Posttraumatic Stress Disorder Severity and Insomnia-Related Sleep Disturbances: Longitudinal Associations in a Large, Gender-Balanced Cohort of Combat-Exposed Veterans.

Few studies have investigated the range and severity of insomnia-related sleep complaints among veterans with posttraumatic stress disorder (PTSD), and the temporal association between insomnia and PTSD severity has yet to be examined. To examine these associations, a large, gender-balanced cohort of veterans (N = 1,649) of the Iraq and Afghanistan conflicts participated in longitudinal assessments of PTSD and insomnia-related symptoms over a period of 2.5 years following enrollment (range: 2-4 years). Data were obtained from multiple sources, including interviews, self-report assessments, and electronic medical record data. Three-fourths (74.0%) of veterans with PTSD diagnoses at Time 1 (T1) reported insomnia-related sleep difficulties on at least half the nights during the past 30 days, and one-third of participants had received a prescription for a sedative-hypnotic drug in the past year. Veterans without PTSD had fewer sleep problems overall, although the prevalence of sleep problems was high among all study participants. In longitudinal, cross-lagged panel models, the frequency of sleep problems at T1 independently predicted increases in PTSD severity at Time 2 (T2), B = 0.27, p < .001, after controlling for gender and relevant comorbidities. Conversely, T1 PTSD severity was associated with increasing sleep complaints at T2 but to a lesser degree, B = 0.04, p < .001. Moderately high rates of sedative-hypnotic use were seen in veterans with PTSD, with more frequent use in women compared to men (40.4% vs. 35.0%). Sleep complaints were highly prevalent overall and highlight the need for increased clinical focus on this area.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Gravedad del TEPT y Trastornos del Sueño Relacionados con el Insomnio: Asociaciones Longitudinales en una gran Cohorte, Balanceados por Género. de Veteranos Expuestos al Combate SUEÑO, INSOMNIO Y SEVERIDAD DE TEPT Pocos estudios han investigado el rango y la gravedad de las quejas del sueño relacionadas con el insomnio entre veteranos con trastorno de estrés postraumático (TEPT) y la asociación temporal entre el insomnio y la severidad del TEPT aún no se han examinado. Para examinar estas asociaciones, una gran cohorte de veteranos (N = 1,649) de los conflictos de Irak y Afganistán, balanceados por género, participaron en evaluaciones longitudinales de TEPT y síntomas relacionados con el insomnio durante un período de 2.5 años posteriores a la inscripción (rango: 2-4 años). Los datos se obtuvieron de múltiples fuentes, incluyendo entrevistas, autoevaluaciones y datos de registros médicos electrónicos. Tres cuartos (74.0%) de los veteranos con diagnóstico de TEPT en el tiempo 1 (T1) informaron dificultades de sueño relacionadas con el insomnio en al menos la mitad de las noches durante los últimos 30 días, y un tercio de los participantes habían recibido una prescripción de un fármaco sedante-hipnótico en el último año. Los veteranos sin TEPT tenían menos problemas de sueño en general, aunque la prevalencia de problemas de sueño fue alta entre todos los participantes del estudio. En los modelos longitudinales de panel con retardo cruzado, la frecuencia de los problemas de sueño en T1 predijeron independientemente aumentos en la severidad del TEPT en el Tiempo 2 (T2), B = 0.27, p <.001, después controlar por género y comorbilidades relevantes. Por el contrario, la gravedad del TEPT en T1 se asoció con un aumento de las quejas de sueño en T2 pero en menor grado, B = 0.04, p <.001. Se observaron tasas moderadamente altas de uso de hipnóticos-sedativos en veteranos con TEPT, con un uso más frecuente en mujeres comparadas con hombres (40.4% vs. 35.0%). En general las quejas de sueño fueron altamente prevalentes y destacan la necesidad de una mayor focalización clínica en esta área.

Using the World Health Organization Disability Assessment Schedule 2.0 to assess disability in veterans with posttraumatic stress disorder.

The introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was accompanied by the elimination of the Global Assessment of Functioning (GAF) scale, which was previously used to assess functioning. Although the World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0) was offered as a measure for further study, widespread adoption of the WHODAS 2.0 has yet to occur. The lack of a standardized instrument for assessing posttraumatic stress disorder (PTSD)-related disability has important implications for disability compensation. Accordingly, this study was designed to determine and codify the utility of the WHODAS 2.0 for assessing PTSD-related disability. Veterans from several VA medical centers (N = 1109) were included. We examined PTSD using several definitions and modalities and considered results by gender and age. Across definitions and modalities, veterans with PTSD reported significantly greater WHODAS 2.0 total (large effects; all ts > 6.00; all ps < .01; all Cohen's ds > 1.03) and subscale (medium-to-large effects; all ts > 2.29; all ps < .05; all Cohen's ds > .39) scores than those without PTSD. WHODAS 2.0 scores did not vary by gender; however, younger veterans reported less disability than older veterans (small effects; all Fs > 4.30; all ps < .05; all η2s < .05). We identified 32 as the optimally efficient cutoff score for discriminating veterans with and without PTSD-related disability, although this varied somewhat by age and gender. Findings support the utility of the WHODAS 2.0 in assessing PTSD-related disability.

Is Suicidal Behavior in Mood Disorders Altered by Comorbid PTSD?

BACKGROUND: Suicide is a leading cause of death among US veterans. Associations between depression, posttraumatic stress disorder (PTSD), and suicidal behaviors have been found in this population, yet minimal research has explored how manifestations of self-injurious behavior (SIB) may vary among different diagnostic presentations. AIMS: This study aimed to identify clinically useful differences in SIB among veterans who experience comorbid mood disorder and PTSD (CMP) compared with those who experience a mood disorder alone (MDA). METHOD: Participants were 57 US military veterans who reported an incident of intentional SIB. The semistructured Post Self-Injury/Attempted Self-Injury Debriefing Interview was used to examine characteristics of the SIB. RESULTS: Veterans diagnosed with CMP were more likely than those with MDA to (a) report that the SIB was impulsive and (b) to be under the influence of substances at the time of self-injury. LIMITATIONS: Generalizability may be limited by small sample size and predominantly European American, male demographics. While highly relevant to routine clinical practice, caution is recommended, as study diagnoses were attained from medical records rather than structured interviews. CONCLUSION: Safety planning that emphasizes protection against impulsive suicide attempts (e.g., means restriction) may be especially important among veterans with comorbid mood disorder and PTSD.

Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

In response to high suicide rates among veterans, the Department of Veterans Affairs (VA) has mandated that veterans at risk for suicide be given Safety Plans (SP). Research on the efficacy of SPs, however, is unclear and no prior study has examined the degree to which more personally relevant (i.e., higher quality) SPs may be associated with better outcomes or evaluate which components of SPs may be most effective at reducing suicidal behavior. The goal of the present study was to examine whether more personally relevant (i.e., higher quality) SPs reduce future suicide-related outcomes (psychiatric hospitalization, self-harm, and suicide attempts), and to determine which components of a SP may be most effective at reducing these outcomes. Participants were 68 individuals enrolled in a longitudinal national registry of returning military veterans receiving care from the VA, and who had at least one suicide-related event in the VA Suicide Prevention Applications Network. Data were collected between December 2009 and September 2016 and were analyzed between March 2016 and February 2017. Scores of SP quality were used to predict suicide-related outcomes. SP quality was low. Higher SP quality scores predicted a decreased likelihood of future suicide behavior reports (note entered into veteran's chart after a report of any self-harm behavior, including a suicide attempt). Higher scores on Step 3 (people and places that serve as distractions) predicted a decreased likelihood of future suicide behavior reports. More personally relevant SPs may reduce future suicide-related outcomes among veterans. Low SP quality scores highlight the need for training around SP implementation in the VA.

A longitudinal study of risk factors for suicide attempts among Operation Enduring Freedom and Operation Iraqi Freedom veterans.

BACKGROUND: Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF; LeardMann et al., 2013). Identification of factors with the greatest contribution to suicide risk among veterans is needed to inform risk assessment and to identify intervention targets. METHODS: This study examined predictors of suicide attempts among participants in the Veterans After-Discharge Longitudinal Registry; a nationwide cohort of OEF/OIF veterans enrolled in Department of Veterans Affairs (VA) services. Veterans with and without probable posttraumatic stress disorder (PTSD) were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio. Participants (N = 1,649) were assessed at two time points, roughly 2 years apart (M = 28.74 months, SD = 8.72). RESULTS: Seventy-four participants (4.49%) attempted suicide during the follow-up period. The strongest predictors of suicide attempts among the full sample were suicidal intent, attempt history, suicide ideation, PTSD symptoms, alcohol use disorder (AUD) symptoms, and depression. Veterans with multiple risk factors were particularly vulnerable; of veterans with 0, ≥1, ≥2, ≥3, or ≥ 4 of these risk factors, 0%, 7.81%, 10.31%, 18.45%, and 20.51% made a suicide attempt, respectively. CONCLUSIONS: This prospective study identified several strong predictors of suicide attempts among OEF/OIF veterans which may be important targets for suicide prevention efforts. Further, co-occurrence of multiple risk factors was associated with markedly greater risk for suicide attempts; veterans with multiple risk factors appear to be at the highest risk among OEF/OIF veterans enrolled in VA care.

The Association Between Masculinity and Nonsuicidal Self-Injury.

Several known risk factors for nonsuicidal self-injury (NSSI), such as negative emotionality and deficits in emotion skills, are also associated with masculinity. Researchers and clinicians suggest that masculine norms around emotional control and self-reliance may make men more likely to engage in self-harm. Masculinity has also been implicated as a potential risk factor for suicide and other self-damaging behaviors. However, the association between masculinity and NSSI has yet to be explored. In the current study, a sample of 912 emerging adults from two universities in the Northeastern United States completed a web-based questionnaire assessing adherence to masculine norms, engagement in NSSI, and known risk factors for NSSI (demographics and number of self-injurers known). Stronger adherence to masculine norms predicted chronic NSSI (five or more episodes throughout the life span) above and beyond other known risk factors. Adherence to masculine norms was related to methods of NSSI. Clinical implications are discussed, including discussions of masculine norms in treatment settings. Future research should examine what specific masculine norms are most closely linked to NSSI and other self-damaging behaviors.

Examining the diagnostic utility of the DSM-5 PTSD symptoms among male and female returning veterans.

BACKGROUND: Posttraumatic stress disorder (PTSD) diagnostic criteria have been criticized for including symptoms that overlap with commonly comorbid disorders, which critics argue undermines the validity of the diagnosis and inflates psychiatric comorbidity rates. In response, the upcoming 11th edition of the International Classification of Diseases (ICD-11) will offer PTSD diagnostic criteria that are intended to promote diagnostic accuracy. However, diagnostic utility analyses have not yet assessed whether these criteria minimize diagnostic errors. The present study examined the diagnostic utility of each PTSD symptom in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for males and females. METHODS: Participants were 1,347 individuals enrolled in a longitudinal national registry of returning veterans receiving care at a Department of Veterans Affairs (VA) facility. Doctoral level clinicians assessed all participants using the PTSD module of the Structured Clinical Interview for DSM. RESULTS: Of the 20 symptoms examined, the majority performed in the fair to poor range on test quality indices. Although a few items did perform in the good (or better) range, only half were ICD-11 symptoms. None of the 20 symptoms demonstrated good quality of efficiency. Results demonstrated few sex differences across indices. There were no differences in the proportion of comorbid psychiatric disorders or functional impairment between DSM-5 and ICD-11 criteria. CONCLUSIONS: ICD-11 PTSD criteria demonstrate neither greater diagnostic specificity nor reduced rates of comorbidity relative to DSM-5 criteria and, as such, do not perform as intended. Modifications to existing symptoms or new symptoms may improve differential diagnosis.

Network models of DSM-5 posttraumatic stress disorder: Implications for ICD-11.

Recent proposals for revisions to the 11th edition of the International Classification of Diseases (ICD-11) posttraumatic stress disorder (PTSD) diagnostic criteria have argued that the current symptom constellation under the Diagnostic and Statistical Manual of Mental Disorders-5 is unwieldy and includes many symptoms that overlap with other disorders. The newly proposed criteria for the ICD-11 include only 6 symptoms. However, restricting the symptoms to those included in the ICD-11 has implications for PTSD diagnosis prevalence estimates, and it remains unclear whether these 6 symptoms are most strongly associated with a diagnosis of PTSD. Network analytic methods, which assume that psychiatric disorders are networks of interrelated symptoms, provide information regarding which symptoms are most central to a network. We estimated network models of PTSD in a national sample of veterans of the Iraq and Afghanistan wars. In the full sample, the most central symptoms were persistent negative emotional state, efforts to avoid external reminders, efforts to avoid thoughts or memories, inability to experience positive emotions, distressing dreams, and intrusive distressing thoughts or memories; that is, 3 of the 6 most central items to the network would be eliminated from the diagnosis under the current proposal for ICD-11. An empirically defined index summarizing the most central symptoms in the network performed comparably to an index reflecting the proposed ICD-11 PTSD criteria at identifying individuals with an independently assessed DSM-5 defined PTSD diagnosis. Our results highlight the symptoms most central to PTSD in this sample, which may inform future diagnostic systems and treatment. (PsycINFO Database Record

Mild Traumatic Brain Injury, PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans.

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After-Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID-IV PTSD module; all other variables were assessed by self-report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η(2) p = .11, p < .001; females, η(2) p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long-term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.

Pilot trial of gender-based motivational interviewing for increasing mental health service use in college men.

Men are considerably less likely to seek professional and nonprofessional help for mental disorders. Prior findings indicate that adherence to masculine norms contributes to stigma about internalizing disorders and help seeking. There are currently no empirically supported interventions for increasing help seeking in men with internalizing symptoms. To address this need, we conducted a pilot study of gender-based motivational interviewing (GBMI) for men with internalizing symptoms. GBMI is a single session of assessment and feedback integrating gender-based and motivational interviewing principles (Addis, 2012). College men (N = 35) with significant internalizing symptoms and no recent help seeking were randomized to either GBMI or a no-treatment control and were followed for 2 months. GBMI had a significant effect on seeking help from parents and a trend for seeking professional help, but did not have a significant effect on seeking help from friends or partners. The size of the effect of GBMI on professional and nonprofessional help seeking ranged from small to medium. GBMI shows promise for improving men's help-seeking behaviors and warrants further development and investigation.

The effect of enemy combat tactics on PTSD prevalence rates: A comparison of Operation Iraqi Freedom deployment phases in a sample of male and female veterans.

OBJECTIVE: Research suggests that the nature of combat may affect later development of posttraumatic stress disorder (PTSD) in combat veterans. Studies comparing rates of PTSD across different conflicts indicate that the use of asymmetric or guerilla-style tactics by enemy fighters may result in higher rates of PTSD among U.S. military personnel than the use of symmetric tactics, which mirror tactics used by U.S. forces. Investigations of the association between enemy combat tactics and PTSD across conflicts were limited because of cohort effects and a focus on male veterans. The current study examined rates of PTSD diagnosis in a sample of male and female veterans deployed to Operation Iraqi Freedom (OIF), a conflict with 3 distinct phases marked by varying enemy tactics. METHOD: Participants were 738 veterans enrolled in Project VALOR (Veterans' After-Discharge Longitudinal Registry) who deployed once to OIF. Participants completed a clinician interview as well as self-report measures. RESULTS: Male veterans deployed during the OIF phase marked by asymmetric tactics were more than twice as likely to be diagnosed with PTSD as those deployed during the other 2 phases, even after controlling for extent of combat exposure, demographic characteristics, and other deployment-related risk factors for PTSD. Differing rates of PTSD across the 3 OIF phases were not observed among female participants. CONCLUSION: The nature of combat (specifically, asymmetric enemy tactics) may be a risk factor for the development of PTSD among males. Factors other than enemy tactics may be more important to the development of PTSD among females. (PsycINFO Database Record

A Pilot Trial of Gender-Based Motivational Interviewing for Help-Seeking and Internalizing Symptoms in Men.

There has been limited research on interventions addressing the psychosocial barriers to men's underutilization of formal and informal help. To address this gap in the literature, we report on the development of Gender-Based Motivational Interviewing (GBMI) for men with internalizing symptoms and present the findings of a pilot trial. GBMI is a single session of assessment and feedback that integrates gender-based and motivational interviewing principles. Community-dwelling men (N = 23) with elevated internalizing symptoms and no recent history of formal help-seeking were randomized to either GBMI or control conditions and were followed for three months. The effect of GBMI on internalizing and externalizing symptoms ranged from small to large across follow-ups. GBMI had a small to moderate effect on stigma. There was no effect on help-seeking attitudes or intentions. GBMI increased use of informal help seeking (e.g. parents and partners) and had no effect on formal help seeking. None of these findings were statistically significant. Study weaknesses included baseline differences in help-seeking variables between conditions. This initial evaluation suggested that GBMI shows promise for improving mental health functioning while further research is need to determine its effect on help-seeking.