Michele Bedard-Gilligan

Cognitive Processing Therapy for Veterans with Comorbid PTSD and Alcohol Use Disorders

Posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) frequently present comorbidity in veteran populations. Traditionally those with alcohol dependence have been excluded from PTSD treatment outcome studies, thus we do not know how those with alcohol dependence may tolerate or respond to PTSD-specific interventions; no studies to date have examined the extent to which cognitive PTSD interventions are tolerated or effective for those with comorbid PTSD/AUD. The present study examines the extent to which CPT is tolerated by and effective in treating PTSD symptoms for veterans with PTSD and AUD, as compared to veterans with PTSD only in an outpatient treatment setting. Data were obtained through chart review of 536 veterans diagnosed with PTSD who had received at least 1 session of CPT at a Midwestern US Veterans Affairs hospital. Nearly half (n=264, 49.3%) of the veterans in the study exhibited a current or past AUD diagnosis. Participants were grouped into the following diagnostic groups: current AUD (past 12 months), past AUD (prior to 12 months), and no AUD. Participants completed an average of 9 sessions of CPT with no significant difference between AUD diagnostic groups on the number of CPT sessions completed. Individuals with past AUD had higher initial symptoms of self-reported PTSD symptoms than those with no AUD. All groups reported significant reductions in PTSD symptoms and depression over time. Overall, the results suggest that CPT appears well tolerated among veterans with comorbid AUD and is associated with significant reductions in symptoms of PTSD and depression in an outpatient treatment setting.

Dissociation and memory fragmentation in post-traumatic stress disorder: An evaluation of the dissociative encoding hypothesis

Several prominent theories of post-traumatic stress disorder (PTSD) posit that peritraumatic dissociation results in insufficient encoding of the trauma memory and that persistent dissociation prevents memory elaboration, resulting in memory fragmentation and PTSD. In this review we summarise the empirical literature on peritraumatic and trait dissociation and trauma narrative fragmentation as measured by meta-memory and rater/objective coding. Across 16 studies to date, the association between dissociation and fragmentation was most prominent when examining peritraumatic dissociation and patients own ratings of memory fragmentation. This relationship did not hold when examining trait dissociation or rater-coded or computer-generated measures of fragmentation. Thus initial evidence points more towards a strong self-reported association between constructs that is not supported on more objective fragmentation coding. Measurement overlap, construct ambiguity, and exclusion of potential confounds may underlie lack of a strong association between dissociation and objective-rated fragmentation.

Alcohol-involved Assault: Associations with posttrauma alcohol use, consequences, and expectancies

Victim alcohol consumption is common prior to sexual assault, and a burgeoning literature suggests that victims who were intoxicated during assault may differ in post-assault adjustment compared to those who were not impaired. Less is known about potential relationships between experiencing an alcohol-involved assault (AIA) and later drinking behavior. In this study, we examined the relationships between sexual assault, subsequent drinking behavior and consequences, and alcohol expectancies in a sample of 306 undergraduate women who reported current alcohol use and reported either no trauma history (n=53), non-AIA (n=69), or AIA (n=184). Differences emerged for alcohol use (F(2, 298)=12.78, p<.001), peak blood alcohol content (F(2, 298)=9.66, p<.001), consequences (F(2, 296)=7.38, p<.005), and positive alcohol expectancies (F(14, 796)=1.93, p<.05). In particular, women with an AIA reported greater alcohol use and positive expectancies compared to women with no trauma history and women with a non-alcohol influenced assault. In addition, both assault groups reported greater drinking consequences than women with no trauma history. Findings suggest that it is the women who are assaulted while under the influence of alcohol who evidence more alcohol use and alcohol-related problems following assault.

Individual differences in trauma disclosure

BACKGROUND AND OBJECTIVES Findings on disclosure and adjustment following traumatic events have been mixed. Better understanding of individual differences in disclosure may help us better understand reactions following trauma exposure. In particular, studying disclosure patterns for those with and without psychopathology and for different types of emotional experiences may help clarify the relationship between disclosure, event emotionality, trauma exposure, and PTSD. METHODS In this study, 143 men and women with (n=67) and without (n=43) chronic PTSD and without trauma exposure (n=33) provided information on disclosure for a traumatic/severe life event, a negative event, and a positive event. RESULTS Individuals with PTSD reported greater difficulty disclosing their traumatic event compared to those with trauma exposure no PTSD and those with no-trauma exposure. However, individuals with PTSD reported disclosing the traumatic event a similar number of times and with similar levels of detail to those with trauma exposure but no PTSD. Both sexual and childhood trauma were associated with greater disclosure difficulty. LIMITATIONS Although control event types (positive, negative) were selected to control for the passage of time and for general disclosure style, they do not control for salience of the event and results may be limited by control events that were not highly salient. CONCLUSIONS The present findings point to a dynamic conceptualization of disclosure, suggesting that the differential difficulty of disclosing traumatic events seen in individuals with PTSD is not simply a function of the amount of disclosure or the amount of details provided.

An Investigation of Depression, Trauma History, and Symptom Severity in Individuals Enrolled in a Treatment Trial for Chronic PTSD

OBJECTIVE To explore how factors such as major depressive disorder (MDD) and trauma history, including the presence of childhood abuse, influence diverse clinical outcomes such as severity and functioning in a sample with posttraumatic stress disorder (PTSD). METHOD In this study, 200 men and women seeking treatment for chronic PTSD in a clinical trial were assessed for trauma history and MDD and compared on symptom severity, psychosocial functioning, dissociation, treatment history, and extent of diagnostic co-occurrence. RESULTS Overall, childhood abuse did not consistently predict clinical severity. However, co-occurring MDD, and to a lesser extent a high level of trauma exposure, did predict greater severity, worse functioning, greater dissociation, more extensive treatment history, and additional co-occurring disorders. CONCLUSION These findings suggest that presence of co-occurring depression may be a more critical marker of severity and impairment than history of childhood abuse or repeated trauma exposure. Furthermore, they emphasize the importance of assessing MDD and its effect on treatment seeking and treatment response for those with PTSD.

The Relationship Between Assault and Physical Health Complaints in a Sample of Female Drinkers Roles of Avoidant Coping and Alcohol Use

Trauma exposure and PTSD are associated with poorer physical health. Psychological and behavioral mechanisms may help account for this relationship. In this study, we tested avoidant coping and alcohol use as mediators of the relationship between trauma exposure, PTSD, and self-reported physical health complaints in female drinkers. In 827 college women, we compared three groups: women with no trauma history, women with a sexual assault but no PTSD, and women with a sexual assault and PTSD, on avoidant coping, alcohol use, and physical health complaints. We found that PTSD was positively associated with alcohol use and that PTSD and trauma exposure were associated with increased avoidant coping. We also found that avoidant coping mediated the relationship between trauma, PTSD, and physical health complaints. Alcohol use did not predict physical health but was associated with PTSD. These results suggest that in female college students, coping may be more critical in the PTSD/physical health relationship than alcohol and have implications for targeting coping in young trauma-exposed women to improve physical health.

Effects of Sexual Assault on Alcohol Use and Consequences Among Young Adult Sexual Minority Women

Objective: The purpose of this study was to examine effects of sexual assault victimization on later typical alcohol use and alcohol-related consequences among young sexual minority women (SMW). Method: Data were collected over 4 annual assessments from a national sample of 1,057 women who identified as lesbian or bisexual and were 18- to 25-years-old at baseline. Marginal structural modeling, an analytic approach that accounts for time-varying confounding through the use of inverse probability weighting, was used to examine effects of sexual assault and its severity (none, moderate, severe) on typical weekly number of drinks consumed and number of alcohol-related consequences 1-year later as well as 2-year cumulative sexual assault severity on alcohol outcomes at 36-month follow-up. Results: Findings showed that compared with not experiencing any sexual assault, severe sexual assault at the prior assessment was associated with a 71% higher number of typical weekly drinks (count ratio [CR] = 1.71; 95% confidence interval [CI] [1.27, 2.31]) and 63% higher number of alcohol-related consequences (CR = 1.63; 95% CI [1.21, 2.20]). Effects were attenuated when comparing moderate to no sexual assault; however, the linear trend across sexual assault categories was statistically significant for both outcomes. There were also effects of cumulative levels of sexual assault severity over 2 years on increased typical drinking and alcohol-related consequences at end of follow-up. Conclusions: Sexual assault may be an important cause of alcohol misuse among SMW. These findings further highlight the need for strategies to reduce the risk of sexual assault among SMW.

Changes in Temporal Attention Inhibition Following Prolonged Exposure and Sertraline in the Treatment of PTSD

OBJECTIVE Attentional inhibitory deficits expressed as difficulty ignoring irrelevant stimuli in the pursuit of goal-directed behavior may serve as a fundamental mechanism of posttraumatic stress disorder (PTSD). Evidence of inhibitory processes as central to extinction suggests that exposure-based treatments may act more directly on the inhibitory deficits implicated in PTSD, whereas, in facilitating serotonergic neurotransmission, selective serotonin reuptake inhibitors (SSRIs) may be less direct and bring about general neurochemical changes in the fear circuitry. If these inhibitory deficits underlie PTSD, then inhibition should improve with successful treatment, with those treated with prolonged exposure (PE) potentially resulting in greater changes in inhibition than those treated with sertraline. METHOD Changes in temporal attentional inhibition, using an attentional blink (AB) paradigm, were examined at pre- and posttreatment in 49 individuals (74.5% female, 66.7% Caucasian, age M = 37.69, SD = 12.8 years) with chronic PTSD. Participants completed 10 weeks of either PE or sertraline. RESULTS Individuals who made greater improvements with PE showed faster improvements in temporal inhibition on the critical inhibitory lag of AB than those who made greater improvements with sertraline (d = 0.94). These changes could not be accounted for by basic attention. CONCLUSIONS Greater improvement in fundamental attentional inhibitory processes with better treatment response to PE, compared with sertraline, suggests potential specificity in how PTSD treatments normalize inhibitory processes, such that exposure-based treatments like PE may target inhibitory processes and improve basic inhibitory functioning.

Daily-level associations between PTSD and cannabis use among young sexual minority women

INTRODUCTION Sexual minority women have elevated trauma exposure and prevalence of posttraumatic stress disorder (PTSD) compared to heterosexual women and they are also more likely to use cannabis, although no research has examined relationships between PTSD and cannabis use in this population. Daily-level methodologies are necessary to examine proximal associations between PTSD and use. METHODS This study included 90 trauma-exposed young adult women who identified as sexual minorities (34.4% identified as lesbian and 48.9% identified as bisexual) and evaluated daily-level associations between their PTSD symptoms and cannabis use. Participants were assessed at two measurement waves, one year apart, each consisting of 14 consecutive daily assessments. RESULTS Cannabis use occurred on 22.8% of the days. Results from generalized linear mixed effects models showed that a persons mean level of PTSD symptom severity across days was strongly associated with same-day likelihood of cannabis use (OR=2.67 for 1 SD increase in PTSD score; p<0.001). However, daily deviation from ones average PTSD score was not associated with cannabis use on the same day. CONCLUSIONS Findings suggest that PTSD severity may confer general risk for cannabis use, rather than being a state-dependent risk factor.

Is Trauma Memory Special? Trauma Narrative Fragmentation in PTSD: Effects of Treatment and Response

Seminal theories posit that fragmented trauma memories are critical to posttraumatic stress disorder (PTSD) and that elaboration of the trauma narrative is necessary for recovery. According to fragmentation theories, trauma narrative changes, particularly for those receiving trauma-focused treatment, should accompany symptom reduction. Trauma and control narratives in 77 men and women with chronic PTSD were examined pre- and posttreatment, comparing prolonged exposure (PE) and sertraline. Utilizing self-report, rater coding, and objective coding of narrative content, fragmentation was compared across narrative types (trauma, negative, positive) by treatment modality and response, controlling for potential confounds. Although sensory components increased with PE (d = 0.23–0.44), there were no consistent differences in fragmentation from pre- to posttreatment between PE and sertraline or treatment responders and nonresponders. Contrary to theories, changes in fragmentation may not be a crucial mechanism underlying PTSD therapeutic recovery.