Treatment length and symptom improvement in prolonged exposure and present-centered therapy for posttraumatic stress disorder: Comparing dose-response and good-enough level models in two manualized interventions.

OBJECTIVE: The dose-response model of change in psychotherapy posits that each session of therapy is incrementally beneficial across patients. The contrasting good-enough level model suggests that patients improve at different rates in therapy and discontinue treatment when they are satisfied with their improvement. Support for each theory has been mixed, and many prior studies have relied on samples of patients receiving unstructured treatment approaches. We conducted this study to compare these two theories across two manualized treatments for posttraumatic stress disorder (PTSD). METHOD: Two hundred eighty-four female veterans and military service members with PTSD (Mage = 44.79; 54.6% White non-Hispanic, 6.7% Black non-Hispanic, 37% other) were randomized to receive 10 sessions of prolonged exposure (PE), a trauma-focused therapy, or present-centered therapy (PCT), a non-trauma-focused therapy. Participants completed the PTSD Checklist (PCL) at even-numbered treatment sessions, and the timing of dropout/treatment completion was monitored. RESULTS: The point of highest risk for dropout differed between the treatments, with risk in PE corresponding to the beginning of imaginal exposures. In the PE condition, but not in PCT, a higher number of sessions completed increased the likelihood of achieving reliable clinically significant improvement. Across treatments, the rate of change in PTSD symptoms did not differ according to the number of sessions completed (b = 0.06, p = .687). CONCLUSIONS: Findings support the dose-response model of change in psychotherapy. There were notable differences in dropout across the treatment conditions, including rates, timing, and implications for outcomes. These differences likely reflect differences in content between the protocols. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A personalized index to inform selection of a trauma-focused or non-trauma-focused treatment for PTSD.

PTSD treatment guidelines recommend several treatments with extensive empirical support, including Prolonged Exposure (PE), a trauma-focused treatment and Present-Centered Therapy (PCT), a non-trauma-focused therapy. Research to inform treatment selection has yielded inconsistent findings with single prognostic variables that are difficult to integrate into clinical decision-making. We examined whether a combination of prognostic factors can predict different benefits in a trauma-focused vs. a non-trauma-focused psychotherapy. We applied a multi-method variable selection procedure and developed a prognostic index (PI) with a sample of 267 female veterans and active-duty service members (mean age 45; SD = 9.37; 53% White) with current PTSD who began treatment in a randomized clinical trial comparing PE and PCT. We conducted linear regressions predicting outcomes (Clinician-Administered PTSD Scale score) with treatment condition, the PI, and the interaction between the PI and treatment condition. The interaction between treatment type and PI moderated treatment response, moderated post-treatment symptom severity, b = 0.30, SEb = 0.15 [95% CI: 0.01, 0.60], p = .049. For the 64% of participants with the best prognoses, PE resulted in better post-treatment outcomes; for the remainder, there was no difference. Use of a PI may lead to optimized patient outcomes and greater confidence when selecting trauma-focused treatments.

Psychometric properties of a brief measure of posttraumatic stress disorder-related impairment: The Brief Inventory of Psychosocial Functioning.

This study validated the Brief Inventory of Psychosocial Functioning (B-IPF), an abridged version of the 80-item Inventory of Psychosocial Functioning (IPF; Bovin et al., 2018). The B-IPF-a 7-item self-report questionnaire that assesses posttraumatic stress disorder (PTSD)-related psychosocial functional impairment-was developed for use in settings in which the full IPF would be too time intensive to administer. In this study, we examined the psychometric properties of the B-IPF among a sample of 362 veterans recruited from 2 Veterans Affairs hospitals. The B-IPF demonstrated high internal consistency (Cronbach's alpha = .84) and adequate test-retest reliability (r = .65, p < .001). The B-IPF was strongly correlated with the IPF (r = .71, p < .01) and had higher correlations with measures of mental health impairment and quality of life (all rs > ∥.50∥; all ps < .001) than with a measure of physical health impairment (i.e., the Physical Component Summary; r = -.34; p < .001), which demonstrated strong construct validity. In addition, the B-IPF displayed strong criterion-related validity, with higher correlations with a PTSD symptom measure, (r = .63, p < .05), and measures of other internalizing disorders (all rs > .44; all ps < .05) and a lower correlation with a measure of an externalizing disorder (r = .14; p < .05). These results indicate that the B-IPF is a reliable and valid instrument for assessing PTSD-related impairment. The strong psychometric properties of the instrument, in addition to its length, make it ideal for settings in which time is a factor. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Residual symptoms following prolonged exposure and present-centered therapy for PTSD in female veterans and soldiers.

BACKGROUND: Despite the effectiveness of evidence-based treatments for posttraumatic stress disorder (PTSD), some symptoms, such as sleep disturbance, can be difficult to treat regardless of treatment type. METHODS: We examined residual PTSD symptoms in 235 female veterans and soldiers who were randomized to receive 10 weekly sessions of either Prolonged Exposure (PE) or Present-Centered Therapy (PCT). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale. Analyses examined the effects of PE and the effects of clinically significant improvement (loss of diagnosis, operationalized as meaningful symptom reduction and no longer meeting diagnostic criteria). RESULTS: Both treatments resulted in reductions in PTSD symptoms. PE had lower conditional probabilities than PCT of retaining intrusive memories, avoidance of people/places, detachment/estrangement, and restricted range of affect. Loss of diagnosis had lower conditional probabilities of almost all symptoms, although hyperarousal symptoms-especially irritability/anger (60.7%) and sleep difficulties (50.9%)-were the most likely to remain. CONCLUSIONS: Results are consistent with previous findings on sleep difficulties being difficult to treat, but also show that hyperarousal symptoms overall may not be resolved even after substantial improvement. Additional strategies may be needed to treat the full range of PTSD symptoms in some patients.

Development and validation of a measure of PTSD-related psychosocial functional impairment: The Inventory of Psychosocial Functioning.

This study describes the three-phase development and validation of the Inventory of Psychosocial Functioning (IPF), an 80-item, self-report measure of posttraumatic stress disorder (PTSD)-related psychosocial functional impairment. In Phase I, we conducted 12 focus groups with male and female veterans (n = 53) to identify and operationalize the domains of psychosocial impairment associated with PTSD. This information was used to develop the IPF. We subsequently evaluated the psychometric properties of the newly developed inventory in Phases II (n = 276) and III (n = 368) using two independent samples of veterans. We found that the overall IPF score demonstrated stronger correlations with measures of mental health-related impairment (all rs > |.39|; all ps < .05) and weaker correlations with measures of physical health-related impairment (all rs < |.29|; all ps < .05). Overall IPF scores were most strongly associated with PTSD and other disorders associated with the anxious-misery factor of the three-factor model of psychiatric comorbidity (all rs > .56; all ps < .05) and less strongly associated with disorders associated with the fear factor (all rs < .48; all ps < .05) and the externalizing factor (r = .16; p < .05). The IPF demonstrated strong test-retest reliability (r = .77; p < .05). Our results suggest that the IPF is a valid and reliable measure of PTSD-related psychosocial functional impairment. (PsycINFO Database Record

SYMPTOM BENCHMARKS OF IMPROVED QUALITY OF LIFE IN PTSD.

BACKGROUND: Although research has shown that PTSD symptom change relates to improved quality of life, the question of how much improvement in PTSD symptoms is necessary to result in meaningful improvements in quality of life remains unanswered. We used data from a randomized clinical trial of psychotherapy for PTSD in female military veterans and active duty personnel to examine the correspondence between benchmarks of improvement in PTSD symptoms and changes in quality of life. METHODS: Participants were 235 female veterans and Army soldiers who were randomized to 10 weekly sessions of Prolonged Exposure or Present-Centered Therapy. We operationalized PTSD symptom change in terms of four progressively stringent mutually exclusive definitions-No Response, Response, Loss of Diagnosis, and Remission-successively comparing each category to the prior one: No Response versus Response, Response versus Loss of Diagnosis, and Loss of Diagnosis versus Remission. Outcomes were clinically meaningful improvements and good endpoints in domains of clinician-rated and self-reported quality of life. RESULTS: Response was associated with improvement on almost all measures, but with only one good endpoint. Loss of Diagnosis was associated with improvement on all measures except self-rated social functioning and with achieving a good endpoint on all measures. Remission was associated with improvement in clinician-rated social impairment and a good endpoint in clinician-rated occupational impairment. CONCLUSIONS: For most domains of quality of life, treating a patient until the patient no longer meets diagnostic criteria would be optimal. For some domains, further improvements may result by helping a patient achieve remission.

The influence of the dissociative subtype of posttraumatic stress disorder on treatment efficacy in female veterans and active duty service members.

OBJECTIVE: A dissociative subtype of posttraumatic stress disorder (PTSD) was recently added to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) and is thought to be associated with poor PTSD treatment response. METHOD: We used latent growth curve modeling to examine data from a randomized controlled trial of prolonged exposure and present-centered therapy for PTSD in a sample of 284 female veterans and active duty service members with PTSD to test the association between the dissociative subtype and treatment response. RESULTS: Individuals with the dissociative subtype (defined using latent profile analysis) had a flatter slope (p = .008) compared with those with high PTSD symptoms and no dissociation, such that the former group showed, on average, a 9.75 (95% confidence interval [-16.94, -2.57]) lesser decrease in PTSD severity scores on the Clinician Administered PTSD Scale (Blake et al., 1995) over the course of the trial. However, this effect was small in magnitude. Dissociative symptoms decreased markedly among those with the subtype, though neither treatment explicitly addressed such symptoms. There were no differences as a function of treatment type. CONCLUSIONS: Results raise doubt about the common clinical perception that exposure therapy is not effective or appropriate for individuals who have PTSD and dissociation, and provide empirical support for the use of exposure treatment for individuals with the dissociative subtype of PTSD.

Differential effects of prolonged exposure on posttraumatic stress disorder symptoms in female veterans.

OBJECTIVE: We compared the effect of Prolonged Exposure (PE) on posttraumatic stress disorder (PTSD) symptom clusters and individual symptoms relative to a nonspecific comparison therapy (present-centered therapy; PCT) to identify the unique benefits of PE. We used data from a 12-site randomized clinical trial that found PE to be more effective than PCT for reducing PTSD symptom severity. METHOD: Participants were 284 female veterans and active duty soldiers with PTSD (M age = 44.8 years, range = 22-78; 45.4% non-White). Participants were randomized to 10 weekly sessions of PE or PCT and assessed before and after treatment and at 3- and 6-month follow-ups. The primary measure of PTSD symptoms and symptom clusters (reexperiencing, avoidance, numbing, and hyperarousal) was the Clinician-Administered PTSD Scale (CAPS; Weathers et al., 2001) but we also assessed self-reported PTSD using the PTSD Checklist-Specific Version (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993). RESULTS: Almost all clinician-rated and self-reported symptoms improved from pre- to posttreatment in both conditions. In the analyses of clinician-rated PTSD, PE had greater benefit than PCT on avoidance and numbing clusters. PE also had greater benefit on most individual symptoms in these clusters as well as on distress related to reminders. In the analyses of self-reported PTSD, PE had greater benefit than PCT on all clusters and on most individual symptoms. CONCLUSION: PE may be especially helpful for individuals with significant avoidance and numbing. Giving patients information about how a treatment can help with the symptoms that create the greatest burden can facilitate choosing the treatment that is best for them.

Comparison of clinician- and self-assessments of posttraumatic stress symptoms in older versus younger veterans.

Assessment of posttraumatic stress disorder (PTSD) in older adults has received limited investigation. The purpose of this study was to compare the severity of PTSD symptoms in treatment-seeking older and younger U.S. veterans with PTSD. Participants were 360 male and 284 female veterans enrolled in 2 separate clinical trials of psychotherapy for PTSD. About 4% of the participants were age 60 years or older. Symptoms were assessed before treatment using clinician-rated and self-report measures. For men, only numbing symptoms were lower in older veterans; this was so in clinician ratings, d = 0.76, and self-reports, d = 0.65. For women, clinician-rated hyperarousal symptoms were lower in older veterans, d = 0.57. Clinician-rated and self-reported symptoms were strongly related, Bs = 0.95 and 0.80 in the male and female samples, respectively. Among men, clinician-rated and self-reported reexperiencing and hyperarousal symptoms were associated only in younger veterans. Accurate assessment of PTSD symptoms in older adults is essential to identifying and implementing effective treatment. Our findings suggest that some symptoms may be lower in older men, and that some symptoms of PTSD may be underdetected in older women. Future research should assess the combined effect of gender and age on PTSD symptom presentation.

Work-related outcomes among female veterans and service members after treatment of posttraumatic stress disorder.

OBJECTIVE: This study examined the effect of treatment for posttraumatic stress disorder (PTSD) on work-related quality-of-life outcomes and the relationship between clinically significant change during treatment and work-related outcomes. Additional analyses explored whether current depression and employment status moderated the effects of treatment and clinically significant change. METHODS: Participants were 218 female veterans and soldiers with current PTSD who participated in a randomized clinical trial of treatment for PTSD. They received ten weekly sessions of prolonged exposure or present-centered therapy and were assessed before and after treatment and at three- and six-month follow-ups. Outcomes were clinician-rated and self-rated occupational impairment and self-rated satisfaction with work. RESULTS: Both treatment groups had improvements in occupational impairment, and the degree of improvement by the two groups was similar. There was no pre- to posttreatment change in work satisfaction. At the end of treatment, participants who no longer met diagnostic criteria for PTSD had greater improvements in all domains of work-related quality of life than participants who still had PTSD. CONCLUSIONS: Although prolonged exposure resulted in better PTSD symptom outcomes than present-centered therapy in the randomized clinical trial, it did not result in better work-related quality-of-life outcomes. The improvement in occupational impairment associated with loss of diagnosis suggests the importance of continuing treatment until clinically meaningful change has been attained.

The dissociative subtype of PTSD: a replication and extension.

BACKGROUND: The nature of the relationship between dissociation and posttraumatic stress disorder (PTSD) has clinical and nosological importance. The aim of this study was to evaluate the evidence for a dissociative subtype of PTSD in two independent samples and to examine the pattern of personality disorder (PD) comorbidity associated with the dissociative subtype of PTSD. METHODS: Latent profile analyses were conducted on PTSD and dissociation items reflecting derealization and depersonalization in two samples of archived data: Study 1 included 360 male Vietnam War Veterans with combat-related PTSD; Study 2 included 284 female Veterans and active duty service personnel with PTSD and a high base rate of exposure to sexual trauma. RESULTS: The latent profile analysis yielded evidence for a three-class solution in both samples: the model was defined by moderate and high PTSD classes and a class marked by high PTSD severity coupled with high levels of dissociation. Approximately 15% of the male sample and 30% of the female sample were classified into the dissociative class. Women (but not men) in the dissociative group exhibited higher levels of comorbid avoidant and borderline PD diagnoses. CONCLUSIONS: Results provide support for a dissociative subtype of PTSD and also suggest that dissociation may play a role in the frequent co-occurrence of PTSD and borderline PD among women. These results are pertinent to the on-going revisions to the DSM and suggest that consideration should be given to incorporating a dissociative subtype into the revised PTSD criteria.

Work-related quality of life and posttraumatic stress disorder symptoms among female veterans.

BACKGROUND: Posttraumatic stress disorder (PTSD) can have pervasive, negative effects on multiple aspects of quality of life. We investigated the relationship between PTSD symptom clusters and work-related quality of life among female veterans. Although prior studies have shown that PTSD symptom clusters are differentially related to work-related quality of life, no study has assessed these relationships in women specifically. METHODS: Participants were 253 female veterans with current PTSD. We assessed three components of work-related quality of life (employment status, clinician-rated occupational impairment, and self-rated occupational satisfaction) and performed analyses with and without adjusting for self-reported depression symptoms. RESULTS: None of the PTSD symptom clusters were associated with employment status. All PTSD symptom clusters had significant independent associations with occupational impairment. All PTSD symptom clusters except avoidance were significantly associated with lower occupational satisfaction, but none had independent associations with occupational satisfaction. No single PTSD symptom cluster emerged as most strongly associated with occupational outcomes. Symptoms of depression had substantial associations across all occupational outcomes, independent of PTSD symptoms. CONCLUSION: Knowledge about how PTSD relates to occupational outcomes in women veterans is important for addressing the needs of this growing segment of the VA patient population, in which PTSD is a prevalent condition. Because PTSD had differential relationships with the three components of work-related quality of life, measuring only one component, or using an aggregate measure, may obscure important distinctions. Resolving depression symptoms also may be integral to achieving meaningful recovery.

Sexual function outcomes in women treated for posttraumatic stress disorder.

BACKGROUND: This study examined dysfunctional sexual behavior and sexual concerns in women treated for posttraumatic stress disorder (PTSD). There were three objectives: to characterize the relationship between symptoms of PTSD and sexual outcomes, to examine the effect of treatment on sexual outcomes, and to examine the relationship between change in PTSD and change in sexual outcomes. METHODS: Female veterans and active duty personnel with PTSD (n = 242), 93% of whom had experienced sexual trauma, were randomly assigned to receive 10 weekly sessions of either Prolonged Exposure or Present-Centered Therapy. PTSD and sexual outcomes were assessed before and after treatment and then 3 and 6 months later. RESULTS: At baseline, the reexperiencing, numbing, and hyperarousal symptom clusters were related to one or both sexual outcomes. Although prior analyses had shown that Prolonged Exposure resulted in better PTSD outcomes, there were no differences between treatments for either dysfunctional sexual behavior or sexual concerns. However, loss of PTSD diagnosis was associated with improvements in sexual concerns. CONCLUSIONS: The findings suggest that clinically meaningful improvements in PTSD are necessary in order to reduce sexual problems in traumatized women.

Posttraumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan.

The wars in Iraq and Afghanistan-Operation Iraqi Freedom and Operation Enduring Freedom, or OEF/OIF-have created unique conditions for promoting the development of psychological difficulties such as posttraumatic stress disorder (PTSD). PTSD is an important outcome because it can affect quality of life, impairing psychosocial and occupational functioning and overall well-being. The literature on PTSD and quality of life in OEF/OIF Veterans is at an early stage, but the consistency of the evidence is striking. Our review indicates that the findings on PTSD and quality of life in OEF/OIF veterans are comparable to findings obtained from other war cohorts and from nonveterans as well. Even though the duration of PTSD in OEF/OIF Veterans is much shorter than in Vietnam Veterans, for example, those with PTSD in both cohorts are likely to experience poorer functioning and lower objective living conditions and satisfaction. The review ends with discussion of the implications of the evidence for research and clinical practice.

Exploration of gender differences in how quality of life relates to posttraumatic stress disorder in male and female veterans.

Significant gaps exist in our knowledge about gender differences in quality of life among individuals with posttraumatic stress disorder (PTSD). We addressed these gaps by using data from two randomized clinical trials of veterans treated in Department of Veterans Affairs settings: 358 male Vietnam veterans who received group therapy and 203 female veterans who received individual psychotherapy. Using confirmatory factor analysis, we found that a four-factor structure for the Quality of Life Inventory provided the best fit for both groups. Overall quality of life was poor in men and women, and in general, they did not differ in quality of life or in how PTSD was associated with quality of life; the few statistically significant differences were small and clinically insignificant. For both men and women, numbing was uniquely associated with reduced quality of life. We suggest that quality of life should receive increased attention in research and clinical efforts to help veterans with PTSD.

Domains of quality of life and symptoms in male veterans treated for posttraumatic stress disorder.

This study examined the relationship between domains of quality of life and posttraumatic stress disorder (PTSD) symptoms in 319 male veterans in a randomized trial of group psychotherapy. Confirmatory factor analyses suggested a 4-factor model of quality of life (achievement, self-expression, relationships, and surroundings) fit better than a unidimensional model. Clinically meaningful symptom change was associated with greater change in all quality of life domains. At pretreatment, numbing symptoms uniquely predicted all quality of life domains. Change in avoidance and hyperarousal uniquely predicted change in achievement. Change in reexperiencing uniquely predicted change in self-expression. Change in numbing uniquely predicted change in relationships. Examining change in PTSD symptoms and quality of life domains may provide important information for treatment planning and evaluation.

Longitudinal analysis of the relationship between symptoms and quality of life in veterans treated for posttraumatic stress disorder.

This study examined how change in posttraumatic stress disorder (PTSD) symptoms relates to change in quality of life. The sample consisted of 325 male Vietnam veterans with chronic PTSD who participated in a randomized trial of group psychotherapy. Latent growth modeling was used to test for synchronous effects of PTSD symptom change on psychosocial and physical health-related quality of life within the same time period and lagged effects of initial PTSD symptom change on later change in quality of life. PTSD symptoms were associated with reduced quality of life before treatment. There were synchronous effects of symptom change on change in quality of life but no significant lagged effects. Results indicate the importance of measuring quality of life in future investigations of PTSD treatment.

A longitudinal study of retirement in older male veterans.

In this study, the authors examined the effect of retirement on psychological and physical symptoms in 404 older male veterans who were taking part in an ongoing longitudinal study. Hierarchical linear modeling was used to analyze symptom trajectories from preretirement, peri-retirement, and postretirement periods in veterans with either lifetime full or partial posttraumatic stress disorder (PTSD), trauma exposure only, or no traumatic exposure. As expected, the PTSD group experienced greater increases in psychological and physical symptoms during retirement, relative to the other groups. Retirement due to poor health in the PTSD group did not account for the findings regarding physical symptoms. Results indicate that clinicians should recognize and address the potential for older individuals with PTSD to experience difficulties during retirement.

Risk factors for the development versus maintenance of posttraumatic stress disorder.

This study examined risk factors for posttraumatic stress disorder (PTSD) in Vietnam veterans: 68 women and 414 men of whom 88 were White, 63 Black, 80 Hispanic, 90 Native Hawaiian, and 93 Japanese American. Continuation ratio logistic regression was used to compare the predictive power of risk factors for the development versus maintenance of full or partial PTSD. The development of PTSD was related to premilitary, military, and postmilitary factors. The maintenance of PTSD was related primarily to military and postmilitary factors. Multivariate analyses identified different models for development and maintenance. We conclude that development of PTSD is related to factors that occur before, during, and after a traumatic event, whereas failure to recover is related primarily to factors that occur during and after the event.

A descriptive analysis of PTSD chronicity in Vietnam veterans.

This study examined the chronicity of PTSD in 530 male and female Vietnam veterans who were drawn from 2 large, ethnically diverse samples. Delayed onset was common, as was a failure to fully remit: 78% of the 239 veterans with full or partial lifetime PTSD were symptomatic in the 3 months prior to assessment. Cluster analysis identified 4 subtypes of posttraumatic response, with women most likely to be in a delayed onset cluster, and minority men most likely to be in a severe chronic cluster. The extent of chronicity observed in this sample underscores the need for treatments that address the persistence of posttraumatic symptoms.