A dynamical systems analysis of change in PTSD symptoms, depression symptoms, and suicidal ideation among military personnel during treatment for PTSD.

OBJECTIVE: The connections among posttraumatic stress disorder (PTSD), depression, and suicidal ideation are elusive because of an overreliance on cross-sectional studies. In this secondary analysis of pooled data from three clinical trials of 742 military personnel, we examined the dynamic relationships among PTSD, depression, and suicidal ideation severity assessed repeatedly during and after outpatient treatment for PTSD. METHODS: We conducted dynamical systems analyses to explore the potential for coordinated change over time in psychotherapy for PTSD. RESULTS: Over the course of psychotherapy, PTSD, depression, and suicidal ideation severity changed in coordinated ways, consistent with an interdependent network. Results of eigenvalue decomposition analysis indicated the dominant change dynamic involved high stability and resistance to change but indicators of cycling were also observed, indicating participants "switched" between states that resisted change and states that promoted change. Depression (B = 0.48, SE = 0.11) and suicidal desire (B = 0.15, SE = 0.01) at a given assessment were associated with greater change in PTSD symptom severity at the next assessment. Suicidal desire (B = 0.001, SE < 0.001) at a given assessment was associated with greater change in depression symptom severity at the next assessment. Neither PTSD (B = -0.004, SE = 0.007) nor depression symptom severity (B = 0.000, SE = 0.001) was associated with subsequent change in suicidal ideation severity. CONCLUSIONS: In a sample of treatment-seeking military personnel with PTSD, change in suicidal ideation and depression may precede change in PTSD symptoms but change in suicidal ideation was not preceded by change in PTSD or depression symptoms.

The motivated appeal to hypocrisy: the relation of motivational threats to message rejection.

Few studies have focused on the conditions in which individuals perceive hypocrisy in others. The current study introduces and tests the Motivated Appeal to Hypocrisy (MAtH) hypothesis. This hypothesis examines core social psychological motivational threats and asks (a) whether these are related to the accounts of individuals in charging others with hypocrisy, and (b) whether these perceptions of hypocrisy are associated with reductions in the persuasiveness of persons targeted as hypocrites. Study 1 (N=201) was based on qualitative coding of stories and revealed, as expected, that violations of core social motives involving belongingness, understanding, control, self-enhancement, and trust are involved in participants' stories of hypocrisy. Study 2 (N=237) used a multilevel correlational approach and demonstrated that violations of core social motives significantly predict perceptions of hypocrisy and the rejection of a person's message or advice. The relation between social motive violations and message rejection was mediated by perceptions of hypocrisy.

Acculturative Orientations Among Hispanic/Latinx Caregivers in the ABCD Study: Associations With Caregiver and Youth Mental Health and Youth Brain Function.

Background: Population-based neuroscience offers opportunities to examine important but understudied sociocultural factors such as acculturation. Acculturation refers to the extent to which an individual retains their cultural heritage and/or adopts the receiving society's culture and is particularly salient among Hispanic/Latinx immigrants. Specific acculturative orientations have been linked to vulnerability to substance use, depression, and suicide and are known to influence family dynamics between caregivers and their children. Methods: Using data from first- and second-generation Hispanic/Latinx caregivers in the Adolescent Brain Cognitive Development (ABCD) Study (N = 1057), we examined how caregivers' acculturative orientation affects their mental health, as well as the mental health and brain function of their children. Neuroimaging analyses focused on regions associated with self- and affiliation-based social processing (ventromedial prefrontal cortex, insula, and temporoparietal junction). Results: We identified 2 profiles of caregiver acculturation: bicultural (retains heritage culture while adopting U.S. culture) and detached (discards heritage culture and rejects U.S. culture). Bicultural caregivers exhibited fewer internalizing and externalizing problems than detached caregivers; furthermore, youth exhibited similar internalizing effects across caregiver profiles. In addition, youth with bicultural caregivers displayed increased resting-state brain activity (i.e., fractional amplitude of low-frequency fluctuations and regional homogeneity) in the left insula, which has been linked to psychopathology; however, differences in long-range functional connectivity were not significant. Conclusions: Caregiver acculturation is an important familial factor that has been linked to significant differences in youth mental health and insula activity. Future work should examine sociocultural and neurodevelopmental changes across adolescence to assess health outcomes and determine whether localized, corticolimbic brain effects are ultimately translated into long-range connectivity differences.

The benefits of making peace with pain: chronic pain acceptance moderates the indirect effect of perceived burdensomeness between pain severity and suicidal cognitions.

OBJECTIVE: The purpose of this study was (1) to examine the degree to which perceived burdensomeness mediates the relationship between pain severity and suicidal cognitions and (2) to determine whether this mediated relationship was moderated by pain acceptance. We predicted that high levels of pain acceptance would buffer relationships on both paths of the indirect effect. METHODS: Two-hundred seven patients with chronic pain completed an anonymous self-report battery of measures, including the Chronic Pain Acceptance Questionnaire, the Interpersonal Needs Questionnaire, the Suicidal Cognitions Scale, and the pain severity subscale of the West Haven-Yale Multidimensional Pain Inventory. Conditional process models were examined with Mplus. RESULTS: Chronic pain acceptance significantly moderated both paths of the mediation model. Results from the conditional indirect effect model indicated that the indirect effect was significant for those with low (b = 2.50, P = .004) and medium (b = 0.99, P = .01) but not high (b = 0.08, P = .68) levels of pain acceptance and became progressively stronger as pain acceptance scores decreased. The nonlinear indirect effect became nonsignificant at acceptance scores 0.38 standard deviation above the mean-a clinically attainable treatment target. CONCLUSIONS: Higher acceptance mitigated the relationship between pain severity and perceived burdensomeness and the relationship between perceived burdensomeness and suicidal cognitions in this clinical sample of patients experiencing chronic pain. Findings indicate that any improvement in pain acceptance can be beneficial, and they provide clinicians with a clinical cut-point that might indicate lower vs higher suicide risk.

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial.

STUDY OBJECTIVES: Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment. METHODS: In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment. RESULTS: Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment. CONCLUSIONS: Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561. CITATION: Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

Cannabis use disorder uniquely predicts educational impairment in college students over and above other mental health disorders.

Objective: The impact of cannabis use disorder (CUD) on education functioning and GPA was examined within the context of co-occurring alcohol use disorder (AUD), major depressive disorder (MDD), and post-traumatic stress disorder (PTSD). Participants: Undergraduates (N = 210) who reported using cannabis within the past six months were recruited. Methods: Hierarchical multiple regression analyses were used to determine whether CUD symptom severity and presence of probable CUD diagnosis predicted educational impairment and current GPA, over and above other mental health conditions. Results: CUD symptom severity, but not probable CUD, significantly predicted greater educational impairment, over and above probable PTSD and MDD, which were also significant predictors. CUD symptom severity, but not probable CUD, significantly predicted lower GPA. Conclusion: In addition to other common mental health conditions, CUD may be an important area of assessment and intervention for university counseling centers to foster student academic success.

Patterns of acute stress disorder in a sample of blast-injured military service members: A latent profile analysis.

OBJECTIVE: The primary aims of this study were to identify latent profiles of acute stress disorder (ASD) symptoms and to evaluate postconcussive symptom differences across the identified profiles as measured by the Acute Stress Disorder Scale and the Military Acute Concussion Evaluation, respectively. METHOD: Participants (N = 315) in the current study were predominantly active-duty (75.0%), enlisted (97.8%) males (97.4%) serving in the U.S. Army (87.8%). Approximately, half of the sample reported being married or engaged (51.1%) and was on average 25.94 (SD = 6.31) years old. Participants were referred to the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq, to be evaluated as part of routine clinical assessment for neurocognitive and psychological symptoms following exposure to a blast. RESULTS: A 3-profile solution was identified as the most parsimonious and best-fitting model based on statistical model fit indices. Blast injured service members in Profile 3 had greater ASD total and subscale severity compared to the other 2 subgroups, with effect size estimates largely differing by hyperarousal and reexperiencing symptoms. Furthermore, Profiles 2 and 3 were more likely to demonstrate postconcussive symptoms compared to Profile 1. CONCLUSIONS: Findings provide novel information on heterogenous ASD symptom profiles during the acute phase following a blast injury and highlight the relationship between psychological and physical symptoms. Classification of blast-injured service members may help identify at-risk individuals who would benefit from further clinical care and mitigate long-term psychological and neurocognitive issues. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Hyperarousal symptoms linger after successful PTSD treatment in active duty military.

OBJECTIVE: Evidence-based psychotherapies are efficacious at reducing posttraumatic stress disorder (PTSD) symptoms, but military and veteran samples improve less than civilians. The objective of this secondary analysis of two clinical trials of cognitive processing therapy (CPT) was to determine if hyperarousal symptoms were more resistant to change compared with other PTSD symptom clusters in active duty service members. METHOD: Service members completed the PTSD Checklist for the DSM-5 (PCL-5) pre- and post-CPT. Symptoms were coded present if rated 2 (moderate) or higher on a 0-4 scale. Cutoffs for reliable and clinically significant change classified 21%, 18%, and 61% of participants as recovered, improved, and suboptimal responders, respectively. Data analyses focused on the posttreatment status of symptoms that were present at baseline to determine their persistence as a function of treatment outcome. Generalized linear mixed effects models with items treated as a repeated measure estimated the proportions who continued to endorse each symptom and compared hyperarousal symptoms with symptoms in other clusters. RESULTS: Among improved participants, the average hyperarousal symptom was present in 69% compared with 49% for symptoms in other clusters (p < .0001). Among recovered patients, hyperarousal symptoms were present for 26%, while symptoms in the reexperiencing (2%), avoidance (3%), and negative alterations (4%) clusters were almost nonexistent (p < .0001). CONCLUSIONS: Even among service members who recovered from PTSD after CPT, a significant minority continue to report hyperarousal symptoms while other symptoms remit. Hyperarousal symptoms may require additional treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The impact of prior head injury on outcomes following group and individual cognitive processing therapy among military personnel.

This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment-related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non-HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p < .001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p < .001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p = .060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p = .003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings.

Military Injuries-Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study.

BACKGROUND: Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves. OBJECTIVE: In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE. METHODS: We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another. RESULTS: This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022. CONCLUSIONS: New national initiatives aim to incorporate the caregiver into the veteran's treatment plan; however, we know little about the impact of caregiving-both positive and negative-on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/30975.

Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial.

BACKGROUND: Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment. METHODS: The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome. RESULTS: Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant. CONCLUSIONS: CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

Development and psychometric validation of the Dispositional Recovery and Dysfunction Inventory: a tool to assess for positive and negative cognitions following trauma exposure.

BACKGROUND: Recovery from trauma can be naturally occurring or facilitated through psychotherapy. Few brief measures exist to provide clinicians with dispositional, empirical assessments of patient's sentiments during psychotherapy. AIMS: This manuscript presents the Dispositional Recovery and Dysfunction Inventory (DRDI), a measure created to assist clinicians in evaluating patient's treatment progress during psychotherapy, as well as evaluate its factor structure, reliability estimates, measurement invariance, and correlates. METHOD: The DRDI was created based on feedback from experts with experience treating posttraumatic stress disorder (PTSD) and was structurally validated in two distinct populations. Exploratory factor analysis was conducted in sample 1 consisting of (n=401) university students. Confirmatory factor analysis, measure validity and structure validation were then conducted in sample 2 (n=249) composed of 49% individuals with clinically significant PTSD symptoms. RESULTS: Exploratory and confirmatory factor analysis revealed that the DRDI was best represented by a two-factor correlated traits model representing sentiments related to dispositional recovery and dysfunctional cognitions. The recovery subscale exhibited relationships with convergent measures including authenticity and psychological hardiness (r values of .30 to .60). The dysfunctional beliefs subscale exhibited relationships with convergent measures: PTSD, depression, suicidality and stress (r values of .55 to 80). Measurement invariance across gender and PTSD status was observed. CONCLUSION: Initial findings indicate that the DRDI has the potential to be a useful tool to assess individuals' beliefs about their propensity to recover from and thrive through adversity.

Temporal-dimensional examination of the Scale for Suicidal Ideation in a cohort of service members in treatment for PTSD.

OBJECTIVE: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. METHOD: We performed a secondary analysis of archived data from 742 active-duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). RESULTS: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic and was related to variables other from suicidal ideation. CONCLUSION: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors and limiting opportunities for proactive and timely intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter.

OBJECTIVE: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. BACKGROUND: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. METHODS: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. RESULTS: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms. CONCLUSION: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Dynamics of risk: Recent changes in psychological inflexibility precede subsequent changes in returning US veterans' posttraumatic stress.

OBJECTIVES: As a malleable risk-factor, psychological inflexibility is implicated in the development and maintenance of posttraumatic stress symptoms (PTS). Unfortunately, limited research has addressed whether changes in psychological inflexibility are antecedent to changes in PTS severity over time, or whether such changes are mutually dependent. METHODS: Utilizing bivariate latent difference score modeling, this longitudinal study sequenced intraindividual changes in psychological inflexibility and PTS severity within a sample of 305 returning US veterans. Veterans' self-reported psychological inflexibility and PTS severity were assessed quarterly over 1 year. RESULTS: Results indicated that early reductions in psychological inflexibility potentiated later declines in veterans' PTS severity, accounting for veterans' prior levels of psychological inflexibility and PTS severity. CONCLUSIONS: These findings underscore the unique role of changes in psychological inflexibility as an important mechanism of change in PTS severity and provide empirical support for an antecedent model of the role of psychological inflexibility in PTS recovery.

Written exposure therapy for posttraumatic stress symptoms and suicide risk: Design and methodology of a randomized controlled trial with patients on a military psychiatric inpatient unit.

Studies of active duty service members have shown that military personnel who screen positive for posttraumatic stress disorder (PTSD) are more than twice as likely to make a suicide attempt. Evidence-based PTSD treatments can reduce suicidal ideation; however, it can be challenging to provide evidence-based, trauma-focused, PTSD treatment to high-risk patients on an acute psychiatric inpatient unit because the priority of care is stabilization. Treatment for PTSD requires more time and resources than are typically afforded during inpatient hospitalizations. Written Exposure Therapy is an evidence-based, five-session, trauma-focused treatment for PTSD that may overcome the implementation challenges of providing PTSD treatment in an acute inpatient psychiatric treatment setting. This paper describes the design, methodology, and protocol of a randomized clinical trial. The goal of the study is to determine if five 60-min sessions of Written Exposure Therapy enhanced with Crisis Response Planning for suicide risk reduces the presence, frequency, and severity of suicidal ideation, suicidal behavior, rehospitalization, and non-suicidal, self-injurious behaviors. The study also will determine if Written Exposure Therapy for Suicide reduces posttraumatic stress symptom severity among military service members, veterans, and other adult military beneficiaries admitted to an acute psychiatric inpatient unit for comorbid suicide ideation or attempt and PTSD symptoms compared with Treatment as Usual. The study is designed to enhance the delivery of care for those in acute suicidal crisis with comorbid PTSD symptoms.

Efficacy of individual and group cognitive processing therapy for military personnel with and without child abuse histories.

Objective: Many clinicians question whether patients with a history of childhood trauma will benefit from trauma-focused treatment. In this secondary analysis, we examined whether reports of childhood abuse moderated the efficacy of cognitive processing therapy (CPT) for active-duty military with posttraumatic stress disorder (PTSD). Methods: Service members (N = 254, mean age 33.11 years, 91% male, 41% Caucasian) were randomized to receive individual or group CPT (n = 106 endorsing and n = 148 not endorsing history of childhood abuse). Outcomes included baseline cognitive-emotional characteristics [Posttraumatic Cognitions Inventory (PTCI), Trauma-Related Guilt Inventory (TRGI), Cognitive Emotion Regulation Questionnaire-Short Form (CERQ)], treatment completion, and symptom outcome (PTSD Checklist, Beck Depression Inventory-II). We predicted participants endorsing childhood abuse would have higher scores on the PTCI, TRGI, and CERQ at baseline, but be noninferior on treatment completion and change in PTSD and depression symptoms. We also predicted those endorsing childhood abuse would do better in individual CPT than those not endorsing abuse. Results: Those endorsing childhood abuse primarily experienced physical abuse. There were no baseline differences between service members with and without a history of childhood abuse (all p ≥ .07). Collapsed across treatment arms, treatment completion and symptom reduction were within the noninferiority margins for those endorsing versus not endorsing childhood abuse. History of abuse did not moderate response to individual versus group CPT. Conclusions: In this primarily male, primarily physically abused sample, active-duty military personnel with PTSD who endorsed childhood abuse benefitted as much as those who did not endorse abuse. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Identifying suicidal subtypes and dynamic indicators of increasing and decreasing suicide risk in active duty military personnel: Study protocol.

OBJECTIVES: Several recent studies have demonstrated that posttraumatic stress disorder (PTSD) and insomnia treatments are associated with significant reductions in suicidal ideation (SI) among service members. However, few investigations have evaluated the manner in which suicide risk changes over time among military personnel receiving PTSD or insomnia treatments. This paper describes the study protocol for a project with these aims: (1) explore potential genetic, clinical, and demographic subtypes of suicide risk in a large cohort of deployed service members; (2) explore subtype change in SI as a result of evidence-based psychotherapies for PTSD and insomnia; (3) evaluate the speed of change in suicide risk; and (4) identify predictors of higher- and lower-risk for suicide. METHODS: Active duty military personnel were recruited for four clinical trials (three for PTSD treatment and one for insomnia treatment) and a large prospective epidemiological study of deployed service members, all conducted through the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR Consortium). Participants completed similar measures of demographic and clinical characteristics and subsets provided blood samples for genetic testing. The primary measures that we will analyze are the Beck Scale for Suicide Ideation, Beck Depression Inventory, and the PTSD Checklist for DSM-IV. DISCUSSION: Results from this study will offer new insights into the presence of discrete subtypes of suicide risk among active duty personnel, changes in risk over time among those subtypes, and predictors of subtypes. Findings will inform treatment development for military service members at risk for suicide.