The outbreak of the Israel-Hamas war on October 7, 2023, has presented unprecedented challenges to older adults' mental health, including increased posttraumatic stress, anxiety, and depression. The current study examined potential war- and age-related factors associated with probable posttraumatic stress disorder (PTSD), clinical depression (probable depression), and generalized anxiety disorder (probable anxiety) among older adults during the ongoing war. Moreover, due to the continued threat of death, we examined whether death anxiety is an additional contributing factor to older adults' probable PTSD, depression, and anxiety. Data were collected January-March 2024 from 554 community-dwelling older adults (M = 73.90 years, SD = 7.35, range: 61-96 years) who completed online scales assessing sociodemographic variables, war exposure (distance from the Gaza Strip, exposure to terror attacks/blasts), and age-related constructs (assistance in daily activities [ADL], cognitive decline, physical illnesses, death anxiety). Increased ADL was associated with probable depression, B = 0.62, OR = 1.87, and anxiety, B = 0.42, OR = 1.53, and cognitive decline was associated with probable depression, B = 1.52, OR = 4.56. Older adults with high levels of death anxiety were almost 3 times as likely to meet the criteria for probable PTSD, B = 1.05, OR = 2.85, and more than 1.5 as likely to meet the criteria for probable depression, B = 0.54, OR = 1.71, and anxiety, B = 0.50, OR = 1.65. The importance of death anxiety as a potential risk factor for negative psychological outcomes among older adults during war is discussed.

In this paper, I provide a concise overview of the state of the scientific study of moral injury (MI). I argue that the state of science is immature, characterized by the lack of a paradigmatic theory and a lack of rigor in terms of construct definition and measurement. Because researchers, clinicians, and the media reify the results of empirical and clinical outcome studies that are chiefly exploratory and fraught with internal validity problems, enthusiasm about MI continues to far outweigh scientific and actionable, practice-based knowledge. I posit that the field needs to have epistemic humility about MI, focus on building a paradigmatic model to generate and test hypotheses that will ultimately create knowledge about the causes and consequences of MI, and employ evidence-based assessment and intervention approaches to mitigate and treat the problem. To facilitate research in this area, I summarize the social-functional theory of moral behavior and a new theory of MI based on it. I also make recommendations for future research to advance the field into a normal science, which requires hypothesis-driven research and valid measurement.

Despite a varied selection of available trauma-focused evidence-based psychotherapies (TF-EBPs) for posttraumatic stress disorder (PTSD), few veterans receive a full course of an evidence-based treatment. A better understanding of and alignment with veterans' PTSD treatment goals could be one way to improve treatment engagement and adherence, consistent with veteran-oriented care within the U.S. Department of Veterans Affairs (VA) Healthcare System. Few studies have examined veterans' specific goals or reasons for seeking treatment for PTSD. We conducted a qualitative analysis using secondary data from a randomized controlled trial (RCT) of 175 veterans who were randomized to receive a TF-EBP for PTSD. Veterans completed a self-report questionnaire at baseline and were asked to identify three distinct goals for treatment using a short-answer format. Two authors coded the data and identified themes. Three themes were identified: improvements in PTSD symptoms, personal well-being and growth, and improvements in social roles and interpersonal functioning. These findings suggest that veterans with PTSD have both symptom reduction goals and functional goals at the outset of treatment. The findings also emphasize the importance of broadening the scope of treatment outcome monitoring and assessment to better reflect patient-centered care and veterans' specific goals.

Following the death of a loved one, both approach behaviors related to the deceased (i.e., engagement with feelings, memories, and/or reminders of the deceased) and the avoidance of reminders of the death are theorized to precipitate severe and persistent grief reactions, termed prolonged grief. The "approach-avoidance processing hypothesis" holds that these behavioral tendencies occur simultaneously in prolonged grief disorder (PGD). We tested this hypothesis using a novel free-viewing attention task. Bereaved adults (N = 72, 81.9% female) completed a survey assessing prolonged grief symptoms, depressive symptoms, and lingering attachment and a free-viewing task assessing voluntary attention toward pictures of the deceased and combinations of the deceased with loss-related words (i.e., loss-reality reminders). A main finding was that participants with higher prolonged grief symptom levels, ρ(70) = .32, p = .006, and more lingering attachment, ρ(70) = .26, p = .030, showed stronger attentional focus toward pictures of the deceased. No significant association emerged between either prolonged grief symptom levels or lingering attachment and attention toward loss-reality reminders. The findings suggest that higher prolonged grief symptom levels may be characterized by persisting approach tendencies toward the deceased. Countering excessive proximity-seeking to the deceased in therapy could be beneficial for bereaved adults who show severe and persistent grief reactions.

The processing of positive memories technique (PPMT) entails detailed narration and processing of specific positive autobiographical memories (AM) and has shown promise in improving posttraumatic stress disorder (PTSD) symptoms. We examined whether participants receiving PPMT reported decreases in PTSD and depressive symptom severity, negative affect levels/reactivity, posttrauma cognitions, and positive emotion dysregulation, as well as increases in positive affect levels/reactivity and the number of retrieved positive AMs across four PPMT sessions. Individuals (N = 70) recruited from the community completed surveys at baseline (pre-PPMT), each PPMT session, and after completing all four PPMT sessions. Multilevel linear growth models indicated session-to-session decreases in PTSD severity, β = -.17, p < .001; depressive symptom severity, β = -.13, p < .001; negative affect levels, β = -.13, p < .001; positive affect reactivity, β = -.14, p = .014; and posttrauma cognitions, β = -.12, p < .001; and session-to-session increases in negative affect reactivity, β = .18, p = .001. Paired-samples t tests indicated decreases in retrieved positive AMs, d = 0.40, p = .001, including specific positive AMs, and negative AMs, d = 0.23, p = .022, and increases in retrieved overgeneral positive AMs, d = -0.38, p = .002, from baseline to postintervention. Thus, PPMT may help decrease PTSD and depression severity, negative affect, posttrauma cognitions, and negative AM recall tendencies. Clinicians may need to incorporate additional skills into the PPMT framework to improve positive affect processes that can be sustained over time.

Research suggests a bidirectional association between sleep disturbances and posttraumatic stress disorder (PTSD) symptoms. However, most studies have been conducted with group-level data, which do not necessarily capture the associations between PTSD symptoms and sleep within an individual over time. This study aimed to add to the literature concerning the association between sleep and PTSD and extend these findings to investigate the effect of sleep disturbances on positive affect. Ecological momentary assessment (EMA) was used to examine the daily temporal dynamics of sleep disturbances (i.e., self-reported difficulty initiating and maintaining sleep, disturbing dreams) and PTSD symptoms over 14 days in a sample of 41 trauma-exposed individuals. Multilevel models were employed to disambiguate within-person effects (i.e., intraindividual variability) from between-person effects (i.e., interindividual variability). Difficulty sleeping predicted increased PTSD symptoms at both the within-person, β = .11, and between-person levels, β = .38, as did disturbing dreams, within: β = .14, between: β = .31. Participants with higher PTSD symptom levels were likely to report increased difficulty sleeping at night, β = .40. Positive affect was unrelated to sleep at the within-person level but increased average sleep difficulty predicted lower positive affect at the between-person level. The findings indicate that sleep difficulties must be considerably more substantial than usual to affect PTSD symptoms in a noticeable way.

Although empirical support for the International Statistical Classification of Diseases and Related Health Problems (11th ed.; ICD-11) distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing, research into the ICD-11 CPTSD model in prison staff is lacking. This study used latent profile analysis (LPA) to (a) determine if there are distinct groups of trauma-exposed prison governors (i.e., "wardens" in the United States and Canada) who have symptom profiles consistent with the distinction between PTSD and CPTSD and (b) identify predictors and posttraumatic maladaptive beliefs associated with the latent profiles. Trauma-exposed prison governors (N = 385) completed the International Trauma Questionnaire (ITQ) and a measure of traumatic life events. LPA was used to extract profiles using the six ITQ symptom clusters and revealed four profiles: CPTSD (8.4%), PTSD (14.4%), disturbances in self-organization (DSO; 11.0%), and low symptoms (66.3%). Membership in the CPTSD and DSO profiles was associated with cumulative traumatization, odds ratios (OR) = 1.42 and OR = 1.26, respectively, and poorer health, OR = 2.84 and OR = 1.64, respectively, relative to the low symptom profile, and membership in the PTSD profile was associated with younger age, OR = 0.91, relative to the low symptom profile. The CPTSD profile showed the highest level of posttraumatic maladaptive beliefs. This study yields empirical support for the ICD-11 CPTSD model in prison staff. The results provide additional support for the validity of ITQ measurement of PTSD and CPTSD.

Individuals exposed to disasters are at high risk of developing mental health conditions, yet the availability of mental health practitioners is often limited. The aim of this scoping review was to examine the quality of the evidence for psychosocial interventions that can be delivered by non-mental health workers in the context of disasters. Searches were performed in PsycInfo, EMBASE, Family & Society Studies Worldwide, CINAHL, Global Health, PubMed, and SCOPUS, from inception through to November 2024, to identify studies of relevance. Only studies investigating psychosocial interventions that could be delivered by non-mental health clinicians in a non-hospital or clinic setting were included. In total, 69 primary intervention studies examining 27 universal interventions and 10 indicated interventions were identified. Studies were rated on quality and risk of bias, and GRADE was used to rank the evidence for each intervention. For universal interventions, no study had an evidence rating above "very low" to support confidence in a significant impact on clinical outcomes. For indicated interventions, Problem Management Plus (PM+) and Self-Help Plus (SH+) had an evidence rating of "high" in the postdisaster context, and Skills for Life Adjustment and Resilience (SOLAR) had a "low" evidence rating; the remaining interventions were given "very low" ratings. Despite the high number of psychosocial interventions that target postdisaster distress, very few have been tested using rigorous methodologies with large samples. Future research should include methodologies that test interventions at scale and recognize the impacts of compounding disasters.

Problematic anger affects up to 30% of individuals who have experienced trauma. Digital mental health approaches, such as ecological momentary assessment (EMA) delivered via smartphone and wearable devices (i.e., wearables), hold significant potential for the development of novel digital technology treatments. The objective of this cohort study was to examine the acceptability, feasibility, and outcomes from 10 days of usage of a digital mental health tool combining EMA and wearable use among trauma-exposed adults with problematic anger. We used mixed methods to examine feasibility and acceptability and explored quantitative changes in mental health symptoms among participants over the study period (N = 98, 80.4% women, M = 38 years). Quantitative and qualitative data revealed that regular EMA combined with a wearable was feasible and acceptable in the sample. We observed reductions in problem anger, p < .001, repeated-measures d (d) = -0.81, 95% CI [-1.04, -0.59]; and posttraumatic stress disorder symptoms, p = .025, d = -0.26, 95% CI [-0.55, -0.03], over the 10 days of monitoring. Qualitative findings suggest that by regularly "checking in" on anger symptoms, participants improved their self-awareness and ability to self-manage their mood. These findings provide valuable learnings for building future personalized digital mental health tools.

Posttraumatic growth (PTG) is characterized as the experience of positive psychological change following exposure to traumatic stress. However, studies examining the association between posttraumatic stress disorder (PTSD) symptoms and PTG have demonstrated mixed results. Further, although higher levels of social support have been shown to predict higher ratings of PTG, there are limited longitudinal findings regarding how interpersonal functioning may affect the association between PTSD symptoms and PTG. In this study, we examined interpersonal functioning in romantic relationships and friendships as mediators of the relation between PTSD symptom severity and PTG and examined potential sex differences among these associations. Participants were 1,427 veterans who completed self-report questionnaires across three time points. A parallel mediation analysis indicated that romantic relationship, β = -.01, 95% CI [-.03, -.001], and friendship, β = -.02, 95% CI [-.04, -.001], functioning were both indirectly associated with PTG in the full sample. Moreover, sex-stratified models indicated that romantic relationship functioning was a significant mediator for male veterans, β = -.02, 95% CI [-.05, -.01], whereas friendship functioning was a significant mediator for female veterans, β = -.04, 95% CI [-.08, -.01]. Together, these findings suggest that interpersonal functioning is an important factor in PTG, and targeting romantic relationship and friendship functioning in the context of trauma-focused treatment may be valuable and can help build a pathway from PTSD symptoms to PTG among female and male veterans.

Public safety personnel (PSP), such as police officers, firefighters, correctional workers, and paramedics, routinely face work stressors that increase their risk of developing posttraumatic stress disorder (PTSD). PSP may additionally face moral transgressions in the workplace (e.g., witnessing human suffering, working within broken systems), heightening the risk of moral injury (MI) in this population. Research among military personnel and health care workers shows an association between MI and PTSD; however, less is known about the association between these constructs among PSP. Canadian PSP completed an online survey between June 2022 and June 2023, including a demographic questionnaire and measures of PTSD, MI, dissociation, depression, anxiety, stress, and childhood adversity. Latent variable structural equation modeling (SEM) was performed to ascertain the impact of a latent MI construct (i.e., shame, trust violation, functional impairment) on a latent PTSD construct (i.e., intrusions, avoidance, negative alterations in cognition and mood, hyperreactivity, depersonalization, derealization). Sex, age, depression, anxiety, stress, and childhood adversity were included as covariates. A total of 314 PSP were included in the data analysis. A latent variable SEM regressing PTSD onto MI and including covariates accounted for 83.7% of the variance in PTSD. MI was the strongest predictor compared to all covariates and was significantly associated with PTSD symptoms, β = .506, p < .001, above and beyond the impacts of sex, age, depression, anxiety, stress, and childhood adversity. These findings are consistent with research among military members and health care providers and highlight the importance of further exploring MI among PSP.

Traumatic stress reactions (TSRs) exist on a continuum that includes posttraumatic stress disorder (PTSD), highly comorbid psychopathology, and resilience, highlighting the need for comprehensive and integrative approaches capable of capturing the full spectrum of heterogeneous reactions. Here, we used a transdiagnostic and multidimensional method to characterize clinical phenotypes of TSRs in a nationally representative sample of U.S. military veterans. The Middle-Out Approach was used to evaluate self-reported PTSD, generalized anxiety, major depressive symptoms, and physical and mental functioning to identify discrete latent classes of TSRs and their demographic, military and trauma history, and psychosocial correlates. Cross-sectional data were analyzed from 3,727 U.S. veterans who participated in the National Health and Resilience in Veterans Study. Latent class analysis identified five classes of veterans: low TSR (61.3%), anxious/depressive (16.6%), avoidant arousal (9.2%), dysphoric arousal (8.2%), and high TSR (4.7%). Veterans in the dysphoric arousal and high TSR classes demonstrated lower functioning than other classes, which showed similar levels of moderate-to-high functioning despite symptom differences. Classes distinguished between resilience to PTSD symptoms versus resilience to all symptoms and functioning domains and were differentially associated with demographic characteristics, trauma and military histories, and psychosocial characteristics. The results suggest that veterans exhibit different clinical phenotypes of TSRs, which may help inform etiology, diagnostic subtypes, and personalized treatment. Further, although most veterans with psychopathology experience functional impairment, a sizable subset demonstrates high functioning despite psychopathology symptoms.

Lifetime exposures to potentially psychologically traumatic events (PPTEs) among Royal Canadian Mounted Police (RCMP) cadets starting the Cadet Training Program (CTP) appear lower than exposures reported by serving RCMP, but the prevalence of PPTE exposures during the CTP remains unknown. The current study assessed PPTE exposures during the CTP and examined associations with mental disorders among RCMP cadets. Participants were cadets (n = 449, 24.7% women) from the larger RCMP Longitudinal Study who self-reported critical incidents, PPTE exposures, and mental health disorder symptoms at pretraining and predeployment. Most participants reported no exposures to a PPTE (n = 374, 83.3%) during the CTP. Participants who reported any PPTE exposure (n = 75, 16.7%; i.e., direct or indirect) most commonly reported serious transport accidents, physical assault, and sudden accidental death. The most common direct PPTEs (i.e., "happened to me") during the CTP were physical assault (n = 13), other unwanted or uncomfortable sexual experience (n = 11), and serious transportation accident (n = 8). The total number of PPTE types reported at predeployment was associated with increased odds of screening positive for any mental health disorder, aOR = 1.22, 95% CI [1.01, 1.49], p = .049, and positively associated with mental health disorder symptoms, ps < .001. These results provide the first assessment of PPTE exposure among RCMP cadets during the CTP, indicating that 16.7% of cadets experience PPTEs directly or indirectly. The PPTEs reported by cadets may help inform additional opportunities to further increase safety during training.

Given their sudden onset and life-threatening consequences, strokes and transient ischemic attacks (TIAs) can trigger posttraumatic stress disorder (PTSD). To gain a deeper understanding of the potential influence of factors in patients' descriptions of these medical events on PTSD, we conducted a standardized trauma interview with a convenience sample of patients hospitalized for suspected stroke/TIA (N = 98) to assess the details and emotional experience of the stroke/TIA event. Three researchers reviewed the interviews and the research literature on risk and protective factors for PTSD. From this analysis, a codebook with descriptions, examples, and scoring protocols for eight Likert scale, two categorical, and four binary codes was developed. Upon demonstrating sufficient interrater reliability, the research team scored all narratives. Three superordinate themes were identified in the analysis: distress (e.g., fear, helplessness), potential protective factors (e.g., positive expectancies, concern for loved ones), and level of detail (e.g., somatic detail, emotional detail). Differences in perceptions, themes, and expectations emerged in the narratives, indicating a wide range of responses following stroke/TIA. Additionally, patient age was negatively correlated with scores for the fear, r = -.34, p < .001, and negative consequences, r = -.24, p = .018, codes and positively associated with the likelihood of having positive expectancies, OR = 1.05, 95% CI [1.00, 1.10], p = .039. These findings provide a more comprehensive understanding of how patients reflect on their experiences post-stroke/TIA and can inform future research on the contributions of trauma narrative characteristics and emotional responses to PTSD risk.

Negative mental health outcomes are prevalent among veterans exposed to military-related stressors and are associated with social isolation. Limited research exists on resilience following military separation and its impact on social isolation in veterans. We examined resilience against military-related stressors and 2-year longitudinal associations with social isolation indicators; gender differences were also explored. U.S. military veterans (N = 351, 70.4% men) who deployed to the wars in and around Iraq and Afghanistan following the September 11, 2001, terrorist attacks (9/11) were recruited as part of a longitudinal assessment study examining predictors of postdeployment adjustment. Using a residualization approach, resilience was approximated as low stressor reactivity (SR), calculated by regressing mental health onto military-related stressor exposure. Military-related stressors were significantly associated with posttraumatic stress disorder (PTSD) related to both events during post-9/11 deployment (deployment event) and outside of post-9/11 deployment (other event), functional disability, and depression. After correcting for multiple comparisons, only SR derived from depressive symptoms predicted more closeness difficulties in social relationships longitudinally, B = 0.50, q = .023. Women also demonstrated higher SR than men regarding other event-related PTSD symptoms, B = -0.52, q < .001; functional disability, B = -0.28, q = .028; and depression, B = -0.34, q = .012. Results suggest that veterans with higher depressogenic reactivity to military-related stressors were more likely to endorse discomfort with closeness than those with lower depressogenic reactivity. Women veterans may also be more impacted by nondeployment traumatic distress, psychosocial dysfunction, and depression in response to military-related stressors.

Few studies have considered the influence of cultural factors on the associations between posttraumatic stress disorder (PTSD) and key emotion regulation strategies, such as expressive suppression and reappraisal. This study investigated the influences of cultural background and self-construal orientation on PTSD symptoms and both suppression and reappraisal. Chinese Australian (n = 129) and European Australian (n = 140) trauma survivors completed an online survey assessing suppression and reappraisal (Emotion Regulation Questionnaire), cultural values (Self Construal Scale), and PTSD symptoms (PTSD Checklist for DSM-5). We hypothesized that participants in the Chinese Australian group would report higher levels of suppression and reappraisal than those in the European Australian group and that self-construal and cultural group would moderate both the associations between PTSD symptoms and both suppression reappraisal. Correlation and moderation analyses were performed to examine these hypotheses. Chinese Australian participants reported higher levels of reappraisal than European Australian participants, η  = .05, p < .001. Regardless of cultural group, there was no significant association between reappraisal and PTSD symptoms, B = 0.10, p = .849, 95% CI [-0.93,1.13]. Cultural group and self-construal moderated the association between suppression and PTSD symptoms, ΔR = .02, p = .007, whereas a positive association was observed between suppression and PTSD symptoms; however, this association was not significant for Chinese Australians who endorsed higher levels of interdependence. These findings suggest that suppression may be less strongly associated with PTSD symptoms for Chinese Australians who value interdependence. This finding highlights the importance of considering cultural values in PTSD treatment approaches.

Social support is protective in the recovery from mental health diagnoses. However, well-intended support can also interfere with treatment, as in the case of accommodation, when a support person changes their behaviors to alleviate a patient's distress. This paper describes a scoping review of the research literature regarding posttraumatic stress symptoms (PTSS) and accommodation, conducted using the Preferred Reporting Items extension for Scoping Review Guidelines (PRISMA-ScR). A total of 26 articles were included in the review. Designs and settings were mixed, but most studies examined accommodation by female adult intimate partners of male military members, veterans, and first responders with PTSS. Most participants were White. Accommodation was typically associated with negative relationship outcomes, and some couples treatments (e.g., cognitive behavioral conjoint therapy interventions) were associated with improvements in PTSS accommodation. Future work on PTSS accommodation should prioritize recruiting more diverse participants (i.e., gender, race, ethnicity, military status, types of support people). In addition, researchers should continue to examine accommodation as a mediator or moderator variable. Further examination of accommodation and PTSS may provide helpful insights into the involvement of support people in treatment to increase treatment effectiveness.

Attentional bias and deficits in attentional control are associated with posttraumatic stress disorder (PTSD) symptoms. Attention control training (ACT) may address these factors. We reviewed randomized controlled trials (RCTs) of ACT for PTSD to address unanswered questions about ACT's effectiveness, tolerability, and implementation. Studies were included if they were an RCT that used an adult sample, recruited participants with a PTSD diagnosis, and had ACT as at least one treatment arm. The PTSD Trials Standardized Data Repository (PTSD-Repository) and additional databases were searched to identify PTSD RCTs published through May 2024. Seven studies met the inclusion criteria (N = 407). The effect size for ACT versus a comparison condition on PTSD symptoms was large, but the confidence interval (CI) overlapped with 0, g = 0.75, 95% CI [-0.63, 2.12]. The same pattern was observed for attention bias variability, g = 1.04, 95% CI [-0.90, 2.98]. There was a significant within-group effect of ACT on self-reported PTSD symptoms, g = -1.43, 95% CI [-2.83, -0.03]. Risk of bias varied, with high risk of bias being primarily due to bias in the measurement of the outcome. These effects should be interpreted cautiously given the significant heterogeneity and wide confidence intervals observed. It remains unclear for whom and under what conditions ACT may be most effective. Future studies should move beyond response time measures, employ an inactive comparator, and examine the mechanism of action to determine whether ACT could be a viable intervention for PTSD.

Prior research has rarely examined how people understand or react to the names of psychological treatments. In the case of evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such reactions may be relevant to the low rates of uptake of such treatments. Participants who screened positive for PTSD (n = 887) completed questions assessing their initial reactions to PTSD treatment names as well as how a different name would affect their openness to treatment. In addition, they gave brief responses to open-ended questions about the reason for their initial reactions, and content analysis was used to better understand these reasons. The results indicated that among the treatment name options, cognitive processing therapy (CPT) and present-centered therapy (PCT) were viewed most positively. Approximately 40% of the sample preferred plain language alternatives for treatment names. Content analyses focused on descriptions of the treatments-which could be accurate or inaccurate-as well as whether respondents evaluated a treatment name itself as positive or negative. Some names conveyed treatments more accurately (e.g., CPT and written exposure therapy) than others (e.g., eye movement desensitization and reprocessing and prolonged exposure [PE]). Some names were also evaluated more positively (e.g., PCT) than others (e.g., PE). The general term "trauma-focused therapy" was seen as positive and clear. Addressing the ways patients react to psychological terms and treatment names could help clarify misperceptions about evidence-based psychotherapies and promote more widespread uptake of effective treatments for PTSD.

Few studies have examined anger concerns among postpartum women despite their risk of mood dysregulation. This study examined the performance of the Dimensions of Anger Reactions-5 (DAR-5) scale, a brief screen for problematic anger, in a sample of 1,383 postpartum women in Wisconsin who received perinatal home visiting services. We aimed to analyze the discriminant validity and measurement invariance of the DAR-5, the occurrence of problematic anger symptoms and their co-occurrence with mental health concerns, and the association between elevated anger levels and exposure to potentially traumatic events in childhood and adulthood. Descriptive statistics for anger symptoms and their associations with depression, anxiety, and PTSD were calculated. Psychometric properties of the DAR-5 were assessed via confirmatory factor analyses, and associations between trauma exposure and anger were evaluated as bivariate and partial correlations. Approximately 21% of the sample exhibited problematic anger based on an established DAR-5 cutoff score (≥ 12). Anger symptoms co-occurred with posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms, though the DAR-5 sufficiently distinguished anger from these correlated symptom profiles. The DAR-5 also demonstrated acceptable measurement invariance across levels of trauma exposure. Higher levels of trauma exposure in childhood and adulthood significantly increased the risk of problematic anger even after controlling for PTSD, anxiety, and depressive symptoms, partial range: .07-.16. The findings suggest the DAR-5 is a valid brief screen for anger in postpartum women. Increased attention should be paid to elevated anger and the co-occurrence of other mental health concerns following childbirth.

Posttraumatic stress disorder (PTSD) often occurs following mass casualty events, yet the connection between the number of individuals injured in an event and PTSD risk in smaller-scale events (i.e., involving one or several injured persons) remains unclear. We conducted a registries-based study cross-referencing three databases across the continuum of care for military trauma patients hospitalized for traumatic injuries. The study population was categorized into three groups based on the number of injured individuals involved (i.e., single injured person, two to four [2-4] injured people, and five or more [≥ 5] injured people), and PTSD prevalence was assessed using long-term disability claim diagnoses. Overall, 4,030 military personnel were included (age at injury: Mdn = 20 years), and 18.3% were subsequently diagnosed with PTSD, with the highest prevalence in events involving ≥ 5 injured individuals (35.8%). Regression analyses adjusted for potential confounders revealed that being injured in an event with 2-4 injured persons, OR = 1.68, 95% CI [1.31, 2.15], or ≥ 5 injured persons, OR = 2.36, 95% CI [1.79, 3.13], was associated with increased odds of developing PTSD compared to being the sole injured person. The findings suggest a direct association between the number of injured individuals in an event and PTSD prevalence among traumatic injury survivors. The results underscore the importance of early diagnosis and interventions to prevent PTSD in individuals injured in multicasualty and mass casualty events.

Cognitive processing therapy (CPT) is a well-known trauma-focused treatment that aims to generate more adaptive posttrauma cognitions and emotions. Changes in cognitions are theorized to be the mechanism by which CPT leads to improvement in posttraumatic stress disorder (PTSD) symptoms. The present study aimed to explore associations between changes in PTSD symptom clusters during CPT. We hypothesized that early changes in negative alterations in cognitions and mood (NACM) would correlate with later changes in other symptom clusters. Data were collected from 296 veterans participating a 7-week PTSD residential treatment program at a U.S. Veterans Affairs medical center. PTSD symptoms were assessed at pretreatment (Week 1), midtreatment (Week 4), and posttreatment (Week 7). Cross-lagged path analyses demonstrated that pretreatment-to-midtreatment improvement in NACM was correlated with midtreatment-to-posttreatment improvement in avoidance, β = .52, though this association was bidirectional, suggesting pretreatment-to-midtreatment improvements in either cluster may be correlated with midtreatment-to-posttreatment improvements. Similarly, pretreatment-to-midtreatment improvement in intrusions, β = .40, and arousal, β = .49, were correlated with later improvement in avoidance, suggesting avoidance may improve after improvement in other clusters. Interestingly, pretreatment-to-midtreatment arousal improvement was significantly correlated with midtreatment-to-posttreatment NACM improvement, β = .27, though the reverse was nonsignificant, whereas a bidirectional association between arousal and intrusions emerged, β = .34, β = .53. Early changes in arousal were correlated with later changes in several other symptom clusters, whereas other clusters demonstrated bidirectional associations. These results may inform understanding of symptom improvement timing across CPT, which may aid in treatment selection and planning.

Though social support (SS) and communal mastery (CM) are resilience factors among American Indian and Alaska Natives (AIAN), they have not been examined as trauma treatment predictors in this at-risk group. This study evaluated whether SS and CM were associated with improved treatment response in a sample of 73 AIAN women with posttraumatic stress disorder (PTSD) symptoms. Participants received culturally adapted CPT and were assessed for PTSD, CM, and SS. Data were analyzed using linear mixed-effects models. SS predicted improved PTSD, β = -.16, SE = .05, p = .003, and mental health, β = .16, SE = .05, p = .005, but not physical health. CM predicted improved PTSD, β = -.93, SE = .34, p = .008; mental health, β = .90, SE = .36, p = .013; and physical health, β = .95, SE = .31, p = .003. In a combined model, SS predicted improvements in PTSD, β = -.15, SE = .04, p < .001, and mental health, β = .12, SE = .06, p = .037, whereas CM did not. CM predicted improved physical health, β = 1.04, SE = .33, p = .003, whereas SS did not. Results highlight the benefits of SS and CM in trauma treatment outcomes for AIAN women, consistent with prior work, and further underscore the differential role of SS versus CM on mental versus physical health. Future work should explore how orientation to close and communal-level relationships may inform the protective benefits of social resources among AIAN.

Bisexual+ (e.g., bisexual, pansexual, queer) women experience higher rates of sexual violence (SV) and posttraumatic stress disorder (PTSD) than heterosexual and lesbian women, as well as unique identity-related minority stress. We examined between- and within-person associations between bisexual minority stress and PTSD symptoms related to SV in a sample of young bisexual+ women (N = 133) who reported adult SV (M = 22.0 years, range: 18-25 years; 85.0% White; 99.3% cisgender). We analyzed data from four waves of data collection (baseline to 3-month follow-up) using multilevel models. Controlling for SV severity, there was a significant within-person effect of antibisexual stigma from lesbian/gay people on PTSD, β = .17, p = .010, suggesting that at waves when women experienced more stigma, they also reported higher PTSD symptom levels. At the between-person level, women who reported higher levels of antibisexual stigma from heterosexual people, β = .26, p = .043, and anticipated binegativity, β = .29, p = .005, on average across study waves also reported higher average levels of PTSD. Additionally, anticipated binegativity explained the association between average antibisexual stigma and PTSD, β = .15, p = .014, 95% CI [0.45, 4.61]. Bisexual minority stress may be associated with higher PTSD symptom severity following SV among young bisexual+ women, and the anticipation of binegativity may be a target mechanism in this association. Study findings highlight the importance of examining the joint contributions of SV and minority stress to identify novel targets for future research and practice to address PTSD symptoms.

The PTSD Checklist for DSM-5 (PCL-5) is the most widely used self-report measure of posttraumatic stress disorder (PTSD) and is frequently modeled as having four correlated factors consistent with the DSM-5 symptom structure. Some researchers have argued that item order may influence factor structure. Although two studies have examined this, they were both based on DSM-IV criteria, and neither utilized a randomized design. Thus, this study aimed to determine whether item order impacts the factor structure of the PCL-5, using two independent samples of community participants (N = 347, 67.7% female, 85.3% White) and veterans (N = 409, 83.6% male, 61.9% Black/African American). Approximately half of each sample was randomized to receive the PCL-5 in the original fixed order, whereas the other half received a uniquely randomized version. We compared the DSM-5 four-factor model to several theoretically relevant models and found improved model fit in the seven-factor hybrid model, community sample: ∆χ = 153.87, p < .001; veterans: ∆χ = 152.61, p < . 001. Consequently, the DSM-5 four-factor and seven-factor hybrid models were retained for invariance testing. Across both samples, measurement invariance was examined between the randomized and fixed-order groups. Configural invariance, partial metric invariance, and partial scalar invariance were achieved in both samples, ps = .054-.822, suggesting that the fit of the DSM-5 four-factor structure and the seven-factor hybrid model, as measured using the PCL-5, are not due to order effects. These findings support the continued use of the PCL-5 in a fixed fashion.

Anger can adversely impact functioning in veterans. Psychological aggression, which is related to but distinct from anger, is particularly detrimental to veterans' mental health. Research examining anger and psychological aggression following individual therapy for posttraumatic stress disorder (PTSD) has demonstrated small effect sizes. Treatments that directly target conflict management and interpersonal functioning, both regarding content and delivery to veterans and their loved ones (e.g., couples-based PTSD treatments), may be more effective in alleviating anger symptoms. This study examined whether larger reductions in anger and psychological aggression would be observed in a couples-based intervention compared to an active comparator at posttreatment and follow-up. Data were derived from a randomized trial comparing brief cognitive-behavioral conjoint therapy for PTSD (bCBCT) and PTSD family education (PFE). Participants were 137 veterans and their intimate partners (bCBCT: n = 92, PFE: n = 45). We observed within-condition significant reductions in angry temperament, d = -0.47, p < .001, and angry reaction, d = -0.26, p = .004, among veterans in bCBCT but not PFE, |d|s = 0.13-0.17, ps = .166-.268. Veterans and partners in both conditions reported reductions in psychological aggression, |d|s = 1.09-1.46, ps < .001. There were no significant differences between the treatment conditions on any outcome, ps = .103-.443, and there were no significant changes in anger between posttreatment and follow-up, |d|s = 0.07-0.24, ps = .052-.582. Couples-based interventions for PTSD, including bCBCT and PFE, can be effective in improving aspects of anger among veterans and their intimate partners.