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Kuester A, Schumacher S, Niemeyer H, Engel S, Spies J, Weiß D, Muschalla B, Burchert S, Tamm S, Weidmann A, Bohn J, Willmund G, Rau H, Knaevelsrud C. Attentional bias in German Armed Forces veterans with and without posttraumatic stress symptoms - An eye-tracking investigation and group comparison. J Behav Ther Exp Psychiatry 2022; 76:101726. [PMID: 35180658 DOI: 10.1016/j.jbtep.2022.101726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 12/22/2021] [Accepted: 02/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Most eye tracking based paradigms evidence patterns of sustained attention on threat coupled with low evidence for vigilance to or avoidance of threat in posttraumatic stress symptoms (PTSS). Still, eye tracking data on attention bias is particularly limited for military population. This eye tracking study investigated attentional bias in PTSS in a sample of German Armed Forces veterans. METHODS Veterans with deployment-related PTSS (N = 24), veterans with deployment-related traumatization without PTSS (N = 28), and never-deployed healthy veterans (N = 18) were presented with pairs of combat and neutral pictures, pairs of general threat and neutral pictures, and pairs of emotional and neutral faces. Their eye gazes were tracked during a free viewing task. 3 x 3 x 2 mixed general linear model analyses were conducted. Internal consistency of attention bias indicators was calculated for the entire sample and within groups. RESULTS Veterans with PTSS dwelled longer on general threat AOIs in contrast to non-exposed controls and shorter on general threat and combat associated neutral AOIs in contrast to both control groups. Veterans with PTSS entered faster to general threat AOIs than non-exposed controls. Veterans with PTSS showed circumscribed higher attention fluctuation in contrast to controls. Internal consistency varied across attention bias indicators. LIMITATIONS Statistical power was reduced due to recruitment difficulties. CONCLUSIONS Evidence is provided for the maintenance hypothesis in PTSS. No robust evidence is provided for hypervigilant behavior in PTSS. Findings on attention bias variability remain unclear, calling for more investigations in this field.
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Affiliation(s)
- Annika Kuester
- Department of Psychiatry, Psychotherapy and Psychosomatics, Brandenburg Medical School Theodor Fontane, Germany; Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany.
| | - Sarah Schumacher
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Helen Niemeyer
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Sinha Engel
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Jan Spies
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Deborah Weiß
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Beate Muschalla
- Institute of Psychology, Technische Universität Braunschweig, Germany
| | - Sebastian Burchert
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Sascha Tamm
- Center for Applied Neuroscience, Division of Experimental and Cognitive Neuropsychology, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Anke Weidmann
- Theodor Fliedner Foundation, Fliedner Hospital Berlin, Germany
| | - Johannes Bohn
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
| | - Gerd Willmund
- Department for Military Mental Health, German Armed Forces, Military Hospital Berlin, Germany
| | - Heinrich Rau
- Department for Military Mental Health, German Armed Forces, Military Hospital Berlin, Germany
| | - Christine Knaevelsrud
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Germany
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Engel S, Schumacher S, Niemeyer H, Kuester A, Burchert S, Klusmann H, Rau H, Willmund GD, Knaevelsrud C. Associations between oxytocin and vasopressin concentrations, traumatic event exposure and posttraumatic stress disorder symptoms: group comparisons, correlations, and courses during an internet-based cognitive-behavioural treatment. Eur J Psychotraumatol 2021; 12:1886499. [PMID: 33968321 PMCID: PMC8078934 DOI: 10.1080/20008198.2021.1886499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Background: Posttraumatic stress disorder (PTSD) is characterized by impairments in extinction learning and social behaviour, which are targeted by trauma-focused cognitive behavioural treatment (TF-CBT). The biological underpinnings of TF-CBT can be better understood by adding biomarkers to the clinical evaluation of interventions. Due to their involvement in social functioning and fear processing, oxytocin and arginine vasopressin might be informative biomarkers for TF-CBT, but to date, this has never been tested. Objective: To differentiate the impact of traumatic event exposure and PTSD symptoms on blood oxytocin and vasopressin concentrations. Further, to describe courses of PTSD symptoms, oxytocin and vasopressin during an internet-based TF-CBT and explore interactions between these parameters. Method: We compared oxytocin and vasopressin between three groups of active and former male service members of the German Armed Forces (n = 100): PTSD patients (n = 39), deployed healthy controls who experienced a deployment-related traumatic event (n = 33) and non-deployed healthy controls who never experienced a traumatic event (n = 28). PTSD patients underwent a 5-week internet-based TF-CBT. We correlated PTSD symptoms with oxytocin and vasopressin before treatment onset. Further, we analysed courses of PTSD symptoms, oxytocin and vasopressin from pre- to post-treatment and 3 months follow-up, as well as interactions between the three parameters. Results: Oxytocin and vasopressin did not differ between the groups and were unrelated to PTSD symptoms. PTSD symptoms were highly stable over time, whereas the endocrine parameters were not, and they also did not change in mean. Oxytocin and vasopressin were not associated with PTSD symptoms longitudinally. Conclusions: Mainly due to their insufficient intraindividual stability, single measurements of endogenous oxytocin and vasopressin concentrations are not informative biomarkers for TF-CBT. We discuss how the stability of these biomarkers might be increased and how they could be better related to the specific impairments targeted by TF-CBT.
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Affiliation(s)
- Sinha Engel
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Sarah Schumacher
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Helen Niemeyer
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Annika Kuester
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Sebastian Burchert
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Hannah Klusmann
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Heinrich Rau
- Department for Military Mental Health, German Armed Forces, Military Hospital Berlin, Berlin, Germany
| | - Gerd-Dieter Willmund
- Department for Military Mental Health, German Armed Forces, Military Hospital Berlin, Berlin, Germany
| | - Christine Knaevelsrud
- Division of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
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Niemeyer H, Knaevelsrud C, Schumacher S, Engel S, Kuester A, Burchert S, Muschalla B, Weiss D, Spies J, Rau H, Willmund GD. Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms. BMC Psychiatry 2020; 20:205. [PMID: 32375754 PMCID: PMC7204035 DOI: 10.1186/s12888-020-02595-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 04/12/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day. METHODS Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models. RESULTS Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%. CONCLUSIONS The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans. TRIAL REGISTRATION Australian Clinical Trials Registry ACTRN12616000956404.
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Affiliation(s)
- Helen Niemeyer
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195, Berlin, Germany.
| | - Christine Knaevelsrud
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Sarah Schumacher
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Sinha Engel
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Annika Kuester
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Sebastian Burchert
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Beate Muschalla
- grid.6738.a0000 0001 1090 0254Department of Clinical Psychology, Psychotherapy and Diagnostics, Institute of Psychology, Technische Universität Braunschweig, Braunschweig, Germany
| | - Deborah Weiss
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Jan Spies
- grid.14095.390000 0000 9116 4836Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universität Berlin, Freie Universität Berlin, Schwendenerstr. 27, 14195 Berlin, Germany
| | - Heinrich Rau
- German Armed Forces, Military Hospital Berlin, Department for Military Mental Health, Berlin, Germany
| | - Gerd-Dieter Willmund
- German Armed Forces, Military Hospital Berlin, Department for Military Mental Health, Berlin, Germany
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Cunitz K, Bühler A, Willmund GD, Ziegenhain U, Fegert JM, Zimmermann P, Kölch MG. [Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany]. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2019; 47:503-526. [PMID: 31269864 DOI: 10.1024/1422-4917/a000675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany Abstract. Military personnel who have been deployed in war zones or other unstable regions are at an increased risk to develop mental health disorders, including posttraumatic stress disorder. Likewise, their children are at high risk to develop mental health problems as well as emotional and behavioral difficulties. Most research on prevalence of mental health problems as well as on interventions within this group was conducted in the USA. In Germany, no systematic intervention for children of military members focusing on their experiences of deployment exist. The systematic literature review aimed to analyze existing intervention programs in the USA, in particular for children of military members regarding evidence, type and addressed target group (parents, children, both). Compared to the social welfare and health care systems in the USA, the German systems are different. Hence, a second aim was to examine the transferability of these programs to the specific needs of children of German military members (Bundeswehr). 27 intervention programs could be included in the review. Programs, directly or indirectly, are addressing the needs of children of a deployed parent. They are usually focusing on the "emotional cycle of deployment" (phase of preparation of deployment, separation phase of deployment and the return of the deployed parent). The programs mainly focused on parenting skills, family reactions to stress, coping strategies of families, and the feeling of coherence within the family. Only 20 % of the interventions could be assigned to the type of indicated prevention. Nine interventions have shown positive effects (either in RCT or non-experimental designs). Several elements of the programs are transferable to the German situation of children of military members. In particular, contents which address the specific situation of families with a military member are desperately needed in Germany. Transferability is limited by the non-comparability of health care and social welfare systems in the USA and in Germany.
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Affiliation(s)
- Katrin Cunitz
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm
| | - Antje Bühler
- Psychotraumazentrum der Bundeswehr, Bundeswehrkrankenhaus, Berlin
| | | | - Ute Ziegenhain
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm
| | - Jörg M Fegert
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm
| | - Peter Zimmermann
- Psychotraumazentrum der Bundeswehr, Bundeswehrkrankenhaus, Berlin
| | - Michael G Kölch
- Klinik für Kinder- und Jugendpsychiatrie/Psychotherapie, Universitätsklinikum Ulm.,Klinik für Psychiatrie, Neurologie, Psychosomatik und Psychotherapie im Kindes- und Jugendalter, Universitätsmedizin Rostock
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Danker-Hopfe H, Sauter C, Kowalski JT, Kropp S, Ströhle A, Wesemann U, Zimmermann PL. Effect of deployment related experiences on sleep quality of German soldiers after return from an International Security Assistance Force (ISAF) mission to Afghanistan. Psychiatry Res 2018; 270:560-567. [PMID: 30343242 DOI: 10.1016/j.psychres.2018.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
Abstract
The aim of the present study was to investigate the effect of experiencing potentially traumatic events during deployment on post-deployment sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) and the Addendum for Post-Traumatic Stress Disorder (PTSD) of the Pittsburgh Sleep Quality Index (PSQI-A). Deployment related experiences were quantified on a standardised list of the Mental Health Advisory Team of the U.S. armed forces. The original sample consisted of 118 soldiers of the German armed forces who were deployed to Afghanistan for six months. The present analyses focused on data assessed after deployment (n = 70) and in a three-month follow-up (n = 51). Results indicate that immediately after return experiences during deployment had an independent significant effect on sleep quality but not three months later. Immediately after return depressive and stress symptoms significantly affected sleep quality while three months later somatic symptoms were significant. At both time points sleep prior to deployment was a significant predictor of sleep quality following deployment. Given the importance of sleep quality prior to deployment as a known independent risk factor for newly occurring mental disorders after deployment, these results underline the need to improve sleep quality already at an early stage.
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Affiliation(s)
- Heidi Danker-Hopfe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Competence Centre of Sleep Medicine at Campus Benjamin Franklin, Berlin, Germany.
| | - Cornelia Sauter
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Competence Centre of Sleep Medicine at Campus Benjamin Franklin, Berlin, Germany
| | - Jens T Kowalski
- German Armed Forces Office, Applied Military Psychology and Research Division, c/o University of the Federal Armed Forces Hamburg, Hamburg, Germany
| | - Stefan Kropp
- Asklepios Fachklinikum Teupitz, Department of Psychiatry and Psychotherapy, Teupitz, Germany; Asklepios Fachklinikum Lübben, Department of Psychiatry and Psychotherapy, Lübben, Germany
| | - Andreas Ströhle
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Berlin, Germany
| | - Ulrich Wesemann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Bundeswehr Hospital Berlin, Berlin, Germany
| | - Peter L Zimmermann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Bundeswehr Hospital Berlin, Berlin, Germany
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Trautmann S, Goodwin L, Höfler M, Jacobi F, Strehle J, Zimmermann P, Wittchen HU. Prevalence and severity of mental disorders in military personnel: a standardised comparison with civilians. Epidemiol Psychiatr Sci 2017; 26:199-208. [PMID: 27086743 PMCID: PMC6998688 DOI: 10.1017/s204579601600024x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/22/2016] [Indexed: 11/06/2022] Open
Abstract
AIMS Provision and need for mental health services among military personnel are a major concern across nations. Two recent comparisons suggest higher rates of mental disorders in US and UK military personnel compared with civilians. However, these findings may not apply to other nations. Previous studies have focused on the overall effects of military service rather than the separate effects of military service and deployment. This study compared German military personnel with and without a history of deployment to sociodemographically matched civilians regarding prevalence and severity of 12-month DSM-IV mental disorders. METHOD 1439 deployed soldiers (DS), 779 never deployed soldiers (NS) and 1023 civilians were assessed with an adapted version of the Munich Composite International Diagnostic interview across the same timeframe. Data were weighted using propensity score methodology to assure comparability of the three samples. RESULTS Compared with adjusted civilians, the prevalence of any 12-month disorder was lower in NS (OR: 0.7, 95% CI: 0.5-0.99) and did not differ in DS. Significant differences between military personnel and civilians regarding prevalence and severity of individual diagnoses were only apparent for alcohol (DS: OR: 0.3, 95% CI: 0.1-0.6; NS: OR: 0.2, 95% CI: 0.1-0.6) and nicotine dependence (DS: OR: 0.5, 95% CI: 0.3-0.6; NS: OR: 0.5, 95% CI: 0.3-0.7) with lower values in both military samples. Elevated rates of panic/agoraphobia (OR: 2.7, 95% CI: 1.4-5.3) and posttraumatic stress disorder (OR: 3.2, 95% CI: 1.3-8.0) were observed in DS with high combat exposure compared with civilians. CONCLUSIONS Rates and severity of mental disorders in the German military are comparable with civilians for internalising and lower for substance use disorders. A higher risk of some disorders is reduced to DS with high combat exposure. This finding has implications for mental health service provision and the need for targeted interventions. Differences to previous US and UK studies that suggest an overall higher prevalence in military personnel might result from divergent study methods, deployment characteristics, military structures and occupational factors. Some of these factors might yield valuable targets to improve military mental health.
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Affiliation(s)
- S. Trautmann
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - L. Goodwin
- Department of Psychological Medicine, King's Centre for Military Health Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M. Höfler
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - F. Jacobi
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - J. Strehle
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - P. Zimmermann
- Centre for Psychiatry and Posttraumatic Stress, Federal Armed Forces Hospital Berlin, Berlin, Germany
| | - H.-U. Wittchen
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
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