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Daily Schedule

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Pre-Meeting Institutes (PMIs)

Additional fee required. Learn more about PMIs.

All times are listed in U.S. Eastern TIme. This schedule is preliminary and subject to change.​ 


Not attending any PMIs? Jump to the annual meeting schedule.

Monday, October 26

10am – 2pm PMI 1: How to Do Telemental Health Treatment for PTSD in the VA: The Basics and Beyond
2pm – 6pm  PMI 2: Intensive Treatments for PTSD: A Practical Guide to Delivering Evidence-Based PTSD Treatments in 1-3 Weeks
2pm – 6pm  PMI 3 (Part 1 of 2): Peer Support and Self-Care Model for Those in High Risk Jobs

Tuesday, October 27

2pm – 6pm PMI 4: Introduction to a Systems Focused Model for Addressing Childhood Traumatic Stress and its Adaptation for Special Populations
2pm – 6pm PMI 5: Enhancing Competence in Cognitive Processing Therapy for PTSD: Improving Skills for Detecting Assimilation and Harnessing the Power of Socratic Dialogue
2pm – 6pm PMI 3 (Part 2 of 2): Peer Support and Self-Care Model for Those in High Risk Jobs

Wednesday, October 28

10am – 2pm  PMI 6 (Part 1 of 2): A Practical Introduction to Network Modeling in R: From Cross-Sectional Models to Short-Term Dynamics 
10am – 2pm  PMI 7: Assessment of ICD 11 PTSD and Complex PTSD using the International Trauma Interview: A Training Workshop

Thursday, October 29

10am – 2pm PMI 6 (Part 2 of 2): A Practical Introduction to Network Modeling in R: From Cross-Sectional Models to Short-Term Dynamics
2pm – 6pm PMI 8: Breaking Barriers to Healing, Education, and Social Justice: Addressing Trauma Induced by Structural Racism and Other Societal Oppressions in Schools and Other Institutions

Friday, October 30

10am – 2pm PMI 9: How to Identify and Correct Common Pitfalls in the Delivery of Prolonged Exposure for PTSD: Learning from Videotaped Sessions of Therapy Gone Awry
10am – 2pm PMI 10: Trauma Affect Regulation: Guide for Education and Therapy (TARGET) in Practice and Research

ISTSS Annual Meeting

This schedule is evolving as we work to implement a virtual meeting. Check back regularly for updates as we add additional meeting offerings.


All times are listed in U.S. Eastern TIme. 

 

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Tracks

Mass Violence and Migration

Trauma in Specific Populations

Child and Adolescent Trauma
Professionals (e.g., military/veterans, journalists, health care workers)
Public Health

Pathology, Assessment and Intervention

Biology and Medical
Assessment and Diagnosis
Clinical Interventions (e.g., treatment trials)
Mode, Methods and Ethics
Wednesday, November 4
Thursday, November 5
Friday, November 6
Saturday, November 7
Monday, November 9
Tuesday, November 10
Wednesday, November 11
Thursday, November 12
Friday, November 13
Saturday, November 14

Wednesday, November 4

10am – 11: 30am

Opening Session: Missing & Murdered: Understanding the Role of Intergenerational Trauma in the Ongoing Crisis of Violence Faced by Indigenous Women and Girls


Connie Walker

2pm – 3:15pm Panel: Identifying and Addressing the Needs of Children and Families of US Veterans: A Panel Discussion on the White Paper by the NCTSN-VA Subcommittee 

Mayer Bellehsen, Gregory Leskin, Rebecca Schwartz, Wesley Sanders, Valentina Stoycheva, Shelley Fenstermacher, Ernestine Briggs-King, Angela Tunno, Curry John, Julian Ford, Abigail Gewirtz, Samantha Schneider

The impact of military service extends beyond service members to affect their children and family members as well. The strains of deployment, transition into civilian life, and trauma transmission lead to unique challenges for these children and families. Upon separation from the military, these families and children are not tracked to evaluate their needs and often lose access to health care benefits as well (Sherman, 2014). Further, there is fragmentation of care as Veterans obtain care through the Veterans Administration (VA) and family members seek care with community providers who are not familiar with this populaiton. While the VA has undertaken efforts to meet the needs of the children and families of Veterans, significant gaps remain. The National Child Traumatic Stress Network (NCTSN)-VA Subcommittee was formed to address these gaps and focused its initial efforts on drafting a white paper that reviewed and surveyed the needs of children and families of Veterans.

This panel session will focus on the results of this forthcoming white paper. It will include a series of brief presentations that synthesize the research literature and needs, report on survey data collected from experts, and identify resources. Subsequently, panelists will discuss recommendations and strategies to address the needs of these children and families while also engaging in Q&A from the audience.
2pm – 3:15pm Workshop: Trauma Recovery Center model; An Integrative Approach to Reaching Underserved Survivors of Violence

Ivonne Meija, Robyn Peace

In this workshop, a team of mental health professionals will introduce and describe an evidence-based multidisciplinary model of care, known as the Trauma Recovery Center (TRC), that is centered on providing comprehensive culturally-affirming, community-based mental health services to survivors of community and interpersonal violence, many of whom are largely underserved and face insurmountable barriers to connecting with support services after victimization.
 
The presenters will discuss the core components of the TRC model (e.g., trauma-informed practices, assertive outreach, evidence-based therapeutic models) that are essential to the success of program implementation. In addition, workshop attendees will receive detailed handouts and specific tools/strategies to support with implementation of assertive outreach (e.g., home and community visits) within the context of clinics and institutions unaccustomed to this approach. Audio segments (of which consent will be obtained from all participants) will be utilized to illustrate the effectiveness of this model in engaging marginalized survivors of violence. 
2pm – 3:15pm Panel: The Inconvenient Truth: A Panel on Race and Trauma

Ernestine Briggs, Rocio Chang-Angulo, Heather Pane Seifert, Briana Woods-Jaeger, Angela Tunno

Trauma disproportionately affects underrepresented minority and marginalized populations. For many, experiences of trauma are compounded by historical trauma (slavery), discrimination (police violence), and systemic disadvantage (poverty). Panelists will discuss the interplay of race and trauma and its pernicious effects on youth from different perspectives (clinical, training, research, service systems). We will also address topics including racism, intersectionality, & cultural humility to promote resiliency from an equity lens. We have assembled a panel of experts for this conversation. Dr. Chang will reflect on the impact of race and trauma from a clinical perspective. Dr. Pane Seifert will describe the utility of cultural humility in training professionals (enhancing engagement) and recommendations for dissemination of EBTs. Dr. Woods-Jaeger will describe paradigm shifts needed to address social determinants of health in research and the utility of community-based participatory research in mitigating inequities for marginalized communities. Dr. Tunno will describe needed system transformations to reduce racism, disparities, and disproportionalities (implicit bias in child welfare). Dr. Briggs will serve as the moderator/discussant, providing the panelists and audience with thought-provoking questions that will challenge assumptions and lead to subsequent conversations.
2pm – 3:15pm Symposium: Scalable screening and intervention to address mental health problems in Syrian refugees
  • A Controlled Trial of a Lay Provider Delivered Behavioral Intervention for Syrian Refugees and their Children
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  • Richard Bryant, Marit Sijbrandij, Aemal Akhtar
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  • Refugees are exposed to many distressing events, including detention in refugee camps, and have higher rates of mental disorders. The World Health Organization has developed Problem Management Plus (PM+) as a group program to reduce psychological distress after trauma and adversity. This study reports the first evaluation of PM+ in a refugee camp. The study randomized 480 adult Syrian refugees in the Azraq Refugee Camp in Jordan to either group PM+ or Treatment as Usual (TAU). Participants were independently assessed prior to the program, immediately following the program, and 3 months later. Outcome variables included the anxiety, depression, functioning, posttraumatic stress, and grief. Children’s psychological wellbeing was also assessed in one child of each participant, as well the parenting behaviour of participants. Of the 650 adult refugees were screened in the camp, 96% met the cut-off for psychological distress and 76% met criteria for functional impairment. 480 participants were randomized to PM+ or TAU. At baseline 85% of refugees met criteria for depression, 84% for anxiety, and 84% for PTSD. The 3-month assessment will be presented to determine the gains made by refugees and their children. These findings will be discussed in terms of implementation of scalable programs in refugee settings, and specifically how these can benefit participants and their children.
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  • Scalable Screening for Posttraumatic Stress Disorder in Arabic-Speaking Adults
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  • Anne de Graaff, Pim Cuijpers, Irene Sferra, Jana Uppendahl, Ralph de Vries, Marit Sijbrandij
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  • The prevalence of posttraumatic stress disorder (PTSD) in refugee populations, such as Syrian refugees is high, and psychometrically sound screening instruments for time-efficient and scalable identification of cases are needed. However, there is a paucity of research on the validity of screening instruments across different cultural and linguistic groups, such as among Arabic-speaking populations. 
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  • We conducted a systematic review on the diagnostic test accuracy (DTA) of brief instruments screening for psychological distress, including PTSD symptoms among Arabic-speaking adult populations. Five databases (i.e., PsycINFO, PubMed, EMBASE, Cochrane Library and Scopus) were searched. DTA was determined by comparing the outcomes of the screening instrument (e.g., PTSD Checklist) with the outcomes of a reference standard (e.g., Structured Clinical Interview for the DSM) in the same research subjects. 
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  • Our review included 36 studies for in total 20 index tests, with sample sizes ranging from 29 to 365 (total N = 4796). Most studies (89%) were conducted in Arabic countries. Sensitivity and specificity estimates for PTSD instruments ranged from .72 to .89 and from .54 to .78, respectively. Implications for the use and scale-up of screening methods in Arabic-speaking populations will be discussed. 
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  • PM+ a Scalable Psychological Intervention in Syrian Refugees in Switzerland - Results from the Pilot Study
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  • Naser Morina, Julia Spaaij, Nikolai Kiselev, Hanspeter Moergeli, Monique Pfaltz, Ulrich Schnyder, Matthis Schick
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  • Around 20,000 Syrian refugees are currently living in Switzerland. Given the high prevalence of distress, they are vulnerable to the development of common mental health disorders. To offer these individuals adequate mental health care, appropriate interventions, which are effective and easy to deliver, are urgently needed. Problem Management Plus (PM+) is an evidence-based, low-intensity intervention delivered by trained lay-helpers from the same cultural background. The aim of the pilot RCT was to test the feasibility and acceptability of individual PM+ in Syrian refugees in Switzerland. 59 Syrians with elevated distress levels and impaired functioning were included and randomized to either the intervention condition (n=31), receiving five sessions of PM+, or the enhanced TAU condition (n=28). 

  • First results show that at the post assessment, individuals who received PM+ had significantly lower symptom scores of depression and PTSD compared to baseline. Furthermore, participants in the intervention arm also reported a significant reduction in post-migration living stressors. The results suggest that PM+, delivered by lay-helpers, might be a feasible, well-accepted and effective treatment option for refugees. The importance, as well as the challenges, of implementing and scaling-up low-intensity interventions in high-income countries, such as Switzerland, will be discussed.
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  • A Randomised Trial of Treating Psychological Distress in Syrian Refugee Adolescents
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  • Aemal Akhtar, Maha Ghatasheh, Ibrahim Aqel, Richard Bryant
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  • Most refugees in the world today are youth, and they are at markedly higher rates of mental disorder than other youth. Most host countries of refugees do not have the specialist resources to manage mental health needs of refugees. The World Health Organization has developed a brief group program called Early Adolescent Skills for Emotions (EASE) to address common mental disorders affected by adversity and trauma. This trial is the first controlled evaluation of EASE. This trial randomized 445 Syrian refugee adolescents in Jordan to either EASE or Enhanced Usual Care (EUC). EASE comprises seven group sessions, as well as three sessions for caregivers. The primary outcome is reduction in overall child-reported psychological distress as measured by the Pediatric Symptom Checklist, with 3 months post-treatment as the primary end-point. Secondary child-reported outcomes include post-traumatic stress symptoms, depression symptoms, daily functioning, and wellbeing. Outcomes also include parenting style and caregiver psychological distress. The 3-month assessment will be presented following linear mixed modelling to determine the relative gains made by youth and their caregivers in PM+ and TAU. The outcomes will be discussed in the context of the need to address the significant mental distress experienced by refugees.
5pm – 6:15pm Invited Speaker: Translating Traumatic Stress Science and Practice for Policymakers: Promoting the Needs of Underserved Communities Through Public Policy

Diane Elmore Borbon, PhD, MPH
5pm – 6:15pm Symposium: CERV-PTSD: VA Cooperative Study #591, a Randomized Clinical Trial of Prolonged Exposure and Cognitive Processing Therapy in Veterans
  • Chair: Paula Schnurr
  • Discussant: Chris Crowe
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  • CERV-PTSD: VA Cooperative Study #591, a Randomized Clinical Trial of Prolonged Exposure and Cognitive Processing Therapy in Veterans
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  • Paula Schnurr, Kathleen Chard, Josef Ruzek, Bruce Chow, Patricia Resick, Edna Foa, Brian Marx, Ying Lu, Grant Huang, Mei-Chiung Shih
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  • CERV-PTSD is a randomized controlled trial of two of the most effective treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Despite evidence that PE and CPT are effective, there is limited evidence about their effectiveness relative to one another. The primary objective was to compare the effectiveness of PE and CPT for reducing PTSD symptom severity. The secondary objective was to compare the effectiveness of PE and CPT for reducing the severity of comorbid mental health problems and service utilization and improving functioning and quality of life. The tertiary objective was to examine whether discrepancy between patient preferences and treatment assignment reduces treatment effectiveness. Exploratory analyses will examine whether participant characteristics predict differential response. The study randomized 916 male and female veterans with military-related PTSD to receive PE or CPT. The standard dose of treatment was 12 weekly sessions but could range from 10-14 depending on treatment response. The primary outcome was clinician-rated PTSD symptoms, measured during and after treatment and then 3 and 6 months later. CERV-PTSD is designed to advance the delivery of care for PTSD by providing conclusive information about whether one treatment is better than the other, overall, and for different types of patients.

  • Treatment Outcome Results from the CERV-PTSD Study of PE and CPT in Veterans

  • Kathleen Chard, Paula Schnurr, Josef Ruzek, Bruce Chow, Patricia Resick, Edna Foa, Brian Marx, Michelle Bovin, Matthew Friedman, Kristina Caudle, Lisa Zehm, Grant Huang, Mei-Chiung Shih
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  • The CERV-PTSD study is a 17-site randomized clinical study of Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) conducted by the Veterans Health Administration.  To date, the only comparison of PE and CPT was conducted in women, largely with a history of interpersonal violence.  The goal of this study was to determine if PE or CPT was more successful in treating PTSD in Veterans and to determine if one therapy was associated with a higher completion rate. CERV-PTSD randomized 916 men and women from multiple eras, with any trauma that occurred while in military service. The study therapists were trained in the national VA dissemination of PE and CPT and the study included weekly consultation and random fidelity checks of therapy sessions. Analyses included changes in PTSD, Depression, and related health and wellness variables across genders and trauma types.
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  • Effects of Participant Preferences for Treatment on Response to Prolonged Exposure and Cognitive Processing Therapy for PTSD

    Josef Ruzek, Paula Schnurr, Kathleen Chard, Bruce Chow, Patricia Resick, Edna Foa, Brian Marx, Matthew Friedman, Kristina Caudle, Mei-Chiung Shih

    Little research has addressed the treatment preferences of patients diagnosed with posttraumatic stress disorder (PTSD), and almost none has assessed actual patients’ PTSD psychotherapy preferences. Relatively little is known about the impact of treatment preference on treatment dropout, completion, and effectiveness.  To date, there have been no direct comparisons of preferences for the evidence-based treatments most available in Departments of Veterans Affairs and Defense health care systems. This presentation describes the treatment preferences of Veterans participating in a large, randomized controlled trial of two of the most effective treatments for PTSD, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Relative preferences for PE versus CPT will be compared, and sociodemographic and clinical factors related to preference will be investigated. The presentation will also examine whether receiving preferred treatment affects a range of treatment outcomes, including PTSD symptoms, functioning, quality of life, and service utilization. Improved understanding of patient preferences represents an important opportunity for improving access to evidence-based services, and may assist in efforts to increase treatment initiation as well as improve treatment engagement, retention, and outcomes.

    Assessment of PTSD Treatment Outcomes in a Multisite Clinical Trial using a Centralized Assessment Protocol

    Brian Marx, Michelle Bovin, Kristina Caudle, Lisa Zehm, Chen TeChieh, Bruce Chow, Mei-Chiung Shih, Paula Schnurr

    Instead of embedding independent assessors at each site, for Cooperative Study #591, we elected to use a centralized pool of trained assessors, located in Boston at the National Center for PTSD, who would conduct diagnostic interviews via telephone. We made this choice for several reasons: cost effectiveness, convenience for study participants, reduced likelihood of breaking the blind, and improved ability to monitor and supervise assessors, thereby increasing the quality of the assessments. In this presentation, we will present an overview of our assessment protocol, assessor training and monitoring procedures, and estimates of assessor reliability. We will also review some of the lessons learned from our experience with this landmark study and considerations for applying these lessons to future PTSD clinical trials.

5pm – 6:15pm Late Breaking (To Be Determined)
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Thursday, November 5

10am – 11:15am Invited Panel: The Digital Revolution: Harnessing Technology to Enhance Treatment of Trauma-Related Disorders

Moderator: Jennifer Wild, ​DClinPsy

Panelists: Anke Ehlers, PhD; Greg Reger, PhD; Karen Seal MD, MPH; Eric Kuhn, PhD

10am – 11:15am Symposium: Innovations to Forecast Long-term PTSD Outcome Based on Emergency Department Data from Around the Globe
  • Skin Conductance in the Emergency Department Immediately Following a Trauma can Predict Post-Traumatic Symptom Trajectories
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  • Rebecca Hinrichs, Tanja Jovanovic, Xinming An, Samuel McLean, Kerry Ressler
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  • Post-traumatic stress disorder (PTSD) is a complex and heterogeneous syndrome that can develop in 10-20% of trauma exposed individuals. There is a need to quickly identify individuals at the highest risk for developing PTSD and other post-traumatic sequelae to deploy effective early interventions. One of the hallmarks of PTSD is increased psychophysiological arousal driven by the autonomic nervous system.  Recording skin conductance using a novel mobile app offers a noninvasive, quantitative, biological measure that is associated with current PTSD status and symptom severity.  This study measured SC using the eSense app on an iPad in n=699 patients recruited from EDs in the U.S. as part of the multi-site AURORA study. The baseline SC level of patients in the ED environment immediately post-trauma predicted PTSD symptoms 3-months after the trauma (PCL5, r=0.097, p=0.010). Baseline SC level in the ED is related to probability of being in different post-traumatic trajectory domains of pain (r=-0.109, p=0.004), sleep (r=0.084, p=0.026), avoidance (r=0.107, p=0.005), re-experiencing ((r=0.128, p=0.001), somatic symptoms (r=0.122, p=0.001) and thinking/concentration/fatigue difficulties (r=0.090, p=0.017).  This is the first study of this magnitude to use a physiological biomarker on a mobile device as a predictor of future symptoms.
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  • Obtaining Accurate PTSD Prognosis from Acute Post-Trauma Biomedical Data: a Machine Learning Multicenter Cohort Study.
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  • Mirjam van Zuiden, Marit Sijbrandij, Isaac Galatzer-Levy, Joanne Mouthaan, Miranda Olff, Katharina Schultebraucks, 
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  • Current prognostic models for PTSD do not sufficiently account for its heterogenic course, hampering accurate risk classification. We applied machine learning on a range of biomedical information collected within 48 hours post-trauma to forecast long-term PTSD risk. We included n=417 patients admitted to two urban academic Level-1 Trauma Centers in Amsterdam upon suspected serious injury. Cross-validated multi-nominal classification of self-reported PTSD symptom trajectories over 12 months and bimodal classification of end-point clinician-rated PTSD diagnosis was performed using extreme Gradient Boosting and evaluated on a hold-out set. We applied interpretable machine learning (SHAP values) to interpret derived models and most relevant prognostic features. We achieved good prediction of PTSD symptom trajectories over 12 months (multiclass AUC = 0.89) and end-point PTSD diagnostic status (AUC = 0.89). The most relevant prognostic features between models largely overlapped, including acute endocrine and psychophysiological reactivity and hospital-prescribed pharmacotherapy. Thus, by applying machine learning, we accurately predicted individual risk for long-term PTSD using biomedical information collected within 48 hours post-trauma. These results facilitate future targeted preventive interventions for PTSD, as they may enable early risk detection.
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  • Predicting posttraumatic stress disorder in the emergency department: opportunities and challenges for harnessing machine learning using routinely collected data
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  • Katharina Schultebraucks, Arieh Shalev, Vasiliki Michopoulos, Jennifer Stevens, Tanja Jovanovic, Kerry Ressler, Isaac Galatzer-Levy, 
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  • Emergency Departments (EDs) are often the first contact of trauma-survivors with the healthcare system providing a unique opportunity to screen for risk of posttraumatic stress disorder (PTSD). Since EDs struggle with overcrowding, cost-effectiveness and low added burden for ED personnel remains of high clinical priority. We developed and externally validated a predictive model using routinely collected data from electronic medical records along with a brief clinical stress assessment.
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  • A multi-layer ensemble classification was used to develop a prediction model of PTSD symptom severity through 12 months after ED admission. We examined the relation between predictive features and predicted outcomes to provide an interpretation in a human interpretable form (Explainable Machine Learning).
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  • Clinical prognosis of post-acute distress was achieved with good predictive accuracy (AUC=.86; precision=.86; recall=.86; f1-score=.86). Prognostic tests on independent longitudinal cohorts of ED patients demonstrate internal and external validity.
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  • Our results show the opportunity for leveraging PTSD risk prediction in emergency medical settings based on accessible and readily available information. This approach may improve efficacy of early prevention strategies. We show that the implementation of a brief risk assessment into the electronic medical records can improve the prediction accuracy.
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  • Using Likelihood Estimates Scores Assess PTSD Risk Following Traumatic Events
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  • Arieh Shalev
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  • Early interventions can reduce the prevalence of PTSD among recent survivors. Evaluating PTSD risk shortly after trauma exposure is a prerequisite for efficient prevention. Most studies of PTSD prediction evaluated the contribution of early predictors (e.g., gender, age, trauma severity, heart rate or education) to developing PTSD. These group based ‘classification’ models have failed to produce useful tools for personalized prediction. The work presented here will summarize two studies by the International Consortium to Predict PTSD (ICPP) in which case prediction (“Who will develop PTSD”) was replaced by likelihood estimate (“How likely to develop PTSD is each trauma survivor”). The studies efficiently produced PTSD likelihood scores for each of >2400 trauma survivors admitted to a general hospital care. Early symptoms, trauma severity, gender and history of traumatic events significantly affected risk estimates. The resulting nomogram was further molded into a web-based prediction tool. Likelihood estimates are used across medicine to guide clinical and preventive action (e.g., cancer mortality risk, stroke likelihood under blood thinners). The educational goal of this presentation is to introduce this new approach and present tools available to the public.
10am – 11:15am Panel: To Share or Not to Share?: Advancing Knowledge on Health Disparities in Traumatic Stress and Addictions through FAIR Data

Denise Hien, Nancy Kassam-Adams, Jessica Hamblen, Simonne Wright, Maya O'Neil, Sonya Norman, Antonio Morgan-Lopez, Soraya Seedat, Marit Sijbrandij, Eirini Karyotaki 

Traumatic stress related mental health and addiction outcomes remain areas in need of new discovery, particularly regarding health disparities. Our body of knowledge has grown exponentially; thus a critical mass of studies provide data that can be pooled, re-examined, and synthesized, allowing nuanced analyses not possible with single studies. Broader calls for Findable, Accessible, Inter-operable, and Re-usable (“FAIR”) data support these goals. We will contrast four national & international collaborative FAIR data projects focused on traumatic stress: Project Harmony (Hien & Morgan-Lopez), and Project TUTTI (Wright, Seedat, Sijbrandij, and Karyotaki), two meta-analyses with individual patient data for clinical trials in PTSD and substance use disorders; the Prospective Studies of Acute Child Trauma & Recovery (PACT/R) Data Archive (Kassam-Adams), a resource promoting preservation and re-use of child trauma research data; and the PTSD-Repository (O’Neil, Hamblen, & Norman), an initiative making harmonized, study-level data of adult PTSD treatment RCTs publicly available in an updatable, web-based format designed for data interaction and manipulation. We will describe challenges and feasible approaches for FAIR data efforts, how attendees can access these resources, and potential uses for clinical, research, policy, and patient/family stakeholders.
10am – 11: 15am Symposium: Not Everyone Responds Equally: Evaluating and Predicting Treatment Response Trajectories in Residential and Intensive Outpatient Treatment Programs for Veterans/Service Members with PTSD
  • Chair: Philip Held
  • Discussant: Kathleen Chard
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  • Early Response to Massed Prolonged Exposure in a Two-Week Intensive Outpatient Program for Veterans with PTSD
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  • Mark Burton, Kathryn Black, Jessica Maples-Keller, Sheila Rauch, Barbara Rothbaum
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  • Prolonged Exposure (PE) is an effective intervention for PTSD (Watts et al., 2013), and many are likely to respond early to treatment (Graham et al., 2018). The Emory Healthcare Veterans Program has developed a novel PE treatment delivery model providing massed PE daily over two weeks and shows strong effects and high retention rates (Rauch et al., 2020). However, it remains unknown whether early response occurs in massed PE, who responds early, and how early response may predict treatment outcome. 

  • Preliminary results from an effectiveness sample of Veterans diagnosed with PTSD receiving treatment (N = 167) showed large reductions in PTSD symptoms after 2 weeks (n = 167; d = 1.34), with19.4% of showing early response (at least 20% symptom reduction) after 2-3 days of treatment and 40.4% showing early response after 4-5 days. Preliminary data suggested demographic variables (e.g., age, gender, minority-status, marriage-status) did not predict early response, nor did baseline PTSD or depression severity. However, early responders had lower symptom severity scores at post-treatment. 
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  • Many individuals are likely to respond very rapidly to massed PE. Identifying these individuals early in treatment will further accelerate the ability to provide fast relief from PTSD symptoms using a massed exposure format.
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  • What’s Leftover? Examining Residual Symptoms Following CPT within a Residential Setting
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  • Merdijana Kovacevic, Nicole Pukay-Martin, Kathleen Chard
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  • Although Veterans experience significant benefit from PTSD treatment, some symptoms appear particularly resistant to change despite treatment completion, with some Veterans retaining a PTSD diagnosis. Examining symptoms retained posttreatment, or residual symptoms, has implications for understanding treatment effectiveness; however, prior research focuses on DSM-IV symptoms. Thus, the present study examined DSM-5 PTSD residual symptoms among 277 men and women Veterans that completed CPT within a VA residential program. Residual symptoms with the highest conditional probabilities were sleep difficulties (83.33%) and hypervigilance (69.73%). Preliminary logistic regression results indicated lower probabilities of retaining any individual symptom among Veterans that lost a PTSD diagnosis (n = 118); however, hyperarousal symptoms, particularly sleep difficulties (67.65% probability), were high even among those no longer meeting PTSD diagnostic criteria. Logistic regression results showed that higher post-treatment depression symptom severity was predictive of residual sleep symptoms among Veterans that lost a PTSD diagnosis, after controlling for demographic and baseline characteristics. While CPT resulted in improvements for Veterans, sleep was a treatment-resistant symptom requiring further exploration and/or treatment. Clinical and research implications will be discussed.
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  • Predicting Treatment Response Trajectories of Veterans who Completed 3-week Cognitive Processing Therapy-Based Intensive PTSD Treatment
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  • Philip Held, Jenna Bagley, Dale Smith
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  • Despite the effectiveness of intensive PTSD treatment programs (ITPs), little is known about individuals’ different responses to treatment. The present study examined ITP treatment response trajectories as well as predictors of treatment response.
     
    Data were drawn from 328 veterans who completed a 3-week Cognitive Processing Therapy-based PTSD ITP. PTSD (CAPS-5, PCL-5) and depression severity (PHQ-9) and posttraumatic cognitions (PTCI) were assessed before, repeatedly during, and after treatment. Latent trajectory modeling was performed to identify response trajectories and predictors.
     
    Four distinct trajectories were identified based on closeness of correspondence between group membership proportions and apriori theory. A total of 35.1% of veterans no longer screened positive for PTSD prior to completing the 3-week treatment period. One group (31.7% of individuals) did not change significantly over the course of treatment. Higher pre-treatment CAPS-5, PHQ-9, PCL-5, and PTCI predicted greater likelihood of being in worse trajectories.
     
    Findings suggest that some individuals may succeed in even briefer treatments whereas others may require additional time in treatment to achieve comparable treatment gains. Further research is needed to determine how treatment trajectories predictors can be used to tailor treatments to individual needs.
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  • Psychological Comorbidity: Predictors of Residential Treatment Response among U.S. Service Members with PTSD
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  • Kristen Walter, Cameron McCabe, Jessica Watrous, Jessica Beltran, Naju Madra, Justin Campbell
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  • Residential posttraumatic stress disorder (PTSD) research in military samples mainly shows that PTSD and depression symptoms significantly improve over treatment but often remain at elevated levels. Identifying those who respond to residential treatment versus those who do not, or even worsen, is critical given the extensive resources required for such programs. This study examined predictors of treatment response among 282 male service members treated in a Department of Defense residential PTSD program. Service members were classified using established criteria as recovered, improved, indeterminate (referent), or deteriorated in terms of self-reported PTSD and depression symptoms. For PTSD symptoms, multinomial logistic regression results found that higher pretreatment PTSD severity (AOR=0.92, p=.010) and alcohol use (AOR=0.95, p=.029) predicted lower odds of being in the deteriorated group. Longer pretreatment sleep duration (AOR=1.37, p=.049) and greater depression severity (AOR=1.36, p=.018) predicted higher odds of being improved. Service members who discharged early (AOR=0.27, p=.022) were less likely to be recovered. For depression symptoms, higher pretreatment impairment (AOR=0.83, p=.027) trended toward lower odds of being improved. Results reveal clinical characteristics better suited for residential PTSD treatment and highlight implications for comorbid conditions.
10am – 11:15am Flash Talks Session 1
2pm – 3:15pm Panel: What Did You Learn in School Today? Barriers and Opportunities in the Implementation of School-Based Interventions for Diverse Youth Exposed to Trauma

Tali Raviv, Colleen Cicchetti, Lisa Jaycox, Audra Langley, Mandy Habib

Lack of access to mental health services is a pervasive issue impacting millions of youth, and traumatized individuals are less likely to seek health services than non-trauma exposed youth (Guterman, Hahm, & Cameron, 2002). Delivering mental health services through schools can address some barriers (Jaycox et al, 2010), and there is evidence that school-based interventions for trauma are effective (Herrenkohl, Hong, & Verbrugge, 2019). However, schools face challenges in implementation of evidence-based practices (Nadeem, Saldana, Chapman, & Schaper, 2018). Domitrovich and colleagues (2008) identify an ecological model of macro (e.g., district policies), school (e.g., leadership), and individual (e.g., attitudes) factors that influence implementation. This panel will discuss challenges at each of these levels, such as training accessibility, engagement of diverse youth, and cross-service system collaboration.  Panelists will discuss novel solutions to these barriers identified by research and practice, providing examples from national dissemination of four school-based interventions for trauma: Cognitive Behavioral Intervention for Trauma in Schools, Bounce Back, Structured Psychotherapy for Adolescents Responding to Chronic Stress, and Strengthening Transition Resilience of Newcomer Groups.  Discussions will include recommendations for future research and practice.
2pm – 3:15pm Symposium: The Fragmented Life: Examining the Relationship between Obstructive Sleep Apnea and Posttraumatic Stress Disorder
  • Sleep-Disordered Breathing and Suicidality in PTSD
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  • Steven Woodward, Ned Arsenault, Andrea Jamison
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  • Insomnia is a risk factor for suicide. What about sleep apnea? Gupta and Jarosz (2015) found high correlations between measures of apnea and suicidality in civilians. Bishop (2020) found support for this association in Veterans.

    We studied 208 Veterans engaged in inpatient treatment for PTSD who provided a mean of 82 nights of mattress actigraphy, a sleep recording method that yields respiratory indices. Fifty participants also underwent a night of objective apnea screening.

    Seventy-percent of the sample endorsed thoughts of suicide. They were 15 pounds heavier, spent 21 more minutes in bed, exhibited more respiratory rate variability, more tidal volume instability (TVI), and more snoring. They endorsed more depression but not more PTSD. In a logistic regression accounting for shared variance and including BDI, weight, and TVI accounted for significant unique variance in the presence/absence of suicidal thoughts. Within the objectively-tested subsample, thoughts of suicide were also associated with higher apnea-hypopnea indices (AHI), but only weight accounted for unique variance.

    Weight and TVI, correlates of sleep apnea, accounted for variance in thoughts of suicide. Their strong performance may be due to low error variance relative to AHI. The data support the proposition that sleep apnea must be considered when seeking to reduce suicidality by improving sleep. 
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  • PTSD and Sleep Apnea are Associated with Elevated C-Reactive Protein in Returning Veterans
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  • Laura Straus, Peter Colvonen, Daniel Bertenthal, Thomas Neylan, Aoife O'Donovan
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  • PTSD and sleep disorders are associated with systemic inflammation, which may be a key element linking these conditions to negative health outcomes. We examined medical records for 16,576 Iraq/Afghanistan veterans who had high-sensitivity C-reactive protein (CRP) results. In generalized linear models controlling for demographics, we examined the impact of mental health and sleep disorders on continuous CRP value as well as risk of elevated CRP (>3mg/L). PTSD was the most common mental health disorder in this population (n = 7,632). Veterans with mental health disorders (coeff=.14, p<.001) and comorbid sleep/mental health disorders (coeff=.21, p<.001) had higher continuous CRP values compared to veterans without either condition. Additionally, veterans with mental health disorders (ARR=1.12, p=.004) and comorbid sleep/mental health disorders (ARR=1.15, p=.001) were more likely to have CRP values >3mg/L compared to veterans without either condition. Examining relative risks of different sleep disorders revealed sleep apnea diagnosis conferred greatest risk for elevated CRP. Overall, results suggested comorbid mental health/sleep disorders, especially sleep apnea, are associated with elevated CRP, indicating these patients are at highest risk for poor health outcomes. Future studies should investigate directionality of relationships among sleep disruption, PTSD, and inflammation
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  • Examining the Association between Subjective and Objective Measures of Obstructive Sleep Apnea Risk in Veterans with Posttraumatic Stress Disorder and Insomnia
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  • Robert Lyons, Laura Barbir, Sonya Norman, Robert Owens, Peter Colvonen
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  • Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) frequently co-occur in veterans. Traditional self-report OSA screening focuses on age, high blood pressure, and body mass index (BMI). However, these risk factors may not generalize to younger veterans with PTSD. As such, extant self-report screening measures for OSA (e.g., STOP-BANG) may not adequately screen OSA in younger veterans. To test this, we compared STOP-BANG total scores to objective OSA testing in 48 veterans [mean(sd) age=43.67±13.20; BMI=31.03±4.46] seeking treatment for PTSD and insomnia. Apnea-hypopnea events per hour (AHI; 7.41±7.08), recorded by objective testing (Nox T-3), were used to diagnose OSA severity (low ge 5, moderate ge 15, severe ge 30). Three binary logistic regressions examined if STOP-BANG total scores (3.71±1.60) were associated with the presence of OSA using objective severity cutoff scores. Total STOP-BANG scores were not significantly associated with OSA severity using moderate and severe cutoffs. STOP-BANG total was significantly associated with mild OSA cutoff (OR=1.70, p=.02), with poor sensitivity (66.7%) and specificity (61.9%). Findings suggest that the STOP-BANG is not adequate for screening OSA in younger veterans. Additional research should focus on developing more sensitive screening tools to aid in detecting OSA in younger veterans.
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  • Obstructive Sleep Apnea screening and treatment on a residential unit for Veterans with PTSD and Substance Use Disorder
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  • Guadalupe Rivera, Jae Park, Moira Haller, Sonya Norman, Peter Colvonen
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  • Individuals with co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have worse outcomes than individuals with a single disorder with residential units have higher PTSD/SUD severity. Obstructive sleep apnea (OSA) is highly co-occurring with both disorders, yet often goes undiagnosed. Given OSA is associated with worse outcomes for PTSD and SUDs, screening for OSA in a residential treatment program is critical. This study examined the feasibility of incorporating OSA screening and treatment onto a Substance Abuse and Residential Rehabilitation Treatment Program (SARRTP). OSA was diagnosed using Nox T3 recorders (AHI >5). Participants logged their sleep-wake schedule and wore an actigraphy. Participants were 44 veterans admitted onto the SARRTP PTSD track who consented to screening. 54.5% of Veterans screened positive for OSA, while 45.5% screened negative. 36.4% were newly told of the diagnosable OSA, 9.1% were previously diagnosed and using a Continuous Positive Airway Pressure (CPAP), and 9.1% were previously diagnosed but were not using a CPAP. Finally, most newly diagnosed individuals (70.0%) consenting to CPAP treatment. OSA screening on the unit was feasible and effective in diagnosing OSA. Rates of undiagnosed OSA were remarkably high. Future studies should examine OSA treatment on PTSD/SUD treatment outcomes.
2pm – 3:35pm Case Studies:
  • A Clinical Case Mixed-Methods Study Exploring Black Male Grief Reactions to Loss and Trauma: Decreasing Pathology to Increase Healing and Services among African American/Black Men in the United States 
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  • Allen Lipscomb
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  • Grief is a common response to loss among all people regardless of race, class or gender. Despite its universality, it is hypothesized that variation exists in how it is experienced and expressed among African American/Black men in the United States. Much research centers on the recognition of grief as a complex, multidimensional phenomenon that is influenced by a variety of external factors. Although studies on grief and loss have helped identify stages around grief, loss and bereavement in general, empirical research has yet to examine these factors for African American/Black men.  The purpose of this qualitative exploratory mixed-methods case study was to explore the unique grief reactions among Racialized Black Identified Men in the United States in order to contribute to best practice guidelines for their emotional and mental health well-being. In addition, a Critical Race Theory (CRT) lens is utilized to enhance understanding of the historical and culturally nuances that exist and complicates the grief experience for this vulnerable population. Results suggest the importance of culturally-reflexive clinical practice interventions around understanding and assisting African American/Black men who are grieving.
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  • It Helps to Talk About It: Integrating Culture in the Application of EMDR with African American Clients in Psychotherapy 
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  • Traci Terrance
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  • This case study presentation adds to the discussion of integrating cultural considerations in the provision of eye-movement desensitization and reprocessing (EMDR) to meet the needs of Black clients. Statistics indicate that African Americans experience a disproportionate burden of poor mental health in comparison to our White counterparts, yet utilize mental health services at about a 50% lesser rate. Faced with these disparities, mental health professionals experience the challenge of adhering to evidence-based treatment models, while creating both culturally sensitive and culturally responsive services to engage Black Americans in the therapeutic process. As a model that relies heavily on therapists’ ability to “stay out of the way”, EMDR may inadvertently create a clinical barrier that does not consider the cultural relevance of “nnommo”—the spoken word—in Black culture. Through explication of the eight phases of EMDR, this multimodal case study presentation walks through the process of trauma therapy with four African American individuals while integrating discussion of core concepts including cultural humility, along with the foundational understanding of oral traditions that shape African Americans’ contemporary ways of being and knowing. Suggestions for cultural integration within the treatment approach will be discussed involving audience interaction.
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  • The Global Psychotrauma Screen Adaptation for Children and Adolescents Using the Delphi Method
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  • Emma Grace, Miranda Olff
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  • Recent research indicates that children and adolescents are underserved age groups in assessment and treatment for trauma (Gadeberg et al., 2017; Grassetti et al., 2018; Lang & Connell, 2018). To address this gap, we have adapted the Global Psychotrauma Screen (GPS) for children and adolescents using the Delphi method (Helmer, 1967). Prior research provided a substantial evidence on the validity of the Delphi method in developing and adapting assessment and treatment interventions in healthcare (RAND Corp., 2020). Following a step-by-step guide developed for this study, ten PhD students and graduates who specialize in trauma services and have up to 15 years of professional experience with children and adolescents worked in two groups adapting the child and adolescent versions respectively. Each member independently revised the GPS in four rounds. After each round, the project leader consolidated the results using NVivo.12 (QSR International, 2015); then, the team members revised the consensus version. The results indicated that the three items on dissociative symptoms were the most difficult to revise. The final consensus versions of the GPS for children and adolescents will be demonstrated and discussed with the audience. Discussion will focus on recommendations for future research on validation and replication of the GPS child and adolescent versions.
3:45pm – 4:45pm

SIG Meetings:

  • Genomics and Trauma SIG
  • Intergenerational Transmission of Trauma and Resilience SIG
  • Trauma and Substance Use Disorders SIG
  • Diversity and Cultural Competence SIG
5pm – 6:15pm Panel: Bringing Research to Rurality: Practical Applications and Lessons Learned from Implementing Evidence-Based Care in Rural Areas

Lisa-Ann Cuccurullo, Michelle Bowen, Sacha McBain, Katherine Dondanville, Karin Thompson

Rural residents are less likely to received evidence-based care (EBC) for PTSD. In efforts to increase EBC for PTSD, rural areas are often overlooked. The panel will discuss their work increasing EBC for PTSD in rural locations. Dr. Cuccurullo is a psychologist at NCPTSD and facilitator on an Office of Rural Health project increasing PTSD EBC at rural VAs. She will speak to implementation strategies and lessons learned. Ms. Bowen, is a social worker at the Memphis VA and regional PTSD mentor, driving the PTSD EBC in her region to the highest average in the US, with some of the nation’s most rural veterans. She will discuss spearheading change. Dr. McBain is a psychologist at the University of Arkansas, working in rural emergency rooms, in early assessment after a trauma; introducing EBC to new patients. She will discuss early EBC and the development of vital partnerships. Dr. Dondanville is a psychologist at the STRONG STAR Training Initiative increasing community access to CPT in border regions of Texas, 53% of those trained are bilingual. She will review borderland rurality and bilingual training. Dr. Thompson is a psychologist, Houston VA PTSD team lead, and researcher at the South Central MIRECC which focuses on rural health. She will act as moderator and discussant. The panel will share experiences of implementation and highlight cultural differences in rural communities
5pm – 6:15pm Symposium: Advancing Neural Models of Posttraumatic Stress Disorder
  • Chair: Belinda Liddell
  • Discussant: Richard Bryant
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  • The Hijacked Self: Altered Functional Connectivity between the Periaqueductal Gray and the Default Mode Network in Posttraumatic Stress Disorder
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  • Braeden Terpou, Maria Densmore, Jean Theberge, Paul Frewen, Margaret McKinnon, Andrew Nicholson, Ruth Lanius
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  • The proposed study estimates the directionality of the functional connectivity between the periaqueductal gray (PAG) and the mid-line cortices of the default mode network (DMN) (i.e., precuneus (PCN), medial prefrontal cortex (mPFC)) during subliminal, trauma-related stimulus processing in participants with posttraumatic stress disorder (PTSD) as compared to controls. Effective connectivity between the PAG and the PCN, as well as between the PAG and the mPFC are assessed using dynamic causal modeling, where several models are evaluated and the strength of effective connectivity parameters are then compared group-specifically. Effective connections are measured during subliminal, neutral and subliminal, trauma-related stimulus conditions. In PTSD, stronger effective connectivity between the PAG and the mid-line cortices of the DMN were revealed as compared to controls, where the effective connections were also modulated more significantly during subliminal, trauma-related stimulus conditions in participants with PTSD as compared to controls. These effective connectivity dynamics were revealed to be driven primarily by the PAG towards the mid-line cortices of the DMN in participants with PTSD. These findings are discussed largely with regard to self-related processes, which are facilitated by the DMN and are reported often to show clinical disturbances in participants with PTSD.
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  • Network Biomarkers of Excessive Fear Overgeneralization in Trauma Exposed Adults
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  • Yuval Neria
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  • We examined the neural signature of fear overgeneralization in trauma-exposed adults. fMRI responses in the salience (SN), executive control (ECN), and default mode (DMN) were assessed in 86 trauma-exposed adults (TEs) and 37 healthy controls (HCs). The task includes pre-acquisition, acquisition, and two generalization sessions. Generalization-gradients were measured by the slopes from CS+, through GSs, to CS- in the generalization sessions (i.e., LDS). Group (TE vs. HC) by time (Session1 vs 2) repeated measures ANOVA was carried out to test the generalization-gradients changes over time. Significant group by session interaction of LDS was found in SN (p=0.02, F=5.398), and significant group effects were found in both SN (p=0.048, F=3.968) and ECN (p=0.014, F=6.118). This effect was driven by increased generalization-gradients from session 1 to 2 in the HCs, while this pattern remained unchanged for TEs. Finally, inverse correlation was found between generalization in SN and ECN (r=-0.37, p=.002), and SN and DMN (r=-0.373, p=0.002). Our findings underscore the role SN, a network related to bottom-up processes of threat detection, may play in overgeneralization. In addition, connectivity between the SN and both ECN and DMN, known for their top-down executive control and memory processes, may be key to modulation of overgeneralization after trauma exposure.
     
  • Opponent Emotion Dysregulation Neural Profiles Associated with Fear vs Dysphoric PTSD Symptoms in Torture Survivors
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  • Belinda Liddell, Gin Malhi, Kim Felmingham, Angela Nickerson, Jessica Cheung, Tim Outhred, Pritha Das
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  • Emotion regulation difficulties may be a key mechanism underlying the adverse psychological consequences of torture, but the brain systems affected have not been mapped. In this study, 49 male torture survivors (N = 26 with PTSD [DSM-5]) participated in an fMRI study where they were instructed in using reappraisal strategies to view negative images (versus watch). A 2 factor between-subject analysis comparing torture exposure and PTSD diagnosis revealed no significant group differences during the reappraisal of negative cues.. However, when we examined PTSD symptoms on 2 factors - fear (i.e. re-experiencing, hypervigilance symptoms) and dysphoria (i.e. active avoidance, mood alterations, anxiety-related hyperarousal) – significant group effects emerged. The torture survivor group showed an emotion under-regulation pattern with stronger fear symptoms, reflected in reduced activity in key regulatory prefrontal regions including the dorsolateral and dorsomedial prefrontal cortices compared to the non-torture group (p<.05 family-wise error-corrected). By contrast, dysphoric symptoms were associated with an over-regulation neural profile in torture survivors, who exhibited stronger activity in the DLPFC and VLPFC (p<.05 FWE-corrected). These findings highlight how mapping the brain mechanisms underlying torture trauma might inform treatment.
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  • Neural Activity During Response Inhibition as a Predictor of Trauma-Focused Psychotherapy for Posttraumatic Stress Disorder
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  • Richard Bryant, Leanne Williams, Kim Felmingham, David Forbes, Gin Malhi, Mayuresh Korgaonkar
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  • Up to one-half of PTSD patients do not respond to trauma-focused CBT. Consequently, there is a need to understand the neural mechanisms that characterize TF-CBT response. Ability to manage negative emotions is crucial for TF-CBT, however we do not know whether the neural mechanisms of inhibitory functions predict response to TF-CBT. PTSD patients (n=40) were assessed during a response inhibition task whilst undergoing functional magnetic imaging (fMRI) and event-related potentials (ERP) in separate sessions before undergoing 9 sessions of TF-CBT. Reduced activation in the left precuneus and the right superior parietal cortex predicted greater improvement in dysphoric PTSD symptoms. ERP responses during response inhibition indicated that lower P3 peak latency predicted greater improvement of dysphoric symptoms. There were no significant predictors of changes of fear symptoms. These markers were able to predict treatment response with 73% accuracy. These findings indicate that neural activity associated with response inhibition can act as a predictive biomarker of TF-CBT response for PTSD symptoms.
5pm – 6:15pm Symposium: “Should I stay or should I go?”: Advancing the Study of Attendance in Comorbid PTSD and Substance Use Disorder Clinical Trials
  • Chair: Teresa Lopez-Castro
  • Discussant: Sonya Norman
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  • Characteristics of Early Dropout in a Pharmacotherapy and Behavioral Trial for PTSD and Alcohol Use Disorder
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  • Tanya Saraiya, Kevin Gray, Elizabeth Santa Ana, Stacey Sellers, Hannah Shoemaker, Claire Stark, Sudie Back
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  • Minimal research has examined participant dropout in medication trials for co-occurring PTSD and alcohol use disorder (PTSD+AUD). Moreover, most individuals who leave behavioral PTSD treatments dropout in the early sessions, even though early improvement predicts retention and outcome (Holmes et al., 2019). This study assessed factors associated with early dropout in a combined pharmacotherapy and behavioral trial for PTSD+AUD. Early dropout was defined as eligible individuals who left the study between the randomization appointment and the first two treatment sessions. Participants were randomized to receive 2400 mg/daily of N-Acetylcysteine or placebo for 12 weeks. All participants received weekly cognitive behavioral therapy for AUD. Baseline demographic and clinical characteristics were compared among participants who dropped out early (n = 30) to those who remained in treatment (n = 97; Total N = 127). Mann-Whitney tests and Chi-square tests revealed that participants who dropped out early reported higher levels of self-blame for their PTSD (X2 (1) = 5.92, p = .02) and a greater ability to resist drinking alcohol (Mann-Whitney = 1931, p = .007) than participants who remained in treatment. Although preliminary, findings suggest that greater self-blame and self-perceptions of ability to resist craving may be associated with increased risk for early treatment dropout.
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  • A Machine Learning Approach to Studying Attendance in Comorbid PTSD and Substance Use Disorder Trials

  • Yihong Zhao, Skye Fitzpatrick, Lesia Ruglass, Denise Hien
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  • High dropout rates characterize randomized clinical trials (RCTs) for comorbid posttraumatic stress disorder (PTSD) and substance use disorders (SUDs), leading to bias in estimation of treatment effects. Using a data-driven approach, this study investigated the association of patient level characteristics and session attendance in a RCT for comorbid PTSD and SUDs.  Weekly data from individuals who attended at least one session of either Concurrent Treatment of PTSD and SUDs using Prolonged Exposure (n=34) or relapse prevention (n=39) were included. A machine learning method, Random Forest algorithm, was used to identify a set of potential risk factors and moderators for the total sessions completed. A Poisson regression model was then used to assess the association between the identified factors and attendance. Results supported prior findings that greater improvement on PTSD symptoms (slope of change in a weekly administered PTSD scale) was associated with greater session attendance (p=0.011). Age moderated the relationship (p=0.004)—greater PTSD symptom improvement was linked to fewer sessions attended among younger patients and more sessions among older patients. Notably, this interaction  was replicated in an independent RCT data set. This study underscores the utility of machine learning methods to examine attendance predictors and their meaningful interactions.
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  • Detecting Dropout Risk via Session by Session Measures in an RCT of Integrated Treatments for Veterans with Comorbid PTSD and AUD
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  • Alexander Kline, Kaitlyn Panza, Matthew Worley, Abigail Angkaw, Ryan Trim, Sonya Norman
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  • Integrated interventions for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are effective, but many patients prematurely drop from treatment. Little is known about dropout risk factors within treatment, limiting our ability during therapy to identify patients unlikely to complete treatment. We examined weekly measures assessing PTSD, substance use, and patient satisfaction as potential within-treatment markers of dropout risk, administered to Veterans (N = 119) during an RCT of integrated exposure therapy versus integrated coping skills therapy for PTSD and AUD. Per “reliable exacerbation” metrics (Foa et al., 2002), PTSD exacerbations were infrequent across treatment and were similar between completers (27.3%) and dropouts (17.8%), p = .38. Only 3% of dropouts experienced exacerbations in the interval immediately preceding dropout. Alcohol use exacerbations followed a similar pattern. Patients’ early ratings of treatment satisfaction at the first (p = .002, d = 0.65) and third (p = .03, d = 0.49) sessions were higher among eventual completers compared to dropouts. Results will be contextualized with qualitative dropout data. Exacerbations occurred infrequently and rarely predicted immediate dropout. Further study of within-treatment measures and indicators proximal to dropout may help identify at-risk patients and inform treatment strategies.
5pm – 6:15pm Symposium: Suicide Risk and Trauma in Veterans: Novel Research on Risk Factors and Methods of Intervention
  • Chair: Kirsten Dillon
  • Discussant: Amy Williams
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  • Interpersonal Violence Throughout the Lifespan: Associations with Suicidal Ideation and Suicide Attempt among a National Sample of Female Veterans
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  • Ryan Holliday, Jeri Forster, Alexandra Schneider, Christin Miller, Lindsey Monteith
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  • Interpersonal violence (i.e., physical and sexual violence) across the lifespan is prevalent among female veterans. There is limited knowledge regarding the role of different types of interpersonal violence throughout the lifespan on suicidal ideation (SI) and suicide attempt (SA) among female veterans. Furthermore, suicide research has focused on those accessing Veterans Health Administration (VHA) care, limiting understanding of non-VHA female Veterans. This study examined if physical and sexual violence at differing time points (i.e., pre-military, during military service) were associated with SI and SA at subsequent time points. 407 female veterans, including those currently using, formerly using, or who never used VHA care participated in a national survey assessing history of interpersonal violence, SI, and SA. Logistic regression analyses were conducted. Pre-military sexual, but not physical, violence was associated with military SI and SA. Pre-military and military physical and sexual violence were associated with post-military SI, but only pre-military and military sexual violence were associated with post-military SA. Generally, sexual violence is more strongly associated with subsequent SI and SA than physical violence. Research on modifiable mechanisms by which sexual violence influences suicide risk among female veterans is necessary.
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  • Influence of Suicidal Ideation on Mental Health Care Following Risk Assessment among Iraq and Afghanistan War Veterans with Posttraumatic Stress Disorder
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  • Nicholas Holder, Erin Madden, Amanda Khan, Brian Shiner, Yongmei Li, Thomas Neylan
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  • Suicidal ideation (SI) is common among veterans diagnosed with posttraumatic stress disorder (PTSD). Evidence-based psychotherapy (EBP) for PTSD is recommended for veterans with low to moderate acute suicide risk, and can reduce PTSD symptoms and SI. However, it is unclear how SI affects treatment selection. To address this, we identified 51,759 post-9/11 veterans with a PTSD diagnosis and a suicide risk assessment within 60 days of their first mental health visit. Dependent variables included EBP initiation and number of non-EBP and EBP sessions in the six months following risk assessment. We assessed the influence of SI on dependent variables with a logistic regression and two negative binomial regressions. At initial risk assessment, 17% of veterans with PTSD endorsed SI in the past month. After accounting for demographics and comorbidities, SI was associated with a higher number of non-EBP sessions (RR:1.39, CI95:1.32-1.46). We also found no association between SI and EBP initiation (OR:1.08, CI95:0.98-1.18) or number of EBP sessions (RR:1.09, CI95:0.95-1.26). In the six months after initial risk assessment, veterans who endorsed SI received non-EBP psychotherapy sessions at a higher rate, but this did not prevent them from receiving EBP. Further research is needed to understand how SI influences treatment planning, and how early care decisions affect long-term outcomes.
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  • Bridging the Access Gap for Suicide Interventions using Home Based Telemental Health
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  • Leslie Morland, Chandra Khalifian, Chelsey Wilks, Colin Depp, Kathleen Grubbs, Craig Bryan
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  • Veterans encounter numerous obstacles to accessing mental health care, including suicide-specific interventions (Classen et al., 2014; Maguen et al., 2019). The VA has devoted considerable resources to improving access by developing a robust technology infrastructure to deliver services through home-based telemental health (HBTMH). HBTMH has demonstrated clinical safety and effectiveness (Morland, et al., 2019) however, there is little to no research on feasibility, effectiveness or implementation guidance for use with high-risk Veterans. The most recent VA/DOD Clinical Practice Guidelines for the Assessment and Management of Patients at Risk for Suicide indicate “insufficient evidence” with regard to recommendations on the role technology can play in facilitating suicide-specific interventions suggesting a significant gap in clinical knowledge/research on the role of technology in connecting veterans with suicide-specific interventions.  This study presents data on the delivery of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT; Rudd, Bryan, & Wertenberger, 2015), over a HBTMH modality with Veterans seeking care though a large TMH program. This presentation will discuss findings, including data on safety and feasibility, clinical and process outcomes, and adaptations to the intervention for in home delivery. Clinical and Research implications will be discussed.
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  • A Network Analysis of Trauma, Previous Suicide Attempts, and Suicidal Ideation in OEF/OIF Veterans
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  • Robert Graziano, Kirsten Dillon, Frances Aunon, Eric Elbogen
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  • The mechanisms by which trauma and suicide are linked remain unclear. Additionally, other factors such as depression and substance use have been shown to predict suicidal ideation (SI) and the interplay between trauma exposure and these factors is not well understood. As such, there is a gap in our knowledge of what factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how two variables relate within the context of a network of symptoms may bridge this gap by offering granular data about the interrelationships between trauma exposure, SI, and other factors. As such, the current study used network analysis to study the relationship between trauma exposure, PTSS, SI, previous suicide attempts, and a host of factors related to attempting suicide in 3877 OEF/OIF military veterans. Partial correlation network results found history of childhood abuse to be the strongest predictor of previous suicide attempts. Drug misuse was also slightly related to previous suicide attempts. Further, depression severity, while not related to previous suicide attempts, was the strongest predictor of SI and negatively related to social support. These results offer valuable information in both predicting suicide risk and differentiating targets for interventions lowering suicide risk. 
     
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Friday, November 6

10am – 11:15am Invited Speaker: Providing Trauma-Focused Cognitive Behavioral Therapy via Telehealth Before, During and After the COVID-19 Pandemic

Michael De Arellano
10am – 11:15am Workshop: Sí se Puede: Prolonged Exposure Psychotherapy with Latinx Survivors of Sexual Assault 

Natalia Garcia, Agustina Eiff, Carolina Perez, Lori Zoellner

Although there is a robust literature supporting prolonged exposure therapy (PE) as a gold-standard treatment for PTSD (Cusack et al., 2016; Watkins, Sprang, & Rothbaum, 2018), treatment-seeking Latinx individuals in the United States are less likely to receive evidence-based care due to limited resources in community health centers (Alcántara, Casement, & Lewis-Fernández, 2013; Alegria et al., 2008). Furthermore, culturally relevant challenges for Latinx individuals, such as mental health stigma, language barriers, and lower socioeconomic status may interfere with effective treatment delivery (e.g., Alegria et al., 2008; Valentine et al., 2017). This workshop will address strategies for providing culturally responsive implementation of this evidence-based treatment when working with Latinx sexual assault survivors suffering from PTSD. We will focus on how to build trust and rapport, deliver effective psychoeducation, provide culturally informed case management, and identify and problem solve systemic barriers related to the intersection of race, class, and literacy. This workshop will address how to provide culturally responsive treatment without compromising treatment fidelity in order to improve clinical outcomes among Latinx sexual assault survivors.
10am – 11:15am Workshop: Evidence-based Prescribing for Posttraumatic Stress Disorder

Jonathan Bisson, Mathew Hoskins

There is strong research evidence to support the pharmacological treatment of PTSD as a second line to trauma-focused psychological interventions.  Unfortunately, a lot of prescribing does not adhere to the current evidence base and more people with PTSD would likely benefit from medication if it did.  The Cardiff PTSD Prescribing Algorithm, which encourages a measurement-based approach to care, was developed to help clinicians make appropriate decisions about the pharmacological treatment of people with PTSD, primarily based on the ISTSS Guidelines’ evidence-based recommendations.  

This workshop will help participants increase their understanding and skills with respect to: a) the existing and emerging scientific evidence, b) the dissemination and implementation of evidence-based approaches to the treatment of PTSD, and c) improving access to care through improved training and delivery methods.  The presenter will specifically discuss the development of the algorithm from the ISTSS guidelines and the results of a parallel systematic review of augmentation of pharmacological therapy with other pharmacological agents.  The workshop will cover details of recommended medications, doses, dose escalation and pharmacological alternatives according to response and tolerability.
10am – 11: 15am

Symposium: Long-Term Consequences of Traumatic Childhood Experiences—Novel Insights and Future Directions
 

  • Negative Affect, Distrust and Emotion Processing in Individuals with Adverse Childhood Experiences– a Daily Life Study
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  • Sara Schmitz, Johanna Hepp, Inga Niedtfeld
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  • Previous cross-sectional, laboratory evidence suggests that adverse childhood experiences (ACE) are associated with interpersonal distrust and deficits in emotion processing. However, whether these associations hold in the daily lives of those affected remains unexplored. The purpose of the present study was to test these associations in individuals with ACE, using Ambulatory Assessment (AA). We tested whether ACE were related to (i) momentary distrust and (ii) a negatively biased evaluation of emotional faces. Moreover, we investigated whether ACE moderated the association (iii) between momentary negative affect and distrust, and (iv) between negative affect and a negatively biased evaluation of emotional faces. To this end, we combined self-reports with behavioral tasks on emotion processing and a distrust game implemented in the AA study. A sample of 60 individuals with ACE provided data at six time points over 7 days. Based on multilevel models, we found that ACE were associated with distrust and a negatively biased evaluation of emotional faces in daily life. Furthermore, ACE positively moderated the association between negative affect and distrust, and between negative affect and a negatively biased evaluation of emotional faces. We discuss opportunities that the current results and newly implemented AA tasks hold for trauma research.
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  • Latent Classes of Child Acute Stress Disorder Symptoms after Single-Incident Trauma: Findings from an International Data Archive
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  • Marthe Egberts, Nancy Kassam-Adams, Annegret Krause-Utz, Lonneke Lenferink 
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  • Many children show acute stress disorder (ASD) symptoms after potentially traumatic events (PTEs). However, little is known about subgroups of child ASD symptoms. The objective of this study was to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership. A sample of 2287 children and adolescents (5–18 years) was derived from the international Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive. Latent Class Analysis (LCA) was used to determine subgroups based on ASD symptoms. A three-step approach was used to examine predictors of class membership. A three-class solution was found, consisting of a low- (42%), intermediate- (43%) and high- (15%) ASD symptom severity class. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be girls, have a younger age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). This study provides new information on children at risk for ASD after PTEs. Additional analyses will be performed to examine associations with later stress symptoms The findings are relevant to inform risk screening, as well as prevention and intervention programs.
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  • Integrating eHealth Tools in Pediatric Medical Care to Screen and Monitor for Child Traumatic Stress: Progress and Challenges in Development and Evaluation
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  • Nancy Kassam-Adams, Flaura Winston, Meghan Marsac
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  • Screening and monitoring (sometimes referred to as “watchful waiting”) is part of recommended best practices in the aftermath of trauma exposure. But even in the medical setting in which potentially traumatic exposures are known to the professionals caring for a child, obtaining accurate and timely follow-up screening or monitoring has been challenging. This presentation will report on progress in developing and testing an integrated set of eHealth tools aimed at achieving broader reach in regularly assessing child self-reported traumatic stress and pain after medical events. The system combines a game-based interface for children (delivered on a tablet) where they rate their symptoms, with weekly text messages and a personalized online information portal for parents. Tools were developed with child and parent input and have demonstrated usability; screening measures have demonstrated concurrent validity.  A trial is now underway to assess the predictive validity of game-based assessments as well as the effectiveness of parent information tools in helping parents feel informed and confident in caring for their child. The presentation will (a) describe the user-centered development process and results to date, and (b) discuss methodological challenges in evaluating eHealth tools to support child trauma recovery given a rapidly evolving technological and health system contexts.
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  • Childhood Trauma Severity Underlies Increased Distractibility by Social Cues in Borderline Personality Disorders – The Effectiveness of an Emotional Working Memory Training
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  • Annegret Krause-Utz, Julia-Caroline Walther, Susanne Schweizer, Christian Schmahl, Stefanie Lis, Martin Bohus
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  • Emotion dysregulation and interpersonal problems are core features of borderline personality disorder (BPD), closely linked to complex childhood trauma. Symptoms often persist after successful therapy. Computerized emotional working memory training (eWMt), targeting inhibitory control of socio-emotional stimuli, improved emotion regulation in healthy individuals (Schweizer et al., 2013). Objective was to evaluate the effectiveness of an adapted eWMt in BPD. Methods: Sixty-eight BPD patients and 28 healthy controls (HC) performed two experimental tasks: an adapted working memory (WM) task with socio-emotional distractors and an emotion regulation (ER) task. In a randomized control trial, BPD patients were then assigned to either the eWMt (n=37) or an active control group (placebo training: n=31). After training, they performed experimental tasks again. Results: Before training, BPD patients showed more ER deficits and WM impairments after social distractors than HC. Childhood trauma severity mediated these group differences (b(SE)=43.41(21.88), CI: [0.47, 86.30], Z=2.30, p=.021). The eWMt, but not the Placebo training, improved WM for social distractors, regardless of childhood trauma severity. WM improvements further predicted ER gains after eWMT. Implications of these novel unpublished findings, providing first evidence for the effectiveness of an eWMt in BPD, are discussed.
11:45am – 12:45pm SIG Meetings:
  • Early Interventions SIG 
  • Sexual Orientation and Gender Diversity (SOGD) SIG
  • Trauma and Justice SIG
  • Moral Injury SIG
2pm – 3:15pm

Keynote Speaker: What is Global Mental Health?


Pamela Y. Collins, MD, MPH

5pm – 6:15pm Symposium: Moving from “Should We?” to “How Can We?”: Implementation of Interventions for Trauma Survivors in the Criminal Justice System
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  • Exploring the Need for Trauma-Informed Practices in Juvenile Justice Settings: Results from the North Carolina Trauma-Informed Communities Project
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  • Katelyn Donisch, Angela Tunno
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  • Studies suggest that over 90% of youth in juvenile justice (JJ) settings have experienced at least one traumatic event in their lifetime (Abram et al., 2004). Given the prevalence of exposure in this population, JJ settings are recognizing the importance of implementing trauma-informed practices to address youth trauma stress, prevent re-traumatization, and minimize secondary traumatic stress (STS) among staff. As part of the North Carolina Community Mental Health Services Block Grant, the North Carolina Trauma-Informed Communities Project (NC TICP) has supported the implementation of trauma-informed practices in six communities in North Carolina. Consistent with the planning phase of the Consolidated Framework for Implementation Research (CFIR), NC TICP conducted a needs assessment across the six communities to determine the current use of and need for trauma-informed practices. The needs assessment was adapted from the Trauma System Readiness Tool developed for the Chadwick Trauma-Informed Systems Project. Over 1,675 participants completed the assessment, with 86 participants identifying as JJ or court system staff. This study will provide descriptive data on trauma awareness, trauma-informed practices, and associated barriers across four domains: 1) impact of traumatic stress on JJ youth; 2) caregiver trauma history; 3) STS among staff, and 4) service coordination.
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  • Implementing and Sustaining SHARE: An Exposure-Based Psychotherapy Group for Incarcerated Women Survivors of Sexual Violence
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  • M. Kathryn Allison, Lindsey Roberts, Marie Karlsson, Ana Bridges, JoAnn Kirchner, Melissa Zielinski
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  • Although incarcerated women are a highly victimized population, therapy for sexual violence victimization (SVV) sequela is not routinely offered in prison. SHARE is a group therapy for SVV survivors that was successfully implemented and sustained in a women’s corrections center. Here, we conducted a retrospective process evaluation to identify implementation factors and strategies that led to SHARE’s success. We structured interviews according to the EPIS framework. Participants (N=22) were incarcerated women, members of the SHARE treatment team, and corrections center staff. We found that positive inter-organizational and interpersonal relationships were key across phases, as were the synergies between the strengths and needs of each organization involved in implementation. For example, the university-based treatment team had training in SVV treatment, but needed practice sites that have access to people in need of SVV treatment. Conversely, the corrections center had many people in need of SVV treatment, but staff had little or no training in SVV. Over fifteen unique strategies were used to support SHARE implementation. Incarcerated women reported a strong need for SHARE and did not report any concerns about receiving trauma therapy in a carceral setting. Community-academic partnerships may be a particularly feasible way to expand access to SVV therapy for incarcerated women.
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  • Strategies Used to Support Implementation of PTSD Treatment in Drug Court: A Retrospective Examination and Future Directions
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  • Ilana Berman, Morgan Hill, Melissa Zielinski
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  • Drug treatment courts offer an alternative to incarceration for people facing criminal charges largely due to addiction. Given the high co-occurrence of trauma exposure and substance use, a high percentage of people in drug courts have experienced trauma and have PTSD symptoms. This project features a retrospective look back at strategies used to support trauma therapy implementation (formal screenings; needs assessments; clinical and meeting notes; conversations with implementation and treatment staff) in a county drug court since 2016. Over 85% of participants endorsed trauma exposure and 26% clinically-significant PTSD symptoms demonstrating need for trauma therapy. Interviews with staff revealed strong receptivity to group trauma treatment yet participation was low. Review of ERIC strategies to support intervention uptake (see Powell et al., 2015) indicated use of more than 10 strategies (e.g., assess for readiness; identify and prepare champions) in implementation of a group therapy for women affected by sexual violence. Recent strategies shifted to reexamine the implementation and tailor strategies (e.g., change service sites, create new clinical teams) to better align with barriers faced. These efforts highlight strategies that yielded growth in participation and areas where strategies may still be required to expand reach.
5pm – 6:15pm Symposium: Longitudinal course of trauma-related sequelae
  • Chair: Daniel Lee
  • Discussant: Terence Keane
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  • The twenty-year course of posttraumatic stress disorder symptoms among veterans
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  • Daniel Lee,  Lewina Lee, Michelle Bovin, Samantha Moshier, Sunny Dutra, Sarah Kleiman
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  • Although numerous longitudinal studies have examined heterogeneity in PTSD symptom course, the long-term course of the disorder remains poorly understood. This study sought to understand and predict long-term PTSD symptom course among a nationwide sample of OEF/OIF veterans enrolled in Veterans Health Administration services. We assessed PTSD symptoms at four time points over approximately 4.5 years (M = 55.11 months, SD = 6.89). Participants (N = 1,353) with and without probable PTSD were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio to fully explore the heterogeneity of PTSD symptom course and the effect of sex on symptom course. By coding time as years since index trauma, we estimated the course of PTSD symptoms over 20 years. Results indicate symptom course is most appropriately characterized by substantial heterogeneity. On average, veterans experienced initial PTSD symptom severity above the diagnostic threshold following trauma exposure, which worsened slightly in the first few years following trauma exposure, then gradually improved. Results highlight the heterogeneity and chronicity of PTSD symptom course among veterans and the urgency of the need to ensure access to evidence-based care and improve available treatments.
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  • Longitudinal Analysis of PTSD and Illicit Drug Use Problems Among Male and Female OEF/OIF Veterans
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  • Nicholas Livingston, Daniel Lee, Colin Mahoney, Brian Marx, Terence Keane
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  • Little is known about the longitudinal course of posttraumatic stress disorder (PTSD) and drug use. Given the high prevalence of PTSD and drug use among veterans, understanding PTSD effects could help reduce their risk of drug use, impairment, and improve health long-term. Using data from 1,242 veterans (Mage=42.3, 51% female), we examined PTSD symptoms, drug use, and related problems, each measured twice 15-37 months apart (M=30 months), using cross-lagged panel analysis. We observed autoregressive effects for PTSD and drug problems, indicating each predicted future levels of the same construct. PTSD symptom severity predicted future drug problems while covarying autoregressive effects; drug problems did not predict future PTSD severity. Lastly, the prospective effect of PTSD on drug use was significant for cannabis, tranquilizer, and methamphetamine use, but not for opioids, cocaine, inhalants, or hallucinogens. Interventions targeting both drug use and PTSD seem warranted in light of finding that each predict drug problems 1-3 years later. PTSD effects on future cannabis, tranquilizer, and methamphetamine use highlight need for 1) intervention targeting use of these drugs, 2) prescription use and diversion monitoring (if prescribed cannabis, tranquilizers), and 3) research to identify PTSD criterion associated with the drug use patterns and problems observed.
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  • Same-Day and Next-Day Associations between PTSD Symptom Cluster Severity and Co-Use of Prescription Opioid and Sedative/Hypnotic/Anxiolytic Medications
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  • Christal Badour, Jessica Flores, Caitlyn Hood 
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  • Co-use of prescription opioids and sedatives/hypnotics/anxiolytics (SHAs) frequently contributes to opioid overdose deaths. Despite clear links between posttraumatic stress disorder (PTSD) and non-medical prescription opioid use (NMPOU; use without a prescription; use more frequently, in a higher dose, or for reasons other than prescribed), there is a dearth of research examining daily-level processes associated with co-use of opioids and SHAs among individuals with PTSD. This 4-week daily diary study examined how symptoms of PTSD concurrently and prospectively predicted opioid/SHA co-use patterns among a sample of 40 community-recruited adults (60.0% female) with clinical or subclinical PTSD and recent NMPOU. 31.6% of participants reported same-day opioid/SHA co-use during the study (M=10.67 days, SD=7.37). Controlling for same-day alcohol/cannabis use, and prior day opioid use, PTSD-reexperiencing symptoms were associated with increased odds of same-day co-use (OR=1.20, 95% CI [1.08,1.35]), whereas PTSD-avoidance symptoms were associated with decreased odds of same-day co-use (OR=0.64, 95% CI [0.53,0.78]). PTSD symptom clusters did not predict next-day odds of co-use. Clinical implications and considerations for using experience-sampling designs to study proximal relations between PTSD and substance use will be discussed.
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  • Trajectories of Suicidal Ideation in U.S. Military Veterans: Results from a 7-Year, Nationally Representative, Prospective Cohort Study
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  • Lorig Kachadourian,Ilan Harpaz-Rotem, Steven Southwick, Robert Pietrzak
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  • Suicide is a significant problem in U.S. military veterans. Research on suicidal ideation (SI), a risk factor for suicide, has mostly been cross-sectional. We examined the nature and determinants of predominant trajectories of SI in a nationally representative, prospective study of U.S. military veterans. Latent growth mixture modeling was used to identify trajectories of SI in 2,302 veterans over a 7-year period. Sociodemographic, health, and psychosocial determinants of these trajectories were then evaluated. The majority of veterans (n=2,167) evidenced a no/low SI risk trajectory (2.7% average likelihood of SI over time); 102 an intermediate SI risk trajectory (57.8% average likelihood of SI over time); and 34 a high SI risk trajectory (92.0% average likelihood of SI over time). Major depressive disorder (MDD), greater hostility/aggression (H/A) and posttraumatic growth (PG), and lower optimism and social support (SS) predicted an intermediate vs. low SI risk trajectory. Male sex (MS), suicide attempt history (SAH), MDD, greater H/A, and lower optimism and SS predicted a high vs. low risk trajectory. MS, SAH, and low SS predicted a high vs. intermediate risk trajectory. A significant minority of veterans have an intermediate-to-high SI risk trajectory over a 7-year period. Common and unique factors differentiate these trajectories, which is important for prevention efforts.
5pm – 6:15pm Panel: Intensive Delivery of Evidence-based Treatment for PTSD across Diverse Contexts: Successes, Challenges, and Strategies for Implementation

Jennifer Wachen, Cynthia Yamokoski, Elizabeth Goetter, Kris Morris, Terri Weaver

Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are effective treatments for posttraumatic stress disorder, yet it can be challenging for patients to complete a full course of therapy. Delivering CPT and PE in an intensive format may reduce dropout and improve treatment outcomes. This panel will discuss the implementation of intensive CPT and PE in different formats with diverse populations in both research and clinical contexts. Dr. Yamokoski will discuss an intensive outpatient program at VA Northeast Ohio based upon massed-delivery (3-5X per week) of PE or CPT with veterans. Dr. Goetter will present on two intensive programs for PTSD at the Home Base Program serving veterans and their families: The Intensive Clinical Program (two weeks of daily individual CPT or PE) and the Accelerated Clinical Treatment program (2x daily, individual PE delivered over a 4-day weekend). Dr. Morris will discuss an intensive 5-day combined group and individual CPT program delivered in a randomized clinical trial of massed CPT with active duty military. Dr. Weaver will present a pilot study of individual CPT delivered over 5 days with female victims of interpersonal violence through the Center for Trauma Recovery. Dr. Wachen will moderate a discussion of strategies that have contributed to the success of implementing these interventions in novel formats and unique contexts.
5pm – 6:15pm Panel: Adapting and Disseminating Self-Care and Peer Support Guidance for Health Care Providers During the COVID-19 Pandemic

Patricia Watson, Sonya Norman. Jessica Hamblen

Best practices in behavioral health highlight the need for interventions to be sensitive to the needs of the intended populations and offered in the most accessible way. The need for mental health interventions to be tailored to the stress associated with the Covid-19 outbreak, coupled with limited time, resources, and availability of mental health support, created new challenges for existing support models.  Additionally, a high demand was created for rapid development and dissemination of Covid-19-specific information related to mental and healthcare provider self-care and coworker support. This panel will describe lessons learned in creating and adapting patient care, provider self-care, and coworker support materials in the context of a rapidly evolving and ongoing threat public health crisis, based on a flexible, evidence-informed framework for managing the stress associated with ongoing threat situations. Dissemination efforts will also be described, including world-wide webinars, consultation efforts, and material development for first responders, mental health and healthcare providers.  The panelists will lessons learned, aimed at adapting flexible frameworks and dissemination strategies in other extended disasters and public health crises.
5pm – 6:15pm Flash Talks Session 2
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Saturday, November 7

10am – 11:15am Workshop: How Do I Explain A Drug Overdose to a Seven-Year-Old? The Application of Trauma-Focused Cognitive Behavioral Therapy for Parental Substance Misuse: Strategies and Clinical Considerations

Jessica Griffin, Jessica Wozniak, Lisa Blanchard, Jessica Dym Bartlett

Parental Substance Misuse (PSM) is often a breeding ground for trauma including child abuse, neglect, and traumatic grief (e.g., due to overdose). PSM is a public health crisis, with 1 in 8 youth in the U.S. impacted. Data from our statewide child trauma center shows that 40% of referrals to trauma-focused evidence-based treatment involve PSM. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) continues to be the most widely disseminated EBT for youth who experience trauma. Yet, clinicians struggle with navigating TF-CBT with youth impacted by PSM grappling most with one issue: promoting safe and stable nurturing relationships (e.g., largest factor in recovery from traumatic events) in the face of impaired caregiving. PSM often results in inconsistent, unavailable caregiving, and inability to buffer youth from stress and promote resilience. Presenters include national experts in three areas: TF-CBT, substance misuse, and evaluation of trauma interventions for youth. The presentation will provide an overview of the impact of PSM on youth and complexities of engaging caregivers in recovery as well as strategies to address these complexities. TF-CBT components will be discussed relative to PSM. Evaluation findings, handouts, and a list of psychoeducational resources will be provided. This session will be interactive, using videos, didactics, case vignettes, and group exercises.
10am – 11:15am Symposium: Complex Posttraumatic Stress Disorder—New Treatment-Related Insights and Challenges
  • Chair: Annegret Krause-Utz
  • Discussant: Marylene Cloitre
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  • Does complex PTSD predict and moderate trauma-focused treatment outcomes for patients with PTSD?
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  • Chris Hoeboer, Rianne de Kleine, Danielle Oprel, Maartje Schoorl, Willem Van der Does, Agnes van Minnen
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  • One reason for the introduction of CPTSD to the ICD-11 was the relevance of the construct for treatment indications (e.g., Berliner et al., 2019). The present study assessed whether CPTSD predicted and moderated treatment outcomes of a randomized controlled trial comparing Prolonged Exposure (PE), intensified PE (iPE) and Skills Training in Affective and Interpersonal Regulation followed by PE (STAIR+PE). It was hypothesized that CPTSD would predict worse treatment outcomes (across treatments) and lead to better treatment effects in STAIR+PE compared to PE and iPE. We included 149 patients with childhood-abuse related PTSD. CPTSD was measured with the International Trauma Questionnaire (Cloitre et al., 2018). The main outcome was change in clinician-assessed PTSD symptoms (measured with the CAPS-5) pre to post-treatment. Analyses were based on an intention-to-treat sample using mixed effect models. Results showed that 54% of the patients met criteria for the CPTSD diagnosis at baseline. CPTSD was related to more severe PTSD symptoms and higher comorbidity at baseline. Importantly, CPTSD did not predict or moderate treatment outcome. These results indicate that CPTSD might be a relevant construct for identifying a subgroup of patients with more severe comorbid symptoms, but it is not predictive of treatment outcome, nor does it appear to indicate differential treatment outcome.
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  • What Predicts Response to DBT-PTSD and CPT – Post-hoc Analysis of a Large Multicenter RCT
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  • Martin Bohus, Nikolaus Kleindienst, Christian Schmahl
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  • We recently compared the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD), a new specifically designed phase-based treatment program, with cognitive processing therapy (CPT), one of the best empirically supported treatments for PTSD. We included 193 women with PTSD after CA, plus 3 or more DSM-5 criteria for BPD including affective instability. Participants received equal dosage and frequency of DBT-PTSD or CPT: up to 45 individual sessions within one year and 3 additional sessions during the following three months. Intent-to-treat analysis revealed significantly improved CAPS-scores in both groups (pre-post effect-sizes d=1.35 for DBT-PTSD, and d=0.98 for CPT) and significant superiority of DBT-PTSD. Participants in the DBT-PTSD group were less likely to drop out early (25.5% vs 39.0%, P=.046) and had a higher chance to achieve symptomatic remission (58.4% vs 40.7%, P=.02), reliable improvement (74.5% vs 55.8%, P=.006) and reliable recovery (57.1% vs 38.6%, P=.Ol). This presentation will show post-hoc analyses of the data, conducted to unravel potential moderators and mediators for general and treatment specific treatment response.
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  • Challenges in Speaking Up about Child Sexual Abuse: Perspectives of Teenagers and Young Adults and Impact on Mental Health
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  • Delphine Collin-Vezina, Ramona Alaggia, Rosaleen McElvaney
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  • Although the taboo of child sexual abuse (CSA) might not be as prominent, veiled issues may still prevent victims from reaching out to reveal the abuse they suffer.  Research has uncovered the pathways to disclosures and the factors influencing the willingness of victims to talk about the abuse; yet, this literature rests largely on adult survivors’ retrospective accounts with few studies specifically aimed at understanding disclosure from the youth’s perspectives. A qualitative study was undertaken to gain greater insights on two main questions: (1) What are the factors that impede or facilitate both informal and formal CSA disclosures? (2) What are the perceived and actual outcomes of telling? The total sample for this study is 38 participants aged 14 to 25, recruited from two Canadian cities and one Irish city. All participants self-reported CSA before the age of 18. Consensual Qualitative Research Method informed the analysis and several trustworthiness strategies were used to ascertain the quality of the data generated. The analyses shed great light on the challenges that young people continue to face when disclosing abuse to peers, family and authorities, including feelings of shame and losing control over the process; yet, positive outcomes were also reported by participants, including an improved sense of belonging and support.
10am – 11:15am Symposium: Sleep and PTSD: From Mechanisms to Treatment Outcomes
  • Chair: Laura Straus
  • Discussant: Thomas Neylan
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  • PTSD, Biological Sex and Sleep Effects on Emotional Learning and Memory
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  • Anne Richards, Samantha Hubachek, Cassandra Dukes, Russell Huie, Kim Felmingham, Steven Woodward
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  • PTSD symptoms revolve around the distressing memory of a traumatic event. Research on factors contributing to the formation and/or consolidation of memories for distressing events (i.e. “emotional” memory) may therefore provide valuable information about the development and maintenance of PTSD. Published research in both animals and humans has utilized fear conditioning as a model of implicit emotional memory processes in PTSD. Human studies have also examined declarative emotional memory consolidation to study disturbed memory processes in PTSD. Biological sex and objective sleep disturbance have been proposed to play a role in PTSD development and/or maintenance. This talk will present findings from an ongoing laboratory-based study examining the role of biological sex, PTSD diagnosis and symptom levels, and objectively measured sleep on the consolidation of emotional memory. Forty-seven male and female trauma-exposed adults aged 18-50 completed a fear conditioning (fear-potentiated startle) session followed by a computer-based visual-imagery encoding session prior to a polysomnography-measured 2-hour afternoon nap opportunity. Following the nap, participants underwent a computer-based image recall session followed by a fear extinction task. Findings for the complete sample (target N=60) will be presented and implications for future research will be described.
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  • Sleep Disturbance and Posttraumatic Stress among Veterans: The Mediating Role of Emotion Regulation
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  • Lia Smith, Brooks King-Casas, Pearl Chiu, David Graham, Wright Williams
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  • Post 9/11 veterans have consistently demonstrated high rates of posttraumatic stress disorder (PTSD). Emotion regulation difficulties and sleep disturbance are targetable via intervention and pertinent to the development and maintenance of PTSD. However, research has yet to explore the effects of sleep disturbance and emotion regulation difficulties in terms of PTSD in veterans. We hypothesized that higher levels of sleep disturbance and greater emotion regulation difficulties would be associated with higher PTSD symptom severity; and that sleep disturbance would exert an indirect effect on PTSD symptom severity through emotion regulation difficulties. Covariates included gender and depression symptom severity. Participants included 45 veterans (82%male,Mage=33.9). Mediation analyses were conducted and results indicated that higher levels of sleep disturbance (b=.04,p<.01) and greater emotion regulation difficulties (b=.05,p<.01), respectively, were significantly associated with greater PTSD symptom severity. Sleep disturbance exerted an indirect effect on PTSD symptom severity through emotion regulation difficulties (b=.04,p<.001). This represents a first step in better understanding these clinically important associations and elucidates the potential utility of incorporating emotion regulation skills and sleep interventions into treatment programs for PTSD in veterans.
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  • Actigraphic Sleep Efficiency Trajectories and Intraindividual Variability over the Course of Residential PTSD Treatment
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  • Katherine Miller, Andrea Jamison, Gisselle Tamayo, Ned Arsenault, Steven Woodward
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  • Despite findings that sleep problems persist following PTSD treatment, the longitudinal course of sleep changes during treatment is limited. This study used latent class linear mixed model (LCMM) to identify subgroups of actigraphic-estimated sleep efficiency (SE) trajectories during 50 days in a VA-funded PTSD Residential Treatment Program and predictors of those groups. Participants were 197 male military Veterans drawn from a prospective, longitudinal study of Veterans engaging in residential PTSD treatment. Participants slept on mattress actigraphs, providing nightly SE estimates. LCMM results found 2 trajectories: ‘good sleepers’, defined as actigraphic SE ³85% over time (n=152, 77%), and ‘sleep deteriorating’ group, defined as actigraphic SE £ 85% that worsened over time (n=45, 23%). After accounting for multiple predictors, membership in the sleep deteriorating class was predicted by elevated intra-individual variability in actigraphic SE (OR=1.42, p<0.001) and a marginal effect for elevated apnea-hypopnea index (OR=1.04, p=0.05). Contrary to reports of sleep complaints in this population, most Veterans in this sample had adequate SE across treatment. Yet, nearly a quarter had a worsening of sleep, highlighted by high variability, throughout the treatment process. There is a need for assessment and targeting of sleep disturbance during the course of PTSD treatment.
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  • Treatment with Imagery Rehearsal Therapy and/or Mianserin in Trauma-affected Refugees: Results from a Randomized Controlled Trial
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  • Hinuga Sandahl, Lone Baandrup, Poul Jennum, Erik Mortensen, Jessica Carlsson Lohmann
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  • The present randomized controlled trial examined sleep enhancing treatment in trauma-affected refugees, aiming to assess whether add-on treatment to treatment as usual (TAU) with Imagery Rehearsal Therapy (IRT) and/or mianserin can improve sleep quality, symptoms of PTSD and depression, and level of functioning and quality of life. The study included 240 refugees, diagnosed with PTSD. Contrary to hypothesis, IRT and/or mianserin added to TAU were not found to be superior to TAU. Except for level of functioning, add-on treatment with IRT did not reach a statistical or clinically relevant difference in comparison to non-IRT. However, there was a consistent tendency of add-on treatment with IRT improving sleep quality, symptoms of PTSD and depression, and quality of life and level of functioning, with IRT showing a non-significant advantage over non-IRT. Compared to non-mianserin, treatment with mianserin added to TAU had no significant effect on sleep quality, severity of nightmares, symptoms of PTSD and depression, or on quality of life and level of functioning. The low treatment response point to further analysis of the complex factors, such as adherence to psychopharmacological treatment, which may impact the ability of trauma-affected refugees to participate in and profit from the various treatments offered.
10am – 11: 15am Symposium: Current Research Utilizing Ambulatory Assessment to Investigate PTSD and Associated Correlates and Impairments
  • Incorporating Symptom Fluctuation Metrics from the Field of Ambulatory Assessment into Traumatic Stress Research
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  • Bryce Hruska, Maria Pacella-LaBarbara, Richard George, Douglas Delahanty
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  • Symptom fluctuation is a core feature of PTSD. However, research in the traumatic stress field relies on average symptom levels as the gold standard statistic informing our understanding of this disorder. This presentation will introduce two metrics derived from ambulatory assessment reflecting symptom fluctuation. These metrics consist of the mean square successive difference (MSSD) – representing the overall degree of symptom fluctuation occurring during a sampling period – and the probability of acute change (PAC) – representing the likelihood of observing dramatic symptom fluctuation (i.e., changes that are larger than 90% of all fluctuations). Using data from 68 injury survivors who completed thrice-daily PTSD assessments for 7 days at 6-weeks post-injury, we demonstrate that probable 6-week PTSD is associated with greater overall symptom fluctuation across the day (b = 1.48, IRR = 4.39, SE = 2.18, p = .003). Further, these fluctuations were more dramatic from measurement occasion to measurement occasion among those meeting probable PTSD (b = 1.54, OR = 4.65, SE = 2.64, p = .007). These findings illustrate that the MSSD and the PAC are statistics that may more accurately correspond with PTSD diagnostic conceptualizations. Consequently, they may represent alternative clinical endpoints worthy of inclusion in traumatic stress interventions.
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  • Feasibility of Using Ecological Momentary Assessment (EMA) and Fitbit Devices to Monitor Post-Injury Psychological and Physiological Responses Associated with Pain
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  • Maria Pacella-LaBarbara, Brian Suffoletto, James Huber, Melissa Repine, Linda Park, Robert Krafty, Anne Germain, Clifton Callaway
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  • Given the lack of intensive, prospective data about acute psychological processes and pain, we examined the: 1) associations between maladaptive psychological processes and pain intensity and interference after motor-vehicle crash (MVC); 2) feasibility of daily text messages, website prompts and Fitbit devices to monitor post-injury responses. To date, 18 adults were enrolled in the Emergency Departments (EDs) of two Level 1 trauma centers within 24 hours post-MVC. At 7pm from Day 1 to Day 14 post–injury, subjects received five questions via text (pain severity, interference, and catastrophizing), and up to 8 items via a website link (depression, posttraumatic stress disorder [PTSD], and fear-avoidance). Subjects also wore a Fitbit device. Subjects were ≈ 37 years, primarily female (77.5%) and White (61.1%). Responses to daily text messages (84%), website items (70%), and compliance with Fitbits was satisfactory (73%). Pain catastrophizing, PTSD, depression, and fear-avoidance were positively associated with pain intensity (B’s = 0.21-0.47; p’s < 0.001) and interference (B = 0.23-0.69; p’s < 0.001). We will also discuss Fitbit patterns for heart rate and activity. This post-injury EMA protocol was feasible; although preliminary, these results support further inquiry regarding how these relationships change over time, and which variables are candidates for early intervention.
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  • Fine-Grained Assessment of Avoidance Behavior Using Ecological Momentary Assessment to Develop Behavioral Economic Metrics
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  • Meghan McDevitt-Murphy, Robert Dvorak, James Murphy, John Roache
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  • Behavioral economics (BE), which fuses behavioral psychology and microeconomics, may offer insight in understanding PTSD. The behavioral model of PTSD highlights the role of avoidance in maintaining the syndrome; avoidance is negatively reinforced by a reduction in aversive affect. In the BE framework, the reinforcing value of avoidance could be a useful construct that quantifies individual differences in avoidance patterns that may explain unique variance in outcomes such as functional impairment. Most PTSD assessment instruments include only two avoidance items (per DSM-5 criteria), providing a limited scale to assess this key behavioral process. We used ecological momentary assessment (EMA) to assess patterns of avoidance in veterans’ (N = 70; 87.5% male) natural environments. Using a mobile app to collect real-time information (multiple times per day, for 3 weeks) about activity engagement, emotional state, and context, we calculated metrics to reflect proportional time allocation across different categories, quantifying the reinforcing value of these activities. Results suggest that the reinforcing value of avoidance (Rav) explained unique variance in functional impairment post-EMA, even after controlling for total PTSD severity on the CAPS (r2 change=.06; F = 14.44; p<.001). This paper will also explore the affective states associated with instances of avoidance.
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  • Assessing the Correspondence of Experience Sampling Reports of PTSD Symptoms with Past Month Retrospective Reports
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  • Talya Greene, Sharon Sznitman, Ateka Contractor, Marc Gelkopf
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  • The study investigated the correspondence of twice-daily ESM reports of traumatic stress symptoms over a one month period during an armed conflict, with a retrospective aggregate assessment of past month traumatic stress symptoms for the same time period. The aim was to investigate the reliability of retrospective reports, and to assess biases due to peak (e.g., worst report) or recency (reports made on the last day of the month) effects. Participants (n=96) provided ESM reports on traumatic stress symptoms twice a day for 30 days via smartphone. We found that mean scores were more predictive of the one-month retrospective assessment, compared with peak reports or most recent reports. Regarding correlations between ESM mean and one month scores of individual symptoms, distorted blame had the lowest correspondence, while concentration difficulties had the highest association. These findings have implications both for identifying individuals at risk of developing PTSD, as well as for diagnostic approaches.
2pm – 3:15pm

Invited Speaker: The Ebb and Flow of Suicide Risk: Implications for Treatment​


Craig J. Bryan, PsyD, ABPP

2pm – 3:15pm Symposium: Evidence Based Treatments for PTSD in VHA Settings: Trends, Dosing, and Effectiveness
  • Effectiveness and Comparative Effectiveness of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in Clinical Practice
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  • Shira Maguen, Erin Madden, Nicholas Holder, Yongmei Li, Karen Seal, Thomas Neylan
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  • We compared Cognitive Processing Therapy (CPT) to non-EBP treatment; Prolonged Exposure (PE) to non-EBP treatment; and CPT to PE in a national healthcare system to determine their real-word effectiveness. We conducted three comparative effectiveness emulated trials using VA electronic medical records from Iraq and Afghanistan War Veterans with PTSD who initiated mental health outpatient care from 10/01-6/17. Observation years with PTSD symptom data were divided into a series of 112 trial start dates. PTSD symptoms at baseline and 24 weeks later were examined using the PTSD checklist (PCL). Patients could be enrolled in as many of these person-trials (PT) as they were eligible. Emulated trials compared groups of PT defined by treatment received and matched by propensity scores. There were 684 CPT PT matched to 684 non-EBP PT. Those completing >8 CPT sessions had a 6.3 point greater PCL reduction than non-EBP (95%CI: 4.6, 8.0). There were 378 PE PT matched to 378 non-EBP PT. Those completing >8 PE sessions had a 5.7 point greater PCL reduction than non-EBP (95%CI: 2.9, 8.4). There were 232 PE PT matched to 232 CPT PT. Those completing >8 PE sessions had similar PCL reduction to those completing >8 CPT sessions. PTSD symptom improvement was modest for all groups in a clinical setting. Patients improved similarly for both EBPs, demonstrating equal effectiveness in clinical care.
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  • Identifying the Median Effective Dose of Two Evidence-Based Psychotherapies for Posttraumatic Stress Disorder
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  • Nicholas Holder, Brian Shiner, Yongmei Li, Erin Madden, Thomas Neylan, Karen Seal
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  • For optimal outcomes, flexibility in treatment length has been encouraged for two posttraumatic stress disorder (PTSD) psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE). However, little empirical data exists regarding the number of sessions before improvement is expected. The median effective dose (MED), defined as the number of sessions at which there is a 50% probability of experiencing clinically meaningful improvement (CMI), can help clinicians understand when improvement is anticipated. To identify the MED of CPT and PE, data were collected from post-9/11 veterans who received CPT (n=26,189) and PE (n=10,234) in VHA between 2001-2017 and had PTSD symptom data. Cox proportional hazards regressions were used to determine how number of CPT/PE sessions, with covariates, affected CMI (>10-point PTSD checklist reduction). Kaplan-Meier curves were plotted to determine MED. The MED was eight sessions for CPT and four sessions for PE. Individual vs. group CPT was associated with a greater likelihood of CMI in fewer sessions (HR:1.31, CI95:1.23-1.39). Other significant covariates had small effects. For CPT and PE, response occurred soon after introduction of critical therapeutic elements. Patients, clinicians, and researchers can utilize these findings to manage treatment expectations and identify when to consider changing the treatment plan.
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  • How Do Gender and Military Sexual Trauma Impact PTSD Symptoms in Cognitive Processing Therapy and Prolonged Exposure?
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  • Amanda Khan, Nicholas Holder, Yongmei Li, Brian Shiner, Erin Madden, Karen Seal
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  • Among veterans receiving evidence-based psychotherapy, the effects of gender and military sexual trauma (MST) on treatment outcome are unclear. This study examined how gender and MST impact PTSD symptoms following cognitive processing therapy (CPT) and prolonged exposure (PE). We conducted a national, retrospective cohort study of all post 9/11 veterans who had a PTSD diagnosis from 10/01-9/17 at a VHA facility and >1 psychotherapy visit. Inclusion criteria was completion of >8 CPT/PE sessions and pre and post PCLs (N = 9,711). Mixed-effects linear regression models were conducted, per treatment, to test associations between changes in PTSD symptoms and gender, MST, and their interactions with time. In adjusted models, only the gender by time interaction on pre-to-post-CPT change was significant (p < .001); the decrease in women’s PCL was 2.67 points greater, compared to men. No other significant effects were found for either treatment. Women veterans had greater reductions in PTSD symptoms from CPT. There were no differences by gender for PE, suggesting men and women veterans benefit similarly. MST status, regardless of gender, did not impact PTSD outcomes for either treatment. Both CPT and PE may thus be effective for veterans with and without MST.
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  • Trends in Medication Use among Patients with Posttraumatic Stress Disorder from 2009 to 2018: A National VA Data Study
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  • Beth Cohen, Nicholas Holder, Anne Woods, Shira Maguen, Thomas Neylan, Karen Seal, Nancy Bernardy, Ilse Weichers 
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  • Pharmacotherapy for PTSD is complex and several recent trials have led to changes in the clinical practice guideline (CPG). However, it is not clear whether prescribing trends have changed in response. We examined prescribing trends of several medications commonly used for PTSD from 2009-2018 using national VA data. Patients were included in the analytic sample in the year of their first PTSD diagnosis and were counted each year that they had >=1 VA visit or received a medication (N=1,353,416). We examined the proportion of patients receiving prescriptions for selective serotonin reuptake inhibitors (SRIs), selective serotonin/norepinephrine reuptake inhibitors (SNRIs), atypical antipsychotics (AAPs), mirtazapine, prazosin, trazodone, and tricyclic antidepressants. From 2009-2018 the percentage of patients receiving at least one medication declined by 8.4%. The largest change in prescription rates were SSRIs (-12.3%) and SNRIs (+6.4%). AAP use decreased 5.4% from 2009-2018, with most change (-4.2%) from 2009-2015. Consistent with the CPG, SSRIs/SNRIs were the most common prescription and providers seem to respond to guideline changes, such as recommendations against AAP use. Reductions in the percentage of patients receiving medications may reflect symptom improvement, increased access to evidence-based psychotherapy, effectiveness concerns, and/or adverse side effects.
2pm – 3:15pm Panel: The Roles of Individual- and Community-Level Social and Interpersonal Factors in Conferring Vulnerability or Resilience in Trauma Survivors

Kathryn Macia, Patrick Palmieri, Deidre Anglin, Sarah Murray, M. Rose Barlow,  Judith Bass, Brianna Byllesby, Eve Carlson

Social and interpersonal factors play important roles in both vulnerability and resilience to mental health problems after trauma. If such factors are mechanisms of trauma responses, they would also be promising targets for intervention. This panel will begin with brief presentations demonstrating how a range of social and interpersonal variables were related to later mental health symptoms in five diverse samples. Social and interpersonal variables studied include social connectedness, social support, social constraints, interpersonal conflict, relationship stress, recent intimate partner violence, sexual-violence stigma, discrimination, and community-level social and cultural context. Populations studied include U.S. samples of patients hospitalized after traumatic injury or sudden illness, active military personnel returning from deployment, veterans seeking primary care services, trauma-exposed homeless veterans in residential treatment, and second-generation immigrant young adults exposed to trauma. The final sample consisted of women with a history of sexual violence in conflict-affected areas of Eastern Congo. The panel will conclude with a discussion among panelists and the audience about social and interpersonal mechanisms of trauma responses and recovery and about the clinical and public health implications for intervention at the individual and community levels.
2pm – 3:15pm Symposium: Bridging the Science and Practice Gap in PTSD Treatment: Understanding and Addressing Clinician-Level Barriers to the Dissemination and Implementation of Prolonged Exposure Therapy
  • Chair: Alexandra Klein
  • Discussant: Sonya Norman
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  • Implementation of PE in the Army: Is Consultation Necessary for Effective Dissemination
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  • Thea Gallagher
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  • Objective: This randomized trial compares two therapist training protocols in Prolonged Exposure therapy (PE) and their effects on provider attitudes and behavior across three Army behavioral health settings. Method: 128 behavioral health provider participants were randomized to one of two PE training models: Standard PE training, comprised of a 4-day workshop only, and Extended PE training, comprised of a 4-day workshop plus expert case consultation. Following completion of training, providers were free to select the interventions of their choosing with all PTSD patients. Providers completed Provider Measures of Attitudes assessing current treatment practices and beliefs related to PE before and after the PE workshop and at 3-month intervals until 18-months post-training. Providers invited their patients with PTSD symptoms to participate in the study, and completed brief Procedures Used in Treatment Checklists following each therapy session to track their chosen interventions. Results: Data collection was completed in January 2018. Participating providers were predominantly social workers (61.2%) and psychologists (34%) who identified with a cognitive-behavioral (56.3%) or integrative/eclectic (20%) theoretical orientation. Providers completed an average of 7.92 sessions ( SD = 3.65) with participating patients.
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  • A Novel PTSD Treatment Delivery Model to Improve Implementation, Increase Access, and Reduce Cost of Care for PTSD Through an Intensive Outpatient Program
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  • Mark Burton, Kathryn Black, Sheila Rauch, Barbara Rothbaum
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  • Prolonged Exposure (PE) is an effective treatment for Posttraumatic Stress Disorder (PTSD; Watts et al., 2013). However, many Veterans face barriers to care, such as a lack of availability of services in their communities (Hoge et al., 2004) and higher likelihood of dropout (Kehle-Forbes, et al., 2014). Accessible interventions can improve treatment retention and reduce treatment burden on mental health service systems from Veterans receiving sub-optimal PTSD treatment (Tuerk et al., 2013).

    The Emory Healthcare Veterans Program (EHVP) has developed an intensive outpatient program (IOP) that provides PE in a massed, two-week format for Veterans. The program has seen approximately 547 Veterans to date who see on average a 41% drop in PTSD and 39% drop in depression in two weeks of therapy.

    Annual cost savings of 12% were calculated based on the superior retention rate for the EHVP-IOP (96.3%; Rauch et al., 2020) and the estimated 2-fold increase in healthcare utilization costs for those who dropout of therapy (Tuerk et al., 2013).  In addition, preliminary analyses suggest those who were not referred to follow-up care had significantly lower PCL scores at post-treatment (M = 10.17; SD = 13.28) than those who were referred (M = 25.44, SD = 18.32).

    IOP formats are affective for PTSD symptom reduction, can improve access to care and reduce burden on the mental health system.
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  • Effectiveness of a Consultation Program for Prolonged Exposure: Examining Outcomes of Patients, Trainees, and Consultants-in-Training
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  • Andrew Sherrill, Liza Zwiebach, Mark Burton, Sheila Rauch,  Barbara Rothbaum
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  • Prolonged exposure (PE; Foa, Hembree, Rothbaum, & Rauch., 2019) is a first-line treatment for PTSD (Cusack et al, 2016). Implementation science recommends a concentrated episode of didactic instruction followed by a period of expert consultation (Rosen et al., 2016). However, PE trainees rarely have access to follow-up consultation.
     
    The Emory University Prolonged Exposure Consultant Training Program aims to improve access to expert consultation within community settings. This six-month training course includes weekly video conference calls between Emory PE consultation experts, community PE consultants-in-training, and community PE providers. Consultants-in-training are assessed within the following skill domains: the consultation relationship, general psychotherapy skills, PE-specific skills, trainee barriers to delivery, and implementation.
     
    To date, 31 consultants-in-training have graduated (100% completion rate). During their training, they provided consultation to 71 trainees, 44 of whom demonstrated sufficient competency in PE with at least two cases. On average, PE trainees showed 95% adherence to the manual and a score of 86% on the PE knowledge test. Trainees’ use of PE increased by 127% following the program and consultants-in-training’ provision of PE consultation increased by 27%. Lessons learned through the development of this training program will be discussed.
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  • Overcoming Barriers to Utilization of Exposure Therapy for PTSD: Modifying Clinician Beliefs as a Possible Strategy
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  • Alexandra Klein, Alexandra Bowling, Alexander Kline, Norah Feeny
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  • Exposure therapies, such as prolonged exposure (PE), are first-line interventions for PTSD but remain underutilized. Providers’ negative beliefs are a barrier to implementation, and their modification may increase utilization. This study examined two strategies aimed at enhancing clinicians’ beliefs towards PE for PTSD and subsequent PE utilization. Clinicians (N = 155) were randomized to one of three PE rationale conditions: basic description; clinician perspective; and patient perspective. Participants were re-randomized to write or not write arguments for utilizing PE. Before and after PE rationales and at one-month follow-up, participants completed the Therapist Beliefs about Exposure Scale (Deacon et al., 2013) and questions about utilization. Participants reported marginal yet durable belief change across all rationale conditions, hp2= .21, with greatest belief change in the clinician description of PE condition,d = 0.35. Across conditions, belief change was not impacted by writing condition, nor was it associated with hypothetical PE utilization. Fewer years of experience, hp2 = .09, and less baseline PE utilization, hp2 = .04, were associated with greater belief change. Addressing negative beliefs from a clinician perspective may be a brief, cost-effective strategy to increase buy-in. Complementary strategies to increase utilization are critical.
2pm – 3:15pm Workshop: Pediatric Approach to Trauma, Treatment and Resilience (PATTeR): A Novel and Successful Way to Train Pediatricians to Recognize and Respond to Trauma

Heather Forkey, Andrea Ocampo, Jessica Griffin

A pediatric, mental health and cultural expert from NCTSN describe a novel educational curriculum to educate medical providers about childhood trauma recognition and response.  Pediatricians are likely to be the first, and sometimes only, professionals with the opportunity to assess the myriad symptoms demonstrated by children experiencing trauma.  Yet, many children do not benefit from early response because symptoms of childhood trauma are often missed or misdiagnosed by the pediatric provider. Presenters will discuss the development of a trauma-informed curriculum, The Pediatric Approach to Trauma Treatment and Resilience (PATTeR), developed from the sciences of trauma-informed mental health care, attachment, resilience, and evidence-based parenting education, for pediatric care settings.   Creative solutions to recruiting members from a large professional organization will be reviewed.  The main themes and delivery of two curricula, trauma aware and trauma responsive, to pediatricians from across the United States serving predominantly high-risk populations via a novel interactive, case-based learning system (ECHO) will be discussed.  Overall, PATTeR ECHO is a viable way to educate pediatricians and their teams about complex childhood trauma and resilience and to improve their knowledge and skills and their ability to incorporate those skills into practice.
5pm – 6:15pm Symposium: Disasters in the Era of Climate Change: Innovations in Understanding Disasters’ Impact on Children and Families
  • Before the Storm: Impact of Disaster Evacuation Experiences on Parental and Youth Mental Health and Well-Being
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  • Annette La Greca, Naomi Tarlow, Kaitlyn Brodar, BreAnne Danzi, Jonathan Comer
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  • Climate-related disasters are on the rise and may lead to significant psychological distress in children and parents. Yet, little is known about the impact of before-the-storm stressors. Hurricane Irma led to one of the largest mass evacuations in US history and provided an opportunity to study evacuation stress. We examined: parents’ reports of overall evacuation stress and specific types of stressors; and the impact of evacuation stress on parents’ and children’s symptoms of PTSD, anxiety, and depression. Parents (N=554) in South FL directly affected by Irma completed surveys 3-months post-hurricane, and also reported on their child. Parents who evacuated reported more before-the-storm stress than those who sheltered in place (p<.05). Before-the-storm stressors focused on transportation issues and family decision-making/conflict. Further, parents with more before-the-storm stress reported more symptoms of PTSD (b=.13, p<.001), anxiety (b=.16, p<.05), and depression (b=.18, p<.01) than those with less stress; similar findings emerged for youth (p’s<.05). Findings indicate that parents and children are vulnerable before and after disasters. Better preparation efforts are essential to address parents’ and children’s emotional needs. Families can be encouraged to develop Family Disaster Plans to reduce evacuation stress and identify ways to make evacuation less traumatizing.
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  • Why Family Communication Matters: The Role of Co-Rumination and Topic Avoidance in Understanding Post-Disaster Mental Health
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  • Erika Felix, Tamara Afifi, Sean Horan, Haley Meskunas, Adam Garber
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  • Although families can be a source of support post-disaster, depending on how they communicate about their stress, their attempts at support can be helpful or harmful. This study explored the moderating role of topic avoidance and co-rumination on post-disaster mental health among 485 parent-child dyads following severe floods in Texas. Parents (69.0% female) and their oldest child between the ages of 10-19 years (M = 13.75 years, SD = 2.56) reported their flood exposure, life stressors since the disaster, topic avoidance, co-rumination, and posttraumatic stress (PTSS), depression, anxiety. Structural equation models tested a moderated-mediation model of whether communication processes moderated the associations of flood exposure and life stressors on mental health. They did not moderate the association of flood exposure to PTSS, but did for depression and anxiety. At mean and high levels of topic avoidance, there was a significant, positive association between flood exposure and child anxiety and depression. Co-rumination impacted both parents and children. For both, flood exposure increased risk for depression and anxiety at high levels of co-rumination. Results for life stressors were nuanced. Overall, this suggests that communication can influence post-disaster mental health and can be a point of intervention to support long term recovery and resilience.
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  • Reciprocal Post-Flood Recovery Process Between Parents and Youths
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  • Kotaro Shoji, Erika Felix, Tamara Afifi, Charles Benight
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  • The present study examined the relationship how parents and children interact and influence each other to cope with post-disaster challenges and demands. We collected data on the exposure levels, posttraumatic distress, trauma coping self-efficacy, and communal coping from 510 parent-youth dyads sufferring from the Memorial Day Weekend flood of 2015 in Texas. Parent participants were predominantly female (69.0%) and Caucasian (62.2%). Children's age ranged from 10 to 19 years old. We performed network analyses among posttraumatic distress (PTD), trauma coping self-efficacy (CSE), and communal coping for the dyads with low, moderate, and high levels of flood exposure. Results showed that there was strong positive connectivity between the same parental and youth variables for all exposure levels. Among the low exposure group, youth’s CSE had negative and strong connectivity with parental PTD. There was weak to moderate connectivity between youth CSE and parental communal coping and between parental communal coping and youth PTD among the moderate exposure group. Finally, there was a positive and weak connection between parental CSE and youth PTD among the high exposure group. The findings suggest that the exposure levels affect the connectivity among the study variables. These findings indicate that parents and children influence each other in the post-flood recovery process.
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  • Validating the Hurricane Related Traumatic Experiences Measure: Understanding Disaster Exposure Among Children
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  • Betty Lai, Annette La Greca, Daniel Cooper, Kate Guastaferro, Barbora Hoskova, Mary Lou Kelley
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  • Worldwide, approximately 100 million children are exposed to disasters each year. After disasters, children are vulnerable to developing physical and mental health problems. Evidence underscores that there is a dose-response relationship between these negative outcomes and disaster exposure. Yet, to our knowledge there have been no validation studies on child disaster exposure measures. In this study, we evaluate the most widely used measure of child disaster exposure, the Hurricane Related Traumatic Experiences (HURTE) questionnaire. This validation study is conducted with data from the Child Disaster Data Integration Project, an initiative which pooled data from studies of children’s psychological distress following disasters. Data from these individual studies spanned four disasters, Hurricane Andrew (1992), Charley (2004), Katrina (2005), and Ike (2008). In total, 1707 children (53.61% female) were recruited from elementary, middle, and high schools that were in or near hurricane paths of destruction (nAndrew = 568, nCharley = 384, nKatrina = 426, nIke = 329). Aim 1 of this study was to determine the dimensionality/factor structure of the HURTE. Aim 2 was to evaluate the construct validity of the HURTE, examining measurement invariance for the HURTE across gender, age, and time since disaster exposure. Implications for researchers and clinicians will be discussed.
5pm – 6:15pm Symposium: Biological indicators of trauma-related psychopathology in diverse pediatric cohorts
  • Chair: Lana Grasser
  • Discussant: Nicole Nugent
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  • Evidence for Physiological and Behavioral Pathways From Caregiver Trauma to Their Children’s Risk for Internalizing Disorders
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  • Anais Stenson, Georgina Hartzell, Sanne van Rooij, Sean Minton, Tanja Jovanovic
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  • Caregiver trauma can have intergenerational effects which may be conferred via both behavioral and biological pathways, and prior research indicates that there may be sex differences in these effects. We tested whether caregiver trauma and post-traumatic stress symptoms (PTSS) impacted internalizing symptoms and psychophysiological markers of risk in children. N=140 African-American caregivers reported their trauma exposure, PTSS and their children’s internalizing symptoms. Children completed a fear conditioning task; eyeblink startle responses during the presentation of threat and safety signals were assessed via electromyogram. Caregiver level of trauma exposure was positively associated with child internalizing symptoms, r=.36, p<.0001. The relationship between caregiver trauma and children’s startle to safety was moderated by sex, p = .004, such that more caregiver trauma was associated with lower startle for boys, r=-.31, p=.03, and higher startle for girls, r=.29, p=.047. Caregiver trauma was correlated with startle to threat only in girls, r(46)=.32, p=.03. PTSS fully mediated the association between caregiver trauma and child internalizing symptoms, p=.007, but not the association between caregiver trauma and children’s startle response. These results suggest that caregivers’ trauma history impacts children both directly and via increased PTSS symptoms.
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  • Alterations in Fear-Extinction Neural Circuitry Linked to Trauma Exposure and Posttraumatic Stress Symptoms in Children
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  • Hilary Marusak, Aneesh Hehr, Amanpreet Bhogal, Craig Peters, Allesandra Iadipaolo, Christine Rabinak
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  • Childhood trauma is extremely prevalent among urban cohorts and is a leading risk factor for anxiety and posttraumatic stress disorder, which are characterized by deficits in fear-extinction and dysfunction in fear-extinction neural circuitry. The present study tests the impact of childhood trauma and posttraumatic stress symptoms (PTSS) on fear-extinction and underlying neural circuitry. 44 Detroit-area children (45% trauma-exposed; 6-11 yrs) completed fear conditioning and extinction on day one, and extinction recall during fMRI on day two. Conditioned fear was measured using skin conductance, subjective ratings, and approach/avoidant behavior. There were no group differences in conditioned fear responses during fear conditioning or extinction. During extinction recall, however, trauma-exposed children failed to approach the previously-extinguished cue (t(18)=0.12,p=0.91). This avoidant behavioral response was accompanied by higher activation in fear-relevant brain regions, including the dorsal anterior cingulate and anterior insula (Zs>3.6,pFWE<0.04), in trauma-exposed children relative to controls. Children with higher PTSS showed poorer differentiation between threat and safety during conditioning and extinction recall (rs<-0.4,ps<0.05). These data suggest that fear-extinction and underlying neural circuitry is sensitive to trauma exposure and PTSS in childhood.
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  • Difference in Neural Response to Fearful Stimuli in At-Risk Children With High BMI
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  • Sean Minton, Sanne van Rooij, Anais Stenson, Timothy Ely, Mariam Reda, Jennifer Stevens, Vasiliki Michopoulos, Tanja Jovanovic
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  • Stress and trauma in childhood have been linked to obesity and changes in the brain’s fear circuitry. The aim of this study was to assess if neural fear responses differ between high versus average body mass index (BMI) children impacted by traumatic violence exposure. Children (N=36) were recruited through an ongoing study on the effects of trauma in an at-risk population. Violence exposure was measured by the Violence Exposure Scale for Children-Revised. An emotional Go/NoGo fMRI task measured the brain’s response to fearful versus neutral faces in the amygdala, hippocampus and ventromedial prefrontal cortex. Violence exposure was positively correlated with higher BMI (r=0.268, p=0.048). Tests of group differences in neural responses in the fear neurocircuitry between high and average BMI groups indicated that fearful versus neutral faces evoked significantly more activation in the hippocampus of high BMI compared to average BMI children [F(1,34)=5.439,p=0.027). This effect remained significant after controlling for violence exposure. These findings suggest that the hippocampus of high BMI children responds differently to fearful stimuli compared to average BMI children. Research into common factors that may be responsible for high BMI and sensitivity to fear cues is needed. Exercise interventions could be an inexpensive treatment to address obesity and stress disorders.
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  • Greater Exposure to Trauma in Refugee Youth Increases Threat Reactivity, and Psychophysiology Differentially Predicts Hyperarousal Symptoms
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  • Lana Grasser, Bassem Saad, Hiba Abu Suhaiban, Dalia Mammo, Celine Bazzi, Tanja Jovanovic, Arash Javanbakht
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  • Refugee youth are exposed to high rates of trauma and greater than average rates of trauma-related disorders. Identifying biomarkers of trauma-related disorders is critical to predict risk, course of illness, and determine treatment. We aimed to examine the biomarkers of trauma-related symptoms in Syrian refugee youth. Psychophysiological responses and self-report questionnaires were collected in n=31 Syrian refugee youth (age 10-17 years) ~2.5 years following resettlement in the United States. Psychophysiological variables included skin conductance response (SCR) to trauma interview and fear-potentiated startle (FPS) to conditioned threat cue. Level of trauma exposure was positively correlated with severity of PTSD and anxiety symptoms, and SCR to trauma reminder (p’s<.05). Regression analyses showed that FPS to threat cue was not correlated with total PTSD or anxiety symptoms, but was specifically associated with severity of hyperarousal symptoms, R2=.16, p=.04. SCR to trauma reminders was significantly associated with hyperarousal symptom severity, R2=.22 p=.01. Reactivity to threat cues increases with trauma load, which predicts greater severity of posttraumatic stress. SCR and FPS were specifically associated with hyperarousal symptoms. Together data indicating that measures of sympathetic reactivity may serve as biomarkers of hyperarousal symptoms in Syrian refugee youth.
5pm – 6:15pm Panel: Bridging Science and Practice to Reach Trauma Survivors and Their Families: Lessons Learned in Adapting CBCT for PTSD

Alexandra Macdonald, Skye Fitzpatrick, Steffany Fredman, Leslie Morland, Anne Wagner

Cognitive-Behavioral Conjoint Therapy for PTSD (CBCT for PTSD; Monson & Fredman, 2012) is a couple-based psychotherapy for PTSD with effect sizes on par with, or superior to, first-line individual treatments for PTSD that also enhances intimate relationship functioning. However, schedule constraints and logistical barriers can make it challenging for couples to attend all 15 weekly sessions and complete the full course of treatment. To maximize treatment engagement and retention, researchers have adapted CBCT for PTSD in multiple ways. This panel assembles researchers who have investigated an abbreviated, intensive, multi-couple group retreat version (Dr. Steffany Fredman), an abbreviated, telehealth delivery version (Dr. Leslie Morland), an intensive version augmented with MDMA and telehealth sessions (Dr. Anne Wagner), and an online, self-help version (Dr. Skye Fitzpatrick). Panelists will discuss (1) motivations for adapting CBCT for PTSD; (2) strategies used for translating CBCT for PTSD elements in a range of implementation contexts; (3) clinical “lessons learned” about the relative effectiveness of the different adaptations; and (4) recommendations for which trauma survivors and their families may be particularly well suited for the traditional protocol versus one of its adapted formats.
5pm – 6:15pm Symposium: Examining Psychological Outcomes in Trauma Affected Populations in Low-Resource Contexts: The Importance of Triangulation Methods
  • Chair: Sara Romero
  • Discussant: Angela Nickerson
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  • Explaining Suicide In An Under-Served Community: A Mixed Method Study Applying The Cultural Theory Of Suicide To Trauma-Exposed Indian Women From Slums
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  • Anushka Patel, Sasha Rojas
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  • Background: High rates of gender-based violence increase suicidal outcomes among socioeconomically marginalized Indian women. Although suicidal outcomes and depression are well-linked, studies employing a trauma-informed lens are lacking in India. This mixed-method study (1) documents the prevalence of suicidal ideation (SI) following trauma and (2) applies the cultural theory of suicide (Chu et al., 2010) to examine stressors leading to SI, expression of SI, and cultural sanctions of SI among trauma-exposed Indian women from slums.

    Method: 110 Indian women from slums completed surveys on trauma exposure (adapted Harvard Trauma Questionnaire) and depression (PHQ-9). 47 women completed qualitative interviews. Deductive coding, using the cultural theory of suicide, was applied to women’s interviews who endorsed current SI (n=18).

    Results: 44% endorsed current SI. Stressors leading to SI included trauma exposure, chronic emotional abuse, poverty, and social discord. SI was expressed through idioms of ‘tension,’ extreme hopelessness caused by poverty, and desire for escape. Suicide was not socially sanctioned, and women were blamed for SI-related distress.  

    Discussion: Findings suggest suicide prevention in India should (1) target structural and interpersonal drivers of suicide, (2) assess SI through idioms of distress, and (3) enhance community cohesion and psycho-education.
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  • PTSD severity, khat use and trauma exposure among Somalis in Mogadishu
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  • Sagal Ahmed, Andrew Rasmussen
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  • Khat is a psychostimulant that is cultivated and commonly used in Eastern Africa and the Arabian Peninsula. Existing research on khat suggests that problematic patterns of use are tied to several negative mental health outcomes, but there is limited research to inform the development of culturally appropriate and sustainable evidence-based treatments that address comorbidity (Odenwald & Al’Absi, 2017). Due to the high rates of conflict in regions where elevated khat use has been reported, the current study examined the relationship between trauma exposure, khat use, and PTSD symptoms through the lens of the self-medication hypothesis. A sample of 104 khat users residing in Mogadishu was recruited through locale-based sampling methods and a mixed-methods approach was taken in order to develop a culturally appropriate treatment protocol. This study expanded on the existing body of work by determining PTSD symptom severity mediates the relationship between trauma exposure and khat use among a conflict-affected community sample in Mogadishu, Somalia. This presentation will discuss the applicability of a self-medication model in which PTSD symptom severity mediates the relationship between trauma exposure and khat dependence. Additionally, qualitative data regarding motives for use will be discussed in light of its applicability to treatment acceptability in this population.
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  • Striking a balance between universal and culturally specific presentations of trauma-related distress among refugee survivors of gender-based violence: A mixed-methods study
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  • Claire Greene, Wietse Tol
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  • The tension between emic and etic characterizations of psychological distress in cross-cultural research has resulted in disparate measurement methods that favor cultural specificity or universality(Kleinman 1977). This study employs a mixed-methods approach to explore the intersection of culturally specific idioms of distress and common mental disorder symptoms among Congolese refugee survivors of gender-based violence in Tanzania. Adult refugees completed qualitative free listing(n=40), key informant interviews(n=15) or quantitative assessments using the Hopkins Symptom Checklist to measure anxiety and depressive symptoms and the Harvard Trauma Questionnaire to measure post-traumatic stress symptoms(n=311). This presentation describes expressions of distress identified through thematic analysis of qualitative data and factor analysis of quantitative data. An integrated analysis converged on three idioms of distress that were distinct from mental disorders in their symptom constellations: deep sadness (huzuni), many thoughts/stress (msongo wa mawazo) and fear (hofu). This mixed-methods approach serves as a model for measurement that maximizes the relevance of culturally specific expressions of distress, while simultaneously allowing for the utilization of common mental health screening tools to promote the generalizability and comparability of cross-cultural research.
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  • Mexicans’ Perceptions of Trauma and its Relation to Post-Trauma Outcomes: An Examination Using a Social Comparison Theoretical Framework
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  • Sara Romero, Andrew Rasmussen, Abraham Lipton
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  • This study is the first to incorporate a social comparison theoretical framework (Blanton, 2013) to explain the relationship between perceptions of trauma difficulty and PTSD symptom severity and functional impairment for a sample of trauma-affected Mexicans. Using this framework, four types of social comparison processes were identified that underlie a person’s appraisal of competence in managing the degree of difficulty perceived to be associated with experiencing a future trauma event similar to the worst trauma event reported on the LEC-5 (Weathers et al., 2013). This study examined the temporal relationship between perceptions of trauma difficulty and post trauma outcomes for trauma-affected Mexicans (n = 902) residing in low-resourced communities. The path analyses findings indicated that the set of underlying social comparison processes informing perceptions of trauma difficulty mediated the relationship between the ‘time since the worst trauma event’ occurred and PTSD symptom severity and degree of functional impairment. This presentation will discuss the importance of identifying underlying social comparison processes informing Mexicans’ perception of trauma difficulty and clinical implications will be shared to inform clinicians how a person’s perception of their social context can maintain or buffer against the presence of PTSD symptoms and functional impairment.
5pm – 6:15pm Flash Talks Session 3
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Monday, November 9

10am – 11: 15am Invited Speaker: Genetic Influences on Posttrauma Risk and Resilience

Ananda B. Amstadter, PhD
10am – 11:15am Panel: Implementing a Centralized Referral System for Childhood Trauma: Bridging the Gap Between Families and Evidence-Based Treatment for Diverse Populations

Jessica Griffin, Rebecca Vivrette, Zlatina Kostova, Jessica Dym Bartlett

Standards of care for trauma-informed practice have improved, but gaps in service delivery remain. Referral uptake to evidence-based treatment (EBT) is often delayed, with wait times reaching 6-9 months. The purpose of this panel is to describe the development of LINK-KID, a Centralized Referral System (CRS) implemented at the Child Trauma Training Center at the University of Massachusetts Medical School, which aims to reduce wait times and service gaps for youth seeking trauma-focused treatment. International panelists will present mixed-methods data on network development, implementation, and outcomes, including barriers/facilitators to implementation, number/type of referrals, wait times, and treatment completion. Initial results of LINK-KID implementation are promising, with over 3,500 children and families being referred for trauma-focused EBTs and average treatment initiation wait times decreasing from 6 months to 43 days. We will particularly highlight outcomes for groups of families facing serious barriers to treatment and who are at risk for disengagement (e.g., children of parents who misuse substances, transition-age youth, youth who are sexually exploited). Overall, this panel will highlight lessons learned from implementing a CRS for childhood trauma, with recommendations for future work in telehealth-based referral networks.
10am – 11:15am Symposium: Personalizing Interventions for Sexual Assault Survivors: Unpacking Barriers to and Moderators of Treatment
  • Chair: Emma PeConga
  • Discussant: Amy Street
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  • Examining the Impact of Personality Profiles and Sexual Assault on PTSD Treatment Outcome
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  • Alexandra Klein, Allison Baier, Rosemary Walker, Mark Burton, Lori Zoellner, Norah Feeny\
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  • Personality traits are associated with the development and severity of PTSD. It is unclear how personality impacts outcomes and whether this differs by trauma type. Latent profile analysis examined associations between baseline personality profiles and post-treatment symptoms in a sample of patients receiving prolonged exposure or sertraline (N= 200). Index trauma (sexual assault [SA; n= 97] vs. other [NSA; n= 103]) was examined as a moderator. Three-classes were identified: a low stability class distinguished by elevated neuroticism and low agreeableness, conscientiousness, extraversion, and openness (SA = 28.9%; NSA = 20.4%); a moderate stability class characterized by elevated neuroticism and moderate levels on the other traits (SA = 48.5%; NSA = 57.3%); and a high stability class identified by low neuroticism and elevated levels on the other traits (SA = 17.5%; NSA = 20.4%). In the NSA group, those in the high stability class reported lower PTSD (d =0.87) and depression (d =0.97) symptoms post-treatment than those in the low stability class. No differences between baseline classes and post-treatment symptoms emerged in the SA group. Relative to those with NSA, individuals with a SA index trauma may present to treatment with less stable personality. While both groups responded to treatment,those with NSA and highly stable personality may experience additive benefits.
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  • Intervention Development for Women with Sexual Assault Histories Who Engage in Heavy Drinking: A Mixed Methods Approach​
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  • Natasha Gulati, Jessica Blayney, Anna Jaffe, Debra Kaysen, Cynthia Stappenbeck
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  • Sexual assault (SA) among college women is a widespread problem associated with myriad negative sequalae including heavy drinking. However, no interventions have been developed to target heavy drinking in this at-risk group nor do existing alcohol interventions address factors that contribute to heavy drinking, such as emotion regulation and distress tolerance. Incorporating participants into intervention development is an important precursor to intervention testing. Heavy drinking college women with SA histories (N = 21) participated in a pilot study to assess a brief web-based intervention comprised of alcohol reduction and regulatory (i.e., emotion regulation, distress tolerance) skills adapted from cognitive behavioral therapy and dialectical behavior therapy. Participants completed nine, 10-minute skill modules and provided feedback on each module. Content analysis resulted in qualitative themes related to intervention content, delivery, and improvements. Quantitative feedback indicated that participants were more familiar with some skills (e.g., alcohol reduction) than others (e.g., regulatory) and at the time of pilot testing, found the intervention more relevant for other women than themselves. Results support incorporating participant feedback early into web-based intervention development to improve engagement and satisfaction with the final product.
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  • Assessment of Sexual Victimization History among Treatment Seeking Veterans and Impact on Symptom Severity
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  • Vanessa Tirone, Jenna Bagley, Victoria Steigerwald, Dale Smith, Ashton Lofgreen, Kaitlin Thompson, Kelsey Petrey
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  • Identifying cases of Military Sexual Trauma (MST) is a critical step in linking survivors with services. This study will compare the accuracy of the MST screen to comprehensive assessments of sexual victimization and examine the impact of adulthood sexual victimization characteristics on symptom severity pre and post treatment. A total of 200 veterans (current n=70, 39% female) will be recruited from an intensive PTSD treatment program (ITP). Preliminary data suggest the screen is particularly poor at identifying several types of experiences among men, including harassment, nonconsensual contact, coercion, and rape, with sensitivity ranging from .22 to .33. Most participants endorse exposure to both assault and harassment as civilians and service members (41%) or no victimization (26%). Military harassment and assault characteristics are unrelated to pre-treatment PTSD and depression severity. Total number of civilian harassment types appears to be related to PTSD symptom severity, (r = .29, CI = -.01, .54) but is likely underpowered. Civilian assault severity is also positively correlated with PTSD severity (r = .34, CI = .04, .58). Neither civilian victimization type is related to depression severity. Analyses in the full sample will evaluate moderators of sensitivity and the association between assault characteristics and treatment outcomes.
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  • Treatment Beliefs and Utilization of Military Sexual Trauma Related Mental Health Care
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  • Christine Hahn, Caitlin McLean, Jessica Turchik, Rachel Kimerling
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  • We examined associations with classes of treatment beliefs to receiving mental health care related to military sexual trauma (MST) and days to access care among a national sample of male and female Veterans (N = 1,185). Participants screened positive for MST within the prior two months and reported a perceived need for MST-related mental health treatment. We conducted a latent class analysis and identified 4 classes of treatment beliefs related to MST-related mental health care: low barriers, with few negative beliefs; high barriers, with pervasive negative beliefs; and two additional classes characterized by stigma-related beliefs and negative perceptions of care. Generalized estimating equations with propensity score weighting, covariates (i.e., gender, positive mental health screens), and cluster by facility were conducted. Results indicated that Veterans had high access to treatment, with 80% of Veterans having a MST-related mental health visit within 30 days of screening positive for MST and over 90% having a mental visit within 180 days. Additional results on the association between treatment beliefs and treatment engagement will be presented, and implications on enhancing access and treatment engagement among Veterans who report perceived barriers to MST-related mental health care will be discussed.
10am – 11:15am Symposium: Prolonged Grief: From Population to Lab
  • Chair: Rita Rosner
  • Discussant: Mary-Frances O'Connor
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  • Prevalence of Prolonged Grief Disorder in a Respresentative Population-Based German Sample
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  • Rita Rosner, Hannah Comtesse, Anna Vogel, Bettina Doering
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  • Prolonged Grief Disorder (PGD) has been newly introduced to ICD-11 (WHO, 2018). PGD requires separation distress and accessory symptoms to a functionally impairing degree for at least six months after the loss. PGD is similar to its DSM-5 counterpart Persistent Complex Bereavement Disorder (PCBD). As yet, there is no prevalence data based on representative samples available. We used the Prolonged Grief-13 with 9 additional items as a questionnaire to cover all ICD-11 criteria as well as sociodemographic and loss-related variables. Out of 5393 contacted households 2531 participants aged 14-95 (47%) provided valid data. N= 947 participants reported a significant loss (prevalence loss: 37%). Average time since loss was 104 months. Diagnostic agreement for PGD and PCBD was κ= 0.68, but improved when the number of accessory symptoms for PGD was heightened to four. The conditional prevalence for PGD was 4.2% and for PCBD 2.5%. The population prevalence was 1.6% for PGD and 0.9% for PCBD. Correlates of PGD were lower income, a close relation to the deceased, and unexpectedness of the loss. Results indicate that PGD is prevalent in the population. Limitations were the overall small number of bereaved participants and the use of a questionnaire.
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  • Prolonged grief in refugees confronted with ambiguous or confirmed loss
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  • Hannah Comtesse, Rita Rosner
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  • People often disappear in the context of natural disasters, displacement, or armed conflicts. Such an ambiguous loss is accompanied by persistent uncertainty about the whereabouts of the disappeared person. This study investigated the psychopathological consequences of ambiguous loss in contrast to confirmed loss in refugees to Germany. We conducted semi-structured interviews with 81 refugees with disappeared (n= 34) and deceased relatives (n= 47), predominately from Syria, Iraq, and Iran (mean age: 33 years, 27% women). 26% of participants with disappeared relatives met the criteria for prolonged grief disorder (PGD) in contrast to 14% with deceased relatives. Compared to participants with deceased relatives, participants with disappeared loved ones displayed more severe symptoms of PGD (t= 2.62, p= .011) and depression (t= 2.10, p= .039). There were no group differences in post-traumatic stress symptoms or the number of traumatic experiences. Even after controlling for common correlates of PGD (cumulative trauma exposure, multiple loss, social support), ambiguous loss was associated with higher PGD symptom severity than confirmed loss (b= .31, p= .019). These results show a higher psychological burden after the loss of a significant other to disappearance, indicating that this could be a specific risk group.
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  • A Pull to Be Close: The Effect Of Oxytocin on Approach Behavior in Complicated Grief
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  • Brian Arizmendi, Mary-Frances
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  • Bereaved people experiencing complicated grief demonstrate approach or avoidance behaviors thought to interfere with integration of the loss, such as maladaptive focus on the deceased, or alternatively, avoiding reminders of the death. However, previous studies show conflicting results on behavioral measures of approach/avoidance bias and bereavement adaptation. Further, the mechanisms of these behaviors are unclear, although the oxytocinergic system may be implicated, given its known involvement in attachment and social salience. Widowed older adults (n = 37) completed an approach-avoidance task measuring implicit bias for personalized and generic grief-related stimuli. In a double-blinded, randomized, counterbalanced design, each participant attended both an intranasal oxytocin session and a placebo session. In the placebo session, participants lower in complicated grief demonstrated an implicit approach bias across all stimuli. Intranasal oxytocin increased average reaction times overall. Specifically, implicit avoidance bias decreased for photos of the deceased partner in the complicated grief group, but oxytocin did not significantly affect behavior in the non-complicated group. Findings emphasize the need for greater conceptual clarity in designing grief-relevant tasks and support the hypothesis that the oxytocin system may be implicated in complicated grief.
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  • Cumulative Midlife Loss is Associated with Carotid Atherosclerosis in African-American Women
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  • Tené Lewis, Miriam Van Dyke, Karen Matthews, Emma Barinas-Mitchell
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  • African-American women have elevated rates of cardiovascular disease compared to women of other race/ethnicities, and race/ethnicity-related stressors are hypothesized to play a role. We examined the association between an understudied race/ethnicity-related stressor, midlife loss (e.g. deaths of friends or family members) and a marker of cardiovascular risk, carotid intima media thickness (IMT) in 443 African-American, 744 White, 185 Chinese and 80 Hispanic women from the Study of Women’s Health Across the Nation (SWAN). Participants were queried about overall, and upsetting losses for each of 12 years, and IMT was assessed in Year 12. Race/ethnicity stratified regression models examined the association between cumulative upsetting losses and IMT, adjusting for relevant risk factors. A race/ethnicity interaction was observed (p=.04) and there was an association between ≥3 upsetting losses (versus none) and IMT among African-American (p<.008), but not White, Chinese, or Hispanic women. Thus, midlife loss may be one path by which race/ethnicity impacts cardiovascular risk for African-American women. SWAN is supported by NIH, through NIA, NINR and ORWH (Grants U01NR004061; U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495). This abstract is solely the responsibility of the authors, not official views of NIA, NINR, ORWH or NIH.
11:45am – 12:45pm SIG Meetings:
  • Complex Trauma SIG
  • Psychodynamic Research and Practice SIG
  • Research Methodology SIG
  • Lifestyle Interventions for Traumatic Stress (LIFTS) SIG
2pm – 3:15pm Symposium: Innovations in Research, Assessment, and Intervention with Youth and Families from Underserved Communities: Insights from the Field
  • Intergenerational Transmission of Maltreatment and Association with Posttraumatic Stress Symptoms and Aggression in Children: Findings from Parent-child Dyads in Burundi, Africa
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  • Ruby Charak, Joop de Jong, Lidewyde Berckmoes, Ria Reis
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  • Studies investigating intergenerational transmission of maltreatment (IGTM) are driven by samples from high-income countries whereas prior literature suggests that child maltreatment (CM) rates in low-and middle-income countries are higher (Charak et al., 2019). The present study aimed to examine IGTM, and association with posttraumatic stress symptoms and aggression in children in 227 parent-child dyads from Burundi, Africa. Furthermore, mechanistic factors in parents' and children were examined. Parents’ were above the age of 18 years and children were from 12-18 years (M/SD = 14.76/1.88; 57.7% female). Data were collected in the Spring of 2015 and in Kirundi language. The range of histories of CM in parents was 20.7%-69.5%, and for children, it was 21.1%-89.4%. Findings indicated support for IGTM in that histories of CM in parents’ was associated with CM in children (B = .19, p < .01); this association was significantly mediated by parent-child connectedness (β = .04, 95%CI: .01 to .10) and parents’ depression scores (β = .08, CI: .03 to .15). In children, posttraumatic stress symptoms mediated the association between CM and aggression (β = .07, 95%CI: .04 to .11). Continued efforts need to be made to make the region less volatile, in developing CM preventative strategies, and resources need to be directed towards making health care services accessible in low-income nations.
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  • Preliminary Validation of a Screening Instrument to Assess Risk for Commercial Sexual Exploitation Among Children Involved in the Child Welfare System
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  • Carlomagno Panlilio, Carly Dierkhising
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  • Accurate identification of children experiencing commercial sexual exploitation (CSE) remains largely unaddressed which decreases their access to much needed services. To test the psychometric properties of a potential instrument to identify CSE, analyses were done using the National Survey of Child and Adolescent Well-being (NSCAW). Risk indicator items were informed by question stems used in the SEY Risk Assessment tool employed by Child Welfare Caseworkers Canada. SEY items were mapped onto similar variables from NSCAW, resulting in an overlap of 26 items. A total risk score was calculated by adding across all risk indicators (α = 0.73). Total risk score significantly predicted the likelihood of CSE (β = 0.29, SE = 0.05, OR = 1.34, p < 0.001), measured by child being paid for sex as a proxy. Results of ROC analyses indicated that the instrument was good at discriminating CSE vs. non-CSE victimization (AUC = 0.85, p < 0.001; 95% CI = 0.77 to 0.92) and an optimal threshold of 6 points (Youden index J = 0.57) was found to hypothetically distinguish between those at risk vs. those who are not at risk of being victimized by CSE. Next steps are to pilot the SEY Risk Assessment with social workers working with those who have experienced CSE to assess the validity of the instrument in practice.
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  • Self-Attributed Moral Injury Mediates the Association Between Trauma Exposure and Offending Behavior Among Juvenile Justice-Involved Youth
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  • Mallory Kidwell, Patricia Kerig
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  • Research on the construct of moral injury (MI; Litz et al., 2009) has highlighted the harmful effects of perceived moral transgressions on those who encounter interpersonal trauma. MI may be particularly important for understanding the experiences of traumatized youth in the juvenile justice (JJ) system, who represent a large but understudied and underserved community. Theory suggests that MI during trauma exposure (TE) has the potential to disrupt ongoing moral development and foster negative behaviors in adolescence. However, a major limitation of the research to date is that the MI concept has rarely been studied among youth. To address this gap, this study investigated whether dimensions of MI statistically mediated the association between TE and offending in an ethnically diverse sample of JJ youth (N=98; 78% boys; Mage=16.0) who completed self-report measures of TE, MI, and offending. Total MI (indirect=.22, SE=.09, 95% CI[.04,.40]) and self-attributed forms of MI through commission with agency (indirect=.15, SE=.07, 95% CI[.02,.29]) and omission (indirect=.26, SE=.11, 95% CI[.07,.53]) statistically mediated the association between TE and offending in separate mediation models, whereas other-attributed forms of MI did not. These results suggest that self-attributed MI following TE may play a role in fostering delinquency and suggest insights for informing interventions.
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  • Improving Efforts to Engage Caregivers of Justice-involved Youth: Lessons Learned from a Pilot Intervention
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  • Carly Baetz, Felicia McNair, Sasha Stok, Ava Alexander
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  • It is now well-established that youth in juvenile justice (JJ) settings exhibit high rates of trauma exposure and trauma-related mental health disorders (McNair et al., 2019). To address these mental health problems, efforts have been made in recent years to increase the availability of trauma-specific interventions for youth in JJ settings. However, although research has found that caregiver involvement in youths’ treatment can improve outcomes (Dowell & Ogles, 2010), effective engagement of caregivers of justice-involved youth is often lacking (Walker et al., 2015). Secure JJ facilities in particular present unique challenges and barriers to engagement. As a result, little is known about the impact of caregiver involvement in the delivery of evidence-based treatment for youth exhibiting trauma-related symptoms in secure JJ settings. For the proposed presentation, the presenters will discuss the adaptation of an evidence-based intervention (TARGET) aimed at increasing caregiver knowledge and engagement in the delivery of trauma-informed services to youth in two secure juvenile detention settings in a large Northeastern city. The presentation will focus on the adaptation and implementation of the curriculum, as well as the evaluation process and lessons learned from the initial implementation.
2pm – 3:15pm Workshop: Aging Behind Prison Walls: Trauma Care, Human Rights, and Social Justice

Tina Maschi, Keith Morgen

Over the past two decades there has been a growing awareness of the rapid rise of the global rise of the aging prison population crisis as a human rights and social justice issue. This skyrocketing pattern of health and justice disparities that disproportionality affect racial/ethnic minorities, people with trauma histories, as well as other psychiatric/physical disorders, and suggests we have reached a critical omega point, in which the unprecedented number of older adults in prison, are poised to grow old and even die in prison. This workshop draws from over a decade of published empirical (quantitative and qualitative) research to address how clinicians within the prison system can address trauma in older adults.  The workshop explores how individual, family, and community coping and resilience can be leveraged by professionals to improve the provision of care and justice to help facilitate the well-being of older adults within the prison system. Specific clinical issues will include data-driven/case study reviews of the following: (1) The role of resilience and coping strengths within an older adult prison population and (2) How to integrate resilience/coping into trauma care within a system influencing access to autonomy, services, rights, and social justice.
2pm – 3:15pm Symposium: Forging Social Bonds Among Minority and Underserved Populations via Technology
  • Improving social functioning and PTSD through a web-based program: STAIR for rural women Veterans with military sexual trauma
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  • Marylene Cloitre, Christie Jackson, Adam Jacobs, Sarah Speicher, Rayan Shammet, Amber Amspoker, Terri Fletcher, Jan Lindsay
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  • PTSD is associated with erosion of social support and difficulty engaging with social networks. Women Veterans who live in rural areas and who feel stigmatized due to experiences of military sexual trauma (MST) have expressed concerns about low or negative social support. This presentation reviews the results of webSTAIR, a 10-session web-based version of Skills Training in Affective and Interpersonal Regulation which provides interventions to improve emotional and social well-being. Qualitative and quantitative data will be presented regarding webSTAIR as delivered in two different “blended models” combining web use and therapist coaching. Study 1 provided therapist guidance as the client engaged in the session in real time via a shared screen. Study 2 provided therapist coaching asynchronously after the client had completed every two sessions. Both delivery models provided substantial improvement in community engagement and interpersonal relationships (ES=0.66-1.02) as well as reductions in PTSD and depression (ES=0.90-1.50). Results for the asynchronous model were somewhat superior to the “real time” model. We consider the benefit of interpersonal interventions and mechanisms underlying their ability to resolve PTSD symptoms and explore the potential synergistic relationship between self-guided work and therapist coaching.
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  • Social Support Exchange through a Web-based ART Adherence Intervention for Sexual Minority Men
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  • Christina Sun, Thembekile Shato, Ashlynn Steinbaugh, Sharanya Pradeep, K Rivet Amico, Keith Horvath
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  • Sexual minority men not only have high rates of trauma exposure but also are disproportionately affected by HIV. Peer-to-peer social support is a recommend strategy for increasing sense of connection and may contribute to adherence to life-saving antiretroviral therapy (ART). This study qualitatively explores the dimensions of social support within a technology-delivered peer-to-peer intervention (Thrive With Me). Participants were encouraged to engage one another by posting and replying to messages with topics left to their discretion. A total of 1,751 messages were analyzed. Participants discussed and problem solved ART non-adherence by sharing examples of and seeking assistance for missing doses and providing informational social support. Within posts about healthcare, participants sought and provided emotional and/or informational support about mental health concerns, health issues not exclusive of HIV, and healthcare system navigation. HIV care social support messages included discussion about lab results, side effects, and changing medication regimens. Our study indicates that technology-based ART adherence interventions that leverage peer-to-peer interactivity is a promising approach to fostering social support, particularly emotional and informational. The results and implications of this work may benefit other communities that experience high levels of trauma.
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  • Effects of Internet-based CBT on Caregiver Burden and Social Relationships
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  • Evaldas Kazlauskas, Ieva Biliunaite, Austeja Dumarkaite, Inga Truskauskaite-Kuneviciene, Robbert Sanderman, Gerhard Andersson
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  • There is a growing number of individuals in society who are taking care of elderly, sick or traumatized family members globally. The aim of this pilot RCT study was to evaluate the effects of internet-based CBT intervention for caregivers, such as spouses. In total 63 participants were included in the study, 90,5% female, age M=52.2; SD=8.4, who all reported significant psychological difficulties associated with a burden of prolonged care of a seriously sick family member. Participants were randomly allocated to either an eight-week internet-delivered CBT intervention or waiting list group (31 and 32 participants, respectively). Outcome measures included caregiver burden (CBI), depression, anxiety, and perceived stress. Social relationships were measured using the 5-item subscale of the CBI measure. We found moderate between-group effect sizes (ES) of the internet-intervention for caregiver burden ES=0.63, on social relationship ES=0.63, depression ES=0.62, anxiety ES=0.68, and stress ES=1.01. The program led to a reduction in depression, anxiety, and stress. It also resulted in reductions in caregiver burden and improvement in social relationships. Participants reported greater social engagement after the intervention. The results indicate that technology-based interventions can provide an increase in a sense of social connection to others.
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  • Self-Esteem Predicts Increased Help-Seeking Following an Online Mental Health Stigma Reduction Intervention for Refugee Men
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  • Angela Nickerson, Yulisha Byrow, Tadgh McMahon, Natalie Mastrogiovanni
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  • There are over 70 million forcibly displaced persons internationally. Despite high rates of posttraumatic stress disorder, refugees (especially men) are relatively unlikely to seek help for psychological symptoms. We found that an online intervention targeting self-stigma (“Tell Your Story”) resulted in significant increases in help-seeking behaviours compared to a waitlist control group in refugee men (Nickerson et al., 2019, Psychological Medicine). The mechanisms underlying changes in help-seeking behavior amongst refugees, however, are poorly understood. In this study we aimed to investigate the longitudinal associations between shame, self-esteem, self-stigma related to help-seeking, help-seeking intentions and help-seeking behaviors in 85 refugee men who had received the TYS intervention. A cross-lagged path analysis revealed that greater self-esteem predicted subsequent reductions in shame (β = -0.17), and subsequent increases in help-seeking behavior (β = -0.17). These findings point to self-esteem as being a key intervention target for programs seeking to increase access and uptake of mental health treatment for refugees with PTSD.
2pm – 3:15pm Symposium: What does race have to do with it? Toward a comprehensive understanding of racial discrimination and stress-related health outcomes for African Americans
  • Interpersonal Trauma and Posttraumatic Stress Disorder Among Black Women: Does Racial Discrimination Matter?
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  • Sierra Carter, Yara Mekawi, Brittney Brown, Ana Martinez de Andino, Negar Fani, Vasiliki Michopoulos, Abigail Powers
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  • There is evidence that Black women’s more frequent, severe, and chronic posttraumatic stress disorder (PTSD) symptomatology compared to Whites cannot be explained by disparities in socioeconomic status or trauma exposure. One factor that may be important to consider is racial discrimination, which is associated with numerous negative mental health outcomes yet has not been studied in the context of interpersonal traumas for Black women. This presentation  will focus on filling the gap by examining the independent and interactive roles of racial discrimination and interpersonal trauma in predicting PTSD symptoms in a community sample of trauma-exposed, African American women (n = 292). Findings revealed that greater experiences of racial discrimination were associated with more severe PTSD symptoms overall (r = .34) and was related to all PTSD symptom clusters (r’s = .25 to .32). Furthermore, we found a significant interaction between experiences of racial discrimination and experiences of interpersonal trauma on overall PTSD symptom severity (F(3, 288) = 29.34, MSE = 133.51, p <.01) such that association between interpersonal trauma and PTSD symptom severity was stronger for participants who experienced more racial discrimination. These results suggest that racial discrimination experiences exacerbate the association between traumatic experiences and PTSD symptoms.
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  • Racism Undermines Self-Compassion and Predicts Distress in African Americans
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  • Natalie Watson-Singleton
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  • African Americans report more race-based stress than other ethnic groups in the United States. Unfortunately, racist experiences have been linked to African Americans’ health consequences, including poor mental health. Yet, the mediators in the racism-distress link warrant further investigation. The construct of self-compassion reflects compassionate and uncompassionate behavior: Self-Kindness versus Self-Judgment, Common Humanity versus Isolation, and Mindfulness versus Over-identification. Whereas compassionate behavior relates to wellbeing, uncompassionate behavior leads to psychopathology. However, no studies have examined the associations between racist experiences and uncompassionate behavior – how people treat themselves during times of suffering. Uncompassionate behavior may be activated during racist encounters and contribute to higher distress. Data from 130 African American college students were used to investigate if three types of uncompassionate behavior – self-judgment, isolation, and overidenfication – mediated the link between racist experiences and psychological distress. Racist experiences were associated with more self-judgment, isolation, and overidenfication, but only self-judgment emerged as a mediator. Thus, reducing uncompassionate behavior in the midst of race-based suffering may be one strategy to prevent adverse mental health in this population.
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  • Mechanisms underlying racial health inequities: The role of anger expression and social support in the link between lifetime adversity and epigenetic age acceleration among Black adults
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  • Brooke McKenna, Yara Mekawi, Seyma Katrinli, Abigail Powers, Jennifer Stevens, Alicia Smith, Vasiliki Michopoulos
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  • Experiencing racial discrimination increases risk for the development of various adverse mental health outcomes (e.g., posttraumatic stress). Although there is growing evidence linking racial discrimination to adverse physical outcomes (e.g., cardiovascular disease), little is known about associations with epigenetic age acceleration, a measure of biological age associated with early mortality. Even less is known about the mechanisms through which racial discrimination may be associated with accelerated aging, as well as how they might operate in the context of protective factors, such as social support. In a predominantly African American community sample (n = 275), the present study explored the conditional indirect effect of racial discrimination on accelerated aging through self-reported anger. We found that greater racial discrimination was indirectly associated with age acceleration through increased anger, but only for those with low social support (accounting for SES and trauma exposure), IE = .08, 95% CI [.03, .14]. These results suggest racial discrimination – particularly in the context of low social support – may elicit anger, which, in turn, may initiate epigenetic alterations. These findings lay the groundwork for longitudinal studies designed to delineate temporal processes involved in the association between racial discrimination and adverse health outcomes.
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  • Towards Healing Racial Trauma: Integrating Racial Socialization into Trauma Focused Cognitive Behavioral Therapy for African American Youth
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  • Isha Metzger
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  • African American youth are more likely than their peers from other racial and ethnic groups to experience traumatic racist and discriminatory encounters. Unfortunately, evidenced-based treatments for interpersonal trauma have been less effective among these youth likely due to these treatments not addressing racial trauma. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a gold-standard evidence-based treatment for youth and their caregivers shown to be highly effective in reducing trauma-related symptoms. Racial socialization is a protective process utilized by caregivers in which cultural pride is instilled and cognitive, emotional, and behavioral coping strategies are used to combat racial barriers and prepare African American youth to cope with racial stressors. In this presentation, we will discuss a systematic process used to follow the PRACTICE Model underlying TF-CBT (Psychoeducation, Relaxation, Affective Modulation, Cognitive Coping, Trauma Narrative, In-Vivo Gradual Exposure, Conjoint Parent-Child Sessions, and Enhancing Future Safety), and we will provide specific suggestions for including racial socialization in TF-CBT for African American youth. We will conclude by discussing implications for the research and clinical community to best promote healing from racial trauma for African American youth.
5pm – 6:15pm Symposium: Novel Approaches to Identify Biomarkers of Post-Traumatic Stress Disorder
  • PTSD Is Associated With Increased DNA Methylation Across Regions of SPATC1L and HLA-DPB1
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  • Seyma Katrinli, Yuanchao Zheng, Aarti Guatam, Rasha Hammamieh, Ruoting Yang, Varun Kilaru, Adriana Lori, Rebecca Hinrichs, Abigail Powers, Charles Gillespie
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  • Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder characterized by re-experiencing, avoidance and hyperarousal symptoms that cause negative alterations in cognition, mood and physiologic health. Recent evidence links changes in DNA methylation of CpG cites to PTSD. Here, we aimed to identify differentially methylated regions (DMRs) associated with PTSD. DNA methylation data profiled from blood samples using the MethylationEPIC BeadChip was used to perform a DMR analysis in 187 PTSD cases and 367 trauma-exposed controls from the Grady Trauma Project. DMRs were assessed with bumphunter. We identified 2 regions that are consistently differentially methylated in PTSD, after multiple test adjustment. These regions were in the promoter of SPATC1L (p=6.11 x 10-5) and in the gene body of HLA-DPB1 (p=2.47 x 10-4). The DMR in the promoter of SPATC1L was also replicated in an independent group of GTP samples (p=0.021), as well as significantly associated with PTSD in post-mortem brains samples from an independent cohort (p=0.001). Both DMRs included expression quantitative trait methylation (eQTM) and methylation quantitative trait locus (meQTL) CpGs. This study suggest that PTSD is associated with distinct methylation patterns in SPATC1L and HLA region, with possible functional implications.
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  • The Impact of Social Adversity and Stress-relevant DNA Methylation on Prospective Risk for Post-traumatic Stress: A Machine Learning Approach
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  • Agaz Wani, Allison Aiello, Karestan Koenen, Annie Qu, Derek Wildman, Monica Uddin
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  • Background: Social adversity, such as low socioeconomic position, discrimination, and isolation, has been associated with an increased risk of psychopathology.  Genomic variation at glucocorticoid receptor regulatory network (GRRN) genes has been associated with sensitivity to social adversity and risk for psychopathology. Here we test the Impact of Social Adversity and Stress-relevant DNA Methylation (DNAm) on Prospective Risk for Post-traumatic Stress. Methods: We performed longitudinal and cross-sectional analysis on DNA methylation derived from whole blood samples (n = 456) from 180 trauma-exposed civilians from the Detroit Neighbourhood Health Study. We applied a random forest (RF) machine learning model to assess the relationships among GRRN gene DNAm, trauma exposure, social adversity, and prospective risk for post-traumatic stress symptom severity (PTSS) as a response variable. Results: In the longitudinal analysis, the RF model predicted PTSS with an accuracy of 85.75%, mean absolute error (MAE) of 5.82, and root mean squared error (RMSE) of 7.33. In the cross-sectional analysis, the RF model showed an accuracy = 90.6%, MAE = 3.74, and RMSE = 5.14. The highly predictive CpGs were cg02562122: CDK5, cg18664856: AKT1, and cg16308790, cg11716803:  NFATC1. Conclusion: Results indicate a high predictive association between DNAm, trauma exposure, social adversity, and PTSS. 
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  • PTSD and Depression Symptoms Associated with Leukocyte Telomere Length
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  • Andrew Ratanatharathorn, Andrea Roberts, Lori Chibnik, Karmel Choi, Immaculata De Vivo, Yongjoo Kim, Laura Kubzansky, Kristen Nishimi, Eric Rimm, Jennifer Sumner, Karestan Koenen
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  • Lifetime trauma, posttraumatic stress disorder (PTSD), and depression are associated with physical health outcomes. One proposed mechanism by which PTSD and depression affect physical health is by shortening leukocyte telomere length (LTL), but given their comorbidity prior studies have not examined each disorder’s effect on LTL. We conducted an analysis of LTL in a subset of the Nurses Health Study II (N = 1,891). DNA was extracted from peripheral blood leukocytes and telomere repeat copy number to single gene copy number was determined by quantitative real-time PCR telomere assay. Linear regression models assessed the association between lifetime trauma, PTSD, and depression with telomere length after accounting for health behaviors and medical conditions previously associated with LTL. Trauma, PTSD, and depression were not associated with LTL individually, however participants with PTSD and depression had shorter LTL equivalent to being 9.1 years older  (95% CI: 1.8, 19.5 years). Further examination found that only participants with the highest number of PTSD symptoms had shorter LTL equivalent to 11.1 additional years of aging (95% CI: 2.6, 24.0 years). Sensitivity analyses examining inclusion criteria, childhood abuse, and misclassification did not account for the association. These results indicate that severe psychological distress may be associated with shorter LTL.
5pm – 6:15pm Symposium: Exploring Cyber IPV as a Potential Source of Trauma Exposure and Related Posttraumatic Reactions
  • Exploring the potential of trauma in the misuse of electronic communication: A meta-analysis of the cyber IPV and its comparison to face-to-face IPV
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  •  Ohad Gilbar, Ruby Charak, Oscar Trujillo, Jorge Cantu, Valeria Cavazos, Iris Lavi
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  • The use of technology as a medium of communication in the social milieu is a catalyst for studies on how technology impacts aggression in intimate relationships. Similar to face-to-face IPV (F2F-IPV), cyber IPV can potentially lead to traumatic reactions (Melander & Marganski, 2020), and hence, be considered a traumatic event. To date, no meta-analytic study has examined the phenomenon of cyber IPV; thus, the rates of types of cyber IPV are unclear. The aim of the current research was to use a meta‐analytic approach to address two study aims: (i) to examine the association between cyber IPV and F2F-IPV victimization and perpetration; and (ii) to investigate gender differences in the association between cyber IPV and F2F-IPV victimization and perpetration. Findings from 22 studies showed positive medium effect size for the correlation between cyber and F2F-IPV perpetration [standardized mean difference = .42 (95% Confidence Interval [0.34, 0.51]) and victimization [standardized mean difference = .47 (95% Confidence Interval [0.35, 0.60]). Furthermore, for both perpetration and victimization, the magnitude of the correlation was higher among men compared to women, indicating that cyber IPV is more likely to co-occur with F2F-IPV among men. Findings have implications for preventative strategies in that IPV interventions should also focus on alleviating instances of cyber IPV.
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  • Does Cyber IPA Increase Risk for Mental Health Problems Beyond That Attributable to In-Person IPA?
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  • Laura Watkins, Rosalita Benedicto, David DiLillo
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  • Intimate partner aggression (IPA) is an interpersonal trauma that has repeatedly been linked to problematic mental health outcomes, such as depression, anxiety, and stress. However, few studies have examined the relationship between cyber IPA victimization (i.e., IPA enacted through technology) and mental health problems. The current study addressed this limitation by examining if cyber IPA victimization, including psychological, sexual, and stalking cyber IPA, contributes to mental health problems above and beyond in-person IPA, including physical, psychological, and sexual IPA. The sample included 455 adults who were currently in a romantic relationship and recruited through Amazon’s MTurk system. A multivariate regression examined in-person and cyber IPA as unique predictors of depression, anxiety, and stress. Findings revealed that higher levels of in-person psychological victimization were related to greater reported levels of stress and depression. Greater cyber sexual IPA was related to higher levels of anxiety and depression beyond that attributable to in-person IPA. These associations were not moderated by gender. Findings revealed that cyber IPA, particularly sexual cyber IPA, has unique effects on mental health outcomes, suggesting the importance of assessing, preventing, and intervening with cyber IPA victimization.
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  • The Mediating role of Attitude towards Violence in the Association between Witnessing Parental Violence and Cyber Intimate Partner Perpetration in Hispanic Emerging Adults
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  • Ines Cano-Gonzalez, Ruby Charak, Ayleen Flores
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  • Little is known of the risk and mechanistic factors of cyber-perpetration among intimate partners (cyber IPV) in Hispanics. The intergenerational transmission of violence hypothesis (ITV; Widom, 1989) suggests that individuals who witness interparental violence (WPV) during childhood may learn to justify violence in turn increasing the probability of cyber IPV in adulthood. The present study tested the mediating role of attitude towards IPV in the association between WPV and cyber-IPV in men and women. Participants were 1,242 Hispanic emerging adults (nfemale=900) in the age range of 18-29 years (M/SDfemale=20.50/2.43; M/SDmale=20.43/2.26) attending a University in South Texas. Findings support the ITV hypothesis in that those with exposure to mother-to-father violence had attitudes condoning IPV that lead to cyberpsychological, cybersexual, and cyberstalking perpetration (women: βrange = .01 to .03 [95% CI = .002 to .01 to .032 to .052]; men: βrange = .01 to .02 [95% CI = .002 to .009 to .033 to .045]). Notably, father-to-mother WPV was not significantly associated with attitude towards IPV although it was associated with cyber IPV types. Findings will be discussed in the context of Hispanic culture wherein a family’s needs take precedence (i.e., familismo), and mothers’ are the primary caregiver and expected to play a key role in keeping a family together (i.e., marianismo).
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  • Examining Past-Month PTSD Symptoms as Moderators of the Proximal Associations among Daily Alcohol Use, Negative Affect, and Cyber Intimate Partner Violence Perpetration
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  • Meagan Brem, Ryan Shorey, Tara Cornelius, Gregory Stuart
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  • According to I3 theory (Finkel & Eckhardt, 2013), distal impelling factors (e.g., PTSD symptoms) interact with proximal risk factors to facilitate violence. We tested the hypothesis that, controlling for daily drug use (DU), (1) the odds of cyber intimate partner violence (CIPV) perpetration increase as daily alcohol use (AU) increases, but only when negative affect (NA) is present, and (2) past-month PTSD symptoms strengthen these associations. We explored sex as a moderator. Undergraduates (N = 236) reported their past-month PTSD symptoms (PCL-5; Weathers et al., 2013) followed by daily assessments of AU (number of drinks consumed before the first CIPV event), DU (yes/no), NA (six items; Watson et al., 1988), and CIPV (six yes/no items) for 60 days. Multilevel modeling revealed the AU x NA x PTSD interaction was not significant and did not vary by sex. The odds of CIPV on a DU day were greater than the odds of CIPV on a non-DU day, but only for men with low PTSD symptom levels. Main effects revealed that each one-point increase in PTSD symptoms associated with a 117.30% increase in CIPV odds. Each one-point increase in NA associated with a 101.92% increase in CIPV odds. Each drink consumed associated with a 172.85% increase in odds of subsequent CIPV for men, but not women. Past-month PTSD symptoms may pose risks for CIPV, even after accounting for proximal risk factors.
5pm – 6:15pm Symposium: News and Social Media in the Wake of Mass Violence and School Shootings
  • Chair: Ariel Durosky
  • Discussant: Elana Newman
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  • Local and National Coverage of School Shootings: A comparison between Columbine and Parkland
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  • Ariel Durosky, Elana Newman
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  • Since the Columbine shootings, best practices for reporting mass trauma events have been recommended as such coverage can impact public perceptions. For example, the importance of minimizing the use of perpetrators’ names has been suggested to reduce incidents of copycats. Similarly, increasing the focus on victims and survivors, is recommended to emphasize the importance of victims’ lives. To investigate whether coverage of school shootings has indeed changed over time, a content analysis of a total of 642 local and national print articles following Columbine and Parkland shootings was conducted. More recent coverage was expected to follow best practice recommendations. Chi-square analyses indicated overall, Parkland articles were more likely to reference perpetrators by name, X2 (1, N = 642) = 4.94, p < .05, and more likely to reference victims by name, X2 (1, N = 642) = 56.74, p < .001, when compared to Columbine articles. Findings indicate reporting has changed over time; however, some changes may not align with suggested practices. Other best practice analyses and implications will be presented, including framing of gun control, references to firearms used, providing mental health resources, and discussion of perpetrators’ mental health.
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  • The Effects of Traditional Media and Social Media on Those Impacted by Mass Violence
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  • Melissa Brymer
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  • With the evolution of mass communication comes the rapid and continuous sharing of information through a diverse assortment of traditional and social media platforms. The benefits and consequences of how mass communication affects individuals in the aftermath of mass violence is an important area of investigation. This project conducted 200 interviews with individuals affected by 10 different mass violent events that occurred around the United States. Interview participants included victims, family members of victims, first responders, mental health/health providers, local public officials, and journalists who were directly impacted by these events. The interviews explored their perceptions of the media and how media and social media influenced their course of recovery. All interviews were transcribed and coded for text segments using Atlas ti software. This presentation will describe and discuss the main themes reported by the participants, including how media both positively and negatively affected their initial and ongoing responses, their perceptions of social connectedness, and their appraisal of ongoing and future threats. Implications of the findings for community recovery programs after mass violence will be discussed.
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  • Comparing Media Attention and Emotion on Twitter Following the Stoneman Douglas High School Shooting
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  • Sean Goldy, Nickolas Jones, Melissa Brymer, Roxane Cohen Silver
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  • School shootings can have far-reaching emotional impacts, as can exposure to media coverage of such events. However, research has not yet explored how the intensity and duration of emotional responses to mass violence might vary over distance and parallel media attention over time. We investigated emotional responses to the 2018 Stoneman Douglas High School shooting in Parkland, Florida using Twitter data from users across 4 major metropolitan areas in Florida, and compared these responses to media coverage of the event. Over 5 million tweets from over 107,351 users who tweeted within a 12-week window surrounding the shooting were obtained. Negative emotion increased more than positive emotion decreased on the day of the shooting and remained elevated for 13 days. Comparing trajectories of specific negative emotions, we found that sadness increased the most (and more than anger and anxiety). Expressions of sadness were less pronounced in communities that were further from the school. Likewise, sadness remained elevated for shorter durations as distance from the shooting increased. Examining event-related tweets from local Florida news stations, we found that these emotional trajectories also paralleled news coverage of the shooting. Our findings suggest that expressions of anguish in the wake of a collective trauma follow the extent of media coverage in areas near the event.
5pm – 6:15pm Workshop: Implementing Cognitive Processing Therapy with Patients with Borderline Personality Disorder

Sarah Voss Horrell

Borderline Personality Disorder (BPD) is highly comorbid with PTSD, with rates ranging from 25% to 56% in BPD samples (Shah & Zanarini, 2018). Positive outcomes following DBT are less robust in individuals with comorbid PTSD (Barnicot & Priebe, 2013), and having PTSD contributes significantly to risk for future suicide attempts in BPD patients (Wedig et al., 2012; Zanarini et al. 2006). Cognitive processing therapy (CPT), an effective PTSD treatment (VA/DOD, 2017), is rarely used to treat PTSD in this population. In contrast to provider concerns that engaging in PTSD treatment will exacerbate symptoms, studies examining a combined approach to treatment of BPD and PTSD have shown promise. Harned and colleagues (2012; 2014; 2018) found that individuals with comorbid PTSD/BPD who received DBT in combination with prolonged exposure (PE) showed better outcomes than those receiving DBT alone. Since patient choice is potentially an important factor in treatment retention for PTSD (Le, Doctor, Zoellner, & Feeny, 2018), alternative treatment options are desired.  In this workshop, historical outcome data will be presented for individuals who completed CPT following DBT. Strategies for conducting CPT with comorbid PTSD/BPD individuals will be demonstrated, including managing life threatening and therapy-interfering behaviors, and addressing emotional invalidation.
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Tuesday, November 10

10am – 11:15am Keynote Speaker: Tim Dalgleish, PhD
11:45am – 12:45pm SIG Meetings:
  • Sleep Disorders and Traumatic Stress
  • Traumatic Loss and Grief SIG
  • Child Trauma SIG
  • Trauma, Health and Primary Care SIG
2pm – 3:15pm

Invited Panel: Responding to Public Health Emergencies: Mental Health Considerations During the Coronavirus Disease '19 (COVID-19) Pandemic—United States, 2020

 

Moderator: Judy Bass
Panelists: Robyn Cree, PhD; Rebecca Leeb, PhD; Craig W. Thomas PhD, MS

2pm – 3:15pm Panel: Innovative prevention practices after trauma: Increasing and expanding mental health resources to reach more and improve outcomes

Robin Gurwitch, Melissa Brymer, Steven Berkowitz, Brooks Keeshin, Marleen Wong

With more disasters and other traumatic events happening around the world, there remain many individuals, particularly in underserved communities, who are not reached by mental health services. Although there has been an increase in evidence-based treatments, these are often extremely challenging for dissemination and implementation due to barriers such as accessibility, complexity, trained providers, and cost. Fortunately, trauma-informed, evidence-informed, and evidence-based prevention services can begin to fit this need. By providing training in mental health prevention services to existing health and mental health professionals and expanding training to include paraprofessionals and lay people in these prevention services, more high-risk individuals and families can be reached. Prevention efforts are one important practice intended to mitigate adverse outcomes after trauma exposure. This highly interactive panel will discuss several prevention services, which can be used in a variety of settings and with multiple populations as well as targeted prevention services delivered within existing frameworks such as hospitals and schools. The importance of ethnic and cultural considerations will be included in the discussion.
2pm – 3:15pm Symposium: Early transdiagnostic biomarkers of future mental health in the AURORA study
  • Association Between Peritraumatic Psychological Factors and Experimental Pain Sensitivity in the AURORA Study
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  • Jennifer Pierce, Nicole Short, Steven Harte, Yinyao Ji, Xinming An, Kerry Ressler, Jennifer Stevens, Tanja Jovanovic, Lauren Lebois, Sanne van Rooij
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  • Experimental paradigms to assess pain sensitivity (i.e., quantitative sensory testing [QST]) may illuminate mechanisms of the association between trauma and pain. This study assessed associations between peritraumatic psychological factors and QST outcomes. Participants completed an emergency department assessment following trauma, including self-report surveys of peritraumatic distress and dissociation. At two-weeks, a subset of participants (n=425) completed QST including cold pressor test (CPT), and assessments of pressure pain threshold (PPT) and conditioned pain modulation (CPM). Correlations between QST outcomes and baseline symptoms were assessed. Higher levels of peritraumatic distress were associated with lower PPT (r = -.13, p = .014), less efficient CPM (r = -.16, p = .004), and lower CPT pain tolerance (r = -.1, p = .048). Higher peritraumatic distress and dissociation were associated with more intense pain aftersensations following the CPT (r = .22, p < .001; r = .15, p = .005, respectively). The present findings suggest that peritraumatic distress and dissociation are associated, albeit weakly, with higher pain sensitivity and lower endogenous pain inhibition. QST may help identify mechanisms that underlie the association between pain and trauma.
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  • Fear-Potentiated Startle in the Acute Aftermath of Trauma and Associations with Symptom Trajectories
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  • Tanja Jovanovic, Antonia Seligowski, Samuel McLean, Kerry Ressler
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  • Fear conditioning is a useful translational tool for studying fear acquisition and extinction in the context of PTSD. Previous work has shown that PTSD is associated with the impaired ability to inhibit fear responses to conditioned safety signals and deficient fear extinction. The current study aimed to examine whether these biomarkers would predict symptom trajectories. Participants were recruited from emergency departments as part of the multi-site AURORA study, and self-reported symptoms over 8 weeks were analyzed using latent growth modeling. At 2 weeks post trauma, a laboratory fear conditioning and extinction session was conducted with fear-potentiated startle measured via electromyogram recordings of the eyeblink muscle contraction. Preliminary results in N=123 showed successful fear conditioning to the threat cue (F=54.47, p<0.0001), and on average, decreased FPS to threat cue with extinction (F=67.27, p<0001). However, individual differences in fear extinction were associated with future symptom trajectories. Individuals who had poorer extinction had a higher probability of being in the non-recovering trajectory, F=7.57, p=0.007, and those who were classified into the recovery trajectory demonstrated significantly better extinction, p=0.028. These data suggest that dysregulated fear responses measured using laboratory tasks are predictive of future negative outcomes.
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  • Resting state connectivity assessed in the acute aftermath of trauma predicts future posttraumatic and depressive symptoms
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  • Nathaniel Harnett, Sanne van Rooij, Timothy Ely, Lauren Lebois, Vishnu Murty, Tanja Jovanovic, Samuel McLean, Kerry Ressler
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  • Despite the high lifetime prevalence (50-90%) of trauma exposure, there is significant individual variability in the development of long-term psychiatric outcomes such as posttraumatic stress disorder (PTSD) and depression. Identifying neural signatures of PTSD susceptibility may be useful for developing early detection tools to optimize acute clinical interventions. To that end, we utilized functional magnetic resonance imaging to investigate resting-state networks (RSNs) of recently traumatized (within 2-weeks) individuals (n = 109) as part of the ongoing AURORA study. We assessed the relationship between 3-month PTSD symptom severity and five acutely measured a priori RSNs: the default mode network (DMN), salience network, left and right central executive network, and an arousal network (AN) that comprised the amygdala, hippocampus, and brainstem. DMN connectivity to the inferior temporal gyrus (ITG) was positively related to future PTSD symptoms while AN connectivity to the dorsolateral prefrontal cortex was inversely related to future PTSD symptoms (all p < 0.001, corrected). These patterns were also associated with 3-month depression symptoms. The present findings suggest assessments of RSNs in the acute aftermath of trauma may capture susceptibility to general posttraumatic dysfunction and may be a promising neural marker of debilitating posttraumatic outcomes.
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  • Functional MRI Predictors of Posttrauma Psychiatric Symptom Trajectories
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  • Jennifer Stevens, Nathaniel Harnett, Lauren Lebois, Sanne van Rooij, Timothy Ely, Vishnu Murty, Tanja Jovanovic, Samuel McLean, Kerry Ressler
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  • Only a minority of trauma survivors have impairing mental health symptoms over the long term. Biomarkers that predict risk for chronic symptoms are of very high value to the field. We sought to identify early post-trauma “biotypes” based solely on neuroimaging features, and to characterize risk for future psychiatric symptoms for each biotype. In an initial cohort of n=69 scanned 2 weeks post-trauma, we conducted an unsupervised clustering analysis of fMRI activation across 3 tasks (Threat, Reward, Inhibition), within brain regions previously linked with longitudinal stress vulnerability. A best-fit 4-cluster solution identified profiles of 1) high reactivity to threat and reward, 2) low reward reactivity, 3) low engagement across all tasks, and 4) high reward responsivity. Critically, the same profiles emerged in a replication cohort of n=77, uninformed by the first analysis. Cluster 1 showed the highest trajectories of future PTSD and substance use emerging over the next 3 months post-trauma, p=.03. Clusters 3 and 4 appeared resilient. Future analyses will incorporate additional biomarkers such as inflammatory markers at the time of trauma and on the day of MRI (2 weeks post-trauma), and outcomes up to 12 months post-trauma. Findings have transdiagnostic relevance for the understanding of how psychiatric disorders emerge following a major stressor.
2pm – 3:15pm Panel: Psychedelic-Assisted Psychotherapy for PTSD: Theory, Technique and Context

Harold Kudler, Robert Koffman, Mark Bates, Rachel Yehuda

Psychedelics have long been employed by traditional healers to promote physical and mental recovery. The US Food and Drug Administration recently granted MDMA and psilocybin Breakthrough Therapy designation to accelerate study of their efficacy in psychiatric disorders while ketamine clinics multiply apace. Less obvious is the role which psychotherapy plays in the application and effectiveness of these compounds. This panel, designed to engage researchers, clinicians and policy makers, features Robert Koffman, M.D., CAPT, USN (Ret), first Senior Consultant for Integrative Medicine & Behavioral Health at the National Intrepid Center of Excellence, Mark Bates, PhD, LtCol, USAF (Ret), former branch chief, Psychological Health Promotion, DoD Psychological Health Center of Excellence, Rachel Yehuda, PhD, Director, Center for Psychedelic Psychotherapy and Trauma at the Icahn School of Medicine, Mount Sinai, and Harold Kudler, M.D., past Mental Health policy lead, U.S. Department of Veterans Affairs, who will review the pharmacological and psychological evidence base for psychedelic-assisted psychotherapy for PTSD, describe its clinical application and consider the role altered states (sweat lodges, Mesmerism, hypnosis, sodium amytal and psychedelics) have played over the centuries in clinical and cultural efforts to transcend psychological trauma.
2pm – 3:15pm Symposium: Mechanisms underlying the psychological effects of refugee trauma
  • Chair: Belinda Liddell
  • Discussant: Ulrich Schnyder
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  • The Impact of Pre-migration Trauma and Post-migration Stress on Refugee Adaptation: Investigating the Role of Emotion Regulation
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  • Yulisha Byrow, Belinda Liddell, Meaghan O'Donnell, Tadgh McMahon, Greg Benson, Vicki Mau, Angela Nickerson
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  • Introduction. There is an emerging body of research documenting the negative effects of pre-migration trauma and post-migration on emotion regulation in refugee youth and adults. To date, there are no studies that have examined the effects of adversity (pre-migration trauma and post-migration stress) on key indicators of adaptation in the resettlement environment. In an Australian based sample of 144 young adult refugees (18-24 years old), we investigated the impact of pre-migration trauma and post-migration stress on social engagement, mental health and functional impairment via emotion regulation. Method. Path analysis was conducted to examine direct and indirect associations between pre-migration trauma and post-migration stress on social engagement, mental health, and functional impairment via emotion regulation. Results. Findings showed direct relationships between trauma exposure and increased functional impairment, greater severity of PTSD, and higher social engagement. Post-migration stress was related with increased functional impairment and greater severity of PTSD, via emotion regulation difficulties. Discussion. These findings highlight emotion regulation as a key mechanism by which post-migration stressors impact functional impairment and mental health outcomes for young refugees resettling in Australia.
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  • Investigating the Relationship between Distinctive Patterns of Spontaneous Emotion Regulation, Negative Affect and Psychopathology among Traumatised Refugees: A Latent Profile Analysis
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  • Philippa Specker, Angela Nickerson
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  • Introduction: Although refugees are often exposed to traumatic reminders, little is known about the emotion regulation (ER) strategies that they employ under stress, nor how effective different approaches may be at reducing distress. This was the first study to identify individual differences in patterns of spontaneous ER among refugees, and explore their unique associations with negative affect and PTSD. Method: Spontaneous reappraisal and suppression was measured among 82 refugees following a 5-minute exposure to trauma-salient images. Negative affect was indexed at pre and post. Latent Profile Analysis (LPA) was conducted to identify distinct profiles of participants based on differing levels of ER use. Results: LPA revealed two distinct profiles: a High Variability profile (37%; high suppression/moderate-high reappraisal) and a Low Variability profile (63%; low suppression/moderate reappraisal). The Low Variability profile was associated with increased negative affect (p<.001) and greater PTSD symptoms (p=.044) compared to the High Variability profile. Discussion: Our findings suggest that a more variable ER approach following stressor exposure results in lower distress and is associated with less PTSD. Better understanding the links between ER, negative affect and psychopathology has important implications for the development of effective treatments for refugees.
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  • Prolonged Grief Disorder in Treatment-Seeking Refugees—Association with Self-Efficacy and Emotion Regulation
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  • Naser Morina, Oriane Lacour, Julia Spaaij, Angela Nickerson, Ulrich Schnyder, Roland von Känel, Richard Bryant, Matthis Schick
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  • Background: While Prolonged Grief Disorder (PGD) among refugees has recently started to attract scientific attention, knowledge regarding associated psychological factors remains limited. Given the multifactorial context of persecution, trauma, displacement and exile-related difficulties, obtaining a better understanding of PGD in refugees is crucial because PGD may affect psychological well-being, level of functioning and social integration. Methods: In a sample of treatment-seeking refugees in Switzerland (N=88), we examined the relationship between severity of PGD and potentially associated factors such as emotion regulation, perceived self-efficacy, as well as potentially traumatic events and post-migration living difficulties. Results: In a regression analysis, difficulties in emotion regulation and lower perceived self-efficacy were associated with greater severity of PGD, while post-migration living difficulties and potentially traumatic events did not emerge as significant factors. Conclusion: These findings suggest that emotion regulation and perceived self-efficacy are associated with PGD in treatment-seeking refugees, and are thus potential targets for treatment interventions.
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  • Mechanisms Underlying the Impact of Family Separation on the Mental Health of Resettled Refugees
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  • Belinda Liddell, Yulisha Byrow, Meaghan O'Donnell, Vicki Mau, Nicole Batch, Tadgh McMahon, Greg Benson, Richard Bryant, Angela Nickerson
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  • Forcibly displaced people commonly experience prolonged separation from family, with adverse effects on post-traumatic stress symptoms, but there is limited research on the underlying mechanisms causing these negative consequences. In this study, a large convenience sample (N = 1085) of resettled refugees in Australia completed an online battery of mental health, psychological and social measures. The group separated from all their family (23.3%) reported higher PTE exposure and post-migration stress compared to non-separated refugees, with family separation predicting elevated PTSD, depression but not disability symptoms, even after accounting for sex, age and PTE exposure. Multi-group path analyses showed that in the separated group, high levels of collectivistic self-identity predicted increased PTSD, depression and disability via perceived social-related stressors (ie loneliness, isolation), whereas in the non-separated group, collectivistic self-identity predicted elevated depression via perceived economic-related stressors (ie unemployment). The findings support previous observations of the negative impact of family separation on PTSD and depression symptoms, but extend this by demonstrating its effect may be modulated by the quality of the settlement environment and cultural factors that dictate how much self-identity is interconnected with family and others.
5pm – 6:15pm Symposium: Understanding Risks and Protective Factors for Intergenerational Trauma: Findings from Innovative Interventions with Mothers and Babies
  • Adverse Childhood Experiences, Clinical Diagnoses, and Maternal Functioning Among Perinatal Women with Moderate-to-Severe Psychiatric Illness
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  • Nora Erickson, Helen Kim, Jessica Kuendig
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  • Introduction: The Mother-Baby Day Hospital (MBDH) is a partial hospitalization program for perinatal women. As a two-generation, trauma-informed program in an urban safety net hospital, MBDH addresses maternal well-being and parenting in the context of individual, psychosocial, and systemic risks. This study explores patients’ adverse childhood experiences (ACEs) in relation to mental health diagnoses and symptoms. Methods:  MBDH patients who graduated from April 2013-September 2019 completed questionnaires. ACE scores were analyzed in relation to clinical diagnoses and self-reported depression, anxiety, postpartum bonding, and maternal functioning. Results: Within the sample (N=366), 195 completed the ACE questionnaire (M=3.85, SD=2.83). For each one-unit increase in ACE score, the odds of having a trauma-related diagnosis increased by 1.16 (p=.01). Controlling for pre-treatment scores, post-treatment maternal functioning differed based on ACE category (F(2, 153)=5.80, p=.004); individuals reporting 0 ACEs had significantly higher post-treatment maternal functioning compared to those with 1-3 ACEs and ≥ 4 ACEs. Conclusion: Clinical assessment of ACEs can aid in understanding trauma symptoms and perceptions of maternal functioning. In high-risk groups, interrelationships between childhood adversity, psychological symptoms, and parenting capacity may have treatment implications.
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  • Attachment Insecurity Moderates the Link between Maternal Childhood Neglect and Postpartum Bonding to the Infant
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  • Megan Julian, Nicola Bernard, Jonathan Handelzalts, Rena Menke, Maria Muzik
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  • Understanding factors that buffer the intergenerational transmission of risk is critical to mitigating the impact of trauma on future generations. Mothers with a history of childhood adversity, such as neglect, are at increased risk of parenting difficulties in adulthood; but some mothers with a history of neglect are resilient. Attachment relationships in adulthood may provide mothers with additional support and an alternative model for caregiving. Mothers’ adult attachment relationships were examined as a moderator between childhood experiences of neglect and bonding with one’s infant in adulthood. 88 postpartum women seeking outpatient psychiatric care completed self-report measures on adverse childhood experiences, adult attachment, mental health symptoms, and bonding. Over and above the effects of maternal mental health on bonding, childhood neglect predicted bonding difficulties only in mothers with more insecure attachment styles (β = .35; semipartial r = .23). These results suggest adult attachment as a potential point of intervention to reduce the intergenerational transmission of risk. Improving the quality of adult attachment relationships may provide mothers with an alternative model for caregiving relationships, reducing the likelihood that they may re-enact childhood experiences of emotionally disengaged parenting with their own children.
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  • Infant Mental Health Home Visiting Mitigates Impact of Maternal Adverse Childhood Experiences on Toddler Language Competence: A Randomized Controlled Trial
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  • Jessica Riggs, Katherine Rosenblum, Maria Muzik, Sarah Freeman, Alissa Huth-Bocks, Nora Erickson

  • This study examined the impact of maternal childhood adversity (ACEs) on subsequent child language competence. Participation in Infant Mental Health Home Visiting (IMH-HV) treatment was expected to mitigate this association.

    Data come from a community sample of 62 families who participated in an RCT testing the efficacy of IMH-HV. Parents were eligible based on child age (< 24 months at enrollment) and endorsement of socio-demographic risks. Visits and intervention took place in participants’ homes. ACEs were collected at baseline; child language screening was conducted at 12 months by evaluators blind to condition. Participants randomized to treatment received IMH-HV; randomized to control condition received treatment as usual.

    Mother age ranged from 19- to 44-years old (M=31.91; SD=5.68); child age ranged from prenatal to 26 months (M=12.06; SD=6.62). Maternal ACE score (M=3.64; SD=2.41) predicted worse child language (t(5,55)= -3.27, p=.002). This effect was moderated by treatment (t(6,54)=1.73, p=.04), indicating no association between maternal ACEs and child language for those receiving IMH-HV.

    Results show that the effects of parent ACEs on early childhood language outcomes may be buffered by participation in IMH-HV. These findings provide support for an in-home, relationally-based treatment that is especially effective for socio-demographically vulnerable families.
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  • PTSD Symptoms Mediate the Link between Parental ACEs and Child Behavioral and Social-Emotional Problems
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  • Julie Ribaudo, Jamie Lawler, Jennie Jester, Maria Muzik, Katherine Rosenblum
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  • Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, are at increased risk of parenting difficulties in adulthood, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression and depression. Little work has been done to understand the mechanism of transmission of exposure to childhood trauma to social-emotional difficulties in children. This study examines the association between high ACEs > 4, symptoms of PTSD (PCL-5) and evidence of child social-emotional difficulties, measured by the Brief Infant Toddler Social Emotional Assessment (BITSEA). Data come from a community sample of 58 families who participated in all waves of a randomized control trial testing the efficacy of an infant mental health home visiting treatment model. Families were eligible based on child age (< 24 months at enrollment) and endorsement of socio-demographic risks. Mediational analyses in PROCESS (Hayes, 2018) revealed a significant mediation model (F(2,55)= 9.2, p < .001), with an indirect effect of parental ACEs on BITSEA problem score through parental PTSD symptoms (β= .16, bootstrapped 95% CI=.03-.30). A higher number of adverse child experiences predicted more PTSD symptoms, which in turn predicted more child problems.
5pm – 6:15pm Symposium: Understanding Lifetime Trauma Profiles, Multidimensional Posttraumatic Sequelae, and Treatment Implications from Large Cohort US Emergency Departments samples
  • The Role of PTSD and Depressive Symptoms in Changing Patterns of Substance Use Post-trauma
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  • Negar Fani, Kerry Ressler
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  • According to self-medication hypotheses, substance use disorders may develop as a consequence of post-traumatic stress. However, there has been little prospective research investigating how the emergence of PTSD and depressive symptoms are related to changes in substance use (SU) patterns after trauma. We used data from a multi-site prospective trauma study (AURORA) to examine how changes in PTSD and depressive symptoms over time influence changes in SU and alcohol use after trauma. Approximately 800 men and women recruited from the emergency department (ED) were given assessments of alcohol and SU, PTSD and depression at the time of ED visit and at 8 weeks post-trauma. Results indicated that overall, increased PTSD symptoms were associated with increased marijuana use over time in men only (r=.12, p=.04). Increases in depressive symptoms corresponded with increased alcohol use frequency over time (r=.12, p=0.000004). Changes in alcohol use were positively correlated with specific PTSD symptom clusters: negative mood and cognitions (r=.1, p=.007), intrusive symptoms (r=.1, p=.04), and anhedonic symptoms (r=.1, p=.03). These findings suggest that that the development of particular post-traumatic sequelae may influence patterns of SU in recently-traumatized individuals. We will discuss factors that may increase risk for SU disorder development in the aftermath of trauma.
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  • Associations Between Latent Classes of Lifetime Trauma with Traditional Diagnoses and Multidimensional Psychiatric Outcomes in a Multisite US Emergency Department Cohort
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  • Archana Basu, Aaron Sarvet, Xinming An, Samuel McLean, Karestan Koenen
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  • Studies examining latent classes of trauma histories in the US general population and in outpatient adults report a 3 or 4 class solution, highlighting the deleterious impact of childhood trauma (O’Donnell et al., 2017). Less is known about individuals presenting for post-trauma evaluations in emergency departments who maybe at a higher risk for psychiatric morbidity. In data from the Advancing Understanding of RecOvery afteR traumA (AURORA) study (n=1600), latent class analyses based on lifetime trauma experience (using the Life Events Checklist for DSM-5) indicated that a 3-class solution best fit the data. Classes were characterized as: Class 1, polytrauma and sexual trauma; Class 2, motor vehicle accidents and physical assault; Class 3, motor vehicle accidents. Regression analyses found that Class 1, relative to Classes 2 and 3, was consistently associated with higher odds for PTSD (OR=4.07, 95%CI = 2.54, 6.52), anxiety (OR=3.48, 95%CI = 2.64, 4.33), depression (OR=3.7, 95%CI = 2.41, 5.68), and dissociation (OR=3.0, 95%CI = 1.91, 4.7), adjusting for sociodemographics. Classes 2 and 3 only differed for PTSD (OR=1.81, 95%CI = 1.28, 2.56). Race-stratified analyses, and associations with 10 RDoC-related constructs (Pain, Loss, Sleep Continuity, Nightmare, Somatic Symptoms, Concentration/ Thinking/Fatigue, Avoidance, Reexperience, Anxious, and Hyperarousal) will be presented).
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  • Patient-Centered Classifications of Mental and Physical Health Symptoms after Sexual Assault: Results from a Large Prospective Study
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  • Nicole Short, Xinming An, Yinyao Ji, Andrew Tungate, Samuel McLean 
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  • Pain, somatic, and mental health symptoms (posttraumatic stress, depression, anxiety) after trauma are highly comorbid, yet traditional diagnostic systems focus only on one of these outcomes, examining a fragment of the survivor experience. We categorized women sexual assault (SA) survivors according to mental health, somatic, and pain symptom profiles. As part of a large study of women presenting to emergency care within 72 hours of SA, 662 participants completed self-report surveys of pain, posttraumatic stress, depression, anxiety, and somatic symptoms. Latent variables for symptom types were developed and K-means clustering was used to identify multidimensional outcome groups. The five latent cluster model provided the best fit. Clusters were qualitatively identified as: high mental health symptom severity with high vs. low physical symptoms; moderate mental health symptom severity with high vs. low physical symptoms; and mild mental health symptoms but higher levels of physical symptoms. Detailed tables and figures regarding multidimensional groups will be presented. Holistic, patient-centered phenotypes of survivors may be possible by incorporating the spectrum of mental and physical health symptoms experienced. Future studies should evaluate whether these phenotypes have advantages over traditional phenotypes in predicting course of symptoms or response to treatment.
5pm – 6:15pm Panel: Supporting Children, Families and Providers Coping with the Coronavirus Pandemic: Adapting to Community and Family Needs Including those Related to Young Children and Children with Disabilities 

Juiet Vogel, Joy Osofsky, Gerard Costa, Howard Osofsky, Peter D'Amico, Sarah Bledsoe

This panel discussion addresses activities and lessons learned in meeting needs of children and families, and the multi-sector professions involved with them, as they dealt with the impact of the coronavirus pandemic. Dr. Joy Osofsky will discuss work with three regional coalitions in the US (Gulf Coast, Northeast, Midwest) through the Terrorism and Disaster Coalition for Child and Family Resilience, a National Child Traumatic Stress Network (NCTSN) Center, and will bring experience from work after Hurricanes Katrina and Rita. Dr. Gerry Costa will review experiences with the Northeast Coalition, with emphasis on infants and young children and those with developmental disabilities. Dr. Juliet Vogel will represent work through the NCTSN STRYDD (Supporting Trauma Recovery for Youth with Developmental Disabilities) Center and will compare this experience with work in the aftermath of 9/11 in metropolitan NYC. Dr. Kathryn Collins from the NCTSN Family Informed Trauma Treatment (FITT) Center will present issues for both providers doing home visits and the family caregivers they assist through the Trauma Adapted Family Connections program in urban Baltimore, Cleveland, and Washington DC. Dr. Howard Osofsky will serve as discussant. 
5pm – 6:15pm Symposium: Advancements in Assesment of PTSD and Related Phenomena
  • Chair: Daniel Lee
  • Discussant: Paula Schnurr
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  • Extending Psychometric Investigations of the Posttrauma Risky Behaviors Questionnaire: Measurement Invariance Across Trauma Types and Count
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  • Ateka Contractor, Nathan Kearns, Nicole Weiss
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  • The Posttrauma Risky Behaviors Questionnaire (PRBQ) is a comprehensive, yet brief assessment of post-trauma reckless and self-destructive behaviors (RSDB). Initial psychometric examination evidenced a unidimensional factor structure, excellent internal consistency, and good convergent validity. Extending PRBQ’s psychometric investigation, we evaluated measurement (non)invariance of RSDB construct across trauma types and count among 1,174 trauma-exposed students (Mage = 20.28; 74.6% female). Confirmatory factor analysis confirmed the unidimensional measurement model (CFI=.92, RMSEA=.06; SRMR=.08). The PRBQ-assessed RSDB construct demonstrated configural (factor structure), metric (factor loadings; ΔCFI=.008), and scalar invariance (intercepts; ΔCFI=.009) across subgroups indexing non-interpersonal (n=538) vs. interpersonal (n=387) traumas. However, this construct indicated configural invariance with metric non-invariance (ΔCFI=.027) across subgroups reporting one (n=296) vs. multiple (n=649) trauma types. Partial invariance analyses indicated that items 3 (problematic gambling), 11 (property destruction), and 7 (illegal behaviors) contributed to construct non-equivalence. Findings indicate meaningful comparison of the RSDB construct across trauma types; for trauma count comparisons, items assessing gambling, illegal behaviors, and property destruction may need to be modified.
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  • The Role of Measurement Error in the Utilization of PTSD Assessment Instruments
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  • Frank Weathers, Sarah Whiteman, Lindsay Kramer, Jessica Petri
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  • In psychometric theory, reliability refers to consistency of test scores over repeated measurements. Facets of measurement over which reliability may be estimated include items, occasions, forms, and raters. Although reliability estimates are routinely reported in dedicated psychometric papers, the effect of unreliability or measurement error is often overlooked in applied research questions in clinical assessment, such as comparing different nosological systems, different structured interviews, or different diagnostic scoring rules. In this presentation, several rec ent examples from the PTSD assessment literature will be used to illustrate how insufficient consideration of the effect of measurement error can lead to erroneous interpretations and conclusions regarding empirical findings. In one example, less than perfect associations between DSM-IV and DSM-5 PTSD criteria, which have been interpreted as adverse substantive differences between the criteria sets, are shown instead to be attributable to the test-retest reliabilities of their respective assessment instruments, viz., the PCL-S and PCL-5.  In a second example, the case is made that the optimal scoring rule for the CAPS-5 should be the rule that minimizes measurement error and thus maximizes interrater and test-retest reliability. Conceptual and practical implications are discussed.
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  • The Diagnostic Utility of a New Four-Item Short Form of the PCL-5
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  • Michelle Bovin, Rachel Kimerling, Frank Weathers, Annabel Prins, Brian Marx, Edward Post, Paula Schnurr
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  • Structured interviews are needed to establish a PTSD diagnosis but are time-consuming and costly. Questionnaires are more efficient, but full versions may be too lengthy in some settings. Accordingly, Zuromski and colleagues (2019) developed a four‐item short‐form (Z-SF4) of the PTSD Checklist for DSM-5 (PCL‐5; Weathers et al., 2013). Although the Z-SF4 closely replicated PCL-5 diagnostic decisions, its diagnostic utility has not been tested against a gold standard PTSD interview. The current study compared the diagnostic utility of the Z-SF4 with that of the full PCL-5 and a randomly generated 4-item short-form (R-SF4) against a PTSD diagnosis based on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013). Participants were 489 primary-care-seeking Veterans. Time between PCL-5 and CAPS-5 administration ranged from 1-30 days. The highest quality of efficiency (κ[.5]) for the full PCL-5 was .58 (cutoff of 32), .54 for the Z-SF4 (cutoff of 6), and .52 for the R-SF4 (cutoff of 8). When the time between PCL-5 and CAPS-5 administration was 1-7 days, κ[.5] increased substantially, to .76 for the full PCL-5 (cutoff of 30), .72 for the Z-SF4 (cutoff of 9), and .74 for the R-SF4 (cutoff of 10). Results indicate that 4-item versions of the PCL-5 yield somewhat lower efficiency than the full PCL-5, and that a random four-item version performs comparably to the Z-SF4.
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  • Item response theory analysis of the CAPS-5 and SCID-5 PTSD module among Veterans
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  • Daniel Lee, Stephanie Ellickson-Larew, Michelle Bovin, Frank Weathers,  Paula Schnurr, Denise Sloan, Terence Keane, Brian Marx
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  • The degree to which items on measures of DSM-5 PTSD symptoms distinguish between individuals high and low in symptom severity and assess the full range of underlying symptom cluster dimensions remains poorly understood. This study used item response theory (IRT) analyses to examine item performance on the CAPS-5 and SCID-5 PTSD module among a large sample of veterans combined from three studies (total N = 1,675). For both the SCID-5 PTSD module and CAPS-5, dissociative amnesia and reckless behavior evidenced the least discrimination between individuals high and low in severity on respective symptom clusters. Aside from these items, most items reflected the same narrow portion of underlying symptom cluster dimensions of moderate severity (item difficulty for cued emotional reactivity = -.30, for cued physiological reactivity = -.33). Collectively, results suggest dissociative amnesia and reckless behavior have substantial error and are less representative of respective underlying constructs, that many items measure a similar, narrow portion of the constructs rather than the full range and therefore lack incremental value, and that these results are consistent across diagnostic interviews. Results highlight several opportunities to improve DSM-5 measure efficiency and expand how items capture the full range of symptom severity.
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Wednesday, November 11 

8:00am – 9:00am SIG Meetings:
  • Gender and Trauma SIG
  • Trauma Assessment and Diagnosis SIG
  • Military SIG
  • Postpartum Trauma SIG
10am – 11:15am Symposium: Adaptations to Child Trauma Evidence-Based Treatments in Research and Practice
  • Chair: Jason Lang
  • Discussants: Rochelle Hanson
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  • Adaptations of evidence-based interventions to address traumatic events among children and adolescents: A systematic review
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  • Brittany Lange, Ashley Nelson, Jason Lang, Shannon Stirman
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  • Background: Trauma is highly prevalent globally and associated with adverse outcomes. Evidence-based interventions (EBIs) have been developed to mitigate these effects. Often, these EBIs are adapted by practitioners, however, little is known about how EBIs for child trauma have been adapted.
    Objective: To determine: 1) why existing EBIs designed to address traumatic events experienced by children are being adapted; 2) what processes are used to determine what elements of the intervention should be adapted; 3) what components of the intervention are adapted; and 4) if different adaptations affect intervention outcomes. Methods: Nine databases were searched for academic literature. Grey literature was located through search engines and key websites. Study screening, data extraction using FRAME, and quality determinations using the Evidence Project Risk of Bias Tool were completed by two authors. Results: 39 studies were included. Common reasons for adaptations were to improve fit with recipients and to address cultural factors. All interventions were proactively adapted, with researchers most often being the ones to determine what elements were adapted. Modifications were most frequently made to content and context. Adapted interventions were found to largely remain efficacious. Conclusion: Key considerations for practitioners planning to adapt EBIs will be presented.
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  • Outpatient Mental Health Care for Children Exposed to Trauma: Are There Evidence-Based Treatments for Adjustment Disorders?
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  • Phyllis Lee, Jason Lang, Tim Marshall
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  • Adjustment disorder is one of the most commonly diagnosed mental health conditions and many who are exposed to potentially traumatic events (PTEs) receive this diagnosis, yet no EBTs have been developed or tested to treat it. The study’s objective was to examine the extent to which children with adjustment disorder received “off-label” EBTs (e.g., cognitive/behavioral therapy) in a statewide behavioral health system and whether use of EBTs was associated with differences in clinical outcomes. Participants were a diverse sample of 46,729 children (55% male, 40% Hispanic, 36% White, 15% Black) from 25 outpatient clinics reporting administrative data to the state, including demographics, diagnosis, EBT use, and symptom severity change (Ohio Scales; Ogles et al., 1999). More than half reported exposure to PTEs. Almost one third received a primary diagnosis of adjustment disorder and it was the most common diagnosis in this sample. Children with adjustment disorder were significantly less likely to receive EBTs compared to children with diagnoses of conduct problems, depression, anxiety, or PTSD (X2=60.7, p<.001); however, those who received cognitive/behavioral EBTs improved significantly more than those who did not (F=20.8, p<.001). Results indicate that EBTs not developed for adjustment disorder can be helpful for treating children exposed to trauma with this common diagnosis.
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  • Extending the Reach of Evidence Based Trauma Treatment: Tailoring of Trauma Focused CBT for Implementation in El Salvador
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  • Regan Stewart, Rosaura Orengo-Aguayo, Bianca Villalobos, Aubrey Dueweke, Andel Nicasio, Michael de Arellano
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  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a cognitive behavioral, exposure-based intervention that addresses PTSD symptoms for children ages 3 to 18. Efficacy for TF-CBT has been established through numerous randomized controlled trials in a range of populations in the U.S. and globally; however, TF-CBT has yet to be evaluated in Latin American countries. In particular, Salvadorian children and adolescents are a vulnerable population with high rates of exposure to physical and sexual abuse, violence due to gangs, parental separation, and natural disasters. The current project was an open pilot feasibility trial (n=120) of TF-CBT investigating feasibility, initial efficacy in community-based locations (schools and a community clinic), and tracking of implementation strategies utilized throughout the project. Qualitative and quantitative data will be presented on pre-post treatment outcomes, tailoring of the intervention, and implementation strategies utilized in this unique context. Additional topics discussed will include the use of a community-based participatory approach, the complexities of partnering with a local agency, lessons learned, and recommendations for future steps to promote the dissemination and implementation of trauma-focused treatments in Latin American countries.
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  • Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) with Commercially Sexually Exploited and Trafficked Youth: Clinical Outcomes and Training and Dissemination Strategies
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  • Kelly Kinnish, Elizabeth Perry, Melissa Osborne, Shannon Self-Brown
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  • Background: Youth who have experienced commercial sexual exploitation and trafficking (CSE/T) often have complex needs, including trauma-related mental health impacts and PTSD. The complex and compound factors that contribute to CSE/T vulnerability, along with high rates of trauma exposure and impacts underscore the importance of prioritizing access to and flexible application of EBTs tailored to meet their needs. Project Intersect provides intensive training in CSE/T-specific advanced applications of TF-CBT to a network of therapists serving CSE/T clients. Objective: To determine: 1) feasibility of TF-CBT with CSE/T youth, 2) treatment impact, and 3) how treatment impact for CSE/T youth compares to other published TF-CBT studies. Methods: Youth (n=30) completed UCLA-PTSD Reaction Index and broad-band measures pre- and post-treatment. Results: Youth reported significant and clinically meaningful improvements in PTSD symptoms (p=.002; d =.90) from baseline (M=34.35) to graduation (M=17.24). Effect sizes were comparable to 4 published studies of TF-CBT in community settings with non-CSE/T youth (ave. Cohen’s d across studies=.92; current study=.90). Conclusion: TF-CBT is a viable treatment option for CSE/T youth. Challenges and barriers will be discussed as well as training, dissemination, and delivery strategies to better tailor treatment and increase access to services.
10am – 11:15am Panel: Complex PTSD: Global Barriers, Opportunities and Innovations to Reach Underserved Communities

Carolyn Yeager, Elizabeth Carll, Christine Courtois, Thanos Karatzias

Complex posttraumatic stress disorder (C-PTSD), often experienced by vulnerable populations, is finally receiving long-delayed recognition as advances in research and clinical applications increase. In this complex trauma SiG-sponsored panel, experts from the field will address barriers, opportunities and innovations associated with the dissemination of treatment for C-PTSD. Dr. Carll will provide a global perspective on complex trauma relating to the ongoing global violence, conflicts, disasters, and chronic illnesses, highlighting her work with member states of the UN General Assembly. Dr. Courtois will offer an overview of the essential elements in treating this population, drawing from recent professional practice guidelines and her updated edition of Complex Traumatic Stress Disorders. Rationale and evidence for using flexible, multimodular approaches for the treatment of C-PTSD will be presented by Professor Karatzias, along with a new treatment protocol, Enhanced STAIR for C-PTSD (ESTAIR). Finally, innovative opportunities and adaptions necessary to extend the reach of C-PTSD interventions through technology will be presented by Dr. Yeager. Discussion will conclude with recommendations for future research and practice. The audience will be invited to join the panel in discussing barriers, opportunities, and innovations needed to reach this significant population.
10am – 11:15am Symposium: The Neurobiology of Racial Discrimination and Racial Disparities in Health in Highly Trauma-exposed Populations 
  • Examining the Biomarkers of Racial Discrimination and Its Influence on Health for African Americans: The Importance of Understanding Contextual Factors
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  • Sierra Carter, Tanja Jovanovic, Mei Ling Ong, Man Kit Lei, Steven Beach, Ronald Simons, Frederick Gibbons
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  • Research indicates that racial discrimination is a particularly important facet of the set of social stressors that exert acute/chronic effects on health outcomes, particularly for African Americans (AA). Research has also shown that chronic stress from racial discrimination can evoke physiological changes within body systems leading to premature illness and mortality. Yet, limited research has considered how contextual factors, such as socioeconomic status (SES) and trauma exposure, could influence this process. This presentation will discuss study findings that examined how racial discrimination is linked to biomarkers of accelerated aging and allostatic load with a focus on context. One study found a significant indirect effect of racial discrimination (age 10-15) on aging through adult maladjustment (depression, self-esteem, self-confidence; age 20-29; β = .021[.001, .057]) , accounting for 32% of the total variance. SES significantly moderated the association between racial discrimination and adult adjustment. This led to a greater indirect effect of discrimination on aging among those raised in higher SES households. In another study, results revealed that racial discrimination was positively correlated with higher levels of circulating cell-free mitochondrial DNA, consistent with increased allostatic load, and independent of trauma exposure.
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  • Racial disparities in environmental adversity contribute to race-related differences in the neuroanatomy of PTSD
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  • Nathaniel Harnett, Nathalie Dumornay, Lauren Lebois, Kerry Ressler
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  • Although Black-American (BA) individuals are disproportionately exposed to environmental adversities that contribute to the development of posttraumatic stress disorder (PTSD) compared to White-American (WA) individuals, the potential for race disparities in environmental adversity to impact the neural circuitry of PTSD in children is not well studied. We utilized data from the Adolescent Brain Cognitive Development study to investigate the relationship between environmental adversity and neural circuitry of PTSD in children (nBA = 1837, nWA = 7459). BA children were exposed to more environmental adversity (e.g., neighborhood disadvantage [t(8838) = -24.54, p < 0.001, d = 0.68]), and a greater proportion had PTSD-related impairment, compared to WA children [X2(1) = 12.00, p < 0.001, 6% BA vs 4% WA]. Further, BA children exhibited reduced gray matter in the ventromedial PFC, hippocampus, and amygdala, but greater white matter integrity of the uncinate fasciculus (all p < 0.001). Importantly, environmental stressors were also significantly associated with brain structure (e.g., uncinate fasciculus: [F(4,7673) = 4.90, p < 0.001, R = 0.05]). The present findings suggest disparate exposures to environmental adversity contribute to differences in the neural circuitry of PTSD and have important implications for our understanding of the impact of social inequalities in mental health.
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  • Associations of Experiences of Discrimination on Avoidance Behaviors and Emotion Regulation in a High Trauma Sample of African Americans
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  • Amanda Liew, Negar Fani, Sierra Carter
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  • Race-related traumatic stress theory (Carter, 2007) considers that racial discrimination may be experienced as psychological trauma, producing symptoms comparable to post-traumatic stress disorder (PTSD). Studies in low-trauma populations suggest that race-related stress may lead to avoidant coping strategies—however, little is known about the unique associations of discrimination with avoidance strategies in high-trauma populations, which was the goal of this study. We investigated relationships between discrimination (assessed with the Experiences of Discrimination Questionnaire (EDQ)), post-trauma avoidance, as well as forms of emotion dysregulation and substance use in a sample of African American men and women recruited as part of the Grady Trauma Project (n=490; mean age=41 ± 12). We observed unique associations of racial discrimination experiences with avoidance, emotion dysregulation and substance use after controlling for lifetime trauma exposure. Partial correlations revealed that discrimination experiences were positively correlated with post-trauma avoidance, emotional dysregulation, dissociation, and drug abuse (ps<0.05). We will discuss how experiences of discrimination may uniquely influence development of avoidant behaviors that can negatively impact quality of life in marginalized populations with high trauma exposure.
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  • Effects of Racial Discrimination on Attention Network Disruptions in a Traumatized Population
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  • Negar Fani, Nathaniel Harnett, Sierra Carter
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  • Although much is known about the effects of trauma and PTSD on attentional processes, no studies have examined how experiences of racial discrimination may have unique or additive effects on these processes, which was the goal of this study. Fifty-five African-American women with varying levels of trauma exposure and PTSD, as well as experiences of racial discrimination, performed an attentional control task (affective stroop, AS) that included trauma-related and neutral distractor images. We observed that, during attention to trauma vs neutral images, more perceived racial discrimination was associated with significantly greater response in brain regions involved with attention and emotion regulation, including the ventromedial and dorsolateral prefrontal cortex, even after accounting for trauma and PTSD severity (p<.001). After accounting for effects of trauma and PTSD, errors on AS trials were significantly associated with perceived experiences of racism, particularly trauma-related distractor trials (r=-.45, p=.001). These findings suggest that experiences of racial discrimination may lead to increased response in brain regions involved with attention regulation. This network imbalance may indicate that experiences of perceived discrimination disrupt attention network efficiency, leading to an over-modulation of response to incoming emotionally-salient information.
10am – 11: 15am Panel: A Cross Cultural Collaboration in the Adaptation of an Assessment and Intervention Program for Yazidi Refugee Women Abducted by ISIS

Marylene Cloitre, Ari Zivotofsky, Yaakov Hoffman

This panel describes a cross-cultural collaboration among NGOs, universities, and clinical programs in Israel, Germany, Iraq, Kurdistan and the United States to develop a culturally appropriate, trauma-informed assessment and intervention program for Yazidi women abducted by ISIS now living in Kurdistan refugee camps. The first panelist (Yaakov Hoffman) will describe the development and successful implementation of an assessment program to identify rates of PTSD and complex PTSD among Yazidi women. Findings of high rates of post traumatic stress disorders provided persuasive evidence and motivation for the development an intervention program. The second panelist (Ari Zivotofsky) will describe the development of a cross-cultural collaboration to identify mental health needs and relevant interventions, the stakeholders involved and the barriers to and facilitators of this process. The third panelist (Marylene Cloitre) will describe the adaptation of the selected intervention, Skills Training in Affective and Interpersonal Regulation (STAIR) through the construction of a narrative about a young Yazidi woman living in the camps developed by 15 Yazidi women participating in a workshop. Role-playing of interventions as well as sharing of Yazidi music, rituals and cultural values over five days of workshop contributed to iterative cycles of revision of the treatment.
2pm – 3:15pm Invited Speaker: Experimental Designs for Developing Technology-Based Interventions: on Factorial Designs, SMARTs and MRTs


Inbal (Billie) Nahum-Shani, PhD

2pm – 3:15pm Symposium: Translational Tools for Addressing Secondary Traumatic Stress in Professionals: Innovations for Research and Practice
  • Initial Development Validation of the Functional Impairment due to Secondary Trauma Scale (FISTS)
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  • Brian Bride
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  • Though several instruments are available to measure symptoms of secondary traumatic stress (STS) are available, to date there is no validated measure of functional impairment that may result from STS. The Functional Impairment due to Secondary Trauma Scale (FISTS) a 7-item self-report instrument that requires respondents to rate distress or impairment using a 5-point Likert scale, was developed to address this gap. A mailed survey containing these items was completed by 522 social workers. Analysis included evaluation items based on qualitative and quantitative data and resulted in the elimination of two items. A confirmatory factor analysis was conducted of the final, 5-item version of the FISTS with results indicating that the it is a reliable (alpha = .88) and construct valid (RMSEA = 0.10; TLI = .97; SRMSR = .018) measure.
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  • Analysis of Implementation Drivers of STS-Informed Organizational Change and Individual Experiences of STS and Burnout
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  • Adrienne Whitt-Woosley
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  • A challenge for high-risk helping professions is to understand how both individuals and organizations can prevent and address the impact of secondary traumatic stress and burnout, two highly correlated conditions. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) tool was developed to evaluate the use of policies, practices and training activities that organizations could use to remove barriers to individual coping with indirect trauma and promote resiliency (Sprang et al., 2014). Application of the National Implementation Research Network’s (NIRN) implementation process framework to the STSI-OA found that domain activities loaded onto the three implementation drivers of competency, organization and leadership (Sprang, Ross, & Miller, 2018). This study of at-risk professionals (N=382) examined associations between composite scores for these three drivers derived from the STSI-OA items and individual measures of STS and BO. The three drivers of STS organizational change were significantly correlated with both STS and BO and accounted for 18.2 and 18.8 percent of the variance in these conditions respectively. This suggests that organizational policies and practices have a considerable effect on the STS and BO experiences of individuals. Discussion of these findings and implications for systems from an organizational change perspective will be provided.
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  • Support for Teachers Affected by Trauma (STAT): An Online Curriculum for Educators Experiencing Secondary Traumatic Stress
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  • James Caringi
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  • One in four students in public schools have experienced a traumatic event (U.S. Department of Education, 2012).  While secondary traumatic stress (STS) has recently been gaining the attention of public school systems, the evidence of the impact of STS on teachers is just beginning to be explored (Caringi & Stanick, 2015). Support for Teachers Affected by Trauma (STAT) is a five module on-line curriculum that addresses the impact of secondary traumatic stress, primarily on educators but ideally for any individual working in a school.  The modules cover the following five concepts:  (1) Knowledge of secondary trauma and others types of trauma such as complex or historical; (2) Risk factors for STS; (3) Personal inventory and assessment of secondary traumatic stress; (4) Impact of secondary trauma across five life domains; (5) Self-care strategies to address STS.  The goal of STAT is: (1) help bring much needed awareness and understanding to how secondary traumatic stress can impact educators; and (2) demonstrate how secondary trauma can be mitigated through an effective self-care techniques and building resiliency strategies.  These goals are accomplished through web based user friendly features that are grounded in adult centered learning. Pilot data on the initial effectiveness of STAT collected in 2019 will be presented and explored.
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  • Diagnostic and Translational Utility of the Secondary Traumatic Stress Clinical Algorithm
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  • Ginny Sprang, Adrienne Whitt-Woosley, Jessica Eslinger
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  • Objective: Current tools available to measure and understand secondary traumatic stress (STS) do not account for whether the symptoms are functionally-related to indirect trauma, determine functional impairment caused by the STS symptoms, and/or consider the duration of the disturbance. The STS Clinical Algorithm (STS-CA) was developed to make these distinctions, so that interventions can be tailored to need.  This study investigates: 1) the diagnostic concordance between the STS-CA findings and scores on the Secondary Traumatic Stress Scale (STSS) how STS-CA outcomes map onto STSS quartiles; and 3) reasons for diagnostic discrepancies between the two assessments. Method: Three trained interviewers used the STS-CA to guide the determination of clinical outcome (N=109). Results: There was fair to good diagnostic concordance (κ =.598, p = .000) between the STS-CA and the STSS, with the former demonstrating more specificity in delineating those with atypical cluster presentations or little to no functional impairment that prohibited a PTSD diagnosis. Implications: Effective treatment of STS requires proper identification and delivery of protocols that are tailored to the unique ways that STS manifests. This study examines the utility of the STS-CA in guiding this process and creates STS categories to organize and classify intervention strategies.
2pm – 3:15pm Panel: Identifying Biological Markers of Posttraumatic Stress Disorder (PTSD): Recent Findings and Efforts Across Modalities to Enhance Rigor and Robustness

Andreas Jeromin, Heather Lasseter, Lauren Chaby, Renato Polimanti,  Jennifer Sumner, Andrew Thompson, Lee Lancashire, Magali Haas, 

PTSD affects nearly 1 in 5 veterans and increases adverse health outcomes, yet only two pharmacotherapies have been FDA approved and no therapeutics have reached the clinic in two decades. Thus, identifying biomarkers of PTSD is critical to enable the discovery and development of therapeutics and diagnostics. Mounting evidence implicates multiple biological modalities in PTSD psychopathology such that deep phenotyping is necessary to understand this complex disease. Panelists will evaluate evidences of biological features of interest in PTSD from inflammation, metabolomics, and genetics. Substantial datasets are available from large cohorts, enabling systems biology approaches using banked samples. However, achieving data quality necessary for data harmonization and biomarker identification requires key pillars of rigor and robustness, achieved in part by optimizing assay performance. Thus, panelists will discuss (i) effects of variation in technical assays on data quality and replicability and (ii) recent comprehensive technical assay comparisons for inflammation and metabolomics, conducted by the Research Alliance for PTSD/TBI Innovation and Development Diagnostics (RAPID-Dx). The panel will conclude with discussion of practical strategies and ongoing efforts to optimize research into the development and qualification of biomarkers for trauma-related brain disorders.
2pm – 3:15pm Symposium: Current Research on the Nature and Impact of Dissociation
  • Chair: Hillary Hodgdon
  • Honorary Co-Chair: Michael Suvak
  • Discussant: John Briere
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  • PTSD and its dissociative subtype through the lens of the insula: Insula resting-state functional connectivity and its predictive validity using machine learning
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  • Sherain Harricharan, Andrew Nicholson, Janine Thome, Maria Densmore, Margaret McKinnon, Jean Theberge, Paul Frewen, Richard W.J. Neufeld, Ruth Lanius
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  • Posttraumatic stress disorder (PTSD) typically involves reliving and hypervigilance states; however, the PTSD dissociative subtype (PTSD+DS) presents with additional depersonalization and derealization symptoms. To further examine these contrasting symptom profiles, we investigated insula resting-state functional connectivity among PTSD, PTSD+DS, and healthy controls. Using SPM12 and PRONTO software, we implemented a seed-based resting-state functional connectivity approach, along with multiclass gaussian process classification machine-learning, respectively, to evaluate the predictive validity of insula connectivity among individuals with PTSD (n=84), PTSD+DS (n=49) and age-matched healthy controls (n=51). Controls showed increased right insula connectivity with the frontal lobe. By contrast, PTSD showed increased bilateral insula connectivity with subcortical structures. Strikingly, PTSD+DS showed increased bilateral insula connectivity with posterior cortices. Moreover, machine-learning analyses were able to classify PTSD, PTSD+DS and controls using insula subregion connectivity patterns with 80.4% balanced accuracy (p<0.01). Overall, PTSD and PTSD+DS showed distinct insula functional connectivity patterns during rest. Furthermore, machine-learning algorithms utilized insula connectivity patterns to discriminate between participant groups with high predictive accuracy.
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  • Trajectories of Dissociation among Youth in Residential Care
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  • Hilary Hodgdon, Michael Suvak, Kayla Lord, Lia Martin, Kari Beserra, Ernestine Briggs-King
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  • Residential treatment serves youth with severe mental health symptoms (Lyons et al., 2000) often the result of traumatic events. Dissociation, or interruptions in the integration of thoughts, feelings, and experiences into consciousness and memory (Giesbrecht et al., 2008), has been linked to trauma exposure and various forms of maladaptation (e.g., PTSD, dysregulated emotions, risky behavior). Elucidating the course and predictors of dissociation in youth in residential treatment can inform the development of mental health interventions. We conducted latent growth curve modeling to evaluate trajectories of dissociation in 490 youth in residential care (age 12-18, M = 15.94, 42% male) who completed the Adolescent Dissociative Experiences Scale (A-DES) at admission and every three months for 18 months to examine the nature of change and identify predictors. The A-DES showed a quadratic pattern of change characterized by accelerating decreases (the rate of decrease growing over time) with an overall large effect size overall decrease from admission to 18 months (d = -.76). Gender emerged as a significant predictor of change in dissociation with girls (d = -1.10) exhibiting significantly larger decreases than boys (d = -.54). Cumulative trauma exposure (Trauma History Profile) was positively associated with dissociation at admission but did not predict change over 18 months.
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  • The Latent Structure of the Adolescent Dissociative Experiences Scale
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  • Denise Kyte, Hilary Hodgdon, Rosemarie DiBiase, Michael Suvak
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  • The DSM-5 conceptualizes dissociation as a multi-dimensional construct including amnesia, derealization, depersonalization, and identity disruption factors. The Adolescent Dissociative Experiences Scale (A-DES, Armstrong, et al., 1997) is the most widely used self-report measure of adolescent dissociation. The development of the A-DES was guided by a four-factor model (absorption and imaginative involvement, amnesia, depersonalization/derealization, and passive influence). A recent confirmatory factor analysis (CFA) of the A-DES by Kerig et al. (2016) using data from adolescents (n = 784) who reported high levels of trauma exposure found that a three-factor model, with depersonalization/derealization, amnesia, and loss of conscious control factors, best fit the data. We replicated and extended the work of Kerig et al. using data from 1157 treatment-seeking adolescents, most with high levels of trauma exposure. Kerig et al.’s findings were replicated, with a three-factor model best fitting the data. However, a bifactor CFA model fit the data better and identified a strong general factor that accounted for 87.0% of the common variance among items, which supports a uni-dimensional latent structure. Only the general dissociation factor was associated with cumulative trauma exposure (assessed by the Trauma History Profile), however, this association was small (r = .10, p < .01).
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  • Investigating the Links Among Trauma Exposure, Dissociation, Posttraumatic Reckless/Self-Destructive Behavior, and Adolescent Offending
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  • Patricia Kerig, Crosby Modrowski, Lucybel Mendez
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  • One particularly underserved group of traumatized youth is comprised of the racially diverse adolescents who are involved in the US justice system. A key to designing effective interventions will be new research that refines our understanding of the specific mechanisms accounting for the links among trauma exposure, posttraumatic symptoms, and adolescent offending. In this regard, it is notable that levels of dissociation are consistently found to be disproportionately high among justice-involved youth (Modrowski & Kerig, 2017), and dissociation has been theorized to increase the likelihood of DSM-5 Criterion E posttraumatic reckless/self-destructive behavior (RSDB) (Layne et al., 2014) and subsequent offending (Zhou et al., 2017). To test these hypotheses, this study examined interrelations among trauma exposure, dissociation, RSDB, and offending in a sample of 301 detained adolescents (20% girls, 62% ethnic minority) who completed validated self-report measures. Results of multiple mediation analysis demonstrated an indirect effect linking trauma exposure and self-reported offending sequentially through dissociation and RSDB, B = .05, p = .001. These results extend our understanding of the association between dissociation and posttraumatic reckless behavior in adolescence and have valuable implications for refining treatment targets for this underserved population.
5pm – 6:15pm

Keynote Speaker: Traumatic Stress Science in the 21st Century: Lost in Translation?


Benjamin E. Saunders, PhD

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Thursday, November 12
8:00am – 9:00am SIG Meetings:
  • Aging, Trauma, and the Life Course SIG
  • Dissemination and Implementation SIG
  • Terrorism and Bioterrorism Related Trauma SIG 
  • Trauma in Higher Education and Training SIG
10am – 11:15am Workshop: The Kovler Center Child Trauma Program (KCCTP): Providing Mental Health Services to Refugee and Immigrant Children

Nicole St. Jean, Tarik Endale, Dina Birman

Our world is in a global migration crisis and clinical services must adapt to meet the critical needs of families who are forced to relocate. This workshop will describe the development, implementation, and initial outcomes of the Kovler Center Child Trauma Program (KCCTP), an innovative child trauma program that serves immigrant and refugee youth and families from around the world. While research has documented mental health needs of refugee youth, few studies have described and assessed the service delivery systems (Birman et al.  2005). As a member of the National Child Traumatic Stress Network (NCTSN), KCCTP delivers case management, community outreach and training, and evidence-based therapies such as trauma-focused cognitive-behavior therapy (TF-CBT), cognitive-behavioral intervention for trauma in schools (CBITS), and Supporting Transition Outcomes to Newcomer Groups (STRONG) to address trauma experienced in home country or during the migration and resettlement process. Implementation of programming has involved essential cultural adaptions and responsiveness when working with families from over 20 countries who speak more than 24 different languages. This presentation will describe the service delivery model, clinician practices, evaluation process and outcomes. Reflections on implementation challenges and strategies will be offered.
10am – 11:15am Symposium: Alcohol and Sexual Assault: Innovative Approaches to Increase Reach to Vulnerable and Underserved Populations 
  • The Role of Race and Ethnicity in Posttraumatic Stress Disorder, Hazardous Alcohol Use, and Discrimination Experiences among Recent Sexual Assault Victims
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  • Kate Walsh, Amanda Gilmore, Patricia Frazier, Linda Ledray, Ron Acierno, Kenneth Ruggiero, Dean Kilpatrick, Heidi Resnick
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  • Race and ethnicity have been shown to affect the relationship between sexual violence and mental health outcomes with racism, sexism, and poverty increasing mental health problems following sexual violence (Bryant-Davis et al., 2009). The current study examined posttraumatic stress disorder (PTSD) symptoms, hazardous alcohol use, and discrimination experiences among 121 women age 15 and older who presented to the emergency department for a rape-related medical exam and completed follow-up questionnaires at 6 months. Approximately 45% of the sample (n = 54) identified as non-Hispanic white, 29.8% (n = 36) as non-Hispanic black, 6.6% (n = 8) as non-Hispanic Native American, 7.4% (n = 9) as non-Hispanic mixed race, and 11.6% (n = 14) as Hispanic. Non-Hispanic black and non-Hispanic mixed race participants reported significantly more discrimination types and greater frequency of discrimination compared to all other groups (ps <.05). Non-Hispanic white women evidenced a trend for lower PTSD symptoms compared to non-Hispanic mixed race participants (p = .08), and non-Hispanic Native American women had significantly higher hazardous alcohol use compared to non-Hispanic black women (p = .03). Post-sexual assault programming should address complex patterns of PTSD symptoms, hazardous alcohol use, and discrimination for women of different racial and ethnic backgrounds.
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  • Sexual assault and alcohol use among women in substance use treatment: Impact of PTSD on this relationship
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  • Angela Moreland
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  • Half of women who engage in substance use treatment also report histories of sexual assault (Charney, Palacios‐Boix, & Gill, 2007), which is associated with increased PTSD, depression, and revictimization (Ullman, 2016). This study compared alcohol use rates, relapse rates, and psychological symptoms in women with and without a history of sexual victimization presenting for substance use treatment, as well as racial differences. Participants were 108 women recruited from a substance use treatment center. Results indicated that women who reported sexual assault had significantly higher depression, PTSD, and past 3-month alcohol use, and relapse compared to women who did not report any sexual assault history. Mediation analyses suggested that PTSD symptoms mediated the relationship between sexual assault history and alcohol use such that women who reported sexual assault reported higher PTSD symptoms; elevated PTSD symptoms were positively associated with higher alcohol use. Results indicated significant differences by race, with African American women experiencing less depression and PTSD than White women. The role of alcohol use may be particularly relevant for substance using women with a history of PTSD as a means of coping with trauma symptoms, and may highlight the importance of engagement in trauma treatment in addition to substance use treatment.
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  • Reaching Sexual and Gender Minority College Students through Alcohol and Sexual Assault Prevention: Findings from an Open Pilot Trial
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  • Amanda Gilmore, Ruschelle Leone, Daniel Oesterle, Lindsay Orchowski, Kelly Davis, Debra Kaysen
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  • Although it is widely known that sexual assault is common on college campuses and prevention programs are widespread, sexual and gender minorities (SGM) are an underserved population in terms of prevention on college campuses despite their heightened risk for both alcohol use and sexual assault. Alcohol and Sexual Assault Prevention (ASAP) is the only program that targets alcohol and sexual assault risk among SGM college students. The current study presents findings from an open pilot (n=24) assessing the preliminary usability of Alcohol and Sexual Assault Prevention (ASAP), a web-based program that targets alcohol use, sexual assault risk reduction, sexual assault perpetration prevention, and sexual assault bystander intervention for (1) cisgender heterosexual men, (2) cisgender heterosexual women, and (3) individuals who identify as SGM. In a pre-post study design, it was found that participants were satisfied with the information quality, interface quality, and system usefulness of ASAP. Participants reported reductions in injunctive drinking norms and greater prosocial bystander intentions, and men were more aware of the problem of sexual assault on their campus and had greater intentions to make changes to prevent sexual assault. Results are promising in demonstrating preliminary usability and efficacy of ASAP in an underserved population.
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  • Efficacy of a Tailored Web-based Alcohol intervention to Improve Regulatory Skills and Reduce PTSD Symptom Severity Among Heavy Drinking College Women with Sexual Assault Histories
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  • Cynthia Stappenbeck, Natasha Gulati, Jessica Blayney, Anna Jaffe, Anna Peddle, Debra Kaysen, Brennah Ross
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  • College is a time of high risk for sexual assault (SA) and heavy drinking. Women with SA histories often have difficulty regulating and tolerating distress, which can lead to a pattern of drinking to cope that interferes with recovery. Thus, college is a critical time to intervene around SA-related concerns to improve outcomes. However, survivors of SA do not seek in-person treatment at rates consistent with their level of difficulties, and for those who do, many colleges do not have adequate capacity. To meet the needs of this population that may otherwise go unaddressed, we developed and evaluated a web-based alcohol intervention to improve distress tolerance and emotion regulation skills. College women with SA histories (N=200) were randomized to an assessment only control in which they completed 14 daily diary assessments, pre- and post-treatment surveys and 1- and 6-month follow-up surveys, or an intervention condition in which they completed the same assessments and received an intervention module following each daily assessment. Women who received the intervention reported improved emotion regulation and distress tolerance and reduced PTSD symptom severity over time compared to control. Results provide support for this brief web-based intervention to improve regulatory skills and reduce PTSD symptom severity that can be widely disseminated to increase access to care.
10am – 11:15am

Panel: Treating Complex Traumatic Stress Disorders: Expert Guidance for Integrated Evidence-based Practice


Julian Ford, Ulrich Schnyder, Kathy Steele, Deborah Korn, Christine Courtois

In this panel, experts representing a wide spectrum of treatment models will describe essential evidence-based and evidence-supported practices that clinicians in practice and researchers can use as a guide in navigating (and preserving the fidelity of) the complexity of treating complex traumatic stress disorders in children and adults with attention to the influence of gender, sexual orientation, race, ethnicity, culture, socioeconomic status, and disability. Moderators Julian Ford and Christine Courtois will introduce the varied therapeutic approaches available, drawing on a wide range of evidence-based cognitive, behavioral, experiential, affect regulation, narrative, relational, psychodynamic, and eclectic interventions and evidence-supported complementary, mindfulness, somatosensory, structural integration, group, family, and couples interventions for PTSD and complex traumatic stress disorders. They and panelists Ulrich Schnyder, Kathy Steele, and Deborah Korn will discuss how common and unique elements and processes from the array of treatment models can enable practitioners and researchers to address key issues including timing and individualizing trauma memory processing, recognizing and preventing or managing dissociative fragmentation and extreme crises, enhancing affect regulation and acquired attachment security, and developing and sustaining a therapeutic alliance.

10am – 11: 15am Symposium: Preliminary Results from Trauma and Anxiety Technology Interventions for Veterans
  • Chair: Greg Reger
  • Discussant: Lori Zoellner
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  • Evaluation of a Treatment Companion Mobile Application During Prolonged Exposure: Preliminary Findings for PE Coach
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  • Greg Reger, Lori Zoellner, Monica Kletke, Elizabeth Stevens, Aaron Norr
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  • PE Coach is a well-designed VA app that supports prolonged exposure (PE), one of the most efficacious treatments for PTSD. Research suggests that PE therapists find the app helpful in supporting patients but little is known about how patients react to using the app, or whether the app impacts salient clinical outcomes, such as homework adherence. In this study, Veterans diagnosed with PTSD were randomized to use PE Coach during PE sessions 1-3 or 4-6, counterbalanced across participants. After completing the sixth session of PE, Veterans selected how they prefered to finish treatment (with or without the app) and evaluated the app’s usability (System Usability Scale; SUS). Homework adherence was monitored throughout treatment (Utility of Techniques Inventory; UTI). Preliminary results to date found that 8/9 Veterans (89%) preferred PE with PE Coach. PE Coach usability was highly rated. Based on normative data for technology usability ratings, the average PE Coach usability score was in the 90th percentile. Of the eight Veterans who have completed 6 sessions or more, seven of them had higher UTI scores during the period they used PE Coach. The average difference in UTI scores was 7 points, (PE Coach M = 52.1; Usual PE M = 45.0). These preliminary results support important hypotheses regarding the potential value of PE Coach during treatment.
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  • Pilot Trial of a Transdiagnostic Internet-Based Intervention for Anxiety Sensitivity Among VA Primary Care Patients
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  • Aaron Norr, Andrea Katz, Janelle Nguyen, Norman Schmidt, Greg Reger
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  • Internet-based interventions can reach Veterans who are not receiving adequate treatment for mental health conditions, including PTSD, by reducing barriers to care. The Cognitive Anxiety Sensitivity Treatment (CAST) is an Internet-based program that targets anxiety sensitivity (fear of anxiety sensations). CAST has shown efficacy in community samples for symptoms of PTSD, anxiety, and depression. A single-arm mixed-methods pilot study was conducted to examine acceptability, usability, and effectiveness among VA patients (N=25). Veterans completed a treatment appointment and a 1-month follow up. Veteran’s found the program to be highly acceptable and usability ratings (SUS=70) were higher than the meta-analytic average. Significant reductions were found between baseline and follow up for PCL-5, ASI-3, GAD-7, and PHQ-9 scores (d’s=0.61–1.12). Results from the qualitative matrix analysis highlighted strengths/weaknesses for the program across 4 domains: usability, content, impact on the participant, and applicability to Veteran populations. The results of the current study suggest that the CAST program is acceptable/usable for VA patients and demonstrated preliminary effectiveness. Areas for improvement of Internet-based interventions for Veterans include: separating into smaller chunks, more military specific examples, and adding opportunity to discuss with other Veterans.
     
  • The Impact of Virtual Reality Exposure on Psychophysiology
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  • Michael Gramlich, Derek Smolenski, Skip Rizzo, JoAnn Difede, Barbara Rothbaum, Greg Reger, Frank Andrasik
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  • This study tested the impact of prolonged exposure (PE) and virtual reality exposure (VRE) on heart rate (HR), galvanic skin conductance (GSR), and peripheral skin temperature (SKT) during exposure to the trauma memory across 10 sessions among active duty soldiers with combat-related PTSD. We gathered data from 61 combat veterans of Iraq/Afghanistan. The analyses evaluated data collected every 5 minutes during an exposure session and compared to PCL-C and CAPS outcomes using multi-level modeling. Participants in the PE group had higher HR arousal (x2(7)=17.72, p=.013) and higher SKT arousal (x2(7)=18.82, p=.009) than those in the VRE group. Participants in the PE group had stronger within-session decreases in HR (95%CI[-0.31,-0.01], d=0.26) and SKT (95%CI[-0.49e-02,-0.19e-02], d=0.51) compared to VRE participants. Participants did not display between-session decreases in physiology, regardless of treatment assignment (ps>.05). Examining change in within and between session physiology did not predict treatment outcome measures, even after accounting for treatment assignment (ps>.05). Overall, these findings suggest exposure to traumatic memories activate arousal across treatment sessions and were not related to outcome measures. Perhaps, the combination of physiological activation paired with successful practice tolerating distress maximizes treatment outcome.
12pm – 1:15pm Multi-Media: Use of Innovative Strategies and Multimedia Resources to Raise Awareness and Implement Trauma-informed Practices for Transition Age Youth across Systems

Cassandra Kisiel, Victor Labruna, Tawny Spinelli

Transition Age Youth (TAY) face many challenges as they navigate the process of recovery from trauma and transition from child-serving systems and into adulthood. Both child and adult systems may lack adequate resources to address the complex needs of TAY; this vulnerable population of youth can “slip through the cracks” without access to trauma-informed care. Thus enhancing trauma-informed education and interventions and identifying effective strategies to address the needs of TAY are critical. This multimedia session will illustrate innovative resources/approaches developed with the National Child Traumatic Stress Network and focused on TAY in child welfare, juvenile justice, and school settings. Presenters will highlight two novel approaches for addressing the needs of TAY including: 1) a documentary film illustrating trauma-related needs and strengths of a diverse group of system-involved youth, and 2) training methods for disseminating trauma-focused interventions to underserved youth across settings. Both techniques are designed to engage providers, caregivers and TAY in raising awareness and addressing the unique needs of TAY. We will also share lessons learned and data from statewide initiatives across service settings. Discussion will focus on identifying needs and ideas for integrating these approaches into practice across systems through education and intervention.
2pm – 3:15pm Symposium: Disaster Recovery Dynamics in Underserved versus Resourced Populations: A Critical Analysis From Hurricanes to Fires
  • The Impact of Natural Disaster on Young Adults: A Comparison Across Mainland United States and Puerto Rico
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  • Erika Felix, Melissa Janson, Natalia Jaramillo, Krzysztof Kaniasty, Glorisa Canino, Sonia Rubens, Annette La Greca
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  • Concern is growing for how climate change can impact the frequency and severity of natural disasters, with implications for population mental health. This multi-hazard, multi-site study focused on young adults in the developmental phase of emerging adulthood (ages 18-25 years). Following wildfires in California, and hurricanes in Texas, Florida, and Puerto Rico (PR), university students (N=916) completed online surveys about their disaster exposure, life stressors since the disaster, mental health, and beliefs about the world. Analyses explored patterns for the total sample, and by region and hazard. T-tests revealed that participants in PR reported significantly more stressors since the disaster (4.05 PR vs. 1.36 US), more symptoms of anxiety, depression, and posttraumatic stress (PTSS), and that their beliefs about the world changed less, compared to students in the mainland U.S. (all p<.001). Hierarchical regressions assessed the contributions of disaster exposure, life stressors, and beliefs on mental health by total sample and region. Patterns were similar for depression and anxiety, where greater life stressors and change in beliefs significantly predicted greater symptoms. There were regional differences on predictors of PTSS though. Implications of the post-disaster recovery context on the mental health of young adults will be discussed.
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  • Reciprocal Relations among PTSD, Coping, and Self-Efficacy in Rural Hurricane Survivors
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  • Heather Littleton, Charles Benight, Ashley Allen, Laura Haney, Emma Muscari

  • Low coping self-efficacy appraisals and reliance on avoidant and ruminative coping strategies are posited to lead to PTSD symptomology following trauma.  However, little work has examined potential reciprocal relations among these constructs, with extant studies having conflicting results.  The current study therefore sought to examine the reciprocal relations between hurricane-related PTSD and hurricane-related avoidant and ruminative coping as well as coping self-efficacy among a racially diverse sample of rural Hurricane Florence survivors (n = 142). Participants completed measures of hurricane-related PTSD, coping, and coping self-efficacy at baseline (T1; 5-7 months post hurricane) and then at 3 months (T2) and 6 months (T3).  Results of cross-lagged panel analyses supported that PTSD symptomology predicted problem avoidance coping at T2 and T3 (β = .15, .19), but problem avoidance did not predict PTSD at T2 or T3. PTSD symptomology predicted emotional avoidance coping at T2 and T3 (β = .28, .31) and emotional avoidance coping predicted PTSD symptomology at T2 (β = .13). Finally, PTSD symptomology predicted coping self-efficacy at T2 and T3 (β = -.15, -.31) and coping self-efficacy predicted PTSD symptomology at T3 (β = -.26). Implications of the findings for understanding disaster coping and recovery are discussed.
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  • Linear or Nonlinear? The Role of Perceived Sleep Quality and Coping Self-efficacy in Predicting Traumatic Distress among California Wildfire Survivors Across Time
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  • Aaron Harwell, Kotaro Shoji, Erika Felix, Charles Benight
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  • Self-regulation shift theory (SRST) describes the dynamics of self-regulation during posttraumatic adaptation, arguing that a subset of people will experience the self-determination violation effect. This effect, characterized by a broken sense of self-determination after exceeding a critical threshold of incongruence between expected and current perceived coping abilities, is thought to coincide with nonlinear shifts in functioning. Yet to be explored within SRST, is the impact of sleep quality, which may represent a key catalyst of nonlinear adaptation. Sleep, a core element of traumatic distress, is vital to self-regulation. This study involved 58 wildfire survivors who completed baseline and six-month surveys on their sleep, traumatic distress, disaster exposure, and coping self-efficacy (CSE). A mixed-effects cusp catastrophe model conducted on baseline to six-month traumatic distress scores did not evidence a significant nonlinear shift when disaster exposure functioned as the asymmetry controlling factor and sleep and CSE as bifurcation factors. Comparatively, the fit of a linear regression model was significant, with both higher sleep impairment (β = .32, p < .05) and lower CSE ratings (β = -.23, p < .05) predicting greater traumatic distress. Further investigation of factors that differentially associate with linear versus nonlinear shifts in functioning is warranted.
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  • Social Support Following Disasters: An Update on Empirical Advances and Recommendations for Future Research
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  • Krzysztof Kaniasty
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  • Disasters cause substantial and enduring psychological harm, yet many contemporary empirical studies examining post disaster mental health report impressive hardiness of survivors and note that relatively small portions of studied samples exhibit severe levels of psychological distress. There are many psychological and social resources and processes that empower humans to show resilience and recover successfully from calamities. Chief among them is the individual and collective capacity to maintain and augment, in times of adversity, survivors’ perceptions of being supported and belonging to a cohesive social group and community. Historically, two very different, at times conflicting, dynamic processes have been described in the literature as emerging in the aftermath of disasters: the initial outpouring of immense mutual helping and solidarity, followed by a subsequent sense of loss in the quality of interpersonal and community relationships. This presentation will focus on recent empirical findings in the area of disaster mental health to establish whether or not the parsimonious categorization of post disaster social support and community dynamics, along the two axes of mobilization and deterioration processes, can be still considered a reliable framework for understanding post disaster individual and communal resilience.
2pm – 3:15pm Symposium: Genomic perspectives on the impact of childhood abuse and adversity 
  • Chair: Nicole Nugent
  • Discussant: Nicole Nugent
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  • Polygenic Scores for Childhood Maltreatment and PTSD Predict Lifetime Cannabis Use via Adolescent Traits and Behaviors
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  • Leslie Brick, Chelsie Benca-Bachman, Rohan Palmer
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  • Molecular genetic research indicates that PTSD and childhood maltreatment (CM) are heritable and genetically correlated with several psychiatric traits. Further, PTSD is highly comorbid with cannabis use disorder, though few studies have examined their genetic overlap. The Transmissible Liability Index (TLI; an index of adolescent risk behaviors and traits) is heritable, genetically correlated with cannabis use (CU), and may be an important link between genetic liability and subsequent substance use. Thus, given the relationship between trauma and substance use, our objectives were to determine whether polygenic scores (PGS) for PTSD/CM were predictive of TLI and whether TLI mediated the relationship between PGS and lifetime CU. Data were from the National Longitudinal Study of Adolescent to Adult Health (N=4726 unrelated individuals of European Ancestry). Genome-wide association summary statistics from several large, published studies were used to derive Best Linear Unbiased Prediction estimates to generate PGS. Mediation analysis was used to characterize whether PGS were related to CU indirectly via the TLI. Results indicated that PGS for PTSD (b=.05, p<.01) and CM (b=.06, p=.01) were associated with higher TLI. Overall, findings indicate that PGS for trauma phenotypes are indirectly related to lifetime CU via greater liability indexed by adolescent traits and behaviors.
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  • Experience of Childhood Abuse is Associated with Polygenic Risk for Autism, Attention Deficit Hyperactivity Disorder, Schizophrenia, Major Depressive Disorder, and Neuroticism
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  • Andrew Ratanatharathorn, Karestan Koenen, Lori Chibnik, Peter Kraft, Janet Rich-Edwards, Marc Weisskopf, Andrea Roberts
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  • People who experience childhood abuse are at increased risk for mental illness. Twin studies suggest that part of this association is due to individuals who have experienced childhood abuse carrying genetic loading for mental illness. However this hypothesis has never been tested with genetic data. Using polygenic risk scores for attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), bipolar disorder (BPD), major depressive disorder (MDD), neuroticism, and schizophrenia, we tested whether genetic risk for mental illness was associated with increased risk of experiencing three types of childhood abuse: physical/emotional abuse, physical assault, and sexual abuse, in a cohort of women (N=11,315). ADHD and MDD genetic risk scores were associated with higher risk of experiencing each type of abuse, while neuroticism, schizophrenia, BPD, and ASD genetic scores were associated with higher risk of experiencing physical/emotional abuse and physical assault. Sensitivity analyses examining potential bias from differential recall of childhood abuse, parental socioeconomic status, and population stratification were consistent with the main findings. We found that genetic risk for mental illness was associated with experiencing childhood abuse, which may account in part for the increased risk for mental illness in individuals who have experienced childhood abuse.
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  • Epigenetic Signatures of Early Life Adversity in Youth: Cross-sectional and Longitudinal Associations
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  • Jennifer Sumner, Xu Gao, Simone Gambazza, Julia Knox, Andrea Baccarelli, Katie McLaughlin
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  • Early life adversity (ELA) may become biologically embedded via changes in DNA methylation (DNAm). We examined if specific ELA exposures were associated with DNAm cross-sectionally and longitudinally in 113 youth aged 8-16 years. At baseline and a 2-year follow-up, youths provided saliva for DNA and ELA was assessed, including presence/absence of abuse, interpersonal violence, and neglect. DNAm was measured with the EPIC array. Analyses examined 1) cross-sectional associations of each ELA type with DNAm and 2) longitudinal associations of exposure to each ELA type between baseline and follow-up with change in DNAm. Models adjusted for age, sex, ancestry PCs, cell-type PCs, and batch effects. Multiple testing was accounted for by controlling the FDR at 5%. In cross-sectional analyses, 2 CpG sites were significantly associated with abuse, 3 CpG sites were significantly associated with interpersonal violence, and 4 CpG sites were significantly associated with neglect. One CpG site was common to all ELA types but was associated with only abuse and interpersonal violence when adjusting for neglect. Two CpG sites were related to neglect when accounting for abuse. Neglect was significantly associated with DNAm change in 1 CpG site, even when accounting for abuse. Findings indicate that distinct ELA types may be characterized by different DNAm patterns that already manifest in youth.
2pm – 3:15pm Symposium: New advances in optimizing and augmenting current PTSD treatment: From the lab to the clinic
  • Boosting reappraisal of negative emotional memories with transcranial direct current stimulation
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  • Birgit Kleim, Rosa Bohlender, Nadja Dörig, Marius Moisa, Erich Seifritz, Christian Ruff
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  • Reappraisal of painful emotional memories helps us navigate through life effectively and is a cental element in trauma-focused cognitive behavior therapy (CBT). Here we apply transcranial direct current stimulation (tDCS) to enhance the effectiveness of reappraisal. In a randomized, sham-controlled, 2x2 between-subject and double-blinded study, we applied single sessions of anodal and sham tDCS over the right dorsolateral prefrontal cortex (DLPFC) of 101 healthy participants while reappraising or engaging in a control task. We hypothesized that (i) reappraising a personal negative emotional memory decreases memory-related negative valence, arousal and evaluations and leads to improved decision making, and (ii) tDCS leads to additional changes in these reappraisal outcomes. In line with these hypotheses, participants’ distressing autobiographical emotional memories were rated as less negative and less arousing following reappraisal. Anodal tDCS stimulation during reappraisal was associated with significant additional reductions in negative valence compared to sham stimulation. Our results indicate that tDCS may enhance some of the effects of reappraisal. If replicated, our findings point to potential benefits elicited by tDCS stimulation that may help to optimize current treatment approaches for emotional disorders, such as trauma-focused CBT.
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  • The impact of aerobic exercise on Brain Derived Neurotrophic Factor, fear extinction and response to exposure therapy
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  • Kim Felmingham, David Forbes, Simon Rosenbaum, Barbara Rothbaum, Sevil Ince
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  • This research examines the impact of aerobic exercise on Brain Derived Neurotrophic Factor (BDNF), fear extinction learning and exposure therapy responses in Posttraumatic Stress Disorder. Increased BDNF has been shown to facilitate fear extinction recall in healthy controls, and to improve fear extinction and exposure therapy response in PTSD patients.  The most robust way to increase central BDNF is via aerobic exercise.  This study examined the impact of aerobic exercise (vs gentle stretching control condition) in 30 healthy controls, serum BDNF was examine at baseline and following aerobic exercise and participants then completed a fear conditioning and extinction task.  Initial analyses reveal that serum BDNF levels are increased following aerobic exercise and there is improved fear extinction learning in this group compared to the control group.  Implications for exposure treatment for PTSD will be discussed, and the protocol of an ongoing clinical trial (comparing exercise+prolonged exposure vs gentle stretching and prolonged exposure) will be outlined.  Implications for adjuncts to facilitate exposure therapy for PTSD will be discussed.
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  • MDMA Facilitation of Fear Memory Extinction
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  • Barbara Rothbaum, Jessica Maples- Keller, Tanja Jovanovic, Seth Norrholm, Sheila Rauch, Boadie Dunlop
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  • 3,4-methylenedioxymethamphetamine (MDMA) has been observed to have lasting positive effects on symptoms of PTSD when combined with psychotherapy. Our group had previously shown that MDMA facilitates the extinction of fear in a rodent model (Young, et al., 2017). Given that many PTSD patients respond well to exposure-based therapies that rely on principles of extinction learning, it is hypothesized that MDMA may improve the effects of exposure-based therapy, particularly in treatment-resistant patients. The aim of the present study is to inform translational research by evaluating the impact of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) on extinction of fear learning following experimental startle and fear consolidation in a sample of healthy humans. Participants (n =34) were randomized to receive MDMA or pill placebo prior to extinction training. Fear conditioning was performed on Visit 1 (day 1); fear extinction training on MDMA or placebo was conducted on Visit 2 (Day 2); fear extinction recall was conducted on Visit 3 (Day 4). The primary objective of this study is to assess whether individuals who receive MDMA prior to extinction of conditioned fear will show lower startle responses during extinction recall compared to participants who receive placebo. As of 3/19/2020. 31 participants of the 34 have been completed as the study was paused for COVID-19.
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  • Do Attentional Deficits Differentially Predict PTSD Response to PE versus PE plus Sertraline?
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  • Emma PeConga, Peter Rosencrans, Alexandra Klein, Norah Feeny, Lori Zoellner
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  • Impairments in attention are associated with reduced response to CBT for PTSD that utilizes cognitive skills to mediate change (Crocker et al., 2018). Augmenting CBT with executive control training may enhance outcomes (Kuckertz et al., 2014). However, little is known about whether attention deficits impact the effectiveness of exposure-based treatments or if SSRI’s could mitigate this effect as they may broadly enhance cognitive functioning (e.g., Castellano et al. 2016). In a large clinical trial (NCT 01600456), 142 patients with PTSD completed a Flanker task (Eriksen & Eriksen, 1974), measuring attentional control, prior to receiving PE or PE plus sertraline. At baseline, higher attention deficits were not associated with age or PTSD severity. Using multi-level modeling, controlling for age and treatment type, worse attentional deficits at pre-treatment moderated PTSD symptom reduction (β = -3.23, p = .02, d = 0.28), particularly for avoidance symptoms (β = -1.47, p = .04, d = 0.25). Augmenting PE with sertraline did not alter this relationship (β = .07, ns). Impaired ability to modulate attention may slightly impair PTSD outcomes for PE, and pharmacological interventions did not mitigate this effect. Factors to mitigate these attentional deficits such as enhancing exposure engagement, better logistics management, or cognitive control training may help enhance outcomes.
2pm – 3:15pm   Workshop: Causal Discovery for Traumatic Stress Research: Advancing Knowledge on Etiology, when Experiments are not an Option  

Glenn Saxe, Sisi Ma

This workshop introduces participants to Computational Causal Discovery (CCD) methods for discovering causal factors from observational (i.e. non-experimental) data sets. These methods are proven mathematically to be able to correctly identify causal mechanisms from observational data under broad conditions, and they have demonstrated success when applied to various types of biomedical data, including data on risk factors for traumatic stress. However, many investigators in the field are unfamiliar with these methods and their potential for revealing causal factors. A causal factor is – by definition – a factor that – if changed – changes the likelihood of an outcome. Thus, knowledge on causal factors are required to advance knowledge on improving traumatic stress outcomes. Human experimental research can seldomly be conducted to discover causal factors, for practical and ethical reasons. This workshop begins with audience discussion to identify the research questions of greatest interest to participants, and then presentations will be oriented towards clarifying how CCD methods may be applied to answer these questions. Once participants are well oriented to the nature of CCD methods and their application, several examples of successful application of CCD methods to discover causal factors for traumatic stress will be presented and discussed.
5pm – 6:15pm Invited Panel: Early Intervention—What I’ve Changed My Mind On

Moderators: Meaghan O'Donnell, PhD and Nancy Kassam-Adams, PhD
Panelists: Jon Bisson, MD; Richard Bryant, PhD; Andrés Fresno, PhD; Richard Meiser-Stedman, PhD; Patricia Watson, PhD
5pm – 6:15pm Symposium: Understanding barriers to and dropout from trauma-focused care for women veterans in VA
  • Chair: Lillian Reuman
  • Discussant: Dawne Vogt
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  • Gender Differences in Therapy Experiences Contributing to Prolonged Exposure and Cognitive Processing Therapy Non-Completion
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  • Shannon Kehle-Forbes, Cassandra Fleming, Princess Ackland, Laura Meis, Melissa Polusny, Helen Valenstein-Mah
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  • At least one-third of veterans who initiate prolonged exposure (PE) and cognitive processing therapy (CPT) do not complete. Prior interventions designed to enhance treatment engagement among military personnel with PTSD have demonstrated differential effects for men and women. Tailoring engagement interventions by gender may improve their effectiveness; as such, we examined gender differences in therapy experiences that contributed to PE and CPT non-completion for male and female Veterans. Semi-structured interviews were conducted with a national sample of veterans who completed (n = 60; 20 women) and prematurely discontinued (n = 68; 24 women) PE and CPT. Constant comparative methods were used to identify differences in the therapy experiences of men and women, with a focus on factors related to therapeutic alliance. Preliminary analyses suggest that consistent with overall study findings, a strong working alliance facilitated completion for men and women. Unique contributors of alliance ruptures emerged; male veterans were particularly concerned by interactions that caused them to question their providers’ expertise. Women veterans were more likely to discuss not being believed or being invalidated by their provider and concerns regarding a lack of provider warmth. Implications for tailoring engagement interventions will be discussed.
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  • Emotion Dysregulation Predicts Dropout from Prolonged Exposure among Women Veterans with Military Sexual Trauma-Related Posttraumatic Stress Disorder
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  • Amanda Gilmore, Cristina Lopez, Wendy Muzzy, Brown Wilson, Anouk Grubaugh, Daniel Oesterle, Ron Acierno
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  • Although Prolonged Exposure (PE) is an evidence-based treatment, premature termination (i.e., dropout) is common. Treatment dropout from PE among women veterans with military sexual trauma (MST)-related posttraumatic stress disorder (PTSD) is also unfortunately common. However, it is unclear what factors are associated with treatment dropout from PE among women veterans with MST-related PTSD. We conducted secondary data analysis with an ongoing randomized clinical trial that telemedicine delivery of PE to in person delivery of PE for women veterans with MST-related PTSD (n = 118). Results revealed that 53.4% prematurely dropped out of PE (n = 63). The only factor associated with treatment dropout was difficulties with emotion regulation at baseline (Odds Ratio = 1.034, p = .010). In conclusion, emotion regulation may be a key component to consider within PE to mitigate premature termination.
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  • Identifying women veterans' beliefs and barriers regarding family involvement in PTSD treatment
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  • Lillian Reuman, Johanna Thompson-Hollands
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  • Women Veterans face unique considerations when deciding whether to include a family member (FM) in treatment for posttraumatic stress disorder (PTSD). Most research has focused on heterosexual male Veterans with PTSD; it remains unclear if and why women Veterans may be less likely to include FMs. To explore willingness to include a FM in treatment, women seeking treatment at a VA PTSD clinic (n = 71) completed measures assessing demographics, PTSD symptoms, and treatment preferences. The sample was diverse: 66% identified as heterosexual, 62% identified as White, and ages ranged from 22-70 years old. On average, Veterans endorsed clinically-significant PTSD symptoms (MPCL-5 = 41.78). Upon intake, Veterans were moderately willing to include a FM in treatment (M =5.34) and slightly more willing to include a FM in the future (M =6.24). Being married or identifying as non-heterosexual were associated with greater willingness to include a FM. Veterans tended to prefer including a partner rather than a child or parent. A subsample of female Veterans participated in qualitative interviews focused on beliefs and barriers regarding FM involvement in PTSD treatment. Major themes will be presented and future directions discussed. Our results will help clinicians and researchers determine if and how FM involvement might be most acceptable to treatment-seeking female Veterans with PTSD.
5pm – 6:15pm Symposium: Advances in PTSD Treatment
  • Chair: Meaghan O'Donnell
  • Discussant: Paula Schnurr
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  • Moderators and Mediators of PTSD Treatment Outcomes: Comparing Cognitive Processing Therapy and Written Exposure Therapy
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  • Brian Marx, Johanna Thompson-Hollands, Daniel Lee, Denise Sloan
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  • We have made significant advances in identifying effective PTSD treatments. The challenge now is gaining a better understanding of patient characteristics that predict success in specific PTSD treatments and the mechanisms through which these treatments reduce PTSD symptoms. In this presentation, we will describe both moderator and mediator analyses from a randomized controlled trial comparing Cognitive Processing Therapy (CPT) and Written Exposure Therapy (WET) for PTSD. Participants with PTSD (N = 126) were randomized to CPT or WET. PTSD symptoms and hypothesized mechanisms were assessed at each session and at each follow-up assessment. Moderator analyses revealed that participants with higher estimated intelligence at baseline experienced significantly greater PTSD symptom reduction through the 24-week assessment in CPT but not WET. Regarding mediators, change in negative trauma-related beliefs paralleled PTSD symptom reduction across session and follow-up assessments and correlated with symptom reduction in both conditions, but did not temporally precede symptom reduction. Between-session change in post-session self-rated pleasantness temporally preceded symptom reduction in WET but did not predict symptom reduction. Our findings have implications for treatment selection as well as suggest that previously proposed mechanisms instead may be correlates of symptom change.
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  • Massed prolonged exposure as a treatment for PTSD: A randomised controlled trial
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  • Lisa Dell, Meaghan O'Donnell, Richard Bryant, Stephanie Hodson, David Morton, Malcolm Battersby, David Forbes
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  • While many people respond well to evidenced based treatments of PTSD it may be that changing the delivery method will help improve engagement with, and response to, PTSD treatment. Method: In this randomised controlled trial (RCT) we tested if Prolonged Exposure delivered intensively over two weeks (massed delivery) would be comparable to Prolonged Exposure delivered in a standard 10 weekly session format (standard delivery). The study design was a multi-sited, non-inferiority two group RCT with assessments at pre, post and 12-month follow-up. Approximately 110 serving and ex-serving military members with PTSD will participate in this trial. Recruitment to the trial will be completed in June 2020. Data analysis will follow the intention to treat principle. Results: Analysis with (quantitative) outcome measures at each of the follow up time points will be performed using linear regression with change from baseline as the dependent variable, treatment group as the covariate of interest, and adjusting for the baseline value of the outcome measure and the stratification variables used in the randomisation. Results will be presented. Conclusion: Commentary will include usefulness (or not) of massed PE, and about treatment preference. Implication for targeting of treatment will be discussed. 
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  • Can a transdiagnostic, non-trauma focused intervention treat PTSD?
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  • Meaghan O'Donnell, Winnie Lau, Katherine Chisholm, James Agathos, Jonathon Little, Andrea Putica, Matthew Gallagher
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  • The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP: Barlow, Farchione, Bullis, et al., 2017) is an intervention that targets common mechanisms across multiple disorders. This study represents the first randomised controlled trial of UP in the treatment of trauma-related psychopathology including posttraumatic stress disorder (PTSD), depression and anxiety symptoms. Methods: Adults who developed PTSD, depression or an anxiety disorder after serious injury (N = 43) were randomly assigned to 10–14 weekly 60-minute sessions of UP (n = 22) or Usual Care (UC; n = 21). The primary treatment outcome was PTSD symptom severity using the PCL-5. ANCOVA compared primary outcome scores between groups at post-treatment and follow-up 6-months post-treatment by controlling for intake scores. Results: Participants within UP showed statistically significantly reductions in PCL-5 (Cohen’s d = 1.63), scores compared to those receiving UC. These effects were maintained at 6-month follow-up.  At post-treatment, statistically significant losses in PTSD diagnosis were observed for participants within UP but not UC. Conclusions: This study provides evidence that UP may be an effective non-trauma-focused treatment for PTSD and other trauma-related psychopathology. Non-inferiority studies of UP against a PTSD evidence based treatment like Prolonged Exposure are required.   
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  • How Do We Make Psychotherapy for PTSD More Effective For More People?
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  • Paula Schnurr
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  • We have a number of effective PTSD treatments, but many—even most—people still have some symptoms after a successful course of treatment. Trauma-focused psychotherapy is most effective, and there are also effective non-trauma-focused options. Although the effectiveness of the best psychotherapies for PTSD is comparable to the effectiveness of psychotherapies for other disorders such as depression, there is room to improve PTSD treatment effectiveness. PTSD does not have to be a chronic disorder—we know this from seeing that some people recover and achieve sustained remission. To advance the field we need to address the following key research questions: (1) What strategies make our effective treatments more effective? (2) Where are we with treatment matching—optimizing treatment selection based on a patient’s characteristics and preferences? and (3) What do we do when response is incomplete? These questions will be discussed in commentary of the papers presented in this symposium.
5pm – 6:15pm Symposium: Identifying Barriers and Mechanisms for the Treatment of Racial Trauma Among Black Communities: Implications for Bridging Science and Practice  
  • Ketamine-Assisted Psychotherapy for PTSD Related to Experiences of Racial Discrimination
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  • Monnica Williams, Mailae Halstead, Sara Reed
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  • This presentation will describe ketamine-assisted psychotherapy for a client with treatment-resistant, posttraumatic stress disorder (PTSD) as a result of experiences of racism in the workplace, as well as childhood abuse for which she had been previously treated. Presenting symptoms included hypervigilance, social avoidance, hopelessness, and intense recollections, impacting all areas of functioning. Psychoeducation was provided on intergenerational trauma, which was compounded by additional traumatic experiences, potentiating the client’s PTSD and maladaptive coping mechanisms. Ketamine was administered four times over a 13-day span as an off-label, adjunct to psychotherapy. Therapeutic interventions utilized included mindfulness-based CBT, ACT, and Functional Analytic Psychotherapy. The client obtained new skills to respond effectively to negative self-talk, catastrophic thinking, and feelings of helplessness. Treatment led to clinically significant reductions in symptoms, measured by the Posttraumatic Cognitions Inventory and Beck Depression Inventory-II, with gains maintained post-treatment. This case demonstrates effective use of ketamine as an adjunct to psychotherapy for an African American with treatment-resistant PTSD.  Considerations for conducting psychedelic therapies with racialized clients will also be discussed.
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  • EMBRace: The Development of a Racial Socialization Intervention to Reduce Racial Stress and Trauma and Enhance Racial Coping with Black Families
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  • Riana Anderson
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  • Racist environments have consistently predicted Black youth’s poorer psychosocial outcomes during adolescence and over time. In particular, racial stress and trauma interferes with their standard coping processes and, in turn, is associated with more depressive symptoms. However, racial coping has been shown to mitigate the effects of discrimination and promote more desirable psychosocial outcomes in Black youth. Parents influence youth’s racial coping processes through racial socialization, or the racial beliefs and behaviors transmitted between parents and youth. And, while the vast majority of parents utilize racial socialization, few evidence-based clinical interventions have been developed to improve racial socialization practices. Of exception is the therapeutic intervention EMBRace (Engaging, Managing, and Bonding through Race), which seeks to improve familial competencies in the racial stress and coping process. This research presentation will demonstrate a method by which therapeutic intervention can mitigate the pernicious effects of racial discrimination experienced by Black youth. Our preliminary evidence from the pilot of EMBRace with 15 families will demonstrate how racially-specific socialization and coping processes are critical in the reduction of contemporaneous racial stress and trauma and factors relating to later disparities in health for Black youth.
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  • Rumination as a Mediator of the Association Between Racial Discrimination and Mental Health Among Black Youth
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  • Donte Bernard, Colleen Halliday, Harlee Onovbiona, Laura Carpenter, Carla Kmett Danielson
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  • There is a strong corpus of research that has established the deleterious effects of racism related stress and trauma among Black adolescents and young adults. In particular, studies have linked racism-related incidents with an increase in symptoms of depression and anxiety. Rumination represents a specific maladaptive self-regulatory response that may explain the link between racial discrimination and mental health. However, scholars have yet to examine how rumination may shape psychological adjustment earlier in development. Indeed, Black children may be particularly vulnerable to racial discrimination and may ruminate about these negative race-related incidents more than their older counterparts, as they may not possess the skills necessary to adaptively appraise and cope with such experiences. Thus, to advance previous research, we examined rumination as a mediator of the link between racial discrimination and psychological adjustment (i.e., anxiety and depression) among a sample of Black youth (N = 132, mAge = 11.32, SD = 2.44). Consistent with previous literature, rumination was found to mediate the association between discrimination and both indicators of mental health. Results suggest that rumination represents an important and targetable mechanism that can assuage the impact of racial discrimination on the psychological health of Black youth.
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  • Towards Improving Racial Trauma Treatment: A Qualitative Approach to Understanding Barriers and Facilitators to Service Utilization at a Children’s Advocacy Center
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  • Isha Metzger
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  • African Americans are significantly less likely to receive evidence-based services (e.g. forensic interviews, physical exams, mental health assessments, mental health treatment) following stressful life events despite being at greater risk for traumatic experiences, particularly those that are racially motivated. Children’s Advocacy Centers (CACs) are part of the acute response after a concern for interpersonal violence to provide services to children and families to help prevent and treat negative sequelae. However, these organizations do not currently consider racial stress and trauma in their intakes, assessment, or treatments. For this qualitative study, we conducted community based participatory research to identify client, provider, and organizational barriers and facilitators to service and utilization for African American families following trauma exposure. Specifically, we conducted semi-structured in-person key informant interviews with a sample of 15 African American caregivers (mAge = 33.58, SD = 5.25, range = 26 to 42) of CAC-referred. We present qualitative findings on caregivers’ perspectives on (1) satisfaction with service accessibility, delivery and content, (2) perceived racial barriers to service utilization, and (3) cultural considerations and suggestions to facilitate engagement and retention in services.
5pm – 6:15pm Flash Talks Session 4 
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Friday, November 13

10am – 11:15am Invited Speaker: Wrong Place, Wrong Time: Understanding Violence through the Lens of Racial Trauma

John A. Rich, MD, MPH
10am – 11:15am Symposium: Novel Brain-Based Interventions for PTSD and Their Potential Mechanisms of Action 
  • Chair: Sanne van Rooij
  • Discussant: Paul Holtzheimer
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  • Transcranial Magnetic Stimulation for Posttraumatic Stress Disorder
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  • Noah Philip
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  • Posttraumatic stress disorder (PTSD) is a severe and disabling psychiatric disorder; many currently available treatments have modest efficacy or are limited by their side effect profile. To this end, we have been developing transcranial magnetic stimulation (TMS) as a novel intervention for PTSD. TMS uses fluctuating magnetic fields to induce depolarization or changes in targeted brain regions, resulting in polysynaptic effects to improve symptoms. This session will review a variety of novel uses of TMS for PTSD; these will include neuroimaging predictors and mechanisms of treatment success. It will also describe a new form of TMS, called theta burst stimulation, which has emerging evidence it is effective for PTSD.  This session will include several elements of unpublished data, inclusive of the use sparse montage, dry EEG and machine learning to identify and validate neural signals associated with response to active stimulation, compared to sham (N=50), particularly within the delta frequency domain with results (p<.001, corrected for multiple comparisons and several levels of cross validation). This session will thus highlight mechanistic research that can identify brain circuits involved in the disorder, with immediate applications towards the design of novel interventions and refinement of current treatment protocols, with real-world ramifications for clinical care.
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  • Towards Individualized Transcranial Direct Current Stimulation for Posttraumatic Stress Disorder 
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  • Mascha van 't Wout-Frank, Alexis Harle, David Sorensen, Noah Philip

  • Transcranial direct current stimulation (tDCS) shows promise in modulating cognitive processes underlying psychiatric disorders and improving psychiatric symptoms. Individual neuroanatomy affects the electrical current flow generated by tDCS, yet tDCS intensity is currently not determined on an individual basis. Here we present unpublished data on 27 adults demonstrating electrical field variability associated with the application of a fixed, 2 mA tDCS intensity as part of a randomized controlled trial of tDCS plus virtual reality for PTSD. Electrical field values for two neural targets were extracted: one associated with “fear” processing and one associated with “extinction”, given their relevance to PTSD. tDCS intensity was then reverse-calculated in order to estimate what tDCS intensity was needed for each individual to establish the average electrical field associated with both of these neural targets. Results showed a range in obtained electrical field values from 0.12 - 0.34 V/m across both neural targets. Individualized reverse-calculation suggests tDCS intensities should have ranged from 1.36 - 3.04 mA. This indicates that this approach is feasible: the adjusted current range would be within acceptable safety limits for tDCS. Furthermore, this demonstrates the importance and near-term implementation of individualized current density modeling in tDCS research for PTSD.
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  • The Effect of Unilateral Amygdala Ablation on PTSD Symptoms and Neuroimaging Biomarkers
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  • Sanne van Rooij, Kelly Bijanki, Timothy Ely, Jennifer Stevens, Amy Murphy, Sean Minton, Yara Mekawi, Tanja Jovanovic, Jon Willie
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  • Heightened (right) amygdala activation has consistently been observed in PTSD patients and shown to predict PTSD treatment non-response, suggesting the amygdala as a target for therapy. Notably, brain injury inclusive of the amygdala is protective against developing PTSD. Because of its invasive nature, neurosurgical interventions have not been studied for PTSD. Here we describe findings from a unique opportunity to prospectively study the effects of unilateral amygdala laser ablation in treatment-refractory epilepsy patients without otherwise altering care. A total of 12 epilepsy patients have been included in the study, 4 of whom met DSM-5 criteria for PTSD prior to surgery. Follow-up data from 3 patients indicated amelioration of PTSD 12 months after R amygdala ablation (N=2), but not L ablation (N=1). Patient 4 (R ablation) reported profoundly abated PTSD symptoms in the first month after surgery, but objective measures are pending. Furthermore, an fMRI scan pre- and 6 months post-surgery was collected from 5 patients. R amygdala ablation (N=2) resulted in a decrease in L amygdala and increase in vmPFC activation as measured during a fearful faces task, whereas L amygdala ablation resulted in a decrease in vmPFC activation. These findings suggest that specifically R amygdala ablation is associated with improvement of PTSD symptoms and biomarkers.
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  • Deep Brain Stimulation for Post-Traumatic Stress Disorder
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  • Clement Hamani
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  • Deep brain stimulation (DBS) has shown promising results for a number of psychiatric indications. Preclinical models of psychiatric disorders have good validity for studying the effects and mechanisms of DBS. We applied ventromedial prefrontal cortex stimulation to rodents (n=8-11 per group) and showed improvements in post-traumatic stress disorder (PTSD)-type behavior, mainly reduced fear (p=0.02) and anxiety-type responses (p=0.02). In addition, DBS-treated animals had changes in metabolic profile and a decrease in firing of principal cells in the basolateral amygdala(p<0.01), a region intimately involved in mechanisms of fear, anxiety and PTSD. Based on these results, we conducted a clinical trial using DBS to treat patients with refractory PSTD. Preliminary results showing the safety and efficacy of DBS will be presented.
10am – 11:15am Symposium: Treatment of distress in (traumatically) bereaved children and adults
  • “GriefHelp” a CBT Treatment for Disturbed Grief in Children: Findings from a Randomized Controlled Trial
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  • Paul Boelen, Lonneke Lenferink, Mariken Spuij
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  • Objective: Some children fail to recover after the death of a parent or sibling. Few attempts have been made to develop and test treatments for this group. We developed “GriefHelp”, a nine-session, cognitive-behavioral therapy (CBT) based treatment targeting symptoms of prolonged grief disorder (PGD) and other emotional problems. The current RCT sought to examine the efficacy of this approach compared to non-directive supportive counseling. 

    Methods: Over 130 children were assigned to either CBT GriefHelp or supportive counseling – both accompanied by 5 sessions of counseling offered to parents/caretakers. Symptoms of PGD, posttraumatic stress, and depression were assessed before and after treatment and at 6 months follow up. Negative cognitions, avoidance behaviors, and parenting behaviors were also assessed before and after treatment. 

    Results: CBT GriefHelp coincided with stronger declines in symptoms compared to supportive counseling. Reductions in symptoms coincided with reductions in negative cognitions and avoidance.

    Conclusions: CBT GriefHelp is a efficacious approach to alleviate the suffering of children and adolsents getting stuck in their proces of adjustment to the death of a loved one. The effects of this treatment are, at least partially, attributable to its impact on reducing negative cognitions and maladaptive avoidance behaviours.
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  • Relaxation and Mindfulness Interventions Improve Grief Outcomes in Widows and Widowers: A Three-Arm Comparative Trial
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  • Lindsey Knowles, Krystal Jovel, Candace Mayer, Kenneth Bottrill, Alfred Kaszniak, David Sbarra, Erika Lawrence, Mary-Frances O'Connor
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  • Following bereavement, prolonged yearning and grief rumination are repetitive cognitive processes that can lead to disordered grief. Mindfulness training (MT) has been shown to reduce maladaptive repetitive thought in healthy and clinical populations. The current trial examined the feasibility, acceptability, and preliminary efficacy of MT for grief. Ninety‑five widow(er)s between six months to four years post-loss were assigned to a 6‑week MT intervention, Progressive Muscle Relaxation (PMR) intervention or wait‑list condition. They completed self-report measures of grief severity, yearning, grief rumination, and decentering at baseline, weeks 2 and 4, post-intervention/wait-list and 1-month follow-up. The MT and PMR groups reported declines in grief severity and yearning through the 1‑month follow‑up, although only the PMR group showed a difference in rate of decline compared to wait‑list. Moreover, reductions in yearning mediated the declines in grief severity. The MT, PMR, and wait‑list groups showed decreases in grief rumination across all time points. The PMR and wait‑list groups showed significant increases in decentering across time compared to the MT group. The study findings support the feasibility, acceptability, and preliminary efficacy of MT and PMR for improving grief outcomes in widow(er)s and suggest that PMR is most effective compared to the wait‑list control.
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  • The potential effectiveness of a traumatic-grief focused cognitive behavioral therapy for homicidally bereaved children and young people
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  • Suzan Soydas, Geert Smid, Barbara Goodfellow, Rachel Wilson, Eva Alisic, Paul Boelen
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  • Background: Despite growing interest in the mental health of homicidally bereaved children, literature on risk and protective factors and responses to treatment is still scarce and often relies on small samples. 
     
    Objectives: To explore the potential effects of a traumatic grief-focused cognitive behavioral therapy (TG-CBT) and to investigate whether a change in symptoms differs between relevant subgroups of bereaved children and young people.
     
    Methods: We analysed the data of 162 homicidally bereaved children and young people who received TG-CBT. At baseline and end of the TG-CBT, PTS-symptoms were measured with the Children’s Impact of Event Scale-8. To examine the baseline- and change in symptom severity as a function of sociodemographic and homicide related predictors, a latent growth model was deployed in AMOS.
     
    Results and conclusions: Children and young people experienced high levels of stress at baseline and showed substantial improvement at the end of treatment. The current model of TG-CBT shows promising results in improving the mental health of homicidally bereaved children and young people. Several significant sociodemographic and homicide related factors were found; it appears important to tailor treatment considering the complex interplay of emotional, judicial, financial and societal challenges following a homicide.
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  • Disturbed Grief, Posttraumatic Stress, and Depression Symptoms in Disaster-Bereaved People: Symptom-Profiles, Temporal Associations, and Treatment
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  • Lonneke Lenferink, Angela Nickerson, Geert Smid, Jos de Keijser, Paul Boelen
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  • In a Dutch cohort study, we conducted two studies, examining the course of persistent complex bereavement disorder (PCBD), posttraumatic stress disorder (PTSD), and depression in 172 bereaved people after a disaster with flight MH17. People completed surveys 11, 22, 31, and 42 months post-disaster. To identify (predictors of) trajectories of PCBD, PTSD, and depression (study 1) and to examine temporal associations between these symptoms (study 2) latent class growth and cross-lagged analyses were used, resp. In study 3, 39 people were included in an RCT examining the effects of cognitive therapy (CT) + EMDR (vs. waitlist controls).

  • In study 1, a Mild and Chronic PCBD class emerged. For PTSD and depression we found a Mild, Recovered, and Chronic trajectory. Lower education predicted Chronic trajectories. In study 2, changes in PCBD symptoms had a greater impact on changes in PTSD and depression than vice versa. Study 3 showed that PCBD, PTSD, and depression symptoms significantly declined for both groups with a stronger decline in depression after CT+EMDR.

    We found support for differential trajectories across outcomes, suggesting that different profiles may need different treatments. Our findings run counter to the notion that PTSD and depression symptoms should be addressed before grief in treatment. We suggest that CT+EMDR might be useful, but there is room for improvement.
10am – 11:15am Panel: Sustaining Non-Specialists to Deliver Mental Health Services for Trauma Survivors in LMICs: Barriers, Opportunities and Innovations

Jessica Lambert, Mary Bunn, Leah James, Jordan Farrar

A primary barrier to addressing the treatment gap for trauma-affected populations in low-and middle-income countries (LMICs) is a lack of mental health specialists and limited options for formal training. There is increasing evidence that lay persons or non-specialists can be trained to deliver effective psychological interventions for common mental disorders (Singla et al., 2017). Yet, much is left to be learned about implementation and sustainability of such task-shifting approaches for culturally diverse populations in contexts with complex social and political dynamics. This panel will involve a structured discussion of “barriers, opportunities, & innovations” in the implementation of evidence-based interventions by non-specialist providers in LMIC with populations exposed to trauma and adversity. The panelists with varied backgrounds bring expertise in research, program development, and clinical practice. They will summarize the state of knowledge in this area and share lessons learned from mental health programs in post-conflict settings, refugee settlements, and urban slums. Key themes will include long-term training and supervision of non-specialists, preventing and addressing vicarious traumatization among providers, and bridging science and practice to work towards sustainable, effective mental health services for trauma survivors in low resource contexts.
2pm – 3:15pm Symposium: Traumatic Stress and Pregnancy: Implications for Low-Income, High-Risk Women and Children 
  • Intimate Partner Violence Perpetration and Victimization in a High-Risk Sample of Pregnant Women
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  • Jade Kobayashi, Kristyn Wong, Alytia Levendosky, G. Anne Bogat, Joseph Lonstein, Maria Muzik, Amy K. Nuttall
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  • Traumatic experiences in childhood are thought to disrupt the attachment process, resulting in more problematic interpersonal styles and increased risk for intimate partner violence (IPV) in adulthood. More than half of individuals who report IPV victimization also report perpetration. For some couples, pregnancy and the transition to parenthood leads to increased relationship stress, decreases in intimacy, and increased conflict. The situational couple violence theory suggests that bidirectional IPV is considered an aggressive response to interpersonal problems that arise within couple relationships, including during the context of pregnancy. The current study will use person-oriented models to examine risk factors, including childhood trauma and interpersonal problems, to predict patterns of IPV perpetration and victimization in a high-risk sample of women (N = 321) interviewed during pregnancy. Preliminary latent-class analyses using measures of IPV perpetration, victimization, childhood experiences of abuse, and interpersonal problems suggested four classes: high victimization (3%), moderate bi-directional violence (15%), moderate perpetration group (3%), low violence, high childhood trauma (77%). Findings suggest that trauma-informed and relationally focused interventions may be important for reducing risk for IPV during pregnancy.
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  • Effect of Emotion Dysregulation on Prenatal Attachment Quality in Trauma-Exposed Women
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  • Kara Cochran, G. Anne Bogat, Alytia Levendosky, Joseph Lonstein, Amy K. Nuttall, Maria Muzik
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  • During pregnancy, trauma in past and present attachment relationships may become particularly salient and influence the woman’s thoughts and feelings towards her unborn baby. Negative attributions about the fetus have been associated with impairments in postnatal attachment and parenting. Women who lack effective emotion regulation strategies may be more likely to make negative attributions about the fetus. The present study investigated emotion dysregulation as a potential mediator between interpersonal trauma [childhood trauma, intimate partner violence (IPV)] and prenatal attributions. 321 women from an ongoing longitudinal study reported on childhood trauma and IPV during pregnancy. Self-report and physiological (RSA) measures of emotion dysregulation were collected in the 32-34th week of pregnancy, as was a measure of prenatal attributions. Path analyses indicated that childhood trauma and pregnancy IPV positively predicted emotion dysregulation, and emotion dysregulation was associated with more negative attributions. Emotion dysregulation mediated the effects of both childhood trauma, 95% CI [-.12, -.02], and IPV, [-.14, -.02], on prenatal attributions. Women with trauma histories face challenges forming positive relationships with their infants. Interventions targeting emotion regulation during pregnancy may be a promising avenue for mitigating risk.
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  • Associations between Adverse Childhood Experiences (ACEs) and Obstetric Outcomes in Disadvantaged Pregnant Women
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  • Alissa Huth-Bocks, Divya Jasthi, Marie Masotya, Scott Frank, Sarah Ronis, Tamika Williams, Sarah Nagle-Yang
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  • Rates of exposure to traumatic stress and health inequities are high among low-income, African-American individuals. The effects of such experiences are especially relevant for pregnant women due to concerns about both mothers’ and their infants’ psychological and physical health outcomes. The current study presents findings from an innovative, trauma-informed OB/Gyn healthcare setting in an inner-city. Participants included 94 pregnant women (18-39 years; X=26; SD=4.7; 8-38 weeks gestation; X=25; SD=8.1) receiving prenatal care who were referred to a mental health care coordinator due to elevated mental and/or psychosocial risks. Women were mostly publicly-insured (94%), single (90%), and black/African-American (93%). Women completed several rating scales to assess exposure to Adverse Childhood Experiences (ACEs; X=4; SD=2.6) and current mental health symptoms; data on medical health and obstetrical complications were extracted from medical charts. Results revealed that greater childhood adversity, including traumatic stress, was significantly related to more anxiety and mood dysregulation, as well as several obstetrical problems such as hypertension and premature labor; women with >4 ACEs also reported more suicidality. Findings confirm the critical role that primary health care providers have in identifying and providing trauma-informed services to vulnerable populations.
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  • Perinatal Complications for Pregnant Women Exposed to Intimate Partner Violence: The Moderating Role of Posttraumatic Stress Symptoms
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  • Hannah Gilliam, Kathryn Howell, Julia Paulson, Laura Miller-Graff
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  • Both intimate partner violence (IPV) and posttraumatic stress disorder (PTSD) increase risk for poor pregnancy outcomes, but associations between IPV exposure, mental health and perinatal complications remain underexplored. This study assessed the interaction of four types of IPV exposure (i.e. psychological, physical, sexual, injury) and PTSD on perinatal complications (e.g., preeclampsia, gestational diabetes) among 137 IPV-exposed pregnant women (Mage=27.3, SD=6.0). Four regression models were run to test the main and moderating effect of each type of IPV and PTSD on pregnancy complications, controlling for age, childhood trauma and current drug use. All four IPV domains displayed significant interactions with PTSD: psychological aggression (PS; F=2.42, p=.03, R2=0.10, β=.002), physical assault (PA; F=2.37, p<.03, R2=0.10, β=.002), sexual coercion (SE; F=3.36, p<.01, R2=0.14, β=.004), and injury (IN; F=2.73, p=.02, R2=0.11, β=.006). Women who met clinical cut-off for probable PTSD and had higher IPV exposure reported more perinatal problems. Main effects of PTSD were also observed in each model (PS (β=.10, p=.02), PA (β=.11, p=.01), IN (β=.11, p=.01), SE (β=.10, p=.02)), with probable PTSD associated with more complications. The combined effects of clinically significant PTSD symptoms and IPV exposure may be uniquely harmful within the context of perinatal maternal health.
2pm – 3:15pm Symposium: Drinking to Cope: Processes and Factors Underlying Co-Occurring PTSD and Alcohol Use Problems in Varied Trauma-Exposed Populations
  • PTSD Symptom Dynamics Predict Daily Binge Drinking in University Students
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  • Lance Rappaport, Ananda Amstadter
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  • The present study uses ecological momentary assessment to examine whether within-person fluctuations in PTSD symptoms predict when people binge drink. For 14 days, students who experienced a potential traumatic event (N=276) reported nightly on use of alcohol and illicit substances and thrice daily on current affect and symptoms of PTSD, anxiety, and depression. Daily binge drinking was computed following the NIAAA definition and analyzed using multilevel logistic regression. Participants were more likely to binge drink on days during which they reported elevated PTSD symptoms, OR=2.82, 95%CI (1.35, 5.92), p<0.01. Binge drinking was also more likely on weekends, OR=4.21, 95%CI (2.19, 8.10), p<0.0001, and days marked by elevated positive affect, OR=1.60, 95%CI (1.23, 2.08), p<0.001, but not associated with concurrent depressive or anxiety symptoms (p’s>0.29). PTSD symptoms were not associated with use of cannabis or illicit substances (p’s>0.05). In testing the susceptibility model, on the day following a binge drinking episode, participants reported elevated depressive symptoms, B=0.28, 95%CI (0.05, 0.51), p=0.02, though binge episodes were unrelated to subsequent affect or symptoms of PTSD or anxiety (p’s>0.21). Results suggest that, beyond identifying who is at risk for binge drinking, fluctuations in PTSD severity clarify when university students engage in binge drinking.
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  • Distinct Associations of Subjective and Objective Stress Responses with Interpersonal Trauma, PTSD, Stress-Induced Drinking, and Drinking to Cope in Young Adults
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  • Austin Hahn, Carla Kmett, Zachary Adams, Ananda Amstadter, Suzanne Thomas, Kaitlin Bountress, Casey Calhoun
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  • The goal of this study was to understand how interpersonal trauma, posttraumatic stress, acute stress response, and drinking to cope converge to predict stress-induced drinking, a risk factor for alcohol use disorder. Young adults without a substance use disorder were classified into three trauma history groups: 1) interpersonal trauma-exposure history (TE) with posttraumatic stress disorder (PTSD) (n=27); 2) TE without PTSD (n=35); and 3) Control (no trauma-history/no PTSD; n=36). Participants completed a baseline-assessment, including a structured clinical interview to confirm PTSD diagnosis, followed by a standardized stressor (Trier Social Stress Test; TSST) and an alcohol use task. Subjective units of distress and blood serum cortisol were collected at pre- and post-TSST time points. Results indicated that participants in the PTSD group had significantly higher drinking to cope motives, which were associated with greater subjective reactivity; however, neither drinking to cope motives nor subjective reactivity to the TSST predicted post-stressor alcohol consumption for those with PTSD. Possible explanations for the unexpected group differences in stress-induced drinking behavior and suggestions for future research designs that could help clarify the findings of this study will be discussed.
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  • Tension-Reduction Alcohol Expectancies, Post-Traumatic Stress Disorder, and Alcohol Use in a Combat-Exposed Veteran Sample
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  • Brianna Jackson, Christina Sheerin, Ananda Amstadter
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  • The co-occurrence of alcohol use disorder (AUD) and PTSD in trauma-exposed veterans is well-established. The self-medication model has been proposed as a possible explanation for this comorbidity; thus, tension-reduction alcohol expectancies may play a moderating role. Mixed results have been found for alcohol expectancies in the context of PTSD, and it is unknown whether tension-reduction alcohol expectancies are associated with alcohol use in trauma-exposed veteran populations. We examined whether tension-reduction alcohol expectancies (Alcohol Expectancy Questionnaire-Tension Reduction Subscale [AEQ-TR]) moderated the association between PTSD symptoms (via the CAPS) and alcohol use outcomes (i.e., frequency/quantity, binge drinking) in a sample of 387 combat-trauma exposed veterans (89.7% male; Mage=30.3[4.49]). Contrary to expectations, the AEQ-TR did not show main or interaction effects on any alcohol use outcomes (all ps >0.23), even when distress tolerance did. Further, the AEQ-TR was not associated with similar constructs, namely coping drinking motives (r=-.09, p=.09) nor distress tolerance (r=.02, p=.67). Results suggest tension reduction alcohol expectancies may have limited utility in understanding alcohol use in veterans. Future studies should examine alternative measures of alcohol expectancies and how this relationship may differ across trauma type populations.
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  • Latent Profiles of Drinking Motives and their Association with Alcohol Use Outcomes in Combat-Trauma Exposed Veterans in the Context of PTSD
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  • Christina Sheerin, Kaitlin Bountress, Sage Hawn, Ananda Amstadter
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  • The self-medication model posits individuals use alcohol to cope with PTSD and is a readily accepted model of PTSD-alcohol co-occurrence. Thus, among the drinking motives, coping (COP) is most frequently studied in trauma populations. However, enhancement (ENH) and social (SOC) motives may also increase problematic alcohol use but have been less well studied. Using latent profiles incorporating these three motives, we tested their association with alcohol use outcomes (frequency/quantity, binge drinking, AUD) in combat trauma-exposed veterans with and without PTSD (N=175, 89% male, Mage=30.67). A three-profile solution fit best: moderate on SOC, low on COP/ENH (class 1, n=95), moderate on all (class 2, n=59), high on all (class 3, n=21). Those with PTSD were more likely to be in the moderate or high group (classes 2 and 3; X2=17.47, p<.001). Between-subjects MANCOVAs were conducted with latent class membership predicting alcohol use phenotypes, covarying for PTSD severity. Classes 2 and 3 were associated (p<.001) with higher average frequency/quantity and binge drinking than class 1. Class 3 was associated with greater AUD diagnosis likelihood than the other two (p<.001, p=.01, respectively). Moderate to high endorsement on all three drinking motive types is important for understanding problematic alcohol use, but risk for AUD may be more specific to greater drinking motives.
2pm – 3:15pm Workshop: Conceptualizing and Treating the Effects of Trauma within Muslim War-torn Refugee Communities

Norah Feeny, Luul Ahmed, Kawther Musa, Alexandra Klein, Lori Zoellner, Jacob Bentley

This workshop will discuss the varied psychosocial experiences of Muslim refugee populations and a culturally-informed program designed to address trauma-related difficulties associated with war and refugee trauma. We will specifically focus on U.S. Somali refugees including the cultural, religious, and psychological factors that influence the psychosocial functioning of resettled refugees. The role of Islam will be highlighted as a potential route to increase access and uptake of mental health services. We will conclude by providing an overview of Islamic Trauma Healing – a lay-led, mosque-based, culturally-specific trauma-focused cognitive behavioral therapy (Zoellner et al., 2018). Islamic Trauma Healing integrates key components of cognitive restructuring, imaginal exposure, and social support with core Islamic principles to address trauma-related concerns and promote community reconciliation. Pilot data and qualitative analyses regarding acceptance and preliminary efficacy of the program will be presented. Attendees will gain a further appreciation for the refugee experience, a better sense of the centrality of Islam in the lives of many refugees, and a practical understanding of a science-informed, faith-based model for addressing the mental health consequences of war and refugee experiences.
2pm – 3:15pm Symposium: Reaching the Hard-to-Reach: Examining use of Video Telehealth to Provide Evidence-based Psychotherapy for PTSD to Veterans
  • Chair: Ellen Healy
  • Discussant: Kathleen Chard
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  • Comparison of EBPs for PTSD in a Veteran Telehealth Sample
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  • Kathleen Chard, Nicole Pukay-Martin, Colleen Martin
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  • Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD have been examined in various formats and settings, including in-person and telehealth modalities. Previous literature has shown telehealth to be as efficacious as in-person visits in reducing symptoms of PTSD in veteran samples using both CPT and PE; however, few studies have compared the two EBPs for PTSD in an outpatient telehealth sample. In this presentation, outcomes from CPT and PE delivered via telehealth are presented in sample of veterans engaged in outpatient PTSD specialty treatment. Veterans (N = 227) were referred for CPT or PE delivered via televideo. Preliminary analyses included data on measures of PTSD symptomatology over the course of both treatments delivered via telehealth. The sample consisted of mostly White (81.7%), male (89.4%) veterans, who received services mostly via telehealth to home (32.6%). Participants were on average 49.7 years old (SD = 15.26), with initial mean PCL-5 score of 55.63 (SD = 13.28). Veterans attended an average of 8.03 sessions (SD = 5.03). Results of preliminary analyses demonstrated significant decreases in PTSD symptoms in both CPT and PE from pre- to post-treatment (p < .001) but no significant difference between treatments. Clinical implications of conducting CPT and PE via telehealth for veterans in outpatient PTSD treatment are discussed.
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  • In-Person vs. Remote (Telehealth) Delivery of Cognitive Processing Therapy for PTSD
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  • Harrison Weinstein, Erika Roberge, Steven Allen
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  • The PTSD Clinical Team at the Salt Lake City VA Health Care System strives to provide high quality care to all Veterans in our catchment area. Unique challenges present in this care network that serves a diverse Veteran population across three largely rural states (Utah, Nevada, and Idaho). Many Veterans access care through telehealth at one of nine outpatient clinics or from home on personal electronic devices. This study provides an overview of how Veterans receive PTSD care and explores the effectiveness of virtual delivery of Cognitive Processing Therapy in terms of completion rate and outcome data. The results have applicability in terms of clinical decision making and program development in a real world setting with unavoidable limitations. A discussion of patient and staff experiences will be included with emphasis on increasing access to care, optimizing telehealth delivery, and unique challenges that present in this modality.

  • Evaluating PTSD Treatment Outcomes in an Ethnically Diverse and Rural Veteran Population
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  • Madeleine Goodkind
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  • The veteran population seeking PTSD treatment in New Mexico offers a unique opportunity to explore the theme of this year’s ISTSS annual meeting: bridging science and practice to reach underserved communities.  In New Mexico, no ethnic group makes up the majority of the population and it is one of six states considered to be “majority-minority”, with Latino and Native American populations making up the largest non-White groups.  This ethnic and racial diversity extends to the veteran population; in the outpatient PTSD clinic within the New Mexico VA Health Care System over half of treatment-seeking veterans are non-White.  Moreover, 47 percent of veterans enrolled in VA healthcare in New Mexico live in rural areas.  The outpatient PTSD clinic, located at the main VA facility in the largest city in the state, provides 92% of the gold-standard, evidence-based treatment for PTSD (Prolonged Exposure [PE] and Cognitive Processing Therapy [CPT]). In the past five years, over 600 veterans have enrolled in courses of PE or CPT. This presentation will provide data on New Mexico veterans’ response to CPT and PE, examining relationships with ethnic-minority status and geographical location (i.e. distance to VA clinic, telehealth vs in-person treatment, geocoded area-based SES indicators).  These data shed light on efforts to translate evidence-based practice to hard-to-reach populations.​
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  • Examining Telemental Health Delivery in the VA CPT Training Program
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  • Ellen Healy, David Fleck, Isabella Gabrielson, Kathleen Chard
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  • Cognitive processing therapy (CPT) is an evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD). To improve access to mental health care, VHA has implemented telemental health (TMH) through video teleconferencing (VTC) to reach Veterans that would not otherwise have access to EBPs. RCTs show CPT via VTC is equivalent to in-person CPT and produces comparable improvements in PTSD symptoms (Maieritsch et al., 2015 & Morland et al., 2015). Here, program evaluation data collected from the VA CPT Training Program is examined to evaluate how delivery setting (outpatient, residential, and VTC) impacts CPT outcomes among clinicians learning CPT.   Preliminary analyses of training cases showed a high drop-out rate of 50% of VTC cases.  Treatment completers via VTC demonstrated clinically significant reduction in PCL-5 scores from pre- to post-treatment (M change = 21.09, SD = 16.33).  Gender and age is similar for Veterans receiving therapy in outpatient and VTC settings, whereas Veterans receiving residential treatment are younger and a higher proportion are males.  Further analyses will examine the increase in VTC services in light of COVID-19 in the coming months, which are coupled with education efforts to assist clinicians deliver treatments via VTC.  Findings inform CPT Training program efforts to ensure provider comfort with VTC and quality of CPT delivery.
2pm – 3:15pm Flash Talks Session 5 
5pm – 6:15pm Panel: Identifying Socio-Emotional Consequences of Adverse Childhood Experiences: A transcultural approach

Monique Pfaltz, Misari Oe, Laura Jobson, Rachel Hiller, Miranda Olff, Ulrich Schnyder

Adverse childhood experiences (ACEs) are linked to interpersonal difficulties. Identifying underlying factors will help to develop interventions to improve relationships and mental health. Research points to alterations in specific socio-emotional skills (e.g., regulation of closeness and distance, processing of non-verbal signals). Yet, while culture affects socio-emotional processes, most studies are conducted in the US or Europe. We will report results of a workshop (WS) at the University of Zurich in fall 2020, bringing together researchers from Australia, Germany, Japan, the Netherlands, South Africa, and Switzerland to exchange methodological (i.a. experimental) knowledge and initiate transcultural studies. Misari Oe will present data on facial emotion recognition in Japanese outpatients with ACEs. Monique Pfaltz will compare her findings to a Swiss sample. Rachel Hiller will present a study of maltreatment and complex PTSD of young people in out-of-home care in the UK, assessing longitudinal associations with mental health and functional outcomes (e.g., school wellbeing). Laura Jobson will look into cognitive (e.g., working memory) and emotional functioning in Afghan adolescent refugees and novel low-intensity interventions. Finally, Miranda Olff will present the Global Collaboration on Traumatic Stress, which serves as an umbrella for the WS and arising projects.
5pm – 6:15pm    Symposium: Personalized Approaches to Treating PTSD: Can We Improve Clinical Outcomes of Our Evidence-based Practices?  
  • Does Case Formulation Improve Outcomes in Cognitive Processing Therapy for PTSD? A Randomized Controlled Trial
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  • Reginald Nixon, Marja Elizabeth
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  • Cognitive Processing Therapy (CPT) is an evidence-based therapy for PTSD. Although clinicians often use these therapies flexibly and protocol deviations occur, the effects of such deviations are largely unknown. This randomized trial (N =93) examined the effect of using case formulation (CF) to guide protocol deviations that incorporated evidence-based techniques to address challenges to optimal treatment outcomes, with standard CPT the comparator treatment. Assessments occurred at pretreatment, posttreatment and 6-month follow-up (Clinician-Administered PTSD Scale, MINI, PTSD Checklist, Depression Anxiety Stress Scale). Both groups demonstrated large reductions in PTSD and depression (d’s 2.50-3.66 and 1.19-1.79, respectively). Analysis of the full sample showed CPT+CF did not result in superior outcomes, nor did client complexity nor alliance moderate CPT+CF versus CPT outcomes. However, many of those allocated to CPT+CF showed good outcomes without requiring deviations. Although not always consistent across measures and timepoints, subgroup analysis suggested that when clients did not show reduction of PTSD symptoms during therapy, when deviations occurred, this led to improved outcomes for those in CPT+CF relative to CPT alone. The clinical implications of these findings for improving delivery of protocol-driven PTSD treatments such as CPT will be discussed.
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  • Empowering Veterans to Step Down Their Level of Mental Health Care Following Completion of Trauma-Focused Therapy
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  • Shannon Kehle-Forbes, Tara Galovski, Kyle Possemato, Melissa Polusny
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  • Veterans who have successfully completed prolonged exposure (PE) and cognitive processing therapy (CPT) report low self-efficacy for maintaining treatment gains. Therapist support for the practice and reinforcement of PE/CPT skills is completers’ primary treatment need (Kehle-Forbes et al., 2019). We developed a therapist-assisted self-management intervention designed to 1) increase self-efficacy for managing PTSD, 2) facilitate continued use of PE/CPT skills, 3) boost engagement in meaningful activities, and 4) encourage self-management (e.g., step-down from active care). Twelve veterans who completed PE or CPT enrolled in a pilot open trial to assess the feasibility, acceptability, and potential effectiveness of the self-management program (EMPOWER). 92% of participants completed all therapist contacts. Self-report and interview data show high intervention satisfaction and acceptability. 33% of veterans experienced PTSD symptoms improvements and 56% reported stability from pre- to post-EMPOWER. Participants reported M=5.7 (SD=3.29) mental health appointments in the six-months post-PE/CPT completion, 43% fewer visits than the site’s average for PE/CPT completers. Qualitative and quantitative data were equivocal regarding the effect of the intervention on self-efficacy and other secondary outcomes. Program refinements and plans for future testing will be discussed.
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  • The Development of an Early Warning System for Determining the Benefits (or Diminishing Returns) of Increasing the Length of Treatment for PTSD
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  • Tara Galovski, Mathew King, Reginald Nixon, Brian Smith, Jaimie Gradus, Patricia Resick
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  • Galovski et al. (2012) showed that varying the length of Cognitive Processing Therapy resulted in unheralded low rates of treatment non-response (8% versus 34% at session 12). An early warning system for distinguishing for whom added sessions is helpful and for whom there are diminishing returns is critical in reducing the risk of premature therapy termination and compromising optimal dose of therapy. Contrarily, continuing therapy with diminishing returns may prevent engagement in a different treatment with better outcomes. This study combines data from 4 CPT clinical trials (179 PTSD+ civilians) and assesses whether readily available clinical information can discriminate final treatment outcome. Patients who did not show clear, early treatment response were classified as either delayed (PTSD- by post-treatment), partial (clinically significant symptom reduction by post-treatment but PTSD+), or non-responders (no clinically significant symptom reduction). Random forest machine learning was used to forecast outcome using candidate predictors (demographics, comorbidity, trauma history, initial depression and PTSD severity, and PTSD severity at each session). Results indicate that the 3 groups were generally indistinguishable through session 6 (AUCs for all groups < 0.6), suggesting that changing the standard protocol based on (lack of) early treatment response may be untenable.
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  • Massed Cognitive Processing Therapy for Posttraumatic Stress Disorder in Women Survivors of Intimate Partner Violence
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  • Kimberly Werner, Katherine Iverson, Tara Galovski
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  • Cognitive processing therapy (CPT) is a first line intervention for posttraumatic stress disorder (PTSD) and has demonstrated efficacy with large effect sizes. Data suggest that trauma focused treatments can be delivered effectively and efficiently in a massed format to expedite recovery from PTSD. Women survivors of intimate partner violence have a high prevalence of PTSD and encounter numerous barriers to treatment that may be ameliorated by a massed CPT approach to maximize benefits in an accelerated timeline. This pilot study tests the efficacy of individual CPT delivered over the course of 5 days (mCPT) as compared to standard CPT (sCPT) delivery in women survivors of IPV (N=12); six women received mCPT and six received sCPT. Assessments included clinical interviews prior to and 1- and 3-months following treatment for PTSD and symptom monitoring throughout treatment. Both mCPT and sCPT were associated with significant improvement in PTSD (d = 1.44 – 2.06) and depression symptoms (d = .69 – 1.28). No difference was found in CAPS severity between mCPT and sCPT at 1-month (t=0.01, p=0.99) or 3-month (t=0.73. p=0.47). Only one participant in sCPT dropped out of treatment. Findings indicate mCPT was as effective as sCPT delivery in this women IPV cohort pilot study and could show promise for accelerated treatment delivery with meaningful effects on PTSD and depression.
5pm – 6:15pm Symposium: Idioms of distress?: Examining the intersection of trauma and somatic symptoms in displaced communities
  • Chair: Jacob Bentley
  • Discussant: Pamela Collins
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  • Psychotherapy Treatment Impact on Somatic Symptoms among Trauma-Affected Adults from 3 Low- and Middle-Income Country Randomized Trials
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  • Judith Bass, Emily Haroz, Jeremy Kane, Laura Murray, Catherine Lee, Sarah Murray, Debra Kaysen, Paul Bolton
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  • While we have robust evidence on the effectiveness of psychotherapies in low-and middle-income countries for depression, anxiety and posttraumatic stress, we know little about effects on somatic symptoms present across these disorders. Somatic symptoms are easily identified by clients, so knowing more about intervention impacts on them can provide useful information to support community engagement and sustainability. We investigate the impact of two CBT-based treatments, Cognitive Processing Therapy (CPT) and Common Elements Treatment Approach (CETA), on 7 somatic symptoms associated with anxiety, depression and posttraumatic stress disorder: 1) feeling low in energy, slowed down; 2) faintness, dizziness, weakness; 3) nervousness or shakiness inside; 4) heart pounding or racing; 5) trembling;  6) feeling tense or keyed up; and 7) feeling restless, can’t sit still. We studied intervention impact among trauma-affected adults in 4 randomized trials conducted in the Democratic Republic of Congo (DRC), North and South Iraq, and on the Thailand/Myanmar border (n=668 intervention participants; n=593 waitlist controls). Trial results indicate medium to large effect sizes on depression, anxiety and PTSD; impacts on individual somatic symptoms and a somatic summary score will be presented and we will discuss the importance of addressing somatic symptoms in mental health programs.
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  • The Association between Somatic Symptoms, Premigration Trauma and Post-Migration Stress among Tamil Asylum Seekers, Refugees and Immigrants in Australia
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  • Zachary Steel, Derrick Silove
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  • A dose-response association between trauma, PTSD and depression amongst refugees and asylum seeker populations has been extensive documented. The course of these conditions has also been found to be adversely impacted by ongoing exposure to post-migration adversity. The current study examines the extent to which somatic symptoms are associated with premigration trauma and exposure to postmigration stress. 92 asylum seekers and refuges and 104 immigrations completed a the somatic symptom scale of the Symptom Checklist-90 (SCL-90); the Harvard Trauma Events Scale and the Postmigration Living Difficulties Questionnaire. We applied principle components analysis to identify homogenous sets of trauma and post migration difficulties which identified 3 trauma factors and 4 post migration factors . Path-analysis found an association between exposure to trauma events associated with detention and abuse, exposure to violent deaths and flight from conflict account for 12% of model variance. There was no association between self-reported somatic symptoms and factors reflecting post-migration living difficulties. The findings are consistent with a model that suggests that physical symptoms in the post-migration period may be more related to pre-migration traumas than current stressors possible reflecting a close association with the physical impact of trauma conflict affected populations.
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  • Preliminary findings on the reduction of somatic symptoms through a community-based, culturally integrated, and trauma-focused intervention in Somalia
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  • Jacob Bentley, Michael Dolezal, Alexandra Klein, Norah Feeny, Lori Zoellner
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  • Somatic complaints play a central role in the posttraumatic psychological symptom presentation among people from non-Western cultures (Bentley, Thoburn, Stewart, & Boynton, 2011). However, few studies have examined the effect of culturally adapted trauma interventions on reducing somatic symptoms specifically implemented in a low-to-middle income country. We examined the effects of Islamic Trauma Healing – a brief, group- and mosque-based, lay-led intervention – on somatic symptom reduction in a pre-post feasibility study conducted in Somalia. Inclusion criteria were DSM-5 trauma exposure and DSM-5 re-experiencing or avoidance. Participants (N = 26; 12 men, 14 women) reported largest intervention effects for somatic symptoms (g = 2.74, SSS-8). This effect was strong even as compared to other robust indicators of treatment, including symptoms of PTSD (g = 1.91, PSS-SR-5) and depression (g = 2.00, PHQ-9) in addition to subjective mental well-being (g = 1.77, WHO-5). Pre-treatment somatic symptoms were not significantly correlated with other symptoms or well-being. However, post-treatment correlations were observed with posttraumatic avoidance (r = .41, p = .04) and well-being (r = -.49, p = .01). No gender effects on somatic symptoms were observed. Findings have potential to enhance culturally-informed global mental health interventions with non-Western populations.
5pm – 6:15pm Panel: Overcoming Obstacles in the Provision of Trauma Focused Care: A Discussion on Barriers and Solutions for Effective Care in the World Trade Center Health Program

Peter Haugen, Rebecca Rosen, Mayer Bellehsen, Jonathan DePierro, Rebecca Schwartz, Sandra Lowe, Jason Kornrich

The World Trade Center attacks exposed an estimated 60,000 responders and 300,000 survivors to unprecedented traumatic events (Herbert et al., 2006), resulting in PTSD as the most prevalent mental health (MH) diagnosis (Lowell et al, 2018; Rosen et al., 2019). Nearly 50% of responders endorse a desire for MH care, with WTC exposure-related PTSD serving as the primary need-based factor (Diab & DePierro et al., 2019). Yet, there is a lack of data regarding the efficacy/effectiveness of PTSD interventions for first responders (Haugen et al., 2012), and significant barriers to care (9.3%) including MH stigma (33%) exist (Haugen et al., 2017). The WTC Health Program (WTCHP) was created in 2002 to address the MH needs of WTC responders and survivors through independent Clinical Centers of Excellence (CCE) that utilize diverse quality management approaches (Bellehsen et al., 2019).

This panel will discuss the challenges of trauma-focused (TF) service delivery in clinics. Representatives of four independent CCEs will present data related to program effectiveness and explore the barriers and limitations encountered when delivering TF services. Solutions and novel approaches will be discussed, including the use of telehealth, application of process and outcome monitoring metrics, and the use of measurement-based care to guide the development of novel therapeutic protocols (Haugen et al., 2013).
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Saturday, November 14
10am – 11:15am Symposium: Moral Injury in an International Setting 
  • The Impact of Killing, Witnessing Experiences and Personal Threat on Psychological Distress, Alcohol Use and Quality of Life – A Two-Sample Study of Norwegian Veterans from Lebanon and Afghanistan
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  • Andreas Nordstrand, Hans Jakob Bøe, Tore Tveitstul, Christer Gjerstad, Lars Petter Bakker
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  • Killing in combat is generally defined as potentially morally injurious events (pMIEs), due to findings that connects this experience to reports of psychological distress among veterans however studies have yielded conflicting results. The current study examined the impact of reported killing, personal threats and witnessing experiences in relation to psychological distress, alcohol consumption and quality of life for Norwegian veterans who had served in Afghanistan (Study 1, N = 4,053) or in Lebanon (Study 2, N = 10,605). Using a series of linear regression analyses, we investigated the impact of killing and the other war-zone stressors in relation to posttraumatic stress symptoms, manifestations of depression, anxiety, insomnia, alcohol consumption and quality of life.  For Afghanistan-veterans, killing did not appear as a significant predictor (p < .01) of psychological distress, increased alcohol use or reduced quality of life, when controlling for Personal Threat and Witnessing exposure. For Lebanon-veterans, killing remained a significant predictor (p < .01) of increased symptoms of posttraumatic stress, depression, and anxiety, after partialling out the influence of the other war-zone stressors. The two studies produced distinct results. Differences in mission-statements, rules of engagement, training and mental state during killing may explain the diverging outcomes.
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  • Moral Injury in an International Setting - Dutch Armed Forces
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  • Deirdre Rietdijk, Sanne van der Wal, Elbert Geuze, Eric Vermetten
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  • So far, no empirical research has been conducted on potentially morally injurious events (pMIEs) during recent military operations of the Dutch Armed Forces. Objective: The current study will therefore assess the extent and impact of pMIEs on mental health in a cohort of Dutch Afghanistan veterans (N = 1007). Methods: First, a descriptive inventory is presented on the amount and types of experienced pMIEs during deployment. Secondly, the impact of pMIEs on psychological wellbeing over time is assessed with a series of mixed models using longitudinal measures of posttraumatic stress symptoms and depressive symptoms over a five-year follow-up period. REsults: The study will shed light on a potential relationship of pMIEs with the onset and development of posttraumatic stress symptoms using previously identified trajectories of symptom development. Conclusions: The presented findings will provide more insight on the effects of pMIEs on the mental health of Dutch military personnel and veterans and can therefore contribute to more customized prevention tools and interventions.
  Symposium: Moving Forward with Complex PTSD: International Advances in Our Understanding of the Complex PTSD Diagnosis and Its Functional Impact on Adults, Children, and Families
  • Complex PTSD in Childhood: Evolution and Validation of Developmental Trauma Disorder
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  • Julian Ford, Joseph Spinazzola
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  • Complex PTSD has a rapidly growing evidence base with adults, but far less with children despite evidence that childhood exposure to complex forms of traumatic stressors has complex sequelae. Developmental Trauma Disorder (DTD; Ford et al., 2018; Spinazzola et al., 2018; van der Kolk et al., 2019) has received initial empirical support as a complex PTSD syndrome for children. A replication of the first DTD field trial assessed 271 high risk children receiving community mental health services (49% of color; 66% living in step, foster, adoptive, or kin families or in residential treatment centers; 39% diagnosed with PTSD; median = 4 psychiatric diagnoses other than PTSD) with the Traumatic Events Screening Instrument, the DTD Structured Interview, and K-SADS-PL. In multivariate regression analyses, DTD was uniquely associated with traumatic separation from caregiver(s) and emotional abuse, and major depression and oppositional defiant disorder. PTSD was uniquely associated with physical violence and sexual trauma, and generalized anxiety disorder. Combined DTD and PTSD were associated with caregiver impairment and conduct disorder. Results indicate that assessment and treatment for children experiencing significant mental health problems who were exposed to traumatic stressors may benefit from adaptations to address developmental/relational sequelae as well as PTSD.
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  • Confirmatory Factor Analysis of the International Trauma Questionnaire among Northern Ireland Veterans
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  • Cherie Armour, Martin Robinson, Jana Ross
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  • Introduction: The concept of C-PTSD has been proposed to explain a syndrome of PTSD symptoms in addition to Disturbances in Self-Organisation (Cloitre et al., 2009). In line with recently codified ICD-11 criteria a bespoke measure of C-PTSD has been developed and validated; the International Trauma Questionnaire (ITQ; Cloitre et al., 2018). Objectives: This study examines the factor structure of this measure extending the validity of this measure for use in the NI military veteran population. Methods: This investigation utilises Confirmatory Factor Analysis to test seven previously validated factor models of C-PTSD from across a variety of other trauma populations, in a NI military veteran sample (N = 357). These models range from a univariate model to six factors, in addition to more elaborate second-order models. Results: Results supported a six-factor first order, two-factor second order model consistent with the findings of research with other populations. These findings support the conceptual structure and validity of ICD-11 C-PTSD and the ITQ. Conclusion: This presentation provides a conceptual overview of C-PTSD and associated symptoms and competing factor models. The ICD-11 concept of C-PTSD provides an alternative model and this concept provides a psychometrically valid framework for assessing post-traumatic stress reactions.
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  • Intergenerational Transmission of Complex PTSD: Relationships between Maternal Complex PTSD Symptoms, Parenting, and Children’s Adjustment
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  • Kristin Samuelson, Krista Engle, Tyler Powers, Hallie Johnson
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  • Research has explored intergenerational transmission of PTSD, but little is known about the effects of Complex PTSD on parenting and children’s functioning. In a study of 52 mother-child dyads (60% African-American and majority low SES) conducted prior to the ICD-11 diagnosis of C-PTSD, we examined mother’s PTSD (CAPS for DSM-IV) and C-PTSD symptoms (four domains of a self-report measure of Disorders of Extreme Stress symptoms that correspond to ICD-11 symptoms), an observational measure of parenting behaviors, mother- and child-report of parenting, and mothers’ report of children’s behavior. Path analyses revealed that severity of mothers’ disruptions in self-perception and systems of meaning predicted observed parenting behaviors during play coded with the Emotional Availability Scale (hostility: b = .25 and .47, p = .02 and <.001, intrusiveness: b = .27 and .52, p = .02 and <.001). Disruptions in systems of meaning predicted child report of negative parenting behaviors (b = -.37, p = .003) and mother report of authoritarian parenting (b = .57, p < .001). Mothers' affect dysregulation and disruption in self-perception predicted children’s internalizing and externalizing behaviors and affect dysregulation. In contrast, PTSD symptom severity was not related to any outcome, indicating that symptoms unique to C-PTSD symptoms play a role in parenting and children’s adjustment.
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  • Toward a Biopsychosocial Conceptualization of Complex PTSD: The Role of Psychological and Cognitive Flexibility
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  • Krista Engle, Margaret Talbot, Kristin Samuelson 
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  • As the ICD-11 Complex PTSD (C-PTSD) diagnosis is validated in diverse, international samples, identifying unique mechanisms of the disorder is needed. The development of a biopsychosocial conceptualization of C-PTSD will require the use of objective measures to understand neurobiological underpinnings. The construct of psychological flexibility may better explain the pervasive rigidity seen in C-PTSD than emotion dysregulation, a construct considered central to C-PTSD. Data were collected from 96 trauma-exposed adults. Two three-step hierarchical multiple regressions demonstrated that self-report measures of psychological/cognitive flexibility (e.g., Cognitive Flexibility Inventory) and neuropsychological measures of cognitive flexibility (e.g., Trail Making Test) explained a significant amount of the variance in C-PTSD symptom severity (13%, F change(7, 81) = 3.76, p = .001), but not PTSD symptom severity (p = .06), over and above the variance explained by emotion dysregulation. Specifically, a measure of perceived ability to flexibly regulate emotions, self-reported cognitive control, and performance on Trails were significantly associated with C-PTSD symptom severity. These findings provide preliminary evidence that psychological/cognitive flexibility may play a significant role in C-PTSD symptom development and expand our understanding of mechanisms and treatment targets.
10am – 11:15am Symposium: Beyond the Basics: Using Advanced Analytic Techniques to Examine the Relation Between PTSD and Comorbid Conditions
  • Chair: Matthew Price
  • Discussant: Damion Grasso
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  • Dynamic Relations Between Posttraumatic Stress Symptoms and Depression Symptoms in Daily Life
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  • Talya Greene
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  • A large body of literature indicates that PTSD and depression are highly comorbid. Little is known, however, about the dynamic relationships between these two phenomena in daily life, and particularly whether increases in the symptoms of one disorder trigger increases in the other. The current study examined the bidirectional relations of PTSD and depression using experience sampling methodology. Participants (n=91) who had previously been exposed to at least one traumatic event, reported on PTSD symptoms and depression symptoms twice a day for 17 days via their smartphone. We used a bivariate VAR(1) dynamic structural equation model to examine the cross-lagged associations between these two diagnostic constructs. Overall, mean scores of PTSD symptoms and depression symptoms were highly correlated. We found that elevations in PTSD symptoms predicted increases in depression symptoms at the next measurement point, but elevations in depression symptoms did not predict subsequent elevations in PTSD symptoms. This has implications for the way that we both conceptualise and treat comorbid PTSD and depression.
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  • Wont You Be My Neighbor?: Network Symptoms Communities Within PTSD, GAD, and Depression in Large Community Cohort of Trauma-Exposed Individuals

  • Zoe Brier, Alison Legrand, Laurent Hébert-Dufresne, Matthew Price
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  • Comorbid mental health disorders are highly common in trauma exposed individuals with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD) among the most common co-occurring conditions. Network models of psychopathology offer a novel method to understand this comorbidity. The present study examined communities of symptoms within a network of these disorders. Data were obtained from a large community sample (N=1184) of trauma exposed adults. Network analyses identified a sparsely connected (19.4%) network. Reliability tests suggested that all metrics of centrality (strength, betweenness, and closeness) were well above the cutoff (all>0.5). The infograph community detection algorithm identified 5 distinct communities: (1) MDD & GAD, (2) PTSD intrusion & avoidance, (3) PTSD hyperarousal, (4) dysphoria & numbing symptoms, and (5) sleep & concentration difficulties. The MDD & GAD community had the greatest density with the sleep and concentration difficulties community (24%). The remaining PTSD communities were less connected to MDD & GAD (> 17%).  D7-restricted positive emotions had the highest strength (z = 2.63). These results indicate that there are numerous pathways by which depression and GAD are comorbid. Symptoms of sleep & concentration are the likely pathway by which comorbidity between PTSD and depression occur.
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  • Extending our Understanding of the Association between Posttraumatic Stress Disorder and Positive Emotion Dysregulation: A Network Analysis Approach
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  • Alexa Raudales, Nicole Weiss, Ateka Contractor, Talya Greene, Nicole Short
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  • PTSD has empirically-established associations with positive emotion dysregulation. Extending existing research, we utilized a network approach to examine relations between PTSD symptom clusters (intrusions, avoidance, negative alterations in cognitions and mood [NACM], alterations in arousal and reactivity [AAR]) and positive emotion dysregulation dimensions (nonacceptance, impulse control, goal-directed behavior). We identified (1) differential relations of PTSD symptom clusters with positive emotion dysregulation, and (2) central symptoms accounting for the PTSD and positive emotion dysregulation inter-group interconnections. Participants were 371 trauma-exposed community individuals (Mage = 43.68; 70.9% females; 34.5% white). Study results indicated the key role of AAR and intrusions clusters in the PTSD group and impulse control difficulties in the positive emotion dysregulation group. Regarding cross-group connectivity patterns, findings indicate the pivotal role of AAR in positive emotion dysregulation dimensions and nonacceptance of positive emotions and impairment in goal-directed behavior in the context of positive emotions in PTSD symptom clusters. The current study indicates the potentially central role of particular PTSD symptom clusters and positive emotion dysregulation dimensions, informing assessment and treatment targets.
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  • Examining Unique and Prospective Relationships Among Posttraumatic Stress Disorder and Self-Injurious Thoughts and Behaviors Using Network Analysis
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  • Elizabeth Spitzer, Natasha Benfer, Kelly Zuromski, Brian Marx, Tracy Witte
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  • Background: This study utilized the network approach to elucidate how individual posttraumatic stress disorder (PTSD) symptoms may drive and maintain self-injurious thoughts and behaviors (SITB). Methods: We estimated cross-sectional networks in two samples of trauma-exposed adults (Sample 1 N = 349 adults; Sample 2 N = 1,307 Veterans) to identify PTSD symptoms that may act as bridges to SITB. Additionally, we conducted a cross-lagged panel network in Sample 2 to clarify the temporal relationship between PTSD symptoms and SITB. Finally, in both samples, we conducted logistic regressions to examine the utility of PTSD symptoms in prospectively predicting SITB, over a 15-day period (Sample 1) and over a two-year period (Sample 2). Results: Negative beliefs and risky behaviors emerged as highly influential PTSD symptoms on SITB in both cross-sectional networks. In the cross-lagged panel network, distorted blame emerged as highly influential on SITB over time. Finally, risky behaviors, unwanted memories, and psychological distress served as the strongest predictors of SITB across the two samples. Conclusions: Our results suggest that treatments targeting negative beliefs and risky behaviors may prevent SITB. Treatments targeting distorted blame and unwanted memories may help reduce SITB for individuals with a history of combat trauma.
10am – 11: 15am Workshop: Disseminating Evidence-Based Approaches to Services for Traumatised Young People in Georgia

Jonathan Bisson, Nino Makhashvili,  Jana Javakhishvili

Ilia State University and Cardiff University have collaborated for over a decade to disseminate and implement evidence-based approaches to prevent, assess and treat trauma-related problems in Georgia.  20% of Georgians live in relative poverty, 200,000 are internally displaced and experience significant barriers to access health care.  The mental health care system for young people is under-developed but the Georgian Government’s National Action Plan and funding from the European Commission allowed the development of a specialized mental health service for young people.  Funding from the UK’s Medical Research Council has allowed evaluation of the service and also the dissemination and implementation of novel research methodology in Georgia.  

This workshop will help participants increase their understanding and skill in working in low-resource, underserved settings, and recognize potential approaches to improving access to care, reducing treatment burden, adapting treatments and novel implementation activities designed to be sustainable in the future.  The presenters will specifically discuss the adaptation of a cognitive behavioural therapy with a trauma focus with a strong evidence base in other settings for use in Georgia and then consider how this and other interventions, assessment and evaluation approaches were developed and adapted for use in the new service.   
10am – 11:15am Symposium: Understanding Vulnerability After Disasters: Within-Group Research Findings to Inform Preparedness and Response
  • Putting the Disaster in Context: A Life Course Model of Trauma and Mental Health Among Low-Income Survivors of Hurricane Katrina
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  • Sarah Lowe, Ethan Raker, Mariana Arcaya, Meghan Zacher, Mary Waters, Jean Rhodes
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  • There is robust evidence that potentially traumatic events (PTEs) during disasters are predictive of adverse postdisaster mental health outcomes, including posttraumatic stress symptoms (PTSS) and psychological distress (PD) (Goldman & Galea, 2014). Few studies have explored the role of other PTEs over the life course in shaping postdisaster mental health, however. Based on the broader literature on trauma and mental health (e.g., Benjet et al., 2016; Kessler et al., 2017), we hypothesized a path model linking predisaster PTEs to long-term postdisaster PTSS and PD via predisaster PD, short-term postdisaster symptoms, and disaster-related and postdisaster PTEs. We tested this model using data from a longitudinal study of low-income, primarily non-Hispanic Black mothers assessed prior to Hurricane Katrina and one, four, and 12 years thereafter (N=821). Models showed good fit with the data (RMSEA range: <.01 to .04; all CFIs >.99), and 44.1% to 67.4% of the effect of predisaster PTEs on long-term postdisaster symptoms was indirect. Descriptive differences were observed across models including PTSS versus PD, and models including all PTEs versus assaultive violence events only. The results suggest the importance of incorporating disaster preparedness in clinical work with trauma survivors, and attending to other lifetime PTEs when working in postdisaster contexts.
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  • Household Displacement and Risk of Violence Among Children and Youth: Post-Earthquake Haiti
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  • Betty Lai, Melissa Osborne, Shannon Self-Brown, Greta Massetti, Elizabeth Swedo, Natasha DeVeauuse Brown
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  • Increasing evidence suggests that disasters are a potential community-level risk factor for violence against youth. This is concerning, as over 100 million youth globally are exposed to disasters each year. This presentation will examine associations between displacement after the 2010 Haiti Earthquake, exposure to violence, and negative health outcomes among youth aged 13 to 24 years old. Our aims were to: 1) evaluate factors associated with displacement, 2) examine whether younger, as opposed to older, displaced youth reported higher levels of victimization, and 3) evaluate the extent to which a dose response relationship existed between disaster and violence exposure and negative health outcomes for youth. Specifically, data from 1,457 female and 1,459 male youth who completed the Violence Against Children Survey in Haiti were examined. Of these youth, 405 females and 376 males reported being displaced after the earthquake. Findings indicated that there were no sociodemographic differences between those who were displaced versus not displaced. Younger displaced youth, compared to older displaced youth, were at greater risk for violence and mental distress. There was a dose response relationship between violence and disaster exposure and thoughts of ending life. Implications for researchers and clinicians will be discussed.
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  • Understanding the Link Between Pre-Disaster Health Conditions and Post-Disaster Mental Health Among Hurricane Irma/Maria Survivors in Puerto Rico
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  • Zerbrina Valdespino-Hayden, Petty Tineo, Jessica Bonumwezi, Carlamarie Noboa Ramos, Omar Acevedo Arús, Paula Inés Ríos Jiménez, Kaumudi Joshipura, Sarah Lowe
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  • It is well established that persons with preexisting physical and mental health conditions are at increased risk for adverse psychiatric outcomes after disasters (e.g., Goldman & Galea, 2014). However, it is unclear whether the increased risk is in part due to their association with greater disaster exposure, and most studies have relied on retrospective reports of predisaster functioning. This study includes overweight adults in San Juan who were interviewed both prior to and after Hurricanes Irma and Maria (N = 229; 77.7% female; Mean Age = 51.14). Mediation analysis was conducted to assess the indirect effects of a predisaster depression diagnosis and a count of predisaster physical health conditions on postdisaster depression and posttraumatic stress symptoms via exposure to disaster-related stressors (e.g., property damage, displacement, lack of access to medical care) controlling for demographic covariates. Both predisaster health indices were significantly associated with higher postdisaster depression symptoms (p < .05), but the indirect effects via disaster-related stressors were non-significant. For posttraumatic stress symptoms, the direct and indirect effects of both predisaster health indices were non-significant. Future research is needed to understand other pathways through which predisaster health conditions might be linked to postdisaster psychiatric symptoms.
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  • Hurricane Michael and Adverse Mental Health and Social Risk Factors among Pregnant Women
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  • Emily Harville, Ke Pan, Maureen Lichtveld
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  • Pregnant women may be particularly vulnerable to adverse mental health consequences after natural disaster. We assessed changes in mental health and social risk factors in pregnant women in counties affected by Hurricane Michael (October 2018). Data from the Healthy Start screener for the state of Florida was used.  Prenatal risk factors (unplanned pregnancy, mental health services, high stress, use of tobacco or alcohol, young children at home or with special needs, trouble paying bills) were compared in the year before and year after Hurricane Michael, and compared to trends in counties that were less affected, as defined by FEMA disaster declarations (n=18887 in level 1 counties). Logistic regression was used for binary outcomes, adjusting for maternal age, race, BMI, and education. Overall Healthy Start risk score did not change (median score 4 in both time period): post-Michael women were more likely to report receiving mental health services (23% vs. 21%, p<0.01) but also that their pregnancy was planned (51.2% vs. 48.3%, p<0.01). They were less likely to report using tobacco (11.5% vs. 13.6%, p<0.01) or that they had a child with special needs.  Results were similar when limited to three months after the storm. Hurricane Michael was associated with a largely unchanged or even improved risk profile for pregnant women in the area.
2pm – 3:15pm

Invited Panel: Using Evidence-Based Practices to Address PTSD Among Diverse Communities: Barriers, Opportunities and Innovations in Addressing Cultural Adaptation of PTSD Treatments
 

Moderator: Debra Kaysen, PhD ABPP
Panelists: Angela Nickerson, PhD; Annjeanette Belcourt, PhD; Monnica Williams, PhD; Luana Marques, PhD

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