Jack Tsai

Dimensional structure of DSM-5 posttraumatic stress symptoms: support for a hybrid Anhedonia and Externalizing Behaviors model.

Several revisions to the symptom clusters of posttraumatic stress disorder (PTSD) have been made in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Central to the focus of this study was the revision of PTSDs tripartite structure in DSM-IV into four symptom clusters in DSM-5. Emerging confirmatory factor analytic (CFA) studies have suggested that DSM-5 PTSD symptoms may be best represented by one of two 6-factor models: (1) an Externalizing Behaviors model characterized by a factor which combines the irritability/anger and self-destructive/reckless behavior items; and (2) an Anhedonia model characterized by items of loss of interest, detachment, and restricted affect. The current study conducted CFAs of DSM-5 PTSD symptoms assessed using the PTSD Checklist for DSM-5 (PCL-5) in two independent and diverse trauma-exposed samples of a nationally representative sample of 1484 U.S. veterans and a sample of 497 Midwestern U.S. university undergraduate students. Relative fits of the DSM-5 model, the DSM-5 Dysphoria model, the DSM-5 Dysphoric Arousal model, the two 6-factor models, and a newly proposed 7-factor Hybrid model, which consolidates the two 6-factor models, were evaluated. Results revealed that, in both samples, both 6-factor models provided significantly better fit than the 4-factor DSM-5 model, the DSM-5 Dysphoria model and the DSM-5 Dysphoric Arousal model. Further, the 7-factor Hybrid model, which incorporates key features of both 6-factor models and is comprised of re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptom clusters, provided superior fit to the data in both samples. Results are discussed in light of theoretical and empirical support for the latent structure of DSM-5 PTSD symptoms.

The Role of Coping, Resilience, and Social Support in Mediating the Relation Between PTSD and Social Functioning in Veterans Returning from Iraq and Afghanistan

Abstract Posttraumatic stress disorder (PTSD) is one of the most common psychiatric disorders among veterans returning tfrom Iraq and Afghanistan. Little research has examined variables that may mediate the relation between PTSD and aspects of social functioning, such as relationship satisfaction and family functioning. In this cross-sectional study, a total of 164 veterans who were seeking VA primary care or mental health care within one year after returning from Iraq and/or Afghanistan were screened for PTSD and completed a series of questionnaires that assessed social functioning, coping, and life satisfaction. Results showed that the 86 (52%) veterans who screened positive for PTSD reported greater difficulties in their relationships with romantic partners, less cohesion in their families, less social support, poorer social functioning, and lower life satisfaction compared to other treatment-seeking veterans. Less social support from the community, excessive worry, decreased acceptance of change, and lower availability of secure relationships mediated the association between PTSD and poor social functioning. The relation between PTSD and lower partner satisfaction was mediated by greater cognitive social avoidance and lower availability of secure relationships. These results suggest that psychotherapeutic interventions that address these mediating variables may help improve social functioning in treatment-seeking veterans with PTSD.

Associations of multiple domains of self-esteem with four dimensions of stigma in schizophrenia

Research suggests global self-esteem among persons with schizophrenia may be negatively affected by stigma or stereotyped beliefs about persons with severe mental illness. Less clear however, is whether particular dimensions of self-esteem are linked to particular domains of stigma. To examine this we surveyed a range of self-esteem dimensions including lovability, personal power, competence and moral self-approval and four domains of stigma: Stereotype endorsement, Discrimination experience, Social withdrawal and Stigma rejection. Participants were 133 adults with diagnoses of schizophrenia or schizoaffective disorder. Stepwise multiple regressions controlling for a possible defensive response bias suggested that aspects of self-esteem related to lovability by others were more closely linked with lesser feelings of being alienated from others due to mental illness. Aspects of self-esteem related to the ability to manage ones own affairs were more closely associated with the rejection of stereotypes of mental illness. A sense of being able to influence others was linked to both the absence of discrimination experiences and the ability to ward off stigma. Implications for treatment are discussed.

Dimensional structure of DSM-5 posttraumatic stress disorder symptoms: results from the National Health and Resilience in Veterans Study.

OBJECTIVE To evaluate the prevalence of DSM-5 posttraumatic stress disorder (PTSD) and factor structure of PTSD symptomatology in a nationally representative sample of US veterans and examine how PTSD symptom clusters are related to depression, anxiety, suicidal ideation, hostility, physical and mental health-related functioning, and quality of life. METHOD Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of 1,484 US veterans conducted from September through October 2013. Confirmatory factor analyses were conducted to evaluate the factor structure of PTSD symptoms, and structural equation models were constructed to examine the association between PTSD symptom clusters and external correlates. RESULTS 12.0% of veterans screened positive for lifetime PTSD and 5.2% for past-month PTSD. A 5-factor dysphoric arousal model and a newly proposed 6-factor model both fit the data significantly better than the 4-factor model of DSM-5. The 6-factor model fit the data best in the full sample, as well as in subsamples of female veterans and veterans with lifetime PTSD. The emotional numbing symptom cluster was more strongly related to depression (P < .001) and worse mental health-related functioning (P < .001) than other symptom clusters, while the externalizing behavior symptom cluster was more strongly related to hostility (P < .001). CONCLUSIONS A total of 5.2% of US veterans screened positive for past-month DSM-5 PTSD. A 6-factor model of DSM-5 PTSD symptoms, which builds on extant models and includes a sixth externalizing behavior factor, provides the best dimensional representation of DSM-5 PTSD symptom clusters and demonstrates validity in assessing health outcomes of interest in this population.

Does Housing Chronically Homeless Adults Lead to Social Integration

OBJECTIVE Supported housing programs have been successful in helping homeless adults obtain housing. This study examined whether improvements in social integration occur after clients obtain supported housing. METHODS Measures of social integration were examined for 550 chronically homeless adults with mental illness who participated in the 11-site Collaborative Initiative to Help End Chronic Homelessness. Social integration was conceptualized as a multidimensional construct of variables in six domains: housing, work, social support, community participation, civic activity, and religious faith. Changes in baseline measures related to the six domains and their interrelationships were examined at six and 12 months after entry into the supported housing program. RESULTS Chronically homeless adults showed substantial improvements in housing but remained socially isolated and showed limited improvement in other domains of social integration, which were only weakly correlated with one another. CONCLUSIONS More attention is needed to develop rehabilitation interventions in supported housing programs to improve social integration of chronically homeless adults. Because improvements in some domains of social integration were only weakly related, it may be necessary to intervene in multiple domains simultaneously.

Measuring recovery orientation in a hospital setting.

Measuring the process of delivering recovery oriented services is a necessary complement to measuring recovery outcomes. Programs that are recovery oriented promote partnerships with consumers, emphasize consumer choice, and instill hope. This study examined the psychometric properties of the provider version of the Recovery Self Assessment (RSA) in a sample of hospital workers. The RSA demonstrated good to excellent internal consistency, test-retest reliability, and adequate convergent and discriminant validity. The RSA may be a reliable and valid measure of recovery orientation that can be used to assess a variety of mental health programs.

Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: Results from the National Health and Resilience in Veterans Study

BACKGROUND While posttraumatic stress disorder (PTSD) symptoms in the recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are clustered into four factors, emerging confirmatory factor analytic studies suggest that this disorder is best characterized by seven symptom clusters, including re-experiencing, avoidance, negative affect, anhedonia, externalizing behaviors, and anxious and dysphoric arousal symptoms. To date, however, data are lacking regarding the relation between this novel model of DSM-5 PTSD symptoms and measures of clinical significance in this population (e.g., functioning). METHODS Using data from the National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally representative sample of 1484 U.S. veterans, we evaluated clinical and functional correlates of a novel 7-factor model of DSM-5 PTSD symptoms. RESULTS Differential patterns of associations were observed between DSM-5 PTSD symptom clusters, and psychiatric comorbidities, suicidal ideation, hostility, and functioning and quality of life. Anhedonia symptoms, in particular, were strongly related to current depression, as well as reduced mental functioning and quality of life. Externalizing behaviors were most strongly related to hostility, supporting the convergent validity of this construct. LIMITATIONS Cross-sectional design and employment of self-report measures. CONCLUSIONS These results suggest that a more refined 7-factor model of DSM-5 PTSD symptoms may provide greater specificity in understanding associations with comorbid psychopathology, suicidal ideation, and functioning and quality of life in U.S. veterans. They further suggest that prevention and treatment efforts that target distinct aspects of the PTSD phenotype may be more effective in mitigating key clinical and functional outcomes in this population.

Housing Preferences and Choices Among Adults with Mental Illness and Substance Use Disorders: A Qualitative Study

Housing is a crucial issue for adults with severe mental illness and co-occurring substance use disorders, as this population is particularly susceptible to housing instability and homelessness. We interviewed 40 adults with dual disorders, living in either supervised or independent housing arrangements, to examine housing preferences, decision making processes surrounding housing choices, and perceived barriers to housing. We found that many clients indicated their housing preferences had changed over time, and some clients related housing preferences to recovery. Although the majority of clients preferred independent housing, many also described benefits of supervised housing. Clients’ current living situations appeared to be driven primarily by treatment provider recommendations and availability of housing. Common barriers to obtaining desired housing were lack of income and information. These findings have implications for supported housing models and approaches to providing housing for clients.

Smoking Among Chronically Homeless Adults: Prevalence and Correlates

OBJECTIVE Cigarette smoking is one of the leading preventable causes of death, and adults who are chronically homeless have among the highest death rates. This study examined the prevalence and correlates of smoking in this population. METHODS Data were analyzed for 754 chronically homeless adults who were receiving mental health, primary care, and supported housing services at 11 U.S. sites in a federal initiative, the Collaborative Initiative to Help End Chronic Homelessness. The prevalence of current smoking (past three months), sociodemographic and clinical correlates of smoking, and change in smoking status (nonsmoker, self-limiting smoker, or regular smoker) over a one-year period were examined by use of stepwise multinomial regression analysis. RESULTS Overall, 80% of the 754 chronically homeless adults reported current cigarette smoking; 48% of the smokers reported trying to limit their smoking, and 75% of the smokers had discussed smoking with a health care professional. No significant overall change in smoking status was found during the study year; however, change in alcohol and drug use was associated with change in smoking status in the same direction. Having a diagnosis of posttraumatic stress disorder and reducing alcohol use predicted quitting or limiting smoking. CONCLUSIONS A large majority of chronically homeless adults reported being current smokers. Smoking cessation interventions, integrated with alcohol and drug treatment, that target this population are needed.

Use of the internet and an online personal health record system by US veterans: comparison of Veterans Affairs mental health service users and other veterans nationally

OBJECTIVE The Department of Veterans Affairs (VA) operates one of the largest nationwide healthcare systems and is increasing use of internet technology, including development of an online personal health record system called My HealtheVet. This study examined internet use among veterans in general and particularly use of online health information among VA patients and specifically mental health service users. METHODS A nationally representative sample of 7215 veterans from the 2010 National Survey of Veterans was used. Logistic regression was employed to examine background characteristics associated with internet use and My HealtheVet. RESULTS 71% of veterans reported using the internet and about a fifth reported using My HealtheVet. Veterans who were younger, more educated, white, married, and had higher incomes were more likely to use the internet. There was no association between background characteristics and use of My HealtheVet. Mental health service users were no less likely to use the internet or My HealtheVet than other veterans. DISCUSSION Most veterans are willing to access VA information online, although many VA service users do not use My HealtheVet, suggesting more education and research is needed to reduce barriers to its use. CONCLUSION Although adoption of My HealtheVet has been slow, the majority of veterans, including mental health service users, use the internet and indicate a willingness to receive and interact with health information online.