Terry L. Schell

Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.

All symptoms are not created equal: the prominent role of hyperarousal in the natural course of posttraumatic psychological distress.

This 3-wave longitudinal study examined the natural course of posttraumatic stress disorder symptoms using data collected from young adult survivors of community violence. Three key findings emerged. 1. Mean levels of distress for each symptom cluster decreased over time, with reexperiencing decreasing most rapidly. 2. Cross-lagged panel analysis revealed that hyperarousal strongly influences, but is not generally influenced by, other symptoms clusters. 3. Trajectory analysis demonstrated that respondents for whom hyperarousal was the most pronounced baseline symptom showed lower overall symptom improvement relative to trauma exposed counterparts for whom hyperarousal was a less prominent early symptom. Implications for theory, research, and clinical practice are discussed.

Reappraising the link between peritraumatic dissociation and PTSD symptom severity: evidence from a longitudinal study of community violence survivors.

Cross-lagged panel analysis of longitudinal data collected from young adult survivors of community violence was used to examine the relationship between recall of peritraumatic dissociation and posttraumatic stress disorder (PTSD) symptom severity. Recollections of peritraumatic dissociation assessed within days of exposure differed from recollections measured at 3- and 12-month follow-up interviews. Peritraumatic dissociation was highly correlated with PTSD symptoms within each wave of data collection. Baseline recollections of peritraumatic dissociation were not predictive of follow-up PTSD symptom severity after controlling for baseline PTSD symptom severity. This pattern of results replicates previous work demonstrating a correlation between peritraumatic dissociation and subsequent symptom severity. However, findings are not consistent with the prevailing view that peritraumatic dissociation leads to increased PTSD symptom severity.

The role of hyperarousal in the manifestation of posttraumatic psychological distress following injury.

The authors examined the temporal relation among posttraumatic stress disorder symptom clusters, using data derived from a longitudinal study of survivors of orofacial injury (N = 264). They conducted cross-lagged panel analyses, with self-reported symptom data collected at 1, 6, and 12 months postinjury. Results demonstrate that hyperarousal was a potent predictor of subsequent symptoms of reexperiencing and avoidance as well as hyperarousal. By contrast, neither reexperiencing nor avoidance was significantly related to other symptom clusters other than themselves over time. These findings underscore the distinctive nature of hyperarousal in the manifestation of posttraumatic psychological distress over time. Implications for theory, clinical intervention, and future research are discussed.

All PTSD symptoms are highly associated with general distress: ramifications for the dysphoria symptom cluster.

This study used longitudinal data collected from two trauma-exposed samples, survivors of community violence (N = 294) and wildfire evacuees (N = 234), to examine a key claim underlying a proposed reformulation of the symptom structure of posttraumatic stress disorder (PTSD). This theory, which we term the PTSD-dysphoria model, posits that 8 of 17 symptoms of PTSD reflect dysphoria or general psychological distress and might be deemphasized to improve the utility of the PTSD construct (Simms, Watson, & Doebbeling, 2002). For each sample, we analyzed PTSD symptoms and measures of general distress administered at 2 time points. A consistent pattern of findings was observed across assessments for each sample: All 17 PTSD symptoms were highly associated with measures of general distress. Moreover, we found no evidence that dysphoria symptoms were more highly correlated than PTSD-specific symptoms with general distress. Results call into question both the conceptual basis and the clinical utility of differentiating between symptoms that appear to be relatively specific to PTSD and those that seem more broadly characteristic of general psychological distress.

Prevalence of Posttraumatic Stress Disorder and Major Depression After Trauma Center Hospitalization

BACKGROUND Individuals hospitalized after physical trauma are at heightened risk for mental disorders. We examined prevalence rates of both posttraumatic stress disorder (PTSD) and major depression at 6 and 12 months in a sample of 677 individuals experiencing different types of trauma who were representative of physical trauma survivors hospitalized in Los Angeles County trauma centers. Demographic and injury-related risk factors for these disorders were also evaluated. METHODS Bivariate logistic regressions estimated risk for PTSD and depression at either 6 or 12 months associated with baseline risk factors. RESULTS At 6 months, 31% of participants met screening criteria for probable PTSD and 31% met criteria for probable depression. At 12 months, 28% and 29% met criteria for PTSD and depression, respectively. There were also high rates of comorbidity; depression and PTSD co-occurred in 21% of individuals at 6 months and in 19% of patients at 12 months. Bivariate logistic regressions indicated that preexisting disability and lower education were associated with higher odds of PTSD at either 6 or 12 months. African Americans and Hispanics had higher odds of PTSD compared with non-Hispanic Caucasians. Assault-related injury (versus accident), more severe injury, and longer hospitalizations were also associated with greater odds of PTSD. By contrast, higher odds of depression at 6 or 12 months were only associated with preexisting disability, losing consciousness, more severe injury, and longer hospitalizations. CONCLUSIONS Key demographic and injury characteristics may enhance identification of at-risk trauma survivors who would benefit from targeted screening, patient education, and early intervention efforts.

Barriers to Mental Health Care Utilization for U.S. Cambodian Refugees

Asian Americans encounter barriers to mental health care, some of which are structural, whereas others may be cultural. Using data from a probability sample (N = 490) drawn from the largest Cambodian refugee community in the United States, the authors assessed the extent to which structural and cultural barriers were experienced. Surprisingly, a relatively small proportion endorsed commonly cited cultural barriers such as distrust of Western care (4%) and greater confidence in alternative care (5%), whereas most endorsed structural barriers such as high cost (80%) and language (66%). Among those with a probable diagnosis, a similar pattern was found. Findings suggest that structural, not culturally based, barriers are the most critical obstacles to care in this U.S. Cambodian refugee community.

Posttraumatic Distress and Physical Functioning: A Longitudinal Study of Injured Survivors of Community Violence

This study examines the cross-lagged relationships between posttraumatic distress symptoms and physical functioning, using a sample of 413 persons who were hospitalized for injuries resulting from community violence. Posttraumatic distress was assessed at 1 week, 3 months, and 12 months postinjury, and posttraumatic physical functioning was assessed at 3 months and 12 months. Structural equation modeling was used to assess the prospective relationship between posttraumatic distress symptoms and physical functioning while controlling for demographic characteristics and objective measures of injury severity. Results indicate that posttraumatic distress and physical functioning are reciprocally related. Individuals with high levels of psychological distress at 1 week posttrauma have worse physical functioning at 3 months. Psychological distress at 3 months was not significantly associated with subsequent change in physical functioning at 12 months. Individuals with poor physical functioning at 3 months had higher than expected levels of psychological distress at 12 months. These findings demonstrate a reciprocal relationship between physical and mental health following traumatic injury. Interventions targeting physical recovery may influence subsequent mental health, and therapies aimed at improving early mental health may also have long-term benefits for physical recovery.

Spanish and English versions of the PTSD Checklist–Civilian version (PCL-C): Testing for differential item functioning

Interpretation of ethnic differences in PTSD is predicated on demonstration that differences are not due to measurement bias. This is difficult when multiple languages are used in the assessment. This study used confirmatory factor analysis to examine possible differential item functioning (DIF) across English and Spanish versions of the PTSD Checklist-Civilian Version (PCL-C). Data were derived from two assessments of Hispanics (Ns = 304, 213), who were hospitalized with physical injuries. After correction for multiple testing, univariate tests revealed no statistically significant DIF effects; multivariate tests revealed some indication of DIF at the initial assessment only. This bias was inconsistent across waves and unlikely to be substantively consequential, indicating that the two versions of the PCL-C were generally equivalent.

Using Facebook to Recruit Young Adult Veterans: Online Mental Health Research

Background Veteran research has primarily been conducted with clinical samples and those already involved in health care systems, but much is to be learned about veterans in the community. Facebook is a novel yet largely unexplored avenue for recruiting veteran participants for epidemiological and clinical studies. Objective In this study, we utilized Facebook to recruit a sample of young adult veterans for the first phase of an online alcohol intervention study. We describe the successful Facebook recruitment process, including data collection from over 1000 veteran participants in approximately 3 weeks, procedures to verify participation eligibility, and comparison of our sample with nationally available norms. Methods Participants were young adult veterans aged 18-34 recruited through Facebook as part of a large study to document normative drinking behavior among a large community sample of veterans. Facebook ads were targeted toward young veterans to collect information on demographics and military characteristics, health behaviors, mental health, and health care utilization. Results We obtained a sample of 1023 verified veteran participants over a period of 24 days for the advertising price of approximately US