State of the Science of Cognitive Processing Therapy.

This state of the science review provides an overview of the history and findings of cognitive processing therapy (CPT), one of the most recommended treatments for posttraumatic stress disorder, acute stress disorder, and comorbid conditions. After an introduction to CPT and the randomized controlled trials that have been conducted, the effects of CPT on comorbid conditions are reviewed, as well as new combination treatments. Cognitive mediators of change are described. Different formats for CPT that have been developed are described, as well as patient, therapy, and therapist factors in outcome; applicability across diverse populations; efforts to disseminate CPT; and ongoing studies into the future.

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

BACKGROUND: Religion/spirituality (R/S) is an important and commonly used resource for coping with difficult experiences and has been shown to reduce the development of posttraumatic stress disorder (PTSD) symptoms following a trauma. However, it is not clear how R/S affects response to treatment of PTSD. OBJECTIVE: The aim of this paper was to understand how Veterans' R/S and sense of purpose were related to clinical outcomes when engaging in Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE). It was predicted that Veterans identifying as R/S would have a higher sense of purpose, be more likely to complete treatment, and have greater symptom change during treatment. METHOD: The study included 91 military Veterans from a VA Medical Center outpatient PTSD Clinical Team who initiated CPT or PE and responded to a question about the importance of R/S in their lives at intake. RESULTS: Forty nine percent of the Veterans in this sample reported R/S were important to them and had mixed feelings about whether their life had a clear sense of purpose. Neither R/S nor sense of purpose were associated with treatment completion or response to PTSD treatment. CONCLUSION: These findings suggest that once PTSD has developed, R/S or sense of purpose may not play a significant role in completion of or response to evidence-based psychotherapies (EBPs) for PTSD. EBPs for PTSD are equally effective for Veterans identifying as R/S and those who do not, which may be reflective of administering EBPs in a culturally responsive manner.

Changes in emotion regulation difficulties and PTSD symptom severity in an intensive treatment program for PTSD.

BACKGROUND: Greater difficulties in emotion regulation (ER) and decreased use of adaptive ER strategies have been associated with higher levels of posttraumatic stress disorder (PTSD) symptoms. To date, limited research has explored whether ER improves with PTSD treatment or whether such improvements are linked with improvements in PTSD symptoms. METHODS: Veterans and service members with PTSD (N = 223) participated in a 2-week intensive treatment program (ITP) based in Cognitive Processing Therapy (CPT). ER was measured using the Difficulties in Emotion Regulation Short Form (DERS-SF) at baseline and on days 4 and 9 of treatment. PTSD symptoms were reported on the PTSD Symptom Checklist for DSM-5 (PCL-5) at baseline, on days 3, 5, 6, and 8 of treatment, and at post-treatment. RESULTS: DERS-SF scores decreased during treatment (Mchange = 5.12, d = 0.38). Baseline DERS-SF did not predict overall PCL-5 scores across timepoints (p = .377). However, scores on the DERS-SF over time were significantly associated with PCL-5 improvement over the course of treatment (p < .001, R2b = 0.07). Finally, improvements in all subscales of the DERS-SF across time except clarity were significantly associated with improvement in PCL-5 over time. LIMITATIONS: Additional treatment components in the ITP beyond CPT may have contributed to ER improvements. Conclusions are also limited by the use of self-report data. CONCLUSIONS: An intensive CPT-based treatment program for veterans and service members can lead to improved ER in two weeks. ER improvements are associated with PTSD symptom severity during the ITP.

Veterans' 12-month PTSD and depression outcomes following 2- and 3-week intensive cognitive processing therapy-based treatment.

Background: Growing evidence indicates that daily delivery of evidence-based PTSD treatments (e.g. Cognitive Processing Therapy (CPT)), as part of intensive PTSD treatment programmes (ITPs), is feasible and effective. Research has demonstrated that a 2-week CPT-based ITP can produce equivalent outcomes to a 3-week ITP, suggesting shorter treatment can also be highly effective. However, the extent to which ITP length and composition impact longer-term outcomes needs further study.Objective: We examined whether PTSD and depression symptoms 3-, 6-, and 12-months following completion of a 2-week ITP could be considered non-inferior, or equivalent, to those of a 3-week ITP.Method: Data from 638 veterans who participated in a 2-week CPT-based ITP were evaluated against 496 veterans who participated in a 3-week CPT-based ITP. A Bayes factor approach was used to examine whether PTSD and depression severity outcomes of the 2-week ITP could be considered equivalent to the 3-week ITP.Results: Participants across both ITPs reported large PTSD (d = 0.98) and moderate to large depression symptom reductions (d = 0.69) from baseline to 12-month follow-up. The PTSD and depression symptom reductions seen in the 2-week ITP were determined to be equivalent to those of the 3-week ITP.Conclusions: Low follow-up completion was a limitation. Future research might replicate the present findings using samples with greater follow-up rates and explore whether adjunctive services impact other relevant constructs, such as quality of life and functioning.

This study demonstrated that intensive PTSD treatment programmes for veterans can produce large and lasting PTSD and depression symptoms reductions.A 2-week intensive PTSD treatment programme that offered 37 fewer clinical hours was just as effective as a 3-week programme for veterans, with lasting symptom improvement up to 12 months after treatment.The 2-week programme focused primarily on individual Cognitive Processing Therapy delivered twice per day whereas the 3-week programme combined individual and group CPT and had a much larger number of adjunctive services.

Effect of PTSD treatment on cardiovascular reactivity during trauma memory recall and correspondence with symptom improvement.

ABSTRACTBackground: Prior research has shown PTSD treatment leads to reductions in cardiovascular reactivity during trauma recall, but the extent to which such reductions are associated with changes in PTSD symptoms is less clear. Moreover, such relationships have not been investigated in a cognitively focused PTSD treatment.Objective: To examine changes in cardiovascular reactivity to the trauma memory in patients receiving cognitive processing therapy (CPT), CPT with a written trauma account, and a written account only condition. We also examined the association of such changes with symptom improvement.Method: 118 women with PTSD secondary to interpersonal violence completed pre- and post-treatment assessments of PTSD symptoms and cardiovascular reactivity during a script-driven imagery task.Results: Results indicated a significant but modest reduction in cardiovascular reactivity in CPT conditions. Changes in cardiovascular reactivity and reexperiencing symptoms were significantly associated among the whole sample. Among individuals with the greatest reactivity to the trauma memory at pretreatment, associations were also seen with changes in total PTSD, numbing, and trauma-related guilt.Conclusions: Results indicate that previous findings on the effect of PTSD treatment on cardiovascular reactivity during trauma recall extend to cognitively oriented treatment. Baseline cardiovascular reactivity may influence the extent to which reductions in PTSD symptoms and reactivity during trauma recall are related.

Cognitive Processing Therapy leads to reduced heart rate reactivity when recalling a trauma memory.Decreases in heart rate reactivity are associated with reduced reexperiencing symptoms.Changes in heart rate reactivity and PTSD symptoms are more closely related among patients with greater pretreatment reactivity.

Heart rate reactivity during trauma recall as a predictor of treatment outcome in cognitive processing therapy for PTSD.

Emotional engagement when recollecting a trauma memory is considered a key element of effective trauma-focused therapy. Research has shown that reduced physiological reactivity during trauma recall is associated with worse treatment outcomes for posttraumatic stress disorder (PTSD), but this has yet to be examined in a cognitively oriented treatment. This study examined whether pretreatment heart rate (HR) reactivity during trauma recall predicts PTSD symptom improvement and treatment dropout during Cognitive Processing Therapy (CPT) for PTSD. Participants were 142 women with PTSD secondary to interpersonal violence enrolled in one of two clinicals trials. HR reactivity reflected the mean increase in HR after listening to two 30-s scripts of the trauma memory prior to treatment. Linear mixed-effects models showed the effect of HR reactivity on change in total PTSD symptoms was not significant, but lower HR reactivity predicted less improvement in reexperiencing and avoidance and was associated with increased dropout. Findings suggest pretreatment physiological reactivity to the trauma memory may be a prognostic indicator of some elements of treatment response in CPT. Results tentatively support the importance of emotional activation during trauma recall in cognitive treatment of PTSD, though more research is needed to clarify how low HR reactivity impacts treatment.

Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive?

OBJECTIVE: Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD: The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS: Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION: Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.

Brain derived neurotrophic factor and treatment outcomes among veterans attending an intensive treatment program for posttraumatic stress disorder.

Brain derived neurotrophic factor (BDNF) may play an important role in the success of treatment for posttraumatic stress disorder (PTSD). Pre- and post-treatment blood samples were analyzed for 40 veterans who completed a 3-week intensive outpatient treatment for PTSD. The treatment included Cognitive Processing Therapy, mindfulness, and yoga as core treatment components. PTSD symptoms were assessed at pre-treatment, post-treatment, and 3-month follow-up. Participants reported large decreases in PTSD symptoms from pre-to post-treatment (d = 1.46, p < 0.001) and pre-treatment to 3-month follow-up (d = 0.91, p < 0.001). Unexpectedly, participants demonstrated a decrease in BDNF from pre-to post-treatment (d = 0.64, p < 0.001). Changes in BDNF from pre-to post-treatment were not significantly associated with PTSD symptom improvement. However, higher levels of post-treatment BDNF were significantly associated with lower PTSD symptoms at 3-month follow-up (n = 27, r = -0.57, p = 0.002) and greater improvements in PTSD symptoms from pre-treatment to 3-month follow-up (n = 27, r = 0.50, p = 0.008). Higher levels of post-treatment BDNF may facilitate the long-term success of intensive PTSD treatment. Further research with larger samples is needed to evaluate the processes by which BDNF may affect consolidation of improvements after completion of PTSD treatment.

Emotion regulation and heart rate variability may identify the optimal posttraumatic stress disorder treatment: analyses from a randomized controlled trial.

Introduction: High variability in response and retention rates for posttraumatic stress disorder (PTSD) treatment highlights the need to identify "personalized" or "precision" medicine factors that can inform optimal intervention selection before an individual commences treatment. In secondary analyses from a non-inferiority randomized controlled trial, behavioral and physiological emotion regulation were examined as non-specific predictors (that identify which individuals are more likely to respond to treatment, regardless of treatment type) and treatment moderators (that identify which treatment works best for whom) of PTSD outcome. Methods: There were 85 US Veterans with clinically significant PTSD symptoms randomized to 6 weeks of either cognitive processing therapy (CPT; n = 44) or a breathing-based yoga practice (Sudarshan kriya yoga; SKY; n = 41). Baseline self-reported emotion regulation (Difficulties in Emotion Regulation Scale) and heart rate variability (HRV) were assessed prior to treatment, and self-reported PTSD symptoms were assessed at baseline, end-of-treatment, 1-month follow-up, and 1-year follow-up. Results: Greater baseline deficit in self-reported emotional awareness (similar to alexithymia) predicted better overall PTSD improvement in both the short- and long-term, following either CPT or SKY. High self-reported levels of emotional response non-acceptance were associated with better PTSD treatment response with CPT than with SKY. However, all significant HRV indices were stronger moderators than all self-reported emotion regulation scales, both in the short- and long-term. Veterans with lower baseline HRV had better PTSD treatment response with SKY, whereas Veterans with higher or average-to-high baseline HRV had better PTSD treatment response with CPT. Conclusions: To our knowledge, this is the first study to examine both self-reported emotion regulation and HRV, within the same study, as both non-specific predictors and moderators of PTSD treatment outcome. Veterans with poorer autonomic regulation prior to treatment had better PTSD outcome with a yoga-based intervention, whereas those with better autonomic regulation did better with a trauma-focused psychological therapy. Findings show potential for the use of HRV in clinical practice to personalize PTSD treatment. Clinical trial registration: ClinicalTrials.gov identifier, NCT02366403.

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

BACKGROUND: Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT. METHOD: Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality. CONCLUSION: If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.

Crisis response planning rapidly reduces suicidal ideation among U.S. military veterans receiving massed cognitive processing therapy for PTSD.

Posttraumatic stress disorder (PTSD) is common among U.S. military veterans and is associated with increased risk of suicidal thoughts and behaviors. Crisis response planning (CRP), a brief safety planning-type intervention, has been shown to rapidly reduce suicidal ideation and suicide attempts in emergency and acute care settings. CRP's effectiveness when combined with trauma-focused therapies remains unknown. In this randomized pragmatic clinical trial with one-year follow-up, 157 U.S. military personnel and veterans were randomly assigned to receive CRP or self-guided safety planning (SP) prior to beginning massed cognitive processing therapy (CPT) for PTSD. Among 51 (32.5 % of sample) participants endorsing suicidal ideation at baseline, reductions in the severity of suicidal ideation were significantly larger and faster in CRP (F(11,672)= 15.8, p < .001). Among 106 participants denying suicidal ideation at baseline, 8.5 % of CRP participants versus 11.9 % of SP participants (OR=0.69, 95 % CI=0.19-2.52) reported new-onset suicidal ideation during any follow-up assessment. PTSD symptoms significantly reduced over time with no differences between groups. Results support the effectiveness of CRP for rapidly reducing suicidal ideation and managing suicide risk during outpatient treatment for PTSD.

The use of practice assignments in cognitive processing therapy to promote cognitive and emotional change: A case study.

Cognitive processing therapy (CPT) is a first-line treatment for posttraumatic stress disorder (PTSD). The primary goals of CPT are to identify and challenge dysfunctional cognitions resulting from the trauma to promote a more balanced set of beliefs and reduce manufactured emotions; encouraging expression of natural emotions further promotes symptom improvement. Between-session assignments (homework) are an integral part of learning and practicing the skills developed during CPT, and these assignments are theorized to reinforce the proposed mechanisms of symptom change. This article begins with a brief description of the theoretical foundations of CPT and an overview of the session content of the CPT protocol, followed by a case study illustrating the use of CPT with the written account (CPT + A) with a survivor of childhood sexual assault. Although the client demonstrated some avoidance, her successful completion of practice assignments throughout treatment allowed her to identify and examine thoughts contributing to feelings of guilt and self-blame as well as negative beliefs about the world. She was able to reduce her assimilated and overaccommodated stuck points to form a more balanced view of the trauma, and also process her natural emotions, resulting in a significant reduction of PTSD symptoms. The role of homework at each session and how the assignments addressed the proposed mechanisms of change in CPT are discussed, and recommendations to increase clients' engagement in practice assignments in CPT are provided.

Predictors of dropout in cognitive processing therapy for PTSD: An examination of in-session treatment processes.

Dropout rates for treatments for adult posttraumatic stress disorder (PTSD) are high. Process research can reveal client factors during treatment that predict dropout. An observational coding system was used to code client processes in audio-recorded early sessions of cognitive processing therapy (CPT), a gold-standard treatment for PTSD. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET), with higher rates of dropout in CPT than WET (39.7% vs. 6.4%). Participants in this study were 53 treatment-seeking adults with PTSD who were in the CPT arm of the trial and completed the CAPS-5 at pretreatment and at least one session. Of these, 15 (28.3%) dropped out of CPT early (completing ≤9 sessions) and 38 (71.7%) completed treatment. Sessions were coded with an observational coding system on a four-point scale (0 = absent to 3 = high) for maladaptive trauma-related responses (overgeneralized beliefs, ruminative processing, avoidance), affective engagement (negative emotions, physiological distress), and adaptive processing (cognitive emotional processing). Binary logistic regressions showed that more physiological distress and cognitive emotional processing predicted lower dropout, whereas more avoidance predicted higher dropout. Negative emotion, ruminative processing, and overgeneralization were not significant predictors. These findings highlight potential early indicators of treatment engagement that could be targeted to reduce dropout and perhaps facilitate further therapeutic change.

Using the Personalized Advantage Index to determine which veterans may benefit from more vs. less comprehensive intensive PTSD treatment programs.

Background: Intensive PTSD treatment programs (ITPs) are highly effective but tend to differ greatly in length and the number of adjunctive services that are provided in conjunction with evidence-based PTSD treatments. Individuals' treatment response to more or less comprehensive ITPs is poorly understood.Objective: To apply a machine learning-based decision-making model (the Personalized Advantage Index (PAI)), using clinical and demographic factors to predict response to more or less comprehensive ITPs.Methods: The PAI was developed and tested on a sample of 747 veterans with PTSD who completed a 3-week (more comprehensive; n = 360) or 2-week (less comprehensive; n = 387) ITP.Results: Approximately 12.32% of the sample had a PAI value that suggests that individuals would have experienced greater PTSD symptom change (5 points) on the PTSD Checklist for DSM-5 in either a more- or less comprehensive ITP. For individuals with the highest 25% of PAI values, effect sizes for the amount of PTSD symptom change between those in their optimal vs. non-optimal programs was d = 0.35.Conclusions: Although a minority was predicted to have benefited more from a program, there generally was not a substantial difference in predicted outcomes. Less comprehensive and thus more financially sustainable ITPs appear to work well for most individuals with PTSD.

A Personalized Advantage Index (PAI) was developed for a 3-week (more comprehensive) and a 2-week (less comprehensive) intensive PTSD treatment program to predict treatment responses.Using the PAI, approximately 12% of the sample was predicted to have experienced meaningfully greater in another program than the one in which they participated.Findings suggest a less comprehensive and more financially sustainable 2-week intensive PTSD treatment program would work well for most veterans in the present study.

Sudden gains in PTSD symptoms and social functioning in cognitive processing therapy for posttraumatic stress disorder.

OBJECTIVE: Sudden gains (SGs) are rapid symptom improvements between two consecutive therapy sessions that predict treatment outcomes. This study investigated SGs in posttraumatic stress disorder (PTSD) symptoms, interpersonal relationship functioning, and social role functioning in Cognitive Processing Therapy (CPT). METHOD: Participants were 121 patients and 81 therapists involved in a parent randomized controlled hybrid implementation-effectiveness trial of CPT. Descriptive analyses examined the frequency and timing of different forms of SGs. Multilevel modeling examined the impact of the three SGs on outcomes. RESULTS: PTSD SGs occurred more often and at different sessions than SGs in facets of social functioning. Most individuals experienced only one form of SG and there were no significant clinical or demographic differences in those who had PTSD only SGs, social functioning only SGs, or both SGs. PTSD SGs and interpersonal relationship functioning SGs both predicted changes in PTSD symptoms and interpersonal difficulties over time, but not changes in social role functioning. SGs in social role functioning predicted all three forms of outcomes. CONCLUSIONS: The findings suggest that there are multiple forms of SGs in CPT beyond primary symptom changes that are predictive of patient outcomes. Clinicians should highlight various SGs that patients experience to further enhance outcomes.

Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment.

BACKGROUND: Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format. METHODS: The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness. DISCUSSION: There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program. TRIAL REGISTRATION: ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.

Is adherence to dialectic behaviour therapy for post-traumatic stress disorder (PTSD) and cognitive processing therapy related to treatment outcome in PTSD after childhood abuse?

Background: Literature on the association between therapist adherence and treatment success in the treatment of post-traumatic stress disorder (PTSD) is scarce, and the results are mixed.Objective: To examine the relationship between therapist adherence to dialectical behaviour therapy for PTSD (DBT-PTSD) and cognitive processing therapy (CPT) on treatment outcome in women with PTSD and emotion regulation difficulties after interpersonal childhood abuse.Method: Videotaped therapy sessions from 160 female participants of a large randomized controlled trial [Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse. JAMA Psychiatry, 77(12), 1235. jamapsychiatry.2020.2148] were rated. Adherence to CPT and DBT-PTSD was assessed using two specifically developed rating scales.Results: Higher therapist adherence was associated with a greater reduction of clinician-rated PTSD symptom severity. This effect was more pronounced in the CPT group than in the DBT-PTSD group. Adherence was also related to a greater reduction of self-rated PTSD symptoms, borderline symptoms, and dissociation intensity.Conclusion: Our results indicate that higher therapist adherence can lead to better treatment outcomes in PTSD treatments, especially in CPT.

Higher therapist adherence to cognitive processing therapy was associated with higher treatment gains in women with post-traumatic stress disorder (PTSD) after childhood abuse.Adherence was related to higher reductions in symptom severity of PTSD, borderline symptoms, and dissociation intensity.Adherence to dialectical behaviour therapy for PTSD did not show a strong association with treatment outcome.

Does treatment specific-, disorder specific- or general therapeutic competence predict symptom reduction in posttraumatic stress disorder?

Background: Literature on the association between therapist competence and treatment success in posttraumatic stress disorder (PTSD) treatments is scarce and results are mixed.Aims/Objective: The relationship between different types of therapeutic competence, therapeutic alliance, and PTSD symptom reduction in patients treated with Dialectical Behaviour Therapy for PTSD (DBT-PTSD) or Cognitive Processing Therapy (CPT) was assessed. Competence types were PTSD-specific competence, treatment specific competence, and general competence in cognitive behaviour therapy (CBT).Method: Videotaped therapy sessions from N = 160 women with PTSD and emotion regulation difficulties after child abuse participating in a large randomised controlled trial (Bohus et al., 2020) were rated. Three therapeutic competence-types were assessed using specifically developed rating scales. Alliance was assessed via patient ratings with the Helping Alliance Questionnaire (HAQ). PTSD symptoms were assessed at pre- and post-treatment via clinician rating with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and via self-rating with the PTSD-Checklist for DSM-5 (PCL-5).Results: No significant association between competence and clinician or self-rated PTSD symptoms was found. PTSD specific competence predicted clinician rated PTSD symptom severity on a trend level. Alliance predicted both clinician and self-rated PTSD symptom reduction.Conclusion: Our results provide a starting point for future research on different competence types and their association with PTSD treatment gains. Therapists were highly trained and received weekly supervision, hence a restricted competence range is a possible explanation for non-existing associations between competence and PTSD symptom reduction in our sample. More research in naturalistic settings, such as dissemination studies, is needed.

Three different types of therapeutic competence and their association to treatment gains in women with posttraumatic stress disorder after child abuse were assessed.Therapist competence was high in all three domains of competence.No association was found between any of the competence types and reduction in posttraumatic stress disorder symptoms.

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

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

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment.

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.