Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors

The effects of Religiosity, Spirituality, and sense of purpose on posttraumatic stress disorder treatment outcomes among Veterans

BACKGROUND

Religion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD.

OBJECTIVE

The aim of this paper was to understand how Veterans' R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment.

METHOD

The study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake.

RESULTS

Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment.

CONCLUSION

These findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.

Differential posttraumatic stress disorder symptom cluster response to stellate ganglion block: secondary analysis of a randomized controlled trial

Empirically supported treatments for posttraumatic stress disorder (PTSD) exist, but research suggests these therapies are less effective, acceptable, and feasible to deliver to active duty service members (SMs) compared to civilians. Stellate ganglion block (SGB) procedure, in which a local anesthetic is injected around the cervical sympathetic chain or stellate ganglion to temporarily inhibit sympathetic nervous activity, is gaining popularity as an alternative PTSD treatment in military settings. However, it is unknown whether certain PTSD symptoms are more responsive to SGB than others. The current study involved a secondary analysis of data collected from a previous randomized controlled trial of SGB compared to sham (normal saline) injection (N = 113 SMs). PTSD symptoms were assessed via clinical interview and self-report at baseline and 8 weeks post-SGB or sham. Logistic regression analyses showed that the marked alterations in arousal and reactivity PTSD symptom cluster demonstrated the greatest symptom severity reductions after SGB, relative to sham. The reexperiencing cluster also showed pronounced response to SGB in clinician-rated but not self-reported outcomes. Post-hoc item-level analyses suggested that arousal and reactivity cluster findings were driven by reductions in hypervigilance, concentration difficulties, and sleep disturbance, whereas clinician-rated reexperiencing cluster findings were driven by reductions in physiological reactions to trauma cues, emotional reactions to trauma cues, and intrusions. Our findings align with a burgeoning literature positioning SGB as a potential novel or adjunctive PTSD treatment. Results could guide future hypothesis-driven research on mediators of therapeutic change during SGB for PTSD symptoms in SMs.

A protocol for a randomized controlled trial of exposure and response prevention for veterans with obsessive compulsive disorder

BACKGROUND

Obsessive compulsive disorder (OCD) is effectively treated with exposure and response prevention (ERP), yet very few veterans receive ERP for OCD within the Veterans Health Administration (VHA). Veterans are a clinically complex population, and no prior research has evaluated the effectiveness of ERP in veterans with OCD or comorbid OCD and posttraumatic stress disorder (PTSD). Given the limited accessibility of ERP-trained providers within VHA, assessment of video telehealth (VTH) delivery of ERP is warranted.

METHODS

A sample of 160 veterans with OCD (80 diagnosed with comorbid PTSD) will be randomly assigned to receive up to 16 sessions of ERP or a stress management training control delivered via VTH. Assessments will occur at baseline, posttreatment, and 6-month follow-up. The primary outcome will evaluate the impact of ERP on participants' functioning, and secondary outcomes will include quality of life and OCD symptoms. At posttreatment, qualitative interviews with veterans, clinicians, and administrators will explore barriers and facilitators to treatment delivery, and the implementation potential of ERP.

CONCLUSIONS

Results will provide direction for the treatment of OCD and comorbid PTSD in veterans, as well as guidance for future implementation efforts for ERP within VHA.

CLINICALTRIALS

gov Identifier:NCT05240924.

Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT.

METHOD

Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality.

CONCLUSION

If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.

[Personalized psychotherapy of posttraumatic stress disorder : Overview on the selection of treatment methods and techniques using statistical procedures]

BACKGROUND

A relevant heterogeneity of treatment effects in posttraumatic stress disorder (PTSD) is discussed with respect to the debate about the necessity of phase-based treatment and in light of the new diagnosis of complex PTSD and has recently been proven; however, there has been little personalization in the treatment of PTSD. This article presents the current state of research on the personalized selection of specific psychotherapeutic methods for the treatment of PTSD based on patient characteristics using statistical methods.

METHODS

A systematic literature search was conducted in the PubMed (including Medline), Embase, Web of Science Core Collection, Google Scholar, PsycINFO and PSYNDEX databases to identify clinical trials and reviews examining personalized treatment for PTSD.

RESULTS

A total of 13 relevant publications were identified, of which 5 articles were predictor analyses in samples without control conditions and 7 articles showed analyses of randomized controlled trials (RCT) with a post hoc comparison of treatment effects in optimally and nonoptimally assigned patients. In addition, one article was a systematic review on the treatment of patients with comorbid borderline personality order and PTSD.

DISCUSSION

The available manuscripts indicate the importance and benefits of personalized treatment in PTSD. The relevant predictor variables identified for personalization should be used as a suggestion to investigate them in future prospective studies.

Treatment of comorbid sleep disorders and posttraumatic stress disorder in U.S. active duty military personnel: A pilot randomized clinical trial

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT-I&N) and cognitive processing therapy (CPT) for PTSD are first-line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT-I&N delivered before CPT, CBT-I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT-I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = -0.36; insomnia, d = -0.77; sleep efficiency, d = 0.62; and nightmares, d = -.53. Compared to participants who received CBT-I&N delivered before CPT, those who received CBT-I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = -0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone.

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial

STUDY OBJECTIVES

Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment.

METHODS

In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment.

RESULTS

Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment.

CONCLUSIONS

Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561.

CITATION

Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Advancing health equity by understanding race disparities and other factors associated with PTSD symptom improvement following evidence-based psychotherapy

Several studies found that Black veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than White veterans following PTSD evidence-based psychotherapies (EBPs). We aimed to understand this disparity among veterans receiving EBPs by modeling race with demographic, clinical, and service utilization factors. Using electronic health records, we employed a cohort study of Iraq and Afghanistan War Veterans who initiated PTSD EBP treatment and completed > 2 PTSD symptom measures (N = 21,751). Using hierarchical Bayesian logistic regressions, we modeled the probability of PTSD symptom improvement. Black race was associated with less PTSD improvement (mean posterior odds ratio [MPOR] = 0.92; 95 % plausibility interval [PI] = 0.84, 1.0), as was group therapy (MPOR = 0.67; 95 % PI = 0.62, 0.73). Factors associated with greatest improvement included prolonged exposure (MPOR = 1.35; 95 % PI = 1.25, 1.45) and treatment density (MPOR = 1.40; 95 % PI = 1.36, 1.45). On average, Black veterans evidenced PTSD EBP improvement disparities. Clinical and utilization did not fully account for these disparities, although disproportionate representation of Black veterans in group CPT may explain some of these differences. Understanding experiences such as race-based trauma and chronic racism and discrimination is critical to provide Black veterans with the most effective PTSD care.

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Exploring the psychometric properties of the externalizing spectrum inventory-brief form in a Swedish forensic psychiatric inpatient sample

BACKGROUND

The Externalizing Spectrum Inventory-Brief Form (ESI-BF) [1] is a 160-item self-report instrument designed for the assessment of externalizing psychopathology, yet few studies to date have evaluated its psychometric properties, structural fit, and criterion validity in forensic psychiatric settings.

METHODS

Here, we investigated these aspects in a sample of forensic psychiatric inpatients (n = 77) from a maximum-security forensic psychiatric hospital in Sweden. We firstly investigated the reliability. Secondly, using confirmatory factor analysis, the structure of the ESI-BF. And thirdly, using a Bayesian approach, assessed how the three ESI-BF subfactors relate to criterion measures of antisocial behaviors, substance use, and lifetime externalizing spectrum diagnoses.

RESULTS

The ESI-BF demonstrated good to adequate reliability and internal consistency, with all but four facet scales exhibiting α and ω values ≥ 0.80. Average inter-item correlations for the facet scales ranged from 0.31 to 0.74. However, all structural models exhibited poor to mediocre fit, with model fit values for the CFI being 0.66, 0.79 and 0.87 and RMSEA values of 0.14, 0.12 and 0.09. for the unidimensional correlated factors and bifactor model, respectively. Regarding criterion validity, all subscales of the item-based ESI-BF three-factor model exhibited robust correlations with the Life History of Aggression total, aggression and antisocial/consequences subscales, with correlations ranging from 0.29 to 0.55. All ESI-BF subfactors demonstrated robust associations, yet with different externalizing outcomes, lending tentative support to its criterion validity.

CONCLUSION

Despite remaining ambiguities regarding its structural fit, the ESI-BF may be promising for assessing externalizing psychopathology in forensic psychiatric populations. However, further investigation of the ESI-BF is needed before any firm conclusions can be drawn about its appropriateness in forensic psychiatric settings.

Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members

LAY SUMMARY

Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.

A comparison of the CAPS-5 and PCL-5 to assess PTSD in military and veteran treatment-seeking samples

Background: This study was an examination of the puzzling finding that people assessed for symptoms of posttraumatic stress disorder (PTSD) consistently score higher on the self-report PTSD Checklist for DSM-5 (PCL-5) than the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Both scales purportedly assess PTSD severity with the same number of items, scaling, and scoring range, but differences in scores between measures make outcomes difficult to decipher.Objective: The purpose of this study was to examine several possible psychometric reasons for the discrepancy in scores between interview and self-report.Method: Data were combined from four clinical trials to examine the baseline and posttreatment assessments of treatment-seeking active duty military personnel and veterans.Results: As in previous studies, total scores were higher on the PCL-5 compared to the CAPS-5 at baseline and posttreatment. At baseline, PCL-5 scores were higher on all 20 items, with small to large differences in effect size. At posttreatment, only three items were not significantly different. Distributions of item responses and wording of scale anchors and items were examined as possible explanations of the difference between measures. Participants were more likely to use the full range of responses on the PCL-5 compared to interviewers.Conclusions: Suggestions for improving the congruence between these two scales are discussed. Administration of interviews by trained assessors can be resource intensive, so it is important that those assessing PTSD severity are afforded confidence in the equivalence of their assessment of PTSD regardless of the assessment method used.

Examining trauma cognition change trajectories among initial PTSD treatment non-optimal responders: a potential avenue to guide subsequent treatment selection

BACKGROUND

Despite their general effectiveness, 14-50% of individuals do not fully respond to evidence-based treatments for posttraumatic stress disorder (PTSD). Although changes in negative posttrauma cognitions (NPCs) are considered a likely PTSD treatment mechanism, less is known about how NPCs change among individuals who continue to be symptomatic following treatment (non-optimal responders).

OBJECTIVE

The objective of this study was to examine NPC change trajectories among individuals who were determined to be non-optimally responsive to intensive PTSD treatment.

METHOD

Using a 3-week Cognitive Processing Therapy-based intensive PTSD treatment sample (ITP; N = 243), the present study examined the number of distinct NPC change trajectories among non-optimal responders via Group Based Trajectory Modeling and assessed predictors of non-optimal responders' NPC change trajectory membership. Analyses were replicated in a separate 2-week ITP sample (N = 215).

RESULTS

In both non-optimal responder samples, two trajectories emerged; a no NPC change group which represented those with an overall lack of NPC change throughout treatment and an NPC change group which represented those with an overall reduction of NPCs occurring primarily later in treatment. Changes in PTSD symptom severity during treatment was the only consistent predictor of NPC change trajectory group membership among treatment non-optimal responders across ITPs.

CONCLUSIONS

Findings suggest NPC change among non-optimal responders is nuanced and may inform subsequent intervention selection, resulting in testable hypotheses for future research.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial

OBJECTIVE

To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD.

METHOD

Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days.

RESULTS

At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days.

CONCLUSION

Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT01663337).

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, M_diff = 5.75, p = .003, and PHQ-9, M_diff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial

BACKGROUND

Several efficacious psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available; however, the comparative effectiveness of these treatments represents a major gap in the literature. The proposed study will compare the effectiveness of two leading PTSD treatments - Prolonged Exposure (PE) therapy and pharmacotherapy with paroxetine or venlafaxine extended release - as well as the combination of PE and medication.

METHODS

In a randomized clinical trial, veterans with PTSD (N = 450) recruited across six Veterans Affairs Medical Centers will complete assessments at baseline, mid-treatment (Week 7), post-treatment (Week 14), and follow-up (Weeks 27 and 40). The primary outcome will be change in (both clinician-rated and self-reported) PTSD severity. Depression symptoms, quality of life, and functioning will also be measured and examined as secondary outcomes. Baseline demographic and clinical data will be used to develop "personalized advantage indices" (PAIs), with the goal of identifying who is most likely to benefit from which treatment.

CONCLUSIONS

This planned trial will yield findings to directly inform clinical practice guidelines for PTSD, by providing comparative effectiveness data to support recommendations about what can be considered the "first-line" treatment option(s) for PTSD. Further, findings from this trial have the potential to guide treatment planning for individual patients, through implementation of PAIs developed from study data, in service of "personalized medicine."

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT04961190.

The Role of Implicit Memory in the Development and Recovery from Trauma-Related Disorders

Post-traumatic Stress Disorder is a chronic condition that occurs following a traumatic experience. Information processing models of PTSD focus on integrating situationally triggered sensory-emotional memories with consciously accessible autobiographical memories. Review of the nature of implicit memory supports the view that sensory-emotional memories are implicit in nature. Dissociation was also found to be associated with the development and severity of PTSD, as well as deficits in autobiographical memory. Moreover, disorganized attachment (DA) was associated with greater degrees of dissociation and PTSD, and like the defining neural activation in PTSD, was found to be associated with basal ganglia activity. In addition, subcortical neuroception of safety promotes a neurophysiological substrate supportive of social engagement and inhibition of fear-based responses. Furthermore, activation of representations of co-created imagined scenes of safety and secure attachment are associated with increases in this neurophysiological substrate. Repeated priming of secure attachment imagery was associated with modification of internal working models of DA along with reductions in dissociation and recovery from complex PTSD. In conclusion, it is posited that adequate recovery from extensive trauma experiences requires more than conscious elaboration of traumatic autobiographical memories and that the application of implicit nonconscious memory modification strategies will facilitate more optimal recovery.

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial

BACKGROUND

Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment.

METHODS

The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome.

RESULTS

Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant.

CONCLUSIONS

CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

Effect of Written Exposure Therapy vs Cognitive Processing Therapy on Increasing Treatment Efficiency Among Military Service Members With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) occurs more commonly among military service members than among civilians; however, despite the availability of several evidence-based treatments, there is a need for more efficient evidence-based PTSD treatments to better address the needs of service members. Written exposure therapy is a brief PTSD intervention that consists of 5 sessions with no between-session assignments, has demonstrated efficacy, and is associated with low treatment dropout rates, but prior randomized clinical trials of this intervention have focused on civilian populations.

OBJECTIVE

To investigate whether the brief intervention, written exposure therapy, is noninferior in the treatment of PTSD vs the more time-intensive cognitive processing therapy among service members diagnosed with PTSD.

DESIGN, SETTING, AND PARTICIPANTS

The study used a randomized, noninferiority design with a 1:1 randomization allocation. Recruitment for the study took place from August 2016 through October 2020. Participants were active-duty military service members diagnosed with posttraumatic stress disorder. The study was conducted in an outpatient setting for service members seeking PTSD treatment at military bases in San Antonio or Killeen, Texas.

INTERVENTIONS

Participants received either written exposure therapy, which consisted of 5 weekly sessions, or cognitive processing therapy, which consisted of 12 twice-weekly sessions.

MAIN OUTCOMES AND MEASURES

Participants were assessed at baseline and at 10, 20, and 30 weeks after the first treatment session. The primary outcome measure was PTSD symptom severity assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Noninferiority was defined as the difference between the 2 groups being less than the upper bound of the 1-sided 95% CI-specified margin of 10 points on the CAPS-5.

RESULTS

Overall, 169 participants were included in the study. Participants were predominantly male (136 [80.5%]), serving in the Army (167 [98.8%]), with a mean (SD) age of 34 (8) years. Eighty-five participants were randomly assigned to written exposure therapy, with 65 (76.5%) completing all treatment sessions, and 84 to cognitive processing therapy, with 47 (54.8%) completing all treatment sessions. Findings indicated that written exposure therapy was noninferior to cognitive processing therapy, with the largest difference in change in outcome between the treatment conditions of 3.96 points on the outcome measure. The 1-sided 95% CI upper limit was less than 10 points across time points in both groups and ranged from 4.59 at week 30 to 6.81 at week 10. Within-condition effect sizes ranged from a Cohen d of 0.48 for the written exposure therapy group in the intention-to-treat analysis at week 10 to 0.95 for the cognitive processing therapy group in the per-protocol analysis at week 10, and between-condition effect size ranged from 0.06 in the intention-to-treat analysis at week 30 to 0.22 in the per-protocol analysis at week 10.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, support was found for an effective and more efficient PTSD treatment approach for service members. Future research should determine who does and does not benefit from PTSD treatment to best maximize treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03033602.