Treatment Improves Symptoms Shared by PTSD and Disordered Eating

Eating disorders and posttraumatic stress disorder (PTSD) are debilitating conditions that frequently co‐occur. Although the two disorders have different clinical presentations, they share associated features, including cognitive disturbances, emotion dysregulation, dissociation, and impulsivity. We hypothesized that reductions in PTSD symptoms following cognitive processing therapy (CPT) and its treatment components (CPT without the written account or the written account only) would be associated with improvements in symptoms common to PTSD and eating disorders. Participants in the current investigation included women with PTSD (N = 65) who reported a history of rape or physical assault, were in a randomized dismantling study of CPT, and completed the Eating Disorder Inventory‐2 (EDI‐2) at pre‐ and posttreatment. Latent growth modeling results indicated that decreases in PTSD symptom scores were significantly associated with reductions in the Impulse Regulation, Interoceptive Awareness, Interpersonal Distrust, Ineffectiveness, and Maturity Fears subscales of the EDI‐2. Thus, PTSD treatment affected symptoms shared by PTSD and eating disorders. Currently, there are no clear guidelines for treatment of comorbid PTSD and eating disorders. Traditional CPT may impact symptoms common to both, but additional therapy may be needed for specific disordered eating attitudes and behaviors.     

Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape

This study examines the relationship between posttraumatic stress disorder (PTSD) and dissociative experiences in a sample of 158 recent female assault victims (74 rape, 84 nonsexual assault) and 46 comparison subjects who had not been assaulted within the last year. Results indicated that victims had elevated scores on the Dissociative Experiences Scale (DES) as compared to the comparison subjects, but that this elevation was not as high as for other traumatized samples. The level of dissociation reported by assault victims declined significantly over the three month course of the study. DES scores were related to PTSD diagnosis and symptom severity, but only among nonsexual assault victims. In rape victims, there was no correlation between dissociation and PTSD. Recent victims with a history of childhood sexual abuse were significantly more dissociative than those who did not report such a history. These results are discussed with regard to vulnerability factors for developing PTSD subsequent to a criminal assault.     

The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder

This study investigated sudden gains, i.e., rapid and stable improvements, in posttraumatic stress disorder (PTSD) symptoms that may occur in cognitive–behavioral therapy. Twenty‐nine of 72 participants (39.2%) experienced a sudden gain during treatment. Mixed model ANOVAs analyzed sudden gains impact on clinician‐rated PTSD symptom severity, patient‐rated PTSD symptom severity, and patient‐rated depressive symptom severity. Sudden gains in PTSD symptomology were associated with greater reductions in PTSD symptom severity for the avoidance/numbing and hyperarousal symptom clusters at posttreatment. By 6‐month follow‐up, the sudden gains group had maintained those reductions in symptoms, but the nonsudden gains group had achieved equal reductions in symptom severity. Participants experiencing sudden gains on PTSD measures had lower depression severity at posttreatment and follow‐up.     

The Role of Impulsivity in the Association Between Posttraumatic Stress Disorder Symptom Severity and Substance Use in Male Military Veterans

High rates of posttraumatic stress disorder (PTSD) and comorbid substance use disorder (SUD) are prevalent in military veterans. However, few studies have investigated impulsivity as a risk factor for engaging in substance use behavior for individuals who are experiencing PTSD symptoms. The present study evaluated impulsivity as a moderator of the association between PTSD symptoms and alcohol/drug use. Male military veterans (N = 106) completed self-report measures of alcohol use behavior, drug use behavior, and impulsivity. Participants also completed a structured diagnostic interview to assess for PTSD. The findings indicated that impulsivity moderated the relation between total PTSD symptoms and alcohol use, B = 0.01, p = .035, along with associations between alcohol use and two of the symptom clusters: PTSD reexperiencing symptoms, B = 0.01, p = .016; and PTSD avoidance/numbing symptoms, B = 0.01, p = .029. Veterans with high levels of impulsivity were at significantly higher risk of engaging in alcohol use than veterans with low-to-average levels. Impulsivity did not potentiate the relation between PTSD hyperarousal symptoms and alcohol use nor did it moderate the association between any of the PTSD variables and drug use. Impulsivity appears to serve as a significant risk factor for alcohol use, but not drug use, for male veterans experiencing PTSD symptoms. Future studies are necessary to replicate and expand upon these findings, particularly to facilitate the development of integrated evidence-based treatments that target both alcohol use and impulsivity within the context of PTSD.     

Alcohol‐involved assault and the course of PTSD in female crime victims

Although alcohol use has been associated with increased risk of victimization, little is known about how victim substance use at the time of assault may affect posttraumatic stress disorder (PTSD) symptom development. The present study is a longitudinal examination of substance use on PTSD symptom severity and course. A community sample of female crime victims (n = 60) were assessed within 5 weeks of sexual or physical assault with 3 and 6 month postassault follow‐ups. Twenty‐three participants had consumed alcohol or alcohol/drugs prior to the assault (38%) and 37 had consumed neither alcohol nor drugs. Analyses were conducted using hierarchical linear modeling. Participants who had consumed alcohol had lower initial intrusive symptoms, but their symptoms improved less over time.     

Dissociative Processes and Symptoms of Posttraumatic Stress in Vietnam Veterans

The diagnostic taxonomy of posttraumatic stress disorder (PTSD) is a contentious issue. Commentators are divided as to whether PTSD should remain grouped with the anxiety disorders or conceptualized as a dissociative disorder. This study sought to clarify the issue by investigating the extent to which anxiety and dissociative processes differentially predict the severity of each of the three symptom clusters in PTSD. Seventy-four Australian veterans of the Vietnam War were assessed on measures of dissociation, trait anxiety, and posttraumatic stress symptomatology. Multiple regression analyses showed that all three symptoms clusters were predicted by anxiety, but the clusters differed in the pattern of their relationship with dissociation variables. The failure of pathological dissociation to predict PTSD symptoms prompts a reconsideration of the point at which dissociative mechanisms may impact on this disorder. The findings are consistent with current classification of combat-related PTSD as an anxiety disorder.     

The Effects of Prolonged Exposure on Substance Use in Patients With Posttraumatic Stress Disorder and Substance Use Disorders

Despite research demonstrating the benefit of exposure-based therapy for posttraumatic stress disorder (PTSD) in patients with co-occurring substance use disorders, there remains a strong clinical expectation that this treatment will exacerbate substance use or other psychiatric symptoms. The present study evaluated within-session and session-to-session changes in (a) craving and use of substances for a range of drug classes and (b) symptoms of PTSD and other psychiatric distress in a sample of 44 SUD patients who received prolonged exposure (PE) therapy for PTSD. Visual analog scales showed no within-session increases in craving, except for cocaine, within Session 8. Across sessions, craving scores dropped for heroin, methadone, benzodiazepines, and cocaine; no increases in craving were found. Past-week substance use reported at each session did not differ. The severity of PTSD symptoms and self-reported serious emotional problems decreased from Session 1 to subsequent sessions, with no increases or decreases in other psychiatric, social, or medical problems. Finally, PTSD severity was unrelated to substance use reported 1 or 2 weeks later. Substance use during the past week was associated with higher PTSD severity scores at the next session, B = 6.86 (SE = 2.87), p = .018, but was not associated 2 weeks later. These findings indicate that the concern that exposure therapy for PTSD will increase SUD patients’ substance use or other psychiatric symptoms may be unwarranted, and, thus, SUD patients, including those who are actively using, should have access to effective treatments for PTSD, like PE.     

Fear-Potentiated Startle and Posttraumatic Stress Symptoms in Urban Police Officers

We studied the effects of increasing threat conditions on self-reported emotion, eyeblink electromyogram, and skin conductance responses to startling sounds in 55 police officers who endorsed a range of PTSD (posttraumatic stress disorder) symptoms. We found that contextual threat affected both physiologic and self-reported emotional responses. Greater PTSD symptom severity was related to greater physiologic responses under the low and medium but not under the high threat condition. The relationship between PTSD symptoms and physiologic responses was neither explained by self-reported emotional responses nor preexisting reported exaggerated startle symptoms. Our results emphasize the importance of contextual threat and suggest that laboratory measures of startle improve upon self-reported exaggerated startle alone in indexing PTSD symptom severity in urban police officers.     

Anger: Cause or Consequence of Posttraumatic Stress? A Prospective Study of Dutch Soldiers

Many studies have shown that individuals with posttraumatic stress disorder (PTSD) experience more anger over time and across situations (i.e., trait anger) than trauma‐exposed individuals without PTSD. There is a lack of prospective research, however, that considers anger levels before trauma exposure. The aim of this study was to prospectively assess the relationship between trait anger and PTSD symptoms, with several known risk factors, including baseline symptoms, neuroticism, and stressor severity in the model. Participants were 249 Dutch soldiers tested approximately 2 months before and approximately 2 months and 9 months after their deployment to Afghanistan. Trait anger and PTSD symptom severity were measured at all assessments. Structural equation modeling including cross‐lagged effects showed that higher trait anger before deployment predicted higher PTSD symptoms 2 months after deployment (β = .36), with stressor severity and baseline symptoms in the model, but not with neuroticism in the model. Trait anger at 2 months postdeployment did not predict PTSD symptom severity at 9 months, and PTSD symptom severity 2 months postdeployment did not predict subsequent trait anger scores. Findings suggest that trait anger may be a pretrauma vulnerability factor for PTSD symptoms, but does not add variance beyond the effect of neuroticism.     

Cognitive–Behavioral Treatment of Posttraumatic Stress in Patients With Implantable Cardioverter Defibrillators: Results From a Randomized Controlled Trial

Approximately 20% of patients with implantable cardioverter defibrillators (ICDs) suffer from posttraumatic stress disorder (PTSD) due to a history of cardiac arrest, device implantation, and ICD shock. There has been very little examination of treatment of PTSD symptoms in these patients. This study evaluated the effect of a specific cognitive–behavioral therapy (CBT) intervention for ICD patients with high levels of PTSD symptoms: a manualized program consisting of 8 telephone sessions with a trained counselor, a patient education book, and a stress management procedure on compact disc. Participants were 193 ICD patients, who were randomized to CBT or usual cardiac care (UCC) who completed self‐report surveys at the time of recruitment and 6 and 12 months after initial measurement. Previous publication on the primary research evaluation questions reported that the CBT condition resulted in greater improvement on PTSD and depression symptoms than the UCC for the general population of ICD patients, but did not evaluate the effect on those with elevated symptoms of PTSD. The authors conducted secondary analyses of the effect of treatment on high and low PTSD symptom groups based on a cutoff for the Impact of Event Scale‐Revised (Weiss & Marmar, 1997). Participants in the CBT group who had high symptoms experienced significantly greater symptom reduction from baseline to 12 months (d = 2.44, p = .021) than the UCC group (d = 1.12). Participants with low symptoms had small reductions regardless of group assignment (d = 0.16, p = .031). ICD‐focused CBT was sufficient to produce a large, statistically significant reduction in PTSD symptoms in ICD patients with indications for treatment.     

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.     

Alexithymia and PTSD symptoms in urban police officers: cross-sectional and prospective findings

The relationship of alexithymia to posttraumatic stress disorder (PTSD) symptomatology was examined cross-sectionally in 166 urban police officers surveyed between 1998 and 1999 and prospectively in 54 of these officers who participated in a follow-up survey after the September 11, 2001 (9/11) terrorist attacks. In cross-sectional analyses, alexithymia scores were positively associated with PTSD symptom levels and self-reported childhood emotional abuse--neglect, but not with cumulative level of critical incident exposure. Alexithymia scores accounted for 11.2% of the variance in PTSD symptoms prior to accounting for additional predictors, but did not retain significance in the final model. In prospective analyses, alexithymia scores significantly predicted 9/11-related PTSD symptom severity over and above pre-9/11 PTSD symptoms.     

Assessment of posttraumatic stress disorder in Cambodian refugees using the Clinician-Administered PTSD Scale: psychometric properties and symptom severity

Posttraumatic stress disorder (PTSD) symptoms were assessed by using the Clinician-Administered PTSD Scale (CAPS) in a consecutive sample of Cambodian refugees attending a psychiatric clinic in the United States. Psychometric properties of the translated CAPS and severity of PTSD-related symptoms were examined. The CAPS demonstrated adequate psychometric properties, including coefficient alpha (.92) and item-total correlations (.48-.85). Of the sample 56% (101/179) met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, criteria for current PTSD. Those patients who met criteria for current PTSD had significantly higher CAPS total scores (M = 65.3, SD = 18.1) than those who did not meet the criteria (M = 13.9, SD = 16.7).     

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One‐Year Prognosis

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6‐site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist ‐Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow‐ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbach's α = .87, .92, .95, .95, at assessments 1–4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.     

Multivariate prediction of posttraumatic symptoms in psychiatric inpatients

Based on a conceptual framework for the long-term effects of childhood abuse, this study examined the capacity of childhood family environment (caretaker dysfunction, neglect, perceived social support), violent abuse (physical and sexual), and individual variables (other abuse) to predict adult psychiatric symptoms of PTSD, dissociation, and depression. Complete interview data were obtained from 178 psychiatric inpatients who varied greatly on abuse status and severity. Results of multiple regressions of predictor variables onto the three outcome variables showed that the predictor variables accounted for 15% (for depression) to 42% (for PTSD) of the variance in these symptoms and that violent abuse uniquely accounted for a significant proportion of the variance in outcomes for all three of the symptom groups studied.     

Avoidance symptoms and assessment of posttraumatic stress disorder in Arab immigrant women

This study investigates whether the avoidance symptom criterion required for a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) diagnosis of posttraumatic stress disorder (PTSD) is overly conservative. Arab immigrant women (N = 453), many of whom reported experiencing multiple traumatic events, completed the Posttraumatic Diagnostic Scale in Arabic as part of a face to face interview. Analyses indicated all but one avoidance symptom was reported less frequently than reexperiencing and arousal symptoms. However, those who fully met reexperiencing, avoidance, and arousal symptom criteria had worse symptom severity and functioning than those who fully met reexperiencing and arousal symptom criteria, but only partially met avoidance symptom criterion. Study findings support importance of the PTSD avoidance symptom criterion.     

Combat, Dissociation, and Posttraumatic Stress Disorder in Australian Vietnam Veterans

The specificity of various wartime stressors for different posttraumatic stress disorder (PTSD) symptoms is inconsistently reported in the literature. Combat, wounding, and peritraumatic dissociation have not been assessed together in their effects on each of the various PTSD symptom clusters. This cohort study of a random sample of male Australian Army Vietnam veterans yielded psychiatric assessments of 641 subjects. PTSD measures comprised symptom criteria for reexperiencing, numbing and avoidance, hyperarousal, and PTSD diagnosis both lifetime and current within the past month. Logistic regression is used to examine the effects of combat, wounding, and peritraumatic dissociation together on PTSD. Combat experiences comprised four components derived from a principal components analysis of combat experiences: direct combat exposure, exposure to death and injury, exposure to civilian death and injury, and exposure to mutilation. Each was differentially related to reexperiencing, avoidance, hyperarousal, and PTSD diagnosis. Being wounded was not related to lifetime or current PTSD and peritraumatic dissociation was related to all diagnostic components of PTSD in the presence of other variables.     

Heart rate of motor vehicle accident survivors in the emergency department, peritraumatic psychological reactions, ASD, and PTSD severity: a 6-month prospective study

This small-scale study investigates the relationships between the heart rate of motor vehicle accident survivors presenting in the emergency department (ED) and acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) symptom severity. It also examines the relationships between the survivor's heart rate in the ED and peritraumatic dissociation and peritraumatic distress reported 2 weeks posttrauma. Fifty motor vehicle accident (MVA) survivors were assessed 2 weeks, 1 (N = 42), 3 (N = 37), and 6 months (N = 37) post-MVA. The heart rate in the ED predicted self-reported ASD symptom severity and clinician-rated PTSD symptom severity at 6 months but not at 1 or 3 months. Survivors' heart rate in the ED was significantly correlated with peritraumatic dissociation but not peritraumatic distress. These findings support the role of elevated ED heart rate as a predictor of both ASD and chronic PTSD symptom severity and may help to clarify the discrepant findings of previous research.     

Low predictive power of peritraumatic dissociation for PTSD symptoms in accident survivors

To test the predictive power of peritraumatic dissociation for the development of psychopathology, the authors assessed symptoms of peritraumatic dissociation (Peritraumatic Dissociative Experiences Questionnaire; PDEQ), posttraumatic stress disorder (Clinician-Administered PTSD Scale; CAPS), anxiety and depression (Hospital Anxiety and Depression Scale; HADS) in a sample of 214 accident victims 5 days postaccident (T1). Six months later (T2), CAPS and HADS were administered again. Acute stress disorder (ASD) and PTSD symptom levels were surprisingly low. In sequential regression analyses, initial reexperiencing and hyperarousal significantly predicted PTSD symptom level (T2) over several possibly confounding variables controlled for. Peritraumatic dissociation explained less than 3% of variance. For PTSD scores, 38% overall variance explanation was obtained; the variance for HADS scores was low. Possible explanations for the low-predictive power of peritraumatic dissociation for posttraumatic psychopathology in the sample are discussed.     

Posttraumatic stress disorder and functional impairment among World Trade Center Health Registry enrollees 14–15 years after the September 11, 2001, terrorist attacks

The September 11, 2001, terrorist attacks on the World Trade Center (WTC) in New York City (9/11) had health-related consequences, including posttraumatic stress disorder (PTSD). PTSD is associated with functional impairment, which varies by symptom severity and other factors. This study aimed to identify predictors of functional impairment in individuals with low versus high PTSD symptom severity levels. WTC Health Registry enrollees exposed to 9/11 were surveyed four times between 2003 and 2015; cumulated data for individuals who endorsed at least one symptom on the PTSD Checklist–Civilian Version (PCL-C) at Wave 4 (2015–2016) were included (N = 30,287) and examined cross-sectionally. Individuals were classified based on PCL-C scores as having low/no (2–29) or high levels of PTSD symptom severity (≥ 44). Functional impairment was defined as subsequent difficulties in daily living. Among low/no PTSD severity participants, adjusted odds ratios (aORs) for the associations between functional impairment and poor self-rated health (vs. good), low social support (vs. high), and no physical activity (vs. active) were 1.23–1.92. In the same group, low versus high household income was associated with more functional impairment, aOR = 1.34, 95% CI [1.13, 1.59]. Among participants with high-level PTSD symptoms, women, aOR = 1.70, 95% CI [1.31, 2.20], and Hispanic enrollees, aOR = 1.76, 95% CI [1.31, 2.36], were more likely to report an absence of impairment. Self-rated health, social support, and physical activity emerged as important predictors of PTSD-related functional impairment across PTSD symptom severity levels, supporting clinical interventions targeting these factors.