Combat-related Posttraumatic Stress Disorder Research Articles

Posttraumatic stress disorder is associated with altered gut microbiota that modulates cognitive performance in veterans with cirrhosis.

Posttraumatic stress disorder (PTSD) is associated with cirrhosis in veterans, and therapeutic results are suboptimal. An altered gut-liver-brain axis exists in cirrhosis due to hepatic encephalopathy (HE), but the added impact of PTSD is unclear. The aim of this study was to define linkages between gut microbiota and cognition in cirrhosis with/without PTSD. Cirrhotic veterans (with/without prior HE) underwent cognitive testing [PHES, inhibitory control test (ICT), and block design test (BDT)], serum lipopolysaccharide-binding protein (LBP) and stool collection for 16S rRNA microbiota composition, and predicted function analysis (PiCRUST). PTSD was diagnosed using DSM-V criteria. Correlation networks between microbiota and cognition were created. Patients with/without PTSD and with/without HE were compared. Ninety-three combat-exposed male veterans [ (58 yr, MELD 11, 34% HE, 31% combat-PTSD (42 no-HE/PTSD, 19 PTSD-only, 22 HE-only, 10 PTSD+HE)] were included. PTSD patients had similar demographics, alcohol history, MELD, but worse ICT/BDT, and higher antidepressant use and LBP levels. Microbial diversity was lower in PTSD (2.1 ± 0.5 vs. 2.5 ± 0.5, P = 0.03) but unaffected by alcohol/antidepressant use. PTSD (P = 0.02) and MELD (P < 0.001) predicted diversity on regression. PTSD patients showed higher pathobionts (Enterococcus and Escherichia/Shigella) and lower autochthonous genera belonging to Lachnospiraceaeae and Ruminococcaceae regardless of HE. Enterococcus was correlated with poor cognition, while the opposite was true for autochthonous taxa regardless of PTSD/HE. Escherichia/Shigella was only linked with poor cognition in PTSD patients. Gut-brain axis-associated microbiota functionality was altered in PTSD. In male cirrhotic veterans, combat-related PTSD is associated with cognitive impairment, lower microbial diversity, higher pathobionts, and lower autochthonous taxa composition and altered gut-brain axis functionality compared with non-PTSD combat-exposed patients. Cognition was differentially linked to gut microbiota, which could represent a new therapeutic target.NEW & NOTEWORTHY Posttraumatic stress disorder (PTSD) in veterans with cirrhosis was associated with poor cognitive performance. This was associated with lower gut microbial diversity in PTSD with higher pathobionts belonging to Enterococcus and Escherichia/Shigella and lower beneficial taxa belonging to Lachnospiraceaeae and Ruminococcaceae, with functional alterations despite accounting for prior hepatic encephalopathy, psychoactive drug use, or model for end-stage liver disease score. Given the suboptimal response to current therapies for PTSD, targeting the gut microbiota could benefit the altered gut-brain axis in these patients.

Symptom structure of PTSD and co-morbid depressive symptoms - a network analysis of combat veteran patients.

Despite extensive research, symptom structure of posttraumatic stress disorder (PTSD) is highly debated. The network approach to psychopathology offers a novel method for understanding and conceptualizing PTSD. However, extant studies have mainly used small samples and self-report measures among sub-clinical populations, while also overlooking co-morbid depressive symptoms. PTSD symptom network topology was estimated in a sample of 1489 treatment-seeking veteran patients based on a clinician-rated PTSD measure. Next, clinician-rated depressive symptoms were incorporated into the network to assess their influence on PTSD network structure. The PTSD-symptom network was then contrasted with the network of 306 trauma-exposed (TE) treatment-seeking patients not meeting full criteria for PTSD to assess corresponding network differences. Finally, a directed acyclic graph (DAG) was computed to estimate potential directionality among symptoms, including depressive symptoms and daily functioning. The PTSD symptom network evidenced robust reliability. Flashbacks and getting emotionally upset by trauma reminders emerged as the most central nodes in the PTSD network, regardless of the inclusion of depressive symptoms. Distinct clustering emerged for PTSD and depressive symptoms within the comorbidity network. DAG analysis suggested a key triggering role for re-experiencing symptoms. Network topology in the PTSD sample was significantly distinct from that of the TE sample. Flashbacks and psychological reactions to trauma reminders, along with their strong connections to other re-experiencing symptoms, have a pivotal role in the clinical presentation of combat-related PTSD among veterans. Depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems.

Development of a Consensus-Based OT Treatment Template for Veterans With Combat-Related Posttraumatic Stress Disorder (PTSD)

Abstract Date Presented 04/04/19 This poster presents a model OT treatment template for veterans with PTSD. Utilizing a modified Delphi method of consensus attainment, the study surveyed Canadian OTs to identify treatment template components. The resulting treatment template is present-focused, occupation-focused, occupation-based, and built upon the Canadian Model of Occupational Performance and Engagement, Behavioral Activation, and Acceptance and Commitment Therapy. Primary Author and Speaker: Steven Gerardi

Lifetime trauma exposure among those with combat-related PTSD: Psychiatric risk among U.S. military personnel

Research has described the association between lifetime trauma exposure and psychiatric symptoms among various cohorts, but little is known about the effect of lifetime trauma histories on the symptom expression of active-duty military personnel diagnosed with combat-related posttraumatic stress disorder (PTSD). Active-duty soldiers (N = 162) were diagnosed with PTSD from deployments to Iraq or Afghanistan using the Clinician Administered PTSD Scale. Soldiers then completed self-report measures of depression, anxiety, and PTSD. Lifetime exposure to categories of trauma types and the intensity of exposure was reported on the Life Events Checklist. The number of categories of trauma that happened to them significantly predicted the severity of depression, anxiety, and PTSD symptoms, as well as a positive screen for likely depression diagnosis based on self-reported symptoms. Direct exposure to trauma explained most of the association, as witnessing trauma and hearing about trauma did not explain symptoms beyond events that happened to participants. Interpersonal traumatic events were not associated with psychiatric functioning after controlling for non-interpersonal traumatic events. Assessment of trauma history among post-9/11 service members and veterans should include the frequency and variety of lifetime trauma exposure, given the association with psychiatric functioning.

Severity and Symptom Trajectory in Combat-Related PTSD: a Review of the Literature.

Combat-related posttraumatic stress disorder is increasingly recognized as having a variable course in returning veterans. Relatively few studies have identified predictors of illness duration or severity in this population. This review sought to synthesize the existing literature. The existing literature remains limited and heterogeneous. However, several studies identified hyperarousal and pre-deployment dissociation as predictive of disease severity, and re-experiencing as predictive of suicidality in veterans with combat-related PTSD. No other pre-, peri-, or posttraumatic psychosocial predictors of individual symptoms or overall disease severity have been identified in replicated studies. Important clinical factors to explore in the assessment of PTSD in combat veterans may now include hyperarousal and a history of dissociation as these may predict disease severity, and re-experiencing as this has been identified as a significant predictor of suicidality. Further study into this topic may reveal biological or more sensitive psychosocial markers predicting illness severity and prognosis.

Testing a variable-length Cognitive Processing Therapy intervention for posttraumatic stress disorder in active duty military: Design and methodology of a clinical trial.

Combat-related trauma exposures have been associated with increased risk for posttraumatic stress disorder (PTSD) and comorbid mental health conditions. Cognitive Processing Therapy (CPT) is a 12-session manualized cognitive-behavioral therapy that has emerged as one of the leading evidence-based treatments for combat-related PTSD among military personnel and veterans. However, rates of remission have been less in both veterans and active duty military personnel compared to civilians, suggesting that studies are needed to identify strategies to improve upon outcomes in veterans of military combat. There is existing evidence that varying the number of sessions in the CPT protocol based on patient response to treatment improves outcomes in civilians. This paper describes the rationale, design, and methodology of a clinical trial examining a variable-length CPT intervention in a treatment-seeking active duty sample with PTSD to determine if some service members would benefit from a longer or shorter dose of treatment, and to identify predictors of length of treatment response to reach good end-state functioning. In addition to individual demographic and trauma-related variables, the trial is designed to evaluate factors related to internalizing/externalizing personality traits, neuropsychological measures of cognitive functioning, and biological markers as predictors of treatment response. This study attempts to develop a personalized approach to achieving positive treatment outcomes for service members suffering from PTSD. Determining predictors of treatment response can help to develop an adaptable treatment regimen that returns the greatest number of service members to full functioning in the shortest amount of time.

Enhancing Completion of Cognitive Processing Therapy for Posttraumatic Stress Disorder with Quetiapine in Veterans with Mild Traumatic Brain Injury: a Case Series.

To evaluate the outcomes of the antiarousal medications valproate, risperidone, and quetiapine on completion of treatment of cognitive processing therapy (CPT) for PTSD. A case series of fifty treatment-seeking adult (≥18years) veterans with mild traumatic brain injury and combat-related PTSD who had unsuccessful trials of 2 or more first-line agents and previously declined treatment with trauma-focused therapy, seen at the psychiatric outpatient services of the local Polytrauma Rehabilitation Center from January 1, 2014, through December 31, 2017. Patients were prescribed valproate (n = 8), risperidone (n = 17), or quetiapine (n = 25) and were referred for individual weekly treatment with CPT. Outcome measurements of interest were measures of engagement and completion rate of CPT, PTSD Checklist total score (range, 0-80; higher scores indicate greater PTSD severity) and arousal subscale score (range, 0-24; higher scores indicate greater arousal severity), and clinical observations of sleep variables. Of the 50 patients included in the study, 48 (96%) were men; mean (SD) age was 36 (8)years. Eighteen (86%) patients initially receiving quetiapine and none taking valproate or risperidone became adequately engaged in and completed CPT. Among patients who completed CPT, the mean decrease in the PTSD Checklist score was 25 [95% CI, 30 to 20] and 9 (50%) patients no longer met criteria for PTSD. These preliminary findings support quetiapine as an adjunctive medication to facilitate CPT. A pragmatic trial is needed to evaluate the efficacy, safety, and feasibility of quetiapine to improve engagement in and completion rate of CPT.

Multi-site Confirmatory Efficacy Treatment Trial of Combat-related PTSD

Multi-site Confirmatory Efficacy Treatment Trial of Combat-related PTSD

Combat-related posttraumatic stress disorder and longitudinal hyper-responsivity to trauma-related visual stimuli: stability over 2 years

Introduction: Soldiers with combat-related posttraumatic stress disorder (PTSD) show survival-mode functioning, implying generalized hyper-arousal along with a memory bias for trauma-related stimuli. To date, a precise spatiotemporal characterization of maladaptive neurophysiological responses underlying experiential trauma reminders in PTSD is lacking. We used magnetoencephalography to investigate rapid evoked responses during visual processing and delayed recognition of war-related versus neutral pictures in soldiers with PTSD and trauma-exposed peers who did not develop PTSD. Methods: The sample consisted of 24 soldiers with PTSD who had served in Afghanistan and 28 war-exposed soldiers without PTSD, matched for combat exposure, military experience, and rank. We completed longitudinal follow-up studies 2 years later with 35 of these same soldiers, 13 with PTSD and 22 control participants. We analysed brain activation evoked by visual processing and delayed recognition tasks that involved both war-related and neutral pictures, and we used a mixed-effects model to determine whether changes in activity occurred between the two test periods. Results: In the visual processing task, soldiers with PTSD showed rapid-onset and sustained hyper-activation for war-related imagery in the left temporal pole and superior frontal gyrus and the right calcarine. In contrast, control soldiers exhibited greater activity for war-related imagery in the left temporal–parietal junction and right inferior frontal gyrus. In the delayed recognition task, both groups showed increased activity in occipital cortices for war images compared with neutral images. A crucial finding was that, compared with control participants, the PTSD group also showed elevated and sustained activation in limbic areas for war imagery. Discussion: These results characterize the evoked neurophysiology underlying hyper-responsivity found in soldiers with PTSD at the juncture of stress and memory in contrast to their trauma-exposed peers without PTSD.

Evaluation of an Integrative Post-Traumatic Stress Disorder Treatment Program.

Post-traumatic stress disorder (PTSD) and combat-related stress can be refractory, pervasive, and have a devastating impact on those affected, their families, and society at large. Challenges dealing with symptoms may in turn make a servicemember more susceptible to problems, including alcohol abuse, interpersonal conflict, and occupational problems. An effective treatment strategy will address multifactorial issues by using a holistic multimodal approach. Back on Track is an intensive outpatient program utilizing a holistic philosophy and multimodal treatments to provide a whole systems approach for the treatment of combat-related stress reactions and PTSD in active duty servicemembers. An explanatory, sequential, mixed-methods program evaluation was conducted to assess the effectiveness of a PTSD and combat stress treatment program. Quantitative outcomes were collected and analyzed on 595 participants at pre- and postinterventions and 6-week follow-up and qualitative data were gathered through participant interviews. The manualized program uses a multimodal, psychoeducational group therapy format with a holistic approach for treating combat stress, increasing resiliency, and assisting with reintegration. Rotating providers visit from other programs and services to deliver content in bio-psycho-social-spiritual domains, including didactic lectures on mindfulness and the relaxation response and daily sessions of yoga nidra and meditation. The primary outcome measure was PTSD symptom severity assessed with the PTSD Checklist-Military Version (PCL-M). Secondary outcomes included self-efficacy, knowledge, use, and satisfaction. Quantitative data were contextualized with interview data. Results demonstrated a highly statistically significant effect of the program when comparing within-subject PCL-M scores before and after program participation, signed rank S (N = 595) = -47,367, p < 0.001. This translates to a moderate effect size, Cohen's d (N = 595) = -0.55, 95% confidence interval = -0.62 to -0.47, and a mean decrease of 7 points on the PCL-M at postintervention, demonstrating response to treatment. There were significant increases in knowledge and self-efficacy and high levels of satisfaction with the program overall, content, materials, and delivery. The treatment program has served ∼800 servicemembers since inception and has since expanded to five installations. The provision of whole systems care where the approach is holistic, multimodal, and multidisciplinary may be a way forward for the successful treatment of PTSD and other debilitating behavioral health conditions in military contexts and beyond.

The Influence of Just World Beliefs on the Stigmatization of Combat-Related PTSD

The fear of stigmatization by nonmilitary community members has been identified as a significant barrier to care for military members seeking mental health services. Research exploring the constructs that contribute to the stigmatizing views of military-specific mental health issues is absent from current literature. This study examined the predictive value of just world beliefs on specific constructs of stigmatizing attitudes (i.e., mental health ideology, social restriction, benevolence) toward individuals with combat-related posttraumatic stress disorder. The findings provide guidance regarding the development of antistigma interventions and educational campaigns that may reduce levels of stigmatization by community members, with the long-term goal of diminishing military members' fear of community stigmatization as a barrier to seeking mental health services.

Combat-related posttraumatic stress disorder: the historical evolution of concept from 'irritable heart syndrome' to 'psycho-organic disorder'

Nowadays PTSD is the most urgent problem in the field of world psychiatry due to its academic, practical, epidemiological significance and other aspects. The authors present a historical review of different conteptions explaining the development of posttraumatic stress disorder. Attention is drawn to the description of evolution of PTSD from psychogenic to complex forms, with the formation of bio-psycho-social approach to the problem. The dynamics of the development of PTSD diagnostic crireria according to the current international classifications is analyzed.

Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder

ImportanceMeta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone.ObjectiveTo determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD.Design, Setting, and ParticipantsThe Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months’ duration. Analyses were on an intent-to-treat basis.InterventionParticipants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized.Main Outcomes and MeasuresThe primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24.ResultsOf 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,–9.39; 95% CI, −11.62 to −7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, –9.39; sertraline plus enhanced medication management group, –10.37; and prolonged exposure therapy plus sertraline group, –9.99; P = .81).Conclusions and RelevanceNo difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline.Trial RegistrationClinicalTrials.gov Identifier: NCT01524133

Therapeutic horseback riding as a complementary intervention for military service members with PTSD

Abstract The aim of this study was to examine the efficacy and potential effectiveness of an 8-week therapeutic horseback riding [THR] program for veterans with combat-related posttraumatic stress disorder [PTSD]. Eighty-nine military service members diagnosed with PTSD participated in either the THR group (n = 51) or the comparison group (n = 38). Group mean score differences in PTSD and depression symptoms, quality of life, functioning and disability scores were compared at baseline, 4 weeks, and post intervention. THR participants reported clinically meaningful improvement in PTSD (-13.02 points) and depression (-7.65 points) symptoms and mental health scores (+ 9.61 points) overtime. In comparison, change in comparison group mean scores indicated less improvement in the same variables. Group differences in PTSD and depression symptom scores and mental health scores increased pre to post intervention, resulting in a moderate to large effect size (g = -0.43 to 0.62). Two-month follow-up reflected sustained improvement in key variables. Outcomes of the study support the potential effectiveness of THR as complementary intervention for military service members with combat-related PTSD.

Genetic Variants of the Brain-Derived Neurotrophic Factor and Metabolic Indices in Veterans With Posttraumatic Stress Disorder.

Posttraumatic stress disorder (PTSD) is a trauma and stressor related disorder that may develop after exposure to an event that involved the actual or possible threat of death, violence or serious injury. Its molecular underpinning is still not clear. Brain-derived neurotrophic factor (BDNF) modulates neuronal processes such as the response to stress, but also weight control, energy and glucose homeostasis. Plasma BDNF levels and a functional BDNF Val66Met (rs6265) polymorphism were reported to be associated with PTSD, as well as with increased body mass index (BMI) and dyslipidaemia in healthy subjects and patients with cardio-metabolic diseases, but these results are controversial. The other frequently studied BDNF polymorphism, C270T (rs56164415), has been associated with the development of different neuropsychiatric symptoms/disorders. As far as we are aware, there are no data on the association of BDNF Val66Met and C270T polymorphisms with metabolic indices in PTSD. Due to high rates of obesity and dyslipidaemia in PTSD, the aim of this study was to elucidate the association of BDNF Val66Met and C270T polymorphisms with BMI and lipid levels in veterans with PTSD. We hypothesized that BDNF variants contribute to susceptibility to metabolic disturbances in PTSD. The study included 333 Caucasian males with combat related PTSD, diagnosed according to DSM-5 criteria. Genotyping of the BDNF Val66Met and C270T polymorphisms was performed using the real-time PCR method. Results were analyzed using hierarchical multiple linear regression and the Mann–Whitney test, with p-value corrected to 0.005. The results showed that BDNF Val66Met and BDNF C270T polymorphisms were not significantly associated with BMI, total cholesterol, LDL-cholesterol, HDL-cholesterol or triglycerides. Although the BDNF C270T polymorphism was nominally associated only with HDL-cholesterol in veterans with PTSD, this significance disappeared after controlling for the effect of age. Namely, slightly higher plasma HDL values in T allele carriers, compared to CC homozygotes, were associated with differences in age. Our results, controlled for the critical covariates, revealed that BDNF Val66Met and C270T were not significantly associated with metabolic indices in veterans with PTSD and that these genetic variants do not contribute to susceptibility to metabolic disturbances in PTSD.

Quantitatively Improved Treatment Outcomes for Combat-Associated PTSD With Adjunctive Art Therapy: Randomized Controlled Trial

This article describes a randomized, controlled trial (N = 38) that compared art therapy in conjunction with cognitive processing therapy (CPT) to CPT alone for veterans with combat-related posttraumatic stress disorder. Participants were randomized to either the experimental condition of 8 sessions of CPT and 8 sessions of individual art therapy or to the control condition of 8 sessions of CPT and 8 individual sessions of supportive psychotherapy. Outcome measures included the Beck Depression Inventory–II (BDI–II), PTSD Checklist–Military (PCL–M), and self-ratings of perceived treatment benefits. Experimental group participants had statistically significantly greater reduction in PCL–M and BDI–II scores compared to the control group and the perceived benefit of treatment was greater for art therapy as compared to CPT.

Association Between Trust and Mental, Social, and Physical Health Outcomes in Veterans and Active Duty Service Members With Combat-Related PTSD Symptomatology.

Background: Trust represents a complex emotion and interpersonal concept which assumes abandoning control over a given situation or set of circumstances, in turn yielding such control to another party. Advances in our knowledge of post-traumatic stress disorder and moral injury have underscored the need to more closely examine how trust stands to impact health outcomes in these disorders. The aim of the present study is to examine and identify relationships linking general trust with select health outcomes in a mixed sample of Veterans and Service members with a self-reported history of deployment to a combat theater and PTSD symptomatology.Methods: This study applied a cross-sectional methodology, surveying n = 427 participants recruited across six sites. This included 373 Veterans and 54 active duty Service members in the United States. Measures included demographic characteristics, combat exposure, general trust, post-traumatic stress disorder symptomatology, depressive/anxiety symptomatology, alcohol use, social involvement, religiosity, and physical health. Data were analyzed descriptively as well as using Pearson correlations, Student's t-test, and multivariate regression.Results: Several significant relationships were identified, indicating an inverse relationship between trust and PTSD, depressive, and anxiety symptomatology. Greater levels of trust were also significantly associated with increased social interaction and religiosity. Lastly, no significant associations were identified with either physical functioning or pain level.Conclusion: The findings suggest that trust is correlated with a variety of health outcomes in Veterans and Service members affected by combat-related PTSD. Additional, hypothesis-driven research, informed by longitudinal data, is needed to better understand how trust stands to impact health outcomes, including the development of strategies and intervention options for repairing trust.

Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers.The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the provider's office to the participant's home, and (3) In-Home CPT in which the provider delivers treatment in the participant's home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Public stigma for men and women veterans with combat-related posttraumatic stress disorder

No investigations have fully evaluated the range of public stigma for United States’ military veterans with combat-related Post Traumatic Stress Disorder (PTSD). Previous investigations have also focused exclusively on men and have not included women veterans, who have been increasingly exposed to combat in recent military operations, are at higher risk for developing PTSD compared to men, and who represent the fastest growing segment of the population joining the military. In this investigation, undergraduate participants (N = 262; 44% women; mean age 20 years) completed measures of veteran familiarity and PTSD symptoms, were randomly assigned to watch a video of either a veteran man or woman describing their combat experiences and PTSD symptoms and completed a public stigma questionnaire. Men participants ascribed more responsibility for combat-related PTSD to veterans than women, and the woman veteran was ascribed more responsibility for her PTSD than the man veteran by both women and men participants. The man veteran was appraised as more dangerous and fear provoking than the woman veteran. There was a trend suggesting the man veteran elicited more anger than the woman veteran. Participants reported wanting to segregate and coerce the man veteran into treatment more than the woman veteran. Veteran familiarity was associated with decreased perception of danger, anger and fear, while experiencing PTSD was associated with increased perception of danger, anger, and fear. These findings provide a preliminary assessment of public stigma for veterans with combat-related PTSD and are the first to incorporate women veterans with combat-related PTSD.

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.