Faculty Bibliography

Children and young people (CYP) within the Child Welfare System (CWS) often experience a range of trauma-related difficulties. However, systematic use of evidence-based measures to support mental health assessment and care planning appeared to be lacking within CWS in Singapore. This study evaluated the use of evidence-based measures to inform care planning in out-of-home residential care in Singapore. Participants were 65 CYP in care. Measures consisted of the Child PTSD Symptom Scale for DSM-5 (CPSS-5), Assessment Checklist for Children (ACC) and Adolescents (ACA), Child Behavior Checklist (CBCL) and Youth Self-Report (YSR). Care plans were identified based on the measures' clinical criteria and validated against the Child and Adolescent Needs and Strengths (CANS) and Adverse Childhood Experience (ACE) questionnaire. More intensive measurement-based care plans were associated with higher service needs and lower strengths on the CANS, and higher ACE exposure. However, there was limited support for the validity of care plans when evaluated against the CANS and ACE questionnaire. Methodological implications for mental health assessment are discussed. Compared to service-allocation-as-usual, measurement-based care plans identified more cases that may require intensive psychological intervention. Overall, study findings provided some support for the use of assessment measures to supplement care planning in residential care. "˜This study evaluated the use of evidence-based measures to inform care planning in out-of-home residential care in Singapore"™. Key Practitioner Messages: A comprehensive approach to care planning for CYP in out-of-home residential care should include the use of multi-informant evidence-based mental health assessment measures. The use of mental health assessment measures may reduce information gaps and complement the use of service needs assessment tools. Measurement-based care planning may provide added value to supplement existing standard psychological care planning practices in out-of-home residential care.

OBJECTIVE:Adverse Childhood Experiences (ACEs) have consistently been associated with a range of negative psychological and physical outcomes in adulthood. Despite the strength of this association, no studies to date have investigated psychological processes that might underlie this relationship. The current study evaluated emotion regulation as a potential mediator between ACEs and three outcomes: PTSD symptoms, depression and poor physical health, all of which are frequently co-occurring among women with ACEs. METHOD/METHODS:Mediational analyses were conducted with baseline data from a sample of 290 women enrolled in a clinical trial for PTSD. Emotion regulation was assessed with the Difficulties in Emotional Regulation Scale (DERS), PTSD with the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), depression with the Brief Symptom Inventory Depression subscale (BSI-D) and physical health with a shortened version of Medical Outcomes Study Short Form (SF-8). RESULTS:Emotion regulation significantly mediated the relationship between ACEs and all three outcomes. The estimates of the standardized indirect effects of ACEs on the health outcomes as mediated through DERS scores were as follows: PTSD β = 0.1, p < .001; depression β = 0.16, p < .001; physical health β = 0.07, p = .002. CONCLUSION/CONCLUSIONS:Interventions that focus on improving emotion regulation skills might provide an efficient "transdiagnostic" treatment strategy for both psychological and physical health problems. The study successfully tested a mediational model that identified a common pathway influencing both mental and physical health symptoms. (PsycINFO Database Record

Posttraumatic stress disorder (PTSD) is associated with abnormalities in functional connectivity of a specific cortico-limbic network; however, less is known about white matter abnormalities providing structural connections for this network. This study investigated whether the diagnosis and symptoms of PTSD are associated with alterations in fractional anisotropy (FA), an index reflecting white matter organization, across six, a priori-defined tracts. White matter FA was quantified by diffusion tensor imaging using 3 T-MRI among 57 male, combat-exposed veterans with no history of moderate to severe head injuries or current alcohol dependence: 31 met criteria for PTSD and 26 were demographically comparable, combat-exposed controls without PTSD. Clinician-administered and self-report questionnaires assessed PTSD severity, dissociation, and mood. PTSD + veterans had significantly higher FA than exposed controls in the superior fronto-occipital fasciculus (SFOF) and borderline higher FA in the anterior corona radiata (ACR) and cingulum (CGC), controlling for age and neurovascular comorbidities. When lifetime alcohol use disorders was included, only the association of PTSD with SFOF-FA remained significant. Among PTSD + veterans, higher SFOF-FA was associated with greater mood disturbance, dissociative symptoms, and re-experiencing, while lower FA of the uncinate fasciculus (UF) was associated with greater mood disturbance symptoms. Compared to combat-exposed controls without PTSD, veterans with PTSD exhibited higher white matter FA in the SFOF, and a similar tendency in the ACR and CGC, tracts involved in conflict-processing and spatial attention. Prior alcohol use might explain the associations of PTSD with ACR-FA and CGC-FA but not the association with SFOF-FA.

BACKGROUND: Few studies have longitudinally examined predictors of posttraumatic stress disorder (PTSD) in a nationally representative sample of US veterans. We examined predictors of warzone-related PTSD over a 25-year span using data from the National Vietnam Veterans Longitudinal Study (NVVLS). METHODS: The NVVLS is a follow-up study of Vietnam theater veterans (N = 699) previously assessed in the National Vietnam Veterans Readjustment Study (NVVRS), a large national-probability study conducted in the late 1980s. We examined the ability of 22 premilitary, warzone, and postmilitary variables to predict current warzone-related PTSD symptom severity and PTSD symptom change in male theater veterans participating in the NVVLS. Data included a self-report Health Questionnaire survey and a computer-assisted telephone Health Interview Survey. Primary outcomes were self-reported PTSD symptoms assessed by the PTSD Checklist for DSM-5 (PCL 5) and Mississippi PTSD Scale (M-PTSD). RESULTS: Predictors of current PTSD symptoms most robust in hierarchical multivariable models were African-American race, lower education level, negative homecoming reception, lower current social support, and greater past-year stress. PTSD symptoms remained largely stable over time, and symptom exacerbation was predicted by African-American race, lower education level, younger age at entry into Vietnam, greater combat exposure, lower current social support, and greater past-year stressors. CONCLUSIONS: Findings confirm the robustness of a select set of risk factors for warzone-related PTSD, establishing that these factors can predict PTSD symptom severity and symptom change up to 40 years postdeployment.

Functional Analytic Psychotherapy (FAP) is a behavioral psychotherapy intervention that emphasizes the development of an intimate and intense therapeutic relationship as the vehicle of therapeutic change. Recently, research has provided preliminary support for a FAP therapist training (FAPTT) protocol in enhancing FAP competency. The present study aimed to expand on this research by examining the effects of FAPTT on FAP-specific skills and competencies and a set of broadly desirable therapist qualities (labelled awareness, courage and love in FAPTT) in a sample of therapist trainees in Singapore. The study also evaluated the feasibility and acceptability of FAP in the Singaporean context. Twenty-five students enrolled in a master's in clinical psychology program were recruited and randomly assigned to receive either eight weekly sessions of a FAPTT course or to a waitlist condition. All participants completed measures assessing empathy, compassionate love, trait mindfulness, authenticity and FAP-specific skills and competencies pre- and post-training, and at 2-month follow-up. A post-course evaluation was administered to obtain participants' qualitative feedback. Results indicated that compared with the waitlisted group, FAPTT participants reported significant increases in overall empathy, FAP skill and treatment acceptability from pre- to post-training. Improvements were observed on several outcome variables at 2-month follow-up. Participants reported finding the training to be both feasible and acceptable, although several raised issues related to the compatibility of the treatment with the local cultural context. Overall, the findings suggest that FAPTT is effective for improving specific FAP competencies and selected broadly desirable therapist qualities among therapist trainees. Copyright © 2016 John Wiley & Sons, Ltd.

BACKGROUND: Several psychiatric disorders may be characterized by peripheral telomere shortening. However, it is unclear whether telomere shortening is associated with these psychiatric disorders per se or, rather, with underlying dimensional parameters that are often, but not necessarily, associated with them. We explored the association between dimensional psychopathological measures and telomere length (TL) in granulocytes among veterans independent of psychiatric diagnosis. METHODS: Seventy-six combat-exposed male veterans (41 psychiatrically healthy, 18 with Posttraumatic Stress Disorder [PTSD] and 17 with concomitant PTSD and Major Depressive Disorder [MDD]) had TL assayed. Assessments included Clinician-Administered PTSD Scale (CAPS), Beck Depression Inventory-II (BDI-II), Early Trauma Inventory (ETI), Symptom Checklist-90-R Global Severity Index (SCL-90-GSI), Perceived Stress Scale (PSS) and Positive and Negative Affect Schedule (PANAS). Correlations were corrected for age, BMI, antidepressants and ethnicity. RESULTS: Across subjects, TL was negatively correlated with early trauma (p<0.001), global psychopathological severity (p=0.044) and perceived stress (p=0.019), positively correlated with positive affect (p=0.026), not significantly correlated with symptom severity of PTSD, depression or negative affect. Across these dimensions, early trauma and positive affect were associated with TL after excluding subjects with somatic illnesses. LIMITATIONS: The study was cross-sectional with a moderate sample size and only male combat-exposed subjects. CONCLUSIONS: These preliminary findings suggest that early trauma, severity of perceived stress and general psychopathological symptoms are more closely associated with shorter TL than is the severity of core diagnostic symptoms of PTSD or MDD, whereas positive affect is associated with longer TL. Larger-scale studies should assess TL associated with specific psychiatric dimensions, apart from only categorical psychiatric diagnoses, to develop more specific biologically-relevant endophenotypes.

Background: Circulating hematopoietic progenitor cells (PCs; CD34+ and CD34+/KDR+) facilitate neurogenesis and neovascularization, promoting increased cortical thickness and white matter integrity in animal models. However, it unknown whether low PCs are associated with trauma symptoms or neurovas-cular health among veterans. Objectives: Determine whether lower PCs are associated with: (1) posttraumatic stress disorder (PTSD) diagnosis, duration and symptoms, (2) decreased prefrontal cortical (PFC) thickness, and (3) reduced white matter integrity, indexed by white matter hypointen-sities (WMH), and tracts relevant to fear processing: the Uncinate Fasciculus (UF) and Inferior Fronto-Occipital Fasciculus (IFOF). Methods: 100 male and 8 female combat-exposed veterans reported PTSD symptoms (43 PTSD+) and were studied by 3T MRI, acquiring whole brain T1-weighted images and, for a subsample (n = 54), diffusion tensor images. PCs were characterized by flow cytometry. Results: Higher CD34+/KDR+ counts were related to greater PFC thickness (DM-PFC and DL-PFC), while higher CD34+ counts were related to better IFOF (but not UF) integrity and fewer WMH, controlling for age, gender, smoking, cardiovascular comorbidities and head injury. In PTSD+ subjects, CD34+/KDR+ counts were inversely related to time since the worst trauma, but not PTSD diagnosis or current symptoms. Conclusions: PCs are associated with enhanced white matter integrity and PFC thickness, with potential implications for neurovascular plasticity and fear processing. In patients with PTSD, PCs may exhibit accelerated depletion with increasing time post-trauma

The National Vietnam Veterans Longitudinal Study (NVVLS) is the second assessment of a representative cohort of US veterans who served during the Vietnam War era, either in Vietnam or elsewhere. The cohort was initially surveyed in the National Vietnam Veterans Readjustment Study (NVVRS) from 1984 to 1988 to assess the prevalence, incidence, and effects of post-traumatic stress disorder (PTSD) and other post-war problems. The NVVLS sought to re-interview the cohort to assess the long-term course of PTSD. NVVLS data collection began July 3, 2012 and ended May 17, 2013, comprising three components: a mailed health questionnaire, a telephone health survey interview, and, for a probability sample of theater Veterans, a clinical diagnostic telephone interview administered by licensed psychologists. Excluding decedents, 78.8% completed the questionnaire and/or telephone survey, and 55.0% of selected living veterans participated in the clinical interview. This report provides a description of the NVVLS design and methods. Together, the NVVRS and NVVLS constitute a nationally representative longitudinal study of Vietnam veterans, and extend the NVVRS as a critical resource for scientific and policy analyses for Vietnam veterans, with policy relevance for Iraq and Afghanistan veterans

Importance: The long-term course of readjustment problems in military personnel has not been evaluated in a nationally representative sample. The National Vietnam Veterans Longitudinal Study (NVVLS) is a congressionally mandated assessment of Vietnam veterans who underwent previous assessment in the National Vietnam Veterans Readjustment Study (NVVRS). Objective: To determine the prevalence, course, and comorbidities of war-zone posttraumatic stress disorder (PTSD) across a 25-year interval. Design, Setting, and Participants: The NVVLS survey consisted of a self-report health questionnaire (n = 1409), a computer-assisted telephone survey health interview (n = 1279), and a telephone clinical interview (n = 400) in a representative national sample of veterans who served in the Vietnam theater of operations (theater veterans) from July 3, 2012, through May 17, 2013. Of 2348 NVVRS participants, 1920 were alive at the outset of the NVVLS, and 81 died during recruitment; 1450 of the remaining 1839 (78.8%) participated in at least 1 NVVLS study phase. Data analysis was performed from May 18, 2013, through January 9, 2015, with further analyses continued through April 13, 2015. Main Outcomes and Measures: Study instruments included the Mississippi Scale for Combat-Related PTSD, PTSD Checklist for DSM-IV supplemented with PTSD Checklist for DSM-5 items (PCL-5+), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and Structured Clinical Interview for DSM-IV, Nonpatient Version. Results: Among male theater veterans, we estimated a prevalence (95% CI) of 4.5% (1.7%-7.3%) based on CAPS-5 criteria for a current PTSD diagnosis; 10.8% (6.5%-15.1%) based on CAPS-5 full plus subthreshold PTSD; and 11.2% (8.3%-14.2%) based on PCL-5+ criteria for current war-zone PTSD. Among female veterans, estimates were 6.1% (1.8%-10.3%), 8.7% (3.8%-13.6%), and 6.6% (3.5%-9.6%), respectively. The PCL-5+ prevalence (95% CI) of current non-war-zone PTSD was 4.6% (2.6%-6.6%) in male and 5.1% (2.3%-8.0%) in female theater veterans. Comorbid major depression occurred in 36.7% (95% CI, 6.2%-67.2%) of veterans with current war-zone PTSD. With regard to the course of PTSD, 16.0% of theater veterans reported an increase and 7.6% reported a decrease of greater than 20 points in Mississippi Scale for Combat-Related PTSD symptoms. The prevalence (95% CI) of current PCL-5+-derived PTSD in study respondents was 1.2% (0.0%-3.0%) for male and 3.9% (0.0%-8.1%) for female Vietnam veterans. Conclusions and Relevance: Approximately 271000 Vietnam theater veterans have current full PTSD plus subthreshold war-zone PTSD, one-third of whom have current major depressive disorder, 40 or more years after the war. These findings underscore the need for mental health services for many decades for veterans with PTSD symptoms.