Posttraumatic Stress Disorder Checklist-Military Version Research Articles

Combat readiness, alcohol abuse, and posttraumatic stress disorder among Uganda peoples’ defence forces soldiers

BackgroundThis cross-sectional study assessed combat readiness, alcohol abuse and post-traumatic stress disorder (PTSD) among Uganda Peoples’ Defense Forces (UPDF) soldiers returning from Operation Lightning Thunder (OLT) in South Sudan and Central African Republic.MethodsOne hundred fifty participants recruited from UPDF soldiers who had recently withdrawn from OLT, and were based in Singo Peace Support Operation School were screened for combat readiness, alcohol abuse and PTSD. The Perceived Combat Readiness Questionnaire, Alcohol Use Disorder Identification Test, and PTSD checklist military version were used to measure the variables. Inferential analyses were performed to determine the association between combat readiness, alcohol abuse, and PTSD, while controlling for sociodemographic factors.ResultsWe found that 16% of UPDF soldiers met positive screening results for PTSD, and 21% met the positive screening results for moderate substance use disorder. UPDF soldiers who benefited from combat readiness were less likely to develop PTSD or alcohol abuse. Our results showed a mediating effect of alcohol abuse on combat readiness and PTSD among soldiers with UPDF.ConclusionOur results highlight the high rates of PTSD and alcohol abuse among UPDF soldiers returning from military deployment. These findings provide insight into the role of combat readiness in reducing the risk of alcohol abuse and vulnerability to PTSD in the aftermath of military deployment.

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.

Identifying Predictors of Positive and Negative Affect at Mid-Deployment Among Military Medical Personnel.

Positive and negative affect influence an individual's ability to utilize available physical, psychological, and social resources to maximize responses to life events. Little research has examined the factors that influence the development of positive affect or reduction of negative affective responses among deployed military personnel. The present study aimed to investigate the relationship between deployment-related stressors and symptoms of behavioral health concerns with affectivity among deployed U.S. service members. Participants were 1148 U.S. Air Force medical personnel deployed to Balad, Iraq, between 2004 and 2011. All participants completed self-report measures of PTSD symptoms, general military and combat exposure, stress, and affectivity. The Institutional Review Board at Wilford Hall Medical Center, the Air Force Personnel Survey Program, and the U.S. Army's Joint Combat Casualty Research Team reviewed and approved the study. Most respondents (89%, 1,018/1,139) reported a positive military experience, but many respondents reported exposure to a potentially traumatic event during deployment. For example, seeing dead or seriously injured Americans (47%, 523/1,123) was the most common exposure reported by participants. A large portion of personnel (21%, 232/1,089) reported clinical levels of PTSD symptoms (score of 33 or higher on the Posttraumatic Stress Disorder Checklist-Military version). Risk factors, including PTSD symptoms, combat exposure, and stress, explained 39% of the variance in negative affect, R2 = 0.39, F(1046) = 224.96, P < .001. Conversely, these risk and resilience factors, including PTSD symptoms, combat exposure, stress, and general military experiences, explained 28% of the variance in positive affect, R2 = 0.28, F(1050) = 103.79, P < .001. No significant gender differences were found between models predicting positive and negative affect. Negative mood states may be partly an epiphenomenon of PTSD, which has been shown to be safely and effectively treated in the deployed environment. Social support during deployments is uniquely associated with a positive mood. These findings extend beyond the military and into any high-stress occupation wherein leaders could interpret these findings as a need to build or reinforce efforts to provide opportunities to sustain healthy relationships in personnel. These critical indigenous resources support mission readiness and enable the maintenance of positive psychological health.

A Baseline Model of PTSD From the ACES Cohort.

Post-traumatic stress disorder (PTSD) is a primary military psychiatric condition with complex etiology including strong genetic and/or environmental influences. Environmental influences and demographics can play a role in supporting underlying genetic traits for clinical utility evaluation as risk modifying factors. We are undertaking an IRB approved study to evaluate polygenic scores of PTSD risk in the adverse childhood experience and serotonin (ACES) transporter cohort. Baseline demographic characteristics and statistical modeling of 291 active duty service members from ACES cohort were used and excluded individuals with traumatic brain injury-induced loss of consciousness, pre-deployment PTSD or anxiety disorder, and pre-deployment prescription of antidepressants or psychoactive medications. Summary of categorical and numerical variables were evaluated using chi-square and t-test, respectively. We model PTSD risk and associated scores using linear and logistic regressions. The ACES subset was 79.1% males, multi-ancestry, and mean age of 38.3 years. Most PTSD individuals received behavioral therapy (89.6%) and/or prescribed antidepressants (67%) had higher scores in ACES, combat exposure scales, PTSD checklist military version, neurobehavioral symptom inventory, Pittsburg sleep quality index, insomnia severity index, and composite autonomic symptom score surveys and were less likely to expect future deployment. A positive correlation between age, total months deployed, ACES, CES, PCL-M, and positive-PTSD diagnosis were consistent but not in older individuals, who were more likely and frequently deployed although increasing risk for combat exposure. Demographic characteristics of the ACES cohort fit a coherent model of risk for PTSD to evaluate polygenic scores. Additional research is merited to understand PTSD effects on these confounding factors.

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).

Disentangling effects of remote mild traumatic brain injury characteristics and posttraumatic stress on processing speed and executive function in veterans.

Mild traumatic brain injury (mTBI) and posttraumatic stress are prevalent in military service members and share objective and subjective cognitive symptoms, complicating recovery. We investigated the effects of remote mTBI characteristics and current posttraumatic stress symptoms on neuropsychological performance in 152 veterans with a history of remote mTBI and current cognitive concerns. Participants completed clinical neuropsychological evaluations within a Veterans Affairs Level-II TBI/Polytrauma outpatient clinic (i.e. tertiary trauma care center for US military veterans outside of a research or teaching hospital setting). Archival data analysis of mTBI injury characteristics, clinical diagnoses, scores on the Posttraumatic Stress Disorder Checklist-Military Version (PCL-M) and performance on tests of processing speed, attention and executive function was conducted. Hierarchical linear regression demonstrated that elevated PCL-M scores were associated with slower performance on trail making test (TMT) Parts A and B (p < .016). PCL-M symptoms moderated the effect of alteration of consciousness (AOC) on TMT performance, with endorsement of AOC associated with better performance, but only when PCL-M scores were high (p < .005). Follow-up mediation analyses demonstrated that PCL-M score fully mediated the relationship between AOC and TMT-A performance and partially mediated the relationship between AOC and TMT-B performance. Post-hoc analyses meant to separate the impact of processing speed on TMT-B were all non-significant. Remote mTBI characteristics, specifically AOC, were not associated with decrements in cognitive performance. Posttraumatic symptoms were associated with worse processing speed, suggesting that psychological distress and psychopathology are contributing factors in understanding and treating persistent cognitive distress following remote mTBI.

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.

Lipids from ocular meibum and tears may serve as biomarkers for depression and post-traumatic stress disorder.

There is a need to develop biomarkers for diagnosis and prediction of treatment responses in depression and post-traumatic stress disorder (PTSD). Cross-sectional study examining correlations between tear inflammatory proteins, meibum and tear sphingolipids, and symptoms of depression and PTSD-associated anxiety. Ninety individuals filled depression (Patient Health Questionnaire 9, PHQ-9) and PTSD-associated anxiety (PTSD Checklist-Military Version, PCL-M) questionnaires. In 40 patients, a multiplex assay system was used to quantify 23 inflammatory proteins in tears. In a separate group of 50 individuals, liquid chromatography-mass spectrometry was performed on meibum and tears to quantify 34 species of sphingolipids, encompassing ceramides, monohexosyl ceramides and sphingomyelins. The mean age of the population was 59.4 ± 11.0 years; 89.0% self-identified as male, 34.4% as White, 64.4% as Black, and 16.7% as Hispanic. The mean PHQ-9 score was 11.1 ± 7.6, and the mean PCL-M score was 44.3 ± 19.1. Symptoms of depression and PTSD-associated anxiety were highly correlated (ρ =0.75, p < 0.001). Both PHQ9 and PCL-M scores negatively correlated with multiple sphingolipid species in meibum and tears. In multivariable models, meibum Monohexosyl Ceramide 26:0 (pmol), tear Ceramide 16:0 (mol%), meibum Monohexosyl Ceramide 16:0 (mol%), and tear Ceramide 26:1 (mol%) remained associated with depression and meibum Monohexosyl Ceramide 16:0 (mol%), meibum Monohexosyl Ceramide 26:0 (pmol), tear Sphingomyelin 20:0 (mol%), and tear Sphingosine-1-Phosphate (mol%) remained associated with PTSD-associated anxiety. Certain meibum and tear sphingolipid species were related to mental health indices. These interactions present opportunities for innovative diagnostic and therapeutic approaches for mental health disorders.

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.

Higher self-reported posttraumatic stress symptoms are associated with poorer working memory in active-duty service members.

Posttraumatic stress is a significant issue facing military service members and can negatively impact working memory (WM), which is critical for performance success. Yet, few studies have examined the link between self-reported posttraumatic stress symptoms (PTSS) and WM performance in active-duty military cohorts. The present study utilized hierarchical linear modeling to examine this relationship by considering PTSS and underlying symptom clusters as well as WM demands related to load and affective interference in an active-duty military cohort (N = 515). PTSS severity was assessed via the posttraumatic stress disorder checklist-military version (PCL-M), and behavioral performance was measured on a delayed-recognition WM task that manipulated mnemonic load (low vs. high load) and affective interference (negative combat-related vs. neutral civilian images presented during the delay interval). Examination of the relationship between PCL-M and WM performance demonstrated that higher total PCL-M scores (especially higher numbing and hyperarousal symptoms) were associated with poorer WM task performance, b = -0.083, p = .003, 95% CI [-0.137, -0.029], even after controlling for combat experiences and previous deployment status. This relationship was stronger on trials with negative, b = -0.114, p < .001, 95% CI [-0.175, -0.054], compared to neutral distracters, b = -0.052, p = .093, 95% CI [-0.112, 0.009]. These results suggest that PTSS are associated with performance costs on a WM task with combat-related negative distracters. Broadly, these findings highlight the need to address PTSS in active-duty cohorts and further investigate vulnerabilities related to cognitive demands and psychological health. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychological Adaptive Mechanism Maturity Predicts Good Outcomes in Treatment for Refractory PTSD.

Background: Post-traumatic Stress Disorder (PTSD) severity follows a bell-shaped curve ranging from mild to severe. Those in the severe range often receive the most intensive treatments, including targeted residential rehabilitation stays. These are expensive and welcome ways to improve their effectiveness. We hypothesized that positive change among subjects treated in a 45-day residential rehabilitation format would be associated with the maturity levels of measurable Psychological Adaptive Mechanisms (PAMs), alternately ego defense mechanisms.Methods: In this association study, adult male patients (N = 115) with a history of combat related PTSD treated in a residential rehabilitation setting completed the Defense Style Questionnaire (DSQ) on admission, as well as the Post-Traumatic Stress Disorder Checklist-Military Version (PCL-M) and the Mississippi Scale for Combat-Related Post-traumatic Stress Disorder (M-PTSD) on admission and again at discharge. This allowed prospectively calculated change scores on each of the PTSD measures for each patient. The change scores allowed association testing with averaged admission DSQ scores using Pearson's correlation probability with significance held at p < 0.05.Results: As hypothesized, averaged individual Mature scores on the DSQ were associated with improved change scores on both the PCL-M (p = 0.03) and the M-PTSD (p = 0.04). By contrast neither averaged DSQ Neurotic or Immature scores associated significantly with either PTSD scale change scores.Conclusion: These results, the first of their kind to our knowledge, suggest that patients presenting with predominantly Mature level PAMs are likely to benefit from residential rehabilitation treatment of PTSD. By contrast, those presenting with Neurotic or Immature PAMs predominantly are less likely to encounter positive change in this type of treatment. Although residential treatment is often reserved for the most refractory PTSD cases, it appears that those endorsing Mature level PAMs will make use of residential treatment whereas other forms of treatment may be better suited to those with Neurotic and Immature adjustment mechanisms.

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.

An interdisciplinary approach to the screening, diagnosis, and treatment of OEF/OIF Veterans with mild traumatic brain injury

Objective To implement an Integrated TBI Screening Clinic (ITSC) during the mandatory TBI evaluation process at the Department of Veterans Affairs. Referral outcomes were examined regarding Veterans who were determined to need a full neuropsychological evaluation versus those for whom mental health treatment was clinically indicated. Correlations among cognitive measures, posttraumatic stress disorder (PTSD), anxiety, depression, and insomnia symptoms were also examined. Method This study was a retrospective chart review study that included 138 Veterans seen between 2011 and 2014 in a post-deployment primary care clinic. Descriptive statistics and correlations were completed using the: screening Module of the Neuropsychological Assessment Battery (S-NAB), PTSD Checklist-Military version (PCL-M), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Insomnia Severity Index (ISI). Results 19.8% of Veterans required a referral for a full neuropsychological exam and 72.7% were referred for additional mental health services (with some Veterans being referred to both). Significant correlations were found among higher PTSD, depression, anxiety symptoms, with poorer attention and memory (all p < .05). Only PTSD was significantly correlated with poorer executive functioning (r = 0.19, p < .05). Conclusion Integration of a multidisciplinary neuropsychological screening exam during a primary care visit with OEF/OIF Veterans may assist in better delineating symptoms.

Changes in Physical Activity and Sleep Among Veterans Using a Service Dog as a Rehabilitation Modality for Post-traumatic Stress Disorder: An Open-Label Single-Arm Exploratory Trial Using Actigraphy-Based Measures

Little is known about the changes occurring after acquiring a service dog (SDPTSD) trained for the management of post-traumatic stress disorder (PTSD) symptoms on physical activity and sleep among veterans. To quantify, using actigraphy measures, changes in physical activity and sleep before and after acquiring a SDPTSD. A total of 18 veterans with chronic PTSD wore an actigraph wGT3X-BT during 7 days, 3 months before (T−3) and 9 months after (T+9) acquiring their SDPTSD. They also completed online questionnaires at both measuring times: Life Space Assessment, Pittsburgh Sleep Quality Index, Post-traumatic Stress Disorder Checklist-Military version and Beck Depression Inventory II. Non-parametric statistics compared results between T−3 and T+9 and Cohen’s d effect sizes (E.S.) determined the magnitude of changes. Veterans remained sedentary during most of their awake time at T+9 (p = 0.173; E.S. = 0.249), whereas the percentage of time dedicated to moderate physical activity (p = 0.038, E.S. = 0.38) and the number of steps/day (p = 0.008; E.S. = 0.49) increased. These changes were accompanied by expanded mobility patterns into their neighborhood (p = 0.002; E.S. = 0.52) and outside of town (p = 0.03, E.S. = 0.36). Actigraphy measures showed no change in sleep parameters despite reported improvements in sleep efficiency (p = 0.006; E.S. = 0.45), quality (p = 0.04, E.S. = 0.35), and disturbances (p = 0.001; E.S. = 0.55). Decreased PTSD (p ≤ 0.001; E.S. = 0.60) and depressive (p ≤ 0.001; E.S. = 0.60) symptoms were reported. Acquiring a SDPTSD represents a promising rehabilitation intervention for veterans with PTSD that improves moderate physical activity and the number of steps/day while reportedly triggering positive changes on mobility patterns, sleep quality, and psychiatric symptoms. The present exploratory trial provides the rationale for studying larger groups of participants in controlled studies over longer periods of time.

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.

Adverse Childhood Experience, Genes, and PTSD Risk in Soldiers: A Methylation Study.

Epigenetics can serve as a marker of susceptibility to many known psychiatric diseases. DNA methylation patterns of multiple genes have been studied in both civilian populations and military personnel with post-traumatic stress disorder (PTSD). Many of these genes serve various functions that span the hypothalamic-pituitary-adrenal axis, immune system, and central nervous system (CNS) growth factors and neurotransmission. It is thought that the methylation levels of such genes may be able to identify individuals who are at higher risk of developing PTSD. Our study seeks to establish whether previously reported PTSD genes possess a particular methylation pattern that is predictive of PTSD in active duty military members with combat exposure. This is an institutional review board (IRB)-approved, cross-sectional, case control, gene-environment interaction study. About 170 active military members with and without PTSD were recruited. Patients with a history of structural brain damage, traumatic brain injury (TBI) resulting in loss of consciousness, predeployment diagnosis of PTSD or anxiety disorder, and predeployment prescription of an antidepressant or psychoactive medication were excluded. Validated measures of childhood trauma and adversity (adverse childhood experience [ACE] score), PTSD symptoms (PTSD check-list military version [PCL-M]), and combat exposure scales (CES) were measured via validated questionnaires for all subjects. After extracting DNA from peripheral blood provided by the 170 subjects, we determined methylation percentages, via pyrosequencing assays, for nine target areas within the following seven genes: BDNF, NR3C1, MAN2C1, TLR8, SLC6A4, IL-18, and SKA2. These genes are commonly reported in the literature as being highly correlated with PTSD and early-life traumatic experiences.Methylation levels were measured as a percentage at specific sites within the previously mentioned genes. Data were examined with SPSS v 22.0 Statistics and JMP v13.1 software using a general linear model for methylation × trauma (CES scores) split by diagnosis of PTSD or not, methylation versus childhood trauma (ACE scores), and methylation versus PTSD severity (PCL-M score). Two-way ANOVA was performed to control for antidepressant use. A two-tailed Student t-test was performed for PTSD analyses and was correlated with PTSD diagnosis, demographic information as well as ACE score, PCL-M score, and CES scores. Differentially methylated sites that were highly associated with PTSD diagnosis were found in three of seven candidate genes: BDNF, NR3C1, and MAN2C1. When compared to controls, patients with PTSD diagnosis had significantly lower levels of methylation, even after controlling for antidepressant use. PCL-M, ACE, and CES scores were significantly associated with PTSD diagnosis. Our study suggests that methylation of key genes involved in synaptic plasticity and the hypothalamic-pituitary-adrenal axis is associated with lower levels of methylation in military PTSD subjects exposed to combat when compared to their non-PTSD counterparts. Strengths of this study include controlling for antidepressant use and excluding TBI patients. Similar studies in an active duty population of this size are scarce. What is not clear is whether methylation changes are driving PTSD symptomology or whether they are merely a marker of disease. Future areas of research include prospective studies that measure methylation pre- and postcombat exposure in the same individual.

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.

Transcendental Meditation May Be as Effective as Exposure Therapy for PTSD

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessTranscendental Meditation May Be as Effective as Exposure Therapy for PTSDNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:3 Jan 2019https://doi.org/10.1176/appi.pn.2019.12b12AbstractVeterans with PTSD who participated in transcendental meditation sessions over a 12-week period showed symptom improvements similar to those who participated in prolonged exposure therapy sessions.Exposing people with posttraumatic stress disorder (PTSD) to their traumatic memories has been regarded as an important, if not essential, part of the therapeutic process. This is the basis of prolonged exposure therapy, in which people with PTSD relive their trauma in a safe environment, so that the memories are no longer associated with fear, distress, and other negative emotions.A study of veterans with PTSD now shows that transcendental meditation is comparable to prolonged exposure therapy—considered the gold standard psychotherapy for PTSD. Transcendental meditation involves the silent repetition of a personal mantra to achieve restful alertness and avoid distracting thoughts.The study findings were published November 15, 2018, in Lancet Psychiatry.“Our findings provide further evidence that PTSD treatments can be effective without an exposure component. Because trauma exposure can be difficult for patients, similarly effective treatments that do not require exposure could be appealing to veterans and other groups with PTSD,” wrote lead author Sanford Nidich, Ed.D., a professor of physiology and education at the Maharishi University of Management Research Institute in Iowa, and colleagues.Transcendental meditation might be an especially appealing alternative since it is a relatively effortless technique, Nidich said. “There is no intense concentration or contemplation needed; a person just learns to progressively experience a quieter and calmer state of mind.”Transcendental meditation is also consistent with military culture, noted Vernon Barnes, Ph.D., of Augusta University, in an editorial that accompanied the study: “Transcendental meditation is self-empowering, completely transportable, and inconspicuous. The technique can be practiced anywhere at any time, without specialized equipment or the need for personnel support.”The study by Nidich and colleagues included 203 veterans from the Veterans Administration San Diego Healthcare System who had a current diagnosis of PTSD resulting from an event during active military service. The participants were randomly assigned to receive 12 sessions of transcendental meditation, prolonged exposure therapy, or PTSD health education (which served as the control group) over 12 weeks. The meditation and health education sessions were provided in group settings, while the exposure therapy was given in one-on-one settings.The researchers used the clinician-administered PTSD scale (CAPS) and participant-administered PTSD Checklist–Military version (PCL-M) to assess PTSD symptoms at the start of the study and again after 12 weeks. The study participants were also asked about depressive symptoms using the nine-item Patient Health Questionnaire (PHQ-9).After 12 weeks, the veterans undergoing transcendental meditation and exposure therapy experienced comparable results in terms of reducing clinician- and patient-rated PTSD symptoms as well as depressive symptoms. Both treatments were superior to providing health education.Nidich noted that patients who received transcendental meditation had greater improvements on all three behavioral scales (CAPS, PCL-M, and PHQ-9) compared with those who received prolonged exposure, though these results were in the statistical margin of error. CAPS scores, for example, decreased by an average of 16 points in the meditation group, 11 points in the prolonged exposure group, and 2.5 points in the health education group. (A reduction of 10 points or more is considered clinically meaningful.)The goal of the study was not to prove one method is superior to the other, Nidich said. Rather, the goal was to examine whether these two treatments are on equal footing, so that veterans with PTSD would have another evidence-based option to choose from when considering treatment.It is also possible that transcendental meditation and exposure therapy can be used together for even greater PTSD improvements, he continued. “This approach hasn’t been tested yet, but I don’t see any reason why they can’t work together, even though one intervention is trauma focused and the other is not,” he said. Such an approach would just need to involve good communication between the psychotherapist and the certified meditation instructor to avoid any potential confusion on behalf of veterans as to when they should think about their trauma.This study was supported by grants from the U.S. Department of Defense. ■An abstract of “Non-Trauma-Focused Meditation Versus Exposure Therapy in Veterans With Posttraumatic Stress Disorder: A Randomised, Controlled Trial” can be accessed here. The accompanying commentary, “Transcendental Meditation and Treatment for Posttraumatic Stress Disorder,” is available here. ISSUES NewArchived

PTSD symptom clusters and suicide attempts among high-risk military service members: A three-month prospective investigation.

Suicide rates within the U.S. military are elevated, and the assessment and treatment of posttraumatic stress disorder (PTSD) has been identified as one potential conduit for suicide risk reduction. Despite increased interest in examining whether PTSD symptom clusters differentially predict suicide-related outcomes, to our knowledge no study has examined this question utilizing a prospective design for which suicide attempts is the outcome. Thus, the present study assessed whether PTSD symptom clusters differentially predict suicide attempts at 3-month follow-up and examined the moderating role of combat exposure. Participants were 758 military service members referred for psychiatric evaluation for suicide-related concerns and who provided both baseline and follow-up data (76.8% male, Mage = 25.20 y [SDage = 6.22 y], 61.6% White/Caucasian, 28.2% combat-exposed). Baseline PTSD symptom clusters scores were derived from an abbreviated version of the PTSD Checklist-Military Version (PCL-M). Suicide attempts occurring from baseline to follow-up were assessed with the Suicide Attempt Self-Injury Interview (SASII). Logistic regression models were utilized, controlling for baseline suicide risk severity (i.e., frequency of suicidal ideation, levels of suicidal intent, past suicide plans and attempts) and sociodemographic characteristics. The hyperarousal symptom cluster was the only significant predictor of subsequent suicide attempts and, moreover, this association was significant for combat-exposed service members but not for non-combat-exposed service members. PTSD hyperarousal symptoms, characterized in part by overarousal (e.g., agitation), should be considered in military suicide risk assessment and prevention efforts, particularly for combat-exposed service members. (PsycINFO Database Record (c) 2018 APA, all rights reserved).