Diane T. Castillo

A Latent Class Analysis of Dissociation and Posttraumatic Stress Disorder: Evidence for a Dissociative Subtype

CONTEXT The nature of the relationship of dissociation to posttraumatic stress disorder (PTSD) is controversial and of considerable clinical and nosologic importance. OBJECTIVES To examine evidence for a dissociative subtype of PTSD and to examine its association with different types of trauma. DESIGN A latent profile analysis of cross-sectional data from structured clinical interviews indexing DSM-IV symptoms of current PTSD and dissociation. SETTINGS The VA Boston Healthcare System and the New Mexico VA Health Care System. PARTICIPANTS A total of 492 veterans and their intimate partners, all of whom had a history of trauma. Participants reported exposure to a variety of traumatic events, including combat, childhood physical and sexual abuse, partner abuse, motor vehicle accidents, and natural disasters, with most participants reporting exposure to multiple types of traumatic events. Forty-two percent of the sample met the criteria for a current diagnosis of PTSD. MAIN OUTCOME MEASURES Item-level scores on the Clinician-Administered PTSD Scale. RESULTS A latent profile analysis suggested a 3-class solution: a low PTSD severity subgroup, a high PTSD severity subgroup characterized by elevations across the 17 core symptoms of the disorder, and a small but distinctly dissociative subgroup that composed 12% of individuals with a current diagnosis of PTSD. The latter group was characterized by severe PTSD symptoms combined with marked elevations on items assessing flashbacks, derealization, and depersonalization. Individuals in this subgroup also endorsed greater exposure to childhood and adult sexual trauma compared with the other 2 groups, suggesting a possible etiologic link with the experience of repeated sexual trauma. CONCLUSIONS These results support the subtype hypothesis of the association between PTSD and dissociation and suggest that dissociation is a highly salient facet of posttraumatic psychopathology in a subset of individuals with the disorder.

The MMPI-2 Restructured Clinical Scales in the Assessment of Posttraumatic Stress Disorder and Comorbid Disorders

This study examined the psychometric properties of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Restructured Clinical Scales (RCSs) in individuals with posttraumatic stress disorder (PTSD) receiving clinical services at Department of Veterans Affairs medical centers. Study 1 included 1,098 men who completed the MMPI-2 and were assessed for a range of psychological disorders via structured clinical interview. Study 2 included 136 women who completed the MMPI-2 and were interviewed with the Clinician Administered Scale for PTSD. The utility of the RCSs was compared with that of the Clinical Scales (CSs) and the Keane PTSD (PK) scale. The RCSs demonstrated good psychometric properties and patterns of associations with other measures of psychopathology that corresponded to current theory regarding the structure of comorbidity. A notable advantage of the RCSs compared with the MMPI-2 CSs was their enhanced construct validity and clinical utility in the assessment of comorbid internalizing and externalizing psychopathology. The PK scale demonstrated incremental validity in the prediction of PTSD beyond that of the RCSs or CSs.

ANGER IN PTSD: GENERAL PSYCHIATRIC AND GENDER DIFFERENCES ON THE BDHI

Anger was examined through the use of the Buss Durkee Hostility Inventory (BDHI) in male veterans with combat-related posttraumatic stress disorder (PTSD),male veterans with other psychiatric disorders, and women with sexual-trauma-related PTSD. Male veterans with PTSD scored higher on the BDHI Assault, Irritability, Negativism, and Verbal Hostility scales than male veterans with other psychiatric diagnoses, which supports past research. In addition, male veterans with combat-related PTSD scored higher than women with sexual-trauma-related PTSD on the Assault, Indirect Hostility, Irritability, and Verbal Hostility scales of the BDHI. Scale differences are attributed to diagnosis and gender, while some nonsignificant differences are discussed as characteristic of PTSD.

PTSD and conflict behavior between veterans and their intimate partners.

This study examined the influence of trauma history and PTSD symptoms on the behavior of veterans and their intimate partners (287 couples; N=574) observed during conflict discussions and coded using the Rapid Marital Interaction Coding System (Heyman, 2004). Dyadic structural equation modeling analyses showed that PTSD was associated with more frequent displays of hostility and psychological abuse and fewer expressions of acceptance and humor in both veterans and their partners. Findings provide new insight into the social and emotional deficits associated with PTSD and emphasize the importance of addressing the trauma histories and PTSD of both partners when treating veteran couples with relationship disturbance.

A Latent Class Analysis of Dissociation and PTSD: Evidence for a Dissociative Subtype

CONTEXT The nature of the relationship of dissociation to posttraumatic stress disorder (PTSD) is controversial and of considerable clinical and nosologic importance. OBJECTIVES To examine evidence for a dissociative subtype of PTSD and to examine its association with different types of trauma. DESIGN A latent profile analysis of cross-sectional data from structured clinical interviews indexing DSM-IV symptoms of current PTSD and dissociation. SETTINGS The VA Boston Healthcare System and the New Mexico VA Health Care System. PARTICIPANTS A total of 492 veterans and their intimate partners, all of whom had a history of trauma. Participants reported exposure to a variety of traumatic events, including combat, childhood physical and sexual abuse, partner abuse, motor vehicle accidents, and natural disasters, with most participants reporting exposure to multiple types of traumatic events. Forty-two percent of the sample met the criteria for a current diagnosis of PTSD. MAIN OUTCOME MEASURES Item-level scores on the Clinician-Administered PTSD Scale. RESULTS A latent profile analysis suggested a 3-class solution: a low PTSD severity subgroup, a high PTSD severity subgroup characterized by elevations across the 17 core symptoms of the disorder, and a small but distinctly dissociative subgroup that composed 12% of individuals with a current diagnosis of PTSD. The latter group was characterized by severe PTSD symptoms combined with marked elevations on items assessing flashbacks, derealization, and depersonalization. Individuals in this subgroup also endorsed greater exposure to childhood and adult sexual trauma compared with the other 2 groups, suggesting a possible etiologic link with the experience of repeated sexual trauma. CONCLUSIONS These results support the subtype hypothesis of the association between PTSD and dissociation and suggest that dissociation is a highly salient facet of posttraumatic psychopathology in a subset of individuals with the disorder.

Effectiveness of Group-Delivered Cognitive Therapy and Treatment Length in Women Veterans with PTSD

The effectiveness and length of group-delivered cognitive treatment for Posttraumatic Stress Disorder (PTSD) was examined in a sample of women veterans. The sample included 271 primarily non-Hispanic white (61%) and Hispanic (25%) women veterans treated in 8-, 10-, or 12-group length sessions with manualized cognitive therapy for PTSD. Outcome was measured with the PTSD Symptom Checklist (PCL) in an intention-to-treat analysis (N = 271), in completer subjects (n = 172), and with group as the unit of analysis (n = 47 groups). Significant decreases in PTSD were found in the full sample (effect size [ES] range = 0.27 to 0.38), completers (ES range = 0.37 to 0.54), and group as the unit of analysis (ES range = 0.71 to 0.92), suggesting effectiveness of cognitive group treatment for PTSD. PCL scores significantly improved in the 8, 10, and 12 group lengths, with no differences between each. Clinical improvement showed a third decreasing 10 or more PCL points and 22% no longer meeting PTSD diagnostic criteria, with the best results in the 10-session group. The results suggest group-delivered cognitive therapy is an effective, efficient, time-limited treatment for PTSD.

Group Exposure Therapy Treatment for Post-traumatic Stress Disorder in Female Veterans

OBJECTIVES The purpose of this study was to examine the application of a group exposure therapy model, the content of which consisted solely of repeated imaginal exposure during sessions, in a clinical sample of female veterans with post-traumatic stress disorder (PTSD). Establishing group delivery of exposure therapy will expand options, increase efficiency, and introduce group curative factors. METHODS Eighty-eight female veterans with PTSD completed a six-session exposure group, three participants per group, as a component of a larger treatment program. The PTSD symptom checklist (PCL) was used as the outcome measure and administered in each session. RESULTS Pre/post-paired t-tests showed significant improvement in PTSD on the PCL, with 40% of completers showing at least a 10-point drop in the PCL scores. In addition, a repeated measures analysis of variance showed a significant main effect and a significant quadratic equation, with expected initial increases in the PCL followed by a decrease below baseline at session 6. CONCLUSIONS The group exposure treatment protocol showed positive outcomes on PTSD symptoms in a real-world clinical sample of female veterans. The implications include an expansion of exposure treatment choices for veterans with PTSD and increased options for therapists.

Group-delivered cognitive/exposure therapy for PTSD in women veterans: A randomized controlled trial.

OBJECTIVE Group delivery of posttraumatic stress disorder (PTSD) treatment has several advantages, however group research is not comparable to individual trials. This study extends the group literature by improving methodology in examining the efficacy of a 3-module (cognitive, exposure, skills) group treatment for PTSD, establishes a format for the delivery of group exposure therapy, and compares 3 treatment modules within the group. METHOD Eighty-six Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) women veterans were randomized to a 16-week, 3-member group treatment (Tx) or a waitlist (WL) condition. The primary (Clinician Administered PTSD Scale [CAPS]) and secondary (Medical Outcomes Study Short Form-36 [SF-36], Quality of Life Inventory [QOLI], and PTSD Checklist [PCL]) outcome measures were administered at baseline, post Tx/WL, and at 3- and 6-months post Tx (PCL additionally at pre/post for each treatment module). RESULTS PTSD symptoms significantly improved in Tx arm participants (p < .001, ES = 1.72; unit of analysis group: n = 14), as did mental and physical life functioning (SF-36; p < .001), and quality of life (QOLI; p < .001). The WL significantly improved on the SF-36 (mental; p = .04) and QOLI (p = .02). Clinical improvement (CAPS) in the Tx arm reflected a treatment response (≥10-point decrease) in 77% and loss of PTSD diagnosis (<45) in 52% of participants, comparable to individual prolonged exposure (PE) treatment. Finally, PCL scores significantly lowered in exposure and cognitive modules. CONCLUSIONS This study supports the use of group format for PTSD with 3 modules using improved methodology, with a novel, 3-member group which allows repeated in-session weekly imaginal exposures. The results suggest future examination of group delivered PE. (PsycINFO Database Record

Ethnic differences in symptoms among female veterans diagnosed with PTSD.

Among U.S. male Vietnam veterans, Hispanics have been shown to have higher rates of posttraumatic stress disorder (PTSD) than African Americans and non-Hispanic Whites (Kulka et al., 1990). In terms of gender, Tolin and Foas (2006) meta-analysis suggested women experience higher rates of PTSD than men. This study examined ethnic differences in PTSD and other symptomatology among 398 female veterans (63% non-Hispanic White, 28% Hispanic, 9% African American) seeking treatment for PTSD from 1995 to 2009 at a Veterans Administration (VA) behavioral health clinic. The following symptom clusters were examined: anxiety/PTSD, depression, anger/hostility, and psychotic/dissociative symptoms. Few differences were found among the groups, suggesting the 3 ethnic groups studied were more similar than different. African American female veterans, however, scored higher on measuring ideas of persecution/paranoia, although this may reflect an adaptive response to racism. These findings warrant further investigation to elucidate this relationship.

Neurocognitive Correlates of Successful Treatment of PTSD in Female Veterans.

BACKGROUND The influence of psychotherapy on neurocognition in post-traumatic stress disorder (PTSD) has not been examined methodically. This is despite evidence that pre-treatment learning and memory has been associated with treatment success and that executive function theories emphasize weak executive functions (especially inhibition/switching) are associated with PTSD. OBJECTIVES To determine (1) if higher pre-treatment learning/memory, inhibition/switching, or both predict treatment success; and (2) if treatment success is associated with specific improvement in inhibition/switching and not learning/memory or working memory, another aspect of executive function. METHODS Pre-treatment neurocognition and neurocognitive changes (inhibition/switching, learning/memory, working memory) were examined in female veterans with PTSD. They were evaluated before and after 16-weeks of group psychotherapy for PTSD that included three counterbalanced modules (cognitive restructuring therapy, exposure therapy, skills training) with fidelity checks for therapist adherence. RESULTS Only pre-treatment learning/memory predicted better treatment outcome. Treatment success was associated with improvement in inhibition/switching only, even after controlling for mild traumatic brain injury, and changes in depressive symptoms, working memory, and learning/memory. CONCLUSIONS Our finding that learning/memory predicted treatment success is consistent with previous studies. We extended these studies by showing that the effect was restricted to learning/memory, which is contrary to the executive function theory of PTSD. In contrast, the fact that only inhibition/switching significantly improved with better treatment success is consistent with its potential importance in maintaining PTSD symptoms. Future research should determine whether inhibition/switching abilities are a risk for development and maintenance of PTSD or whether such abilities have a broader reciprocal relationship with PTSD symptom change. (JINS, 2016, 22, 643-651).