Faculty Bibliography

We respond to Bonanno's (2013) comment on our longitudinal evaluation of sexual assault survivors. Bonanno posits that minor disruption in functioning is the modal response to any stressor or trauma, yet most women we studied had marked initial symptoms in the immediate months following assault, which gradually improved over time. We argue that sexual violence is one example of intentional and malicious victimization, which differs from other experiences studied by Bonanno, such as spinal cord injury. Our study also differed from most previous studies in that it specifically examined the acute reactions period, which is the only period that can distinguish between resilience and recovery: Both trajectories ultimately involve good adaptation, but are distinguished by the degree of initial postevent disruption. We address Bonanno's contention that our results should be dismissed on methodological and statistical grounds. Our findings suggest that prior research about the frequency of resilience may in part be confounded by the degree and type of stress exposure.

Since the start of the wars in Afghanistan and Iraq, the U.S. military has implemented several population-based initiatives to enhance psychological resilience and prevent psychological morbidity in troops. The largest of these initiatives is the Army's Comprehensive Soldier Fitness (CSF) program, which has been disseminated to more than 1 million soldiers. However, to date, CSF has not been independently and objectively reviewed, and the degree to which it successfully promotes adaptive outcomes and prevents the development of deployment-related mental health disorders such as post-traumatic stress disorder (PTSD) is uncertain. This paper critically evaluates the theoretic foundation for and evidence supporting the use of CSF.

BACKGROUND: Comorbidity in psychological disorders is common following exposure to a traumatic event. Relatively little is known about the manner in which changes in the symptoms of a given type of psychological disorder in the acute period following a trauma impact changes in symptoms of another disorder. This study investigated the relationship between changes in posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the first 12 weeks following sexual assault. METHODS: Participants were 126 women who had been sexually assaulted in the previous 4 weeks. RESULTS: Lower level mediation analyses revealed that changes in PTSD symptoms had a greater impact on changes in depression and anxiety than vice versa. CONCLUSIONS: The finding highlights the role of PTSD symptoms in influencing subsequent change in other psychological symptoms. These findings are discussed in the context of models detailing the trajectory of psychological disorders following trauma, and clinical implications are considered.

Approximately 20% of the two million troops who have deployed to Iraq and Afghanistan may require treatment for posttraumatic stress disorder (PTSD). We review treatment outcome studies on individual outpatient therapy for military-related PTSD, and consider the extent to which veterans initiate and complete available PTSD treatments. We conclude with considerations for future research.

The authors examined heterogeneity in posttraumatic stress disorder (PTSD) symptom presentation among veterans (n = 335) participating in the clinical interview subsample of the National Vietnam Veterans Readjustment Study. Latent class analysis was used to identify clinically homogeneous subgroups of Vietnam War combat veterans. Consistent with previous research, three classes emerged from the analysis, namely, veterans with no disturbance (61.4% of the cohort), intermediate disturbance (25.6%), and pervasive disturbance (12.5%). The authors also examined physical injury, war-zone stressor exposure, peritraumatic dissociation, and general dissociation as predictors of class membership. The findings are discussed in the context of recent conceptual frameworks that posit a range of posttraumatic outcomes and highlight the sizable segment of military veterans who suffer from intermediate (subclinical) PTSD symptoms.

D-Cycloserine (DCS) is a partial NMDA receptor agonist that has been shown to enhance therapeutic response to exposure-based treatments for anxiety disorders, but has not been tested in the treatment of combat-related posttraumatic stress disorder (PTSD). The aim of this randomized, double-blind, placebo-controlled trial was to determine whether DCS augments exposure therapy for PTSD in veterans returning from Iraq and Afghanistan and to test whether a brief six-session course of exposure therapy could effectively reduce PTSD symptoms in returning veterans. In contrast to previous trials using DCS to enhance exposure therapy, results indicated that veterans in the exposure therapy plus DCS condition experienced significantly less symptom reduction than those in the exposure therapy plus placebo condition over the course of the treatment. Possible reasons for why DCS was associated with poorer outcome are discussed. Clinicaltrials.gov Registry #: NCT00371176; A Placebo-Controlled Trail of D-Cycloserine and Exposure Therapy for Combat-PTSD; www.clinicaltrials.gov/ct2/results?term=NCT00371176.

Although validity scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 1989) have proven useful in the detection of symptom exaggeration in criterion-group validation (CGV) studies, usually comparing instructed feigners with known patient groups, the application of these scales has been problematic when assessing combat veterans undergoing posttraumatic stress disorder (PTSD) examinations. Mixed group validation (MGV) was employed to determine the efficacy of MMPI-2 exaggeration scales in compensation-seeking (CS) and noncompensation-seeking (NCS) veterans. Unlike CGV, MGV allows for a mix of exaggerating and nonexaggerating individuals in each group, does not require that the exaggeration versus nonexaggerating status of any individual be known, and can be adjusted for different base-rate estimates. MMPI-2 responses of 377 male veterans were examined according to CS versus NCS status. MGV was calculated using 4 sets of base-rate estimates drawn from the literature. The validity scales generally performed well (adequate sensitivity, specificity, and efficiency) under most base-rate estimations, and most produced cutoff scores that showed adequate detection of symptom exaggeration, regardless of base-rate assumptions. These results support the use of MMPI-2 validity scales for PTSD evaluations in veteran populations, even under varying base rates of symptom exaggeration.

PURPOSE: we determined the test performance characteristics of four brief post-traumatic stress disorder (PTSD) screening tests in a civilian primary care setting. METHODS: this was a cross-sectional cohort study of adults attending a family medicine residency training clinic in the southeastern USA. Four hundred and eleven participants completed a structured telephone interview that followed an index clinic visit. Screening tests included: PTSD Symptom Checklist-Civilian Version (17 items), SPAN (four items), Breslau's scale (seven items) and Primary Care PTSD screen (PC-PTSD) (four items). A modified Clinician-Administered PTSD Scale was used to determine past month PTSD for comparison. Receiver operating characteristic analysis based on area under the curve (AUC) was used to assess diagnostic efficiency (>0.80 desired). Cut-off scores were selected to yield optimal sensitivity and specificity (>80%). RESULTS: past month PTSD was substantial (women = 35.8% and men = 20.0%; P < 0.01). AUC values were PTSD Symptom Checklist (PCL) (0.897), SPAN (0.806), Breslau's scale (0.886) and PC-PTSD (0.885). Optimal cut-scores yielded the following sensitivities and specificities: PCL (80.0% and 80.7%; cut-off = 43), SPAN (75.9% and 71.6%; cut-off = 3), Breslau's scale (84.5% and 76.4%; cut-off = 4) and PC-PTSD (85.1% and 82.0%; cut-off = 3). Overall and gender-specific screening test performances were explored. CONCLUSIONS: results confirm: (i) PTSD was common, especially among women; (ii) all four PTSD screening tests were diagnostically adequate; (iii) Two of four PTSD screening tests showed adequate sensitivity and specificity (>80%) and (iv) The PC-PTSD screening test (four items) appeared to be the best single screening test. There are few studies to establish the utility of PTSD screening tests within civilian primary care.

Research suggests that military unit cohesion may protect against the development of post-traumatic stress disorder (PTSD). However, equivocal findings have led researchers to hypothesize a potential curvilinear interaction between unit cohesion and warzone stress. This hypothesis states that the protective effects of cohesion increase as warzone stress exposure intensifies from low to moderate levels, but at high levels of warzone stress exposure, cohesion loses its protective effects and is potentially detrimental. To test this theory, we conducted a test for curvilinear moderation using a sample of 705 Air Force medical personnel deployed as part of Operation Iraqi Freedom. Results did not support the curvilinear interaction hypothesis, although evidence of cohesion's protective effects was found, suggesting that unit cohesion protects against PTSD regardless of level of stress exposure.