This page features a curated list of recent PTSD clinical research articles published in peer-reviewed medical and psychological journals, with an emphasis on PTSD treatment for military veterans and their families.
Elliott, Jonathan E., Ryan A. Opel, Dennis Pleshakov, Tara Rachakonda, Alexander Q. Chau, Kristianna B. Weymann, and Miranda M. Lim. "Posttraumatic Stress Disorder Increases the Odds of REM Sleep Behavior Disorder and Other Parasomnias in Veterans with and without Comorbid Traumatic Brain Injury." Sleep 43, no. 3 (Mar 2020): zsz237. https://doi.org/10.1093/sleep/zsz237
Study Objectives: To describe the crude prevalence of rapid eye movement (REM) sleep behavior disorder (RBD) following traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) in Veterans, given potential relationships between TBI, PTSD, RBD, and neurodegeneration.
Methods: Veterans (n = 394; 94% male; 54.4 ± 15.5 years of age) were prospectively/cross-sectionally recruited from the VA Portland Health Care System and completed in-lab video-polysomnography and questionnaires.
TBI and PTSD were assessed via diagnostic screening and medical record review. Subjects were categorized into four groups after assessment of REM sleep without atonia (RSWA) and self-reported dream enactment:
(1) “Normal,” neither RSWA nor dream enactment,
(2) “Other Parasomnia,” dream enactment without RSWA,
(3) “RSWA,” isolated-RSWA without dream enactment, and
(4) “RBD,” RSWA with dream enactment.
Crude prevalence, prevalence odds ratio, and prevalence rate for parasomnias across subjects with TBI and/or PTSD were assessed.
Results: Overall prevalence rates were:
Other Parasomnia: 31%
RSWA (REM sleep without atonia): 7%
RBD (rapid eye movement sleep behavior disorder): 9%
The prevalence rate of RBD increased to 15% in PTSD subjects [age adjusted POR (prevalence odds ratio): 2.81 (1.17–4.66)] and to 21% in TBI + PTSD subjects [age adjusted POR: 3.43 (1.20–9.35)].
No subjects met all diagnostic criteria for trauma-associated sleep disorder (TASD), and no overt dream enactment was captured on video.
Conclusions: The prevalence of RBD and related parasomnias is significantly higher in Veterans compared with the general population and is associated with PTSD and TBI + PTSD.
Considering the association between idiopathic-RBD and synucleinopathy, it remains unclear whether RBD (and potentially TASD) associated with PTSD or TBI + PTSD similarly increases risk for long-term neurologic sequelae.
Statement of Significance: Idiopathic REM sleep behavior disorder (RBD) and neuropsychiatric trauma (e.g. traumatic brain injury; TBI and/or post-traumatic stress disorder; PTSD) are both independently associated with subsequent neurodegeneration (e.g. Parkinson’s Disease or a related synucleinopathy).
Given the purported relationships between TBI, PTSD, RBD, and neurodegeneration, we sought to determine the crude prevalence and related associations of RBD following TBI and PTSD among Veterans.
Our data show that the prevalence of RBD and related parasomnias is significantly higher in Veterans with PTSD and TBI + PTSD compared with Veterans without a history of neuropsychiatric trauma.
Accordingly, the present study fills a critical gap in the literature by providing evidence associating neuropsychiatric trauma with RBD and related parasomnias.
Atonia - lack of normal muscle tone; muscular weakness.
Rapid eye movement (REM) sleep behavior disorder - a sleep disorder in which you physically act out vivid, often unpleasant dreams with vocal sounds and sudden, often violent arm and leg movements during REM sleep — sometimes called dream-enacting behavior.
Synucleinopathy - also called α-synucleinopathies, are neurodegenerative diseases characterised by the abnormal accumulation of alpha-synuclein protein in neurons, nerve fibres, or glial cells. There are three main types of synucleinopathy: Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). SOURCE: Wikipedia, Synucleinopathy.
Trauma associated sleep disorder (TASD) - A proposed new sleep disorder diagnosis characterized by nightmares and disruptive nocturnal behaviors that develop after traumatic experiences. See these articles by COL Vincent Mysliwiec MD (USA Ret.) & colleagues:
Huang, Wei, Theodore M. Johnson, Nancy G. Kutner, Sean N. Halpin, Paul Weiss, Patricia C. Griffiths, and Donald L. Bliwise. "Acupuncture for Treatment of Persistent Disturbed Sleep: A Randomized Clinical Trial in Veterans With Mild Traumatic Brain Injury and Posttraumatic Stress Disorder." Journal of Clinical Psychiatry 80, no. 1 (2019): 18m12235. https://doi.org/10.4088/JCP.18m12235
Objective: To evaluate real, as compared with sham, acupuncture in improving persistent sleep disturbance in veterans with mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD).
Methods: This sham-controlled randomized clinical trial at a US Department of Veterans Affairs Medical Center (2010–2015) included 60 veterans aged 24–55 years (mean of 40 years) with history of mTBI of at least 3 months and refractory sleep disturbance.
Most of these participants (66.7%) carried a concurrent DSM-IV clinical diagnosis of PTSD. For the present study, they were randomized into 2 groups and stratified by PTSD status using the PTSD Checklist–Military Version. Each participant received up to 10 treatment sessions.
The primary outcome measure was change in baseline-adjusted global Pittsburgh Sleep Quality Index (PSQI) score following intervention. Secondary outcomes were wrist-actigraphy–assessed objective sleep measurements. Comorbid PTSD was analyzed as a covariate.
Results: Mean (SD) pre-intervention global PSQI score was 14.3 (3.2) [mean = 14.3; standard deviation = 3.2].
Those receiving real acupuncture had a global PSQI score improvement of 4.4 points (relative to 2.4 points in sham, p = .04) and actigraphically measured sleep efficiency (absolute) improvement of 2.7% (relative to a decrement of 5.3% in sham, p = .0016).
Effective blinding for active treatment was maintained in the study. PTSD participants presented with more clinically significant sleep difficulties at baseline; acupuncture was effective for both those with and without PTSD.
Conclusions: Real acupuncture, compared with a sham needling procedure, resulted in a significant improvement in sleep measures for veterans with mTBI and disturbed sleep, even in the presence of PTSD.
These results indicate that an alternative-medicine treatment modality like acupuncture can provide clinically significant relief for a particularly recalcitrant problem affecting large segments of the veteran population.
Trial Registration: ClinicalTrials.gov identifier: NCT01162317
Williams, M Wright, David Graham, Nicole A Sciarrino, Matt Estey, Katherine L McCurry, Pearl Chiu, and Brooks King-Casas. “Does Validity Measure Response Affect CPT Group Outcomes in Veterans with PTSD?” Military Medicine, epub before print, 18 Nov 2019. https://doi.org/10.1093/milmed/usz385
If a C&P examiner indicates that you exaggerated symptoms (or exhibited "suboptimal effort") during your compensation and pension exam, consider:
(1) The psychologist might have misinterpreted test results or jumped to conclusions;
(2) You might have exaggerated symptoms without a clear, conscious plan to do so—people frequently exaggerate, often subconsciously, for various understandable reasons;
(2a) If #2 might apply to you, and VBA denied your claim, don't despair!
Appeal VBA's decision—talk with your veterans service officer about the options, and seriously consider retaining a veterans law attorney.
(2b) Remember that this PTSD clinical research suggests you can be just successful in PTSD treatment than any other veteran with PTSD.
A report of exaggeration could prejudice some people—in other words, they might think you are not serious about getting better. Don't overreact to such people, but also don't let them tell you treatment won't work for you.
(3) If you consciously planned and intended to exaggerate PTSD symptoms, then it's important to ask yourself why you did that. People intentionally exaggerate psych problems for many reasons other than "malingering".
We all have cognitive biases.
If you think you don't, you probably have more implicit biases lurking in your brain than your colleagues.
After you've seen a number of veterans entering PTSD treatment to (seemingly) "get their PTSD diagnosis" for a disability claim, it's easy to develop a belief like, "a lot of these vets don't really want to get better".
Of course, your belief might be true for some vets, but can you discern with great accuracy who is genuinely motivated for treatment and who isn't? I know I can't, and I seriously doubt the vast majority of mental health clinicians can make such predictions accurately.
Therefore if you find yourself thinking, "psych testing showed he was exaggerating, therefore he's not motivated for PTSD treatment", catch yourself!
Remember this PTSD clinical research and challenge that cognitive bias before it impairs your professional judgement.
Introduction: There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments.
Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable.
Symptom exaggeration has also been considered a “cry for help,” associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD.
Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response.
Materials and Methods: We recruited Veterans, aged 18–50 who served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era, from mental health clinics and fliers posted in a large Veterans Affairs Medical Center.
Veterans met inclusion criteria if they were diagnosed with PTSD via a clinician-administered assessment. Sixty-one Veterans consented to participate and self-selected into a cognitive processing therapy (CPT) group or treatment-as-usual.
We offered self-selection because low recruitment rates delayed treatment start dates and were consistent with a Veteran-centered care philosophy.
Veterans were assessed before and after treatment to determine the impact of assessment effort and symptom exaggeration scores on measures of PTSD and depressive symptoms and resilience. This study examined whether assessment effort failure and symptom exaggeration were associated with compromised psychotherapy outcomes in Veterans with PTSD undergoing CPT group.
We hypothesized that a pattern of responding consistent with both effort and symptom exaggeration would result in higher (ie, more severe) pre- and post-treatment scores on PTSD and depressive symptom outcome measures and lower resiliency when compared to Veterans providing good effort and genuine responding.
Hypotheses were evaluated using bivariate correlation analyses, analysis of variance, and chi-square analyses.
Results: Pre-treatment scores on measures of PTSD and depressive symptoms were higher among Veterans whose pattern of responding was consistent with poor assessment effort and symptom exaggeration; these Veterans also scored lower on a measure of resiliency.
At post-treatment, there were no differences between Veterans displaying good and failed effort testing on measures of PTSD and depressive symptoms or in whether they completed treatment. Post-treatment resiliency scores remained significantly lower in those with failed effort testing.
Conclusion: These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment.
These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.
McCaslin, Shannon E., Marylene Cloitre, Thomas C. Neylan, Donn W. Garvert, Ellen Herbst, and Charles Marmar. "Factors Associated with High Functioning Despite Distress in Post-9/11 Veterans". Rehabilitation Psychology, epub ahead of print. http://doi.org/10.1037/rep0000271
Objective: This study aimed to identify modifiable factors associated with perceived functioning among veterans with high symptoms of posttraumatic stress disorder (PTSD).
Method: Two hundred fifty-one post-9/11 veterans completed a survey of psychosocial symptoms and functioning; a subset participated in a follow-up survey (n = 109). Latent profile analysis (LPA) at baseline identified groups that differed by level of functioning (high/low). Items utilized in the LPA analysis were derived from the World Health Organization Quality of Life—Brief self-report measure. Veterans with high PTSD symptoms in both groups were compared and logistic regression was utilized to predict group membership.
Results: Veterans with high functioning/high symptoms (n = 45) had significantly lower alcohol use and sleep problems, and higher postdeployment social support, posttraumatic growth, and optimism than veterans with low functioning/high symptoms (n = 100).
Fewer sleep difficulties and higher postdeployment social support and optimism were associated with membership in the high functioning/high symptom group.
Conclusions: These findings support the importance of identifying factors that can facilitate higher social, occupational, and general functional capacity for those with high levels of PTSD symptomatology.
This research offers important insights and specific action steps veterans with PTSD can take to help themselves.
(1) Strengthen your social support network. Taking this step requires vulnerability, which is frightening. However, taking the risk of talking about emotional pain with family and friends yields countless benefits, including less severe PTSD symptoms, as this article describes.
But don't worry too much about having to be emotionally vulnerable. While that anxiety-producing act will help tremendously, it isn't the only type of social support that helps.
Simply taking the time (and the making the commitment) to spend time with friends and family doing almost anything (drinking or getting high frequently is one of the exceptions) also "counts" as social support, which will significantly boost mood, outlook, and functioning.
(2) Choose either total abstinence or moderate use of alcohol.
Excessive alcohol use will almost always make PTSD symptoms worse.
Excessive alcohol use means binge drinking (4 or more standard drinks for women—5 or more standard drinks for men—within about 2 hours), or heavy drinking (8 or more standard drinks a week for women; 15 or more standard drinks a week for men).
A standard drink contains 0.6 ounces (17.7 mL) of ethanol (ethyl alcohol, the type of alcohol found in beer, wine, and liquor).
12 ounce beer (5% alcohol) = 12 x 0.05 = 0.6 ounces alcohol
5 ounces table wine (12% alcohol) = 5 x 0.12 = 0.6 ounces alcohol
1.5 ounces liquor, such as vodka, gin, whiskey, or tequila (80 proof = 40% alcohol) = 1.5 x 0.40 = 0.6 ounces alcohol.
(3) If you are having trouble sleeping, improve your sleep by taking action:
(a) Talk with your doctor. Tell your primary care physician, psychiatrist, or psychologist about your sleep difficulties. He or she will discuss various treatment options with you such as good sleep hygiene, cognitive-behavioral treatment (CBT) for insomnia, medication, acupuncture, and other interventions.
Hawkins, Eric J., Simon B. Goldberg, Carol A. Malte, and Andrew J. Saxon. "New Coprescription of Opioids and Benzodiazepines and Mortality Among Veterans Affairs Patients With Posttraumatic Stress Disorder". Journal of Clinical Psychiatry 80, no. 4 (2019): 18m12689. https://doi.org/10.4088/JCP.18m12689
ERIC J HAWKINS PHD
VA PUGET SOUND HCS (S116ATC)
1660 S COLUMBIAN WAY
SEATTLE WA 98108-1532
Background: Opioids and benzodiazepines are commonly coprescribed medications. The mortality risk associated with their concurrent use is unknown.
Objective: To estimate the all-cause mortality risk for patients newly prescribed opioids and benzodiazepines concurrently relative to patients prescribed benzodiazepines only, opioids only, or neither medication.
Methods: This propensity score–matched, retrospective, cohort study included 17,476 patients receiving Veterans Affairs (VA) health care between October 1, 2009, and September 30, 2011, and diagnosed with posttraumatic stress disorder identified using ICD-9-CM code 309.81.
One-year total and cause-specific mortality was assessed by hazard ratios and subhazard ratios, adjusted for propensity score, age, baseline psychiatric and medical comorbidity, and daily medication dose.
Results: Concurrent users (n = 4,369) were propensity score matched 1:1 with benzodiazepine-only users, opioid-only users, and nonusers.
One year after medication start, the concurrent cohort had higher rates of all-cause mortality (116 deaths) relative to benzodiazepine-only (75 deaths; adjusted hazard ratio = 1.52; 95% CI, 1.14–2.03), opioid-only (67 deaths; 1.76; 95% CI, 1.32–2.35), and nonuser (60 deaths; 1.85; 95% CI, 1.30–2.64) cohorts.
Risk of overdose death was greater among patients in the concurrent cohort relative to patients in the benzodiazepine-only (adjusted subhazard ratio = 2.59; 95% CI, 1.00–6.66), opioid-only (2.58; 95% CI, 1.09–6.11), and nonuser (9.16; 95% CI, 2.27–37.02) cohorts.
For circulatory disease–related deaths, the adjusted subhazard ratio for concurrent medication users was 1.81 (95% CI, 1.01–3.24) relative to nonusers.
Conclusions: New coprescription of opioids and benzodiazepines was associated with increased all-cause mortality and overdose death compared with new prescription of benzodiazepines only, opioids only, or neither medication and increased circulatory disease–related death relative to neither medication.
* The VA fully funded this important research, and all the researchers are VA employees, which demonstrates VA's willingness to examine itself via empirical investigations.
* The researchers analyzed data from 2009–2011. Since that time, the nation and VA have recognized the dangers of long-term opioid prescriptions, and the increased dangers of combining opioid medication with a benzodiazepine such as Xanax (alprazolam), Klonopin (clonazepam), or Ativan (lorazepam).
The VA has taken steps to reduce opioid prescriptions1,2 and has embraced the multi-disciplinary, multi-modal treatment of chronic pain.3
Some problems persist, as evidenced by a May 2018 Government Accountability Office report, Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed, but patient safety has improved significantly over the last 10 years.
1. Lin, Lewei A., Amy SB Bohnert, Robert D. Kerns, Michael A. Clay, Dara Ganoczy, and Mark A. Ilgen. "Impact of the Opioid Safety Initiative on Opioid-related Prescribing in Veterans." Pain 158, no. 5 (2017): 833-839.
2. Pharmacy Benefits Management (PBM) Academic Detailing Service, Veterans Health Administration, "Safe and Responsible Use of Opioids for Chronic Pain: A Patient Information Guide", ver. 2 (rev. October 2018).
3. Meyer, Laurence and Friedhelm Sandbrink, "VHA Response to the Opioid Epidemic and Comprehensive Addiction and Recovery Act of 2016 (CARA)", National Academies of Sciences, Engineering, and Medicine (NASEM) presentation (10 Jan 2019).
Stefanovics, Elina A. and Robert A. Rosenheck. "Predictors of Post-discharge Suicide Attempt Among Veterans Receiving Specialized Intensive Treatment for Posttraumatic Stress Disorder". Journal of Clinical Psychiatry 80, no. 5 (2019):19m12745. https://doi.org/10.4088/JCP.19m12745
Objective: There has been increasing concern about the high risk of suicide among US veterans, especially those with posttraumatic stress disorder (PTSD). Among those at greatest risk are veterans recently discharged from inpatient or specialized intensive treatment programs, but little is known about clinical correlates of suicide attempts among such veterans and this information that might facilitate prevention efforts.
Methods: National program evaluation data were obtained at program entry and 4 months after discharge from 30,384 veterans from 57 sites (fiscal years 1993–2011) who were discharged from specialized intensive PTSD programs nationally in the Veterans Health Administration.
Rates of attempted suicide were 10.6% in the 4 months prior to admission and 3.4% in the 4 months following discharge. Bivariate analyses and multivariable logistic regression were used to identify baseline characteristics, especially PTSD symptoms, associated with suicide attempts prior to admission and after discharge.
Further analyses examined the association of changes in symptoms and other outcomes with reported post-discharge suicide attempts.
Results: Suicide attempts both prior to admission and after discharge were associated with psychiatric and substance abuse comorbidity and especially suicidal ideation and violent behavior.
Clinical changes independently associated with post-discharge suicide attempts included increased suicidal thoughts (β = 0.96, P < .001), violent behavior (β = 0.49, P < .001), and alcohol use (β = 0.56, P < .001).
Conclusions: In this longitudinal study, violent behavior assessed at admission and as a change measure after discharge, along with suicidal ideation and alcohol use, were associated with suicide attempts.
Additional therapeutic attention to violent behavior and alcohol use, quite likely reflecting underlying impulsivity, may help reduce the risk of suicide attempts.
Both authors are affiliated with:
* Corresponding author:
Elina A. Stefanovics, PhD, Yale University School of Medicine, VA Connecticut Healthcare System/116A, 950 Campbell Ave, West Haven, CT 06516 (email@example.com).
Berke, Danielle S., Julie Yeterian, Candice Presseau, Luke Rusowicz-Orazem, Nora K. Kline, William P. Nash, and Brett T. Litz. Dynamic Changes in Marines’ Reports of PTSD Symptoms and Problem Alcohol Use Across the Deployment Cycle. Psychology of Addictive Behaviors 33, no. 2 (2019): 162-170. https://doi.org/10.1037/adb0000430
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 [Service Members] with greater PTSD symptom severity upon returning from deployment may increase alcohol use in the weeks immediately following homecoming.
The relationship between PTSD and substance use disorders is an important factor in PTSD C&P exams. If a veteran's posttraumatic stress disorder is service-connected, and if the veteran also suffers from a substance use disorder, the VA mental health examiner must determine if the substance use disorder is "proximately due to or the result of" PTSD or if PTSD has aggravated a pre-existing substance use disorder.1
This research suggests, at least with this cohort of U.S. Marines, that the causal relationship goes both ways.
Moore, Bret A. and Walter E. Penk, eds. Treating PTSD in Military Personnel, Second Edition: A Clinical Handbook. New York: Guildford, 2019. [Publication date: 3 Apr 2019]
Pre-order from Guilford Press for $38.75 (List price: $45.00).
Description (from publisher):
This state-of-the-science guide to assessing and treating posttraumatic stress disorder (PTSD) in active-duty service members and veterans has now been extensively revised with 65% new material.
Leading authorities review available evidence-based treatments, including individual, group, and couple and family therapy approaches.
Knowledge about military culture, the stressors experienced by service members, and common challenges for both military and civilian practitioners is woven through the volume and reflected in the vivid case examples.
Chapters on specific clinical issues delve into co-occurring affective, anxiety, substance use, and sleep disorders; treatment of particular types of trauma; suicide prevention; and more.
New to This Edition
Chapters on additional treatments: mindfulness-based behavioral and cognitive therapies, stress inoculation training, cognitive-behavioral conjoint therapy, group therapy, and complementary and alternative therapies.
Chapters on additional clinical issues: chronic pain, moral injury, complex traumatic stress disorders, and posttraumatic growth.
Updated throughout with the latest treatment research and DSM-5 diagnostic changes.
Review by Dr. Brian Marx
“Moore and Penk have once again assembled a 'who’s who' of leading researchers to present the latest on evidence-based treatments for PTSD in military personnel. The second edition of this handbook is an absolute 'must read' for anyone who provides care to this population. The detailed insights into important considerations for working with military personnel, careful attention to clinical issues that frequently co-occur with PTSD, and clearly presented case examples that illustrate how to implement the various treatments successfully are what make this volume stand apart.”
—Brian P. Marx, PhD, National Center for PTSD, VA Boston Healthcare System; Department of Psychiatry, Boston University School of Medicine.
1. Disabilities that are proximately due to, or aggravated by, service-connected disease or injury, 38 C.F.R. § 3.310.
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