Melissa E. Milanak

National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM‐IV and DSM‐5 Criteria

Prevalence of posttraumatic stress disorder (PTSD) defined according to the American Psychiatric Associations Diagnostic and Statistical Manual fifth edition (DSM-5; 2013) and fourth edition (DSM-IV; 1994) was compared in a national sample of U.S. adults (N = 2,953) recruited from an online panel. Exposure to traumatic events, PTSD symptoms, and functional impairment were assessed online using a highly structured, self-administered survey. Traumatic event exposure using DSM-5 criteria was high (89.7%), and exposure to multiple traumatic event types was the norm. PTSD caseness was determined using Same Event (i.e., all symptom criteria met to the same event type) and Composite Event (i.e., symptom criteria met to a combination of event types) definitions. Lifetime, past-12-month, and past 6-month PTSD prevalence using the Same Event definition for DSM-5 was 8.3%, 4.7%, and 3.8% respectively. All 6 DSM-5 prevalence estimates were slightly lower than their DSM-IV counterparts, although only 2 of these differences were statistically significant. DSM-5 PTSD prevalence was higher among women than among men, and prevalence increased with greater traumatic event exposure. Major reasons individuals met DSM-IV criteria, but not DSM-5 criteria were the exclusion of nonaccidental, nonviolent deaths from Criterion A, and the new requirement of at least 1 active avoidance symptom.

Behavioral Activation and Therapeutic Exposure: An Investigation of Relative Symptom Changes in PTSD and Depression During the Course of Integrated Behavioral Activation, Situational Exposure, and Imaginal Exposure Techniques

Effectiveness of exposure therapy for posttraumatic stress disorder (PTSD) may be adversely influenced by comorbid disorders. The present study investigated behavioral activation and therapeutic exposure (BA-TE), a new integrated treatment designed specifically for comorbid symptoms of PTSD and depression. Combat veterans with PTSD (N = 117) completed eight sessions of BA-TE that included two phases of treatment: (a) behavioral activation (BA) in which some activities involved situational exposures and (b) BA and situational exposures with imaginal exposures. Findings supported improvements in symptoms of PTSD, and overlapping symptoms of PTSD and depression, but not in nonoverlapping symptoms of depression. The findings also demonstrated a relatively consistent rate of change in PTSD and depression symptoms during BA-TE, despite the addition of imaginal exposures midway through the treatment. Together, these findings provide preliminary support for BA-TE as a treatment for PTSD and depression, and highlight the utility of transdiagnostic treatments in addressing comorbidity and symptom overlap.

Psychological trauma and schizotypal personality disorder.

Two studies examined the relation between psychological trauma and schizotypal symptoms. In Study 1, in which 1,510 adults completed telephone interviews, both childhood maltreatment and the experience of an injury or life-threatening event were significantly associated with schizotypal symptoms. In Study 2, in which 303 adults (oversampled for having elevated levels of schizotypal symptoms) completed extensive in-person assessments, both childhood maltreatment and meeting posttraumatic stress disorder (PTSD) Criterion A were significantly associated with schizotypal symptoms. The links between schizotypal symptoms and at least some forms of psychological trauma could not be fully accounted for by shared variance with antisocial and borderline personality disorders, absorption/dissociation, PTSD symptom severity, family history of psychotic disorder, or signs of neurodevelopmental disturbance (as indexed by minor physical anomalies and inconsistent hand use). Schizotypal symptoms were more strongly associated with childhood maltreatment among men than among women, whereas schizotypal symptoms were more strongly associated with PTSD Criterion A among women than among men. Finally, among men, the association between childhood maltreatment and schizotypal symptoms was moderated by signs of neurodevelopmental disturbance.

Prevalence and features of generalized anxiety disorder in Department of Veteran Affairs primary care settings

Generalized anxiety disorder (GAD) is a highly prevalent distressing condition for individuals in both community and community primary care settings. However, despite the high prevalence of GAD identified in epidemiological studies, little is known about GAD and its related symptoms and impairments in veteran populations. The present study investigated the prevalence, comorbidity, physical and mental health impairment, and healthcare utilization of veteran participants with GAD, as well as comparing symptoms of GAD and posttraumatic stress disorder (PTSD). Veterans (N=884) participated in a cross-sectional investigation in primary care clinics in four Veteran Affairs Medical Centers (VAMCs) and completed diagnostic interviews and self-report questionnaires; a chart review was conducted to assess their VAMC healthcare utilization. A large number of participants (12%) met diagnostic criteria for GAD, reporting significantly worse emotional health, pain, and general health, in addition to increased mental healthcare utilization and antidepressant medications. In addition, GAD was found in 40% of participants with PTSD, resulting in more severe symptoms and impairment than in patients with GAD alone. These findings provide evidence of high prevalence and severe impairment associated with GAD in veterans and highlight the need for improved recognition, assessment, and treatments for GAD.

Frequency and Severity of Comorbid Mood and Anxiety Disorders in Prescription Opioid Dependence

BACKGROUND AND OBJECTIVES Comorbid substance use disorders and mood and anxiety disorders are associated with more severe psychiatric symptoms, social and occupational impairment, and economic burden. To date, the majority of research has focused on comorbidity in illicit drug users, rather than prescription drug users. To address this gap in the literature, the present cross-sectional study investigated the clinical profiles of individuals with prescription opioid dependence with or without comorbid mood and anxiety disorders. METHODS Ninety individuals with prescription opioid use were recruited to participate in the study procedures. All participants completed a structured clinical interview and series of self-report measures. RESULTS AND CONCLUSIONS Of the 85 individuals with prescription opioid dependence, 47.1% (n = 40) were diagnosed with a comorbid mood or anxiety disorder. The findings showed that individuals with prescription opioid dependence and comorbid mood and anxiety disorders demonstrated significantly more severe alcohol use, psychiatric symptoms, and sleep impairment than individuals without comorbidity. SCIENTIFIC SIGNIFICANCE The findings highlight the frequency and severity of co-occurring mood and anxiety disorders in individuals with prescription opioid dependence and suggest that integrated interventions are needed to address these growing problems.

The relationship between PTSD symptom factors and emotion.

The relationship between posttraumatic stress disorder (PTSD) symptom factors and two facets of emotion were examined. Emotional congruence effects were examined using an affective priming word pronunciation (naming) task, and negative affect was measured using self-report. Current PTSD symptoms were assessed using the Clinician-Administered PTSD Scale in 95 adults with trauma histories. Two alternative PTSD symptom factor structures were examined, one of which included an emotional numbing factor, and one of which included a dysphoria factor. Emotional congruence effects were significantly associated with an emotional numbing factor, but not with any other PTSD factors. Negative affect was significantly associated with a dysphoria factor, but not with any other PTSD factors.

An examination of sleep quality in veterans with a dual diagnosis of PTSD and severe mental illness

Poor sleep quality is one of the most frequently reported symptoms by veterans with Posttraumatic Stress Disorder (PTSD) and by veterans with severe mental illness (SMI; i.e., schizophrenia spectrum disorders, bipolar disorder, major depression with or without psychotic features). However, little is known about the compounding effects of co-occurring PTSD/SMI on sleep quality in this population. Given the high rates of comorbidity and poor functional outcomes associated with sleep dysfunction, there is a need to better understand patterns of poor sleep quality in this population. The present study provides a description of sleep quality in veterans with a dual diagnosis of PTSD/SMI relative to veterans with PTSD only. Results indicated that, despite similar reports of PTSD symptom severity between the groups, veterans with PTSD/SMI reported higher levels of poor sleep quality than veterans only diagnosed with PTSD. Specifically, veterans with PTSD/SMI reported significantly greater difficulties with sleep onset and overall more sleep disturbance than their non-SMI counterparts. Implications of the findings are discussed within the context of an existing model of insomnia and suggest that more comprehensive sleep assessment and the provision of targeted sleep interventions may be helpful for those with a dual diagnosis of PTSD/SMI.

Rating Procedures for Improving Identification of Exposure to Potentially Traumatic Events When Using Checklist Measures

ABSTRACT Although interviews provide the best assessment of potentially traumatic events (PTEs), their use is not always feasible in research or clinical settings when time and other resources are scarce. Relying alternatively on checklists to identify PTE histories is problematic, however, as they will overestimate PTE rates. Thus, this study aimed to develop new rating procedures that could be used quickly and easily to enhance the accuracy of PTE assessment when use of interviews is prohibitive. A large (N = 640) college sample completed a PTE checklist and follow-up questions designed to gather details about each endorsed event. The new rating procedures were applied to follow up responses, allowing comparison of participants with PTE histories identified by (1) checklist alone and (2) the new rating procedures. Results indicated that the new rating procedures were efficient and demonstrated adequate-to-good inter-rater reliability for all trauma types. The checklist substantially overestimated the PTE rate in the present sample for all types of trauma. Further, participants with a PTE history based on the rating procedures endorsed greater posttraumatic reexperiencing and avoidance than did those with a PTE history based on the checklist alone. The new rating procedures therefore have the ability to improve PTE assessment, perhaps particularly in research settings, and will enhance the validity of conclusions that can be reached in future studies when interviews cannot be used.

The association between PTSD and facial affect recognition

The major aims of this study were to examine how, if at all, having higher levels of PTSD would be associated with performance on a facial affect recognition task in which facial expressions of emotion are superimposed on emotionally valenced, non-face images. College students with trauma histories (N = 90) completed a facial affect recognition task as well as measures of exposure to traumatic events, and PTSD symptoms. When the face and context matched, participants with higher levels of PTSD were significantly more accurate. When the face and context were mismatched, participants with lower levels of PTSD were more accurate than were those with higher levels of PTSD. These findings suggest that PTSD is associated with how people process affective information. Furthermore, these results suggest that the enhanced attention of people with higher levels of PTSD to affective information can be either beneficial or detrimental to their ability to accurately identify facial expressions of emotion. Limitations, future directions and clinical implications are discussed.

PTSD symptoms and overt attention to contextualized emotional faces: Evidence from eye tracking

Abnormal patterns of attention to emotional faces and images are proposed by theories of posttraumatic stress disorder (PTSD), and this has been demonstrated empirically. However, few studies have examined how PTSD symptoms are associated with attention to emotional faces in the context of emotional background images. Eye tracking data were collected from seventy-eight undergraduates with a history of experiencing at least one traumatic event as they completed the Contextual Recognition of Affective Faces Task (CRAFT; Milanak and Berenbaum, 2014), which requires subjects to identify the emotion depicted by faces superimposed on an emotional background image. Greater PTSD symptom severity was associated with more time spent looking at background contexts and less time looking at target faces. This is consistent with greater susceptibility to distraction by task-irrelevant emotional stimuli. The duration of each gaze fixation upon fear faces was shorter for those with greater PTSD symptoms, and this pattern was marginally significant for disgust faces. These findings suggest that PTSD symptoms may relate to greater attention toward non-facial background scenes and less attention toward facial stimuli, especially when conveying a fear or disgust expression.