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Kimerling R.,National Center for Posttraumatic Stress Disorder
Women's health issues : official publication of the Jacobs Institute of Women's Health | Year: 2011

Although sexual trauma is associated with poorer patient perceptions of health care quality, few studies have investigated this relationship in settings with comprehensive policies surrounding detection and treatment of sexual trauma, such as the Veterans Health Administration (VHA). We examined the association of military sexual trauma (MST) with patient satisfaction with VHA outpatient care among men and women. This is a cross-sectional study of a national representative sample of 164,632 VHA outpatients (5,758 women and 158,884 men) from fiscal year 2007. Measures included MST status, patients' ratings of overall satisfaction with VHA care in the last 2 months, and nine other dimensions of patient satisfaction. We assessed bivariate and multivariate associations between MST and overall satisfaction and each dimension of patient satisfaction. Multivariate models were adjusted for demographic characteristics, health status, and medical utilization. All analyses were stratified by gender. The proportion of patients reporting very good or excellent overall satisfaction was 78.5% for men and 72.3% for women. Findings showed that, once confounding was controlled, men and women veterans' MST status was not associated with satisfaction ratings of VHA health care overall. However, women veterans with a history of MST rated the dimensions of overall coordination and education and information less favorably than women veterans without an MST history. Post hoc analysis of individual items in these domains suggested that areas of improvement might include greater attention to provider-patient communication, including communication across multiple providers. There was no association between men's MST status and subdomains of health care satisfaction. Patient ratings of overall satisfaction of VHA care are high. Opportunities exist, however, to educate providers on the special coordination needs of female veterans with histories of MST. These female veterans might benefit from care coordination. When investigating satisfaction in patients with histories of sexual trauma, our findings suggest the importance of adjusting analyses for important patient characteristics. Published by Elsevier Inc.

Mansfield A.J.,University of North Carolina at Chapel Hill | Mansfield A.J.,National Center for Posttraumatic Stress Disorder | Kaufman J.S.,McGill University | Engel C.C.,Uniformed Services University of the Health Sciences | Gaynes B.N.,University of North Carolina at Chapel Hill
Archives of Pediatrics and Adolescent Medicine | Year: 2011

Objective: To characterize the risk of mental health diagnoses among children of US military personnel associated with parental deployment in support of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Design: Nonrandomized, retrospective cohort study (2003-2006). Setting: Electronic medical record data for outpatient care. Participants: Children (N=307 520) aged 5 to 17 years with at least 1 active-duty US Army parent. Main Exposure: Number of months of parental deployment for OIF and OEF. Main Outcome Measures: A mental health diagnosis was defined as having at least 1 mental healthrelated International Classification of Diseases, Ninth Revision, code out of 4 possible codes for a given outpatient medical visit. Diagnoses were further classified into 1 of 17 disorder categories. Results: Overall, children with parental deployment represented an excess of 6579 mental health diagnoses during the 4-year period compared with children whose parents did not deploy. After the children's age, sex, and mental health history were adjusted for, excess mental health diagnoses associated with parental deployment were greatest for acute stress reaction/adjustment, depressive, and pediatric behavioral disorders and increased with total months of parental deployment. Boys and girls showed similar patterns within these same categories, with more diagnoses observed in older children within sex groups and in boys relative to girls within age groups. Conclusions: A dose-response pattern between deployment of a parent for OIF and OEF and increased mental health diagnoses was observed in military children of all ages. Findings may be used to inform policy, prevention, and treatment efforts for military families facing substantial troop deployments. ©2011 American Medical Association. All rights reserved.

Horn C.A.C.,New York University | Pietrzak R.H.,National Center for Posttraumatic Stress Disorder | Pietrzak R.H.,Yale University | Corsi-Travali S.,New York University | Neumeister A.,New York University
Psychoneuroendocrinology | Year: 2014

Introduction: Recent confirmatory factor analytic studies of the dimensional structure of posttraumatic stress disorder (PTSD) suggest that this disorder may be best characterized by five symptom dimensions-re-experiencing, avoidance, numbing, dysphoric arousal, and anxious arousal. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation in PTSD and has been attributed to enhanced glucocorticoid responsiveness. However, little is known about how altered HPA-axis function is related to this contemporary phenotypic model of PTSD. Methods: We compared morning plasma cortisol levels of drug-free civilian adults with PTSD (N=29) to trauma-exposed (TC; N=12) and non-trauma-exposed healthy controls (HC; N=23). We then examined the relation between cortisol levels and a contemporary 5-factor 'dysphoric arousal' model of PTSD symptoms among individuals with PTSD. Results: After adjustment for white race/ethnicity, education, lifetime alcohol use disorder, and current smoking status, the PTSD (Cohen's d=1.1) and TC (Cohen's d=1.3) groups had significantly lower cortisol levels than the HC group; cortisol levels did not differ between the TC and PTSD groups. Except for age (r=46), none of the other demographic, trauma-related, or clinical variables, including lifetime mood/anxiety disorder and severity of current depressive and anxiety symptoms, were associated with cortisol levels. In a stepwise linear regression analysis, age (β=44) and severity of emotional numbing symptoms (β=35) were independently associated with cortisol levels in the PTSD group; none of the other PTSD symptom clusters or depression symptoms were significant. Post hoc analyses revealed that severity of the emotional numbing symptom of restricted range of affect (i.e., unable to have loving feelings) was independently related to cortisol levels (β=35). Conclusion: These results suggest that trauma-exposed civilian adults with and without PTSD have significantly lower cortisol levels compared to healthy, non-trauma-exposed adults. They further suggest that low cortisol levels among adults with PTSD may be specifically linked to emotional numbing symptomatology that is unique to the PTSD phenotype and unrelated to depressive symptoms. © 2013 Elsevier Ltd.

Cardena E.,Lund University | Carlson E.,National Center for Posttraumatic Stress Disorder
Annual Review of Clinical Psychology | Year: 2011

Acute stress disorder (ASD) was introduced into the Diagnostic and Statistical Manual (DSM) taxonomy in 1994 to address the lack of a specific diagnosis for acute pathological reactions to trauma and the role that dissociative phenomena play both in the short- and long-term reactions to trauma. In this review, we discuss the history and goals of the diagnosis and compare it with the diagnoses of acute stress reaction, combat stress reaction, and posttraumatic stress disorder (PTSD). We also evaluate the research on the validity and limitations of ASD as a diagnosis, the relationship between peritraumatic dissociation and other symptomatology, the extent to which PTSD is predicted by previous ASD or peritraumatic dissociation, and other important issues such as impairment and risk factors related to ASD. We conclude with our recommendations for changes in DSM-5 criteria and the development of more sophisticated research that considers ASD as but one of two or possibly three common acute posttraumatic syndromes. Copyright © 2011 by Annual Reviews. All rights reserved.

Fanning J.R.,National Center for Posttraumatic Stress Disorder | Fanning J.R.,Yale University | Pietrzak R.H.,National Center for Posttraumatic Stress Disorder | Pietrzak R.H.,Yale University
Journal of Psychiatric Research | Year: 2013

Older men have a higher rate of suicide than the general population, but little is known about the prevalence and correlates of suicidality among older male veterans. In this study, we evaluated the prevalence, and risk and protective factors associated with current suicidal ideation (SI) and past suicide attempt (SA) in a contemporary, nationally representative sample of older male veterans. We analyzed data from 1962 male veterans aged 60 or older who participated in the National Health and Resilience Veterans Survey (NHRVS) between October and December 2011. Bivariate analyses and multivariate logistic regression were used to evaluate risk and protective factors associated with current SI and past SA in the full sample, and separately among combat and non-combat veterans. Six percent of the sample reported past 2-week SI, and combat veterans were more likely to contemplate suicide (9.2%) than non-combat (4.0%) veterans. Lifetime SA was reported by 2.6% of respondents. Major depression and physical health difficulties were the strongest risk factors for SI in combat veterans, while generalized anxiety disorder (GAD) was the strongest risk factor for SI in non-combat veterans. Posttraumatic stress disorder (PTSD) was independently associated with SI in both groups of veterans, and social connectedness was negatively related to SI in both groups. These results suggest that a significant proportion of older male veterans in the United States contemplates suicide, with higher rates of SI among combat than non-combat veterans. Interventions designed to mitigate psychological distress and physical difficulties, and to promote social connectedness may help mitigate suicidality risk in this population. © 2013.

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