Internet-delivered computerized cognitive & affective remediation training for the treatment of acute and chronic posttraumatic stress disorder: Two randomized clinical trials.

Treatment of posttraumatic stress disorder (PTSD) is time and cost-intensive. New, readily implementable interventions are needed. Two parallel randomized clinical trials tested if cognitive/affective computerized training improves cognitive/affective functions and PTSD symptoms in acute (N = 80) and chronic PTSD (N = 84). Adults age 18-65 were recruited from an Israeli hospital emergency room (acute) or from across the United States (chronic). Individuals were randomized to an active intervention (acute N = 50, chronic N = 48) that adaptively trains cognition and an affective positivity bias, or a control intervention (acute N = 30, chronic N = 36) of engaging computer games. Participants, blind to assignment, completed exercises at home for 30 min/day over 30 days (acute) or 45 min/day over 45 days (chronic). Primary outcomes were computerized cognitive/affective function metrics. Secondary outcomes were Clinician-Administered PTSD Scale (CAPS) total scores. In chronic PTSD, the active arm demonstrated facilitated speed of fearful face identification (F = 20.96, q < 0.001; d = 1.21) and a trend towards improvement in total PTSD symptoms (F = 2.91, p = 0.09, d = 0.47), which was due to improvement in re-experiencing symptoms (F = 6.14, p = 0.015; d = 0.73). Better cognitive performance at baseline moderated the training effect and was associated with more favorable improvements on both metrics. Cognitive and affective training does not have widespread benefit on symptoms and cognitive/affective functions in PTSD. Future studies targeting re-experiencing a priori, stratifying on cognitive capacity, and with modified methods to infer on mechanisms and optimized training parameters may be warranted. ClinicalTrials.gov Identifiers: NCT01694316 &NCT02085512.

Cognitive Flexibility Predicts PTSD Symptoms: Observational and Interventional Studies.

Introduction: Post-Traumatic Stress Disorder (PTSD) is a prevalent, severe and tenacious psychopathological consequence of traumatic events. Neurobehavioral mechanisms underlying PTSD pathogenesis have been identified, and may serve as risk-resilience factors during the early aftermath of trauma exposure. Longitudinally documenting the neurobehavioral dimensions of early responses to trauma may help characterize survivors at risk and inform mechanism-based interventions. We present two independent longitudinal studies that repeatedly probed clinical symptoms and neurocognitive domains in recent trauma survivors. We hypothesized that better neurocognitive functioning shortly after trauma will be associated with less severe PTSD symptoms a year later, and that an early neurocognitive intervention will improve cognitive functioning and reduce PTSD symptoms. Methods: Participants in both studies were adult survivors of traumatic events admitted to two general hospitals' emergency departments (EDs) in Israel. The studies used identical clinical and neurocognitive tools, which included assessment of PTSD symptoms and diagnosis, and a battery of neurocognitive tests. The first study evaluated 181 trauma-exposed individuals one-, six-, and 14 months following trauma exposure. The second study evaluated 97 trauma survivors 1 month after trauma exposure, randomly allocated to 30 days of web-based neurocognitive intervention (n = 50) or control tasks (n = 47), and re-evaluated all subjects three- and 6 months after trauma exposure. Results: In the first study, individuals with better cognitive flexibility at 1 month post-trauma showed significantly less severe PTSD symptoms after 13 months (p = 0.002). In the second study, the neurocognitive training group showed more improvement in cognitive flexibility post-intervention (p = 0.019), and lower PTSD symptoms 6 months post-trauma (p = 0.017), compared with controls. Intervention- induced improvement in cognitive flexibility positively correlated with clinical improvement (p = 0.002). Discussion: Cognitive flexibility, shortly after trauma exposure, emerged as a significant predictor of PTSD symptom severity. It was also ameliorated by a neurocognitive intervention and associated with a better treatment outcome. These findings support further research into the implementation of mechanism-driven neurocognitive preventive interventions for PTSD.

Evaluating web-based cognitive-affective remediation in recent trauma survivors: study rationale and protocol.

Background: The immediate aftermath of traumatic events is a period of enhanced neural plasticity, following which some survivors remain with post-traumatic stress disorder (PTSD) whereas others recover. Evidence points to impairments in emotional reactivity, emotion regulation, and broader executive functions as critically contributing to PTSD. Emerging evidence further suggests that the neural mechanisms underlying these functions remain plastic in adulthood and that targeted retraining of these systems may enhance their efficiency and could reduce the likelihood of developing PTSD. Administering targeted neurocognitive training shortly after trauma exposure is a daunting challenge. This work describes a study design addressing that challenge. The study evaluated the direct effects of cognitive remediation training on neurocognitive mechanisms that hypothetically underlay PTSD, and the indirect effect of this intervention on emerging PTSD symptoms. Method: We describe a study rationale, design, and methodological choices involving: (a) participants' enrolment; (b) implementation and management of a daily self-administered, web-based intervention; (c) reliable, timely screening and assessment of treatment of eligible survivors; and (d) defining control conditions and outcome measures. We outline the rationale of choices made regarding study sample, timing of intervention, measurements, monitoring participants' adherence, and ways to harmonize and retain interviewers' fidelity and mitigate eventual burnout by repeated contacts with recently traumatized survivors. Conclusion: Early web-based interventions targeting causative mechanisms of PTSD can be informed by the model presented in this paper.

El período inmediatamente posterior a los eventos traumáticos es un período de mayor plasticidad neuronal, después del cual algunos sobrevivientes siguen con trastorno de estrés postraumático (TEPT) mientras que otros se recuperan. La evidencia señala que las deficiencias en reactividad emocional, regulación de las emociones y funciones ejecutivas más amplias contribuyen de manera crítica al TEPT. La evidencia que comienza a hacer su aparición sugiere además que los mecanismos neuronales que subyacen a estas funciones siguen siendo plásticos en la edad adulta y que la reeducación específica de estos sistemas puede mejorar su eficacia y reducir la probabilidad de desarrollar un TEPT. La administración de entrenamiento neurocognitivo específico poco después de la exposición al trauma es un desafío desalentador. Este trabajo describe un diseño de estudio que aborda ese desafío. El estudio evaluó los efectos directos del entrenamiento en reparación cognitiva sobre los mecanismos neurocognitivos que hipotéticamente subyacen al TEPT y el efecto indirecto de esta intervención en los síntomas de TEPT que surgen. Método: Describimos una justificación para el estudio, unas opciones de diseño y una metodología que implican (a) inscribir a los participantes; (b) implementar y administrar una intervención diaria autoadministrada, basada en la web; (c) detectar y evaluar, de modo oportuno y fiable, el tratamiento de los sobrevivientes que resultan elegibles; y (d) definir las condiciones de control y las medidas de los resultados. Resumimos la justificación de las decisiones que se tomaron con respecto a la muestra del estudio, el momento de la intervención, las mediciones, el seguimiento del compromiso de los participantes y el modo de armonizar y retener la fidelidad de los entrevistadores y mitigar el agotamiento debido al contacto repetido con sobrevivientes recientemente traumatizados. Conclusión: las intervenciones tempranas basadas en la web que se dirigen a los mecanismos que causan el TEPT pueden basarse en el modelo presentado en este documento.