Posttraumatic Stress Disorder and Comorbidity: Untangling the Gordian Knot

The high rates of psychiatric comorbidity for individuals with posttraumatic stress disorder (PTSD) have long been noted. The conceptual, clinical and aetiological relationships between PTSD and other disorders are so interwoven and multi-determined that understanding and treating posttraumatic psychopathology can feel like trying to untangle the legendary Gordian knot. This paper examines the varying streams of research seeking to better understand this extensive comorbidity. These streams of research include examination of the bi-directional relationships in the development of PTSD and key mood, anxiety and substance use disorders; the study of the shared manifest and common higher order features across these disorders and investigations of underlying biopsychosocial vulnerabilities. Finally, the paper examines the preliminary findings emerging using the new DSM-5 criteria for PTSD and queries whether these revised criteria will address the issue of comorbidity and assist in untangling the knot of posttraumatic comorbidity.     

Prevalence and Predictors of Suicidal Ideation Among U.S. Law Enforcement Officers

Police officers have often been reported to experience high rates of suicide compared to the general population. Suicidal ideation (SI) is considered a strong predictor of suicidal acts. However, few studies have examined SI in U.S. law enforcement officers. This study investigated the prevalence of SI and the association between SI and amount of subjective work-related traumatic stress, personal relationship stress, work-related but non-traumatic stress, age, depression, posttraumatic stress disorder symptoms, alcohol use, and posttraumatic growth among law enforcement officers (N?=?193) from a Midwestern state. Multiple regression analysis demonstrated that greater depression symptoms significantly predicted greater SI among officers.     

The Prevalence of Mental Health Problems in Men Arrested for Domestic Violence

The problem of male perpetrated intimate partner violence (IPV) is widespread. In an effort to identify risk factors for perpetrating IPV, researchers have examined mental health problems among perpetrators. However, the majority of research in this area has examined personality psychopathology and/or limited their investigation to posttraumatic stress disorder (PTSD) or depression. Thus, the present study examined self-reported Axis I psychopathology among men arrested for domestic violence (N?=?308). Results replicated past research showing high rates of PTSD and depression. In addition, the prevalence of generalized anxiety disorder (GAD), panic disorder, social phobia, and alcohol and drug disorders were very high. All types of mental health problems were positively associated with aggression perpetration. Males meeting probable diagnostic classification reported significantly more frequent aggression than males not meeting diagnostic classification, even after controlling for social desirability. Directions for future research and implications of these findings are discussed.     

Comorbid Pain and PTSD: Integrating Research and Practice with MVC Survivors

Following a serious motor vehicle crash (MVC), an individual may develop posttraumatic stress disorder (PTSD) as well as chronic pain. To date, little work has been done that can empirically guide practitioners with an evidence-based approach for psychological interventions in this population. Issues related to the changing definitions of PTSD and ways in which we conceptualize pain-related concerns are discussed, with implications for understanding the complex interrelationships between these two conditions. Theoretical and practical understanding of the common processes which contribute to the comorbidity of PTSD and pain is shared, along with information regarding assessment and applications from the limited treatment literature. Suggestions drawn from clinical practice are offered regarding assessment and treatment for individuals diagnosed with PTSD and pain in a MVC population.     

Treatment of human-caused trauma: attrition in the adult outcomes research

Attrition or dropout is the failure of a participant to complete, comply, or the prematurely discontinuation or discharge from treatment, resulting in lost data and affecting outcomes. This review of 10 years of adult posttraumatic stress disorder (PTSD) treatment outcome literature specific to Criterion A events of human origin examines how attrition is defined and addressed, methodologically and statistically. Of the 13 experimental or quasi-experimental studies, 11 report attrition information. Compared to treatment completers, attriters more often had elevated pretest scores on PTSD and other symptom measures. The characteristics of dropouts given the intentional nature of the traumatic events reviewed in this study are shared to inform clinical practice. Recommendations for consistent methods in examining, analyzing, and interpreting treatment outcome data are also discussed.     

Beyond fear: the role of peritraumatic responses in posttraumatic stress and depressive symptoms among female crime victims

This study examines peritraumatic (and posttrauma) responses in a sample of female crime victims who had been sexually or physically assaulted within the previous 2 months. Women were interviewed about their emotional and behavioral responses during the trauma and assessed for posttraumatic stress disorder and depression symptomatology. Results indicate that women experience a wide range of behavioral and emotional responses during a traumatic event and that these responses have implications for posttrauma adjustment. Women who experienced behaviors typical of a freeze response are more likely to have a greater degree of symptomatology after the assault. Peritraumatic emotions, other than fear, such as sadness, humiliation, and anger, also appear to be related to posttrauma depression symptoms. These findings highlight the necessity of exploring the full range of possible reactions during a trauma.     

Intimate partner violence, depression, and posttraumatic stress disorder as additional predictors of low birth weight infants among low-income mothers

Estimates of intimate partner violence (IPV) during pregnancy vary by population being studied, measures, and other methodological limitations, hindering the ability to gauge the relationship between IPV and negative birth outcomes. The authors report aggregated data from a subsample (n = 148) of the first three waves of the Women's Employment Study. The authors compared groups of women who did and did not give birth to low birth weight infants on demographic, material deprivation, risk behavior, mental health, and IPV factors. The prevalence of domestic violence was more than twice as high for women with low birth weight infants as those women who had a normal weight infant. When considering additional risk factors, including food insufficiency, substance dependence, and depression and/or posttraumatic stress disorder, IPV remained a significant indicator, but it was most strongly associated with low birth weight among women also experiencing depression and/or posttraumatic stress disorder.     

Posttraumatic Stress Disorder in the DSM-5: Group Difference Commentary

This article provides a commentary on the proposed Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 changes with respect to diagnosing posttraumatic stress disorder (PTSD) in diverse cultural groups in clinical and forensic settings. PTSD is the most common diagnosis in personal injury litigants (Koch et al. 2006). By reviewing the symptoms that have been changed in the DSM-5 draft for PTSD in terms of ethnoracial and minority–cultural factors, this article highlights the lack of data needed in the area and that the DSM project should pay more attention to such factors.     

Posttraumatic Stress Disorder: Current Concepts and Controversies

The diagnosis of posttraumatic stress disorder (PTSD) sometimes is raised in compensation claims, in tort settings, and in other medical–legal settings. Accordingly, health-care and legal professionals working in these areas need to be familiar with the current findings and controversies concerning the disorder. The purpose of this article is twofold. First, we review the most important findings concerning the clinical features, etiology, and treatment of PTSD. Second, we examine six major controversies concerning the disorder that are relevant to psychologists and other medical–legal practitioners: (a) the issue of what qualifies as a traumatic stressor, (b) the question of whether traumatic stress causes brain damage, (c) the validity of the concept of delayed-onset PTSD, (d) the recovered memory controversy, (e) the question of whether PTSD can arise when the person has no memory of the trauma (e.g., due to concussion), and (f) issues concerning PTSD malingering. Throughout this article we offer recommendations for psychological and other medical–legal practice in relation to the evaluation of PTSD claims.     

Intimate partner violence and miscarriage: examination of the role of physical and psychological abuse and posttraumatic stress disorder

Despite research documenting high rates of violence during pregnancy, few studies have examined the impact of physical abuse, psychological abuse, and posttraumatic stress disorder (PTSD) on miscarriage. Secondary analysis of data collected by the Chicago Women's Health Risk Study permitted an exploration of the relationships among physical abuse, psychological abuse, PTSD, and miscarriage among 118 primarily ethnic minority women. The interaction between maximum severity of abuse and age provided the best multivariate predictor of miscarriage rate, accounting for 26.9% of the variance between live birth and miscarriage outcome. Mean scores of psychological abuse, physical violence, forced sex, and PTSD were significantly higher in the miscarriage group than in the live birth group. Women who experience physical violence and psychological abuse during pregnancy may be at greater risk for miscarriage. Prospective studies can confirm findings and determine underlying mechanisms. Routine screening for traumatic stress and PTSD may reduce rates of miscarriage.     

Scale 8 Elevations on the MMPI-2 among Women Survivors of Childhood Sexual Abuse: Evaluating Posttraumatic Stress, Depression, and Dissociation as Predictors

This paper investigated elevations on Scale 8 of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in women survivors of childhood sexual abuse (CSA) in order to assess whether symptoms of posttraumatic stress disorder, depression, or dissociation account for such elevations. Participants were 73 women seeking outpatient treatment for CSA after-effects at a university-based community mental health center. A stepwise multiple regression analysis was conducted, including measures of commonly reported symptoms in CSA survivors: depression, posttraumatic stress, and dissociation. Regression analyses revealed that the Beck Depression Inventory (BDI) and Dissociative Experiences Scale (DES) accounted for the most variance in Scale 8 scores (59%), with the BDI as the best predictor. The Impact of Event Scale (IES) did not predict Scale 8 scores significantly above that achieved by the model above. Cross-validation results indicated good generalizability. Results suggest that depression and dissociation contribute most to scores on Scale 8. Implications of these findings for the clinical and empirical use of the MMPI-2 with CSA survivors are discussed.     

Underlying Dimensions of DSM-5 Posttraumatic Stress Disorder and Major Depressive Disorder Symptoms

This study examined the relationship between the underlying latent factors of major depression symptoms and DSM-5 posttraumatic stress disorder (PTSD) symptoms (American Psychiatric Association, 2013). A nonclinical sample of 266 participants with a trauma history participated in the study. Confirmatory factor analyses were conducted to evaluate the fit of the DSM-5 PTSD model and dysphoria model, as well as a depression model comprised of somatic and nonsomatic factors. The DSM-5 PTSD model demonstrated somewhat better fit over the dysphoria model. Wald tests indicated that PTSD’s negative alterations in cognitions and mood factor was more strongly related to depression’s nonsomatic factor than its somatic factor. This study furthers a nascent line of research examining the relationship between PTSD and depression factors in order to better understand the nature of the high comorbidity rates between the two disorders. Moreover, this study provides an initial analysis of the new DSM-5 diagnostic criteria for PTSD.     

A classification of psychological factors leading to violent behavior in posttraumatic stress disorder

Posttraumatic stress disorder has long been linked to violent behavior. However, the exact nature of that association remains poorly characterized due to the limitations of knowledge in the area of phenomenology, contextual factors, the biology, and the nature of the aggression involved in the disorder. A clear understanding of the genesis of violence in posttraumatic stress disorder can be helpful to those involved in assessing psychiatric-legal issues relevant to the disorder and in its therapeutic management. In this article, we review the potential psychological links between posttraumatic stress disorder secondary to combat exposure and violent behavior and suggest a tentative classification of the main psychological causes of violence in that syndrome.     

Posttraumatic Stress Disorder’s Traumatic Stressor Criterion: History, Controversy, and Clinical and Legal Implications

This paper discusses posttraumatic stress disorder’s (PTSD) traumatic stressor criterion (Criterion A) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The history of the stressor criterion is detailed, including how it has changed over time in successive versions of the DSM. We discuss controversy over the stressor criterion, regarding arguments about whether it is too conservative or too liberal. Studies comparing Criterion A and non-Criterion A events in their association with PTSD are discussed, including the finding across studies that non-Criterion A events are just as (or more) likely to result in PTSD. Potential explanations to account for this finding are discussed, including presentation of solutions to Criterion A’s limitations. Finally, legal implications for Criterion A in evaluating individuals presenting with PTSD in civil and criminal cases are discussed.     

The Psychological Impact of Traumatic Events on Children

The past decade has seen accumulating research detailing the psychological consequences of a range of traumatic events upon children and young people. This paper summarizes some of the psychological consequences, including posttraumatic stress disorder, and describes the presentation and course in children. Treatment studies are reviewed and the need for further research with children involved in a range of events highlighted. In particular, there is a need to develop and evaluate early interventions and to identify factors that mediate or moderate negative consequences.     

Complex Histories and Complex Presentations: Implementation of a Manually-Guided Group Treatment for Traumatized Adolescents

It is consistently recognized that children and adolescents who have repeatedly experienced or witnessed violence are at significant risk for a multitude of lasting difficulties across many domains of functioning. Adolescents in residential settings often have extensive trauma histories and experience profound behavioral, emotional, and interpersonal difficulties. Unfortunately, there are few structured trauma-informed treatments that have been implemented in residential settings, and even fewer that have been evaluated. This article describes the core components of Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS), a manually-guided trauma-informed group treatment, and provides clinical examples within residential facilities for adolescents with emotional and behavioral difficulties and extensive victimization histories. Preliminary data on self-reported emotional, behavioral, and posttraumatic stress symptoms are presented.     

Posttraumatic Stress Disorder in DSM-5: New Criteria,New Measures,and Implications for Assessment

The diagnostic criteria for posttraumatic stress disorder (PTSD) were substantially revised for Diagnostic and Statistical Manual of Mental Disorders—5th edition (DSM-5). This in turn necessitated revision of DSM-correspondent assessment measures of PTSD. We describe the various changes to the PTSD diagnostic criteria and the corresponding changes to National Center for PTSD measures. We also discuss the implications of the new criteria for assessment of trauma exposure and PTSD. Although the DSM-5 version of PTSD departs significantly in some respects from previous versions, we conclude that there is fundamental continuity with the original DSM-III conceptualization of PTSD as a chronic, debilitating mental disorder that develops in response to catastrophic life events.     

Toward a Typology of High-Risk Major Stressful Events and Situations in Posttraumatic Stress Disorder and Related Psychopathology

The diagnosis of posttraumatic stress disorder (PTSD) was introduced in 1980 with the publication of the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition (DSM-III). DSM-III put forward a novel syndrome consisting of intrusive, avoidance/numbing, and arousal symptoms as distinctive psychopathology following exposure to traumatic events. The traumatic stressors, although expanded in later editions published in 1987 (DSM-III-R) and 1994 (DSM-IV), focus on life-threatening events and situations. However, at least 12 studies, most of them recent, have found associations between the PTSD symptoms and the PTSD symptom syndrome with stressors, such as unemployment and divorce that would not qualify, even in the broadened DSM-IV diagnosis, as traumatic stressors. These findings challenge the basic assumption on which the PTSD diagnosis is based, the assumption that exposure to life-threatening stressors is the primary cause of a unique set of stress response symptoms. The purpose of this paper is to show how to confront this challenge by developing a typology of stressful situations and events that can be tested systematically for their relation to the PTSD symptom syndrome and other relevant variables. The typology includes but is not limited to the types of situations and events defined as "traumatic" in the DSMs.     

Failings of Trauma‐Specific and Related Psychological Tests in Detecting Post‐Traumatic Stress Disorder in Forensic Settings

Judges and juries tend to be particularly impressed by test data, especially quantitative test data. Psychometric tests specific for assessing the presence of post‐traumatic stress disorder (PTSD) are commonly employed by forensic mental health evaluators. Most of these instruments, however, have been designed to detect PTSD in treatment or research, and not forensic, settings. Those who rely on these measures without adequate awareness of their often significant limits in correctly identifying malingering may induce finders of fact to inordinately confidently accept the presence of PTSD. This article reviews problematic structural and content components of trauma‐specific and related instruments used to evaluate PTSD and discusses the utility of specific techniques liable to be used in forensic settings to “fool” these measures.     

Treating low-income and minority women with posttraumatic stress disorder: a pilot study comparing prolonged exposure and treatment as usual conducted by community therapists

Twenty-one female psychiatric outpatients with chronic posttraumatic stress disorder (PTSD) are randomly assigned to prolonged exposure (PE; n = 9) for PTSD or treatment as usual (TAU; n = 12). Participants are predominantly low income and African American with complex trauma and psychiatric histories. Treatment is delivered by community therapists with no prior training in behavior therapy for anxiety disorders. Clients who completed PE show a greater improvement in PTSD symptoms, general anxiety, and depression than clients who completed TAU. These findings provide preliminary evidence suggesting that PE is an effective treatment for core PTSD symptoms, even when delivered by community therapists in a front-line services clinic.