Psychosocial functioning in veterans with combat-related PTSD: An evolutionary concept analysis.

Objective: This study assessed the efficacy, acceptability, and safety of pharmaceutical management for combat-related post-traumatic stress disorder (PTSD) to provide a clinical decision-making basis for clinicians. Method: A comprehensive search was conducted using Ovid MEDLINE, Ovid EMBASE, Cochrane Library, Scopus, ScienceDirect, and Web of Science for randomized controlled trails (RCTs), which reported pharmaceutical management and placobo for adults with combat-related PTSD, that were published until April 21, 2021. The effectiveness, acceptability, and adverse events (AEs), were designed as interested outcomes. The change in total symptoms of combat-related PTSD according to the clinician rating scale was defined as primary outcome, and the others were defined as secondary outcomes. Results: Twenty-two RCTs with 1,221 patients were involved. Compared with placebo, overall active comparators had statistical differences for all outcomes, including the change in total symptoms of combat-related PTSD [SMD = −0.36, 95%CI (−0.62,−0.09)], depression [SMD = −0.28, 95%CI (−0.45,−0.10)], anxiety [SMD = −0.44, 95%CI (−0.64,−0.23)], re-experience [SMD = −0.33, 95%CI (−0.52,−0.13)], avoidance [SMD = −0.24, 95%CI (−0.43,−0.05)], and hyper-arousal [SMD = −0.26, 95%CI (−0.48,−0.03)]. Compared with the placebo, in terms of acceptability, overall active comparators did not significantly decrease all-cause discontinuance rates [RR = 0.97, 95%CI (0.78,1.20)], and the significance decreased due to AEs [RR = 2.42, 95%CI (1.41,4.13)]. Nevertheless, overall there was no statistically significant difference for overall AEs, including somnolence, sedation, dizziness, paresthesia, anxiety, blurred vision, generalized anxiety disorder, and sleep disturbance. All funnel plots were symmetrical and no publication bias was found. Conclusion: Active drugs, especially amitriptyline, imipramine, and quetiapine, had a positive effect on the improvement of combat-related PTSD symptoms. Despite there being no significant increase in the AEs of the active drugs, the fact that the discontinuation rates of these drugs, including risperidone, imipramine, and topiramate, were increased deserves attention. Furthermore, as active drugs were effective across ethnic groups and battlefields, active drug regimens were revealed to be more appropriate for treating people with symptoms of extreme severe PTSD (≥80) or PTSD that is at least 8 weeks old. In addition, current evidence was from adults under 60 years of age and male combat-related PTSD. Whether this evidence can be extended to other populations of combat-related PTSD needs to be confirmed by subsequent high-quality, large-sample studies.

Introduction Combat veterans are at high risk for the development of posttraumatic stress disorder (PTSD) and substance use disorders. Ketamine has been shown to be an effective treatment for numerous mental health disorders, although research on its efficacy in combat-related PTSD in veterans is very limited. Methods The study population consisted of 30 US military veterans with combat-related PTSD. Participants underwent a standard induction series of six 1-hour ketamine infusions with the goal of obtaining a transpersonal dissociative experience. Participants were given a series of self-report questionnaires to assess for changes in symptoms of depression, PTSD, and substance use prior to the first and sixth infusions. Results Symptoms of depression as measured by change in score on the Patient Health Questionnaire decreased significantly from an average of 18.9 to 9.5 ( P < .001). Similarly, symptoms of PTSD as measured by change in score on the PSTD Checklist for DSM-5 dropped significantly from an average of 56.2 to 31.3 ( P < .001). Self-reported levels of substance use did not significantly decrease during the study period, although the level of use trended down. Conclusions This observational study suggests that high-dose ketamine infusion therapy, which induced a transpersonal dissociative experience, could be a valuable tool in the treatment of combat-related PTSD. Further study is needed to better elucidate ketamine's mechanism of action with regards to the treatment of PTSD.

Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity. To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury. This was a single-site, 3-parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022. Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache. Co-primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment. A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported -3.4 (95% CI, -5.4 to -1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported -1.4 (95% CI, -3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported -6.5 (95% CI, -12.7 to -0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported -8.9 (95% CI, -15.9 to -1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups. This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability. ClinicalTrials.gov Identifier: NCT02419131.

GENERAL COMMENTARY article Front. Hum. Neurosci., 07 November 2013Sec. Brain Health and Clinical Neuroscience Volume 7 - 2013 | https://doi.org/10.3389/fnhum.2013.00747

Cognitive decrements in executive function and processing speed have been found in post-9/11 Veterans who have mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD). Decision making (DM) involves the coordination of cognitive sub-processes involving different brain regions known to be impacted by mTBI and/or PTSD, and so may be expected to be compromised. The ability to incorporate context is important because it plays a role in almost every cognitive and social process. However, DM abilities, including DM that requires taking context into account, are not typically assessed or investigated in Veterans. We prospectively recruited Veterans deployed to Iraq or Afghanistan who had the following characteristics: (1) no TBI before deployment, (2) mTBI because of blast only, (3) current PTSD (diagnosed within 6 months), and (4) ≤49 years of age. Deployed Veterans with no mTBI or PTSD served as the comparison group. Veterans with mTBI and comorbid PTSD (mTBI + PTSD; n = 9) and Veterans without mTBI or PTSD (n = 8) performed the Cognitive Bias Task, a DM task in which participants are asked to make a decision based on preference, and the extent to which choices are influenced by contextual information is measured. To further understand any association between DM and mTBI + PTSD, participants also filled out questionnaires to measure neurobehavioral and PTSD symptoms. Because normality was violated in both groups, Fisher's Exact and Mann-Whitney tests and Spearman's rank order correlations were used. Although Veterans without mTBI + PTSD made context-dependent choices, Veterans with mTBI + PTSD made context-independent choices (p = .034), similar to prior research examining individuals with severe TBI and left lateralized frontal lobe brain lesions. As expected, Veterans with mTBI + PTSD also demonstrated elevated scores on the symptom measures. Symptom measure scores were correlated with Cognitive Bias Task (CBT) scores and revealed a negative correlation between somatic, and marginally cognitive and arousal symptoms, and the extent to which context was incorporated into decisions. Veterans an average of 4.0 years after blast injury who had active PTSD (mTBI + PTSD) did not incorporate contextual information when making their decisions. Because understanding context is required in many everyday activities, if findings replicate in studies with larger samples, clinical testing for DM difficulties and training for context incorporation may improve everyday function in Veterans with mTBI + PTSD.

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

Introduction: Being bullied, also known as peer victimization, is a significant social stressor robustly associated with Post-Traumatic Stress Disorder (PTSD) symptoms, pain catastrophizing, and poor physical health. Although much of the research on this topic has been correlational, longitudinal studies have found that being bullied predicts the development of physical health and mental health symptoms in children and college students. However, the interrelationships (mediation) between PTSD, pain catastrophizing, and physical health as they relate to peer victimization is unclear. In the current study we sought to better establish a pathway among peer victimization, PTSD symptoms, pain catastrophizing, and physical health symptoms. Method: College students (N = 275) in an engineering and technology research university in upstate New York participated. Participants completed assessments of peer victimization, PTSD symptoms, pain catastrophizing, and physical health symptoms. Results: Consistent with previous research, peer victimization was significantly correlated with frequency and severity of physical health problems, PTSD symptoms (reexperiencing, avoidance, and arousal), and pain catastrophizing (rumination, magnification, and helplessness). Significant mediational models were also established, where both PTSD symptoms and pain magnification each mediated the association between peer victimization and severity of health problems. Conclusions: The current research further elucidates the interrelationship among PTSD symptoms, pain catastrophizing, and health problems resulting from peer victimization. The current study expands the current understanding of interrelationships of these variables and provides implications for interventions and treatment. Keywords: Peer victimization, bullying, PTSD symptoms, physical health

Low baseline and yohimbine-stimulated plasma neuropeptide Y (NPY) levels in combat-related PTSD

Prospective network of post-traumatic stress disorder (PTSD) symptoms across adolescent survivors with distinct trajectories of PTSD: A cohort study of the Wenchuan earthquake

A postmortem human brain collection to study posttraumatic stress disorder (PTSD) is critical for uncovering the molecular mechanisms that contribute to this psychiatric disorder. We describe here the PTSD brain collection at the Lieber Institute for Brain Development in Baltimore, Maryland, consisting of postmortem brain donations acquired between 2012 and 2017. Thus far, 87 brains from individuals meeting DSM-5 criteria for PTSD were collected after consent was obtained from legal next-of-kin, and subsequently clinically characterized for molecular studies. PTSD brain donors had high rates of comorbid diagnoses, including depression (62.1%), substance abuse (74.7%), drug-related death (69.0%), and suicide completion (17.2%). PTSD cases were subdivided into two categories: combat-related PTSD (n = 24) and noncombat/domestic PTSD (n = 63). The major differences between the combat-related and domestic PTSD cohorts were sex, drug-related death, and the prevalence of bipolar disorder (BPD) comorbidity. The combat-related group was entirely male, with only one BPD subject (4.2%), and had significantly fewer drug-related deaths (45.8%) in contrast to the domestic group (31.8% male, 36.5% bipolar, and 77.8% drug-related deaths). Medical examiners' offices, particularly in areas with higher military populations, are an excellent source for PTSD brain donations of both combat-related and domestic PTSD.

Background: Filipino migrant workers in Macao are vulnerable to posttraumatic stress disorder (PTSD) symptoms and addictive behaviours due to trauma histories, postmigration stressors, and access to alcohol and gambling venues. While PTSD addiction comorbidity is well-established in the existing literature, such research among migrant workers is lacking. Objective: The current study investigated differential relations between PTSD symptoms and addictive behaviours in a polytrauma exposed sample of Filipino domestic workers in Macao (SAR), China. Methods: Data were collected from 1375 Filipino migrant workers; data from a subsample of 1200 participants who reported an index traumatic event and PTSD symptoms were used in the analyses. Participants responded to the PTSD Checklist for DSM-5, gambling disorder symptoms checklist from DSM-5, and The Alcohol Use Disorders Identification Test. We estimated a regularized partial correlation network structure of PTSD symptoms and addictive behaviours employing graphical LASSO and extended Bayesian information criterion. Results: PTSD symptoms of arousal and negative emotions had bridge connections with gambling disorder symptoms; while PTSD symptoms of arousal, restricted affect, negative emotions, and emotional reactivity had bridge connections with alcohol misuse. Conclusions: PTSD's arousal and negative emotion symptoms were common in the networks of PTSD and addictive behaviours, while PTSD's restricted affect and emotional reactivity symptoms were unique to the network of PTSD and alcohol misuse. Treatment of the comorbidity of PTSD and addictive behaviours may yield optimal effects when tailored to these symptoms.

Individuals with post-traumatic stress disorder (PTSD) have an elevated risk of developing cardiovascular disease. Emerging research suggests that blood pressure variability (BPV) may serve as an early indicator for increased cardiovascular disease risk. However, the relationship between post-traumatic stress symptom severity and symptom clusters, and comorbid conditions such as depression, with BPV is unclear. Purpose: The primary objective of this study was to investigate the relationship between the severity of PTSD and depression symptoms, PTSD symptom clusters, and beat-to-beat blood pressure variability (BPV) in a sample of individuals diagnosed with PTSD. We hypothesized that participants with greater PTSD symptom severity would have increased BPV. Methods: Twenty participants (mean age = 46 ± 10 yr; 70% males; 75% African American) with diagnosed PTSD were enrolled. PTSD severity and symptom clusters were assessed via the PTSD Checklist (PCL-5) and depression symptoms were assessed via Beck's Depression Inventory (BDI). Beat-to-beat blood pressure was recorded via finger photoplethysmography for a five-minute duration. BPV indices were calculated as the coeffcient of variation (CV), standard deviation (SD), and average real variability (ARV) for systolic, diastolic, and mean blood pressure. Pearson correlations were conducted to evaluate the association between symptoms and BPV outcomes. Participants were also categorized into two groups based on symptom severity. Independent t-tests were used to compare those with mild to moderate symptoms (n = 7) relative to participants with severe and extreme PTSD symptoms (n = 13). Results: PTSD symptom severity was significantly correlated with depression symptoms (r = 0.83, p &lt; 0.001). However, there were no significant correlations between BPV measures and either PTSD or depression symptoms. We did observe moderate non-significant correlations between the PTSD intrusive symptom cluster and diastolic and mean blood pressure CV (r = 0.33 and r = 0.29, p &gt; 0.05). Similar moderate correlations were observed between depression symptoms and diastolic and mean blood pressure CV (r = 0.31 and r = 0.29, p &gt; 0.05). No significant differences were observed between the two symptom severity groups in terms of systolic, diastolic, and mean blood pressure for CV, SD, and ARV (systolic CV 0.61 ± 0.17 vs. 0.62 ± 0.17 %, p &gt; 0.05, diastolic CV, 0.70 ± 0.06 vs. 0.72 ± 0.16 %, p &gt; 0.05, and mean blood pressure CV 0.63 ± 0.09 vs. 0.65 ± 0.15 %, p &gt; 0.05 for mild to moderate and severe to extreme PTSD symptoms, respectively). Conclusions: Contrary to our hypothesis, those with greater PTSD symptom severity did not have significantly greater BPV. In summary, our data demonstrate that higher PTSD symptoms are not associated with beat-to-beat BPV; however, the moderate correlations suggest that larger studies are needed to determine if PTSD intrusive symptoms and depression symptoms, are related beat-to-beat BPV indices. VA Merit I01-CX001065, and DOD PR210574. M. McGranahan is supported by NIDDK training grant TL1DK129502 and U2CDK129501. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Moral injury describes the deleterious effects of acts of commission (e.g., killing noncombatants), omission (e.g., failing to prevent a massacre), or betrayal (i.e., by a trusted authority figure) during military service that transgress accepted behavioral boundaries and norms. Transgressive acts are proposed to lead to a guilt- and shame-based syndrome consisting of post-traumatic stress disorder (PTSD) symptoms, demoralization, self-handicapping, and self-injury. In this study, we tested a frequently cited model of moral injury and assessed the associations between potentially transgressive acts, moral injury outcomes, and guilt and fear. Additionally, we sought to clarify the relative contribution of transgressive and nontransgressive/general combat exposure to moral injury. On the basis of previous research and theory, we anticipated that the transgressive acts would be related to outcomes through guilt and that nontransgressive combat exposure would be related to outcomes through fear. Secondary analysis was conducted on data from a sample of combat-exposed male veterans at a Midwestern Veterans Affairs (VA) medical center (N = 190) who participated in a larger parent study on postdeployment readjustment. Structural equation modeling was used to test the pathways from transgressive and nontransgressive combat exposure to PTSD symptoms and suicidality through combat-related guilt and combat-related fear. The institutional review boards of the Midwestern VA medical center and the university of the affiliated researchers approved the study. In total, 38% (n = 72) of the sample reported a potentially transgressive act as one of their three worst traumatic events. The most common potentially transgressive act was killing an enemy combatant (17%; n = 32). In structural equation modeling analyses. potentially transgressive acts were indirectly related to both suicidality (β = 0.09, p < 0.01) and PTSD symptoms (β = 0.06, p < 0.05) through guilt. General combat exposure was indirectly related to PTSD through fear, β = 0.19, p < 0.01. Combat exposure was not directly or indirectly related to suicidality. Overall, these findings suggest that veterans with a history of potentially transgressive acts may present to the VA with a constellation of symptoms that are associated with combat-related guilt. Transgressive acts were identified using a qualitative approach, allowing a broader sampling of this domain. Results were limited by the use of self-report data and by gathering data from participants who were Veterans seeking compensation and pension evaluations for PTSD. The clinical implications suggest that focusing on fear-related outcomes and ignoring guilt- and shame-based reactions may lead to an incomplete case conceptualization. Clinicians working with veterans with moral injury are encouraged to prepare themselves for the discomfiting therapeutic experiences of bearing witness to and empathizing with clients' memories of their actions, which may include atrocities. Effective and empathic treatments that address the guilt and shame associated with transgressive acts are needed to adequately care for returning veterans.

Research is limited regarding the role of high-risk behaviors, trauma, and posttraumatic stress disorder (PTSD) symptoms in people with severe mental illnesses (SMI).The current survey of 276 community mental health clients diagnosed with either a schizophrenia spectrum disorder or a major mood disorder examined the mediating role of lifetime high-risk behaviors with regard to lifetime traumatic events and PTSD symptom severity measured by the PTSD Symptom Scale-Interview version. Structural equation modeling revealed that lifetime high-risk behaviors had significant direct effects on PTSD symptom severity, and high-risk behaviors partially mediated the relationship between lifetime trauma and PTSD symptom severity. Lifetime trauma had the greatest total effect on PTSD symptoms, followed by primary Axis I diagnosis and lifetime high-risk behaviors. Implications for practice with people with SMI include more thorough assessments of trauma, PTSD, and high-risk behaviors and use of coping skills approaches to reduce high-risk behaviors. Limitations of the study include the cross-sectional nature of the data. KEY WORDS: high-risk behaviors; major mood disorders; posttraumatic stress disorder; schizophrenia; severe mental illness ********** People with severe mental illnesses (SMIs), including schizophrenia spectrum disorders (SSDs) and major mood disorders (MMDs), experience higher rates of trauma, such as physical and sexual abuse and exposure to violence, than do people in the general public (Mueser et al., 1998; Resnick, Bond, & Mueser, 2003), and they show rates of posttraumatic stress disorder (PTSD) four to five times greater (between 33% and 43%) than do people in the general population (about 8%) (Mueser et al., 1998; O'Hare, Sherrer, & Shen, 2006). People with SMI are also more likely to engage in high-risk behaviors--such as suicide attempts, substance abuse, drug overdoses, unprotected sex, and self-mutilation--and to demonstrate behaviors associated with more severe psychiatric symptoms, have more frequent hospitalizations, be at increased risk of trauma, and have poorer treatment outcomes (Gearon, Kaltman, Brown, & Bellack, 2003; Mueser et al., 1998; O'Hare et al., 2006). Few research investigations have focused on the relationship of high-risk behaviors to trauma and PTSD. Given that the consequences of high-risk behaviors can be retraumatizing, the current study tests whether high-risk behaviors mediate the relationship between lifetime trauma and PTSD symptom severity. AIMS OF THE CURRENT STUDY The relationships among traumatic events, high-risk behaviors, and PTSD remain poorly understood in the SMI population (Butler, Mueser, Sprock, & Braff, 1996; Mueser, Rosenberg, Goodman, & Trumbetta, 2002; O'Hare et al., 2006). Although PTSD symptoms in this population have been shown to be positively related to other measures of emotional distress (O'Hare et al. 2006; Resnick et al., 2003), there is only limited research on the linkages between the frequency of lifetime trauma and PTSD. In addition, the relationship between lifetime trauma and high-risk behaviors is even less understood. Although a recent study of clients, most of whom participated in the current investigation, showed that subjective distress from highrisk behaviors--that is, overdosing on medication, self-mutilation, and suicide attempts--mediated the connection between trauma-related subjective distress and PTSD symptoms (O'Hare et al., 2006), it is not known if high-risk events mediate the relationship between lifetime traumatic events and PTSD symptoms. Discovery of such a link could help improve our understanding of the mediating role of high-risk behaviors with regard to traumatic events and PTSD symptom severity. Gender is a key factor to consider when examining trauma, high-risk events, and PTSD. Women with serious psychiatric disorders appear to be at greater risk for certain stressors, including sexual abuse and interpersonal violence as adults, and men are more likely to witness serious acts of violence (Goodman et al. …

Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF–OIF Veterans