Browsing by Subject "Post-traumatic stress disorder"

Behavioral symptoms of dementia cause considerable distress for persons with dementia and their caregivers and are related to adverse outcomes that have significant social and economic impact. Thus, behavioral symptoms represent one of the most challenging aspects of dementia care. Over the past three decades, research on behavioral symptoms of dementia has laid the foundation for development of non-pharmacological interventions by identifying underlying mechanisms of symptom development. However, the research has largely overlooked how the needs of military veterans may influence development and treatment of behavioral symptoms of dementia, including those needs associated with co-occurring dementia and posttraumatic stress disorder (PTSD). This dissertation aimed to develop knowledge related to behavioral symptoms of dementia among older veterans with and without PTSD by synthesizing current understanding of neurocognitive and psychiatric comorbidities of PTSD among veterans as well as explicating relationships among background factors, proximal factors, and behavioral symptoms of dementia among veterans living in residential care using the need-driven, dementia-compromised behavior (NDB) model.

This dissertation includes a systematic review in Chapter 2 that synthesized the patterns of neurocognitive and psychiatric comorbidities of PTSD in older veterans and revealed a substantial gap in the literature with regards to understanding manifestations and treatment of behavioral symptoms of dementia among older veterans with co-occurring dementia and PTSD. The primary study of this dissertation that encompasses Chapters 3 and 4 utilized an exploratory sequential mixed methods design using secondary data derived from the evaluation dataset of the STAR-VA training program. In Chapter 3, a qualitative study, as the first phase of the mixed methods study, analyzed text data that captured the interdisciplinary care team’s observation of behavioral symptoms of dementia and their circumstances for the subsample of 33 veterans from the STAR-VA dataset. This qualitative study described how behavioral symptoms of dementia are manifested among veterans with and without PTSD in the context of personal, interpersonal/social, and environmental factors that trigger the symptoms. Findings demonstrated that behavioral symptoms of dementia are heterogeneous, with distinct clusters of triggers that are multi-level, thereby warranting an interdisciplinary, multi-level approach to developing person-centered interventions. In addition, findings from this qualitative study informed the development of the second phase of the sequential mixed methods study in Chapter 4 that aimed to test hypothesized pathways between background factors, interpersonal triggers (proximal factors), and behavioral symptoms of rejection of care and aggression and to explore the moderating effect of PTSD on the hypothesized pathways. The mixed methods approach integrated quantitative data measured by standardized scales and text data for 315 veterans derived from the STAR-VA dataset. After converting text data into categorical variables, structural equation modeling (SEM) was performed to compare the patterns of relationships among background factors, interpersonal triggers, and behavioral symptoms of rejection of care and aggression between veterans with and without PTSD. The direct effect of interpersonal triggers and the indirect effect of background factors through interpersonal triggers on rejection of care and aggression emphasizes the importance of developing and implementing psychosocial interventions that improve interpersonal relationships. The multi-group SEM revealed that the full model was not moderated by PTSD. However, the differential direct and indirect effect of background factors and interpersonal triggers as a proximal factor on the behavioral outcomes between veterans with and without PTSD suggest potential different mechanisms of behavioral outcomes between veterans depending upon whether or not PTSD is present. Evidence for the PTSD-moderated mediating effect of interpersonal triggers on the relationship between depression and rejection of care was demonstrated, suggesting the need to develop targeted interventions for veterans with dementia and PTSD who have greater depressive symptoms.

The new knowledge generated from this dissertation helps to clarify complex patterns of associations among background factors such as PTSD and proximal factors and behavioral symptoms of dementia consistent with the NDB model, strengthening the foundation for development of novel approaches to designing and implementing person-centered care for veterans with co-occurring dementia and PTSD.

Nearly 60% of the US population experiencing posttraumatic stress disorder have not received a meaningful clinical response from traditional interventions (Akiki & Abdallah, 2018). Early research using psychedelics in tandem with psychotherapy may offer a more effective option (Feduccia et al., 2019) and has been shown to provide or contribute to long-term relief or remission from PTSD symptoms (in small samples). Funding for psychedelic-assisted therapy (PAT) clinical-trials has increased to nearly billions (Phelps et al., 2022) and while the research is propitious, it is far from complete. Concerns about safety and generalizability have begun to surface (Love, 2022), including recent allegations of abuse. Though abuse is an issue within all clinical practice, risk is amplified by the non-ordinary state of consciousness experienced in high-dose PAT trials. In the US, treatment models using mind-altering substances are shaped by FDA-approved clinical research trials, which in turn define ethical practices and standards of care. By examining how existing regulations recommend governance for the informed consent process and reviewing publicly available documents from PAT trials, I aim to: 1) illuminate how risk and accountability are currently communicated to PAT participants; and 2) suggest how existing research policy might be updated to make working with trauma patients under non-ordinary states of consciousness safer and more ethically robust.

Posttraumatic stress disorder (PTSD) is common, chronic, and associated with greater risk of postoperative mortality in veterans. Therefore, the purpose of this dissertation was to determine if elective outpatient surgery had a persistent and deleterious effect on the physical or mental health of veterans, and also to explore factors that contributed to postoperative health change in this population. A longitudinal, mixed method, quasi-experimental, nonequivalent control group study was conducted. Physical and mental health, depressive symptom severity, posttraumatic symptom severity, and pain severity were measured in 29 veterans with PTSD before undergoing outpatient elective surgery, one week after surgery, one month after surgery, and three months after surgery. For comparison, parallel data were collected from a control group of 31 veterans with PTSD at enrollment, one week after enrollment, one month after enrollment, and three months after enrollment. Subjects who displayed clinically significant or distressing changes in health status after surgery were interviewed to identify factors associated with postoperative health change. Subjects in the surgical group reported significant declines in subjective physical and mental health at one week, but not one or three months after outpatient elective surgery. Depressive symptoms severity and posttraumatic symptom severity were unchanged after surgery by surgery. Subjects reported that this physical and mental distress was driven by acute postoperative pain, but that underlying chronic pain remained influential throughout their postoperative course.

Involuntary episodic memories are memories that come into consciousness without preceding retrieval effort. These memories are commonplace and are relevant to multiple mental disorders. However, they are vastly understudied. We use a novel paradigm to elicit involuntary memories in the laboratory so that we can study their neural basis. In session one, an encoding session, sounds are presented with picture pairs or alone. In session two, in the scanner, sounds-picture pairs and unpaired sounds are reencoded. Immediately following, participants are split into two groups: a voluntary and an involuntary group. Both groups perform a sound localization task in which they hear the sounds and indicate the side from which they are coming. The voluntary group additionally tries to remember the pictures that were paired with the sounds. Looking at neural activity, we find a main effect of condition (paired vs. unpaired sounds) showing similar activity in both groups for voluntary and involuntary memories in regions typically associated with retrieval. There is also a main effect of group (voluntary vs. involuntary) in the dorsolateral prefrontal cortex, a region typically associated with cognitive control. Turning to connectivity similarities and differences between groups again, there is a main effect of condition showing paired > unpaired sounds are associated with a recollection network. In addition, three group differences were found: (1) increased connectivity between the pulvinar nucleus of the thalamus and the recollection network for the voluntary group, (2) a higher association between the voluntary group and a network that includes regions typically found in frontoparietal and cingulo-opercular networks, and (3) shorter path length for about half of the nodes in these networks for the voluntary group. Finally, we use the same paradigm to compare involuntary memories in people with posttraumatic stress disorder (PTSD) to trauma-controls. This study also included the addition of emotional pictures. There were two main findings. (1) A similar pattern of activity was found for paired > unpaired sounds for both groups but this activity was delayed in the PTSD group. (2) A similar pattern of activity was found for high > low emotion stimuli but it occurred early in the PTSD group compared to the control group. Our results suggest that involuntary and voluntary memories share the same neural representation but that voluntary memories are associated with additional cognitive control processes. They also suggest that disorders associated with cognitive deficits, like PTSD, can affect the processing of involuntary memories.