Pilot Cases of Combined Cognitive Processing Therapy and Smoking Cessation for Smokers With Posttraumatic Stress Disorder.

Posttraumatic stress disorder (PTSD) and smoking are often comorbid, and both problems are in need of improved access to evidence-based treatment. The combined approach could address two high-priority problems and increase patient access to both treatments, but research is needed to determine whether this is feasible and has promise for addressing both PTSD and smoking. We collected data from 15 test cases that received a treatment combining two evidence-based treatments: cognitive processing therapy-cognitive version (CPT-C) for PTSD and integrated care for smoking cessation (ICSC). We explored two combined treatment protocols including a brief (six-session) CPT-C with five follow-up in-person sessions focused on smoking cessation (n=9) and a full 12-session CPT-C protocol with ICSC (n=6). The combined interventions were feasible and acceptable to patients with PTSD making a quit attempt. Initial positive benefits of the combined treatments were observed. The six-session dose of CPT-C and smoking cessation resulted in 6-month bioverified smoking abstinence in two of nine participants, with clinically meaningful PTSD symptom reduction in three of nine participants. In the second cohort (full CPT-C and smoking treatment), both smoking and PTSD symptoms were improved, with three of six participants abstinent from smoking and four of six participants reporting clinically meaningful reduction in PTSD symptoms. Results suggested that individuals with PTSD who smoke are willing to engage in concurrent treatment of these problems and that combined treatment is feasible.

Nonnightmare distressed awakenings in veterans with posttraumatic stress disorder: response to prazosin.

Twenty-two veterans with posttraumatic stress disorder (PTSD) were assessed for trauma-related nightmares and nonnightmare distressed awakenings (NNDA) before and after treatment with the alpha-1 adrenoreceptor antagonist prazosin at an average bedtime dose of 9.6 mg/day. Ratings combining frequency and intensity dimensions of trauma-related nightmares decreased from 3.6 to 2.2, NNDA from 5.2 to 2.1, and sleep difficulty from 7.2 to 4.1 per week. These results suggest that increased brain adrenergic activity may contribute to the pathophysiology of both trauma-related nightmares and NNDA in PTSD.

Preliminary findings from a clinical demonstration project for veterans returning from Iraq or Afghanistan.

Military veterans are at high risk for nicotine dependence. This clinical demonstration project used invitational letters, referral to the National Cancer Institute's Smoking Quitline, and local Veteran Affairs prescriptions for tobacco cessation to evaluate whether this low-cost method would potentially reduce smoking in separated veterans who served in Afghanistan and Iraq. Three cohorts (500 each) of recently separated veterans from Afghanistan and Iraq were contacted by survey letters. Interested veterans received follow-up telephone calls using standardized scripts. They were referred to the National Cancer Institute's Smoking Quitline (1-877-44U-QUIT) and offered local Veteran Affairs pharmacologic treatment for smoking cessation. Forty-three percent of respondents who were smokers were interested in the clinical program; of these, 77% participated. At 2 months follow-up, 38% of participants self-reported maintained smoking abstinence. Results suggested that the intervention was feasible and assisted the small number of veterans who participated.

Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD.

Iraq and Afghanistan War veterans were grouped by level of posttraumatic stress disorder (PTSD) symptomatology and compared on self-report measures of trait anger, hostility, and aggression. Veterans who screened positive for PTSD reported significantly greater anger and hostility than those in the subthreshold-PTSD and non-PTSD groups. Veterans in the subthreshold-PTSD group reported significantly greater anger and hostility than those in the non-PTSD group. The PTSD and subthreshold-PTSD groups did not differ with respect to aggression, though both groups were significantly more likely to have endorsed aggression than the non-PTSD group. These findings suggest that providers should screen for anger and aggression among Iraq and Afghanistan War veterans who exhibit symptoms of PTSD and incorporate relevant anger treatments into early intervention strategies.

A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder.

BACKGROUND: Excessive brain responsiveness to norepinephrine appears to contribute to post-traumatic stress disorder (PTSD), particularly at night. Prazosin, a brain active alpha-1 adrenergic receptor antagonist, significantly reduced trauma nightmares and sleep disturbance in 10 Vietnam War combat veterans in a previous placebo-controlled crossover study. The current parallel group trial in a larger sample of veterans evaluated prazosin effects on trauma nightmares, sleep quality, global clinical status, dream characteristics, and comorbid depression. METHODS: Forty veterans (mean age 56 +/- 9) with chronic PTSD and distressing trauma nightmares and sleep disturbance were randomized to evening prazosin (13.3 +/- 3 mg/day) or placebo for 8 weeks. RESULTS: In the evaluable sample (n = 34), primary outcome measures demonstrated that prazosin was significantly superior to placebo for reducing trauma nightmares and improving sleep quality and global clinical status with large effect sizes. Prazosin shifted dream characteristics from those typical of trauma-related nightmares toward those typical of normal dreams. Blood pressure changes from baseline to end study did not differ significantly between prazosin and placebo. CONCLUSIONS: Prazosin is an effective and well-tolerated treatment for trauma nightmares, sleep disturbance and global clinical status in veterans with chronic PTSD.

Telephone self-monitoring among alcohol use disorder patients in early recovery: a randomized study of feasibility and measurement reactivity.

Frequent symptom self-monitoring protocols have become popular tools in the addiction field. Interactive Voice Response (IVR) is a telephone monitoring system that has been shown to be feasible for collecting frequent self-reports from a variety of research populations. Little is known, however, about the feasibility of using IVR monitoring in clinical samples, and few controlled trials exist assessing the impact of any type of frequent self-report monitoring on the behaviors monitored. This pilot study with patients in early recovery from an alcohol use disorder (n=98) evaluated compliance with two IVR monitoring protocols, subjective experiences with monitoring, and change in symptoms associated with monitoring (i.e., measurement reactivity). Participants were randomly assigned to call an IVR system daily for 28 days, once per week for 4 weeks, or only to complete 28-day follow-up assessment including retrospective drinking reports. Monitoring calls assessed alcohol craving, substance use, emotional well-being, and PTSD symptoms. Most monitoring participants completed calls on at least 75% of scheduled days (72.2% and 59.2% for daily and weekly, respectively). Including reconstructed data from follow-up of missed calls yielded 77.8% and 74.1% of maximum data points, respectively. Most monitoring participants indicated the protocol was manageable and reported positive or no effects of monitoring on urges to use alcohol, actual drinking, and PTSD symptoms. Analyses of measurement reactivity based on assessment one month after randomization found no significant group differences on drinking, craving for alcohol, or PTSD-related symptoms. Results suggest that IVR technology is feasible and appropriate for telephone symptom monitoring in similar clinical samples.

Prazosin reduces nightmares in combat veterans with posttraumatic stress disorder.

BACKGROUND: Preclinical and clinical observations suggest that the centrally active alpha1-adrenergic antagonist prazosin might alleviate trauma content nightmares and other symptoms in combat veterans with chronic posttraumatic stress disorder (PTSD). METHOD: In this retrospective chart review study, we analyzed data from 59 consecutive combat veterans with previously treatment-resistant chronic PTSD (DSM-IV criteria) and severe intractable trauma content nightmares to whom prazosin had been prescribed. Nightmare severity was quantified using the recurrent distressing dreams item of the Clinician Administered PTSD Scale (CAPS). Change in overall PTSD severity exclusive of nightmares was estimated by assigning a Clinical Global Impressions-Change scale (CGI-C) score based on chart review. RESULTS: Mean +/- SEM recurrent distressing dreams item scores improved significantly (7.0 +/- 0.2 to 3.5 +/- 0.3, p <.0001) in the 36 patients who completed at least 8 weeks of prazosin treatment at their maximum titrated dose. The mean maximum prazosin dose achieved in these 36 patients was 9.6 +/- 0.9 mg/day. Recurrent distressing dreams scores also improved in the total group who filled their prazosin prescriptions (N = 51) (7.1 +/- 0.2 to 4.2 +/- 0.3, p <.0001). In a comparison group of 8 patients who did not fill their prazosin prescriptions but continued in outpatient treatment, there was no significant change in CAPS recurrent distressing dreams score (6.8 +/- 0.5 to 6.7 +/- 0.4). There also was at least some improvement in CGI-C ratings of overall PTSD severity exclusive of nightmares in a substantial majority of patients receiving prazosin, but not in the 8 comparison subjects. There were no serious adverse effects attributable to prazosin. CONCLUSION: These observations suggest that prazosin may relieve symptomatic distress in PTSD, and they provide rationale for placebo-controlled trials of prazosin for PTSD trauma content nightmares and other PTSD symptoms.

Risk of misinterpretation of MMPI Schizophrenia scale elevations in chronic pain patients.

Seventy-three chronic pain patients with elevated MMPI Schizophrenia (Sc) scale scores (T score greater than 70) were compared with 55 psychotic and 87 non-psychotic psychiatric patients with elevated Sc scores to examine group differences in item content patterns on the Harris and Lingoes subscales. Chronic pain patients evidenced lower scores on all Harris and Lingoes Sc subscales, except for the Bizarre Sensory Experiences subscale on which they scored significantly higher than the psychiatric groups. Results demonstrate that Sc is elevated in many chronic pain patients because they endorse somatic symptoms and items suggestive of depression and inertia, whereas psychotics endorse more items reflecting bizarre and disordered thinking, social alienation and defective inhibition, and non-psychiatric patients endorse more depression, despair, thought disorganization and social alienation. These data suggest that high Sc scores of many chronic pain patients reflect symptoms and sequelae of their physical problems, and do not necessarily reflect severe psychopathology.