Benjamin D. Dickstein

Heterogeneity in the course of posttraumatic stress disorder: Trajectories of symptomatology

Unconditional and conditional trajectories of posttraumatic stress disorder (PTSD) symptomatology were examined using a sample of U.S. soldiers deployed on a NATO-led peacekeeping mission to Kosovo. Data were collected at 4 time points, ranging from the weeks leading up to deployment to 9-months post deployment. Latent class growth analysis revealed 4 unique symptom trajectories: resilience, recovery, delayed, and unrealized anxiety. Variables identified as significant predictors of trajectory class included previous traumatic events, combat exposure, peacekeeping daily hassles, depression, alcohol use, aggressive behavior, stress reactivity, and military rank. Results from this study add to the literature detailing the variability in PTSD course, as well as to the literature pertaining to predictors of PTSD onset and course.

Targeting self-stigma in returning military personnel and veterans: A review of intervention strategies.

Research suggests that mental health-related stigma significantly decreases the use of mental health services by military personnel and veterans. The goal of this article is to review what is known about mental health stigma as it relates to military personnel and veterans, as well as to offer an interpretive review of self-stigma intervention strategies that have been applied within the field. Target areas for future work and the concerns and challenges faced by interventionists are discussed.

Unit Cohesion and PTSD Symptom Severity in Air Force Medical Personnel

Research suggests that military unit cohesion may protect against the development of post-traumatic stress disorder (PTSD). However, equivocal findings have led researchers to hypothesize a potential curvilinear interaction between unit cohesion and warzone stress. This hypothesis states that the protective effects of cohesion increase as warzone stress exposure intensifies from low to moderate levels, but at high levels of warzone stress exposure, cohesion loses its protective effects and is potentially detrimental. To test this theory, we conducted a test for curvilinear moderation using a sample of 705 Air Force medical personnel deployed as part of Operation Iraqi Freedom. Results did not support the curvilinear interaction hypothesis, although evidence of cohesions protective effects was found, suggesting that unit cohesion protects against PTSD regardless of level of stress exposure.

Co-occurring posttraumatic stress and depression symptoms after sexual assault: a latent profile analysis.

BACKGROUND Symptoms of posttraumatic stress disorder (PTSD) and depression frequently co-occur, but their distinctiveness following trauma remains unclear. We examined patterns of PTSD and depression symptoms after sexual assault to evaluate the extent to which assault survivors primarily reported symptoms of both disorders or whether there were meaningfully distinct subgroups with discordant PTSD and depression symptoms. METHODS Latent profile analysis was used to examine self-reported PTSD and depression symptoms among 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months post-assault. RESULTS At all time points, a 4-class solution fit the data best, revealing four subgroups with low, low-moderate, high-moderate, and severe levels of both PTSD and depression symptoms. Within each subgroup, PTSD symptom severity co-occurred with comparable depression symptom severity. At no time point were there reliable subgroups with discordant PTSD and depression symptom severities. Emotional numbing, hyperarousal, and overall PTSD symptom severity reliably distinguished each class from the others. Class membership at 1-month post-assault predicted subsequent class membership and functional impairment. LIMITATIONS Additional research is needed to evaluate predictors of class membership, temporal stability of classes, and generalizability to other trauma populations. CONCLUSIONS Co-occurring and comparably severe PTSD and depression symptoms are pervasive among female sexual assault survivors. The absence of a distinct subset of individuals with only PTSD or depression symptoms suggests that PTSD and depression may be manifestations of a general posttraumatic stress response rather than distinct disorders after trauma. Integrated treatments targeting both PTSD and depression symptoms may therefore prove more efficient and effective.

Latent Classes of PTSD Symptoms in Vietnam Veterans

The authors examined heterogeneity in posttraumatic stress disorder (PTSD) symptom presentation among veterans (n = 335) participating in the clinical interview subsample of the National Vietnam Veterans Readjustment Study. Latent class analysis was used to identify clinically homogeneous subgroups of Vietnam War combat veterans. Consistent with previous research, three classes emerged from the analysis, namely, veterans with no disturbance (61.4% of the cohort), intermediate disturbance (25.6%), and pervasive disturbance (12.5%). The authors also examined physical injury, war-zone stressor exposure, peritraumatic dissociation, and general dissociation as predictors of class membership. The findings are discussed in the context of recent conceptual frameworks that posit a range of posttraumatic outcomes and highlight the sizable segment of military veterans who suffer from intermediate (subclinical) PTSD symptoms.

Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy.

OBJECTIVE Although cognitive processing therapy (CPT) has strong empirical support as a treatment for posttraumatic stress disorder (PTSD), studies have not directly examined the proposed change mechanisms that underlie CPT-that change in trauma-related cognitions produces change in PTSD and depression symptoms. To improve the understanding of underlying mechanisms of psychotherapeutic change, this study investigated longitudinal association between trauma-related cognitions, PTSD, and depression among veterans receiving CPT during a 7-week residential PTSD treatment program. METHOD All 195 veterans met DSM-IV-TR diagnosis for PTSD. The sample was 53% male with a mean age of 48 years. Self-reported race was 50% White and 45% African American. The Posttraumatic Cognitions Inventory was used to assess trauma-related cognitions. The PTSD Checklist and Beck Depression Inventory-II were used to assess PTSD and depression, respectively. Cross-lagged panel models were used to test the longitudinal associations between trauma-related cognitions, PTSD, and depression. Measures were administered at three time points: pre-, mid-, and posttreatment. RESULTS Change in posttraumatic cognitions (self-blame; negative beliefs about the self) preceded change in PTSD. In addition, (a) change in negative beliefs about the self preceded change in depression, (b) change in depression preceded change in self-blame cognitions, and (c) change in depression preceded change in PTSD. CONCLUSION Findings support the hypothesized underlying mechanisms of CPT in showing that change in trauma-related cognitions precedes change in PTSD symptoms. Results suggest that reduction of depression may be important in influencing reduction of PTSD among veterans in residential PTSD treatment.

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.

Comparing Response to Cognitive Processing Therapy in Military Veterans With Subthreshold and Threshold Posttraumatic Stress Disorder

Research suggests that subthreshold posttraumatic stress disorder (PTSD) symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. However, it does not appear that any studies to date have investigated whether subthreshold PTSD can effectively be treated with evidence-based, trauma-focused treatment. Accordingly, we tested response to cognitive processing therapy (CPT) in 2 groups of military veterans receiving care at a VA outpatient specialty clinic, 1 with subthreshold PTSD at pretreatment (n = 51) and the other with full, diagnostic PTSD (n = 483). Multilevel analysis revealed that both groups experienced a significant decrease in PTSD symptoms over the course of therapy (the full and subthreshold PTSD groups experienced an average decrease of 1.79 and 1.52 points, respectively, on the PTSD Checklist with each increment of time, which was coded from 0 at pretreatment to 13 at posttreatment). After controlling for pretreatment symptom severity, a between-groups difference was not found. These results suggest that CPT is an effective form of treatment among military veterans, and that its effectiveness does not differ between subthreshold and threshold groups.

The distinctiveness of prolonged grief and posttraumatic stress disorder in adults bereaved by the attacks of September 11th

BACKGROUND Prolonged Grief Disorder (PGD) is a new diagnosis proposed for inclusion in the DSM-V. Although some studies have shown the distinctiveness of PGD and posttraumatic stress disorder (PTSD), this relationship has yet to be tested within a context of sudden, violent loss. METHOD We conducted an exploratory factor analysis (EFA) using self-report data collected from a sample of 587 bereaved adults who lost friends and relatives in the attacks of September 11th. Participants completed a 9-item PGD screening measure and the 17-item PTSD Checklist. RESULTS A five factor solution representing two distinct constructs emerged from our analysis. Although two PGD items loaded onto factors containing PTSD symptoms, these items assessed non-specific symptomatology (i.e., generalized negative affect). Thus, overall, our results support the distinctiveness of PGD and PTSD within a context of sudden, violent loss. LIMITATIONS Data were collected using self-report. The representativeness of our sample is uncertain. CONCLUSIONS These findings provide a stringent test of construct validity and suggest that PGD warrants inclusion in the diagnostic nosology. Adding PGD to the DSM-V will help clinicians better assess and treat psychopathology resulting from grief.

Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive-behavioral treatment for posttraumatic stress disorder (PTSD) and a front-line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy-cognitive therapy only (CPT-C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT-C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT-C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self- and clinician-reported PTSD and self-reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment-wise α correction was applied, this effect did not remain significant.