The mediating role of posttraumatic stress disorder symptoms in pain cognitions among Veterans with chronic pain.

Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (n = 103; mean age 43.66; SD = 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.

Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats.

The intent of this study is to examine treatment impact and efficiency observed when cognitive behavioral treatments for posttraumatic stress disorder (PTSD) are delivered in-person or using telehealth. This study pooled data from 268 veterans enrolled in two PTSD clinical trials. In both trials, treatment was delivered using in-home telehealth (telehealth arm), in-home in-person (in-home arm), and in-office care, where patients traveled to the Department of Veterans Affairs for either office-based telehealth or office-based in-person care (office arm). Average age was 44 (SD = 12.57); 80.9% were males. The PTSD Checklist for DSM-5 (PCL-5) was used to assess symptom severity. Treatment impact was measured by (a) the proportion of participants who completed at least eight treatment sessions and (b) the proportion with a reliable change of ≥ 10 points on the PCL-5. Treatment efficiency was measured by the number of days required to reach the end point. The proportion of participants who attended at least eight sessions and achieved reliable change on the PCL-5 differed across treatment formats (ps < .05). Participants in the in-home (75.4%) format were most likely to attend at least eight treatment sessions, followed by those in the telehealth (58.3%) and office (44.0%) formats, the latter of which required patients to travel. Participants in the in-home (68.3%, p < .001) format were also more likely to achieve reliable change, followed by those in the telehealth (50.9%) and office (44.2%) formats. There were no significant differences in the amount of time to complete at least eight sessions. Delivery of therapy in-home results in a significantly greater likelihood of achieving both an adequate dose of therapy and a reliable decrease in PTSD symptoms compared to telehealth and office formats. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The interactions between patient preferences, expectancies, and stigma contribute to posttraumatic stress disorder treatment outcomes.

Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three-arm, equipoise-stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in-home, in-office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in-office conditions, η2 = .12-.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in-home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in-office conditions, η2 = .20. The results show the robustness of evidence-based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence-based therapies for PTSD. Strategies to address these factors are discussed.

Mechanisms of change in posttraumatic headache-related disability: A mediation model.

OBJECTIVE: To explore whether the association between change in headache management self-efficacy and posttraumatic headache-related disability is partially mediated by a change in anxiety symptom severity. BACKGROUND: Many cognitive-behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache-related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. METHODS: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive-behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self-efficacy and headache-related disability, along with partial mediation through change in anxiety symptoms was tested. RESULTS: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self-efficacy and headache-related disability (b = -0.45, p < 0.001; 95% confidence interval [CI: -0.58, -0.33]). The total effect of change of headache management self-efficacy scores on change in Headache Impact Test-6 scores was significant with a moderate-to-strong effect (b = -0.57, p = 0.001; 95% CI [-0.73, -0.41]). There was also an indirect effect through anxiety symptom severity change (b = -0.12, p = 0.003; 95% CI [-0.20, -0.04]). CONCLUSIONS: In this study, most of the improvements in headache-related disability were related to increased headache management self-efficacy with mediation occurring through change in anxiety. This indicates that headache management self-efficacy is a likely mechanism of change of posttraumatic headache-related disability with decreases in anxiety explaining part of the improvement in headache-related disability.

Mindfulness-Based Interdisciplinary Pain Management Program for Complex Polymorbid Pain in Veterans: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effects of interdisciplinary pain management on pain-related disability and opioid reduction in polymorbid pain patients with 2 or more comorbid psychiatric conditions. DESIGN: Two-arm randomized controlled trial testing a 3-week intervention with assessments at pre-treatment, post-treatment, 6-month, and 12-month follow-up. SETTING: Department of Veterans Affairs medical facility. PARTICIPANTS: 103 military veterans (N=103) with moderate (or worse) levels of pain-related disability, depression, anxiety, and/or posttraumatic stress disorder randomly assigned to usual care (n=53) and interdisciplinary pain management (n=50). All participants reported recent persistent opioid use. Trial participants had high levels of comorbid medical and mental health conditions. INTERVENTIONS: Experimental arm-a 3-week, interdisciplinary pain management program guided by a structured manual; comparison arm-usual care in a large Department of Veterans Affairs medical facility. MAIN OUTCOME MEASURES: Oswestry Disability Index (pain disability); Timeline Followback Interview and Medication Event Monitoring System (opioid use). Analysis used generalized linear mixed model with all posttreatment observations (posttreatment, 6-month follow-up, 12-month follow-up) entered simultaneously to create a single posttreatment effect. RESULTS: Veterans with polymorbid pain randomized to the interdisciplinary pain program reported significantly greater decreases in pain-related disability compared to veterans randomized to treatment as usual (TAU) at posttreatment, 6-month, and 12-month follow-up. Aggregated mean pain disability scores (ie, a summary effect of all posttreatment observations) for the interdisciplinary pain program were -9.1 (95% CI: -14.4, -3.7, P=.001) points lower than TAU. There was no difference between groups in the proportion of participants who resumed opioid use during trial participation (32% in both arms). CONCLUSION: These findings offer the first evidence of short- and long-term interdisciplinary pain management efficacy in polymorbid pain patients, but more work is needed to examine how to effectively decrease opioid use in this population.

Cognitive Behavioral Therapy for Veterans With Comorbid Posttraumatic Headache and Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial.

Importance: Posttraumatic headache is the most disabling complication of mild traumatic brain injury. Posttraumatic stress disorder (PTSD) symptoms are often comorbid with posttraumatic headache, and there are no established treatments for this comorbidity. Objective: To compare cognitive behavioral therapies (CBTs) for headache and PTSD with treatment per usual (TPU) for posttraumatic headache attributable to mild traumatic brain injury. Design, Setting, and Participants: This was a single-site, 3-parallel group, randomized clinical trial with outcomes at posttreatment, 3-month follow-up, and 6-month follow-up. Participants were enrolled from May 1, 2015, through May 30, 2019; data collection ended on October 10, 2019. Post-9/11 US combat veterans from multiple trauma centers were included in the study. Veterans had comorbid posttraumatic headache and PTSD symptoms. Data were analyzed from January 20, 2020, to February 2, 2022. Interventions: Patients were randomly assigned to 8 sessions of CBT for headache, 12 sessions of cognitive processing therapy for PTSD, or treatment per usual for headache. Main Outcomes and Measures: Co-primary outcomes were headache-related disability on the 6-Item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5) assessed from treatment completion to 6 months posttreatment. Results: A total of 193 post-9/11 combat veterans (mean [SD] age, 39.7 [8.4] years; 167 male veterans [87%]) were included in the study and reported severe baseline headache-related disability (mean [SD] HIT-6 score, 65.8 [5.6] points) and severe PTSD symptoms (mean [SD] PCL-5 score, 48.4 [14.2] points). For the HIT-6, compared with usual care, patients receiving CBT for headache reported -3.4 (95% CI, -5.4 to -1.4; P < .01) points lower, and patients receiving cognitive processing therapy reported -1.4 (95% CI, -3.7 to 0.8; P = .21) points lower across aggregated posttreatment measurements. For the PCL-5, compared with usual care, patients receiving CBT for headache reported -6.5 (95% CI, -12.7 to -0.3; P = .04) points lower, and patients receiving cognitive processing therapy reported -8.9 (95% CI, -15.9 to -1.9; P = .01) points lower across aggregated posttreatment measurements. Adverse events were minimal and similar across treatment groups. Conclusions and Relevance: This randomized clinical trial demonstrated that CBT for headache was efficacious for disability associated with posttraumatic headache in veterans and provided clinically significant improvement in PTSD symptom severity. Cognitive processing therapy was efficacious for PTSD symptoms but not for headache disability. Trial Registration: ClinicalTrials.gov Identifier: NCT02419131.

Complex pain phenotypes: Suicidal ideation and attempt through latent multimorbidity.

BACKGROUND: Given the relatively high rates of suicidal ideation and attempt among people with chronic pain, there is a need to understand the underlying factors to target suicide prevention efforts. To date, no study has examined the association between pain phenotypes and suicide related behaviors among those with mild traumatic brain injuries. OBJECTIVE: To determine if pain phenotypes were independently associated with suicidal ideation / attempt or if comorbidities within the pain phenotypes account for the association between pain phenotypes and suicide related behaviors. METHODS: This is a longitudinal retrospective cohort study of suicide ideation/attempts among pain phenotypes previously derived using general mixture latent variable models of the joint distribution of repeated measures of pain scores and pain medications/treatment. We used national VA inpatient, outpatient, and pharmacy data files for Post-9/11 Veterans with mild traumatic injury who entered VA care between fiscal years (FY) 2007 and 2009. We considered a counterfactual causal modeling framework to assess the extent that the pain phenotypes during years 1-5 of VA care were predictive of suicide ideation/attempt during years 6-8 of VA care conditioned on covariates being balanced between pain phenotypes. RESULTS: Without adjustment, pain phenotypes were significant predictors of suicide related behaviors. When we used propensity scores to balance the comorbidities present in the pain phenotypes, the pain phenotypes were no longer significantly associated with suicide related behaviors. CONCLUSION: These findings suggest that suicide ideation/attempt is associated with pain trajectories primarily through latent multimorbidity. Therefore, it is critical to identify and manage comorbidities (e.g., depression, post-traumatic stress disorder) to prevent tragic outcomes associated with suicide related behaviors throughout the course of chronic pain and mild traumatic brain injury management.

PTSD symptoms and tinnitus severity: An analysis of veterans with posttraumatic headaches.

OBJECTIVE: Tinnitus and posttraumatic stress disorder (PTSD) are among the top service-connected disabilities within the Veterans Health Administration. Extant research shows that there is considerable overlap between tinnitus-related distress and PTSD, including sleep difficulty, irritability, hyperarousal, and concentration problems. However, no studies have prospectively examined the relationship between the two disorders. The purpose of this study was to examine that relationship. METHOD: Participants (N = 112) with posttraumatic headache completed measures of tinnitus and PTSD. Correlational analyses and analyses of variance were conducted to examine the associations with PTSD symptom clusters and factors of tinnitus-related distress. RESULTS: Approximately, half of participants with tinnitus demonstrated severe impairment. Correlational analyses indicated that reexperiencing, avoidance, negative emotions and cognitions, and hyperarousal PTSD symptoms were significantly related to many factors of tinnitus-related distress, including intrusiveness of tinnitus, perceived loudness, awareness, and annoyance. Participants with severe tinnitus demonstrated significantly greater reexperiencing, negative mood/cognitions, hyperarousal, and PTSD total severity compared to those with mild or moderate tinnitus. CONCLUSIONS: Trauma therapists should assess for the presence of tinnitus in order to more fully conceptualize key health problems of help-seeking patients. Heightened psychological symptoms seemingly related to PTSD may be a function of tinnitus-related distress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial.

BACKGROUND: Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment. METHODS: The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome. RESULTS: Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant. CONCLUSIONS: CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Persistent posttraumatic headaches and functioning in veterans: Injury type can matter.

OBJECTIVE: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. BACKGROUND: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. METHODS: This study used a nested-cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache-Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. RESULTS: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache-related disability, depression symptoms, or severity of PTSD symptoms. CONCLUSION: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study.

Study design for a randomized clinical trial of cognitive-behavioral therapy for posttraumatic headache.

Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in PTH unique from other types of headaches. The treatments under study differed in clinical focus and dose (i.e., number of treatment sessions), but the trial was designed to balance the treatments as well as possible. Finally, while the primary endpoints for pain research can vary from assessments of pain intensity to objective and subjective functional measures, this trial of PTH interventions chose carefully to establish clinically relevant endpoints and to maximize the opportunity to detect significant differences between groups with two primary outcomes. All these issues are discussed in this manuscript.

Targeting Chronic Pain in Primary Care Settings by Using Behavioral Health Consultants: Methods of a Randomized Pragmatic Trial.

BACKGROUND: Manualized cognitive and behavioral therapies are increasingly used in primary care environments to improve nonpharmacological pain management. The Brief Cognitive Behavioral Therapy for Chronic Pain (BCBT-CP) intervention, recently implemented by the Defense Health Agency for use across the military health system, is a modular, primary care-based treatment program delivered by behavioral health consultants integrated into primary care for patients experiencing chronic pain. Although early data suggest that this intervention improves functioning, it is unclear whether the benefits of BCBT-CP are sustained. The purpose of this paper is to describe the methods of a pragmatic clinical trial designed to test the effect of monthly telehealth booster contacts on treatment retention and long-term clinical outcomes for BCBT-CP treatment, as compared with BCBT-CP without a booster, in 716 Defense Health Agency beneficiaries with chronic pain. DESIGN: A randomized pragmatic clinical trial will be used to examine whether telehealth booster contacts improve outcomes associated with BCBT-CP treatments. Monthly booster contacts will reinforce BCBT-CP concepts and the home practice plan. Outcomes will be assessed 3, 6, 12, and 18 months after the first appointment for BCBT-CP. Focus groups will be conducted to assess the usability, perceived effectiveness, and helpfulness of the booster contacts. SUMMARY: Most individuals with chronic pain are managed in primary care, but few are offered biopsychosocial approaches to care. This pragmatic brief trial will test whether a pragmatic enhancement to routine clinical care, monthly booster contacts, results in sustained functional changes among patients with chronic pain receiving BCBT-CP in primary care.

Stakeholder Engagement in Pragmatic Clinical Trials: Emphasizing Relationships to Improve Pain Management Delivery and Outcomes.

BACKGROUND: The NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC. DESIGN: Our collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT? SUMMARY: Our experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively.

Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study.

BACKGROUND: Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion. METHOD: A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury. RESULT: 127 participants (66%; 95% CI: 59-72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; p ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt; p = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for DSM-5 = 1.3, 95% CI = -27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = -6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = -2.7, 15.6). CONCLUSIONS: Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months. CLINICALTRIALS.GOV IDENTIFIER: NCT02419131.

Intensive, Multi-Couple Group Therapy for PTSD: A Nonrandomized Pilot Study With Military and Veteran Dyads.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD.

Five-year Pain Intensity and Treatment Trajectories of Post-9/11 Veterans With Mild Traumatic Brain Injury.

Pain is a pervasive problem that affects nearly half of the U.S. Veterans deployed in support of the Global War on Terror (Post-9/11 Veterans) and over half of the Post-9/11 Veterans with diagnosed traumatic brain injury (TBI). The goal of the current study was to identify pain phenotypes based on distinct longitudinal patterns of pain scores in light of pain treatment among Post-9/11 Veterans over 5 years of care using latent growth mixture analysis stratified by TBI status. Five pain phenotypes emerged: 1) simple low impact stable pain, 2) complex low impact stable pain, 3) complex low impact worsening pain, 4) complex moderate impact worsening pain, and 5) complex high impact stable pain. Baseline pain scores and slopes were significantly higher in Veterans with mild TBI for some phenotypes. The mild TBI cohort was younger, had more men, more whites, less blacks, less education, more unmarried, more Marines and Army, more active duty in comparison to the no TBI cohort. Distinct trajectories in pain treatment were apparent among the pain intensity subgroups. PERSPECTIVE: The complexity of pain in patients with mTBI is categorically different than those with no TBI. Pain in patients with mTBI is heterogeneous with distinct phenotypes which may explain poor outcomes in this group. Identification of the individual differences may have a significant impact on the success of interventions.

Negative Life Events (NLEs) Contributing to Psychological Distress, Pain, and Disability in a U.S. Military Sample.

Introduction: The objective was to explore how negative life events (NLEs, e.g., litigation related to pain and disability, failing most recent physical fitness test, and financial difficulties) are related to pain coping and psychological adjustment to pain in active duty military personnel. Materials and Methods: Data were gathered as part of the Evaluation of Suicidality, Cognitions, and Pain Experience study, a DoD-funded cross-sectional assessment of chronic pain and emotional coping among a cohort of military members. The investigators examined data from 147 respondents with complete survey and pain assessment data. Results: The sample was active duty, male (62.6%), in a relationship or married (83.0%), and had children (68.7%). The majority of the sample endorsed zero NLEs (72.0%); 23.8% endorsed one NLE, 4.2% endorsed two NLEs, and no one endorsed all three NLEs. A significantly higher proportion of participants endorsing one or more NLEs reported suicidal ideation compared to those who reported no NLEs (χ2(2) = 8.61, p = 0.014). A higher number of endorsed NLEs coincided with higher symptom severity related to psychosocial distress (depression, thwarted belongingness, perceived burdensomeness, PTSD, and suicide cognitions) and poor pain coping (rumination, helplessness, and less acceptance of chronic pain). Conclusions: Findings revealed that NLEs may impart a significant burden on military pain sufferers. Greater numbers of endorsed NLEs are associated with increased psychosocial distress and poor pain coping. Future longitudinal studies examining long-term psychosocial distress/poor pain coping as related to NLEs would help to elaborate the long-term consequences of NLEs on pain coping and psychosocial distress.

Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD.

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers. The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the provider's office to the participant's home, and (3) In-Home CPT in which the provider delivers treatment in the participant's home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Current Patterns of Training in Personality Assessment During Internship.

OBJECTIVE: Training in broad-based objective and projective personality assessments has been a mainstay of applied psychology. Stedman (2007) and Piotrowski (2015) have documented a decline in projective training during internship. This study investigated internship directors' current expectations regarding graduate school training with objective and projective instruments, their ratings of the importance of that training, and current training patterns with objective and projective instruments during internship. METHOD: Participants were 355 psychology internship programs, representing 46.1% of the Association of Psychology Postdoctoral and Internship Centers. RESULTS: Results indicated the following current internship training patterns: Minnesota Multiphasic Personality Inventory (68% to 51%), Personality Assessment Inventory (59% to 25%), Millon Clinical Multiaxial Inventory (51% to 34%), Rorschach (35 to 26%), story telling (41% to 19%), sentence completion (41% to 18%), and drawings (36% to 9%). Adult program directors reported higher percentages for objective tests; child program directors reported higher percentages for projective tests. CONCLUSION: A decreased valuation of projective techniques is now typical of current internship training programs.