and postmilitary factors. The maintenance of PTSD was related primarily to military and postmilitary factors. Multivariate analyses identified different models for development and maintenance. We conclude that development of PTSD is related to factors that occur before, during, and after a traumatic event, whereas failure to recover is related primarily to factors that occur during and after the event.

Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial

CONTEXT

Posttraumatic stress disorder (PTSD) is a prevalent condition associated with intimate relationship problems, and intimate relationship factors have been shown to affect individual PTSD treatment outcomes.

OBJECTIVE

To compare cognitive-behavioral conjoint therapy for PTSD (a manualized couple therapy delivered to patients with PTSD and their significant others to simultaneously treat PTSD symptoms and enhance relationship satisfaction) with a wait-list condition.

DESIGN, SETTING, AND PARTICIPANTS

Randomized controlled trial of heterosexual and same-sex couples (n = 40 couples; n = 80 individuals) in which one partner met criteria for PTSD according to the Clinician-Administered PTSD Scale, conducted from 2008 to 2012 in a Department of Veterans Affairs outpatient hospital setting in Boston, Massachusetts, and a university-based research center in Toronto, Ontario, Canada. Symptoms of PTSD, comorbid conditions, and relationship satisfaction were collected by blinded assessors at baseline, at mid treatment (median, 8.00 weeks [range, 1.71-20.43 weeks] after baseline), and at posttreatment (median, 15.86 weeks [range, 7.14-38.57 weeks] after baseline). An uncontrolled 3-month follow-up (median, 38.21 weeks [range, 28.43-50.57 weeks] after baseline) was also completed.

INTERVENTION

Couples were randomly assigned to take part in the 15-session cognitive-behavioral conjoint therapy for PTSD protocol immediately (n = 20) or were placed on a wait list for the therapy (n = 20).

MAIN OUTCOME MEASURES

Clinician-rated PTSD symptom severity was the primary outcome and was assessed with the Clinician-Administered PTSD Scale. Intimate relationship satisfaction, assessed with the Dyadic Adjustment Scale, patient- and partner-rated PTSD symptoms, and comorbid symptoms were secondary outcomes.

RESULTS

PTSD symptom severity (score range, 0-136) was significantly more improved in the couple therapy condition than in the wait-list condition (mean change difference, -23.21; 95% CI, -37.87 to -8.55). Similarly, patients' intimate relationship satisfaction (score range, 0-151) was significantly more improved in couple therapy than in the wait-list condition (mean change difference, 9.43; 95% CI, 0.04-18.83). The time × condition interaction effect in the multilevel model predicting PTSD symptoms (t37.5 = -3.09; P = .004) and patient-reported relationship satisfaction (t68.5 = 2.00; P = .049) revealed superiority of the couple therapy compared with the wait list. Treatment effects were maintained at 3-month follow-up.

CONCLUSION

Among couples in which one partner was diagnosed as having PTSD, a disorder-specific couple therapy, compared with a wait list for the therapy, resulted in decreased PTSD symptom severity and patient comorbid symptom severity and increased patient relationship satisfaction.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00669981.

Estimating population prevalence of posttraumatic stress disorder: an example using the PTSD checklist

The PTSD Checklist (PCL) is among the most widely used self-report instruments for assessing PTSD. To determine PCL's performance on a population level, the authors combined data from published studies that compared the PCL with structured diagnostic interviews. Weighted average sensitivities and specificities were calculated for cutoff categories most often reported in the literature. Weighted average sensitivity decreased from .85 to .39 and specificity increased from .73 to .97 for cutoffs ranging from 30 to 60. The PCL's ability to accurately estimate PTSD prevalence varied as a function of cutoff and true PTSD prevalence. In populations with a true PTSD prevalence of 15% or less, cutoff values below 44 will substantially overestimate PTSD prevalence. Uncalibrated use of the PCL for prevalence estimation may lead to large errors.

Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans

We used path analysis to model the effects of combat exposure, posttraumatic stress disorder (PTSD) symptoms, and health behaviors on physical health. Participants were 921 male military veterans from the Normative Aging Study. Their mean age at time of study was 65. Measures of combat exposure, PTSD symptoms, smoking, and alcohol problems were used to predict subsequent self-reported physical health status. Both combat exposure and PTSD were correlated with poorer health. In path analysis, combat exposure had only an indirect effect on health status, through PTSD, whereas PTSD had a direct effect. Smoking had a small effect on health status but did not mediate the effects of PTSD, and alcohol was unrelated to health status. We conclude that PTSD is an important predictor of physical health and encourage further investigation of health behaviors and other possible mediators of this relationship.

A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update

Clinical practice guidelines (CPGs) are used to support clinicians and patients in diagnostic and treatment decision-making. Along with patients' preferences and values, and clinicians' experience and judgment, practice guidelines are a critical component to ensure patients are getting the best care based on the most updated research findings. Most CPGs are based on systematic reviews of the treatment literature. Although most reviews are now restricted to randomized controlled trials, others may consider nonrandomized effectiveness trials. Despite a reliance on similar procedures and data, methodological decisions and the interpretation of the evidence by the guideline development panel can result in different recommendations. In this article, we will describe key methodological points for 5 recently released CPGs on the treatment of posttraumatic stress disorder in adults and highlight some of the differences in both the process and the subsequent recommendations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The dissociative subtype of PTSD: a replication and extension

BACKGROUND

The nature of the relationship between dissociation and posttraumatic stress disorder (PTSD) has clinical and nosological importance. The aim of this study was to evaluate the evidence for a dissociative subtype of PTSD in two independent samples and to examine the pattern of personality disorder (PD) comorbidity associated with the dissociative subtype of PTSD.

METHODS

Latent profile analyses were conducted on PTSD and dissociation items reflecting derealization and depersonalization in two samples of archived data: Study 1 included 360 male Vietnam War Veterans with combat-related PTSD; Study 2 included 284 female Veterans and active duty service personnel with PTSD and a high base rate of exposure to sexual trauma.

RESULTS

The latent profile analysis yielded evidence for a three-class solution in both samples: the model was defined by moderate and high PTSD classes and a class marked by high PTSD severity coupled with high levels of dissociation. Approximately 15% of the male sample and 30% of the female sample were classified into the dissociative class. Women (but not men) in the dissociative group exhibited higher levels of comorbid avoidant and borderline PD diagnoses.

CONCLUSIONS

Results provide support for a dissociative subtype of PTSD and also suggest that dissociation may play a role in the frequent co-occurrence of PTSD and borderline PD among women. These results are pertinent to the on-going revisions to the DSM and suggest that consideration should be given to incorporating a dissociative subtype into the revised PTSD criteria.

Symptoms of dissociation in humans experiencing acute, uncontrollable stress: a prospective investigation

OBJECTIVE

Peritraumatic dissociation has been associated with subsequent development of posttraumatic stress disorder, but supporting data have been largely retrospective. The current study was designed to assess the nature and prevalence of dissociative symptoms in healthy humans experiencing acute, uncontrollable stress during U.S. Army survival training.

METHOD

In study 1, 94 subjects completed the Clinician-Administered Dissociative States Scale after exposure to the stress of survival training. In study 2, 59 subjects completed the Brief Trauma Questionnaire before acute stress and the dissociative states scale before and after acute stress. A randomly selected group of subjects in study 2 completed a health problems questionnaire after acute stress.

RESULTS

In study 1, 96% of subjects reported dissociative symptoms in response to acute stress. Total scores, as well as individual item scores, on the dissociation scale were significantly lower in Special Forces soldiers compared to general infantry troops. In study 2, 42% of subjects reported dissociative symptoms before stress and 96% reported them after acute stress. Dissociative symptoms before and after stress were significantly higher in individuals who reported a perceived threat to life in the past. Forty-one percent of the variance in reported health problems was accounted for by poststress dissociation scores.

DISCUSSION

Symptoms of dissociation were prevalent in healthy subjects exposed to high stress. Stress-hardy individuals (Special Forces soldiers) experienced fewer symptoms of dissociation, compared to individuals who were less hardy. These data support the idea that the nature of response to previously experienced threatening events significantly determines the nature of psychological and somatic response to subsequent stress.

Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder

This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous effects of PTSD symptom change on psychosocial and physical health-related quality of life within the same time period and lagged effects of initial PTSD symptom change on later change in quality of life. PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous effects of symptom change on change in quality of life but no significant lagged effects. Results indicate the importance of measuring quality of life in future investigations of PTSD treatment.

Employment outcomes and PTSD symptom severity

A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.

Do all psychological treatments really work the same in posttraumatic stress disorder?

A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746-758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008)meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

Posttraumatic stress disorder and war-zone exposure as correlates of perceived health in female Vietnam War veterans

Previous studies have identified traumatic exposure and posttraumatic stress disorder (PTSD) as predictors of physical health complaints without considering the relationship between exposure and PTSD. This study examined the unique associations of war-zone exposure and PTSD with perceived physical health outcomes in a nontreatment-seeking sample of 109 female veterans of the Vietnam War who responded to a series of psychological, exposure, and health questionnaires. Both PTSD and exposure were associated with reports of negative health outcomes when each variable was not adjusted for the other. The effects associated with exposure decreased when PTSD was controlled for, whereas the effects associated with PTSD remained when exposure was controlled for. Results suggest that effects of traumatic exposure on perceived health are partially mediated by increases in PTSD after exposure, supporting studies on the effects of stress on health.