Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial.

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Neurocognitive Correlates of Successful Treatment of PTSD in Female Veterans.

BACKGROUND: The influence of psychotherapy on neurocognition in post-traumatic stress disorder (PTSD) has not been examined methodically. This is despite evidence that pre-treatment learning and memory has been associated with treatment success and that executive function theories emphasize weak executive functions (especially inhibition/switching) are associated with PTSD. OBJECTIVES: To determine (1) if higher pre-treatment learning/memory, inhibition/switching, or both predict treatment success; and (2) if treatment success is associated with specific improvement in inhibition/switching and not learning/memory or working memory, another aspect of executive function. METHODS: Pre-treatment neurocognition and neurocognitive changes (inhibition/switching, learning/memory, working memory) were examined in female veterans with PTSD. They were evaluated before and after 16-weeks of group psychotherapy for PTSD that included three counterbalanced modules (cognitive restructuring therapy, exposure therapy, skills training) with fidelity checks for therapist adherence. RESULTS: Only pre-treatment learning/memory predicted better treatment outcome. Treatment success was associated with improvement in inhibition/switching only, even after controlling for mild traumatic brain injury, and changes in depressive symptoms, working memory, and learning/memory. CONCLUSIONS: Our finding that learning/memory predicted treatment success is consistent with previous studies. We extended these studies by showing that the effect was restricted to learning/memory, which is contrary to the executive function theory of PTSD. In contrast, the fact that only inhibition/switching significantly improved with better treatment success is consistent with its potential importance in maintaining PTSD symptoms. Future research should determine whether inhibition/switching abilities are a risk for development and maintenance of PTSD or whether such abilities have a broader reciprocal relationship with PTSD symptom change. (JINS, 2016, 22, 643-651).

Group-delivered cognitive/exposure therapy for PTSD in women veterans: A randomized controlled trial.

OBJECTIVE: Group delivery of posttraumatic stress disorder (PTSD) treatment has several advantages, however group research is not comparable to individual trials. This study extends the group literature by improving methodology in examining the efficacy of a 3-module (cognitive, exposure, skills) group treatment for PTSD, establishes a format for the delivery of group exposure therapy, and compares 3 treatment modules within the group. METHOD: Eighty-six Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) women veterans were randomized to a 16-week, 3-member group treatment (Tx) or a waitlist (WL) condition. The primary (Clinician Administered PTSD Scale [CAPS]) and secondary (Medical Outcomes Study Short Form-36 [SF-36], Quality of Life Inventory [QOLI], and PTSD Checklist [PCL]) outcome measures were administered at baseline, post Tx/WL, and at 3- and 6-months post Tx (PCL additionally at pre/post for each treatment module). RESULTS: PTSD symptoms significantly improved in Tx arm participants (p < .001, ES = 1.72; unit of analysis group: n = 14), as did mental and physical life functioning (SF-36; p < .001), and quality of life (QOLI; p < .001). The WL significantly improved on the SF-36 (mental; p = .04) and QOLI (p = .02). Clinical improvement (CAPS) in the Tx arm reflected a treatment response (≥10-point decrease) in 77% and loss of PTSD diagnosis (<45) in 52% of participants, comparable to individual prolonged exposure (PE) treatment. Finally, PCL scores significantly lowered in exposure and cognitive modules. CONCLUSIONS: This study supports the use of group format for PTSD with 3 modules using improved methodology, with a novel, 3-member group which allows repeated in-session weekly imaginal exposures. The results suggest future examination of group delivered PE. (PsycINFO Database Record

The neurocognitive performance of female veterans with posttraumatic stress disorder.

Neurocognitive problems are common with posttraumatic stress disorder (PTSD) and are important to understand because of their association with the success of PTSD treatment and its potential neural correlates. To our knowledge, this is the first neurocognitive study in an all-female U.S. veteran sample, some of whom had PTSD. We examined neurocognitive performance and assessed whether learning deficits, common in PTSD, were associated with executive functioning. Veterans with PTSD (n = 56) and without (n = 53) were evaluated for psychiatric and neurocognitive status. The PTSD group had a lower estimated IQ (d = 0.53) and performed more poorly on all neurocognitive domains (d range = 0.57-0.88), except verbal retention (d = 0.04). A subset of the 2 groups that were matched on IQ and demographics similarly demonstrated poorer performance for the PTSD group on all neurocognitive domains (d range = 0.52-0.79), except verbal retention (d = 0.15). Within the PTSD group, executive functioning accounted for significant variance in verbal learning over and above IQ and processing speed (ΔR(2) = .06), as well as depression (ΔR(2) = .07) and PTSD severity (ΔR(2) = .06). This study demonstrated that female veterans with PTSD performed more poorly than females without PTSD on several neurocognitive domains, including verbal learning, processing speed, and executive functioning. Replication of these results using a control group of veterans with more similar trauma exposure, history of mild traumatic brain injury, and psychiatric comorbidities would solidify these findings.

Effectiveness of Group-Delivered Cognitive Therapy and Treatment Length in Women Veterans with PTSD.

The effectiveness and length of group-delivered cognitive treatment for Posttraumatic Stress Disorder (PTSD) was examined in a sample of women veterans. The sample included 271 primarily non-Hispanic white (61%) and Hispanic (25%) women veterans treated in 8-, 10-, or 12-group length sessions with manualized cognitive therapy for PTSD. Outcome was measured with the PTSD Symptom Checklist (PCL) in an intention-to-treat analysis (N = 271), in completer subjects (n = 172), and with group as the unit of analysis (n = 47 groups). Significant decreases in PTSD were found in the full sample (effect size [ES] range = 0.27 to 0.38), completers (ES range = 0.37 to 0.54), and group as the unit of analysis (ES range = 0.71 to 0.92), suggesting effectiveness of cognitive group treatment for PTSD. PCL scores significantly improved in the 8, 10, and 12 group lengths, with no differences between each. Clinical improvement showed a third decreasing 10 or more PCL points and 22% no longer meeting PTSD diagnostic criteria, with the best results in the 10-session group. The results suggest group-delivered cognitive therapy is an effective, efficient, time-limited treatment for PTSD.

Ethnic Differences in Personality Disorder Patterns among Women Veterans Diagnosed with PTSD.

Personality Disorders (PDs) impair the ability to function socially and occupationally. PD prevalence rates among veterans who have also been diagnosed with posttraumatic stress disorder (PTSD) range from 45%-79%. This study examined ethnic differences in PDs assessed with the Millon Clinical Multiaxial Inventory-III in 260 non-Hispanic white (64%), Hispanic (27%), and African American (9%), mostly single, women veterans in treatment for PTSD. After adjusting for covariates including number and sexual-nature of trauma, findings revealed the adjusted odds ratio of having a cluster A PD was almost three times higher for African Americans (p = 0.046) then the other two ethnic groups, which may be driven by the paranoid PD scale and potentially reflects an adaptive response to racial discrimination. In cluster designation analysis, the odds were twice as high of having a cluster B PD with childhood trauma (p = 0.046), and a cluster C PD with sexual trauma (p = 0.004), demonstrating the significance of childhood and sexual trauma on long-term chronic personality patterns in women veterans. These results highlight the importance of using instruments with demonstrated diagnostic validity for minority populations.

Externalizing and internalizing subtypes of posttraumatic psychopathology and anger expression.

Subtypes of posttraumatic psychopathology were replicated and extended in 254 female veterans with posttraumatic stress disorder (PTSD). Cluster analyses on Minnesota Multiphasic Personality Inventory-2 and Personality Psychopathology Five scales (Harkness, McNulty, & Ben-Porath, ) yielded internalizing and externalizing psychopathology dimensions, with a third low psychopathology group (simple PTSD). Externalizers were higher than the internalizers and the simple PTSD groups on the antisocial, substance, and aggression scales; internalizers were higher on depression and anxiety scales. Further validation included an independent measure of psychopathology to examine anger (Buss-Durkee Hostility Inventory, [BDHI]; Buss & Durkee, ). Externalizers were higher on extreme behavioral anger scales (assault and verbal hostility); and externalizers and internalizers were higher than the simple PTSD subjects on other anger scales. Positive correlations between the BDHI scales and the PTSD symptom of "irritability and anger outbursts" were found across scales in the total sample (range: r = .19-.36), on the assault scale in externalizers (r = .59), and the verbal hostility scale in both internalizers (r = .30) and simple PTSD (r = .37) groups, suggesting the broad utility of the symptom in the diagnosis. The results demonstrate the generalizability of the internalizing/externalizing typology to the female veteran population and highlight clinically relevant distinctions in anger expression within PTSD.

Group exposure therapy treatment for post-traumatic stress disorder in female veterans.

OBJECTIVES: The purpose of this study was to examine the application of a group exposure therapy model, the content of which consisted solely of repeated imaginal exposure during sessions, in a clinical sample of female veterans with post-traumatic stress disorder (PTSD). Establishing group delivery of exposure therapy will expand options, increase efficiency, and introduce group curative factors. METHODS: Eighty-eight female veterans with PTSD completed a six-session exposure group, three participants per group, as a component of a larger treatment program. The PTSD symptom checklist (PCL) was used as the outcome measure and administered in each session. RESULTS: Pre/post-paired t-tests showed significant improvement in PTSD on the PCL, with 40% of completers showing at least a 10-point drop in the PCL scores. In addition, a repeated measures analysis of variance showed a significant main effect and a significant quadratic equation, with expected initial increases in the PCL followed by a decrease below baseline at session 6. CONCLUSIONS: The group exposure treatment protocol showed positive outcomes on PTSD symptoms in a real-world clinical sample of female veterans. The implications include an expansion of exposure treatment choices for veterans with PTSD and increased options for therapists.

The MMPI-2 restructured clinical scales in the assessment of posttraumatic stress disorder and comorbid disorders.

This study examined the psychometric properties of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Restructured Clinical Scales (RCSs) in individuals with posttraumatic stress disorder (PTSD) receiving clinical services at Department of Veterans Affairs medical centers. Study 1 included 1,098 men who completed the MMPI-2 and were assessed for a range of psychological disorders via structured clinical interview. Study 2 included 136 women who completed the MMPI-2 and were interviewed with the Clinician Administered Scale for PTSD. The utility of the RCSs was compared with that of the Clinical Scales (CSs) and the Keane PTSD (PK) scale. The RCSs demonstrated good psychometric properties and patterns of associations with other measures of psychopathology that corresponded to current theory regarding the structure of comorbidity. A notable advantage of the RCSs compared with the MMPI-2 CSs was their enhanced construct validity and clinical utility in the assessment of comorbid internalizing and externalizing psychopathology. The PK scale demonstrated incremental validity in the prediction of PTSD beyond that of the RCSs or CSs.