Research studies suggest racial/ethnic differences in posttraumatic stress disorder (PTSD) diagnosis and symptom severity. Few studies to date, however, have examined the extent to which these ...findings are due to differences in measurement properties of existing PTSD scales. This study examined measurement equivalence across race/ethnicity in the Clinician-Administered PTSD Scale (CAPS) by testing for differential item functioning (DIF) in the item response theory (IRT) framework. Participants were 506 trauma-exposed women (M = 39.41 years, SD = 8.94) who participated in the National Drug Abuse Treatment Clinical Trials Network Women and Trauma Study. PTSD severity score estimates were improved upon as part of IRT estimation incorporating symptom "weights" (i.e., factor loadings) and group-specific DIF. Six symptoms from the CAPS showed DIF, with the majority of differences in measurement driven by White/African American and White/Latina differences, particularly for (a) avoidance of thoughts and (b) a sense of foreshortened future. Despite both racial/ethnic minority groups being slightly (not significantly) more likely to receive a PTSD diagnosis, African Americans (p = .014; Cohen's d = −.22) and Latinas (p < .001; d = −.73) had significantly lower PTSD severity scores than Whites as estimated under IRT with group-specific DIF. Examination of PTSD severity scores based on symptom counts revealed these differences were either dampened (White/Latina difference d = −.39) or entirely negated (White/African American difference d = −.08). The findings suggest the importance of considering differences in symptom relevance across race/ethnicity and their impact on capturing symptom severity parallel to diagnostic criteria. Implications for clinical practice are discussed.
Public Significance Statement
The current study examined measurement equivalence across race/ethnicity in the Clinician-Administered PTSD Scale by testing for differential item functioning in the item response theory framework. The findings suggest that considering differences in posttraumatic stress disorder (PTSD) symptom relevance across race/ethnicity is critical for increasing accuracy in diagnostic criteria and estimation of PTSD severity.
Substance use trends during the COVID-19 pandemic have been extensively documented. However, relatively less is known about the associations between pandemic-related experiences and substance use.
In ...July 2020 and January 2021, a broad U.S. community sample (N = 1123) completed online assessments of past month alcohol, cannabis, and nicotine use and the 92-item Epidemic-Pandemic Impacts Inventory, a multidimensional measure of pandemic-related experiences. We examined links between substance use frequency, and pandemic impact on emotional, physical, economic, and other key domains, using Bayesian Gaussian graphical networks in which edges represent significant associations between variables (referred to as nodes). Bayesian network comparison approaches were used to assess the evidence of stability (or change) in associations between the two timepoints.
After controlling for all other nodes in the network, multiple significant edges connecting substance use nodes and pandemic-experience nodes were observed across both time points, including positive- (r range 0.07–0.23) and negative-associations (r range −0.25 to −0.11). Alcohol was positively associated with social and emotional pandemic impacts and negatively associated with economic impacts. Nicotine was positively associated with economic impact and negatively associated with social impact. Cannabis was positively associated with emotional impact. Network comparison suggested these associations were stable across the two timepoints.
Alcohol, nicotine, and cannabis use had unique associations to a few specific domains among a broad range of pandemic-related experiences. Given the cross-sectional nature of these analyses with observational data, further investigation is needed to identify potential causal links.
•Alcohol, cannabis, and nicotine use during the COVID-19 pandemic were measured.•Associations with COVID-19 pandemic-related experiences were modeled in a network.•Substances had distinct associations with pandemic impact domains.•Associations were stable in two assessments spanning 7 months.•The use of cross-sectional observational data is a key limitation.
To test whether an integrated prolonged exposure (PE) approach could address posttraumatic stress disorder (PTSD) symptoms effectively in individuals with co-occurring substance use disorders (SUD), ...we compared concurrent treatment of PTSD and SUD using PE (COPE) to relapse prevention therapy (RPT) for SUD and an active monitoring control group (AMCG).
We conducted a randomized 12-week trial with participants (n = 110; 64% males; 59% African Americans) who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for full or subthreshold PTSD and SUD. Participants were randomly assigned to COPE (n = 39), RPT (n = 43), or AMCG (n = 28).
At the end-of-treatment, COPE and RPT demonstrated greater reduction in PTSD symptom severity relative to AMCG (COPE-AMCG = -34.06, p < 0.001; RPT-AMCG = -22.58, p = 0.002). Although the difference between COPE and RPT was not significant in the complete sample, the subset of participants with full (vs. subthreshold) PTSD demonstrated significantly greater reduction of PTSD severity in COPE relative to RPT. Both treatments were superior to AMCG in reducing the days of primary substance use (COPE-AMCG = -0.97, p = 0.01; RPT-AMCG = -2.07, p < 0.001). Relative to COPE, RPT showed significantly more improvement in SUD outcome at end-of-treatment (RPT-COPE = -1.10, p = 0.047). At 3-month follow-up, COPE and RPT maintained their treatment gains and were not significantly different in PTSD severity or days of primary substance use.
COPE and RPT reduced PTSD and SUD severity in participants with PTSD + SUD. Findings suggest that among those with full PTSD, COPE improves PTSD symptoms more than a SUD-only treatment. The use of PE for PTSD was associated with significant decreases in PTSD symptoms without worsening of substance use.
•Compared empirical groupings of full and subthreshold PTSD against PTSD diagnoses.•Full PTSD patients showed large within-group differences in clinical profile.•The tested empirical method is a ...potential useful nosological approach for DSM-VI.
: Most of the work on understanding subthreshold PTSD has focused on inconsistencies in defining subthreshold PTSD and how those inconsistencies impact prevalence rates. The present study distinguishes between full and subthreshold PTSD using empirical categorization and assesses the circumstances under which empirical categorization is discordant with full and subthreshold PTSD diagnoses.
: Using data from the NIDA CTN Women and Trauma Study (N = 353), we use a modernized adaptation of the Jacobson and Truax (1991) framework, assessing whether patients were above or below an empirical threshold on latent PTSD severity scores estimated under categorical confirmatory factor analysis; the empirical categorizations were then crossed with the diagnoses to form four diagnostic by empirical categorization groupings.
: Compared to a reference group (full PTSD diagnosis and empirical categorization), patients who had a full PTSD diagnosis but a subthreshold empirical categorization had lower symptom endorsement rates on 15 PTSD symptoms, were more likely to be married, ethnic minorities with fewer lifetime traumas. Conversely, patients with a subthreshold PTSD diagnosis and a full PTSD empirical grouping looked similar to “Full/Fulls”, only differing on avoidance symptoms.
: Alternative definitions of subthreshold PTSD and coding of symptom endorsement may impact results. The use of DSM-IV symptoms (though reconciled against overlapping symptoms from DSM-5) is also a key limitation.
: Empirical categorization can be a useful supplement to diagnosis in distinguishing subthreshold PTSD from full PTSD, using a methodology that could provide a platform for melding dimensional and categorical nosology approaches in the DSM.
We conducted a systematic review and network meta-analyses (NMA) of psychotherapy and pharmacologic treatments for individuals with co-occurring posttraumatic stress disorder (PTSD) and alcohol or ...other drug use disorder (AOD). A comprehensive search spanning 1995-2019 yielded a pool of 39 studies for systematic review, including 24 randomized controlled trials for the NMA. Study interventions were grouped by target of treatment (PTSD + AOD, PTSD-only, and AOD-only) and approach (psychotherapy or medication). Standardized mean differences (SMD) from the NMA yielded evidence that at the end of treatment, integrated, trauma-focused therapy for PTSD + AOD was more effective at reducing PTSD symptoms than integrated, non-trauma-focused therapy (SMD = −0.30), AOD-focused psychotherapy (SMD = −0.29), and other control psychotherapies (SMD = −0.43). End-of-treatment alcohol use severity was less for AOD medication compared to placebo medication (SMD = −0.36) and trauma-focused therapy for PTSD + placebo medication (SMD = −0.67), and less for trauma-focused psychotherapy + AOD medication compared to PTSD medication (SMD = −0.53), placebo medication (SMD = −0.50), and trauma-focused psychotherapy + placebo medication (SMD = −0.81). Key limitations include the small number of studies in the NMA for pharmacologic treatments and the lack of demographic diversity apparent in the existing literature. Findings suggest room for new studies that can address limitations in study sample composition, sample sizes, retention, and apply new techniques for conducting comparative effectiveness in PTSD + AOD treatment.
Public Significance Statement
Roughly half of individuals with posttraumatic stress disorder (PTSD) also meet the criteria for an alcohol and other drug use disorder (AOD) with numerous and costly public health consequences. A systematic review and network meta-analysis characterized the evidence base of psychotherapy and pharmacological interventions for PTSD and AOD. Integrated, trauma-focused interventions targeting both PTSD and AOD were more effective at reducing PTSD symptoms than integrated non-trauma-focused, AOD-focused psychotherapy, and other control psychotherapies. AOD medications with and without trauma-focused therapies were more effective in reducing alcohol use severity than placebo controls. Few treatment studies reported adverse events for any intervention outcomes.
Two groups of healthy young adults were exposed to 3 weeks of cognitive training in a modified version of the visual flanker task, one group trained to discriminate the target (discrimination ...training) and the other group to ignore the flankers (inhibition training). Inhibition training, but not discrimination training, led to significant reductions in both Garner interference, indicating improved selective attention, and in Stroop interference, indicating more efficient resolution of stimulus conflict. The behavioral gains from training were greatest in participants who showed the poorest selective attention at pretest. Electrophysiological recordings revealed that inhibition training increased the magnitude of Rejection Positivity (RP) to incongruent distractors, an event-related potential (ERP) component associated with inhibitory control. Source modeling of RP uncovered a dipole in the medial frontal gyrus for those participants receiving inhibition training, but in the cingulate gyrus for those participants receiving discrimination training. Results suggest that inhibitory control is plastic; inhibition training improves conflict resolution, particularly in individuals with poor attention skills.
High rates of cannabis use among people with posttraumatic stress disorder (PTSD) have raised questions about the efficacy of evidence-based PTSD treatments for individuals reporting cannabis use, ...particularly those with co-occurring alcohol or other substance use disorders (SUDs). Using a subset of four randomized clinical trials (RCTs) included in Project Harmony, an individual patient meta-analysis of 36 RCTs (total N = 4046) of treatments for co-occurring PTSD+SUD, we examined differences in trauma-focused (TF) and non-trauma-focused (non-TF) treatment outcomes for individuals who did and did not endorse baseline cannabis use (N = 410; 70% male; 33.2% endorsed cannabis use). Propensity score-weighted mixed effects modeling evaluated main and interactive effects of treatment assignment (TF versus non-TF) and baseline cannabis use (yes/no) on attendance rates and within-treatment changes in PTSD, alcohol, and non-cannabis drug use severity. Results revealed significant improvements across outcomes among participants in all conditions, with larger PTSD symptom reductions but lower attendance among individuals receiving TF versus non-TF treatment in both cannabis groups. Participants achieved similar reductions in alcohol and drug use across all conditions. TF outperformed non-TF treatments regardless of recent cannabis use, underscoring the importance of reducing barriers to accessing TF treatments for individuals reporting cannabis use.
•Treatment outcomes for PTSD+SUD are similar for those with and without cannabis use.•Trauma-focused outperforms non-trauma-focused treatment for PTSD severity reduction.•PTSD, alcohol and drug use decrease during trauma- and non-trauma-focused treatment.•Trauma-focused treatment is efficacious for individuals with recent cannabis use.•Reducing access barriers to evidence-based treatments is a priority.
Multiple factor analytic and item response theory studies have shown that items/symptoms vary in their relative clinical weights in structured interview measures for posttraumatic stress disorder ...(PTSD). Despite these findings, the use of total scores, which treat symptoms as though they are equally weighted, predominates in practice, with the consequence of undermining the precision of clinical decision‐making. We conducted an integrative data analysis (IDA) study to harmonize PTSD structured interview data (i.e., recoding of items to a common symptom metric) from 25 studies (total N = 2,568). We aimed to identify (a) measurement noninvariance/differential item functioning (MNI/DIF) across multiple populations, psychiatric comorbidities, and interview measures simultaneously and (b) differences in inferences regarding underlying PTSD severity between scale scores estimated using moderated nonlinear factor analysis (MNLFA) and a total score analog model (TSA). Several predictors of MNI/DIF impacted effect size differences in underlying severity across scale scoring methods. Notably, we observed MNI/DIF substantial enough to bias inferences on underlying PTSD severity for two groups: African Americans and incarcerated women. The findings highlight two issues raised elsewhere in the PTSD psychometrics literature: (a) bias in characterizing underlying PTSD severity and individual‐level treatment outcomes when the psychometric model underlying total scores fails to fit the data and (b) higher latent severity scores, on average, when using DSM‐5 (net of MNI/DIF) criteria, by which multiple factors (e.g., Criterion A discordance across DSM editions, changes to the number/type of symptom clusters, changes to the symptoms themselves) may have impacted severity scoring for some patients.
The present study introduced a modernized approach to Jacobson and Truax's (1991) methods of estimating treatment effects on individual‐level (a) movement from the clinical to the normative range and ...(b) reliable change on posttraumatic stress disorder (PTSD) severity. Participants were 450 trauma‐exposed women (M age = 39.2 years, SD = 8.9, range: 18–65 years) who presented to seven geographically diverse community mental health and substance use treatment centers. Data from 53 of these women, none of whom met the criteria for full or subthreshold PTSD, were used to establish the normative range. Using moderated nonlinear factor analysis (MNLFA) scale scoring, which weights symptoms by their clinical relevance, a significantly larger proportion of participants moved into the normative range for PTSD severity scores and/or exhibited reliable changes after treatment compared to the same individuals’ movement when using symptom counts. Further, approximately 24% of the participants showed discrepant judgments on reliable change indices (RCI) between MNLFA scores and symptom counts, likely due to the false assumption that the standard error of measurement is equal for all levels of underlying PTSD severity when estimating RCIs with symptom counts. An MNLFA approach to estimating underlying PTSD severity can provide clinically meaningful information about individual‐level change without the de facto assumption that PTSD symptoms have equivalent weight. Study implications are discussed with regard to a joint emphasis on (a) measurement models that highlight differential symptom weighting and (b) treatment‐arm differences in individual‐level outcomes rather than the current overemphasis of treatment‐arm differences on group‐averaged trajectories.
•Emotion dysregulation (ED) has been associated with PTSD and substance use disorders (SUD).•ED moderated response to integrated, prolonged exposure treatment for PTSD/SUD (COPE, Concurrent treatment ...of PTSD and Substance Use Disorders Using Prolonged Exposure, Back et al., 2017).•Those with high ED showed more PTSD improvement in COPE compared with relapse prevention for SUD.•Those with low ED showed more SUD improvement in relapse prevention for SUD compared with COPE.•Findings suggest ED may serve as a treatment matching variable for PTSD/SUD.
A goal of clinical trials is to identify unique baseline characteristics that can inform treatment planning. One such target is emotion dysregulation (ED), which contributes to the maintenance of co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) and may be a potential moderator of treatment response. We examined the moderating impact of ED severity on treatment outcomes in an urban, socioeconomically disadvantaged, and racially/ethnically diverse sample with complex trauma and severe SUDs. Participants with co-occurring PTSD and SUD (PTSD+SUD) were randomized to Concurrent Treatment with Prolonged Exposure (COPE, n=39), Relapse Prevention Therapy (RPT, n=43), or an active monitoring control group (AMCG, n=28). Baseline ED severity moderated treatment outcomes such that high ED was associated with greater reduction in PTSD severity among those who received COPE relative to RPT and AMCG. In contrast, low ED was associated with greater reduction in substance use among those in RPT relative to COPE and AMCG. Implications for individualizing and optimizing treatment selection for PTSD+SUD are discussed.
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