Sonya B Norman

University of California, San Diego | UCSD · Department of Psychiatry

Objective: The goals of the present study were to (a) examine change in rates of problem alcohol/substance use among a sample of veterans between their last year of military service and their first year following separation, (b) identify predictors of continued problem use in the first year after separation, and (c) evaluate the hypothesis that av...

Background: Self-report measures are important in substance use assessment, yet they are susceptible to reporting errors. Urine drug screens (UDS) are often considered a more valid alternative. However, collecting in-person UDS may not always be feasible, contributing to the need to understand factors that influence the validity of self-reported s...

Objective: Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and a...

Trauma-informed beliefs often decrease during posttraumatic stress disorder (PTSD) treatment. This may also extend to anxiety sensitivity (AS), defined as a fear of anxiety-related sensations and beliefs that anxiety is dangerous and/or intolerable. However, little is known about how AS changes during exposure-based and psychopharmacological PTSD t...

Background: Little is known about environmental factors that may influence associations between genetic liability to suicidality and suicidal behavior. Methods: This study examined whether a suicidality polygenic risk score (PRS) derived from a large genome-wide association study (N = 122,935) was associated with suicide attempts in a population...

Trauma-focused treatments — psychotherapies that focus on trauma as a central component of treatment and use cognitive, emotional or behavioural techniques to facilitate the processing of a traumatic experience — are first-line interventions for post-traumatic stress disorder (PTSD). Although trauma-focused interventions are effective in treating P...

Objective To examine the longitudinal associations between dimensions of COVID-19 pandemic-related moral distress (MD) and moral injury (MI)-related guilt in a large sample of frontline COVID-19 healthcare workers (FHCWs).Methods: Data from a diverse occupational cohort of 786 COVID-19 FHCWs were collected during the initial peak of the COVID-19 pa...

Childhood sexual abuse (CSA) and military sexual trauma (MST) are prevalent among veterans. Such exposures are associated with adverse mental-health sequelae, including elevated risk for suicidal thoughts and behaviors. Nonetheless, prior studies have largely focused upon discrete experiences of CSA or MST in circumscribed samples. In the current s...

Trauma‐exposed veterans receiving mental health care may have an elevated risk of experiencing COVID‐19–related difficulties. Using data from several ongoing clinical trials (N = 458), this study examined exposure to COVID‐19–related stressors and their associations with key sociodemographic factors and mental health outcomes. The results showed th...

Background Questions persist about how often potentially morally injurious events (PMIEs) are associated with posttraumatic stress disorder (PTSD) and depression. Methods This study examined the overlap of morally injurious events with probable PTSD and depression in a nationally representative sample of U.S. combat veterans (n = 1,321, mean age 5...

Objective Suicidal intent is a risk factor for engagement in suicidal behavior, use of violent means, and suicide mortality. Yet, scarce research has examined factors associated with suicidal intent among U.S. military veterans, a population at high risk for suicide. This study examined vulnerability factors associated with suicidal intent in a po...

Background Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is common and concurrent treatment is recommended. Relatively little is known about which evidence-based psychotherapies for PTSD are most effective for patients with varying substance use profiles. We aim to examine the comparative effectiveness of...

Background Dispositional gratitude has been implicated as a psychological characteristic that may modulate risk for mental health outcomes. Using a population-based sample of U.S. military veterans, this study evaluated the association between dispositional gratitude and the development of psychopathology and suicidal behaviors over a 7-year period...

Loneliness was deemed a behavioral epidemic even prior to the COVID-19 pandemic. The COVID-19 pandemic and the subsequent social distancing policy measures have raised concerns about increased social isolation and loneliness, especially in vulnerable populations such as military veterans. However, little is known about the impact of the pandemic on...

Introduction Trauma‐related guilt is common, associated with posttraumatic mental health problems, and can persist after posttraumatic stress disorder (PTSD) treatment. We compared the efficacy of two six‐session psychotherapies, Trauma‐Informed Guilt Reduction (TrIGR) and Supportive Care Therapy (SCT), for reducing trauma‐related guilt. TrIGR help...

Many individuals with posttraumatic stress disorder (PTSD) report increased negative affect (NA) and decreased positive affect (PA). Little is known about whether treatments for PTSD improve PA. We conducted a secondary analysis of a randomized clinical trial comparing integrated exposure therapy (I-PE) to integrated coping skills therapy (I-CS) fo...

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Us...

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019–2020 National Health and Resilience in...

Suicide is a major public health problem in U.S. military veterans, but little is known about factors associated with remission from suicide attempts in this population. We aimed to identify risk and protective correlates of remission from suicidal thoughts and behavior (STB) in U.S. veterans with a prior suicide attempt. Data were analyzed from th...

Background The reported prevalence of military sexual trauma (MST) has increased over the past decades in the United States, yet scarce population-based studies have examined the prevalence, correlates, and health burden of MST in the general veteran population. Methods Data were from the 2019–2020 National Health and Resilience in Veterans Study,...

Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic...

We calculated the reliable change index (RCI) and clinically significant change (CSC) values for two widely used measures of posttraumatic stress disorder (PTSD): The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) and examined how symptom changes at these thresholds related to improvements in psychosoc...

Background/objective: The present study leveraged the expertise of an international group of posttraumatic stress and substance use disorder (PTSD+SUD) intervention researchers to identify which methods of categorizing interventions which target SUD, PTSD, or PTSD+SUD for populations with both PTSD+SUD may be optimal for advancing future systemati...

Background: Population-based data on risk factors for suicide attempts among veterans remains limited. Methods: A national probability sample of 2307 veterans was followed over the course of four timepoints spanning seven years to examine how a range of baseline risk factors predict incident suicide attempt. Suicide attempt data were aggregated in...

Background Alcohol use disorder (AUD) is a prevalent public health concern in the U.S. that disproportionately affects veterans relative to civilians. Given changes to the demographic composition of the veteran population and AUD diagnostic criteria in the DSM-5, updated knowledge regarding the epidemiology of DSM-5 AUD in a national sample of vete...

Objective: Psychiatric and substance use disorders are prevalent among U.S. military veterans, yet many veterans do not engage in treatment. The authors examined characteristics associated with use of mental health care in a nationally representative veteran sample. Methods: Using 2019-2020 data from the National Health and Resilience in Veteran...

Introduction This study investigated the role of coping strategies in mediating the relationship between the 7-factor model of posttraumatic stress disorder (PTSD) symptoms and alcohol misuse in veterans. Methods Data were analyzed from 615 veterans from a nationally representative study of U.S. veterans who met criteria for probable full or subth...

A substantial body of evidence supports the use of integrated treatments for posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Integrated trauma-focused exposure therapies reduce PTSD symptoms more than comparison treatments, including integrated coping skills therapies, but demonstrate lower attendance, raising questions regardi...

Introduction: Little is known about the relationship between moral distress and mental health problems. We examined moral distress in 2579 frontline healthcare workers (FHCWs) caring for coronavirus disease 2019 (COVID-19) patients during the height of the spring 2020 pandemic surge in New York City. The goals of the study were to identify common...

Background To evaluate the prevalence of lifetime non-suicidal self-injury (NSSI) among U.S. military veterans, and identify sociodemographic, military, psychiatric, and clinical correlates associated with NSSI. Methods Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a contemporary, nationally representative...

Background: Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. Methods:...

Background: Obstructive sleep apnea (OSA) is often comorbid with both substance use disorders (SUD) and posttraumatic stress disorder (PTSD), yet frequently goes undiagnosed and untreated. We present data on the feasibility and acceptability of objective OSA diagnosis procedures, findings on OSA prevalence, and the relationship between OSA and bas...

Importance The COVID-19 pandemic has raised considerable concerns about increased risk for suicidal behavior among US military veterans, who already had elevated rates of suicide before the pandemic. Objective To examine longitudinal changes in suicidal behavior from before the COVID-19 pandemic to nearly 10 months into the pandemic and identify r...

Background Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (...

Objective: US military veterans have high rates of suicide relative to civilians. However, little is known about the prevalence and correlates of suicidal behaviors in the general US veteran population. Methods: Data were from the National Health and Resilience in Veterans Study, a representative survey of US veterans conducted in 2019-2020 (n = 4...

Objective Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those...

Background Substance use is a strong risk factor for suicidal behavior. To date, however, no known study has evaluated optimal cut-off scores on substance use severity measures to identify individuals who may be at elevated risk for suicide. Methods Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, which surve...

Co-occurring posttraumatic stress disorder and alcohol use disorder (PTSD/AUD) is associated with poorer psychosocial functioning than either disorder alone; however, it is unclear if psychosocial functioning improves in treatment for PTSD/AUD. This study examined if psychosocial functioning improved in integrated treatments for PTSD/AUD, and if ch...

The onset of the COVID‐19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in‐person to telemental health. In the present study, we explored the impact of the pandemic on individuals’ ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the associat...

Objective: This study aimed to characterize the current prevalence of loneliness, and the relation between loneliness severity and psychiatric and physical health conditions, suicidality, and functional measures in a predominantly older sample of U.S. military veterans. Methods: This cross-sectional study used data from the National Health and Resi...

Objective: The co-occurrence of substance use disorders (SUD) and trauma-exposure is a risk factor for suicidal thoughts and behaviors (STB). However, traditional methods of measurement for suicidal thoughts and behaviors are limited by an overreliance on dichotomous (i.e., yes or no) and averaged/summed scale score measurements. Further, among tra...

Objective: The current study is an analysis of predictors of posttraumatic stress disorder (PTSD) treatment response in a clinical trial comparing (1) prolonged exposure plus placebo (PE + PLB), (2) PE + sertraline (PE + SERT), and (3) sertraline + enhanced medication management (SERT + EMM) with predictors including time since trauma (TST), self-r...

Background The coronavirus disease-2019 (COVID-19) pandemic has caused myriad health, social, and economic stressors. To date, however, no known study has examined changes in mental health during the pandemic in the U.S. military veteran population. Methods Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, a n...

Background Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population‐based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suici...

Background and Objectives Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear. Methods Data from a randomized controlled...

OBJECTIVE Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from...

Background There have been reports of increased alcohol consumption during the COVID-19 pandemic in the general population. However, little is known about the impact of the pandemic on the prevalence of alcohol use disorder (AUD), especially in high-risk samples such as U.S. military veterans. Methods Data were analyzed from the 2019-2020 National...

This paper describes Project Harmony, a Virtual Clinical Trial (VCT) funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to harmonize and analyze data from over 40 independent psychological, pharmacologic and/or combined pharmacological treatment studies for posttraumatic stress disorder and comorbid alcohol and other drug use...

Poor sleep quality is common among Veterans with posttraumatic stress disorder (PTSD) and history of traumatic brain injury (TBI). However, the relationship between sleep quality and treatment outcomes following trauma-focused interventions is less well-understood in this population. We sought to better understand whether 1) sleep quality changed a...

Background Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly comorbid and are associated with significant functional impairment and inconsistent treatment outcomes. Data-driven subtyping of this clinically heterogeneous patient population and the associated underlying neural mechanisms are highly needed to identify who...

PTSD is associated with serious problems in interpersonal functioning, including higher rates of marital conflict and divorce, disrupted relationships with family and friends, estrangement from others and social isolation. Cognitive behavioral and trauma focused treatments are effective for treating PTSD symptoms, but a substantial proportion of in...

More than half of U.S. states legalized medical or recreational sale and possession of cannabis since the prevalence of cannabis use was last estimated among U.S. military veterans in 2014. To provide updated estimates of the prevalence and correlates of cannabis use, cannabis use disorder (CUD), and medical cannabis card possession in this populat...

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur. Integrated treatments are effective, but not all patients respond and predicting outcome remains difficult. In this study, latent class analysis (LCA) identified symptom-based subgroups of comorbid PTSD/AUD among 119 veterans with PTSD/AUD from a randomized con...

The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the mental health of the general population. However, less is known about its impact on vulnerable populations, such as veterans with pre-existing psychiatric conditions. Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally...

Background Integrated interventions for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are effective, but many patients prematurely drop out from treatment. Little is known about within-treatment risk factors for dropout, limiting the ability during therapy to identify patients at risk for attrition. Methods We examin...

A growing body of evidence has shown consistent support for the association between trauma-related guilt and posttraumatic stress disorder (PTSD). However, factors that account for this association are not well understood. The present study examined psychological inflexibility as a potential mediator between trauma-related guilt and PTSD symptoms i...

Alcohol use disorder (AUD) and cannabis use disorder (CUD) are each associated with increased suicidal behavior, but it is unclear how their comorbidity relates to suicide risk. Understanding these associations in U.S. military veterans is especially important, given their heightened risk for suicide, high prevalence of AUD, and increasing access t...

Comorbid post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common, defined by greater severity and impairment than either disorder alone, and associated with poor treatment attendance. Exposure therapies are effective in treating PTSD+AUD, yet substance use is still cited as a potential contraindication for exposure. This stud...

Background Cannabis use is associated with psychiatric illness and suicidality, which are prevalent among U.S. military veterans. However, the psychiatric burden of cannabis use and cannabis use disorder (CUD) among veterans is unclear. Using data from a nationally representative sample of veterans, we evaluated associations of lifetime cannabis us...

Guilt, shame, and moral injury (MI) are common reactions following exposure to traumatic events and are associated with greater severity of several mental health problems, including posttraumatic stress disorder (PTSD), depression, increased risk of suicidal ideation and poorer psychosocial functioning. Trauma-Informed Guilt Reduction (TrIGR) is a...

The unprecedented effects and duration of the COVID-19 crisis are likely to elevate the population's level of anxiety due to psychological stress, economic hardship, and social isolation. This effect may be especially potent for individuals with preexisting mental health conditions, such as posttraumatic stress disorder (PTSD). Prolonged Exposure (...

Background Clinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD tre...

BACKGROUND A burgeoning body of research suggests that specific types of combat experiences may be a stronger predictor of suicidality among veterans than a history of combat exposure itself. To date, however, little population-based data exist about these associations in representative samples of veterans. This study examined the association betwe...

Post-traumatic stress disorder (PTSD) is associated with neuro-physiological abnormalities reflecting increased anticipatory anxiety and reactivity to traumatic cues. It remains unclear whether neural mechanisms associated with PTSD treatment responsiveness, i.e. hyperactivation of the affective salience network in the brain, extend to a comorbid P...

To the Editor The JAMA Insights article by Dr Steenkamp and colleagues¹ highlighted the need to improve treatment outcomes of posttraumatic stress disorder (PTSD) for veterans and service members. However, we are concerned because the article failed to accurately characterize the recommendations of the Department of Veterans Affairs (VA)/Department...

Objective: Patients with posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are often not offered exposure therapy for PTSD due to concerns that symptoms may worsen. This study examined whether initiating exposure would cause exacerbation of PTSD, alcohol use, depression, or suicidal ideation (SI) among patients with PTSD/AUD part...

Given the extensive research on posttraumatic stress disorder (PTSD) treatment, a single, updatable repository of data from PTSD treatment studies would be useful for clinical, research, and policy stakeholders. To meet this need, we established a preliminary dataset of abstracted PTSD trial data, which serve as the basis for the PTSD Trials Standa...

Background Posttraumatic stress disorder (PTSD) has been associated with exaggerated threat processing and deficits in emotion modulation circuitry. It remains unknown how neural circuits are associated with response to evidence‐based treatments for PTSD. Method We examined associations between PTSD symptoms and indicators of neural response in ke...

Although prolonged exposure (PE) and SSRI antidepressants are effective in treating posttraumatic stress disorder (PTSD), previous studies have shown that some symptoms tend to persist. The current study compared sertraline hydrochloride plus enhanced medication management (EMM), PE plus placebo, or PE plus sertraline hydrochloride in the likelihoo...

Background Despite advances in the treatment of suicidality over the last decade, a significant proportion of veterans with suicidal ideation do not utilize mental health treatment. To date, however, few population-based studies have examined factors that may facilitate or impede mental healthcare engagement among veterans currently contemplating s...

BACKGROUND Military veterans with a history of childhood abuse are at increased risk for suicidality. To date, however, little research has examined whether exposure to childhood abuse may heighten veterans’ susceptibility to the effects of combat exposure and increase risk for suicidal behavior. This study examined whether childhood abuse has an a...

During the unprecedented COVID-19 pandemic, people around the world have faced a myriad of heart-rending and ethically difficult scenarios (e.g., not being able to tend to a sick or dying loved one) that may lead to subsequent guilt, shame, or moral injury. Trauma-informed guilt reduction therapy is a brief intervention that helps clients accuratel...

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur, and this comorbidity (PTSD–SUD) is associated with more severe symptoms and functional impairment than either disorder alone. Growing evidence indicates that trauma related guilt, typically concerning negative appraisals of one’s actions or inaction during a t...

Although some studies have demonstrated residual symptoms in patients who have participated in posttraumatic stress disorder (PTSD) treatment, no studies to date have assessed residual PTSD symptoms following treatment for comorbid alcohol use disorder (AUD) and PTSD (PTSD/AUD). We examined residual symptoms of PTSD and AUD in 73 veterans with PTSD...

Background Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown. Methods Eligible patients (n = 1079), were 30–70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics....

Objective: The co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common. Individuals with PTSD/AUD commonly drink to cope with PTSD symptoms, which maintains PTSD/AUD, and may result in increased craving for alcohol. Negative affect is implicated in negative reinforcement models of craving. Further, Emotional P...

Objective: Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiometabolic disease. Clinically meaningful PTSD improvement is associated with a lower risk for diabetes, but it is not known if similar associations exist for incident hypertension, hyperlipidemia, and clinically relevant weight loss (i.e., ≥5% loss). Metho...

Despite the well-known co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain, large gaps remain in understanding how these two conditions influence each other. The aim of the present study was to examine the association between trauma-related guilt and pain among veterans with PTSD. Participants were 140 veterans enrolling in treat...