Prediction of work functioning following accidental injury: The contribution of PTSD symptom severity and other established risk factors

Responses to a mail survey were used to investigate the contribution of PTSD symptom severity to work functioning in 69 previously employed adult survivors of accidental injury approximately 8 months post‐hospitalization. Associations of PTSD symptom severity with other established risk factors for poor work functioning were also examined. Participants were initially divided into three groups based on PTSD symptom severity and analysis of variance undertaken to determine the differences in work functioning between survivors with PTSD, subclinical PTSD, and no PTSD. As anticipated, survivors with PTSD reported significantly poorer work functioning than those with subclinical PTSD and no PTSD. Those with subclinical PTSD, however, reported significantly lower levels of work functioning than survivors with no PTSD, suggesting that this population may also be at risk of poor outcomes and in need of vocational interventions post‐accident. To determine the influence of PTSD symptom severity on work functioning over and above other established risk factors, a two‐model hierarchical regression that included the established risk factors in the first model and PTSD in the final model was undertaken. Results revealed that PTSD symptom severity uniquely predicted work functioning after controlling for the influence of other contributing risk factors. A composite of seven risk factors, including PTSD symptom severity, was shown to predict 62% (57% adjusted) of the variance in work functioning but only pre‐accident occupation, physical functioning, and PTSD severity significantly contributed to the prediction. Findings suggest that the rehabilitation management of people with PTSD or subclinical PTSD following accidental injury would benefit from early identification by the established predictors together with an integrated approach to physical, psychological, and vocational interventions.     

Post-Traumatic Stress Disorder as a Consequence of a Toxic Spill in Northern California

This study examined the development of post-traumatic stress disorder (PTSD) and associated features in residents of Dunsmuir, California, following a toxic spill. Classification of PTSD was based on a cutoff score from the Impact of Event Scale. It was predicted that greater exposure to the spill would increase the risk of PTSD and associated symptoms among spill residents; that those classified with PTSD would report more symptoms than would those without PTSD and controls; and that litigants would be classified with PTSD more than would nonlitigants. Results suggest that spill residents classified with PTSD had greater levels of tension, depression, anxiety, anger, fatigue, and confusion than did spill residents without PTSD and control residents with and without PTSD. Spill residents with PTSD reported more memory problems and sleep disorders than did those without PTSD and control residents with and without PTSD. Measures of physiological arousal showed that spill residents had higher systolic blood pressure several hours after a stressful interview than did control residents without PTSD. Pulse rates several hours after a stressful interview were higher for spill residents with and without PTSD than for control residents with PTSD. Results suggest that exposed residents are at risk for developing PTSD and associated symptoms.     

Linking attentional control and PTSD symptom severity: the role of rumination

Although deficits in attentional control have been linked to posttraumatic stress disorder (PTSD), the mechanism that may account for this association has not been fully elucidated. The present study examined rumination as a mediator of the relationship between attentional control and PTSD symptoms. Veterans with PTSD and trauma-exposed veterans without PTSD completed measures of attentional control, rumination, and PTSD symptom severity. As predicted, the findings showed that veterans with PTSD reported significantly lower levels of attentional control than veterans without PTSD. Veterans with PTSD also reported significantly higher levels of rumination than veterans without PTSD. Subsequent analysis of the total sample revealed that the relationship between attentional control and PTSD symptom severity was accounted for by excessive rumination. Attentional control may contribute to PTSD symptoms through excessive rumination. Attentional control and rumination may be important targets for PTSD interventions.     

Psychotic symptoms in posttraumatic stress disorder

Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.     

Trauma-Related Negative Cognitions Mediate the Relationship Between Avoidant Personality Beliefs and Impeded Response to Psychotherapy for PTSD

There is strong research evidence for the association of personality pathology and posttraumatic stress disorder (PTSD), as well as trauma-related negative cognitions (TRNC) and PTSD symptoms. However, the relationship between personality pathology and TRNC in the context of PTSD is mostly unknown. In the present study, we aimed to examine whether avoidant and borderline personality beliefs (PB, indicator of personality pathology) could predict therapy outcome in PTSD, and whether the relationship between PB and therapy outcome could be mediated by TRNC. Sixty patients with PTSD were assessed for PB, TRNC and PTSD symptoms at baseline, and for PTSD symptoms at the termination of Prolonged Exposure Therapy. Baseline avoidant PB predicted significant variance in PTSD symptoms at termination over and above baseline PTSD symptoms (16% reduction in treatment effect per SD on avoidant PB). Moreover, TRNC at baseline fully mediated the relationships between baseline avoidant PB and PTSD symptoms at termination. This is the first study to show that avoidant PB predicts treatment response in PTSD, and that patients with avoidant beliefs are more vulnerable to have TRNC, which are associated with impeded therapy response. Our results highlight the importance of targeting both dysfunctional PB and TRNC in PTSD interventions.     

A Pilot Study of the Effects of Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder on Parenting

Parental posttraumatic stress disorder (PTSD) is associated with parenting difficulties. Cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD) improves PTSD symptoms, relationship adjustment, and partners’ mental health functioning. However, the impact of CBCT for PTSD on parenting competency is unknown. In this pilot study, the effects of CBCT for PTSD on parenting competency were investigated in 14 individuals (6 patients with PTSD and 8 partners) who had children under age 18. Results suggested that most participants perceived themselves as competent in their parenting prior to treatment, and some enhancements in competency occurred following CBCT for PTSD. Moreover, changes in parenting competency were associated with improvements in patient-rated PTSD. Adjunctive interventions targeting parenting and goals for future research are discussed.     

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.     

Predictors of Partner Engagement in PTSD Treatment

A telephone survey was conducted to identify predictors of treatment engagement in 83 cohabitating female partners of 83 Vietnam theater veterans with combat-related post-traumatic stress disorder (PTSD). The survey assessed veterans for their trauma history and PTSD symptoms. Partners were assessed for caregiver burden, patient–partner involvement, PTSD treatment engagement, self-efficacy relating to PTSD, beliefs about benefits of PTSD treatment, and PTSD treatment barriers. Significant predictors of partner PTSD treatment engagement were the couple’s income, patient–partner involvement, and partner caregiver burden. These findings have implications for family interventions that may increase partner PTSD treatment engagement and improve PTSD treatment outcome.     

Dimensionality of posttraumatic stress disorder symptoms in children exposed to disaster: results from confirmatory factor analyses.

Factor analytic studies of trauma victims' posttraumatic stress disorder (PTSD) have offered conflicting hypotheses about how to conceptualize PTSD into symptom categories. The present study used confirmatory factor analyses of self-reported PTSD symptomatology from 5,664 child and adolescent victims of Hurricane Hugo to compare 10 models of PTSD dimensionality. PTSD was best represented by a 2nd-order PTSD factor that manifests in 3 symptom clusters (Intrusion/Active Avoidance, Numbing/Passive Avoidance, and Arousal). This model was cross-validated on 3 age groups (late childhood, early adolescence, and late adolescence), and results indicated factorial invariance across groups. PTSD symptoms varied in relative centrality to the underlying dimensions of PTSD, which differed in their relations with anxiety and degree of traumatic exposure. Implications for classification criteria and an empirically supported theory of PTSD are discussed.     

A longitudinal test of the bi-directional relations between avoidance coping and PTSD severity during and after PTSD treatment

Avoidance coping and symptoms of posttraumatic stress disorder (PTSD) covary. However, relatively little research has examined the bi-directional relation between these constructs among individuals in treatment for PTSD. The current longitudinal study examined the reciprocal associations between avoidance coping and PTSD symptom severity during and after residential PTSD treatment among a sample of 1073 military veterans (88.9% male; M_age = 52.39 years) with chronic, treatment-resistant PTSD. Greater avoidance coping at intake predicted more severe PTSD symptoms at discharge, and severity of PTSD symptoms at discharge predicted increased avoidance at follow-up. Conversely, PTSD symptom severity at intake was not related to avoidance coping at discharge, and in turn avoidance coping at discharge was not related to PTSD symptom severity at follow-up. These findings offer a number of important clinical implications including evidence suggesting avoidance may predict poorer treatment response among individuals seeking treatment for chronic PTSD, and that greater end-of-treatment PTSD symptom severity may predict increased avoidance following treatment.     

Trauma and posttraumatic stress disorder in people with schizophrenia

This study evaluated the hypothesis that trauma and posttraumatic stress disorder (PTSD) severity would be positively associated with schizophrenia symptoms. Forty-seven clients with schizophrenia were assessed for schizophrenia severity and for lifetime trauma history and PTSD symptoms in 2 independent symptom interviews; 35 (74%) participants reported at least 1 event in which there was threat of harm or life threat and subjective distress, and 6 (13%) had current PTSD. Trauma across the life span was associated with greater severity of PTSD. Within the total sample, PTSD symptoms were associated with greater emotional distress, but not with schizophrenia-specific symptoms. Distress among clients with schizophrenia and PTSD suggests the need for routine assessment of PTSD and development of PTSD interventions in this population.     

False memories in women with self-reported childhood sexual abuse: an empirical study

Although controversy exists about the validity of memories of childhood abuse, little is known about memory function in individuals reporting childhood abuse. This study assessed memories for previously presented words, including the capacity for false memory of critical lures not actually present in the word list, in 63 subjects, including abused women with posttraumatic stress disorder (PTSD), abused women without PTSD, and men and women without abuse or PTSD. Abused women with PTSD had a higher frequency of false recognition memory of critical lures (95%) than abused women without PTSD (78%), nonabused women without PTSD (79%), or nonabused men without PTSD (86%). PTSD women also showed poorer memory for studied words and increased insertions of non-studied words other than critical lures. These findings are consistent with a broad range of memory alterations in abused women with PTSD.     

Traumatic Experiences and PTSD Among Adolescent Congolese Refugees in Uganda: A Preliminary Study

The study examined experienced traumatic events and the related Post-Traumatic Stress Disorder (PTSD) amongst a sample of 89 adolescent Congolese refugees (56 females and 33 males) at a refugee camp in Uganda. Data was collected using a questionnaire, and analyzed for trauma moderation by demographics and mediation by PTSD symptom scores. Findings indicate a prevalence of PTSD of 49.4% overall, with 75% of the female refugees meeting the PTSD criteria. The refugees with PTSD had high intrusive, avoidance and arousal scores, in addition to moderate to severe PTSD symptom severity scores. Trauma load was a significant predictor of PTSD among adolescent refugees. Our findings point to the high prevalence of PTSD resulting from an increased trauma load and being a female.     

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up.Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.     

Social capital and PTSD among PLWHA in China: the mediating role of resilience and internalized stigma

Post-traumatic Stress Disorder (PTSD) is frequent among people living with HIV/AIDS (PLWHA). Few studies have investigated social-psychological predictors of PTSD in China. This study aimed to examine relationships between social capital, stigma, resilience and PTSD among PLWHA in China, and to provide effective suggestions for PTSD intervention. A cross-sectional study of 520 PLWHA was conducted from November 2015 to January 2016. Survey data were collected using anonymous self-reported questionnaire. Multivariable analyses were used to examine related factors of PTSD, and causal mediation analyses were conducted to assess whether stigma and resilience were mediators. Results indicated that higher risk of PTSD was independent associated with stronger stigma, decreasing social capital and lower resilience. There was an indirect relationship of social capital on PTSD mediated through resilience and HIV-related stigma. Therefore, PTSD intervention programs should not only pay attention to the role of social capital on PTSD, but also attach importance to stigma and resilience on PTSD symptoms.     

Parameters of Aggressive Behavior in a Treatment-Seeking Sample of Military Personnel: A Secondary Analysis of Three Randomized Controlled Trials of Evidence-Based PTSD Treatments

Aggressive behavior is prevalent among veterans of post-9/11 conflicts who have posttraumatic stress disorder (PTSD). However, little is known about whether PTSD treatments reduce aggression or the direction of the association between changes in PTSD symptoms and aggression in the context of PTSD treatment. We combined data from three clinical trials of evidence-based PTSD treatment in service members (N = 592) to: (1) examine whether PTSD treatment reduces psychological (e.g., verbal behavior) and physical aggression, and; (2) explore temporal associations between aggressive behavior and PTSD. Both psychological (Estimate = -2.20, SE = 0.07) and physical aggression (Estimate = -0.36, SE = 0.05) were significantly reduced from baseline to posttreatment follow-up. Lagged PTSD symptom reduction was not associated with reduced reports of aggression; however, higher baseline PTSD scores were significantly associated with greater reductions in psychological aggression (exclusively; ß = -0.67, 95% CI = -1.05, -0.30, SE = -3.49). Findings reveal that service members receiving PTSD treatment report substantial collateral changes in psychological aggression over time, particularly for participants with greater PTSD symptom severity. Clinicians should consider cotherapies or alternative ways of targeting physical aggression among service members with PTSD and alternative approaches to reduce psychological aggression among service members with relatively low PTSD symptom severity when considering evidence-based PTSD treatments.     

Assessing Family Coordination in Divorced Families

Posttraumatic stress disorder (PTSD) and partner relationship difficulties commonly co-occur among Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF). This study reports upon results for six male OEF-OIF Veterans with PTSD and their female relationship partners who completed cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD), which is a treatment that targets reductions in PTSD and couple distress. Case- and group-level data supported reductions in Veterans' PTSD symptoms and female partners' relationship distress. These findings suggest that CBCT for PTSD may be a promising intervention for OEF-OIF Veterans' PTSD and their partners.     

Examining the relation between PTSD and insomnia on aggression

Posttraumatic stress disorder (PTSD) symptoms and poor sleep have been identified as potential causals factor in aggression, violence, and impulsive behavior. Given the high cost of aggression to society and public health, identifying modifiable factors related to aggression, such as insomnia, may guide treatment strategies to help decrease aggression. Participants were 143 Veterans seeking treatment for PTSD at a VA outpatient PTSD clinic. Linear and logistic regression analyses were used to examine the relation between PTSD and insomnia on aggression. Results from bivariate analyses indicated that while both PTSD and insomnia severity were associated with higher aggression scores independently, when PTSD and insomnia were examined together, PTSD severity was the only significant predictor of aggression. Interaction effects yielded nonsignificant results suggesting that poor sleep did not moderate the PTSD and aggression relation. Results suggest that addressing PTSD symptoms as a first treatment target may be more important for decreasing risk for aggression than targeting insomnia. More research is needed to understand whether treating PTSD and insomnia reduces aggression in Veterans.     

Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma

Breslau, Peterson, and Shultz (2008) reported that prior trauma alone, in the absence of PTSD, did not predict an increased PTSD risk, relative to no prior trauma. Only prior trauma that resulted in PTSD predicted an increased PTSD risk following a subsequent trauma. Recently, Cougle, Resnick, and Kilpatrick (2009) proposed that the effect of prior trauma might vary by type of prior trauma, a possibility not considered in Breslau et al. They report that childhood sexual or physical assault, in the absence of PTSD, increased the PTSD risk following a subsequent trauma. This report examines the PTSD effects of prior assaultive violence, using data from Breslau et al. (1998). The study assessed PTSD in relation to up to three events. Analysis was performed on the subset with PTSD assessment for two distinct events, the earliest trauma and a subsequent trauma (n = 967), using as reference persons with no prior trauma (n = 972). Neither prior assaultive violence nor other prior traumas, in the absence of PTSD, influenced the subsequent risk of PTSD. In contrast, prior PTSD increased considerably the PTSD risk of a subsequent trauma. The limitations in Cougle et al. (2009) and in this study and future research directions are discussed.     

The role of attentional biases in PTSD: is it interference or facilitation?

Although attentional biases have been demonstrated in individuals with posttraumatic stress disorder (PTSD), the cognitive methodologies used have not allowed for disambiguation of two types of attentional biases. It remains unclear if PTSD involves difficulty disengaging attention from threatening stimuli (interference) or facilitated detection. To differentiate between attentional interference and facilitation, 57 male Vietnam-era veterans (30 High PTSD and 27 Low PTSD) completed a visual search task with a lexical decision component. High PTSD veterans who engaged in the interference task first showed increased interference to threat-relevant words relative to Low PTSD veterans. However, no evidence was found for facilitated detection of threatening stimuli in PTSD.