Psychometric properties of a brief measure of posttraumatic stress disorder-related impairment: The Brief Inventory of Psychosocial Functioning.

This study validated the Brief Inventory of Psychosocial Functioning (B-IPF), an abridged version of the 80-item Inventory of Psychosocial Functioning (IPF; Bovin et al., 2018). The B-IPF-a 7-item self-report questionnaire that assesses posttraumatic stress disorder (PTSD)-related psychosocial functional impairment-was developed for use in settings in which the full IPF would be too time intensive to administer. In this study, we examined the psychometric properties of the B-IPF among a sample of 362 veterans recruited from 2 Veterans Affairs hospitals. The B-IPF demonstrated high internal consistency (Cronbach's alpha = .84) and adequate test-retest reliability (r = .65, p < .001). The B-IPF was strongly correlated with the IPF (r = .71, p < .01) and had higher correlations with measures of mental health impairment and quality of life (all rs > ∥.50∥; all ps < .001) than with a measure of physical health impairment (i.e., the Physical Component Summary; r = -.34; p < .001), which demonstrated strong construct validity. In addition, the B-IPF displayed strong criterion-related validity, with higher correlations with a PTSD symptom measure, (r = .63, p < .05), and measures of other internalizing disorders (all rs > .44; all ps < .05) and a lower correlation with a measure of an externalizing disorder (r = .14; p < .05). These results indicate that the B-IPF is a reliable and valid instrument for assessing PTSD-related impairment. The strong psychometric properties of the instrument, in addition to its length, make it ideal for settings in which time is a factor. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Heart Rate Variability and Cognitive Bias Feedback Interventions to Prevent Post-deployment PTSD: Results from a Randomized Controlled Trial.

Introduction: There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed. Materials and Methods: This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB. Results: Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers. Conclusion: Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

Development and validation of a measure of PTSD-related psychosocial functional impairment: The Inventory of Psychosocial Functioning.

This study describes the three-phase development and validation of the Inventory of Psychosocial Functioning (IPF), an 80-item, self-report measure of posttraumatic stress disorder (PTSD)-related psychosocial functional impairment. In Phase I, we conducted 12 focus groups with male and female veterans (n = 53) to identify and operationalize the domains of psychosocial impairment associated with PTSD. This information was used to develop the IPF. We subsequently evaluated the psychometric properties of the newly developed inventory in Phases II (n = 276) and III (n = 368) using two independent samples of veterans. We found that the overall IPF score demonstrated stronger correlations with measures of mental health-related impairment (all rs > |.39|; all ps < .05) and weaker correlations with measures of physical health-related impairment (all rs < |.29|; all ps < .05). Overall IPF scores were most strongly associated with PTSD and other disorders associated with the anxious-misery factor of the three-factor model of psychiatric comorbidity (all rs > .56; all ps < .05) and less strongly associated with disorders associated with the fear factor (all rs < .48; all ps < .05) and the externalizing factor (r = .16; p < .05). The IPF demonstrated strong test-retest reliability (r = .77; p < .05). Our results suggest that the IPF is a valid and reliable measure of PTSD-related psychosocial functional impairment. (PsycINFO Database Record

PHIT for Duty, a Mobile Application for Stress Reduction, Sleep Improvement, and Alcohol Moderation.

Post-traumatic stress and other problems often occur after combat, deployment, and other military operations. Because techniques such as mindfulness meditation show efficacy in improving mental health, our team developed a mobile application (app) for individuals in the armed forces with subclinical psychological problems as secondary prevention of more significant disease. Based on the Personal Health Intervention Toolkit (PHIT), a mobile app framework for personalized health intervention studies, PHIT for Duty integrates mindfulness-based relaxation, behavioral education in sleep quality and alcohol use, and psychometric and psychophysiological data capture. We evaluated PHIT for Duty in usability and health assessment studies to establish app quality for use in health research. Participants (N = 31) rated usability on a 1 (very hard) to 5 (very easy) scale and also completed the System Usability Scale (SUS) questionnaire (N = 9). Results were (mean ± SD) overall (4.5 ± 0.6), self-report instruments (4.5 ± 0.7), pulse sensor (3.7 ± 1.2), sleep monitor (4.4 ± 0.7), sleep monitor comfort (3.7 ± 1.1), and wrist actigraphy comfort (2.7 ± 0.9). The average SUS score was 85 ± 12, indicating a rank of 95%. A comparison of PHIT-based assessments to traditional paper forms demonstrated a high overall correlation (r = 0.87). These evaluations of usability, health assessment accuracy, physiological sensing, system acceptability, and overall functionality have shown positive results and affirmation for using the PHIT framework and PHIT for Duty application in mobile health research.

Improving assessment of race, ethnicity, and culture to further veteran PTSD research.

OBJECTIVE: Racial and ethnic disparities in posttraumatic stress disorder (PTSD) and its treatment have been documented for both civilians and military veterans. To better understand the presence of disparities and factors that might contribute to them, accurate assessment of race and ethnicity is critical; however there still remains unstandardized assessment and challenges to implementation. The authors highlight specific problems in the assessment of race and ethnicity in research, such as missing data, misclassification, classification categories too limited to reflect many peoples' social identities, and inappropriate aggregation of ethnoracial subgroups. CONCLUSIONS: A proposal is made for a minimal uniform assessment standard of race and ethnicity. Additional recommendations incorporate principles proposed by the Institute of Medicine that allow for more granular assessment of race and ethnicity to better capture individual identity and cultural factors as they relate to the assessment, experience and management of PTSD. (PsycINFO Database Record

Heart rate variability: Pre-deployment predictor of post-deployment PTSD symptoms.

Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores.

Toward Preventing Post-Traumatic Stress Disorder: Development and Testing of a Pilot Predeployment Stress Inoculation Training Program.

The objective of this pilot study was to design, develop, and evaluate a predeployment stress inoculation training (PRESIT) preventive intervention to enable deploying personnel to cope better with combat-related stressors and mitigate the negative effects of trauma exposure. The PRESIT program consisted of three predeployment training modules: (1) educational materials on combat and operational stress control, (2) coping skills training involving focused and relaxation breathing exercises with biofeedback, and (3) exposure to a video multimedia stressor environment to practice knowledge and skills learned in the first two modules. Heart rate variability assessed the degree to which a subset of participants learned the coping skills. With a cluster randomized design, data from 351 Marines randomized into PRESIT and control groups were collected at predeployment and from 259 of these who responded to surveys on return from deployment. Findings showed that the PRESIT group reduced their physiological arousal through increased respiratory sinus arrhythmia during and after breathing training relative to controls. Logistic regression, corrected for clustering at the platoon level, examined group effects on post-traumatic stress disorder (PTSD) as measured by the Post-traumatic Stress Checklist after controlling for relevant covariates. Results showed that PRESIT protected against PTSD among Marines without baseline mental health problems. Although limited by a small number of participants who screened positive for PTSD, this study supports the benefits of PRESIT as a potential preventive strategy in the U.S. military personnel.

Effect of Symptom Over-Reporting on Heart Rate Variability in Veterans With Posttraumatic Stress Disorder.

Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.

The impact of multiple concussions on emotional distress, post-concussive symptoms, and neurocognitive functioning in active duty United States marines independent of combat exposure or emotional distress.

Controversy exists as to whether the lingering effects of concussion on emotional, physical, and cognitive symptoms is because of the effects of brain trauma or purely to emotional factors such as post-traumatic stress disorder or depression. This study examines the independent effects of concussion on persistent symptoms. The Defense Automated Neurobehavioral Assessment, a clinical decision support tool, was used to assess neurobehavioral functioning in 646 United States Marines, all of whom were fit for duty. Marines were assessed for concussion history, post-concussive symptoms, emotional distress, neurocognitive functioning, and deployment history. Results showed that a recent concussion or ever having experienced a concussion was associated with an increase in emotional distress, but not with persistent post-concussive symptoms (PPCS) or neurocognitive functioning. Having had multiple lifetime concussions, however, was associated with greater emotional distress, PPCS, and reduced neurocognitive functioning that needs attention and rapid discrimination, but not for memory-based tasks. These results are independent of deployment history, combat exposure, and symptoms of post-traumatic stress disorder and depression. Results supported earlier findings that a previous concussion is not generally associated with post-concussive symptoms independent of covariates. In contrast with other studies that failed to find a unique contribution for concussion to PPCS, however, evidence of recent and multiple concussion was seen across a range of emotional distress, post-concussive symptoms, and neurocognitive functioning in this study population. Results are discussed in terms of implications for assessing concussion on return from combat.

A personal health information toolkit for health intervention research.

With the emergence of mobile health (mHealth) apps, there is a growing demand for better tools for developing and evaluating mobile health interventions. Recently we developed the Personal Health Intervention Toolkit (PHIT), a software framework which eases app implementation and facilitates scientific evaluation. PHIT integrates self-report and physiological sensor instruments, evidence-based advisor logic, and self-help interventions such as meditation, health education, and cognitive behavior change. PHIT can be used to facilitate research, interventions for chronic diseases, risky behaviors, sleep, medication adherence, environmental monitoring, momentary data collection health screening, and clinical decision support. In a series of usability evaluations, participants reported an overall usability score of 4.5 on a 1-5 Likert scale and an 85 score on the System Usability Scale, indicating a high percentile rank of 95%.

Virtual reality graded exposure therapy with arousal control for the treatment of combat related posttraumatic stress disorder: a follow up case series.

Important challenges confronting DOD/military medical care are that of maintaining or increasing quality of care and increasing the effectiveness of treatments for warriors diagnosed with Posttraumatic Stress Disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy with Arousal Control (VR-GET) has demonstrated a positive treatment effectiveness resulting in significant reductions of PTSD symptom severity. This positive treatment effectiveness has been maintained for up to 22 weeks after VR-GET therapy was completed. A robust methodology for the assessment of Virtual Reality efficacy suggests that the ideal time for follow-up begins at twelve months. Others have suggested that follow-up should occur between two and four years post treatment. In this report we describe the outcome of VR-GET for the treatment of combat-related PTSD with three warriors between five and seven years following their having completed treatment.

Effect of virtual reality PTSD treatment on mood and neurocognitive outcomes.

Virtual reality (VR) is an emerging tool to help treat posttraumatic stress disorder (PTSD). Previously published studies have shown that VR graded exposure therapy (VR-GET) treatment can result in improvements in PTSD symptoms. Less is known about the impact on depression, general anxiety, and neuropsychological functioning in patients with PTSD. This study examined changes in self-reports of PTSD, depression, and anxiety before and after treatment, and also examined neuropsychological functioning as assessed by a computerized test of simple reaction time, procedural reaction time, and performance on the congruent, incongruent, emotional, and neutral (match the color of the "nonsense word") Stroop tests. Results showed that subjects treated with VR-GET showed significant reductions in PTSD and anxiety severity and significant improvements on the emotional Stroop test. Changes in depression and other measures of neuropsychological function were not significant. Change scores on the emotional Stroop test did not correlate with changes in self-report measures of PTSD. Overall, these findings support the use of VR-GET as a treatment for PTSD but indicate that benefits may be narrowly focused. Additional treatments may be needed after or alongside VR-GET for service members with neuropsychological impairments.

AltitudeOmics: the integrative physiology of human acclimatization to hypobaric hypoxia and its retention upon reascent.

An understanding of human responses to hypoxia is important for the health of millions of people worldwide who visit, live, or work in the hypoxic environment encountered at high altitudes. In spite of dozens of studies over the last 100 years, the basic mechanisms controlling acclimatization to hypoxia remain largely unknown. The AltitudeOmics project aimed to bridge this gap. Our goals were 1) to describe a phenotype for successful acclimatization and assess its retention and 2) use these findings as a foundation for companion mechanistic studies. Our approach was to characterize acclimatization by measuring changes in arterial oxygenation and hemoglobin concentration [Hb], acute mountain sickness (AMS), cognitive function, and exercise performance in 21 subjects as they acclimatized to 5260 m over 16 days. We then focused on the retention of acclimatization by having subjects reascend to 5260 m after either 7 (n = 14) or 21 (n = 7) days at 1525 m. At 16 days at 5260 m we observed: 1) increases in arterial oxygenation and [Hb] (compared to acute hypoxia: PaO2 rose 9±4 mmHg to 45±4 while PaCO2 dropped a further 6±3 mmHg to 21±3, and [Hb] rose 1.8±0.7 g/dL to 16±2 g/dL; 2) no AMS; 3) improved cognitive function; and 4) improved exercise performance by 8±8% (all changes p<0.01). Upon reascent, we observed retention of arterial oxygenation but not [Hb], protection from AMS, retention of exercise performance, less retention of cognitive function; and noted that some of these effects lasted for 21 days. Taken together, these findings reveal new information about retention of acclimatization, and can be used as a physiological foundation to explore the molecular mechanisms of acclimatization and its retention.

Defense Automated Neurobehavioral Assessment (DANA)-psychometric properties of a new field-deployable neurocognitive assessment tool.

The Defense Automated Neurobehavioral Assessment (DANA) is a new neurocognitive assessment tool that includes a library of standardized cognitive and psychological assessments, with three versions that range from a brief 5-minute screen to a 45-minute complete assessment. DANA is written using the Android open-source operating system and is suitable for multiple mobile platforms. This article presents testing of DANA by 224 active duty U.S. service members in five operationally relevant environments (desert, jungle, mountain, arctic, and shipboard). DANA was found to be a reliable instrument and compared favorably to other computer-based neurocognitive assessments. Implications for using DANA in far-forward military settings are discussed.

The effectiveness of VR exposure therapy for PTSD in returning warfighters.

In the decade following the attack on the World Trade Center, over 2.3 million American military personnel were deployed to Iraq and Afghanistan. Lengthy tours of duty and multiple re-deployments were characteristic of these operations. Research findings demonstrate that prolonged exposure to combat increases the risk of developing posttraumatic stress disorder (PTSD). The current study was a randomized controlled clinical trial designed to assess the effectiveness of a novel intervention to treat combat-related PTSD in returning Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) warfighters. A cognitive behavior treatment approach augmented with virtual reality exposure therapy (VRE) was developed, and administered for 10 treatment sessions over 5 weeks. Comparisons with a control group receiving minimal attention (MA) for 5 weeks revealed that the VRE group had significant reductions in the avoidance/numbing symptoms on the Clinician Administered PTSD Scale (CAPS). The VRE group also had significant reductions in guilt at post-treatment compared to the control group.

PHIT for duty, a mobile approach for psychological health intervention.

The goal of this effort is to support prevention of psychological health problems through innovation in mobile personal health assessment and self-help intervention (SHI). For the U.S. military, we are developing and evaluating a field-deployable personalized application, PHIT for DutyTM, to help build resilience in healthy troops and support prevention in high-risk personnel. PHIT for Duty is delivered using any smartphone or tablet with optional nonintrusive physiological and behavioral sensors for health status monitoring. The application integrates a suite of health assessments with an intelligent advisor that recommends, tailors, and presents self-help advisories. PHIT for Duty is intended for secondary prevention of psychological health problems in persons who have been exposed to psychological trauma and may be showing some symptoms of distress, but have not been diagnosed with any psychological disease or disorder.

Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan.

This study was an open-label, single-group, treatment-development project aimed at developing and testing a method for applying virtual reality exposure therapy (VRET) to active duty service members diagnosed with combat post-traumatic stress disorder (PTSD). Forty-two service members with PTSD were enrolled, and 20 participants completed treatment. The PTSD Checklist-Military version, Patient Health Questionnaire-9 for depression, and the Beck Anxiety Inventory were used as outcome measures. Of those who completed post-treatment assessment, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post treatment. Average PSTD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Intention-to-treat analyses showed that statistically significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up. There were no adverse events associated with VRET treatment. This study provides preliminary support for the use of VRET in combat-related PTSD. Further study will be needed to determine the wider utility of the method and to determine if it offers advantages over other established PTSD treatment modalities.

A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Lessons learned from 350 virtual-reality sessions with warriors diagnosed with combat-related posttraumatic stress disorder.

Virtual-reality (VR) therapy has been distinguished from other psychotherapy interventions through the use of computer-assisted interventions that rely on the concepts of "immersion," "presence," and "synchrony." In this work, these concepts are defined, and their uses, within the VR treatment architecture, are discussed. VR therapy's emphasis on the incorporation of biofeedback and meditation, as a component of the VR treatment architecture, is also reviewed. A growing body of research has documented VR therapy as a successful treatment for combat-related Posttraumatic Stress Disorder (PTSD). The VR treatment architecture, utilized to treat 30 warriors diagnosed with combat-related PTSD, is summarized. Lastly, case summaries of two warriors successfully treated with VR therapy are included to assist with the goal of better understanding a VR treatment architecture paradigm. Continued validation of the VR treatment model is encouraged.