Impact of PTSD on post-concussive symptoms, neuropsychological functioning, and pain in post-9/11 veterans with mild traumatic brain injury.

Prior work suggested that post-traumatic stress disorder (PTSD) worsens post-concussive symptoms (PCS), neuropsychological functioning, and pain-related outcomes in post-9/11 veterans. However, the impact of PTSD in the context of mild traumatic brain injury (mTBI) is not entirely clear. We evaluated possible differences among veterans with deployment-related mTBI with and without PTSD, and a comparison group. We hypothesized that veterans with comorbid mTBI and PTSD would report more PCS, perform worse on neuropsychological tasks, and report greater pain intensity and maladaptive pain coping relative to those without PTSD. Ninety (15 female, 75 male) post-9/11 veterans completed measures of psychiatric functioning, PCS, deployment-related mTBI, pain intensity, pain coping, and a brief neuropsychological evaluation. Veterans with comorbid mTBI and PTSD reported significantly higher PCS across domains, and greater pain intensity and maladaptive coping. They also performed more poorly on measures of recall, but not on measures of attention, encoding, or executive functioning. Findings suggest that PTSD results in greater PCS in the context of mTBI, and is associated with greater pain catastrophizing, worse recall, greater pain intensity, and greater illness-focused coping than in mTBI alone. PCS symptoms, recall, and pain coping may be of clinical importance for post-9/11 veterans with the "polytrauma triad."

Functional Neuroanatomy of Emotion and Its Regulation in PTSD.

Posttraumatic stress disorder (PTSD) is a devastating disorder, linked to profound mental, physical, occupational, and functional impairment. In addition, it is a highly complex disorder, characterized by symptom heterogeneity across multiple domains. Nevertheless, emotion dysregulation arising from the exaggerated response to threat or from the inability to regulate negative emotional states plays a defining role in the pathophysiology of PTSD. In order to improve our understanding of how emotion dysregulation manifests in this illness, functional neuroimaging research over the past 20 years provides great insight into underlying neuroanatomy of each component of emotion dysregulation in the context of PTSD. While prior reviews exist on the topic of neuroimaging findings in PTSD, the present review synthesizes that work through the lens of emotion and its regulation. Studies that employed tasks of emotional responding and symptom provocation, implicit regulation (e.g., emotional Stroop and interference), explicit regulation (e.g., cognitive reappraisal), and fear conditioning/extinction were reviewed. Findings demonstrate that emotion dysregulation in PTSD arises from complications within a large neurocircuitry involving the amygdala, insula, hippocampus, anterior cingulate cortex, and prefrontal cortex. Although an exaggerated response in the amygdala and insula to negative emotional triggers is pervasive, PTSD is also marked by deficient appraisal, resolution, and management of negative emotional states subserved by the anterior cingulate cortex and prefrontal cortex during regulation. These findings further support the importance of studying emotion-regulation deficits in tandem with exaggerated symptom provocation in order to better understand the constellation of symptoms present in those with PTSD.

Individual differences in combat experiences and error-related brain activity in OEF/OIF/OND veterans.

Increased error-related negativity (ERN) has been implicated in the pathophysiology of multiple forms of psychopathology. Although there is increasing evidence that the ERN can be shaped by environment and experience, no studies to date have examined this question in a clinical sample. In the current study, we examined the influence of combat exposure on the ERN using electroencephalogram (EEG) in a sample of military veterans with a high prevalence of psychopathology. Participants included sixty-seven U.S. military veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). The degree of combat exposure was assessed using the Deployment Risk and Resilience Inventory-2 (DRRI-2) and Combat Exposure Scale (CES). A well-validated flanker task was used to elicit the ERN during continuous EEG recording. Results revealed that veterans who reported experiencing greater combat exposure exhibited a more enhanced ERN, even when adjusting for broad anxiety and posttraumatic stress disorder (PTSD) symptoms. The association between combat exposure and ERN was not moderated by PTSD symptom severity. The current study demonstrates that greater combat exposure is associated with a more enhanced ERN among OEF/OIF/OND veterans. This enhanced ERN may be one mechanism that places veterans at greater risk for developing psychiatric disorders following exposure to combat. Future longitudinal studies are needed to directly test whether the ERN mediates the relation between level of combat exposure and the development of internalizing disorders.

Differential impact of post-deployment stress and PTSD on neural reactivity to emotional stimuli in Iraq and Afghanistan veterans.

For many veterans returning from combat in Iraq and Afghanistan, the transition from military to civilian life is complicated by an array of postdeployment stressors. In addition to significant stress associated with reintegration after deployment, many returning veterans also contend with the added burden conferred by PTSD symptoms. While the relationship between PTSD symptoms and the neurobiological substrates of emotion dysregulation has begun to be studied, even less is known about the effects of postdeployment stress on neural function. In order to assess the relationship among a neural measure of attention to emotion (i.e. the late positive potential; LPP), PTSD symptoms and postdeployment stressors, EEG was recorded and examined in a linear mixed model of 81 OEF/OIF/OND veterans. Results revealed a main effect for postdeployment stressors such that increased postdeployment stress was associated with a relatively enhanced LPP across all emotion types. There was also a main effect for PTSD symptoms such that greater symptoms were related to a relatively blunted LPP across all emotion types. Findings may have important implications for understanding how both current stress and PTSD symptoms affect motivated attention as measured by the LPP. Moreover, this work highlights the need to consider the effects of current stress, in addition to PTSD symptoms, on the functioning of returning veterans.

Neural indices of emotional reactivity and regulation predict course of PTSD symptoms in combat-exposed veterans.

After diagnosis, veterans with posttraumatic stress disorder (PTSD) display significant variability in the natural course of illness (Bonanno et al., 2012)). Cross-sectional work reveals that abnormal neural response during emotion reactivity-measured using the late positive potential (LPP)-correlates with PTSD symptom severity; however, whether the LPP during emotional reactivity and regulation predicts symptoms over time is unknown. The current study examined the LPP during emotion reactivity and regulation as predictors of PTSD symptoms over one year in OEF/OIF/OND combat-exposed veterans. At baseline, participants completed an Emotion Regulation Task (ERT) during electroencephalogram recording. The Clinician Administered PTSD Scale (CAPS) was completed at baseline (N=86), 6-months (N=54) and 1-year (N=49) later. During ERT, participants viewed negative pictures; partway through they were instructed to "reappraise" (i.e., reduce negative affect/regulate) or "look" (i.e., passively react). Change in LPP during emotional reactivity (ΔLPP-E) and reappraisal (ΔLPP-R) were calculated and used in multilevel mixed modeling to predict CAPS over time. Findings demonstrated that deficiency in reappraisal (ΔLPP-R) predicted more overall symptoms over time, while greater neural responses to emotion (ΔLPP-E) and greater change in neural response as a function of reappraisal (ΔLPP-R) predicted a decline in avoidance symptoms over time. Together, results support the utility of neural markers of emotional reactivity and regulation as predictors of PTSD symptoms-and change in symptoms-across one year.

Impact of posttraumatic stress symptom dimensions on amygdala reactivity to emotional faces.

Posttraumatic stress disorder (PTSD) is highly prevalent and associated with impairment, even at the subthreshold level. It is therefore important to identify biological processes that contribute to the pathophysiology of posttraumatic stress symptoms (PTSS). Although neuroimaging research has highlighted the importance of heightened amygdala reactivity to aversive stimuli in PTSS, not all studies have yielded evidence of this relationship. Given that PTSS is comprised of four, factor analytically distinct dimensions of symptoms - re-experiencing, avoidance, hyperarousal, and negative cognitions and mood - it is possible that heightened amygdala reactivity to aversive stimuli is specific to certain PTSS clusters. In a sample of 45 trauma-exposed individuals, the present study therefore examined how specific PTSS clusters relate to amygdala responding during functional magnetic resonance imaging (fMRI) to both negative and positive emotional faces during a well-validated social-emotional task, the Emotional Face Assessment Task (EFAT). Results indicated that hyperarousal symptoms were positively associated with left amygdala reactivity across all emotional face conditions. There was no interaction of hyperarousal by condition (i.e., fearful, sad, angry, or happy faces), and other PTSS clusters were not associated with amygdala reactivity. These results indicate that the hyperarousal cluster of PTSS may have a unique relationship with amygdala reactivity to socioemotional information. The results also corroborate a growing literature suggesting that trauma-exposed individuals characterized by high PTSS hyperarousal symptoms may display exaggerated psychophysiological reactivity to appetitive and aversive stimuli.

PTSD symptoms are associated with visual retrieval performance in OEF/OIF/OND veterans.

Posttraumatic stress disorder (PTSD) is associated with poorer performance on neuropsychological tests in veterans. However, prior studies have generally compared individuals with PTSD to control groups, often excluding individuals with moderate symptoms. The present study evaluated neuropsychological performance among OEF/OIF/OND veterans as a function of overall PTSD severity, while also exploring potential associations between cognitive performance and PTSD symptom clusters. Using a brief neuropsychological battery, clinical interviews, and self-report instruments, we evaluated neuropsychological and psychiatric functioning in 90 OEF/OIF/OND veterans. When controlling for the effects of premorbid intellectual functioning and combat exposure, higher PTSD severity predicted worse visual retrieval performance, but not attention, verbal retrieval, visual learning, or executive functioning performance. A trend was observed where higher PTSD symptoms predicted worse verbal learning performance. All PTSD symptom clusters were associated with visual retrieval performance within the full sample. Avoidance and numbing symptoms were associated with verbal learning in the full sample. Findings suggest that among OEF/OIF/OND veterans with a range of PTSD symptoms, the assessment of visual memory may have implications for clinical practice.

An electrocortical investigation of emotional face processing in military-related posttraumatic stress disorder.

PTSD is a disorder of emotion dysregulation. Although much work has intended to elucidate the neural underpinnings of the disorder, much remains unknown about the neurobiological substrates of emotion dysregulation in PTSD. In order to assess the relationship between a neural measure of attention to emotion (i.e. the late positive potential; LPP) and PTSD symptoms, EEG was recorded and examined as a potential predictor of military-related PTSD symptoms in a sample of 73 OEF/OIF/OND veterans. Results revealed that higher PTSD symptoms were related to an attenuated LPP response to angry facial expressions. This finding was not observed for happy or fearful faces. The current study provides initial evidence that, in a relatively young, mostly male sample of OEF/OIF/OND veterans, hyporeactivity to angry faces at the neural level may provide phenotypic data to characterize individual differences in PTSD symptom severity. This work may assist in future studies that seek to examine useful psychophysiologic targets for treatment and early interventions.

Affective and cognitive correlates of PTSD: Electrocortical processing of threat and perseverative errors on the WCST in combat-related PTSD.

PTSD is characterized by both affective and cognitive dysfunction. Affectively, PTSD is associated with both heightened emotional reactivity and disengagement. Cognitively, perseverative thinking is a core feature of the disorder. In order to assess the interactive effects of affective and cognitive correlates of PTSD symptoms, 47 OEF/OIF/OND veterans completed an emotional faces matching task while EEG (i.e., late positive potential; LPP) was recorded, and separately completed the Wisconsin Card Sorting Test (WCST) to assess perseverative errors. There was no relationship between PTSD symptoms and either perseverative errors or EEG reactivity to faces. However, an interaction was found such that high perseverative errors on the WCST and a relatively enhanced LPP to angry faces was associated with greater PTSD symptoms, while low errors on the WCST and a relatively blunted LPP to angry faces also related to greater PTSD symptoms. These findings suggest that emotion-cognition interactions are important for understanding PTSD, and that distinct emotion-cognition constellations interact with symptoms.

Impact of alcohol use disorder comorbidity on defensive reactivity to errors in veterans with posttraumatic stress disorder.

Converging lines of evidence suggest that individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) may be characterized by heightened defensive reactivity, which serves to maintain drinking behaviors and anxiety/hyperarousal symptoms. However, it is important to note that very few studies have directly tested whether individuals with PTSD and AUD exhibit greater defensive reactivity compared with individuals with PTSD without AUD. Therefore, the aim of the current study was to test this emerging hypothesis by examining individual differences in error-related negativity (ERN), an event-related component that is larger among anxious individuals and is thought to reflect defensive reactivity to errors. Participants were 66 military veterans who completed a well-validated flanker task known to robustly elicit the ERN. Veterans were comprised of 3 groups: controls (i.e., no PTSD or AUD), PTSD-AUD (i.e., current PTSD but no AUD), and PTSD + AUD (i.e., current comorbid PTSD and AUD). Results indicated that individuals with PTSD and controls generally did not differ in ERN amplitude. However, among individuals with PTSD, those with comorbid AUD had significantly larger ERNs than those without AUD. These findings suggest that PTSD + AUD is a neurobiologically unique subtype of PTSD, and the comorbidity of AUD may enhance defensive reactivity to errors in individuals with PTSD. (PsycINFO Database Record

Differences in PTSD Symptomatology Among Latinos with Childhood and Adult Trauma: The Moderating Effect of Acculturation.

The development of PTSD has been shown to be dependent on a variety of factors, including ethnicity, whether the trauma was experienced as a child or adult, and acculturation. Using 104 Latinos who had completed treatment for substance abuse disorder(s), this study compared PTSD symptomatology for individuals reporting their worst traumatic event (WTE) in childhood versus adulthood. The moderating effect of acculturation was also examined. Although many studies have reported on the pernicious effects of childhood trauma, very few have provided direct comparisons of child and adult trauma in terms of PTSD symptoms. Results indicated that those reporting their WTE in childhood had greater PTSD symptomatology than those reporting in adulthood. Acculturation moderated the relationship between timing of the trauma and PTSD symptoms. Specifically, those who reported their WTE in childhood and had the lower levels of acculturation reported the higher number of PTSD symptoms. Implications and future directions are discussed.

An electrocortical investigation of voluntary emotion regulation in combat-related posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) - a debilitating disorder characterized by severe deficits in emotion regulation - is prevalent among U.S. military veterans. Research into the pathophysiology of PTSD has focused primarily on emotional reactivity, showing evidence of heightened neural response during negative affect provocation. By comparison, studies of brain functioning during the voluntary regulation of negative affect are limited. In the current study, combat-exposed U.S. military veterans with (n=25) and without (n=25) PTSD performed an emotion regulation task during electroencephalographic (EEG) recording. The late positive potential (LPP) was used as a measure of sustained attention toward, and processing of, negative and neutral pictures, and was scored prior to and after instructions to either maintain or down-regulate emotional response using the strategy of cognitive reappraisal. Results showed that groups did not differ in picture-elicited LPP amplitude either prior to or during cognitive reappraisal; reappraisal reduced the LPP in both groups over time. Time-dependent increases in LPP amplitude as a function of emotional reactivity maintenance were evident in the non-PTSD group only. This latter finding may signal PTSD-related deficits in sustained engagement with emotion-processing over the course of several seconds.

Reduced default mode network connectivity following combat trauma.

Recent studies show decreased functional connectivity in the default mode network (DMN) in PTSD; however, few have directly examined combat trauma specifically. There is limited understanding of how combat itself may affect the DMN. Some literature suggests that trauma exposure, rather than PTSD, can disrupt the DMN. To further elucidate the effect of trauma and PTSD on the DMN, we investigated DMN functional connectivity during the resting-state in veterans with PTSD, combat-exposed controls, and never-traumatized healthy controls. Results revealed that DMN connectivity was reduced in veterans exposed to combat trauma with and without PTSD compared to healthy civilian controls. Specifically, both groups of veterans demonstrated weaker connectivity within a network involving the precuneus, medial prefrontal cortex (mPFC) and right superior parietal lobule regardless of whether the mPFC or precuneus was chosen as a seed region. Findings suggest that the experience of trauma, rather than the pathology of PTSD, may be related to DMN changes.

What Promotes Wisdom in 12-Step Recovery?

Research investigations on twelve-step groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) have addressed a number of resources associated with 12-step recovery. However, little is known about the role of wisdom, and whether aspects of 12-step participation might increase this resource among 12-step members. An exploratory analysis revealed that participants who reported having a "spiritual awakening" and considered themselves "members" of 12-step groups reported significantly higher levels of wisdom. Twelve-step meeting attendance was not significantly related to wisdom scores. Findings suggest certain aspects of 12-step involvement are associated with wisdom and may play a role in substance abuse recovery.

Evaluating a bilingual voluntary community-based healthcare organization.

The current study compared traditional recovery homes for individuals with substance use disorders with homes that had been modified to feature culturally congruent communication styles. Findings indicated significant increases in employment income, with the size of the change significantly greater in the culturally modified houses. Significant decreases in alcohol use over time were also found, with larger decreases over time in the traditional recovery homes. Use of prescribed medications and days using drugs significantly decreased over time, but not differentially for those in the two types of recovery homes. The implications of these findings are discussed.

Pretrauma risk factors for posttraumatic stress disorder: a systematic review of the literature.

As it has become clear that most individuals exposed to trauma do not develop PTSD, it has become increasingly important to examine pretrauma risk factors. However, PTSD research has overwhelmingly relied on retrospective accounts of trauma, which is beleaguered by problems of recall bias. To further our understanding of PTSD's etiology, a systematic review of 54 prospective, longitudinal studies of PTSD published between 1991 and 2013 were examined. Inclusion criteria required that all individuals were assessed both before and after an index trauma. Results revealed six categories of pretrauma predictor variables: 1) cognitive abilities; 2) coping and response styles; 3) personality factors; 4) psychopathology; 5) psychophysiological factors; and 6) social ecological factors. The results indicated that many variables, previously considered outcomes of trauma, are pretrauma risk factors. The review considered these findings in the context of the extant retrospective PTSD literature in order to identify points of overlap and discrepancy. Pretrauma predictor categories were also used to conceptualize variable risk for PTSD. Limitations and directions for future research are discussed.

The relationship between wisdom and abstinence behaviors in women in recovery from substance abuse.

BACKGROUND AND AIMS: Wisdom is theorized to be an important construct in recovery from substance abuse. In order to explore the role of wisdom in substance abuse recovery behaviors, the present study had two goals. First, it sought to examine the factor structure of a wisdom scale, the Foundational Value Scale (FVS) in a community sample of women in recovery from substance abuse. Second, the study examined how wisdom predicted the women's beliefs about their ability to abstain from future substance use. METHODS: 116 women in recovery from substance abuse disorders were recruited from self-run recovery homes and a substance abuse recovery convention. RESULTS: Results from an exploratory factor analysis indicated that a modified version of the FVS has good internal consistency reliability and is composed of three wisdom-related dimensions. The three factors were then used to create a higher-order wisdom factor in a structural equation model (SEM) that was used to predict abstinence self-efficacy behaviors. Results from the SEM showed that the wisdom factor was predictive of greater abstinence self-efficacy behaviors. CONCLUSION: The FVS was found to be a reliable measure with women in recovery from substance abuse. In addition, wisdom predicted beliefs about self-efficacy such that those who reported higher levels of wisdom felt more confident in their abilities to abstain from alcohol. SCIENTIFIC SIGNIFICANCE: The results of this study indicate that wisdom is an important construct in the abstinence behaviors of women who are in recovery from substance abuse disorders.

Gender differences in intimate partner violence on substance abuse, sexual risks, and depression among a sample of South Africans in Cape Town, South Africa.

Because men account for nearly half of the HIV cases in South Africa, it is critical to understand the contexts in which they live and the behaviors in which they engage. The purpose of this study was to describe and examine gender differences in intimate partner violence on substance abuse, sexual risks, and depression among a sample of South Africans in Cape Town. We found that recent exposure to intimate partner violence among men was associated with all forms of drug use, whereas women who were recently abused were more likely to suffer from depression and problem drinking. We also found high levels of problem drinking among both men (58%) and women (42%). Men were more likely to use drugs. Exposure to community violence increased sexual risk behaviors among men. Overall, these gender differences have important implications for alcohol and drug prevention strategies as they relate to HIV transmission risk.