Impulsivity as a multifactorial construct and its relationship to PTSD severity and threat sensitivity

Changes to the DSM-5's conceptualization of posttraumatic stress disorder (PTSD) highlight the importance of impulsivity within the context of PTSD-related arousal dysregulation. While the relationship between PTSD and threat sensitivity is well defined, how they relate to impulsivity remains understudied. We examined the relationship between PTSD symptom severity, threat sensitivity, and impulsivity. 124 participants completed the PTSD Checklist (PCL-C) and the Barratt Impulsiveness Scale 11th ed (BIS-11). BIS-11 items were separated to define cognitive and behavioral impulsivity subdomains. A trauma-exposed subsample of 39 participants were also exposed to no, ambiguous, and high threat conditions in a threat-enhanced acoustic startle paradigm with psychophysiological response as the outcome variable. PTSD severity was significantly associated with greater overall impulsivity and behavioral impulsivity. Greater overall impulsivity and both cognitive and behavioral impulsivity subdomains were significantly associated with psychophysiological magnitudes across threat conditions in the traumatized subsample. Our results suggest PTSD severity may linked to behavioral impulsivity and both cognitive and behavioral impulsivity are associated with threat sensitivity and hyperarousal. Assessing impulsivity within the context of PTSD, particularly in terms of its cognitive and behavioral subdomains, may provide important, clinically relevant information

Veterans Health Administration Screening for Military Sexual Trauma May Not Capture Over Half of Cases Among Midlife Women Veterans.

BACKGROUND: Approximately 1 in 3 women veterans endorse military sexual trauma (MST) during Veterans Health Administration (VHA) screening. Higher rates have been reported in anonymous surveys. OBJECTIVE: We compared MST identified by VHA screening to survey-reported MST within the same sample and identified participant characteristics associated with discordant responses. METHODS: Cross-sectional data were drawn from an observational study of women veterans aged 45-64 enrolled in VHA care in Northern California, with data from mail- and web-based surveys linked to VHA electronic health records (EHRs). Between March 2019 and May 2020, participants reported sociodemographic characteristics, current depressive (Patient Health Questionnaire-9) and posttraumatic stress (PTSD checklist for DSM-5) symptoms, and MST (using standard VHA screening questions) in a survey; depression and posttraumatic stress disorder diagnoses (ICD-10 codes) and documented MST were identified from EHRs. Associations between sociodemographic characteristics, mental health symptoms and diagnoses, and discordant MST reports (EHR-documented MST vs. MST reported on survey, not in EHR) were examined with multivariable logistic regression. RESULTS: In this sample of midlife women veterans (n = 202; mean age 56, SD = 5), 40% had EHR-documented MST, and 74% reported MST on the survey. Sociodemographic characteristics, mental health symptoms, and diagnosed depression were not associated with discordant MST responses. Women with an EHR-documented PTSD diagnosis had fivefold higher odds of having EHR-documented MST (vs. survey only; odds ratio 5.2; 95% confidence interval 2.3-11.9). CONCLUSIONS: VHA screening may not capture more than half of women who reported MST on the survey. VHA screening may underestimate true rates of MST, which could lead to a gap in recognition and care for women veterans

Lifetime history of interpersonal partner violence is associated with insomnia among midlife women veterans.

OBJECTIVE: Over a third of women in the United States report a lifetime history of intimate partner violence. Although a recent review found that intimate partner violence is related to poor subjective sleep, the majority of studies involved reproductive-aged women and used suboptimal measures of interpersonal violence and/or insomnia. We examined the relationship between lifetime intimate partner violence and current clinical insomnia in a cross-sectional sample of midlife women veterans. METHODS: Cross-sectional data were drawn from the Midlife Women Veterans Health Survey. Women Veterans (N = 232) aged 45 to 64 years enrolled in Department of Veterans Affairs health care in Northern California completed an adapted version of the Extended-Hurt, Insult, Threaten, Scream to assess lifetime history of intimate partner violence (screening threshold score and any physical, sexual, and psychological intimate partner violence) and the Insomnia Severity Index to assess current insomnia. RESULTS: In multivariable analyses, lifetime history of intimate partner violence was associated with twofold to fourfold odds of current clinical insomnia, including overall intimate partner violence (odds ratio, 3.24; 95% confidence interval, 1.57-6.69), physical intimate partner violence (odds ratio, 2.01; 95% confidence interval, 1.09-3.70), psychological intimate partner violence (odds ratio, 3.98; 95% confidence interval, 2.06-7.71), and sexual intimate partner violence (odds ratio, 2.09; 95% confidence interval, 1.08-4.07). CONCLUSIONS: Lifetime history of intimate partner violence is common and may be associated with clinical insomnia during midlife. Findings highlight the importance of screening midlife women for intimate partner violence and recognizing the potential role of this traumatic exposure on womens health

Sex differences in fear conditioning in posttraumatic stress disorder

Rationale/statement of the problem: Women are twice as likely as men to develop Posttraumatic stress disorder (PTSD). Abnormal acquisition of conditioned fear has been suggested as a mechanism for the development of PTSD. While some studies of healthy humans suggest that women are either no different or express less conditioned fear responses during conditioning relative to men, differences in the acquisition of conditioned fear between men and women diagnosed with PTSD has not been examined. Methods: Thirty-one participants (18 men, 13 women) with full or subsyndromal PTSD completed a fear-conditioning task. Participants were shown computer-generated colored circles that were paired (CS + ) or unpaired (CS − ) with an aversive electrical stimulus, and skin conductance levels were assessed throughout the task. Results: Repeated measures ANOVA analyses indicated a significant sex by stimulus interaction during acquisition, F(1, 232) = 5.16, p <0.05. Women had greater differential conditioned skin conductance responses (CS+ trials compared to CS− trials) than did men, suggesting greater acquisition of conditioned fear in women with PTSD. Conclusion: In contrast to studies of healthy individuals, we found enhanced acquisition of conditioned fear in women with PTSD. Greater fear conditioning in women may either be a pre-existing vulnerability trait or an acquired phenomenon that emerges in a sex-dependent manner after the development of PTSD. Characterization the underlying mechanisms of these differences is needed to clarify sex-related differences in the pathophysiology of PTSD

Child abuse interacts with hippocampal and corpus callosum volume on psychophysiological response to startling auditory stimuli in a sample of veterans

Child abuse (CA), which is linked to posttraumatic stress disorder (PTSD), has been associated with a reduction in both hippocampal and corpus callosum (CC) volume. However, few studies have explored these relationships on psychophysiological variables related to trauma exposure. Therefore, we assessed whether the interaction between CA and hippocampal and CC volume were associated with enhanced fear potentiated psychophysiological response patterns in a sample of Veterans. 147 Veteran participants who were part of a larger study of Gulf War Illness were exposed to startling sounds in no, ambiguous, and high threat conditions and also provided MRI data. The Clinician Administered PTSD Scale and Trauma History Questionnaire were used to measure PTSD and CA respectively. Psychophysiological response was measured by EMG, SCR, and heart rate. Repeated-measures mixed linear models were used to assess the significance of CA by neural structure interactions. CA interacted with both hippocampal and CC volume on psychophysiological response magnitudes, where participants with CA and smaller hippocampal volume had greater EMG (p < 0.01) and SCR (p < 0.05) magnitudes across trials and over threat conditions. Participants with CA and smaller CC volume had greater SCR magnitudes across trials and over threat conditions (p < 0.01). Hippocampal and genu volume mediated CA and psychophysiological response magnitude. CA may impact psychophysiological response via a reduction in hippocampal and CC volume. Volumetric reduction in these structures may indicate a neurofunctional, CA-related increase in threat sensitivity, which could portend increased PTSD susceptibility and adverse interpersonal and social consequences across the lifespan

Racial/ethnic disparities in the diagnosis and management of menopause symptoms among midlife women veterans

ObjectiveRacial/ethnic disparities in menopause symptoms and hormone therapy management remain understudied among women served by the Veteran's Health Administration, despite the unique racial/ethnic diversity of this population. Thus, we determined racial/ethnic disparities in medical record-documented menopause symptoms and prescribed menopausal hormone therapy among women veterans.MethodsWe conducted cross-sectional analyses of national Veteran's Health Administration electronic health record data from 2014 to 2015. We used logistic regression models to compare medical-record documented menopause symptoms and treatment (eg, vaginal estrogen or systemic hormone therapy) by self-identified race/ethnicity, adjusting for age, body mass index, and depression. Models examining hormone treatment were adjusted for menopause symptoms.ResultsAmong 200,901 women veterans (mean age 54.3, SD 5.4 y; 58% non-Hispanic/Latinx White, 33% non-Hispanic/Latinx Black, 4% Hispanic/Latinx, and 4% other), 5% had documented menopause symptoms, 5% were prescribed vaginal estrogen, and 5% were prescribed systemic hormone therapy. In fully adjusted multivariable models, non-Hispanic/Latinx Black women veterans had lower odds of documented menopause symptoms relative to non-Hispanic/Latinx White women (OR 0.82, 95% CI: 0.78-0.86). Moreover, non-Hispanic/Latinx Black women (OR 0.74, 95% CI: 0.70-0.77), as well as Hispanic/Latinx women (OR 0.68, 95% CI: 0.61-0.77), had lower likelihood of systemic hormone therapy prescription. Hispanic/Latinx women had higher odds of vaginal estrogen prescription (OR 1.12 95% CI: 1.02-1.24) than non-Hispanic/Latinx White women. Non-Hispanic/Latinx Black women had lower likelihood of estrogen use (OR 0.78 95% CI: 0.74-0.81) than non-Hispanic/Latinx White women.ConclusionDespite evidence suggesting higher menopause symptom burden among Black women in community samples, documented menopause symptoms and hormone therapy were less common among Black, compared with White, women veterans. Additionally, Hispanic/Latinx women veterans had lower odds of prescribed systemic menopause therapy and yet higher odds of prescribed vaginal estrogen, despite no difference in documented symptoms. These findings may signal important disparities in symptom reporting, documentation, and/or treatment for minority women veterans

The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle-Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top-down (i.e., disorder-first approach) or bottom-up (i.e., symptom-first approach), constructs are evaluated from the middle out (i.e., presentation-first approach), unconstrained by higher-order disorders or lower-order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle-order phenotypes, representing person-centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person-centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable-centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.</p

Sex differences in objective measures of sleep in post‐traumatic stress disorder and healthy control subjects

A growing literature shows prominent sex effects for risk for post-traumatic stress disorder and associated medical comorbid burden. Previous research indicates that post-traumatic stress disorder is associated with reduced slow wave sleep, which may have implications for overall health, and abnormalities in rapid eye movement sleep, which have been implicated in specific post-traumatic stress disorder symptoms, but most research has been conducted in male subjects. We therefore sought to compare objective measures of sleep in male and female post-traumatic stress disorder subjects with age- and sex-matched control subjects. We used a cross-sectional, 2&nbsp;×&nbsp;2 design (post-traumatic stress disorder/control&nbsp;×&nbsp;female/male) involving83 medically healthy, non-medicated adults aged 19-39&nbsp;years in the inpatient sleep laboratory. Visual electroencephalographic analysis demonstrated that post-traumatic stress disorder was associated with lower slow wave sleep duration (F(3,82) &nbsp;=&nbsp;7.63, P&nbsp;=&nbsp;0.007) and slow wave sleep percentage (F(3,82) &nbsp;=&nbsp;6.11, P&nbsp;=&nbsp;0.016). There was also a group&nbsp;×&nbsp;sex interaction effect for rapid eye movement sleep duration (F(3,82) &nbsp;=&nbsp;4.08, P&nbsp;=&nbsp;0.047) and rapid eye movement sleep percentage (F(3,82) &nbsp;=&nbsp;4.30, P&nbsp;=&nbsp;0.041), explained by greater rapid eye movement sleep in post-traumatic stress disorder females compared to control females, a difference not seen in male subjects. Quantitative electroencephalography analysis demonstrated that post-traumatic stress disorder was associated with lower energy in the delta spectrum (F(3,82) &nbsp;=&nbsp;6.79, P&nbsp;=&nbsp;0.011) in non-rapid eye movement sleep. Slow wave sleep and delta findings were more pronounced in males. Removal of post-traumatic stress disorder subjects with comorbid major depressive disorder, who had greater post-traumatic stress disorder severity, strengthened delta effects but reduced rapid eye movement effects to non-significance. These findings support previous evidence that post-traumatic stress disorder is associated with impairment in the homeostatic function of sleep, especially in men with the disorder. These findings suggest that group&nbsp;×&nbsp;sex interaction effects on rapid eye movement may occur with more severe post-traumatic stress disorder or with post-traumatic stress disorder comorbid with major depressive disorder