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From World War I until today, the United States has failed to provide adequate transition support to millions of veterans leaving military service. Instead of providing meaningful jobs, access to quality health care and education, and fair and equitable housing, veterans learn that when their military service is done, they are now fighting a new battle--a failed bureaucracy that has let them and other veterans down for the past 100 years. It's not as if we as a nation haven't tried. The Veterans Health Administration (VHA) has seen the largest increase in funding in its history and has been given several free passes when the budget axe arrives. Federal funding and grants for education have also enjoyed similar financial favor; and housing opportunities have been increased. Yet on a rudimentary level, we as a nation cannot stop believing that GI Joe and Jane can't wait to come back home and pick up right where they left off before their military services began. The truth is, that person is gone and is not coming back. Many veterans, particularly those with PTSD are lost when returning home. [This book] hopes to break this cycle. In their own words, veterans, caregivers, and the family members that love them are given the opportunity to tell us what is truly broken in the military to civilian transition. Advances in clinical treatment, the presentation of a new, fast-track job training program, and new awareness for the challenges facing all military veterans changes our way of understanding of who the twenty-first century veteran is. Through this understanding, we can change their lives and they can change ours. -- Back cover.

Background Combat post-traumatic stress disorder (PTSD) involves significant suffering, impairments in social and occupational functioning, substance use and medical comorbidity, and increased mortality from suicide and other causes. Many veterans continue to suffer despite current treatments. Deep brain stimulation (DBS) has shown promise in refractory movement disorders, depression and obsessive-compulsive disorder, with deep brain targets chosen by integration of clinical and neuroimaging literature. The basolateral amygdala (BLn) is an optimal target for high-frequency DBS in PTSD based on neurocircuitry findings from a variety of perspectives. DBS of the BLn was validated in a rat model of PTSD by our group, and limited data from humans support the potential safety and effectiveness of BLn DBS. Methods/Design We describe the protocol design for a first-ever Phase I pilot study of bilateral BLn high-frequency DBS for six severely ill, functionally impaired combat veterans with PTSD refractory to conventional treatments. After implantation, patients are monitored for a month with stimulators off. An electroencephalographic (EEG) telemetry session will test safety of stimulation before randomization to staggered-onset, double-blind sham versus active stimulation for two months. Thereafter, patients will undergo an open-label stimulation for a total of 24 months. Primary efficacy outcome is a 30% decrease in the Clinician Administered PTSD Scale (CAPS) total score. Safety outcomes include extensive assessments of psychiatric and neurologic symptoms, psychosocial function, amygdala-specific and general neuropsychological functions, and EEG changes. The protocol requires the veteran to have a cohabiting significant other who is willing to assist in monitoring safety and effect on social functioning. At baseline and after approximately one year of stimulation, trauma script-provoked 18 FDG PET metabolic changes in limbic circuitry will also be evaluated. Discussion While the rationale for studying DBS for PTSD is ethically and scientifically justified, the importance of the amygdaloid complex and its connections for a myriad of emotional, perceptual, behavioral, and vegetative functions requires a complex trial design in terms of outcome measures. Knowledge generated from this pilot trial can be used to design future studies to determine the potential of DBS to benefit both veterans and nonveterans suffering from treatment-refractory PTSD. Trial registration PCC121657 , 19 March 2014.

Background Outcome expectancy, or the degree to which a client believes that therapy will result in improvement, is related to improved treatment outcomes for multiple disorders. There is a paucity of research investigating this relation in regards to posttraumatic stress disorder (PTSD). Additionally, the bulk of the research on outcome expectancy and treatment outcomes has relied mostly on self‐report outcome measures. Methods The relation between outcome expectancy on self‐report measures, clinician‐rated measures, and two biological indices (fear‐potentiated startle and cortisol reactivity) of PTSD symptoms was explored. The sample included combat veterans (N = 116) treated with virtual reality exposure therapy for PTSD. Results Results supported a negative association between outcome expectancy and both self‐report and clinician‐rated symptoms at the conclusion of treatment, but outcome expectancy was related to the magnitude of change during treatment for self‐report measures only. Outcome expectancy was unrelated to biological measures of treatment response. Conclusions These findings suggest that outcome expectancy may be related to patient and clinician perceptions of outcomes, but not biological indices of outcome for PTSD.

\"They called it Shell Shock provides a new perspective on the psychological reactions to the traumatic experiences of combat. In the Great War, soldiers were incapacitated by traumatic disorders at an epidemic scale that surpassed anything known from previous armed conflicts. Drawing upon individual histories from British and German servicemen, this book illustrates the universal suffering of soldiers involved in this conflict and its often devastating consequences for their mental health. Dr Stefanie Linden explains how shell shock challenged the fabric of pre-war society, including its beliefs about gender (superiority of the male character), class (superiority of the officer class) and scientific progress. She argues that the shell shock epidemic had enduring consequences for the understanding of the human mind and the power that it can exert over the body.\"

Acute stress disorder involves prominent symptoms of threat avoidance. Preliminary cross-sectional data suggest that such threat-avoidance symptoms may also manifest cognitively, as attentional threat avoidance. Confirming these findings in a longitudinal study might provide insights on risk prediction and anxiety prevention in traumatic exposures. Attention-threat bias and post-traumatic symptoms were assessed in soldiers at two points in time: early in basic training and 23 weeks later, during advanced combat training. Based on random assignment, the timing of the repeat assessment occurred in one of two schedules: for a combat simulation group, the repeat assessment occurred immediately following a battlefield simulation exercise, and for a control group, the assessment occurred shortly before this exercise. Both groups showed no threat-related attention bias at initial assessments. Following acute stress, the combat simulation group exhibited a shift in attention away from threat whereas the control group showed no change in attention bias. Stronger threat avoidance in the combat simulation group correlated with severity of post-traumatic symptoms. Such an association was not found in the control group. Acute stress may lead some individuals to shift their attention away from threats, perhaps to minimize stress exposure. This acute attention response may come at a psychological cost, given that it correlates with post-traumatic stress disorder (PTSD) symptoms. Further research is needed to determine how these associations relate to full-blown PTSD in soldier and civilian populations.

BACKGROUND:Patients with posttraumatic stress disorder (PTSD) have significant medical morbidity, which may be mediated by hypothalamic pituitary axis (HPA) dysfunction and reflected in cortisol output. Many veterans with PTSD are hesitant to engage in trauma-focused exposure treatments; therefore briefer, non–exposure-based treatments are needed; one such promising approach is an abbreviated Primary Care brief Mindfulness Program (PCbMP). OBJECTIVE:This study investigated the relationship between dose-response to participation in a veterans PCbMP program and diurnal cortisol. Cortisol reflects HPA function and PTSD is associated with HPA dysregulation. RESEARCH DESIGN:Veterans with PTSD were identified in PC and randomly assigned to treatment as usual (TAU, n=21) or participation in brief 4-week Mindfulness Based Stress Reduction program (n=19). SUBJECTS:Veterans (n=40) (mean age, 48±16 y; 90% men) with PTSD referred through their VA PC provider and randomly assigned to PCbMP or TAU. MEASURE:As an objective indicator of HPA function, salivary diurnal cortisol was measured from samples collected across 2 consecutive days at baseline and follow-up. RESULTS:Analyses revealed that significant changes in cortisol were associated with PCbMP treatment engagement and dosing (number of mindfulness program sessions completed). Veterans completing 4 mindfulness-based meditation sessions significantly reduced their cortisol awakening response (P≤0.05); and had significant changes in cortisol area under the curve increase compared with TAU participants (P≤0.05). Results indicate that PCbMP has a beneficial physiological impact on veterans with PTSD with a minimum of 4 weeks of practice.

BACKGROUND:Several evidence-based treatments are available to veterans diagnosed with posttraumatic stress disorder (PTSD). However, not all veterans benefit from these treatments or prefer to engage in them. OBJECTIVES:The current study explored whether (1) a mantram repetition program (MRP) increased mindful attention among veterans with PTSD, (2) mindful attention mediated reduced PTSD symptom severity and enhanced psychological well-being, and (3) improvement in mindful attention was due to the frequency of mantram repetition practice. RESEARCH DESIGN:Data from a randomized controlled trial comparing MRP plus treatment as usual (MRP+TAU) or TAU were analyzed using hierarchical linear models. SUBJECTS:A total of 146 veterans with PTSD from military-related trauma were recruited from a Veterans Affairs outpatient PTSD clinic (71 MRP+TAU; 75 TAU). MEASURES:The Clinician Administered PTSD Scale (CAPS), PTSD Checklist (PCL), the Brief Symptom Inventory-18 depression subscale, Health Survey SF-12v2, and Mindfulness Attention Awareness Scale (MAAS) were used. Frequency of mantram repetition practice was measured using wrist-worn counters and daily logs. RESULTS:Intent-to-treat analyses indicated greater increases in mindful attention, as measured by the MAAS, for MRP+TAU as compared with TAU participants (P<0.01). Mindful attention gains mediated previously reported treatment effects on reduced PTSD symptoms (using both CAPS and PCL), reduced depression, and improved psychological well-being. Frequency of mantram repetition practice in turn mediated increased mindful attention. CONCLUSIONS:The MRP intervention and specifically, mantram practice, improved mindful attention in veterans with PTSD, yielding improved overall psychological well-being. MRP may be a beneficial adjunct to usual care in veterans with PTSD.

Tetris has been proposed as a preventive intervention to reduce intrusive memories of a traumatic event. However, no neuroimaging study has assessed Tetris in patients with existing posttraumatic stress disorder (PTSD) or explored how playing Tetris may affect brain structure. We recruited patients with combat-related PTSD before psychotherapy and randomly assigned them to an experimental Tetris and therapy group (n = 20) or to a therapy-only control group (n = 20). In the control group, participants completed therapy as usual: eye movement desensitization and reprocessing (EMDR) psychotherapy. In the Tetris group, in addition to EMDR, participants also played 60 minutes of Tetris every day from onset to completion of therapy, approximately 6 weeks later. Participants completed structural MRI and psychological questionnaires before and after therapy, and we collected psychological questionnaire data at follow-up, approximately 6 months later. We hypothesized that the Tetris group would show increases in hippocampal volume and reductions in symptoms, both directly after completion of therapy and at follow-up. Following therapy, hippocampal volume increased in the Tetris group, but not the control group. As well, hippocampal increases were correlated with reductions in symptoms of PTSD, depression and anxiety between completion of therapy and follow-up in the Tetris group, but not the control group. Playing Tetris may act as a cognitive interference task and as a brain-training intervention, but it was not possible to distinguish between these 2 potential mechanisms. Tetris may be useful as an adjunct therapeutic intervention for PTSD. Tetris-related increases in hippocampal volume may ensure that therapeutic gains are maintained after completion of therapy.

By combining computational, morphological, and functional analyses, this study relates latent markers of associative threat learning to overt post-traumatic stress disorder (PTSD) symptoms in combat veterans. Using reversal learning, we found that symptomatic veterans showed greater physiological adjustment to cues that did not predict what they had expected, indicating greater sensitivity to prediction errors for negative outcomes. This exaggerated weighting of prediction errors shapes the dynamic learning rate (associability) and value of threat predictive cues. The degree to which the striatum tracked the associability partially mediated the positive correlation between prediction-error weights and PTSD symptoms, suggesting that both increased prediction-error weights and decreased striatal tracking of associability independently contribute to PTSD symptoms. Furthermore, decreased neural tracking of value in the amygdala, in addition to smaller amygdala volume, independently corresponded to higher PTSD symptom severity. These results provide evidence for distinct neurocomputational contributions to PTSD symptoms.PTSD symptom severity in combat veterans was associated with enhanced sensitivity to prediction errors and lower neural tracking of value and learning rate, providing evidence for neurocomputational contributions to trauma-related psychopathology.