The Impact of Infidelity on Combat‐Exposed Service Members

This study examined relationships between combat‐exposed Operation Enduring Freedom/Operation Iraqi Freedom veterans’ experiences related to infidelity during deployment (i.e., indicating that a partner was unfaithful or reporting concern about potential infidelity) and postdeployment mental health, as well as the role of subsequent stress exposure and social support in these associations. The sample consisted of 571 individuals (338 men). There were 128 participants (22.2%) who indicated that their partners were unfaithful during their most recent deployment. Of the remaining 443 participants, 168 (37.8%) indicated that they were concerned that their partners might have been unfaithful. Individuals who indicated that their partners were unfaithful exhibited higher levels of posttraumatic stress symptomatology (β = .08; f²= .18) and depression symptom severity (β = .09; f² = .14), compared to individuals who did not indicate that their partners were unfaithful. For both men and women, reported infidelity was associated with mental health indirectly via postdeployment life stressors, whereas infidelity concerns were indirectly associated with mental health via postdeployment life stressors for men only. Findings suggested that infidelity can have a significant impact on combat‐exposed veterans’ mental health and highlight the need for additional research on this understudied topic within the military population.     

Trauma‐Related Correlates of Alcohol Use in Recently Deployed OEF/OIF Veterans

The co‐occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorders (AUDs) is well documented. Little is known about the factors that contribute to alcohol use and the development of AUDs among military personnel following deployment. The primary aim of this study was to examine trauma‐related correlates of alcohol use in recently deployed Operation Enduring Freedom/Operation Iraqi Freedom veterans. Members of the Rhode Island National Guard and Army Reserves (N = 238) completed an in‐person, initial assessment an average of 6 months postdeployment. Multiple regression analyses examined predictors of drinking outcomes (combat exposure, total PTSD symptoms, and PTSD symptom clusters) after accounting for gender, age, and history of AUD. Results indicated that total PTSD symptoms, but not combat exposure, significantly predicted alcohol use at the initial assessment. When PTSD symptom clusters were considered separately, reexperiencing symptoms (Cluster B) were the strongest predictor of total alcohol use (B = 3.58, p = .002) and heavy drinking episodes (B = 0.31, p = .005). Implications for these findings include early identification of risk factors that could lead to the development of AUDs, and the importance of integrated treatment approaches for co‐occurring PTSD and AUD among veterans postdeployment.     

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.     

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

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

Factorial invariance of posttraumatic stress disorder symptoms across three veteran samples

Research generally supports a 4-factor structure of posttraumatic stress disorder (PTSD) symptoms. However, few studies have established factor invariance by comparing multiple groups. This study examined PTSD symptom structure using the Davidson Trauma Scale (DTS) across three veteran samples: treatment-seeking Vietnam-era veterans, treatment-seeking post-Vietnam-era veterans, and Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veteran research participants. Confirmatory factor analyses of DTS items demonstrated that a 4-factor structural model of the DTS (reexperiencing, avoidance, numbing, and hyperarousal) was superior to five alternate models, including the conventional 3-factor model proposed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Results supported factor invariance across the three veteran cohorts, suggesting that cross-group comparisons are interpretable. Implications and applications for DSM-IV nosology and the validity of symptom measures are discussed.     

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.     

A Preliminary Study of an Internet‐Based Intervention for OEF/OIF Veterans Presenting for VA Specialty PTSD Care

This preliminary study sought to evaluate the feasibility and potential effectiveness of a cognitive–behavioral, web‐based intervention for posttraumatic stress in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans who are not able to participate, or not eligible to participate, in evidence‐based posttraumatic stress disorder (PTSD) treatments. The study used an uncontrolled pre‐posttest design with a sample of 24 OEF/OIF veterans presenting to a VA PTSD specialty clinic. Participants used the afterdeployment.org, Post‐Traumatic Stress (PTS) Workshop, which was supplemented with brief weekly telephone calls. Half of the participants (n = 12) completed at least 5 of the 8 workshop sessions. At posttreatment, 40.0% of completers demonstrated reliable reductions on PTSD symptoms and overall d = 1.04. Treatment satisfaction and acceptability was generally positive based on Likert ratings. This web‐based intervention for PTS appears to be a feasible and potentially helpful intervention for veterans who may not otherwise receive psychosocial interventions. Given the minimal resources required and the potential reach, this web‐based intervention could be a viable addition to services provided to OEF/OIF veterans seeking PTSD specialty care. Efforts to further develop and more rigorously evaluate this approach are warranted.     

Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S. veterans

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ≥ 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.     

Military Sexual Assault in Transgender Veterans: Results From a Nationwide Survey

There is limited understanding about the frequency of military sexual assault (MSA) in transgender veterans, characteristics associated with MSA, or subsequent mental and behavioral health problems. To address this gap, we used an online national survey of 221 transgender veterans to identify prevalence of MSA and to assess its association with demographic characteristics, past history of sexual victimization, and stigma‐related factors. We also evaluated the association between MSA and several mental and behavioral health problems. Overall, 17.2% of transgender veterans experienced MSA, but rates differed significantly between transgender women (15.2%) and transgender men (30.0%). Using adjusted regression models, MSA was associated with adult sexual assault prior to military service, odds ratio (OR) = 4.05, 95% CI [1.62, 10.08], and distal minority stress during military service, OR = 2.98, 95% CI [1.28, 6.91]. With respect to health outcomes, MSA was associated with past‐month posttraumatic stress disorder (PTSD) symptom severity, B = 10.18, 95% CI [3.45, 16.91]; current depression symptom severity, B = 3.71, 95% CI [1.11, 6.30]; and past‐year drug use, OR = 3.17, 95% CI [1.36, 7.40]. Results highlight the vulnerability of transgender veterans to MSA, and the need for military prevention programs that acknowledge transgender individuals’ heightened risk. Furthermore, clinicians should consider clinical screening for PTSD, depression, and drug use in transgender veterans who have a history of MSA.     

Predictors of suicidal ideation in veterans with PTSD related to military sexual trauma

Predictors of suicidal ideation (SI) were examined in a sample of veterans (N = 128) diagnosed with posttraumatic stress disorder (PTSD) related to military sexual trauma. Suicidal ideation was predicted by both depressive symptom severity and posttraumatic symptom severity in separate correlation analyses. When controlling for the effects of depressive and posttraumatic symptom severity on one another in the prediction of SI in a single multiple regression model, however, only depressive symptoms independently predicted SI. These analyses suggest that the contribution of PTSD symptom severity to the prediction of SI is reduced by adding depressive symptoms. Hyperarousal symptom severity, however, was found in a separate multiple regression model to contribute independently to the prediction of SI controlling for depressive symptom severity.     

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

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

Gender differences in mental health outcomes among Afghanistan veterans exposed to war zone trauma

Research has sought to identify whether women have an increased risk of developing mental health problems following military trauma compared to men, but the results are mixed. This study examined gender differences in a range of mental health outcomes within three levels of war zone trauma exposure and investigated gender differences in risk and protective factors associated with clinical mental health problems. Using data from a cross-sectional, postdeployment survey, a sample of Norwegian veterans of recent military operations in Afghanistan (N = 6,205, 8.3% women) were sorted according to reported war zone trauma exposure level (low, medium, high), then assessed for symptoms of posttraumatic stress disorder (PTSD), posttraumatic distress, anxiety, depression, insomnia, and alcohol problems. The findings revealed that men who reported low war zone exposure had lower levels of posttraumatic distress symptoms than women, d = -0.20, p = .040, but were more likely to report symptoms of alcohol problems within the low, d = 0.33, p < .001; medium, d = 0.39, p < .001; and high, d = 0.37, p = .049, exposure groups; however, these differences disappeared when all symptom variables were combined into one clinical mental health problem variable. Women with a clinical mental health problem were less likely to report war zone exposure than men, OR = 0.93, 95% CI [0.90, 0.97], p = .001. Findings suggest that although gender differences in mental health symptoms exist, male and female veterans with mental health problems may share more similarities than previously recognized.     

Social Information Processing in Anger Expression and Partner Violence in Returning U.S. Veterans

We examined social information processing factors that could represent pathways through which posttraumatic stress disorder (PTSD) symptoms relate to anger expression and intimate partner violence (IPV) perpetration in returning U.S. veterans. The sample included 92 male Operation Enduring Freedom/Operation Iraqi Freedom veterans, primarily Caucasian (77.4%), with smaller numbers of African American, Asian, Hispanic or Latino, American Indian or Alaskan Native, and other minority participants (9.7%, 2.2%, 2.2%, 3.2%, and 5.3% respectively). The average age was 40.37 (SD = 9.63) years. Data were collected through self‐report questionnaires (PTSD Checklist, State‐Trait Anger Expression Scale, Revised Conflict Tactics Scales) and the Articulated Thoughts in Simulated Situations experimental protocol. Laboratory‐based assessment of cognitive biases and hostile attributions were tested as mediators of associations between PTSD symptoms and anger expression and IPV. Among the PTSD symptom clusters, hyperarousal symptoms were most strongly associated with anger expression (r = .50) and IPV perpetration (r = .27). Cognitive biases mediated associations between PTSD total scores and 3 of 4 PTSD cluster scores as well as anger expression. Hostile attribution biases were also associated with IPV perpetration (r = .23). We discuss the implications of these findings for understanding social information processing mechanisms for the relationship between PTSD symptoms and aggression.     

Deployment Risk and Resilience Inventory‐2 (DRRI‐2): An Updated Tool for Assessing Psychosocial Risk and Resilience Factors Among Service Members and Veterans

The Deployment Risk and Resilience Inventory (DRRI) is a widely used instrument for assessing deployment‐related risk and resilience factors among war veterans. A revision of this instrument was recently undertaken to enhance the DRRI's applicability across a variety of deployment‐related circumstances and military subgroups. The resulting suite of 17 distinct DRRI‐2 scales is the product of a multiyear psychometric endeavor that involved (a) focus groups with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans to inform an assessment of the content validity of original DRRI measures, (b) examination of item and scale characteristics of revised scales in a national sample of 469 OEF/OIF veterans, and (c) administration of refined scales to a second national sample of 1,046 OEF/OIF veterans to confirm their psychometric quality. Both classical test theory and item response theory analytical strategies were applied to inform major revisions, which included updating the coverage of warfare‐related stressors, expanding the assessment of family factors throughout the deployment cycle, and shortening scales. Finalized DRRI‐2 scales demonstrated strong internal consistency reliability and criterion‐related validity. The DRRI‐2 can be applied to examine the role that psychosocial factors play in postdeployment health and inform interventions aimed at reducing risk and enhancing resilience among war veterans.     

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self‐report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory‐II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = ?3.00, 95% CI [?3.22, ?2.78]; t(210) = ?13.5; p < .001, and in depressive symptoms, B = ?1.46, 95% CI [?1.64, ?1.28]; t(192) = ?8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.     

Prevalence of a Positive Screen for PTSD Among OEF/OIF and OEF/OIF‐Era Veterans in a Large Population‐Based Cohort

Multiple studies have reported the prevalence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans; however, these studies have been limited to populations who use the Department of Veterans Affairs (VA) for health care, specialty clinic populations, or veterans who deployed. The 3 aims of this study were to report weighted prevalence estimates of a positive screen for PTSD among OEF/OIF and nondeployed veterans, demographic subgroups, and VA health care system users and nonusers. The study analyzed data from the National Health Study for a New Generation of U.S. Veterans, a large population‐based cohort of OEF/OIF and OEF/OIF‐era veterans. The overall weighted prevalence of a positive screen for PTSD in the study population was 13.5%: 15.8% among OEF/OIF veterans and 10.9% in nondeployed veterans. Among OEF/OIF veterans, there was increased risk of a positive screen for PTSD among VA health care users (OR = 2.71), African Americans (OR = 1.61), those who served in the Army (OR = 2.67), and those on active duty (OR = 1.69). The same trend with decreased magnitude was observed in nondeployed veterans. PTSD is a significant public health problem in OEF/OIF‐era veterans, and should not be considered an outcome solely related to deployment.     

Military and Premilitary Trauma,Attachment Orientations,and Posttraumatic Stress Disorder Severity Among Male and Female Veterans

Samples in prior studies examining attachment theory in the military have been predominantly composed of male combat veterans. Given the rates of sexual trauma among female veterans and differences in the association between attachment and posttraumatic stress disorder (PTSD) severity for sexual trauma survivors, it was necessary to consider the attachment characteristics of veterans within a mixed‐sex sample. Participants were a mixed‐sex veteran sample seeking inpatient trauma‐related treatment (N = 469). Using independent samples t tests, we examined sex differences in attachment. Consistent with our hypothesis, women reported a higher level of attachment anxiety than did men, t(351) = ?2.12, p = .034. Women also reported a higher level of attachment avoidance, t(351) = ?2.44, p = .015. Using hierarchical regression, we examined the contribution of attachment anxiety and avoidance to PTSD severity, partialing out variance accounted for by demographic variables and traumatic experiences. Consistent with our hypotheses, attachment avoidance predicted PTSD severity on the Clinician‐Administered PTSD Scale for DSM‐IV (CAPS), β = .20, p < .001, and the PTSD Checklist–Civilian Version (PCL‐C), β = .18, p < .001. Attachment anxiety did not predict CAPS severity but did predict PCL‐C severity, β = .11, p = .020. These results suggest the association between attachment avoidance and PTSD is not exclusive to combat trauma and may apply more generally to the larger veteran population. Higher levels of attachment anxiety and avoidance among female veterans potentially implicate the presence of greater attachment fearfulness among this particular subpopulation of veterans.     

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

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

Compensation and Treatment: Disability Benefits and Outcomes of U.S. Veterans Receiving Residential PTSD Treatment

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma‐related symptoms in addition to providing service‐connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.