Anica Pless Kaiser

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

ABSTRACTBACKGROUNDPosttraumatic 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.OBJECTIVEThe 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.DESIGNWe 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.PARTICIPANTSA 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.MEASURESThe 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 RESULTSThe 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.CONCLUSIONSThe PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.

From Late-Onset Stress Symptomatology to Later-Adulthood Trauma Reengagement in Aging Combat Veterans: Taking a Broader View

About a decade ago we proposed the notion of late-onset stress symptomatology, to characterize the later-life emergence of symptoms related to early-life warzone trauma among aging combat Veterans. We hypothesized that aging-related challenges (role transition and loss, death of family members and friends, physical and cognitive decline) might lead to increased reminiscence, and possibly distress, among Veterans who had previously dealt successfully with earlier traumatic events. Recently, we have reexamined our earlier ideas, to better reflect our developing understanding of this phenomenon, and to incorporate more contemporary perspectives on posttraumatic growth and resilience. As a result, we have broadened our conceptualization to later-adulthood trauma reengagement (LATR). We suggest that in later life many combat Veterans confront and rework their wartime memories in an effort to find meaning and build coherence. Through reminiscence, life review, and wrestling with issues such as integrity versus despair, they intentionally reengage with experiences they avoided or managed successfully earlier in life, perhaps without resolution or integration. This article links LATR to classic gerontologic notions, and elaborates how the LATR process can lead positively to personal growth or negatively to increased symptomatology. We also address the role of preventive intervention in enhancing positive outcomes for Veterans who reengage with their wartime memories in later life.

Sleep Quality as a Potential Mediator Between Psychological Distress and Diabetes Quality of Life in Veterans With Type 2 Diabetes

OBJECTIVE The goal of this study was to explore sleep quality as a potential mediator between depression symptoms and diabetes quality of life (DQOL), and anxiety symptoms and DQOL. METHOD Participants were 83 male and 3 female veterans with type 2 diabetes (Mage = 62.4). Self-report measures were completed during the baseline assessment of a larger intervention study conducted at the VA Boston Healthcare System. RESULTS Depression symptoms, anxiety symptoms, and sleep quality were all associated with DQOL. Additionally, sleep quality had a partial indirect effect on the relationships between depression symptoms and DQOL, and between anxiety symptoms and DQOL. CONCLUSIONS These findings suggest that sleep quality may have an important role in the way that psychological distress affects diabetes quality of life.

Temporal Associations Among Chronic PTSD Symptoms in U.S. Combat Veterans.

The present study examined fluctuation over time in symptoms of posttraumatic stress disorder (PTSD) among 34 combat veterans (28 with diagnosed PTSD, 6 with subclinical symptoms) assessed every 2 weeks for up to 2 years (range of assessments = 13-52). Temporal relationships were examined among four PTSD symptom clusters (reexperiencing, avoidance, emotional numbing, and hyperarousal) with particular attention to the influence of hyperarousal. Multilevel cross-lagged random coefficients autoregression for intensive time series data analyses were used to model symptom fluctuation decades after combat experiences. As anticipated, hyperarousal predicted subsequent fluctuations in the 3 other PTSD symptom clusters (reexperiencing, avoidance, emotional numbing) at subsequent 2-week intervals (rs = .45, .36, and .40, respectively). Additionally, emotional numbing influenced later reexperiencing and avoidance, and reexperiencing influenced later hyperarousal (rs = .44, .40, and .34, respectively). These findings underscore the important influence of hyperarousal. Furthermore, results indicate a bidirectional relationship between hyperarousal and reexperiencing as well as a possible chaining of symptoms (hyperarousal → emotional numbing → reexperiencing → hyperarousal) and establish potential internal, intrapersonal mechanisms for the maintenance of persistent PTSD symptoms. Results suggested that clinical interventions targeting hyperarousal and emotional numbing symptoms may hold promise for PTSD of long duration.

Correlates of life satisfaction among aging veterans.

BACKGROUND The purpose of this study was to document the associations of stressors (combat exposure, retirement concerns, and late-life stressful events), personal resources (social support, sense of mastery, and positive appraisal of military experiences), and functional health (both physical and mental) with life satisfaction in older veterans. METHODS Participants were 562 male combat veterans (mean age = 70). Self-report questionnaires were administered via mail survey. A hierarchical multiple regression analysis was performed. RESULTS Each step of the regression analysis demonstrated a significant contribution to variance in life satisfaction (48% in total). Although stressors were significant when entered as a set, their influence dissipated in the presence of personal resources and functional health. For the full model, seven of 11 independent variables were unique and significant predictors, including all personal resource factors and both functional health indices. Sense of mastery was most potent. CONCLUSIONS Even in the presence of stressors, personal resources and functional health appear to serve protective roles in explaining levels of life satisfaction among aging veterans.

Positive Adjustment Among American Repatriated Prisoners of the Vietnam War Modeling the Long-Term Effects of Captivity

A longitudinal life span model of factors contributing to later-life positive adjustment was tested on 567 American repatriated prisoners from the Vietnam War. This model encompassed demographics at time of capture and attributes assessed after return to the United States (reports of torture and mental distress) and approximately three decades later (later-life stressors, perceived social support, positive appraisal of military experiences, and positive adjustment). Age and education at time of capture and physical torture were associated with repatriation mental distress, which directly predicted poorer adjustment 30 years later. Physical torture also had a salutary effect, enhancing later-life positive appraisal of military experiences. Later-life events were directly and indirectly (through concerns about retirement) associated with positive adjustment. Results suggest that the personal resources of older age and more education and early-life adverse experiences can have cascading effects over the life span to impact well-being in both positive and negative ways.

Distinguishing late-onset stress symptomatology from posttraumatic stress disorder in older combat veterans.

Objective: To assess the discriminant validity of late-onset stress symptomatology (LOSS) in terms of its distinction from posttraumatic stress disorder (PTSD). Method: The LOSS Scale, PTSD Checklist – Civilian Version, and related psychological measures were administered to 562 older male combat veterans via a mailed questionnaire. Analyses focused on: (a) comparing associations of LOSS and PTSD with other psychological variables and (b) examining a hypothesized curvilinear relationship between LOSS and PTSD scores. Results: Compared to PTSD, LOSS was more strongly associated with concerns about retirement and less strongly associated with depression, anxiety, sense of mastery, and satisfaction with life. LOSS also demonstrated a curvilinear relationship with PTSD, such that the positive association between LOSS and PTSD diminished at higher levels of PTSD. Conclusion: LOSS is conceptually and statistically more strongly associated with a normative late-life stressor than is PTSD, but is less strongly related to mental health symptoms and emotional well-being. Additionally, LOSS seems more related to subthreshold PTSD than it is to clinically significant PTSD. The present findings support the discriminant validity of LOSS.

Women Vietnam Veterans: Do PTSD Symptoms Mediate Effects of Warzone Service on Health?

We used regression models to assess the impact of warzone stress on physical and mental health of 975 female Vietnam veteran nurses, and whether current PTSD symptoms mediated these relations. Womens Vietnam Memorial Project members were surveyed in 1998, with analyses adjusted for age, length of military service, and current health symptoms. Findings suggest that among women nurses deployed to Vietnam, the effects of warzone stress many years earlier on current health are both direct and indirect, mediated by PTSD symptoms. The legacy of wartime deployment remains, although muted in its expression, in military nurses nearly 30 years after their return.

Long-term effects of coping with extreme stress: Longitudinal study of Vietnam-era repatriated prisoners of war†

Captivity stressors and coping strategies were assessed shortly after the repatriation of Vietnam-era prisoners of war, and physical and mental health were assessed almost three decades later. Given research on coping goodness-of-fit, specifically the extent to which coping effects depend on situational controllability, we proposed that endorsement of the usefulness of avoidance-based strategies in captivity would be predictive of better later-life health. Findings indicated that approach-based and avoidance-based coping both moderated the link between physical torture and later physical health functional status, whereas approach-based coping moderated the link between injuries at capture and later mental health. Specifically, greater endorsement of avoidance-based coping was associated with better long-term physical health for prisoners who experienced the most physical torture. Lower endorsement of approach-based coping was associated with better long-term mental health for prisoners who reported the most injuries at the time of capture.

Health Status and Treatment-Seeking Stigma in Older Adults with Trauma and Posttraumatic Stress Disorder

This study compared health status across four trauma/posttraumatic stress disorder (PTSD) groups of older adults with depression, anxiety, and/or at-risk drinking who attended primary care appointments (N = 1,199; mean age = 73.5 yr), mostly at Department of Veterans Affairs hospitals. The trauma and PTSD categories were PTSD (n = 81), partial PTSD (n = 127), trauma only (n = 323), and no trauma (n = 668). Physical and mental health-related quality of life (HQL), indices of social and economic impairment and stigma regarding treatment-seeking were compared among groups. Group differences were found for several indicators of functional impairment; the PTSD group had fewer close friends and higher treatment-seeking stigma beliefs related to having a disorder. Linear mixed modeling examined associations between trauma/PTSD group and HQL. After accounting for covariates, the trauma/PTSD groups differed across the Medical Outcome Study Short Form-36 scales and component scores (indicated by significant group by scale interaction). Differences among groups were confined to mental health measures; those with PTSD had worse HQL. Post hoc analyses examined the number of comorbid psychiatric diagnoses by trauma/PTSD group. Overall, findings indicate that mental HQL varies among older adults with trauma and PTSD and that although treatment-related stigma does not differ among groups, it does affect HQL.