A pilot randomized effectiveness trial of the unified protocol in trauma-exposed veterans.

BACKGROUND: The unified protocol (UP) is a promising transdisgnostic treatment for emotional disorders; limited data exists with trauma-exposed populations. This study compared effectiveness of the UP, presented centered therapy (PCT), and treatment as usual (TAU) in trauma-exposed veterans presenting to routine care. METHOD: Trauma-exposed veterans with one or more emotional disorder diagnoses participated in a pilot hybrid-1 effectiveness/preimplementation study. Thirty-seven male and female veterans were randomized to one of three conditions. RESULTS: Multilevel growth curve modeling demonstrated improvement over time across conditions with large effect sizes (range: -2.15 to -3.32), with the UP demonstrating the greatest change. The between group effect sizes for reductions in number of comorbid diagnoses were medium to small and statistically significant (TAU and UP, d = 0.49, p = .056; TAU and PCT d = 0.18, p = .166, UP and PCT d = 0.31, p = .229). Only the UP led to a decrease in the number of comorbid diagnoses (d = -0.71). Psychosocial functioning varied by group, with slight increases in impairment in PCT and TAU, and medium effect size reduction in the UP. Only the UP exhibited significant decreases in self-reported anxiety and depression. Between group differences for UP and PCT were medium to large and statistically significant for depression across two measures (d = -0.72 to d = -1.40). CONCLUSIONS: This represents the first trial examining effectiveness of the UP, PCT, and TAU in trauma-exposed veterans. Despite a small sample, large effect size differences demonstrated promising advantages for the UP. Trial Registration Number: NCT02944994.

Problematic driving in former service members: An evaluation of the Driving Behavior Survey in veterans with posttraumatic stress disorder.

Despite high levels of traffic-related mortality, injury, and impairment among former service members, measures validated to assess problematic driving in this population remain limited. The current study examined characteristics of the Driving Behavior Survey (DBS) in male veterans (76.3% White; age: M = 56.4, SD = 12.3) meeting criteria for PTSD. Confirmatory factor analyses indicated acceptable fit of a 3-factor model specifying dimensions of anxiety-based performance deficits, exaggerated safety/caution, and hostile/aggressive driving behavior. Concurrent associations with indices of anxiety, depression, trauma history, and clinician-rated PTSD were consistent with small (r = .10-.29) to medium (r = .30-.49) effects. Discriminative validity was noted through elevations in performance deficit (d = .26), safety/caution (d = .50), and hostile/aggressive (d = .39) scales relative to published data from student drivers. Scores comparable to civilian motorists with accident-related PTSD help to qualify the severity of problematic driving behavior in trauma-exposed veterans.

Alliance across group treatment for veterans with posttraumatic stress disorder: The role of interpersonal trauma and treatment type.

OBJECTIVE: Examine initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. METHOD: One hundred and seventy-eight male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or non-interpersonal) impacted initial levels of alliance or change in alliance over time. RESULTS: Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a non-interpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05), but did not have significantly different initial alliance ratings. CONCLUSIONS: The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance.

Eating disorder symptoms and comorbid psychopathology among male and female veterans.

OBJECTIVE: Eating disorder (ED) symptoms have gone mostly unexamined among veterans. The current study assessed rates of bulimia nervosa (BN) and binge eating disorder (BED) symptoms and diagnoses and their associations with common comorbidities among male and female veterans. METHOD: Participants were US military veterans who screened positive for trauma histories and/or a probable Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) posttraumatic stress disorder (PTSD) diagnosis (n=499). Symptoms of PTSD were assessed using the Clinician-Administered PTSD Scale, and symptoms of EDs, mood, and substance use disorders were assessed using the Structured Clinical Interview for the DSM-IV. RESULTS: Lifetime rates of BN and BED diagnoses were comparable to civilian populations, and a considerable range of lifetime and current BN and BED symptoms were identified. In multivariate models, PTSD and depression severity were most consistently associated with BN and BED symptom severity, with depression most strongly associated with EDs for women. CONCLUSIONS: Findings highlight the importance of screening for ED symptoms among male and female veterans, particularly those that present with PTSD and depression symptomatology. Future examinations of the temporal order of such relationships and the degree to which ED symptoms and associated symptoms impact veteran functioning are warranted.

Validation of the use of video teleconferencing technology in the assessment of PTSD.

The Veterans Health Administration (VHA) has promoted the use of telehealth technologies to deliver mental health care to veterans with limited access to services on account of geographic and other barriers. The use of technology to deliver interventions to veterans with posttraumatic stress disorder (PTSD) has been a particular focus within VHA. Much less attention has been paid to the use of telehealth technologies to diagnose veterans with PTSD for both treatment and/or disability compensation purposes, in spite of the need for such services. The literature evaluating the use of video teleconferencing methods in the assessment of PTSD is limited; to our knowledge, only 1 previous study has been published. The current study evaluated the psychometric characteristics of the Clinician Administered PTSD Scale (CAPS) administered by video teleconferencing with a larger and more diverse sample of veterans. The CAPS raters had high interrater reliability and there were strong correlations between face-to-face CAPS assessments and video teleconferencing CAPS assessments for diagnosis and total severity. The results suggest that the CAPS can and should be used via video teleconferencing with veterans who have barriers to face-to-face evaluations.

The driving behavior survey as a measure of behavioral stress responses to MVA-related PTSD.

Numerous treatments are available that address the core symptoms of posttraumatic stress disorder (PTSD). However, there are a number of related behavioral stress responses that are not assessed with PTSD measures, yet these behavioral stress responses affect quality of life. The goal of the current study was to investigate whether a recently developed measure of behavioral stress response, the Driving Behavior Survey (DBS), was sensitive to change associated with treatment among a group of participants diagnosed with PTSD. The DBS indexes anxious driving behavior, which is frequently observed among individuals with motor vehicle accident-related PTSD. Participants (n = 40) were racially diverse adults (M age = 40.78, 63% women) who met diagnostic criteria for motor vehicle accident-related PTSD. Hierarchical linear modeling analyses indicated that participants who were assigned to a brief, exposure-based intervention displayed significant reductions on the DBS subscales relative to participants assigned to the wait-list control condition (r = .41­.43). Moreover, mediational analyses indicated that the observed reductions on the DBS subscales were not better accounted for by reductions in PTSD. Taken together, these findings suggest that the DBS subscales are sensitive to changes associated with PTSD treatment and can be used to augment outcome assessment in PTSD treatment trials.

The Driving Behavior Survey as a measure of behavioral stress responses to MVA-related PTSD.

Numerous treatments are available that address the core symptoms of posttraumatic stress disorder (PTSD). However, there are a number of related behavioral stress responses that are not assessed with PTSD measures, yet these behavioral stress responses affect quality of life. The goal of the current study was to investigate whether a recently developed measure of behavioral stress response, the Driving Behavior Survey (DBS), was sensitive to change associated with treatment among a group of participants diagnosed with PTSD. The DBS indexes anxious driving behavior, which is frequently observed among individuals with motor vehicle accident-related PTSD. Participants (n=40) were racially diverse adults (M age=40.78, 63% women) who met diagnostic criteria for motor vehicle accident-related PTSD. Hierarchical linear modeling analyses indicated that participants who were assigned to a brief, exposure-based intervention displayed significant reductions on the DBS subscales relative to participants assigned to the wait-list control condition (r=.41-.43). Moreover, mediational analyses indicated that the observed reductions on the DBS subscales were not better accounted for by reductions in PTSD. Taken together, these findings suggest that the DBS subscales are sensitive to changes associated with PTSD treatment and can be used to augment outcome assessment in PTSD treatment trials.

Properties of the Driving Behavior Survey among individuals with motor vehicle accident-related posttraumatic stress disorder.

Data suggest anxious drivers may engage in problematic behaviors that place themselves and others at increased risk of negative traffic events. Three domains of problematic behavior--exaggerated safety/caution, performance deficits, and hostile/aggressive behaviors--previously were identified during development of the Driving Behavior Survey (DBS), a novel measure of anxiety-related behavior. Extending this research, the current study examined the psychometric properties of DBS scores among individuals with posttraumatic stress disorder (PTSD) subsequent to motor vehicle trauma (N=40). Internal consistencies and 12-week test-retest reliabilities for DBS scales ranged from good to excellent. Comparison of scores to normative student data indicated dose-response relationships for safety/caution and performance deficit subscales, with increased frequency of anxious behavior occurring within the PTSD sample. Associations with standard clinical measures provide additional evidence for anxiety-related driving behavior as a unique marker of functional impairment, distinct from both avoidance and disorder-specific symptoms.

Written exposure therapy for veterans diagnosed with PTSD: a pilot study.

There is a need to identify alternative treatment options for posttraumatic stress disorder (PTSD), especially among veterans where PTSD tends to be more difficult to treat and dropout rates are especially high. One potential alternative is written exposure therapy, a brief intervention shown to treat PTSD among civilians effectively. This study investigated the feasibility and tolerability of written exposure therapy in an uncontrolled trial with a sample of 7 male veterans diagnosed with PTSD. Findings indicated that written exposure therapy was well tolerated and well received. Only 1 of the 7 veterans dropped out of treatment, no adverse events occurred during the course of treatment, and veterans provided high treatment satisfaction ratings. Clinically significant improvements in PTSD symptom severity were observed for 4 veterans at posttreatment and 6 veterans at the 3-month follow up. Moreover, 5 of the 7 veterans no longer met diagnostic criteria for PTSD 3 months following treatment. These findings suggest that written exposure therapy holds promise as a brief, well tolerated treatment for veterans with PTSD. However, additional research using randomized controlled trial methodology is needed to confirm its efficacy.

Predictors of intimate partner violence revictimization: the relative impact of distinct PTSD symptoms, dissociation, and coping strategies.

Psychological distress and coping strategies following intimate partner violence (IPV) victimization may impact survivors' risk for future IPV. The current study prospectively examined the impact of distinct posttraumatic stress disorder (PTSD) symptom clusters (reexperiencing, avoidance, numbing, and hyperarousal), dissociation, and coping strategies (engagement and disengagement coping) on IPV revictimization among recently abused women. Women (N = 69) who were seeking services for IPV and experienced their most recent episode of physical IPV between 2 weeks and 6 months prior to study enrollment completed measures of physical IPV, psychological distress, and coping strategies at baseline and at 6-month follow-up. The women averaged 36 years of age and 67% of the sample was African American. Separate Poisson regression analyses revealed that PTSD hyperarousal symptoms, dissociation, engagement coping, and disengagement coping each significantly predicted physical IPV revictimization at the 6-month follow-up (with effect sizes ranging from a 1.20-1.34 increase in the likelihood of Time 2 physical IPV with a 1 SD increase in the predictor). When these significant predictors were examined together in a single Poisson regression model, only engagement and disengagement coping were found to predict physical IPV revictimization such that disengagement coping was associated with higher revictimization risk (1.29 increase in the likelihood of Time 2 physical IPV with one SD increase in disengagement coping) and engagement coping was associated with lower revictimization risk (1.30 decrease in the likelihood of Time 2 physical IPV with one SD increase in engagement coping). The current findings suggest that coping strategies are important and potentially malleable predictors of physical IPV revictimization.