Augmenting Virtual Reality Exposure Therapy for Social and Intergroup Anxiety With Transcranial Direct Current Stimulation.

OBJECTIVES: Exposure therapy is a cornerstone of social anxiety treatment, yet not all patients respond. Symptoms in certain social situations, including intergroup (ie, out-group) contexts, may be particularly resistant to treatment. Exposure therapy outcomes may be improved by stimulating neural areas associated with safety learning, such as the medial prefrontal cortex (mPFC). The mPFC also plays an important role in identifying others as similar to oneself. We hypothesized that targeting the mPFC during exposure therapy would reduce intergroup anxiety and social anxiety. METHODS: Participants (N = 31) with the public speaking subtype of social anxiety received active (anodal) or sham transcranial direct current stimulation (tDCS) targeting the mPFC during exposure therapy. Exposure therapy consisted of giving speeches to audiences in virtual reality. To target intergroup anxiety, half of the public speaking exposure trials were conducted with out-group audiences, defined in this study as audiences of a different ethnicity. RESULTS: Contrary to hypotheses, tDCS did not facilitate symptom reduction. Some evidence even suggested that tDCS temporarily increased in-group favoritism, although these effects dissipated at 1-month follow-up. In addition, collapsing across all participants, we found reductions across time for public speaking anxiety and intergroup anxiety. CONCLUSIONS: The data provide evidence that standard exposure therapy techniques for social anxiety can be adapted to target intergroup anxiety. Transcranial direct current stimulation targeting the mPFC may boost safety signaling, but only in contexts previously conditioned to signal safety, such as an in-group context.

Longitudinal associations between moral injury perceptions and mental health among healthcare workers during the pandemic.

OBJECTIVE: The COVID-19 pandemic strained the healthcare system and resulted in higher rates of potentially morally injurious events. These events are perceived as violating one's own moral code, so a more precise construct label could be moral injury perceptions (MIPs). MIPs may exacerbate stress-related symptoms. However, consistent with the broader literature on mood-congruent cognitive bias, stress symptoms may also exacerbate MIPs. To test this bidirectional hypothesis, we examined the relationship between MIPs and stress symptoms among healthcare workers during the first year of the pandemic. METHOD: Online questionnaires for MIPs and stress-related symptoms (i.e., pandemic-related posttraumatic stress [PTSS], perceived stress, depression, and anxiety) were completed in April/May 2020 (time point one [T1]; N = 184), 1 month later (time point 2 [T2]; N = 135), and 6 months later (time point three [T3]; N = 112). RESULTS: Findings from cross-lagged panel modeling favored unidirectional models, but the direction of the relationship varied by symptom type. Perceived stress, PTSS, and depression, all predicted increased MIPs at a later time point. However, in a reversal of direction, MIPs predicted increased anxiety. CONCLUSIONS: Results suggest that MIPs may function as both a predictor and an outcome of stress-related symptoms. Mood-congruent cognitive biases could account for why depression, PTSS, and perceived stress predicted subsequent MIPs, whereas MIPs may have exacerbated more generalized anxiety about the future. Broadly, these findings highlight the importance of early access to mental health services for healthcare workers during public health crises to disrupt the relationship between MIPs and stress-related symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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).

The protective effects of perceived cohesion on the mental health of first responders.

First responders are repeatedly exposed to traumatic and stressful situations. Perceived cohesion can mitigate the potentially harmful psychological impact of these stressors. While the positive effects of cohesion have been established in other trauma-exposed populations such as the military, these effects have not been examined in first responders. Furthermore, prior studies have not ruled out the possibility that perceived cohesion may be acting as a proxy for another well-established protective factor, social support. We therefore examined how perceived cohesion among first responder organizations impacts psychological health and resilience, even after accounting for the effects of social support. First responders (N = 182) completed measures of perceived cohesion, social support, psychological symptoms (including depression, stress, anxiety, posttraumatic stress symptoms, secondary traumatic stress symptoms, and burnout), and psychological resilience. Even after controlling for social support, perceived cohesion was associated with lower levels of psychological symptoms (ß = -.18 to -.33; p < .05; for secondary traumatic stress, posttraumatic stress, depression, and each facet of burnout) and higher levels of resilience (ß = .37; p < .05). These results suggest that perceived cohesion promotes psychological health among first responders, even after controlling for social support. Thus, perceived cohesion does not seem to be acting as a mere proxy for social support. Further examination of how perceived cohesion benefits first responders could lay the groundwork for interventions to improve their mental health and psychological resilience. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The association of distress tolerance and mindful awareness with mental health in first responders.

Mindful awareness (MA) and distress tolerance are emerging as robust predictors of mental health in populations with high levels of stress and trauma exposure, such as first responders. The combination of both protective factors may have potentiating benefits for mental health. First responders might especially benefit from high levels of MA if they are able to tolerate distressing present-moment experiences as needed. In this study, cross-sectional data were used to test whether distress intolerance (DI) moderated the relationship between MA and mental health. First responders (N = 176) completed an online assessment battery including measures of MA (Mindful Attention Awareness Scale), DI (Distress Intolerance Index), and mental health outcomes (i.e., Depression, Anxiety, and Stress Scale; Posttraumatic Stress Disorder [PTSD] Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th edition [DSM-5]; Secondary Traumatic Stress Scale; abbreviated Maslach Burnout Inventory; compassion satisfaction subscale of the Professional Quality of Life Scale; Satisfaction with Life Scale; and Brief Resilience Scale). Multiple regression models demonstrated that among first responders with higher DI, MA had a stronger association with lower anxiety and depression symptoms. Interactions between MA and DI were not significant for other outcome measures. However, higher MA and lower DI each independently predicted lower stress (lower posttraumatic stress, secondary traumatic stress, and general stress); higher MA independently predicted better occupational health (lower burnout and higher compassion satisfaction); and lower DI independently predicted positive mental health (greater resilience and life satisfaction). Results highlight the independent associations of high MA and low DI with first responders' mental health and underscore the importance of studying of interventions that promote both of these protective factors in first responders. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association between physical activity and mental health among first responders with different service roles.

Objective: Studies suggest that physical activity (PA) improves psychological recovery in trauma-exposed populations like first responders. However, trauma exposure varies among first responders in relation to their unique service roles and duties. The purpose of this study was to examine the interaction effect of service role (traditional vs. emotional support first responders) and PA on mental health outcomes. Method: Traditional (n = 133) and emotional support (n = 31) first responders completed assessments of physical activity level, along with mental health outcome measures (posttraumatic stress disorder, secondary traumatic stress [STS], burnout, compassion satisfaction, and depression, anxiety, and stress [DAS]). Multiple regression models, controlling for social desirability and stress exposure, were used to examine service role as a moderator of the relationship between PA and mental health outcomes. Results: First responder role (traditional vs. emotional support) moderated the relationship between PA and STS (ß = .20, p = .04) and DAS (ß = .24, p = .01). Although not predictive for traditional first responders, higher PA was surprisingly associated with higher STS (trend level, ß = .17, p = .06) and DAS (ß = .19, p = .03) for emotional support first responders. Conclusions: Findings revealed differential responding to PA among first responder subgroups, which suggests that first responders in different service roles may have unique patterns of response to stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Compassion for Oneself and Others Protects the Mental Health of First Responders.

OBJECTIVES: First responders are at elevated risk for psychological distress from frequent exposure to potentially traumatic events. Self-compassion may buffer against the negative impact of these stressors, and the potential emotional challenges of having high levels of compassion for others. However, little is known about the psychological impact of compassion in first responders. We examined how self-compassion, compassionate love for others, and service role interacted to predict mental health in a diverse group of first responders. METHODS: First responders (N = 171) with both traditional and emotional support roles completed an online survey including measures of self-compassion, compassionate love, psychological distress, post-traumatic stress, secondary traumatic stress, burnout, resilience, compassion satisfaction, and life satisfaction. RESULTS: Greater self-compassion and compassionate love both independently predicted less depersonalization (|ß|s ≥ .18, ps < .01). Greater self-compassion predicted less general psychological distress, post-traumatic stress, secondary traumatic stress, and emotional exhaustion, as well as greater resilience and life satisfaction (|ß|s ≥ .35, ps < .001). Greater compassionate love predicted greater personal accomplishment and compassion satisfaction for all first responders (|ß|s ≥ .30, ps < .001); for traditional first responders only, greater self-compassion predicted greater personal accomplishment and compassion satisfaction (role x self-compassion; |ß|s ≥ .16, ps < .05). Emotional support first responders reported less emotional exhaustion and greater resilience than traditional first responders (|ß|s ≥ .21, ps < .05). CONCLUSIONS: Self-compassion and compassionate love each play important roles in promoting mental health among first responders. Programs designed to increase compassion could be beneficial in this population. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12671-020-01527-y.

Augmenting exposure therapy with pre-extinction fear memory reactivation and deepened extinction: A randomized controlled trial.

BACKGROUND: Pre-extinction fear memory reactivation (PE-FMR) and deepened extinction (DE) enhance long-term extinction of shock-conditioned fear, and may also enhance long-term extinction of naturally acquired fear. Preliminary data suggest that PE-FMR may additionally boost the speed of fear reduction during exposure therapy. DESIGN: Randomized controlled trial, factorial design. METHODS: Participants with elevated fears of either spiders or snakes were randomized to (1) exposure therapy alone (n = 41), (2) exposure therapy + PE-FMR (n = 42), (3) exposure therapy + DE (n = 41), or (4) exposure therapy + PE-FMR + DE (n = 42). Participants were assessed at baseline, post-treatment, and one-week follow-up on subjective and behavioral indices of phobia. Because treatment length was tailored to speed of fear reduction, survival analyses were used to examine the speed of fear reduction during treatment. RESULTS: DE did not improve clinical outcomes at post-treatment or follow-up, whereas PE-FMR produced more rapid fear reduction and was able to achive equivalent outcomes even when the duration of exposure therapy (tailored to speed of fear reduction) was shortened by an average of 21%. CONCLUSIONS: Data suggest that PE-FMR is a promising strategy for reducing the overall duration of exposure-based therapies. CLINICAL TRIAL REGISTRATION: (clinicaltrials.gov)NCT02160470.

Air Force Medical Personnel: Perspectives Across Deployment.

INTRODUCTION: Contingency operations during the past 18 years have exposed millions of U.S. military service members to numerous combat and operational stressors. Despite this, a relative dearth of literature has focused on the experiences of deployed military medical personnel. As such, the present study aimed to address this gap in the literature by conducting individual and small group interviews with Air Force medical personnel who had recently returned from a deployment to Iraq. Interviews targeted self-reported factors related to psychological risk and resiliency across the deployment cycle, while also seeking recommendations for future military medical personnel preparing for medical deployments. MATERIALS AND METHODS: Inductive thematic analyses were conducted on transcripts from 12 individual and structured group interviews conducted with recently deployed U.S. Air Force medical personnel (N = 28). An interview script consisting of 18 prompts was carefully developed based on the experiences of study personnel. Two team members (n = 1 research psychologist; n = 1 military medical provider) coded exemplars from interview transcripts. A third team member (research psychologist) reviewed coded exemplars for consistency and retained themes when saturation was reached. RESULTS: In total we report on 6 primary themes. Participants reported feeling prepared to conduct their mission while deployed but often felt unprepared for the positions they assumed and the traumas they commonly experienced. Most participants reported deployment to be a rewarding experience, citing leader engagement, and social support as key protective factors against deployment-related stressors. Finally, following deployment, participants largely reported positive experiences reintegrating with their families but struggled to reintegrate into their workplace. CONCLUSION: Findings from the present study indicate that the military is largely doing a good job preparing Air Force medical providers to deploy. Results of the present study indicate that military medical personnel would benefit from: (1) increased predictability surrounding deployment timelines, (2) improved cross-cultural training, (3) advanced training for atypical injuries in unconventional patient populations, and (4) improvements in postdeployment workplace reintegration. The present research has the potential to positively impact the overall quality of life for deploying military service members and their families; while simultaneously highlighting the successes and shortfalls in the deployment process for U.S. military medical personnel.

Does trauma-focused exposure therapy exacerbate symptoms among patients with comorbid PTSD and substance use disorders?

BACKGROUND: Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD). AIM: This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD. METHOD: Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment. RESULTS: At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment. CONCLUSIONS: This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.

Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms.

While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.

Deployed Military Medical Personnel: Impact of Combat and Healthcare Trauma Exposure.

Introduction: Limited research has been conducted on the impact of deployment-related trauma exposure on post-traumatic stress symptoms in military medical personnel. This study evaluated the association between exposure to both combat experiences and medical duty stressors and post-traumatic stress symptoms in deployed military medical personnel. Materials and Methods: U.S. military medical personnel (N = 1,138; 51% male) deployed to Iraq between 2004 and 2011 were surveyed about their exposure to combat stressors, healthcare stressors, and symptoms of post-traumatic stress disorder (PTSD). All participants were volunteers, and the surveys were completed anonymously approximately halfway into their deployment. The Combat Experiences Scale was used as a measure of exposure to and impact of various combat-related stressors such as being attacked or ambushed, being shot at, and knowing someone seriously injured or killed. The Military Healthcare Stressor Scale (MHSS) was modeled after the Combat Experiences Scale and developed for this study to assess the impact of combat-related healthcare stressors such as exposure to patients with traumatic amputations, gaping wounds, and severe burns. The Post-traumatic Stress Disorder Checklist-Military Version (PCL-M) was used to measure the symptoms of PTSD. Results: Eighteen percent of the military medical personnel reported exposure to combat experiences that had a significant impact on them. In contrast, more than three times as many medical personnel (67%) reported exposure to medical-specific stressors that had a significant impact on them. Statistically significant differences were found in self-reported exposure to healthcare stressors based on military grade, education level, and gender. Approximately 10% of the deployed medical personnel screened positive for PTSD. Approximately 5% of the sample were positive for PTSD according to a stringent definition of caseness (at least moderate scores on requisite Diagnostic and Statistical Manual for Mental Disorders criteria and a total PCL-M score ≥ 50). Both the MHSS scores (r(1,127) = 0.49, p < 0.0001) and the Combat Experiences Scale scores (r(1,127) = 0.34, p < 0.0001) were significantly associated with PCL-M scores. However, the MHSS scores had statistically larger associations with PCL-M scores than the Combat Experiences Scale scores (z = 5.57, p < 0.0001). The same was true for both the minimum criteria for scoring positive for PTSD (z = 3.83, p < 0.0001) and the strict criteria PTSD (z = 1.95, p = 0.05). Conclusions: The U.S. military has provided significant investments for the funding of research on the prevention and treatment of combat-related PTSD, and military medical personnel may benefit from many of these treatment programs. Although exposure to combat stressors places all service members at risk of developing PTSD, military medical personnel are also exposed to many significant, high-magnitude medical stressors. The present study shows that medical stressors appear to be more impactful on military medical personnel than combat stressors, with approximately 5-10% of deployed medical personnel appearing to be at risk for clinically significant levels of PTSD.

Heterogeneity in Short-Term Suicidal Ideation Trajectories: Predictors of and Projections to Suicidal Behavior.

OBJECTIVE: Little is known about suicidal ideation stability, including whether stability is heterogeneous or homogeneous between individuals. Studies of this kind are necessary to understand the progression from suicidal ideation to action. METHOD: This study examined suicidal ideation trajectories, using growth mixture modeling, in a sample of 359 past/current military service members (M age = 32.1 years, SD = 7.7; 88.3% male). Self-reported suicidal ideation information was collected at baseline and follow-up sessions at months 1, 3, 6, and 12. Following extraction of the best-fitting solution, predictors of trajectory status were examined and trajectory status was used to predict suicidal behavior between baseline and month 12 assessments. RESULTS: Results revealed four trajectories, Low-Stable (n = 125), Moderate-Stable (n = 101), High-Stable (n = 76), and High-Rapidly Declining (n = 57). In general, the High-Stable trajectory had the highest levels of perceived burdensomeness, thwarted belongingness, PTSD symptoms, and drug use. The High- and Moderate-Stable trajectories had the highest rates of suicidal behavior between baseline and month 12. CONCLUSIONS: Suicidal ideation, even in individuals with elevated ideation, is not a homogeneous construct over time. Stability of suicidal ideation might be an important risk factor, even if ideation is only moderately elevated.

Cortisol, Testosterone, and Prospective Risk for War-zone Stress-Evoked Depression.

Introduction: The major challenges of efforts to reveal biological risk factors and biomarkers of depression include the complexity of underlying systems, interactions with other systems, and contextual factors governing their expression. Altered endocrine function is believed to be a central contributor to depressive illness, but across studies, evidence for a link between endocrine markers and depression has been mixed, inconclusive, or conditional in nature. In the present study, we evaluated basal testosterone (T), cortisol (C), and CO2 inhalation-stress-reactivity measures of these hormones (TR, CR) as pre-deployment moderators of the later impact of war-zone stressors on depression symptoms in-theater. Materials and Methods: At pre-deployment, U.S. soldiers (N = 120) completed demographic, clinical and hormone measures, and during deployment, they completed monthly, web-based assessments of war-zone stressors and depression symptoms (N = 533 observations). Mixed effects models estimated the effects of the pre-deployment hormone profiles in moderating war-zone stressors' impact on in-theater depression. Models also tested whether hormonally linked risk for later stress-evoked depression depends on pre-existing depression. Results: Controlling for pre-deployment depression, high T was protective; whereas TR had depressogenic effects that were amplified by pre-deployment depression. Further, high C was protective, but heightened CR was depressogenic, but only among those with elevated pre-deployment depression. Conclusions: Findings highlight the importance of examining basal and reactivity measures of endocrine function, and use of prospective, longitudinal models to test hypothesized causal pathways associated with depression vulnerability in the war-zone. Results also suggest that pre-existing depression and cortisol may work in tandem to increase vulnerability for later stress-evoked depression in the war-zone.

Acute Assessment of Traumatic Brain Injury and Post-Traumatic Stress After Exposure to a Deployment-Related Explosive Blast.

Introduction: Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) are two of the signature injuries in military service members who have been exposed to explosive blasts during deployments to Iraq and Afghanistan. Acute stress disorder (ASD), which occurs within 2-30 d after trauma exposure, is a more immediate psychological reaction predictive of the later development of PTSD. Most previous studies have evaluated service members after their return from deployment, which is often months or years after the initial blast exposure. The current study is the first large study to collect psychological and neuropsychological data from active duty service members within a few days after blast exposure. Materials and Methods: Recruitment for blast-injured TBI patients occurred at the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq. Patients were referred from across the combat theater and evaluated as part of routine clinical assessment of psychiatric and neuropsychological symptoms after exposure to an explosive blast. Four measures of neuropsychological functioning were used: the Military Acute Concussion Evaluation (MACE); the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS); the Headminder Cognitive Stability Index (CSI); and the Automated Neuropsychological Assessment Metrics, Version 4.0 (ANAM4). Three measures of combat exposure and psychological functioning were used: the Combat Experiences Scale (CES); the PTSD Checklist-Military Version (PCL-M); and the Acute Stress Disorder Scale (ASDS). Assessments were completed by a deployed clinical psychologist, clinical social worker, or mental health technician. Results: A total of 894 patients were evaluated. Data from 93 patients were removed from the data set for analysis because they experienced a head injury due to an event that was not an explosive blast (n = 84) or they were only assessed for psychiatric symptoms (n = 9). This resulted in a total of 801 blast-exposed patients for data analysis. Because data were collected in-theater for the initial purpose of clinical evaluation, sample size varied widely between measures, from 565 patients who completed the MACE to 154 who completed the CES. Bivariate correlations revealed that the majority of psychological measures were significantly correlated with each other (ps ≤ 0.01), neuropsychological measures were correlated with each other (ps ≤ 0.05), and psychological and neuropsychological measures were also correlated with each other (ps ≤ 0.05). Conclusions: This paper provides one of the first descriptions of psychological and neuropsychological functioning (and their inter-correlation) within days after blast exposure in a large sample of military personnel. Furthermore, this report describes the methodology used to gather data for the acute assessment of TBI, PTSD, and ASD after exposure to an explosive blast in the combat theater. Future analyses will examine the common and unique symptoms of TBI and PTSD, which will be instrumental in developing new assessment approaches and intervention strategies.

Predictors of Treatment Discontinuation During Prolonged Exposure for PTSD.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a 'sufficient dose' of psychotherapy, potentially limiting treatment gains. AIMS: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. METHOD: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. RESULTS: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. CONCLUSIONS: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.

Relations Between Thwarted Belongingness, Perceived Burdensomeness, and History of Suicide Attempts and Readiness for Mental Health Treatment in High-Risk Veterans, Reserves, and Active Duty Service Members.

Suicide rates for service members and veterans are growing rapidly in the United States. Despite availability of evidence-based approaches, a large number of high-risk individuals are reluctant to seek out treatment. The present study used the interpersonal theory of suicide, involving 3 primary predictors of death by suicide to investigate treatment readiness in high-risk U. S. veterans, reserves, and active duty service members. Four hundred and two service members were recruited. Inclusion criteria involved (a) reporting active suicidal ideation and (b) denying active behavioral health treatment. All participants completed a self-report battery that assessed burdensomeness, thwarted belongingness, lifetime suicide attempts, and perceptions about treatment. Regression analyses revealed that thwarted belongingness was significantly predictive of treatment perceptions and readiness, in that higher or more severe scores on the thwarted belongingness scale were significantly related to lower or less likely treatment perceptions and readiness scores. The findings suggested that, in high-risk service members, thwarted belongingness is predictive of lower treatment readiness, and contributes to the growing literature on perceived stigmas, treatment barriers and readiness, and suicidal behaviors and risk factors.

Substance use disorders in military veterans: prevalence and treatment challenges.

Substance use disorders (SUDs) are a significant problem among our nation's military veterans. In the following overview, we provide information on the prevalence of SUDs among military veterans, clinical characteristics of SUDs, options for screening and evidence-based treatment, as well as relevant treatment challenges. Among psychotherapeutic approaches, behavioral interventions for the management of SUDs typically involve short-term, cognitive-behavioral therapy interventions. These interventions focus on the identification and modification of maladaptive thoughts and behaviors associated with increased craving, use, or relapse to substances. Additionally, client-centered motivational interviewing approaches focus on increasing motivation to engage in treatment and reduce substance use. A variety of pharmacotherapies have received some support in the management of SUDs, primarily to help with the reduction of craving or withdrawal symptoms. Currently approved medications as well as treatment challenges are discussed.

The influence of traumatic brain injury on treatment outcomes of Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) in veterans.

BACKGROUND: The co-occurrence of posttraumatic stress disorder (PTSD), substance use disorders (SUD), and traumatic brain injury (TBI) in veterans of Operations Enduring/Iraqi Freedom and New Dawn has received much attention in the literature. Although hypotheses have been presented and disseminated that TBI history will negatively influence treatment response, little data exist to support these claims. The present study investigates the influence of TBI history on response to COPE (Concurrent Treatment of PTSD and SUD Using Prolonged Exposure), a 12-session, integrated psychotherapy designed to address co-occurring PTSD and SUD. METHOD: Participants were 51 veterans with current PTSD and SUD enrolled in a clinical trial examining COPE. Assessments of PTSD symptoms, substance use, and depression were collected at baseline and each treatment session. A TBI measure was used to dichotomize veterans into groups with and without a history of TBI (ns=30 and 21, respectively). RESULTS: Participants with and without TBI history demonstrated significant improvements in PTSD and depression symptoms during the course of treatment. However, participants with TBI history experienced less improvement relative to participants without TBI history. CONCLUSIONS: The present findings suggest that, although patients with a TBI history respond to treatment, their response to treatment was less so than that observed in patients without a TBI history. As such, identification, symptom monitoring, and treatment practices may require alteration and further special consideration in individuals with PTSD, SUD and TBI.

Dual-hormone stress reactivity predicts downstream war-zone stress-evoked PTSD.

BACKGROUND: The crucial role of the hypothalamic-pituitary-adrenal axis (HPA) in stress-related homeostasis suggests dysregulated HPA involvement in the pathogenesis of post-traumatic stress disorder (PTSD), yet most studies examining linkages between HPA axis measures and PTSD have yielded null findings. One untested explanation for this inconsistency is a failure to account for simultaneous adrenal and gonadal influence. Here we tested the singular and interactive effects of cortisol (CR) and testosterone (TR) reactivity as moderators of war-zone stress evoked PTSD emergence in the war-zone. METHODS: U.S. soldiers (N=120) scheduled for deployment to Iraq completed pre-deployment measures of CR and TR stress reactivity to a CO2 inhalation challenge. Once deployed, monthly assessments of exposure to traumatic war-zone stressors and PTSD symptoms were collected via a web-based assessment system. RESULTS: Cortisol hypo-reactivity potentiated the pathogenic impact of war-zone stressors only in soldiers for whom the CO2 challenge did not elevate testosterone, suggesting that the dual hormone stress reactivity profile of blunted cortisol and testosterone may confer increased risk for PTSD emergence by potentiating the pathogenic effects of war-zone stressors. CONCLUSIONS: Findings underscore the utility of assessing both HPA and HPG stress reactivity when assessing PTSD vulnerability and may help inform efforts for enhanced soldier screening and inoculation to war-zone stressors.