Abigail C. Angkaw

Diagnostic Utility of the Posttraumatic Stress Disorder (PTSD) Checklist for Identifying Full and Partial PTSD in Active-Duty Military

The aim of this study was to determine optimally efficient cutoff scores on the Posttraumatic Stress Disorder Checklist (PCL) for identifying full posttraumatic stress disorder (PTSD) and partial PTSD (P-PTSD) in active-duty Marines and Sailors. Participants were 1,016 Marines and Sailors who were administered the PCL and Clinician-Administered PTSD Scale (CAPS) 3 months after returning from Operations Iraqi and Enduring Freedom. PCL cutoffs were tested against three CAPS-based classifications: full PTSD, stringent P-PTSD, and lenient P-PTSD. A PCL score of 39 was found to be optimally efficient for identifying full PTSD. Scores of 38 and 33 were found to be optimally efficient for identifying stringent and lenient P-PTSD, respectively. Findings suggest that the PCL cutoff that is optimally efficient for detecting PTSD in active-duty Marines and Sailors is substantially lower than the score of 50 commonly used by researchers. In addition, findings provide scores useful for identifying P-PTSD in returning service members.

Post-Traumatic Stress Disorder, Depression, and Aggression in OEF/OIF Veterans

Aggression is a problem among some combat veterans. Post-traumatic stress disorder (PTSD) is associated with physical aggression in veterans, and co-occurring depression increases the risk of committing aggressive acts. Few studies have examined the impact of PTSD on various forms of aggression. While using a standardized multidimensional measure of aggression, this study examines the impact of depressive symptoms on the relationship between PTSD and various forms of aggression in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) veterans. Depressive symptoms are hypothesized to mediate the relationship between PTSD and four types of aggression: (1) physical aggression toward others, (2) physical aggression toward objects, (3) physical aggression toward self, and (4) verbal aggression. Seventy-two OEF/OIF veterans completed assessment batteries and clinical interviews upon enrollment into a postdeployment mental health clinic. Study results partially supported the study hypotheses; depressive symptoms indirectly mediated the relationship between PTSD and two forms of aggression: verbal aggression and physical aggression toward self. In contrast to some prior studies of intimate partner violence in veterans with PTSD, no mediation relationship between depression and physical aggression toward others was found. Study results have implications for the development of interventions to treat aggressive behaviors in OEF/OIF veterans with PTSD and depression.

Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans

OBJECTIVES This study examined: (a) the relationship between self-reported posttraumatic stress disorder (PTSD) symptoms and risk of obstructive sleep apnea (OSA) in a younger, Iraq and Afghanistan (OEF/OIF/OND) veteran sample seeking treatment for PTSD; and (b) the relationships between PTSD symptom scores and each risk factor of OSA (snoring, fatigue, high blood pressure/BMI). METHODS Participants were 195 Iraq and Afghanistan veterans presenting to a VA outpatient PTSD clinic for evaluation. Veterans were 21 to 59 years old (mean 33.40, SD 8.35) and 93.3% male (n = 182). Logistic regressions were run to examine whether veterans with greater PTSD symptom severity had an increased probability of screening as high risk for OSA, even after controlling for known risk factors (older age, positive smoking status, and use of CNS depressants). RESULTS Of 159 veterans screened, 69.2% were assessed as being at high risk for OSA. PTSD symptom severity increased the risk of screening positive for OSA. PTSD symptom severity increased risk of screening positive for snoring and fatigue, but not high blood pressure/BMI. CONCLUSIONS OEF/OIF/OND veterans with PTSD screen as high risk for OSA at much higher rates than those seen in community studies and may not show all classic predictors of OSA (i.e., older and higher BMI). This study is the first to suggest that the Berlin may be a useful screener for OSA in a younger OEF/OIF/OND veteran population with PTSD. Screening of younger veterans with PTSD for OSA should be standard care, and polysomnography and OSA interventions should be readily available to younger veterans.

Does Reintegration Stress Contribute to Suicidal Ideation Among Returning Veterans Seeking PTSD Treatment

Although posttraumatic stress disorder (PTSD) and other psychiatric symptoms are well-established risk factors for suicidal ideation among returning veterans, less attention has been paid to whether the stress of reintegrating into civilian society contributes to suicidal ideation. Utilizing a sample of 232 returning veterans (95% male, mean age = 33.63 years) seeking PTSD treatment, this study tested whether reintegration difficulties contribute to suicidal ideation over and above the influence of PTSD symptoms, depression symptoms, and potential substance misuse. Logistic regressions indicated that reintegration stress had a unique effect on suicidal ideation over and above PTSD and depression symptoms. Reintegration stress interacted with substance misuse to predict suicidal ideation, such that the effect of reintegration stress on suicidal ideation was much larger for those with potential substance misuse. Exploratory analyses also examined which types of reintegration difficulties were associated with suicidal ideation, and found that difficulty maintaining military friendships, difficulty getting along with relatives, difficulty feeling like you belong in civilian society, and difficulty finding meaning/purpose in life were all significantly associated with suicidal ideation, beyond the effects of psychiatric symptoms and potential substance misuse. Findings highlight the importance of addressing reintegration stress for the prevention of suicide among returning veterans. Implications for treatment are discussed.

Shame versus trauma-related guilt as mediators of the relationship between PTSD symptoms and aggression among returning veterans

OBJECTIVE It is well established that posttraumatic stress disorder (PTSD) is associated with various forms of aggression, though the mechanisms by which PTSD is related to aggression are not fully understood. Some research suggests that the tendency to experience shame, but not guilt, contributes to aggression in individuals with a history of interpersonal trauma. This study tested the hypothesis that trait shame but not trauma-related guilt would mediate the relationship between PTSD symptoms and verbal and physical aggression in veterans with combat/military-related trauma seeking PTSD treatment. METHOD In a sample of 127 returning veterans (95% male, mean age = 32.93), negative binomial path analyses tested multiple mediational models in which shame versus trauma-related guilt (separate models entered the effects of global guilt, guilt cognitions, and guilt distress) were examined as mediators of PTSD symptoms on verbal and physical aggression separately. RESULTS Results indicated that shame partially mediated the association of PTSD symptoms with verbal aggression but not physical aggression when accounting for trauma-related guilt. Although PTSD symptoms were associated with higher scores on all aspects of trauma-related guilt, guilt did not significantly mediate relations between PTSD symptoms and verbal or physical aggression when accounting for shame. CONCLUSION These results indicate that it is worthwhile to examine whether addressing shame in PTSD treatment may also reduce verbal aggression in returning veterans. (PsycINFO Database Record

Alcohol-Related Consequences Mediating PTSD Symptoms and Mental Health–Related Quality of Life in OEF/OIF Combat Veterans

Veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have been found to be at increased risk for post-traumatic stress disorder (PTSD) and alcohol use disorders, leading to negative mental health-related quality of life (MHRQoL). The current study examined the unique impact of alcohol consumption levels versus alcohol-related consequences on the relationship between PTSD symptoms and MHRQoL in a sample of OEF/OIF combat veterans (N = 205, median age 29, 95% men). Mediation analyses indicated that the effect of PTSD symptoms on MHRQoL was explained only by alcohol-related consequences and not by alcohol consumption. Findings highlight the importance of including alcohol-related consequences in clinical assessment and intervention programs for OEF/OIF veterans. Additionally, this study enhances knowledge regarding the underlying mechanisms of functional impairment related to PTSD and alcohol use disorders.

Peritraumatic Behavior Questionnaire - Observer Rated: Validation of the objective version of a measure for combat-related peritraumatic stress.

AIM To validate the first third-person-rated measure assessing combat-related peritraumatic stress symptoms and evaluate its psychometric properties and war-zone applicability. METHODS The valid assessment of peritraumatic symptoms in the theater of military operations represents a significant challenge in combat-related, mental health research, which mainly relies on retrospective, subjective self-report ratings. This longitudinal observational study used data from actively deployed troops to correlate third-person observer ratings of deployment peritraumatic behaviors [Peritraumatic Behavior Questionnaire - Observer Rated (PBQ-OR)] collected on a bi-monthly basis with post-deployment (1-wk follow-up) ratings of the previously validated PBQ self-rate version (PBQ-SR), and (3-mo follow-up) clinician assessed and self-report posttraumatic stress disorder (PTSD) symptoms (Clinician Administered PTSD Scale, PTSD Checklist). Cronbachs alpha (α) and correlation coefficients were calculated to assess internal reliability and concurrent validity respectively. RESULTS Eight hundred and sixty male Marines were included in this study after signing informed consents at pre-deployment (mean age 23.2 ± 2.6 years). Although our findings were limited by an overall sparse return rate of PBQ-OR ratings, the main results indicate satisfactory psychometric properties with good internal consistency for the PBQ-OR (α = 0.88) and high convergent and concurrent validity with 1-wk post-deployment PBQ-SR ratings and 3-mo posttraumatic stress symptoms. Overall, later PBQ-OR report date was associated with higher correlation between PBQ-OR and post-deployment measures. Kappa analysis between PBQ-OR and PBQ-SR single items, showed best agreement in questions relating of mortal peril, desire for revenge, and experience of intense physical reactions. Logistic regression demonstrated satisfactory predictive validity of PBQ-OR total score with respect to PTSD caseness (OR = 1.0513; 95%CI: 1.011-1.093; P = 0.02). CONCLUSION Since no comparable tools have been developed, PBQ-OR could be valuable as real-time screening tool for earlier detection of Service Members at risk.

Evidence-based psychotherapy completion and symptom improvement among returning combat veterans with PTSD.

Objective: Despite the availability of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) in the Veterans Health Administration, treatment completion rates are low and not all veterans benefit from these treatments. Understanding factors associated with PTSD EBP completion and symptom improvement is critical to improving completion rates and effectiveness. Method: This chart review study used the Andersen Behavioral Model to examine whether predisposing characteristics (nonmodifiable characteristics such as demographics), enabling factors (modifiable logistic variables that can facilitate or impede treatment use), and need factors (clinical characteristics such as symptom severity or comorbidities) predicted treatment completion or symptom improvement following PTSD EBP treatment among 82 Iraq and Afghanistan combat veterans. Logistic regression was used to examine treatment completion, and repeated measures analysis of variance was used to examine changes in PTSD and depression symptoms following treatment. Results: EBP completers had greater improvement in PTSD symptoms than did EBP dropouts. Need factors (lack of comorbid substance use disorders and having problems with family members/significant others) were related to treatment completion, whereas enabling resources (receiving individual rather than group treatment) were related to symptom improvement. Conclusions: This is one the first studies to use a comprehensive model to examine factors relevant to treatment completion and symptom improvement. Results suggest that nonmodifiable predisposing characteristics do not drive treatment completion and symptom improvement, underscoring the potential importance of targeting enabling resources and needs factors for intervention.

Differential relationships of guilt and shame on posttraumatic stress disorder among veterans.

Objective: Despite important conceptual differences between shame and guilt, literature distinguishing these emotions in relation to posttrauma functioning for veterans has been largely theoretical. This is the first study to concurrently examine trauma-related guilt and internalized shame in relation to PTSD severity as the dependent variable. Our primary aim was to examine guilt and shame on PTSD symptom severity within the same model. A secondary aim was to evaluate whether trauma-related guilt can occur independent of shame. Method: Participants were 144 veterans seeking PTSD treatment. Regression analysis was used for our primary aim. Chi-square was used for our secondary aim to examine the percentage of participants categorized one standard deviation above (high) and below (low) the mean for shame and guilt. Results: Entered together, internalized shame (&bgr; = .44, p < .001) and guilt-related distress (&bgr; = .32, p < .001) were related to PTSD severity. Guilt cognitions and global guilt were unrelated to PTSD. Analyses showed significant differences in participants categorized as low/high shame and low/high global guilt (&khgr;2 = 14.22, p < .001), guilt-related distress (&khgr;2 = 15.09, p < .001), and guilt cognitions (&khgr;2 = 13.16, p < .001). Across guilt subscales, “shame-free” trauma-related guilt did not exist (0%). Conclusions Internalized shame and guilt distress were both related to PTSD severity; however, shame added variance not already accounted for by guilt. Tangney, Stuewig, and Mashek (2007) stipulate that guilt becomes maladaptive when fused with shame; however, our results indicate trauma-related guilt is possibly always fused with shame.

Piloting cognitive–behavioral therapy for insomnia integrated with prolonged exposure.

Objective: Approximately 35–61% of individuals with posttraumatic stress disorder (PTSD) report insomnia. Further, upward of 70% report clinically significant insomnia following PTSD treatment. There are converging lines of evidence suggesting that insomnia not only independently affects daytime functioning and worsens PTSD symptoms but also may compromise response to PTSD treatment, such as prolonged exposure (PE). Taken together, integrated insomnia and PTSD treatment may increase client-centered care and treatment outcomes. Method: This article reviews the theory and evidence for treating sleep prior to PTSD treatment, describes the key elements of integrated cognitive–behavioral treatment for insomnia (CBT-I) and PE (2NITE protocol), and presents pilot data from a sample of 12 treatment-seeking veterans with PTSD and insomnia who completed the 2NITE protocol. Sleep data were collected with sleep diaries and actigraphy watches. Results: The Client Satisfaction Questionnaire indicated high satisfaction with the 2NITE protocol (mean score 29.66 out of 32 points). On average, there were statistical and clinically significant changes in all measures, including a 20.17-point decrease in the PTSD Checklist DSM–5, a 11.75-point decrease in the insomnia severity index, an 18.58-point increase in the World Health Organization Quality of Life index, a 11% increase in sleep efficiency, and a 51-min increase in total sleep time from the actigraphy data. Conclusions: Among individuals with insomnia and PTSD, integrating CBT-I and PE with the 2NITE protocol represents a logical, innovative, and empirically informed method for augmenting existing treatments and optimizing outcomes that justifies further investigation.