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.     

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.     

Risk factors for the presence and persistence of posttraumatic stress symptoms following traumatic brain injury in U.S. service members and veterans

This study aimed to identify risk factors predictive of the presence and persistence of posttraumatic stress disorder (PTSD) symptom reporting following traumatic brain injury (TBI). Participants were 1,301 U.S. service members and veterans (SMVs) divided into four groups: uncomplicated mild TBI (mTBI; n = 543); complicated mild, moderate, severe, and penetrating TBI (n = 230); injured controls (n = 340); and noninjured controls (n = 188). We examined 25 factors related to demographic, injury-related, military-specific, treatment/health care need, and mental health/social support variables. Seven factors were statistically associated with the presence of DSM-IV-TR symptom criteria for PTSD: premorbid IQ, combat exposure, depression, social participation, history of mTBI, need for managing mood and stress, and need for improving memory and attention, p < .001 (51.3% variance). When comparing the prevalence of these risk factors in a longitudinal cohort (n = 742) across four PTSD trajectory groups (i.e., asymptomatic, improved, developed, persistent), a higher proportion of participants in the persistent PTSD group reported worse depression, a lack of social participation, and history of mTBI. Additionally, a higher proportion of participants in the persistent and developed PTSD groups reported the need for managing mood/stress and improving memory/attention. When considered simultaneously, the presence of ≥ 1 or ≥ 2 risk factors was associated with a higher proportion of participants in the developed and persistent PTSD groups, ps < .001. These risk factors may be useful in identifying SMVs at risk for the development and/or persistence of PTSD symptoms who may need intervention.     

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.     

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.     

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.     

Deployment‐Related Psychiatric and Behavioral Conditions and Their Association with Functional Disability in OEF/OIF/OND Veterans

Understanding the factors that influence veterans’ functional outcome after deployment is critical to provide appropriately targeted care. Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) have been related to disability, but other psychiatric and behavioral conditions are not as well examined. We investigated the impact of deployment‐related psychiatric and behavioral conditions on disability among 255 OEF/OIF/OND service members and veterans. Structured clinical interviews assessed TBI and the psychiatric conditions of depression, PTSD, anxiety, and substance use. Self‐report questionnaires assessed disability and the behavioral conditions of sleep disturbance and pain. Over 90% of participants had a psychiatric and/or behavioral condition, with approximately half presenting with ≥ 3 conditions. Exploratory factor analysis revealed 4 clinically relevant psychiatric and behavioral factors which accounted for 76.9% of the variance: (a) depression, PTSD, and military mTBI (deployment trauma factor); (b) pain and sleep (somatic factor); (c) anxiety disorders, other than PTSD (anxiety factor); and (d) substance abuse or dependence (substance use factor). Individuals with the conditions comprising the deployment trauma factor were more likely to be substantially disabled than individuals with depression and PTSD, but no military mTBI, OR = 3.52; 95% CI [1.09, 11.37]. Depression, PTSD, and a history of military mTBI may comprise an especially harmful combination associated with high risk for substantial disability.     

Military Sexual Assault as a Mediator of the Association Between Posttraumatic Stress Disorder and Depression Among Lesbian,Gay, and Bisexual Veterans

Lesbian, gay, and bisexual (LGB) civilians report higher rates of sexual assault, posttraumatic stress disorder (PTSD), and depression compared to their heterosexual counterparts. In this study, we compared military sexual assault (MSA), PTSD, and depression in LGB individuals and their non‐LGB peers in two community samples of veterans (N = 2,583). Participants were selected for inclusion if they identified as LGB (n = 110) and were matched 1 to 3 on gender and age with non‐LGB veterans (n = 330). Chi‐square analyses showed significant differences for LGB veterans compared to non‐LGB veterans for experiencing MSA (32.7% vs. 16.4%, respectively), p < .001; probable PTSD (41.2% vs. 29.8%, respectively), p = .039; and probable depression (47.9% vs. 36.0%, respectively), p = .039. Multivariable logistic regression analyses showed LGB veterans were 1.93 times more likely to have experienced MSA compared to non‐LGB veterans, 95% CI [1.30, 2.88], p = .001. The experience of MSA significantly mediated associations with probable PTSD, odds ratio (OR) = 1.43, 95% CI [1.13, 1.80], p = .003, and probable depression, OR = 1.32, 95% CI [1.07, 1.64], p = .009. As the experience of MSA fully mediates the presence of PTSD and depression among LGB veterans, we highly recommend health providers assess for MSA among LGB veterans, especially those who meet clinical thresholds for PTSD and depression.     

Complicated Grief Among Military Service Members and Veterans Who Served After September 11, 2001

Minimal research is available on the prevalence and impact of complicated grief (CG) in military service members and veterans, despite high reported rates of loss in this population. The present study aimed to examine prevalence rates of CG in a sample of treatment‐seeking military service and members and veterans who served after September 11, 2001. Additionally, the study aimed to examine characteristics associated with CG as well as the association between CG and quality of life. In a sample of 622 military service members and veterans who served after September 11, 2001, 502 reported a significant loss (80.7%). Usable data were available for a total of 468 participants. Of these 468 participants, 30.3% (n = 142) met diagnostic criteria for CG, as defined by a score of 30 or more on the Inventory of Complicated Grief (ICG; Prigerson et al., 1995). We conducted a series of t tests and chi‐square tests to examine the differences between individuals who met criteria for CG and those who did not. The presence of CG was associated with worse PTSD, d = 0.68, p < .001; depression, d = ?1.10, p < .001; anxiety, d = ?1.02, p < .001; stress, d = 0.99, p < .001; and quality of life, d = 0.76, p < .001. Multiple regression analyses examined the independent impact of CG on quality of life. Complicated grief was associated with poorer quality of life above and beyond PTSD, β = ?.12, p = .017. In addition, in a separate regression, CG was associated with poorer quality of life above and beyond depression, β = ?.13, p < .001. Overall, our findings highlight the impact of CG on this population, and have implications for assessment and treatment.     

Deliberate Self‐Harm and Suicidal Ideation Among Male Iraq/Afghanistan‐Era Veterans Seeking Treatment for PTSD

The objectives of the present research were to examine the prevalence of deliberate self‐harm (DSH) among 214 U.S. male Iraq/Afghanistan‐era veterans seeking treatment for posttraumatic stress disorder (PTSD) and to evaluate the relationship between DSH and suicidal ideation within this population. Approximately 56.5% (n = 121) reported engaging in DSH during their lifetime; 45.3% (n = 97) reported engaging in DSH during the previous 2 weeks. As hypothesized, DSH was a significant correlate of suicidal ideation among male Iraq/Afghanistan‐era veterans, OR = 3.88, p < .001, along with PTSD symptom severity, OR = 1.03, p < .001, and combat exposure, OR = 0.96, p = .040. A follow‐up analysis identified burning oneself, OR = 17.14, p = .017, and hitting oneself, OR = 7.93, p < .001, as the specific DSH behaviors most strongly associated with suicidal ideation. Taken together, these findings suggest that DSH is quite prevalent among male Iraq/Afghanistan‐era veterans seeking treatment for PTSD and is associated with increased risk for suicidal ideation within this population. Routine assessment of DSH is recommended when working with male Iraq/Afghanistan veterans seeking treatment for PTSD.     

Surveying Treatment Preferences in U.S. Iraq–Afghanistan Veterans With PTSD Symptoms: A Step Toward Veteran‐Centered Care

This study examined health care barriers and preferences among a self‐selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = ?0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help‐seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help‐seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.     

Efficacy of Psychological Intervention for Children with Concurrent Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are common conditions following motor vehicle accidents (MVAs). Mild TBI and PTSD not only share similar features but may also coexist and interact. Nonetheless, research on psychotherapeutic interventions for PTSD in patients with a history of mTBI, particularly regarding pediatric populations, is limited. The present study compared the efficacy of the prolonged exposure treatment protocol for children and adolescents (PE-A) with PTSD and mTBI (n = 16) versus PTSD alone (n = 21); treatment commenced at least 3 months following an MVA. Emotional status and cognitive functioning were assessed pre- and postintervention using questionnaires and standardized neuropsychological tests. Participants from both groups benefitted from the intervention, as reflected in their emotional status via increased ratings of well-being and decreased ratings of PTSD, anxiety, depression, and postconcussive symptoms, η² = .21–.50. Ratings of cognitive function also improved for cognitive flexibility, η² = .30; executive function in everyday life, η² = .27; and attention and inhibition, η² = .16. Parental PTSD was the strongest predictor of improvement after intervention, sr² = .35. Thus, it appears that PE-A is an effective intervention for children with MVA-related PTSD regardless of its comorbidity with mTBI.     

Characteristics of U.S. Veterans Who Begin and Complete Prolonged Exposure and Cognitive Processing Therapy for PTSD

This retrospective chart‐review study examined patient‐level correlates of initiation and completion of evidence‐based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment‐seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider‐matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.     

Breathing‐Based Meditation Decreases Posttraumatic Stress Disorder Symptoms in U.S. Military Veterans: A Randomized Controlled Longitudinal Study

Given the limited success of conventional treatments for veterans with posttraumatic stress disorder (PTSD), investigations of alternative approaches are warranted. We examined the effects of a breathing‐based meditation intervention, Sudarshan Kriya yoga, on PTSD outcome variables in U.S. male veterans of the Iraq or Afghanistan war. We randomly assigned 21 veterans to an active (n = 11) or waitlist control (n = 10) group. Laboratory measures of eye‐blink startle and respiration rate were obtained before and after the intervention, as were self‐report symptom measures; the latter were also obtained 1 month and 1 year later. The active group showed reductions in PTSD scores, d = 1.16, 95% CI [0.20, 2.04], anxiety symptoms, and respiration rate, but the control group did not. Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1‐year follow‐up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD.     

A Dyadic Analysis of the Influence of Trauma Exposure and Posttraumatic Stress Disorder Severity on Intimate Partner Aggression

This study used structural equation modeling to evaluate a mediation model of the relationship between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and perpetration of intimate partner physical and psychological aggression in trauma‐exposed veterans and their cohabitating spouses (n = 286 couples; 88% male veteran and female spouse, 80.8% White, non‐Hispanic). Dyadic data analyses were used to simultaneously evaluate actor and partner effects using the actor–partner interdependence model (Kashy & Kenny, 2000). The primary hypothesis was that PTSD would mediate the association between trauma exposure and intimate partner physical and psychological aggression with these effects evident both within and across members of a couple (i.e., actor and partner effects). The best‐fitting model included (a) equivalent actor and partner direct effects of trauma on veterans’ acts of psychological aggression (β = .17 to .20, p = .001), and (b) equivalent actor and partner indirect effects via PTSD on veterans’ acts of physical aggression (β = .08 to .10, p < .001). There were no direct or indirect effects predicting the spouses’ aggression. Results suggest it is important to consider the trauma histories and possible presence of PTSD in both partners as this may be a point of intervention when treating distressed couples.     

Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care

Collaborative care (CC) increases access to evidence‐based pharmacotherapy and psychotherapy. The study aim was to identify the characteristics of rural veterans receiving a telemedicine‐based CC intervention for posttraumatic stress disorder (PTSD) who initiated and engaged in cognitive processing therapy (CPT) delivered via interactive video. Veterans diagnosed with PTSD were recruited from 11 community‐based outpatient clinics (N = 133). Chart abstraction identified all mental health encounters received during the 12‐month study. General linear mixed models were used to identify characteristics that predicted CPT initiation and engagement (attendance at 8 or more sessions). For initiation, higher PTSD severity according to the Clinician Administered PTSD Scale (d = ?0.39, p = .038) and opt‐out recruitment (vs. self‐referral; d = ?0.49, p = .010) were negative predictors. For engagement, major depression (d = ?1.32, p = .006) was a negative predictor whereas a pending claim for military service connected disability (d = 2.02, p = .008) was a positive predictor. In general, veterans enrolled in CC initiated and engaged in CPT at higher rates than usual care. Those with more severe symptoms and comorbidity, however, were at risk of not starting or completing CPT.     

Effectiveness of Prolonged Exposure and Cognitive Processing Therapy for U.S. Veterans With a History of Traumatic Brain Injury

This retrospective analysis of previously existing nonrandomized clinical data examined the effectiveness of completing prolonged exposure (PE) or cognitive processing therapy (CPT) in a sample of 41 U.S. veterans at a Veterans Affairs medical center. The sample included 19 veterans with diagnoses of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) and 22 veterans with PTSD only. Diagnostic groups did not significantly differ on PTSD and depression symptom reduction, F(2, 36) = 0.05, p = .951; Pillai's trace = 0.00, partial η²= .00. Veterans who completed PE showed greater symptom reduction than those who completed CPT, F(2, 36) = 12.10, p < .001; Pillai's trace = 0.40, partial η² = .40, regardless of TBI status. Overall, our results suggested that TBI status should not preclude individuals from being offered trauma‐focused PTSD treatment.     

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.     

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.