No abstract

This study details results of an open trial of a group psychological treatment for Veterans with posttraumatic stress disorder (PTSD) and chronic posttraumatic nightmares called "Imagery Rescripting and Exposure Therapy" (IRET). IRET is a variant of a successful imagery rescripting treatment for civilian trauma-related nightmares that was modified to address the needs of the Veteran population. Thirty-seven male U.S. Veterans with PTSD and nightmares attended 6 multicomponent group sessions. Findings indicated that the intervention significantly reduced frequency of nightmares and PTSD severity, as well as increased hours of sleep. Unlike the few open trials examining treatment of nightmares in Veterans, effect sizes in this study were similar to those that have been found in the civilian randomized controlled trial. These preliminary findings suggest that a nightmares treatment can be adapted to successfully reduce distress associated with combat Veterans' chronic nightmares. Clinical and research implications are discussed.

Ongoing concerns exist in the literature regarding the construct of posttraumatic stress disorder (PTSD) and how to best conceptualize and measure this disorder. We compared the traditional DSM-IV PTSD symptom criteria (i.e., symptoms from clusters B, C, and D) to a revised criterion set that omits overlapping mood and other anxiety symptoms on PTSD prevalence, PTSD diagnostic caseness, associated psychiatric comorbidity, functional status, and structural validity using a cross-sectional, multi-site primary care sample of 747 veterans. After removing items theorized to overlap with mood and other anxiety disorders, PTSD prevalence was identical using both criterion sets (i.e., 12%). Overall, there were few statistically significant differences in PTSD caseness, associated psychiatric comorbidity, functional status, and structural validity across the two diagnostic criterion sets. These data provide further support that removing items that overlap with other psychiatric disorders does not significantly impact the prevalence of PTSD, its associated comorbidity and functional impairment, or its structural validity. Although the revised criterion set represents a more parsimonious model, the current study findings generally support the strong construct validity of PTSD. The implications of these study findings for research and clinical practice are discussed.

W La Revue canadienne de psychiatrie, vol 53, no 9, septembre 2008 594Objectives: To examine the health-related quality of life (HRQOL) in deployed Canadian Forces peacekeeping veterans, addressing associations with posttraumatic stress disorder (PTSD), and depression severity.Methods: Participants (n = 125) were consecutive male veterans who were referred for a psychiatric assessment. Instruments administered included the Clinician-Administered PTSD Scale, Hamilton Depression Scale, Short-Form-36 Health Survey, and sociodemographic characteristics.Results: Mental HRQOL was significantly lower for peacekeepers with, than without, PTSD. Using univariate analyses, PTSD and depression severity were each significantly negatively related to mental HRQOL. In sequential regression analyses controlling for age, we found that PTSD and depression severity significantly predicted both mental and physical HRQOL. Conclusions:Veterans with PTSD have significant impairments in mental and physical HRQOL. This information is useful for clinicians and Veterans Affairs administrators working with the newer generation of veterans, as it stresses the importance of including measures of quality of life in the psychiatric evaluation of veterans to better address their rehabilitation needs.Can J Psychiatry 2008;53(9):594-600 Clinical Implications· Veterans with significant symptoms of PTSD and depression present with significant physical and mental impairment. · Understanding the functional impairment in veterans with PTSD can assist with rehabilitation. · It is important to include measures of quality of life in the comprehensive evaluation of veterans to better address their health care needs. Limitations· A male sample of veterans with a service-related disability limits generalizability. · HRQOL was based on the Short-Form-36 Health Survey. · Inherent to a cross-sectional study, at best we can establish an association but not causality.

The use of imagery in psychotherapy has received surprisingly little attention from researchers despite its long history in psychology and the significance of imagery in a number of psychological disorders. One procedure warranting increased attention is imagery rescripting, an imagery technique in which an image is modified in some way to decrease distress. Imagery rescripting is relatively new with a small but growing empirical base. This article briefly reviews hypothesized mechanisms for therapeutic change via imagery techniques, emphasizing imagery rescripting, and how they might be relevant in the treatment of posttraumatic stress disorder (PTSD). We review studies employing imagery rescripting as a component of treatment, followed by recommendations for future direction.

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 nonCriterion 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.

To the Editor: Studying the relationship between posttraumatic stress disorder (PTSD) and health-related quality of life (HRQoL) in older veterans is important, given these individuals' high exposure to traumatic events during combat and their increasing health care needs due to advanced age, which may compound the already greater health care utilization and increased health costs associated with PTSD. 1,2 Many factors can influence the susceptibility to PTSD among elderly veterans, including diminished functional and cognitive capacity and ongoing life stressors. 3,4 Current stressors such as retirement or the death of a loved one may precipitate a worsening of PTSD, and, as this population of veterans ages, one can expect not only a worsening of HRQoL due to physical illnesses such as chronic cardiovascular diseases, but also an increase in claims for psychiatric illnesses related to service, such as PTSD. 3,5 Although rates of PTSD in World War II and Korean War veterans were reported to be 7% to 9% in veterans who had never sought psychiatric treatment and as high as 37% to 80% in veterans in psychiatric treatment-seeking populations, 6-13 research on PTSD and its impact on HRQoL in the elderly veteran population is lacking. 14,15 The relationship between PTSD and HRQoL has been well established in younger combat veterans. [16][17][18][19][20][21][22] The few studies that have focused on HRQoL in older veterans have demonstrated a decrease in HRQoL among individuals suffering from PTSD. 21,23,24 The primary goal of this study was to examine the impact of PTSD on HRQoL impairment in older veterans, as well as the extent to which PTSD severity and depression, which is often comorbid with PTSD, 25,26 predict HRQoL impairment. A secondary goal was to examine the relationship between HRQoL and the PTSD symptom clusters of reexperiencing, avoidance/numbing, and hyperarousal.Method. Participants and procedures. Participants were 120 consecutive male World War II and Korean War veterans referred to Veterans Affairs (VA) Canada for a comprehensive psychiatric assessment between September 2000 and December 2008 to determine both new and current pension entitlement for a psychiatric condition and to assess the degree of impairment. The data presented here are based on the results of a retrospective file review of data gathered in the context of the psychiatric assessment, after receipt of Institutional Review Board approval from the Office of Research Ethics at the University of Western Ontario, London, Ontario, Canada.Instruments. The Clinician-Administered PTSD Scale (CAPS) 27 was administered by a trained clinician to diagnose and assess frequency and intensity of the 17 DSM-IV PTSD symptoms. The 21-item Hamilton Depression Rating Scale (HDRS) 28 was used to assess severity of depressive symptoms. HRQoL was assessed using the SF-36 Health Survey (SF-36), 29 which measures functional impairment in 8 domains or subscales. The 8 SF-36 scales can be collapsed into 2 summary scores: a physical component summary (PCS) sco...

This study examined therapists' fidelity to a manualized multi-component cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Therapists' competence and adherence was assessed by clinicians at the master's level or higher who rated 20% of randomly selected audiotaped sessions (n = 57 sessions, coded by two independent raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged above "very good" (6 on 7-point Likert scale). Findings suggest that therapists can effectively deliver a manualized cognitive-behavioral intervention for PTSD, with exposure therapy, to patients with severe mental illness without compromise to the structure of sessions and/or to the therapeutic relationship. These data add needed support for the implementation of cognitivebehavioral interventions, including exposure therapy, as effective treatments for PTSD in complicated patient populations such as those with severe forms of mental illness. KeywordsPTSD; cognitive-behavioral therapy; therapist fidelity; schizophrenia; severe mental illness There is now a well-established body of literature documenting the extreme vulnerability of adults with severe mental illness (SMI) to both the experience of trauma and the subsequent development of posttraumatic stress disorder (PTSD). Rates of trauma exposure among adults with SMI range from 87% to 96% and include high rates of both physical and sexual assault (Cusack, Grubaugh, Knapp, & Frueh, 2006;Mueser et al., 2004). Rates of PTSD in this population are also high, ranging from 19% to 43% Mueser et al., 2004), which is consistently higher than PTSD rates found in the general population of trauma survivors (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995 (Briere, Woo, McRae, Foltz, & Sitzman, 1997;Goodman et al., 2001). Together, these data suggest that adults with SMI are highly susceptible to the adverse consequences of trauma, highlighting the importance of delivering effective traumarelated services to this population.Despite the prevalence of trauma and PTSD among patients with SMI, trauma related symptomatology is frequently overlooked and untreated in this population (Cusack, Frueh, & Brady, 2004;Cusack et al., 2006;Frueh et al., 2002;Mueser et al., 1998). There is also limited empirical treatment outcome data for persons with PTSD and SMI. This is unfortunate given that effective psychosocial treatments have been developed for other traumatized groups. Although cognitive behavioral therapy (CBT) has been evidenced to be efficacious in treating a wide-range of symptoms in individuals with SMI (Dickerson, 2000;Gaudiano, 2005;Gould, Mueser, Bolton, Mays, & Goff, 2001; National Institute of Clinical Evidence, 2002;Pilling et al., 2002), only a handful of studies have examined CBT for PTSD in this population (Hamblen, Jankowski, Rosenberg, & Mueser, 2004;Rosenberg, Mueser, Jankowsk...