Faculty Bibliography

OBJECTIVE: There has been significant debate about the optimal factor structure of posttraumatic stress disorder (PTSD). In military and veteran samples, most available studies have employed self-report measures, assessed PTSD cross-sectionally, used treatment-seeking samples, and assessed symptoms years after deployment. We extend previous studies by comparing the factor structure of clinician-assessed and self-report Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) PTSD in a nontreatment seeking sample at 4 time points spanning the deployment cycle. METHOD: The data source for this study was the Marine Resiliency Study (MRS), a longitudinal study of 4 battalion cohorts of active-duty male Marines deployed to Iraq and Afghanistan between 2008 and 2012. We examined the fourth cohort (N = 892), which was evaluated 1 month predeployment, and 1, 5, and 8 months postdeployment. RESULTS: Confirmatory factor analyses (CFA) revealed that the 5-factor solution best fit the data across all time points, and across both interview and self-report assessments. CONCLUSION: The temporal consistency and convergence demonstrated by our analyses underscores the validity of the 5-factor model among service members exposed to warzone stressors. In particular, the findings suggest that diagnostic criteria for PTSD may benefit from disaggregating hyperarousal symptoms in military samples. (PsycINFO Database Record

Cannabidiol (CBD), a Cannabis sativa constituent, is a pharmacologically broad-spectrum drug that in recent years has drawn increasing interest as a treatment for a range of neuropsychiatric disorders. The purpose of the current review is to determine CBD's potential as a treatment for anxiety-related disorders, by assessing evidence from preclinical, human experimental, clinical, and epidemiological studies. We found that existing preclinical evidence strongly supports CBD as a treatment for generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder when administered acutely; however, few studies have investigated chronic CBD dosing. Likewise, evidence from human studies supports an anxiolytic role of CBD, but is currently limited to acute dosing, also with few studies in clinical populations. Overall, current evidence indicates CBD has considerable potential as a treatment for multiple anxiety disorders, with need for further study of chronic and therapeutic effects in relevant clinical populations.

Contemporary models of PTSD disaggregate this disorder into sub-clusters that differentially impact functioning. Severity of different types of PTSD symptoms in the acute posttrauma period may be predictive of the course of PTSD over time. Few research studies, however, have examined the predictive utility of PTSD sub-clusters. This study sought to determine the relative predictive validity of 4 sub-clusters, namely reexperiencing, strategic avoidance, emotional numbing, and hyperarousal, assessed within 1 month of a sexual assault. Women (N=120) who had been sexually assaulted completed self-report measures at 1 and 4 months postassault. Linear regression analyses revealed that early reexperiencing and emotional numbing sub-clusters uniquely contributed to the prediction of PTSD symptoms at month 4 (strategic avoidance and hyperarousal did not). To help explain and contextualize these findings, we explored the extent to which posttraumatic cognitions mediated the relationship between acute reexperiencing and emotional numbing and later PTSD symptoms. Simultaneous multiple mediation analyses revealed that general negative cognitions about the self significantly mediated the relationship between both reexperiencing and emotional numbing and month 4 PTSD symptoms. These findings have significant clinical implications, pointing to the importance of targeting posttraumatic cognitions in the acute posttrauma phase. (PsycINFO Database Record

BACKGROUND: Symptom-level variation in posttraumatic stress disorder (PTSD) has not yet been examined in the early post-deployment phase, but may be meaningful etiologically, prognostically, and clinically. METHODS: Using latent class analysis (LCA), we examined PTSD symptom heterogeneity in a cohort of participants from the Marine Resiliency Study (MRS), a longitudinal study of combat Marines deployed to Iraq and Afghanistan (N=892). Typologies of PTSD symptom presentation were examined at one month pre-deployment and again one, five, and eight months post-deployment. RESULTS: Heterogeneity in PTSD symptom presentation was evident at each assessment point, and the degree of symptom heterogeneity (i.e., the number of classes identified) differed by time point. Symptom patterns stabilized over time from notable symptom fluctuations during the early post-deployment period to high, medium, and low symptom severity by eight months post-deployment. Hypervigilance and exaggerated startle were frequently endorsed by participants in the initial month post-deployment. Flashbacks, amnesia, and foreshortened future were infrequently endorsed. Greater combat exposure, lifespan trauma, and avoidant coping generally predicted worse outcomes. LIMITATIONS: Data were self-report and may have limited generalizability due to our lack of women and inclusion of only combat Marines. Attrition and re-ranging of data resulted in significant missing data and affected the representativeness of the sample. CONCLUSIONS: Symptom-level variability is highest in the month following deployment and then stabilizes over time. Should post-deployment assessments occur too soon, they may capture common and transient early post-deployment reactions, particularly anxious arousal.

We examined the course of PTSD symptoms in a cohort of U.S. Marines (N = 867) recruited for the Marine Resiliency Study (MRS) from a single infantry battalion that deployed as a unit for 7 months to Afghanistan during the peak of conflict there. Data were collected via structured interviews and self-report questionnaires 1 month prior to deployment and again at 1, 5, and 8 months postdeployment. Second-order growth mixture modeling was used to disaggregate symptom trajectories; multinomial logistic regression and relative weights analysis were used to assess the role of combat exposure, prior life span trauma, social support, peritraumatic dissociation, and avoidant coping as predictors of trajectory membership. Three trajectories best fit the data: a low-stable symptom course (79%), a new-onset PTSD symptoms course (13%), and a preexisting PTSD symptoms course (8%). Comparison in a separate MRS cohort with lower levels of combat exposure yielded similar results, except for the absence of a new-onset trajectory. In the main cohort, the modal trajectory was a low-stable symptoms course that included a small but clinically meaningful increase in symptoms from predeployment to 1 month postdeployment. We found no trajectory of recovery from more severe symptoms in either cohort, suggesting that the relative change in symptoms from predeployment to 1 month postdeployment might provide the best indicator of first-year course. The best predictors of trajectory membership were peritraumatic dissociation and avoidant coping, suggesting that changes in cognition, perception, and behavior following trauma might be particularly useful indicators of first-year outcomes. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Large cohort studies suggest that most military personnel experience minimal posttraumatic stress disorder (PTSD) symptoms following warzone deployment, an outcome often labeled resilience. Very low symptom levels, however, may be a marker for low exposure, not resilience, which requires relatively high-magnitude or high-frequency stress exposure as a precondition. We used growth mixture modeling (GMM) to examine the longitudinal course of lifetime PTSD symptoms following combat exposure by disaggregating deployed U.S. Marines into upper, middle, and lower tertiles of combat exposure. All factor models fit the data well; Tucker-Lewis Index (TLI) and comparative fit index (CFI) values ranged from .91 to .97. Three distinct trajectories best explained the data within each tertile. The upper tertile comprised True Resilience (73.2%), New-Onset Symptoms (18.3%), and Pre-existing Symptoms (8.5%) trajectories. The middle tertile also comprised True Resilience (74.5%), New-Onset Symptoms (16.1%), and Pre-existing Symptoms (9.4%) trajectories. The lower tertile comprised Artifactual Resilience (86.3%), Pre-existing Symptoms (7.6%), and New-Onset Symptoms (6.1%) trajectories. True Resilience involved a clinically significant symptom increase followed by a return to baseline, whereas Artifactual Resilience involved consistently low symptoms. Conflating artifactual and true resilience may inaccurately create the expectation of persistently low symptoms regardless of warzone exposure.

OBJECTIVES: Prior research on mental health stigma in military personnel has been cross-sectional. We prospectively examined the course of perceived mental health stigma in a cohort of deployed U.S. combat Marines. METHODS: Participants (N = 768) were assessed 1 month before a 7-month deployment to Afghanistan, and again at 1, 5, and 8 months postdeployment. We also examined three predictors of the course of stigma: post-traumatic stress disorder symptom severity, vertical and horizontal unit cohesion, and mental health treatment utilization while deployed. RESULTS: Perceptions of stigma remained largely stable across the deployment cycle, with latent growth curve analyses revealing a statistically significant but small decrease in stigma over time. Lower post-traumatic stress disorder symptoms and greater perceived vertical and horizontal support predicted decreases in stigma over time, whereas mental health treatment utilization in theater did not predict the course of stigma. CONCLUSIONS: Perceived stigma was low and largely stable over time.

Comments on the article by B. E. Karlin and G. Cross (see record 2013-31043-001). Karlin and Cross described innovations in disseminating evidence-based psychotherapies in the Veterans Health Administration (VHA), including therapies for posttraumatic stress disorder (PTSD). The multidimensional model they presented aims to promote the delivery of evidence-based psychotherapies nationally in order to redress the research-to-practice gap reflected in the infrequent use of evidence-based psychotherapies for PTSD in the VHA (Shiner et al., 2013). In the present authors' view, however, the validity of this otherwise worthy strategic goal is built upon the questionable assumption that there is strong and sufficient evidence to support the use of the therapies being disseminated. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Heterogeneity in glucocorticoid response to experimental stress conditions has shown to differentiate individuals with healthy from maladaptive real-life stress responses in a number of distinct domains. However, it is not known if this heterogeneity influences the risk for developing stress related disorders or if it is a biological consequence of the stress response itself. Determining if glucocorticoid response to stress induction prospectively predicts psychological vulnerability to significant real life stressors can adjudicate this issue. To test this relationship, salivary cortisol as well as catecholamine responses to a laboratory stressor during academy training were examined as predictors of empirically identified distress trajectories through the subsequent 4 years of active duty among urban police officers routinely exposed to potentially traumatic events and routine life stressors (N = 234). During training, officers were exposed to a video vignette of police officers exposed to real-life trauma. Changes in salivary 3-methoxy-4-hydroxyphenylglycol (MHPG) and cortisol in response to this video challenge were examined as predictors of trajectory membership while controlling for age, gender, and baseline neuroendocrine levels. Officers who followed trajectories of resilience and recovery over 4 years mounted significant increases in cortisol in response to the experimental stressor, while those following a trajectory of chronic increasing distress had no significant cortisol change in response to the challenge. MHPG responses were not associated with distress trajectories. Cortisol response prospectively differentiated trajectories of distress response suggesting that a blunted cortisol response to a laboratory stressor is a risk factor for later vulnerability to distress following significant life stressors.