Improving function through primary care treatment of posttraumatic stress disorder study outcomes: A randomized controlled trial of prolonged exposure for primary care in veterans.

INTRODUCTION: Despite high cost and wide prevalence of posttraumatic stress disorder (PTSD) in veteran populations, and Veterans Health Administration (VA)-wide mental health provider training in evidence-based treatments for PTSD, most veterans with PTSD do not receive best practices interventions. This may be because virtually all evidence-based PTSD treatment is offered through specialty clinics, which require multiple steps and referrals to access. One solution is to offer PTSD treatment in VA primary care settings, which are often the first and only contact point for veterans. METHOD: The present study, Improving Function Through Primary Care Treatment of PTSD (IMPACT), used a randomized controlled design to compare an adaptation of prolonged exposure for PTSD to primary care (PE-PC) versus best practices Primary Care Mental Health Integration (PCMHI) clinic treatment as usual (TAU) in terms of both functioning and psychological symptoms in 120 veterans recruited between April 2019 and September 2021. RESULTS: Participants were mostly males (81.7%) with a mean age of 43.6 years (SD = 12.8), and more than half were non-White veterans (50.8%). Both conditions evinced significant improvement over baseline across functioning, PTSD, and depression measures, with no differences observed between groups. As observed in prior studies, PTSD symptoms continued to improve over time in both conditions, as measured by structured clinical interview. DISCUSSION: Both PE-PC and best-practices TAU are effective in improving function and reducing PTSD severity and depression severity. Although we did not observe differences between the two treatments, note that this study site and two PCMHI clinics employ primarily cognitive behavioral therapies (e.g., exposure and behavioral activation). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Management of Chronic Pain and PTSD in Veterans With tDCS+Prolonged Exposure: A Pilot Study.

INTRODUCTION: Chronic pain and posttraumatic stress disorder (PTSD) are prevalent comorbid conditions, particularly in Veterans; however, there are few integrated treatments for chronic pain and PTSD. Instead, interventions are typically implemented separately and may involve addictive opioids. Although there are highly effective, non-pharmacological treatments for PTSD, they are plagued by high dropout, which may be exacerbated by comorbid pain, as these PTSD treatments typically require increased activity. Importantly, a noninvasive pain treatment, tDCS (transcranial direct current stimulation) shows indications of effectiveness and may be integrated with psychological treatments, even when delivered via telehealth. This study examines the feasibility and initial efficacy of integrating home telehealth tDCS with prolonged exposure (PE), an evidence-based PTSD treatment. MATERIALS AND METHODS: Thirty-nine Veterans were contacted, 31 consented to evaluation, 21 were enrolled, and 16 completed treatment and provided pre- and post-treatment data at one of two Veterans Affairs Medical Centers. Transcranial direct current stimulation sessions corresponded with PE exposure assignments, as there is theoretical reason to believe that tDCS may potentiate extinction learning featured in PE. RESULTS: Patients evinced significant improvement in both pain interference and PTSD symptoms and a trend toward improvement in depression symptoms. However, a significant change in pain intensity was not observed, likely because of the small sample size. DISCUSSION: The findings provide initial support for the feasibility of an entirely home-based, integrated treatment for comorbid PTSD and pain.

Individual symptom reduction and post-treatment severity: Varying levels of symptom amelioration in response to prolonged exposure for post-traumatic stress disorder.

Many patients evince significant post-traumatic stress disorder (PTSD) symptoms after a dose of an evidence-based treatment (EBT) for PTSD. Little research systematically addresses if individual PTSD symptoms are more or less resistant to change through an EBT for PTSD or have greater or lesser post-treatment severity levels. Two studies within VA medical centers provided data. Study 1 (n = 81) was drawn from a randomized clinical trial of Prolonged Exposure (PE), an EBT for PTSD. Study 2 (n = 225) was drawn from two PTSD specialty clinics employing PE. Symptoms were assessed pre- and post-treatments via semi-structured clinician interview (Study 1) and patient self-report (Studies 1 and 2). Most individual symptoms reduced about the same amount through the course of treatment except for avoidance, which showed greater reductions. High heterogeneity in post-treatment symptom severity was found with troubled sleep and hypervigilance displaying above average levels, and traumatic amnesia, foreshortened future, and flashbacks displaying below average levels. Method of symptom measurement had a modest impact on results, as semi-structured clinical interview results were moderately more differentiated than self-report measures. Results were generally consistent between an efficacy (i.e., extremely high, potentially artificial methodological control) and effectiveness (i.e., relatively more real world) context. Primary limitation is analysis of single items on semi-structured clinician interview and patient self-report scale when psychometric validation studies did not interpret measures this way. Moreover, DSM-IV criteria for PTSD were assessed. EBT augmentation and new treatment development should focus on further reducing both PTSD symptoms in general and on the specific symptoms of troubled sleep and hypervigilance, which persist to a greater degree. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Technology-enhanced in vivo exposures in Prolonged Exposure for PTSD: A pilot randomized controlled trial.

In vivo exposures (IVEs) are a key component of exposure-based treatments, during which patients approach fear-provoking, yet safe, situations in "real life." This pilot study assessed the use of a wearable technology (Bio Ware) during IVEs to enhance Prolonged Exposure (PE) therapy for PTSD. Bio Ware provides a clinician dashboard with real-time physiological and subjective data for clinicians to use for virtually guided IVEs. Participants (N = 40) were randomized to a Guided group that received standard PE and virtual, clinician-guided IVEs with the Bio Ware device, or a Non-Guided group that received standard PE and used the Bio Ware device on their own for IVEs. Multilevel linear models with bootstrapping were completed on the intent-to-treat (ITT; N = 39) and per-protocol samples (PP; n = 23), defined as completing at least eight sessions of PE and using the Bio Ware system during ≥ 1 IVEs. In the PP sample, there were significant effects of treatment condition (b = -14.55, SE = 1.47, 95% CI [-17.58, -11.78], p < .001) and time (b = -1.98, SE = 0.25, 95% CI [-2.47, -1.48], p < .001). While both groups showed reductions in PTSD symptoms, the Guided group evidenced significantly greater reductions than the Non-Guided group. These findings demonstrate the feasibility and safety of leveraging Bio Ware for virtual, clinician-guided IVEs during PE therapy for PTSD and suggest that virtual, clinician-guided exposures may enhance treatment outcomes. CLINICAL TRIAL REGISTRATION: NCT04471207.

Reduced working memory performance in PTSD and suicide among veterans presenting for treatment.

Suicide is among the leading causes of death in the United States, underscoring the continued need to understand the mechanisms underlying suicide risk. A growing body of research has examined the role of working memory deficits in suicidal thoughts and behaviors (STBs), yet little research has evaluated putative pathways via which working memory impairments may heighten suicide risk. Elevated posttraumatic stress symptoms (PTSS) represent one plausible mechanism through which poor working memory performance may increase STBs. The present study utilized data from 140 treatment-seeking veterans who presented for an intake evaluation in the PTSD Clinical Team of a large VA Medical Center. Veterans completed self-report measures, a semi-structured PTSD evaluation, and a digit span working memory test. In addition to concurrent suicidal ideation assessed during the intake, additional information regarding past suicide attempts, presence of a safety plan, documentation of past suicidal behaviors, and engagement with suicide crisis lines were collected via electronic medical records. Consistent with hypotheses, a significant indirect path emerged such that poor working memory performance predicted greater suicidal ideation, greater likelihood of a past suicide attempt, and greater latent suicide risk via increased PTSS. However, no direct effect of working memory on STBs or indirect paths of PTSS on STBs via working memory emerged. These findings suggest that the relation between working memory and STBs may be explained by PTSS severity.

Improving function through primary care treatment of PTSD: The IMPACT study protocol.

Despite the availability of effective psychological interventions for PTSD, access to and retention in these interventions remains problematic. Of note, the Veterans Health Administration (VHA) developed and implemented post-deployment health surveys that screen for PTSD in primary care (PC), but effective PC-based, psychological intervention treatment options have yet to be established. To address the literal physical gap between where the patients first present for care (i.e., primary care) and where they must go to receive first-line treatment for PTSD (i.e., specialty mental health), study investigators developed a 4-6 visit Prolonged Exposure for Primary Care (PE-PC) treatment that has shown efficacy in reduction of PTSD. To extend previous work to recovery-based mental health care, the Improving Function Through Primary Care Treatment of PTSD (IMPACT) study examined function as assessed by the World Health Organization Disability Assessment Schedule [WHODAS 2.0; (Axelsson, Lindsäter, Ljótsson, Andersson, & Hedman-Lagerlöf, 2017)]. Veterans presenting in VHA primary care mental health integration (PCMHI) clinics with PTSD or significant subsyndromal PTSD who met minimal inclusion and exclusion criteria were randomly assigned to PE-PC or treatment as usual (TAU). If proven effective in improving function, PE-PC would provide a new access point for high quality PTSD care and allow greater numbers of veterans to access effective PTSD treatment. Trial Registration: http://ClinicalTrials.gov: NCT03581981.

Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology.

Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.

Enhancing prolonged exposure therapy for PTSD among veterans with oxytocin: Design of a multisite randomized controlled trial.

Posttraumatic stress disorder (PTSD) is the most highly prevalent mental health disorder among U.S. military Veterans. Prolonged Exposure (PE) therapy is one of the most widely used evidence-based treatments for PTSD, but there is substantial room for improvement in outcomes and retention rates. Accumulating data suggest that oxytocin offers a promising pharmacological approach towards achieving this goal. Therefore, the primary objective of this two-site Phase II study is to examine the ability of oxytocin (vs. placebo) administration combined with PE therapy to (1) reduce PTSD symptom severity, (2) accelerate the rate of PTSD symptom improvement, and (3) improve PE adherence and retention rates. To accomplish these objectives, we will employ a randomized, double-blind, placebo-controlled trial and use standardized, repeated dependent measures of change at five time points (baseline, mid-treatment, end of treatment, and 3 and 6 month follow-up). Intranasal oxytocin (40 IU) will be administered directly prior to each PE therapy session. Findings from this study will provide critical new information regarding the efficacy of oxytocin to augment psychosocial treatment for PTSD, as well as information regarding the physiological mechanisms underlying PTSD and positive treatment response. ClinicalTrials.gov Identifier: NCT04228289.

When chaos is the norm: How some veterans with PTSD are continuing to engage in trauma-focused treatments during the COVID-19 pandemic.

The COVID-19 pandemic has caused many Veterans Healthcare Administration providers working with veterans diagnosed with posttraumatic stress disorder to question the feasibility and appropriateness of continuing to provide trauma-focused treatment during this crisis. The Veterans Healthcare Administration is in a unique position to continue to provide trauma-informed care because of its capacity to offer telemental health services. Data from a Veterans Affairs medical center's posttraumatic stress disorder clinical team suggest that not only are veterans interested in continuing with treatment but also that the treatments can be modified to accommodate the current climate. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Emotional Processing of Imaginal Exposures Predicts Symptom Improvement: Therapist Ratings Can Assess Trajectory in Prolonged Exposure for Posttraumatic Stress Disorder.

Research on mechanisms of change in prolonged exposure therapy (PE), an evidence-based treatment for posttraumatic stress disorder (PTSD), is ongoing. Two putative mechanisms of change are engagement during imaginal exposure and trauma-related belief change. The PE Therapist Questionnaire (PETQ), a novel measure based on the emotional processing theory underlying PE, was developed as a practical tool for therapists to use to assess (a) patient engagement during imaginal exposures and (b) perspective shifts during postimaginal processing. Patients (N = 151) at a U.S. Veterans Affairs medical center PTSD specialty clinic completed self-report measures of PTSD and depression symptoms prior to sessions. Study therapists (n = 17) completed the PETQ postsession. Rational construction and psychometric analyses suggested a two-component solution for the PETQ: imaginal and processing. The imaginal factor did not relate to PTSD and depression symptoms. The processing factor correlated with current and next-session PTSD and depression symptoms, with medium effect sizes, rs = -.41 to -.45, ps < .001. Controlling for current-session PTSD and depression, a higher level of processing predicted lower next-session PTSD severity, with a small effect size, ß = -.38, p < .04. Postexposure emotional processing, which supports positive changes in maladaptive trauma-related beliefs and tolerance of emotional distress, predicted future symptom improvement, highlighting the importance of processing components in PE. Further, the use of therapist observations may offer ancillary methods less influenced by correlation of within-patient subjective ratings and concomitant risk of construct overlap in mechanisms research.

An adjunctive human-animal interaction intervention for veterans with PTSD: study protocol for a randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. METHODS/DESIGN: The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. DISCUSSION: It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. TRIAL REGISTRATION: ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

The efficacy of 90-minute versus 60-minute sessions of prolonged exposure for posttraumatic stress disorder: Design of a randomized controlled trial in active duty military personnel.

OBJECTIVE: Posttraumatic stress disorder (PTSD) can have devastating effects on multiple aspects of functioning. Thus, it is imperative to increase access to evidence-based treatment for PTSD. Prolonged Exposure therapy (PE) has extensive empirical support and is one of the first-line PTSD treatments included in civilian, veteran, and military clinical practice guidelines. However, the standard 90-min PE session format can constitute a significant barrier to its adoption in routine clinical care settings, which typically schedule 60-min appointment sessions. If the length of PE sessions could be reduced from 90 to 60 min without compromising treatment efficacy and efficiency, this would remove a major barrier to PE adoption. METHOD: This paper describes the rationale and methods of a randomized controlled noninferiority trial comparing 90-min versus 60-min PE sessions (including 40- vs. 20-min imaginal exposures, respectively) among 160 active duty military personnel with PTSD. The aims of this study are to: (1) examine the efficacy and efficiency (i.e., rate of symptom improvement) of 90- versus 60-min PE; (2) assess change in psychophysiological markers of treatment response across conditions; and (3) test mechanisms of change underlying the efficacy of PE. RESULTS/CONCLUSIONS: The results of this study will inform dissemination efforts in military, veteran, and civilian sectors. Further, identifying mechanisms of therapeutic change will answer important theoretical questions about how PE works, in order to refine and increase the efficacy and efficiency of PE to better meet the needs of individuals with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl.

The alpha-2 adrenergic receptor antagonist, yohimbine, can facilitate fear extinction in animals and humans. One potential mechanism is increased noradrenergic activity and associated arousal in the presence of conditioned stimuli. Accordingly, yohimbine might augment prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD), where heightened exposure-oriented arousal is a theorized driver and empirical predictor of treatment success. A double-blind placebo-controlled randomized trial (NCT 01031979) piloted yohimbine augmentation in 26 males with combat-related PTSD. Participants were given one-time dose of yohimbine or placebo prior to the first imaginal exposure. Subsequently, both arms completed standard PE. The primary outcome was trauma-cued heart-rate reactivity a week after the drug/exposure visit, a highly specified, objective measure sensitive to incremental change. Secondary outcomes included arousal during the drug/exposure visit and slope of distress, PTSD, and depression over the course of PE. Consistent with hypothesis, yohimbine led to higher objective and subjective arousal during the drug/exposure visit and to lower trauma-cued heart-rate reactivity one-week later. One dose of yohimbine also led to greater between-session habituation and more rapid improvement on depression, but not PTSD, over the course of care. Results of this controlled pilot indicate support for continued investigation of yohimbine-augmented exposure therapy for PTSD.

Hyperarousal Symptoms Explain the Relationship Between Cognitive Complaints and Working Memory Performance in Veterans Seeking PTSD Treatment.

OBJECTIVE: Comorbidity and symptom overlap between traumatic brain injury and posttraumatic stress disorder (PTSD) in veterans returning from deployment present challenges with respect to differential diagnosis and treatment. Both conditions frequently manifest with attention and working memory deficits, though the underlying neuropsychological basis differs. This study evaluated whether hyperarousal symptoms explain the relationship between subjective and objective measures of cognition in a veteran sample. PARTICIPANTS AND PROCEDURES: One-hundred three veterans completed the military version of the PTSD Checklist (PCL), the Neurobehavioral Symptom Inventory, and the Wechsler Memory Scale, 3rd edition digit span task with adequate effort. RESULTS: Hierarchical regression suggested that hyperarousal, but not other PTSD symptoms, explained the relationship between neurobehavioral symptoms and cognitive functioning. This relationship was present regardless of whether veterans met full PTSD diagnostic criteria or screened positive on a traumatic brain injury screener and was robust to other moderators. CONCLUSION: These findings highlight the importance of considering traumatic brain injury and PTSD symptom overlap, particularly the relationship between hyperarousal symptoms and attention and working memory deficits, in conceptualizing cases and treatment planning.

TAKING THE PULSE OF PROLONGED EXPOSURE THERAPY: PHYSIOLOGICAL REACTIVITY TO TRAUMA IMAGERY AS AN OBJECTIVE MEASURE OF TREATMENT RESPONSE.

BACKGROUND: Physiological reactivity to trauma-related cues is a primary symptom of PTSD and can be assessed objectively using script-driven imagery paradigms. However, subjective self-reported symptom measures are the most common outcome indices utilized in PTSD treatment trials and clinic settings. We examined physiological reactivity during a short trauma imagery task as an objective index of response to PTSD treatment, optimized for use in routine clinical care settings. METHODS: Participants were 35 male combat veterans receiving prolonged exposure (PE) therapy in a Veterans Affairs outpatient clinic. In addition to traditional subjective self-reported and clinician-rated symptom measures, patients also completed a script-driven imagery task in which heart rate (HR) and skin conductance (SC) were recorded at three assessment points across treatment. We examined changes in subjective symptom measures and objective trauma-specific physiological reactivity over the course of PE, and investigated the association between pretreatment physiological reactivity and treatment response. RESULTS: Patients who completed PE showed significantly diminished HR and SC reactivity to trauma imagery across therapy. Additionally, individuals showing greater trauma-specific HR reactivity at pretreatment showed greater reductions in subjectively reported PTSD symptoms at posttreatment. CONCLUSIONS: Findings support the utility of physiological reactivity during trauma imagery as an objective outcome measure that has the potential to be incorporated into evidence-based PTSD treatment in routine clinical settings, or prospective studies related to the individualization of care at pretreatment.

Utilizing Telehealth to Support Treatment of Acute Stress Disorder in a Theater of War: Prolonged Exposure via Clinical Videoconferencing.

BACKGROUND: Posttraumatic stress disorder (PTSD) and acute stress disorder are prevalent mental health diagnoses associated with the military operations in Iraq and Afghanistan and are especially significant in service members returning from combat. Prolonged exposure (PE) therapy is a highly effective behavioral treatment for these symptoms, and providing this treatment as soon as possible, even in the midst of a soldier's combat deployment, has strong potential benefits. MATERIALS AND METHODS: In the current case study, telehealth technology was used to support the delivery of PE therapy to treat a service member diagnosed with acute stress disorder in a war zone. PE was conducted face-to-face on the relatively secure Forward Operating Base for the first half of therapy and via clinical videoconferencing (CV) to the service member's remote combat outpost during the later stages of therapy. The service member exhibited marked improvements in symptoms over 10 sessions. RESULTS: Results are consistent with previous empirical findings and highlight the potential benefits of using telehealth to deliver evidenced-based treatment for traumatic stress disorders in a war zone. This case study provides a preliminary working model for delivering PE in a combat environment using multiple delivery systems. CONCLUSIONS: Benefits and clinical utility of CV-delivered exposure therapy are discussed, particularly for providers pending future operational deployments (e.g., including members of the military, independent government agencies, and first responders) and for those treating patients in remote locations.

PTSD in active combat soldiers: to treat or not to treat.

In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.

Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome.

Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.

Health service utilization before and after evidence-based treatment for PTSD.

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.

Affective engagement for facial expressions and emotional scenes: the influence of social anxiety.

Pictures of emotional facial expressions or natural scenes are often used as cues in emotion research. We examined the extent to which these different stimuli engage emotion and attention, and whether the presence of social anxiety symptoms influences responding to facial cues. Sixty participants reporting high or low social anxiety viewed pictures of angry, neutral, and happy faces, as well as violent, neutral, and erotic scenes, while skin conductance and event-related potentials were recorded. Acoustic startle probes were presented throughout picture viewing, and blink magnitude, probe P3 and reaction time to the startle probe also were measured. Results indicated that viewing emotional scenes prompted strong reactions in autonomic, central, and reflex measures, whereas pictures of faces were generally weak elicitors of measurable emotional response. However, higher social anxiety was associated with modest electrodermal changes when viewing angry faces and mild startle potentiation when viewing either angry or smiling faces, compared to neutral. Taken together, pictures of facial expressions do not strongly engage fundamental affective reactions, but these cues appeared to be effective in distinguishing between high and low social anxiety participants, supporting their use in anxiety research.