State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder.

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.

A pilot randomized controlled trial of online written exposure therapy delivered by peer coaches to veterans with posttraumatic stress disorder.

This pilot randomized clinical trial (RCT) sought to examine the preliminary efficacy of an internet-based version of written exposure therapy delivered to veterans through an online program supported by peer coaches. Veterans (N = 124) with clinically significant posttraumatic stress disorder (PTSD) symptoms were randomly assigned to imaginal exposure either via writing (written exposure) or verbal recounting (verbal exposure). The online treatment involved four to eight sessions of imaginal exposure preceded and followed by an online chat with a peer coach. Participants completed assessments at baseline, posttreatment, and 3-month follow-up. Half of the participants never started treatment; among those who started treatment, the mean number of sessions completed was 4.92. At posttreatment, participants in both conditions reported clinically meaningful improvements in PTSD symptoms, d = 1.35; depressive symptoms, d = 1.10; and functioning, d = 0.39. Although participants in both treatment conditions demonstrated significant improvements in PTSD symptom severity, equivalence results were inconclusive, as the 95% confidence interval of the change score difference exceeded the specified margin and overlapped with 0. Estimated mean change scores demonstrated that both conditions showed significant reductions at posttreatment and follow-up. Although engagement with the online program was a significant challenge, the findings suggest that written exposure therapy is effective for improving PTSD symptoms, depressive symptoms, and functioning when adapted for internet-based delivery and facilitated by peer coaches. Using technology to deliver exposure therapy and task-shifting the role of the therapist to peer coaches are promising strategies to increase access to effective PTSD care.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury.

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

Moving beyond symptom reduction: A meta-analysis on the effect of exposure therapy for PTSD on quality of life.

OBJECTIVES: Quality of life (QOL) is a multidimensional construct including emotional well-being, life satisfaction, and physical health. Individuals with posttraumatic stress disorder (PTSD) consistently report low QOL, highlighting the importance of assessing the effectiveness of first-line PTSD treatments (e.g., exposure-based therapies) on QOL. This meta-analysis examined the efficacy of exposure therapy for PTSD on QOL compared to control conditions (e.g., waitlist, medication, treatment-as-usual) at posttreatment and follow-up (ranging from 1 month to 2 years). METHODS: Building on a previous meta-analysis of exposure-based therapy for PTSD, we searched PsycINFO and Medline in December 2021, July 2022, and March 2023 to include randomized controlled trials of exposure-based treatments for adult PTSD assessing QOL. We screened 295 abstracts for initial eligibility; 20 articles met inclusion criteria and were included (N = 2729 participants). Risk of bias was evaluated using the Cochrane Risk of Bias tool 2.0. RESULTS: At posttreatment, exposure-based therapies showed a medium effect on QOL relative to control conditions (k = 25, g = 0.67). This effect was not observed at follow-up for the small subset of studies with follow-up data (k = 8, g = 0.16). At posttreatment, effect size varied significantly as a function of the control condition (p < .0001). There were no differences in QOL effects across exposure therapies at posttreatment or follow-up (p = .09). CONCLUSION: Exposure therapy was associated with greater improvement in QOL compared to control conditions at posttreatment. Exposure was not superior to control conditions at follow-up, and the longer-term impact of exposure on QOL is unclear. The implications of these findings are discussed, along with the need for more PTSD treatment studies to examine QOL outcomes at posttreatment and follow-up.

The mental health impact of COVID-19-related stressors among treatment-seeking trauma-exposed veterans.

Trauma-exposed veterans receiving mental health care may have an elevated risk of experiencing COVID-19-related difficulties. Using data from several ongoing clinical trials (N = 458), this study examined exposure to COVID-19-related stressors and their associations with key sociodemographic factors and mental health outcomes. The results showed that exposure to COVID-19-related stressors was common, higher among veterans who were racial/ethnic minorities d = 0.32, and associated with elevated posttraumatic stress disorder (PTSD), r = .288, and depressive symptom severity, r = .246. Women veterans experienced more difficulty accessing social support, d = 0.31, and higher levels of COVID-19-related distress, d = 0.31, than men. Qualitative data were consistent with survey findings and highlighted the broader societal context in veterans' experience of COVID-19-related distress. These findings may inform future research on the impact of the pandemic on veterans, particularly those who are women and members of minoritized racial/ethnic groups, as well as mental health treatment planning for this population.

The Impact of COVID-19 on Psychotherapy Participation Among Individuals With Posttraumatic Stress Disorder Enrolled in Treatment Research.

The onset of the COVID-19 pandemic disrupted many aspects of daily life and required a rapid and unprecedented shift in psychotherapy delivery from in-person to telemental health. In the present study, we explored the impact of the pandemic on individuals' ability to participate in posttraumatic stress disorder (PTSD) psychotherapy and the association between the impact of COVID-19 impact on health and financial well-being and psychotherapy participation. Participants (N = 161, 63.2% male, Mage = 42.7 years) were United States military veterans (n = 108), active duty military personnel (n = 12), and civilians (n = 6), who were participating in one of nine PTSD treatment trials. The results indicate a predominately negative COVID-19 impact on therapy participation, although some participants (26.1%) found attending therapy sessions through telehealth to be easier than in-person therapy. Most participants (66.7%) reported that completing in vivo exposure homework became harder during the pandemic. Moreover, the impact of the pandemic on PTSD symptom severity and daily stress were each associated with increased difficulty with aspects of therapy participation. The findings highlight the unique challenges to engaging in PTSD treatment during the pandemic as well as a negative impact on daily stress and PTSD severity, both of which were related to treatment engagement difficulties.

Editorial: Applications of Cognitive and Behavioral Therapy in Response to COVID-19.

The corona virus (COVID-19) continues to have a devastating health, economic, and social impact on our local and international communities. Cognitive and Behavioral Therapies (CBTs), as a family of therapies that posit cognitive, behavioral, emotional, and interpersonal change processes in the understanding and successful treatment of mental health disorders, have risen to the challenge. This special issue represents contributions from CBT experts on the impact on psychopathology, new assessment methods, adaptations of integrated behavioral health, telehealth, psychology training, and discusses a public health framework. The issue includes a series of articles offering guidance for the clinician on interventions for those impacted by trauma, CBT for youth and families, and telehealth for psychotic spectrum disorders and group therapy for social anxiety.

Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers.

Leveraging technology to provide evidence-based therapy for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), during the COVID-19 pandemic helps ensure continued access to first-line PTSD treatment. Clinical video teleconferencing (CVT) technology can be used to effectively deliver PE while reducing the risk of COVID-19 exposure during the pandemic for both providers and patients. However, provider knowledge, experience, and comfort level with delivering mental health care services, such as PE, via CVT is critical to ensure a smooth, safe, and effective transition to virtual care. Further, some of the limitations associated with the pandemic, including stay-at-home orders and physical distancing, require that providers become adept at applying principles of exposure therapy with more flexibility and creativity, such as when assigning in vivo exposures. The present paper provides the rationale and guidelines for implementing PE via CVT during COVID-19 and includes practical suggestions and clinical recommendations.

Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions?

In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) Predictores de Respuesta Excelente Versus Parcial a la Terapia De Exposición Prolongada: ¿Quién Necesita Más Sesiones? RESPUESTA A LA EXPOSICIÓN PROLONGADA POR TEPT En la práctica, la duración de la psicoterapia está determinada por la respuesta del paciente al tratamiento. La identificación de predictores para las respuestas al tratamiento es de gran utilidad clínica para guiar a los clínicos en su planificación de tratamiento. Características demográficas, historia de trauma, comorbilidad y una reducción temprana de los síntomas del trastorno de estrés postraumático (TEPT) fueron examinados como predictores de respuesta excelente versus respuesta parcial a la terapia de exposición prolongada (EP) para el TEPT. Las participantes fueron 96 mujeres sobrevivientes de asalto con TEPT crónico que recibieron al menos ocho sesiones de EP con o sin reestructuración cognitiva. Las participantes fueron clasificadas como respondedores excelentes (n = 27) o respondedores parciales (n = 69) en función de si lograron al menos un 70% de mejoría en el autoinforme de severidad del TEPT en la Escala de Síntomas Auto-reportados de TEPT al final de la sesión 8. Los respondedores excelentes terminaron la terapia después de la sesión 9, y se ofreció tres sesiones adicionales a los respondedores parciales. Se realizó una regresión logística para investigar los predictores de respuesta a la EP. Los resultados mostraron violencia interpersonal previa y comorbilidad de trastorno por consumo de alcohol asociados con respuesta parcial. Comorbilidad de trastorno depresivo y reducción temprana del síntoma de TEPT se asoció con una excelente respuesta. Ser tratado por un experto en terapia de comportamiento cognitivo (TCC) predijo una respuesta excelente superior para los pacientes con antecedentes de violencia interpersonal. El modelo dio cuenta del 56.6% de la varianza en la respuesta al tratamiento y predijo correctamente el estado del respondedor para el 83.3% de la muestra. Estos hallazgos contribuyen a la esfera de comprensión de los factores que predicen o moderan la respuesta a la EP y tienen implicaciones para planificación del tratamiento.

Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel.

The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.

Caffeine Use in Military Personnel With PTSD: Prevalence and Impact on Sleep.

Background: Caffeine use is highly prevalent among active duty military personnel and can be beneficial to performance in the short term. However, regular caffeine use has been found to contribute to sleep disturbances, which are elevated among the significant number of military personnel with posttraumatic stress disorder (PTSD). The current study is the first to examine caffeine use and its relationship with sleep disturbances in military personnel seeking treatment for PTSD. Participants: Active duty military personnel (N = 366) who had returned from deployments to Afghanistan or Iraq and were seeking treatment for PTSD. Methods: Pearson correlations were used to examine the relationships between caffeine use, sleep disturbances, and PTSD symptom clusters. Results: The majority of the sample (89%) reported some caffeine use, with coffee being the largest contributor to total caffeine intake. Contrary to hypotheses, higher caffeine use was associated with lower insomnia symptom severity; follow-up analysis indicated that this was due to elevated insomnia symptom severity in those reporting no caffeine use. Caffeine use was not associated with any other measures of sleep disturbance or with PTSD symptoms. Conclusions: Caffeine use was not associated with greater reported sleep disturbances in this sample, possibly because those with elevated insomnia symptom severity abstained from any caffeine, or because insomnia symptoms were elevated in this sample.

Factor Structure and Psychometric Properties of the Peritraumatic and Posttraumatic Emotions Questionnaires Among Active Duty Military Personnel With Posttraumatic Stress Disorder.

The Peritraumatic Emotions Questionnaire (Peri-TEQ) and Posttraumatic Emotions Questionnaire (Post-TEQ) are self-report measures of emotions experienced during and after a traumatic event, respectively. The factor structure and psychometric properties of the Peri- and Post-TEQ were investigated among 474 military personnel with posttraumatic stress disorder (PTSD) following deployment. Exploratory factor analysis and confirmatory factor analysis were conducted to test the factor structure of the scales. Internal consistency, composite reliability, convergent validity, and discriminant validity were also assessed. Four factors were identified for the Peri-TEQ (Fear, Humiliation, Anger, and Sadness), and three factors were identified for the Post-TEQ (Fear, Anger-Hurt, and Humiliation). The full scales and all subscales demonstrated adequate-to-good internal consistency, Cronbach's αs = .722-.893. The subscales demonstrated adequate-to-good composite reliability, Cronbach's αs = .763-.861. The Peri- and Post-TEQ demonstrated good convergent validity with measures of PTSD symptoms, rs = .229-.601, ps < .001, and depressive symptoms, rs = .284-.470, ps < .001, and good discriminate validity with measures of resilience, ps = .116-.940, and unit cohesion, Peri-TEQ, p = .304 and Post-TEQ, r = -.123, p = .008. The Humiliation subscales demonstrated good convergent validity with guilt cognitions, rs = .315-.341, ps < .001, and the Anger subscales demonstrated good convergent validity with state anger, rs = .260-.347, ps < .001. The Peri- and Post-TEQ are reliable, valid self-report measures of emotions during and in response to remembering a trauma. The results support the use of these measures in research investigating trauma-related emotions.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial.

Importance: Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective: To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants: Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions: Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures: Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results: Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93). Conclusions and Relevance: Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration: clinicaltrials.gov Identifier: NCT01049516.

The effect of treatment on quality of life and functioning in OCD.

BACKGROUND: Given that obsessive compulsive disorder (OCD) is associated with impaired quality of life (QoL) and functioning, it is important examine whether therapeutic recovery from OCD leads to improvements on these important secondary outcomes. Only a few studies have examined how measures of OCD symptom severity relate to QoL and functioning among patients receiving treatment for OCD. METHODS: OCD severity was measured with the Obsessive-Compulsive Inventory-Revised (OCI-R), a self-report scale of OCD, and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), an interview measure of OCD. Participants were 100 adults with a primary diagnosis of OCD on serotonin reuptake inhibitors (SRIs) enrolled in a randomized clinical trial comparing SRI augmentation with either exposure and response prevention (EX/RP) therapy, risperidone, or pill placebo. At baseline, mid-treatment, and post-treatment, patients completed assessments for OCD symptoms and QoL/functioning measures. Multilevel modeling was used to assess changes in QoL/functioning over the course of treatment and to compare such changes across treatment conditions. RESULTS: Improvements in QoL/functioning were significantly greater among those receiving EX/RP compared to those receiving risperidone. Compared to pill placebo, EX/RP performed better on measures of functioning but not QoL. Greater improvement in individual OCI-R scores was associated with greater improvements in QoL/functioning, regardless of condition. In addition, Y-BOCS scores appeared to moderate improvements in QoL over the course of all treatment conditions, such that those with higher Y-BOCS scores showed the greatest improvements in QoL over time. CONCLUSIONS: Improvements in QoL/functioning were associated with reduction in OCD symptom severity. The implications on OCD treatment and clinical research are discussed.

Changes in PTSD and Depression During Prolonged Exposure and Client-Centered Therapy for PTSD in Adolescents.

Depressive symptoms are common among individuals with posttraumatic stress disorder (PTSD). Prolonged exposure therapy (PE) for PTSD has been found to alleviate both PTSD and depressive symptoms, but relatively little is known about the pattern of PTSD and depressive symptom change during treatment. This study aimed to investigate the relationship between changes in PTSD and depression during PE for adolescent (PE-A) and client-centered therapy (CCT). The moderating role of PE-A versus CCT and the possible differences across symptom clusters of PTSD were also examined. Participants were 61 female adolescents with sexual-assault-related PTSD randomized to PE-A (n = 31) or CCT (n = 30). Participants completed the Beck Depression Inventory and the Child PTSD Symptom Scale at pre-, mid-, and posttreatment and before each treatment session. Multilevel mediation analysis indicated a reciprocal but asymmetrical relationship between changes in PTSD and depression during treatment in the overall sample. Moderated mediation analysis showed that the reciprocal relation was observed only during PE-A. Reductions in PTSD led to reductions in depression to a greater extent (48.7%), 95% confidence interval [30.2, 67.2], than vice versa (22.0%), [10.6, 33.4]. For participants receiving CCT, reduction in PTSD led to reductions in depression (31.6%), [11.8, 51.4], but not vice versa (7.4%), [-7.1, 21.9]. The reciprocal relationship between PTSD and depression was also observed across different symptoms clusters of PTSD. Our findings suggest that changes in PTSD led to changes in depressive symptoms to a greater extent than vice versa across PE-A and CCT.

Treating Posttraumatic Stress Symptoms Among People Living with HIV: a Critical Review of Intervention Trials.

The prevalence rate of posttraumatic stress disorder (PTSD) among people living with HIV (PLWH) is significantly higher than the rate among the general population. Moreover, PTS symptoms have been linked with numerous negative health-related outcomes in PLWH. While these findings suggest that studies evaluating the efficacy of treatments for PTS symptoms among PLWH are sorely needed, according to prior reviews, such studies are lacking. The purpose of the present systematic review was to provide an updated critical evaluation of treatment studies that targeted PTS among PLWH. Following PRIMSA guidelines, we searched PubMed and PsycINFO and identified eight articles (representing seven studies) evaluating the impact of various individual and group treatments on PTS symptoms. The limited evidence base to date precludes clinical recommendations for this population. Future studies should examine the efficacy of existing evidence-based treatments for PTSD among PLWH and then, if necessary, evaluate the impact of any treatment modifications for this population.

The Efficacy of Exposure Therapy for Anxiety-Related Disorders and Its Underlying Mechanisms: The Case of OCD and PTSD.

In this review we describe the intricate interrelationship among basic research, conceptualization of psychopathology, treatment development, treatment outcome research, and treatment mechanism research and how the interactions among these areas of study further our knowledge about psychopathology and its treatment. In describing the work of Edna Foa and her colleagues in anxiety disorders, we demonstrate how emotional processing theory of anxiety-related disorders and their treatment using exposure therapy have generated hypotheses about the psychopathology of posttraumatic stress disorder and obsessive-compulsive anxiety disorder that have informed the development and refinement of specific treatment protocols for these disorders: prolonged exposure and exposure and response (ritual) prevention. Further, we have shown that the next step after the development of theoretically driven treatment protocols is to evaluate their efficacy. Once evidence for a treatment's efficacy has accumulated, studies of the mechanisms involved in the reduction of the targeted psychopathology are conducted, which in turn inform the theory and further refine the treatments. We conclude our review with a discussion of how the knowledge derived from Foa and colleagues' programmatic research together with knowledge emerging from basic research on extinction learning can inform future research on the psychopathology of anxiety disorders and their treatments.

Influence of Sleep Disturbance on Global Functioning After Posttraumatic Stress Disorder Treatment.

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R2 = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.

Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems.

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.

The Impact of User Engagement With Exposure Components on Posttraumatic Stress Symptoms in an mHealth Mobile App: Secondary Analysis of a Randomized Controlled Trial.

Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of "Renew" (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users' self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app (ΔF3,62=4.42; P=.007). The number of characters written during imaginal exposure (ß=.37; P=.009) and the amount of time spent completing exposure activities (ß=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD.