Increased Resilience is Associated with Positive Treatment Outcomes for Veterans with Comorbid PTSD and Substance Use Disorders.

OBJECTIVE: Resilience has been associated with less severe psychiatric symptomatology and better treatment outcomes among individuals with posttraumatic stress disorder (PTSD) and substance use disorders. However, it remains unknown whether resilience increases during psychotherapy within the comorbid PTSD and substance use disorder population with unique features of dual diagnosis, including trauma cue-related cravings. We tested whether veterans seeking psychotherapy for comorbid PTSD and substance use disorder reported increased resilience from pre- to posttreatment. We also tested whether increased resilience was associated with greater decreases in posttreatment PTSD and substance use disorder symptoms. METHODS: Participants were 29 male veterans (Mage = 49.07 years, SD = 11.24 years) receiving six-week residential day treatment including cognitive processing therapy for PTSD and cognitive behavioral therapy for substance use disorder. Resilience, PTSD symptoms, and trauma cue-related cravings were assessed at pre- and posttreatment. RESULTS: Veterans reported a large, significant increase in resilience posttreatment (Mdiff = 14.24, t = -4.22, p < .001, d = 0.74). Greater increases in resilience were significantly associated with fewer PTSD symptoms (ß = -0.37, p = .049, sr = -.36) and trauma-cued cravings (ß = -0.39, p = .006, sr = -.38) posttreatment when controlling for pretreatment scores and baseline depressive symptoms. CONCLUSIONS: Results suggest that evidence-based psychotherapy for comorbid PTSD and substance use disorder may facilitate strength-based psychological growth, which may further promote sustained recovery.

Improving PTSD Symptoms and Preventing Progression of Subclinical PTSD to an Overt Disorder by Treating Comorbid OSA With CPAP.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) and posttraumatic stress disorder (PTSD) are common in United States veterans. These conditions often coexist and symptoms overlap. Previous studies reported improvement in PTSD symptoms with continuous positive airway pressure (CPAP) therapy for comorbid OSA but its effect has not been assessed in a non-PTSD cohort. We have prospectively assessed the effect of CPAP therapy on clinical symptom improvement as a function of CPAP compliance levels among PTSD and non-PTSD veterans. METHODS: Veterans in whom OSA was newly diagnosed were enrolled in our study (n = 192). Assignment to PTSD and non-PTSD cohorts was determined by chart review. Each patient completed the military version of the PTSD Checklist (PCL), Epworth Sleepiness Scale (ESS), and reported nightmare frequency (NMF) at baseline and 6 months after CPAP therapy. CPAP adherence was objectively documented from machine compliance data. RESULTS: We had complete data for 177 veterans (PTSD n = 59, non-PTSD n = 118) for analysis. The mean ages were 51.24 years in the PTSD cohort and 52.36 years in the non-PTSD cohort (P = .30). In the PTSD cohort, the mean total PCL score (baseline = 66.06, post-CPAP = 61.27, P = .004, d = -0.34) and NMF (baseline = 4.61, post-CPAP = 1.49, P = .0001, d = -0.51) decreased after 6 months of CPAP treatment. Linear regression analysis showed that the CPAP compliance was the only significant predictor for these changes among veterans with PTSD (PCL score: P = .033, R2 = .65; NMF; P = .03, R2 = .61). Further analysis by CPAP compliance quartiles in this cohort (Q1 = 0% to 25%, Q2 = 26% to 50%, Q3 = 51% to 75%, Q4 > 75%) revealed that mean total PCL score declined in Q2 (change = -3.91, P = .045, d = 0.43), Q3 (change = -6.6, P = .002, d = 0.59), and Q4 (change = -7.94, P = .037, d = 0.49). In the non-PTSD cohort, the PCL score increased despite CPAP therapy in lower CPAP compliance quartiles Q1 (change = 8.71, P = .0001, d = 0.46) and Q2 (change = 4.51, P = .046, d = 0.27). With higher CPAP compliance (in Q3 and Q4) in this cohort, the mean total PCL scores slightly improved with CPAP but they were not statistically significant (P > .05). CONCLUSIONS: CPAP treatment reduces total PCL score and NMF in veterans with PTSD and OSA. Those with overt PTSD respond to even lower CPAP compliance, whereas non-PTSD patients require higher compliance to achieve any symptom improvement. Poor CPAP compliance results in increased PCL score in non-PTSD veterans and may lead to overt PTSD if the OSA remains undertreated. COMMENTARY: A commentary on this article appears in this issue on page 1121.

An investigation of the relationship between borderline personality disorder and cocaine-related attentional bias following trauma cue exposure: the moderating role of gender.

Elevated rates of borderline personality disorder (BPD) have been found among individuals with substance use disorders (SUDs), especially cocaine-dependent patients. Evidence suggests that cocaine-dependent patients with BPD are at greater risk for negative clinical outcomes than cocaine-dependent patients without BPD and BPD-SUD patients dependent on other substances. Despite evidence that cocaine-dependent patients with BPD may be at particularly high risk for negative SUD outcomes, the mechanisms underlying this risk remain unclear. The present study sought to address this gap in the literature by examining cocaine-related attentional biases among cocaine-dependent patients with (n = 22) and without (n = 36) BPD. On separate days, participants listened to both a neutral and a personally-relevant emotionally evocative (i.e., trauma-related) script and then completed a dot-probe task with cocaine-related stimuli. Findings revealed a greater bias for attending to cocaine-related stimuli among male cocaine-dependent patients with (vs. without) BPD following the emotionally evocative script. Study findings suggest the possibility that cocaine use may have gender-specific functions among SUD patients with BPD, with men with BPD being more likely to use cocaine to decrease contextually induced emotional distress. The implications of our findings for informing future research on cocaine use among patients with BPD are discussed.

Mental health needs of cohabiting partners of Vietnam veterans with combat-related PTSD.

The objectives of this study were to perform an initial needs assessment of partners of Vietnam veterans with combat-related posttraumatic stress disorder (PTSD) and to assess the partners' current rates of treatment use. A telephone survey was conducted with 89 cohabitating female partners of male combat veterans who were receiving outpatient PTSD treatment at two Department of Veterans Affairs medical centers. Although large majorities of partners rated individual therapy and family therapy to help cope with PTSD in the family as highly important, only about one-quarter of the partners had received any mental health care in the previous six months. The most commonly requested service was a women-only group.

Perceived coping ability mediates the relationship between PTSD severity and heart rate recovery in veterans.

Most psychophysiological studies of PTSD have not assessed physiological recovery, correlational relationships between PTSD severity and physiological measures within clinical populations, or mediation by cognitive appraisal. Relationships of PTSD severity to psychophysiological reactivity (to acoustic startle), habituation, and recovery were assessed in 29 combat veterans, and mediation by cognitive appraisal (perceived threat and coping ability) was assessed in a subset (n = 16) of participants. Heart rate (HR) recovery was linearly related to PTSD severity. Perceived ability to cope with the lab task, but not perceived threat inherent in the task, mediated the HR recovery-PTSD association. Potential implications of delayed HR recovery for functioning, treatment outcome, and health-risk in PTSD are presented. Cognitive appraisal may represent an important target for treatments.

Single-voxel proton MR spectroscopy of right versus left hippocampi in PTSD.

Previous magnetic resonance (MR) volume imaging and proton MR spectroscopy studies have suggested a reduction in the hippocampal size and/or neuronal/axonal density in posttraumatic stress disorder (PTSD). The lack of agreement on the laterality of the hippocampal dysfunction prompted this study. A total of 20 veterans (18 men and two women) and one female non-veteran participated in this study conducted in accordance with approved human study protocols. Six of the male veterans and the female non-veteran were without PTSD. Vietnam veterans formed a large subset of the study subjects. Single-voxel proton MR spectra were obtained from the hippocampal region bilaterally on a clinical MR scanner operating at 1.5 T. Analysis of the proton MR spectra showed a decrease in hippocampal NAA/creatine ratio in PTSD subjects significantly higher on the left than the right for the entire study group, as well as for the Vietnam subset. It was concluded that the hippocampal dysfunction in PTSD is lateralized with the left side being more impaired than the right.

Effects of brief training on application of the Global Assessment of Functioning Scale.

31 staff members within one VA medical center were briefly trained in using the Global Assessment of Functioning scale. At both pre- and posttraining participants provided Global Assessment of Functioning scores and identified their GAF-derivation strategies for two vignettes describing hypothetical patients. Analysis showed that initially there was inter- and intrarater inconsistency in strategy for deriving scores and that training increased consistency. Participants persisted in giving ratings that exceeded the criterion score. However, training significantly reduced Global Assessment of Functioning scores for one vignette, bringing scores closer to the criterion, and a significant number of people gave lower ratings after training. The study highlights common errors and points to the need for formal training in use of the scale.