The Complex Trauma Inventory: A Self‐Report Measure of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder

The work group revising the criteria for trauma‐related disorders in the International Classification of Diseases (ICD‐11) made several changes. Specifically, they simplified the criteria for posttraumatic stress disorder (PTSD) and added a new trauma disorder called complex PTSD (CPTSD). These proposed changes to taxonomy require new instruments to assess these novel constructs. We developed a measure of PTSD and CPTSD (the Complex Trauma Inventory; CTI) according to the proposed domains, creating several items to assess each domain. We examined the factor structure of the CTI in two separate samples of diverse college students (n ₁ = 391; n ₂ = 391) who reported exposure to at least one traumatic event and at least occasional functional impairment. After reducing the original 50 items in the item pool to 20 items, confirmatory factor analyses supported two highly correlated second‐order factors—PTSD and disturbances in self‐organization (DSO)—with PTSD (i.e., reexperiencing, avoidance, sense of threat) and DSO (i.e., affect dysregulation, negative self‐concept, and disturbances in relationships), each loading on three of the six ICD‐11‐consistent first‐order factors, root mean square error of approximation (RMSEA) = .056, 95% confidence interval (CI) [.048, .064], comparative fit index (CFI) = .956, Tucker‐Lewis index (TLI) = .948, standardized root mean square residual (SRMR) = .043, Bayesian information criterion (BIC) = 641.55, χ²(163) = 361.02, p < .001. Internal consistencies for PTSD and DSO were good to excellent (Cronbach's αs = .89 to .92). Supplementary analyses supported the gender invariance of the CFA model, as well as convergent and discriminant validity of the CTI. The validity of the CTI supports the distinction between CPTSD and PTSD. Moreover, the CTI will assist clinicians with diagnosis, symptom tracking, treatment planning, and assessing outcomes.     

An Empirical Crosswalk for the PTSD Checklist: Translating DSM‐IV to DSM‐5 Using a Veteran Sample

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) introduced numerous revisions to the fourth edition's (DSM‐IV) criteria for posttraumatic stress disorder (PTSD), posing a challenge to clinicians and researchers who wish to assess PTSD symptoms continuously over time. The aim of this study was to develop a crosswalk between the DSM‐IV and DSM‐5 versions of the PTSD Checklist (PCL), a widely used self‐rated measure of PTSD symptom severity. Participants were 1,003 U.S. veterans (58.7% with PTSD) who completed the PCL for DSM‐IV (the PCL‐C) and DSM‐5 (the PCL‐5) during their participation in an ongoing longitudinal registry study. In a randomly selected training sample (n = 800), we used equipercentile equating with loglinear smoothing to compute a “crosswalk” between PCL‐C and PCL‐5 scores. We evaluated the correspondence between the crosswalk‐determined predicted scores and observed PCL‐5 scores in the remaining validation sample (n = 203). The results showed strong correspondence between crosswalk‐predicted PCL‐5 scores and observed PCL‐5 scores in the validation sample, ICC = .96. Predicted PCL‐5 scores performed comparably to observed PCL‐5 scores when examining their agreement with PTSD diagnosis ascertained by clinical interview: predicted PCL‐5, κ = 0.57; observed PCL‐5, κ = 0.59. Subsample comparisons indicated that the crosswalk's accuracy did not differ across characteristics including gender, age, racial minority status, and PTSD status. The results support the validity of this newly developed PCL‐C to PCL‐5 crosswalk in a veteran sample, providing a tool with which to interpret and translate scores across the two measures.     

Examining the Discriminant Validity of Complex Posttraumatic Stress Disorder and Borderline Personality Disorder Symptoms: Results From a United Kingdom Population Sample

Complex posttraumatic stress disorder (CPTSD) was added to the diagnostic nomenclature in the 11th revision of the International Classification of Diseases (ICD‐11). Although considerable evidence exists supporting the construct validity of CPTSD, the distinguishability of CPTSD symptoms from those of borderline personality disorder (BPD) has been questioned. The present study examined the discriminant validity of CPTSD and BPD symptoms among a trauma‐exposed population sample from the United Kingdom (N = 546). Participants completed self‐report measures of CPTSD and BPD symptoms, and their latent structure was assessed using exploratory structural equation modeling (ESEM). A three‐factor model with latent variables reflecting PTSD, disturbances in self‐organization (DSO), and BPD symptoms provided the best fit of the data, χ²(399, N = 546) = 1,650, p < .001; CFI = .944; TLI = .930; RMSEA = .077, 90% CI [.073, .081]. We identified multiple symptoms distinctive to individual constructs (e.g., disturbed relationships and suicidality) as well as symptoms shared across the constructs (e.g., affective dysregulation). The PTSD, β = .24; DSO, β = .23; and BPD, β = .27, latent variables were positively and significantly associated with childhood interpersonal trauma. The current findings support the discriminant validity of CPTSD and BPD symptoms and highlight various phenomenological signatures of each construct as well as demonstrate how these constructs share important similarities in symptom composition and exogenous correlates.     

Alternative Models of DSM‐5 Posttraumatic Stress Disorder in Portuguese Adolescents Exposed to Trauma and Childhood Adversity

The factor structure of DSM‐5 posttraumatic stress disorder (PTSD) has been extensively debated, with evidence supporting the recently proposed seven‐factor hybrid model. However, few studies examining PTSD symptom structure have assessed the implications of these proposed models on diagnostic criteria and PTSD prevalence. In the present study, we examined seven alternative DSM‐5 PTSD models within a confirmatory factor analysis (CFA), using the Child PTSD Symptom Scale–Self‐Report for DSM‐5 (CPSS‐5). Additionally, we generated prevalence rates for each of the seven models by using a symptom‐based diagnostic algorithm and assessed whether substance abuse, depression, anxiety symptoms, and daily functioning were differentially associated with PTSD depending on the model used to derive the diagnosis. Participants were 317 adolescents aged 13–17 years (M = 15.93, SD = 1.23) who had experienced a DSM‐5 Criterion A trauma and/or childhood adversity. The CFA results showed good fit indices for all models, with the seven‐factor hybrid model presenting the best fit. The rates of PTSD diagnosis varied according to each model. The four‐factor DSM‐5 model presented the highest rate (30.6%), and the seven‐factor hybrid model presented the lowest rate (17.4%). Similar to the CFA analysis, the inclusion criteria for the diagnosis based on the hybrid model also presented the strongest associations with daily functional impairment, odds ratio (OR) = 1.48, 95% CI [1.25, 1.75]; and adverse childhood experiences, OR = 1.46, 95% CI [1.16, 1.82]. Research and clinical implications of these results are discussed, and suggestions for future investigation are presented.     

A Comparison of DSM‐5 and DSM‐IV Diagnostic Criteria for Posttraumatic Stress Disorder in Traumatized Refugees

The aim of this study was to compare the prevalence rate and factor structure of posttraumatic stress disorder (PTSD) based on the diagnostic criteria of the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV; DSM‐5; American Psychiatric Association, 1994, 2013) in traumatized refugees. There were 134 adult treatment‐seeking, severely and multiply traumatized patients from various refugee backgrounds were assessed in their mother tongue using a computerized set of questionnaires consisting of a trauma list, the Posttraumatic Diagnostic Scale, and the new PTSD items that had been suggested by the DSM‐5 Task Force of the American Psychiatric Association. Using DSM‐IV, 60.4% of participants met diagnostic criteria for PTSD; using DSM‐5, only 49.3% fulfilled all criteria (p < .001). Confirmatory factor analysis of DSM‐IV and DSM‐5 items showed good and comparable model fits. Furthermore, classification functions in the DSM‐5 were satisfactory. The new Cluster D symptoms showed relatively high sensitivity, specificity, positive predictive power, and negative predictive power. The DSM‐5 symptom structure appears to be applicable to traumatized refugees. Negative alterations in cognitions and mood may be especially useful for clinicians, not only to determine the extent to which an individual refugee is likely to meet criteria for PTSD, but also in providing targets for clinical intervention.     

Service Dogs for Veterans and Military Members With Posttraumatic Stress Disorder: Replication With the PTSD Checklist for DSM‐5

Psychiatric service dogs are an emerging complementary intervention for veterans and military members with posttraumatic stress disorder (PTSD). Recent cross‐sectional studies have documented significant, clinically relevant effects regarding service dogs and PTSD symptom severity. However, these studies were conducted using the PTSD Checklist (PCL) for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The present study aimed to replicate and advance these findings using the latest version of the PCL for the fifth edition of the DSM (PCL‐5). Participants included 186 military members and veterans who had received a PTSD service dog (n = 112) or who were on the waitlist to receive one in the future (n = 74). A cross‐sectional design was used to investigate the association between having a service dog and PCL‐5 total and symptom cluster scores. After controlling for demographic variables, there was a significant association between having a service dog and lower PTSD symptom severity both in total, B = ‐14.52, p < .001, d = ‐0.96, and with regard to each symptom cluster, ps < .001, ds = ‐0.78 to ‐0.94. The results replicated existing findings using the largest sample size to date and the most recent version of the PCL. These findings provide additional preliminary evidence for the efficacy of service dogs as a complementary intervention for military members and veterans with PTSD and add to a growing body of foundational research serving to rationalize investment in the further clinical evaluation of this emerging practice.     

Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM‐5 and ICD‐11: Clinical and Behavioral Correlates

The American Psychiatric Association and the World Health Organization provide distinct trauma‐based diagnoses in the fifth edition of the Diagnostic and Statistical Manual (DSM‐5), and the forthcoming 11th version of the International Classification of Diseases (ICD‐11), respectively. The DSM‐5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD‐11 proposes two “sibling” disorders: PTSD and complex PTSD (CPTSD). The objectives of the current study were to: (a) compare prevalence rates of PTSD/CPTSD based on each diagnostic system; (b) identify clinical and behavioral variables that distinguish ICD‐11 CPTSD and PTSD diagnoses; and (c) examine the diagnostic associations for ICD‐11 CPTSD and DSM‐5 PTSD. Participants in a predominately female clinical sample (N = 106) completed self‐report scales to measure ICD‐11 PTSD and CPTSD, DSM‐5 PTSD, and depression, anxiety, borderline personality disorder, dissociation, destructive behaviors, and suicidal ideation and self‐harm. Significantly more people were diagnosed with PTSD according to the DSM‐5 criteria (90.4%) compared to those diagnosed with PTSD and CPTSD according to the ICD‐11 guidelines (79.8%). An ICD‐11 CPTSD diagnosis was distinguished from an ICD‐11 PTSD diagnosis by higher levels of dissociation (d = 1.01), depression (d = 0.63), and borderline personality disorder (d = 0.55). Diagnostic associations with depression, anxiety, and suicidal ideation and self‐harm were higher for ICD‐11 CPTSD compared to DSM‐5 PTSD (by 10.7%, 4.0%, and 7.0%, respectively). These results have implications for differential diagnosis and for the development of targeted treatments for CPTSD.     

Change in Event Centrality and Posttraumatic Stress Disorder Symptoms During Intensive Treatment

Event centrality, defined as the extent to which a traumatic event becomes a core component of a person's identity (Berntsen & Rubin, 2006), is both a correlate and predictor of posttraumatic stress disorder (PTSD) symptoms, over and above event severity. These findings suggest that decreasing the perceived centrality of a traumatic event to one's identity might result in decreases in PTSD symptom severity. To date, few studies have examined how centrality is affected by PTSD treatment. The present study tested the hypotheses that change in centrality would be associated with both change in PTSD symptom severity and discharge PTSD symptom severity in an exposure‐based PTSD partial hospitalization program (N = 132; 86.0% White; 85.2% female; M age = 36 years). At discharge (i.e., after approximately 6 weeks of treatment), both PTSD symptoms and centrality had significantly decreased, ds = .70 and .98, respectively, with large effect sizes. Decreases in Centrality of Events Scale (CES) scores at posttreatment, baseline CES scores, and baseline PTSD Checklist for DSM‐5 (PCL‐5) scores were associated with change (i.e., decrease) in PCL‐5 scores, p < .001, as well as with posttreatment PCL‐5 scores, p < .001. Decreases in CES scores over time, baseline CES scores, and baseline PCL‐5 scores explained 31% of the variance in PCL‐5 change and 34% of the variance in posttreatment PCL‐5 scores. The results indicate the potential importance of decreasing the centrality of a traumatic event in PTSD treatment and recovery.     

National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM‐IV and DSM‐5 Criteria

Prevalence of posttraumatic stress disorder (PTSD) defined according to the American Psychiatric Association's Diagnostic and Statistical Manual fifth edition (DSM‐5; 2013) and fourth edition (DSM‐IV; 1994) was compared in a national sample of U.S. adults (N = 2,953) recruited from an online panel. Exposure to traumatic events, PTSD symptoms, and functional impairment were assessed online using a highly structured, self‐administered survey. Traumatic event exposure using DSM‐5 criteria was high (89.7%), and exposure to multiple traumatic event types was the norm. PTSD caseness was determined using Same Event (i.e., all symptom criteria met to the same event type) and Composite Event (i.e., symptom criteria met to a combination of event types) definitions. Lifetime, past‐12‐month, and past 6‐month PTSD prevalence using the Same Event definition for DSM‐5 was 8.3%, 4.7%, and 3.8% respectively. All 6 DSM‐5 prevalence estimates were slightly lower than their DSM‐IV counterparts, although only 2 of these differences were statistically significant. DSM‐5 PTSD prevalence was higher among women than among men, and prevalence increased with greater traumatic event exposure. Major reasons individuals met DSM‐IV criteria, but not DSM‐5 criteria were the exclusion of nonaccidental, nonviolent deaths from Criterion A, and the new requirement of at least 1 active avoidance symptom.     

Trauma‐Exposed Community‐Dwelling Women and Men Respond Similarly to the DAR‐5 Anger Scale: Factor Structure Invariance and Differential Item Functioning

Anger is associated with the development of posttraumatic stress disorder (PTSD) and with poor treatment outcomes. The Dimensions of Anger Reactions Scale‐5 (DAR‐5) has demonstrated preliminary evidence of unitary factor structure and sound psychometric properties. Gender‐based differences in psychometric properties have not been explored. The current study examined gender‐based factor structure invariance and differential item functioning of the DAR‐5 and gender differences in PTSD symptoms as a function of anger severity using a community sample of adults who had been exposed to trauma. Data were collected from 512 trauma‐exposed community‐dwelling adults (47.9% women). Confirmatory factor analyses, Mantel‐Haenszel χ² tests and a comparison of characteristic curves, and 2‐way analyses of variance, respectively, were used to assess gender‐based factor structure invariance, gender‐based response patterns to DAR‐5 items, and gender differences in PTSD symptoms as a function of anger. The unitary DAR‐5 factor structure did not differ between men and women. Significant gender differences in the response pattern to the DAR‐5 items were not present. Trauma‐exposed individuals with high anger reported greater overall PTSD symptoms (p < .001), regardless of gender. The DAR‐5 can be used to assess anger in trauma‐exposed individuals without concern of gender biases influencing factor structure or item functioning. Findings further suggested that the established relationship between anger and PTSD severity did not differ by gender.     

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.     

Finalizing PTSD in DSM‐5: Getting Here From There and Where to Go Next

The process that resulted in the diagnostic criteria for posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5; American Psychiatric Association; 2013 ) was empirically based and rigorous. There was a high threshold for any changes in any DSM‐IV diagnostic criterion. The process is described in this article. The rationale is presented that led to the creation of the new chapter, “Trauma‐ and Stressor‐Related Disorders,” within the DSM‐5 metastructure. Specific issues discussed about the DSM‐5 PTSD criteria themselves include a broad versus narrow PTSD construct, the decisions regarding Criterion A, the evidence supporting other PTSD symptom clusters and specifiers, the addition of the dissociative and preschool subtypes, research on the new criteria from both Internet surveys and the DSM‐5 field trials, the addition of PTSD subtypes, the noninclusion of complex PTSD, and comparisons between DSM‐5 versus the World Health Association's forthcoming International Classification of Diseases (ICD‐11) criteria for PTSD. The PTSD construct continues to evolve. In DSM‐5, it has moved beyond a narrow fear‐based anxiety disorder to include dysphoric/anhedonic and externalizing PTSD phenotypes. The dissociative subtype may open the way to a fresh approach to complex PTSD. The preschool subtype incorporates important developmental factors affecting the expression of PTSD in young children. Finally, the very different approaches taken by DSM‐5 and ICD‐11 should have a profound effect on future research and practice.     

Traumatic Event Exposure,Posttraumatic Stress Disorder,and Sleep Disturbances in a National Sample of U.S. Adults

Posttraumatic stress disorder (PTSD) is a highly prevalent, debilitating disorder found to develop after exposure to a potentially traumatic event (PTE). Individuals with PTSD often report sleep disturbances, specifically nightmares and insomnia, which are listed within the criteria for PTSD. This research examined prevalence of insomnia and nightmares within a national sample of 2,647 adults (data weighted by age and sex to correct for differences in sample distribution) who had been exposed to one or more PTEs. Prevalence of self‐reported sleep disturbance, sleep disturbances by PTE type, and gender differences were examined. All participants completed a self‐administered, structured online interview that assessed exposure to stressful events and PTSD symptoms. Among individuals who met DSM‐5 criteria for PTSD, a large majority (more than 92%) reported at least one sleep disturbance. Insomnia was relatively more prevalent than PTE‐related nightmares among individuals with PTSD and among all PTE‐exposed individuals. A higher number of PTEs experienced significantly increased the likelihood of both trauma‐related nightmares and insomnia, McFadden's pseudo R² = .07, p < .001. Women exposed to PTEs were more likely to endorse experience of insomnia, χ²(1, N = 2,647) = 99.13, p < .001, φ = .194, and nightmares compared to men, χ²(1, N = 2,648) = 82.98, p < .001, φ = .177, but this gender difference was not significant among individuals with PTSD, ps = .130 and .050, respectively. Differences in sleep disturbance prevalence by PTE type were also examined. Implications for treatment and intervention and future directions are discussed.     

The DSM‐5 Got PTSD Right: Comment on Friedman (2013)

Friedman in his article in this issue describes the posttraumatic stress disorder (PTSD) diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5) and provides considerable information about the process that resulted in the revisions, as well as how PTSD in the DSM‐5 differs from proposals for PTSD in the International Classification of Mental Disorders and Related Health Problems (ICD‐11). In this commentary, I argue that (a) the placement of PTSD in the DSM‐5 category of Trauma and Stressor‐Related Disorders is a major advance because it draws attention to the role of “nurture” when there is an overemphasis on “nature” by some; (b) the broader construct of PTSD in DSM‐5 is justified because it includes clinically important problems and can be reliably diagnosed; and (c) the web surveys contributed substantially to the provision of data needed to support proposed changes. Concerns are raised about the proposed ICD‐11 approach, and the case is presented that substantial evidence should be required before these proposed changes are made because they differ substantially from a DSM‐5 PTSD diagnosis that has demonstrated reliability and validity.     

Posttraumatic Stress Disorder in Very Young Children: Diagnostic Agreement Between ICD‐11 and DSM‐5

The prevalence of posttraumatic stress disorder (PTSD) in very young children depends on the diagnostic criteria. Thus far, studies have investigated the International Classification of Diseases (11th rev.; ICD‐11) criteria for PTSD only in samples of children older than 6 years of age. The aim of this study was to test the diagnostic agreement between the ICD‐11 and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM‐5) criteria for children who are 6 years old and younger. Caregivers of children aged 3–6 years in foster care in Germany (N = 147) and parents of children aged 1–4 years who had attended a hospital in Switzerland following burn injuries (N  = 149) completed a questionnaire about children's PTSD. Rates of PTSD were calculated according to ICD‐11 (considering a specific and a more general conceptualization of intrusive memories) and DSM‐5 criteria and were compared using McNemar's tests and Cohen's kappa. The proportion of children who met the ICD‐11 criteria was 0.6–25.8% lower than the proportion of PTSD cases according to the DSM‐5 criteria. The diagnostic agreement between each ICD‐11 algorithm and DSM‐5 was moderate, κ = 0.52–0.66. A systematic investigation of adaptions of the ICD‐11 avoidance cluster identified alternative symptom combinations leading to higher agreement with the DSM‐5 requirements. Furthermore, DSM‐5 had higher predictive power for functional impairment than the ICD‐11 algorithms. In conclusion, the findings suggest that the ICD‐11 criteria show less sensitivity in very young children, which can be explained by the more stringent avoidance cluster.     

The Cycle of Violence: Associations Between Exposure to Violence,Trauma‐Related Symptoms and Aggression—Findings from Congolese Refugees in Uganda

War‐related trauma exposure has been linked to aggression and enhanced levels of community and family violence, suggesting a cycle of violence. Reactive aggression—an aggressive reaction to a perceived threat—has been associated with posttraumatic stress disorder (PTSD). In contrast, appetitive aggression—a hedonic, intrinsically motivated form of aggression—seems to be negatively related to PTSD in offender and military populations. This study examined the associations between exposure to violence, trauma‐related symptoms and aggression in a civilian population. In semistructured interviews, 290 Congolese refugees were questioned about trauma exposure, PTSD symptoms, and aggression. War‐related trauma exposure correlated positively with exposure to family and community violence in the past month (r = .31, p < .001), and appetitive (r = .18, p = .002) and reactive aggression (r = .29, p < .001). The relationship between war‐related trauma exposure and reactive aggressive behavior was mediated by PTSD symptoms and appetitive aggression. In a multiple sequential regression analysis, trauma exposure (β = .43, p < .001) and reactive aggression (β = .36, p < .001) were positively associated with PTSD symptoms, whereas appetitive aggression was negatively associated (β = ?.13, p = .007) with PTSD symptoms. Our findings were congruent with the cycle of violence hypothesis and indicate a differential relation between distinct subtypes of aggression and PTSD.     

Patterns of Treatment Disengagement and Personality Traits Associated With Posttraumatic Stress Disorder in Recent‐Era U.S. Veterans Receiving Cognitive Processing Therapy

Low treatment engagement is a barrier to implementation of empirically supported treatments for posttraumatic stress disorder (PTSD) among veterans. Understanding personality traits that predict dropout may help focus attempts to improve engagement. The current study included 90 veterans who served in recent conflicts in Iraq and/or Afghanistan and participated in a trial of cognitive processing therapy for PTSD. Goals were to characterize (a) personality correlates of PTSD, (b) patterns of engagement (i.e., attendance and homework completion), and (c) personality correlates of reduced engagement. Higher levels of PTSD symptoms were associated with a range of characteristics, including affective lability, r = .44 p < .001; anxiety, r = .38, p < .001; identity problems, r = .57, p < .001; intimacy problems, r = .34, p = .001; low affiliation, r = .33, p = .002; oppositionality, r = .36, p = .001; restricted expression, r = .35, p = .001; and suspiciousness, r = .50, p < .001. Notably, veterans with worse PTSD symptoms endorsed more cognitive dysregulation, r = .40, p < .001; and less insecure attachment, r = .14, p = .190, than expected. Only 52.2% of veterans completed the 12‐session course of treatment and 31.0% of participants completed fewer than six sessions. Personality traits did not predict attendance or homework completion. Disengagement continues to be a significant issue in trauma‐focused treatment for veterans with PTSD. Understanding veteran‐level factors, such as personality traits, may be useful considerations for future research seeking to understand and improve engagement.     

Associations Between Trauma‐Related Rumination and Symptoms of Posttraumatic Stress and Depression in Treatment‐Seeking Female Veterans

Trauma‐related rumination is a cognitive style characterized by repetitive negative thinking about the causes, consequences, and implications of a traumatic experience. Frequent trauma‐related rumination has been linked to posttraumatic stress disorder (PTSD) and depression in civilian samples but has yet to be examined among military veterans. This study extended previous research by examining trauma‐related rumination in female veterans who presented to a Veterans Affairs women's trauma recovery clinic (N = 91). The study had two main aims: (a) to examine associations between trauma‐related rumination and specific PTSD symptoms, adjusting for the overlap between trauma‐related rumination and other relevant cognitive factors, such as intrusive trauma memories and self‐blame cognitions; and (b) to assess associations between trauma‐related rumination, PTSD, and depression, adjusting for symptom comorbidity. At intake, patients completed a semistructured interview and self‐report questionnaires. Primary diagnoses were confirmed via medical record review. Trauma‐related rumination was common, with more than 80% of patients reporting at least sometimes engaging in this cognitive style in the past week. After adjusting for other relevant cognitive factors, trauma‐related rumination was significantly associated with several specific PTSD symptoms, r_ps = .33–.48. Additionally, the severity of trauma‐related rumination was associated with overall PTSD symptom severity, even after adjusting for comorbid depression symptoms, r_p² = .35. In contrast, the association between trauma‐related rumination and depressive symptom severity was not significant after adjusting for comorbid PTSD symptoms, r_p² = .008. These results highlight trauma‐related rumination as a unique contributing factor to the complex clinical presentation for a subset of trauma‐exposed veterans.     

Long‐Term Trajectories of PTSD in Vietnam‐Era Veterans: The Course and Consequences of PTSD in Twins

We estimated the temporal course of posttraumatic stress disorder (PTSD) in Vietnam‐era veterans using a national sample of male twins with a 20‐year follow‐up. The complete sample included those twins with a PTSD diagnostic assessment in 1992 and who completed a DSM‐IV PTSD diagnostic assessment and a self‐report PTSD checklist in 2012 (n = 4,138). Using PTSD diagnostic data, we classified veterans into 5 mutually exclusive groups, including those who never had PTSD, and 4 PTSD trajectory groups: (a) early recovery, (b) late recovery, (c) late onset, and (d) chronic. The majority of veterans remained unaffected by PTSD throughout their lives (79.05% of those with theater service, 90.85% of those with nontheater service); however, an important minority (10.50% of theater veterans, 4.45% of nontheater veterans) in 2012 had current PTSD that was either late onset (6.55% theater, 3.29% nontheater) or chronic (3.95% theater, 1.16% nontheater). The distribution of trajectories was significantly different by theater service (p < .001). PTSD remains a prominent issue for many Vietnam‐era veterans, especially for those who served in Vietnam.     

Prevalence and Correlates of Posttrauma Distorted Beliefs: Evaluating DSM‐5 PTSD Expanded Cognitive Symptoms in a National Sample

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5; American Psychiatric Association [APA], 2013) modified the diagnostic criteria for posttraumatic stress disorder (PTSD), including expanding the scope of dysfunctional, posttrauma changes in belief (symptoms D2—persistent negative beliefs and expectations about oneself or the world, and D3—persistent distorted blame of self or others for the cause or consequences of the traumatic event). D2 and D3 were investigated using a national sample of U.S. adults (N = 2,498) recruited from an online panel. The prevalence of D2 and D3 was substantially higher among those with lifetime PTSD than among trauma‐exposed individuals without lifetime PTSD (D2: 74.6% vs 23.9%; D3: 80.6% vs 35.7%). In multivariate analyses, the strongest associates of D2 were interpersonal assault (OR = 2.39), witnessing interpersonal assault (OR = 1.63), gender (female, OR = 2.11), and number of reported traumatic events (OR = 1.88). The strongest correlates of D3 were interpersonal assault (OR = 3.08), witnessing interpersonal assault (OR = 1.57), gender (female, OR = 2.30), and number of reported traumatic events (OR = 1.91). The findings suggested the expanded cognitive symptoms in the DSM‐5 diagnostic criteria better capture the cognitive complexity of PTSD than those of the DSM‐IV.