Evaluating the efficacy of cognitive restructuring and exposure therapies on secondary school chemistry students' test anxiety: A randomized trial.

BACKGROUND: This study explored how cognitive restructuring (CR) and cognitive exposure therapy (CET) impacted test anxiety in chemistry students from Nsukka, Enugu State. Three research questions and hypotheses guided the investigation. METHOD: A quasi-experimental design with a pretest, posttest, and 2 experimental groups was employed. The study involved 154 SSII chemistry students from 4 purposefully chosen schools within Nsukka. The Chemistry Test Anxiety Scale, Cognitive Restructuring Chemistry Treatment Package, and Cognitive Exposure Chemistry Treatment Package served as the data collection instruments. The Chemistry Text Anxiety Scale's internal consistency, measured by Cronbach alpha, was found to be 0.86, indicating good reliability. Descriptive statistics (mean and standard deviation) addressed the research questions, while Analysis of Covariance tested the hypotheses at a 0.05 significance level. RESULTS: Results showed that the students who were exposed to CR therapy had pretest mean test anxiety score of M̄ = 78.31, standard deviation (SD) = 8.63 and posttest mean test anxiety of mean [M] = 27.06, SD = 5.71, while those exposed to cognitive exposure had a pretest mean test anxiety score of M = 77.39, SD = 8.68 and a posttest mean test anxiety score of M = 32.62, SD = 11.04. The reduction in text anxiety scores of -51.25 and -44.77 for the students exposed to CR and cognitive exposure respectively. The students exposed to CR therapy had lesser posttest mean test anxiety score than those exposed to CET. The results revealed that students receiving CR therapy displayed lower posttest anxiety scores compared to those receiving CET. Additionally, no significant interaction between treatment and gender on test anxiety was found. CONCLUSION: It was concluded that CR therapy is better than CET in the management of test anxiety among chemistry students. Based on these findings, it was recommended that cognitive behavioral therapists should be invited periodically to educate students on the negative effects of irrational thoughts on academic performance.

Distress variability during exposure therapy and its relationship with PTSD symptom decline.

BACKGROUND AND OBJECTIVES: Inhibitory Learning Theory (ILT) framework implies that in-session distress variability may promote extinction learning and thereby enhance exposure therapy efficacy. Thus far, research has mainly focused on in-session distress reduction. The aim of the current study was to assess whether in-session distress variability predicts next session PTSD symptom decline in PTSD patients receiving prolonged exposure (PE). METHODS: Eighty-six patients with PTSD received 14 to 16 sessions of PE. Using dynamic panel models, we assessed the temporal relation (i.e., within-persons) between in-session distress variability and PTSD symptom decline. Moreover, we assessed the averaged relation (i.e., between-persons) between in-session distress variability and PTSD symptom decline. RESULTS: Temporal analyses showed that in-session distress variability did not precede PTSD symptom improvement. Averaged analyses showed that distress variability was related to PTSD symptom improvement. LIMITATION: The operationalization of distress variability appeared to deviate from its theoretical conceptualization. CONCLUSIONS: In absence of distress reduction, distress variability can vary. However, our findings suggest that in-session distress variability does not drive symptom reduction during PE. In contrast, averaged over participants, distress variability was related to symptom improvement, suggesting that those with a more variable distress pattern across sessions show better treatment response. More empirical work is needed to shed light on the effect of distress variability during exposure sessions on treatment outcome and to offer grounds for clinical recommendations.

Working alliance in exposure-based treatments of posttraumatic stress disorder related to childhood abuse.

OBJECTIVES: Working alliance is considered an important determinant of outcome of psychotherapy. Patients with posttraumatic stress disorder (PTSD) following childhood abuse (CA-PTSD) may have challenges in building interpersonal relationships, including working alliance. Phase-based treatment provides an opportunity to strengthen alliance prior to trauma-focused treatment. This study aimed to compare the development of working alliance among patients with CA-PTSD in three variants of prolonged exposure (PE) therapy: standard PE, intensive PE (iPE), and skill training in affective and interpersonal regulation + prolonged exposure (STAIR + PE). We also examined the effect of alliance on treatment outcome and dropout. METHOD: Self-reported PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (Blevins et al., 2015) and patient-rated Working Alliance Inventory (Tracey & Kokotovic, 1989) were assessed in a clinical trial. We analyzed data from 138 adult patients (76.1% female; 42% non-Western). Analyses were performed using mixed-effects models. RESULTS: Patients established a satisfactory alliance early in treatment, which increased over time. For PE and STAIR + PE, a larger decrease in PTSD symptom severity was related to a higher alliance in the subsequent session, but not the other way around. In STAIR + PE, a higher alliance in Phase 1 was related to lower PTSD symptoms in Phase 2. In all conditions, a higher initial working alliance was related to a lower chance of treatment dropout. CONCLUSION: In the treatment of CA-PTSD, all three variants of prolonged exposure foster positive development of the working alliance. Across conditions, working alliance did not precede symptom decline. Therapists should strive for a strong alliance at the beginning of treatment as this reduces the likelihood of dropout. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Post-treatment alterations in white matter integrity in PTSD: Effects on symptoms and functional connectivity a secondary analysis of an RCT.

Post-traumatic stress disorder (PTSD) has been linked to altered communication within the limbic system, including reduced structural connectivity in the uncinate fasciculus (UNC; i.e., decreased fractional anisotropy; FA) and reduced resting-state functional connectivity (RSFC) between the hippocampus and ventromedial prefrontal cortex (vmPFC). Previous research has demonstrated attenuation of PTSD symptoms and alterations in RSFC following exposure-based psychotherapy. However, the relationship between changes in structural and functional connectivity patterns and PTSD symptoms following treatment remains unclear. To investigate this, we conducted a secondary analysis of data from a randomized clinical trial of intensive exposure therapy, evaluating alterations in UNC FA, hippocampus-vmPFC RSFC, and PTSD symptoms before (pre-treatment), 7 days after (post-treatment), and 30 days after (follow-up) the completion of therapy. Our results showed that post-treatment changes in RSFC were positively correlated with post-treatment and follow-up changes in UNC FA and that post-treatment changes in UNC FA were positively correlated with post-treatment and follow-up changes in PTSD symptoms. These findings suggest that early changes in functional connectivity are associated with sustained changes in anatomical connectivity, which in turn are linked to reduced PTSD symptom severity.

Effectiveness of Narrative Exposure Therapy for Treatment of PTSD Following Childhood Trauma: A Single-Case Series Design.

BACKGROUND: Narrative exposure therapy (NET) has shown promising outcomes for treating posttraumatic stress disorder (PTSD) in refugees and veterans. Its effectiveness in patients with PTSD following childhood trauma is, however, still unknown. AIMS: We investigated whether NET is an effective treatment for patients with PTSD following childhood trauma. METHOD: We studied treatment outcomes of nine adult patients in an outpatient setting. An AB single-case series design was used with a baseline of 4 weeks prior to treatment. Participants filled in weekly online questionnaires to assess their PTSD symptoms (using the Posttraumatic Diagnostic Scale [PDS]) and their experienced quality of life (using the Manchester Short Assessment of Quality of Life [MANSA]). Data were analysed visually and using a mixed-effect model. RESULTS: Results revealed no significant reduction of PTSD symptoms during NET treatment, nor an increase in quality of life, as compared to baseline. CONCLUSIONS: The results of our study do not underscore the effectiveness of NET treatment for patients with PTSD following childhood trauma. Further research is needed to study the effectiveness of NET in this population.

Investigating an Acceptance and Commitment Therapy-Based Exposure Therapy Intervention in Treatment-Refractory OCD and Related Disorders: Changes in Psychological Flexibility, Treatment Engagement, and Treatment Perceptions.

While exposure therapy is the most effective psychological treatment for obsessive-compulsive disorder (OCD), anxiety, and traumatic stress-related disorders, it is not universally effective, indicating a need for further treatment optimization. This study investigated a shift in approach to exposure therapy with 29 treatment-refractory adults in an OCD clinic not responding to standard treatment, comprising habituation-based exposure therapy. Participants completed standard exposure as a continuation of standard clinic treatment, followed by an acceptance and commitment therapy (ACT) consultation session to assess psychological inflexibility processes interfering with treatment progress, and then an ACT-based exposure targeting behavior change through increasing psychological flexibility. After each exposure, participants and independent raters reported levels of psychological flexibility, rituals, distress, treatment engagement, and treatment perceptions. We observed that the shift to ACT-based exposure was associated with greater psychological flexibility, treatment engagement, treatment acceptability, and treatment preference. These findings suggest that there may be situations where ACT-based exposure has particular utility.

The Impact of User Engagement With Exposure Components on Posttraumatic Stress Symptoms in an mHealth Mobile App: Secondary Analysis of a Randomized Controlled Trial.

Background: Mobile mental health apps are a cost-effective option for managing mental health problems, such as posttraumatic stress disorder (PTSD). The efficacy of mobile health (mHealth) apps depends on engagement with the app, but few studies have examined how users engage with different features of mHealth apps for PTSD. Objective: This study aims to examine the relationship between app engagement indices and PTSD symptom reduction using data from an unblinded pilot randomized controlled trial of "Renew" (Vertical Design), an exposure-based app for PTSD with and without coaching support. Because exposure is an effective approach for treating PTSD, we expected that engagement with exposure activities would be positively related to symptom reduction, over and above overall app usage. Methods: Participants were veterans (N=69) with clinically significant PTSD symptoms who were recruited online using Facebook advertisements and invited to use the Renew app as often as they wanted over a 6-week period. Participants completed screening and assessments online but provided informed consent, toured the app, and completed feedback interviews via telephone. We assessed users' self-reported PTSD symptoms before and after a 6-week intervention period and collected app usage data using a research-instrumented dashboard. To examine overall app engagement, we used data on the total time spent in the app, the number of log-in days, and the number of points that the user gained in the app. To examine engagement with exposure components, we used data on total time spent completing exposure activities (both in vivo and imaginal), the number of in vivo exposure activities completed, and the number of characters written in response to imaginal exposure prompts. We used hierarchical regression analyses to test the effect of engagement indices on change in PTSD symptoms. Results: Usage varied widely. Participants spent an average of 166.09 (SD 156.52) minutes using Renew, over an average of 14.7 (SD 10.71) mean log-in days. Engagement with the exposure components of the app was positively associated with PTSD symptom reduction (F6,62=2.31; P=.04). Moreover, this relationship remained significant when controlling for overall engagement with the app (ΔF3,62=4.42; P=.007). The number of characters written during imaginal exposure (ß=.37; P=.009) and the amount of time spent completing exposure activities (ß=.36; P=.03) were significant contributors to the model. Conclusions: To our knowledge, this is the first study to show a relationship between symptom improvement and engagement with the active therapeutic components of an mHealth app (ie, exposure) for PTSD. This relationship held when controlling for overall app use, which suggests that it was engagement with exposure, specifically, that was associated with symptom change. Future work to identify ways of promoting greater engagement with self-guided exposure may help improve the effectiveness of mHealth apps for PTSD.

Multifaceted, Brief Intensive Home-Based Exposure Treatment in Patients with Obsessive-Compulsive Disorder Who are Nonresponsive to Regular Cognitive Behavior Therapy: An Uncontrolled Pilot Study.

OBJECTIVE: To test a multifaceted treatment program for patients with obsessive-compulsive disorder (OCD) who did not respond to regular cognitive behavior therapy (CBT). The treatment addresses several factors that may play a role in maintaining OCD. METHODS: We designed a treatment consisting of a 6-day intensive, individual exposure in vivo with response prevention (ERP) format, with 24 therapist-assisted treatment hours at the patient's home and 12 self-controlled ERP hours, including behavioral activation and family interventions. Next, we investigated the effect (obsessive-compulsive symptoms, comorbidity, functioning, quality of life, OCD-related interaction patterns) and feasibility (dropout, treatment satisfaction, and organization) of this program using pre-post-tests, pre-follow-up tests, and qualitative data from patients, family members, and therapists. RESULTS: In a sample of 22 participants, obsessive-compulsive symptoms (Y-BOCS pre: 28.7, post: 15.9; Wilcoxon S-R tests P<0.01) improved significantly, as did most other effect measures. Results were largely, but not completely, preserved at 3-month follow-up. There was only 1 dropout. Patients, family members, and therapists were satisfied with the treatment. Implementation of the treatment did not pose difficulties. CONCLUSIONS: In nonresponders with OCD, a multifaceted, brief, intensive home-based ERP program targeting factors maintaining OCD is promising and feasible. Extra care is needed to maintain improvement.

Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial.

INTRODUCTION: Persistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments. METHODS AND ANALYSIS: We will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14-18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire). ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board-Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov #NCT05365776.

Prolonged Exposure for Posttraumatic Stress Disorder in Patients Exhibiting Psychotic Symptoms: A Scoping Review.

BACKGROUND: Trauma is a significant risk factor for developing psychosis. Nevertheless, psychosis is often considered grounds for not receiving trauma-focused therapy due to concerns of exacerbating psychotic symptoms. Prolonged exposure (PE) is a recognized and effective evidence-based therapy modality for the treatment of severe trauma. OBJECTIVE: To assess the available empirical evidence for PE as a feasible treatment programme for posttraumatic stress disorder (PTSD) in patients with psychotic symptoms. METHOD: A systematic literature search was conducted using the databases Scopus, PsycINFO (OVID) and PubMed MEDLINE in December 2023 with a priori defined eligibility criteria. The literature search identified 1226 articles, of which eight met the eligibility criteria. Five studies exploring the effects of PE treatment on patients diagnosed with PTSD and suffering from comorbid psychotic experiences were included. Three studies containing follow-up data or secondary analysis on PTSD and psychotic symptoms from original studies fulfilling the inclusion and exclusion criteria were included. Each study was assessed for quality to estimate the risk of bias. RESULTS: Acknowledging the scarcity of available evidence, the results of the scoping review indicate that PE may be an effective treatment approach for reducing PTSD symptoms in patients with PTSD and comorbid psychotic symptoms. The reviewed studies found no iatrogenic effects, including no increase in psychotic symptoms. CONCLUSION: PE appears to be a possibly effective PTSD treatment for patients suffering from PTSD and comorbid psychotic symptoms or disorders. However, the evidence is scarce, and larger confirmative trials are required for more conclusive evidence.

A pilot study of the role of the BDNF Val66Met polymorphism in response to exercise-augmented exposure therapy for posttraumatic stress disorder.

Brain-Derived Neurotrophic Factor (BDNF) is implicated in extinction learning, which is a primary mechanism of exposure therapy for posttraumatic stress disorder (PTSD). Brief aerobic exercise has been shown to promote BDNF release and augment extinction learning. On the premise that the Val allele of the BDNF Val66Met polymorphism facilitates greater release of BDNF, this study examined the extent to which the Val allele of the BDNF polymorphism predicted treatment response in PTSD patients who underwent exposure therapy combined with aerobic exercise or passive stretching. PTSD patients (N = 85) provided saliva samples in order to extract genomic DNA to identify Val/Val and Met carriers of the BDNF Val66Met genotype, and were assessed for PTSD severity prior to and following a 9-week course of exposure therapy combined with aerobic exercise or stretching. The sample comprised 52 Val/Val carriers and 33 Met carriers. Patients with the BDNF high-expression Val allele display greater reduction of PTSD symptoms at posttreatment than Met carriers. Hierarchical regression analysis indicated that greater PTSD reduction was specifically observed in Val/Val carriers who received exposure therapy in combination with the aerobic exercise. This finding accords with animal and human evidence that the BDNF Val allele promotes greater extinction learning, and that these individuals may benefit more from exercise-augmented extinction. Although preliminary, this result represents a possible avenue for augmented exposure therapy in patients with the BDNF Val allele.

Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders.

OBJECTIVE: Imaginal exposure is a novel intervention for eating disorders (EDs) that has been investigated as a method for targeting ED symptoms and fears. Research is needed to understand mechanisms of change during imaginal exposure for EDs, including whether within- and between-session distress reduction is related to treatment outcomes. METHOD: Study 1 tested four sessions of online imaginal exposure (N = 143). Study 2 examined combined imaginal and in vivo exposure, comprising six imaginal exposure sessions (N = 26). ED symptoms and fears were assessed pre- and posttreatment, and subjective distress and state anxiety were collected during sessions. RESULTS: Subjective distress tended to increase within-session in both studies, and within-session reduction was not associated with change in ED symptoms or fears. In Study 1, between-session reduction of distress and state anxiety was associated with greater decreases in ED symptoms and fears pre-to posttreatment. In Study 2, between-session distress reduction occurred but was not related to outcomes. CONCLUSIONS: Within-session distress reduction may not promote change during exposure for EDs, whereas between-session distress reduction may be associated with better treatment outcomes. These findings corroborate research on distress reduction during exposure for anxiety disorders. Clinicians might consider approaches to exposure-based treatment that focus on distress tolerance and promote between-session distress reduction.

Comparing the effect of prolonged exposure therapy (PET) and metacognitive therapy (MCT) on the quality of life among veterans with PTSD.

Veterans' quality of life (QoL) can be drastically affected by posttraumatic stress disorder (PTSD). We compared prolonged exposure therapy (PET) with metacognitive therapy (MCT) in their effects on quality of life (QoL) among veterans with post-traumatic stress disorder (PTSD). Overall, 57 veterans with PTSD were randomly assigned to three groups MCT (N = 17), PET (N = 17), and Control (N = 23). The 36-item short-form survey (SF-36) was used to evaluate QoL pretest, posttest, and after a 3-month follow-up. The MCT was based on the practice of detached mindfulness, controlling rumination/anxiety, and challenging negative beliefs about symptoms. The PET was based on in-vivo and imaginal exposure to trauma-related events, and discontinuation of avoidance-oriented coping strategies. Both MCT and PET groups significantly improved QoL at posttest and follow-up, compared with the control group (P < .001); however, the MCT and PET groups showed no significant difference at posttest (P = .644) or follow-up (P = .646). Our results support the efficacy of PET as the standard for PTSD treatment, while also signifying the effectiveness of MCT at increasing the QoL in war-related PTSD at a 3-month follow-up.

Study protocol for a single-blind, parallel-group, randomized, controlled superiority trial of intensive versus weekly delivered prolonged exposure for adults with post-traumatic stress disorder.

BACKGROUND: Prolonged exposure (PE) therapy is widely recognized as an effective treatment for post-traumatic stress disorder (PTSD) and is often considered one of the primary options for addressing this condition. Nevertheless, a significant proportion of patients (30-51%) fail to demonstrate clinically significant symptom changes. One of the reasons is that a high proportion of patients drop out from treatment, which often lasts for a minimum of 3-4 months. Hence, there is an urgent need for PTSD treatments that can be delivered to decrease dropout rates. A more intensive PE treatment approach has been suggested to decrease dropout rates and in addition achieve faster recovery rates and has shown promising effects on reducing PTSD symptoms but needs to be tested against firsthand treatment. METHODS: This single-blind, randomized controlled trial (N = 140) will compare an intensive delivery format of prolonged exposure (iPE) against standard weekly delivered sessions of PE. The primary outcome is change on the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Secondary outcomes include self-rated measures of symptoms of PTSD and complex PTSD, depression and quality of life, speed of recovery, cost effectiveness, dropout rates, and adverse events. DISCUSSION: This study will be the first to compare iPE with first-line treatment in a psychiatric outpatient setting. One of the key strengths of this study lies in its implementation within a clinical setting and the broad eligibility criteria. Additionally, the utilization of gold-standard assessment measures ensures the accuracy and reliability of the outcomes. However, several potential challenges may arise during the study's execution. These challenges may include difficulties in participant recruitment, ensuring adequate participant retention, adherence to the treatment protocol, and maintaining therapist retention mostly due to recruitment taking place at one single clinic. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT05934175. Registered on June 6, 2023. Open Science Framework (OSF) https://osf.io/7qsb3 . Registered on September 2, 2023.

Sequenced Treatment Effectiveness for Posttraumatic Stress (STEPS) Trial: A protocol for a pragmatic comparative effectiveness trial with baseline results.

BACKGROUND: There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments. METHOD: Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5). RESULTS: Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline. CONCLUSION: Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.

Improving Exposure Therapy: Rationale and Design of an International Consortium.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, this article describes the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. This article discusses directions for expanding the consortium's activities and its impact on a global scale.

Is repeated mistake-making an effective treatment strategy for perfectionism? Findings from a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Perfectionism has been linked to self-criticism, procrastination, and psychological disorders. In a previous study, an exposure-based treatment for perfectionism (ETP), which included exposures targeted at concern over mistakes, showed positive outcomes when compared to waitlist. The aim of this study was to further investigate ETP by comparing it to a stress-management condition and assessing durability of treatment effects by conducting a one-month follow-up assessment. METHODS: Eighty-five individuals with elevated perfectionism were randomly assigned to receive ETP (n = 43) or a stress management treatment (n = 42). ETP involved repeatedly practicing mistake-making by completing computerized tasks engineered to cause individuals to make mistakes. The stress management condition included listening to videos and answering questions about healthy habits, such as diet, exercise, and sleep, as well as viewing calming videos. Participants completed eight treatment sessions as well as baseline, post-test, and one month follow-up self-report questionnaires. RESULTS: Contrary to predictions, compared to ETP, stress management led to significantly lower overall perfectionism, depression, generalized anxiety, and social anxiety at post and significantly lower depression, generalized anxiety, and social anxiety at follow-up. Further, individuals who completed ETP did not habituate to the exposure tasks, but distress increased from the first to the last treatment session. LIMITATIONS: The duration of treatment was relatively brief. CONCLUSIONS: This study highlights the importance of using active psychological control conditions in treatment outcome studies and the need to test various components of treatments for perfectionism to observe what may be effective or even potentially iatrogenic.

Ketamine-enhanced prolonged exposure therapy in veterans with PTSD: A randomized controlled trial protocol.

BACKGROUND: The 2023 VA/DoD Clinical Practice Guideline for the Management of PTSD recommends individual, manualized trauma-focused such as Prolonged Exposure (PE) over pharmacologic interventions for the primary treatment of PTSD. Unfortunately, clinical trials of trauma-based therapies in the military and veteran population showed that 30% to 50% of patients did not demonstrate clinically meaningful symptom change. Ketamine, an FDA-approved anesthetic with potent non-competitive glutamatergic N-methyl-d-aspartate antagonistic properties, has demonstrated to enhance the recall of extinction learning and decrease fear renewal without interference of extinction training in preclinical studies. METHODS: We plan to conduct a single site RCT comparing three ketamine treatment vs. active placebo (midazolam) adjunct to PE therapy among Veterans with PTSD. Pharmacological phase will start simultaneously with PE session 1. Infusions will be administered 24 h. prior to PE session for the first 3 weeks. After PE is completed (session 10), patients will be assessed during a 3-month follow-up period at various time points. We estimate that out of 100 veterans, 80 will reach time point for primary outcome measure and will be considered for primary analysis. Secondary outcomes include severity of depression and anxiety scores, safety and tolerability of ketamine-enhanced PE therapy, cognitive performance during treatment and early improvement during PE related to the rate of dropouts during PE therapy. DISCUSSION: Results of the proposed RCT could provide scientific foundation to distinguish the essential components of this approach, enhance the methodology, elucidate the mechanisms involved, and identify sub-PTSD populations that most likely benefit from this intervention.