Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder.

Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = -.41 to -.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, ß = -.38, p < .04. Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.

Hyperarousal Symptoms Explain the Relationship Between Cognitive Complaints and Working Memory Performance in Veterans Seeking PTSD Treatment.

OBJECTIVE: Comorbidity and symptom overlap between traumatic brain injury and posttraumatic stress disorder (PTSD) in veterans returning from deployment present challenges with respect to differential diagnosis and treatment. Both conditions frequently manifest with attention and working memory deficits, though the underlying neuropsychological basis differs. This study evaluated whether hyperarousal symptoms explain the relationship between subjective and objective measures of cognition in a veteran sample. PARTICIPANTS AND PROCEDURES: One-hundred three veterans completed the military version of the PTSD Checklist (PCL), the Neurobehavioral Symptom Inventory, and the Wechsler Memory Scale, 3rd edition digit span task with adequate effort. RESULTS: Hierarchical regression suggested that hyperarousal, but not other PTSD symptoms, explained the relationship between neurobehavioral symptoms and cognitive functioning. This relationship was present regardless of whether veterans met full PTSD diagnostic criteria or screened positive on a traumatic brain injury screener and was robust to other moderators. CONCLUSION: These findings highlight the importance of considering traumatic brain injury and PTSD symptom overlap, particularly the relationship between hyperarousal symptoms and attention and working memory deficits, in conceptualizing cases and treatment planning.

Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl.

The alpha-2 adrenergic receptor antagonist, yohimbine, can facilitate fear extinction in animals and humans. One potential mechanism is increased noradrenergic activity and associated arousal in the presence of conditioned stimuli. Accordingly, yohimbine might augment prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD), where heightened exposure-oriented arousal is a theorized driver and empirical predictor of treatment success. A double-blind placebo-controlled randomized trial (NCT 01031979) piloted yohimbine augmentation in 26 males with combat-related PTSD. Participants were given one-time dose of yohimbine or placebo prior to the first imaginal exposure. Subsequently, both arms completed standard PE. The primary outcome was trauma-cued heart-rate reactivity a week after the drug/exposure visit, a highly specified, objective measure sensitive to incremental change. Secondary outcomes included arousal during the drug/exposure visit and slope of distress, PTSD, and depression over the course of PE. Consistent with hypothesis, yohimbine led to higher objective and subjective arousal during the drug/exposure visit and to lower trauma-cued heart-rate reactivity one-week later. One dose of yohimbine also led to greater between-session habituation and more rapid improvement on depression, but not PTSD, over the course of care. Results of this controlled pilot indicate support for continued investigation of yohimbine-augmented exposure therapy for PTSD.

TAKING THE PULSE OF PROLONGED EXPOSURE THERAPY: PHYSIOLOGICAL REACTIVITY TO TRAUMA IMAGERY AS AN OBJECTIVE MEASURE OF TREATMENT RESPONSE.

BACKGROUND: Physiological reactivity to trauma-related cues is a primary symptom of PTSD and can be assessed objectively using script-driven imagery paradigms. However, subjective self-reported symptom measures are the most common outcome indices utilized in PTSD treatment trials and clinic settings. We examined physiological reactivity during a short trauma imagery task as an objective index of response to PTSD treatment, optimized for use in routine clinical care settings. METHODS: Participants were 35 male combat veterans receiving prolonged exposure (PE) therapy in a Veterans Affairs outpatient clinic. In addition to traditional subjective self-reported and clinician-rated symptom measures, patients also completed a script-driven imagery task in which heart rate (HR) and skin conductance (SC) were recorded at three assessment points across treatment. We examined changes in subjective symptom measures and objective trauma-specific physiological reactivity over the course of PE, and investigated the association between pretreatment physiological reactivity and treatment response. RESULTS: Patients who completed PE showed significantly diminished HR and SC reactivity to trauma imagery across therapy. Additionally, individuals showing greater trauma-specific HR reactivity at pretreatment showed greater reductions in subjectively reported PTSD symptoms at posttreatment. CONCLUSIONS: Findings support the utility of physiological reactivity during trauma imagery as an objective outcome measure that has the potential to be incorporated into evidence-based PTSD treatment in routine clinical settings, or prospective studies related to the individualization of care at pretreatment.

Reduced working memory performance in PTSD and suicide among veterans presenting for treatment.

Suicide is among the leading causes of death in the United States, underscoring the continued need to understand the mechanisms underlying suicide risk. A growing body of research has examined the role of working memory deficits in suicidal thoughts and behaviors (STBs), yet little research has evaluated putative pathways via which working memory impairments may heighten suicide risk. Elevated posttraumatic stress symptoms (PTSS) represent one plausible mechanism through which poor working memory performance may increase STBs. The present study utilized data from 140 treatment-seeking veterans who presented for an intake evaluation in the PTSD Clinical Team of a large VA Medical Center. Veterans completed self-report measures, a semi-structured PTSD evaluation, and a digit span working memory test. In addition to concurrent suicidal ideation assessed during the intake, additional information regarding past suicide attempts, presence of a safety plan, documentation of past suicidal behaviors, and engagement with suicide crisis lines were collected via electronic medical records. Consistent with hypotheses, a significant indirect path emerged such that poor working memory performance predicted greater suicidal ideation, greater likelihood of a past suicide attempt, and greater latent suicide risk via increased PTSS. However, no direct effect of working memory on STBs or indirect paths of PTSS on STBs via working memory emerged. These findings suggest that the relation between working memory and STBs may be explained by PTSS severity.

When chaos is the norm: How some veterans with PTSD are continuing to engage in trauma-focused treatments during the COVID-19 pandemic.

The COVID-19 pandemic has caused many Veterans Healthcare Administration providers working with veterans diagnosed with posttraumatic stress disorder to question the feasibility and appropriateness of continuing to provide trauma-focused treatment during this crisis. The Veterans Healthcare Administration is in a unique position to continue to provide trauma-informed care because of its capacity to offer telemental health services. Data from a Veterans Affairs medical center's posttraumatic stress disorder clinical team suggest that not only are veterans interested in continuing with treatment but also that the treatments can be modified to accommodate the current climate. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

An adjunctive human-animal interaction intervention for veterans with PTSD: study protocol for a randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. METHODS/DESIGN: The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. DISCUSSION: It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. TRIAL REGISTRATION: ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

The efficacy of 90-minute versus 60-minute sessions of prolonged exposure for posttraumatic stress disorder: Design of a randomized controlled trial in active duty military personnel.

OBJECTIVE: Posttraumatic stress disorder (PTSD) can have devastating effects on multiple aspects of functioning. Thus, it is imperative to increase access to evidence-based treatment for PTSD. Prolonged Exposure therapy (PE) has extensive empirical support and is one of the first-line PTSD treatments included in civilian, veteran, and military clinical practice guidelines. However, the standard 90-min PE session format can constitute a significant barrier to its adoption in routine clinical care settings, which typically schedule 60-min appointment sessions. If the length of PE sessions could be reduced from 90 to 60 min without compromising treatment efficacy and efficiency, this would remove a major barrier to PE adoption. METHOD: This paper describes the rationale and methods of a randomized controlled noninferiority trial comparing 90-min versus 60-min PE sessions (including 40- vs. 20-min imaginal exposures, respectively) among 160 active duty military personnel with PTSD. The aims of this study are to: (1) examine the efficacy and efficiency (i.e., rate of symptom improvement) of 90- versus 60-min PE; (2) assess change in psychophysiological markers of treatment response across conditions; and (3) test mechanisms of change underlying the efficacy of PE. RESULTS/CONCLUSIONS: The results of this study will inform dissemination efforts in military, veteran, and civilian sectors. Further, identifying mechanisms of therapeutic change will answer important theoretical questions about how PE works, in order to refine and increase the efficacy and efficiency of PE to better meet the needs of individuals with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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

In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.

Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome.

Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.

Affective engagement for facial expressions and emotional scenes: the influence of social anxiety.

Pictures of emotional facial expressions or natural scenes are often used as cues in emotion research. We examined the extent to which these different stimuli engage emotion and attention, and whether the presence of social anxiety symptoms influences responding to facial cues. Sixty participants reporting high or low social anxiety viewed pictures of angry, neutral, and happy faces, as well as violent, neutral, and erotic scenes, while skin conductance and event-related potentials were recorded. Acoustic startle probes were presented throughout picture viewing, and blink magnitude, probe P3 and reaction time to the startle probe also were measured. Results indicated that viewing emotional scenes prompted strong reactions in autonomic, central, and reflex measures, whereas pictures of faces were generally weak elicitors of measurable emotional response. However, higher social anxiety was associated with modest electrodermal changes when viewing angry faces and mild startle potentiation when viewing either angry or smiling faces, compared to neutral. Taken together, pictures of facial expressions do not strongly engage fundamental affective reactions, but these cues appeared to be effective in distinguishing between high and low social anxiety participants, supporting their use in anxiety research.

Defensive mobilization in specific phobia: fear specificity, negative affectivity, and diagnostic prominence.

BACKGROUND: Understanding of exaggerated responsivity in specific phobia-its physiology and neural mediators-has advanced considerably. However, despite strong phenotypic evidence that prominence of specific phobia relative to co-occurring conditions (i.e., principal versus nonprincipal disorder) is associated with dramatic differences in subjective distress, there is yet no consideration of such comorbidity issues on objective defensive reactivity. METHODS: A community sample of specific phobia (n = 74 principal; n = 86 nonprincipal) and control (n = 76) participants imagined threatening and neutral events while acoustic startle probes were presented and eyeblinks (orbicularis occuli) recorded. Changes in heart rate, skin conductance level, and facial expressivity were also measured. RESULTS: Principal specific phobia patients far exceeded control participants in startle reflex and autonomic reactivity during idiographic fear imagery. Distinguishing between single and multiple phobias within principal phobia and comparing these with nonprincipal phobia revealed a continuum of decreasing defensive mobilization: single patients were strongly reactive, multiple patients were intermediate, and nonprincipal patients were attenuated-the inverse of measures of pervasive anxiety and dysphoria (i.e., negative affectivity). Further, as more disorders supplanted specific phobia from principal disorder, overall defensive mobilization was systematically more impaired. CONCLUSIONS: The exaggerated responsivity characteristic of specific phobia is limited to those patients for whom circumscribed fear is the most impairing condition and coincident with little additional affective psychopathology. As specific phobia is superseded in severity by broad and chronic negative affectivity, defensive reactivity progressively diminishes. Focal fears may still be clinically significant but not reflected in objective defensive mobilization.

Aversive picture processing: effects of a concurrent task on sustained defensive system engagement.

Viewing a series of aversive pictures prompts emotional reactivity reflecting sustained defensive engagement. The present study examined the effects of a concurrent visual task on autonomic, somatic, electrocortical, and facial components of this defensive state. Results indicated that emotional activation was largely preserved despite continuous visual distraction, although evidence of attenuation was observed in startle reflex and electrocortical measures. Concurrent task-specific reactivity was also apparent, suggesting that motivational circuits can be simultaneously activated by stimuli with intrinsic survival significance and instructed task significance and that these processes interact differently across the separate components of defensive engagement.

Threat of suffocation and defensive reflex activation.

The current study examined emotional reflex reactions of participants threatened with respiratory distress caused by imposing a resistive load at inspiration. Cues signaling threat (breathing MAY be difficult) and safe periods were intermixed while startle reflexes, heart rate, skin conductance, and facial EMG activity were measured. Compared to safe cues, threat cues elicited significant startle potentiation, enhanced skin conductance, heightened corrugator EMG changes, and pronounced "fear bradycardia" consistent with defensive activation in the context of threatened respiratory dysfunction. These data indicate that anticipating respiratory resistance activates defensive responding, which may mediate symptomatology in patients with panic and other anxiety disorders.

Electrocortical and electrodermal responses covary as a function of emotional arousal: a single-trial analysis.

Electrophysiological studies of human visual perception typically involve averaging across trials distributed over time during an experimental session. Using an oscillatory presentation, in which affective or neutral pictures were presented for 6 s, flickering on and off at a rate of 10 Hz, the present study examined single trials of steady-state visual evoked potentials. Moving window averaging and subsequent Fourier analysis at the stimulation frequency yielded spectral amplitude measures of electrocortical activity. Cronbach's alpha reached values >.79, across electrodes. Single-trial electrocortical activation was significantly related to the size of the skin conductance response recorded during affective picture viewing. These results suggest that individual trials of steady-state potentials may yield reliable indices of electrocortical activity in visual cortex and that amplitude modulation of these indices varies with emotional engagement.