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.

Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report.

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.

Symptom change prior to treatment discontinuation (dropout) from a naturalistic Veterans Affairs evidence-based psychotherapy clinic for PTSD and depression.

Dropout or treatment discontinuation from evidence-based psychotherapies (EBPs) has been a concern for clinicians as it is thought that such discontinuation prevents patients from achieving a full course of therapy and obtaining maximum benefit. Recent studies, however, suggest that treatment discontinuation may sometimes be due to symptom improvement. The purpose of the current evaluation was to examine change in self-reported symptoms in participants who completed versus did not complete treatment in a Veterans Affairs outpatient clinic offering EBPs for both depression and posttraumatic stress disorder (PTSD). Data were collected from 128 participants who had at least one treatment session postintake and had been discharged from the clinic. Data were collected on self-reported PTSD and depression symptoms. Of the 128 veterans, 61 completed treatment and 67 did not complete treatment (54.0% noncompletion in PTSD EBPs and 48.7% noncompletion in depression EBPs). Of those who did not complete, 47 were enrolled in a PTSD EBP and 20 in a depression EBP. Of those who did not complete a PTSD EBP, 51.1% had no change in PTSD symptoms prior to treatment discontinuation, whereas 12.8% had a symptom increase, and 27.7% had a symptom decrease. Of those who did not complete a depression EBP, 55% had no change in depression symptoms prior to treatment discontinuation, 15% had a symptom increase, and 30% had a decrease. Overall, results suggest that treatment discontinuation is not as straightforward as it may seem and that prematurely discontinuing an EBP may not necessarily represent treatment failure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Understanding veteran barriers to specialty outpatient PTSD clinical care.

OBJECTIVE: Veterans seeking treatment for posttraumatic stress disorder (PTSD) commonly report general and veteran-specific barriers to treatment such as stigma and challenges with navigating the Veterans Health Affairs (VHA) system. This study aimed to characterize barriers endorsed by a national sample of veterans seeking care in VHA PTSD specialty outpatient clinics, as well as to examine the impact of demographics on endorsed barriers. METHODS: This study included 17,069 veterans referred to PTSD specialty outpatient clinics in the VHA during Fiscal Year 2019. Barriers to care, demographics, clinical concerns, and PTSD symptom severity (PCL-5) were assessed at intake. RESULTS: Veterans (mean age=47.6 years, 83.3% male) endorsed an average of 2.39 barriers. The most commonly endorsed barriers included difficulty interacting with others (37.9%), difficulty being in public (33.8%), work (30.3%), concern for finances (20%), and difficulty getting out of bed (19.5%). A significant minority of veterans (22%) endorsed no barriers. Male sex (23.1%) and White race (23.6%) were associated with a greater likelihood of reporting no barriers. CONCLUSIONS: These findings indicate the need for a comprehensive approach to addressing multi-faceted barriers for veterans seeking treatment in PTSD specialty clinics. Findings also highlight the potential importance of tailoring strategies to reduce barriers based on demographic and clinical characteristics such as race, sex, and degree of avoidance. Future research should seek to longitudinally examine the impact of barriers on treatment engagement.

Feasibility of an intensive outpatient treatment program for posttraumatic stress disorder within the veterans health care administration.

Trauma-focused treatments for posttraumatic stress disorder (PTSD), such as Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT), are effective and supported by various Clinical Practice Guidelines; however, drop-out rates for the treatments are as high as 40% within clinical programs. One promising solution is delivering the evidence-based psychotherapies (EBPs) three or more times per week within an intensive outpatient program (IOP) for PTSD. The present study examined the feasibility and effectiveness of a relatively low-resourced PTSD IOP within a larger PTSD program at the Veterans Healthcare Administration. The intensive program offers two tracks (2 week or 4 week) grounded in the massed delivery of PE and CPT. Over a 12-month period, 351 veterans completed an assessment for PTSD and 172 started within one of the local PTSD programs (e.g., weekly, IOP, or residential). Results of the study demonstrated that the IOP is an acceptable (i.e., 87.3% completion rate) and effective (e.g., PTSD Checklist for Diagnostic and Statistical Manual [DSM-5] [PCL-5] decrease effect size d = 1.80) treatment option. There was also adequate demand for the program (e.g., 37.2% of patients engaged in care with the PTSD programs started the IOP), and the program was implemented with fidelity to the design. Taken together, the results of this study demonstrate that this low-resource IOP model is a promising approach to improve completion rates within the continuum of care for the treatment of PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Improving engagement and retention to treatment within VHA PTSD specialty care: Evolution of an outpatient program design.

The Veteran's Health Administration (VA) and Department of Defense (DoD) posttraumatic stress disorder (PTSD) clinical practice guidelines (2017) recommend individual, trauma-focused therapy as the gold standard of treatment for PTSD (i.e., evidence-based practices [EBP]). Moreover, these guidelines encourage the use of individual shared decision-making (SDM) to increase engagement and completion of EBPs for PTSD in line with current literature. This study retrospectively evaluated three models of program design of a VA PTSD specialty clinic over the past 8 years. In line with previous literature, the study hypothesized that leveraging individualized SDM in the clinic design would lead to increased completion of EBPs for PTSD. Analyses indicated an impact as the models shifted from a group-based model to an individualized model. Specifically, as compared to veterans who completed a group-based design, a greater proportion of those enrolled in the clinic were more likely to complete an EBP. These results may suggest that individualized, patient-centered treatment planning may be related to patient engagement in EBPs for PTSD in contrast with group-based models. Other programmatic changes, such as changes in treatment options presented to patients, a movement to focus on EBPs for PTSD, and expanded clinic hours and telehealth options, possibly impacted veteran engagement and completion in EBPs. The study highlights the potential impacts of a changing patient population within the clinic over a relatively short period. The observations are discussed, and limitations are highlighted. The study shares the hope for additional randomized prospective studies of program designs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial.

Importance: Posttraumatic stress disorder (PTSD) is a prevalent and serious mental health problem. Although there are effective psychotherapies for PTSD, there is little information about their comparative effectiveness. Objective: To compare the effectiveness of prolonged exposure (PE) vs cognitive processing therapy (CPT) for treating PTSD in veterans. Design, Setting, and Participants: This randomized clinical trial assessed the comparative effectiveness of PE vs CPT among veterans with military-related PTSD recruited from outpatient mental health clinics at 17 Department of Veterans Affairs medical centers across the US from October 31, 2014, to February 1, 2018, with follow-up through February 1, 2019. The primary outcome was assessed using centralized masking. Tested hypotheses were prespecified before trial initiation. Data were analyzed from October 5, 2020, to May 5, 2021. Interventions: Participants were randomized to 1 of 2 individual cognitive-behavioral therapies, PE or CPT, delivered according to a flexible protocol of 10 to 14 sessions. Main Outcomes and Measures: The primary outcome was change in PTSD symptom severity on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) from before treatment to the mean after treatment across posttreatment and 3- and 6-month follow-ups. Secondary outcomes included other symptoms, functioning, and quality of life. Results: Analyses were based on all 916 randomized participants (730 [79.7%] men and 186 [20.3%] women; mean [range] age 45.2 [21-80] years), with 455 participants randomized to PE (mean CAPS-5 score at baseline, 39.9 [95% CI, 39.1-40.7] points) and 461 participants randomized to CPT (mean CAPS-5 score at baseline, 40.3 [95% CI, 39.5-41.1] points). PTSD severity on the CAPS-5 improved substantially in both PE (standardized mean difference [SMD], 0.99 [95% CI, 0.89-1.08]) and CPT (SMD, 0.71 [95% CI, 0.61-0.80]) groups from before to after treatment. Mean improvement was greater in PE than CPT (least square mean, 2.42 [95% CI, 0.53-4.31]; P = .01), but the difference was not clinically significant (SMD, 0.17). Results for self-reported PTSD symptoms were comparable with CAPS-5 findings. The PE group had higher odds of response (odds ratio [OR], 1.32 [95% CI, 1.00-1.65]; P < .001), loss of diagnosis (OR, 1.43 [95% CI, 1.12-1.74]; P < .001), and remission (OR, 1.62 [95% CI, 1.24-2.00]; P < .001) compared with the CPT group. Groups did not differ on other outcomes. Treatment dropout was higher in PE (254 participants [55.8%]) than in CPT (215 participants [46.6%]; P < .01). Three participants in the PE group and 1 participant in the CPT group were withdrawn from treatment, and 3 participants in each treatment dropped out owing to serious adverse events. Conclusions and Relevance: This randomized clinical trial found that although PE was statistically more effective than CPT, the difference was not clinically significant, and improvements in PTSD were meaningful in both treatment groups. These findings highlight the importance of shared decision-making to help patients understand the evidence and select their preferred treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01928732.

Engaging frontline workers in policy development to support the implementation of measurement-based care: Lessons learned from a field-based workgroup.

Measurement-Based Care (MBC) is the use of patient-reported outcome measures repeatedly over the course of treatment to track progress and empower both providers and patients to collaboratively set goals and plan treatment. The Measurement-Based Care in Mental Health Initiative within the Department of Veterans Affairs' Office of Mental Health and Suicide Prevention partnered with the Post Traumatic Stress Disorder (PTSD) Mentoring Program to create an interdisciplinary field-based workgroup. The workgroup included psychologists, clinical social workers, and mental health counselors from PTSD Clinical Teams. The task of the workgroup was to create guidelines for best practice in delivery of MBC in PTSD Clinical Teams given anticipated policy requiring MBC to be used in PTSD Clinical Teams. Framed in the Strategic Action Field Framework for Policy Implementation Research, the current paper evaluates this hybrid top-down and bottom-up process of policy development. Major barriers included difficulty with the workgroup as an authentic bottom-up process, inability to reach the entire field (e.g., focus groups not widely attended by providers), and limited diversity in the workgroup. Facilitators included using consensus to make decisions, support provided to workgroup members by national operations partners, and collaboration and mutual respect among workgroup members. Workgroup members noted an equal, respectful partnership between operations partners and the workgroup; they reported feeling empowered and believed the viewpoints of the field were included in the guidelines. Further, due to the COVID-19 pandemic, the workgroup included more guidelines specific to telehealth into the guidelines. This hybrid model provides a process through which frontline workers can inform policy development and implementation.

PTSD networks of veterans with combat versus non-combat types of index trauma.

BACKGROUND: Network analysis has become popular among PTSD researchers for studying causal structure or interrelationships among symptoms. However, some have noted that results do not seem to be consistent across studies. Preliminary evidence suggests that trauma type may be one source of variability. METHODS: The current study sought to examine the PTSD networks of veterans with combat versus non-combat index trauma. Participants included 944 veterans who completed the PTSD Checklist for DSM-5 at intake at two VA PTSD clinics. RESULTS: There were many similarities between the combat and non-combat trauma networks, including strong edges between symptoms that were theoretically related or similar (e.g., avoidance) and negative emotion being a highly central symptom. However, correlations of edge weights (0.509) and node centrality (0.418) across networks suggested moderate correspondence, and there appeared to be some differences associated with certain symptoms. Detachment was relatively more central and the connections of negative emotion with blame and lack of positive emotion with reckless behavior were stronger for veterans with combat-related index trauma. LIMITATIONS: The data were cross-sectional, which limits the ability to infer directional relationships between symptoms. In addition, the sample was likely not large enough to directly test for differences between networks via network comparison tests. CONCLUSIONS: Although there were many similarities, results also suggested some variability in PTSD networks associated with combat versus non-combat index trauma that could have implications for conceptualizing and treating PTSD among veterans.

Treatment choice among veterans with PTSD symptoms and substance-related problems: Examining the role of preparatory treatments in trauma-focused therapy.

Although common practice in Veterans Affairs (VA) PTSD clinics, it is unclear whether preparatory treatment improves trauma-focused treatment (TFT) completion and outcomes. Furthermore, little is known about whether treatment-seeking veterans in naturalistic settings would chose to prioritize preparatory treatment if given the option of a phase-based approach or direct access to TFT, and how substance-related problems (SRPs) influence this treatment choice. The first aim of this study was to explore how co-occurring SRPs (ranging from none to moderate/severe) influence PTSD treatment choices in a naturalistic setting where veterans were offered a choice between a phase-based approach (i.e., preparatory treatment) or direct access to TFT. The study also examined whether initial treatment choice and severity of co-occurring SRPs influenced TFT completion and outcomes. The second aim was to investigate whether preparatory treatment led to superior TFT completion or outcomes, irrespective of co-occurring SRPs. Analyses were conducted using archival data from 737 United States veterans referred for outpatient VA PTSD treatment. SRPs did not predict initial treatment choice or the length of preparatory group participation. Neither SRPs nor preparatory group participation predicted TFT completion or outcomes (measured as change in PTSD and depression symptoms from pre- to post-TFT). Preparatory group participation did not predict improved TFT completion or outcomes, irrespective of co-occurring SRPs. These findings suggest that veterans with PTSD symptoms and co-occurring SRPs may make similar treatment choices and benefit from either a phase-based approach or direct TFT initiation, and preparatory treatments may not increase patient readiness for veterans seeking TFT. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Employment outcomes from VA vocational services involving transitional work for veterans with a diagnosis of posttraumatic stress disorder.

OBJECTIVE: Transitional work (TW) for veterans with psychiatric disabilities is the predominant model of vocational rehabilitation in the Veterans Health Administration (VA). Although, on average, TW employment outcomes have been demonstrated to be inferior to supported employment, little is known about the potential subgroup of veterans for which TW may be most effective. This study of veterans with posttraumatic stress disorder (PTSD) examines differences in competitive employment outcomes and identifies characteristics of veterans who chose to engage in TW compared with those who did not. METHOD: A post hoc comparative subgroup analysis of veterans with PTSD randomly assigned to TW as part of a randomized controlled trial was conducted. Veterans were divided into 2 subgroups: those who engaged in TW (n = 141) and nonengagers (n = 129). Differences in baseline characteristics were examined and 18-month employment outcomes were compared. RESULTS: There were no differences in 18-month employment outcomes between TW engagers and nonengagers. Compared with TW engagers, those that did not engage in TW were 2.5 times more likely to get a competitive job within the first 6 months and were less likely to obtain lower skilled jobs. Younger age, adequate housing, personal means of transportation, and recent work history factor into the odds of gaining and maintaining competitive work. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Consistent with past research, engagement in TW did not result in improved long-term competitive employment outcomes for veterans with PTSD. Those who did not engage in TW were more likely to gain a competitive job within the first 6 months. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individual and group cognitive processing therapy: Effectiveness across two Veterans Affairs posttraumatic stress disorder treatment clinics.

OBJECTIVE: In accordance with Veterans Affairs (VA) policy, VA posttraumatic stress disorder (PTSD) clinics offer evidence-based treatments including cognitive processing therapy (CPT). To facilitate access to care, CPT is offered in both group and individual formats in many VA PTSD clinics. Group and individual delivery of CPT have been directly compared in active duty samples, but these findings have not been extended to VA populations. The present article directly compares the effectiveness of group and individual CPT with a written trauma account (CPT+A) across two VA PTSD clinics. METHOD: Veterans (N = 465) completed initial evaluations and enrolled in either group CPT+A (N = 146) or individual CPT+A (N = 319). Self-report measures of PTSD and depression symptoms were collected at pre-, mid-, and posttreatment; combined across treatment sites; and analyzed using hierarchical linear modeling. RESULTS: PTSD and depression symptoms reduced significantly over the course of group and individual CPT+A. Medium treatment effects were found for group CPT+A (d = .66 for PTSD, d = .68 for depression), and large treatment effects were found for individual CPT+A (d = .96 for PTSD, d = .79 for depression). CONCLUSION: Individual CPT+A led to significantly greater PTSD and depression symptom reduction than group CPT+A, indicating that in VA outpatient PTSD clinic settings, individual CPT+A may be a more effective approach than group CPT-A. In addition, PTSD symptoms reduced significantly more for Caucasian veterans than for African American veterans during CPT+A, indicating the importance of providing culturally competent trauma-focused care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Prospective associations between DSM-5 PTSD symptom clusters and suicidal ideation in treatment-seeking veterans.

Posttraumatic stress disorder (PTSD) rates are higher in military veterans than in the civilian population. Meta-analyses have found strong and consistent associations between PTSD and suicide risk. Several studies have demonstrated a concurrent reduction in suicidal ideation (SI) with reduction of PTSD symptoms during trauma-focused treatment. However, it is unclear whether changes in specific PTSD symptom clusters are most strongly associated with these changes in SI. This study prospectively examined associations between PTSD symptom clusters and SI to better specify mechanisms of change during treatment. Participants were 160 veterans (87% male, 63% Caucasian, 64% combat trauma) who completed a course of evidence-based trauma-focused therapy at a VA hospital. The Patient Health Questionnaire-9 and Posttraumatic Stress Disorder Checklist-5 were used to assess depression, SI frequency, and PTSD symptoms. Binary logistic regression analyses found that the cognitive/mood alteration cluster was the only significant independent predictor of SI at termination. Post hoc analysis of variance Bonferroni tests indicated those who decreased SI frequency had a greater reduction in intrusive, cognitive/mood alteration, and hyperarousal symptoms relative to those who increased or had no change in SI. A within-cluster item analysis revealed that baseline symptom D3 (blame self/others) was the only significant independent predictor for baseline SI, whereas baseline symptom D6 (detachment) was the only significant independent predictor for SI at termination. This discrepancy may be explained by reductions in guilt during treatment, as 79% of the sample elected to receive cognitive processing therapy. Given these associations, PTSD patients with SI may benefit from a treatment emphasis on reducing cognitive/mood alteration symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Using a Clinician-Administered Interview to Examine the Overlap in Posttraumatic Stress Disorder Criteria D and E.

Although the diagnosis of posttraumatic stress disorder (PTSD) is often criticized for including symptoms that overlap with one another, only one study has explored the impact of symptom reporting. Using a clinician-rated interview for PTSD (N = 558), the current study examined overlap between PTSD criteria D1, D2, and D3 ("target D symptoms") and criterion E symptoms of similar content (i.e., E1 and E3). Furthermore, their impact on meeting criterion and disorder cutoffs was examined. Results revealed that target symptoms were endorsed in conjunction more than half the time. Criteria D and E also were often coded together. Removal of target D symptoms resulted in 24.7% of participants no longer meeting criterion D, but no reduction in the diagnosis of PTSD. This article is one of the first to report the functioning of the new criterion D symptoms, and the results have diagnostic implications for research and clinical work.

Examining various subthreshold definitions of PTSD using the Clinician Administered PTSD Scale for DSM-5.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association [APA], 2013) includes Other- and Unspecified- Trauma and Stressor-Related Disorders to capture subthreshold Posttraumatic Stress Disorder (PTSD) symptoms. However, the DSM-5 does not specify the number or type of symptoms needed to assign them. The purpose of the current study was to extend our understanding of subthreshold PTSD by comparing four commonly used definitions adapted to the DSM-5 PTSD criteria in an outpatient treatment-seeking sample. METHODS: Veterans (N = 193) presenting to PTSD clinics were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Participants reported a criterion A traumatic event, but did not meet criteria for threshold-PTSD. We hypothesized that the number of veterans captured would be highest when fewer specific criterion sets were required by the subthreshold definition. RESULTS: Our hypothesis was upheld in that the more criteria required by the subthreshold PTSD definition, the lower the number of veterans counted within the group. LIMITATIONS: The study consisted primarily of trauma treatment-seeking male veterans, with chronic PTSD symptoms. In addition, the sample size was small and was collected as part of routine clinical care. CONCLUSIONS: These results support previous contentions around careful decision making when defining what constitutes subthreshold PTSD in research and clinical work. It also points to the need for continued research to better understand the diagnostic and treatment implications of subthreshold PTSD.

27 ways to meet PTSD: Using the PTSD-checklist for DSM-5 to examine PTSD core criteria.

Posttraumatic stress disorder (PTSD) has been criticized for including symptoms that substantially overlap with other depression and anxiety disorders. To address this concern, Brewin et al. (2009) reformulated the diagnosis around a core symptom set. Although several studies have examined the utility of the core criteria in predicting diagnostic status, none have done so using a self-report screening instrument. The sample included 617 veterans presenting for outpatient psychological services. As a part of the intake process, veterans completed the PTSD Checklist for DSM-5 (PCL-5) and were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). Veterans meeting core criteria on the PCL-5 were over 22 times more likely to meet PCL-5 diagnosed PTSD than veterans who met the core criteria on the PCL-5 but did not meet PCL-5 diagnosed PTSD (OR = 22.94; CI [12.76, 41.25]). Further, veterans who met core criteria on the PCL-5 were over 2 times more likely (OR = 2.34; 95.0% CI [1.53, 3.59]) to meet CAPS-5 diagnosed PTSD than veterans who met the core criteria on the PCL-5 but did not meet CAPS-5 diagnosed PTSD. Findings from the current study have implications for the assessment and classification of PTSD.

Diagnostic Accuracy of the Veteran Affairs' Traumatic Brain Injury Screen.

OBJECTIVE: To comprehensively estimate the diagnostic accuracy and reliability of the Department of Veterans Affairs (VA) Traumatic Brain Injury (TBI) Clinical Reminder Screen (TCRS). DESIGN: Cross-sectional, prospective, observational study using the Standards for Reporting of Diagnostic Accuracy criteria. SETTING: Three VA Polytrauma Network Sites. PARTICIPANTS: Operation Iraqi Freedom, Operation Enduring Freedom veterans (N=433). MAIN OUTCOME MEASURES: TCRS, Comprehensive TBI Evaluation, Structured TBI Diagnostic Interview, Symptom Attribution and Classification Algorithm, and Clinician-Administered Posttraumatic Stress Disorder (PTSD) Scale. RESULTS: Forty-five percent of veterans screened positive on the TCRS for TBI. For detecting occurrence of historical TBI, the TCRS had a sensitivity of .56 to .74, a specificity of .63 to .93, a positive predictive value (PPV) of 25% to 45%, a negative predictive value (NPV) of 91% to 94%, and a diagnostic odds ratio (DOR) of 4 to 13. For accuracy of attributing active symptoms to the TBI, the TCRS had a sensitivity of .64 to .87, a specificity of .59 to .89, a PPV of 26% to 32%, an NPV of 92% to 95%, and a DOR of 6 to 9. The sensitivity was higher for veterans with PTSD (.80-.86) relative to veterans without PTSD (.57-.82). The specificity, however, was higher among veterans without PTSD (.75-.81) relative to veterans with PTSD (.36-.49). All indices of diagnostic accuracy changed when participants with questionably valid (QV) test profiles were eliminated from analyses. CONCLUSIONS: The utility of the TCRS to screen for mild TBI (mTBI) depends on the stringency of the diagnostic reference standard to which it is being compared, the presence/absence of PTSD, and QV test profiles. Further development, validation, and use of reproducible diagnostic algorithms for symptom attribution after possible mTBI would improve diagnostic accuracy.

Examining the latent structure mechanisms for comorbid posttraumatic stress disorder and major depressive disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is a complex psychiatric illness that can be difficult to diagnose, due in part to its comorbidity with major depressive disorder (MDD). Given that researchers have found no difference in prevalence rates of PTSD and MDD after accounting for overlapping symptoms, the latent structures of PTSD and MDD may account for the high comorbidity. In particular, the PTSD Negative Alterations in Cognition and Mood (NACM) and Hyperarousal factors have been characterized as non-specific to PTSD. Therefore, we compared the factor structures of the Diagnostic and Statistical Manual of Mental Disorders, 5thedition (DSM-5) PTSD and MDD and examined the mediating role of the PTSD NACM and Hyperarousal factors on the relationship between MDD and PTSD symptom severity. METHODS: Participants included 598 trauma-exposed veterans (Mage = 48.39, 89% male) who completed symptom self-report measures of DSM-5 PTSD and MDD. RESULTS: Confirmatory factor analyses indicated an adequate-fitting four-factor DSM-5 PTSD model and two-factor MDD model. Compared to other PTSD factors, the PTSD NACM factor had the strongest relationship with the MDD Affective factor, and the PTSD NACM and Hyperarousal factors had the strongest association with the MDD Somatic factor. Further, the PTSD NACM factor explained the relationship between MDD factors and PTSD symptom severity. More Affective and Somatic depression was related to more NACM symptoms, which in turn were related to increased severity of PTSD. LIMITATIONS: Limitations include the reliance on self-report measures and the use of a treatment-seeking, trauma-exposed veteran sample which may not generalize to other populations. CONCLUSIONS: Implications concerning the shared somatic complaints and psychological distress in the comorbidity of PTSD and MDD are discussed.

Sometimes Less is More: Establishing the Core Symptoms of PTSD.

Historically, the symptoms of posttraumatic stress disorder (PTSD) have garnered attention and controversy due to symptom overlap with other disorders. To improve diagnostic specificity, researchers have proposed to reformulate PTSD symptoms into a parsimonious set of core criteria. The core symptoms consisted of recurrent distressing dreams or flashbacks; internal or external avoidance; and hypervigilance or exaggerated startle. The purpose of this study was to examine a previously proposed set of "core" PTSD criteria in identifying cases of PTSD within a veteran sample. Veterans (N = 383) presenting to a Veterans Affairs (VA) Medical Center PTSD clinic for psychological services were assessed using the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). A logistic regression analysis revealed that the core criteria accurately identified 79% of veterans with PTSD (OR = 11.57). Findings support a parsimonious set of core criteria in the assessment and diagnosis of PTSD. Future studies should replicate these findings in diverse, nonveteran samples.

Trauma-Related Pain, Reexperiencing Symptoms, and Treatment of Posttraumatic Stress Disorder: A Longitudinal Study of Veterans.

Research has demonstrated a strong positive association between posttraumatic stress disorder (PTSD) symptoms and physical pain. However, few studies have explored the impact of pain problems on the symptoms and treatment of PTSD, and results remain inconsistent. This longitudinal study examined whether trauma-related and trauma-unrelated pain differentially and uniquely predicted reexperiencing symptoms. We also examined whether levels of reexperiencing symptoms mediated the relationship between pain intensity and posttreatment symptoms of avoidance, numbing, and hyperarousal (ANH). Analyses were conducted using archival data from 99 treatment-seeking veterans who reported the etiology and intensity of their pain and severity of PTSD symptoms pre- and posttreatment. Among veterans with trauma-related pain, pain intensity (a) uniquely corresponded to greater posttreatment reexperiencing symptoms (b = 1.09), and (b) was indirectly predictive of ANH symptoms via the reexperiencing symptoms (b = 1.93). However, veterans with trauma-unrelated pain evidenced no associations between pain intensity and reexperiencing (b = 0.04) or ANH symptoms (b = 0.06). We thus found that trauma-related pain was indirectly related to poor PTSD treatment outcomes via reexperiencing symptoms. These findings offer additional insight into factors that may influence PTSD treatment outcomes for pain-suffering trauma survivors.