Experience and impact of inappropriate patient sexual behaviors within a large VA healthcare system.

Inappropriate patient sexual behaviors (IPSBs) can negatively impact work performance, job satisfaction, and the psychological well-being of clinicians and staff. Although the Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, the rate of IPSBs in VHA hospitals is unknown. The unique demographic and cultural characteristics of military populations may be associated with IPSBs. To evaluate the extent and impact of IPSBs within a large VA healthcare system (VAHS), a survey was disseminated to all staff. Among the 32% of staff who responded (N = 1359), over half (n = 789; 58.1%) of participants reported at least one instance of IPSB during the past year; this included 67.9% (n = 644) of staff who identified as women and 33.4% (n = 126) of staff who identified as men. There was a significantly greater impact of IPSBs for women, as compared to men, on psychological well-being (X2 1 = 60.4, p < .001, odds ratio [OR] = 4.55, 95% confidence interval [CI]: [3.08, 6.79]), work satisfaction (X2 1 = 43.0, p < .001, OR = 3.51, 95% CI: [2.40, 5.18]), and workplace practices (X2 1 = 48.9, p < .001, OR = 4.02, 95% CI: [2.69, 6.11]). The results of this project highlight the need for overcoming barriers to reducing the pervasiveness and impact of these experiences.

Design and methods of a randomized controlled trial evaluating the effects of the PE Coach mobile application on prolonged exposure among veterans with PTSD.

BACKGROUND: Little is known about the impact of mobile applications (apps) designed to support patients progressing through an evidence-based psychotherapy. Prolonged exposure (PE) is an efficacious treatment for posttraumatic stress disorder (PTSD) and PE Coach is a treatment companion app that may increase patient engagement with the active components of PE, thereby supporting recovery. METHODS: This paper describes a randomized clinical trial that will evaluate PE delivered with and without PE Coach at post-treatment, and 1-month and 4-months post-treatment. Veterans with PTSD (N = 124) will be randomized (1:1) to conditions and complete up to 15 treatment sessions based on a priori defined termination criteria. We hypothesize that compared to PE without PE Coach, PE with the app will result in greater improvements in PTSD-related social and occupational functioning (primary outcome is the PTSD-Related Functioning Inventory), quality of life, and greater reductions in functional impairment, neurobehavioral symptoms, depression, and suicidal ideation (Aim 1). We also hypothesize that including PE Coach will reduce assessor-masked PTSD symptom severity, relative to PE without the app, as assessed by the revised Clinician-Administered PTSD Scale for DSM-5 (Aim 2). We hypothesize that PE Coach will facilitate increased treatment adherence, as measured by completion of PE homework (Aim 3). We will explore the impact of PE Coach on treatment engagement, as measured by reduced treatment dropout. CONCLUSION: Data on the outcomes of PE Coach can inform dissemination efforts and help evaluate the return on investment to guide future mental health app development. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.govNCT04959695.

Acceptability, feasibility, and utility of a safety aid reduction treatment in underserved veterans: a pilot investigation.

Access to mental health services, particularly for veterans residing in underserved communities, remain scarce. One approach to addressing availability barriers is through the use of group-based transdiagnostic or unified treatment protocols. One such protocol, Safety Aid Reduction Treatment (START), previously termed False Safety Behavior Elimination Treatment (FSET), has received increasing empirical support. However, prior research has only examined this treatment among civilians with a primary anxiety diagnosis. Thus, the purpose of the current study was to replicate and extend prior research by examining the acceptability, feasibility, and utility of START among veterans, particularly those living in underserved communities, and across a wider array of diagnoses. Veterans (n = 22) were assessed prior to, immediately after, and one month following the 8-week treatment. The majority of veterans found START useful and acceptable. Additionally, recruitment and retention rates suggest that the treatment was feasible. Notably, results revealed reductions in overall anxiety, depression, and safety aid usage, which were maintained throughout the brief follow-up period. These findings add to a growing body of literature highlighting the utility of transdiagnostic approaches in the amelioration of various anxiety and related disorders. Limitations include the small sample size and uncontrolled design.

A preliminary assessment of the link between anxiety sensitivity cognitive concerns and suicidal thoughts through dissociative symptoms.

Anxiety sensitivity (AS) and AS subfactors (physical, cognitive, and social) have been found to have robust associations with suicide risk. While the direct association between AS subfactors and suicide risk have been explored, little is known about how specific mechanisms, such as dissociation, might explain this relationship. This study aimed to run three analyses to examine the direct and indirect effects of suicidal thoughts and AS via dissociative symptoms. We predicted that dissociation would be a pathway through which AS physical concerns (ASPC) and AS cognitive concerns (ASCC) predicts suicidal ideation. Participants included 84 undergraduate students from a Southeastern University who were elevated on ASCC. Participants completed measures examining dissociative experiences, anxiety sensitivity, and current suicidal ideation. Results revealed that dissociation had a significant indirect effect with ASPC but not ASCC. The current preliminary study showed that ASCC had direct associations with suicide risk; however, those with lower levels of ASPC and dissociation may also be more likely to develop suicide risk. Future research should explore the possibility that the dissociation/ASPC and ASCC pathways are separate, but related, paths to suicidality.

Mobile applications may be the future of veteran mental health support but do veterans know yet? A survey of app knowledge and use.

Given the substantial investment in the development of mental health mobile applications (apps), information about penetration in the patient populations of interest is critical. This study describes the proportion of veterans who are knowledgeable of and utilize the Department of Veteran Affairs (VA) and Department of Defense (DoD) mental health apps. A cross-sectional survey of 140 veterans was conducted in primary care and outpatient mental health clinics at a large VA facility. Ninety-one percent of veterans (n = 127) reported smartphone ownership. Of these, 42.5% and 20.4% had heard of and used at least one of the 22 VA/DoD mental health apps, respectively. When veterans were asked to pick the individual VA/DoD apps they had previously used from a list, the proportion of participants who reported prior use ranged from 0% (Moving Forward) to 6.5% (Mindfulness Coach). Treatment for psychiatric problems relevant to the apps did not predict veteran knowledge/use of the VA/DoD apps. Rates of app use remained low among veterans reporting symptoms/diagnoses apps were designed to address (e.g., 7.5% of veterans who reported posttraumatic stress disorder (PTSD) had used PTSD Coach). The most common barrier to app use (endorsed by 65.7% of participants) was awareness of the apps. Expansion of existing VA/DoD efforts to educate patients and providers treating relevant conditions is indicated. Evaluation of evidence-based mobile health support specialists in clinical settings may also be indicated. This study provides critical information to guide future dissemination efforts and to help evaluate the impact of investments to date. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Virtual Standardized Patients for Mental Health Education.

PURPOSE OF REVIEW: The training of psychiatrists and other mental health professionals requires education on a range of interpersonal, communication, and psychotherapy techniques. Classroom and workshop training must be augmented by experiential learning with feedback for skill implementation with fidelity. Virtual standardized patients (VSPs) are computerized conversational agents that can support experiential learning through standardized, consequence-free training environments at reduced costs. RECENT FINDINGS: Research on mental health VSPs is rife with feasibility and acceptability pilot studies across various training populations and settings. Users have generally reported positive reactions to training with VSPs, though frustrations with some VSP speech recognition or VSP response relevance has been reported. Several studies have demonstrated a promising transfer of clinical skills from VSP training to human standardized patients and randomized trials supporting improved skill relative to reading or academic study are encouraging. As technology improves and natural language processing and accurate computer response generation for broad ranging conversational topics emerges, the field would benefit from research on the characteristics of effective VSPs for a range of purposes and trainee populations. Well-designed randomized evaluations of VSPs relative to best practices in education are needed, particularly regarding the impact of VSPs on clinical practice among actual patients.

A randomized controlled trial evaluating the efficacy of a brief computerized anxiety sensitivity reduction intervention for health anxiety.

It is estimated that individuals with severe health anxiety (HA) utilize 41 %-78 % more healthcare resources than individuals with identified medical diagnoses. Thus, identifying targets for intervention and prevention efforts for HA that are appropriate for primary care or specialty clinic settings is imperative. The aim of the present investigation was to evaluate the effect of a single-session, computerized anxiety sensitivity (AS) intervention on AS and HA. Participants were 68 university students (79.4 % female; Mage = 19.68) with elevated levels of AS and HA. Participants were randomized to either the AS intervention condition or an active control condition and completed self-report and behavioral follow-up assessments at post-intervention, 1-week follow-up, and 1-month follow-up. Results indicated a significant Time x Condition interaction for ASI-3 at each follow-up assessment (all ps < .001), such that individuals in the active condition exhibited greater reductions in AS compared to the control condition. There was no significant Time x Condition interaction for HA at any follow-up. Mediation analyses revealed a significant indirect effect of Condition on changes in HA through changes in AS. No significant effects were observed for behavioral outcomes. Findings suggest that this intervention successfully reduces AS among those who are high in HA and AS and may indirectly contribute to reductions in HA over time through reductions in AS.

Psychophysiology during exposure to trauma memories: Comparative effects of virtual reality and imaginal exposure for posttraumatic stress disorder.

BACKGROUND: This investigation involved an in-depth examination of psychophysiological responses during exposure to the trauma memory across 10 sessions among active duty soldiers with combat-related posttraumatic stress disorder (PTSD) treated by Prolonged Exposure (PE) or Virtual Reality Exposure (VRE). We compared psychophysiological changes, session-by-session, between VRE and traditional imaginal exposure. METHODS: Heart rate (HR), galvanic skin response (GSR), and peripheral skin temperature were collected every 5 min during exposure sessions with 61 combat veterans of Iraq/Afghanistan and compared to the PTSD Checklist (PCL-C) and Clinician-Administered PTSD Scale (CAPS) outcomes using multilevel modeling. RESULTS: Over the course of treatment, participants in the PE group had higher HR arousal compared to participants in the VRE group. With reference to GSR, in earlier sessions, participants demonstrated a within-session increase, whereas, in later sessions, participants showed a within-session habituation response. A significant interaction was found for GSR and treatment assignment for within-session change, within-person effect, predicting CAPS (d = 0.70) and PCL-C (d = 0.66) outcomes. CONCLUSION: Overall, these findings suggest that exposure to traumatic memories activates arousal across sessions, with GSR being most associated with reductions in PTSD symptoms for participants in the PE group.

Posttraumatic Stress Disorder Symptom Cluster Structure in Prolonged Exposure Therapy and Virtual Reality Exposure.

The emotional processing theory of posttraumatic stress disorder (PTSD) posits that avoidance is central to PTSD development and maintenance. Prolonged exposure (PE) therapy, which clinically focuses on avoidance reduction, has strong empirical support as a PTSD treatment. Virtual reality exposure (VRE) has been utilized to accelerate avoidance reduction by increasing multisensory engagement. Although some exposure therapy studies have found associations between avoidance and PTSD symptoms, others have indicated that reexperiencing or hyperarousal symptoms drive symptom trajectories. Using a cross-lagged panel design, the present secondary data analysis examined temporal associations between clinician-assessed PTSD symptom clusters during treatment with PE, VRE, or a waitlist control condition. There were no significant differences between PE and VRE regarding symptom clusters at any assessment. Compared to the waitlist condition, individuals who received VRE or PE exhibited earlier reductions in avoidance/numbing symptoms, ß = -.19, 95% CI [-.33, -.05], followed by reductions in hyperarousal symptoms, ß = -.21, 95% CI [-.33, -.09]. Hyperarousal symptoms predicted changes in later avoidance/numbing and reexperiencing outcomes across treatment: pretreatment to midtreatment, ß = .29, 95% CI [.17, .42]; midtreatment to posttreatment, ß = .23, 95% CI [.07, .39]. Reexperiencing symptoms predicted changes in hyperarousal outcomes earlier in treatment, ß = .22, 95% CI [.02, .37], whereas avoidance/numbing symptoms predicted changes in hyperarousal outcomes later in treatment, ß = .18, 95% CI [.04, .32]. These findings support the efficacy of exposure therapy in addressing avoidance/numbing symptoms and highlight the potential importance of hyperarousal symptoms in relation to other symptom clusters.

The Association Between Posttraumatic Stress Symptoms and Anxiety Sensitivity in a College Sample.

BACKGROUND/OBJECTIVES: One-half of all U.S. adults will experience at least one traumatic event, and of those, approximately 11% develop posttraumatic stress disorder (PTSD) symptoms. Despite efficacious treatments for PTSD, one-third of people diagnosed still express symptoms after treatment.Thus, it is important to identify underlying factors that may be associated with PTSD symptom clusters to improve treatment efficacy. One potential factor is anxiety sensitivity (AS), or "the fear of fear," and includes three different subfactors: physical, cognitive, and social concerns, yet few studies have examined this association using the Anxiety Sensitivity Index-3. METHOD: Participants included 65 undergraduate students from a Southeastern University who were elevated on anxiety sensitivity cognitive concerns and experienced at least one traumatic event. Participants completed measures of trauma exposure, anxiety sensitivity, posttraumatic stress symptoms, and suicidal ideation. RESULTS: Results revealed that AS physical symptoms had the most robust association with potential PTSD symptoms and individual PTSD symptom clusters with the exception of the avoidance and numbing cluster. CONCLUSIONS: These findings may help clarify the nature of the relationship between PTSD symptoms and AS using the most updated measure of AS (ASI-3).

Posttraumatic Stress Disorder Treatment Effects on Cardiovascular Physiology: A Systematic Review and Agenda for Future Research.

Posttraumatic stress disorder (PTSD) is linked to both altered physiological functioning and poorer cardiovascular health outcomes, including an increased risk for cardiovascular disease and cardiovascular-related mortality. An important question is whether interventions for PTSD might ameliorate the risk for poorer health by improving cardiovascular physiological intermediaries. To begin to characterize the literature addressing this question, we conducted a systematic review of empirical studies examining the impact of PTSD interventions on cardiovascular physiological intermediaries, including blood pressure (BP), heart rate (HR), cardiac impedance, and subclinical atherosclerosis. Outcomes included both tonic (i.e., resting) cardiovascular functioning and cardiovascular reactivity (CVR). A total of 44 studies met the inclusion criteria. There was mixed evidence regarding whether PTSD treatment improved tonic cardiovascular functioning. There was stronger evidence that PTSD treatments reduced CVR to trauma-related stressors, particularly for higher-quality studies of cognitive behavioral interventions. No studies examined cardiac impedance or subclinical atherosclerosis. The studies had a high degree of heterogeneity in the populations sampled and interventions tested. Moreover, they generally included small sample sizes and lacked control conditions. Interventions for PTSD may improve cardiovascular physiological outcomes, particularly CVR to trauma cues, although additional methodologically rigorous studies are needed. We outline changes to future research that would improve the literature regarding this important question, including the more frequent use of control groups and larger sample sizes.

Virtual Standardized Patients vs Academic Training for Learning Motivational Interviewing Skills in the US Department of Veterans Affairs and the US Military: A Randomized Trial.

Importance: Despite the need for effective and scalable training in motivational interviewing (MI) that includes posttraining coaching and feedback, limited evidence exists regarding the effectiveness of using virtual (computerized) standardized patients (VSPs) in such training. Objective: To evaluate the efficacy of training with a VSP on the acquisition and maintenance of MI skills compared with traditional academic study. Design, Setting, and Participants: This study was a 2-group, parallel-training randomized trial of 120 volunteer health care professionals recruited from a Department of Veterans Affairs and Department of Defense medical facility. Motivational interviewing skill was coded by external experts blinded to training group and skill assessment time points. Data were collected from October 17, 2016, to August 12, 2019. Interventions: After a computer course on MI, participants trained during two 45-minute sessions separated by 3 months. The 2 randomized training conditions included a branching storyline VSP, which provided MI skill rehearsal with immediate and summative feedback, and a control condition, which included academic study of content from the computerized MI course. Main Outcomes and Measures: Measurement of MI skill was based on recorded conversations with human standardized patients, assessed using the Motivational Interviewing Treatment Integrity 4.2.1 coding system, measured at baseline, after training, and after additional training in the randomized condition 3 months later. Results: A total of 120 volunteers (83 [69%] women), with a mean (SD) of 13.6 (10.3) years of health care experience, participated in the study; 61 were randomized to receive the intervention, and 59 were randomized to the control group. Those assigned to VSP training had significantly greater posttraining improvement in technical global scores (0.23; 95% CI, 0.03-0.44; P = .02), relational global scores (0.57; 95% CI, 0.33-0.81; P = .001), and the reflection-to-question ratio (0.23; 95% CI, 0.15-0.31; P = .001). Differences were maintained after the 3-month additional training session, with more improvements achieved after the 3-month training for the VSP trainees on the reflection-to- question ratio (0.15; 95% CI, 0.07-0.24; P = .001). Conclusions and Relevance: This randomized trial demonstrated a successful transfer of training from a VSP to human standardized patients. The VSP MI skill outcomes were better than those achieved with academic study and were maintained over time. Virtual standardized patients have the potential to facilitate dissemination of MI and may be useful for training in other evidence-based skills and treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT04558060.

Pilot trial of a transdiagnostic computerized anxiety sensitivity intervention among VA primary care patients.

People in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of Veterans at Department of Veteran's Affairs (VA) medical centers. Barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. This study evaluated the Cognitive Anxiety Sensitivity Treatment (CAST), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. VA primary care patients with elevated anxiety sensitivity (N = 25) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a VA primary care setting. Participants completed an initial visit, that included the intervention, and a one-month follow-up. Veterans found CAST to be generally acceptable, with strong usability ratings. Qualitative analyses identified areas of strength and areas for improvement for use with VA primary care Veterans. Repeated measures ANCOVAs revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. CAST could potentially have a large public health impact if deployed across VA medical centers as a first-step intervention for a range of mental health presenting concerns.

The impact of exposure therapy on stigma and mental health treatment attitudes among active duty U.S. soldiers with combat related PTSD.

Although cognitive behavioral interventions improve attitudes toward mental health treatment and reduce stigma, little is known about which types of attitudes change, or how this change occurs. Active duty soldiers with PTSD (N = 162) were randomized to 10 sessions of exposure therapy or a waitlist. Soldiers were assessed for PTSD and completed measures of stigma and attitudes towards mental health services before randomization and after 5- and 10- sessions of therapy. At post-treatment, soldiers in exposure therapy demonstrated significant improvements in openness to talking about mental health problems and concerns about what others may think if they knew they were seeking mental health treatment, relative to those in the waitlist. There were significant indirect effects from treatment to changes in stigma and attitudes towards mental health treatment through changes in PTSD symptoms at post-treatment. There was also a significant indirect effect from treatment to changes in stigma at post-treatment through changes in attitudes towards mental health treatment at mid-treatment, suggesting attitude change may occur first. Baseline characteristics did not moderate treatment's change in stigma or attitudes. Improvements in PTSD symptoms and positive changes in attitudes towards mental health treatment appear to separately predict later reductions in stigma.

Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder.

OBJECTIVE: A key symptom of posttraumatic stress disorder (PTSD) is hyperreactivity to trauma-relevant stimuli. Though physiological arousal is reliably elevated in PTSD, the question remains whether this arousal responds to treatment. Virtual reality (VR) has been posited to increase emotional engagement during prolonged exposure therapy (PE) for PTSD by augmenting imaginal exposures with trauma-relevant sensory information. However, the comparative effects of VR exposure therapy (VRE) have received limited empirical inquiry. METHOD: Ninety active-duty soldiers with combat-related PTSD participating in a randomized-controlled trial to receive PE, VRE, or a waitlist-control (WL) condition had their physiological reactivity, indexed by galvanic skin response (GSR), to their trauma memories assessed at pre-, mid-, and posttreatment. RESULTS: Although both VRE and PE conditions showed reduced GSR reactivity to trauma memories from pre- to posttreatment, only the VRE group differed significantly from WL. Across the sample, reductions in GSR were significantly correlated with reductions in self-reported PTSD and anxiety symptoms. CONCLUSIONS: This was the first study comparing effects of VRE and PE on psychophysiological variables. Given previous research finding limited differences between VRE and PE in PTSD symptom reduction, these findings lend support to the rationale for including VR in exposure therapy protocols while raising important questions about the potential benefits of VRE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Impact of Exposure Therapy on Resting Heart Rate and Heart Rate Reactivity Among Active-Duty Soldiers With Posttraumatic Stress Disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is linked to poor health, including cardiovascular disease. These effects may be a result of increased tonic cardiovascular function and cardiovascular reactivity. Despite PTSD's negative health burden, relatively little is known about whether frontline treatments for PTSD may alleviate cardiovascular risk. METHODS: The current study was a secondary analysis of a larger intervention study of active-duty soldiers with PTSD (n = 104; mean [SD] age = 30.6 [6.7] years; 6% women) randomized to an exposure therapy-either prolonged exposure (PE) or virtual reality exposure (VRE)-or a waitlist control condition. We examined change in participants' resting heart rate (HR) and HR reactivity from baseline (before randomization) to midtreatment and posttreatment using residualized change regression models. RESULTS: The results of the study demonstrated decreased resting HR (B = -5.06, p = .024) and HR reactivity (B = -2.46, p = .005) from baseline to posttreatment of PE and VRE relative to waitlist. Exploratory analyses found that changes in resting HR and HR reactivity were not significantly correlated with either self-reported or clinician-rated PTSD symptom change. CONCLUSIONS: These results suggest that PE and VRE for PTSD may alleviate some cardiovascular health risk associated with PTSD, improving cardiovascular functioning.RCT Registration: ClinicalTrials.gov (identifier: NCT01193725).

Effectiveness of the Intent to Complete and Intent to Attend Intervention to Predict and Prevent Posttraumatic Stress Disorder Treatment Drop Out Among Soldiers.

Active duty military service members have high dropout rates for trauma-focused treatment in both clinical practice and research settings. Measuring patients' intent to complete (ITC) and intent to attend (ITA) treatment have been suggested as methods to reduce dropout, but no studies have examined the effectiveness of such measures. In an attempt to reduce high dropout rates, measures of ITC and ITA were included in a randomized controlled trial evaluating prolonged exposure (PE) and virtual reality exposure (VRE) in active duty soldiers with posttraumatic stress disorder (PTSD). Participants (N = 108) were randomized to either PE or VRE, and the last 49 to enroll were administered a measure of ITC at enrollment and a measure of ITA at the end of every session. A score of 7 or below triggered a problem-solving discussion with the individual's therapist. The results revealed that the ITA assessment predicted treatment dropout after controlling for mental health stigma, PTSD symptoms, and age, odds ratio (OR) = 0.24, p = .023. Additionally, participants who completed the ITA assessment were less likely to drop out than those who were not administered the ITA, OR = 0.29 p = .002. The ITC did not predict treatment dropout OR = 0.98, p = .402. These findings suggest that assessing ITA throughout trauma-focused therapy may reduce treatment dropout rather than solely measuring ITC prior to starting psychotherapy. Based on these preliminary findings, future research should randomize the measurement of ITA in clinical trials to evaluate its impact on treatment dropout.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) La efectividad de la intención de completar y la intención de asistir a la intervención para predecir y prevenir el abandono del tratamiento para el TEPT del soldado INTENCIÓN DE ASISTIR A LA TERAPIA DE EXPOSICIÓN PARA EL TEPT Los miembros del servicio militar en servicio activo tienen altas tasas de abandono del tratamiento centrado en el trauma, tanto en la práctica clínica como en la investigación. La medición de la intención de los pacientes de completar el tratamiento (ITC en su sigla en inglés) y la intención de asistir (ITA en su sigla en inglés) se han sugerido como métodos para reducir el abandono, pero ningún estudio ha examinado la efectividad de tales medidas. En un intento por reducir las altas tasas de abandono, se incluyeron medidas de la ITC y la ITA en un ensayo controlado aleatorio que evaluaba la exposición prolongada (PE en su sigla en inglés) y la exposición de realidad virtual (VRE en su sigla en inglés) en soldados en servicio activo con trastorno de estrés postraumático (TEPT). Los participantes (N = 108) fueron asignados al azar a PE o VRE, y a los últimos 49 que se inscribieron se les administró una medida de ITC al momento de la inscripción y una medida de ITA al final de cada sesión. Un puntaje de 7 o menos desencadenó una discusión de resolución de problemas con el terapeuta del individuo. Los resultados revelaron que la evaluación ITA predijo el abandono del tratamiento después de controlar el estigma de salud mental, los síntomas del TEPT y la edad, razón de probabilidades (OR) = 0.24, p = .023. Además, los participantes que completaron la evaluación ITA tenían menos probabilidades de abandonar que aquellos que no recibieron la ITA, OR = 0.29, p = .002. El ITC no predijo el abandono del tratamiento OR = 0.98, p = .402. Estos hallazgos sugieren que evaluar la ITA a lo largo de la terapia centrada en el trauma puede reducir el abandono del tratamiento en lugar de solo medir el ITC antes de comenzar la psicoterapia. En base a estos hallazgos preliminares, la investigación futura debe aleatorizar la medición de ITA en ensayos clínicos para evaluar su impacto en el abandono del tratamiento.

Lifetime trauma exposure among those with combat-related PTSD: Psychiatric risk among U.S. military personnel.

Research has described the association between lifetime trauma exposure and psychiatric symptoms among various cohorts, but little is known about the effect of lifetime trauma histories on the symptom expression of active-duty military personnel diagnosed with combat-related posttraumatic stress disorder (PTSD). Active-duty soldiers (N = 162) were diagnosed with PTSD from deployments to Iraq or Afghanistan using the Clinician Administered PTSD Scale. Soldiers then completed self-report measures of depression, anxiety, and PTSD. Lifetime exposure to categories of trauma types and the intensity of exposure was reported on the Life Events Checklist. The number of categories of trauma that happened to them significantly predicted the severity of depression, anxiety, and PTSD symptoms, as well as a positive screen for likely depression diagnosis based on self-reported symptoms. Direct exposure to trauma explained most of the association, as witnessing trauma and hearing about trauma did not explain symptoms beyond events that happened to participants. Interpersonal traumatic events were not associated with psychiatric functioning after controlling for non-interpersonal traumatic events. Assessment of trauma history among post-9/11 service members and veterans should include the frequency and variety of lifetime trauma exposure, given the association with psychiatric functioning.

Relationship between change in in-vivo exposure distress and PTSD symptoms during exposure therapy for active duty soldiers.

OBJECTIVE: The current study sought to examine the relationship between changes in distress for items on in-vivo exposure hierarchies and posttraumatic stress disorder (PTSD) symptom change over the course of exposure therapy. METHODS: Active duty army soldiers (N = 108) were recruited from a military base in the U.S. and were enrolled in a randomized clinical trial comparing Prolonged Exposure (PE), Virtual Reality Exposure (VRE), and a wait-list control for the treatment of PTSD stemming from deployments to Iraq or Afghanistan. PTSD diagnosis followed DSM-IV-TR criteria. Outcome measures were assessed via self-report and clinician interview. The relationships between in-vivo exposure distress, imaginal exposure distress, and PTSD symptoms, were examined in a factor of curves model for participants in the treatment conditions. RESULTS: Analyses revealed that, when controlling for one another, changes in in-vivo exposure distress were significantly associated with changes in PTSD symptoms (ß = 0.75, 95% CI [0.60, 0.90]), while changes in imaginal exposure distress were not (ß = 0.03, 95% CI [-0.27, 0.33]). The model also revealed that after accounting for the shared variation in trajectories of change, symptom clusters did not have unique variation, meaning that symptom clusters did not change independently. CONCLUSION: Results suggest the possibility that in-vivo exposures are more closely tied to changes in overall PTSD symptoms than imaginal exposures during exposure therapy. Furture research should incorporate more frequent measurement of in-vivo exposure distress to better elucidate these relations over the course of treatment.

Virtual reality exposure versus prolonged exposure for PTSD: Which treatment for whom?

BACKGROUND: The majority of studies comparing active psychological treatments for posttraumatic stress disorder (PTSD) do not find significant differences at posttreatment. This was the case in a recent trial examining prolonged exposure (PE) and virtual reality exposure (VRE) among active-duty soldiers with combat-related PTSD. Matching individual patients to specific treatments provides a potential avenue to improve significantly the public health impact of effective treatments for PTSD. A composite moderator approach was used to identify profiles of patients who would see superior PTSD symptom reduction in VRE or PE to inform future treatment matching. METHODS: Active duty U.S. army soldiers (N = 108) were enrolled in a randomized clinical trial comparing VRE and PE in the treatment of PTSD stemming from deployments to Iraq or Afghanistan. Eighteen baseline variables were examined to identify treatment response heterogeneity in two patient groups: those with a superior response to PE and those with a superior response to VRE. The final composite moderator comprised four of 18 baseline variables. RESULTS: Results revealed that patients who were predicted to see greater PTSD symptom reduction in VRE were likely to be younger, not taking antidepressant medication, had greater PTSD hyperarousal symptoms, and were more likely to have greater than minimal suicide risk. CONCLUSIONS: Results suggest that treatment matching based on patient profiles could meaningfully improve treatment efficacy for combat-related PTSD. Future research can build on these results to improve our understanding of how to improve treatment matching for PTSD.