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Malhotra B, Jones LC, Spooner H, Levy C, Kaimal G, Williamson JB. A conceptual framework for a neurophysiological basis of art therapy for PTSD. Front Hum Neurosci 2024; 18:1351757. [PMID: 38711802 PMCID: PMC11073815 DOI: 10.3389/fnhum.2024.1351757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
Post-traumatic stress disorder (PTSD) is a heterogeneous condition that affects many civilians and military service members. Lack of engagement, high dropout rate, and variable response to psychotherapy necessitates more compelling and accessible treatment options that are based on sound neuroscientific evidence-informed decision-making. Art therapy incorporates elements proven to be effective in psychotherapy, such as exposure, making it a potentially valuable treatment option. This conceptual paper aims to inform the neurophysiological rationale for the use of art therapy as a therapeutic approach for individuals with PTSD. A narrative synthesis was conducted using literature review of empirical research on the neurophysiological effects of art therapy, with supporting literature on neuroaesthetics and psychotherapies to identify art therapy factors most pertinent for PTSD. Findings were synthesized through a proposed framework based on the triple network model considering the network-based dysfunctions due to PTSD. Art therapy's active components, such as concretization and metaphor, active art engagement, emotion processing and regulation, perspective taking and reframing, and therapeutic alliance, may improve symptoms of PTSD and prompt adaptive brain functioning. Given the scarcity of rigorous studies on art therapy's effectiveness and mechanisms of alleviating PTSD symptoms, the suggested framework offers a neurophysiological rationale and a future research agenda to investigate the impact of art therapy as a therapeutic approach for individuals with PTSD.
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Affiliation(s)
- Bani Malhotra
- Department of Creative Arts Therapies, Drexel University, Philadelphia, PA, United States
| | - Laura C. Jones
- Brain Rehabilitation Research Center, North Florida/South Georgia Veterans Affairs Medical Center, Gainesville, FL, United States
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
| | - Heather Spooner
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. in support of Creative Forces: NEA Military Healing Arts Network, Bethesda, MD, United States
- Center of Arts in Medicine, University of Florida, Gainesville, FL, United States
| | - Charles Levy
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. in support of Creative Forces: NEA Military Healing Arts Network, Bethesda, MD, United States
| | - Girija Kaimal
- Department of Creative Arts Therapies, Drexel University, Philadelphia, PA, United States
| | - John B. Williamson
- Brain Rehabilitation Research Center, North Florida/South Georgia Veterans Affairs Medical Center, Gainesville, FL, United States
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
- Center for OCD, Anxiety and Related Disorders, Department of Psychiatry, University of Florida, Gainesville, FL, United States
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2
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Babb JA, Zuberer A, Heinrichs S, Rumbika KK, Alfiler L, Lakis GA, Leite-Morris KA, Kaplan GB. Disturbances in fear extinction learning after mild traumatic brain injury in mice are accompanied by alterations in dendritic plasticity in the medial prefrontal cortex and basolateral nucleus of the amygdala. Brain Res Bull 2023; 198:15-26. [PMID: 37031792 DOI: 10.1016/j.brainresbull.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/25/2023] [Accepted: 04/06/2023] [Indexed: 04/11/2023]
Abstract
Mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) have emerged as the signature injuries of the U.S. veterans who served in Iraq and Afghanistan, and frequently co-occur in both military and civilian and populations. To better understand how fear learning and underlying neural systems might be altered after mTBI we examined the acquisition of cued fear conditioning and its extinction along with brain morphology and dendritic plasticity in a mouse model of mTBI. To induce mTBI in adult male C57BL/6J mice, a lateral fluid percussive injury (LFP 1.7) was produced using a fluid pulse of 1.7 atmosphere force to the right parietal lobe. Behavior in LFP 1.7 mice was compared to behavior in mice from two separate control groups: mice subjected to craniotomy without LFP injury (Sham) and mice that did not undergo surgery (Unoperated). Following behavioral testing, neural endpoints (dendritic structural plasticity and neuronal volume) were assessed in the basolateral nucleus of the amygdala (BLA), which plays a critical sensory role in fear learning, and medial prefrontal cortex (mPFC), responsible for executive functions and inhibition of fear behaviors. No gross motor abnormalities or increased anxiety-like behaviors were observed in LFP or Sham mice after surgery compared to Unoperated mice. We found that all mice acquired fear behavior, assessed as conditioned freezing to auditory cue in a single session of 6 trials, and acquisition was similar across treatment groups. Using a linear mixed effects analysis, we showed that fear behavior decreased overall over 6 days of extinction training with no effect of treatment group across extinction days. However, a significant interaction was demonstrated between the treatment groups during within-session freezing behavior (5 trials per day) during extinction training. Specifically, freezing behavior increased across within-session extinction trials in LFP 1.7 mice, whereas freezing behavior in control groups did not change on extinction test days, reflecting a dissociation between within-trial and between-trial fear extinction. Additionally, LFP mice demonstrated bilateral increases in dendritic spine density in the BLA and decreases in dendritic complexity in the PFC. The translational implications are that individuals with TBI undergoing fear extinction therapy may demonstrate within-session aberrant learning that could be targeted for more effective treatment interventions.
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Affiliation(s)
- Jessica A Babb
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Mental Health Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Department of Psychiatry, Harvard Medical School, Boston, MA, 02115 USA.
| | - Agnieszka Zuberer
- Department of Psychiatry and Psychotherapy, University of Tübingen, 72076 Tübingen, Germany; Department of Psychiatry and Psychotherapy, Jena University Hospital, 07743 Jena, Germany.
| | - Stephen Heinrichs
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA.
| | - Kendra K Rumbika
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA.
| | - Lauren Alfiler
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA.
| | - Gabrielle A Lakis
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02218 USA.
| | - Kimberly A Leite-Morris
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118 USA.
| | - Gary B Kaplan
- Research Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Mental Health Service, VA Boston Healthcare System, West Roxbury, MA, 02132 USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118 USA; Department of Pharmacology & Experimental Therapeutics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, 02118 USA.
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3
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Wachen JS, Mintz J, LoSavio ST, Kennedy JE, Hale WJ, Straud CL, Dondanville KA, Moring J, Blankenship AE, Vandiver R, Young-McCaughan S, Yarvis JS, Peterson AL, Resick PA. The impact of prior head injury on outcomes following group and individual cognitive processing therapy among military personnel. J Trauma Stress 2022; 35:1684-1695. [PMID: 36039506 DOI: 10.1002/jts.22870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 12/24/2022]
Abstract
This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment-related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non-HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p < .001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p < .001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p = .060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p = .003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings.
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Affiliation(s)
- Jennifer Schuster Wachen
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Stefanie T LoSavio
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, USA
| | - Jan E Kennedy
- General Dynamics Information Technology, Traumatic Brain Injury Center of Excellence, Joint Base San Antonio-Fort Sam Houston, Texas, USA
| | - Willie J Hale
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Casey L Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Katherine A Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - John Moring
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Abby E Blankenship
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Richard Vandiver
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
| | - Alan L Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Patricia A Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina, USA
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4
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Temkin N, Machamer J, Dikmen S, Nelson LD, Barber J, Hwang PH, Boase K, Stein MB, Sun X, Giacino J, McCrea MA, Taylor SR, Jain S, Manley G. Risk Factors for High Symptom Burden Three Months after Traumatic Brain Injury and Implications for Clinical Trial Design: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. J Neurotrauma 2022; 39:1524-1532. [PMID: 35754333 PMCID: PMC9689769 DOI: 10.1089/neu.2022.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
More than 75% of patients presenting to level I trauma centers in the United States with suspicion of TBI sufficient to require a clinical computed tomography scan report injury-related symptoms 3 months later. There are currently no approved treatments, and few clinical trials have evaluated possible treatments. Efficient trials will require subject inclusion and exclusion criteria that balance cost-effective recruitment with enrolling individuals with a higher chance of benefiting from the interventions. Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, we examined the relationship of 3-month symptoms to pre-injury, demographic, and acute characteristics as well as 2-week symptoms and blood-based biomarkers to identify and evaluate factors that may be used for sample enrichment for clinical trials. Many of the risk factors for TBI symptoms reported in the literature were supported, but the effect sizes of each were small or moderate (< 0.5). The only factors with large effect sizes when predicting 3-month symptom burden were TBI-related (i.e., post-concussive) and post-traumatic stress symptom levels at 2 weeks (respective effect sizes 1.13 and 1.34). TBI severity was not significantly associated with 3-month symptom burden (p = 0.37). Using simulated data to evaluate the effect of enrichment, we showed that including only people with high symptom burden at 2 weeks would permit trials to reduce the sample size by half, with minimal increase in screening, as compared with enrolling an unenriched sample. Clinical trials aimed at reducing symptoms after TBI can be efficiently conducted by enriching the included sample with people reporting a high early symptom burden.
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Affiliation(s)
- Nancy Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Joan Machamer
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Sureyya Dikmen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
| | - Lindsay D. Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Phillip H. Hwang
- Department of Anatomy and Neurobiology, Boston University, Boston Massachusetts, USA
| | - Kim Boase
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Murray B. Stein
- Department of Psychiatry and Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Joseph Giacino
- Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Michael A. McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sabrina R. Taylor
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sonia Jain
- Biostatistics Research Center Herbert Wertheim School of Public Health, University of California, San Diego, California, USA
| | - Geoff Manley
- Brain and Spinal Injury Center, San Francisco California, USA
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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5
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Bredemeier K, Larsen S, Shivakumar G, Grubbs K, McLean C, Tress C, Rosenfield D, DeRubeis R, Xu C, Foa E, Morland L, Pai A, Tsao C, Crawford J, Weitz E, Mayinja L, Feler B, Wachsman T, Lupo M, Hooper V, Cook R, Thase M. A comparison of prolonged exposure therapy, pharmacotherapy, and their combination for PTSD: What works best and for whom; study protocol for a randomized trial. Contemp Clin Trials 2022; 119:106850. [PMID: 35842108 DOI: 10.1016/j.cct.2022.106850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/22/2022] [Accepted: 07/10/2022] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Keith Bredemeier
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Sadie Larsen
- Milwaukee VA Medical Center, 5000 West National Avenue, Milwaukee, WI 53295-1000, USA; Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
| | - Geetha Shivakumar
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Kathleen Grubbs
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA; University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Carmen McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Stanford University, 450 Serra Mall, Stanford, CA 94305, USA.
| | - Carmella Tress
- Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - David Rosenfield
- Southern Methodist University, 6425 Boaz Lane, Dallas, TX 75205, USA.
| | - Rob DeRubeis
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Colin Xu
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Edna Foa
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Leslie Morland
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA; University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Anushka Pai
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Carol Tsao
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226, USA.
| | - Jaclyn Crawford
- Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - Erica Weitz
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Lindiwe Mayinja
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA; Coatesville VA Medical Center, 1400 Black Horse Hill Road, Coatesville, PA 19320-2096, USA.
| | - Bridget Feler
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA.
| | - Tamara Wachsman
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161-0002, USA.
| | - Margaret Lupo
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA.
| | - Vaughan Hooper
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA.
| | - Riley Cook
- Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX 75216-7167, USA.
| | - Michael Thase
- University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA; Corporal Michael J. Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104, USA.
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6
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Mureșanu IA, Grad DA, Mureșanu DF, Dobran SA, Hapca E, Strilciuc Ș, Benedek I, Capriș D, Popescu BO, Perju-Dumbravă L, Cherecheș RM. Evaluation of post-traumatic stress disorder (PTSD) and related comorbidities in clinical studies. J Med Life 2022; 15:436-442. [PMID: 35646173 PMCID: PMC9126456 DOI: 10.25122/jml-2022-0120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/25/2022] [Indexed: 12/14/2022] Open
Abstract
Patients with traumatic brain injury (TBI) of varying severities are experiencing adverse outcomes during and after rehabilitation. Besides depression and anxiety, post-traumatic stress disorder (PTSD) is highly encountered in civilian and military populations. As more prospective and retrospective studies - focused on evaluating new or old psychological therapies in inpatient, outpatient, or controlled environments, targeting patients with PTSD with or without a history of TBI - are carried out, researchers are employing various scales to measure PTSD as well as other psychiatric diagnoses or cognitive impairments that might appear following TBI. We aimed to explore the literature published between January 2010 and October 2021 by querying three databases. Our preliminary results showed that several scales - such as the Clinician-Administered PTSD Scale (CAPS), the Posttraumatic Stress Disorder Checklist Military Version (PCL-M) as well as Specific Version (PCL-S), and Civilian Version (PCL-C) - have been frequently used for PTSD diagnosis and symptom severity. However, heterogeneity in the scales used when assessing and evaluating additional psychiatric comorbidities and cognitive impairments are due to the study aim and therapeutic approaches. Therefore, conducting an intervention focusing on post-TBI PTSD patients requires increased attention to patients' medical history in capturing multiple cognitive impairments and affected neuropsychological processes when designing the study and including validated instruments for measuring primary and secondary neuropsychological outcomes.
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Affiliation(s)
- Ioana Anamaria Mureșanu
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania,Corresponding Author: Ioana Anamaria Mureșanu, RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Cluj, Romania. Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania. E-mail:
| | - Diana Alecsandra Grad
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Public Health, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Dafin Fior Mureșanu
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Elian Hapca
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ștefan Strilciuc
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Irina Benedek
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Neurosciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David Capriș
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Bogdan Ovidiu Popescu
- Department of Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Răzvan Mircea Cherecheș
- RoNeuro Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania,Department of Public Health, Babes-Bolyai University, Cluj-Napoca, Romania
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7
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Weis CN, Webb EK, deRoon-Cassini TA, Larson CL. Emotion Dysregulation Following Trauma: Shared Neurocircuitry of Traumatic Brain Injury and Trauma-Related Psychiatric Disorders. Biol Psychiatry 2022; 91:470-477. [PMID: 34561028 PMCID: PMC8801541 DOI: 10.1016/j.biopsych.2021.07.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/02/2022]
Abstract
The psychological trauma associated with events resulting in traumatic brain injury (TBI) is an important and frequently overlooked factor that may impede brain recovery and worsen mental health following TBI. Indeed, individuals with comorbid posttraumatic stress disorder (PTSD) and TBI have significantly poorer clinical outcomes than individuals with a sole diagnosis. Emotion dysregulation is a common factor leading to poor cognitive and affective outcomes following TBI. Here, we synthesize how acute postinjury molecular processes stemming from either physical or emotional trauma may adversely impact circuitry subserving emotion regulation and ultimately yield long-term system-level functional and structural changes that are common to TBI and PTSD. In the immediate aftermath of traumatic injury, glucocorticoids stimulate excess glutamatergic activity, particularly in prefrontal cortex-subcortical circuitry implicated in emotion regulation. In human neuroimaging work, assessing this same circuitry well after the acute injury, TBI and PTSD show similar impacts on prefrontal and subcortical connectivity and activation. These neural profiles indicate that emotion regulation may be a useful target for treatment and early intervention to prevent the adverse sequelae of TBI. Ultimately, the success of future TBI and PTSD early interventions depends on the fields' ability to address both the physical and emotional impact of physical injury.
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8
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Maruyama BA, Abrams G, Kornblith E, Posecion LF, McQuaid JR, Neylan TC, Groberio J, Chen AJW, Novakovic-Agopian T. Improvement in executive functioning after Goal-Oriented Attentional Self-Regulation training is associated with reduction in PTSD hyperarousal symptoms among veterans with comorbid PTSD and mild TBI. APPLIED NEUROPSYCHOLOGY-ADULT 2021:1-9. [PMID: 34410839 DOI: 10.1080/23279095.2021.1960531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R2 = 0.26, F(1,15) = 5.01, β = -.51, p < .05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans.
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Affiliation(s)
- Brian A Maruyama
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Gary Abrams
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Erica Kornblith
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Lainie F Posecion
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - John R McQuaid
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Thomas C Neylan
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Jessica Groberio
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA
| | - Anthony J-W Chen
- University of California, San Francisco, CA, USA.,Department of Veterans Affairs, VA Northern California Health Care System, Martinez, CA, USA
| | - Tatjana Novakovic-Agopian
- Department of Veterans Affairs, San Francisco VA Health Care System, San Francisco, CA, USA.,University of California, San Francisco, CA, USA
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9
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Emotional Disturbances After Traumatic Brain Injury: Prevalence, Assessment, and Treatment. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-021-00311-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Double Trouble: Treatment Considerations for Patients with Comorbid PTSD and Depression. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40501-020-00213-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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McLean CP, Miller ML, Gengler R, Henderson J, Sloan DM. The efficacy of written exposure therapy versus imaginal exposure delivered online for posttraumatic stress disorder: Design of a randomized controlled trial in Veterans. Contemp Clin Trials 2020; 91:105990. [PMID: 32184198 DOI: 10.1016/j.cct.2020.105990] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/28/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022]
Abstract
Adapting evidence-based treatments for online delivery has potential to significantly increase the reach of effective care to Veterans with posttraumatic stress disorder (PTSD). This paper describes the rationale for and methods of a randomized controlled trial comparing the efficacy and efficiency of written exposure therapy versus imaginal exposure for PTSD delivered in a novel online and variable length format. Participants will be 300 Veterans seeking treatment for clinically significant symptoms of PTSD. Participants will be randomly assigned to either written exposure or imaginal exposure via verbal recounting and will complete between 4 and 8 online therapy sessions facilitated by trained peer support specialists. Treatment is terminated before session 8 if the PTSD symptom improvement criterion is met. Assessments will be conducted at baseline, post-treatment, and at 3-month follow-up. The primary hypotheses are that written exposure therapy will be noninferior to imaginal exposure with respect to treatment efficacy and efficiency. Secondary hypotheses relate to identifying and comparing potential mediators of PTSD treatment outcome, including trauma-related cognitions and emotion regulation.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Stanford University, Department of Psychiatry and Behavioral Sciences, School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - Madeleine L Miller
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA
| | - Richard Gengler
- Prevail Health Solutions, LLC, 105 W Chicago Ave #203, Chicago, IL 60642, USA
| | - Jason Henderson
- Prevail Health Solutions, LLC, 105 W Chicago Ave #203, Chicago, IL 60642, USA
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, 150 S Huntington Ave, Boston, MA 02130, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
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12
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Tanev KS, Federico LE, Terry DP, Clark EL, Iverson GL. Cognitive Impairment and Predicting Response to Treatment in an Intensive Clinical Program for Post-9/11 Veterans With Posttraumatic Stress Disorder. J Neuropsychiatry Clin Neurosci 2020; 31:337-345. [PMID: 31018812 DOI: 10.1176/appi.neuropsych.18090208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined whether objectively measured pretreatment cognitive impairment predicted worse response to treatment for posttraumatic stress disorder. Participants were 113 veterans and active duty service members who participated in a new multidisciplinary 2-week intensive clinical program that included individual trauma-focused cognitive-behavioral therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments (mean age: 39.7 years [SD=8.5]; 20% women). METHODS Prior to treatment, participants completed a brief computerized cognitive battery (CNS Vital Signs) and were operationalized as having cognitive impairment if they scored in the ≤5th percentile on two or more of five core cognitive domains. Participants completed measures of traumatic stress, depression, cognitive self-efficacy, and satisfaction with their ability to participate in social roles before and after treatment. RESULTS There were no significant correlations between pretreatment individual cognitive test scores and change in the clinical outcome measures. One-half of the study sample (49.6%) met criteria for cognitive impairment. In a mixed multivariate analysis of variance, the interaction between cognitive impairment and time was not significant (F=0.83, df=4, 108, p=0.51), indicating that the pre- to posttreatment changes in outcome scores were not significantly different for the cognitively impaired group compared with the cognitively intact group. The multivariate main effect for time was significant (F=36.75, df=4, 108, p<0.001). Follow-up univariate tests revealed significant improvement in traumatic stress, depression, cognitive self-efficacy, and satisfaction with social roles after treatment. CONCLUSIONS Cognitive impairment was not associated with worse response to treatment in veterans with severe and complex mental health problems. Veterans with and without cognitive impairment reported large improvements in symptoms and functioning after treatment.
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Affiliation(s)
- Kaloyan S Tanev
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Lydia E Federico
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Douglas P Terry
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Erika L Clark
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Grant L Iverson
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
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13
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Rosen V, Ayers G. An Update on the Complexity and Importance of Accurately Diagnosing Post-Traumatic Stress Disorder and Comorbid Traumatic Brain Injury. Neurosci Insights 2020; 15:2633105520907895. [PMID: 32391522 PMCID: PMC7198284 DOI: 10.1177/2633105520907895] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/30/2020] [Indexed: 11/30/2022] Open
Abstract
As awareness for diagnosing and screening patients for trauma has grown, more
effective evidence-based treatments are available to treat post-traumatic stress
disorder (PTSD). Despite these gains, several patients are non-responsive to
care and research has shifted to determining barriers for cure or improvement.
With the advent of modern warfare, the combination of intermittent explosive
devices and more robust armor has resulted in service members surviving blasts
that historically would have been lethal, resulting in a rise in traumatic brain
injuries (TBIs). Post-traumatic stress disorder and TBI are often comorbid and
can serve as the aforementioned barriers for cure or improvement for each other
if one goes unrecognized. This mini-review will discuss the importance of
diagnosing both entities, especially when they are comorbid, by examining how
misdiagnosis may interfere with treatment outcomes. Several recent advances in
methods to successfully distinguish between the two disorders will be
reviewed.
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Affiliation(s)
- Valerie Rosen
- Department of Psychiatry, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Gayle Ayers
- Department of Psychiatry, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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14
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Tanev KS, Federico LE, Greenberg MS, Orr SP, Goetter EM, Resick PA, Pitman RK. Baseline Cognitive Performance and Treatment Outcomes From Cognitive-Behavioral Therapies for Posttraumatic Stress Disorder: A Naturalistic Study. J Neuropsychiatry Clin Neurosci 2020; 32:286-293. [PMID: 31948321 PMCID: PMC8887025 DOI: 10.1176/appi.neuropsych.19020032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. METHODS This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively). RESULTS Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD. CONCLUSIONS These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.
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Affiliation(s)
- Kaloyan S. Tanev
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Lydia E. Federico
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | | | - Scott P. Orr
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Elizabeth M. Goetter
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, N.C
| | - Roger K. Pitman
- Department of Psychiatry, Massachusetts General Hospital, Boston
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15
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Shura RD, Epstein EL, Armistead-Jehle P, Cooper DB, Eapen BC. Assessment and Treatment of Concussion in Service Members and Veterans. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Mikolić A, Polinder S, Retel Helmrich IRA, Haagsma JA, Cnossen MC. Treatment for posttraumatic stress disorder in patients with a history of traumatic brain injury: A systematic review. Clin Psychol Rev 2019; 73:101776. [PMID: 31707182 DOI: 10.1016/j.cpr.2019.101776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 01/10/2023]
Abstract
Posttraumatic stress disorder (PTSD) frequently co-occurs with traumatic brain injury (TBI). We conducted a systematic review to evaluate the appropriateness and effectiveness of treatments for PTSD in adult patients with a history of TBI. We searched for longitudinal studies aimed at treatments for PTSD patients who sustained a TBI, published in English between 1980 and February 2019. Twenty-three studies were found eligible, and 26 case studies were included for a separate overview. The quality of eligible studies was assessed using the Research Triangle Institute item bank. The majority of studies included types of cognitive-behavioral therapy (CBT) in male service members and veterans with a history of mild TBI in the United States. Studies using prolonged exposure (PE), cognitive-processing therapy (CPT) or other types of CBT, usually in combination with additional treatments, showed favorable outcomes. A smaller number of studies described complementary and novel therapies, which showed promising results. Overall, the quality of studies was considered low. We concluded that CBT seem appropriate for the patient population with history of TBI. The evidence is less strong for other therapies. We recommend controlled studies of PTSD treatments including more female patients and those with a history of moderate to severe TBIs in civilian and military populations.
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Affiliation(s)
- Ana Mikolić
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands.
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | | | - Juanita A Haagsma
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Maryse C Cnossen
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
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17
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Ackland PE, Greer N, Sayer NA, Spoont MR, Taylor BC, MacDonald R, McKenzie L, Rosebush C, Wilt TJ. Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury. J Affect Disord 2019; 252:493-501. [PMID: 31028994 DOI: 10.1016/j.jad.2019.04.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 03/08/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Co-morbidity of psychiatric conditions with traumatic brain injury (TBI) is common among service members and Veterans from recent deployments. Practice guidelines for mild TBI (mTBI) recommend management of co-occurring psychiatric conditions with existing treatments, but it is unclear whether the effectiveness of treatments for psychiatric conditions is impacted by mTBI. We conducted a systematic literature review to examine the effectiveness and harms of pharmacological and non-pharmacological treatments for posttraumatic stress disorder, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders in the presence of co-morbid deployment-related mTBI. METHODS We searched bibliographic databases for peer-reviewed, English language studies published from 2000 to October 2017. Two reviewers independently completed abstract triage and full text review. RESULTS We identified 7 studies (5 pre-post and 2 secondary analysis). Six assessed psychotherapy and one reported on hyperbaric oxygen therapy (HBO2). Studies comparing outcomes by TBI history found that a history of TBI does not affect treatment outcomes. Harms were reported only for HBO2 and were mild. No study examined the effectiveness of treatments for substance use disorders or suicidal ideation, or the effectiveness of pharmacological interventions for the psychiatric conditions of interest in service members and Veterans with mTBI. LIMITATIONS Studies lacked usual care or wait-list control groups and no randomized trials were found, making the strength of evidence insufficient. CONCLUSIONS Evidence is insufficient to fully assess the impact of TBI on the effectiveness of treatments for psychiatric conditions. Higher quality evidence with definitive guidance for providers treating this population is needed.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN.
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Nina A Sayer
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Department of Psychiatry, University of Minnesota, Minneapolis, MN
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; National Center for PTSD, Honolulu, HI
| | - Brent C Taylor
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Roderick MacDonald
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Lauren McKenzie
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Christina Rosebush
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research (CCDOR), Minneapolis VA Health Care System, One Veterans Drive (152), Minneapolis, MN 55417, USA; Department of Medicine, University of Minnesota, Minneapolis, MN; Minneapolis VA Evidence-based Synthesis Program Center, Minneapolis VA Health Care System, One Veterans Drive (111-O), Minneapolis, MN 55417, USA
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18
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Psychological Intervention in Traumatic Brain Injury Patients. Behav Neurol 2019; 2019:6937832. [PMID: 31191738 PMCID: PMC6525953 DOI: 10.1155/2019/6937832] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/20/2018] [Accepted: 03/19/2019] [Indexed: 01/25/2023] Open
Abstract
Objective To provide a brief and comprehensive summary of recent research regarding psychological interventions for patients surviving a traumatic brain injury. Methods A bibliographical search was performed in PubMed, Cochrane Library, PsycNET, Scopus, ResearchGate, and Google Scholar online databases. Analysis included distribution by year of publication, age stage of participants (paediatric, adult), location of the research team, study design, type of intervention, and main outcome variables. Results The initial search eliciting 1541 citations was reduced to 62 relevant papers. Most publications had adult samples (88.7%). The United States outstands as the country with more research (58.1%); Latin America countries provided no results. Cognitive behavioural therapy (CBT) was the most widely used approach for treatment of (sub)clinical mental disturbances (41.9%). Neuropsychological interventions were scarce (4.8%). Outcome measures included psychiatric disorders (e.g., posttraumatic stress disorder (PTSD), depression, and anxiety) (37.1%), postconcussive symptoms (16.1%), cognitive and functional deficits (48.1%), and social and psychological dimensions (62.9%). Conclusions CBT outstands as the preferred therapeutic approach for treating behavioural and emotional disturbances. Also, other related therapies such as dialectical behaviour, mindfulness, and acceptance and commitment therapies have been proposed, and probably in the years to come, more literature regarding their effectiveness will be available. On the other hand, evidence showed that interventions from the field of neuropsychology are minimal if compared with its contribution to assessment. Future research should be aimed at performing studies on more diverse populations (e.g., nonmilitary communities and paediatric and Latin American populations) and at controlling designs to examine the therapeutic efficacy of psychotherapeutic and neurocognitive rehabilitation interventions and compare amelioration by injury severity, age of patients, and clinical profile, in the hopes of creating better guidelines for practitioners.
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19
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Goodnight JRM, Ragsdale KA, Rauch SAM, Rothbaum BO. Psychotherapy for PTSD: An evidence-based guide to a theranostic approach to treatment. Prog Neuropsychopharmacol Biol Psychiatry 2019; 88:418-426. [PMID: 29786514 DOI: 10.1016/j.pnpbp.2018.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is often a clinically complex disorder, frequently presenting with comorbid clinical conditions. Individuals with PTSD may also present with high-risk symptoms such as substance misuse and suicidal ideation. The clinical complexity of PTSD has precluded some clinicians from providing gold-standard trauma-focused treatment due to concern of iatrogenic effects. However, evidence to date suggests that trauma-focused treatments are safe and effective for PTSD even when higher-risk comorbidity presents. Occasionally, while some patients present with clinical concerns that may benefit from modifications to standard recommended treatment protocols, research suggests there are few absolute contraindications to trauma-focused treatment. The present manuscript provides a review of evidence-based assessment and treatment recommendations for PTSD. A clinical decision-making guide for PTSD across areas of clinical complexity is provided.
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Affiliation(s)
- Jessica R M Goodnight
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States
| | - Katie A Ragsdale
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States
| | - Sheila A M Rauch
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States; VA Atlanta Healthcare System, United States
| | - Barbara O Rothbaum
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States.
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20
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Merritt BP, Kretzmer T, McKenzie-Hartman TL, Gootam P. Neurobehavioral Management of the Polytrauma Veteran. Phys Med Rehabil Clin N Am 2018; 30:133-154. [PMID: 30470418 DOI: 10.1016/j.pmr.2018.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.
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Affiliation(s)
- Bryan P Merritt
- James A. Haley Veterans Hospital, 13000 Bruce B Downs Boulevard #117, Tampa, FL 33612, USA; Department of Neurology, University of South Florida Medical School, 4202 E Fowler Avenue, Tampa, FL 33620, USA.
| | - Tracy Kretzmer
- James A. Haley Veterans Hospital, 13000 Bruce B Downs Boulevard #117, Tampa, FL 33612, USA; Department of Psychology, University of South Florida Medical School, 4202 E Fowler Avenue, Tampa, FL 33620, USA
| | - Tamara L McKenzie-Hartman
- James A. Haley Veterans Hospital, 13000 Bruce B Downs Boulevard #117, Tampa, FL 33612, USA; Defense and Veterans Brain Injury Center (DVBIC), Silver Spring, MD, USA
| | - Praveen Gootam
- James A. Haley Veterans Hospital, 13000 Bruce B Downs Boulevard #117, Tampa, FL 33612, USA; Department of Psychiatry and Behavioral Neurosciences, University of South Florida Medical School, 4202 E Fowler Avenue, Tampa, FL 33620, USA
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21
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Blakey SM, Wagner HR, Naylor J, Brancu M, Lane I, Sallee M, Kimbrel NA, Elbogen EB. Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses? THE JOURNAL OF PAIN 2018; 19:797-806. [PMID: 29526669 PMCID: PMC6026045 DOI: 10.1016/j.jpain.2018.02.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 02/07/2018] [Accepted: 02/27/2018] [Indexed: 12/17/2022]
Abstract
The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed. PERSPECTIVE This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.
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Affiliation(s)
- Shannon M Blakey
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - H Ryan Wagner
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Jennifer Naylor
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mira Brancu
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Ilana Lane
- Durham VA Medical Center, Durham, North Carolina
| | | | - Nathan A Kimbrel
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Eric B Elbogen
- Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina; Durham VA Medical Center, Durham, North Carolina; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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22
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Ragsdale KA, Gramlich MA, Beidel DC, Neer SM, Kitsmiller EG, Morrison KI. Does Traumatic Brain Injury Attenuate the Exposure Therapy Process? Behav Ther 2018; 49:617-630. [PMID: 29937262 DOI: 10.1016/j.beth.2017.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/26/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Abstract
Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.
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23
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Symptom Reporting and Management of Chronic Post-Concussive Symptoms in Military Service Members and Veterans. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2018. [DOI: 10.1007/s40141-018-0173-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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24
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Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members. J Head Trauma Rehabil 2018; 33:E53-E63. [DOI: 10.1097/htr.0000000000000344] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Rosen CS, Matthieu MM, Wiltsey Stirman S, Cook JM, Landes S, Bernardy NC, Chard KM, Crowley J, Eftekhari A, Finley EP, Hamblen JL, Harik JM, Kehle-Forbes SM, Meis LA, Osei-Bonsu PE, Rodriguez AL, Ruggiero KJ, Ruzek JI, Smith BN, Trent L, Watts BV. A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:957-977. [PMID: 27474040 DOI: 10.1007/s10488-016-0755-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.
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Affiliation(s)
- C S Rosen
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA. .,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
| | - M M Matthieu
- School of Social Work, Saint Louis University, Saint Louis, MO, USA
| | - S Wiltsey Stirman
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - J M Cook
- Evaluation Division, National Center for PTSD, VA Connecticut Health Care System, West Haven, CT, USA.,Yale School of Medicine, NEPEC/182, 950 Campbell Avenue, West Haven, CT, USA
| | - S Landes
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - N C Bernardy
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - K M Chard
- Cincinnati Department of Veterans Affairs (VA) Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Crowley
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - A Eftekhari
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - E P Finley
- South Texas Veterans Health Care System, San Antonio, TX, USA.,The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - J L Hamblen
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA.,Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - J M Harik
- Executive Division, National Center for PTSD, Veterans Affairs Medical Center, White River Junction, VT, USA
| | - S M Kehle-Forbes
- Women's Health Sciences Division at VA Boston Healthcare System, National Center for PTSD, Boston, MA, USA.,Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - L A Meis
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - P E Osei-Bonsu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA.,Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - A L Rodriguez
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - K J Ruggiero
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA.,Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - J I Ruzek
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.,Palo Alto University, Palo Alto, CA, USA
| | - B N Smith
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA
| | - L Trent
- Dissemination & Training Division, National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road (334-PTSD), Menlo Park, CA, 94025, USA.,Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - B V Watts
- Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Veterans Affairs Medical Center, White River Junction, VT, USA
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26
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Scholten J, Vasterling JJ, Grimes JB. Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain Inj 2017; 31:1246-1251. [DOI: 10.1080/02699052.2016.1274780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joel Scholten
- US Department of Veterans Affairs, Physical Medicine and Rehabilitation, Veterans Health Administration, Washington, DC, USA
| | - Jennifer J. Vasterling
- Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder and Psychology Service, VA Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
| | - Jamie B. Grimes
- Neurology Department and Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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27
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TBI and Treatment Response in a Randomized Trial of Acceptance and Commitment Therapy. J Head Trauma Rehabil 2017; 32:E35-E43. [DOI: 10.1097/htr.0000000000000278] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Jak A. The Primary Role of Mental Health Treatment in Resolution of Persistent Post-concussive Symptoms. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s40501-017-0119-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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29
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Verbal memory functioning moderates psychotherapy treatment response for PTSD-Related nightmares. Behav Res Ther 2017; 91:24-32. [DOI: 10.1016/j.brat.2017.01.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 01/05/2017] [Accepted: 01/12/2017] [Indexed: 11/24/2022]
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30
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Driesenga SA, Rodriguez JL, Picard T. Evidence-based Treatments for Military-related Posttraumatic Stress Disorder in a Veterans Affairs Setting. Crit Care Nurs Clin North Am 2017; 27:247-70. [PMID: 25981727 DOI: 10.1016/j.cnc.2015.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Posttraumatic stress disorder (PTSD) can have a significant negative impact on the physical, emotional, and mental health of individuals. This article discusses the prevalence, risk factors, and diagnostic criteria for PTSD. Given the high incidence of PTSD in the Veteran population, much attention has been given to assessment and treatment issues. Treatment options for PTSD, including the 2 most effective treatments, prolonged exposure and cognitive processing therapy, are discussed. Special issues concerning the treatment of Veterans are also reviewed.
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Affiliation(s)
- Scott A Driesenga
- Psychology Service, VA Medical Center - Battle Creek, 5500 Armstrong Road, Battle Creek, MI 49037-7314, USA.
| | - Jessica L Rodriguez
- Psychology Service, VA Medical Center - Battle Creek, 5500 Armstrong Road, Battle Creek, MI 49037-7314, USA
| | - Thomas Picard
- Psychology Service, VA Medical Center - Battle Creek, 5500 Armstrong Road, Battle Creek, MI 49037-7314, USA
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31
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Acierno R, Knapp R, Tuerk P, Gilmore AK, Lejuez C, Ruggiero K, Muzzy W, Egede L, Hernandez-Tejada MA, Foa EB. A non-inferiority trial of Prolonged Exposure for posttraumatic stress disorder: In person versus home-based telehealth. Behav Res Ther 2016; 89:57-65. [PMID: 27894058 DOI: 10.1016/j.brat.2016.11.009] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/15/2016] [Accepted: 11/19/2016] [Indexed: 01/17/2023]
Abstract
This is the first randomized controlled trial to evaluate non-inferiority of Prolonged Exposure (PE) delivered via home-based telehealth (HBT) compared to standard in-person (IP) PE. One-hundred thirty two Veterans recruited from a Southeastern Veterans Affairs Medical Center and affiliated University who met criteria for posttraumatic stress disorder (PTSD) were randomized to receive PE via HBT or PE via IP. Results indicated that PE-HBT was non-inferior to PE-IP in terms of reducing PTSD scores at post-treatment, 3 and 6 month follow-up. However, non-inferiority hypotheses for depression were only supported at 6 month follow-up. HBT has great potential to reduce patient burden associated with receiving treatment in terms of travel time, travel cost, lost work, and stigma without sacrificing efficacy. These findings indicate that telehealth treatment delivered directly into patients' homes may dramatically increase the reach of this evidence-based therapy for PTSD without diminishing effectiveness.
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Affiliation(s)
- Ron Acierno
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Nursing, Medical University of South Carolina, Charleston, SC, USA.
| | - Rebecca Knapp
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Peter Tuerk
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Amanda K Gilmore
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Carl Lejuez
- College of Liberal Arts & Sciences, University of Kansas, Lawrence, KS, USA
| | - Kenneth Ruggiero
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Wendy Muzzy
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Leonard Egede
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Melba A Hernandez-Tejada
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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32
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Ragsdale KA, Voss Horrell SC. Effectiveness of Prolonged Exposure and Cognitive Processing Therapy for U.S. Veterans With a History of Traumatic Brain Injury. J Trauma Stress 2016; 29:474-477. [PMID: 27681034 DOI: 10.1002/jts.22130] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 07/07/2016] [Accepted: 07/24/2016] [Indexed: 11/08/2022]
Abstract
This retrospective analysis of previously existing nonrandomized clinical data examined the effectiveness of completing prolonged exposure (PE) or cognitive processing therapy (CPT) in a sample of 41 U.S. veterans at a Veterans Affairs medical center. The sample included 19 veterans with diagnoses of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) and 22 veterans with PTSD only. Diagnostic groups did not significantly differ on PTSD and depression symptom reduction, F(2, 36) = 0.05, p = .951; Pillai's trace = 0.00, partial η2 = .00. Veterans who completed PE showed greater symptom reduction than those who completed CPT, F(2, 36) = 12.10, p < .001; Pillai's trace = 0.40, partial η2 = .40, regardless of TBI status. Overall, our results suggested that TBI status should not preclude individuals from being offered trauma-focused PTSD treatment.
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33
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Cooper DB, Bunner AE, Kennedy JE, Balldin V, Tate DF, Eapen BC, Jaramillo CA. Treatment of persistent post-concussive symptoms after mild traumatic brain injury: a systematic review of cognitive rehabilitation and behavioral health interventions in military service members and veterans. Brain Imaging Behav 2016; 9:403-20. [PMID: 26330376 DOI: 10.1007/s11682-015-9440-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Increased prevalence of traumatic brain injury (TBI) has been associated with service members and veterans who completed combat deployments in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Management of persistent post-concussive symptoms (PCS) has been a challenge to healthcare providers throughout the Military and Veterans Healthcare Systems, as well as civilian healthcare providers, due in part to the chronic nature of symptoms, co-occurrence of behavioral health disorders such as depression, Posttraumatic Stress Disorder (PTSD), and substance use disorders, and fear of a potential stigma associated with psychiatric diagnoses and behavioral health treatment(s). This systematic review examined non-pharmacologic behavioral health interventions and cognitive rehabilitation interventions for PCS in military service members and veterans with a history of mild TBI (mTBI). Six electronic databases were searched with specific term limitations, identifying 121 citations. Ultimately, 19 articles met criteria for inclusion in this systematic review. Studies were broadly categorized into four subtypes: psychoeducational interventions, cognitive rehabilitation, psychotherapeutic approaches, and integrated behavioral health interventions for PCS and PTSD. The review provides an update of the empirical evidence for these four types of interventions for PCS in active duty service members and veterans. Recommendations for future research are discussed, including the need to expand and improve the limited evidence basis on how to manage persistent post-concussive symptoms in this population.
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Affiliation(s)
- Douglas B Cooper
- Defense and Veteran's Brain Injury Center, San Antonio Military Medical Center MCHE MDU (DVBIC), 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA.
- Department of Neurology, San Antonio Military Medical Center, Fort Sam Houston, TX, USA.
| | - Anne E Bunner
- Defense and Veterans Brain Injury Center, Bethesda, MD, USA
| | - Jan E Kennedy
- Defense and Veteran's Brain Injury Center, San Antonio Military Medical Center MCHE MDU (DVBIC), 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200, USA
- Department of Neurology, San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Valerie Balldin
- Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - David F Tate
- Missouri Institute of Mental Health, University of Missouri at St. Louis, St. Louis, MO, USA
| | - Blessen C Eapen
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Carlos A Jaramillo
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, TX, USA
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34
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Strom TQ, Wolf GK, Crawford E, Blahnik M, Kretzmer T. Implementing Prolonged Exposure for Veterans With Comorbid PTSD and Traumatic Brain Injury: Two Case Studies. COGNITIVE AND BEHAVIORAL PRACTICE 2016. [DOI: 10.1016/j.cbpra.2015.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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35
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Lau KM, Madden E, Neylan TC, Seal KH, Maguen S. Assessing for mild TBI among Iraq and Afghanistan veterans: Outcomes of injury severity and neurological factors. Brain Inj 2016; 30:287-94. [PMID: 26910483 DOI: 10.3109/02699052.2015.1089601] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate injury severity markers and neurological symptoms associated with clinician-confirmed mild traumatic brain injury (TBI) among Iraq and Afghanistan veterans. SETTING Department of Veterans Affairs (VA) medical centre and five affiliated community-based outpatient clinics. PARTICIPANTS Three hundred and fifty Iraq and Afghanistan veterans with positive initial VA TBI screens between 1 April 2007 and 1 June 2010 and clinician-confirmed TBI status by 1 December 2010. METHODS Retrospective-cohort study of medical record data. Main measures included clinician-confirmed TBI status, injury severity markers (e.g. loss of consciousness (LOC), post-traumatic amnesia (PTA) or confusion/disorientation) and neurological symptoms. RESULTS Among veterans who screened positive on the initial VA TBI and then received a clinician evaluation, 60% were confirmed to have a TBI diagnosis. Veterans reporting at least one LOC, confusion or PTA were almost 18-times more likely to receive a confirmed TBI diagnosis. Odds of clinician-confirmed TBI were 2.5-3-times greater among those who endorsed dizziness, poor coordination, headaches, nausea, vision problems and/or irritability, compared to those not endorsing these symptoms. Nausea had greatest utility for confirming a TBI. CONCLUSIONS Identification of neurologic symptoms that most contribute to a clinician-confirmed diagnosis of TBI has potential for streamlining detection of TBI and symptoms needed for treatment.
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Affiliation(s)
- Karen M Lau
- a San Francisco VA Medical Center , San Francisco , CA , USA
| | - Erin Madden
- a San Francisco VA Medical Center , San Francisco , CA , USA
| | - Thomas C Neylan
- a San Francisco VA Medical Center , San Francisco , CA , USA.,b Department of Psychiatry
| | - Karen H Seal
- a San Francisco VA Medical Center , San Francisco , CA , USA.,b Department of Psychiatry.,c Department of Medicine , University of California, San Francisco , San Francisco , CA , USA
| | - Shira Maguen
- a San Francisco VA Medical Center , San Francisco , CA , USA.,b Department of Psychiatry
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36
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Co-Occurring Traumatic Brain Injury, PTSD Symptoms, and Alcohol Use in Veterans. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2015. [DOI: 10.1007/s10862-015-9513-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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37
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Wolf GK, Kretzmer T, Crawford E, Thors C, Wagner HR, Strom TQ, Eftekhari A, Klenk M, Hayward L, Vanderploeg RD. Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury. J Trauma Stress 2015. [PMID: 26201688 DOI: 10.1002/jts.22029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.
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Affiliation(s)
- Gregory K Wolf
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - Tracy Kretzmer
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - Eric Crawford
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Christina Thors
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - H Ryan Wagner
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Thad Q Strom
- Mental Health Services for Minneapolis, Department of Veterans Affairs Medical Center, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Afsoon Eftekhari
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto HCS, Menlo Park, California, USA
| | - Megan Klenk
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura Hayward
- Department of Psychology, Syracuse VA Medical Center, Syracuse, New York, USA
| | - Rodney D Vanderploeg
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA.,Departments of Psychiatry and Neurosciences, and Psychology, University of South Florida, Tampa, Florida, USA
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38
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Pelton D, Wangelin B, Tuerk P. Utilizing Telehealth to Support Treatment of Acute Stress Disorder in a Theater of War: Prolonged Exposure via Clinical Videoconferencing. Telemed J E Health 2015; 21:382-7. [DOI: 10.1089/tmj.2014.0111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Dan Pelton
- U.S. Army Individual Ready Reserve
- Anxiety-Solutions, LLC, McLean, Virginia
| | - Bethany Wangelin
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Tuerk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
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39
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Tanev KS, Pentel KZ, Kredlow MA, Charney ME. PTSD and TBI co-morbidity: scope, clinical presentation and treatment options. Brain Inj 2014; 28:261-70. [PMID: 24568300 DOI: 10.3109/02699052.2013.873821] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVE To summarize the literature on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) and their co-morbidity, focusing on diagnosis, clinical symptoms and treatment issues relevant to the clinician. RESEARCH DESIGN Review of the literature. METHODS AND PROCEDURES Pubmed searches were performed using the terms post-traumatic stress disorder, traumatic brain injury, sleep, cognitive, depression, anxiety, treatment and combinations of these terms. Those articles relevant to the objective were included. MAIN OUTCOMES AND RESULTS This study presents pathophysiological, neuroimaging and clinical data on co-morbid PTSD and TBI. It reviews associated conditions, emphasizing the impact of cognitive and sleep problems. It summarizes the emerging literature on treatment effectiveness for co-morbid PTSD and TBI, including psychotherapy, pharmacotherapy and cognitive rehabilitation. CONCLUSIONS Both PTSD and TBI commonly occur in the general population, both share some pathophysiological characteristics and both are associated with cognitive impairment and sleep disruption. PTSD and TBI present with a number of overlapping symptoms, which can lead to over-diagnosis or misdiagnosis. Both conditions are associated with co-morbidities important in diagnosis and treatment planning. More research is needed to elucidate what treatments are effective in PTSD and TBI co-morbidity and on factors predictive of treatment success.
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Affiliation(s)
- Kaloyan S Tanev
- Massachusetts General Hospital , Department of Psychiatry, The Home Base Program, Boston, MA , USA and
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40
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Mørkved N, Hartmann K, Aarsheim LM, Holen D, Milde AM, Bomyea J, Thorp SR. A comparison of Narrative Exposure Therapy and Prolonged Exposure therapy for PTSD. Clin Psychol Rev 2014; 34:453-67. [PMID: 25047447 DOI: 10.1016/j.cpr.2014.06.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 06/10/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022]
Abstract
The purpose of this review was to compare and contrast Prolonged Exposure (PE) and Narrative Exposure Therapy (NET). We examined the treatment manuals to describe the theoretical foundation, treatment components, and procedures, including the type, manner, and focus of exposure techniques and recording methods used. We examined extant clinical trials to investigate the range of treatment formats reported, populations studied, and clinical outcome data. Our search resulted in 32 studies on PE and 15 studies on NET. Consistent with prior reviews of PTSD treatment, it is evident that PE has a solid evidence base and its current status as a first line treatment for the populations studied to this date is warranted. We argue that NET may have advantages in treating complex traumatization seen in asylum seekers and refugees, and for this population NET should be considered a recommended treatment. NET and PE have several commonalities, and it is recommended that studies of these treatments include a broader range of populations and trauma types to expand the current knowledge on the treatment of PTSD.
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Affiliation(s)
- N Mørkved
- The Faculty of Psychology, University of Bergen, Norway
| | - K Hartmann
- The Faculty of Psychology, University of Bergen, Norway
| | - L M Aarsheim
- The Faculty of Psychology, University of Bergen, Norway
| | - D Holen
- The Faculty of Psychology, University of Bergen, Norway
| | - A M Milde
- Department of Biological and Medical Psychology, University of Bergen, Norway; Regional Resource Centre on Violence, Traumatic Stress and Suicide Prevention, Health Bergen, Norway
| | - J Bomyea
- SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Ct., Suite 103, San Diego, CA 92120 USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Drive (116A), San Diego, CA 92161 USA
| | - S R Thorp
- SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Ct., Suite 103, San Diego, CA 92120 USA; Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, 3350 La Jolla Village Drive (116A), San Diego, CA 92161 USA; Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (0851), La Jolla, CA 92093, USA.
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41
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Bahraini NH, Breshears RE, Hernández TD, Schneider AL, Forster JE, Brenner LA. Traumatic brain injury and posttraumatic stress disorder. Psychiatr Clin North Am 2014; 37:55-75. [PMID: 24529423 DOI: 10.1016/j.psc.2013.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI.
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Affiliation(s)
- Nazanin H Bahraini
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychiatry, School of Medicine, University of Colorado, 13001 East 17th Place, Aurora, CO 80045, USA.
| | - Ryan E Breshears
- Wellstar Health System, Psychological Services, 55 Whitcher Street, Suite 420, Marietta, GA 30060, USA; Department of Counseling and Human Development, University of Georgia, 402 Aderhold Hall, Athens, GA 30602, USA
| | - Theresa D Hernández
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychology and Neuroscience, University of Colorado, 1905 Colorado Avenue, Boulder, CO 80309, USA
| | - Alexandra L Schneider
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA
| | - Jeri E Forster
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Biostatistics & Informatics, Colorado School of Public Health, University of Colorado Denver, 13001 E. 17th Place, Aurora, CO 80045, USA
| | - Lisa A Brenner
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychiatry, School of Medicine, University of Colorado, 13001 East 17th Place, Aurora, CO 80045, USA; Department of Neurology, School of Medicine, University of Colorado, 13001 E. 17th Place, Aurora, CO 80045, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado, 13001 E. 17th Place, Aurora, CO 80045, USA
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42
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Wangelin BC, Tuerk PW. PTSD in active combat soldiers: to treat or not to treat. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2014; 42:161-170. [PMID: 25040380 DOI: 10.1111/jlme.12132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.
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Affiliation(s)
- Bethany C Wangelin
- Staff psychologist on the PTSD Clinical Team at the Ralph H. Johnson VA Medical Center in Charleston, SC
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43
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Harch PG. Hyperbaric oxygen therapy for post-concussion syndrome: contradictory conclusions from a study mischaracterized as sham-controlled. J Neurotrauma 2013; 30:1995-9. [PMID: 24004322 DOI: 10.1089/neu.2012.2799] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paul G Harch
- Department of Medicine, Louisiana State University School of Medicine , New Orleans, Louisiana
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44
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Interventions for Mood-Related Issues Post Traumatic Brain Injury: Novel Treatments and Ongoing Limitations of Current Research. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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45
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Wangelin BC, Powers MB, Smits JAJ, Tuerk PW. Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome. Contemp Clin Trials 2013; 36:319-26. [PMID: 23939512 DOI: 10.1016/j.cct.2013.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 07/30/2013] [Accepted: 08/03/2013] [Indexed: 02/06/2023]
Abstract
Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.
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Affiliation(s)
- Bethany C Wangelin
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee St., Charleston, SC, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St., Charleston, SC 29401, United States.
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46
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Sripada RK, Rauch SAM, Tuerk PW, Smith E, Defever AM, Mayer RA, Messina M, Venners M. Mild traumatic brain injury and treatment response in prolonged exposure for PTSD. J Trauma Stress 2013; 26:369-75. [PMID: 23696427 DOI: 10.1002/jts.21813] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A proportion of U.S. veterans returning from Iraq and Afghanistan have experienced mild traumatic brain injury (mTBI), which is associated with increased risk for developing posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) has proven effectiveness in the treatment of PTSD; however, some clinicians have reservations about using PE with individuals with a history of mTBI. We examined the impact of PE for veterans with PTSD and with or without a history of mTBI in a naturalistic sample of 51 veterans who received PE at a Veterans Health Administration PTSD clinic. We also analyzed previously collected data from a controlled trial of 22 veterans randomly assigned to PE or present centered therapy. For both sets of data, we found that PE reduced symptom levels and we also did not detect an effect for mTBI, suggesting that PE may be helpful for individuals with PTSD and a history of mTBI.
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Affiliation(s)
- Rebecca K Sripada
- VA Ann Arbor Health Care System/University of Michigan Medical School, Ann Arbor, Michigan, USA.
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47
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Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care. J Clin Psychol Med Settings 2013. [PMID: 23184276 DOI: 10.1007/s10880-012-9345-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.
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48
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Rees B, Travis F, Shapiro D, Chant R. Reduction in posttraumatic stress symptoms in Congolese refugees practicing transcendental meditation. J Trauma Stress 2013; 26:295-8. [PMID: 23568415 DOI: 10.1002/jts.21790] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This matched single-blind pilot study tested the effect of Transcendental Meditation® (TM) practice on symptoms of posttraumatic stress (PTS) in Congolese refugees. Urban refugees (N = 102) staying around Kampala, Uganda attended introductory meetings. After initial random assignment to the TM group, 30 refugees who revealed that they were unable to attend all meetings and were eliminated from the study. The remaining 21 TM group participants were then instructed in TM and matched with refugees in the control group on age, sex, and baseline scores on the Post-traumatic Stress Disorder Checklist-Civilian (PCL-C). All participants completed the PCL-C measure of PTS symptoms at baseline, and 30-day and 135-day posttests. The PCL-C scores in the control group trended upward. In contrast, the PCL-C scores in the TM group went from 65 on average at baseline indicating severe PTS symptoms to below 30 on average after 30 days of TM practice, and remained low at 135 days. Effect size was high (d > 1.0). Compliance with TM practice was good; most reported regular practice throughout the study. There were no adverse events. All refugees who learned TM completed the study and were able to practice TM successfully, with subsequent substantial reduction in PTS symptoms.
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Affiliation(s)
- Brian Rees
- Colonel, Medical Corps, U.S. Army Reserve, Command Surgeon, 63d Regional Support Command, Moffett Field, CA, USA.
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49
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Steenkamp MM, Litz BT. Psychotherapy for military-related posttraumatic stress disorder: Review of the evidence. Clin Psychol Rev 2013; 33:45-53. [DOI: 10.1016/j.cpr.2012.10.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 08/31/2012] [Accepted: 10/07/2012] [Indexed: 10/27/2022]
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50
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Harch PG, Andrews SR, Fogarty E, Amen DG, Lucarini J, Van Meter KW. Response to Letter to the Editor by Wortzel and Colleagues. J Neurotrauma 2012. [DOI: 10.1089/neu.2012.2544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paul G. Harch
- Department of Medicine, Louisiana State University School of Medicine, New Orleans, Harvey, Louisiana
| | - Susan R. Andrews
- Department of Medicine and Psychiatry, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Edward Fogarty
- Department of Radiology, University of North Dakota School of Medicine, Bismarck, North Dakota
| | | | - Juliette Lucarini
- Administrative Office of Paul G. Harch, M.D., New Orleans, Louisiana
| | - Keith W. Van Meter
- Department of Medicine and Psychiatry, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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