International Society for Traumatic Stress Studies

Military and Veteran Trauma

The ISTSS 34th Annual Meeting is the largest gathering of professionals dedicated to trauma treatment, education, research and prevention. There will be several workshops, symposia and expert trainings on military and veteran trauma. 


Concurrent Session One: Workshop Presentation

Thursday, November 8 | 9:45 AM to 11:00 AM

How to Develop Partnerships to Conduct PTSD Medication Trials

Gleason, Terri, PhD; Smyth, Miriam, PhD; O'Brien, Robert, PhD; Foster, Katrina, PhD; Nord, Kristina, MS
Department of Veteran Affairs, Washington, District of Columbia, USA

In 2016, the Department of Veterans Affairs convened an expert panel to review the status of medications for PTSD.  The evaluation reported a critical need to identify and test new medications (Biological Psychiatry,2017-10-01, Volume 82, Issue 7) due to the current state of only two medications being FDA approved for PTSD and those two drugs are not uniformly effective in PTSD remission. Further the report cited how few ongoing clinical trials were being funded which lead VA to announce a new PTSD Psychopharmacology Initiative (PPI).  The PPI is designed to build relationships with pharmaceutical partners to support identification and testing of new or repurposed compounds for treating PTSD.  Additionally, the PPI has supported an Industry Day to encourage companies to work on this problem, as well as young investigator workshop designed to train scientists to submit funding applications. The goals of this Workshop are to provide an overview of current PTSD medication trials, describe results of the PPI to date, and provide detailed information about partnering in medication trials for PTSD.  The conclusion of the VA expert panel in 2016 is that there is a medication crisis to be addressed for PTSD treatment, and this Workshop is designed to address underlying issues and recommendations for partnering to address this crises.

Concurrent Session Two: Symposium

Thursday, November 8 | 11:15 AM to 12:30 PM

How Are Evidence-based Psychotherapies Delivered in VA Clinics? Drop Out and Engagement in Trauma-focused Treatments

Co-Chairs: Niles, Barbara, PhD; Smidt, Katharine, PhD;
Discussant: Chard, Kathleen, PhD

The Veterans Health Administration (VHA) continues to endorse trauma-focused evidence-based psychotherapies (TF-EBPs) for Posttraumatic Stress Disorder (PTSD) as first-line treatments for PTSD. Research suggests that approximately 36% of patients who initiate a TF-EBP drop out of treatment (Goetter et al., 2015).  While TF-EBPs are effective treatments that can reduce symptoms of PTSD, the therapeutic impact of these treatments may be limited by factors such as veteran non-attendance and dropout (Kehle-Forbes, et al., 2016). Research examining veterans in naturalistic clinical settings conclude that many veterans referred for TF-EBP dropout during treatment (e.g., 43%, Deviva, 2014) or did not attend even one session (e.g., 37.5%, DeViva, 2014). It is essential to examine how TF-EBPs are delivered outside of research studies as VA continues to promote TF-EBPs. The following presentations examine TF-EBP engagement in veteran populations, with focus on treatment paths across clinical settings, methods employed by providers to encourage treatment completion, veteran ambivalence towards beginning a TF-EBP, and dropout and completion rates across PTSD treatments. Implications for future research within naturalistic clinical settings will be discussed.

Examining Efforts to Reduce Trauma-focused Evidence-based Psychotherapy (TF-EBP) Dropout Rates: Comparison across two Rounds of Program Evaluation Data

Smidt, Katharine, PhD1; Niles, Barbara, PhD2; Weinstein, Elizabeth, BA1; Fisher, Lisa, PhD3

1VA Boston Healthcare System, National Center for PTSD, Boston, Massachusetts, USA
2VA Boston Healthcare System, National Center for PTSD, and Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
3VA Boston Healthcare System & Boston University School of Medicine, Boston, Massachusetts, USA

TF-EBPs for PTSD are widely endorsed by the Veterans Health Administration (VHA). Although these interventions effectively reduce symptoms of PTSD, high dropout rates limit their impact. We examined the treatment paths of veterans assigned to individual TF-EBPs across two rounds of program evaluation in a VHA PTSD Outpatient Clinic: 67 veterans in Round 1 (2012-13) and 76 in Round 2 (2015-16). Clinic providers revised the intake process for veterans before collecting Round 2 data, including providing veterans with detailed outlines of treatment offerings, TF-EBP psychoeducation video links, and homework assignments to identify treatment preferences. Veterans then attended a follow-up intake session to further assess their motivation to begin treatment. TF-EBP completion rates significantly increased from 30% to 53 %, p =.03. TF-EBP dropout rates declined from 49% to 31% and Cognitive Processing Therapy completion rates increased from 47% to 61%, although these differences were not significant. In Round 2, veterans were offered Written Exposure Therapy, a 5 session TF-EBP for PTSD, with an 89% completion rate. Providing patients with additional resources about TF-EBP rationales prior to treatment may help increase treatment buy-in. Integrating research findings from clinical populations is critical in order to reduce treatment dropouts in naturalistic clinical settings.

Why Do some Dropout while others Complete? Describing the Diverging Experiences of Veterans Receiving Trauma-focused Therapy

Kehle-Forbes, Shannon, PhD1; Ackland, Princess, PhD, MPH2; Chard, Kathleen, PhD3; Foa, Edna, PhD4; Gerould, Heather, MS5; Lyon, Alexandra, BS5; Meis, Laura, PhD5; Orazem, Robert, PhD5; Polusny, Melissa, PhD6; Schnurr, Paula, PhD7; Spoont, Michele, PhD8; Zickmund, Susan, PhD9

1National Center for PTSD and Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
2Minneapolis VA Health Care System and University of Minnesota Medical School, Minneapolis, Minnesota, USA
3Cincinnati VA Medical Center, Cincinnati, Ohio, USA
4University of Pennsylvania, Philadelphia, Pennsylvania, USA
5Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
6Minneapolis VAHCS, Center for Chronic Disease Outcome Research, University of Minnesota Medical School, Minneapolis, Minnesota, USA
7National Center for PTSD, Executive Division, White River Junction, Vermont, USA
8National Center for PTSD, U.S. Department/Veterans Affairs, Minneapolis, Minnesota, USA
9Salt Lake City Veteran Affairs Medical Center, Salt Lake City, Utah, USA

About one-third of Veterans who initiate prolonged exposure (PE) and cognitive processing therapy (CPT) do not complete. Quantitative studies of dropout from PE and CPT have failed to identify consistent predictors, thereby limiting efforts to improve Veterans’ treatment engagement. To develop a rich understanding of factors associated with PE and CPT dropout, we conducted semi-structured interviews with a national sample of Veterans who completed (n = 60) and prematurely discontinued (n = 68) PE and CPT. Interviews explored the role of treatment response, experience with treatment elements, working alliance, beliefs about PTSD and treatment, social influences, and logistic barriers in Veterans’ level of treatment engagement. Preliminary thematic analyses suggest that differences in the strength of the working alliance; ability to cope with, and the perceived consequences of, increased distress; and internal motivation (e.g., grit) differentiate completers and dropouts. A sizable minority of Veterans believed they were still engaged in PE or CPT, although their providers considered them to be dropouts – highlighting how Veterans and providers develop different understandings of the same treatment episode. Treatment buy in, logistical factors, and treatment beliefs do not appear to be related to dropout. Implications for increasing treatment engagement will be discussed.

When Thoughts of Dropout Arise: Interventions Used in Cognitive Processing Therapy and Prolonged Exposure

Ackland, Princess, PhD, MPH1; Meis, Laura, PhD LP2; Orazem, Robert, PhD3; Gerould, Heather, MS3; Lyon, Alexandra, BS3; Kehle-Forbes, Shannon, PhD4

1Minneapolis VA Health Care System and University of Minnesota Medical School, Minneapolis, Minnesota, USA
2Minneapolis VA Health Care System and University of Minnesota, Minneapolis, Minnesota, USA
3Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
4National Center for PTSD and Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA

Veterans are vulnerable to PTSD yet ~1/3 who initiate Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) do not complete a full course, leading to potential healthcare and societal burden of untreated PTSD. Predictors of psychotherapy dropout are known, but provider and patient response to potential dropout and other CPT/PE engagement issues are less clear and have implications for efforts to increase completion rates. We sought to understand interventions employed by providers and patients following threats to engagement and differences between those who completed vs terminated early. We interviewed a national sample of 128 Veterans—68 dropouts (≤6 sessions) and 60 completers. Semi-structured interviews queried about thoughts of dropping out and attempts and decisions to stay in CPT/PE. Interviews were audio-recorded, professionally transcribed and analyzed using mixed inductive and deductive thematic analysis. Preliminary results suggest four themes—engagement ambivalence was not always disclosed to providers; Veterans made their own attempts to combat ambivalence (e.g., used self-talk to boost motivation); family and friends were cheerleaders and provided instrumental support; and frequency and type of Veteran-reported provider interventions differed for completers and dropouts. Potential impacts on CPT/PE training and clinical practice will be discussed.

A Comparison of Dropout from Evidence-Based PTSD Psychotherapy Across Three Treatment Modalities

Stayton, Laura, PhD; Dickstein, Benjamin, PhD; Chard, Kathleen, PhD
Cincinnati VA Medical Center, Cincinnati, Ohio, USA

Despite the demonstrated effectiveness of treatments such as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for reducing PTSD symptoms among veterans (Chard, Ricksecker, Healy, Karlin, & Resick, 2012; Eftekhari et al., 2013), premature treatment dropout remains an important barrier to symptom amelioration. In a systematic review, Goetter et al. (2015) reported an average dropout rate of 36% in younger Veterans participating in PTSD-focused treatment; however, findings across studies are inconsistent, likely due to differences in study methodology (Imel, Laska, Jakupcak, & Simpson, 2013). The current study aimed to better examine dropout rates in a VA PTSD specialty clinic. Data were collected from 785 veterans who participated in either CPT, PE, or Cognitive-Behavioral Conjoint Therapy (CBCT) for PTSD between 2013-2017. Treatments were delivered in outpatient, residential, and telehealth modalities. Results suggest that residential treatment resulted in the lowest rate of dropout across the three modalities. When comparing dropout among veterans receiving CPT, PE, and CBCT via outpatient and telehealth clinics, no significant differences emerged. Potential implications for clinical practice will be discussed.

Concurrent Session Three: Symposium

Thursday, November 8 | 3:00 PM to 4:15 PM

PTSD and Parenting in Veterans and Service Members, from Epidemiology to Treatment

Chair: Chard, Kathleen, PhD
Discussant: Monson, Candice, PhD, Cpsych

Over the past decade, research on the influence of PTSD on family functioning has burgeoned with U.S. military and veteran samples, with new evidence demonstrating that family support is important to PTSD treatment outcomes. Yet PTSD symptoms also appear to have an adverse impact on family functioning. New studies have sought to extend this work to understand how PTSD may influence and be influenced by the parent-child relationship. Attention to the needs of this vulnerable group of parent-child dyads is growing. This symposium brings together new findings answering some of the most important questions in this area: does parenting status increase risk for PTSD symptoms after trauma exposure, can evidence-based parenting intervention be combined with PTSD treatment to improve outcomes, and what are the barriers to addressing parenting within VA settings? Dr. Blankenship and colleagues will present findings from a longitudinal study of 2,426 service members exploring whether parenting status predicts PTSD symptoms after deployment and various mediators of this relationship. Next, Dr. Chard will present findings from a study examining whether Cognitive Behavioral Couples Therapy (CBCT) for PTSD compared to CBCT + parent management training results in improved couples satisfaction and child behaviors. Finally, Dr. Creech will present findings from a qualitative study of VA providers which sought to examine provider practices and beliefs regarding the provision of parent training at VA. Dr. Candice Monson will serve as the discussant, using her considerable expertise in the area of relationship functioning and PTSD to integrate findings and drive discussion.

Do Couple-Based Treatments for PTSD Improve the Lives of Children

Chard, Kathleen, PhD1; Gilman, Richard, PhD2

1Cincinnati VA Medical Center, Cincinnati, Ohio, USA
2University of Cincinnati, Cincinnati, Ohio, USA

The impact of combat-related PTSD on the veteran and his/her family is considerable. Although there is a national priority to involve the entire family system in the care of veterans, no studies to date have explored how targeting all aspects of a family system may improve the quality of family functioning (in addition to the expected alleviation of PTSD symptoms for the individual veteran).  In this study 34 veterans diagnosed with PTSD from the OEF/OIF campaigns and their partner were randomly assigned to one of two treatment groups: (1) cognitive-behavioral conjoint therapy that contains an embedded parent management training (PMT) module (CBCT-PMT), or (2) CBCT without the parent management training module (CBCT only). Results found that effect sizes were higher for CBCT-PMT than CBCT (only), in terms of PTSD symptom reduction, which were correlated with positive changes in both the partner relationship and positive changes in parent-child relationships (including reduced child problem behaviors). The magnitude of these between-group effect size differences were realized at 3-month post-treatment, further demonstrating the stability of benefits to veterans in the CBCT-PMT group, as well as their family members.

Parental Status and PTSD Among Active Duty Military Personnel

Blankenship, Abby, PhD1; Dondanville, Katherine, PsyD1; DeVoe, Ellen, PhD MSW2; Hale, Willie, PhD1; Straud, Casey, PsyD1; Jacoby, Vanessa, PhD3; Peterson, Alan, PhD1; Williamson, Douglas, PhD4

1University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
2Boston University School of Social Work, Boston, Massachusetts, USA
3University of Texas Health Science Center at San Antonio, Ft Hood, Texas, USA
4Duke University School of Medicine, Durham, North Carolina, USA

Nearly half of today’s service members are parents. Since 9-11, military families have experienced more deployments than previous generations. Research suggests that parental status may increase risk for PTSD. We examined associations between parental status and PTSD in a longitudinal epidemiological study of service members (N=2426) who deployed to OIF or OEF. A multicategorical mediation model was implemented to explore the relative effects of parenting status on PTSD and to determine whether anxiety and depression mediated this relationship. Parental status was coded as: non-parents (NP), custodial parents (CP), and non-custodial parents (NCP). We compared relative total and indirect effects for CP&NCP vs. NP and for CP vs. NCP. Results indicated that the total effect was significant for the CP&NCP vs NP comparison, with CP&NCP exhibiting higher PTSD severity; this relationship was significantly mediated by anxiety and depression, each mediating about a third of the total effect. The total effect was also significant for the CP vs NCP comparison, with NCP exhibiting higher PTSD severity; however, this relationship was not mediated by depression or anxiety. Suggestions for research examining parenting status in relation to service member behavioral health distress will be discussed. Implications for engaging/treating service member parents are considered. 

Addressing the Parenting Needs of Veterans: VA Provider Practices and Perspectives

Creech, Suzannah, PhD1; Brown, Elaine, MA1; Fenstermacher, Shelley, PhD2; Glynn, Shirley, PhD3; McCutcheon, Susan, EdD4

1VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
2VA Greater Los Angeles Healthcare System/VISN 22 MIRECC, Los Angeles, California, USA
3VA Office of Mental Health Services and VA Greater Los Angeles Heatlhcare System, Los Angeles, California, USA
4Veterans Health Administration, Washington, District of Columbia, USA

Calls to increase programming in the area of parent-child functioning for veterans with PTSD have been growing. This study examined VA provider practices and beliefs regarding the provision of parent training interventions. Although parent training is not currently widespread across VA, many clinicians and facilities have been engaged in this work. An understanding of the experiences of these providers is critical to the success of future intervention development and implementation. Qualitative interviews were conducted with 16 providers across the U.S. who have been involved in parent training efforts within VA. Interviews revealed three themes: 1) Potential benefits and content of parent training interventions. 2) Challenges in veteran engagement. 3) Considerations for implementation. The benefits and content theme encompassed provider responses regarding the need for parent training at VA in addition to specific content domains that should be covered. The challenges theme encompassed comments regarding challenges to recruitment including identifying target populations for parenting groups. Considerations for implementation included barriers, leadership support, justice involvement, and children’s mental health problems. Results highlight many consistent intervention content areas as well implementation barriers that must be considered in further program development.

Concurrent Session Four: Panel Presentation

Thursday, November 8 | 4:30 PM to 5:45 PM

"Basic Training for Treaters" and "Warrior Partnership": Teaching Military Culture to Enhance Treatment Alliance in the At-risk Veteran Population

Amen, Shelley, MD PhD1; Burek, Gregory, MD2; Harpaz-Rotem, Ilan, PhD1; Southwick, Steven, MD1

1National Center for PTSD Clinical Neurosciences Division/Yale University Dept. of Psychiatry, West Haven, Connecticut, USA
2Medical College of Wisconsin, Milwaukee, Wisconsin, USA

The 2017 Office of Mental Health and Suicide Prevention reports the suicide rate among US Veterans who use VA services increased 8.8% since 2001, while the rate in those who do not increased by 38.6%.  Of the 20 Veteran suicides daily, only 6 (30%) were users of VA services at time of death, leaving 70% who never began VA care, or importantly, disengaged from treatment.  In 2014, “Ready to Serve” showed a large gap in military cultural competence in community-based providers (Tanielian et al).  Cultural competence improves bidirectional interactions of patient and treater (Kleinman & Benson 2006), while feeling understood is a key factor of resilience in trauma-exposed populations (Pietrzak & Southwick 2011).  This panel, who are all military Veterans, will present 1) “Basic Training for Treaters” describing the unique military identity and vulnerabilities in this culture, 2) “Warrior Partnership” enhancing bidirectional communication of Veterans and treaters by sharing predeployment, deployment and homecoming experiences, and 3) how to circumnavigate and repair damage from psychological “landmines” in the treatment dyad.  We will discuss how methodologies focusing on a cultural formulation can strengthen the therapeutic alliance and resilience in this stoic population at high risk for PTSD, depression, substance abuse, moral injury and suicide following military service.

Concurrent Session Five: Panel Presentation

Friday, November 9 | 9:45 AM to 11:00 AM

Lessons from the Field: Conducting Culturally Competent Research with American Indians, US-Mexico Border Residents, and Veterans

Frankfurt, Sheila, PhD1; Yellow Horse Brave Heart, Maria, PhD2; Chase, Josephine, PhD3; Charak, Ruby, PhD4; Kudler, Harold, MD5

1VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
2University of New Mexico, Albuquerque, New Mexico, USA
3Oglala Lakota College, Kyle, South Dakota, USA
4The University of Texas Rio Grande Valley , Edinburg, Texas, USA
5USA Department of Veterans Affairs, Washington, District of Columbia, USA

At-risk and marginalized groups are at higher risk of trauma exposure and bear a disproportionate trauma-related mental health burden. At the same time, these vulnerable populations are often left out of research on the effects of trauma and intervention development. This panel will bring together clinical research experts to discuss how one conceptualizes, plans, and conducts research in vulnerable populations and develops policy based on that work. Panelists will dialogue with audience members about considerations including conducting research as a member of a marginalized group vs. gaining community members’ trust as an outsider, conceptualizing and assessing complex trauma-related phenomena including historical trauma, intergenerational trauma, and moral injury, and working with families. The development and motivation behind three research projects will anchor discussion of research methods: a completed intervention for historical trauma and unresolved grief among American Indians, an on-going quantitative study of intergenerational trauma in Latino/a families on the Texas/Mexico border, and an in-development mixed methods study of moral injury in U.S. Veterans. Led by mental health policy expert, the discussion will stimulate a unique conversation about the key challenges for conducting ethical, culturally competent, and bidirectional research with vulnerable populations.

Concurrent Session Five: Symposium

Friday, November 9 | 9:45 AM to 11:00 AM

Implications of Interpersonal Relationships for Functioning and Treatment among Military Veterans with PTSD

Chair: Sippel, Lauren, PhD
Discussant: Monson, Candice, PhD, Cpsych

Posttraumatic stress disorder (PTSD) is the most frequently diagnosed psychological disorder among military veterans seeking care at Veterans Administration (VA) medical centers (Ramsey et al., 2017). Among veterans, PTSD is associated with interpersonal problems including poor social connectedness (Wisco et al., 2014), relationship distress (Riggs et al., 1998), and elevated rates of aggression (Taft et al., 2011). Additionally, deterioration of social support predicts return to treatment after a first episode of care (Fontana & Rosenheck, 2010). Social support appears to be critical to trauma recovery, rendering the need for better understanding of the interpersonal problems associated with PTSD and how these problems can be remediated to improve functioning across life domains. This symposium assembles experts in the area of PTSD and interpersonal relationships to showcase investigations of interpersonal relationships as mediators of functioning, predictors of maladaptive behaviors and symptoms, and opportunities for improving treatment outcomes. We will discuss how findings from these studies can lead to development of practices and policies that are more sensitive to the interpersonal contexts in which veterans with PTSD recover.

Dr. Fredman and colleagues will present data demonstrating the mediating role of interpersonal relationship quality in the association between posttraumatic stress and academic dysfunction in student veterans. Dr. Watkins and Dr. Laws will present data from Iraq and Afghanistan US veterans and their partners which revealed that both one’s own and one’s partner’s PTSD symptoms were positively associated with greater psychological intimate partner aggression perpetration. Effects of partner PTSD symptoms on psychological aggression perpetration differed across gender and veteran status. Dr. Sippel and colleagues will present findings showing bidirectional and unique associations between specific PTSD symptom clusters and both structure and quality of social connection among veterans in residential treatment for PTSD. Finally, Dr. Thompson-Hollands and colleagues will present qualitative data collected from veterans who dropped out from, or had very poor engagement with, evidence-based treatments for PTSD. They will focus on veterans’ family members’ experiences of being a support person while the veteran went through treatment, with the goal of identifying themes associated with poor outcome. Dr. Candice Monson, a co-developer of Cognitive Behavioral Conjoint Therapy (Monson & Fredman, 2012), an evidence-based treatment for PTSD delivered in a dyadic format, will discuss how these presentations contribute to the overarching goal of utilizing interpersonal relationships to more effectively treat PTSD among veterans.

Interpersonal Relationship Quality Mediates the Association between Military-related Posttraumatic Stress and Academic Dysfunction among Student Veterans

Fredman, Steffany, PhD1; Marshall, Amy, PhD1; Le, Yunying, MS1; Aronson, Keith, PhD1; Perkins, Daniel, PhD2; Hayes, Jeffrey, PhD1

1Penn State University, University Park, Pennsylvania, USA
2Penn State University, State College, Pennsylvania, USA

Large numbers of veterans are enrolling in higher education. Many experience posttraumatic stress symptoms, and these symptoms are associated with academic dysfunction. However, little is known about the mechanism(s) through which posttraumatic stress increases risk for academic difficulties. This study investigated the indirect effect of posttraumatic stress on academic dysfunction through three indices of perceived interpersonal relationship quality (family distress, family support, and social network support) in a clinical sample of 2,120 student veterans. Participants were further divided into four groups based on relationship status and gender (partnered women, non-partnered women, partnered men, non-partnered men), and moderation by group was examined. For all groups, there were significant indirect effects of posttraumatic stress on academic dysfunction through greater family distress and lower social network support. The overall indirect effect of posttraumatic stress on academic dysfunction was strongest for partnered women and was attributable to a stronger path from family distress to academic dysfunction. Poor relationship quality may be a modifiable risk factor for academic dysfunction among student veterans experiencing posttraumatic stress. Interventions that enhance interpersonal functioning may enhance academic outcomes, particularly for partnered women.   

Exploring the Knowledge, Attitudes, and Experience of Significant Others During Veterans’ Evidence-based Treatment for PTSD

Thompson-Hollands, Johanna, PhD1; Burmeister, Lori, MA2; Rosen, Craig, PhD3; Erickson, Emily, MA4; O’Dougherty, Maureen, PhD5; Meis, Laura, PhD LP6

1VA Boston Health Care System/Boston University, Boston, Massachusetts, USA
2Phoenix VA Healthcare System, Phoenix, Arizona, USA
3VA Palo Alto Health Care System, National Center for PTSD/Stanford University, Menlo Park, California, USA
4No affiliation, Minneapolis, Minnesota, USA
5Metropolitan State University , Saint Paul, Minnesota, USA
6Minneapolis VA Health Care System and University of Minnesota, Minneapolis, Minnesota, USA

Veterans with PTSD drop out of or fail to fully engage with evidence-based treatment at high rates. Clinical Practice Guidelines for VA/DoD strongly recommend using manualized trauma-focused treatments, which are delivered individually to veterans and do not have a formal family component. Little is known about the experience of significant others while veterans undergo these treatments, despite the well-established impact of social support on the maintenance of PTSD symptoms. This study examines qualitative interviews with 21 “support persons” (SPs) of veterans with poor PTSD treatment adherence. Interviews explore multiple aspects of the SPs’ experience while their loved one was in treatment, including the SPs’ level of knowledge around treatment goals and activities, their attitudes toward approaching versus avoiding trauma cues, and their preferences around family inclusion in treatment. Interviews will be coded using the software program Nvivo to allow for analysis and assessment of inter-rater coding reliability. By targeting the SPs of veterans who struggled in treatment, we will identify themes relevant to veterans at high risk of poor outcome. A more comprehensive examination of families’ attitudes, knowledge, and involvement could help to identify ways to better capitalize on veterans’ extended social circle to improve treatment outcome.

Posttraumatic Stress Disorder and Psychological Partner Aggression among U.S. Men and Women Veterans who Served in Iraq and Afghanistan: A Dyadic Analysis

Watkins, Laura, PhD1; Laws, Holly, PhD2

1Emory University School of Medicine, Atlanta, Georgia, USA
2Yale University School of Medicine, New Haven, Connecticut, USA

Posttraumatic stress disorder (PTSD) symptoms have been repeatedly linked to intimate partner aggression (IPA) and previous research has suggested that this association may be stronger among veterans and men. However, few studies have examined veteran status and gender as moderators of the association between PTSD and psychological IPA, taking both partners’ perspectives into account (i.e., within a dyadic framework). The current study aimed to address this limitation by using dyadic multilevel modeling to examine the association between PTSD symptoms and psychological IPA perpetration among a sample of 159 veterans of the conflicts in Iraq and Afghanistan and their partners (N = 318 participants). Findings revealed that both one’s own and one’s partner’s PTSD symptoms were positively associated with greater psychological IPA. In addition, the effects of partner PTSD symptoms on psychological IPA perpetration differed across gender and veteran status. Results suggested that the association of partner PTSD and IPA perpetration may be stronger for male veterans than for female veterans. Findings from the current study are consistent with previous research showing associations between PTSD and IPA, and have clinical implications for treatment of PTSD and IPA among veterans of the conflicts in Iraq and Afghanistan.

Longitudinal Associations among PTSD Symptom Clusters and Social Connection among Military Veterans in Residential Treatment for PTSD

Sippel, Lauren, PhD1; Watkins, Laura, PhD2; Pietrzak, Robert, PhD MPH3; Hoff, Rani, PhD MPH4; Harpaz-Rotem, Ilan, PhD5

1National Center for PTSD Executive Division, Geisel School of Medicine at Dartmouth, White River Junction, Vermont, USA
2Emory University School of Medicine, Atlanta, Georgia, USA
3National Center for PTSD, West Haven, Connecticut, USA
4Northeast Program Evaluation Center / Evaluation Division, National Center for PTSD /Department of Psychiatry, Yale University School of Medicine, West Haven, Connecticut, USA
5National Center for PTSD Clinical Neurosciences Division/Yale University Dept. of Psychiatry, West Haven, Connecticut, USA

Knowing whether PTSD predicts poorer social connection over time (i.e., social erosion) and/or that poor social connection contributes to maintenance of PTSD (i.e., social causation) has implications for PTSD treatment and relapse prevention. Using data from 1,491 veterans engaged in residential treatment for PTSD at 35 VA facilities between 2012-2014, we examined a cross-lagged panel model including a five-factor model of PTSD symptoms and social connection (i.e., distress related to interpersonal conflict and the number of days of contact with supportive loved ones in the previous month) assessed at baseline and four months after discharge, adjusting for sociodemographic, clinical, and treatment characteristics. The strongest effect was more severe baseline dysphoric arousal symptoms (i.e., irritability/anger, poor concentration, and sleep problems) predicting more conflict-related distress at follow-up (B = 0.43). More conflict-related distress at baseline predicted PTSD symptom severity across all five clusters (B’s = 0.10 to 0.14, p’s all < .01). Results support both social causation and social selection models and suggest the greater importance of quality of social connection than frequency of contact. Engaging families in treatment and targeting dysphoric arousal symptoms in particular may improve relationships among veterans receiving residential treatment for PTSD.

Concurrent Session Six: Symposium

Friday, November 9 | 11:15 AM to 12:30 PM

The Flexible Delivery of Cognitive Behavioral Couple Therapy for Posttraumatic Stress Disorder to Overcome Barriers to Care

Chair: Macdonald, Alexandra, PhD
Discussant: Schnurr, Paula, PhD

There are well-documented associations between posttraumatic stress disorder (PTSD) and intimate relationship problems (Lambert et al., 2012; Taft et al., 2011). Cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD; Monson & Fredman, 2012) was developed to treat PTSD and associated relationship difficulties, and there is evidence that the treatment is efficacious in improving both PTSD symptoms and relationship adjustment (Monson et al., 2012). However, the current format of 15 weekly 75-minute sessions delivered over several months poses challenges for treatment engagement and retention. This symposium will include presentations on the evidence for three novel adaptations to CBCT for PTSD designed to promote engagement and retention in both military/veteran and civilian populations. Dr. Leslie Morland will begin by presenting data and information from the pilot phase of a trial of an eight-session version CBCT for PTSD delivered either in-office or via in-home video teleconferencing among a sample of veterans with PTSD. Next, Dr. Steffany Fredman will present data on the initial efficacy of an intensive retreat version of CBCT for PTSD delivered over a single weekend in a multi-dyad format for couples that include a service member or veteran diagnosed with PTSD.  Finally, Dr. Anne Wagner will present results from a pilot study that includes multiple innovations through its use of methylenedioxymethamphetamine (MDMA) administered in conjunction with CBCT for PTSD delivered through a combination of intensive in-person and telehealth sessions. Finally, our discussant, Dr. Paula Schnurr, a world-renowned PTSD clinical trialist, will offer remarks related to the delivery of conjoint interventions for PTSD and their adaptations in healthcare systems and discuss future directions for this work.

This symposium is closely aligned with the goals of this year’s conference. We investigate the public health issues regarding access to mental health, especially among subpopulations at increased risk for PTSD (e.g., veterans and active duty service members). We examine adaptations that include significant innovations, from accelerated delivery (Morland, Fredman, Wagner), to the use of technology (Morland, Wagner), to the inclusion of pharmacological agents medications to enhance the efficacy of existing interventions (Wagner). These represent important advances in the delivery of conjoint interventions for PTSD, as each of these new modalities has the potential to increase access and retention in care.

An Initial Efficacy Study of Cognitive-behavioral Conjoint Therapy for PTSD Delivered in an Intensive Weekend Format for Military and Veteran Couples

Fredman, Steffany, PhD1; Macdonald, Alexandra, PhD2; Monson, Candice, PhD, Cpsych3; Rhoades, Galena, PhD4; Dondanville, Katherine, PsyD5

1Penn State University, University Park, Pennsylvania, USA
2The Citadel, Military College of South Carolina, Charleston, South Carolina, USA
3Ryerson University, Department of Psychology, Toronto, Ontario, Canada
4University of Denver, Denver, Colorado, USA
5University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving both PTSD symptoms and relationship adjustment among couples with PTSD. However, it is challenging for many active duty and Veteran couples to attend all 15 weekly sessions; thus, newer, more efficient delivery formats are needed to maximize engagement and retention. This initial efficacy study investigated an intensive version of CBCT for PTSD delivered over a single weekend in a multi-dyad format for 24 couples that included a Service Member or Veteran diagnosed with PTSD via clinician interview. All couples completed treatment. Assessments conducted one and three months after the intervention revealed significant moderate-to-large or large effect size reductions in clinician-rated PTSD symptoms (ds 0.79 and 1.06, respectively) and in self-reported symptoms of PTSD (ds 0.94 and 1.30, respectively), depression (ds 0.74 and 0.76, respectively), and anxiety (ds 0.83 and 0.82, respectively). Moderate and significant improvements were also observed for partners’ relationship satisfaction three months after treatment (d = 0.62). Delivering CBCT for PTSD through an intensive weekend, multi-group format may be an efficacious and efficient strategy for improving PTSD, comorbid symptoms, and relationship adjustment in military and Veteran couples.

Abbreviated Cognitive Behavioral Couples Therapy into the Home: A Scalable Model for Couples with PTSD

Morland, Leslie, PsyD1; Grubbs, Kathleen, PhD2; Macdonald, Alexandra, PhD3; Monson, Candice, PhD, Cpsych4; Buzzella, Brian, PhD5; Wrape, Elizabeth, PhD5; Wickramasinghe, Induni, BA6; Wells, Stephanie, MS, PhD Student7; Mackintosh, Margaret-Anne, PhD8

1National Center for PTSD, San Diego, California, USA
2San Diego VA/University of San Diego, San Diego, California, USA
3The Citadel, Military College of South Carolina, Charleston, South Carolina, USA
4Ryerson University, Department of Psychology, Toronto, Ontario, Canada
5Veterans Affairs San Diego Healthcare System; Department of Psychiatry, UCSD, San Diego, California, USA
6Veterans Medical Research Foundation, La Jolla, California, USA
7UCSD/SDSU Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
8National Center for PTSD – Dissemination and Training Division, VA Palo Alto Health Care System, Menlo Park, California, USA

Cognitive-Behavioral Conjoint Therapy (CBCT) is a manualized treatment designed to simultaneously reduce posttraumatic stress disorder (PTSD) symptoms and enhance relationship functioning for couples. Evidence exists for the efficacy of CBCT among civilian populations; however, a randomized clinical trial of the efficacy of CBCT for veteran couples is needed to inform implementation across the VA. This presentation will discuss a large RCT underway to evaluate the efficacy and scalability of an abbreviated 8-session CBCT protocol in a veteran population and explore home-based telehealth [HBT] to increase ease and acceptability of family-based care in the VA. Preliminary data on 53 randomized couples will be presented including treatment drop-out data. A pilot phase (n=10) tested the feasibility of recruitment, safety, engagement, retention, and technology. Lessons learned thus far, include (1) developing a protocol for safety and intimate partner violence (IPV) when the couple is in the home and the provider is in the clinic, (2) creating afterhours sessions to accommodate couples’ schedules (3) creating solutions for technological difficulties during home-based sessions, and (4) modifying treatment length to optimize completion, outcomes, and scalability. Forty-nine percent of veterans preferred a HBT modality to receive care and many requested after hours care.

Cognitive-behavioral Conjoint Therapy (CBCT) for PTSD with MDMA: Primary Outcomes from a Pilot Trial

Wagner, Anne, PhD, Cpsych1; Monson, Candice, PhD, Cpsych2; Mithoefer, Ann, BSN3; Mithoefer, Michael, MD3

1Ryerson University, Toronto, Ontario, Canada
2Ryerson University, Department of Psychology, Toronto, Ontario, Canada
3Private Practice, Mount Pleasant, South Carolina, USA

Both CBCT for PTSD (Monson & Fredman, 2012) and MDMA-assisted psychotherapy for PTSD with a non-directive, supportive treatment model (Mithoefer et al., 2011) have demonstrated efficacy in treating PTSD, and CBCT has demonstrated efficacy in enhancing intimate relationship satisfaction. The current study combined CBCT with MDMA delivered to both members of the dyad. The protocol was delivered over two months, with intensive, in-person MDMA-facilitated sessions and with non-MDMA sessions delivered over a video platform to potentially enhance treatment outcomes and barriers to treatment. Results from six couples demonstrate statistically significant and large pre-post effect size improvements in clinician-rated PTSD symptoms (d=1.95), self-reported PTSD symptoms (d=2.13), partner-reported PTSD symptoms (d=1.51), self-reported relationship satisfaction (d=1.96), and partner-reported relationship satisfaction (d=0.97). These pilot results indicate that this combination therapy is safe (no serious adverse events), acceptable (with no participant drop-out through treatment), and feasible with condensed delivery and with video sessions between intensive, in-person MDMA-facilitated sessions. This combination intervention may provide a strong intensive treatment option for dyads, and future directions include testing the intervention with a larger sample and compared to CBCT alone.

Concurrent Session Seven: Symposium

Friday, November 9 | 3:00 PM to 04:15 PM

What If We Don't Talk About Trauma? Evidence-based Alternatives to Trauma-focused Psychotherapy

Chair: Rosen, Craig, PhD;
Discussant: Schnurr, Paula, PhD

Numerous studies confirm the effectiveness of several trauma-focused psychotherapies for treating PTSD. Yet, many patients are unwilling to engage in psychotherapies that involve recounting trauma memories or reexamining beliefs about traumatic events.  This symposium will review the clinical rationales and research evidence for three psychotherapies for PTSD that do not entail discussion of traumatic events. Tracie Shea will provide an overview of Present Centered Therapy (PCT). Brad Belsher will discuss a meta-analysis of studies involving PCT.   Janice Krupnick will present research on Interpersonal Therapy (IPT) for PTSD.  Marylene Cloitre will share findings on Skills Training in Affective and Interpersonal Regulation (STAIR).

Present Centered Therapy for PTSD: Origins, Theoretical Basis, and Key Components

Shea, M., PhD
VA Medical Center, Providence, Rhode Island, USA

Individual and group formats of Present Centered Therapy (PCT) were developed as comparison conditions to control for non-specific therapeutic factors in research on trauma focused treatments for PTSD in Veteran (Schnurr et al., 2003; Schnurr et al., 2007) and non-Veteran samples (McDonough et al., 2005; Classen et al., 2011).  The strategies and interventions of PCT were designed to enhance basic therapeutic factors consistent with the idea of “common factors” that characterize all psychotherapy.  PCT has now been used in numerous studies examining effectiveness of a range of treatments for PTSD.  Although developed as a control, PCT has been included as an empirically supported treatment for PTSD by Division 12 of the American Psychological Association, and more recently, by the VA/DOD Clinical Practice Guidelines for use when trauma focused therapy is not available or not preferred. These recommendations were based on a growing number of trials finding that PCT differed only modestly or sometimes not at all from active treatments under investigation. This presentation will describe the development, rationale, and key components of the individual and group versions of PCT, and discuss implications of PCT findings for research and practice.

Present Centered Therapy for Posttraumatic Stress Disorder in Adults: A Systematic Review of the Evidence

Belsher, Bradley, PhD1; Beech, Erin, MA1; Evatt, Daniel, PhD1; Otto, Jean, PhD1; Rosen, Craig, PhD2; Schnurr, Paula, PhD3

1Department of Defense, Silver Spring, Maryland, USA
2VA Palo Alto Health Care System, National Center for PTSD/Stanford University, Menlo Park, California, USA
3National Center for PTSD, Executive Division, White River Junction, Vermont, USA

Present centered therapy (PCT) for PTSD was developed as a comparator treatment to test whether trauma-focused psychotherapies (TFPs) demonstrated effects beyond common psychotherapeutic benefits in clinical trials.  Several TFPs are now recommended as front-line treatments in clinical practice guidelines. However, a growing body of literature suggests that PCT demonstrates comparable efficacy to that of evidence-based TFPs. Notably, a concern about TFPs are that patients may be unwilling to engage in these treatment or dropout prematurely. PCT may be associated with greater treatment retention relative to TFPs. The aims of this systematic review were to determine whether PCT (1) is more effective in alleviating PTSD symptoms relative to control conditions; (2) is equally effective in alleviating PTSD symptoms relative to TFP based on a priori thresholds; and (3) is associated with greater patient retention and fewer adverse events. A comprehensive search strategy was conducted to retrieve eligible articles and independent review authors assessed risk of bias of included studies. Data will be synthesized and, if appropriate, summary effect estimates will be calculated and compared. The quality of evidence will be assessed using GRADE. Results from this systematic review on the comparative effectiveness of PCT for PTSD will be presented.

Interpersonal Psychotherapy for PTSD (IPT-PTSD) for Veterans

Krupnick, Janice, PhD
Georgetown University School of Medicine, Washington, District of Columbia, USA

While cognitive-behavioral interventions, primarily Prolonged Exposure Therapy and Cognitive-Processing Therapy, have been disseminated as the treatments of choice for Veterans with PTSD, some Veterans do not wish to directly confront the military trauma that gave rise to their PTSD.  Recent research suggests that Interpersonal Psychotherapy (IPT) for PTSD may provide an alternative to these methods for Veterans who either do not choose a trauma-focused approach or for whom these approaches may be inappropriate.  Following a pilot study of women Veterans with PTSD who were successfully treated with individual IPT for PTSD, we are conducting a large-scale, two-site, randomized controlled comparison trial of IPT for PTSD in male and female Veterans with Exposure Therapy (as conducted in VA settings).  This presentation will discuss the ways that IPT was modified for PTSD in Veterans and will discuss the rationale for this type of intervention with this population. 

STAIR as a Stand-alone Treatment: Results from a Randomized Controlled Trial

Cloitre, Marylene, PhD1; Gimeno, Julia, BA2; Ortigo, Kile, PhD3; Weiss, Brandon, PhD4; Jain, Shaili, MD5

1National Center for PTSD-Dissemination and Training Division, Menlo Park, California, USA
2National Center for PTSD (334-PTSD), Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
3National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA
4National Center for PTSD, VA Palo Alto Health Care System/Stanford University School of Medicine, Menlo Park, California, USA
5VA Palo Alto Health Care System, National Center for PTSD/Stanford University, Menlo Park, California, USA

Skills Training in Affective and Interpersonal Regulation (STAIR) combined with exposure therapy has been found to be an effective treatment for PTSD and related symptoms in three randomized controlled trials (RCT). This presentation will report on the benefits of using STAIR as a stand-alone treatment. Results from an RCT comparing a 5-session version of STAIR compared to treatment as Usual (TAU) in primary care in a VA setting will be reported. Preliminary results indicate significant improvement in PTSD symptoms, depression, and problems in emotion regulation and social engagement as compared to TAU, with effect sizes ranging from 1.86 to .87, depending on the outcome. Archival data comparing STAIR to Present Centered Therapy (PCT) will assess differences in symptom change and in potential mediators of these two “non-trauma-focused” treatments. The rationale and design for a recently funded study comparing STAIR to PCT will be presented.  The value of non-trauma focused treatments in regards to increasing patient engagement, reducing dropouts and mechanisms of change will be explored.

Concurrent Session Eight: Panel Presentation

Friday, November 9 | 4:30 PM to 05:45 PM

Military Psychologists and Neuroscientists in Conversation: Conceptualizing the Core Affective Processes of Combat Trauma

Frankfurt, Sheila, PhD1; Carr, Russell, MD2; Freed, Steven, MA PhD Student3; McKinnon, Margaret, PhD4; Nash, William, MD5; McGuire, Adam, PhD1

1VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
2Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
3New School for Social Research, New York, New York, USA
4McMaster University, Hamilton, Ontario, Canada
5Marine Corps, Arlington, Virginia, USA

Military clinicians have long recognized and treated the underlying distressing affective reactions to fighting in war and combat trauma—in particular the complex guilt, shame, rage, and existential and identity crises that arise from one’s actions or inactions that challenge deeply held notions of right and wrong. This aspect of combat trauma has been articulated in the moral injury construct, but the extent to which moral injury differs from combat-related PTSD is unknown given the dearth of empirical and theoretical work in the area. Given the need to identify transdiagnostic underlying processes of psychopathology, a dialogue on the phenomenology and underlying mechanisms of combat trauma, PTSD, and moral injury can provide creative, interdisciplinary perspectives on conceptualizing and treating Veterans’ psychological war wounds. This panel brings together leading clinicians, theoreticians, and researchers to provide brief presentations on (1) conceptualizing and treating combat-related shame, guilt, rage, PTSD, and moral injury; and (2) the neurophysiology of shame, deep identity disturbance, and affect regulation. Presentations will be followed by open exchange among panelists and audience members to stimulate a unique conversation about conceptualizing and treating combat trauma that crosses interdisciplinary lines. 

Concurrent Session Nine: Panel Presentation

Saturday, November 10 | 9:45 AM to 11:00 AM

Integrating Research, Clinical Experience and Public Policy at the Grassroots of Trauma Response

Kudler, Harold, MD1; Van Dahlen, Barbara, PhD2; Phelps, Randy, PhD3; Kobrin, Nancy, PhD4; Somers, Howard, MD5; Somers, Jean, MD5

1USA Department of Veterans Affairs, Washington, District of Columbia, USA
2Give an Hour (non profit), Bethesda, Maryland, USA
3Give an Hour & American Psychological Association, Washington, District of Columbia, USA
4La Universidad de Granada, Tel Aviv, Tel Aviv, Israel
5Operation Engage America, Coronado , California, USA

ISTSS members frequently collaborate with governments and institutions to develop effective, evidence-based responses to traumatic events at local, national and international levels but less attention has been paid to developing grassroots responses to psychological trauma. This is important because it has long been known that culturally appropriate community responses are critical components of effective population health efforts (Ottenberg, Donald J., 1987). Survivors, their families and community members usually outnumber response workers by a significant margin such that there is a clear need to partner with them. Research and practical experience indicate that, to promote resilience and recovery, it is essential to engage and support the efforts of the survivors individually and as a community in order to reinforce their sense of competence and effectiveness (Gist et al., 1998). This session will focus on a wide range of national and international grassroots responses to traumatic stress including: prevention by increasing basic mental health literacy across entire populations; defining and intervening in social processes which may increase the risk of both persecution and violence/terrorism, and; efforts to enhance the homecoming of Veterans in order to support them and their families in the aftermath of war.


Concurrent Session Ten: Symposium

Saturday, November 10 | 11:15 AM to 12:30 PM

Treating the Mind and the Body: The Benefits of Physical Activity Interventions for PTSD

Chair: Walter, Kristen, PhD;
Discussant: Lang, Ariel, PhD MPH

Although evidence-based psychotherapies and pharmacotherapies exist for the treatment of posttraumatic stress disorder (PTSD), individuals may not have access to, benefit from, or wish to seek these interventions. Complementary and alternative medicine approaches, such as physical activity, may be effective in treating PTSD and related symptoms. Physical activity (as either a primary or adjunctive intervention) not only has wide-reaching effects, but is readily accessible. This symposium will address outcomes and considerations for physical activity interventions among various samples with PTSD. The first presentation will provide a foundation by highlighting findings and implications from a systematic review of mind-body treatments for PTSD. The following presentation investigates physical activity, cardiorespiratory fitness, and sedentary behavior among individuals with PTSD in an inpatient setting. Next, data from a randomized controlled trial evaluating whether the efficacy of imaginal exposure can be enhanced by adding an aerobic exercise component among active duty service members will be featured. The symposium will conclude with outcome data from active duty service members with probable PTSD in a surf therapy program. Collectively, these presentations emphasize the influence of physical activity interventions on PTSD and related symptoms, as well as the broad contexts in which they can be implemented.

Cardiorespiratory Fitness, Sedentary Behavior And Physical Activity In Inpatients With PTSD

Chen, Andrew, BSc1; Rosenbaum, Simon, PhD2; Wells, Ruth, BSc Hons Psychology3; Gould, Kirrily, MSc1; Ward, Philip, PhD1; Steel, Zachary, PhD4

1University of New South Wales, Sydney, New South Wales, Australia
2University of New South Wales, Kensington, NSW, Australia
3University of Sydney, Camperdown , NSW, Australia
4University of New South Wales, Randwick, NSW, Australia, Australia

PTSD is associated with physical comorbidity and premature mortality. Sedentary behavior and low cardiorespiratory fitness (CRF) are modifiable risk factors for poor physical and mental health. Understanding the complex bidirectional relationships between PTSD symptoms and physical activity (PA) is of high clinical importance. This cross-sectional study aimed to investigate the relationship between exercise related factors and PTSD symptoms in inpatients with a primary DSM-V diagnosis of PTSD (St. John of God Hospital, Australia). Participants taking beta-blockers or with comorbid substance abuse were excluded. 60 participants (46.9±11.9 years, 94% male) completed questionnaires assessing PA, PTSD symptomatology and completed a submaximal test of CRF (Astrand-Rhyming protocol). Spearman’s Rho correlation coefficients were calculated. 80% had below average age adjusted CRF levels. Mean PCL-C scores were high (63.2±13.7). Only 30% achieved public health recommendations of 150 mins of exercise/week. Participants spent an average of 8.1 hours/day sedentary, and a significant correlation between sedentary time and PTSD symptoms was found (r=0.43, p=0.001). Inpatients with PTSD have poor CRF, engage in high levels of sedentary behavior and low-levels of exercise. Reducing sedentary behavior may be an important target for improving both physical and psychological outcomes.

The Role of Exercise in the Treatment of PTSD

Young-McCaughan, Stacey, PhD1; Peterson, Alan, PhD1; Mintz, Jim, PhD1; Hale, Willie, PhD1; Borah, Elisa, PhD2; Dondanville, Katherine, PsyD1; Borah, Adam, MD3; Yarvis, Jeffrey, PhD4; Litz, Brett, PhD5; Hembree, Elizabeth, PhD6

1University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
2University of Texas at Austin, Austin, Texas, USA
3Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
4U.S. Army, Fort Hood, Texas, USA
5Boston University, Boston , Massachusetts, USA
6University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Purpose: Explore the role of exercise in the treatment of symptoms of PTSD, determining if the efficacy of imaginal therapy could be improved by augmenting the therapy with aerobic exercise.

Design: Experimental, repeated-measures.

Methods: Active duty service members with symptoms of posttraumatic stress (PTSD CheckList–Stressor-specific ≥25) were randomized into one of four groups: 1) aerobic exercise-only, 2) imaginal exercises of exposure therapy-only, 3) imaginal therapy augmented with aerobic exercise, or 4) nurse-led self-care intervention.

Sample: 72 men and women were randomized into the study. Participants were primarily male, Army, non-commissioned officers ranging in age from 22 to 52 seeking treatment for PTSD.

Analysis: Intent-to-treat 2 x 2 factorial design with repeated measures at post-treatment.

Findings: A 3-way statistical analyses of time (pre- to post-treatment), group (aerobic exercise or not), and group (imaginal therapy or not) was not significant; however comparing baseline to post-treatment self-reported symptoms of posttraumatic stress, there was a main effect of time indicating that regardless of the treatment group, symptoms of posttraumatic stress decreased significantly from baseline to post-treatment (p<.001). Post-hoc testing showed that every group except self-care had significant pre- to post-treatment reductions in symptoms.

Breaking the Surface: Psychological Outcomes of Adjunctive Surf Therapy among Service Members with Probable PTSD

Walter, Kristen, PhD1; Otis, Nicholas, BS, BA1; Ray, Travis, BA2; Alexandra, Powell, BA/BS1; Glassman, Lisa, PhD3; Michalewicz-Kragh, Betty, MS4; Thomsen, Cynthia, PhD1

1Naval Health Research Center, San Diego, California, USA
2Oakland University, Rochester, Michigan, USA
3San Diego VA/University of San Diego, San Diego, California, USA
4Naval Medical Center San Diego, San Diego, California, USA

Objective: Various treatments options are available for the many active duty service members who suffer from posttraumatic stress disorder (PTSD). These can include complementary and alternative medicine approaches, such as physical activity. Surf therapy—a water-based, physical activity occurring in a natural setting—may provide beneficial effects to those suffering from PTSD; however, few studies of surf therapy exist. Methods: The current study evaluated intervention outcomes of 40 active duty service members with probable PTSD who participated in a surf therapy program at a military treatment facility. Psychological symptoms were assessed before and after the program, as well as before and after each surf therapy session. Results: Multilevel modeling results demonstrated improvements in self-reported PTSD (β= -14.56, p<.001), depression (β= -2.65, p<.05), anxiety (β= -3.62, p<.01), positive affect (β= 10.73, p<.001), and negative affect (β= -9.33, p<.001) from pre- to post-program. Similarly, immediate improvements from pre- to post-session were found in self-reported depression/anxiety (β= -3.97, p<.001) and positive affect (β= 9.69, p<.001). Conclusions: Results suggest that for service members with PTSD, surf therapy provides both immediate benefits on symptoms and mood, as well as longer-term benefits on psychological symptoms as an adjunctive treatment.

Complementary and Integrative Interventions for PTSD: What is the Evidence Base and how can we Improve It?

Niles, Barbara, PhD1; Weinstein, Elizabeth, BA2; Mori, DeAnna, PhD3; Pless Kaiser, Anica, PhD1
1VA Boston Healthcare System, National Center for PTSD, and Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
2VA Boston Healthcare System, National Center for PTSD, Boston, Massachusetts, USA
3VA Boston Healthcare System & Boston University School of Medicine, Boston, Massachusetts, USA

Complementary and Integrative (CI) interventions for PTSD have been widely utilized in recent years as potential alternatives or supplements to evidence-based psychotherapies. However empirical support has lagged behind the clinical use and it is unclear which, if any, of these interventions are empirically supported. This presentation will report the results of a systematic review of the extant evidence of mind-body treatments for PTSD. A search of the literature identified 22 randomized controlled trials that met inclusion standards. The majority of 9 mindfulness and 6 yoga studies offer empirical support for advantages of these treatments, with moderate to large effect sizes. In all 7 trials of relaxation, it was used as a control treatment. Relaxation may be a viable treatment for PTSD as large within-group symptom improvements were found. This talk will synthesize results from this systematic review and provide the backdrop for the subsequent presentations of novel interventions to address PTSD. Recommendations for improving study design in future CI trials will be offered.  High quality studies are needed to improve the empirical base for these treatments in order to guide policy regarding treatment offerings.

Concurrent Session Eleven: Symposium

Saturday, November 10 | 2:00 PM to 03:15 PM

Longitudinal Course of Mental Health Symptoms among Post 9/11 Military Personnel and Veterans

Chair: Lee, Daniel, MS;
Discussant: Keane, Terence, PhD

Over two and a half million service members have deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). As with previous conflicts, posttraumatic stress disorder (PTSD), comorbid disorders, and associated functional impairment have emerged as major health concerns among OEF/OIF veterans (e.g., Milliken, Auchterlonie, & Hoge, 2007). Despite substantial research effort for several decades, longitudinal trajectories of mental health symptoms among the active duty and veteran populations are not well understood. Two general themes that have emerged from such work are that 1) mental health symptom trajectories are characterized by remarkable heterogeneity among individuals exposed to similar traumas (Bonanno et al., 2012; deRoon-Cassini, Mancini, Rusch, & Bonanno, 2010; Dickstein, Suvak, Litz, & Adler, 2010; Steenkamp, Dickstein, Saltersā€Pedneault, Hofmann, & Litz, 2012), and 2) symptoms tend to be chronic for many, lasting decades for some (Marmar, Schlenger, Henn-Haase, & et al., 2015; Solomon, Horesh, Ein-Dor, & Ohry, 2012; Zahava Solomon  & Mario Mikulincer 2006). Improved understanding of the course of symptom onset and remission is particularly important for OEF/OIF veterans as such findings could help ensure appropriate healthcare resource allocation and inform long-term healthcare policy and planning.

This symposium will present results from four studies examining longitudinal course of PTSD and related mental health symptoms among current and former military service members. In the first presentation, Mr. Fink will present results of a study examining the risk for later developing threshold PTSD among those with subthreshold PTSD among a large sample of US National Guard members. Next, Dr. Meyer will present results of a study examining modifiable psychosocial factors that mediate the relationship between PTSD and depression symptoms and functional disability over a one year period among veterans. Third, Dr. Lee will present results of a study examining longitudinal trajectories of PTSD symptoms among participants in the Veterans After-Discharge Longitudinal Registry (Project VALOR); a large, nationally dispersed sample of OEF/OIF veterans. Finally, Dr. Vasterling will present results from a study examining PTSD symptom trajectories among the VA-DoD Neurocognition Deployment Health Study/VA Cooperative Study #566; a large sample of nationally dispersed active duty soldiers, reservists, and military veterans. Dr. Terrence Keane will serve as discussant. 

Longitudinal Posttraumatic Stress Disorder Symptom Trajectories among Operation Enduring Freedom and Operation Iraqi Freedom Veterans

Lee, Daniel, MS1; Lee, Lewina, PhD2; Bovin, Michelle, PhD3; Moshier, Samantha, PhD4; Dutra, Sunny, PhD Student1; Kleiman, Sarah, PhD5; Rosen, Raymond, PhD6; Keane, Terence, PhD3; Marx, Brian, PhD7

1National Center for PTSD, Boston VA Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
2Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts, USA
3National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA
4VA - National Center for PTSD, Boston, Massachusetts, USA
5Boston VA Medical Center, Jamaica Plain, Massachusetts, USA
6New England Research Institutes, Inc., Watertown, Massachusetts, USA
7National Center for PTSD, VA Boston Healthcare System and Boston University, Boston, Massachusetts, USA

Longitudinal course of posttraumatic stress disorder (PTSD) symptoms is not well understood. Improved understanding of symptom onset and remission is particularly important to ensuring appropriate healthcare resource allocation for Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans. This study aimed to identify PTSD symptom trajectories among a nationwide cohort of OEF/OIF veterans enrolled in VA care. Participants (N = 1,649) were assessed on four occasions over the course of approximately 4.5 years as part of the Veterans After-Discharge Longitudinal Registry (Project VALOR). Participants with and without probable PTSD were sampled at a 3:1 ratio; male and female veterans were sampled at a 1:1 ratio. PTSD symptoms were assessed using the PTSD Checklist. Growth mixture modeling suggested five distinct symptom trajectories: asymptomatic (2.30%), mild (8.85%), subthreshold (21.42%), threshold (17.50%), and severe (49.94%). Symptom severity was generally stable over time in all groups. This study presents one of the largest prospective studies of mental health symptoms among OEF/OIF veterans to date. Results indicate that PTSD symptoms experienced by veterans deployed in support of OEF/OIF may be relatively stable within individuals but also reflect a spectrum of symptom severity between individuals. Predictors of symptom trajectories will be presented. 

Prospective Predictors of Post-deployment Functioning in War Veterans: A Mediational Model of the Effect of Psychological Inflexibility

Meyer, Eric, PhD1; Kimbrel, Nathan, PhD2; DeBeer, Bryann, PhD1; Kittel, Julie, MA3; Gulliver, Suzy, PhD4; Morissette, Sandra, PhD5

1VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, Texas, USA
2Department of Veterans Affairs Medical Center, Veterans Integrated Service Network (VISN) 6 Mental Illness Research, Education and Clinical Center (MIRECC), Durham, North Carolina, USA
3University of Rochester, Rochester, New York, USA
4Texas A&M Health Science Center, Waco, Texas, USA
5University of Texas at San Antonio, San Antonio, Texas, USA

Understanding the process by which warzone exposures and clinical sequalae lead to functional disability is crucial for assisting veterans in their recovery. We examined the influence of psychological inflexibility over time in 309 war veterans (32% female). While challenging to define, one influential model defines psychological inflexibility as rigid dominance of psychological reactions to unwanted internal experiences over personal values in guiding behavioral choices. In this model, we examined which demographic factors and warzone and other exposure variables measured at baseline (age, gender, race, years of education, traumatic brain injury, neuropsychological functioning, lifetime trauma history, pain severity) predicted PTSD/depression symptoms and alcohol consumption 4 months later and whether psychological inflexibility at 8-months mediated the relationships between 4-month PTSD/depression and alcohol consumption and 12-month functional disability. In the final, best fitting, trimmed model, several variables (gender, neuropsychological functioning, combat trauma, pain severity) predicted PTSD/depression and psychological inflexibility partially mediated the effect of PTSD/depression on functional disability (p < .001). Psychological inflexibility is a potential mechanism through which PTSD-depression leads to functional disability in war veterans.

Proportion of Subsequent Psychopathology Conferred by Subthreshold PTSD in a Military Cohort

Fink, David, PhD Student1; Gradus, Jaimie, ScD2; Keyes, Katherine, PhD3; Calabrese, Joseph, MD4; Liberzon, Israel, MD5; Tamburrino, Marijo, MD6; Cohen, Gregory, MSW7; Sampson, Laura, PhD Candidate7; Galea, Sandro, MD, DrPH8

1Columbia University, Mailman School of Public Health, New York , New York, USA
2National Center for PTSD, Boston VA Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
3Columbia University, New York, New York, USA
4Case Western Reserve University, Cleveland, Ohio, USA
5University of Michigan, Ann Arbor, Michigan, USA
6University of Toledo, Toledo, Ohio, USA
7Boston University School of Public Health, Boston, Massachusetts, USA
8Boston University, Boston, Massachusetts, USA

This study identified the relative proportion of later PTSD that can be attributed to earlier subthreshold PTSD compared to earlier diagnosable PTSD. Using the PCL, we classified 3,457 US National Guard members from the state of Ohio into one of three groups: PTSD, subthreshold PTSD (Criteria A, at least one symptom from each cluster), and no PTSD. At each wave from 2008 to 2014, we calculated the exposure rate, risk ratio (RR), and population attributable fraction (PAF) for diagnosable PTSD among participants in each of the three groups. Subthreshold PTSD was twice as prevalent as diagnosable PTSD (11.9% vs. 5.0%), persons with PTSD the previous year had twice the RR for PTSD at follow-up than those with subthreshold PTSD (7.0 vs. 3.4), and the PAF of subsequent PTSD was considerably greater among persons exhibiting subthreshold PTSD compared to chronic PTSD (35% vs. 28%). Results were robust to changes in subthreshold PTSD definition. Subthreshold PTSD accounts for a substantial proportion of future PTSD burden. A focus on interventions that shift the whole distribution of PTSD symptoms, compared to a high-risk approach, is likely to affect the greatest reduction in the burden of PTSD within military populations.

Predicting Long-term PTSD Symptom Trajectories in Iraq-deployed Soldiers: A Prospective Study

Vasterling, Jennifer, PhD1; Aslan, Mihaela, PhD2; Lee, Lewina, PhD3; Ko, John, BS4; Proctor, Susan, Dsc5; Concato, John, MD MPH2

1National Center for PTSD, VA Boston Healthcare System and Boston University, Boston, Massachusetts, USA
2Clinical Epidemiology Research Center, VA Cooperative Studies Program, West Haven, Connecticut, USA
3Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts, USA
4VA Connecticut Health Care System, West Haven, Connecticut, USA
5U.S. Army Research Institute of Environmental Medicine, VA Boston Healthcare System, and Boston University, Boston, Massachusetts, USA

Individuals differ in their emotional responses to psychological trauma exposure, including whether symptoms are maintained, increase, or diminish over time.  Understanding longitudinal patterns of emotional symptom expression and what predicts these patterns can inform prevention and treatment of stress-related psychopathology. Because cross-sectional group averages can disguise individual symptom trajectories, a growing literature has used growth mixture modeling (GMM) to identify individual trajectories of PTSD symptom expression. Fewer GMM studies, however, have included both pre-trauma and long-term assessments as longitudinal components.  This presentation incorporates data from the VA-DoD Neurocognition Deployment Health Study/VA Cooperative Study #566, which began with pre-Iraq deployment assessments, and included both short- and long-term (5+ years following deployment) evaluations. We applied GMM to data drawn from 1097 Soldiers who provided at least 1 pre- and 1 post-deployment assessment, but data reflect an average of 3 assessments per participant. The best model contains 4 classes characterized by resilience (n=174), recovery (n=247), worsening pre-existing symptoms (n=367), and worsening post-deployment onset symptoms (n=309).  The presentation will also include discussion of risk and resilience factors found to be associated with each trajectory class.