Matthew W. King

A critical evaluation of the complex PTSD literature: Implications for DSM‐5

Complex posttraumatic stress disorder (CPTSD) has been proposed as a diagnosis for capturing the diverse clusters of symptoms observed in survivors of prolonged trauma that are outside the current definition of PTSD. Introducing a new diagnosis requires a high standard of evidence, including a clear definition of the disorder, reliable and valid assessment measures, support for convergent and discriminant validity, and incremental validity with respect to implications for treatment planning and outcome. In this article, the extant literature on CPTSD is reviewed within the framework of construct validity to evaluate the proposed diagnosis on these criteria. Although the efforts in support of CPTSD have brought much needed attention to limitations in the trauma literature, we conclude that available evidence does not support a new diagnostic category at this time. Some directions for future research are suggested.

Extinction retention and the menstrual cycle: Different associations for women with posttraumatic stress disorder.

The propensity to acquire and retain conditioned fear responses may contribute to the risk of developing and maintaining posttraumatic stress disorder (PTSD) following a traumatic event. There is growing evidence that the gonadal hormones estrogen and progesterone are associated with how well women retain extinction of previously conditioned fear responses. Thus, sex steroid effects may contribute to the increased prevalence of PTSD in women. For the current study, 32 nonmedicated female trauma survivors with and without PTSD completed a differential fear conditioning task both during the early follicular phase of the menstrual cycle when estradiol and progesterone levels are low, and during the midluteal phase when estradiol and progesterone levels are high. Skin conductance served as the measure of conditioned fear. Women with PTSD, compared to those without, showed impaired retention of extinction learning in the midluteal phase of the menstrual cycle. Therefore, the impact of menstrual phase on extinction retention may differ between women with and without PTSD. These findings raise potential considerations regarding the coordination of psychopharmacologic and trauma exposure-based treatments for PTSD with specific phases of the menstrual cycle.

Gender Differences in Posttraumatic Stress Symptoms Among OEF/OIF Veterans: An Item Response Theory Analysis

Establishing whether men and women tend to express different symptoms of posttraumatic stress in reaction to trauma is important for both etiological research and the design of assessment instruments. Use of item response theory (IRT) can reveal how symptom reporting varies by gender and help determine if estimates of symptom severity for men and women are equally reliable. We analyzed responses to the PTSD Checklist (PCL) from 2,341 U.S. military veterans (51% female) who completed deployments in support of operations in Afghanistan and Iraq (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]), and tested for differential item functioning by gender with an IRT-based approach. Among men and women with the same overall posttraumatic stress severity, women tended to report more frequent concentration difficulties and distress from reminders whereas men tended to report more frequent nightmares, emotional numbing, and hypervigilance. These item-level gender differences were small (on average d = 0.05), however, and had little impact on PCL measurement precision or expected total scores. For practical purposes, mens and womens severity estimates had similar reliability. This provides evidence that men and women veterans demonstrate largely similar profiles of posttraumatic stress symptoms following exposure to military-related stressors, and some theoretical perspectives suggest this may hold in other traumatized populations.

Data mining in psychological treatment research: a primer on classification and regression trees.

Data mining of treatment study results can reveal unforeseen but critical insights, such as who receives the most benefit from treatment and under what circumstances. The usefulness and legitimacy of exploratory data analysis have received relatively little recognition, however, and analytic methods well suited to the task are not widely known in psychology. With roots in computer science and statistics, statistical learning approaches offer a credible option: These methods take a more inductive approach to building a model than is done in traditional regression, allowing the data greater role in suggesting the correct relationships between variables rather than imposing them a priori. Classification and regression trees are presented as a powerful, flexible exemplar of statistical learning methods. Trees allow researchers to efficiently identify useful predictors of an outcome and discover interactions between predictors without the need to anticipate and specify these in advance, making them ideal for revealing patterns that inform hypotheses about treatment effects. Trees can also provide a predictive model for forecasting outcomes as an aid to clinical decision making. This primer describes how tree models are constructed, how the results are interpreted and evaluated, and how trees overcome some of the complexities of traditional regression. Examples are drawn from randomized clinical trial data and highlight some interpretations of particular interest to treatment researchers. The limitations of tree models are discussed, and suggestions for further reading and choices in software are offered.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension

The 4-item Hurt/Insult/Threaten/Scream (HITS) tool accurately detects past-year intimate partner violence (IPV) among female Veterans Health Administration (VHA) patients; however, it lacks a sexual IPV item. This study evaluated the accuracy of an extended HITS (E-HITS), which adds a sexual IPV item, in female VHA patients. A sample of 80 female U.S. veteran VHA patients in New England completed a mail survey (50.0% response rate) that included the 5-item E-HITS and the Revised Conflict Tactics Scales (CTS-2). Women were included if they were in an intimate relationship in the past year. The women averaged 49 years of age and 86.0% of the sample was White. Accuracy of the 4-item HITS was compared to the 5-item E-HITS, using the CTS-2 as the reference. There were 20 women (25.0%) who reported past-year IPV on the CTS-2. The receiver operator characteristic curves demonstrated that the HITS and E-HITS performed nearly identically at their optimal cutoff scores of 6 and 7, respectively. At these cutoff scores, the sensitivity of both tools was .75, 95% CI [.55, .95]. The specificities were similar; .83 for the HITS, 95% CI [.73, .92], and .82 for the E-HITS, 95% CI [.72, .90]. Including a sexual IPV item may be clinically beneficial; it also attains the same accuracy of case identification as the HITS.

Compassion-Based Therapy for Trauma-Related Shame and Posttraumatic Stress: Initial Evaluation Using a Multiple Baseline Design

Accumulating research suggests that shame can strongly contribute to the development and maintenance of posttraumatic stress disorder (PTSD). Interventions that promote self-compassion have shown promise for reducing shame related to various clinical problems, but this approach has not been systematically evaluated for traumatized individuals. The aim of this study was to develop a brief compassion-based therapy and assess its efficacy for reducing trauma-related shame and PTSD symptoms. Using a multiple baseline experimental design, the intervention was evaluated in a community sample of trauma-exposed adults (N=10) with elevated trauma-related shame and PTSD symptoms. Participants completed weekly assessments during a 2-, 4-, or 6-week baseline phase and a 6-week treatment phase, and at 2 and 4weeks after the intervention. By the end of treatment, 9 of 10 participants demonstrated reliable decreases in PTSD symptom severity, while 8 of 10 participants showed reliable reductions in shame. These improvements were maintained at 2- and 4-week follow-up. The intervention was also associated with improvements in self-compassion and self-blame. Participants reported high levels of satisfaction with the intervention. Results suggest that the intervention may be useful as either a stand-alone treatment or as a supplement to other treatments.

Gender Differences in Machine Learning Models of Trauma and Suicidal Ideation in Veterans of the Iraq and Afghanistan Wars

Suicide rates among recent veterans have led to interest in risk identification. Evidence of gender-and trauma-specific predictors of suicidal ideation necessitates the use of advanced computational methods capable of elucidating these important and complex associations. In this study, we used machine learning to examine gender-specific associations between predeployment and military factors, traumatic deployment experiences, and psychopathology and suicidal ideation (SI) in a national sample of veterans deployed during the Iraq and Afghanistan conflicts (n = 2,244). Classification, regression tree analyses, and random forests were used to identify associations with SI and determine their classification accuracy. Findings converged on several associations for men that included depression, posttraumatic stress disorder (PTSD), and somatic complaints. Sexual harassment during deployment emerged as a key factor that interacted with PTSD and depression and demonstrated a stronger association with SI among women. Classification accuracy for SI presence or absence was good based on the receiver operating characteristic area under the curve, men = .91, women = .92. The risk for SI was classifiable with good accuracy, with associations that varied by gender. The use of machine learning analyses allowed for the discovery of rich, nuanced results that should be replicated in other samples and may eventually be a basis for the development of gender-specific actuarial tools to assess SI risk among veterans.

Developing systems that promote veterans’ recovery from military sexual trauma: Recommendations from the Veterans Health Administration national program implementation

ABSTRACT Veterans who experienced sexual assault or sexual harassment during military service (known as military sexual trauma [MST]) present with diverse health care needs and barriers to accessing services. Over the past 20 years, the U.S. Department of Veterans Affairs (VA) has developed and implemented MST-specific health care services to respond to those challenges. The authors summarize 9 recommendations learned from VA’s initiatives that may be helpful for non-VA health care systems interested in developing or enhancing their own services for Veterans who experienced MST. First, they recommend creating a system of care that provides varied options and paths to recovery, reflects and honors the diversity of MST survivors, and offers choice. Second, they describe the importance of ongoing staff education and training not only for specialized trauma providers but also for a wide range of professionals across disciplines. Third, the authors recommend outreach efforts that raise awareness of MST, identify common ‘points of entry’ into the system, and sensitively reduce barriers to care. Finally, they discuss the importance of regular evaluation and feedback to foster continuous improvement. Health care systems and individual providers can use these recommendations to enhance their own services and policies, demonstrate sensitivity to the potential issues associated with MST, and effectively assist survivors.

Accuracy and Acceptability of a Screening Tool for Identifying Intimate Partner Violence Perpetration among Women Veterans: A Pre-Implementation Evaluation

OBJECTIVES Veterans are at heightened risk for perpetrating intimate partner violence (IPV), yet there is limited evidence to inform practice and policy for the detection of IPV perpetration. The present study evaluated the accuracy and acceptability of a potential IPV perpetration screening tool for use with women veterans. DESIGN A national sample of women veterans completed a 2016 web-based survey that included a modified 5-item Extended-Hurt/Insult/Threaten/Scream (Modified E-HITS) and the Revised Conflict Tactics Scales (CTS-2). Items also assessed womens perceptions of the acceptability and appropriateness of the modified E-HITS questions for use in healthcare settings. Accuracy statistics, including sensitivity and specificity, were calculated using the CTS-2 as the reference standard. MAIN OUTCOME MEASURES Primary measures included the Modified E-HITS (index test), CTS-2 (reference standard), and items assessing acceptability. RESULTS This study included 187 women, of whom 31 women veterans (16.6%) reported past-6-month IPV perpetration on the CTS-2. The Modified E-HITS demonstrated good overall accuracy (area under the curve, 0.86; 95% confidence interval, 0.78-0.94). In addition, the majority of women perceived the questions to be acceptable and appropriate. CONCLUSIONS Findings demonstrate that the Modified E-HITS is promising as a low-burden tool for detecting of IPV perpetration among women veterans. This tool may help the Veterans Health Administration and other health care providers detect IPV perpetration and offer appropriate referrals for comprehensive assessment and services.