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1.  Nonsuicidal Self-Injury and Interpersonal Violence in U.S. Veterans Seeking Help for Posttraumatic Stress Disorder 
Psychiatry research  2016;247:250-256.
Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.
PMCID: PMC5191947  PMID: 27930966
PTSD; aggression; deliberate self-harm; NSSI; risk assessment
2.  The Association between Toxic Exposures and Chronic Multisymptom Illness in Veterans of the Wars of Iraq and Afghanistan 
The purpose of this study was to determine if post-9/11 veterans deployed to the Iraq and Afghanistan conflicts experienced toxic exposures and whether they are related to symptoms of Chronic Multisymptom Illness (CMI).
Data from 224 post-9/11 veterans who self-reported exposure to hazards in theater were analyzed using hierarchical regression.
Of the sample, 97.2% endorsed experiencing one or more potentially toxic exposure. In a regression model, toxic exposures and CMI symptoms were significantly associated above and beyond covariates. Follow-up analyses revealed that pesticide exposures, but not smoke inhalation was associated with CMI symptoms.
These findings suggest that toxic exposures were common among military personnel deployed to the most recent conflicts, and appear to be associated with CMI symptoms. Additional research on the impact of toxic exposures on returning Iraq and Afghanistan Veterans’ health is needed.
PMCID: PMC5556390  PMID: 28045798
toxic exposures; veterans; Gulf War Illness; Iraq/Afghanistan; Chronic Multisymptom Illness
3.  Is Cumulative Exposure to Suicide Attempts and Deaths A Risk Factor for Suicidal Behavior among Firefighters? A Preliminary Study 
The present study examined the association between cumulative exposure to suicide attempts and deaths and suicidal behavior in a sample of 61 professional firefighters. On average, firefighters reported 13.1 (SD=16.6) exposures over the course of their lifetime. Cumulative exposure to suicide attempts and deaths was positively correlated with suicidal behavior (r = 0.38, p = 0.004). Moreover, firefighters with 12+ exposures were more likely to screen positive for risk of suicidal behavior (OR = 7.885, p = 0.02). Additional research on the potential impact of cumulative exposure to suicide attempts and deaths on firefighters’ health and safety is needed.
PMCID: PMC5145737  PMID: 27371810
Suicide Contagion; Suicidal Behavior; Trauma
4.  Does Body Mass Index Moderate the Association between Posttraumatic Stress Disorder Symptoms and Suicidal Ideation in Iraq/Afghanistan Veterans? 
Psychiatry research  2016;244:123-129.
Suicide, PTSD, and obesity co-occur at high rates among returning veterans, yet limited research exists regarding the relationship among these variables. Self-report and diagnostic interview data from a longitudinal study of Iraq and Afghanistan veterans (N = 130) enrolled in VA healthcare examined these inter-relations. As hypothesized, body mass index (BMI) significantly moderated the association between PTSD and suicidal ideation such that the association between PTSD and suicidal ideation was strongest among individuals with a high BMI. Programs that focus on health promotion, trauma treatment, and weight management should continue to monitor suicide risk.
PMCID: PMC5556387  PMID: 27479102
5.  A 12-Month Prospective Study of the Effects of PTSD-Depression Comorbidity on Suicidal Behavior in Iraq/Afghanistan-Era Veterans 
Psychiatry research  2016;243:97-99.
Prior findings concerning the association between comorbid posttraumatic stress disorder (PTSD) and depression and suicidal behavior in Iraq/Afghanistan-era veterans have been mixed and limited by reliance on cross-sectional designs and self-report measures. The present study used validated clinical interviews to prospectively assess the effect of comorbid PTSD-depression on suicidal behavior in Iraq/Afghanistan-era veterans. A total of 309 Iraq/Afghanistan-era veterans completed clinical interviews of PTSD and depression at a baseline assessment, and 277 completed a clinical interview of suicidal behavior at a 12-month follow-up assessment (89.6% retention rate). As expected, veterans with comorbid PTSD-depression reported high rates of passive suicidal ideation, active suicidal ideation, active suicidal ideation with specific intent and plan, aborted attempts, interrupted attempts, and actual attempts at the 12-month follow-up. In addition, logistic regressions revealed that comorbid PTSD-depression was the only significant predictor of actual attempts at 12-month follow-up in the total sample (OR=10.671, p=0.007) and in the subset of veterans with PTSD/depression (OR=20.727, p=0.048). Comorbid PTSD-depression was also the only significant predictor of aborted/interrupted suicide attempts at 12-month follow-up in the total sample (OR=37.751, p < 0.007) and in the subset of veterans with PTSD/depression (OR=10.276, p=0.013). In contrast, gender, age, race, sexual orientation, and baseline history of attempts were not statistically significant in any of the models examined (all p’s ≥.10). Taken together, these findings suggest that clinicians should carefully monitor veterans with comorbid PTSD-depression, as this subset of veterans may be at particularly high risk for engaging in future suicidal behavior.
PMCID: PMC5556391  PMID: 27376669
Posttraumatic stress disorder; depression; comorbidity; suicide attempts; suicidal ideation; veterans
6.  Nonsuicidal self-injury and suicide attempts in Iraq/Afghanistan war veterans 
Psychiatry research  2016;243:232-237.
The present study examined the association between history of nonsuicidal self-injury (NSSI) and history of suicide attempts (SA) among 292 Iraq/Afghanistan veterans, half of whom carried a lifetime diagnosis of posttraumatic stress disorder (PTSD). Consistent with hypotheses, veterans who reported a history of NSSI were significantly more likely to report a history of SA than veterans without a history of NSSI. In addition, logistic regression demonstrated that NSSI remained a significant predictor of SA even after a wide range of covariates (i.e., combat exposure, traumatic brain injury, PTSD depression, alcohol dependence) were considered. Taken together, these findings suggest that clinicians working with veterans should include NSSI history as part of their standard risk assessment battery.
PMCID: PMC5560029  PMID: 27419652
Nonsuicidal self-injury; suicide; suicide attempts; suicidal ideation; PTSD; depression; veterans
7.  Reinforcement Sensitivity and Social Anxiety in Combat Veterans 
The present study tested the hypothesis that low behavioral approach system (BAS) sensitivity is associated with social anxiety in combat veterans.
Self-report measures of reinforcement sensitivity, combat exposure, social interaction anxiety, and social observation anxiety were administered to 197 Iraq/Afghanistan combat veterans.
As expected, combat exposure, behavioral inhibition system (BIS) sensitivity, and fight-flight-freeze system (FFFS) sensitivity were positively associated with both social interaction anxiety and social observation anxiety. In contrast, BAS sensitivity was negatively associated with social interaction anxiety only. An analysis of the BAS subscales revealed that the Reward Responsiveness subscale was the only BAS subscale associated with social interaction anxiety. BAS-Reward Responsiveness was also associated with social observation anxiety.
The findings from the present research provide further evidence that low BAS sensitivity may be associated with social anxiety over and above the effects of BIS and FFFS sensitivity.
PMCID: PMC5619664
Reinforcement sensitivity theory; BIS; BAS; trauma; social anxiety; veterans
8.  The Structure of DSM-5 Posttraumatic Stress Disorder Symptoms in War Veterans 
Anxiety, stress, and coping  2015;29(5):497-506.
The objective of the present research was to examine the underlying factor structure of posttraumatic stress disorder (PTSD) as conceptualized in the recently published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). A self-report measure of PTSD symptoms was administered to 258 trauma-exposed Iraq/Afghanistan war veterans. Confirmatory factor analysis was used to compare several different models of PTSD. Confirmatory factor analysis revealed that the best-fitting model was a six-factor model in which symptoms loaded onto the factors of intrusion, avoidance, negative affect, anhedonia, dysphoric arousal, and anxious arousal. These findings have important implications for ongoing conceptualization of PTSD and suggest that additional modifications to the diagnostic criteria for PTSD may still be warranted to more accurately reflect the underlying structure of PTSD symptoms.
PMCID: PMC5032636  PMID: 26275127
Confirmatory factor analysis; DSM-5; post-traumatic stress disorder; PTSD; trauma; veterans; military
9.  The Association Between Military Sexual Trauma and Use of VA and non-VA Healthcare Services among Female Veterans with Military Service in Iraq or Afghanistan 
Journal of interpersonal violence  2016;0886260515625909.
Military sexual trauma (MST) has been linked with increased rates of mental health disorders among veterans. Few studies have addressed how military sexual trauma is related to use of VA and non-VA health care. The purpose of the current study was to (1) examine the association between MST, combat experiences and mental health outcomes (i.e., PTSD and depression) and (2) examine the association of MST and use of VA and non-VA health care services among female veterans who served in Iraq and Afghanistan. Female respondents to a survey assessing OEF/OIF veterans’ needs and health (N=185) completed measures of demographic variables, military history, combat exposure, MST, PTSD and depression symptoms, and use of VA and non-VA healthcare. Overall, 70% of the sample experienced one or more combat-related experiences and 15.7% endorsed MST during deployment to Iraq or Afghanistan. MST and combat exposure were both positively associated with PTSD and depression symptoms even after controlling for the effects of demographic and military history variables; the interaction between MST and combat exposure was not a significant predictor of PTSD or depression symptoms. MST was associated with increased use of VA mental health services in bivariate results but was not independently related to VA service utilization after accounting for PTSD and depression symptoms. MST and combat exposure are significantly related to PTSD and depression symptoms among female OEF/OIF veterans, but there was not a synergistic effect of these two types of trauma in the current study. Approximately half of women who report MST have not used VA healthcare. Continued outreach and education initiatives may be needed to ensure veterans understand the resources available to address MST related mental and physical health problems through the VA.
PMCID: PMC4956588  PMID: 26802046
military sexual trauma; Operation Iraqi Freedom (OIF); Operation Enduring Freedom (OEF); veterans; service use
10.  Predicting Suicide Risk in Trauma Exposed Veterans: The Role of Health Promoting Behaviors 
PLoS ONE  2016;11(12):e0167464.
Returning veterans of the wars in Iraq and Afghanistan experience high rates of post-traumatic stress disorder (PTSD) and suicidal behavior. Suicidal ideation is among the strongest risk factors for completed suicide. Some research suggests an association between PTSD and suicidal ideation, and that health-promoting behaviors—behaviors that sustain or increase well-being—play a role in this association. The current study examined whether health-promoting behaviors moderate the association between PTSD severity and suicidal ideation.
Veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF; N = 108) completed measures of PTSD symptoms, trauma exposure, suicidal ideation, and health-promoting behaviors.
Moderated regression was used to test the hypothesis. Results indicated that health promoting behaviors, β = -.06, p = .001, and PTSD symptoms, β = .36, p < .001, were significantly related to suicidal ideation. Consistent with our main hypothesis, the health promoting behaviors x PTSD interaction term was significantly associated with suicidal ideation, β = -.09, p = .001. The overall model accounted for 13% of the variance in suicidal ideation. Among individuals with high PTSD symptom severity, those who engaged in more health promoting behaviors reported less suicidal ideation than those who engaged in fewer health promoting behaviors.
Health-promoting behaviors could be important for reducing suicidal ideation among veterans with high levels of PTSD symptoms. It is recommended that future research examine health promotion interventions as a means of reducing suicidal ideation.
PMCID: PMC5176167  PMID: 28002490
11.  Chronic Pain Acceptance Incrementally Predicts Disability in Polytrauma-Exposed Veterans at Baseline and 1-Year Follow-Up 
War veterans are at increased risk for chronic pain and co-occurring neurobehavioral problems, including posttraumatic stress disorder (PTSD), depression, alcohol-related problems, and mild traumatic brain injury (mTBI). Each condition is associated with disability, particularly when co-occurring. Pain acceptance is a strong predictor of lower levels of disability in chronic pain. This study examined whether acceptance of pain predicted current and future disability beyond the effects of these co-occurring conditions in war veterans. Eighty trauma-exposed veterans with chronic pain completed a PTSD diagnostic interview, clinician-administered mTBI screening, and self-report measures of disability, pain acceptance, depression, and alcohol use. Hierarchical regression models showed pain acceptance to be incrementally associated with disability after accounting for symptoms of PTSD, depression, alcohol-related problems, and mTBI (total adjusted R2=.57, p<.001, ΔR2=.03, p=.02). At 1-year follow-up, the total variance in disability accounted for by the model decreased (total adjusted R2 =.29, p<.001), whereas the unique contribution of pain acceptance increased (ΔR2=.07, p=.008). Pain acceptance remained significantly associated with 1-year disability when pain severity was included in the model. Future research should evaluate treatments that address chronic pain acceptance and co-occurring conditions to promote functional recovery in the context of polytrauma in war veterans.
PMCID: PMC5032639  PMID: 26233854
chronic pain; acceptance; functioning; disability; posttraumatic stress disorder; veterans
12.  Mindfulness, Self-Compassion, Posttraumatic Stress Disorder Symptoms, and Functional Disability in U.S. Iraq and Afghanistan War Veterans 
Journal of traumatic stress  2015;28(5):460-464.
Mindfulness and self-compassion are overlapping but distinct constructs that characterize how people relate to emotional distress. Both are associated with PTSD and may be related to functional disability. While self-compassion includes mindful awareness of emotional distress, it is a broader construct that also includes being kind and supportive to oneself and viewing suffering as part of the shared human experience – a powerful way of dealing with distressing situations. We examined the associations of mindfulness and self-compassion with PTSD symptom severity and functional disability in 115 trauma-exposed Iraq/Afghanistan war veterans. Mindfulness and self-compassion were each uniquely, negatively associated with PTSD symptom severity. After accounting for mindfulness, self-compassion accounted for unique variance in PTSD symptom severity (f2 = .25; medium ES). After accounting for PTSD symptom severity, mindfulness and self-compassion were each uniquely negatively associated with functional disability. The combined association of mindfulness and self-compassion with disability over and above PTSD was large (f2 = .41). After accounting for mindfulness, self-compassion accounted for unique variance in disability (f2 = .13; small ES). These findings suggest that interventions aimed at increasing mindfulness and self-compassion could potentially decrease functional disability in returning veterans with PTSD symptoms.
PMCID: PMC5032647  PMID: 26426991
mindfulness; self-compassion; PTSD; functioning; disability; veteran
13.  Effect of genetic variation in the nicotinic receptor genes on risk for posttraumatic stress disorder 
Psychiatry research  2015;229(0):326-331.
The present study examined the association between genetic variation in the nicotinic receptor gene family (CHRNA2, CHRNA3, CHRNA4, CHRNA5, CHRNA6, CHRNA7, CHRNA9, CHRNA10, CHRNB2, CHRNB3, CHRNB4) and the occurrence of posttraumatic stress disorder (PTSD). Clinical interviews were used to diagnose PTSD in 925 non-Hispanic Black (NHB) and 743 non-Hispanic White (NHW) participants. Trauma history and smoking status were assessed with self-report. No significant main effects or single nucleotide polymorphism (SNP) * smoking interactions were observed among NHB participants; however, among NHW participants, a novel association between rs12898919 in the cholinergic receptor nicotinic alpha-5 (CHRNA5) gene and PTSD was observed. No other significant main effects or SNP * smoking interactions were identified among NHW participants. While preliminary, these findings provide continued support for the hypothesis that the CHRNA5 gene is associated with increased risk for PTSD. Limitations of the present study include cross-sectional design, relatively small sample sizes for genetic research, use of self-report to assess smoking status, and use of different methods to diagnose PTSD. Additional research in other samples of trauma-exposed participants is needed to identify the specific functional variant(s) responsible for the association observed between CHRNA5 and PTSD risk in the present study.
PMCID: PMC4697753  PMID: 26184988
posttraumatic stress disorder; PTSD; trauma; smoking; nicotine; gene; genetic
14.  Does military sexual trauma moderate the impact of critical warzone experiences? 
Psychiatry research  2015;229(0):596-598.
The present research sought to replicate the finding that military sexual trauma (MST) moderates the effect of critical warzone experiences on mental health outcomes in a sample of male veterans. One-hundred eighty-one male veterans completed measures of MST, critical warzone experiences, and mental health symptoms. The hypothesized interaction was not significant, nor was a significant main effect observed for MST. In contrast, both critical warzone experiences and childhood maltreatment had significant main effects.
PMCID: PMC4697762  PMID: 26210649
PTSD; depression; anxiety
15.  Combined PTSD and Depressive Symptoms Interact with Post-Deployment Social Support to Predict Suicidal Ideation in Operation Enduring Freedom and Operation Iraqi Freedom Veterans 
Psychiatry research  2014;216(3):357-362.
Rates of suicide are alarmingly high in military and veteran samples. Suicide rates are particularly elevated among those with post-traumatic stress disorder (PTSD) and depression, which share overlapping symptoms and frequently co-occur. Identifying and confirming factors that reduce suicide risk among veterans with PTSD and depression is imperative. The proposed study evaluated whether post-deployment social support moderated the influence of PTSD-depression symptoms on suicidal ideation among veterans returning from Iraq and Afghanistan using state of the art clinical diagnostic interviews and self-report measures. Operations Enduring and Iraqi Freedom (OEF/OIF) veterans (n=145) were invited to participate in a study evaluation returning veterans’ experiences. As predicted, PTSD-depression symptoms had almost no effect on suicidal ideation (SI) when post-deployment social support was high; however, when post-deployment social support was low, PTSD-depression symptoms were positively associated with SI. Thus, social support may be an important factor for clinicians to assess in the context of PTSD and depressive symptoms. Future research is needed to prospectively examine the interrelationship between PTSD/depression and social support on suicidal risk, as well as whether interventions to improve social support result in decreased suicidality.
PMCID: PMC5032640  PMID: 24612971
16.  A Bayesian model averaging approach to examining changes in quality of life among returning Iraq and Afghanistan Veterans 
Many Veterans from the conflicts in Iraq and Afghanistan return home with physical and psychological impairments that impact their ability to enjoy normal life activities and diminish their quality of life (QoL). The present research aimed to identify predictors of QoL over an 8-month period using Bayesian model averaging (BMA), which is a statistical technique useful for maximizing power with smaller sample sizes. A sample of 117 Iraq and Afghanistan Veterans receiving care in a southwestern healthcare system was recruited, and BMA examined the impact of key demographics (e.g., age, gender), diagnoses (e.g., depression), and treatment modalities (e.g., individual therapy, medication) on QoL over time. Multiple imputation based on Gibbs sampling was employed for incomplete data (6.4% missingness). Average follow-up QoL scores were significantly lower than at baseline (73.2 initial vs 69.5 4-month and 68.3 8-month). Employment was associated with increased QoL during each follow-up, while posttraumatic stress disorder and black race were inversely related. Additionally, predictive models indicated that depression, income, treatment for a medical condition, and group psychotherapy were strong negative predictors of 4-month QoL but not 8-month QoL.
PMCID: PMC5032641  PMID: 24942672
quality of life; Veterans; Bayesian analysis; mental health
17.  Deployment-Related TBI, Persistent Postconcussive Symptoms, PTSD, and Depression in OEF/OIF Veterans 
Rehabilitation psychology  2011;56(4):340-350.
A substantial proportion of the more than 2 million service members who have served in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) have experienced a traumatic brain injury (TBI). Understanding the long-term impact of TBI is complicated by the non-specific nature of postconcussive symptoms (PCS) and the high rates of co-occurrence among TBI, posttraumatic stress disorder (PTSD), and depression. The goal of the present research was to examine the relations among TBI, persistent PCS, and symptoms of PTSD and depression among returning OEF/OIF Veterans.
Two-hundred and thirteen OEF/OIF Veterans (87% male) completed a semi-structured screening interview assessing deployment-related TBI and current, persistent PCS. Participants also completed self-report measures of combat exposure and current symptoms of PTSD and depression.
Nearly half (46%) of sampled Veterans screened positive for TBI, the majority of whom (85%) reported at least one persistent PCS after removing PCS that overlapped with PTSD and depression. Veterans with deployment-related TBI reported higher levels of combat exposure and symptoms of PTSD and depression. Structural equation modeling was used to assess the fit of three models of the relationships among TBI, combat exposure, persistent PCS, PTSD, and depression. Consistent with hypotheses, the best fitting model was one in which the effects of TBI on both PTSD and depression were fully mediated by non-overlapping persistent PCS.
These findings highlight the importance of addressing persistent PCS in order to facilitate the functional recovery of returning war Veterans.
PMCID: PMC5032644  PMID: 22121940
18.  Neuropsychological Sequelae of PTSD and TBI Following War Deployment Among OEF/OIF Veterans 
Neuropsychology review  2012;22(1):21-34.
Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are highly prevalent among Veterans of the conflicts in Iraq and Afghanistan. These conditions are associated with common and unique neuropsychological and neuroanatomical changes. This review synthesizes neuropsychological and neuroimaging studies for both of these disorders and studies examining their co-occurrence. Recommendations for future research, including utilizing combined neuropsychological and advanced neuroimaging techniques to study these disorders alone and in concert, are presented. It is clear from the dearth of literature that more attention in the literature should be given to examining temporal relationships between PTSD and mTBI, risk and resilience factors associated with both disorders and their co-occurrence, and mTBI-specific factors such as time since injury and severity of injury, utilizing comprehensive, yet targeted cognitive tasks.
PMCID: PMC5032645  PMID: 22350690
20.  Resilience, Traumatic Brain Injury, Depression and Posttraumatic Stress among Iraq/Afghanistan War Veterans 
Rehabilitation psychology  2015;60(3):263-276.
We examined the prospective influence of the resilient, undercontrolled, and overcontrolled personality prototypes on depression and posttraumatic stress disorder (PTSD) symptoms among Iraq/Afghanistan war veterans. After accounting for the possible influence of combat exposure, we expected that the resilient prototype would predict lower depression and PTSD over time and would be associated with adaptive coping strategies, higher social support, lower psychological inflexibility, and higher self-reported resilience relative to the overcontrolled and undercontrolled prototypes, independent of TBI status.
One-hundred twenty-seven veterans (107 men, 20 women; average age = 37) participated in the study. Personality was assessed at baseline, and PTSD and depression symptoms were assessed eight months later. Path analysis was used to test the direct and indirect effects of personality on distress.
No direct effects were observed from personality to distress. The resilient prototype did have significant indirect effects on PTSD and depression through its beneficial effects on social support, coping and psychological inflexibility. TBI also had direct effects on PTSD.
A resilient personality prototype appears to influence veteran adjustment through its positive associations with greater social support and psychological flexibility, and lower use of avoidant coping. Low social support, avoidant coping and psychological inflexibility are related to overcontrolled and undercontrolled personality prototypes, and these behaviors seem to characterize veterans who experience problems with depression and PTSD over time. A positive TBI status is directly and prospectively associated with PTSD symptomology independent of personality prototype. Implications for clinical interventions and future research are discussed.
PMCID: PMC5032656  PMID: 26214528
Resilient personality; PTSD; depression; combat exposure; traumatic brain injury
21.  Self-Compassion as a Prospective Predictor of PTSD Symptom Severity Among Trauma-Exposed U.S. Iraq and Afghanistan War Veterans 
Journal of traumatic stress  2015;28(2):127-133.
U. S. combat veterans of the Iraq and Afghanistan wars have elevated rates of posttraumatic stress disorder (PTSD) compared to the general population. Self-compassion, characterized by self-kindness, a sense of common humanity when faced with suffering, and mindful awareness of suffering, is a potentially modifiable factor implicated in the development and maintenance of PTSD. We examined the concurrent and prospective relationship between self-compassion and PTSD symptom severity after accounting for level of combat exposure and baseline PTSD severity. Participants at baseline assessment were 115 Iraq and Afghanistan war veterans exposed to 1 or more traumatic events during deployment (n = 101 at follow-up). PTSD symptoms were assessed using the Clinician Administered PTSD Scale for DSM-IV at baseline and 12 months. Self-compassion and combat exposure were assessed at baseline via self-report. Self-compassion was associated with baseline PTSD symptoms after accounting for combat exposure (β = −.59; p < .001; ΔR2 = .34; f2 = .67; large effect) and predicted 12-month PTSD symptom severity after accounting for combat exposure and baseline PTSD severity (β = −.24; p = .008; ΔR2 = .03; f2 = .08; small effect). Findings suggest that interventions that increase self-compassion may be beneficial for treating chronic PTSD symptoms among some Iraq and Afghanistan war veterans.
PMCID: PMC5032642  PMID: 25808565
22.  A Test of Whether Coping Styles Moderate the Effect of PTSD Symptoms on Alcohol Outcomes 
Journal of traumatic stress  2014;27(4):478-482.
Coping style may partially account for the frequent co-occurrence of posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD). We hypothesized that PTSD symptom severity, avoidant coping, and action-oriented coping would interact, such that veterans high on PTSD symptoms and avoidant coping and low on action-oriented coping would report more negative alcohol-related consequences and drinking a greater number of drinks per week compared to veterans without all three risk factors. The sample (N = 128) of veterans (85.2% male, M = 37.8 years old, 63.3% Caucasian) completed a diagnostic assessment and self-report measures assessing PTSD, alcohol use disorders, coping styles, and alcohol outcomes. Consistent with the main hypothesis, a three-way interaction among PTSD symptom severity, avoidant coping, and action-oriented coping was found in the predicted direction. In addition, post-hoc descriptive analyses indicated that Veterans with a current PTSD diagnosis, low action-oriented coping, and high avoidant coping had worse alcohol outcomes and were twice as likely to meet criteria for current AUD compared with Veterans with two or fewer risk factors. These findings suggest that the combination of PTSD and maladaptive coping styles may be more important for understanding alcohol-related outcomes than the presence of any of these variables in isolation.
PMCID: PMC5032643  PMID: 25158641
23.  Genome-wide Association Study of Posttraumatic Stress Disorder in a Cohort of Iraq- Afghanistan era Veterans 
Journal of affective disorders  2015;184:225-234.
Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can develop after experiencing traumatic events. A genome-wide association study (GWAS) design was used to identify genetic risk factors for PTSD within a multi-racial sample primarily composed of U.S. veterans.
Participants were recruited at multiple medical centers, and structured interviews were used to establish diagnoses. Genotypes were generated using three Illumina platforms and imputed with global reference data to create a common set of SNPs. SNPs that increased risk for PTSD were identified with logistic regression, while controlling for gender, trauma severity, and population substructure. Analyses were run separately in non-Hispanic black (NHB; n=949) and non-Hispanic white (NHW; n=759) participants. Meta-analysis was used to combine results from the two subsets.
SNPs within several interesting candidate genes were nominally significant. Within the NHB subset, the most significant genes were UNC13C and DSCAM. Within the NHW subset, the most significant genes were TBC1D2, SDC2 and PCDH7. In addition, PRKG1 and DDX60L were identified through meta-analysis. The top genes for the three analyses have been previously implicated in neurologic processes consistent with a role in PTSD. Pathway analysis of the top genes identified alternative splicing as the top GO term in all three analyses (FDR q < 3.5 × 10−5).
No individual SNPs met genome-wide significance in the analyses.
This multi-racial PTSD GWAS identified biologically plausible candidate genes and suggests that post-transcriptional regulation may be important to the pathology of PTSD; however, replication of these findings is needed.
PMCID: PMC4697755  PMID: 26114229
Posttraumatic stress disorder; Combat exposure; Genome-wide association study; Meta-analysis; Gene*environment interaction
24.  Non-suicidal self-injury as a predictor of active and passive suicidal ideation among Iraq/Afghanistan war veterans 
Psychiatry research  2015;227(0):360-362.
The present study examined the association between lifetime non-suicidal self-injury (NSSI) and current suicidal ideation among Iraq/Afghanistan veterans. NSSI was positively associated with passive, active, and concurrent active-passive suicidal ideation at the bivariate level. NSSI remained a predictor of active, OR = 5.15, and concurrent active-passive suicidal ideation, OR = 7.01, when other risk factors were considered. These findings suggest that NSSI may be a particularly useful marker of active suicidal ideation among veterans.
PMCID: PMC4697757  PMID: 25858799
Suicide; non-suicidal self-injury; depression
25.  Effect of the APOE ε4 Allele and Combat Exposure on PTSD among Iraq/Afghanistan-Era Veterans 
Depression and anxiety  2015;32(5):307-315.
The apolipoprotein E (APOE) ε4 allele has been implicated in a range of neuropsychiatric conditions. The present research examined if the ε4 allele of the APOE gene moderated the effect of combat exposure on posttraumatic stress disorder (PTSD) among Iraq/Afghanistan-era veterans.
Participants included 765 non-Hispanic White (NHW) and 859 non-Hispanic Black (NHB) Iraq/Afghanistan-era veterans. A structured interview established psychiatric diagnoses. Combat exposure and PTSD symptom severity were assessed via self-report.
The most common lifetime diagnoses were depression (39.2%), PTSD (38.4%), and alcohol dependence (24.38%). After correcting for multiple comparisons, no significant effects were observed on any of the outcomes among the NHW sample; however, within the NHB sample, significant gene x environment (GxE) interactions were observed for lifetime PTSD (p = .0029) and PTSD symptom severity (p = .0009). In each case, the APOE ε4 allele had no effect on the outcomes when combat exposure was low; however, when combat exposure was high, an additive effect was observed such that ε4 homozygotes exposed to high levels of combat reported the highest rates of PTSD (92%) and the worst symptom severity scores on the Davidson Trauma Scale (M = 79.5).
While preliminary, these findings suggest that the APOE ε4 allele, in conjunction with exposure to high levels of combat exposure, may increase veterans’ risk for developing PTSD.
PMCID: PMC4697754  PMID: 25709077
APOE; genetic; PTSD; depression; veteran; comorbidity

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