Posttraumatic Stress Disorder Checklist-Military Research Articles

Remediation of intrusive symptoms of PTSD in fewer than five sessions: A 30-person pre-pilot study of the RTM Protocol

Introduction: The Reconsolidation of Traumatic Memories (RTM) Protocol is a brief non-traumatizing intervention for the intrusive symptoms of post-traumatic stress disorder (PTSD). It is supported by nearly 25 years of anecdotal and clinical reports. This study reports the first scientific evaluation of the protocol. Methods: A 30-person pilot study using male Veterans with a pre-existing diagnosis of PTSD. Intake criteria included interviews and confirmatory re-diagnosis using the PTSD Checklist–Military version (PCL-M). Of 33 people who met the inclusion criteria, 26 completed treatment using the RTM protocol. A small ( n = 5) wait-list control group was included. All participants were reassessed following treatment using the PCL-M. Results: Of 26 program completers, 25 (96%) were symptom free at 6-week follow-up. Mean PCL-M score at intake was 61 points. At the 6-week follow-up, the mean PCL-M score was 28.8, with a mean reduction in scores of 33 points. Hedges’ g was computed for 6-week follow-up and showed a 2.9 SD difference from intake to follow-up. A wait-list control analysis indicated non-significant symptom changes during the 2-week wait period. Discussion: Results suggest that RTM is a promising intervention worthy of further investigation.

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.

Residual posttraumatic stress disorder and depression symptoms following a residential posttraumatic stress disorder treatment program for U.S. active duty service members.

Even after the most effective posttraumatic stress disorder (PTSD) treatments, symptoms often persist. Understanding residual symptoms is particularly relevant in military populations, who may be less responsive to PTSD interventions. The sample consisted of 282 male service members who engaged in a residential PTSD treatment program at a military treatment facility that provided evidence-based PTSD psychotherapies and adjunctive interventions. PTSD and depression symptoms were assessed before and after treatment and weekly during treatment via the PTSD Checklist-Military Version and Patient Health Questionnaire-8. Logistic regression with Hochberg's step-up procedure compared the likelihood of individual residual symptoms between service members who did (n = 92, 32.6%) and did not (n = 190, 67.4%) experience clinically significant PTSD change (≥ 10-point PTSD Checklist-Military Version reduction). Not achieving clinically significant PTSD change was associated with greater odds of nearly all residual symptoms (OR = 2.03-6.18), excluding two Patient Health Questionnaire-8 items (appetite and psychomotor changes). Among service members experiencing clinically significant PTSD change, concentration difficulties (73.3%), physical reactions to reminders (71.1%), and intrusions (70.8%) were PTSD symptoms most likely to persist. Poor sleep (56.2%), low energy (50.0%), and concentration difficulties (48.3%) were the most common for depression. To our knowledge, this study is the first to examine residual PTSD and depression symptoms following residential PTSD treatment for active duty service members. Given the low rates of clinically significant PTSD change and the high frequency of residual symptoms, strategies may be needed to improve residential PTSD treatment outcomes in the military. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Regional associations of white matter integrity and neurological, post-traumatic stress disorder and autonomic symptoms in Veterans with and without history of loss of consciousness in mild TBI.

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) share overlapping symptom presentations and are highly comorbid conditions among Veteran populations. Despite elevated presentations of PTSD after mTBI, mechanisms linking the two are unclear, although both have been associated with alterations in white matter and disruptions in autonomic regulation. The present study aimed to determine if there is regional variability in white matter correlates of symptom severity and autonomic functioning in a mixed sample of Veterans with and without PTSD and/or mTBI (N = 77). Diffusion-weighted images were processed to extract fractional anisotropy (FA) values for major white matter structures. The PTSD Checklist-Military version (PCL-M) and Neurobehavioral Symptom Inventory (NSI) were used to determine symptom domains within PTSD and mTBI. Autonomic function was assessed using continuous blood pressure and respiratory sinus arrythmia during a static, standing angle positional test. Mixed-effect models were used to assess the regional specificity of associations between symptom severity and white matter, with FA, global symptom severity (score), and white matter tract (tract) as predictors. Additional interaction terms of symptom domain (i.e., NSI and PCL-M subscales) and loss of consciousness (LoC) were added to evaluate potential moderating effects. A parallel analysis was conducted to explore concordance with autonomic functioning. Results from the two-way Score × Tract interaction suggested that global symptom severity was associated with FA in the cingulum angular bundle (positive) and uncinate fasciculus (negative) only, without variability by symptom domain. We also found regional specificity in the relationship between FA and autonomic function, such that FA was positively associated with autonomic function in all tracts except the cingulum angular bundle. History of LoC moderated the association for both global symptom severity and autonomic function. Our findings are consistent with previous literature suggesting that there is significant overlap in the symptom presentation in TBI and PTSD, and white matter variability associated with LoC in mTBI may be associated with increased PTSD-spectra symptoms. Further research on treatment response in patients with both mTBI history and PTSD incorporating imaging and autonomic assessment may be valuable in understanding the role of brain injury in treatment outcomes and inform treatment design.

An Executive Functioning Composite Does Not Moderate the Relationship Between Combat Exposure and Posttraumatic Stress Disorder Symptom Clusters.

Posttraumatic stress disorder (PTSD) is prevalent among U.S. combat Veterans, and associated with poor health and wellbeing. As combat experiences are likely to significantly modify self-, other-, and society-oriented cognitions and heighten risk for PTSD, examination of related cognitive processes may yield new treatment strategies. The cognitive model of PTSD suggests that persistent threat perceptions contribute to symptom worsening. Thus, cognitive processes of shifting perspectives or generating novel interpretations may be particularly relevant to lessen PTSD symptoms. This cross-sectional study examined executive functioning as a moderator to the relationship between combat exposure and PTSD symptom clusters among post-9/11 Veterans. Data from 168 Veterans were drawn from a larger study examining post-deployment mental health and cognitive function. An executive functioning composite derived from Wisconsin Card Sorting Test Perseveration Errors, WAIS-III Similarities, Trail Making Test B, and Stroop Color-Word Inhibition scores was computed. Path analysis was used to test the moderation model. After accounting for age, sex, and estimated premorbid functioning, results indicated that combat exposure was associated with all symptom clusters on the PTSD Checklist-Military. Executive functioning was not significantly associated with the PTSD symptom clusters and did not moderate the relationship between combat exposure and any of the PTSD symptom clusters. Combat exposure is an important dimension of risk related to PTSD in Veterans that warrants regular screening. Moderation by executive functioning was not observed despite theoretical support. Future work could test methodological and sampling reasons for this finding to determine if theoretical adjustment is necessary.

Evaluating Moral Injury in Combat-Deployed and Non-Combat Military Personnel

The factorial structure, measurement invariance, and relevance to posttraumatic stress of the Moral Injury Event Scale (MIES) was evaluated in military personnel as a function of combat role. A total of 245 combat-deployed and 140 non-combat military personnel 19 to 83 years of age (M = 43.97, SD= 12.08) answered questions about their service role(s), deployment history, and military-related PTSD diagnosis history. They also completed the PTSD Checklist-Military Version 5, the Exposure to Danger and Combat scale, the Witnessing Consequences of War scale, and the MIES. Confirmatory factor analysis supported a three-factor model of the MIES consisting of transgressions-self, transgressions-others, and betrayal. This structure demonstrated configural but not metric or scalar invariance between combat and non-combat personnel. Clinical relevance of the measure was supported by regressions showing that the MIES subscales were associated with PTSD symptomatology and PTSD diagnosis independently of measures of combat-related physical dangers or witnessing the consequences of war. We conclude that the MIES can be used to measure three components of moral injury that are relevant to mental health outcomes in military personnel. However, failure of measurement invariance cautions against comparing MIES subscale scores between combat and non-combat personnel.

Evaluation of post-traumatic stress disorder (PTSD) and related comorbidities in clinical studies.

Patients with traumatic brain injury (TBI) of varying severities are experiencing adverse outcomes during and after rehabilitation. Besides depression and anxiety, post-traumatic stress disorder (PTSD) is highly encountered in civilian and military populations. As more prospective and retrospective studies – focused on evaluating new or old psychological therapies in inpatient, outpatient, or controlled environments, targeting patients with PTSD with or without a history of TBI – are carried out, researchers are employing various scales to measure PTSD as well as other psychiatric diagnoses or cognitive impairments that might appear following TBI. We aimed to explore the literature published between January 2010 and October 2021 by querying three databases. Our preliminary results showed that several scales – such as the Clinician-Administered PTSD Scale (CAPS), the Posttraumatic Stress Disorder Checklist Military Version (PCL-M) as well as Specific Version (PCL-S), and Civilian Version (PCL-C) – have been frequently used for PTSD diagnosis and symptom severity. However, heterogeneity in the scales used when assessing and evaluating additional psychiatric comorbidities and cognitive impairments are due to the study aim and therapeutic approaches. Therefore, conducting an intervention focusing on post-TBI PTSD patients requires increased attention to patients' medical history in capturing multiple cognitive impairments and affected neuropsychological processes when designing the study and including validated instruments for measuring primary and secondary neuropsychological outcomes.

Do early responders and treatment non-responders offer guidance to make CPT group a more effective treatment?

Treatment dropout has been problematic with evidence-based treatments for posttraumatic stress disorder (PTSD), including cognitive processing therapy (CPT). This study sought to evaluate whether CPT group contributed to symptom improvement among treatment completers and non-completers. Sixty-one Iraq and Afghanistan combat Veterans self-selected CPT group or treatment as usual (TAU) forming a convenience sample. Defining treatment completion as attending at least ninesessions: 18 completed treatment, 20 dropped-out (DOs); 20 completed TAU, 3 lost to TAU follow-up. Multiple Regression revealed significant pre-post-treatment improvement, the Clinician-Administered PTSDScale (CAPS-IV, F(5,40.1) = 2.53, p = 0.0436). Reviewing DOs' last available PTSD Checklist-Military Version scores before leaving treatment, six achieved clinically significant improvement of >10 points; seven a clinically reliable change of 5-10 points. These findings highlight that CPT group may be effective at reducing trauma-related symptoms among treatment completers and dropouts and point to the utility of a clinical definition of good treatment end-state.

Characteristics of Responders and Non-Responders in a Military Post-Concussion Rehabilitation Program

<h3>Research Objectives</h3> To characterize treatment responders and non-responders as measured by the Neurobehavioral Symptom Inventory (NSI). <h3>Design</h3> Observational retrospective analysis of extant clinical outcomes data. <h3>Setting</h3> Brain Injury Rehabilitation Service at Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX. <h3>Participants</h3> Active duty military patients with a diagnosis of mild traumatic brain injury (mTBI) who received treatment between the years 2007 - 2020 and completed self-report measures as part of routine care. The final dataset included patients who completed NSI and World Health Organization Quality of Life Instrument-Abbreviated Version (WHOQOL-BREF) at both intake and discharge (n=717). The majority of patients were male (82.01%). Mean age was 34.41 years (SD=9.63). The most prevalent military rank was Senior Enlisted (53.56%). <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> NSI, WHOQOL-BREF, Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Post-Traumatic Stress Disorder Checklist Military Version (PCL-M). <h3>Results</h3> Responders reported significantly more distress on the NSI at intake (M=41.81, SD=14.84) than non-responders, (M=33.75, SD=16.08), t(715)=6.92, p < .001, and this was found for all NSI subscales. Females (n=129) responded proportionally more (70.54%) than males (n=588, 55.61%) in comparison to their total gender group. Responders reported a greater functional impact from pain at intake, t(665.733)=-2.16, p < .05) as well as greater satisfaction with social support, t(715)=2.16, p < .05). <h3>Conclusions</h3> Self-reported symptom burden, pain, and social support at intake as well as gender impact response to rehabilitation interventions in this setting. Different programming may be more effective for targeting some populations. <h3>Author(s) Disclosures</h3> None.

A-128 Intraindividual Neurocognitive Variability Is Associated with Poorer Prospective Memory in OEF/OIF/OND Veterans with Comorbid Mild Traumatic Brain Injury History and Current Posttraumatic Stress Disorder

Abstract Objective Mild Traumatic Brain Injury (mTBI) and Posttraumatic Stress Disorder (PTSD) frequently co-occur in service members, and each are associated with increased neurocognitive intraindividual variability (IIV), a proposed indicator of subtle disruptions in executive control, and prospective memory (PM), or “remembering to remember.” The current study sought to examine possible associations between IIV and PM performances among Veterans with comorbid mTBI and PTSD. Methods 46 OEF/OIF/OND Veterans with a history of mTBI and current PTSD enrolled in a VA research study of mTBI completed a standardized neurocognitive battery of 12 measures used to calculate the coefficient of variation (CoV) as an index of IIV, and the Memory for Intentions Screening Test (MIST) as a measure of PM. Veterans also completed clinical questionnaires (i.e., Patient Health Questionnaire-9, PTSD Checklist-Military), and a subset of the sample (n = 31) Veterans completed the Prospective and Retrospective Memory Questionnaire (PRMQ) as a measure of self-reported PM. Results Controlling for age and education, higher CoV was associated with time-based MIST scores (β = −0.02, p = 0.008, η2 = 0.16) and event-based MIST scores (β = −0.02, p = 0.031, η2 = 0.11). CoV was not associated with mood factors in the sample (ps &amp;gt;0.10). In a subset of the total sample, higher CoV was associated with elevated self-reported PM symptoms (r = −0.36, p = 0.046). Conclusions Among Veterans with a history of mTBI and current PTSD, elevated variability of performances across neurocognitive measures was associated with poorer performance-based PM and self-reported PM symptoms. Future studies are needed to examine IIV as a predictor of real-world PM performances (e.g., medication adherence).

The intersection of PTSD symptoms and firearm storage practices within a suicide prevention framework: Findings from a U.S. Army National Guard sample.

Soldiers in the U.S. Army National Guard are at elevated risk for suicide compared to soldiers in the other components. Most suicides by military service members, including members of the U.S. Army National Guard, are enacted with personal firearms. The unsafe storage of firearms is associated with increased risk for death by suicide. Therefore, efforts to elucidate modifiable factors associated with unsafe firearm storage have the potential to inform military suicide prevention efforts. PTSD hyperarousal symptoms are characterized in part by a heightened sense of being "on guard" for potential dangers and might contribute to an increased likelihood of storing firearms unsafely. This study sought to examine if more severe PTSD hyperarousal symptoms are associated with greater unsafe firearm storage practices. Participants were 327 U.S. Army National Guard personnel (M [SD]age = 26.90 [7.45] years; 93.3% male; 77.8% White/Caucasian). Firearm storage practices were assessed via a structured questionnaire. PTSD symptoms (reexperiencing, avoidance, numbing, hyperarousal) were assessed via the PTSD Checklist-Military Version (PCL-M). Logistic regression analyses were utilized. Elevated PTSD hyperarousal symptoms were significantly associated with storing firearms loaded and/or in nonsecure locations, even after controlling for the effects of the other PTSD symptom clusters. Sensitivity analyses revealed that the pattern of findings remained consistent among participants with a deployment history and when controlling for the effects of agitation symptoms. Findings of this study suggest that U.S. Army National Guard personnel who experience elevated PTSD hyperarousal symptoms are more likely to store their firearms unsafely. Implications for military suicide prevention are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Effectiveness of Dexmedetomidine as a Prophylactic Treatment for Emergence Delirium Among Combat Veterans With High Anxiety: A Randomized Placebo-Controlled Trial.

Emergence delirium (ED) is characterized by agitation, confusion, and violent physical and verbal behavior associated with awakening from general anesthesia. Combat exposure among U.S. military veterans has been identified as a risk factor for ED. Preoperative baseline anxiety was shown to be a predictor of ED, and combat veterans are known to be at high risk for anxiety as well as depression and PTSD. Dexmedetomidine is an alpha-2 receptor agonist proven to mitigate ED in several patient populations. Perioperative use of dexmedetomidine demonstrated promising benefits in pediatric ED but has not been evaluated in combat veterans. This study was a multi-site, prospective, randomized controlled investigation of 369 patients with a history of military combat exposure who were scheduled for elective surgery with a general anesthetic as the primary means of anesthesia. The trial was funded by the Tri-Service Nursing Research Program Grant HU0001-14-TS05 (N14-PO3) and approved by the Institutional Review Boards at the Naval Medical Center San Diego, Womack Army Medical Center, Walter Reed National Military Medical Center, and the Uniformed Services University of the Health Sciences, Bethesda, MD. All subjects were administered the State-Trait Anxiety Inventory (STAI) to evaluate baseline anxiety. Those enrolled subjects with a low anxiety level (STAI < 39) (n = 215) were placed in the observational arm of the study. Those with a high anxiety level (STAI ≥ 39) were placed in the experimental arm (n = 153) and were further randomized to treatment with intraoperative dexmedetomidine infusion (1 μg/kg bolus at induction, followed by a 0.6 μg/kg/h infusion continued until emergence) (n = 75) or a placebo intraoperative infusion (n = 75). Following the delivery of the prescribed anesthetic, all subjects were observed for signs of ED using the Pediatric Anesthesia Emergence Delirium (PAED) Scale. The patient and data recorder remained blinded to the randomization results. The central tendencies of demographics and clinical characteristics are reported. PAED among those randomized to dexmedetomidine (median 7, interquartile interval (IQI) 5.2-9.2) tended to be less (P < .0001) than that of those randomized to control (median 12, IQI 10-13). Dexmedetomidine was found to be the most important predictor of PAED (35% relative importance), followed by Patient Health Questionnaire (14%), STAI-Trait (9%), and PTSD Checklist-Military Version (8%); the overall rankings are featured. Randomization to receipt of dexmedetomidine was associated with a 3.7-unit reduction (95% CI 2.5-4.9) in PAED (P < .001) in a linear model controlling for several variables, and the directionality of the effect persisted upon regularization in a penalized linear model. Dexmedetomidine was effective at reducing PAED among combat veterans who were experiencing symptoms of pre-operative anxiety (i.e., STAI-State ≥39). Although psychological morbidity is not unique to the military population, combat veterans carry some of the highest rates of anxiety, PTSD and depression compared to the general population. Dexmedetomidine can be safety employed by anesthesia providers to reduce symptoms of ED in the perioperative period. The double-blind randomized, controlled study design strengthens our analyses; however, this study did not control for the type of surgical procedure or the duration of anesthetic. Furthermore, we only enrolled patients with combat exposure experiencing symptoms of anxiety and did not investigate the role of dexmedetomidine in combat veterans with less anxiety. Further study of the relationship between psychological comorbidities, ED, and dexmedetomidine is warranted.

Examining the Relationship Between Conventional Outcomes and Immersive Balance Task Performance in Service Members With Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) is associated with significant financial cost and reduced military readiness and impacts quality of life for active duty service members (SMs). Post-concussive symptoms can include vestibular impairments, such as chronic dizziness and postural instability, which can be compounded by psychological comorbidities like PTSD. Comprehensive vestibular evaluations are required to assess symptoms and guide clinical decision-making. At the National Intrepid Center of Excellence (NICoE), in addition to traditional vestibular assessments, clinicians can also leverage virtual environments (VEs) in the Computer-Assisted Rehabilitation Environment (CAREN) to further evaluate balance. The objective of this study was to examine the relationship between conventional outcomes and VE performance on immersive balance tasks in the CAREN, determine whether VE performance could predict conventional outcomes, and explore the impact of PTSD. This retrospective analysis included 112 SMs from the NICoE Intensive Outpatient Program who provided informed consent for their clinical data to be used for research purposes. All had a history of mTBI, underwent vestibular evaluations, and completed immersive balance tasks on the CAREN. Conventional outcomes included the Sensory Organization Test (SOT), Functional Gait Assessment (FGA), Activities Balance Confidence (ABC) Scale, and Dizziness Handicap Inventory (DHI). The PTSD Checklist-Military Version was added to account for behavioral symptoms. Computer-Assisted Rehabilitation Environment outcomes included total time to complete the Balance Cubes VE, with the platform static (BC-Static) and with random platform motion (BC-PM) as well as composite scores for the Shark Hunt VE, with (SH-Recall) and without a recall task (SH-Standard). Statistical analyses included independent t-tests to determine group differences, Pearson's correlations to examine relationships between conventional outcomes and VE performance, and binary logistic regressions to determine if VE performance predicted conventional outcomes based on clinically relevant cutoffs. SMs who took less time to complete BC-Static had better overall balance, indicated by higher ABC, SOT, and FGA scores (P <.001). Those with greater self-reported dizziness, higher DHI scores, took longer to complete BC-Static (P < .05). FGA and SOT, objective gait and balance, were similarly correlated to BC-PM performance (P <.001). SMs with higher SOT scores, better balance, also tended to have higher SH-Standard scores (P <.1). SMs, who were above normative SOT, FGA, and ABC cutoffs, completed BC-Static significantly faster than those below (P <.05). This remained true for BC-PM but was only significant for SOT (P = .004). Performance on BC-Static, BC-PM, and SH-Standard was significant predictors of SOT score. For SMs with comorbid mTBI and PTSD, increased functional disability was observed in conventional outcomes and diminished VE performance was noted. Objective balance and gait, SOT and FGA, demonstrated the strongest relationships to immersive VE performance in the CAREN. Our findings suggest that these immersive balance tasks may be effective as an adjunct assessment to examine balance. Future work will focus on moving these VEs from the CAREN to a portable system, which could be more readily utilized in a variety of clinical settings, increasing accessibility.

Path Analysis of the Mediating Roles of Personality, Distress, and Cognitive Flexibility in the Subjective Well-Being of Combat Veterans With Traumatic Brain Injury.

To determine the interrelationships among traumatic brain injury (TBI), maladaptive personality traits (MPT), psychological distress, and cognitive flexibility in the prediction of subjective well-being of post-9/11 veterans concurrently and over time. Five Veterans Affairs (VA) medical centers and 1 VA outpatient clinic in urban, suburban, and rural areas. Five hundred Operation Enduring Freedom/Operation Iraqi Freedom veterans at baseline (219 with TBI), 292 at 18-month follow-up (108 with TBI), drawn from a regional registry and clinic referrals. Path analysis of data from a prospective cohort study. Satisfaction with Life Scale, 36-ltem Short-Form Health Survey (SF-36) Health Scale, Personality Assessment Screener, Beck Depression Inventory-II, Beck Anxiety Inventory, Posttraumatic Stress Disorder Checklist-Military, Trail Making Test, Part B, Delis-Kaplan Executive Function System (D-KEFS) Category-Switching Verbal Fluency, and D-KEFS Color-Word Interference Test. There was no direct effect of TBI on well-being at baseline or 18 months later. Psychological distress, MPT, and cognitive flexibility had significant direct effects on well-being at baseline and 18 months. Baseline model accounted for 66% of the variance in well-being; follow-up model accounted for 43% of well-being variance. Negative influence of distress significantly decreased from baseline to follow-up. Direct negative effect of MPT diminished slightly over 18 months; effect of cognitive flexibility increased. Significant relationships were estimated in prediction of distress by MPT, cognitive flexibility, and TBI. TBI predicted MPT. MPT, cognitive flexibility, and TBI had indirect effects on well-being. TBI had a positive indirect influence on distress. Total effects included 4 significant predictors of well-being at baseline and 18 months: distress, MPT, cognitive flexibility, and TBI. Experience of TBI alone did not predict subjective well-being at baseline or 18 months later. Psychological distress, MPT, and cognitive flexibility had direct effects on well-being at both time points. Interventions aimed at reducing distress and bolstering resilience and cognitive flexibility are recommended to increase subjective well-being in this population.

Bright Light Treatment of Combat-related PTSD: A Randomized Controlled Trial.

Post-traumatic stress disorder (PTSD) is a prevalent consequence of combat with significant associated morbidity. Available treatments for PTSD have had limitations, suggesting a need to explore alternative or adjuvant treatments. Numerous rationales for bright light treatment of PTSD include its benefits for common PTSD comorbidities of depression, anxiety, and circadian misalignment and its relative ease of use with few side effects. The primary aims of this research were to examine the effects of bright light treatment for combat-related PTSD and associated morbidity. A randomized controlled trial was performed in N = 69 veterans with PTSD attributable to combat in Afghanistan and/or Iraq. Following a 1-week baseline, participants were randomized to 4 weeks of daily morning bright light treatment (10,000 lux for 30 min/day) or a control treatment (inactivated negative ion generator). At baseline and at the end of treatment, participants were rated blindly on the Clinician Assessed PTSD Scale (CAPS), the Clinical Global Impressions Scale (CGI), and the Hamilton Depression Scale and rated themselves on the PTSD Checklist-Military (PCL-M). Following baseline and each treatment week, participants completed self-reported scales of state anxiety, depression, and sleep, and sleep and the circadian rhythm of wrist activity were also assessed with wrist actigraphy. Compared with the control treatment, bright light elicited significantly greater improvements in the CAPS and CGI-Improvement. The bright light also elicited a significantly greater rate of treatment response (reduction ≥33%) for the CAPS (44.1% vs. 8.6%) and PCL-M (33% vs. 6%), but no participant had remission from PTSD. Changes in depression, anxiety, and sleep did not differ between treatments. Improvement in CAPS was significantly correlated with a phase advance of the circadian rhythm of wrist activity. The most comprehensive study on the topic to date indicated significant short-term efficacy of bright light treatment on the primary variables (CAPS and CGI) with clinical relevance (i.e., treatment response) in veterans with chronic PTSD who did not report extremely high habitual light exposure. No significant effects were found for anxiety, depression, or sleep disturbance. Further research is warranted, particularly exploration of circadian phase-shifting mechanisms of bright light for PTSD.

Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions.

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness.Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge.Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge.Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

Investigating the Efficacy of Equine Assisted Therapy for Military Veterans With Posttraumatic Stress Symptomology

A unique approach in trauma-focused psychotherapy is the evolving field of Equine Assisted Therapy (EAT), a nontraditional, experiential methodology centered on the therapeutic benefits intrinsic in equines. While there is a plethora of anecdotal and qualitative studies showing effectiveness, evidence-based studies are limited, and those that exist have design and implementation flaws such as small sample size, no control group, lack of counselor-administered curriculum and/or assessments, leaving large empirical gaps. To address these gaps, a quasi-experimental nonrandomized control group design was implemented for this study. Fifty veterans participated with 25 assigned to each, intervention and control groups. Veterans in the intervention group completed 3-hour weekly EAT sessions for 10 weeks and those in the control group continued with treatment as usual. Standardized psychometric assessments were PTSD Checklist—Military Version (PCL-M) and Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale (FACIT-Sp). The ANCOVA revealed no significant difference in mean changes for PCL-M, F(1, 43) = 3.255, p = .078, partial η² = .070, which suggests a medium-small effect size, as well as for the FACIT-Sp, F(1, 43) = .368, p = .547, partial η² = .008, which suggests a small effect size. However, paired samples <em>t</em>-test showed significant reduction in PTSD symptom scores for intervention group when compared to control group. While no conclusion regarding efficacy can be made, the results may be a useful lens to further examine the potential benefits of incorporating a multidimensional, biopsychosocial-spiritual model which could leverage significant outcomes of holistic health for veterans with PTSD symptomology.

Autonomic Reactivity to Acute Mental Stress Differs Between Women and Men with Post Traumatic Stress Disorder (PTSD)

Over 7 million Americans are affected by post‐traumatic stress disorder (PTSD), a debilitating mental illness that is associated with significant cardiovascular disease risk. Women are twice as likely as men to develop PTSD after a traumatic event. A prior study from our laboratory showed that sympathetic nervous system reactivity during combat related and non‐combat related stress is heightened in PTSD; however, this study was conducted in a predominantly male cohort and did not consider the potential influence of sex on neural cardiovascular function in PTSD. The aim of the current study was to determine if women with PTSD have heightened blood pressure (BP), heart rate (HR), and sympathetic reactivity to acute mental stress than men with PTSD. We recruited 15 women and 18 men clinically diagnosed with PTSD and confirmed using the Clinician Administered PTSD Scale (CAPS) and PTSD Checklist‐Military (PCL‐M) surveys. We measured muscle sympathetic nerve activity (MSNA), continuous BP, HR and heart rate variability (HRV) at baseline and during 3 minutes of mental arithmetic. Women and men were matched for race, age (41±2 vs 38±2 years, p=0.191), body mass index (31±2 vs 29±2 kg/m2, p=0.368), CAPS (71 ±9 vs 74 ±4, p=0.732) and PCLM (57 ±5 vs 68 ±4, p=0.129) scores. Likewise, baseline systolic BP (131±5 vs 128±4 mmHg), diastolic BP (76±4 vs 74±2 mmHg) and HR (70±3 vs 64±2 beats/min) were comparable (P&gt;0.05) between women and men. Although resting HRV measures were not different between groups (p&gt;0.05), resting MSNA was higher (p=0.008) in women compared to men (27±3 vs 16±3 bursts/min). In response to mental arithmetic, systolic BP reactivity was higher in women compared to men (Δ+5.1±1 versus Δ+2.2±1 mm Hg, p&lt;0.001). Diastolic BP (p=0.366) and HR (p=0.170) responses were not different. However, MSNA reactivity was higher (p=0.04) in women compared to men (Δ15.2±5 versus Δ6.4±3 bursts/min), suggesting an exaggerated sympathetic response to acute stress. Although RMSSD reactivity was similar between both groups (p=0.347), HF response to mental stress was blunted (p=0.05) in women compared to men, suggesting a greater withdrawal of parasympathetic control of the heart during acute stress. In summary, women with PTSD show an exaggerated blood pressure and sympathetic response to acute mental stress coupled with a blunted parasympathetic control of the heart. These results provide important insight into the physiological mechanisms linking the high risk of PTSD in women and the associated cardiovascular disease and hypertension risk.Support or Funding InformationThis work was supported by National Institutes of Health (NIH) Grant R01 HL135183; NIH R61 AT010457, VA Merit I01CX001065, the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Decatur, Georgia, and the APS STRIDE Undergraduate Summer Research Fellowship, grant program number NHLBI; 1 R25 HL115473‐01.

Collaborative Songwriting Intervention for Veterans with Post-Traumatic Stress Disorder.

Objectives: Given that veterans are significantly more likely to suffer from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, and anxiety than civilians, yet current gold-standard treatments for PTSD are not effective for all patients, the present study sought to examine the feasibility and acceptability of a collaborative songwriting intervention (CSI) while exploring its potential effectiveness in improving physical and mental health outcomes for veterans with PTSD. Design: Ten veterans took part in the CSI. A variety of pre- and postintervention measures were administered, including the Measurement of Current Status (MOCS), the Coping Expectancies Scale (CES), the Post-traumatic Stress Disorder Checklist-Military (PCL-M), and the Patient Health Questionnaire-9 (PHQ-9). Participants also wore a Fitbit to track average heart rate, sleep, and step count. Intervention: The CSI consisted of each veteran meeting with a professional songwriter, trained specifically for co-writing original material with the veteran population. There were three phases of songwriting that took about an hour and 15 min total. Veterans were instructed to listen to their song daily for 5 weeks. Results: Participants reported that the intervention was helpful and relevant to them, and most participants (95%) would refer others to this treatment. We found that the CSI reduced participant's PTSD symptoms (d = 0.869), specifically the Numbing (d = 0.853) and Hyperarousal (d = 1.077) subscales. Depressive symptoms (d = 0.72) and stress reactivity (d = 0.785) also marginally decreased. There was no significant change in physiological data (i.e., sleep, no. of steps) from pre- to postintervention. Conclusion: These data suggest that a CSI is an acceptable intervention for veterans with PTSD that may also improve their PTSD symptoms.

A Nonrandomized Trial of Prolonged Exposure and Cognitive Processing Therapy for Combat-Related Posttraumatic Stress Disorder in a Deployed Setting

For many decades, the U.S. military’s general operational guideline has been to limit the use of trauma-focused treatments for combat and operational stress reactions in military service members until they have returned from deployment. Recently, published clinical trials have documented that active-duty military personnel with combat-related posttraumatic stress disorder (PTSD) can be treated effectively in garrison. However, there are limited data on the treatment of combat and operational stress reactions or combat-related PTSD during military deployments. This prospective, nonrandomized trial evaluated the treatment of active-duty service members (N = 12) with combat and operational stress reactions or combat-related PTSD while deployed to Afghanistan or Iraq. Service members were treated by deployed military behavioral health providers using modified Prolonged Exposure (PE; n = 6) or modified Cognitive Processing Therapy (CPT; n = 6), with protocol modifications tailored to individual mission requirements. The PTSD Checklist–Military Version (PCL-M) total score was the primary outcome measure. Results indicated that both groups demonstrated clinically significant change in PTSD symptoms as indicated by a reduction of 10 points or greater on the PCL-M. Participants treated with modified PE had significant reductions in PTSD symptoms, t = -3.83, p = .01; g = -1.32, with a mean reduction of 18.17 points on the PCL-M. Participants treated with modified CPT had a mean PCL-M reduction of 10.00 points, but these reductions were not statistically significant, t = -1.49, p = .12; g = -0.51. These findings provide preliminary evidence that modified forms of PE and CPT can be implemented in deployed settings for the treatment of combat and operational stress reactions and combat-related PTSD.