Evaluation of Dream Content in Combat-Related PTSD

Nightmares that replicate traumatic events are among the criteria that define posttraumatic stress disorder (PTSD); however, there has been limited systematic assessment of the content of dreams in PTSD. A PTSD dream rating instrument was developed to ope rationalize features attributed to dreams associated with combat-related PTSD that incorporated dimensions from the dream content analysis literature, and its reliability was assessed. Then the instrument was used to characterize dream reports in 18 Vietnam combat veterans diagnosed with PTSD. Approximately half of the group's target dreams contained features characteristic of combat, and all but 3 (17%) were moderately to highly threatening. Fifty-three percent were set at least partially in the present and 79% contained distorted elements. We therefore conclude that target dreams of combat veterans with PTSD vary with regard to replication of trauma and elements normally associated with dreaming, but typically are threatening.     

A prospective analysis of trauma exposure: the mediating role of PTSD symptomatology

Trauma exposure has been associated with increased risk of exposure to additional traumatic events. Reactions to trauma exposure, specifically PTSD symptomatology, may mediate the link between trauma exposure and later traumatic events. Data from a longitudinal sample of Gulf War veterans (N = 2,949) were analyzed using a series of regression models. Higher levels of combat exposure were related to increased reports of PTSD symptomatology immediately upon return as well as increased reports of traumatic events in the 2 years following the Gulf War. PTSD symptomatology partially mediated the link between combat exposure and later trauma. Symptom clusters were also analyzed separately as potential mediators. Implications for the treatment of PTSD and prevention of exposure to multiple traumas are discussed.     

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 (β = .14, p < .001) and postmilitary traumatic events (β = .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.     

Five‐Year Impacts of Family Stressors and Combat Threat on the Mental Health of Afghanistan and Iraq War Veterans

It has been well established that warfare‐related stress puts service members at risk for a range of mental health problems after they return from deployment. Less is known about service members’ experience of family stressors during deployment. The aims of this study were to (a) evaluate whether family stressors would contribute unique variance to posttraumatic stress disorder (PTSD) and depressive symptoms above and beyond combat threat during deployment and (b) examine whether family stressors would amplify the negative effects of combat threat on postmilitary mental health 5 years postdischarge. Study participants reported their experience of objective and subjective family stressors and combat threat during deployment. Objective family stressors demonstrated unique associations with PTSD and depression symptoms and remained significant after accounting for ongoing family stressors reported at follow‐up. A significant interaction was found between objective family stressors and combat threat on PTSD symptoms, r = ?.10. Although the association between combat threat and PTSD was significant for participants who reported high, B = 0.04; and low, B = 0.09, exposure to family stressors, the steeper slope for those exposed to fewer family stressors indicates a stronger effect of combat threat. Follow‐up analyses revealed that veterans who experienced high amounts of family stress and high levels of combat threat reported significantly worse PTSD symptoms than those who reported low family stress, t(256) = 3.98, p < .001. Findings underscore the importance of attending to the role that family stressors experienced during deployment play in service members’ postmilitary mental health.     

Dissociation and Posttraumatic Stress Disorder: A Latent Profile Analysis

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM‐5; American Psychiatric Association, 2013 ) contains a dissociative subtype for posttraumatic stress disorder (PTSD) characterized by significant depersonalization and derealization. In this study the PTSD dissociative subtype was examined using latent profile analysis in a sample of 541 trauma‐exposed college students. Items from the PTSD Checklist and Multiscale Dissociation Inventory were used as latent class indicators. Results supported a 3‐class solution including a well‐adjusted class, a PTSD class, and a PTSD/dissociative class characterized by elevated symptoms of PTSD, depersonalization, and derealization. Significant class differences were found on a number of measures of related psychopathology with Cohen's d effect size estimates ranging from 0.04 to 1.86. Diagnostic and treatment implications regarding the dissociative subtype are discussed.     

Introduction to the Special Issue: Network Analysis of Traumatic Stress

Network analysis has emerged as a promising new statistical methodology for traumatic stress studies. The present special issue of the Journal of Traumatic Stress amalgamates the reports of 10 studies that employed network analysis to further the field's understanding of traumatic stress. The current issue includes reports of network analyses that sought to better understand the impact of different kinds of traumatic events, including childhood and gender-based trauma exposure, on PTSD symptomatology as defined under the DSM-5 and ICD-11, and examined the relation between PTSD symptoms and trauma-related dissociative experiences as well as the impact of psychological treatment on trauma recovery. A variety of research designs from a diverse group of international samples were employed, including concurrent, longitudinal, experience-sampling, and treatment outcome studies. Finally, a commentary on the articles included in this special issue was provided by Dr. Carl Weems.     

A Test of Adolescent Internalizing and Externalizing Symptoms as Prospective Predictors of Type of Trauma Exposure and Posttraumatic Stress Disorder

The present study utilized longitudinal data from a high‐risk community sample (N = 377; 166 trauma‐exposed; 202 males; 175 females; 73% non‐Hispanic Caucasian) to test pretrauma measures of adolescent internalizing and externalizing symptoms as unique prospective predictors of type of trauma exposure and PTSD over and above the influence of correlated family adversity (a composite of family conflict, stress, and parental psychopathology). Data were analyzed with logistic and multinomial logistic regressions. Results indicated that females, but not males, with higher levels of internalizing (OR = 2.91) and externalizing (OR = 2.37) symptoms during adolescence were significantly more likely to be exposed to assaultive violence (over and above family adversity). In fact, males with higher levels of internalizing symptoms were significantly less likely to be exposed to assaultive violence (OR = 0.54). Neither internalizing nor externalizing symptoms uniquely predicted exposure to traumatic events that did not involve assaultive violence. Among trauma‐exposed participants, the unique association between internalizing symptoms and later PTSD yielded an odds ratio of 1.79 (p = .07) over and above the influences of family adversity, type of trauma exposure, and gender. Assaultive violence exposure fully mediated the association between females’ externalizing symptoms and future PTSD. Findings may help inform the prevention of both assaultive violence exposure and PTSD.     

Depression Suppresses Treatment Response for Traumatic Loss–Related Posttraumatic Stress Disorder in Active Duty Military Personnel

There are multiple well‐established evidence‐based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat‐related PTSD in military populations is less responsive to evidence‐based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment‐related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss–related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss–related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = ?4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss–related PTSD, B = 3.75. These findings suggest that evidence‐based treatments for PTSD should better accommodate loss and grief in military populations.     

An Alternative Interpretation of “Intensive” PTSD Treatment Failures

An evaluation of program failures in the treatment of combat-related posttraumatic stress disorder has led some reviewers to conclude that the focus of treatment should be shifted away from combat trauma and directed toward other problems. A more detailed examination of these programs reveals that they rarely involve the systematic use of the most soundly-validated PTSD treatment, trauma-focused therapy.     

Posttraumatic Stress Disorder Symptoms in Korean Conflict and World War II Combat Veterans Seeking Outpatient Treatment

Given important differences in the Korean conflict and World War II, samples of treatment-seeking combat veterans from these wars (30 Korea, 83 World War II) were compared on the prevalence and severity of posttraumatic stress disorder (PTSD). With age, ethnicity, and combat exposure taken into account, the Korean veterans reported significantly more severe symptoms on both interview and self-report PTSD measures. Group differences in the prevalence of current PTSD were in a similar direction but not significant. These results are generally consistent with other studies that have found Korean combat veterans to exhibit higher rates of psychosocial maladjustment than World War II combat veterans. Based on related research with Vietnam veterans, one direction for future investigation is to examine what role stressful postmilitary homecoming experiences may have played in influencing the development and course of combat-related PTSD in the aging cohort of forgotten Korean conflict veterans.     

Are the dissociative criteria in ASD useful?

Acute stress disorder (ASD) is a new DSM-IV diagnostic category, characterized by dissociative, intrusive, avoidance, and hyperarousal symptoms in the first month after a traumatic experience. The goal of the present study was to examine the utility of this diagnosis. In a prospective study, 79 mixed trauma victims who met DSM-IV symptom criteria for PTSD within 1 month following a traumatic event were followed through three months post-event. Dissociative symptoms in ASD only partially captured distress and dysfunction during the first month. Participants with and without ASD showed similar patterns of recovery, with only small differences that disappeared at three months post-event. Interestingly, initial PTSD avoidance but not ASD dissociative symptoms predicted PTSD severity at 3 months.     

The Strongest Correlates of PTSD for Firefighters: Number,Recency, Frequency,or Perceived Threat of Traumatic Events?

Firefighters experience a wide range of traumatic events while on duty and are at risk to develop psychopathology and posttraumatic stress disorder (PTSD). According to cognitive models, the person's interpretation of the traumatic event is responsible for the development of PTSD rather than the traumatic event itself. This cross‐sectional study aimed to explore the contribution of perceived threat to explain PTSD symptoms in Portuguese firefighters, after adjusting for potential confounding factors. A sample of 397 firefighters completed self‐report measures of exposure to traumatic events, psychopathology, and PTSD. Perceived threat explained unique variance in PTSD symptoms, R² = .40, ΔR² = .02, F(10, 367) = 24.55, p < .001, Cohen's f² =.03, after adjusting for psychopathology, number, recency, and frequency of the events, and other potential confounding variables. The association between psychopathology and PTSD was also moderated by perceived threat, R² = .43, ΔR² = .03, F(11, 366) = 25.33, p < .001, Cohen's f² =.05. Firefighters may benefit from interventions that focus on perceived threat to prevent PTSD symptoms.     

Memory Functioning in Adult Women Traumatized by Childhood Sexual Abuse

Memory impairment has been reported in some studies of patients with combat-related posttraumatic stress disorder (PTSD) and in rape victims with PTSD. The authors tested whether explicit memory impairment was evident in adult women who were traumatized by severe sexual abuse in childhood. The California Verbal Learning Test (Delis, Kramer, Kaplan, & Ober, 1987) and the Benton Visual Retention Task (Benton, 1974) were administered to 22 female adult survivors of childhood sexual trauma and to 20 demographically and educationally similar nonvictimized women. No evidence was found of explicit memory impairment in the abuse survivors. Furthermore, neither PTSD severity, dissociative symptom severity, nor extent of preexisting amnesia for childhood trauma contributed to the variance in memory functioning. Additional studies are needed to determine the extent to which impaired explicit memory functioning is a common feature of posttraumatic stress syndromes.     

Peritraumatic Assessment of Autobiographical Memory After Exposure to a Traumatic Event

Posttraumatic stress disorder (PTSD) is commonly acknowledged to be associated with reduced specificity of autobiographical memory (AM). However, very few studies have assessed AM in the peritraumatic phase. The aim of the present study was to examine whether the AM impairment reported in PTSD is present a few days after a traumatic event. We assessed AM in 41 participants who had recently been exposed to trauma, and 34 controls who had never experienced a traumatic situation. The trauma‐exposed participants also completed the Impact of Event Scale‐R (IES‐R), the Inventory of Peritraumatic Distress, and the Peritraumatic Dissociative Experiences Questionnaire. Results showed that autobiographical memories cued by negative words were significantly less specific in the group of trauma‐exposed participants than in the control group (p = .008; d = 0.40). Thus, mild AM impairment was already present three days after trauma exposure, long before acute PTSD set in.     

Adolescent survivors of massive childhood trauma in Cambodia: Life events and current symptoms

Cambodian adolescents who survived massive trauma as children were studied to examine the relation of current trauma symptoms to sex, age, trauma exposure, and other current symptoms. Exposure to traumatic life events was expected to be very high, to relate to age and to other symptoms of current psychological functioning. Questionnaires assessed traumatic life events, post-traumatic stress disorder (PTSD) and other psychiatric symptoms, and current functioning. Results document high levels of stress exposure and current trauma symptoms. Based on self-reports of PTSD symptoms, 37% of the subjects were estimated to fulfill DSM-III-R criteria for PTSD. Trauma symptoms were correlated with exposure (r=.31), although not with symptoms of depressed mood, anxiety, or dissociation. Age was related to high levels of recollected trauma exposure (r=.56). Further studies are needed to identify factors associated with better outcomes and to plot the differential course of PTSD symptom clusters over time.     

Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) commonly co-occur in combat veterans, and this comorbidity has been associated with higher levels of distress and more social and economic costs compared to one disorder alone. In a secondary analysis of a multisite randomized controlled trial of a sample of veterans with combat-related PTSD, we examined the associations among pre-, peri-, and postdeployment adversity, social support, and clinician-diagnosed comorbid MDD. Participants completed the Deployment Risk and Resilience Inventory and the Beck Depression Inventory–II as well as structured clinical interviews for diagnostic status. Among 223 U.S. veterans of the military operations in Iraq and Afghanistan (86.9% male) with primary combat-related PTSD, 69.5% had current comorbid MDD. After adjustment for sex, a linear regression model indicated that more concerns about family disruptions during deployment, f² = 0.065; more harassment during deployment, f² = 0.020; and lower ratings of postdeployment social support, f² = 0.154, were associated with more severe self-reported depression symptoms. Interventions that enhance social support as well as societal efforts to foster successful postdeployment reintegration are critical for reducing the mental health burden associated with this highly prevalent comorbidity in veterans with combat-related PTSD.     

Posttraumatic stress disorder in female veterans with military and civilian sexual trauma

This study examines relationships among military sexual trauma (MST), nonmilitary sexual trauma, and posttraumatic stress disorder (PTSD). A sample of 196 female veterans was assessed for trauma occurring before, during, and after military service, and for current PTSD. The prevalence of MST was higher than that of premilitary and postmilitary sexual trauma. Premilitary trauma did not significantly increase the odds of experiencing MST, but did increase the odds of experiencing postmilitary sexual trauma. Logistic regression analyses revealed MST was more strongly associated with PTSD than was premilitary or postmilitary trauma. Women with MST had the greatest increased odds of developing PTSD. Understanding risk factors for and taking steps to prevent MST may reduce cases of PTSD in female veterans.     

Trauma centrality and PTSD in veterans returning from Iraq and Afghanistan

Research has demonstrated that the extent to which an individual integrates a traumatic event into their identity (“trauma centrality”) positively correlates with posttraumatic stress disorder (PTSD) symptom severity. No research to date has examined trauma centrality in individuals exposed to combat stress. This study investigated trauma centrality using the abridged Centrality of Event Scale (Berntsen & Rubin, 2006) among Operation Enduring Freedom/Operation Iraqi Freedom combat veterans (n = 46). Multiple regression analyses demonstrated that trauma centrality predicted PTSD symptoms. Trauma centrality and PTSD symptoms remained significantly correlated when controlling for depression in subgroups of veterans with or without probable PTSD. This study replicates and extends findings that placing trauma at the center of one's identity is associated with PTSD symptomatology.     

Dissociative states induced by relaxation training in a PTSD combat veteran: Failure to identify trigger mechanisms

PTSD is often treated with anxiety management techniques, including relaxation training. A case report is presented which describes a PTSD combat veteran who experienced dissociative states induced by relaxation training. Hypnotherapy subsequently identified traumatic memories which were recalled during relaxation training but triggering mechanisms for the recall of these traumatic memories were not identified.     

Posttraumatic Stress Disorder in a Nationally Representative Mexican Community Sample

This study describes the public health burden of trauma exposure and posttraumatic stress disorder (PTSD) in relation to the full range of traumatic events to identify the conditional risk of PTSD from each traumatic event experienced in the Mexican population and other risk factors. The representative sample comprised a subsample (N = 2,362) of the urban participants of the Mexican National Comorbidity Survey (2001?2002). We used the World Health Organization's Composite International Diagnostic Interview (CIDI) to assess exposure to trauma and the presence of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM‐IV; American Psychiatric Association, 1994 ) in each respondents’ self‐reported worst traumatic event, as well as a randomly selected lifetime trauma. The results showed that traumatic events were extremely common in Mexico (68.8%). The estimate of lifetime PTSD in the whole population was 1.5%; among only those with a traumatic event it was 2.1%. The 12‐month prevalence of PTSD in the whole population was 0.6%; among only those with a traumatic event it was 0.8%. Violence‐related events were responsible for a large share of PTSD. Sexual violence, in particular, was one of the greatest risks for developing PTSD. These findings support the idea that trauma in Mexico should be considered a public health concern.