Validation of an Electronic Medical Record-Based Algorithm for Identifying Posttraumatic Stress Disorder in U.S. Veterans.

We developed an algorithm for identifying U.S. veterans with a history of posttraumatic stress disorder (PTSD), using the Department of Veterans Affairs (VA) electronic medical record (EMR) system. This work was motivated by the need to create a valid EMR-based phenotype to identify thousands of cases and controls for a genome-wide association study of PTSD in veterans. We used manual chart review (n = 500) as the gold standard. For both the algorithm and chart review, three classifications were possible: likely PTSD, possible PTSD, and likely not PTSD. We used Lasso regression with cross-validation to select statistically significant predictors of PTSD from the EMR and then generate a predicted probability score of being a PTSD case for every participant in the study population (range: 0-1.00). Comparing the performance of our probabilistic approach (Lasso algorithm) to a rule-based approach (International Classification of Diseases [ICD] algorithm), the Lasso algorithm showed modestly higher overall percent agreement with chart review than the ICD algorithm (80% vs. 75%), higher sensitivity (0.95 vs. 0.84), and higher accuracy (AUC = 0.95 vs. 0.90). We applied a 0.7 probability cut-point to the Lasso results to determine final PTSD case-control status for the VA population. The final algorithm had a 0.99 sensitivity, 0.99 specificity, 0.95 positive predictive value, and 1.00 negative predictive value for PTSD classification (grouping possible PTSD and likely not PTSD) as determined by chart review. This algorithm may be useful for other research and quality improvement endeavors within the VA.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Validación de un algoritmo basado en registros médicos electrónicos para identificar el trastorno por estrés postraumático en veteranos de los EE. UU. VALIDACIÓN DE ALGORITOMO DE TEPT Desarrollamos un algoritmo para identificar a los veteranos de EE. UU. con historial de trastorno de estrés postraumático (TEPT), utilizando el sistema de registro médico electrónico (RME) del Departamento de Asuntos de Veteranos (AS). Este trabajo fue motivado por la necesidad de crear un fenotipo válido, basado en RME para identificar miles de casos y controles para un estudio de asociación del genoma del TEPT en los veteranos. Utilizamos la revisión manual de tablas (n = 500) como gold estándar. Tanto para el algoritmo como para la revisión de la tabla, fueron posibles tres clasificaciones: PTSD probable, PTSD posible y probablemente no PTSD. Usamos la regresión Lasso con validación cruzada para seleccionar los factores de pronóstico estadísticamente significativos del TEPT a partir de la RME y luego generar una puntuación de probabilidad pronosticada de ser un caso de TEPT para cada participante en la población del estudio (rango: 0-1.00). Comparando el rendimiento de nuestro enfoque probabilístico (algoritmo Lasso) con un enfoque basado en reglas (algoritmo de Clasificación Internacional de Enfermedades [CIE]), el algoritmo Lasso mostró un porcentaje de acuerdo global modestamente más alto con la revisión de tablas que el algoritmo CIE (80% vs. 75). %), mayor sensibilidad (0.95 frente a 0.84) y mayor precisión (AUC = 0.95 frente a 0.90). Aplicamos un punto de corte de probabilidad de 0.7 a los resultados de Lasso para determinar el estado final de control de caso de TEPT para la población de AV. El algoritmo final tuvo una sensibilidad de 0.99, una especificidad de 0.99, un valor predictivo positivo de 0.95 y un valor predictivo negativo de 1.00 para la clasificación de TEPT (agrupación de TEPT posible y probablemente no TEPT) según lo determinado por la revisión de la tabla. Este algoritmo puede ser útil para otros esfuerzos de investigación y mejora de la calidad dentro del AV.

Sleep Quality Improvement During Cognitive Behavioral Therapy for Anxiety Disorders.

Despite the ubiquity of sleep complaints among individuals with anxiety disorders, few prior studies have examined whether sleep quality improves during anxiety treatment. The current study examined pre- to posttreatment sleep quality improvement during cognitive behavioral therapy (CBT) for panic disorder (PD; n = 26) or generalized anxiety disorder (GAD; n = 24). Among sleep quality indices, only global sleep quality and sleep latency improved significantly (but modestly) during CBT. Sleep quality improvement was greater for treatment responders, but did not vary by diagnosis. Additionally, poor baseline sleep quality was independently associated with worse anxiety treatment outcome, as measured by higher intolerance of uncertainty. Additional intervention targeting sleep prior to or during CBT for anxiety may be beneficial for poor sleepers.

Dorsolateral prefrontal cortex activation during emotional anticipation and neuropsychological performance in posttraumatic stress disorder.

CONTEXT: Posttraumatic stress disorder (PTSD) has been associated with executive or attentional dysfunction and problems in emotion processing. However, it is unclear whether these two domains of dysfunction are related to common or distinct neurophysiological substrates. OBJECTIVE: To examine the hypothesis that greater neuropsychological impairment in PTSD relates to greater disruption in prefrontal-subcortical networks during emotional anticipation. DESIGN: Case-control, cross-sectional study. SETTING: General community and hospital and community psychiatric clinics. PARTICIPANTS: Volunteer sample of 37 women with PTSD related to intimate partner violence and 34 age-comparable healthy control women. MAIN OUTCOME MEASURES: We used functional magnetic resonance imaging (fMRI) to examine neural responses during anticipation of negative and positive emotional images. The Clinician-Administered PTSD Scale was used to characterize PTSD symptom severity. The Wechsler Adult Intelligence Scale, Third Edition, Digit Symbol Test, Delis-Kaplan Executive Function System Color-Word Interference Test, and Wisconsin Card Sorting Test were used to characterize neuropsychological performance. RESULTS: Women with PTSD performed worse on complex visuomotor processing speed (Digit Symbol Test) and executive function (Color-Word Interference Inhibition/Switching subtest) measures compared with control subjects. Posttraumatic stress disorder was associated with greater anterior insula and attenuated lateral prefrontal cortex (PFC) activation during emotional anticipation. Greater dorsolateral PFC activation (anticipation of negative images minus anticipation of positive images) was associated with lower PTSD symptom severity and better visuomotor processing speed and executive functioning. Greater medial PFC and amygdala activation related to slower visuomotor processing speed. CONCLUSIONS: During emotional anticipation, women with PTSD show exaggerated activation in the anterior insula, a region important for monitoring internal bodily state. Greater dorsolateral PFC response in PTSD patients during emotional anticipation may reflect engagement of cognitive control networks that are beneficial for emotional and cognitive functioning. Novel treatments could be aimed at strengthening the balance between cognitive control (dorsolateral PFC) and affective processing (medial PFC and amygdala) networks to improve overall functioning for PTSD patients.

Cognitive impairment and functioning in PTSD related to intimate partner violence.

Posttraumatic stress disorder (PTSD) has been associated with neuropsychological impairments across multiple domains, but consensus regarding the cognitive profile of PTSD has not been reached. In this study of women with PTSD related to intimate partner violence (n = 55) and healthy, demographically similar comparison participants (NCs; n = 20), we attempted to control for many potential confounds in PTSD samples. All participants were assessed with a comprehensive neuropsychological battery emphasizing executive functioning, including inhibition, switching, and abstraction. NCs outperformed PTSD participants on most neuropsychological measures, but the differences were significant only on speeded tasks (with and without executive functioning components). The PTSD group's mean performance was within the average range on all neuropsychological tests. Within the PTSD group, more severe PTSD symptoms were associated with slower processing speed, and more severe dissociative symptoms were associated with poorer reasoning performance. These results suggest that women with PTSD related to intimate partner violence demonstrate slower than normal processing speed, which is associated with the severity of psychiatric symptoms. We speculate that the cognitive slowing seen in PTSD may be attributable to reduced attention due to a need to allocate resources to cope with psychological distress or unpleasant internal experiences.

Screening for social anxiety disorder with the self-report version of the Liebowitz Social Anxiety Scale.

OBJECTIVE: This study examined whether the self-report version of the Liebowitz Social Anxiety Scale (LSAS-SR) could accurately identify individuals with social anxiety disorder and individuals with the generalized subtype of social anxiety disorder. Furthermore, the study sought to determine the optimal cutoffs for the LSAS-SR for identifying patients with social anxiety disorder and its generalized subtype. METHODS: Two hundred and ninety-one patients with clinician-assessed social anxiety disorder (240 with generalized social anxiety disorder) and 53 control participants who were free from current Axis-1 disorders completed the LSAS-SR. RESULTS: Receiver Operating Characteristic analyses revealed that the LSAS-SR performed well in identifying participants with social anxiety disorder and generalized social anxiety disorder. Consistent with Mennin et al.'s [2002: J Anxiety Disord 16:661-673] research on the clinician-administered version of the LSAS, cutoffs of 30 and 60 on the LSAS-SR provided the best balance of sensitivity and specificity for classifying participants with social anxiety and generalized social anxiety disorder, respectively. CONCLUSIONS: The LSAS-SR may be an accurate and cost-effective way to identify and subtype patients with social anxiety disorder, which could help increase the percentage of people who receive appropriate treatment for this debilitating disorder.

Development and validation of an Overall Anxiety Severity And Impairment Scale (OASIS).

Establishing severity and impairment associated with anxiety is important in many settings. We developed a brief (five-item) continuous measure, the Overall Anxiety Severity and Impairment Scale (OASIS), which can be used across anxiety disorders, with multiple anxiety disorders, and with subthreshold anxiety symptoms. Seven hundred eleven college students completed the OASIS and additional self-report assessments of anxiety-related concerns and symptoms. A subset of students completed several measures again 1 month later. Results of a split-sample analysis suggested a single-factor structure, with all five items having salient loadings. The OASIS demonstrated excellent 1-month test-retest reliability, and convergent and divergent validity. The OASIS merits consideration as a brief measure of anxiety-related severity and impairment that can be used across anxiety disorders.