Nancy Jo Dunn

Intimate Partner Aggression Perpetrated and Sustained by Male Afghanistan, Iraq, and Vietnam Veterans With and Without Posttraumatic Stress Disorder

Veterans with posttraumatic stress disorder (PTSD) consistently evidence higher rates of intimate partner aggression perpetration than veterans without PTSD, but most studies have examined rates of aggression among Vietnam veterans several years after their deployment. The primary aim of this study was to examine partner aggression among male Afghanistan or Iraq veterans who served during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) and compare this aggression to that reported by Vietnam veterans with PTSD. Three groups were recruited, OEF/OIF veterans with PTSD (n = 27), OEF/OIF veterans without PTSD (n = 31), and Vietnam veterans with PTSD (n = 28). Though only a few comparisons reached significance, odds ratios suggested that male OEF/OIF veterans with PTSD were approximately 1.9 to 3.1 times more likely to perpetrate aggression toward their female partners and 1.6 to 6 times more likely to report experiencing female perpetrated aggression than the other two groups. Significant correlations among reports of violence perpetrated and sustained suggested many men may have been in mutually violent relationships. Taken together, these results suggest that partner aggression among Iraq and Afghanistan veterans with PTSD may be an important treatment consideration and target for prevention.

Empathic deficits and alexithymia in trauma‐related impulsive aggression

Our long term interest is to develop a developmental model of impulsive aggression based on a confluence of social, psychological and biological features. This approach incorporates neurobiological research, which has identified language processing deficits as a unique characteristic of impulsive aggressors and extends it to include emotional deficits. As an initial test of this hypothesis, we examined whether empathy and alexithymia were associated with impulsive aggression. Regressions were performed to explore the associations among impaired empathy, alexithymia, impulsive aggression, verbal and physical general aggression. Among impulsive aggressive veterans (n=38) recruited from a VA trauma clinic, alexithymia predicted impulsive aggression and empathic deficits predicted verbal aggression. Neither emotional awareness deficit predicted general physical aggression in this middle-aged sample. Results suggested that empathic deficits were associated with general verbal aggression, but alexithymia was uniquely associated with impulsive aggression. Consideration of alexithymia in impulsive aggression has implications for its etiology, prevention and treatment.

Personality disorders in veterans with posttraumatic stress disorder and depression

Little is known about the frequency of the full-range of personality disorders in outpatients with concurrent posttraumatic stress disorder (PTSD) and depression, a common and oftentimes treatment-resistant combination in clinical practice. In a group therapy outcome study, Axis I and II diagnoses were assessed with the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale to select 115 male combat veterans with PTSD and depressive disorder. Within this sample, 52 (45.2%) had one or more personality disorders—most commonly paranoid (17.4%), obsessive-compulsive (16.5%), avoidant (12.2%), and borderline (8.7%)—and 19 (16.5%) had two or more. Documenting a substantial frequency of personality disorders is a first step in devising appropriate interventions for this treatment-resistant combination of disorders.

Characterizing aggression and its association to anger and hostility among male veterans with post-traumatic stress disorder.

OBJECTIVES The basis for the associations among anger, hostility, aggressive behavior, and post-traumatic stress disorder (PTSD) remains unclear. We suggest classifying aggressive behavior may elucidate the associations among these factors. On the basis of diagnostic and neurobiological similarities between impulsive aggression (IA) and PTSD, we proposed that IA was the predominant form of aggression in PTSD and that anger and hostility would not significantly predict PTSD when IA was also included as a predictor. METHODS We used cross-sectional self-report data obtained from two samples of male veterans (N = 136). RESULTS Over 70% of veterans with PTSD reported IA compared to 29% of those without PTSD. IA, not anger, hostility, or premeditated aggression significantly predicted a diagnosis of PTSD. CONCLUSIONS Associations between anger and PTSD may be unique to individuals with IA, and considering impulsive and premeditated aggressors separately may account for the heterogeneity found within samples of aggressive veterans with PTSD.

Treating comorbid panic disorder in veterans with posttraumatic stress disorder.

This study compares the effectiveness of panic control treatment (PCT) with that of a psychoeducational supportive treatment (PE-SUP) in treating panic disorder among a veteran sample with a primary diagnosis of chronic posttraumatic stress disorder (PTSD). Thirty-five patients randomized to receive 10 individual sessions of either PCT or PE-SUP underwent assessments at pretreatment, at 1-week posttreatment, and at a 3-month follow-up. Intent-to-treat analyses of covariance showed that PCT participants significantly improved on panic severity at posttreatment and panic fear at the 3-month follow-up. The PCT group also showed significant reductions in anxiety sensitivity at posttreatment and follow-up compared with that of the PE-SUP group. A significantly higher proportion of persons (63%) in the PCT group was panic free by the follow-up period compared with that of the PE-SUP group (19%). Patient self-report and clinician ratings showed no changes in general anxiety, depression, and PTSD symptoms in either group. These findings indicated that PCT was superior to an active control therapy in reducing the frequency, severity, and distress associated with panic disorder and suggested that brief cognitive-behavioral therapy for panic is effective for persons with chronic PTSD.

Views of hepatitis C virus patients delayed from treatment for psychiatric reasons

Summary.  For patients with chronic hepatitis C virus, certain psychiatric disorders are contraindications for antiviral therapy with interferon‐alpha (IFN). Although these conditions delay a significant portion of patients from beginning therapy, no one has yet portrayed the views of these patients. A qualitative analysis, drawing upon semi‐structured interviews, was developed to generate hypotheses regarding patient views of the treatment disposition process, and to generate strategies for increasing the portion of treatment‐eligible patients. Two focus groups were conducted: one for patients delayed from treatment due to current or recent depression, and one for patients delayed due to current or recent alcohol use. A grounded theory analysis of the interview data were conducted. Patients were generally satisfied with the decision‐making process, based largely on education from, and trust in, physicians. Upon learning their diagnosis, patients reported making healthy behaviour changes regarding alcohol, diet, exercise and herbal remedies. Some patients reported that requiring a period of alcohol abstinence was excessive, as they believed that they could discontinue alcohol use immediately, if so instructed by a physician. Patients seemed to over‐interpret the likelihood of suicide during interferon‐alpha (IFN) therapy. Current or recent psychiatric morbidity delays many patients from beginning interferon therapy. Nonetheless, this may be an optimal time for physicians to encourage healthy behaviours including abstinence from alcohol. Also, physicians may need to extensively assess the use of herbal remedies by patients. To help patients make judgments about beginning therapy, physicians should focus upon risk communication regarding the likelihood of suicide on therapy with interferon.

Influence of Trauma History on Panic and Posttraumatic Stress Disorder in Returning Veterans

The current study examined the role of predeployment sexual and physical abuse, combat exposure, and postdeployment social support in predicting panic disorder and PTSD diagnoses in a large sample of returning veterans. A chart review was conducted for 1740 OEF/OIF veterans who received mental health screenings at a large VA hospital between May 24, 2004 and March 26, 2008. Assessments included psychosocial evaluations conducted by psychiatrists, psychologists, and social workers in addition to self-report measures. Results suggested that the prevalence of panic disorder (6.1%) and PTSD (28.7%) are elevated among OEF/OIF veterans. Veterans reporting higher levels of combat experience were likely to be diagnosed with PTSD (odds ration [OR], 1.17; 95% confidence interval [CI], 1.10-1.25; p < .001) or comorbid panic disorder and PTSD (OR, 1.18; 95% CI, 1.04-1.33; p < .001). Veterans endorsing predeployment sexual abuse were likely to be diagnosed with comorbid panic disorder and PTSD (OR, 3.05; 95% CI, 1.15-8.08; p < .05), as were veterans endorsing predeployment physical abuse (OR, 0.47; 95% CI, 0.22-1.00; p < .05). Panic disorder was also found to be associated with greater risk for suicide attempts than PTSD (χ² = 16.38, p = .001). These findings indicate a high prevalence of panic disorder among returning veterans and highlight the importance for clinicians to assess returning veterans routinely for panic disorder in addition to PTSD.

When Anxiety Symptoms Masquerade as Medical Symptoms: What Medical Specialists Know about Panic Disorder and Available Psychological Treatments

Under-recognition of somatic symptoms associated with panic in primary care settings results in unnecessary and costly diagnostic procedures and inappropriate referrals to cardiologists, gastroenterologists, and neurologists. In the current study specialists’ knowledge regarding the nature and treatment of panic were examined. One-hundred and fourteen specialists completed a questionnaire assessing their knowledge about panic attacks, including their perceptions of psychologists’ role in treating panic. Respondents answered 51% of knowledge items correctly. Although most knew the definition of a panic attack, they knew less about clinical features of panic and its treatment. Specifically, whereas 97.4% believed medication effectively relieves panic symptoms, only 32.5% knew that cognitive-behavioral therapy (CBT) is a first-line treatment. Only 6% reported knowing how to implement CBT, and only 56.1% recognized that psychologists could effectively treat panic. These findings demonstrate significant gaps in specialists’ knowledge about panic and the need to enhance physician knowledge about panic attacks and their treatment.

Intensive weekend group treatment for panic disorder and its impact on co-occurring PTSD: A pilot study.

This pilot study examines the feasibility, acceptability, and potential effectiveness of delivering an intensive weekend group treatment for panic disorder (PD) to Veterans returning from deployments to Iraq and Afghanistan with co-occurring posttraumatic stress disorder (PTSD). The treatment program lasted 6h each day and was delivered by two experienced therapists. Patients received core components of panic treatment, including psychoeducation, cognitive restructuring, and interoceptive exposure. The interoceptive exposure exercises directly targeted anxiety sensitivity, a psychological construct also implicated in the maintenance of PTSD. Eighty-nine percent of patients who expressed interest in the treatment attended a baseline evaluation, and 63% of those who were study eligible initiated treatment. Treatment retention was high, with all 10 patients who initiated treatment completing the program. Veterans reported finding the treatment and delivery format highly acceptable and reported high levels of satisfaction. Panic symptoms improved significantly following the treatment and were maintained at a 7-month follow-up, with 71.4% of the sample reporting being panic free. Co-occurring PTSD symptoms also improved along with symptoms of anxiety and depression. Preliminary findings suggest that brief and intensive group treatments for PD/PTSD are a promising method of delivering cognitive behavioral therapy that may rapidly improve symptoms. This innovative treatment delivery format also may be a cost-effective way of increasing treatment engagement through increased access to quality care.

Impact of panic disorder on quality of life among veterans in a primary care pilot study

Panic disorder is a debilitating and costly mental health condition which commonly presents in primary care settings; however, little is known about the impact of panic disorder on quality of life and health utility valuations among Veterans in primary care. A cross-sectional investigation of quality of life was conducted in a sample of 21 Veterans with panic disorder in a VA primary care clinic. Health utilities were determined using an algorithm based upon the Medical Outcomes Study Short-Form 36 Health Survey (SF-36). Veterans in the current sample reported significantly greater impairment on all eight of the SF-36 subscales in comparison to published norms. Veterans with panic and comorbid mood disorders reported significantly greater impairment on the Vitality, Social Functioning, and Mental Health subscales, while Veterans with panic and comorbid anxiety disorders reported significantly greater impairment on the Physical Functioning and Bodily pain subscales. Health utilities for the current sample were comparable to previous reports of Veterans with PTSD and depression, as well as health utilities of persons with chronic pulmonary disease and irritable bowel syndrome. The findings from this study highlight the devastating nature of panic disorder and reflect the need for increased attention to the identification and treatment of panic disorder in VA primary care settings.