Future thinking in PTSD: Preliminary evidence for altered event construction.

Using a future event fluency task, the current study sought to examine future event construction in PTSD and to identify clinical profiles associated with altered event construction. Thirty-eight trauma exposed war-zone veterans with (n=25) and without (n=13) PTSD generated within one minute as many positive and negative future events as possible in the near and distant future. The PTSD group generated fewer specific, but not generic, events than the no-PTSD group, a difference that was amplified for positive events as a result of comorbid depression. Clinical correlates of event construction varied as a function of event valence.

A Bifactor Evaluation of Self-Report and Clinician-Administered Measures of PTSD in Veterans.

The PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) are two of the most widely used and well-validated PTSD measures providing total and subscale scores that correspond with DSM-5 PTSD symptoms. However, there is little information about the utility of subscale scores above and beyond the total score for either measure. The current study compared the proposed DSM-5 four-factor model to a bifactor model across both measures using a sample of veterans (N = 1,240) presenting to a Veterans Affairs (VA) PTSD specialty clinic. The correlated factors and bifactor models for both measures evidenced marginal-to-acceptable fit and were retained for further evaluation. Bifactor specific indices suggested that both measures exhibited a strong general factor but weak lower-order factors. Structural regressions revealed that most of the lower-order factors provided little utility in predicting relevant outcomes. Although additional research is needed to make definitive statements about the utility of PCL-5 and CAPS-5 subscales, study findings point to numerous weaknesses. As such, caution should be exercised when using or interpreting subscale scores in future research.

Imagining emotional future events in PTSD: clinical and neurocognitive correlates.

Emotional future thinking serves important functions related to goal pursuit and emotion regulation but has been scantly studied in posttraumatic stress disorder (PTSD). The current study sought to characterize emotional future thinking in PTSD and to identify clinical and neurocognitive profiles associated with potential alterations in the level of detail in narratives of imagined future events. Fifty-eight, trauma-exposed, war-zone veterans, who were classified into current PTSD, past PTSD, and no-PTSD groups, were asked to vividly imagine future events in response to positive and negative cue words occurring in the near and distant future. These narratives were scored for internal (i.e., pertaining to the main event) and external (i.e., tangential to the main event) details. Participants also performed neurocognitive tasks of generative ability, working memory, and relational verbal memory. Linear mixed modeling revealed that the current and past PTSD groups generated fewer internal details than the no-PTSD group across positive and negative cue words and across temporal proximity. Partial least squares analysis revealed that symptom severity for all PTSD clusters was inversely associated with production of internal details, albeit with the association relatively weaker for intrusion symptoms. Among the neurocognitive tasks, only relational verbal memory was associated with production of internal details. These findings suggest, as predicted, that functional avoidance may underlie reduced detail generation but also point to potential additional mechanisms to be further investigated. That future event simulation remains overgeneral even when PTSD symptoms abate highlights the importance of addressing alterations in future thinking in this population.

Early predictors of chronic posttraumatic stress disorder symptom trajectories in U.S. Army soldiers deployed to the Iraq war zone.

The course of posttraumatic stress disorder (PTSD) symptoms varies among veterans of war zones, but sources of variation in long-term symptom course remain poorly understood. Modeling of symptom growth trajectories facilitates the understanding of predictors of individual outcomes over time. Although growth mixture modeling (GMM) has been applied to military populations, few studies have incorporated both predeployment and follow-up measurements over an extended time. In this prospective study, 1,087 U.S. Army soldiers with varying military occupational specialties and geographic locations were assessed before and after deployment to the Iraq war zone, with long-term follow-up assessment occurring at least 5 years after return from deployment. The primary outcome variable was the PTSD Checklist-Civilian Version summary score. GMM yielded four latent profiles, characterized as primarily asymptomatic (n = 194, 17.8%); postdeployment worsening symptoms (n = 84, 7.7%); mild symptoms (n = 320, 29.4%); and preexisting, with a chronic postdeployment elevation of symptoms (n = 489, 45.0%). Regression models comparing the primarily asymptomatic class to the symptomatic classes revealed that chronic symptom classes were associated with higher degrees of stress exposure, less predeployment social support, military reservist or veteran status at the most recent assessment, and poorer predeployment visual memory, ORs = 0.98-2.90. PTSD symptom course varies considerably over time after military deployment and is associated with potentially modifiable biopsychosocial factors that occur early in its course in addition to exposures and military status.

Associations of Warzone Veteran and Intimate Partner PTSD Symptoms with Child Depression, Anxiety, Hyperactivity, and Conduct Problems.

Warzone deployment increases risk for posttraumatic stress disorder symptoms (PTSS), including among service members who have children. Parental PTSS are associated with child depression, anxiety, hyperactivity, and conduct problems, yet few studies of child behavioral health outcomes in military populations have accounted for PTSS in both warzone veterans and their partners. Fewer still incorporate non-clinically-recruited samples of nationally dispersed warzone veterans and their families. The current research examines whether children whose parent(s) have higher levels of PTSS exhibit more behavioral health symptoms. One hundred and thirty-three Iraq and Afghanistan War veterans and their cohabitating partners completed clinical interviews and self-report questionnaires. Higher intimate partner PTSS, more extensive child exposure to stressful life events, and being an adolescent were significantly associated with child depression after adjusting for warzone veteran PTSS, demographics, and recent warzone veteran absence from the household. Greater child exposure to stressful life events was also associated with child conduct problems. Treatment of PTSD symptoms experienced by warzone veterans' intimate partners, and preventative interventions aimed at helping the children of warzone veterans cope with stress, may ultimately yield positive benefits for the behavioral health of children in military families.

Neurocognitive Performance Predicts Future Partner Violence Among U.S. Iraq-and Afghanistan-deployed Army Soldiers and Veterans.

Objective: Intimate partner violence (IPV) constitutes a major U.S. national health concern and disproportionately affects military families. Prior research, which has been conducted primarily in civilian populations, suggests that relative neurocognitive weaknesses may increase risk for IPV. This prospective study examined the associations between post-deployment neurocognitive performance and subsequent IPV (5-13 years later) among warzone veterans in the context of psychological health and TBI. Method: Participants were 217 warzone veterans from a nationally-dispersed sample of service members and veterans who had previously deployed to the Iraq war zone and their intimate partners. Warzone veterans had previously completed performance-based neurocognitive assessments at a post-deployment assessment. An average of eight years later, participants completed structured psychiatric interviews and psychometric surveys assessing TBI history, posttraumatic stress disorder (PTSD), depression, alcohol use, and IPV perpetration. Results: Regression analyses revealed that relatively greater psychopathology and history of TBI were significantly associated with more frequent warzone veteran IPV psychological perpetration. Further, relatively poorer post-deployment neurocognitive performance predicted higher subsequent psychological and physical IPV perpetration, adjusting for demographics, psychological health, and TBI. Conclusions: Our findings highlight the importance of identifying both psychological/behavioral and neurocognitive correlates of IPV among warzone veterans. An integrative understanding of IPV risk can help inform both IPV prevention and treatment efforts for warzone veterans.

A cohort study of neuropsychological functioning in spouses of U.S. Gulf War veterans.

AIMS: Veterans of the 1991 Gulf War reported symptoms in their spouses that mirrored veterans' symptoms following their return from the war, including problems with attention and memory. Neuropsychological functioning in these spouses has not been examined with objective tests. This study sought to determine if these spouses exhibited deficits in neuropsychological functioning. MAIN METHODS: Spouses of a national cohort of 1991 Gulf War deployed (n = 470) and non-deployed veterans (n = 524) were examined with neuropsychological tests in 1999-2001. KEY FINDINGS: Neuropsychological tests were factor analyzed yielding five factors: verbal memory, visual memory, attention/working memory, visual organization, and motor speed. Spouses of deployed and nondeployed veterans did not differ on mean factor scores, percentage of impaired factors, or individual test scores. Spouse attention/working memory was related to their having diagnoses of PTSD or anxiety disorders, or self-reported symptoms of current anxiety. Spouse visual memory was related to a diagnosis of current depression. Spouse motor speed was related to their own status of having chronic multisymptom illness (CMI). SIGNIFICANCE: Spouses of Gulf War deployed and nondeployed veterans demonstrated similar neuropsychological functioning, although spouses with psychiatric diagnoses and symptoms, or CMI demonstrated neuropsychological impairments characteristic of those conditions, suggesting that monitoring spouses for these conditions and impairments may be warranted. This pattern of relative weaknesses mirrors some of the previously reported findings for Gulf War veterans, although the veterans displayed neuropsychological impairments beyond what was accounted for by these conditions.

Patterning of individual variability in neurocognitive health among South African women exposed to childhood maltreatment.

There are individual differences in health outcomes following exposure to childhood maltreatment, yet constant individual variance is often assumed in analyses. Among 286 Black, South African women, the association between childhood maltreatment and neurocognitive health, defined here as neurocognitive performance (NP), was first estimated assuming constant variance. Then, without assuming constant variance, we applied Goldstein's method (Encyclopedia of statistics in behavioral science, Wiley, 2005) to model "complex level-1 variation" in NP as a function of childhood maltreatment. Mean performance in some tests of information processing speed (Digit-symbol, Stroop Word, and Stroop Color) lowered with increasing severity of childhood maltreatment, without evidence of significant individual variation. Conversely, we found significant individual variation by severity of childhood maltreatment in tests of information processing speed (Trail Making Test) and executive function (Color Trails 2 and Stroop Color-Word), in the absence of mean differences. Exploratory results suggest that the presence of individual-level heterogeneity in neurocognitive performance among women exposed to childhood maltreatment warrants further exploration. The methods presented here may be used in a person-centered framework to better understand vulnerability to the toxic neurocognitive effects of childhood maltreatment at the individual level, ultimately informing personalized prevention and treatment.

Associations Among Increases in Posttraumatic Stress Symptoms, Neurocognitive Performance, and Long-Term Functional Outcomes in U.S. Iraq War Veterans.

Cross-sectional research suggests that posttraumatic stress symptoms (PTSS) among war zone veterans are associated with functional impairment and poor quality of life. Less is known about the long-term functional repercussions of PTSS. This study of Iraq War veterans examined the associations between increases in PTSS and long-term functional outcomes, including the potential contributions of neurocognitive decrements. Service members and veterans (N = 594) completed self-report measures of functioning and PTSS severity before Iraq War deployment and again after their return (M = 9.3 years postdeployment). Some participants (n = 278) also completed neurocognitive testing at both times. Multiple regression analyses with the full sample-adjusted for TBI, demographic characteristics, military variables, and predeployment PTSS and functioning-revealed that increased PTSS severity over time was significantly associated with unemployment, aOR = 1.04, 95% CI [1.03, 1.06]; poorer work performance; and poorer physical, emotional, and cognitive health-related functioning at long-term follow-up, f2 s = 0.37-1.79. Among participants who completed neurocognitive testing, a decline in select neurocognitive measures was associated with poorer functioning; however, neurocognitive decrements did not account for associations between increased PTSS and unemployment, aOR = 1.04, 95% CI [1.02, 1.07], with the size and direction upheld after adding neurocognitive variables, or poorer functional outcomes, with small increases after adding neurocognitive measures to the models, f2 s = 0.03-0.10. War zone veterans experiencing long-term increased PTSS and/or neurocognitive decrements may be at elevated risk for higher-level functional impairment over time, suggesting that early PTSS management may enhance long-term functioning.

Factors Influencing Family Environment Reporting Concordance Among U.S. War Zone Veterans and Their Partners.

A key challenge in the assessment of family variables is the discrepancies that arise between reports. Although prior research has observed levels of interpartner agreement on the family environment, no studies have investigated factors that may influence agreement. In this study, war zone veterans (WZVs) and their partners (N = 207 couples) completed assessments of the family environment. We examined interpartner agreement in relation to WZV and partner posttraumatic stress disorder (PTSD) symptoms, WZV time away from home, and family size. More severe WZV PTSD symptoms were associated with greater interpartner agreement on family environment, whereas more severe partner PTSD symptoms were associated with reporting more negative perceptions of the family environment relative to WZV reports. Family size was associated with greater interpartner agreement. Factors associated with concordance in this study should be considered by clinicians and researchers seeking to understand and address reporting discrepancies on the family.

Associations of warzone veteran mental health with partner mental health and family functioning: Family Foundations Study.

INTRODUCTION: Warzone participation is associated with increased risk of stress-related psychopathology, including posttraumatic stress disorder (PTSD) and depression. Prior research suggests that the mental health of spouses of warzone veterans (WZVs) is linked to that of their partners. Additionally, PTSD among WZVs has been associated with marital dysfunction. Less is known about the effects of depression among WZVs on partner mental health and family relationships. We sought in this study to examine associations between WZV PTSD and depression and partner mental health and relationship outcomes. METHODS: Using a nationally dispersed sample of Iraq and Afghanistan veterans and their married and unmarried intimate partners, 245 dyads completed structured psychiatric interviews and psychometric surveys assessing family functioning and relationship aggression. RESULTS: Adjusted regression analyses indicated that depression among WZVs was associated with partner depression and anxiety disorders. WZV PTSD and depression were also associated with partner-reported relationship dysfunction, dissatisfaction, and communication issues, and higher rates of intimate partner aggression victimization and perpetration. CONCLUSIONS: Mental health consequences of war extend beyond WZVs to the mental health of their intimate partners and their relationships with intimate partners.

The 20-year course of posttraumatic stress disorder symptoms among veterans.

Although numerous longitudinal studies have examined heterogeneity in posttraumatic stress disorder (PTSD) symptom course, the long-term course of the disorder remains poorly understood. This study sought to understand and predict long-term PTSD symptom course among a nationwide sample of Operations Enduring Freedom and Iraqi Freedom veterans enrolled in Veterans Health Administration services. We assessed PTSD symptoms at 4 time points over approximately 4.5 years (M = 55.11 months, SD = 6.89). Participants (N = 1,353) with and without probable PTSD were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio to fully explore the heterogeneity of PTSD symptom course and the effect of sex on symptom course. By coding time as years since index trauma, we estimated the course of PTSD symptoms over 20 years. Results indicate symptom course is most appropriately characterized by substantial heterogeneity. On average, veterans experienced initial PTSD symptom severity above the diagnostic threshold following trauma exposure, which was initially stable over time and later began to gradually improve. Although results indicate symptoms eventually began to decline, this effect was gradual; most participants continued to meet or exceed the PTSD provisional diagnostic threshold long after trauma exposure. We identified several predictors and correlates of symptom course, including Hispanic ethnicity, postdeployment social support, and co-occurring psychopathology. Results highlight the heterogeneous nature of PTSD symptom course following trauma exposure and the urgency of the need to ensure access to evidence-based care and to improve available treatments. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Long-term negative emotional outcomes of warzone TBI.

OBJECTIVE: Many veterans of the Iraq and Afghanistan Wars have experienced traumatic brain injury (TBI). Although prior work has examined associations between TBI and development of psychiatric syndromes, less is known about associations between TBI and component emotions constituting these syndromes, especially in the long term. The purpose of this study was to examine the long-term emotional consequences of deployment-related TBI. METHODS: As part of VA Cooperative Studies Program #566, we assessed a sample of n = 456 US Army soldiers prior to an index deployment to Iraq, and again an average of 8.3 years (SD = 2.4 years) after their deployment for a long-term follow-up assessment. In this report, we used adjusted regression analyses to examine the relationship of deployment TBI to depression, anxiety, and stress symptom severity measured at the long-term follow-up assessment. A structured interview was used to determine TBI history; the Depression, Anxiety, and Stress Scale, 21-item version (DASS-21) was used to determine emotional status at the follow-up evaluation. RESULTS: Warzone TBI events, particularly when greater than mild in severity, were independently associated with depression, anxiety, and stress severity at long-term follow-up, even after taking into account variance attributable to pre-deployment emotional distress and war-zone stress. Post-hoc analyses did not detect independent associations of either number of events or injury mechanism with outcomes. CONCLUSIONS: These findings highlight the potentially enduring and multi-faceted emotional effects of deployment TBI, underscoring the need for early assessment of negative affectivity in warzone veterans reporting TBI.

Posttraumatic stress disorder and neurocognition: A bidirectional relationship?

There are well-known associations between PTSD and neurocognition, however, the direction of causality between the two is not well-understood. Neurocognition may alter risk of the development and maintenance of PTSD. Conversely, PTSD may pose risk to neurocognitive integrity. With cognitive and neurobiological conceptualizations of PTSD as a backdrop, this review will summarize results from several lines of research including preclinical, human analogue, retrospective, longitudinal, and treatment studies to inform the directional relationships between PTSD and neurocognition. Based on the collective findings from these related literatures, we suggest that a negative feedback loop between PTSD and neurocognition exists but that PTSD treatment and cognitive enhancement strategies may break this loop.

Mental health in spouses of U.S. Gulf War veterans.

Veterans' spouses are at risk for mental distress and substance use. We examined long term psychological functioning in spouses from a national cohort of 1991 Gulf War era veterans. From clinical interviews, spouses of deployed veterans (n = 488) did not have a greater prevalence of post-war mental disorders compared to spouses of non-deployed veterans (n = 536); however, in couples that were living together since the war, there was an increased risk of anxiety disorders or any one disorder. On questionnaires, the impact varied but was most consistently observed in more severe depression and greater functional impairment in spouses of deployed compared to non-deployed veterans. If a veteran developed post-war anxious/depressive disorders or any one mental disorder, the matched spouse was more likely to develop post-war anxious/depressive disorders or any one mental disorder, respectively. Veteran combat exposure did not similarly increase the risk of spouse post-war mental disorders. Greater spouse self-reported symptomatology was observed in spouses of veterans with anxious/depressive disorders even when controlling for deployment. In summary, the war conferred greater risk for spouse mental disorders and distress for spouses of veterans with mental health disorders, with some increased risk for spouses of deployed veterans, especially in couples together since the war.

Associations Between Trauma-Related Rumination and Symptoms of Posttraumatic Stress and Depression in Treatment-Seeking Female Veterans.

Trauma-related rumination is a cognitive style characterized by repetitive negative thinking about the causes, consequences, and implications of a traumatic experience. Frequent trauma-related rumination has been linked to posttraumatic stress disorder (PTSD) and depression in civilian samples but has yet to be examined among military veterans. This study extended previous research by examining trauma-related rumination in female veterans who presented to a Veterans Affairs women's trauma recovery clinic (N = 91). The study had two main aims: (a) to examine associations between trauma-related rumination and specific PTSD symptoms, adjusting for the overlap between trauma-related rumination and other relevant cognitive factors, such as intrusive trauma memories and self-blame cognitions; and (b) to assess associations between trauma-related rumination, PTSD, and depression, adjusting for symptom comorbidity. At intake, patients completed a semistructured interview and self-report questionnaires. Primary diagnoses were confirmed via medical record review. Trauma-related rumination was common, with more than 80% of patients reporting at least sometimes engaging in this cognitive style in the past week. After adjusting for other relevant cognitive factors, trauma-related rumination was significantly associated with several specific PTSD symptoms, rp s = .33-.48. Additionally, the severity of trauma-related rumination was associated with overall PTSD symptom severity, even after adjusting for comorbid depression symptoms, rp 2 = .35. In contrast, the association between trauma-related rumination and depressive symptom severity was not significant after adjusting for comorbid PTSD symptoms, rp 2 = .008. These results highlight trauma-related rumination as a unique contributing factor to the complex clinical presentation for a subset of trauma-exposed veterans.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Asociaciones entre la rumiación relacionada con el trauma y síntomas de estrés postraumático y depresión en Mujeres Veteranas en busca de tratamiento RUMINACIÓN RELACIONADA CON EL TRAUMA EN MUJERES VETERANAS La rumiación relacionada con el trauma es un estilo cognitivo caracterizado por pensamientos negativos repetitivos sobre las causas, consecuencias e implicaciones de una experiencia traumática. Frecuentemente la rumiación relacionada con el trauma se ha relacionado con el trastorno de estrés postraumático (TEPT) y la depresión en muestras de civiles, pero aún no se ha examinado entre los veteranos militares. Este estudio extendió la investigación previa al examinar la rumiación relacionada con el trauma en mujeres veteranas que acudieron a una clínica de recuperación de trauma para mujeres del VA (N = 91). El estudio tenía dos objetivos principales: examinar (a) las asociaciones entre la rumiación relacionada con el trauma y los síntomas específicos de TEPT, ajustándose a la superposición entre la rumiación relacionada con el trauma y otros factores cognitivos relevantes, como los recuerdos intrusivos del trauma y las cogniciones de auto-culpa; y (b) asociaciones entre rumiación relacionada con el trauma, TEPT y depresión, ajustando la comorbilidad de los síntomas. En el momento del ingreso, los pacientes completaron una entrevista semiestructurada y cuestionarios de autoinforme. Los diagnósticos primarios fueron confirmados a través de la revisión de la historia clínica. La rumiación relacionada con el trauma fue común, con más del 80% de los pacientes que informaron que al menos a veces se involucraron en este estilo cognitivo en la última semana. Después de ajustar otros factores cognitivos relevantes, la rumiación relacionada con el trauma se asoció significativamente con varios síntomas específicos de TEPT, rp s = .33 - .48. Además, la gravedad de la rumiación relacionada con el trauma se asoció con la gravedad general de los síntomas del TEPT incluso después de ajustar los síntomas de depresión comórbida, rp 2 = .35. En contraste, la asociación entre la rumiación relacionada con el trauma y la gravedad de los síntomas depresivos no fue significativa después de ajustar los síntomas de trastorno de estrés postraumático comórbido, rp 2 = .008. Estos resultados resaltan la rumiación relacionada con el trauma como un factor único contribuyente a la compleja presentación clínica para un subconjunto de veteranas expuestas a traumas.

Neurocognitive and Information Processing Biases in Posttraumatic Stress Disorder.

PURPOSE OF REVIEW: We review recent research addressing neurocognitive and information processing abnormalities in posttraumatic stress disorder (PTSD), including studies informing direction of causality. We additionally consider neurocognition in the context of co-morbid mild traumatic brain injury (TBI) and psychosocial treatments for PTSD. RECENT FINDINGS: Learning, memory, attention, inhibitory functions, and information processing biases frequently accompany PTSD, reflecting potential bi-directional relationships with PTSD. Although mild TBI is associated with increased risk of PTSD development and maintenance, TBI does not typically contribute significantly to sustained neurocognitive deficits in individuals with PTSD. Whereas better learning and memory is associated with mildly enhanced response to psychosocial interventions, such interventions may also improve neurocognitive performance and can be effectively provided to patients with TBI history. PTSD is associated with cognitive abnormalities in processing both emotionally relevant and emotionally neutral information and, although mild, may underlie some PTSD symptom expression.

Associations of Stress Exposures and Social Support With Long-Term Mental Health Outcomes Among U.S. Iraq War Veterans.

The long-term mental health effects of war-zone deployment in the Iraq and Afghanistan wars on military personnel are a significant public health concern. Using data collected prospectively at three distinct assessments during 2003-2014 as part of the Neurocognition Deployment Health Study and VA Cooperative Studies Program Study #566, we explored how stress exposures prior, during, and after return from deployment influence the long-term mental health outcomes of posttraumatic stress disorder (PTSD), depression, anxiety disorders, and problem drinking. Longer-term mental health outcomes were assessed in 375 service members and military veterans an average of 7.5 years (standard deviation = 1.0 year) after the initial (i.e., "index") Iraq deployment following their predeployment assessment. Anxiety disorder was the most commonly observed long-term mental health outcome (36.0%), followed by depression (24.5%), PTSD (24.3%), and problem drinking (21.0%). Multivariable regression models showed that greater postdeployment stressors, as measured by the Post-Deployment Life Events scale, were associated with greater risk of depression, anxiety disorders, and problem drinking. Anxiety disorder was the only outcome affected by predeployment stress concerns. In addition, greater postdeployment social support was associated with lower risk of all outcomes except problem drinking. These findings highlight the importance of assessing postdeployment stress exposures, such as stressful or traumatic life events, given the potential impact of these stressors on long-term mental health outcomes. This study also highlights the importance of postdeployment social support as a modifiable protective factor that can be used to help mitigate risk of long-term adverse mental health outcomes following war-zone exposure.