[show abstract][hide abstract] ABSTRACT: Empirical evidence suggests that there is a significant genetic influence in the development of posttraumatic stress disorder (PTSD). The serotonin transporter (5-HTT) gene (SLC6A4) has been identified as a prime candidate for the development of the disorder, as 5-HTT is a working target for selective serotonin reuptake inhibitors (SSRIs), first line treatment agents for PTSD. Several studies have reported associations between 5-HTT-linked promoter region (5-HTTLPR) polymorphism variants and increased rates of PTSD in civilian samples. This study investigated the role of the 5-HTTLPR polymorphism, triallelically classified, in a sample of combat veterans with and without PTSD.
Rates of PTSD were examined across three genotypes in a sample of 388 combat veterans. The short/long polymorphism of 5-HTTLPR and the A-G polymorphism within the 5-HTTLPR (rs25531) were genotyped, and statistical analyses were conducted.
There were significant intergroup (PTSD versus non-PTSD) differences in the genotype frequencies of 5-HTTLPR/rs25531 (χ(2) [1, n = 388] = 16.23, P = 5.62 × 10(-5) ). The 5-HTTLPR S'/S' (low transcriptionally efficient) genotype was also associated with the PTSD severity score in the 228 participants who had combat severity data (r = .15, P = 0.03).
The findings are consistent with previous research among civilian populations that have indicated that the low transcriptionally efficient S'/S' genotype of 5-HTTLPR is a risk factor for the development of PTSD after trauma exposure. Our findings are the first to examine this polymorphism and PTSD in a military sample. Additional large-scale investigations are needed to replicate these findings.
Depression and Anxiety 08/2011; 28(12):1067-73. · 4.61 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Veteran's Health Administration (VHA) has launched a large-scale initiative to promote prolonged exposure (PE) therapy, an evidence-based treatment for PTSD. While existing randomized controlled trials (RCTs) unambiguously support the efficacy of PE in civilian and some military populations, there is a need to better understand the course of treatment for combat Veterans of the current wars receiving PE in normative mental healthcare settings. The current study investigates 65 Veterans receiving care at an urban VA medical center. All Veterans were diagnosed with PTSD via a structured interview and treated with PE. Measures of PTSD and depression were collected pre- and post-treatment and every two sessions during treatment. Dependent means t-tests were used to estimate pre- and post-treatment d-type effect sizes. Additionally, hierarchical linear models (HLM) were used to investigate treatment effects over time, relationships between patient characteristics and outcomes, and to provide estimates of R(2)-type effect sizes. Results indicate that PE in regular VA mental healthcare contexts can be as effective as when implemented in carefully conducted RCTs.
Journal of anxiety disorders 11/2010; 25(3):397-403. · 2.68 Impact Factor
[show abstract][hide abstract] ABSTRACT: This case study presents an overview of the conceptualization and treatment of two veterans of the Iraq War who presented for combat-related treatment at a Veterans Administration Medical Center. In addition to posttraumatic stress disorder (PTSD) symptoms of reexperiencing, arousal, and avoidance, the veterans exhibited compulsive checking behaviors that appear to be influenced by theater-specific combat duties and traumatic events. These cases represent what the authors believe to be an increasingly common expression of PTSD in veterans of the Iraq and Afghanistan wars. Both veterans were treated with prolonged exposure therapy, which includes imaginal and in vivo exposure to anxiety-provoking stimuli, processing of traumatic events, and self-assessment of anxiety. Treatment also included in vivo exposure with response prevention techniques borrowed from the literature on obsessive-compulsive disorder to address compulsive checking behaviors within the ecological context of each patient's symptom presentation. Measures related to PTSD and depression were obtained before, during, and after treatment. Treatment was associated with significant declines in symptom severity and improved functioning for both veterans. The unique nature of the conflict in the Middle East represents role challenges for soldiers that affect symptom presentation. Variations in symptom presentation can in turn complicate efforts to identify and appropriately address PTSD-related health concerns in this population. Thus, clinicians and researchers must remain cognizant of how theater-specific duties influence the manifestation and treatment of PTSD in order to provide optimal care to a new generation of veterans.
American Journal of Psychiatry 08/2009; 166(7):762-7. · 14.72 Impact Factor
[show abstract][hide abstract] ABSTRACT: Recent studies suggest that atypical antipsychotics may be effective augmentation strategies for the treatment of posttraumatic stress disorder (PTSD). Limited data were available on the newest agent, aripiprazole, so we aimed to evaluate its efficacy and tolerability in the treatment of PTSD.
A 12-week, prospective, open-label, flexible-dose, adjunctive trial of aripiprazole was conducted in military veterans meeting DSM-IV criteria for PTSD. Concomitant psychiatric medications continued unchanged, except for other neuroleptics which were not allowed. The primary outcome variable was change from baseline in the Clinician Administered PTSD scale (CAPS).
All 17 subjects were male, with an average age of 57 years. Total CAPS scores decreased from 78.2 (SD = 17.8) at baseline to 60.0 (23.5) at study end (p = 0.002). Re-experiencing (CAPS-B) and avoidance/numbing symptoms (CAPS-C) were significantly improved, and trend level reductions were observed in hyperarousal symptoms (CAPS-D). Fifty-three percent (9/17) were considered responders, as defined by a decrease in total CAPS scores of at least 20%. Reductions in the Positive and Negative Symptom Scale (PANSS) total score and positive and general psychopathology subscale scores were statistically significant. The final average dose of aripiprazole was 13.06 (SD = 6.45) mg daily. Nine patients discontinued because of side effects. The most common adverse events consisted of gastro-intestinal disturbances, sedation, and psychomotor activation. Tolerability was improved with lower starting doses (e.g., 5 mg daily) and slow titration.
Addition of aripiprazole to ongoing treatment further reduced PTSD symptoms in military veterans with severe PTSD. These preliminary findings await confirmation in randomized, controlled trials.
[show abstract][hide abstract] ABSTRACT: Case reports and open trials have reported beneficial effects of divalproex in the treatment of posttraumatic stress disorder (PTSD). The objective of this study was to conduct a placebo-controlled study of the efficacy and tolerability of divalproex in chronic PTSD patients.
Patients were randomized to receive placebo or divalproex. The primary outcome measure was the Clinician Administered PTSD Scale (CAPS).
Of 29 patients randomized, 16 received divalproex and 13 placebo. There were no significant differences between groups in mean change from baseline to end point (last observation carried forward) on the CAPS total score or subscales except for a significant decrease in avoidance/numbing scores with placebo. The only significant difference in secondary outcomes was a greater improvement in Clinical Global Impression Scale-Severity favoring placebo.
Divalproex was not superior to placebo in this study. This could be due to lack of efficacy of divalproex in this population, inadequate sample size to detect differences, or other factors. Further study of divalproex is needed to better clarify the role of this agent in PTSD.
Annals of Clinical Psychiatry 01/2009; 21(2):89-94. · 1.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: We compared the efficacy of telepsychiatry and same-room treatment of combat-related post-traumatic stress disorder (PTSD) using cognitive behavioural therapy in 14 weekly, 90-min treatment sessions. Of 97 patients referred for study participation, 38 were randomized (17 into telepsychiatry, 21 into same-room), and approximately 25 (the number differed by instrument) had at least one post-baseline assessment. Measures of clinical and process outcomes were examined. No group differences were found on clinical outcomes at three-month follow-up. Satisfaction with treatment ratings was similar in both groups, with 'strong satisfaction' indicated by veterans in both modalities. Attendance and drop-out were similar in the two groups. The same-room group reported more comfort in talking with their therapist at post-treatment and had better treatment adherence. The results provide preliminary support for the use of telepsychiatry in the treatment of PTSD to improve access to care.
Journal of Telemedicine and Telecare 02/2007; 13(3):142-7. · 1.47 Impact Factor
[show abstract][hide abstract] ABSTRACT: Posttraumatic stress disorder (PTSD) is a highly prevalent, disabling illness. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medication treatment, with sertraline, paroxetine, and fluoxetine being the most studied. More limited but favorable data suggest that citalopram, an SSRI, may also have a role in the treatment of PTSD. Its S-enantiomer escitalopram, which may have faster onset and greater magnitude of effect than citalopram in other conditions, has not yet been investigated in PTSD.
To assess the efficacy, safety, and tolerability of escitalopram in the treatment of PTSD.
A 12-week, prospective, open-label trial of escitalopram was conducted from January 2003 through August 2004 in military veterans with PTSD. Escitalopram was initiated at 10 mg daily for 4 weeks, then increased to 20 mg daily for the remainder of the study. Concomitant psychiatric medications were discontinued at least 2 weeks prior to enrollment. The primary outcome variable was the change from baseline to endpoint in global Clinician-Administered PTSD Scale-Symptom version (CAPS-SX) score. Secondary efficacy measures included the Clinical Global Impressions-Severity of Illness (CGI-S) and -Improvement (CGI-I) scales, the Hamilton Rating Scale for Depression (HAM-D), and the Davidson Trauma Scale (DTS). Posttraumatic stress disorder and comorbid diagnoses were established using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Twenty-four of 25 patients were evaluated for efficacy. The mean global CAPS-SX score decreased from 79.4 (SD = 15.7) at baseline to 61.2 (SD = 24.7) at the end of the study (p = .0002). The CAPS-C avoidance/numbing and CAPS-D hyper-arousal subscale scores decreased significantly from baseline to endpoint (CAPS-C, p = .0171; CAPS-D, p = .0001), with trend-level reductions observed in CAPS-B reexperiencing subscale scores (p = .0593). Forty-five percent of patients (9/20) were much or very much improved at the end of the study (CGI-I of 1 or 2). The HAM-D and DTS also significantly improved (p = .0063 and p = .0004, respectively). Mild to moderate gastrointestinal disturbances were the most common side effects. Only 4 patients discontinued early because of adverse effects.
This preliminary open-label study suggests that escitalopram is both efficacious and well tolerated in PTSD patients. However, randomized controlled studies are needed to confirm these results and to further define its potential role in the treatment of PTSD.
The Journal of Clinical Psychiatry 11/2006; 67(10):1522-6. · 5.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: There are concerns regarding the validity of combat exposure reports of veterans seeking treatment for combat-related post-traumatic stress disorder (PTSD) within US Veterans Affairs Medical Centers.
To verify combat exposure history for a relevant sample through objective historical data.
Archival records were reviewed from the US National Military Personnel Records Center for 100 consecutive veterans reporting Vietnam combat in a Veterans Affairs PTSD clinic. Cross-sectional clinical assessment and 12-month service use data were also examined.
Although 93% had documentation of Vietnam war-zone service, only 41% of the total sample had objective evidence of combat exposure documented in their military record. There was virtually no difference between the Vietnam 'combat' and 'no combat' groups on relevant clinical variables.
A significant number of treatment-seeking Veterans Affairs patients may misrepresent their combat involvement in Vietnam. There are implications for the integrity of the PTSD database and the Veterans Affairs healthcare system.
The British Journal of Psychiatry 07/2005; 186:467-72; discussion 473-5. · 6.61 Impact Factor
[show abstract][hide abstract] ABSTRACT: Post-traumatic stress disorder is an anxiety disorder that may occur after the individual is exposed to severe psychologic trauma such as combat, sexual assault, or childhood physical or sexual abuse. Chronic post-traumatic stress disorder may result in considerable psychologic pain and suffering for the individual in addition to significant functional impairment. In addition to the heterogeneity of symptoms that occur in post-traumatic stress disorder, there may also be extensive comorbidity with other anxiety disorders, mood disorders, psychotic disorders, and other psychiatric disorders. This complicates the treatment picture. Currently, accepted treatments for post-traumatic stress disorder include psychotherapy, in particular cognitive behavioral-based approaches and antidepressant medication. However, many patients are refractory to these initial treatments or have only a partial response. In light of this, may clinicians combine additional classes of psychotropic agents and different psychotherapeutic approaches to enhance treatment response. This article reviews the literature on the use of atypical antipsychotics in the treatment of post-traumatic stress disorder. Most of the research to date has involved combat veterans partially responsive or refractory to treatment, namely with antidepressants. Studies have shown improvement across post-traumatic stress disorder symptom clusters, as well as improvement in comorbid psychotic symptoms or disorders. More research is needed to confirm these recent findings and further delineate the role of atypical antipsychotics in the treatment of post-traumatic stress disorder. Currently, possible indications for their use include treatment-resistant post-traumatic stress disorder and post-traumatic stress disorder with comorbid psychotic features.
Expert Review of Neurotherapeutics 04/2005; 5(2):267-75. · 2.96 Impact Factor
[show abstract][hide abstract] ABSTRACT: Patients with generalized social phobia fear embarrassment in most social situations. Little is known about its functional neuroanatomy. We studied BOLD-fMRI brain activity while generalized social phobics and healthy controls anticipated making public speeches. With anticipation minus rest, 8 phobics compared to 6 controls showed greater subcortical, limbic, and lateral paralimbic activity (pons, striatum, amygdala/uncus/anterior parahippocampus, insula, temporal pole)--regions important in automatic emotional processing--and less cortical activity (dorsal anterior cingulate/prefrontal cortex)--regions important in cognitive processing. Phobics may become so anxious, they cannot think clearly or vice versa.
[show abstract][hide abstract] ABSTRACT: Although posttraumatic stress disorder (PTSD) is relatively common in community epidemiologic surveys (5-6% for men, 10-12% for women), and psychiatric patients with PTSD are known to have poor functioning and high levels of psychiatric comorbidity, there are no studies that address PTSD prevalence, functioning, and burden in primary care settings. This article reports on (1) the prevalence of PTSD using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition diagnostic criteria in Veterans Affairs (VA) primary care settings, (2) associated sociodemographic characteristics and comorbidities, (3) functional status related to PTSD, (4) the extent to which PTSD was recognized by providers and (5) health services use patterns (including specialty mental health) of PTSD patients. Patients were randomly selected from those who had an outpatient visit in FY 1999 at one of four VA hospitals; 888 patients consented (74.1% of 1198 contacted); 746 patients (84.0% of consenting patients; 62.3% of contacted patients) were reached for telephone diagnostic interviews. Diagnostic interviews with the Clinician Administered PTSD Scale yielded estimates of current PTSD prevalence of 11.5%. At statistically significant levels, PTSD was positively associated with a variety of comorbid psychiatric disorders, war zone service, age <65 years, not working, less formal education and decreased functioning. Of patients diagnosed with PTSD by study procedures, 12-month medical record review indicated that providers identified only 46.5% and only 47.7% had used mental health specialty services. PTSD-positive [PTSD(+)] patients who used mental health care in the past 12 months were more apt to be identified as having PTSD than nonmental health service users (78.0% vs. 17.8%). Although PTSD(+) patients had more medical record diagnoses than PTSD-negative [PTSD(-)] patients (6.28 vs. 4.95), their use of primary care, urgent care and inpatient care was not different from PTSD(-) patients.
General Hospital Psychiatry 01/2005; 27(3):169-79. · 2.98 Impact Factor
[show abstract][hide abstract] ABSTRACT: The mainstay of treatment for chronic posttraumatic stress disorder (PTSD) is a combination of psychotherapy and medication treatments. The first-line medications for PTSD are antidepressants, with two selective serotonin reuptake inhibitors (sertraline and paroxetine) currently Food and Drug Administration-indicated for PTSD. However, many patients do not have an adequate response to antidepressants, therefore, combinations with other antidepressants or with other classes of psychotropic medication are often utilized to enhance the therapeutic response. Other agents that have been used include mood stabilizers, anti-adrenergics, anxiolytics, and atypical antipsychotics. The heterogeneity of symptom clusters in PTSD as well as the complex psychiatric comorbidities (eg, with depression or substance abuse) further support the notion that combinations of medications may be needed. To date, there is a paucity of data to support specific strategies for augmenting antidepressants in PTSD. This review will address representative existing studies and discuss several potential pharmacologic strategies for patients suffering from treatment-refractory PTSD.
[show abstract][hide abstract] ABSTRACT: Post-traumatic stress disorder (PTSD) is an anxiety disorder that may develop after an individual experiences severe psychologic
trauma such as combat or rape. Characteristic symptoms of PTSD include re-experiencing symptoms, such as intrusive memories
or dreams of the event, avoidance of reminders of the event, and persistent symptoms of increased arousal such as insomnia
or hypervigilance. Chronic PTSD can result in considerable suffering and functional impairment for the individual. The heterogeneity
of symptoms that may be present in PTSD represent a challenge in the differential diagnosis and treatment of the disorder.
Moreover, chronic PTSD is frequently complicated by comorbid psychiatric disorders including depression and other mood disorders,
substance abuse, dissociative disorders, other anxiety disorders, and psychotic symptoms or disorders. These comorbidities
offer a further challenge in the diagnosis and management of PTSD. This paper discusses the diagnosis and differential diagnosis
of PTSD, and addresses mainstay as well as emerging novel therapeutic approaches to the illness.
Current Psychosis and Therapeutics Reports 01/2004; 2(3):109-115.
[show abstract][hide abstract] ABSTRACT: African American (N = 57) and Caucasian (N = 76) combat veterans with posttraumatic stress disorder (PTSD) at a Veterans Affairs (VA) outpatient PTSD treatment clinic were compared on variables related to clinical symptoms and VA service use. Groups were compared on relevant interview (e.g., Clinician Administered PTSD Scale; D. D. Blake et al. 1990) and self-report measures (e.g., Minnesota Multiphasic Personality Inventory–2; J. N. Butcher, W. G. Dahlstrom, J. R. Graham, A. Tellegen, & B. Kaemmer, 1989). Groups were also compared on demographics, psychiatric comorbidity, VA service use, and disability status. Results revealed few significant between-groups differences, providing further evidence that African American and Caucasian veterans with PTSD do not differ in manifestation of the syndrome or in use of VA services and benefits.
[show abstract][hide abstract] ABSTRACT: This project was developed to evaluate the use of and satisfaction with Veteran's Affairs (VA) medical services and disability benefits among surviving elderly prisoners of war (POWs) in South Carolina.
A single-assessment quantitative survey strategy was implemented to learn more about the service use patterns and satisfaction with care of two groups of male former POWs (N = 87): those who were members of a national POW service organization and those who were not.
Data show that the majority of these POWs had used the VA for medical care in the previous year, received disability compensation through the VA, and were satisfied with VA primary care medical services. Furthermore, differences between these two POW groups were minimal.
Results provide preliminary evidence that many former POWs rely heavily upon the VA for provision of primary medical and specialty care and disability compensation and that POWs are generally satisfied with the VA services and benefits they receive.
Military medicine 09/2003; 168(8):682-7. · 0.77 Impact Factor
[show abstract][hide abstract] ABSTRACT: This article investigated subtypes of symptom patterns among male combat veterans diagnosed with posttraumatic stress disorder (PTSD) through a cluster analysis of their Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Graham, Ben-Porath, Tellegen, Dahlstrom, & Kaemmer, 2001) clinical and validity scales. Participants were 126 veterans seeking outpatient treatment for combat-related PTSD at a Veterans Affairs Medical Center. Two well-fitting MMPI-2 cluster solutions (a four-cluster solution and a three-cluster solution) were evaluated with several statistical methods. A four-cluster solution was determined to best fit the data. Follow-up analyses demonstrated between-cluster differences on MMPI-2 "fake bad" scales and content scales, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), Mississippi Combat PTSD scale (M-PTSD; Keane, Caddall, & Taylor, 1988), and Clinician-Administered PTSD Scale (CAPS-1; Blake et al., 1990). Clusters also were different in disability-seeking status, employment status, and income. Implications for research and clinical practice using the MMPI-2 with combat veterans presenting with PTSD are briefly addressed.
Journal of Clinical Psychology 04/2003; 59(3):385-97. · 2.12 Impact Factor
[show abstract][hide abstract] ABSTRACT: In this 6-week, open-label trial, combat veterans meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) were treated with the atypical antipsychotic quetiapine. The starting dose was 25 mg at bedtime with subsequent titration based on tolerability and clinical response. Primary outcome was measured using the Clinician Administered PTSD Scale (CAPS). Secondary assessments of efficacy included the Positive and Negative Symptom Scale (PANSS), the Hamilton Rating Scale for Depression, and the Clinical Global Impression Scale. Safety and tolerability evaluations included neurologic ratings, vital signs, and assessment of treatment-emergent side effects. Eighteen of 20 patients enrolled in the study completed 6 weeks of open-label treatment. The dose range of quetiapine was 25 to 300 mg daily, with an average of 100+/-70 mg/d. There was significant improvement in CAPS scores, from 89.8+/-15.7 to 67.5+/-21.0 (t=4.863, df=18, <0.005), and composite PANSS ratings from baseline to endpoint. General psychopathology (PANSS) and depressive symptoms (HRSD) were also reduced at the 6-week end point. There were no serious adverse events and no clinically significant changes in vital signs or neurologic ratings. This preliminary open trial suggests that quetiapine is well tolerated and may have efficacy in reducing PTSD symptoms in patients who have not had an adequate response other medications. Studies utilizing a randomized, controlled trial design and larger sample sizes are needed to better define the potential role of quetiapine and other atypical antipsychotics in the treatment of PTSD.
Journal of Clinical Psychopharmacology 02/2003; 23(1):15-20. · 3.51 Impact Factor