Posttraumatic Stress Disorder Avoidance Research Articles

Randomized controlled trial of two internet-based written therapies for world trade center workers and survivors with persistent PTSD symptoms

Posttraumatic stress disorder (PTSD) remains prevalent among individuals exposed to the 9/11 World Trade Center (WTC) terrorist attacks. The present study compared an Internet-based, therapist-assisted psychotherapy for PTSD to an active control intervention in WTC survivors and recovery workers with WTC-related PTSD symptoms (n = 105; 75% syndromal PTSD). Participants were randomized to integrative testimonial therapy (ITT), focused on WTC-related trauma, or modified present-centered therapy (I-MPCT), each comprising 11 assigned written narratives. The primary outcome was baseline-to-post-treatment change in PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5). Secondary measures included PTSD symptom clusters, depressive/anxiety symptoms, functioning, and quality of life. A significant main effect of time was observed for the primary outcome (average “large” effect size improvement, d = 1.49). Significant and “moderate-to-large” main effects of time were also observed for all PTSD symptom clusters, depressive symptoms, quality of life, and mental health-related functioning (d range=0.62–1.33). Treatment and treatment-by-time interactions were not significant. In planned secondary analyses incorporating 3-month follow-up measures, ITT was associated with significantly greater reductions than I-MPCT in PTSD avoidance and negative alterations in cognitions and mood, anxiety, and mental health-related functioning. Both therapies significantly lowered PTSD symptoms, suggesting they may benefit hard-to-reach individuals with chronic WTC-related PTSD symptoms.

Quality of Life in Posttraumatic Stress Disorder: The Role of Posttraumatic Anhedonia and Depressive Symptoms in a Treatment-Seeking Community Sample

Posttraumatic stress disorder (PTSD) is associated with functional impairment and poor quality of life (QoL) across multiple domains, such as social functioning, occupational and educational attainment, physical health, and overall life satisfaction and wellbeing. Yet, there is limited evidence for which PTSD symptom clusters may be more strongly associated with functional impairment and decreased QoL. We used a seven-factor model of PTSD (re-experiencing, avoidance, negative alterations, anhedonia, externalizing, dysphoric arousal, and anxious arousal) to predict QoL using a latent regression model in a sample (N = 537) of adult patients participating in exposure-based PTSD partial hospitalization programs (PHP). QoL was measured by the Quality-of-Life Satisfaction Questionnaire—Short Form (Q-LES-Q-SF). Among posttraumatic symptoms, anhedonia emerged as the only significant predictor in the model (β = −8.60, SE = 3.02, p = 0.004), when controlling for depression scores. The overall model accounted for 40% of the variance in QoL. Depression was also significantly associated with QoL (β = −1.67, SE = 0.15, p < 0.001), controlling for PTSD symptoms. Our findings are congruent with prior research supporting the role of anhedonia and emotional numbing in functional impairment, yet differ in that other factors of PTSD (e.g., re-experiencing, avoidance, negative alterations) were not significant. Understanding which PTSD symptom clusters are more strongly associated with QoL may inform treatment approaches or allow clinicians to tailor treatments. We discuss implications for treatment and future research.

PTSD, depression, and treatment outcomes: A latent profile analysis among active duty personnel in a residential PTSD program

Depression frequently co-occurs with posttraumatic stress disorder (PTSD), including among active duty service members. However, symptom heterogeneity of this comorbidity is complex and its association with treatment outcomes is poorly understood, particularly among active duty service members in residential treatment. This study used latent profile analysis (LPA) to identify symptom-based subgroups of PTSD and depression among 282 male service members in a 10-week, residential PTSD treatment program with evidence-based PTSD psychotherapies and adjunctive interventions. The PTSD Checklist–Military Version and Patient Health Questionnaire-8 were completed by service members at pre- and posttreatment and weekly during treatment. Multilevel models compared subgroups on PTSD and depression symptom change across treatment. LPA indicated four subgroups provided optimal fit: Depressive (high depression severity, low PTSD avoidance; n = 33, 11.7%), Avoidant (high PTSD avoidance, moderate depression severity; n = 89, 31.6%), Moderate (moderate PTSD and depression severity; n = 27, 9.6%), and Distressed (high PTSD and depression severity; n = 133, 47.2%). Treatment response differed across classes for both PTSD and depression outcomes (time × LPA class interaction ps < 0.001). In PTSD models, post-hoc comparisons indicated the Moderate class was associated with less PTSD symptom improvement relative to the other classes (ps < 0.006). In depression models, symptom reduction was greatest for the Distressed and Depressive subgroups relative to the other two classes (ps < 0.009). Study results provide an initial model for two prevalent, impairing disorders among service members and show how these symptom-based subgroups may differentially respond to residential PTSD treatment.

The effectiveness, efficiency, and acceptability of EMDR vs. EMDR 2.0 vs. the Flash technique in the treatment of patients with PTSD: study protocol for the ENHANCE randomized controlled trial.

Several widely studied therapies have proven to be effective in the treatment of post-traumatic stress disorder (PTSD). However, there is still room for improvement because not all patients benefit from trauma-focused treatments. Improvements in the treatment of PTSD can be achieved by investigating ways to enhance existing therapies, such as eye movement desensitization and reprocessing (EMDR) therapy, as well as exploring novel treatments. The purpose of the current study is to determine the differential effectiveness, efficiency, and acceptability of EMDR therapy, an adaptation of EMDR therapy, referred to as EMDR 2.0, and a novel intervention for PTSD, the so-called Flash technique. The second aim is to identify the moderators of effectiveness for these interventions. This study will be conducted among individuals diagnosed with PTSD using a randomized controlled trial design. A total of 130 patients diagnosed with (complex) PTSD will be randomly allocated to either six sessions of EMDR therapy, EMDR 2.0, or the Flash technique. The primary outcomes used to determine treatment effectiveness include the presence of a PTSD diagnosis and the severity of PTSD symptoms. The secondary outcomes of effectiveness include symptoms of depression, symptoms of dissociation, general psychiatric symptoms, and experiential avoidance. All patients will be assessed at baseline, at 4-week post-treatment, and at 12-week follow-up. Questionnaires indexing symptoms of PTSD, depression, general psychopathology, and experiential avoidance will also be assessed weekly during treatment and bi-weekly after treatment, until the 12-week follow-up. Efficiency will be assessed by investigating the time it takes both to lose the diagnostic status of PTSD, and to achieve reliable change in PTSD symptoms. Treatment acceptability will be assessed after the first treatment session and after treatment termination. This study is the first to investigate EMDR 2.0 therapy and the Flash technique in a sample of participants officially diagnosed with PTSD using a randomized controlled trial design. This study is expected to improve the available treatment options for PTSD and provide therapists with alternative ways to choose a therapy beyond its effectiveness by considering moderators, efficiency, and acceptability. The trial was retrospectively registered in the ISRCTN registry at 10th November 2022 under registration number ISRCTN13100019.

Neural processes of emotional conflict detection and prediction of posttraumatic stress disorder symptom clusters in traumatic injury survivors.

Given the prevalence and significant burden of posttraumatic stress disorder (PTSD), identifying early predictors of symptom development following trauma is critical. PTSD is a heterogeneous disorder comprised of distinct symptom clusters-reexperiencing, avoidance, negative mood, and hyperarousal-that contribute to the broad range of possible symptom profiles. Affective and attentional regulation processes, such as emotional conflict detection, are impaired in individuals with PTSD; however, the neural mechanisms underlying these alterations and their predictive utility for the development of PTSD symptoms remain unclear. Traumatic injury survivors (N = 49) without traumatic brain injury were recruited from the emergency department of an urban, Level-1 trauma center. Within 1 month of trauma exposure, participants completed a well-characterized emotional conflict task during a functional magnetic resonance imaging scan. Participants returned 6-month later for a clinical assessment of PTSD symptoms. Using a region-of-interest mask derived from whole-brain voxelwise analyses during emotional conflict detection (vs. no emotional conflict detection) we examined whether differential neural activity predicted 6-month PTSD symptom cluster severity. Greater activation of the right middle frontal gyrus during emotional conflict detection prospectively predicted lower PTSD avoidance symptom severity 6 months later (above and beyond the effects of self-reported baseline PTSD and depressive symptoms, previous traumatic life events, racial discrimination, age, sex, and injury severity). Neural processes of emotion conflict detection measured in the early aftermath of a potentially traumatic event are useful as predictors for the development of PTSD symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A randomized controlled trial of cognitive analytic versus compassion-focused therapy for PTSD in Iran-Iraq War Veterans

LAY SUMMARY Posttraumatic stress disorder (PTSD) is a common, debilitating mental illness with a substantial burden on individuals and society. The authors aimed to compare the effects of cognitive analytic therapy and compassion-focused therapy on Veterans with PTSD. This study showed that a 12-session program of cognitive analytic therapy or an 8-session program of compassion-focused therapy was effective for treating PTSD. The interventions controlled re-experiencing, avoidance, and hyperarousal in PTSD. Also, they decreased depression, anxiety, and numbness in patients with PTSD. Compassion-focused therapy was more effective in controlling avoidance and depression than cognitive analytic therapy.

A Mendelian randomization study of genetic liability to post-traumatic stress disorder and risk of ischemic stroke

Observational studies have shown an association between post-traumatic stress disorder (PTSD) and ischemic stroke (IS) but given the susceptibility to confounding it is unclear if these associations represent causal effects. Mendelian randomization (MR) facilitates causal inference that is robust to the influence of confounding. Using two sample MR, we investigated the causal effect of genetic liability to PTSD on IS risk. Ancestry-specific genetic instruments of PTSD and four quantitative sub-phenotypes of PTSD, including hyperarousal, avoidance, re-experiencing, and total symptom severity score (PCL-Total) were obtained from the Million Veteran Programme (MVP) using a threshold P value (P) of <5 × 10−7, clumping distance of 1000 kilobase (Mb) and r2 < 0.01. Genetic association estimates for IS were obtained from the MEGASTROKE consortium (Ncases = 34,217, Ncontrols = 406,111) for European ancestry individuals and from the Consortium of Minority Population Genome-Wide Association Studies of Stroke (COMPASS) (Ncases = 3734, Ncontrols = 18,317) for African ancestry individuals. We used the inverse-variance weighted (IVW) approach as the main analysis and performed MR-Egger and the weighted median methods as pleiotropy-robust sensitivity analyses. In European ancestry individuals, we found evidence of an association between genetic liability to PTSD avoidance, and PCL-Total and increased IS risk (odds ratio (OR)1.04, 95% Confidence Interval (CI) 1.007–1.077, P = 0.017 for avoidance and (OR 1.02, 95% CI 1.010–1.040, P = 7.6 × 10−4 for PCL total). In African ancestry individuals, we found evidence of an association between genetically liability to PCL-Total and reduced IS risk (OR 0.95 (95% CI 0.923–0.991, P = 0.01) and hyperarousal (OR 0.83 (95% CI 0.691–0.991, P = 0.039) but no association was observed for PTSD case-control, avoidance, or re-experiencing. Similar estimates were obtained with MR sensitivity analyses. Our findings suggest that specific sub-phenotypes of PTSD, such as hyperarousal, avoidance, PCL total, may have a causal effect on people of European and African ancestry’s risk of IS. This shows that the molecular mechanisms behind the relationship between IS and PTSD may be connected to symptoms of hyperarousal and avoidance. To clarify the precise biological mechanisms involved and how they may vary between populations, more research is required.

Longitudinal profiles of sleep during residential PTSD treatment

We investigated longitudinal profiles of objectively measured sleep periods (SP) over the course of residential treatment for posttraumatic stress disorder (PTSD) in a cohort of U.S. male veterans. Participants (N = 190) slept on mattress-actigraphy systems in a Veterans Affairs (VA) residential PTSD program. The final sample included 4078 sleep periods. Latent class mixed model analyses were used to identify between-subject profiles in sleep period durations, controlling for daily medication intake, over the first fifty days of residency. Logistic regression was used to determine the association of pre-treatment characteristics with identified profiles. Three longitudinal profiles of sleep period characterized most of the sample: ‘stable’ (56%), ‘decreasing’ (35%), and ‘increasing’ (8%). Less severe pre-treatment PTSD avoidance symptoms predicted membership in the 'decreasing' class and increased depression symptoms were predictive of membership in the 'increasing' class. Nearly half of the sample reported a summary change of 1 h or more over the course of the initial 50-nights in the program. Future work is needed to identify how these profiles might drive inpatient treatment decisions regarding the provision of adjunctive sleep-focused treatment such as cognitive-behavioral treatment for insomnia or hypnotic medications.

Long-Term Group Nature-Assisted Therapy for Veterans Diagnosed with Chronic PTSD

ABSTRACT Posttraumatic stress disorder (PTSD) is common among veterans. However, many veterans who deal with this condition avoid therapy, and innovative therapeutic solutions are needed. The current article presents a case study of combining nature and group therapy in a long-term, group adventure therapy program for veterans with chronic PTSD. Qualitative data were collected during four focus groups with 10 participants. Thematic content analysis was employed to conceptualize this intervention’s therapeutic components. Three main themes were identified, highlighting how this program enhanced participants’ skills in coping with PTSD avoidance symptoms, because group relations constituted a platform for promoting rehabilitation efforts. Nature was described as a pivotal curative factor, providing added value to this therapeutic model. These findings suggest nature-assisted therapy is a promising supplementary intervention, particularly for clients who fail to gain sufficient improvement via other individual or trauma-focused therapies.

An experimental investigation of spontaneous emotion regulation variability, negative affect, and posttraumatic stress disorder among traumatized refugees.

Emotion regulation (ER) may be an important psychological mechanism underpinning the development, and management, of posttraumatic stress disorder (PTSD) in refugees. Despite this, little is known about the ER strategies that refugees spontaneously deploy under stress, nor how effective different approaches may be at reducing distress. This was the first study to identify individual differences in patterns of spontaneous ER among refugees and explore their unique associations with negative affect and PTSD. Spontaneous reappraisal and suppression use was measured among 82 refugees following a 5-min exposure to trauma-salient images. Negative affect was indexed before and after the exposure task. Latent profile analysis (LPA) was conducted to identify distinct profiles of participants based on differing levels of ER use. LPA revealed two distinct profiles: a high ER variability profile (37%; high suppression/moderate-high reappraisal) and a low ER variability profile (63%; low suppression/moderate reappraisal). The low ER variability profile was associated with increased negative affect during the experimental paradigm, greater PTSD avoidance symptoms, and greater likelihood of insecure visa status compared with the high ER variability profile. Our findings suggest that a more variable ER approach in response to trauma-salient stressors results in lower distress and is associated with less severe PTSD symptoms. Better understanding the links between patterns of ER strategy use and psychopathology has important implications for the development of effective treatments for refugees. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Relationships Between Psychosocial Factors and Mental Health Among Nurses Working With COVID-19 Patients in Japan

Background Nurses who work with COVID-19 patients may suffer high levels of work-related stress, anxiety, and depressive symptoms. These impacts raise concerns about the deterioration of their mental health during this time. Objective This study examines the relationships between psychosocial factors (health, behavior, social, and economic factors) and mental health on among nurses working in a COVID-19 ward in Japan. Design A cross-sectional questionnaire-based study design was adopted. Methods We randomly selected 41 general hospitals that had over 400 beds. The participants were nurses who cared for COVID-19 patients at five hospitals. The questionnaire was completed by 56 nurses (seven men and 49 women) (response rate 46.6%). The survey asked participants about their basic attributes (gender, age, years of experience). It also included the Japanese version of the Patient Health Questionnaire-9, the Japanese version of the Generalized Anxiety Disorder-7, the Japanese version of the Impact of Event Scale-Revised, and the Maslach Burnout Inventory-General Survey to measure depression, anxiety, trauma experience, and burnout, respectively. To determine psychosocial factors, perception of damage from harmful rumors, nurses’ intention to quit their jobs, working environment changes, and changes in daily life were measured. Results Intention to quit was specifically associated with “wanting to continue nursing,” the posttraumatic stress disorder (PTSD) symptom of avoidance, depression, anxiety, and burnout. Nurses who had experienced the impact of harmful rumors in the workplace had high levels of PTSD symptoms, including intrusion, avoidance, and hyperarousal, as well as depression, anxiety disorder, and burnout cynicism. Regarding changes in the working environment, significant differences were confirmed in PTSD symptoms including intrusion, avoidance, and hyperarousal, as well as depression. We also examined the relationship between changes in daily life and mental health. We found that answering affirmatively to “the family income has decreased,” “I’ve had family problems,” and “I cannot do housework” related to mental health disorders among the nurses. Consideration: Psychosocial factors that may have been exacerbated during the COVID-19 pandemic were found to affect nurses’ mental health. Thus, reducing these psychosocial factors and building a mental health support system for nurses is crucial.

Complex Post Traumatic Stress Disorder: A Review

Complex trauma is a diagnosis that occurs due to repetitive, long-term and interpersonal traumatic events and its symptoms are different from post-traumatic stress disorder (PTSD). Although many studies have been conducted on complex trauma for many years, it has not been accepted as a different diagnosis. The 11th Edition of the International Classification of Diseases (ICD-11), published by the World Health Organization in 2018, includes complex post-traumatic stress disorder, a new diagnosis, besides post-traumatic stress disorder (PTSD) under the category of “Stress-Related Disorders”. In addition to the three diagnostic criteria of PTSD (re-experiencing, avoidance, and hypervigilance), 3 new symptoms related to self-organization have been added to this new diagnosis, namely emotion dysregulation, problems in interpersonal relationships, and negative self-concept. In this review study, firstly, the differences in the diagnosis of PTSD according to DSM-5 and ICD-11 were examined. Then, the history, definition and differences between complex PTSD disorder and other disorders were examined. Finally, studies on the methods used in the treatment of Complex PTSD were reviewed.

Vagal control moderates the association between endothelial function and PTSD symptoms in women with T2DM

BackgroundIndividuals with posttraumatic stress disorder (PTSD) are more likely to present with metabolic diseases such as type-2 diabetes mellitus (T2DM), and cardiovascular dysfunction has been implicated in this link. These diseases disproportionately affect women and individuals exposed to chronic environmental stressors (e.g., community violence, poverty). We examined associations among PTSD, cardiovascular indices, and metabolic function in highly trauma-exposed Black women with T2DM. MethodsParticipants (N = 80) were recruited for a follow-up study of stress and T2DM as part of the Grady Trauma Project. PTSD symptoms were assessed with the Clinician Administered PTSD Scale (CAPS-IV). Cardiovascular indices included heart rate (HR), blood pressure (BP), respiratory sinus arrhythmia (RSA), and endothelial function (assessed via flow-mediated dilation; FMD). An oral glucose tolerance test was used as an indicator of metabolic function. ResultsOf the cardiovascular indices, only FMD was significantly associated with PTSD symptoms (CAPS Avoidance symptoms; β = −0.37, p = .042), and glucose tolerance (β = −0.44, p = .019), controlling for age and body mass index. The association between FMD and PTSD Avoidance was moderated by RSA such that the effect of FMD was only significant at low levels of RSA (simple slopes β = −0.87, p = .004). ConclusionsOur results indicate that endothelial function is significantly related to PTSD and glucose tolerance, over and above other cardiovascular measures (HR, BP, RSA). Further, our results suggest that low RSA may be a risk factor for the link between poor endothelial function and PTSD in women with T2DM.

An initial investigation of the association between DSM-5 posttraumatic stress disorder symptoms and nonsuicidal self-injury functions.

Despite the well-established link between posttraumatic stress disorder (PTSD) and nonsuicidal self-injury (NSSI), little is known about factors that may lead to self-injury among trauma-exposed individuals. Moreover, no research to date has examined these relations in the context of the newly revised Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) PTSD criteria. Thus, the purpose of the current study was to explore the associations between DSM-5 PTSD symptom clusters (i.e., intrusion, avoidance, negative alterations in cognitions and mood, alterations in arousal and reactivity) and self-injury functions using a small sample of college students. Participants (N = 81) were recruited for a lifetime history of NSSI and trauma exposure. Findings revealed a statistically significant path from PTSD avoidance symptoms to NSSI social functions and from PTSD negative alterations in cognitions and mood symptoms to NSSI intrapersonal functions, even after controlling for relevant covariates. Results of the current study highlight the importance of assessing for NSSI among trauma-exposed individuals. Considering that NSSI is a risk factor for suicidal behavior and potentially a clinically distinct diagnosis, future research should continue to explore these associations using larger, more diverse clinical samples. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Distress and post-traumatic stress in parents of patients with congenital gastrointestinal malformations: a cross-sectional cohort study

BackgroundCongenital gastrointestinal malformation (CGIM) require neonatal surgical treatment and may lead to disease-specific sequelae, which have a potential psychological impact on parents. The aim of this study is to assess distress and symptoms of post-traumatic stress disorder (PTSD) in parents of patients with CGIM. In this cross-sectional study, seventy-nine parents (47 mothers and 32 fathers) of 53 patients with CGIM completed the Distress Thermometer for Parents (DT-P) and the Self Rating Scale for Posttraumatic Stress Disorders (SRS-PTSD) as part of the multidisciplinary follow-up of their children (aged 5–35 months). Group differences were tested between parents and representative Dutch reference groups with regard to rates of (clinical) distress and PTSD, and severity of overall distress and PTSD, for mothers and fathers separately. Mixed model regression models were used to study factors associated with the risk of (clinical) distress, PTSD and with severity of symptoms of PTSD (intrusion, avoidance and hyperarousal).ResultsPrevalence of clinical distress was comparable to reference groups for mothers (46%) and fathers (34%). There was no difference in severity of overall distress between both mothers as well as fathers and reference groups. Prevalence of PTSD was significantly higher in mothers (23%) compared to the reference group (5.3%) (OR = 5.51, p < 0.001), not in fathers (6.3% vs 2.2.%). Symptoms of intrusion were commonly reported by all the parents (75%). Longer total length of child’s hospital stay was associated with more severe symptoms of intrusion, avoidance and hyperarousal. Child’s length of follow-up was negatively associated with severity of intrusion.ConclusionsHaving a child with CGIM has a huge impact on parents, demonstrated by a higher prevalence of PTSD in mothers, but not fathers, compared to parents in the general population. Monitoring of symptoms of PTSD of parents in follow-up is necessary.

The Effects of a Multi-Family Group Trauma Intervention on Caregiver Posttraumatic Stress Symptom Clusters.

Strengthening Family Coping Resources (SFCR), a multi-family group intervention tailored to families experiencing traumatic stress, is associated with improved post-traumatic stress disorder (PTSD) symptoms and family functioning. To further SFCR research, we examined (1) SFCR's effects on caregiver PTSD symptom clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], alterations in arousal and reactivity); and (2) whether effects differed by caregiver trauma type (interpersonal versus non-interpersonal; intrafamilial versus extrafamilial). Forty-two caregivers of primarily low socioeconomic status reporting trauma histories completed SFCR treatment. Significant decreases in PTSD intrusion, avoidance, and NACM subscale scores emerged from pre- to post-SFCR; there were no differences in subscale score changes by trauma type categorization. Findings support SFCR as a promising treatment for reducing PTSD severity among caregivers reporting diverse traumas.

Longitudinal relationships among posttraumatic stress disorder symptom clusters in response to positive memory processing

Background and objectives: Avoidance, inherent to posttraumatic stress disorder (PTSD) symptomatology, is theoretically and empirically linked to the maintenance of PTSD symptom severity. While research indicates traumatized individuals avoid positive and trauma memories, several PTSD treatments focus exclusively on traumatic memories. We examined the mediating role of PTSD's avoidance in the relationship between processing positive memories and PTSD cluster severity (intrusion, mood/cognitions, arousal). Methods: Sixty-five trauma-exposed college students (Mage = 22.52; 86.10% female) were randomly assigned to 3 conditions: narrating/processing, writing/processing, or control (same task across baseline [T0] and follow-up [T1]). Results: Half-longitudinal mediation models indicated participation in the narrating vs. writing and control conditions predicted decreases in T1 intrusion severity via reduction in T1 avoidance severity. Similarly, participation in the narrating vs. writing and control conditions predicted decreases in T1 mood/cognitions' severity via reduction in T1 avoidance severity. Participation in the narrating vs. writing condition predicted decreases in T1 arousal severity via reduction in T1 avoidance severity. Limitations: Data was obtained from an analogue small-size sample of university students. In addition, sessions were only 6–8 days apart, with the processing component of each session lasting ∼30 min. Conclusions: Processing positive memories may relate to lower PTSD severity via a reduction in PTSD's avoidance, paralleling effects of processing trauma memories. Our findings support future investigations of the mechanisms underlying impacts of positive memory processing in the context of PTSD treatments.

The Italian Version of the International Trauma Questionnaire: Symptom and Network Structure of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder in a Sample of Late Adolescents Exposed to a Natural Disaster.

The 11th revision of the International Classification of Diseases has endorsed substantial changes in Post-Traumatic Stress Disorder (PTSD) and has introduced Complex PTSD (cPTSD). The objective of this study was to assess the symptom and network structure of PTSD and cPTSD using the International Trauma Questionnaire- Italian version (ITQ) and the prevalence of PTSD and cPTSD in a community sample of late adolescents enriched with exposure to a destructive earthquake. A 1,010 high school students participated to the study. Confirmatory Factor Analysis supports that a six first-order correlated factors was the best fitting model of ICD-11 PTSD/cPTSD. The network analysis supports a clear separation between core PTSD symptoms and disturbances in self-organization (DSO) symptoms, avoidance, and negative self-concept were the most central items. The prevalence of PTSD and cPTSD was 9.11 and 4.06%, respectively. Female participants reported higher rates of both PTSD and cPTSD. This is the first study to report on ICD-11 PTSD and cPTSD rates on an Italian adolescence community sample. Consistent with other community samples, we found higher rates of PTSD compared to cPTSD. The results confirmed the factorial validity of the ITQ. The network structure highlights the importance of negative self-concept in cPTSD and avoidance in PTSD.

0471 Identifying Trauma-Informed Adaptations to Cognitive Behavioral Therapy for Insomnia among Women Veterans: Results of an Expert Panel

Abstract Introduction Trauma-informed care is an emerging area of health services research. While trauma-focused care specifically targets symptoms of posttraumatic stress disorder (PTSD), trauma-informed care involves tailoring interventions to meet the unique needs of patients who have experienced trauma. Insomnia and PTSD are common comorbid disorders, but no known previous studies have identified trauma-informed adaptations to cognitive behavioral therapy for insomnia (CBT-I). Methods We identified PTSD clinical presentations that may interfere with the delivery of effective CBT-I and possible adaptations to standard CBT-I that may address these clinical presentations based on a literature review. We then incorporated trauma-informed adaptations into a 5-session CBT-I protocol. Four Veterans Affairs (VA) Expert Trainers in CBT-I were sent the trauma-informed CBT-I materials and rating forms. They were asked to rate the extent to which PTSD clinical presentations serve as barriers to CBT-I (1=low barrier; 5=high barrier), the feasibility of possible adaptations (1=low feasibility; 5=high feasibility), and to provide qualitative feedback. A 60-minute panel meeting was convened and aggregated data from rating forms were presented and discussed. We then revised the trauma-informed CBT-I materials. Panelists reviewed the revised trauma-informed CBT-I materials and completed post-panel rating forms. Results The highest-ranked clinical presentations based on rating forms and panel consensus included: sleep avoidance/nighttime arousal, sleep-related self-efficacy, substance/medication use to induce sleep, and safety behaviors intended to reduce nighttime arousal. Panel meeting consensus identified the following trauma-informed adaptations to CBT-I: PTSD-related nighttime hyperarousal psychoeducation, identification of alternatives to PTSD-related safety behaviors, nightmare psychoeducation, psychoeducation about PTSD avoidance in the context of substance/medication use, cognitive techniques, and behavioral tracking to challenge beliefs and avoidant behaviors. Panelists agreed the revised trauma-informed CBT-I materials adequately addressed the PTSD clinical presentations that may limit the effectiveness of standard CBT-I for patients with comorbid PTSD. Conclusion This was the first study to use an expert panel to identify trauma-informed adaptations to CBT-I. Trauma-informed adaptations, including supplemental materials, may improve CBT-I outcomes for patients with comorbid PTSD. Future studies should incorporate feedback from patients with insomnia and PTSD to refine trauma-informed adaptations to CBT-I further. Support (If Any) VA HSR&amp;D (RCS-20-191, Martin), NHLBI (K23HL143055, Martin)

Insecure Adult Attachment Style and PTSD Symptom Severity among Firefighters: The Role of Distress Tolerance

ABSTRACT Trauma exposure and posttraumatic stress disorder (PTSD) symptoms among firefighters are prevalent and well-documented. Insecure adult attachment style (AAS) and distress tolerance (DT) present two factors with demonstrated relevance to the etiology and maintenance of PTSD. Few studies have examined these constructs in relation to PTSD symptomatology among firefighter populations. The present investigation examined the indirect effect of insecure romantic AAS (i.e., anxious AAS, avoidant AAS) on PTSD symptom severity through DT among firefighters. Exploratory analyses examined this model with each of the PTSD symptom clusters as outcomes. The sample was comprised of 105 firefighters (Mage = 40.43, SD = 9.15, 95.2% male) recruited from various departments in the southern U.S. An indirect effect was calculated using 10,000 bootstrapped samples. Indirect effects models in the primary analyses were significant when both anxious AAS (β = .20, SE = .10, CI = .06-.43) and avoidant AAS (β = .28, SE = .12, CI = .08-.54) were evaluated as predictors. Effects were evident after accounting for gender, relationship status, years of fire service, and trauma load (i.e., number of potentially traumatic event types experienced). Exploratory analyses revealed that anxious and avoidant AAS are both indirectly related to the PTSD intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity symptom clusters through DT. Anxious AAS also demonstrated an indirect association with PTSD avoidance symptoms through DT. Attachment styles may influence PTSD symptoms among firefighters through a firefighter’s perceived ability to withstand emotional distress. This line of inquiry has potential to inform specialized intervention programs for firefighters. Clinical and empirical implications are discussed.