Faculty Bibliography

BACKGROUND:Symptoms of both posttraumatic stress disorder (PTSD) and disturbances in self-organization (DSO) have been suggested to play a role in the association between an individual's childhood physical abuse and neglect and his/her perpetration of IPV in adulthood; however, the two have yet to be studied in one model. Thus, we aimed to examine the interrelations among childhood exposure to violence and physical neglect, exposure to trauma across one's lifetime, ICD-11 CPTSD symptoms (i.e., PTSD and DSO), and IPV severity. METHODS:Participants were 234 men drawn randomly from a national sample of 1600 mandated men receiving treatment for domestic violence in Israel. They completed measures of potentially traumatic exposure, symptoms of CPTSD, child abuse and neglect, and IPV. Structural equation modeling (SEM) was used to examine possible direct and indirect effects of the study variables. RESULTS:Results confirmed the indirect role of CPTSD symptoms in the association between the following types of traumatic exposure - childhood exposure to violence (B = .03, β = .05, SE = .01, p = .05, CI 90% [.041, .143]), childhood exposure to physical neglect (B = .04, β = .04, SE = .02, p < .01, CI 90% [.014, .092]), and lifetime exposure to potentially traumatic events, or PTEs (B = .04, β = .09, SE = .01, p < .001, CI 90% [.006, .074]) - and the perpetration of psychological IPV as an adult. No significant results were found in relation to the perpetration of physical IPV. CONCLUSIONS:The current cross-sectional study findings suggest a preliminary direction regarding the possible direct and indirect effects of ICD-11CPTSD on the severity of IPV psychological perpetration. The clinical implications include the need to focus on both PTSD and DSO symptoms in order to help reduce these potential risk factors for psychological IPV perpetration.

BACKGROUND:Following the recently published 11th version of the WHO International Classification of Diseases (ICD-11), we sought to examine the risk factors and comorbidities associated with posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). METHOD:Cross-sectional and retrospective design. The sample consisted of 1,051 trauma-exposed participants from a nationally representative panel of the UK adult population. RESULTS:A total of 5.3% (95% confidence interval [CI] = 4.0-6.7%) met the diagnostic criteria for PTSD and 12.9% (95% CI = 10.9-15.0%) for CPTSD. Diagnosis of PTSD was independently associated with being female, being in a relationship, and the recency of traumatic exposure. CPTSD was independently associated with younger age, interpersonal trauma in childhood, and interpersonal trauma in adulthood. Growing up in an urban environment was associated with the diagnosis of PTSD and CPTSD. High rates of physical and mental health comorbidity were observed for PTSD and CPTSD. Those with CPTSD were more likely to endorse symptoms reflecting major depressive disorder (odds ratio [OR] = 21.85, 95 CI = 12.51-38.04) and generalized anxiety disorder (OR = 24.63, 95 CI = 14.77-41.07). Presence of PTSD (OR = 3.13, 95 CI = 1.81-5.41) and CPTSD (OR = 3.43, 95 CI = 2.37-4.70) increased the likelihood of suicidality by more than three times. Nearly half the participants with PTSD and CPTSD reported the presence of a chronic illness. CONCLUSIONS:CPTSD is a more common, comorbid, debilitating condition compared to PTSD. Further research is now required to identify effective interventions for its treatment.

PURPOSE/OBJECTIVE:Loneliness is a recognised public-health concern that is traditionally regarded as a unidimensional construct. Theories of loneliness predict the existence of subtypes of loneliness. In this study, latent class analysis (LCA) was used to test for the presence of loneliness subtypes and to examine their association with multiple mental health variables. METHODS:A nationally representative sample of US adults (N = 1839) completed the De Jong Gierveld Loneliness Scale, along with self-report measures of childhood and adulthood trauma, psychological wellbeing, major depression, and generalized anxiety. RESULTS:When treated as a unidimensional construct, 17.1% of US adults aged 18-70 were classified as lonely. However, the LCA results identified four loneliness classes which varied quantitatively and qualitatively: 'low' (52.8%), 'social' (8.2%), 'emotional' (26.6%), and 'social and emotional' (12.4%) loneliness. The 'social and emotional' class were characterised by the highest levels of psychological distress, followed by the 'emotional' class. The 'social' loneliness class had similar mental health scores as the 'low' loneliness class. Childhood and adulthood trauma were independently related to the most distressed loneliness classes. CONCLUSIONS:Current findings provide support for the presence of subtypes of loneliness and show that they have unique associations with mental health status. Recognition of these subtypes of loneliness revealed that the number of US adults aged 18-70 experiencing loneliness was twice as high as what was estimated when loneliness was conceptualized as a unidimensional construct. The perceived quality, not the quantity, of interpersonal connections was associated with poor mental health.

OBJECTIVE:This study aimed to identify modifiable factors associated with perceived functioning among veterans with high symptoms of posttraumatic stress disorder (PTSD). METHOD/METHODS:Two hundred fifty-one post-9/11 veterans completed a survey of psychosocial symptoms and functioning; a subset participated in a follow-up survey (n = 109). Latent profile analysis (LPA) at baseline identified groups that differed by level of functioning (high/low). Items utilized in the LPA analysis were derived from the World Health Organization Quality of Life-Bref self-report measure. Veterans with high PTSD symptoms in both groups were compared and logistic regression was utilized to predict group membership. RESULTS:Veterans with high functioning/high symptoms (n = 45) had significantly lower alcohol use and sleep problems, and higher postdeployment social support, posttraumatic growth, and optimism than veterans with low functioning/high symptoms (n = 100). Fewer sleep difficulties and higher postdeployment social support and optimism were associated with membership in the high functioning/high symptom group. CONCLUSIONS:These findings support the importance of identifying factors that can facilitate higher social, occupational, and general functional capacity for those with high levels of PTSD symptomatology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Over the last two decades, treatment guidelines have become major aids in the delivery of evidence-based care and improvement of clinical outcomes. The International Society for Traumatic Stress Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta-analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.

BACKGROUND:The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions. METHODS:We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality. RESULTS:Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = -0.90 (CBT; k = 27, 95% CI -1.11 to -0.68; moderate quality) to g = -1.26 (EMDR; k = 4, 95% CI -2.01 to -0.51; low quality). CBT and EA each had moderate-large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate-large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome. CONCLUSIONS:The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

BACKGROUND:The ICD-11 includes a new disorder, complex post-traumatic stress disorder (CPTSD). A network approach to CPTSD will enable investigation of the structure of the disorder at the symptom level, which may inform the development of treatments that target specific symptoms to accelerate clinical outcomes.AimsWe aimed to test whether similar networks of ICD-11 CPTSD replicate across culturally different samples and to investigate possible differences, using a network analysis. METHOD/METHODS:We investigated the network models of four nationally representative, community-based cross-sectional samples drawn from Germany, Israel, the UK, and the USA (total N = 6417). CPTSD symptoms were assessed with the International Trauma Questionnaire in all samples. Only those participants who reported significant functional impairment by CPTSD symptoms were included (N = 1591 included in analysis; mean age 43.55 years, s.d. 15.10, range 14-99, 67.7% women). Regularised partial correlation networks were estimated for each sample and the resulting networks were compared. RESULTS:Despite differences in traumatic experiences, symptom severity and symptom profiles, the networks were very similar across the four countries. The symptoms within dimensions were strongly associated with each other in all networks, except for the two symptom indicators assessing aspects of affective dysregulation. The most central symptoms were 'feelings of worthlessness' and 'exaggerated startle response'. CONCLUSIONS:The structure of CPTSD symptoms appears very similar across countries. Addressing symptoms with the strongest associations in the network, such as negative self-worth and startle reactivity, will likely result in rapid treatment response.Declaration of interestA.M. and M.C. were members of the World Health Organization (WHO) ICD-11 Working Group on the Classification of Disorders Specifically Associated with Stress, reporting to the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The views expressed in this article are those of the authors and do not represent the official policies or positions of the International Advisory Group or the WHO.

Introduction/UNASSIGNED:Group Skills Training in Affective and Interpersonal Regulation (STAIR) is an evidence-based, manualized treatment for individuals with post-traumatic stress symptoms, that focuses on improving functioning through mood management (e.g., emotion regulation) and relationship skills development. To date, no study has evaluated the potential benefit of group STAIR among Veterans. Feasibility of delivering STAIR in a mixed-gender group format and the potential impact of gender on outcome were examined. Materials and Methods/UNASSIGNED:Participants (n = 39) were Veterans enrolled in a post-traumatic stress disorder (PTSD) Clinic at a large VA Medical Center. Veterans participated in one of four mixed-gender STAIR groups and completed self-report questionnaires of PTSD symptoms and general psychological distress at pre-treatment and post-treatment. Institutional review board approval was obtained for this study. Results/UNASSIGNED:There was significant pre-treatment to post-treatment improvements in PTSD symptoms as measured by the Post-traumatic Stress Checklist (PCL) (Cohen's d = 0.91), as well as in general psychological distress as measured by the Brief Symptom Inventory (BSI) (Cohen's d = 0.90). Change in PTSD symptoms from pre-treatment to post-treatment did not differ across gender. However, the interaction between gender and time on change in (BSI) was significant, where change in general psychological distress significantly decreased from pre-treatment to post-treatment for male Veterans but not for female Veterans. Conclusion/UNASSIGNED:The results from this study demonstrate the feasibility and initial effectiveness of STAIR delivered in a mixed-gender group format for Veterans with PTSD. It should be noted, however, that male Veterans benefited more from this approach than female Veterans. The findings suggest the value of investigating Veterans' attitudes and beliefs about the benefits and drawbacks of mixed-gender group therapy for trauma-related difficulties.

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

Background: The World Health Organization(WHO) International Classification of Diseases, 11th version (ICD-11), has proposed a new trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD), separate and distinct from posttraumatic stress disorder (PTSD). However, to date, no study has examined CPTSD over time. Objectives: This prospective study aimed to examine predictors and outcomes of latent classes of PTSD and CPTSD following war captivity. Method: A sample of 183 Israeli former prisoners of the 1973 Yom Kippur War (ex-POWs) participated in a 24-year longitudinal study with three waves of measurements (T1: 1991, T2: 2008, and T3: 2015). Participants completed validated self-report measures, and their cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA). Results: Estimated rates of PTSD and CPTSD were high at all waves, with PTSD rates higher than CPTSD. A Latent Class Analysis (LCA) identified three main classes at T2: (1) a small class with low probability to meet PTSD and CPTSD clusters criteria (15.26%); (2) a class high only in PTSD symptoms (42.37%) and (3) a class high only in CPTSD symptoms (42.37%). Importantly, higher levels of psychological suffering in captivity at T1 were associated with higher odds of being in the CPTSD class at T2. In addition, CPTSD at T2 was more strongly associated with low self-rated health, functional impairment, and cognitive performance at T3, compared to the PTSD only class. Conclusions: Adulthood prolonged trauma of severe interpersonal intensity such as war captivity is related to CPTSD, years after the end of the war. Exposure to psychological suffering in captivity is a risk factor for future endorsement of CPTSD symptoms. CPTSD among ex-POWs is a marker for future dire mental health and functional consequences.