Posttraumatic stress disorder and mortality in VA patients with implantable cardioverter-defibrillators.

BACKGROUND: The association between posttraumatic stress disorder (PTSD) and mortality in patients undergoing implantable cardioverter-defibrillator (ICD) placement has not been evaluated in US veterans. HYPOTHESIS: PTSD in veterans with ICD is associated with increased mortality. METHODS: We studied a retrospective cohort of 25 678 veterans who underwent ICD implantation between September 30, 2002, and December 31, 2011. Of these subjects, 3280 carried the diagnosis of PTSD prior to ICD implantation. Primary outcome was all-cause mortality between date of ICD implantation and end of follow-up (September 30, 2013). We used Cox proportional hazard models to compute multivariable adjusted hazard ratios with corresponding 95% confidence intervals for the relation between PTSD diagnosis and death following ICD placement. RESULTS: During a mean follow-up of 4.21 ± 2.62 years, 11 015 deaths were reported. The crude incidence rate of death was 87.8 and 103.9/1000 person-years for people with and without PTSD, respectively. We did not find an association between presence of PTSD before or after ICD implantation and incident death when adjusted for multiple risk factors (hazard ratio: 1.003, 95% confidence interval: 0.948-1.061). In secondary analysis, no statistically significant association was found. CONCLUSIONS: In this retrospective cohort study among more than 25 000 veterans undergoing ICD implantation, almost 13% had a diagnosis of PTSD. Subjects with PTSD were significantly younger, yet they had a higher incidence of coronary heart disease, major cardiac comorbidities, cancer, and mental health conditions. We found no association between presence of PTSD before or after ICD implantation and incident death when adjusting for all covariates.

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans.

The Clinician-Administered PTSD Scale (CAPS) is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder (PTSD). The CAPS was recently revised to correspond with PTSD criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This article describes the development of the CAPS for DSM-5 (CAPS-5) and presents the results of an initial psychometric evaluation of CAPS-5 scores in 2 samples of military veterans (Ns = 165 and 207). CAPS-5 diagnosis demonstrated strong interrater reliability (к = .78 to 1.00, depending on the scoring rule) and test-retest reliability (к = .83), as well as strong correspondence with a diagnosis based on the CAPS for DSM-IV (CAPS-IV; к = .84 when optimally calibrated). CAPS-5 total severity score demonstrated high internal consistency (α = .88) and interrater reliability (ICC = .91) and good test-retest reliability (ICC = .78). It also demonstrated good convergent validity with total severity score on the CAPS-IV (r = .83) and PTSD Checklist for DSM-5 (r = .66) and good discriminant validity with measures of anxiety, depression, somatization, functional impairment, psychopathy, and alcohol abuse (rs = .02 to .54). Overall, these results indicate that the CAPS-5 is a psychometrically sound measure of DSM-5 PTSD diagnosis and symptom severity. Importantly, the CAPS-5 strongly corresponds with the CAPS-IV, which suggests that backward compatibility with the CAPS-IV was maintained and that the CAPS-5 provides continuity in evidence-based assessment of PTSD in the transition from DSM-IV to DSM-5 criteria. (PsycINFO Database Record

Salivary Cortisol and Regional Brain Volumes Among Veterans With and Without Posttraumatic Stress Disorder.

BACKGROUND: Human studies have often found that brain regions rich in glucocorticoid receptors exhibit smaller volume in samples with past trauma and ongoing stress; however, relatively little research has addressed the hypothesis that such smaller volumes can be traced to elevated circulating glucocorticoid hormones (GCs). This issue takes on renewed interest in light of recent proposals to treat symptoms of stress disorders such as posttraumatic stress disorder (PTSD) with exogenous synthetic GCs. We sought to examine the relation of circulating GCs to brain macrostructure among veterans with and without PTSD. METHODS: Participants (n = 90) included combat veterans with and without PTSD. Veterans completed self-report surveys, home-based cortisol samples, reactive cortisol samples over the course of two serial Trier Social Stress Tests, a low-dose dexamethasone suppression test, and structural magnetic resonance brain imaging over the course of 3 to 5 days. RESULTS: No associations were observed between any salivary cortisol index and the volumes of the hippocampus or amygdala. A negative association was observed between evening basal cortisol and both FreeSurfer global volume and BrainImage supratentorial tissue volume. This effect was moderated by PTSD. Also observed was a positive association between reactive cortisol and these same brain volumes. CONCLUSIONS: Estimates of cortical but not hippocampal or amygdala volume were moderately associated with evening basal salivary cortisol and cortisol reactivity to a social stressor. Existing models relating GC receptor density, circulating cortisol levels, and regional brain volumes received little support.

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample.

BACKGROUND: Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common. OBJECTIVE: The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure. DESIGN: We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5. PARTICIPANTS: A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White. MEASURES: The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences. KEY RESULTS: The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 % C.I.: 0.912- 0.969). Whereas a cut score of 3 maximized sensitivity (κ[1]) = 0.93; SE = .041; 95 % C.I.: 0.849-1.00), a cut score of 4 maximized efficiency (κ[0.5] = 0.63; SE = 0.052; 95 % C.I.: 0.527-0.731), and a cut score of 5 maximized specificity (κ[0] = 0.70; SE = 0.077; 95 % C.I.: 0.550-0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report. CONCLUSIONS: The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.

Positive Adjustment Among American Repatriated Prisoners of the Vietnam War: Modeling the Long-Term Effects of Captivity.

A longitudinal lifespan model of factors contributing to later-life positive adjustment was tested on 567 American repatriated prisoners from the Vietnam War. This model encompassed demographics at time of capture and attributes assessed after return to the U.S. (reports of torture and mental distress) and approximately 3 decades later (later-life stressors, perceived social support, positive appraisal of military experiences, and positive adjustment). Age and education at time of capture and physical torture were associated with repatriation mental distress, which directly predicted poorer adjustment 30 years later. Physical torture also had a salutary effect, enhancing later-life positive appraisals of military experiences. Later-life events were directly and indirectly (through concerns about retirement) associated with positive adjustment. Results suggest that the personal resources of older age and more education and early-life adverse experiences can have cascading effects over the lifespan to impact well-being in both positive and negative ways.

Early adversity and combat exposure interact to influence anterior cingulate cortex volume in combat veterans.

OBJECTIVE: Childhood and combat trauma have been observed to interact to influence amygdala volume in a sample of U.S. military veterans with and without PTSD. This interaction was assessed in a second, functionally-related fear system component, the pregenual and dorsal anterior cingulate cortex, using the same sample and modeling approach. METHOD: Anterior cingulate cortical tissues (gray + white matter) were manually-delineated in 1.5 T MR images in 87 U.S. military veterans of the Vietnam and Persian Gulf wars. Hierarchical multiple regression modeling was used to assess associations between anterior cingulate volume and the following predictors, trauma prior to age 13, combat exposure, the interaction of early trauma and combat exposure, and PTSD diagnosis. RESULTS: As previously observed in the amygdala, unique variance in anterior cingulate cortical volume was associated with both the diagnosis of PTSD and with the interaction of childhood and combat trauma. The pattern of the latter interaction indicated that veterans with childhood trauma exhibited a significant inverse linear relationship between combat trauma and anterior cingulate volume while those without childhood trauma did not. Such associations were not observed in hippocampal or total cerebral tissue volumes. CONCLUSIONS: In the dorsal anterior cingulate cortex, as in the amygdala, early trauma may confer excess sensitivity to later combat trauma.

Amygdala volume in combat-exposed veterans with and without posttraumatic stress disorder: a cross-sectional study.

CONTEXT: Data from animal models demonstrate a link between stress exposure and hypertrophic changes in the amygdala; however, studies of adults with posttraumatic stress disorder (PTSD) have failed to find analogous structural alterations. OBJECTIVES: To compare amygdala volumes between a sample of combat veterans with and without PTSD (analysis 1) and examine whether our observation of larger amygdala volume in individuals with PTSD could be accounted for by the presence of trauma exposure in childhood and the severity of combat exposure in adulthood (analysis 2). DESIGN: Cross-sectional magnetic resonance imaging. SETTING: Veterans Affairs Palo Alto Health Care System Inpatient Trauma Recovery Program and Veterans Affairs New England Health Care System Outpatient PTSD program. PARTICIPANTS: Ninety-nine combat-exposed veterans from the Vietnam Conflict or the Persian Gulf War who had been exposed to substantial military operational stress. MAIN OUTCOME MEASURES: Amygdala volume adjusted for total cerebral volume, Life Events Checklist, and the Combat Exposure Scale. RESULTS: Analysis 1 indicated that combat-exposed individuals with PTSD exhibited larger total amygdala volume compared with their non-PTSD counterparts (99 individuals, P = .047). Analysis 2 indicated that greater severity of combat exposure (87 individuals, P = .02), as well as the interaction between the presence of early life trauma and the severity of combat exposure (87 individuals, P = .008), were significantly associated with smaller total amygdala volume. The PTSD diagnosis continued to explain larger amygdala volume (87 individuals, P = .006). CONCLUSIONS: Posttraumatic stress disorder is associated with enlarged amygdala volume, above the variance accounted for by a history of early life trauma and severity of adult trauma exposure. The discrepancy between our and prior findings may be explained by variability in these trauma indices in previous investigations. These findings support additional study of amygdala structure in human stress disorders and further delineation of the role of early and adult trauma on associated neurologic changes.

Concordance between physiological arousal and subjective distress among Vietnam combat veterans undergoing challenge testing for PTSD.

This study examined concordance between physiological arousal and subjective distress during a laboratory challenge task. Data were collected during the multisite VA Cooperative Study 334 in the early 1990s examining psychophysiological arousal among combat-exposed Vietnam veterans with (n = 775) and without (n = 369) posttraumatic stress disorder (PTSD). Study participants were presented with 6 standardized neutral scenes and 6 standardized combat scenes. Participants provided a subjective rating of distress after each slide. During the presentation, levels of heart rate (HR) and skin conductance (SC) were recorded. Using linear mixed effects modeling, both HR level and SC level exhibited significant positive associations with subjective distress ratings (pr = .33, p < .001 and pr = .19, p < .001, respectively). Individuals with PTSD demonstrated greater concordance between their distress ratings and SC level during exposure to combat slides than participants without PTSD (pr = .28, p < .001 vs. pr = .18, p < .001). Although a significant association was found between subjective distress and HR reactivity and SC reactivity, these findings were not moderated by PTSD status. The results of these analyses suggest that patients' reports of distress during exposure-based treatments might serve as approximate measures of actual physiological arousal.

Examining aggression in male Vietnam veterans who receive VA services: the role of traumatic events and combat exposure.

We examined the relationship between trauma exposure and the perpetration of aggression by male Vietnam veterans (N = 1,328) using archival data from a multisite study conducted by the Cooperative Studies Program of the Department of Veteran Affairs (CSP-334) in the early 1990s. Both traumatic events in civilian life and combat exposure were examined as correlates of aggression. Results indicated that pre- and postmilitary traumatic events and combat exposure were all related to perpetration of aggression at the bivariate level; r = .07, r = .20, and r = .13, respectively. When these variables were examined simultaneously, only combat exposure (ß = .14, p < .001) and postmilitary traumatic events (ß = .20, p < .001) were associated with aggression. No interaction effects were found for civilian traumatic events and combat in relation to aggression. Results highlight the importance of attending to the psychological aftermath of exposure to traumatic events experienced during and following deployment before aggressive patterns develop.

Long-term effects of coping with extreme stress: longitudinal study of Vietnam-era repatriated prisoners of war.

Captivity stressors and coping strategies were assessed shortly after the repatriation of Vietnam-era prisoners of war, and physical and mental health were assessed almost three decades later. Given research on coping goodness-of-fit, specifically the extent to which coping effects depend on situational controllability, we proposed that endorsement of the usefulness of avoidance-based strategies in captivity would be predictive of better later-life health. Findings indicated that approach-based and avoidance-based coping both moderated the link between physical torture and later physical health functional status, whereas approach-based coping moderated the link between injuries at capture and later mental health. Specifically, greater endorsement of avoidance-based coping was associated with better long-term physical health for prisoners who experienced the most physical torture. Lower endorsement of approach-based coping was associated with better long-term mental health for prisoners who reported the most injuries at the time of capture.

Catechol-O-methyltransferase Val158Met polymorphism moderates anterior cingulate volume in posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with structural and functional compromise of the anterior cingulate cortex (ACC), which may in turn be associated with impairment of its ability to regulate the amygdala. The Val158Met polymorphism in the catechol-O-methyltransferase gene, which substantially influences dopamine inactivation in the frontal lobe in general and in ACC in particular, may moderate ACC integrity in PTSD. METHODS: We tested this hypothesis in a sample of Vietnam and Persian Gulf War veterans who experienced substantial military operational stress, including 51 who met criteria for PTSD and 48 matched controls who did not. RESULTS: Participants with PTSD were previously reported to have smaller ACC volumes than controls in this sample. A novel repeated-measures analysis of variance was conducted with PTSD diagnosis, Val158Met genotype, and their interaction predicting left and right ACC volume. Genotype was not directly related to ACC volume, but it did significantly interact with the PTSD diagnosis. The difference in ACC volume between the participants without PTSD and participants with PTSD was greater among individuals homozygous for the Val allele than among carriers of the Met allele. This finding was driven largely by the right ACC. Analyses of Caucasian-only, non-Caucasian-only, and male-only subsamples indicated similar patterns. CONCLUSIONS: Our findings suggest Val158Met genotype moderates the effect of PTSD-related processes on right ACC volume.

Common data elements for posttraumatic stress disorder research.

An expert work group with 7 members was formed under the cosponsorship of 5 U.S. federal agencies to identify common data elements for research related to posttraumatic stress disorder (PTSD). The work group reviewed both previous and contemporary measurement standardization efforts for PTSD research and engaged in a series of electronic and live discussions to address a set of predefined aims. Eight construct domains relevant to PTSD were identified: (1) traditional demographics, (2) exposure to stressors and trauma, (3) potential stress moderators, (4) trauma assessment, (5) PTSD screening, (6) PTSD symptoms and diagnosis, (7) PTSD-related functioning and disability, and (8) mental health history. Measures assigned to the core data elements category have relatively low time-and-effort costs in order to make them potentially applicable across a wide range of studies for which PTSD is a relevant condition. Measures assigned to the supplemental data elements category have greater costs but generally demonstrate stronger psychometric performance and provide more extensive information. Accordingly, measures designated as supplemental are recommended instead of or in addition to corresponding core measures whenever resources and study design allow. The work group offered 4 caveats that highlight potential limitations and emphasize the voluntary nature of standardization for PTSD-related measurement.

An evaluation of competing models for the structure of PTSD symptoms using external measures of comorbidity.

Research on the structure of posttraumatic stress disorder (PTSD) symptoms has yielded support for two 4-factor models: the King (King, Leskin, King, & Weathers, 1998) and Simms/Watson models (Simms, Watson, & Doebbeling, 2002). This study evaluated them using data drawn from 1,128 Vietnam veterans by comparing associations with a latent internalizing comorbidity variable and five scales from the MMPI-2 Restructured Clinical (RC) Scales (Tellegen et al., 2003). The Simms/Watson dysphoria factor failed to show evidence of superior convergent or discriminant validity in association with external measures relative to the numbing or hyperarousal factors of the King model. Findings raise questions about proposals to abandon the distinction between numbing and hyperarousal symptoms in favor of a dysphoria-based model.

Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses.

BACKGROUND: This study examined the degree to which combat-related guilt mediated the relations between exposure to combat-related abusive violence and both Posttraumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) in Vietnam Veterans. METHODS: Secondary analyses were conducted on data collected from 1,323 male Vietnam Veterans as part of a larger, multisite study. RESULTS: Results revealed that combat-related guilt partially mediated the association between exposure to combat-related abusive violence and PTSD, but completely mediated the association with MDD, with overall combat exposure held constant in the model. Follow-up analyses showed that, when comparing those participants who actually participated in combat-related abusive violence with those who only observed it, combat-related guilt completely mediated the association between participation in abusive violence and both PTSD and MDD. Moreover, when comparing those participants who observed combat-related abusive violence with those who had no exposure at all to it, combat-related guilt completely mediated the association between observation of combat-related abusive violence and MDD, but only partially mediated the association with PTSD. CONCLUSIONS: These findings suggest that guilt may be a mechanism through which abusive violence is related to PTSD and MDD among combat-deployed Veterans. These findings also suggest the importance of assessing abusive-violence related guilt among combat-deployed Veterans and implementing relevant interventions for such guilt whenever indicated.

Smaller global and regional cortical volume in combat-related posttraumatic stress disorder.

CONTEXT: Two sets of findings predict smaller cerebral cortical gray matter volume in adult posttraumatic stress disorder (PTSD). Measures of intracranial tissue volume and cerebral tissue volume have been observed to be smaller in adolescents with maltreatment-related PTSD. Second, lower intelligence, a risk factor for PTSD, is associated with smaller cerebral tissue volumes. Nevertheless, to our knowledge, only 1 study has observed globally smaller cerebral tissue volume in adults with PTSD. OBJECTIVES: To apply a recently developed method providing improved estimates of cortical volume and to estimate associations between adult PTSD and selected regional cortical volumes not yet investigated. DESIGN: Between-group comparison of global and regional cerebral cortical volumes in adult patients with combat-related PTSD and controls. SETTING: Two Department of Veterans Affairs medical centers with large inpatient and outpatient PTSD catchments. PARTICIPANTS: Ninety-seven combat-exposed veterans of the Vietnam and Persian Gulf wars. MAIN OUTCOME MEASURE: Global and regional cortical volumes determined using the FreeSurfer software program and the Desikan et al parcellation (modified). RESULTS: Cerebral cortical volume, thickness, and area were observed to be smaller in association with adult combat-related PTSD. Robust associations were observed between PTSD and smaller cortical volumes in the parahippocampal gyrus, superior temporal cortex, lateral orbital frontal cortex, and pars orbitalis of the inferior frontal gyrus. CONCLUSIONS: Cerebral cortical volume, thickness, and area may be smaller in adult chronic severe PTSD; however, the extracted structural variables did not mediate relations between intelligence and PTSD. The 4 regions exhibiting especially smaller cortical volumes in this sample share involvement in mechanisms subserving "top-down" facilitation of the identification of objects and words. Compromise of these regions may result in difficulty in relearning pretrauma schemata for interpreting the civilian physical and social environments.

Overview of research addressing ethical dimensions of participation in traumatic stress studies: autonomy and beneficence.

One element of the design of human research studies is ethically informed decision-making. Key issues include the safety, costs, and benefits of participation. Historically, much of this decision-making was based on opinion rather than formal evidence. Recently, however, investigators in the traumatic stress field have begun to collect data that are relevant to these decisions. In this article, the authors focus on issues emanating from the ethical concepts of autonomy and respect for persons and beneficence and nonmaleficence, and then summarize relevant evidence from studies with trauma-exposed individuals. Discussion addresses implications of this evidence for research practice and policy, and identifies some potentially informative data collections opportunities for future trauma studies.

Hippocampal volume and declarative memory function in combat-related PTSD.

The proposition that declarative memory deficits are systematically related to smaller hippocampal volume was tested in a relatively large sample (n = 95) of U.S. military veterans with and without combat-related posttraumatic stress disorder. This correlative analysis was extended by including multiple measures of verbal and visual declarative memory and multiple memory-relevant regional brain volumes that had been shown to exhibit main effects of PTSD in prior work. Small-to-moderate effects were observed on verbal declarative memory in line with a recent meta-analysis; nevertheless, little or no evidence of systematic linear covariation between memory measures and brain volumes was observed.

The MMPI-2 restructured clinical scales in the assessment of posttraumatic stress disorder and comorbid disorders.

This study examined the psychometric properties of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Restructured Clinical Scales (RCSs) in individuals with posttraumatic stress disorder (PTSD) receiving clinical services at Department of Veterans Affairs medical centers. Study 1 included 1,098 men who completed the MMPI-2 and were assessed for a range of psychological disorders via structured clinical interview. Study 2 included 136 women who completed the MMPI-2 and were interviewed with the Clinician Administered Scale for PTSD. The utility of the RCSs was compared with that of the Clinical Scales (CSs) and the Keane PTSD (PK) scale. The RCSs demonstrated good psychometric properties and patterns of associations with other measures of psychopathology that corresponded to current theory regarding the structure of comorbidity. A notable advantage of the RCSs compared with the MMPI-2 CSs was their enhanced construct validity and clinical utility in the assessment of comorbid internalizing and externalizing psychopathology. The PK scale demonstrated incremental validity in the prediction of PTSD beyond that of the RCSs or CSs.

Development and initial validation of a statistical prediction instrument for assessing combat-related posttraumatic stress disorder.

Statistical analyses were used to derive and validate a statistical prediction instrument to determine combat-related posttraumatic stress disorder (PTSD) status. Participants were 1081 Vietnam veterans with and without combat-related PTSD. The statistical prediction instrument, which consisted of 12 well-known risk and resilience variables associated with PTSD, proved to be an accurate and efficient means of detecting PTSD among participants and compared well against other existing self-report measures of PTSD. The instrument's practical applications and its use in clinical appraisals of PTSD are discussed.