Deborah Nazarian

Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S. veterans†

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ≥ 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.

Expressive Writing in the Clinical Context

The use of writing in a therapeutic manner can be traced back to psychotherapeutic traditions that encourage the expression of emotions (see Smyth & Helm, 2003). The majority of psychotherapeutic paradigms, regardless of theoretical orientation, consist of some form of interpersonal disclosure that includes identifying, labeling, and disclosing emotional experiences (Smyth & Helm, 2003). Although individuals may have a desire to disclose their thoughts and emotions about a distressing experience, social constraints may limit such interpersonal disclosure (Lepore, Silver, Wortman, & Wayment, 1996). Some individuals may refrain from discussing negative events due to the social stigma thought to be associated with the experience. Other people may lack a social support system and/or receive insensitive or inappropriate support (Wortman & Silver, 1989). In contrast, written emotional expression offers the opportunity to express one’s thoughts and feelings without regard to social constraints or barriers that might accompany interpersonal disclosure and reduces the likelihood of negative interpersonal responses. Writing has long been a common strategy for expressing strong emotion and has informally been used both personally and in therapeutic settings for a variety of purposes and goals (e.g., Progoff’s intensive journaling; see Smyth & Greenberg, 2000). Despite widespread use, such methods have not been extensively studied within the context of therapy. It is only recently that investigators have begun to systemically examine the effects of structured expressive writing on psychological and physical health. Expressive writing has increasingly been applied as a psychosocial intervention across settings and samples and represents an effective supplemental intervention that clinicians can add to their array of therapeutic tools for clients—both within and outside of the therapy session. The goals of this chapter are to provide an overview of the expressive writing literature as it relates to its use in various health care settings, including its effects among medically ill populations as well as purported mechanisms responsible for these effects. This background information will hopefully serve as the foundation for recommendations on how expressive writing may be used by clinicians and health professionals as a supplement or alternative to traditional forms of care.

A naturalistic study of ambulatory asthma severity and reported avoidant coping styles.

Objective: To examine how the use of dispositional avoidant coping traits prospectively predicts ambulatory asthma severity in daily life. Methods: An ecological momentary assessment (EMA) design enabled examination of stable coping styles across dynamic daily changes of ambulatory peak expiratory flow rate (PEFR), asthma symptoms and stress in the natural environment of patients with asthma. A community sample of 61 adults with asthma reported their typical use of avoidant coping styles and carried palmtop computers that alerted them to record their stress and symptoms five times per day for 1 week. Results: Some aspects of dispositional avoidant coping predicted more asthma symptoms and worse PEFR. Denial and behavioural disengagement as typical coping styles predicted more symptoms and worse PEFR. Mental disengagement was unrelated to symptoms and PEFR. Discussion: These data suggest that individuals with asthma who report typically utilizing avoidant coping may have worse health parameters in momentary reports when examined in their natural environments. Differences between avoidant coping styles emerged, suggesting the existence of moderating factors of coping effectiveness.

Overview of Bioethical Issues in Contemporary PTSD Treatment and Research: Considering Priorities for Future Empirical Ethics Investigation

The last decade has seen a surge in biomedical research advancing the evidence base for the effective clinical management and study of posttraumatic stress disorder (PTSD). The authors review the literature describing ethical issues in conducting PTSD research; controversies over the role of preventive pharmacotherapy for PTSD; and ethical quandaries in the identification, treatment, or empirical investigation of PTSD in postdisaster settings. Findings are synthesized within an ethics framework that utilizes major constructs in the biomedical literature: beneficence/nonmaleficence, informed consent, and autonomy. Gaps and weaknesses in the current evidence base are highlighted. The authors conclude by considering priorities for future empirical ethics investigation in this field.

11 – EXPRESSIVE WRITING

Publisher Summary Expressive writing is a psychosocial intervention that promotes written emotional disclosure of stressful or traumatic events in a structured and confidential manner. Written emotional disclosure is used as an intervention to foster emotional expression without regard to social stigma, and encourages individuals to approach and express their emotions through writing in an experimental setting. The effects of this emotional disclosure are usually compared to writing about emotionally neutral writing topics. The use of writing as a form of therapy appears to have evolved from psychotherapeutic traditions that espoused emotional expression. Expressive writing thus provides a means of expressing and processing emotions that can help avoid the barriers and/or negative consequences that might accompany interpersonal disclosure. Structured expressive writing (as opposed to unstructured) focuses on a specific topic of writing, such as stressful or traumatic life experiences. The majority of experimental studies utilize this form of structured writing within the controlled setting of the laboratory. In the prototypical writing study, disclosure is induced in the laboratory by randomly assigning participants to either an expressive writing group or an emotionally neutral writing condition. Participants in both groups are usually assured of confidentiality and encouraged to write without regard to spelling, style, or grammar. The time and attention are matched between conditions in an attempt to equalize all factors except for the experimental manipulation. Therefore, the sole difference between the experimental and the control groups are the writing instructions.