Publications by authors named "Christopher R Erbes"

73 Publications

Pre-deployment personality traits predict prescription opioid receipt over 2-year post-deployment period in a longitudinal cohort of deployed National Guard soldiers.

Addict Behav 2021 Mar 22;119:106919. Epub 2021 Mar 22.

Minneapolis VA Health Care System, Minneapolis, MN, USA; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Psychology, University of Minnesota, Minneapolis, MN, USA. Electronic address:

Background: While military service members are at risk forpain conditions, receipt of prescribed opioids is associated with a range of serious adverse outcomes. The goal of this study is to examine the association between pre-deployment personality traits and receipt of prescription opioids after return from deployment.

Method: Data were drawn from the Readiness and Resilience in National Guard Soldiers (RINGS) cohort study, an ongoing study of post-deployment health. Participants (N = 522) completed baseline assessments one month prior to deploying to Iraq (2006-2007). At baseline, we assessed personality traits using abbreviated versions of the Personality Psychopathology Five scales from the Minnesota Multiphasic Personality Inventory-2. Follow-up assessments were conducted three months, one year, and two years post-deployment. The primary outcome was total amount of prescribed opioids dispensed from Department of Veterans Affairs outpatient pharmacies in the two-year period following soldiers' return from deployment. Unadjusted and adjusted negative binomial regression models examined the relationships of pre-deployment personality traits, demographics (age, gender, and rank), baseline trauma symptoms, deployment related risk factors (difficult living/working environment, deployment injury, combat exposure), and post-deployment trauma symptoms with post-deployment opioid prescribing.

Results: Disconstraint, negative emotionality, and introversion/low positive emotionality were associated with receipt of more prescribed opioids over the two years after return from deployment. Personality traits measured at baseline remained statistically significantly after adjusting for all eight baseline and deployment risk factors of interest.

Conclusions: Understanding how pre-deployment personality traits contribute to post-deployment prescription opioid use could inform efforts to improve veterans' health.
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http://dx.doi.org/10.1016/j.addbeh.2021.106919DOI Listing
March 2021

Posttraumatic stress disorder and anesthesia: Respect for the military veteran's mind.

J Clin Anesth 2021 Mar 25;71:110242. Epub 2021 Mar 25.

Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Minneapolis, MN, 55417, USA; Department of Anesthesiology, University of Minnesota School of Medicine, B515 Mayo Memorial Building, 420 Delaware St SE, Minneapolis, MN 55455, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2021.110242DOI Listing
March 2021

Corrigendum: Methylation of and in Relation to Treatment Response to Mindfulness Based Stress Reduction for Posttraumatic Stress Disorder.

Front Psychiatry 2021 4;12:642245. Epub 2021 Mar 4.

Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States.

[This corrects the article DOI: 10.3389/fpsyt.2018.00418.].
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http://dx.doi.org/10.3389/fpsyt.2021.642245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970629PMC
March 2021

The Association Between Smoking Abstinence and Pain Trajectory among Veterans Engaged in VA Mental Health Care.

Pain Med 2021 Jan 27. Epub 2021 Jan 27.

VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, MN, USA.

Objective: To prospectively examine associations between smoking and nicotine abstinence and pain trajectory over 12-months among smokers with low, moderate, and severe pain, and to assess whether these associations differ over time.

Design: A secondary analysis of the "Proactive Outreach for Smokers in VA Mental Health" study; a randomized controlled trial of proactive outreach for veteran smokers engaged in VA mental health care.

Methods: Participants were categorized into "low" (n = 616), "moderate" (n = 479), and "severe" pain (n = 656) groups according to baseline pain score. Associations between self-reported abstinence from smoking and nicotine at 6- and 12-months and pain trajectory, measured using the PEG scale (Pain intensity, Enjoyment of life, General activity) composite score, were assessed using general linear mixed models. Interaction tests assessed whether these associations differed at 6- and 12-months. Analyses were conducted within the overall sample and within the separate pain groups.

Results: There were significant interactions in the overall sample and the low and moderate pain groups, such that 7-day point prevalence smoking abstinence was associated with lower pain scores at 6- but not 12-months. In the severe pain group, 7-day abstinence from both smoking and nicotine was associated with lower pain scores across both time points. Six-month prolonged abstinence was not associated with pain scores.

Conclusions: In this prospective analysis conducted among veteran smokers engaged in mental health services, 7-day abstinence from smoking and nicotine was associated with significantly lower levels of pain. Education efforts could help better inform smokers on the relationship between smoking and pain.
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http://dx.doi.org/10.1093/pm/pnab009DOI Listing
January 2021

Adult Emergence Agitation: A Veteran-Focused Narrative Review.

Anesth Analg 2021 02;132(2):353-364

From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.

Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.
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http://dx.doi.org/10.1213/ANE.0000000000005211DOI Listing
February 2021

Adult Emergence Agitation: A Veteran-Focused Narrative Review.

Anesth Analg 2021 02;132(2):353-364

From the Department of Anesthesiology, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.

Emergence agitation (EA) is a self-limited state of psychomotor excitement during awakening from general anesthesia. EA is confined to the emergence period as consciousness is restored, which sharply distinguishes it from other postoperative delirium states. Sporadic episodes of EA may become violent with the potential for harm to both patients and caregivers, but the long-term consequences of such events are not fully understood. Current literature on EA in adults is limited to small-scale studies with inconsistent nomenclature, variable time periods that define emergence, a host of different surgical populations, and conflicting diagnostic criteria. Therefore, true incidence rates and risk factors are unknown. In adult noncardiac surgery, the incidence of EA is approximately 19%. Limited data suggest that young adults undergoing otolaryngology operations with volatile anesthetic maintenance may be at the highest risk for EA. Currently suggested EA mechanisms are theoretical but might reflect underblunted sympathetic activation in response to various internal (eg, flashbacks or anxiety) or external (eg, surgical pain) stimuli as consciousness returns. Supplemental dexmedetomidine and ketamine may be utilized for EA prevention. Compared to the civilian population, military veterans may be more vulnerable to EA due to high rates of posttraumatic stress disorder (PTSD) manifesting as violent flashbacks; however, confirmatory data are limited. Nonetheless, expert military medical providers suggest that use of patient-centered rapport tactics, PTSD trigger identification and avoidance, and grounding measures may alleviate hyperactive emergence phenomena. Future research is needed to better characterize EA in veterans and validate prophylactic measures to optimize care for these patients. This narrative review provides readers with an important framework to distinguish EA from delirium. Furthermore, we summarize current knowledge of EA risk factors, mechanisms, and adult management strategies and specifically revisit them in the context of veteran perioperative health. The anesthesiology care team is ideally positioned to further explore EA and develop effective prevention and treatment protocols.
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http://dx.doi.org/10.1213/ANE.0000000000005211DOI Listing
February 2021

A Pilot Trial of Online Training for Family Well-Being and Veteran Treatment Initiation for PTSD.

Mil Med 2020 03;185(3-4):401-408

Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417.

Introduction: Family members are important supports for veterans with Posttrauamtic Stress Disroder (PTSD), but they often struggle with their own distress and challenges. The Veterans Affairs-Community Reinforcement and Family Training (VA-CRAFT) website was designed to teach family members of veterans with PTSD effective ways to interact with their veterans to encourage initiation of mental health services as well as to care for themselves and improve their relationships. This article presents a pilot investigation of VA-CRAFT.

Materials And Method: Spouse/partners of veterans who had screened positive for PTSD but were not in mental health treatment were randomized to either use the VA-CRAFT website (n = 22) or to a waitlist control condition (n = 19) for 3 months. Veteran mental health service initiation was assessed posttreatment. Spouse/partner distress, caregiver burden, quality of life, and relationship quality were assessed pre and posttreatment. The study was approved by the Minneapolis VA Health Care System Institutional Review Board (IRB).

Results: Differences between groups on veteran treatment initiation were small (Phi = 0.17) and not statistically significant. VA-CRAFT participants reported large and statistically significantly greater decreases in overall caregiver burden (η2 = 0.10) and objective caregiver burden (η2 = 0.14) than control participants. Effects were larger for those with greater initial distress. Effects sizes for other partner outcomes were negligible (η2 = 0.01) to medium (η2 = 0.09) and not statistically significant. Postintervention interviews suggested that only 33% of the VA-CRAFT participants talked with their veterans about starting treatment for PTSD during the trial.

Conclusion: Results from this pilot trial suggest that VA-CRAFT holds initial promise in reducing caregiver burden and as such it could be a useful resource for family members of veterans with PTSD. However, VA-CRAFT does not enhance veteran treatment initiation. It may benefit from enhancements to increase effectiveness and caregiver engagement.
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http://dx.doi.org/10.1093/milmed/usz326DOI Listing
March 2020

International meta-analysis of PTSD genome-wide association studies identifies sex- and ancestry-specific genetic risk loci.

Nat Commun 2019 10 8;10(1):4558. Epub 2019 Oct 8.

Durham VA Medical Center, Research, Durham, NC, USA.

The risk of posttraumatic stress disorder (PTSD) following trauma is heritable, but robust common variants have yet to be identified. In a multi-ethnic cohort including over 30,000 PTSD cases and 170,000 controls we conduct a genome-wide association study of PTSD. We demonstrate SNP-based heritability estimates of 5-20%, varying by sex. Three genome-wide significant loci are identified, 2 in European and 1 in African-ancestry analyses. Analyses stratified by sex implicate 3 additional loci in men. Along with other novel genes and non-coding RNAs, a Parkinson's disease gene involved in dopamine regulation, PARK2, is associated with PTSD. Finally, we demonstrate that polygenic risk for PTSD is significantly predictive of re-experiencing symptoms in the Million Veteran Program dataset, although specific loci did not replicate. These results demonstrate the role of genetic variation in the biology of risk for PTSD and highlight the necessity of conducting sex-stratified analyses and expanding GWAS beyond European ancestry populations.
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http://dx.doi.org/10.1038/s41467-019-12576-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783435PMC
October 2019

Measuring perceived efficacy for coping with posttraumatic stress disorder in the workplace.

Work 2019 ;63(2):283-289

U.S. Department of Veterans Affairs National Center for PTSD, Menlo Park, CA, USA.

Background: PTSD is associated with high levels of vocational difficulty, and research on relationships between PTSD and vocational adjustment may be relevant to vocational rehabilitation services to achieve optimal outcomes. Veteran perception of ability to cope with stressors in the workplace setting may play a role in rehabilitation outcome.

Objective: This article outlines preliminary steps in the development of the Vocational Efficacy in Trauma Survivors Scale (VETSS), to measure perceived efficacy in managing PTSD symptoms in the workplace. This has potential to expand future options for research in vocational rehabilitation for veterans with PTSD.

Methods: Veterans in outpatient treatment for PTSD at a large, mid-western Veterans Affairs Health Care System facility responded to items on the proposed instrument and items on other measures of vocational and psychological functioning to assess the potential validity of items for an instrument to measure vocational self-efficacy among veterans managing PTSD.

Results: In a sample of 63 working veterans who receive outpatient care for PTSD, exploratory factor analysis identified two viable subscales, one tapping Workplace Coping, and another tapping Self-Disclosure.

Conclusions: Preliminary findings indicate that the measure demonstrated acceptable indications of reliability and validity, suggesting promise for future use in vocational rehabilitation research.
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http://dx.doi.org/10.3233/WOR-192929DOI Listing
September 2019

Employment outcomes from VA vocational services involving transitional work for veterans with a diagnosis of posttraumatic stress disorder.

Psychiatr Rehabil J 2019 Sep 4;42(3):257-267. Epub 2019 Apr 4.

Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System.

Objective: Transitional work (TW) for veterans with psychiatric disabilities is the predominant model of vocational rehabilitation in the Veterans Health Administration (VA). Although, on average, TW employment outcomes have been demonstrated to be inferior to supported employment, little is known about the potential subgroup of veterans for which TW may be most effective. This study of veterans with posttraumatic stress disorder (PTSD) examines differences in competitive employment outcomes and identifies characteristics of veterans who chose to engage in TW compared with those who did not.

Method: A post hoc comparative subgroup analysis of veterans with PTSD randomly assigned to TW as part of a randomized controlled trial was conducted. Veterans were divided into 2 subgroups: those who engaged in TW (n = 141) and nonengagers (n = 129). Differences in baseline characteristics were examined and 18-month employment outcomes were compared.

Results: There were no differences in 18-month employment outcomes between TW engagers and nonengagers. Compared with TW engagers, those that did not engage in TW were 2.5 times more likely to get a competitive job within the first 6 months and were less likely to obtain lower skilled jobs. Younger age, adequate housing, personal means of transportation, and recent work history factor into the odds of gaining and maintaining competitive work.

Conclusions And Implications For Practice: Consistent with past research, engagement in TW did not result in improved long-term competitive employment outcomes for veterans with PTSD. Those who did not engage in TW were more likely to gain a competitive job within the first 6 months. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6910199PMC
September 2019

Sticking it out in trauma-focused treatment for PTSD: It takes a village.

J Consult Clin Psychol 2019 Mar;87(3):246-256

Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System.

Objective: One in 3 veterans will dropout from trauma-focused treatments for posttraumatic stress disorder (PTSD). Social environments may be particularly important to influencing treatment retention. We examined the role of 2 support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage veterans to participate in treatment and face distress) and symptom accommodation (changes in loved ones' behavior to reduce veterans' PTSD-related distress).

Method: Veterans and a loved one were surveyed across 4 VA hospitals. All veterans were initiating prolonged exposure therapy or cognitive processing therapy (n = 272 dyads). Dropout was coded through review of VA hospital records.

Results: Regression analyses controlled for traditional, individual-focused factors likely to influence treatment dropout. We found that, even after accounting for these factors, veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than veterans who denied such encouragement.

Conclusions: Clinicians initiating trauma-focused treatments with veterans should routinely assess how open veterans' support systems are to encouraging veterans to face their distress. Outreach to support networks is warranted to ensure loved ones back the underlying philosophy of trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548182PMC
March 2019

Methylation of and in Relation to Treatment Response to Mindfulness Based Stress Reduction for Posttraumatic Stress Disorder.

Front Psychiatry 2018 18;9:418. Epub 2018 Sep 18.

Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States.

Mindfulness Based Stress Reduction (MBSR) is an effective non-pharmacologic treatment for veterans with PTSD. Extensive work has identified epigenetic factors related to PTSD disease risk and pathophysiology, but how these factors influence treatment response is unclear. Serotonin signaling and hypothalamic-pituitary-adrenal (HPA) axis functioning may be perturbed in PTSD and are molecular pathways targeted by PTSD treatments. To identify potential biomarkers for treatment response, we utilized genomic DNA isolated from peripheral blood samples from veterans with PTSD who were responders ( = 11) or non-responders ( = 11) to MBSR as part of a clinical trial. We assessed methylation levels at CpG sites in regions of the serotonin transporter () previously associated with expression and depression outcomes, as well as the Intron 7 region of the FK506 binding protein 5 () containing known glucocorticoid response elements suggested to regulate this gene. Selected subjects were matched across MBSR responder status by baseline symptoms, age, sex, current smoking status, and current antidepressant use. Percent methylation was compared between responders and non-responders at baseline (pre-MBSR treatment). Additionally, percent change in methylation from baseline to post-treatment was compared between responders and non-responders. There was a significant time x responder group interaction for methylation in intron 7 bin 2 [ = 7.492, = 0.013] whereby responders had a decrease in methylation and non-responders had an increase in methylation from before to after treatment in this region. Analyses of the three CpG sites within bin 2 revealed a significant time x responder group interaction for CpG_35558513 [ = 5.551, = 0.029] which resides in a known glucocorticoid response element (GRE). Decreases in methylation after treatment in responders as compared to increases in non-responders suggest that effective meditation intervention may be associated with stress-related pathways at the molecular level. These preliminary findings suggest that DNA methylation signatures within are potential indicators of response to meditation treatment in PTSD and require validation in larger cohorts.
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http://dx.doi.org/10.3389/fpsyt.2018.00418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153325PMC
September 2018

Transcendental meditation for veterans with post-traumatic stress disorder.

Psychol Trauma 2018 Nov 19;10(6):675-680. Epub 2018 Jul 19.

Department of Psychiatry, University of Minnesota, Twin Cities.

Objective: Transcendental Meditation (TM) is a mental technique using a mantra to facilitate meditation. TM has a potential for treating symptoms of posttraumatic stress disorder (PTSD), but its clinical efficacy remains to be clarified. This pilot study evaluated the acceptability, preliminary effectiveness, and neurophysiology of TM for veterans with PTSD.

Method: Twenty-nine veterans (20.7% female) were recruited from a major medical center and enrolled in the study. TM instruction was provided by certified TM teachers from the Maharishi Foundation and consisted of 8 weeks of individual and group-based meditation instruction and practice. Outcomes were assessed at baseline, during treatment, posttreatment, and at 2-month follow-up, and included clinical interviews, self-report questionnaires, and electroencephalography (EEG) recorded during resting and meditation states.

Results: From baseline to posttreatment, participants reported reductions in PTSD symptoms, experiential avoidance, and depressive and somatic symptoms, as well as increases on measures of mindfulness and quality of life. Gains were either maintained or continued to improve through the 2-month follow-up. Compared to baseline, EEG spectral power increased in low-frequency bands (1-7 Hz) at posttreatment and follow-up and only during meditation states suggesting TM-specific changes in brain state associated with the intervention.

Conclusions: TM appears to be an acceptable and effective treatment for veterans with PTSD that warrants further study regarding specific outcomes and beneficial changes in brain function. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000346DOI Listing
November 2018

Sleep Patterns and Problems Among Army National Guard Soldiers.

Mil Med 2018 11;183(11-12):e396-e401

Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, MN.

Introduction: Adequate sleep plays an integral role in the physical and mental health of individuals, while simultaneously influencing their cognitive and work performance. Having recognized this, the U.S. Army has focused efforts on improving soldiers' healthy sleep behaviors. This study examines the extent to which mental health, alcohol use, and certain sleep hygiene behaviors predict sleep problems within an Army National Guard sample (N = 438).

Materials And Methods: This manuscript is part of a larger study approved through the Minneapolis Veterans Affairs Medical Center Institutional Review Board. Mailed surveys were sent to Minnesota Army National Guard soldiers collecting data on sleep hygiene behaviors, mental health symptoms (post-traumatic stress disorder and depression), and alcohol use. Predictors of sleep problems were evaluated with ordinary least squares multiple linear regression analyses, regressing Insomnia Severity Index total scores on demographic variables, post-traumatic stress disorder (PTSD), depression, alcohol use, sleep hygiene factors (routine and consumption activity; both derived from exploratory factor analysis), and technology use (multiple device use and use before bed).

Results: Overall, the majority of participants did not endorse high levels of sleep impairment, while 16.4% screened positive for moderate or even severe levels of clinical insomnia. Bivariate correlations demonstrated that sleep problems were correlated with PTSD symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < 0.001), Sleep Hygiene Routine (r = -0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, p = 0.002). The overall regression model predicting sleep problems was significant (R2 = 0.35, adj R2 = 0.34, F[8,408] = 27.58, p < 0.001). Independent predictors of sleep problems included gender (B = 0.99, β = 0.09, t = 2.10, p = 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depression (B = 1.53, β = 0.20, t = 7.56, p < 0.001), and Sleep Hygiene Routine (B = -0.88, β = -0.23, t = -5.473, p < 0.001). Alcohol use, Sleep Hygiene Consumption, and technology use did not emerge as independent predictors.

Conclusion: Although most soldiers denied sleep problems, a sizeable minority met screening criteria for clinical insomnia. Greater numbers of sleep-related complaints were related to psychological distress including depressive and PTSD symptoms, while adherence to a bedtime routine (Sleep Hygiene Routine) showed an inverse relationship. Alcohol use and sleep hygiene consumption activities were not predictive of sleep problems, suggesting that different sleep hygiene behaviors have differential relationships with sleep problems. Screening and intervention for specific sleep problems may be helpful even very early in Army National Guard service members' careers. Particular focus may be needed for those showing signs of emotional distress, such as PTSD or depression. Future research examining the impact of individual sleep hygiene components is warranted.
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http://dx.doi.org/10.1093/milmed/usy107DOI Listing
November 2018

Psychometric evaluation of a measure of intimate partner communication during deployment.

J Fam Psychol 2018 02;32(1):31-41

Department of Psychiatry, National Center for PTSD-Veterans Affairs Boston Healthcare System.

Intimate partner communication has become a part of the daily routine of military couples during deployment. However, there is a scarcity of research examining the individual and relationship implications of communication during deployment, likely due in part to the lack of existing measures of deployment communication. The current study examined the psychometric characteristics of a newly developed, multidimensional tool for assessing the process and outcomes of deployment communication in a sample of 391 recently deployed male Army National Guard soldiers and their female intimate partners. The Deployment Communication Inventory (DCI) contains 6 Soldier and 6 partner scales that assess (a) frequency of communication, (b) nature of communication (Assurance/Support, Problem-Solving/Disclosure, and Conflict), and (c) perceived consequences of communication (Benefits and Costs). Scales demonstrated good internal consistency reliability and convergent validity with measures of relationship and family functioning and individual mental health. The DCI may serve as a useful assessment tool for examining the impact of deployment communication on military families. (PsycINFO Database Record
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http://dx.doi.org/10.1037/fam0000382DOI Listing
February 2018

Role of social context in posttraumatic stress disorder (PTSD).

Curr Opin Psychol 2017 Apr 24;14:138-142. Epub 2017 Jan 24.

Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, One Veterans Drive (68-2), Minneapolis, MN 55417, USA; Department of Psychiatry, University of Minnesota Medical School, 2450 Riverside Avenue, Minneapolis, MN 55454, USA.

Research has increasingly focused on the role that social circumstances before, during, and after trauma exposure play in risk for posttraumatic stress disorder (PTSD). In this article, we provide an overview of conceptual and methodological challenges to the study of social context's role in PTSD and propose strategies that can mitigate these challenges. Throughout the article, we draw from the current literature to illustrate how attention to these issues can lead to advances in our knowledge of the role of social context in PTSD.
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http://dx.doi.org/10.1016/j.copsyc.2017.01.006DOI Listing
April 2017

Workplace social support in job satisfaction among veterans with posttraumatic stress symptoms: A preliminary correlational study.

PLoS One 2017 4;12(8):e0181344. Epub 2017 Aug 4.

Minneapolis VA Health Care System, Minneapolis, Minnesota, United States of America.

For Veterans managing PTSD symptoms, returning to vocational functioning is often challenging; identifying modifiable variables that can contribute to positive vocational adjustment is critical to improved vocational rehabilitation services. Workplace social support has proven to be important in vocational adjustment in both general population and vocational rehabilitation samples, but this area of inquiry has received little attention among Veterans with PTSD symptoms. In this small correlational study, employed Veterans (N = 63) presenting for outpatient PTSD treatment at a VA Health Care System completed surveys assessing demographic variables, PTSD symptoms, workplace social support, and job satisfaction. Workplace social support contributed to the prediction of job satisfaction. It is of note that workplace social support predicted a larger proportion of the variance in employment satisfaction than PTSD symptoms. Further research on workplace social support as a vocational rehabilitation resource for Veterans with PTSD is indicated.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0181344PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5544179PMC
October 2017

Resilience and Posttraumatic Stress Disorder Symptoms in National Guard Soldiers Deployed to Iraq: A Prospective Study of Latent Class Trajectories and Their Predictors.

J Trauma Stress 2017 08 1;30(4):351-361. Epub 2017 Aug 1.

Minneapolis VA Medical Center, Minneapolis, Minnesota, USA.

This study examined the prospective course of posttraumatic stress disorder (PTSD) symptoms in a cohort of National Guard soldiers (N = 522) deployed to combat operations in Iraq. Participants were assessed 4 times: 1 month before deployment, 2-3 months after returning from deployment, 1 year later, and 2 years postdeployment. Growth mixture modeling revealed 3 distinct trajectories: low-stable symptoms, resilient, 76.4%; new-onset symptoms, 14.2%; and chronic distress, 9.4%. Relative to the resilient class, membership in both the new-onset symptoms and chronic distress trajectory classes was predicted by negative emotionality/neuroticism, odds ratios (ORs) = 1.09, 95% CI [1.02, 1.17], and OR = 1.22, 95% CI [1.09,1.35], respectively; and combat exposure, OR = 1.07, 95% CI [1.02, 1.12], and OR = 1.12, 95% CI [1.02, 1.24], respectively. Membership in the new-onset trajectory class was predicted by predeployment military preparedness, OR = 0.95, 95% CI [0.91, 0.98], perceived threat during deployment, OR = 1.07, 95% CI [1.03, 1.10], and stressful life events following deployment, OR = 1.44, 95% CI [1.05, 1.96]. Prior deployment to Iraq or Afghanistan, OR = 3.85, 95% CI [1.72, 8.69], predeployment depression, OR = 1.27, 95% CI [1.20, 1.36], and predeployment concerns about a deployment's impact on civilian/family life, OR = 1.09, 95% CI [1.02, 1.16], distinguished the chronic distress group relative to the resilient group. Identifying predeployment vulnerability and postdeployment contextual factors provides insight for future efforts to bolster resilience, prevent, and treat posttraumatic symptoms.
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http://dx.doi.org/10.1002/jts.22199DOI Listing
August 2017

At-home partner sleep functioning over the course of military deployment.

J Fam Psychol 2018 02 19;32(1):114-122. Epub 2017 Jun 19.

Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System.

Although the negative effects of deployment on the health of military spouses have been studied, research on sleep disruptions remains limited. This study investigates trajectories of sleep complaints over the course of deployment and predictors of these changes among a cohort of at-home partners. Data were drawn from the Readiness and Resilience in National Guard Soldiers (RINGS-2) project, a prospective, longitudinal study of National Guard soldiers deployed to Iraq/Kuwait (2011-2012) and their intimate partners. Spouses or cohabiting partners (N = 686) of soldiers completed assessments of risk/protective factors 2 to 5 months before their partners' deployment (Time 1), 4 months (Time 2) and 8 months (Time 3) into the deployment, and 2 to 3 months following the soldiers' return (Time 4). Latent class growth analyses (LCGA) revealed quadratic change in partners' sleep over the deployment cycle, characterized by 4 distinct trajectories: resilient (61%), deployment-onset sleep problems (22%), deployment improvement (10%), and chronic (7%) groups. Predeployment and during deployment predictors of partners' sleep complaints varied by group and included negative emotionality, depression symptoms, alcohol use, low negative communication, and family stressors. Understanding the course of sleep complaints and potentially modifiable risk-factors among at-home partners during deployment may be useful for prevention and targeted intervention efforts. (PsycINFO Database Record
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http://dx.doi.org/10.1037/fam0000262DOI Listing
February 2018

Characterizing spouse/partner depression and alcohol problems over the course of military deployment.

J Consult Clin Psychol 2017 Apr;85(4):297-308

Minneapolis VA Healthcare System.

Objective: Spouse/partners of military personnel demonstrate elevated levels of distress during military deployments, yet there is insufficient information about courses of adjustment over time. The current study identified trajectories of depression and alcohol use problems and predictors of those trajectories across the deployment cycle.

Method: National Guard soldiers (N = 1973) and spouses/intimate partners (N = 1020) completed assessments of risk/protective factors and baseline measures of mental health functioning 2 to 5 months prior to soldiers' 1-year deployments (Time 1) to Kuwait/Iraq in support of Operation New Dawn or Afghanistan in support of Operation Enduring Freedom. Partners' mental health was reassessed at 4 months (Time 2) and 8 months (Time 3) after soldiers deployed, and both spouses/partners and soldiers were reassessed 2-3 months postdeployment (Time 4).

Results: Latent class growth modeling of partner depression symptoms over time revealed 4 groups: Resilience (79.9%), Deployment Distress (8.9%), Anticipatory Distress (8.4%), and Post-Deployment Distress (2.7%). Three alcohol misuse trajectories were identified: Resilience (91.3%), Deployment Onset (5.4%), and Deployment Desistance (3.3%). Predeployment predictors of partners' depression symptom trajectories varied by group and included soldier reports of stressors and social support and partner levels of neuroticism, introversion, disconstraint, and reported stressors. Predeployment predictors of alcohol misuse trajectories varied by group, and included soldier levels of alcohol misuse as well as partner neuroticism, disconstraint, and family readiness.

Conclusions: Delineating and predicting trajectories of partner adjustment can allow for better targeted interventions toward those most at risk for heightened distress or alcohol problems over the deployment cycle. (PsycINFO Database Record
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http://dx.doi.org/10.1037/ccp0000190DOI Listing
April 2017

Letter in response to Drs Lee and Hoge's commentary.

Evid Based Ment Health 2017 02;20(1):31

Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA.

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http://dx.doi.org/10.1136/eb-2016-102595DOI Listing
February 2017

The Unhappy Triad: Pain, Sleep Complaints, and Internalizing Symptoms.

Clin Psychol Sci 2016 Jan 16;4(1):96-106. Epub 2016 Jan 16.

Center for Chronic Disease Outcomes Research, Minneapolis Veteran Affairs Health Care System, Department of Psychiatry, University of Minnesota, Minneapolis, MN.

There is limited understanding of the etiology and temporal relations of chronic pain, sleep complaints, and depression/anxiety. Several models have been proposed by which sleep disruption represents a common mechanism for the comorbidity of these symptoms. The goals of this study were to 1) clarify the boundaries of these domains and to 2) examine the relations of these symptoms over time following exposure to stressful and potentially traumatic experiences during a combat deployment. We found support for three distinct domains of sleep complaints, internalizing symptoms, and physical complaints. We tested two competing models that have been proposed in the literature, controlling for negative and positive emotionality. Internalizing symptoms strongly mediated the relation between sleep complaints and pain (total effect = .15, direct effect = -.05). The study suggests that increases in sleep complaints immediately following deployment increase the risk of internalizing symptoms and pain several years after deployment.
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http://dx.doi.org/10.1177/2167702615579342DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4928372PMC
January 2016

A randomized controlled pilot study of CBT-I Coach: Feasibility, acceptability, and potential impact of a mobile phone application for patients in cognitive behavioral therapy for insomnia.

Health Informatics J 2018 03 27;24(1):3-13. Epub 2016 Jun 27.

Minneapolis Veteran Affairs Health Care System, USA; University of Minnesota Medical School, USA.

There has been growing interest in utilizing mobile phone applications (apps) to enhance traditional psychotherapy. Previous research has suggested that apps may facilitate patients' completion of cognitive behavioral therapy for insomnia (CBT-I) tasks and potentially increase adherence. This randomized clinical trial pilot study ( n = 18) sought to examine the feasibility, acceptability, and potential impact on adherence and sleep outcomes related to CBT-I Coach use. All participants were engaged in CBT-I, with one group receiving the app as a supplement and one non-app group. We found that patients consistently used the app as intended, particularly the sleep diary and reminder functions. They reported that it was highly acceptable to use. Importantly, the app did not compromise or undermine benefits of cognitive behavioral therapy for insomnia and patients in both groups had significantly improved sleep outcomes following treatment.
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http://dx.doi.org/10.1177/1460458216656472DOI Listing
March 2018

Social Causation Versus Social Erosion: Comparisons of Causal Models for Relations Between Support and PTSD Symptoms.

J Trauma Stress 2016 Apr;29(2):167-75

University of Minnesota, Medical School, Minneapolis, Minnesota, USA.

Social support is a robust correlate of posttraumatic stress disorder (PTSD) symptoms and of general psychological distress (Ozer, Best, Lipsey, & Weiss, 2003). The nature of the causal relationship between support and PTSD remains the subject of debate, with 2 models, social erosion and social causation, often used to explain findings. Despite extensive research using these models, no studies of which we are aware have included tests of both models within the same series of analyses, across more than 2 time points, in veterans. These competing models were tested in a sample of National Guard soldiers (N = 521) who completed measures of perceived social support and the PTSD Checklist-Military version (Weathers, Litz, Herman, Huska, & Keane, 1993) at 3 months, 15 months, and 27 months following a combat deployment to Iraq. Analyses were run separately for overall PTSD symptoms and the PTSD components of intrusion, trauma-avoidance, dysphoria, and hyperarousal. Both the social erosion (βs ranging from -.10 to -.19) and social causation (βs ranging from -.08 to -.13) hypotheses were supported. Results suggested PTSD-specific symptom dimensions may both erode and be influenced by social support, whereas general psychological distress erodes social support. Implications for clinical intervention and research are discussed.
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http://dx.doi.org/10.1002/jts.22086DOI Listing
April 2016

Using reinforcement sensitivity to understand longitudinal links between PTSD and relationship adjustment.

J Fam Psychol 2017 Feb 14;31(1):71-81. Epub 2016 Apr 14.

Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System.

There is limited research testing longitudinal models of how posttraumatic stress disorder (PTSD) severity leads to impaired relationship adjustment. The present study evaluated 2 potential mechanisms among a longitudinal sample of National Guard soldiers deployed to the Iraq War: (1) sensitivity to cues associated with punishment within intimate relationships and (2) sensitivity to cues associated with incentives in intimate relationships. Participants were surveyed by mail 1 year after an extended 16-month combat deployment and again 2 years later. Using a cross-lagged panel analysis with 2 mediators (relationship-specific threat and incentive sensitivity), findings indicated Time 1 PTSD symptom severity significantly eroded relationship adjustment over time through greater sensitivity to cues of relationship-related punishment, but not through incentive sensitivity. Additionally, findings indicated sensitivity to cues of relationship-related threats maintains symptoms of PTSD while sensitivity to cues of relationship-related incentives maintains relationship adjustment. Finally, PTSD symptoms significantly predicted erosion of relationship adjustment over time; however, associations from relationship adjustment to changes in PTSD severity over time were nonsignificant. Findings are discussed within the context of reinforcement sensitivity theory and emotional processing theory of PTSD. (PsycINFO Database Record
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http://dx.doi.org/10.1037/fam0000195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791525PMC
February 2017

The class-dimensional structure of PTSD before and after deployment to Iraq: Evidence from direct comparison of dimensional, categorical, and hybrid models.

J Anxiety Disord 2016 Apr 11;39:1-9. Epub 2016 Feb 11.

Center for Chronic Disease Outcome Research, Minneapolis VA Healthcare System, B9-152, One Veterans Drive, Minneapolis, MN 55417, USA; Minneapolis VA Healthcare System, B68-2, One Veterans Drive, Minneapolis, MN 55417, USA; University of Minnesota-Department of Psychiatry, F282/2A West, 2450 Riverside Ave S, Minneapolis, MN 55454, USA. Electronic address:

The assumption of specific etiology in posttraumatic stress disorder (PTSD) differentiates the disorder from most other psychiatric conditions. A 'risky test' of the assumption of specific etiology and resultant trauma-related symptom dimensions was conducted through structural modeling of PTSD symptoms in soldiers before (N=522) and after (n=423) a combat deployment to Iraq. If PTSD represents a discrete diagnostic entity that emerges after trauma exposure, we hypothesized either the number of latent classes should increase from pre- to post-deployment or symptom dimensions should qualitatively distinguish affected from unaffected classes following trauma exposure. Comparison of latent structural models revealed best fitting hybrid models for PTSD and depression with strong invariance of symptom dimensions across classes both before and after deployment and only quantitative (i.e., severity) differences between classes. These findings suggest PTSD is generally well-conceptualized as a dimensional syndrome worsened but not necessarily elicited by trauma exposure.
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http://dx.doi.org/10.1016/j.janxdis.2016.02.004DOI Listing
April 2016

Mindfulness-Based Stress Reduction for Posttraumatic Stress Disorder Among Veterans: A Randomized Clinical Trial.

JAMA 2015 Aug;314(5):456-65

Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota3Department of Psychiatry, University of Minnesota, Minneapolis.

Importance: Mindfulness-based interventions may be acceptable to veterans who have poor adherence to existing evidence-based treatments for posttraumatic stress disorder (PTSD).

Objective: To compare mindfulness-based stress reduction with present-centered group therapy for treatment of PTSD.

Design, Setting, And Participants: Randomized clinical trial of 116 veterans with PTSD recruited at the Minneapolis Veterans Affairs Medical Center from March 2012 to December 2013. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Data collection was completed on April 22, 2014.

Interventions: Participants were randomly assigned to receive mindfulness-based stress reduction therapy (n = 58), consisting of 9 sessions (8 weekly 2.5-hour group sessions and a daylong retreat) focused on teaching patients to attend to the present moment in a nonjudgmental, accepting manner; or present-centered group therapy (n = 58), an active-control condition consisting of 9 weekly 1.5-hour group sessions focused on current life problems.

Main Outcomes And Measures: The primary outcome, change in PTSD symptom severity over time, was assessed using the PTSD Checklist (range, 17-85; higher scores indicate greater severity; reduction of 10 or more considered a minimal clinically important difference) at baseline and weeks 3, 6, 9, and 17. Secondary outcomes included PTSD diagnosis and symptom severity assessed by independent evaluators using the Clinician-Administered PTSD Scale along with improvements in depressive symptoms, quality of life, and mindfulness.

Results: Participants in the mindfulness-based stress reduction group demonstrated greater improvement in self-reported PTSD symptom severity during treatment (change in mean PTSD Checklist scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference, 4.95; 95% CI, 1.92-7.99; P=.002) and at 2-month follow-up (change in mean scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively; difference, 6.44; 95% CI, 3.34-9.53, P < .001). Although participants in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (48.9% vs 28.1% with present-centered group therapy; difference, 20.9%; 95% CI, 2.2%-39.5%; P = .03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53.3% vs 47.3%, respectively; difference, 6.0%; 95% CI, -14.1% to 26.2%; P = .55).

Conclusions And Relevance: Among veterans with PTSD, mindfulness-based stress reduction therapy, compared with present-centered group therapy, resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect.

Trial Registration: clinicaltrials.gov Identifier: NCT01548742.
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http://dx.doi.org/10.1001/jama.2015.8361DOI Listing
August 2015

Impact of Deployment-Related Sexual Stressors on Psychiatric Symptoms After Accounting for Predeployment Stressors: Findings From a U.S. National Guard Cohort.

J Trauma Stress 2015 Aug 15;28(4):307-13. Epub 2015 Jul 15.

Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.

This study used a longitudinal research design to examine the impact of predeployment stressors and deployment-related sexual stressors on self-reported psychiatric symptoms of U.S. National Guard soldiers returning from deployments to Iraq or Afghanistan. Prior to deployment, participants completed measures of depression and posttraumatic stress symptoms, along with an inventory of predeployment stressor experiences. At 3-months postdeployment, participants (468 men, 60 women) again completed self-report measures of psychiatric symptoms, along with an inventory of sexual stressors experienced during deployment. We compared a cross-sectional model of sexual stressors' impact on psychiatric symptoms, in which only postdeployment reports were considered, to a longitudinal model in which we adjusted for participants' predeployment stressors and psychiatric symptoms. No participants reported sexual assault during deployment, though sexual harassment was common. The cross-sectional model suggested that deployment-related sexual stressors were significantly associated with postdeployment depression (R(2) = .11) and posttraumatic stress symptoms (R(2) = .10). Once predeployment factors were taken into consideration, however, sexual stressors were no longer significant. The results did not support the notion of lasting negative impact for low-level sexual stressors (e.g., sexual harassment) during deployment after predeployment stressors are accounted for. Future studies of sexual stressors should consider longitudinal designs.
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http://dx.doi.org/10.1002/jts.22019DOI Listing
August 2015

Factors associated with inconsistency in self-reported mild traumatic brain injury over time among military personnel in Iraq.

Br J Psychiatry 2015 Mar 22;206(3):237-44. Epub 2015 Jan 22.

Nathaniel W. Nelson, PhD, Graduate School of Professional Psychology, University of St. Thomas and Minneapolis VA Health Care System, Minneapolis, Minnesota; Carolyn R. Anderson, PhD, Minneapolis VA Health Care System, Minneapolis, Minnesota; Paul Thuras, PhD, Minneapolis VA Health Care System, and Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota; Shannon M. Kehle-Forbes, PhD, Minneapolis VA Health Care System, and Department of Psychiatry, University of Minnesota Medical School, and Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota; Paul A. Arbisi, PhD, Christopher R. Erbes, PhD, Minneapolis VA Health Care System, and Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota; Melissa A. Polusny, PhD, Minneapolis VA Health Care System, and Department of Psychiatry, University of Minnesota Medical School, and Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA.

Background: Estimates of the prevalence of mild traumatic brain injury (mTBI) among military personnel and combat veterans rely almost exclusively on retrospective self-reports; however, reliability of these reports has received little attention.

Aims: To examine the consistency of reporting of mTBI over time and identify factors associated with inconsistent reporting.

Method: A longitudinal cohort of 948 US National Guard Soldiers deployed to Iraq completed self-report questionnaire screening for mTBI and psychological symptoms while in-theatre 1 month before returning home (time 1, T1) and 1 year later (time 2, T2).

Results: Most respondents (n = 811, 85.5%) were consistent in their reporting of mTBI across time. Among those who were inconsistent in their reports (n = 137, 14.5%), the majority denied mTBI at T1 and affirmed mTBI at T2 (n = 123, 89.8%). Respondents rarely endorsed mTBI in-theatre and later denied mTBI (n = 14, 10.2% of those with inconsistent reports). Post-deployment post-traumatic stress symptoms and non-specific physical complaints were significantly associated with inconsistent report of mTBI.

Conclusions: Military service members' self-reports of mTBI are generally consistent over time; however, inconsistency in retrospective self-reporting of mTBI status is associated with current post-traumatic stress symptoms and non-specific physical health complaints.
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http://dx.doi.org/10.1192/bjp.bp.114.149096DOI Listing
March 2015

A pilot examination of the use of narrative therapy with individuals diagnosed with PTSD.

J Trauma Stress 2014 Dec 10;27(6):730-3. Epub 2014 Nov 10.

Mental Health Service Line, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA.

Narrative therapy is a postmodern, collaborative therapy approach based on the elaboration of personal narratives for lived experiences. Many aspects of narrative therapy suggest it may have great potential for helping people who are negatively affected by traumatic experiences, including those diagnosed with posttraumatic stress disorder (PTSD). The potential notwithstanding, narrative therapy is relatively untested in any population, and has yet to receive empirical support for treatment among survivors of trauma. A pilot investigation of the use of narrative therapy with 14 veterans with a diagnosis of PTSD (11 treatment completers) is described. Participants completed structured diagnostic interviews and self-report assessments of symptoms prior to and following 11 to 12 sessions of narrative therapy. After treatment, 3 of 11 treatment completers no longer met criteria for PTSD and 7 of 11 had clinically significant decreases in PTSD symptoms as measured by the Clinician Administered PTSD Scale. Pre- to posttreatment effect sizes on outcomes ranged from 0.57 to 0.88. These preliminary results, in conjunction with low rates of treatment dropout (21.4%) and a high level of reported satisfaction with the treatment, suggest that further study of narrative therapy is warranted as a potential alternative to existing treatments for PTSD.
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http://dx.doi.org/10.1002/jts.21966DOI Listing
December 2014