PTSD in active combat soldiers: to treat or not to treat

Imagery, emotion, and bioinformational theory: From body to brain

The bioinformational theory of emotional imagery is a model of the hypothetical mental representations activated when people imagine emotionally engaging events, and was initially proposed to guide research and practice in the use of imaginal exposure as a treatment for fear and anxiety (Lang, 1979). In this 50 year overview, we discuss the development of bioinformational theory and its impact on the study of psychophysiology and psychopathology, most importantly assessing its viability and predictions in light of more recent brain-based studies of neural functional activation. Bioinformational theory proposes that narrative imagery, typically cued by language scripts, activates an associative memory network in the brain that includes stimulus (e.g., agents, contexts), semantic (e.g., facts and beliefs) and, most critically for emotion, response information (e.g., autonomic and somatic) that represents relevant real-world coping actions and reactions. Psychophysiological studies in healthy and clinical samples reliably find measurable response output during aversive and appetitive narrative imagery. Neuroimaging studies confirm that emotional imagery is associated with significant activation in motor regions of the brain, as well as in regions implicated in episodic and semantic memory retrieval, supporting the bioinformational view that narrative imagery prompts mental simulation of events that critically includes the actions and reactions engaged in emotional contexts.

Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review

Some individuals with posttraumatic stress disorder (PTSD) are at elevated risk of reexposure to trauma during treatment. Trauma-focused cognitive-behavioral therapies (CBT) are recommended as first-line PTSD treatments but have generally been tested with exclusion criteria related to risk for trauma exposure. Therefore, there is limited knowledge on how to best treat individuals with PTSD under ongoing threat of reexposure. This paper systematically reviewed the effectiveness of CBTs for PTSD in individuals with ongoing threat of reexposure. Literature searches yielded 21 studies across samples at ongoing risk of war-related or community violence (n = 14), domestic violence (n = 5), and work-related traumatic events (n = 2). Medium to large effects were found from pre to posttreatment and compared with waitlist controls. There were mixed findings for domestic violence samples on long-term outcomes. Treatment adaptations focused on establishing relative safety and differentiating between realistic threat and generalized fear responses. Few studies examined whether ongoing threat influenced treatment outcomes or whether treatments were associated with adverse events. Thus, although the evidence is promising, conclusions cannot be firmly drawn about whether trauma-focused CBTs for PTSD are safe and effective for individuals under ongoing threat. Areas for further inquiry are outlined.

Implementing Prolonged Exposure Therapy for PTSD in a Context of Ongoing Adversity: A Clinical Case Study

Obstacles regarding the implementation of empirically supported treatments (ESTs) for mental disorders such as post-traumatic stress disorder (PTSD) still require further investigation. One notable obstacle is whether persons in low- and middle-income countries (LMICs) residing in a context of ongoing adversity would benefit from an EST for PTSD. We reflect on the utility of a brief prolonged exposure intervention at a primary care community-counseling center in South Africa. “Sam,” a 45-year-old, female was assessed at baseline, during treatment, postassessment, and at 3-month follow-up. At the beginning of treatment, Sam had a positive diagnosis for PTSD (PSSI-5 = 55, and cutoff is 23) and at the end of treatment (PSSI-5 = 17), and 3-month follow-up (PSSI-5 = 21), she had a negative diagnosis for PTSD. We reflect on the mediating effects that contextual factors such as gang violence had on the treatment process and the feasibility of implementing ESTs for PTSD in LMICs under conditions of ongoing adversity.

The feasibility of prolonged exposure therapy for PTSD in low- and middle-income countries: a review

There is a need in the global south to evaluate and implement empirically supported psychological interventions to ameliorate symptoms of posttraumatic stress disorder (PTSD). Empirically supported treatments (ESTs) have increasingly been developed and implemented, yet the majority people in the global south do not have access to these treatments for mental disorders such as PTSD. Prolonged exposure therapy has accrued substantial empirical evidence to show it as an effective treatment for PTSD. Research on the effectiveness and acceptability of prolonged exposure in a low- and middle-income countries (LMICs) are sparse. This brief report presents a review of prolonged exposure (PE) therapy and its feasibility as a trauma therapy for PTSD in LMICs. First, we present a brief overview of PE as a first-line treatment for PTSD. Second, using South Africa as a case example, we present a brief overview of traumatic stress in South Africa and how mental healthcare has developed since the abolishment of apartheid in 1994. Lastly, we discuss the challenges pertaining to the dissemination and implementation of PE in LMICs and propose future perspectives regarding the implementation of ESTs such as PE in LMICs.

Impact of setting insecurity on Cognitive Processing Therapy implementation and outcomes in eastern Democratic Republic of the Congo

Background: While evidence is growing for the efficacy of trauma-focused mental health interventions in low- and middle-income countries, concerns have been raised about whether these types of interventions can be effectively delivered in contexts with ongoing conflict and violence. Cognitive Processing Therapy (CPT) has been shown to be effective in reducing sexual violence survivors' psychological symptoms in eastern Democratic Republic of the Congo (DRC), a region with a history of chronic conflict. Objective: The purpose of the present study is to assess the degree to which exposure to different levels of ongoing insecurity impacts effectiveness of an evidence-based trauma-focused psychotherapy for sexual violence survivors. Method: Participants were 158 female sexual violence survivors receiving CPT in seven communities in South Kivu. Participants completed weekly assessments of their symptoms of PTSD and depression as part of CPT. Degree of site insecurity was categorized as high or low levels of ongoing insecurity based on information collected from supervisors and clinicians. Hierarchical linear modelling was used to examine change over time moderated by level of insecurity at the site. Results: Overall, women reported a significant reduction in psychological symptoms over time (b = -2.04, p <.001). Residing in a site of greater insecurity was associated with higher initial symptoms (b = 5.91, p <.01), but similar improvement over time (b = -0.30, p =.10) compared to women living in relatively more secure sites. High rates of attendance and treatment completion were observed. Conclusions: These results support the effectiveness of trauma-focused therapies when provided in a well-structured and well-supervised program even in contexts of ongoing conflict and violence.

Post-traumatic stress disorder: ethical and legal relevance to the criminal justice system

Post-Traumatic Stress Disorder is a major public health concern in both civilian and military populations, across race, age, gender, and socio-economic status. While PTSD has been around for centuries by some name or another, its definition and description also continue to evolve. Within the last few years, the American Psychological Association has published the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which includes some major changes in the diagnostic criteria for PTSD. Recent data on epidemiology, etiological theories, and empirically supported methods of treatment, as well as implications for legal processes and criminal justice system personnel, are discussed.