Investigating the correlation of delirium after cardiac surgery with memories and posttraumatic stress disorder consequences of intensive care unit: A prospective cohort study

OBJECTIVES

To explore the differences in post-intensive care unit memory and posttraumatic stress disorder symptoms between patients with and without delirium, and assess the correlations between the two.

DESIGN

Prospective cohort observation study.

SETTING

A cardiac intensive care unit of a tertiary hospital in China. We enrolled 318 consecutive patients after cardiac surgery between December 2017 and March 2019.

MAIN OUTCOME MEASURES

Delirium was assessed using the Confusion Assessment Method for the ICU from intensive care unit admission to discharge. Intensive care unit memory was assessed using the ICU-Memory Tool through face-to-face interviews one week after discharge. Posttraumatic stress disorder was measured telephonically using the Impact of Events Scale-revised questionnaire at three months post-discharge.

RESULTS

Eighty patients each in the delirium and non-delirium groups were enrolled for follow-up interviews. Patients with delirium had vaguer memories of pre-intensive care unit admission and of their stay, and recollected more memories of feelings (vs. without delirium). Posttraumatic stress disorder was diagnosed in 14 patients with and in seven without delirium, with non-significant differences between groups. Delirium did not influence post-intensive care unit factual, feeling, and delusional memories, nor posttraumatic stress disorder and hyperarousal, intrusion, and avoidance. The memories of feelings were positively correlated with the last three (r = 0.285, r = 0.390 and r = 0.373, respectively).

CONCLUSION

Patients with delirium had vague intensive care unit memories. Memories of feelings were positively correlated with symptoms of hyperarousal, intrusion, and avoidance. Delirium did not influence factual, feeling, or delusional memories nor posttraumatic stress disorder incidence and symptoms.

IMPLICATIONS FOR CLINICAL PRACTICE

Interventions are needed to reduce the impact of vague memory in patients with post-intensive care unit delirium. Memories of feelings should be focused on because of their correlation with hyperarousal, intrusion, and avoidance. Delirium prevention and early recognition measures are suggested.

Co-occurring PTSD in intensive OCD treatment: Impact on treatment trajectory vs. response

BACKGROUND

Obsessive-compulsive disorder (OCD) and co-occurring posttraumatic stress disorder (PTSD) is associated with more severe and chronic OCD. However, findings regarding treatment effectiveness of cognitive behavioral treatment (CBT) with exposure and response prevention (ERP) with this comorbidity are mixed. Research aimed at understanding the precise barriers to OCD treatment effectiveness for individuals with co-occurring PTSD may help elucidate unique treatment needs.

METHODS

The current study used linear regression and latent growth curve analysis comparing treatment response and trajectory from patients with OCD (n = 3083, 94.2 %) and OCD + PTSD (n = 191, 5.2 %) who received CBT with ERP in two major intensive OCD treatment programs.

RESULTS

Although patients with OCD + PTSD evidenced similar trajectories of overall severity change, patients at one site required nearly 11 additional treatment days to achieve comparable reduction in OCD severity. Further, at the dimensional level, those with OCD + PTSD had poorer treatment response for unacceptable thoughts and symmetry symptoms. The moderate effect for unacceptable thoughts, indicating the widest gap in treatment response, suggests these symptoms may be particularly relevant to PTSD.

LIMITATIONS

Findings are limited by a naturalistic treatment sample with variation in treatment provision.

CONCLUSIONS

Findings emphasize caution in using a one-size-fits-all approach for patients with co-occurring OCD + PTSD within intensive OCD treatment programs, as broadly defined outcomes (e.g., reduction in overall severity) may not translate to reduction in the nuanced symptom dimensions likely to intersect with trauma. Unacceptable thoughts and symmetry symptoms, when co-occurring with PTSD, may require a trauma-focused treatment approach within intensive OCD treatment.

A First Exploration: Can Eye Movement Desensitization and Reprocessing Improve Cognition in Older Adults With Posttraumatic Stress Disorder?

OBJECTIVES

In older adults, PTSD is associated with decreased verbal learning and executive dysfunction. Therefore, feasibility of EMDR-treatment to improve cognitive performance in older adults with PTSD was examined. Additionally, we investigated pre-treatment correlation with often co-occurring risk factors for cognitive decline (sleep problems, depressive disorder, physical inactivity, childhood traumatic events).

DESIGN

Multicenter design with pre-post measurements.

SETTING

Psychiatric Dutch hospitals Mondriaan Mental Health Center and Altrecht.

PARTICIPANTS

22 treatment-seeking PTSD-outpatients (60-84 years).

INTERVENTION

Weekly one-hour EMDR session during 3, 6, or 9 months.

MEASUREMENTS

PTSD was assessed with Clinician-Administered PTSD-scale for DSM-5 (CAPS-5). Verbal learning memory was measured with Auditory Verbal Learning Test (RAVLT), interference with Stroop Colour-Word Test (SCWT) and working memory with Wechsler Adult Intelligence Scale-Digit Span (WAIS-IV-DS).

RESULTS

A Linear mixed-model showed significant improvement on RAVLT immediate-recall (F (1, 21) = 15.928, P = .001, 95% CI -6.98-2.20), delayed-recall (F (1, 21) = 7.095, P = .015, 95% CI -2.43-.30), recognition (F (21) = 8.885, P = .007, 95% CI -1.70- -.30), and SCWT (F (1 ,21) = 5.504, P = .029, 95% CI 4.38-72.78) but not on WAIS-IV-DS (F (20) = -1.237, P = .230, 95% CI -3.07-.78). There was no significant influence of therapy duration and CAPS-5 pre-treatment scores. There were small-medium nonsignificant correlations between CAPS-5 and cognitive performance pre-post differences, and between most cognitive measures and sleep problems, depressive disorder, and physical inactivity.

CONCLUSIONS

Cognitive functioning on memory and attention possible increased in older adults with PTSD after EMDR treatment. Further research is needed with a larger sample and a control condition to corroborate these findings and to identify the possible mediating role of modifiable risk factors.

Moral injury, race-related stress and post-traumatic stress disorder in a trauma-exposed Black population

BACKGROUND

Race-related stress (RRS) is an unrecognized source of moral injury (MI)-or the emotional and/or spiritual suffering that may emerge after exposure to events that violate deeply held beliefs. Additionally, MI has not been explored as a mechanism of risk for post-traumatic stress disorder (PTSD) in trauma-exposed civilians. We examined relations among exposure to potentially morally injurious events (moral injury exposure, MIE), related distress (moral injury distress, MID), and RRS in Black Americans. Potential indirect associations between RRS and PTSD symptoms via MID were also examined.

METHODS

Black Americans (n = 228; 90.4% female; Mage = 31.6 years. SDage = 12.8 years) recruited from an ongoing study of trauma completed measures assessing civilian MIE and MID, RRS, and PTSD. Bivariate correlations were conducted with MIE and MID, and mediation analysis with MID, to examine the role of MI in the relationship between RRS and PTSD symptom severity.

RESULTS

MIE was significantly correlated with cultural (r = 0.27), individual (r = 0.29), and institutional (r = 0.25) RRS; MID also correlated with cultural (r = 0.31), individual (r = 0.31), and institutional (r = 0.26) RRS (ps < 0.001). We found an indirect effect of RRS on PTSD symptoms via MID (β = 0.10, p < 0.005).

CONCLUSIONS

All types of RRS were associated with facets of MI, which mediated the relationship between RRS and current PTSD symptoms. MI may be a potential mechanism through which RRS increases the risk for PTSD in Black individuals.

The Indirect Effects of Proximal Stressors Associated with Posttraumatic Stress Symptoms Severity among Sexually Victimized Sexual Minority Women: A Cross-Sectional Path Analysis

Sexual minority women (SMW) are at risk for sexual victimization and stressors specifically related to their minority identity (e.g., discrimination). However, SMW experience posttraumatic stress disorder (PTSD) at rates beyond what may be explained by elevated risk for sexual victimization alone. This study aimed to examine the impact of stigma on PTSD symptoms among SMW survivors of sexual victimization. Results indicate that in relation to minority-specific distal stressors (i.e., heterosexist experiences), both minority-specific and general proximal stressors (i.e., internalized heterosexism, negative posttraumatic cognitions) indirectly affected PTSD symptom severity among this cross-sectional sample of sexually victimized SMW.

Longitudinal associations among experiences of sexual assault, posttraumatic stress disorder symptoms, and heavy drinking in young adults

Prior research with young adults has demonstrated clear associations between experiences of sexual assault, symptoms of posttraumatic stress disorder (PTSD), and alcohol use, but most studies have been cross-sectional or have not considered multiple theoretical pathways to understand these associations. Using six waves of data from a longitudinal cohort sample of 1,719 young adults, we examined associations among experiences of past-year sexual assault (i.e., rape, unwanted sexual touching, and physical intimidation in a sexual way), PTSD symptoms, and the frequency of binge drinking over time, allowing for the exploration of symptom-induced, interpersonal risk, and substance-induced pathways for male and female participants. For both male, βs = 2.84 to 6.55, and female participants, βs = 2.96 to 10.1, higher prior levels of PTSD symptoms were associated with larger increases in binge drinking over time. For female participants, higher prior levels of sexual assault were associated with larger increases in PTSD symptoms over time, βs = 3.48 to 4.25, whereas for male participants, higher prior levels of past-year binge drinking were associated with decreases in PTSD symptoms over time, βs = -2.75 to -0.53. Continued efforts are needed to prevent sexual assault among young adults and address PTSD symptoms among those who experience sexual assault. Interventions that target binge drinking are also needed for individuals who experience PTSD symptoms, especially young adults, to address potentially hazardous drinking before problems escalate and become chronic.

Measuring interpersonal trauma: Development and validation of the German version of the victimization experience schedule (VES)

OBJECTIVE

Interpersonal victimization experiences (VEs) significantly affect mental and physical health, particularly in disorders associated with life-time adversities, like fibromyalgia syndrome (FMS) and major depressive disorder (MDD). However, assessing VEs comprehensively remains challenging due to limited tools that encompass sub-traumatic events, such as bullying or discrimination, and contextual dimensions. We aimed to address this gap by validating the Victimization Experience Schedule (VES) in German, examining its reliability, and assessing VEs in clinical populations with FMS and MDD.

METHODS

We investigated the relationship between VEs and clinical symptoms in individuals with FMS, MDD and healthy controls (N = 105) in a case-control study. We also analyzed correlations between different types of VEs and categories of early childhood abuse and posttraumatic-stress-disorder instruments. Additionally, we validated our findings in an independent sample of individuals with FMS (N = 97) from a clinical study.

RESULTS

We observed excellent inter-rater reliability (Kw = 0.90-0.99), and VEs assessed using the VES were in alignment with subcategories of early childhood abuse. The prevalence of VEs extended beyond the categories covered by traditional survey instruments and was higher in individuals with MDD (4.0 ± 2.6) and FMS (5.9 ± 3.1) compared to controls (1.5 ± 1.7). We consistently identified a significant association between the number of VEs, the associated subjective distress, and clinical scores. Furthermore, distinct correlation patterns between VEs and clinical outcomes emerged across different cohorts.

CONCLUSION

Our study emphasizes the VES's value in understanding VEs within MDD and FMS. These experiences span from traumatic to sub-traumatic and correlate with posttraumatic-stress and clinical symptoms, underscoring the VES's importance as an assessment tool.

Causal association of attention-deficit/hyperactivity disorder and autism spectrum disorder with post-traumatic stress disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are two neurodevelopmental disorders that often result in individuals experiencing traumatic events. However, little is known about the connection between ADHD/ASD and post-traumatic stress disorder (PTSD). This study aimed to investigate the genetic associations between these disorders.

METHODS

Genetic correlation analysis was used to examine the genetic components shared between ADHD (38 691 cases and 275 986 controls), ASD (18 381 cases and 27 969 controls) and PTSD (23 212 cases and 151 447 controls). Two-sample Mendelian randomization analyses were employed to explore the bidirectional causal relationships between ADHD/ASD and PTSD.

RESULTS

The results of the genetic correlation analysis revealed significant positive correlations of PTSD with ADHD(r g  = 0.70) and ASD (r g  = 0.34). Furthermore, the Mendelian randomization analysis revealed that genetic liabilities to ADHD [odds ratio (OR) = 1.14; 95% confidence interval (CI), 1.06-1.24; P  = 7.88 × 10 -4 ] and ASD (OR = 1.04; CI, 1.01-1.08; P  = 0.014) were associated with an increased risk of developing PTSD later in life. However, no evidence supported that genetic liability to PTSD could elevate the risk of ADHD or ASD.

CONCLUSION

The findings of this study supported that ADHD and ASD may increase the risk of PTSD, but not vice versa.

Pain Intensity, Pain-Related Anxiety, and Hazardous Drinking Among Individuals With PTSD

OBJECTIVE

Evidence suggests that pain intensity may be indirectly linked to hazardous drinking and PTSD symptom severity via pain-related anxiety. The goal of this analysis was to test the hypotheses in a population with PTSD symptoms that pain intensity would be positively and indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via pain-related anxiety.

METHODS

Heavy drinkers with probable PTSD were recruited via Qualtrics panels (N = 371, 53% Female, Mage = 39.68, SD = 10.86). Linear regression and conditional process models were conducted to examine indirect associations between pain intensity and primary outcomes via pain-related anxiety.

RESULTS

Pain intensity was found to be indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via greater pain-related anxiety.

CONCLUSION

These initial findings suggest that pain-related anxiety may play an important role in relations between the experience of pain and hazardous patterns of alcohol consumption among individuals with probable PTSD. Future research is needed to determine the temporal nature of these associations and to examine the potential utility of treatments that address pain-related anxiety in the context of comorbid pain, PTSD, and hazardous drinking.

Personality functioning, positive outlook for the future, and simple and complex post-traumatic stress disorder

Posttraumatic Stress Disorder (PTSD) and its complex form (C-PTSD) are psychopathological conditions that are related to several personality traits. In particular, the current study aims to investigate the associations of impairment of personality functioning (IPF) and positive outlook for the future (POF) with PTSD and C-PTSD. A sample of 304 Brazilian adults responded to an online survey. IPF was measured according to the alternative model for personality disorders, POF was operationalized using optimism and hope scales, and PTSD and C-PTSD were measured using the ICD-11 model. Data analysis included correlation, structural equation models, multivariate analysis of variance, and multinomial logistic regression. The results showed that IPF and POF were moderately correlated with PTSD and C-PTSD in positive and negative directions, respectively. IPF and POF were more strongly associated with C-PTSD than PTSD. From the categorical approach to psychopathology, IPF and POF were shown to be associated only with C-PTSD. This is the first study that provides empirical data on the association of IPF and POF with both forms of PTSD. Understanding the associations between pathological and resilient personality domains and PTSD and C-PTSD symptoms can support the development of effective interventions.

Cannabis use and trauma-focused treatment for co-occurring posttraumatic stress disorder and substance use disorders: A meta-analysis of individual patient data

High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.

Factor analysis of the neurobehavioral symptom inventory in veterans with PTSD and no history of mild TBI

It is well established that long-term postconcussive symptoms following a mild traumatic brain injury (mTBI) are associated with underlying physical, emotional, and behavioral conditions. The Neurobehavioral Symptom Inventory (NSI) is a measure used to assess neurobehavioral symptoms that can occur following a mTBI and has demonstrated a 3- or 4-factor structure in veterans. The present study aimed to investigate the factor structure of veterans with PTSD without a history of mTBI. A confirmatory factor analysis (CFA) was conducted on a sample of 221 treatment-seeking veterans and service members with PTSD and without a history of mTBI. Results supported a 4-factor structure comprised of vestibular, somatic, cognitive, and affective domains in veterans with PTSD. Subsequent, correlational analyses between the four NSI factors and the four subscales of the Posttraumatic Stress Disorder Checklist - Fifth Edition (PCL-5) revealed high correspondence between the cognitive and affective factors of the NSI and the negative alterations in mood and cognitions and hyperarousal symptom subscales of PTSD. Collectively, findings demonstrated that the NSI functions similarly in veterans with PTSD with or without a history of mTBI. Findings suggest that neurobehavioral symptoms assessed by the NSI appear to be nonspecific and not explicitly associated with mTBI.

Pre-trauma memory contextualization as predictor for PTSD-like behavior in male rats

While many people experience potentially threatening events during their life, only a minority develops posttraumatic stress disorder (PTSD). The identification of individuals at risk among those exposed to trauma is crucial for PTSD prevention in the future. Since re-experiencing trauma elements outside of the original trauma-context is a core feature of PTSD, we investigate if the ability to bind memories to their original encoding context (i.e. memory contextualization) predicts PTSD vulnerability. We hypothesize that pre-trauma neutral memory contextualization (under stress) negatively relates to PTSD-like behavior, in a prospective design using the cut-off behavioral criteria rat model for PTSD. 72 male Sprague Dawley rats were divided in two experimental groups to assess the predictive value of 1) memory contextualization without acute stress (NS-group) and 2) memory contextualization during the recovery phase of the acute stress-response (S-group) for susceptibility to PTSD-like behavior. A powerful extension to regression analysis -path analysis-was used to test this specific hypothesis, together with secondary research questions. Following traumatic predator scent stress, 19.4% of the rats displayed PTSD-like behavior. Results showed a negative relation between pre-trauma memory contextualization and PTSD-like behavior, but only in the NS-group. Pre-trauma memory contextualization was positively related to fear association in the trauma environment, again only in the NS group. If the predictive value of pre-trauma contextualization of neutral information under non-stressful conditions for PTSD susceptibility is replicated in prospective studies in humans, this factor would supplement already known vulnerability factors for PTSD and improve the identification of individuals at risk among the trauma exposed, especially those at high trauma risk such as soldiers deployed on a mission.

Effectiveness of Prefrontal Transcranial Magnetic Stimulation for Depression in Older US Military Veterans

OBJECTIVE

While typical aging is associated with decreased cortical volume, major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) likely exacerbates this process. Cerebral atrophy leads to increased coil-to-cortex distance and when using transcranial magnetic stimulation (TMS), potentially reducing effectiveness in older adults.

METHODS

Data from a large-scale quality improvement project was used. Included veterans eligible for TMS and completed TMS treatment. Age was assessed as a predictive factor of depression outcomes after TMS treatment among veterans. Secondary analyses examined the impact of age on 1) MDD response and remission and 2) MDD change within MDD-only verses comorbid MDD and PTSD groups.

RESULTS

The entire sample included 471 veterans. Primary analysis revealed age as a negative predictor of depression outcomes (p = 0.019). Secondary analyses found age to be a significant predictor of remission (p = 0.004), but not clinical response. Age was not a predictive factor in depression outcomes between those with MDD-only compared to MDD+PTSD.

CONCLUSIONS

Increased age predicts greater MDD symptom reduction after TMS. Although age did not predict response rates, it did predict increased rates of remission in veterans. Age did not differentially predict depression outcomes between those with or without PTSD. The sample size was sufficient to discern a difference in efficaciousness, and limitations were those inherent to registry studies in veterans. This data indicates that TMS can be an important treatment option for older individuals.

Trauma-Associated Sleep Disorder

Trauma-associated sleep disorder (TASD) is a recently described parasomnia that develops following a traumatic event. It consists of trauma-related nightmares, disruptive nocturnal behaviors, and autonomic disturbances, and shares similarities with post-traumatic stress disorder and rapid eye movement behavior disorder. The underlying pathophysiology of TASD and how it relates to other parasomnias are still not entirely understood; proposed treatment is similarly nebulous, with prazosin at the forefront along with management of comorbid sleep disorders. The purpose of this article is to characterize and highlight the clinical features of this condition.

The obstructive sleep apnoea endotypes are similar in elderly trauma-exposed veterans with and without diagnosed PTSD

BACKGROUND

Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only.

METHODS

Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m2).

RESULTS

There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %Veupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %Veupnea), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %Veupnea).

CONCLUSION

The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made.

Ketamine alleviates fear memory and spatial cognition deficits in a PTSD rat model via the BDNF signaling pathway of the hippocampus and amygdala

BACKGROUND

Post-traumatic stress disorder (PTSD) is associated with traumatic stress experiences. This condition can be accompanied by learning and cognitive deficits. Studies have demonstrated that ketamine can rapidly and significantly alleviate symptoms in patients with chronic PTSD. Nonetheless, the effects of ketamine on neurocognitive impairment and its mechanism of action in PTSD remain unclear.

METHODS

In this study, different concentrations of ketamine (5, 10, 15, and 20 mg/kg, i.p.) were evaluated in rat models of single prolonged stress and electrophonic shock (SPS&S). Expression levels of brain-derived neurotrophic factor (BDNF) and post-synaptic density-95 (PSD-95) in the hippocampus (HIP) and amygdala (AMG) were determined by Western blot analysis and immunohistochemistry.

RESULTS

The data showed that rats subjected to SPS&S exhibited significant PTSD-like cognitive impairment. The effect of ketamine on SPS&S-induced neurocognitive function showed a U-shaped dose effect in rats. A single administration of ketamine at a dosage of 10-15 mg/kg resulted in significant changes in behavioral outcomes. These manifestations of improvement in cognitive function and molecular changes were reversed at high doses (15-20 mg/kg).

CONCLUSION

Overall, ketamine reversed SPS&S-induced fear and spatial memory impairment and the down-regulation of BDNF and BDNF-related PSD-95 signaling in the HIP and AMG. A dose equal to 15 mg/kg rapidly reversed the behavioral and molecular changes and promoted the amelioration of cognitive dysfunction. The enhanced association of BDNF signaling with PSD-95 effects could be involved in the therapeutic efficiency of ketamine for PTSD.

Prevalence of occupational moral injury and post-traumatic embitterment disorder: a systematic review and meta-analysis

OBJECTIVES

Occupational moral injury and post-traumatic embitterment disorder (PTED) describe the psychological distress caused by exposure to injustice at work. This meta-analysis aims to determine the prevalence of occupational moral injury and PTED and establish whether prevalence estimates differ depending on occupation.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Google Scholar, PubMed, APA PsycINFO, Web of Science Core Collection, Scopus, ScienceDirect and Sage Journals Online were searched in June 2020 and updated in November 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Observational studies that measured prevalence or average scores of moral injury, or PTED in any occupational group and any geographical location.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened and coded eligible studies. Study design, participant demographics, sampling method, location, measurement tool and prevalence or average scores were extracted. Risk of bias was assessed using the Quality Assessment Checklist for Prevalence Studies tool. Meta-analysis was conducted using random effects models. Results that could not be combined were summarised qualitatively in a narrative synthesis using the Guidance for Systematic Reviews.

RESULTS

In total, 88 studies across armed forces and veterans, healthcare, first responders, educators, journalists, child protection service employees, the unemployed, public-sector employees and mixed occupations were included. Studies included in each separate meta-analysis based on the measure used ranged from 2 to 30. The pooled prevalence of clinically relevant moral injury in healthcare professionals was 45%, and exposure to any potentially morally injurious event (PMIE) across occupations was 67%. Exposure to transgressions by others and betrayal was significantly lower in the armed forces than civilian occupations. Pooled prevalence of PTED across occupations was 26%.

CONCLUSION

Exposure to PMIEs, moral injury symptoms and PTED are prevalent at work and exposure to transgressions by others and betrayal are more likely in civilian occupations than the armed forces.

PROSPERO REGISTRATION NUMBER

CRD42020191766.

Smaller Hippocampal Volume Is Associated With Reduced Posttraumatic Stress Symptoms in Children With Cancer and Survivors Following a Brief Novel Martial Arts-Based Intervention

PURPOSE

Children with cancer and survivors frequently report posttraumatic stress symptoms (PTSS), which are associated with volumetric changes in stress-sensitive brain regions, including the hippocampus.

METHODS

We examined the impact of a novel, 4-week martial-arts-based meditative intervention on cancer-related PTSS in 18 pediatric patients and survivors and whether baseline hippocampal volumes correlate with PTSS severity and/or PTSS changes over time.

RESULTS

Overall, PTSS did not significantly change from baseline to post-intervention. Smaller hippocampal volume was correlated with more severe re-experiencing PTSS at baseline, and greater reductions in PTSS post-intervention.

CONCLUSIONS

Together, hippocampal volume may be a biomarker of PTSS severity and intervention response. Identifying hippocampal volume as a potential biomarker for PTSS severity and intervention response may allow for more informed psychosocial treatments.

[Asthma: a respiratory pathology with a high risk for mental health]

The subjective experience of asthma can be accompanied by significant emotional suffering. The presence of psychiatric comorbidities in asthma is common and worsens the prognosis of asthma. Bidirectional relationships between psychiatric disorders and asthma via inflammatory mechanisms are highlighted. Systematic screening for the most common psychiatric comorbidities such as depression, anxiety disorders and post-traumatic stress disorder is recommended. A multidisciplinary collaboration with a mental health specialist in the presence of psychiatric comorbidity has proven necessary to improve the quality of life and both the somatic and psychiatric prognosis of patients suffering from asthma.

Clinical description of sleep and trauma-related nightmares in a population of French active-duty members and veterans with Post-Traumatic Stress Disorder

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a major public health problem. The most frequent complaints in this pathology are sleep disorders and trauma-related nightmares in particular. Trauma-related nightmares are characteristic of PTSD and impact its severity insofar as they are associated with more severe, longer-lasting symptoms and resistance to first-line treatments. There are specific characteristics associated with military personnel, including overrepresentation of replicative trauma-related nightmares. The aim of this study was to provide an accurate description of sleep patterns and the characteristics of trauma-related nightmares in a population of active-duty members or veterans diagnosed with PTSD.

METHODS

We recruited active-duty service members and veterans receiving treatment for PTSD in the psychiatric departments of five Military Teaching Hospitals (Hôpitaux d'Instruction des Armées, HIA) and described their sleep characteristics using a questionnaire, the Trauma-Related Nightmare Survey French version (TRNS-FR).

RESULTS

Out of 77 patients, 72 (93.5%) who experienced traumatic nightmares were included. This population had very severe clinical manifestations of PTSD, with a mean PCL-S score of 62.6 and an estimated total sleep time of 5.3h (317min). Among these patients, 31% had replicative nightmares and 57.7% had partially replicative nightmares. Nightmares were frequent (4.7 nightmares on average over the previous week), highly realistic, and highly immersive with exacerbated symptoms during the nightmare and also upon awakening.

DISCUSSION

Sleep quality was seriously altered among active-duty service members and veterans treated in Military Hospitals for PTSD with trauma-related nightmares. Certain criteria were identified to help characterize trauma-related nightmares: their level of replication, recurrence and the impact of these symptoms on patients' lives.

CONCLUSION

Long-term traumatic nightmares are a prominent feature in the symptomatology of active service members and veterans suffering from PTSD. This symptom is of particular interest as it may be a sign of changes in the patient's condition and a potential therapeutic target.

Association of mild traumatic brain injury, post-traumatic stress disorder, and other comorbidities on photosensitivity

SIGNIFICANCE

Photosensitivity is common after mild traumatic brain injury. However, this study demonstrates that photosensitivity is also impacted by common comorbidities that often occur with mild traumatic brain injury. Understanding how physical and psychological traumas impact photosensitivity can help improve provider care to trauma survivors and guide novel therapeutic interventions.

PURPOSE

This study aimed to characterize the association between mild traumatic brain injury and common comorbidities on photosensitivity in post-9/11 veterans.

METHODS

Existing data from the Translational Research Center for TBI and Stress Disorders cohort study were analyzed including traumatic brain injury history and post-traumatic stress disorder clinical diagnostic interviews; sleep quality, anxiety, and depression symptoms self-report questionnaires; and photosensitivity severity self-report from the Neurobehavioral Symptom Inventory. Analysis of covariance and multiple ordinal regression models were used to assess associations between mild traumatic brain injury and common comorbidities with photosensitivity severity.

RESULTS

Six hundred forty-one post-9/11 veterans were included in this study. An initial analysis showed that both mild traumatic brain injury and current post-traumatic stress disorder diagnosis were independently associated with higher photosensitivity ratings compared with veterans without either condition, with no interaction observed between these two conditions. Results of the ordinal regression models demonstrated positive associations between degree of photosensitivity and the number of mild traumatic brain injuries during military service and current post-traumatic stress disorder symptom severity, particularly hyperarousal symptoms, even when controlling for other factors. In addition, the degree of sleep disturbances and current anxiety symptoms were both positively associated with photosensitivity ratings, whereas depression symptoms, age, and sex were not.

CONCLUSIONS

Repetitive mild traumatic brain injury, post-traumatic stress disorder, anxiety, and sleep disturbances were all found to significantly impact photosensitivity severity and are therefore important clinical factors that eye care providers should consider when managing veterans with a history of deployment-related trauma reporting photosensitivity symptoms.

A case of prazosin in treatment of rapid eye movement sleep behavior disorder

Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by dream-enactment behaviors that emerge during a loss of REM sleep atonia. Untreated RBD carries risks for physical injury from falls or other traumatic events during dream enactment as well as risk of injury to the bed partner. Currently, melatonin and clonazepam are the mainstay pharmacological therapies for RBD. However, therapeutic response to these medications is variable. While older adults are most vulnerable to RBD, they are also particularly vulnerable to the adverse effects of benzodiazepines, including increased risk of falls, cognitive impairment, and increased risk of Alzheimer disease. Prazosin is a centrally active alpha-1 adrenergic receptor antagonist often prescribed for trauma nightmares characterized by REM sleep without atonia in patients with posttraumatic stress disorder. We report a case of successful RBD management with prazosin in a patient in whom high-dose melatonin was ineffective. Although there was no observable reduction in dream-enactment behaviors with high-dose melatonin, the possibility of a synergistic effect of prazosin combined with melatonin cannot be ruled out. This case report supports further evaluation of prazosin as a potential therapeutic for RBD.

CITATION

Cho Y, Iliff JJ, Lim MM, Raskind M, Peskind E. A case of prazosin in treatment of rapid eye movement sleep behavior disorder. J Clin Sleep Med. 2024;20(2):319-321.

Military exposures and Gulf War illness in veterans with and without posttraumatic stress disorder

Gulf War illness (GWI) is a chronic multisymptom disorder of unknown etiology that is believed to be caused by neurotoxicant exposure experienced during deployment to the Gulf War. Posttraumatic stress disorder (PTSD) covaries with GWI and is believed to play a role in GWI symptoms. The present study examined the association between self-reported military exposures and GWI, stratified by PTSD status, in veterans from the Gulf War Era Cohort and Biorepository who were deployed to the Persian Gulf during the war. Participants self-reported current GWI and PTSD symptoms as well as military exposures (e.g., pyridostigmine [PB] pills, pesticides/insecticides, combat, chemical attacks, and oil well fires) experienced during the Gulf War. Deployed veterans' (N = 921) GWI status was ascertained using the Centers for Disease Control and Prevention definition. Individuals who met the GWI criteria were stratified by PTSD status, yielding three groups: GWI-, GWI+/PTSD-, and GWI+/PTSD+. Multivariable logistic regression, adjusted for covariates, was used to examine associations between GWI/PTSD groups and military exposures. Apart from insect bait use, the GWI+/PTSD+ group had higher odds of reporting military exposures than the GWI+/PTSD- group, adjusted odds ratio (aOR) = 2.15, 95% CI [1.30, 3.56]-aOR = 6.91, 95% CI [3.39, 14.08]. Except for PB pills, the GWI+/PTSD- group had a higher likelihood of reporting military exposures than the GWI- group, aOR = 2.03, 95% CI [1.26, 3.26]-aOR = 4.01, 95% CI [1.57, 10.25]. These findings are consistent with roles for both PTSD and military exposures in the etiology of GWI.

Evaluation of sleep and therapeutic education needs of military with PTSD

Sleep disorders in post-traumatic stress disorder (PTSD) are both diagnostic (nocturnal reliving) and prognostic. Poor sleep worsens the daytime symptomatology of PTSD and makes it resistant to treatment. However, no specific treatment is codified in France to treat these sleep disorders although sleep therapies (cognitive behavioural therapy for insomnia, psychoeducation and relaxation) have proven for years to be effective in treating insomnia. Therapeutic sessions can be part of a therapeutic patient education program, which is a model for the management of chronic pathologies. It allows for an improvement in a patient's quality of life and enhanced medication compliance. We therefore carried out an inventory of sleep disorders of patients with PTSD. First, we collected data by means of sleep diaries concerning the population's sleep disorders at home. Then we assessed the population's expectations and needs regarding its management of sleep, thanks to a semi-qualitative interview. The data from sleep diaries, which was consistent with the literature, showed that our patients suffered from severe sleep disorders that strongly impact their daily lives, with 87% of patients having an increased sleep onset latency, and 88% having nightmares. We observed a strong demand from patients for specific support for these symptoms, 91% expressing an interest in a TPE program targeting sleep disorders. Thanks to the data collected, the emerging themes for a future therapeutic patient education program targeting sleep disorders of soldiers with PTSD are: sleep hygiene; management of nocturnal awakenings, including nightmares; and psychotropic drugs.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, β = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

Durability of deep transcranial magnetic stimulation for veterans with treatment resistant depression with comorbid suicide risk and PTSD symptoms

Evidence supports transcranial magnetic stimulation (TMS) as an effective treatment for symptoms of depression and PTSD; however, there has been limited investigation into the durability of symptoms reduction. The Hampton Veterans Affairs Medical Center's (HVAMC) rTMS clinic used H-coil for dTMS for Veterans with treatment-resistant depression and tracked symptomology at multiple times points up to six months post-treatment. Veterans underwent 30 session of dTMS treatment using the Hesed coil (H1 coil). The PHQ-9, PCL-5, and BSS were administered to Veterans at four time points: pretreatment, post-treatment, three months after treatment, and six months after treatment. In aggregate, there were clinically significant reductions in symptoms of depression (43.47%), PTSD (44.14%) and suicidal ideation (54.02%) at the six month follow-up relative to pretreatment. Results provide evidence of the impact and durability of dTMS on symptoms of MDD, PTSD, and suicidal ideation among Veterans with treatment-resistant depression.

Post-traumatic stress disorder symptoms are frequent among inflammatory bowel disease patients of South Asian descent-A case-control study

BACKGROUND

Post-traumatic stress (PTS) is the psycho-physiological response to a traumatic or life-threatening event and is implicated in inflammatory bowel disease (IBD). IBD-PTS is present in up to 30% of white, non-Hispanic patients. The rates of IBD in Asian populations are expanding, making the exploration of IBD-PTS in this population imperative.

METHODS

Adult patients of South/Southeast (S/SE) Asian decent with IBD for more than 6 months were recruited online via social media and patient-support groups. Participants completed the post-traumatic stress disorder (PTSD) Checklist-5 (PCL-5), the United States National Institutes of Health's Patient-Reported Outcomes Measurement Information System (NIH-PROMIS) -43 profile and demographics. S/SE Asian participants were age and sex matched (1:2) with randomly selected white, non-Hispanic controls. Statistical analyses evaluated differences in IBD-PTS symptoms between groups, the relationship between disease severity and health-related quality of life (HRQoL) and predictors of IBD-PTS severity.

RESULTS

Forty-seven per cent of the 51 S/SE Asian participants met the diagnostic cut-off for PTSD on the PCL-5 compared to 13.6% of 110 IBD controls. The mean global score on the PCL-5 was three times higher in S/SE Asians. Patients of S/SE Asian decent were over five times more likely to have PTSD due to their IBD experiences than controls, nearly doubling when controlling for disease activity. More severe IBD-PTS was present in S/SE Asian patients with active disease and those with extraintestinal manifestations. Higher global levels of IBD-PTS were associated with poorer HRQoL in S/SE Asians where increased hyperarousal from IBD-PTS predicted more sleep disturbance.

CONCLUSIONS

S/SE Asian patients are five times more likely to experience IBD-PTS than their white, non-Hispanic counterparts. Several cultural factors lead to IBD-PTS in S/SE Asian patients that must be considered by IBD providers. Preventing, screening for and treating IBD-PTS in this population appears warranted.

Associations of past-year overall trauma, sexual assault and PTSD with social support for young adult sexual minority women

Background: Young adult sexual minority women (SMW) are at elevated risk for sexual assault (SA), posttraumatic stress disorder (PTSD), and inadequate social support. While SA and PTSD can lead to reductions in social support from close significant others, the impact of SA and PTSD on SMWs' social support has not previously been assessed.Objective: This study examined the associations of past year SA and PTSD with SMW's social support from intimate partners, family, and friends. It was hypothesized that SA and PTSD would be negatively associated with support from partners, family and friends, and that PTSD would moderate the effect of SA on support in early adulthood.Method: Young adult SMW in the United States (N = 235) who were M = 23.93 (SD = 2.15) years old, primarily lesbian or bisexual (n = 186, 79.1%) and White (n = 176, 74.9%) completed measures on past year exposure to SA and non-SA trauma, PTSD, and social support from intimate partners, family and friends.Results: PTSD was associated with less social support from partners, (b  = -0.06, SE = 0.02, p = .010, R2change = .02), family, (b  = -0.06, SE = 0.03, p = .025, R2change = .02), and friends, (b  = -0.07, SE = 0.02, p = .008, R2change = .02). There was a significant interaction between PTSD and SA on social support from partners (b  = -0.01, SE = 0.01, p = .047, R2change = .01). Neither non-SA nor SA trauma was associated with support from family or friends.Conclusions: Results underscore the potential impact of recent SA on intimate partnerships for young adult SMW with more severe PTSD. Future work should explore how addressing PTSD and improving social support quality may help SMW recover from traumatic experiences and ameliorate the effects of SA on intimate partnerships.

A Seeking Safety Mobile App for Recovery from PTSD and Substance Use Disorder: Results of a Randomized Controlled Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) co-occur frequently and have deleterious impact. Seeking Safety (SS) - an evidence-based, present-focused, coping skills model - lends itself to mobile app delivery.

OBJECTIVES

A novel SS mobile app is compared to a control app that lacks the interactivity, social engagement, and feature-richness of the SS app. We hypothesized that the SS app would outperform the control on primary outcome variables (substance use, trauma symptoms) and at least two secondary variables.

METHODS

Outpatients with current PTSD and SUD (n = 116) were randomized to the apps; assessed were pre, post (12 weeks), and 3-month follow-up in this online study.

RESULTS

The SS app outperformed the control on the primary outcomes, but not on secondary outcomes. Also both conditions evidenced significant change over time from pre to post, with gains sustained at follow-up. External medication and supports during the trial did not differ by condition.

CONCLUSION

This first RCT on a SS mobile app had positive results for reduction in substance use and trauma symptoms compared to a control app. This is noteworthy as mental health mobile apps, in general, evidence few positive outcomes. Our substance use finding is also notable as psychosocial interventions in PTSD/SUD populations find it harder to achieve reduction in SUD than trauma symptoms. Our control app may have represented too strong a comparison and weakened our ability to find results on secondary outcomes by condition.

Characterizing and Comparing Evidence-Based Psychotherapy Utilization Among Veterans with Co-occurring PTSD and Substance Use Disorder

Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options.

The Effect of Concussion Mechanism of Injury on Sleep Problems in Active Duty Service Members Following Deployment

INTRODUCTION

Sleep disruption is pervasive in the military and is generally exacerbated during deployment, partially due to increases in operational tempo and exposure to stressors and/or trauma. In particular, sleep disruption is a commonly reported symptom following deployment-related traumatic brain injury (TBI), though less is known about the prevalence of sleep disturbance as a function of whether the TBI was induced by high-level blast (HLB) or direct impact to the head. TBI assessment, treatment, and prognosis are further complicated by comorbidity with posttraumatic stress disorder (PTSD), depression, and alcohol misuse. Here, we examine whether concussion mechanism of injury is associated with differences in the prevalence of self-reported sleep disturbance following deployment in a large sample of U.S. Marines while accounting for probable PTSD, depression, and alcohol misuse.

MATERIALS AND METHODS

This was a retrospective cohort study of active duty enlisted Marines with a probable concussion (N = 5757) who completed the Post-Deployment Health Assessment between 2008 and 2012. Probable concussion was defined as endorsement of a potentially concussive event with corresponding loss or alteration of consciousness. The presence of concussion-related sleep problems was assessed with a dichotomous item. Probable PTSD, depression, and alcohol misuse were assessed using the Primary Care PTSD Screen, the Patient Health Questionnaire-2, and the Alcohol Use Identification Test-Concise, respectively. Logistic regression models investigated the effects of mechanism of injury (HLB vs. impact), PTSD, depression, and alcohol misuse on the presence of sleep problems, adjusting for sex and pay grade. The study was approved by the Naval Health Research Center Institutional Review Board.

RESULTS

Approximately 41% of individuals with a probable deployment-related concussion reported sleep problems following the event; 79% of concussed individuals reporting both HLB and probable PTSD reported sleep problems. All main effects were significantly associated with sleep disturbance in adjusted models. PTSD showed the strongest association with sleep disturbance (adjusted odds ratio [AOR] = 2.84), followed by depression (AOR = 2.43), HLB exposure (AOR = 2.00), female sex (AOR = 1.63), alcohol misuse (AOR = 1.14), and pay grade (AOR = 1.10). A significant HLB × PTSD interaction emerged (AOR = 1.58), which suggests that sleep disturbance was elevated among those with both HLB-induced (vs. impact-induced) concussions and presence (vs. absence) of PTSD. No other significant interactions emerged.

CONCLUSION

To our knowledge, this is the first study to examine the prevalence of concussion-related sleep complaints following deployment as a function of the mechanism of injury in individuals with and without probable PTSD and depression. Individuals with HLB-induced concussion were twice as likely to report sleep problems as those with an impact-induced concussion. Future work should examine these effects longitudinally with validated measures that assess greater precision of exposure and outcome assessment (e.g., blast intensity and type of sleep disturbance).

Disentangling the effects of PTSD from Gulf War Illness in male veterans via a systems-wide analysis of immune cell, cytokine, and symptom measures

BACKGROUND

One-third of veterans returning from the 1990-1991 Gulf War reported a myriad of symptoms including cognitive dysfunction, skin rashes, musculoskeletal discomfort, and fatigue. This symptom cluster is now referred to as Gulf War Illness (GWI). As the underlying mechanisms of GWI have yet to be fully elucidated, diagnosis and treatment are based on symptomatic presentation. One confounding factor tied to the illness is the high presence of post-traumatic stress disorder (PTSD). Previous research efforts have demonstrated that both GWI and PTSD are associated with immunological dysfunction. As such, this research endeavor aimed to provide insight into the complex relationship between GWI symptoms, cytokine presence, and immune cell populations to pinpoint the impact of PTSD on these measures in GWI.

METHODS

Symptom measures were gathered through the Multidimensional fatigue inventory (MFI) and 36-item short form health survey (SF-36) scales and biological measures were obtained through cytokine & cytometry analysis. Subgrouping was conducted using Davidson Trauma Scale scores and the Structured Clinical Interview for Diagnostic and statistical manual of mental disorders (DSM)-5, into GWI with high probability of PTSD symptoms (GWIH) and GWI with low probability of PTSD symptoms (GWIL). Data was analyzed using Analysis of variance (ANOVA) statistical analysis along with correlation graph analysis. We mapped correlations between immune cells and cytokine signaling measures, hormones and GWI symptom measures to identify patterns in regulation between the GWIH, GWIL, and healthy control groups.

RESULTS

GWI with comorbid PTSD symptoms resulted in poorer health outcomes compared with both Healthy control (HC) and the GWIL subgroup. Significant differences were found in basophil levels of GWI compared with HC at peak exercise regardless of PTSD symptom comorbidity (ANOVA F = 4.7, P = 0.01,) indicating its potential usage as a biomarker for general GWI from control. While the unique identification of GWI with PTSD symptoms was less clear, the GWIL subgroup was found to be delineated from both GWIH and HC on measures of IL-15 across an exercise challenge (ANOVA F > 3.75, P < 0.03). Additional differences in natural killer (NK) cell numbers and function highlight IL-15 as a potential biomarker of GWI in the absence of PTSD symptoms.

CONCLUSION

We conclude that disentangling GWI and PTSD by defining trauma-based subgroups may aid in the identification of unique GWI biosignatures that can help to improve diagnosis and target treatment of GWI more effectively.

Traumatic Brain Injury and Post-Traumatic Stress Disorder and Their Influence on Development and Pattern of Alzheimer's Disease Pathology in Later Life

Background

Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are potential risk factors for the development of dementia including Alzheimer's disease (AD) in later life. The findings of studies investigating this question are inconsistent though.

Objective

To investigate if these inconsistencies are caused by the existence of subgroups with different vulnerability for AD pathology and if these subgroups are characterized by atypical tau load/atrophy pattern.

Methods

The MRI and PET data of 89 subjects with or without previous TBI and/or PTSD from the DoD ADNI database were used to calculate an age-corrected gray matter tau mismatch metric (ageN-T mismatch-score and matrix) for each subject. This metric provides a measure to what degree regional tau accumulation drives regional gray matter atrophy (matrix) and can be used to calculate a summary score (score) reflecting the severity of AD pathology in an individual.

Results

The ageN-T mismatch summary score was positively correlated with whole brain beta-amyloid load and general cognitive function but not with PTSD or TBI severity. Hierarchical cluster analysis identified five different spatial patterns of tau-gray matter interactions. These clusters reflected the different stages of the typical AD tau progression pattern. None was exclusively associated with PTSD and/or TBI.

Conclusions

These findings suggest that a) although subsets of patients with PTSD and/or TBI develop AD-pathology, a history of TBI or PTSD alone or both is not associated with a significantly higher risk to develop AD pathology in later life. b) remote TBI or PTSD do not modify the typical AD pathology distribution pattern.

Effects of Antidepressants on Sleep in Post-traumatic Stress Disorder: An Overview of Reviews

Antidepressants are a commonly used, easily accessible, and overall safe treatment option for post-traumatic stress disorder (PTSD). The present review aims to evaluate the efficacy and safety of antidepressants in treating sleep disturbances in patients with PTSD. PubMed and the Cochrane Library were searched (July 2022) for systematic reviews and meta-analyses on the treatment of PTSD. Moreover, PubMed and ClinicalTrials.gov were searched for individual trials investigating the antidepressant treatment of PTSD (up to September 2022), and reference lists of all possibly relevant identified studies were screened. Sleep-related outcomes, i.e., total sleep time, sleep quality, dreams/ nightmares, insomnia, and somnolence, were extracted independently by at least two reviewers. Metaanalytic evaluations were performed wherever possible. 39 randomised controlled trials (RCTs) were identified; data from pooled analyses, reviews, and observational studies were used for antidepressants with a weak evidence base or when their findings were deemed important. Overall, scarce data exist on the effects of antidepressants on sleep outcomes among patients with PTSD. Some evidence may support the use of amitriptyline, nefazodone, paroxetine, and sertraline for improving sleep in patients with PTSD. Τhere was a meta-analytical trend indicating improvement of nightmares with fluoxetine, less insomnia with amitriptyline and more with brofaromine, as well as more somnolence with paroxetine vs. placebo, respectively. However, data from more than 1 RCT with a considerable number of patients were only available for paroxetine. Evidence is insufficient to draw safe conclusions. More and better-designed RCTs, with consistent reporting of sleep-related outcomes, are needed.

High Lifetime Blast Exposure Using the Blast Exposure Threshold Survey Is Associated With Worse Warfighter Brain Health Following Mild Traumatic Brain Injury

The purpose of this study was to extend previous research by examining the relationship between lifetime blast exposure and neurobehavioral functioning after mild TBI (MTBI) by (a) using a comprehensive measure of lifetime blast exposure, and (b) controlling for the influence of post-traumatic stress disorder (PTSD). Participants were 103 United States service members and veterans (SMVs) with a medically documented diagnosis of MTBI, recruited from three military treatment facilities (74.8%) and community-based recruitment initiatives (25.2%, e.g., social media, flyers). Participants completed a battery of neurobehavioral measures 12 or more months post-injury (Neurobehavioral Symptom Inventory, PTSD-Checklist PCLC, TBI-Quality of Life), including the Blast Exposure Threshold Survey (BETS). The sample was classified into two lifetime blast exposure (LBE) groups: High (n = 57) and Low (n = 46) LBE. In addition, the sample was classified into four LBE/PTSD subgroups: High PTSD/High LBE (n = 38); High PTSD/Low LBE (n = 19); Low PTSD/High LBE (n = 19); and Low PTSD/Low LBE (n = 27). The High LBE group had consistently worse scores on all neurobehavioral measures compared with the Low LBE group. When controlling for the influence of PTSD (using ANCOVA), however, only a handful of group differences remained. When comparing measures across the four LBE/PTSD subgroups, in the absence of clinically meaningful PTSD symptoms (i.e., Low PTSD), participants with High LBE had worse scores on the majority of neurobehavioral measures (e.g., post-concussion symptoms, sleep, fatigue). When examining the total number of clinically elevated measures, the High LBE subgroup consistently had a greater number of clinically elevated scores compared with the Low LBE subgroup for the majority of comparisons (i.e., four to 15 or more elevated symptoms). In contrast, in the presence of clinically meaningful PTSD symptoms (i.e., High PTSD), there were no differences between High versus Low LBE subgroups for all measures. When examining the total number of clinically elevated measures, however, there were meaningful differences between High versus Low LBE subgroups for those comparisons that included a high number of clinically elevated scores (i.e., six to 10 or more), but not for a low number of clinically elevated scores (i.e., one to five or more). High LBE, as quantified using a more comprehensive measure than utilized in past research (i.e., BETS), was associated with worse overall neurobehavioral functioning after MTBI. This study extends existing literature showing that lifetime blast exposure, that is largely subconcussive, may negatively impact warfighter brain health and readiness beyond diagnosable brain injury.

World Trade Center workers with asthma and post-traumatic stress disorder perceive airflow limitation more accurately

BACKGROUND

Post-traumatic stress disorder (PTSD) is a major risk factor for increased asthma morbidity among World Trade Center (WTC) workers.

OBJECTIVE

To investigate whether differences in perception of airflow limitation mediate the association of PTSD with worse asthma control in WTC workers.

METHODS

We collected data from WTC workers on asthma control (Asthma Control Questionnaire and Asthma Quality of Life Questionnaire) and daily peak expiratory flow (PEF) measures over 6 weeks. Perception of airway limitation was assessed by comparing guessed vs actual PEF values. Post-traumatic stress disorder was diagnosed using the Structured Clinical Interview. We used unadjusted and adjusted models to compare PEF and perception measures in WTC workers with PTSD with those of workers without PTSD.

RESULTS

Overall, 25% of 224 participants had PTSD. Post-traumatic stress disorder was associated with worse Asthma Control Questionnaire (2.2±0.8 vs 1.1±0.9, P < .001) and Asthma Quality of Life Questionnaire (3.9±1.1 vs 5.4±1.1, P < .001) scores. Adjusted analyses showed no significant differences in PEF between WTC workers with (351.9±143.3 L/min) and those without PTSD (364.6±131.6 L/min, P = .55). World Trade Center workers with PTSD vs those without PTSD had increased proportion of accurate perception (67.0±37.2% vs 53.5±38.1%, P = .01) and decreased underperception (23.3.0±32.1% vs 38.9±37.5%, P = .004) of airflow limitation during periods of limitation. Similar results were obtained in adjusted analyses.

CONCLUSION

This study indicates that differences in perception of airflow limitation may mediate the relationship of PTSD and increased asthma symptoms, given WTC workers with PTSD have worse self-reported asthma control, an increased proportion of accurate perception, and decreased underperception, despite no differences in daily PEF measures.

Assessing the association between probable posttraumatic stress disorder symptoms and quality of life among emergency service workers using path analysis

BACKGROUND

Emergency service workers have highly stressful occupations; the stressors encountered can contribute to the development of mental disorders such as depression, anxiety, and posttraumatic stress disorder (PTSD).

OBJECTIVE

The present study used a conceptual model and survey to identify variables influencing the association between probable PTSD and quality of life (QOL) in emergency service workers.

METHOD

PTSD was assessed using the Impact of Event Scale-Revised. QOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey. Path analysis was used to determine whether stress-coping (Brief Coping Orientation to Problems Experienced [Brief COPE] scores), social support (Multidimensional Scale of Perceived Social Support [MSPSS] scores), and resilience (Connor-Davidson Resilience Scale scores) explain the association between probable PTSD and QOL among 220 emergency service workers in Japan.

RESULTS

Impact of Event Scale-Revised scores were significantly positively associated with Brief COPE Active coping scores and significantly negatively associated with MSPSS scores. Brief COPE Active coping and MSPSS scores were significantly positively associated with Connor-Davidson Resilience Scale scores, which were in turn significantly positively associated with Medical Outcomes Study 36-Item Short-Form Health Survey scores.

CONCLUSION

Active coping in response to stressful situations is important for maintaining good mental health among emergency service workers. Active coping and social support may strengthen resilience, and resilience may improve QOL. Screening for mental health and QOL should include simultaneous assessment of stress-coping, social support, and resilience. Although the findings of this cross-sectional study are important, it could not confirm a causal relationship between PTSD and QOL.

Progesterone Attenuates the Stress Response in Individuals with Alcohol Dependence and Post-Traumatic Stress Disorder - A Pilot Study

OBJECTIVE

Evidence from laboratory studies suggests that progesterone may be effective in reducing stress and craving, and may improve cognitive performance in smokers and individuals with cocaine dependence. The objective of this study was to examine if progesterone would attenuate stress-induced craving, anxiety, affect and physiological measures, as well as improve stress-induced cognitive performance (processing speed and selective attention) in individuals diagnosed with alcohol use disorder (AUD) and post traumatic stress disorder (PTSD).

METHODS

This laboratory study included (n = 13) participants who were diagnosed with current AUD and PTSD who were randomly assigned to recive either progesterone (200mg bid) or placebo in identical looking capsules for 3 days. On the fourth day they completed a laboratory session. In the morning of the test session, they received the last dose of medication and completed the rest of the laboratory procedures. The procedures included presentation in random order of personalized trauma and neutral scripts with relaxation in between. Main outcomes included measure of craving, anxiety, affect and cognitive performance.

RESULTS

Consistent with other research, trauma scripts produced significantly greater increases in craving, anxiety and negative affect when compared with neutral scripts. Progesterone significantly reduced stress-induced symptoms of craving, anxiety, fear, anger and sadness but had no effect on positive emotions (joy, relaxation). Progesterone was effective in ameliorating stress-induced decreases in cognitive performance.

CONCLUSIONS

The findings from this study demonstrate that progesterone can be effective in reducing stress-induced craving, anxiety and negative affect in a laboratory setting in individuals with comorbid AUD and PTSD. Interestingly, progesterone also improved cognitive performance. These findings require replication in a larger clinical trial and may have implications for treatment among individuals with AUD and PTSD.This study was registered as NCT02187224, at www.clinicaltrials.gov.

Examining the Temporal Relation between Posttraumatic Stress Symptoms and Heavy Drinking among Veterans Receiving Mental Health Treatment in Primary Care

OBJECTIVE

Evidence for the use of integrated treatments targeting co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorders is steadily growing. However, limited work has evaluated the temporal association between posttraumatic stress symptoms (PTSS) and alcohol misuse over the course of integrated treatment, with no studies examining such interventions in primary care (PC). The current study examined temporal changes in PTSS and heavy drinking among individuals who received a brief treatment for co-occurring PTSD and alcohol misuse in PC (Primary Care Treatment Integrating Motivation and Exposure; PC-TIME) compared with those who received PC treatment as usual (PC-TAU).

METHOD

A total of 63 veterans (33 randomized to PC-TIME and 30 randomized to PC-TAU) presenting to PC with co-occurring PTSD and alcohol misuse were included in this study. PTSS and heavy drinking were examined at each treatment session for those in PC-TIME. Veterans in both conditions provided reports of PTSS and heavy drinking at baseline, 8-weeks (post-treatment), 14-weeks, and 20-week follow-ups.

RESULTS

Session-by-session findings for PC-TIME demonstrated that PTSS at Session 1 predicted a greater decrease in heavy drinking from Session 1 to Session 2. Moreover, heavy drinking at baseline predicted greater decreases in PTSS at 8-weeks for those in PC-TIME, whereas the reverse association was found for those randomized to PC-TAU. Additionally, heavy drinking at 8-weeks predicted decreased PTSS at 14-weeks for those randomized to PC-TAU.

CONCLUSIONS

The current study evidenced mixed support for the temporal precedence of PTSS and alcohol misuse. Relations between PTSS and heavy drinking appeared to be linked to treatment targets within PC-TIME and varied between treatment condition (PC-TIME versus PC-TAU). Notably, those with greater than average heavy drinking at the initiation of integrated treatment appeared to have greater reductions in PTSS at post-treatment. Results suggest a mutual maintenance model may best characterize the association between co-occurring PTSS and heavy drinking among treatment-seeking individuals.

Inescapable foot shock induces a PTSD-like phenotype and negatively impacts adult murine bone

Post-traumatic stress disorder (PTSD) is associated with osteopenia, osteoporosis and increased fracture risk in the clinical population. Yet, the development of preclinical models to study PTSD-induced bone loss remains limited. In this study, we present a previously unreported model of PTSD in adult female C57BL/6 mice, by employing inescapable foot shock and social isolation, that demonstrates high face and construct validity. A subset of mice exposed to this paradigm (i.e. PTSD mice) display long-term alterations in behavioral and inflammatory indices. Using three-dimensional morphometric calculations, cyclic reference point indentation (cRPI) testing and histological analyses, we find that PTSD mice exhibit loss of trabecular bone, altered bone material quality, and aberrant changes in bone tissue architecture and cellular activity. This adult murine model of PTSD exhibits clinically relevant changes in bone physiology and provides a valuable tool for investigating the cellular and molecular mechanisms underlying PTSD-induced bone loss.

Associations among Trauma Exposure, Post-Traumatic Stress Symptoms and Alcohol Use in Black/African American Treatment-Seeking Adults

OBJECTIVE

Black/African American (AA) individuals are a group at risk for co-occurring posttraumatic stress disorder (PTSD) symptoms and alcohol use due to unique cultural and system-level barriers. Although associations between trauma exposure, PTSD symptoms, and alcohol use are well established across various populations, Black/AA individuals are underrepresented in this literature, and related findings in this population are inconclusive. Thus, the goal of this study was to examine the associations among trauma exposure, PTSD symptoms, and alcohol use in a sample of treatment-seeking, Black/AA adults. We hypothesized that trauma exposure and alcohol use would be positively associated and that this relationship would be mediated by PTSD symptoms.

METHODS

This study conducted secondary analysis of screening data from a PTSD and alcohol use disorder clinical trial. Participants were 96 Black/AA adults (57.3% male; 2.0% Hispanic; M age = 44.73, SD = 11.83) who were seeking treatment for alcohol use and endorsed trauma exposure. Associations between trauma exposure, PTSD symptom severity, and quantity and frequency of alcohol use were tested using bivariate correlations and linear regressions. Hypothesized indirect effects were tested using IBM SPSS Statistics Version 27 PROCESS model 4 with bootstrapping.

RESULTS

Findings illustrated a significant positive association between trauma exposure and PTSD symptoms and between PTSD symptoms and drinks per typical drinking day. PTSD symptoms were not significantly associated with number of drinking days. Tests of indirect effects were significant for trauma exposure on drinks per typical drinking day through PTSD symptoms.

CONCLUSIONS

Results from the test of indirect effects suggest that among Black/AA adults with heavy alcohol use and trauma exposure, trauma exposure is associated with PTSD symptoms, which in turn is associated with quantity of alcohol use. These findings are consistent with research conducted with White/mixed groups and align with tenets of the self-medication model of PTSD-AUD comorbidity. These findings support current practices that highlight the importance of screening for and addressing PTSD and alcohol use in individuals exposed to trauma. Findings from this paper provide initial data on understudied relationships in an underserved sample and several suggestions are made to generate future research and improve clinical care for Black/AA adults.

CLINICAL TRIALS REGISTRY NAME

Pharmacogenetic Treatment With Anti-Glutaminergic Agents for Comorbid PTSD & AUD; ClinicalTrials.gov Identifier: NCT02884908.

Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study

OBJECTIVE

Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format.

METHOD

We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display.

RESULTS

Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes.

CONCLUSION

Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Substance Use after Completion of an Intensive Treatment Program with Concurrent Treatment for Posttraumatic Stress Disorder and Substance Use among Veterans: Examining the Role of PTSD Symptoms

OBJECTIVE

Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are costly and highly co-occurring diagnoses, particularly among veterans, suggesting a need to understand this comorbidity and effectively treat both disorders among this population.

METHODS

The current study aimed to examine substance use outcomes among post-9/11 veterans and service members (N = 48) who completed a two-week intensive outpatient program with concurrent treatment for and PTSD using Prolonged Exposure and substance use. Substance use was assessed at two weeks and three months posttreatment.

RESULTS

The intensive program had high completion rates and demonstrated decreases in substance use at two weeks and three months posttreatment. Additionally, lower PTSD symptoms at treatment completion were related to less substance use posttreatment.

CONCLUSIONS

Concurrent intensive treatment of PTSD and SUDs can lead to symptom improvement in a short period of time. Findings support the self-medication model, such that PTSD symptoms at treatment completion were related to substance use at follow-up.

Randomized, controlled clinical trial of acoustic stimulation to reduce postconcussive symptoms

OBJECTIVE

Effective interventions are needed to address postconcussive symptoms. We report the results of randomized, sham-controlled trial of Cereset Research™ Standard Operating Procedures (CR-SOP), a noninvasive, closed-loop, allostatic, acoustic stimulation neurotechnology previously shown to improve insomnia.

METHODS

Military service members, veterans, or their spouses with persistent symptoms (Neurobehavioral Symptom Inventory [NSI] Score ≥23) after mTBI 3 months to 10 years ago, were randomized to receive 10 sessions of engineered tones linked to brainwaves (LB, intervention), or random engineered tones not linked to brainwaves (NL, sham control). The primary outcome was change in NSI, with secondary outcomes of heart rate variability and self-report measures of sleep, mood, and anxiety.

RESULTS

Participants (n = 106, 22% female, mean age 37.1, 2.8 deployments, 3.8 TBIs) were randomized 1:1 to LB or NL, with no significant differences between groups at baseline. Among all study participants, the NSI declined from baseline 41.0 to 27.2 after (P < 0.0001), with gains largely sustained at 3 months (31.2) and 6 months (28.4). However, there were no significant differences between the LB (NSI declined from 39.9 at baseline to 28.2 post-intervention, 31.5 at 3 months, and 29.4 at 6 months) and NL (NSI declined from 41.5 at baseline to 26.2, 29.9, and 27.3, respectively. Similar patterns were observed for the PCL5 and PHQ-9 and there was no difference in HRV between groups.

INTERPRETATION

Ten hours of acoustic stimulation while resting in a zero-gravity chair improves postconcussive symptoms. However, linking tones to brain electrical activity did not reduce symptoms more than random tones.

REGISTRATION

ClinicalTrials.gov - NCT03649958.

A 28-Year-Old Man with Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and Dissociative Identity Disorder Responding to Aripiprazole Augmentation of Clomipramine Combined with Psychoeducation and Exposure and Response Prevention

BACKGROUND We report the case of a 28-year-old man with comorbidity of OCD, PTSD, and DID responding to aripiprazole augmentation of clomipramine combined with psychoeducation and exposure and response prevention (ERP). CASE REPORT A 28-year-old, well-educated man presented with depression, obsessive thoughts, behavioral impulsivity, and suicidal thoughts/behavior. He was known to be stubborn and sensitive to criticism since childhood. The obsessive thoughts and compulsive behaviors also started at an early age. He had 4 past psychiatric hospitalizations, mostly for dissociative episodes and bizarre behaviors, complicated with significant anxiety and distress from traumatic experiences during doctoral study. He had no-to-minimal responses to various psychotropics and traditional Chinese medicine. A thorough assessment showed he met the diagnostic criteria for OCD, PTSD, and DID. He was then treated with clomipramine in combination with aripiprazole, plus psychoeducation and exposure and response prevention (ERP). His anxiety and irritability significantly improved within 2 months and his obsessive thoughts faded away. At 6-month follow-up, the patient achieved clinical remission. One year later, he remained stable and reported having a normal life. CONCLUSIONS The case illustrates both how impairing the comorbidity of OCD, PTSD, and DID can be and how concurrent use of tricyclic antidepressant (TCA) clomipramine and partial dopamine agonist aripiprazole, together with psychoeducation and ERP, can improve outcomes when other treatment choices fail to be effective.

Enduring association between irritable bowel syndrome and war trauma during the Nicaragua civil war period: A population-based study

BACKGROUND

Psychosocial and physical trauma are known risk factors for irritable bowel syndrome (IBS), including in war veterans, whereas war exposure in civilians is unclear. Nicaragua experienced two wars, 1970-1990: The Sandinistas Revolution (1970s) and The Contra War (1980s). Our aim was to investigate the role of exposure to war trauma in the subsequent development of IBS in the context of an established health surveillance system (11000 households).

AIM

To investigate in a civilian population the relationship between exposure to war trauma and events and the subsequent development of IBS in the context of an established public health and demographic surveillance system in western Nicaragua.

METHODS

We conducted a nested population-based, cross-sectional study focused on functional gastrointestinal disorders based on Rome II criteria. 1617 adults were randomly selected. The Spanish Rome II Modular Questionnaire and Harvard Trauma Questionnaire were validated in Nicaragua. War exposure was assessed with 10 measures of direct and indirect war trauma and post-war effects. Multiple exposures were defined by ≥ 3 measures.

RESULTS

The prevalence of IBS was 15.2% [Female (F) 17.1%, Male (M) 12.0%], war exposure 19.3% (F 9.3%, M 36.7%), and post-traumatic stress disorder (PTSD) 5.6% (F 6.4%, M 4.3%). Significant associations with IBS in the civilian population were observed (adjusted by gender, age, socioeconomic status, education): physical and psychological abuse [adjusted odds ratio (aOR): 2.25; 95% confidence interval: 1.1-4.5], witnessed execution (aOR: 2.4; 1.1-5.2), family member death (aOR: 2.2; 1.2-4.2), and multiple exposures (aOR: 2.7; 1.4-5.1). PTSD was independently associated with IBS (aOR: 2.6; 1.2-5.7).

CONCLUSION

An enduring association was observed in the Nicaragua civilian population between specific civil war-related events and subsequent IBS. Civilian populations in regions with extended armed conflict may warrant provider education and targeted interventions for patients.

Neuropsychological Consequences of Massive Trauma: Implications and Clinical Interventions

Traumatic events, especially massive trauma resulting from catastrophic incidents, wars, or severe abuse can elicit significant neuropsychological alterations, with profound implications for cognitive, emotional, and behavioral functioning. This mini-review delineates the primary neural changes post-trauma and underscores the importance of timely neuropsychological and clinical interventions. Specific brain regions, including the amygdala and prefrontal cortex, undergo physiological changes that can lead to memory impairments, attention deficits, and emotional disturbances. PTSD, a commonly diagnosed condition post-trauma, exemplifies the intricate relationship between trauma and memory processing. Furthermore, the concept of neuroplasticity, the brain's inherent ability to adapt and rewire, offers hope for recovery. Current clinical interventions, such as cognitive behavioral therapy, mindfulness practices, and biofeedback, leverage this neuroplastic potential to foster healing. The review underscores the vital importance of early intervention to mitigate long-term neuropsychological impacts, emphasizing the role of timely and targeted clinical interventions. The synthesis of this knowledge is crucial for clinicians, allowing for informed therapeutic approaches that holistically address both the physiological and psychological dimensions of trauma.

The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study

STUDY OBJECTIVES

Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression.

METHODS

Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories.

RESULTS

We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis.

CONCLUSIONS

Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD.

CITATION

Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.