Barbara L. Niles

Psychometric properties of PTSD Checklist in sample of male veterans.

The psychometric properties of the PTSD Checklist (PCL) were investigated in a sample of treatment-seeking and community-dwelling male veterans. In conjunction with previous reports, results from the present study indicate that the PCL possesses strong, robust psychometric properties. The current investigation suggests a cutoff score of 60-higher than previous investigations-related to posttraumatic stress disorder (PTSD) diagnosis derived from the Clinician-Administered PTSD Scale. This research supports the use of the PCL as a brief self-report measure of PTSD symptomatology.

A Pilot Study of a Randomized Controlled Trial of Yoga as an Intervention for PTSD Symptoms in Women

Posttraumatic stress disorder (PTSD) is a debilitating condition that affects approximately 10% of women in the United States. Although effective psychotherapeutic treatments for PTSD exist, clients with PTSD report additional benefits of complementary and alternative approaches such as yoga. In particular, yoga may downregulate the stress response and positively impact PTSD and comorbid depression and anxiety symptoms. We conducted a pilot study of a randomized controlled trial comparing a 12-session Kripalu-based yoga intervention with an assessment control group. Participants included 38 women with current full or subthreshold PTSD symptoms. During the intervention, yoga participants showed decreases in reexperiencing and hyperarousal symptoms. The assessment control group, however, showed decreases in reexperiencing and anxiety symptoms as well, which may be a result of the positive effect of self-monitoring on PTSD and associated symptoms. Between-groups effect sizes were small to moderate (0.08-0.31). Although more research is needed, yoga may be an effective adjunctive treatment for PTSD. Participants responded positively to the intervention, suggesting that it was tolerable for this sample. Findings underscore the need for future research investigating mechanisms by which yoga may impact mental health symptoms, gender comparisons, and the long-term effects of yoga practice.

Examining Mechanisms of Change in a Yoga Intervention for Women: The Influence of Mindfulness, Psychological Flexibility, and Emotion Regulation on PTSD Symptoms

OBJECTIVE This study explored possible mechanisms through which symptoms of posttraumatic stress disorder (PTSD) were reduced in a randomized controlled trial comparing the effect of a yoga intervention with an assessment control. METHOD We examined whether changes in psychological flexibility, mindfulness, and emotion regulation strategies (expressive suppression and reappraisal) were associated with posttreatment PTSD symptoms for 38 women with Diagnostic and Statistical Manual of Mental Disorders Fourth Edition full or subthreshold PTSD. RESULTS Hierarchical linear regression models revealed that expressive suppression significantly decreased for the yoga group relative to the assessment control. Psychological flexibility increased significantly for the control but not yoga group. However, increases in psychological flexibility were associated with decreases in PTSD symptoms for the yoga but not control group. CONCLUSION Preliminary findings suggest that yoga may reduce expressive suppression and may improve PTSD symptoms by increasing psychological flexibility. More research is needed to replicate and extend these findings.

Posttraumatic stress disorder symptomatology in Vietnam veterans before and after September 11

In the immediate aftermath of the September 11, 2001, terrorist attacks, mental health professionals prepared for widespread psychopathological reactions to the trauma, anticipating that people across the country would be adversely affected even if they were not directly affected by the attacks (Stephenson, 2001). In the general population, researchers found significant psychological distress in the days immediately after the attacks (Schuster et al., 2001) followed by a return to baseline in subsequent weeks (Silver et al., 2002; Schlenger et al., 2002). Certain subgroups of the population who were particularly vulnerable to the effects of the attacks by virtue of their physical proximity to the attacks or by losing a friend or family member exhibited elevated rates of PTSD symptomatology in the weeks after the attacks (Galea et al., 2002; Schlenger et al., 2002). These samples were not followed longitudinally, however, and the long-term psychological consequences for these individuals are unknown. One might also expect to find heightened responsiveness to the attacks in combat veterans with posttraumatic stress disorder (PTSD), a psychological disorder characterized by emotional distress in response to experiences reminiscent of previous trauma (American Psychiatric Association [APA], 1994). There is evidence that veterans with combat-related PTSD experience an increase in PTSD symptoms when faced with actual or anticipated exposure to additional combat (McCarroll et al., 1997; Solomon et al., 1987). Furthermore, research during the first Gulf War found that Vietnam combat veterans closely followed media coverage of the war and that this exposure alone reactivated symptoms of PTSD (Long et al., 1994). In light of this research, a terrorist attack that received extensive media coverage can be expected to trigger intrusive memories and other PTSD symptoms for many combat veterans with pre-existing PTSD. However, analyses of symptom levels and service utilization data in samples of veterans with PTSD have failed to document exacerbations of PTSD symptoms or increases in service utilization after September 11 and have even documented the opposite effects in some samples (Reeves & Liberto, 2001; Rosenheck & Fontanta, in press). Although the findings appear encouraging on the surface, they must be interpreted with caution. It is unclear whether the decrease in symptom reporting and service utilization exhibited in some individuals with PTSD indicate true improvement or reflect a strengthening of avoidance mechanisms symptomatic of exacerbated PTSD. Two methodological issues limit the conclusions that can be drawn from the studies highlighted above and others that have been conducted in the aftermath of September 11. First, these studies evaluated psychological functioning in cross-sections of the population examined at one or a few time points after the disaster. Examining the same individuals longitudinally over a period of time would provide a more complete picture of the course of post-September 11 symptomatology. The second methodological issue pertains to all trauma research: Traumatic events are unanticipated, so psychological functioning is rarely assessed systematically prior to the trauma. Previously published studies examining psychopathology in the aftermath of September 11 did not assess pretrauma symptom levels, making it impossible to distinguish between pre-existing psychopathology and sequelae of the stress of the terrorist attacks. In the current study, based on data drawn from a larger longitudinal investigation of PTSD, we examined Vietnam veterans’ combat-related PTSD severity on a bi-weekly basis before and after September 11, 2001. We hypothesized that the overwhelming media coverage of the death and destruction of September 11 might exacerbate these veterans’ preexisting symptoms of combat-related PTSD. We evaluated this hypothesis by examining participants’ PTSD symptoms for twelve-week intervals around September 11, 2001 and around the six-month and one-year anniversaries of the attacks.

Obstacles to Assessment of PTSD in Longitudinal Research

Despite the burgeoning literature on the assessment, diagnosis, and treatment of posttraumatic stress disorder, there are few empirical findings to guide clinicians and researchers in anticipating how individuals with PTSD will fare over a time span of years. This chapter first briefly overviews current findings about the course of PTSD and then identifies reasons why longitudinal investigations of PTSD have been largely bypassed by PTSD researchers.

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.

Explication and Definition of Mental Health Recovery: A Systematic Review

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope.

Initiation, Dropout, and Outcome From Evidence-Based Psychotherapies in a VA PTSD Outpatient Clinic.

Trauma-focused, evidence-based psychotherapies (TF-EBPs) for posttraumatic stress disorder (PTSD) have been widely promoted in the Veterans Health Administration to provide access to state-of-the-art treatments, but dropout rates may affect the impact of TF-EBPs. The current study summarizes findings from a program evaluation of 67 veterans assigned to trauma-focused treatment in a Veterans Affairs outpatient PTSD clinic. Outcomes of interest include attendance rates, dropout rates and patterns, treatment paths, changes in self-reported symptoms, and clinician ratings. Nine veterans (13.4%) did not attend a first session and 15 (22.4%) dropped out before session 4. Twenty-three (33.8%) received either a modified version of the TF-EBP or switched to a different treatment. Only 11 (16.4%) completed the assigned TF-EBP, but 10 of those 11 (90.9%) were rated by their therapist as improved. These results align with previous research documenting high dropout rates from PTSD treatment in veterans and substantial improvements for those who complete TF-EBPs. Future study of methods to enhance retention in TF-EBP treatments is needed.

Mindfulness and Meditation in the Conceptualization and Treatment of Posttraumatic Stress Disorder

In recent years, mindfulness and meditation-based processes and interventions have received increasing clinical and scholarly attention in the trauma field due to their theoretical and clinical relevance to the etiology, maintenance, and treatment of posttraumatic stress disorder (PTSD). Indeed, there has been a proliferation of literature documenting associations between mindfulness as well as meditation and PTSD symptomatology and supporting the efficacy of such interventions for the treatment of PTSD. Mounting empirical evidence indicates that mindfulness- or meditation-based skills and/or intervention programs may serve as effective stand-alone or adjunctive interventions for PTSD. For populations with a high probability of exposure to intense or chronic potentially traumatizing events, such as police or military personnel, mindfulness- or meditation-based interventions may prevent the development of persistent PTSD. The goal of this chapter is to elucidate the construct of mindfulness in terms of the potential utility in the conceptualization and treatment of PTSD so as to stimulate further scholarly and clinical thought in this domain. Notably, distinct, though related, practices such as meditation are included so as to provide a broad-based picture of relevant clinical and empirical landscapes. The most salient research associated with posttraumatic stress/PTSD, mindfulness, and meditation is reviewed, and the clinical implications of mindfulness and meditation for the treatment of PTSD are discussed. Finally, future research directions that may inform both clinical and research efforts are suggested.