Verbal Learning Deficits in Posttraumatic Stress Disorder and Depression

Verbal learning and memory deficits are frequently reported in posttraumatic stress disorder (PTSD), but may be a product of its psychiatric comorbidities, especially major depressive disorder (MDD). To evaluate this hypothesis, 25 medication‐free patients with PTSD and comorbid MDD were compared to 148 medication‐free patients with equally severe MDD alone and to 96 nonpatients on a measure of verbal learning and memory. Additional measures of attention, working memory, and executive function were administered to evaluate their contribution to verbal memory impairment. Patients with comorbid PTSD and MDD demonstrated the greatest deficit in verbal learning compared to both MDD patients and nonpatients (omnibus effect sizes ranged d = 0.41 to 0.50), one that was not accounted for by other cognitive deficits. Findings suggest that a current diagnosis of PTSD makes a contribution to verbal learning deficits beyond the effect of depression alone.     

Multivariate assessment of explicit memory function in combat veterans with posttraumatic stress disorder

Declarative memory impairment is a frequent complaint of patients suffering from posttraumatic stress disorder (PTSD). We assessed memory, attention, visual spatial skills, and executive function in Vietnam combat veterans with (n = 19) and without (n = 13) PTSD. Although PTSD subjects demonstrated a generalized impairment relative to non-PTSD subjects on a majority of tasks, only attention and memory provided unique and independent prediction of PTSD versus non-PTSD status. Our findings suggest that memory functioning represents a neurocognitive domain of specific relevance to the development of PTSD in trauma-exposed individuals, which can be distinguished from generalized attentional impairment as well as the effects of trauma exposure severity, IQ, comorbid depression, history of alcohol use, and history of developmental learning problems.     

The Association Between Negative Trauma‐Related Cognitions and Pain‐Related Functional Status Among Veterans With Posttraumatic Stress Disorder and Alcohol Use Disorder

Among veterans with posttraumatic stress disorder (PTSD), alcohol use disorders (AUDs) are highly prevalent. Furthermore, PTSD frequently co‐occurs with chronic pain (CP), and CP is associated with an increased risk of AUD. Pain‐related beliefs and appraisals are significantly associated with poorer pain‐related functional status, yet few studies have examined negative trauma‐related cognitions and their impact on pain‐related functional disability in veterans with co‐occurring PTSD and AUD. Accordingly, we examined the association between negative trauma‐related cognitions and pain severity and pain disability in 137 veterans seeking treatment for PTSD and AUD. Using hierarchical multiple linear regression, we found that higher levels of negative trauma‐related cognitions (e.g., “I am completely incompetent”) were associated with a higher level of pain severity, after controlling for PTSD symptom severity and frequency of alcohol use, total R² = .07, ΔR² = .06. Additionally, as hypothesized, we found that higher levels of negative trauma‐related cognitions were associated with higher levels of pain disability, after controlling for PTSD symptom severity, frequency of alcohol use, and pain severity, total R² = .46, ΔR² = .03. Given that negative trauma‐related cognitions contributed to pain severity and pain disability, even when controlling for PTSD severity and frequency of alcohol use, future studies should explore the potential impact of interventions that address negative trauma‐related cognitions (e.g., prolonged exposure or cognitive processing therapy) on pain severity and disability.     

Punishment Learning in U.S. Veterans With Posttraumatic Stress Disorder

Learning processes have been implicated in the development and course of posttraumatic stress disorder (PTSD); however, little is currently known about punishment‐based learning in PTSD. The current study investigated impairments in punishment‐based learning in U.S. veterans. We expected that veterans with PTSD would demonstrate greater punishment‐based learning compared to a non‐PTSD control group. We compared a PTSD group with and without co‐occurring depression (n = 27) to a control group (with and without trauma exposure) without PTSD or depression (n = 29). Participants completed a computerized probabilistic punishment‐based learning task. Compared to the non‐PTSD control group, veterans with PTSD showed significantly greater punishment‐based learning. Specifically, there was a significant Block × Group interaction, F(1, 54) = 4.12, p = .047, η² = .07. Veterans with PTSD demonstrated greater change in response bias for responding toward a less frequently punished stimulus across blocks. The observed hypersensitivity to punishment in individuals with PTSD may contribute to avoidant responses that are not specific to trauma cues.     

Gender Differences in Neurocognitive Performance Among Children With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are frequent sequelae after motor vehicle accidents (MVAs). These two pathologies often have overlapping neurocognitive deficits across several domains, such as attention, memory, and executive functions. The present study was an effort to examine the contribution of gender to these overlapping symptoms. To this end, psychodiagnostic and neuropsychological data were collected on 61 children and adolescents 3 months following MVA. All participants were diagnosed with PTSD, and about half (n = 33) also received a diagnosis of mTBI. Analyses of variance revealed significant interactions between gender and mTBI (), such that girls with mTBIs preformed significantly worse than noninjured girls on measures of executive functions (Cohen's d = 3.88) and sustained attention (Cohen's d = 3.24). Boys, on the other hand, did not differ significantly on any of those measures, irrespective of TBI injury status. Similarly, comparisons to the normative population revealed that, whereas boys showed impaired neurocognitive performances regardless of TBI status, impaired performances in girls were limited to those cases in which the girls were comorbid for PTSD and mTBI. It appears then that whereas PTSD alone might explain boys’ reduced neurocognitive performance, among girls the comorbidity of PTSD and mTBI is required to account for performance deficits.     

Couple Treatment for Alcohol Use Disorder and Posttraumatic Stress Disorder: Pilot Results From U.S. Military Veterans and Their Partners

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15‐session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions. There were 8 veterans who showed clinically reliable pre‐ to posttreatment reduction of PTSD outcomes. There were also significant group‐level reductions in clinician‐, veteran‐, and partner‐rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group‐level reduction in veterans’ percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group‐level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group‐level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52). These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.     

Attachment,Personality Characteristics,and Posttraumatic Stress Disorder in U.S. Veterans of Iraq and Afghanistan

U.S. veterans of Iraq and/or Afghanistan (N = 116) completed an Internet survey with questions related to attachment style in intimate relationships, personality factors, and posttraumatic stress disorder (PTSD). Participants completed the PTSD Checklist‐Military, Experiences in Close Relationships Scale‐Short Form, and the International Personality Item Pool Big Five Short Form Questionnaire. Most participants were male and Caucasian. Hierarchical linear regression analysis results indicated that emotional stability (β = ?.46, p < .001) and attachment avoidance (β = .20, p < .05) were associated with PTSD symptom severity (adjusted R² = .63). An interaction between conscientiousness and attachment anxiety was found (β = ?.26, p < .001; ΔR² = .06), with secure attachment moderating the relationship between conscientiousness and PTSD symptom severity. Results of this study indicate that emotional stability, conscientiousness, and secure relationship attachment styles (low attachment anxiety and avoidance) are important for postcombat mental health.     

The Association Between PTSD and Functional Outcome Is Mediated by Perception of Cognitive Problems Rather Than Objective Neuropsychological Test Performance

Posttraumatic stress disorder (PTSD) has been consistently linked to poorer functional outcomes, including quality of life, health problems, and social and occupational functioning. Less is known about the potential mechanisms by which PTSD leads to poorer functional outcomes. We hypothesized that neurocognitive functioning and perception of cognitive problems would both mediate the relationship between PTSD diagnosis and functioning. In a sample of 140 veterans of the recent wars and conflicts in Iraq and Afghanistan, we assessed PTSD symptoms, history of traumatic brain injury (TBI), depression, self‐report measures of quality of life, social and occupational functioning, and reintegration to civilian life, as well as perception of cognitive problems. Veterans also completed a comprehensive neuropsychological battery of tests. Structural equation modeling revealed that perception of cognitive problems, but not objective neuropsychological performance, mediated the relationship between PTSD diagnosis and functional outcomes after controlling for TBI, depression, education, and a premorbid IQ estimate, b = −6.29, 95% bias‐corrected bootstrapped confidence interval [−11.03, −2.88], showing a large effect size. These results highlight the importance of addressing appraisals of posttrauma cognitive functioning in treatment as a means of improving functional outcomes.     

Self‐Compassion as a Prospective Predictor of PTSD Symptom Severity Among Trauma‐Exposed U.S. Iraq and Afghanistan War Veterans

U.S. combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder (PTSD) compared to the general population. Self‐compassion, characterized by self‐kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD. We examined the concurrent and prospective relationship between self‐compassion and PTSD symptom severity after accounting for level of combat exposure and baseline PTSD severity in 115 Iraq and Afghanistan war veterans exposed to 1 or more traumatic events during deployment. PTSD symptoms were assessed using the Clinician Administered PTSD Scale for DSM‐IV (CAPS‐IV) at baseline and 12 months (n =101). Self‐compassion and combat exposure were assessed at baseline via self‐report. Self‐compassion was associated with baseline PTSD symptoms after accounting for combat exposure (β = ?.59; p < .001; ΔR² = .34; f² = .67; large effect) and predicted 12‐month PTSD symptom severity after accounting for combat exposure and baseline PTSD severity (β = ?.24; p = .008; ΔR² = .03; f² = .08; small effect). Findings suggest that interventions that increase self‐compassion may be beneficial for treating chronic PTSD symptoms among some Iraq and Afghanistan war veterans.     

Emotion Dysregulation and Social Support in PTSD and Depression: A Study of Trauma‐Exposed Veterans

Emotion dysregulation has been associated with impaired interpersonal functioning and increased risk of posttraumatic psychopathology. Given that social support is a robust predictor of psychiatric morbidity following trauma exposure, we examined whether emotion dysregulation was associated with posttraumatic psychopathology through its negative effect on social support. Using self‐report data from 90 military veterans (89.9% men) enrolled in an outpatient psychotherapy program for posttraumatic stress disorder (PTSD), we found that social support partially mediated the effect of emotion dysregulation on PTSD (P_M = .10) and depression symptoms (P_M = .14). When source of support was considered, friend (P_M = .08) and significant other support (P_M = .06) were greater mediators of the effect of emotion dysregulation on depression symptoms than family support (P_M = .01). There were no differential mediating effects for support providers on PTSD symptoms. Our findings indicate that social support is a statistically significant yet clinically limited mechanism through which emotion dysregulation is linked with psychiatric symptoms. Implications for these limitations and alternative potentially relevant interpersonal mechanisms are discussed.     

Mild Traumatic Brain Injury,PTSD, and Psychosocial Functioning Among Male and Female U.S. OEF/OIF Veterans

This study examined the unique and combined relationship between mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) with psychosocial functioning in a cohort of 1,312 U.S. male and female veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) enrolled in the Veterans After‐Discharge Longitudinal Registry (Project VALOR). We assessed mTBI with structured screening questions reflective of current TBI classification standards and PTSD via the SCID‐IV PTSD module; all other variables were assessed by self‐report questionnaires. We identified significant diagnostic group differences in psychosocial functioning for both sexes. Individuals with PTSD, with or without a history of mTBI, reported significantly worse psychosocial functioning than individuals with mTBI alone or neither mTBI nor PTSD (males, η²_p = .11, p < .001; females, η²_p = .14, p < .001), even after adjusting for demographics and severity of chronic pain. The results suggested that veterans experiencing PTSD, regardless of whether they had a history of mTBI, were at increased risk for long‐term psychosocial impairment. Further research examining possible benefits from improved access to resources and treatment to address these needs would be valuable.     

Traumatic Brain Injury,PTSD, and Current Suicidal Ideation Among Iraq and Afghanistan U.S. Veterans

Suicide is a prevalent problem among veterans deployed to Iraq and Afghanistan. Traumatic brain injury (TBI) and psychiatric conditions, such as posttraumatic stress disorder (PTSD), are potentially important risk factors for suicide in this population, but the literature is limited by a dearth of research on female veterans and imprecise assessment of TBI and suicidal behavior. This study examined 824 male and 825 female U.S. veterans who were enrolled in the baseline assessment of the Veterans After‐Discharge Longitudinal Registry (Project VALOR), an observational registry of veterans with and without PTSD who deployed in support of the wars in Iraq and Afghanistan and were enrolled in the Veterans Affairs healthcare system. Results indicated that current depressive symptoms, PTSD, and history of prior TBI were all significantly associated with current suicidal ideation (Cohen's d = 0.91, Cramers’ Vs = .19 and .08, respectively). After adding a number of variables to the model, including psychiatric comorbidity, TBI history was associated with increased risk of current suicidal ideation among male veterans only (RR = 1.55). TBI is an important variable to consider in future research on suicide among veterans of the wars in Iraq and Afghanistan, particularly among male veterans.     

Sleep Quality and Reexperiencing Symptoms of PTSD Are Associated With Current Pain in U.S. OEF/OIF/OND Veterans With and Without mTBIs

Pain, a debilitating condition, is frequently reported by U.S. veterans returning from Afghanistan and Iraq. This study investigated how commonly reported clinical factors were associated with pain and whether these associations differed for individuals with a history of chronic pain. From the Boston metropolitan area, 171 veterans enrolled in the Veterans Affairs Center of Excellence were assessed for current posttraumatic stress disorder (PTSD) symptom severity, current mood and anxiety diagnoses, lifetime traumatic brain injury, combat experiences, sleep quality, and alcohol use. Hierarchical regression models were used to determine the association of these conditions with current pain. Average pain for the previous 30 days, assessed with the McGill Pain Questionnaire, was 30.07 out of 100 (SD = 25.43). Sleep quality, PTSD symptom severity, and alcohol use were significantly associated with pain (R² = .24), as were reexperiencing symptoms of PTSD (R² = .25). For participants with a history of chronic pain (n = 65), only PTSD symptoms were associated with pain (R² = .19). Current pain severity was associated with increased PTSD severity (notably, reexperiencing symptoms), poor sleep quality, and increased alcohol use. These data support the hypothesis that PTSD symptoms influence pain, but suggest that problems with sleep and alcohol use may exacerbate the relationship.     

Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans

We examined the efficacy of a brief, accessible, nonstigmatizing online intervention—writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self‐reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6‐months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes.     

Sleep Variability in Military‐Related PTSD: A Comparison to Primary Insomnia and Healthy Controls

Sleep disturbances are prevalent in posttraumatic stress disorder (PTSD) and are associated with a number of adverse health consequences. Few studies have used comprehensive assessment methods to characterize sleep in Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OEF/OIF/OND) veterans with PTSD. OEF/OIF/OND veterans with PTSD and sleep disturbance (n = 45) were compared to patients with primary insomnia (n = 25) and healthy control subjects (n = 27). Participants were assessed using questionnaire‐based measures as well as daily subjective and objective measures of sleep. The 3 groups were compared with regard to (a) group means, (b) intraindividual (i.e., night‐to‐night) variability of sleep, and (c) interindividual (i.e., within‐group) variability of sleep. In terms of group means, only objective sleep efficiency was significantly worse with PTSD than with primary insomnia (d = 0.54). Those with PTSD differed from those with primary insomnia on measures of intraindividual as well as interindividual variability (d = 0.48–0.73). These results suggested sleep symptoms in OEF/OIF/OND veterans with PTSD are more variable across nights and less consistent across patients relative to sleep symptoms in insomnia patients without PTSD. These findings have implications for research, as well as for personalizing treatment for individuals with PTSD.     

Analysis of Violent Behavior in Vietnam Combat Veteran Psychiatric Inpatients with Posttraumatic Stress Disorder

This study tested the hypothesis that male Vietnam veterans seeking inpatient treatment for PTSD (n = 228) exhibit more violent behavior compared with a mixed diagnostic group of male psychiatric Inpatients without PTSD (n = 64) and a community sample of Vietnam veterans with PTSD not undergoing inpatient treatment (n = 273). Violent acts assessed included property destruction, threats without a weapon, physical fighting, and threats with a weapon. PTSD inpatients engaged in more types of violent behavior than both comparison conditions. Correlates of violence among PTSD inpatients included PTSD symptom severity and, to a lesser degree, measures of substance abuse. These findings justify routine assessment of violent behavior among inpatients with PTSD, as well as application of specialized interventions for anger dyscontrol and aggression.     

Gender Differences in Threat Biases: Trauma Type Matters in Posttraumatic Stress Disorder

Women are diagnosed with posttraumatic stress disorder (PTSD) at twice the rate of men. This gender difference may be related to differences in PTSD experiences (e.g., more hypervigilance in women) or types of trauma experienced (e.g., interpersonal trauma). We examined whether attentional threat biases were associated with gender, PTSD diagnosis, and/or trauma type. Participants were 70 civilians and veterans (38 women, 32 men; 41 with PTSD, 29 without PTSD) assessed with the Clinician Administered PTSD Scale for DSM‐IV who completed a facial dot‐probe attention bias task and self‐report measures of psychiatric symptoms and trauma history. Factorial ANOVA and regression models examined associations between gender, PTSD diagnosis, index trauma type, lifetime traumatic experiences, and attentional threat biases. Results revealed that compared to women without PTSD and men both with and without PTSD, women with PTSD demonstrated attentional biases toward threatening facial expressions, d = 1.19, particularly fearful expressions, d = 0.74. Psychiatric symptoms or early/lifetime trauma did not account for these attentional biases. Biases were related to interpersonal assault index traumas, η_p² = .13, especially sexual assault, d = 1.19. Trauma type may be an important factor in the development of attentional threat biases, which theoretically interfere with trauma recovery. Women may be more likely to demonstrate attentional threat biases due to higher likelihood of interpersonal trauma victimization rather than due to gender‐specific psychobiological pathways. Future research is necessary to clarify if sexual assault alone or in combination with gender puts individuals at higher risk of developing PTSD.     

Military Sexual Assault,Gender, and PTSD Treatment Outcomes of U.S. Veterans

This study examined whether gender and military sexual assault (MSA) were associated with psychiatric severity differences at initiation of treatment for posttraumatic stress disorder (PTSD) and whether MSA and gender predicted psychiatric treatment outcomes. Male (n = 726) and female (n = 111) patients were recruited from 7 U.S. Department of Veterans Affairs (VA) PTSD specialty intensive treatment programs and completed an intake survey; 69% (n = 574) of the participants completed a 4‐month postdischarge follow‐up survey. Measures included current PTSD and depressive symptoms, aggressive/violent behaviors, alcohol and drug use severity, and quality of life. Multilevel multivariate regression analyses were conducted to examine the main and interaction effects of gender and MSA on psychiatric treatment outcomes at 4‐month follow‐up, including demographics, baseline severity, hostile fire, and treatment length of stay. Baseline PTSD severity did not differ by gender or MSA status, but women had more severe depressive symptoms (d = 0.40) and less aggressive/violent symptoms (d = ?0.46) than men. Gender, MSA status, and the interaction between gender and MSA did not predict treatment outcomes as hypothesized. Male and female veterans with and without MSA responded equally well to treatment in VA PTSD intensive treatment programs.     

Comparison of Clinician‐ and Self‐Assessments of Posttraumatic Stress Symptoms in Older Versus Younger Veterans

Assessment of posttraumatic stress disorder (PTSD) in older adults has received limited investigation. The purpose of this study was to compare the severity of PTSD symptoms in treatment‐seeking older and younger U.S. veterans with PTSD. Participants were 360 male and 284 female veterans enrolled in 2 separate clinical trials of psychotherapy for PTSD. About 4% of the participants were age 60 years or older. Symptoms were assessed before treatment using clinician‐rated and self‐report measures. For men, only numbing symptoms were lower in older veterans; this was so in clinician ratings, d = 0.76, and self‐reports, d = 0.65. For women, clinician‐rated hyperarousal symptoms were lower in older veterans, d = 0.57. Clinician‐rated and self‐reported symptoms were strongly related, Bs = 0.95 and 0.80 in the male and female samples, respectively. Among men, clinician‐rated and self‐reported reexperiencing and hyperarousal symptoms were associated only in younger veterans. Accurate assessment of PTSD symptoms in older adults is essential to identifying and implementing effective treatment. Our findings suggest that some symptoms may be lower in older men, and that some symptoms of PTSD may be underdetected in older women. Future research should assess the combined effect of gender and age on PTSD symptom presentation.     

The Dopamine D3 Receptor Gene and Posttraumatic Stress Disorder

The dopamine D₃ receptor (DRD3) gene has been implicated in schizophrenia, autism, and substance use‐disorders and is related to emotion reactivity, executive functioning, and stress‐responding, processes impaired in posttraumatic stress disorder (PTSD). The aim of this candidate gene study was to evaluate DRD3 polymorphisms for association with PTSD. The discovery sample was trauma‐exposed White, non‐Hispanic U.S. veterans and their trauma‐exposed intimate partners (N = 491); 60.3% met criteria for lifetime PTSD. The replication sample was 601 trauma‐exposed African American participants living in Detroit, Michigan; 23.6% met criteria for lifetime PTSD. Genotyping was based on high‐density bead chips. In the discovery sample, 4 single nucleotide polymorphisms (SNPs), rs2134655, rs201252087, rs4646996, and rs9868039, showed evidence of association with PTSD and withstood correction for multiple testing. The minor alleles were associated with reduced risk for PTSD (OR range = 0.59 to 0.69). In the replication sample, rs2251177, located 149 base pairs away from the most significant SNP in the discovery sample, was nominally associated with PTSD in men (OR = 0.32). Although the precise role of the D₃ receptor in PTSD is not yet known, its role in executive functioning and emotional reactivity, and the sensitivity of the dopamine system to environmental stressors could potentially explain this association.