Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis.

Psychotherapies are first-line treatments for most mental disorders, but their absolute outcomes (i.e., response and remission rates) are not well studied, despite the relevance of such information for health care users, providers and policy makers. We aimed to examine absolute and relative outcomes of psychotherapies across eight mental disorders: major depressive disorder (MDD), social anxiety disorder, panic disorder, generalized anxiety disorder (GAD), specific phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and borderline personality disorder (BPD). We used a series of living systematic reviews included in the Metapsy initiative (www.metapsy.org), with a common strategy for literature search, inclusion of studies and extraction of data, and a common format for the analyses. Literature search was conducted in major bibliographical databases (PubMed, PsycINFO, Embase, and the Cochrane Register of Controlled Trials) up to January 1, 2023. We included randomized controlled trials comparing psychotherapies for any of the eight mental disorders, established by a diagnostic interview, with a control group (waitlist, care-as-usual, or pill placebo). We conducted random-effects model pairwise meta-analyses. The main outcome was the absolute rate of response (at least 50% symptom reduction between baseline and post-test) in the treatment and control conditions. Secondary outcomes included the relative risk (RR) of response, and the number needed to treat (NNT). Random-effects meta-analyses of the included 441 trials (33,881 patients) indicated modest response rates for psychotherapies: 0.42 (95% CI: 0.39-0.45) for MDD; 0.38 (95% CI: 0.33-0.43) for PTSD; 0.38 (95% CI: 0.30-0.47) for OCD; 0.38 (95% CI: 0.33-0.43) for panic disorder; 0.36 (95% CI: 0.30-0.42) for GAD; 0.32 (95% CI: 0.29-0.37) for social anxiety disorder; 0.32 (95% CI: 0.23-0.42) for specific phobia; and 0.24 (95% CI: 0.15-0.36) for BPD. Most sensitivity analyses broadly supported these findings. The RRs were significant for all disorders, except BPD. Our conclusion is that most psychotherapies for the eight mental disorders are effective compared with control conditions, but absolute response rates are modest. More effective treatments and interventions for those not responding to a first-line treatment are needed.

Patient experiences in making PTSD treatment decisions.

Although there is a range of effective posttraumatic stress disorder (PTSD) treatments, the number of patients who receive those treatments is disappointingly low (Finley et al., 2015; Maguen et al., 2018). Very little research has examined the patient experience of deciding on a PTSD treatment option and how that experience influences treatment preference and selection. In a sample of 12 veterans and 10 providers, we recorded the sessions in which providers discussed PTSD treatment options with their patients and then interviewed patients to ask their impressions of those same sessions. Specifically, using qualitative analysis, we sought to understand (a) patient preferences and experiences of choosing a PTSD treatment option, (b) what information patients retain from treatment planning sessions, and (c) why patients chose a given treatment. Almost all the patients in this sample chose an evidence-based psychotherapy but could remember little about the options afterward. Patients reported that providers presented options neutrally and that they made shared decisions with their providers. Most could talk through their reasons for coming to a decision and felt comfortable with the decision, but decisions were often made heuristically rather than deliberatively. Surprisingly, a few patients had a hard time explaining why they chose a specific treatment, were not conscious of their exact reasons for choosing a treatment, or seemed unable to remember why they chose a treatment. We also noticed subtle ways in which providers' discussions influenced treatment choice. Implications for practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mixed methods in community psychology: A values-forward synthesis.

Mixed methods research (MMR) combines multiple traditions, methods, and worldviews to enrich research design and interpretation of data. In this virtual special issue, we highlight the use of MMR within the field of community psychology. The first MMR studies appeared in flagship community psychology journals over 30 years ago (in 1991). To explore the uses of MMR in the field, we first review existing literature by identifying all papers appearing in either Journal of Community Psychology or American Journal of Community Psychology in which the word "mixed" appeared. A total of 88 publications were identified. Many of these papers illustrate the pragmatic use of MMR to evaluate programs and to answer different research questions using different methods. We coded articles based on Green et al.'s classifications of the purpose of the mixing: triangulation, development, complementarity, expansion, and initiation. Complementarity was the most frequently used purpose (46.6% of articles), and nearly a quarter of articles mixed for multiple purposes (23.86%). We also coded for any community psychology values advanced by the use of mixed methods. We outline three themes here with corresponding exemplars. These articles illustrate how MMR can highlight ecological analysis and reconsider dominant, individual-level paradigms; center participant and community member experiences; and unpack paradoxes to increase the usefulness of research findings.

"Paper in a day": A model to encourage psychology collaboration and participation in research/program evaluation.

Although psychologists are trained to conduct research as well as clinical work, it can be challenging for psychologists outside of traditional academia to find the time or capacity to engage in research. Providing opportunities for practicing psychologists to conduct research may enhance the generalizability of psychological research, as well as provide benefits to psychologists in terms of collaboration, promotion, and engagement. Yet, several barriers exist, including competing demands on time, lack of institutional support, and limited research confidence. This article describes "Paper in a Day" (PiaD), a novel approach to research engagement that is well-suited for busy practitioners. PiaD considers many of the aforementioned factors and provides a method to navigate the often-daunting prospect of research involvement for the practicing clinician. Through PiaD, two Department of Veterans Affairs (VA) Medical Centers engaged clinicians and trainees in collaborating in a time-limited way to write and publish peer-reviewed articles. The current article outlines the process by which clinicians at these two sites structured research engagement utilizing PiaD, and it was also written utilizing the PiaD model. The authors have now led or participated in the PiaD process five times, with 13 teams of clinicians producing nine peer-reviewed articles and five conference presentations. A brief survey indicated that participants felt engaged in the process and would participate again if given the opportunity. This article outlines barriers and facilitators of the PiaD process, with the hope of encouraging other settings to consider using such a method to enhance research productivity and engagement for psychologists. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Symptom change prior to treatment discontinuation (dropout) from a naturalistic Veterans Affairs evidence-based psychotherapy clinic for PTSD and depression.

Dropout or treatment discontinuation from evidence-based psychotherapies (EBPs) has been a concern for clinicians as it is thought that such discontinuation prevents patients from achieving a full course of therapy and obtaining maximum benefit. Recent studies, however, suggest that treatment discontinuation may sometimes be due to symptom improvement. The purpose of the current evaluation was to examine change in self-reported symptoms in participants who completed versus did not complete treatment in a Veterans Affairs outpatient clinic offering EBPs for both depression and posttraumatic stress disorder (PTSD). Data were collected from 128 participants who had at least one treatment session postintake and had been discharged from the clinic. Data were collected on self-reported PTSD and depression symptoms. Of the 128 veterans, 61 completed treatment and 67 did not complete treatment (54.0% noncompletion in PTSD EBPs and 48.7% noncompletion in depression EBPs). Of those who did not complete, 47 were enrolled in a PTSD EBP and 20 in a depression EBP. Of those who did not complete a PTSD EBP, 51.1% had no change in PTSD symptoms prior to treatment discontinuation, whereas 12.8% had a symptom increase, and 27.7% had a symptom decrease. Of those who did not complete a depression EBP, 55% had no change in depression symptoms prior to treatment discontinuation, 15% had a symptom increase, and 30% had a decrease. Overall, results suggest that treatment discontinuation is not as straightforward as it may seem and that prematurely discontinuing an EBP may not necessarily represent treatment failure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Benchmarking quality of life to posttraumatic stress disorder symptom changes in cognitive processing therapy.

Although there is ample evidence that PTSD is effectively treated by first-line therapies such as Cognitive Processing Therapy (CPT), it is less clear to what degree these treatments improve quality of life (QOL), a common presenting concern of treatment-seeking individuals (Rosen et al., 2013). Only two studies, both conducted in military veteran samples, have examined the magnitude of PTSD symptom change needed in order to achieve corresponding changes in QOL during treatment. The current study aimed to replicate and extend these two previous studies by benchmarking multi-faceted QOL in a civilian sample of primarily female interpersonal violence survivors (N = 115) treated with CPT. We grouped participants into categories of increasingly greater PTSD symptom change: no response, response, loss of diagnosis, and remission. Outcomes were clinically meaningful change and good endpoint across five measures of QOL. Some QOL measures showed clinically meaningful change and/or good endpoint after a response to treatment or loss of diagnosis, but only remission from PTSD was associated with both clinically meaningful change and a good endpoint across all QOL indicators. These findings add to the emerging literature showing that treating PTSD to remission may maximize the likelihood of improvements in quality of life.

Event centrality and posttraumatic stress symptoms after traumatic injury: A longitudinal investigation.

The development of posttraumatic stress symptoms (PTSS) can occur following a traumatic injury, which may include an increase in negative cognitions. One cognitive construct shown to be associated with the development of PTSS is event centrality, or the degree to which an individual views a traumatic experience as central to their life story. Although cross-sectional work has demonstrated a robust connection between event centrality and PTSS, the directionality of this association remains unclear. Most previous work has investigated centrality as a predictor of PTSS, although one recent study suggests that PTSS may, in fact, predict event centrality. The current longitudinal study enrolled adult civilian participants (N = 191) from a Level 1 trauma center following a traumatic injury and assessed both event centrality and PTSS at three points posttrauma (3, 12, and 18 months). A time-constrained random intercept cross-lagged panel analysis showed that PTSS predicted event centrality over the 18-month follow-up period, B = 0.16, p = .021, but event centrality did not predict PTSS, B = -0.27, p = .340. These findings suggest that the development of PTSS following trauma exposure may lead to the perception of the traumatic event as central to an individual's story over time. Further longitudinal research is necessary to determine what variables may influence the connection between PTSS and event centrality.

Improving engagement and retention to treatment within VHA PTSD specialty care: Evolution of an outpatient program design.

The Veteran's Health Administration (VA) and Department of Defense (DoD) posttraumatic stress disorder (PTSD) clinical practice guidelines (2017) recommend individual, trauma-focused therapy as the gold standard of treatment for PTSD (i.e., evidence-based practices [EBP]). Moreover, these guidelines encourage the use of individual shared decision-making (SDM) to increase engagement and completion of EBPs for PTSD in line with current literature. This study retrospectively evaluated three models of program design of a VA PTSD specialty clinic over the past 8 years. In line with previous literature, the study hypothesized that leveraging individualized SDM in the clinic design would lead to increased completion of EBPs for PTSD. Analyses indicated an impact as the models shifted from a group-based model to an individualized model. Specifically, as compared to veterans who completed a group-based design, a greater proportion of those enrolled in the clinic were more likely to complete an EBP. These results may suggest that individualized, patient-centered treatment planning may be related to patient engagement in EBPs for PTSD in contrast with group-based models. Other programmatic changes, such as changes in treatment options presented to patients, a movement to focus on EBPs for PTSD, and expanded clinic hours and telehealth options, possibly impacted veteran engagement and completion in EBPs. The study highlights the potential impacts of a changing patient population within the clinic over a relatively short period. The observations are discussed, and limitations are highlighted. The study shares the hope for additional randomized prospective studies of program designs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Temporary PTSD symptom increases among individuals receiving CPT in a hybrid effectiveness-implementation trial: Potential predictors and association with overall symptom change trajectory.

OBJECTIVE: Concern about symptom worsening with trauma-focused treatment may be one factor hindering the implementation of evidence-based treatments for PTSD, like cognitive processing therapy (CPT), despite evidence for their efficacy. Previous studies have examined the frequency and effect of symptom exacerbation, or temporary symptom increases, on outcomes, but primarily in randomized clinical trials. METHOD: We examined this issue in a community sample of participants receiving CPT from front-line clinicians learning to deliver CPT in a randomized controlled implementation trial of training strategies. Patient participants (n = 183) completed self-report measures of PTSD symptoms at each session. RESULTS: Most participants (67.3%) experienced at least one temporary symptom increase during CPT (only 1.6% continued to have higher symptoms by the end of treatment). Demographic variables, comorbid conditions (i.e., depression, anxiety, substance use), and baseline PTSD symptom levels did not predict symptom increases. Importantly, symptom increases did not predict treatment noncompletion, posttreatment PTSD symptom levels, or loss of probable PTSD diagnosis. Moreover, growth curve modeling revealed that temporary symptom increases did not predict the trajectory of PTSD symptoms over the course of treatment. CONCLUSIONS: The rates of symptom increases, which were higher than in previous studies, may be attributed to a routine care sample or to the differences in session timing and measurement. These results add to a nascent literature documenting that symptom increases may be a normal, transient part of treatment that do not impact a patient's ability to have symptom improvement during a course of CPT. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association between spatial working memory and Re-experiencing symptoms in PTSD.

BACKGROUND AND OBJECTIVES: Few studies have evaluated the link between working memory (WM) and post-traumatic stress disorder (PTSD). Further, it is unknown whether this relationship is accounted for by other relevant variables including negative affect, emotional dysregulation, or general non-WM-related cognitive control deficits, which are associated with PTSD. The purpose of this study was to determine the extent to which a computerized WM task could predict PTSD symptomology incrementally beyond the contribution of other relevant variables associated with PTSD. METHODS: Thirty veterans were eligible to complete emotional symptom questionnaires, a heart-rate variability measure, and computerized tasks (i.e., emotional Stroop and automated complex span tasks). A three-stage hierarchical regression was conducted with the PCL-5 total score and symptom clusters (i.e., re-experiencing, avoidance, hyperarousal, and negative cognition/mood) as the dependent variable. RESULTS: Results revealed that only the re-experiencing symptom cluster was significantly predicted by executive, verbal, and visuospatial WM tasks, which explained an additional 29.7% of the variance over and above other relevant variables. Most notably, the visuospatial task was the only WM task that significantly explained PCL-5 re-experiencing symptoms. LIMITATIONS: This study was based on a small sample of veterans with PTSD and causality cannot be determined with this cross-sectional study. CONCLUSIONS: Overall, the results suggest that deficits in visuospatial WM are significantly associated with PTSD re-experiencing symptoms after controlling for other relevant variables. Further research should evaluate whether an intervention to improve visuospatial WM capacity can be implemented to reduce re-experiencing symptoms.

Low-dose clonidine in veterans with Posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) symptoms of hyperarousal are mediated through sympathetic nervous system hyperactivity. PTSD symptoms, including distressing thoughts and memories, flashbacks, hyperarousal, and sleep disturbances, have been linked with elevated norepinephrine levels in the cerebrospinal fluid. Clonidine, an alpha2-adrenergic agonist, reduces the release of norepinephrine and has been suggested as a treatment for PTSD. However, literature for use of clonidine in PTSD is limited. The objective of this study was to evaluate clinical records of patients with PTSD treated with clonidine to assess reported efficacy and safety. A cohort of veterans with PTSD treated with clonidine at a midwestern VA hospital between July 2015 and January 2018 were studied retrospectively. Medical records of 79 patients with moderate to severe PTSD symptoms were reviewed by three independent clinicians using the Clinical Global Impressions (CGI) scale to quantify symptom severity (CGI-S) before starting clonidine and subjects' change in symptoms (CGI-I) after starting clonidine. Data on adverse events were also collected. Subgroup analyses were conducted on the impact of comorbid diagnoses, concurrent medications, and substance use. Mean CGI-S score at baseline was 4.8 (5 = markedly ill). After treatment with low-dose clonidine, 72% of patients experienced improvement, and 49% scored "much improved" or "very much improved." Adverse effects were reported by 18 out of 79 subjects. In this retrospective analysis of veterans prescribed clonidine for PTSD, CGI-I scores suggested improvement in PTSD symptoms, and minimal side effects were reported. In addition, some comorbid diagnoses and concurrent medications were correlated with variations in outcomes.

The Individualized Addictions Consultation Team Residential Program: A Creative Solution for Integrating Care for Veterans With Substance Use Disorders Too Complex for Other Residential Treatment Programs.

OBJECTIVES: The Veterans Affairs (VA) healthcare system is one of the main providers of substance use treatment within the United States, and many veterans with a substance use disorder (SUD) present with co-occurring diagnoses or other concerns. Though there has been increasing recognition of the need for integration of treatments for SUD and comorbid mental illness, there have been limited studies of such programs, particularly within the VA healthcare system. To address that gap in the literature, this paper examines treatment outcomes in an integrated model of dual diagnosis residential treatment for veterans: the Individualized Addictions Consultation Team (I-ACT) program. Methods: The current paper draws from clinical outcome evaluation data within a residential treatment program at a large Midwestern VA Medical Center (VAMC). The I-ACT program provides residential substance abuse treatment to individuals with a primary SUD and other factors that interfere with the successful completion of a traditional residential rehabilitation program. Between 2017 and 2018, 130 individuals (97.7% men, average age = 60.62 years) entered the I-ACT program. As part of standard measurement-based care, veterans were administered the Brief Addiction Monitor and the Patient Health Questionnaire-9 at admission and discharge. Results: Most individuals (74.6%) who entered I-ACT completed the residential program (average length of stay 34.2 days). Scores on both measures significantly decreased from intake to discharge (p < .001), with the change in depression scores indicating clinically significant improvement. Those with an additional mental health diagnosis achieved similar decreases in substance use symptoms and had lower depression scores at discharge than those with a SUD alone. Conclusions: Our results indicate that even for veterans who may not benefit from traditional SUD treatment programs, a more integrated and personalized residential program can be effective.

Change in Event Centrality and Posttraumatic Stress Disorder Symptoms During Intensive Treatment.

Event centrality, defined as the extent to which a traumatic event becomes a core component of a person's identity (Berntsen & Rubin, 2006), is both a correlate and predictor of posttraumatic stress disorder (PTSD) symptoms, over and above event severity. These findings suggest that decreasing the perceived centrality of a traumatic event to one's identity might result in decreases in PTSD symptom severity. To date, few studies have examined how centrality is affected by PTSD treatment. The present study tested the hypotheses that change in centrality would be associated with both change in PTSD symptom severity and discharge PTSD symptom severity in an exposure-based PTSD partial hospitalization program (N = 132; 86.0% White; 85.2% female; M age = 36 years). At discharge (i.e., after approximately 6 weeks of treatment), both PTSD symptoms and centrality had significantly decreased, ds = .70 and .98, respectively, with large effect sizes. Decreases in Centrality of Events Scale (CES) scores at posttreatment, baseline CES scores, and baseline PTSD Checklist for DSM-5 (PCL-5) scores were associated with change (i.e., decrease) in PCL-5 scores, p < .001, as well as with posttreatment PCL-5 scores, p < .001. Decreases in CES scores over time, baseline CES scores, and baseline PCL-5 scores explained 31% of the variance in PCL-5 change and 34% of the variance in posttreatment PCL-5 scores. The results indicate the potential importance of decreasing the centrality of a traumatic event in PTSD treatment and recovery.

A Randomized Trial of Modified Prolonged Exposure to Prevent the Development of Posttraumatic Stress Disorder in Patients Hospitalized With Traumatic Injuries.

Individuals who require hospitalization after traumatic injuries are at increased risk for developing posttraumatic stress disorder (PTSD); however, few early behavioral interventions have been effective at preventing PTSD within this population. The aim of this pilot study was to assess the feasibility and effectiveness of modified prolonged exposure therapy (mPE) to prevent PTSD and depression symptoms among patients hospitalized after a DSM-5 single-incident trauma. Hospitalized patients were eligible if they screened positive for PTSD risk. Participants (N = 74) were randomly assigned in a parallel-groups design to receive mPE (n = 38) or standard of care treatment (SoC; n = 36) while admitted to the hospital after a traumatic injury. Individuals randomized to the intervention condition received one (42.1%), two (36.8%), or three sessions (15.8%) of mPE, mainly depending on length of stay. There were no significant differences between groups regarding PTSD or depression severity at 1- or 3-months posttrauma, except for more PTSD diagnoses in the intervention group after 1 month, ϕ = -.326. Intervention differences were nonsignificant when we took baseline PTSD symptoms and the nonindependence of the repeated measurements within the data into account. No adverse events were reported. Overall, mPE was no more effective than SoC for hospitalized, traumatic injury survivors with a high PTSD risk. The results may point to a need for a stepped-care approach, where intervention protocols focus on first briefly treating individuals who are actively exhibiting acute stress reactions, then extensively treating those whose symptoms do not decrease over time.

Event centrality following treatment for physical injury in the emergency department: Associations with posttraumatic outcomes.

BACKGROUND: The relationship between event centrality (i.e., the degree to which a stressful event is integrated into one's identity) and acute posttraumatic outcomes after relatively minor physical injury is unknown. We examined pre-injury and Emergency Department (ED) predictors of event centrality at 6-weeks post-injury, and whether event centrality is uniquely associated with 6-week posttraumatic outcomes. METHODS: In the EDs of two Level I trauma centers, 149 patients completed surveys regarding demographic, psychological and injury-related factors within 24 h post-injury; 84 patients (51% male) completed 6-week surveys of event centrality, posttraumatic stress symptoms (PTSS) and trauma-specific QOL (T-QoL). Data were analyzed using linear regression modeling. RESULTS: At least 20% of patients agreed or strongly agreed that the injury changed their life. Hospitalization status and peritraumatic dissociation were significant predictors of event centrality at 6-weeks. After controlling for demographics, ED-related factors and pre-injury PTSS, event centrality was uniquely associated with PTSS (p < .001) and T-QOL (p < .001) at 6 weeks. CONCLUSION: Over and above the effects of the injury itself, event centrality conveyed important information for posttraumatic outcomes at 6 weeks post-injury. The centrality scale is brief and feasible to administer; future work is needed to determine the predictive utility of event centrality on post-injury outcomes.

Validation of Abbreviated Four- and Eight-Item Versions of the PTSD Checklist for DSM-5 in a Traumatically Injured Sample.

Rates of posttraumatic stress disorder (PTSD) are three times higher in traumatically injured populations than the general population, yet limited brief, valid measures for assessing PTSD symptom severity exist. The PTSD Checklist for DSM-5 (PCL-5) is a valid, efficient measure of symptom severity, but its completion is time consuming. Subsequently, abbreviated four- and eight-item versions were developed using the Mini-International Neuropsychiatric Interview-7 PTSD module and validated in Veteran samples. This study aimed to validate these abbreviated versions using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the gold standard for PTSD diagnosis, in a traumatically injured civilian population. Participants were 251 traumatically injured adults (Mage = 42.52 years; 69.3% male; 50.2% Caucasian) recruited from a Level 1 trauma center inpatient unit; 32.3% and 17.9% of participants experienced a motor vehicle crash or gunshot wound, respectively. The CAPS-5 and PCL-5 were administered approximately 6.5 months postinjury. We examined whether compared to the full PCL-5, the abbreviated versions would adequately differentiate between participants with and without a CAPS-5 PTSD diagnosis. The abbreviated versions were highly correlated with the total scale and showed good-to-excellent internal consistency. The diagnostic utility of the abbreviated measures was comparable to that of the total scale regarding sensitivity, suggesting they may be useful as abbreviated screening tools; however, the total scale functioned better regarding specificity. The abbreviated versions of the PCL-5 may be useful screening instruments in the long-term care of traumatic injury survivors and may be more likely to be implemented across routine clinical and research contexts.

Interaction Between Psychiatric Symptoms and History of Mild TBI When Evaluating Postconcussion Syndrome in Veterans.

INTRODUCTION: Symptoms of postconcussive syndrome (PCS) after mild TBI (mTBI) have been shown to resolve quickly, yet new research raises questions about possible long-term effects of this condition. It is not clear how best to address assessment and treatment when someone reports lingering symptoms of PCS. One self-report measure used by the VA and the DoD is the Neurobehavioral Symptom Inventory (NSI), but this measure may be affected by underlying psychiatric symptoms. We investigated whether the NSI is sensitive to mTBI after considering a number of psychiatric and demographic factors. METHODS: This study examined which factors are associated with NSI scores in a Veteran sample (n = 741) that had recently returned from deployment. RESULTS: Post-traumatic stress disorder (PTSD) and depression accounted for most of the variance on the NSI. Although history of mTBI was initially related to NSI, this association was no longer significant after other covariates were considered. CONCLUSIONS: The NSI score was primarily explained by symptoms of PTSD and depression, suggesting that the NSI is not specific to the experience of a brain injury. We recommend cautious interpretation when this measure is used in the chronic phase after mTBI, especially among patients with comorbid depression or PTSD.

A pilot randomized trial of a dual n-back emotional working memory training program for veterans with elevated PTSD symptoms.

Anxiety is characterized by excessive attention to threatening information, leading to impaired working memory (WM) performance and elevated anxious thoughts. Preliminary research indicates that individuals with PTSD show particular difficulty with WM in emotional contexts (Schweizer et al., 2011). Although several studies show that computerized training can improve WM capacity for anxious individuals (Owens et al., 2013; Schweizer et al., 2011; 2013), there has been very little research on WM training for PTSD or with Veterans (Saunders et al., 2015). In a pilot randomized trial, we assigned Veterans with elevated PTSD symptoms to an online emotional WM training, either adaptive (n-back; n = 11) or a less potent training (1-back; n = 10). Overall, both groups showed significant decreases in PTSD symptoms. The n-back group showed a trend of outperforming the 1-back group in improving reexperiencing symptoms (which are likely to be associated with impaired WM functioning). This population anecdotally found the intervention quite challenging, which may be why even the less potent 1-back was still helpful. These preliminary findings justify the effort for developing new WM-focused PTSD intervention for complex, vulnerable populations, particularly as online training can improve accessibility.

An initial review of residual symptoms after empirically supported trauma-focused cognitive behavioral psychological treatment.

OBJECTIVE: Although residual symptoms remain following clinical treatment for posttraumatic stress disorder (PTSD), little is known about the characteristics of these residual symptoms. We aimed to determine the type, severity, and frequency of symptoms that remain after trauma-focused psychotherapy. METHODS: We conducted a systematic review of 51 randomized controlled trials of empirically supported psychosocial interventions for PTSD (68 total treatment arms). Outcomes included: 1) PTSD symptoms and 2) conditions commonly comorbid with PTSD: depression, anxiety, and quality of life impairment. RESULTS: In general, the results revealed that participants who completed PTSD treatment continued to report residual PTSD symptoms: 31% reported clinical symptom levels, and 59% reported subthreshold levels at posttreatment, particularly within the hyperarousal cluster. Residual symptoms also emerged for depression (19% clinical), anxiety (55% clinical), and quality of life (36% clinical). Few differences emerged across treatment types, but differential patterns were revealed for sample/trauma types. CONCLUSIONS: Results suggest a need for focused research attention to and clinical assessment of individual residual symptoms following empirically supported treatment for PTSD to determine whether further treatment sessions are warranted.

Hypersexual Behavior as a Symptom of PTSD: Using Cognitive Processing Therapy in a Veteran with Military Sexual Trauma-Related PTSD.

Hypersexual behavior is a construct that is well recognized yet vaguely conceptualized, leading to some arguments that it may be comprised of multiple etiologies. Childhood sexual abuse is often acknowledged as a common experience among those with sexually addictive behaviors, yet the intersection between PTSD and sexual addiction has not been fully explored. This case illustrates the use of Cognitive Processing Therapy, an empirically supported treatment for PTSD, as a means to treat both PTSD symptoms and hypersexual behaviors in a veteran who had experienced military sexual trauma. Treatment led to a meaningful decrease in both types of symptoms, even in the absence of a structured treatment approach for sexual addiction. It is argued that differential diagnosis, including functional analysis of hypersexual behaviors, is crucial in treatment planning. Further, attention to trauma and PTSD is important in veterans and others for whom PTSD is part of the etiology of hypersexual behavior; trauma-focused CBT therapies can provide a useful treatment approach in these cases.