Publications by authors named "Nora K Kline"

10 Publications

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Predicting Different Types of Intimate Partner Aggression Perpetration: The Roles of Problem Alcohol Use and Distress Tolerance.

J Interpers Violence 2021 Feb 2:886260521990830. Epub 2021 Feb 2.

Clark University, Worcester, MA, USA.

Intimate partner aggression (IPA) victimization and substance use have been well established as risk factors for IPA perpetration (Leonard, 2005; Sprunger et al., 2015). Recent research has identified a negative association between distress tolerance and physical and psychological IPA perpetration, specifically in males in substance use treatment (Shorey et al., 2017). Research examining the interplay of problem substance use, distress tolerance, and other forms of IPA (i.e., sexual coercion, controlling behaviors) in non-clinical samples is limited. The present analysis aimed to examine the potential moderating effect of distress tolerance on problem alcohol use and four types of IPA perpetration (physical assault, psychological aggression, sexual coercion, and controlling behaviors) in a diverse, national sample ( = 323; 44.3% female; 52.9% sexual minority; age = 33.61 years, = 8.71). Results showed that alcohol use and distress tolerance had differing influences on each IPA perpetration type. In line with hypotheses, distress tolerance significantly moderated the relationship between problem alcohol use and two forms of IPA (physical assault and controlling behaviors); this relationship was stronger for individuals with low levels of distress tolerance. Significant interaction effects did not emerge for psychological aggression or sexual coercion. Findings suggest that treatment strategies that focus specifically on increasing distress tolerance may be effective in reducing alcohol-facilitated IPA perpetration involving physical assault and controlling behaviors.
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http://dx.doi.org/10.1177/0886260521990830DOI Listing
February 2021

Parameters of Aggressive Behavior in a Treatment-Seeking Sample of Military Personnel: A Secondary Analysis of Three Randomized Controlled Trials of Evidence-Based PTSD Treatments.

Behav Ther 2021 01 30;52(1):136-148. Epub 2020 Mar 30.

VA Boston Healthcare System and Boston University School of Medicine.

Aggressive behavior is prevalent among veterans of post-9/11 conflicts who have posttraumatic stress disorder (PTSD). However, little is known about whether PTSD treatments reduce aggression or the direction of the association between changes in PTSD symptoms and aggression in the context of PTSD treatment. We combined data from three clinical trials of evidence-based PTSD treatment in service members (N = 592) to: (1) examine whether PTSD treatment reduces psychological (e.g., verbal behavior) and physical aggression, and; (2) explore temporal associations between aggressive behavior and PTSD. Both psychological (Estimate = -2.20, SE = 0.07) and physical aggression (Estimate = -0.36, SE = 0.05) were significantly reduced from baseline to posttreatment follow-up. Lagged PTSD symptom reduction was not associated with reduced reports of aggression; however, higher baseline PTSD scores were significantly associated with greater reductions in psychological aggression (exclusively; ß = -0.67, 95% CI = -1.05, -0.30, SE = -3.49). Findings reveal that service members receiving PTSD treatment report substantial collateral changes in psychological aggression over time, particularly for participants with greater PTSD symptom severity. Clinicians should consider cotherapies or alternative ways of targeting physical aggression among service members with PTSD and alternative approaches to reduce psychological aggression among service members with relatively low PTSD symptom severity when considering evidence-based PTSD treatments.
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http://dx.doi.org/10.1016/j.beth.2020.03.007DOI Listing
January 2021

Betrayal vs. nonbetrayal trauma: Examining the different effects of social support and emotion regulation on PTSD symptom severity.

Psychol Trauma 2020 Oct 19. Epub 2020 Oct 19.

Department of Psychology.

Objective: Betrayal Trauma Theory posits that interpersonal traumas are particularly injurious when the perpetrator is a person that the victim previously trusted and was close to. A relevant protective factor to examine is social support, which may influence PTSD symptomology through its influence on emotion regulation. The aim of the current study was to examine differences in the associations between social support, emotion regulation, and PTSD symptom severity for survivors of betrayal trauma and nonbetrayal trauma.

Method: Two hundred and 73 trauma survivors (age: M = 25.96 years, SD = 9.42 years; 80.2% female; 63.7% White) completed the anonymous, online survey.

Results: Across both groups, emotion regulation mediated the relationship between social support and PTSD symptom severity. A multiple-samples SEM analysis showed that the betrayal group evidenced a weaker relationship between social support and emotion regulation.

Conclusions: Findings suggest that survivors of high betrayal trauma may not engage with their social support in ways that foster emotion regulation skills. Therefore, for high betrayal trauma survivors specifically, group interventions that involve the survivor and close contact(s), may be particularly beneficial in enhancing emotion regulation and decreasing PTSD symptomology. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000983DOI Listing
October 2020

Patterns and predictors of change in trauma-focused treatments for war-related posttraumatic stress disorder.

J Consult Clin Psychol 2019 Nov 26;87(11):1019-1029. Epub 2019 Sep 26.

University of Texas Health Science Center at San Antonio.

Objective: We evaluated patterns and predictors of change from three efficacy trials of trauma-focused cognitive-behavioral treatments (TF-CBT) among service members (N = 702; mean age = 32.88; 89.4% male; 79.8% non-Hispanic/Latino). Rates of clinically significant change were also compared with other trials.

Method: The trials were conducted in the same setting with identical measures. The primary outcome was symptom severity scores on the PTSD Symptom Scale-Interview Version (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993).

Results: Symptom change was best explained by baseline scores and individual slopes. TF-CBT was not associated with better slope change relative to Present-Centered Therapy, a comparison arm in 2 trials. Lower baseline scores (β = .33, p < .01) and higher ratings of treatment credibility (β = -.22, p < .01) and expectancy for change (β = -.16, p < .01) were associated with greater symptom change. Older service members also responded less well to treatment (β = .09, p < .05). Based on the Jacobson and Truax (1991) metric for clinically significant change, 31% of trial participants either recovered or improved.

Conclusions: Clinicians should individually tailor treatment for service members with high baseline symptoms, older patients, and those with low levels of credibility and expectancy for change. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000426DOI Listing
November 2019

An epidemiological evaluation of trauma types in a cohort of deployed service members.

Psychol Trauma 2019 Nov 9;11(8):877-885. Epub 2019 May 9.

Department of Psychiatry and Behavioral Sciences, Duke University.

Objective: Using Stein et al.'s (2012) categorization scheme for typing Criterion A events (i.e., Life Threat to Self, Life Threat to Other, Aftermath of Violence, Traumatic Loss, Moral Injury by Self, and Moral Injury by Other) and extending Litz et al.'s (2018) prior work, we investigated the prevalence of trauma types, prevalence of posttraumatic stress disorder within each trauma type, and associations between trauma types and behavioral and mental health outcomes for an epidemiological sample of service members.

Method: Criterion A events coded by independent raters (kappas = .85-1.00) were used to determine prevalence rates and to conduct two path models examining all trauma types in relation to mental health outcomes.

Results: Consistent with prior research, we found events containing Life Threat to Self (51.1%) and Life Threat to Other (30.8%) to be most prevalent, and a majority of events (62.9%) were coded with one trauma type. Although least prevalent, Aftermath of Violence (12.0%) and Moral Injury by Self (4.8%) were most frequently and strongly associated with worse mental health outcomes. Path models predicted a very small amount of variance in continuous outcomes, thus limiting the interpretation of findings.

Conclusion: More epidemiological research is needed to understand the role of trauma type in relation to mental health among nontreatment-seeking service members. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000465DOI Listing
November 2019

Defining and Measuring Moral Injury: Rationale, Design, and Preliminary Findings From the Moral Injury Outcome Scale Consortium.

J Trauma Stress 2019 06 4;32(3):363-372. Epub 2019 Apr 4.

Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA.

In the current paper, we first describe the rationale for and methodology employed by an international research consortium, the Moral Injury Outcome Scale (MIOS) Consortium, the aim of which is to develop and validate a content-valid measure of moral injury as a multidimensional outcome. The MIOS Consortium comprises researchers and clinicians who work with active duty military service members and veterans in the United States, the United Kingdom, the Netherlands, Australia, and Canada. We describe the multiphase psychometric development process being conducted by the Consortium, which will gather phenomenological data from service members, veterans, and clinicians to operationalize subdomains of impact and to generate content for a new measure of moral injury. Second, to illustrate the methodology being employed by the Consortium in the first phase of measure development, we present a small subset of preliminary results from semistructured interviews and questionnaires conducted with care providers (N = 26) at three of the 10 study sites. The themes derived from these initial preliminary clinician interviews suggest that exposure to potentially morally injurious events is associated with broad psychological/behavioral, social, and spiritual/existential impacts. The early findings also suggest that the outcomes associated with acts of commission or omission and events involving others' transgressions may overlap. These results will be combined with data derived from other clinicians, service members, and veterans to generate the MIOS.
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http://dx.doi.org/10.1002/jts.22380DOI Listing
June 2019

Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members.

Behav Res Ther 2019 07 8;118:7-17. Epub 2019 Mar 8.

Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA; Department of Psychological and Brain Sciences, Boston University, Boston, MA, USA. Electronic address:

Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem. We reported rates and predictors of attendance and dropout in three clinical trials of evidence-based PTSD treatments in military service members (N = 557). Service members attended 81.0% of treatment sessions and 30.7% dropped out. Individually delivered treatment was associated with greater attendance rates (β = 0.23, p < .001) than group therapy; trauma-focused treatments were associated with higher dropout (β = 0.19, p < .001) than Present-Centered Therapy. Age was a significant predictor of session attendance (β = 0.17, p < .001) and drop out (β = -0.23, p < .001). History of traumatic brain injury (TBI) predicted lower attendance rates (β = -0.26, p < .001) and greater dropout (β = 0.19, p < .001). Regardless of treatment type or format, patients who did not drop out were more likely to experience clinically significant gains (d = 0.49, p < .001). Results demonstrate that dropout from PTSD treatments in these trials was significantly associated with treatment outcome and suggest that strategies are needed to mitigate dropout, particularly in group and trauma-focused therapies, and among younger service members and those with TBI.
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http://dx.doi.org/10.1016/j.brat.2019.03.003DOI Listing
July 2019

Dynamic changes in marines' reports of PTSD symptoms and problem alcohol use across the deployment cycle.

Psychol Addict Behav 2019 Mar 20;33(2):162-170. Epub 2018 Dec 20.

Massachusetts Veterans Epidemiological Research and Information Center, Veterans Affairs Boston Healthcare System.

Posttraumatic stress disorder (PTSD) and alcohol misuse are commonly co-occurring problems in active-duty service members (SMs) and veterans. Unfortunately, relatively little is known about the temporal associations between these problems in the acute period following exposure to combat stressors. Discerning the temporal associations between these problems across the deployment cycle could inform prevention and treatment efforts. In this study, we examined the association between PTSD symptom severity and problem alcohol use in a large cohort of United States Marines (n = 758) evaluated prior to deployment and approximately 1, 5, and 8 months postdeployment. Results indicate that problem alcohol use was associated with a subsequent exacerbation of PTSD symptoms between the 1st and 2nd and 2nd and 3rd postdeployment assessments. PTSD symptom severity was associated with increased problem alcohol use between the 1st and 2nd postdeployment assessments. These findings suggest that problem drinking may lead to new onset or worsening of PTSD symptoms over time and that SMs with greater PTSD symptom severity upon returning from deployment may increase alcohol use in the weeks immediately following homecoming. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/adb0000430DOI Listing
March 2019

Common Data Elements in the Assessment of Military-Related PTSD Research Applied in the Consortium to Alleviate PTSD.

Mil Med 2019 05;184(5-6):e218-e226

Massachusetts Veterans Epidemiology Research and Information Center, MAVERIC, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA.

Introduction: Driven by the need to share data, sufficiently power studies, and allow for cross-study comparisons of medical and psychiatric diseases, the President's National Research Action Plan issued in 2013 called for the use of state-of-the-art common data elements (CDEs) for research studies. CDEs are variables measured across independent studies that facilitate methodologically sound data aggregation and study replication. Researchers in the field of military-related post-traumatic stress disorder (PTSD) have suggested applicable CDEs; however, to date, these recommendations have been conceptual and not field-tested. The Consortium to Alleviate PTSD (CAP) - an interdisciplinary and multi-institutional, military-related PTSD research consortium funded by the Departments of Defense and Veterans Affairs - generated and applied CDEs that can be used to combine data from disparate studies to improve the methodological and statistical capabilities of study findings. We provide a description and rationale for the CAP CDEs and details about administration with two main goals: (1) to encourage military-related PTSD researchers to use these measures in future studies and (2) to facilitate comparison, replication, and data aggregation.

Materials And Methods: The CAP compiled mandated (core) and optional CDEs based on the following criteria: (1) construct applicability to military-related PTSD; (2) precedence (use) in prior, related research; (3) published and strong psychometric evidence; (4) no cost (public domain); and (5) brevity, to limit participant burden. We provided descriptive statistics and internal consistency reliabilities for mandated measures from an initial cohort of around 400 participants enrolled in CAP studies.

Results: Mandated CDEs in the CAP were found to have very good internal consistency reliability.

Conclusion: Although further research is needed to determine the incremental validity of these CDEs, preliminary analyses indicated that each mandated measure has very good internal consistency reliability. Investigators designing military-related PTSD research should consider using these field-tested CDEs to facilitate future data aggregation. Feedback based on empirical evidence or practical concerns to improve these CDEs is welcome.
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http://dx.doi.org/10.1093/milmed/usy226DOI Listing
May 2019

Self-Blame and PTSD Following Sexual Assault: A Longitudinal Analysis.

J Interpers Violence 2021 Mar 21;36(5-6):NP3153-NP3168. Epub 2018 Apr 21.

VA Boston Healthcare System, MA, USA.

Sexual assault is a prevalent trauma associated with high rates of posttraumatic stress disorder (PTSD). Social cognitive theories posit that behavioral self-blame (i.e., attributing the cause of the assault to personal peri-event behavior) contributes to the etiology and maintenance of PTSD symptoms. Yet the direction of the association between self-blame and PTSD symptoms in the acute aftermath of sexual assault is unknown. This study evaluated temporal pathways between behavioral self-blame and PTSD symptom severity in an epidemiological sample of sexual assault survivors ( = 126) assessed at four time points in the months immediately following the assault. Results of cross-lagged panel modeling revealed that reports of behavioral self-blame at the first assessment following sexual assault predicted PTSD symptom severity at Time 2. However, there was no association between behavioral self-blame at Time 2 and PTSD symptom severity at Time 3, nor was there an association between behavioral self-blame at Time 3 and PTSD symptom severity at Time 4. Instead, PTSD symptom severity predicted behavioral self-blame at Times 3 and 4. Findings suggest that behavioral self-blame following sexual assault may be particularly relevant to the onset of PTSD symptoms, while PTSD symptoms themselves appear to intensify subsequent perceptions of behavioral self-blame. Clinical implications and limitations are discussed.
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http://dx.doi.org/10.1177/0886260518770652DOI Listing
March 2021