Cognitive-behavioural conjoint therapy versus prolonged exposure for PTSD in military service members and veterans: results and lessons from a randomized controlled trial.

Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive-Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders - provider's treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.

Differential dropout from trial of couple versus individual therapy for PTSD.General pattern of improvements in relationship outcomes in couple therapy for PTSD.PTSD symptoms improved in the individual and couple therapy for PTSD.Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout by condition on trial analyses are discussed.

Pretreatment relationship characteristics predict outcomes from an uncontrolled trial of intensive, multicouple group PTSD treatment.

Cognitive behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is associated with improvements in patients' and partners' mental health and relationship satisfaction. Some pretreatment relationship characteristics have predicted CBCT for PTSD outcomes for patients, but findings were limited to a single community sample consisting primarily of female patients with male partners. A better understanding of whether pretreatment relationship characteristics predict outcomes in other patient populations and whether there are partners who may be particularly responsive to couple therapy for PTSD could optimize treatment matching. This study investigated whether pretreatment partner accommodation and relationship satisfaction predicted patient and partner treatment outcomes from an uncontrolled trial of an abbreviated, intensive, multicouple group version of CBCT for PTSD conducted with 24 active-duty military or veteran couples (96% male patients/female partners). In general, changes in patients' PTSD and comorbid symptoms and relationship satisfaction did not vary by pretreatment partner accommodation or patients' own pretreatment relationship satisfaction. In contrast, pretreatment relationship characteristics predicted partner outcomes. Partners who engaged in higher levels of accommodation pretreatment and partners who reported lower levels of pretreatment relationship satisfaction experienced greater declines in psychological distress following treatment. Also, partners who began the study relationally distressed exhibited significant increases in relationship satisfaction following treatment, whereas those who were not relationally distressed did not. Findings suggest that improvements generally do not vary by pretreatment relationship characteristics for patients, whereas partners who begin treatment with elevated relationship risk factors may be especially likely to experience improvement across outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A dynamical systems analysis of change in PTSD symptoms, depression symptoms, and suicidal ideation among military personnel during treatment for PTSD.

OBJECTIVE: The connections among posttraumatic stress disorder (PTSD), depression, and suicidal ideation are elusive because of an overreliance on cross-sectional studies. In this secondary analysis of pooled data from three clinical trials of 742 military personnel, we examined the dynamic relationships among PTSD, depression, and suicidal ideation severity assessed repeatedly during and after outpatient treatment for PTSD. METHODS: We conducted dynamical systems analyses to explore the potential for coordinated change over time in psychotherapy for PTSD. RESULTS: Over the course of psychotherapy, PTSD, depression, and suicidal ideation severity changed in coordinated ways, consistent with an interdependent network. Results of eigenvalue decomposition analysis indicated the dominant change dynamic involved high stability and resistance to change but indicators of cycling were also observed, indicating participants "switched" between states that resisted change and states that promoted change. Depression (B = 0.48, SE = 0.11) and suicidal desire (B = 0.15, SE = 0.01) at a given assessment were associated with greater change in PTSD symptom severity at the next assessment. Suicidal desire (B = 0.001, SE < 0.001) at a given assessment was associated with greater change in depression symptom severity at the next assessment. Neither PTSD (B = -0.004, SE = 0.007) nor depression symptom severity (B = 0.000, SE = 0.001) was associated with subsequent change in suicidal ideation severity. CONCLUSIONS: In a sample of treatment-seeking military personnel with PTSD, change in suicidal ideation and depression may precede change in PTSD symptoms but change in suicidal ideation was not preceded by change in PTSD or depression symptoms.

Aerobic exercise improves sleep in U. S. active duty service members following brief treatment for posttraumatic stress disorder symptoms.

Introduction: Physical exercise is a lifestyle intervention that can positively impact aspects of physical and psychological health. There is a growing body of evidence suggesting that physical exercise, sleep, and PTSD are interrelated. This study investigated possible relationships. Three research questions were posed: (1) Did randomization to an aerobic exercise intervention reduce insomnia more than being randomized to an intervention without exercise, (2) Did change in sleep predict change in PTSD symptoms, and (3) Did change in sleep impact the relationship between exercise and PTSD symptom reductions? Methods: Data were collected from 69 treatment-seeking active duty service members with PTSD symptoms randomized into one of four conditions; two conditions included aerobic exercise, and two conditions did not include exercise. Participants in the exercise groups exercised five times per week keeping their heart rate > 60% of their heart rate reserve for 20-25 min. Results: At baseline, 58% of participants reported moderate or severe insomnia. PTSD symptom severity decreased following treatment for all groups (p < 0.001). Participants randomized to exercise reported greater reductions in insomnia compared to those in the no exercise group (p = 0.47). However, change in insomnia did not predict change in PTSD symptoms nor did it significantly impact the relationship between exercise and PTSD symptom reductions. Discussion: Adding exercise to evidence-based treatments for PTSD could reduce sleep disturbance, a characteristic of PTSD not directly addressed with behavioral therapies. A better understanding of exercise as a lifestyle intervention that can reduce PTSD symptoms and insomnia is warranted.

DSM-5 criterion-a-based trauma types in service members and veterans seeking treatment for posttraumatic stress disorder.

OBJECTIVE: In posttraumatic stress disorder (PTSD), the assumption of the equipotentiality of traumas ignores potentially unique contexts and consequences of different traumas. Accordingly, Stein et al. (2012) developed a reliable typing scheme in which assessors categorized descriptions of traumatic events into six "types": life threat to self (LTS), life threat to other, aftermath of violence (AV), traumatic loss, moral injury by self (MIS), and moral injury by other (MIO). We extended this research by validating the typing scheme using participant endorsements of type, rather than assesor-based types. We examined the concordance of participant and assesor types, frequency, and validity of participant-based trauma types by examining associations with baseline mental and behavioral health problems. METHOD: Interviewers enrolled military personnel and veterans (N = 1,443) in clinical trials of PTSD and helped them select the most currently distressing Criterion-A trauma. Participants and, archivally, assessors typed the distressing aspect(s) of this experience. RESULTS: AV was the most frequently participant-endorsed type, but LTS was the most frequently rated worst part of an event. Although participants endorsed MIS and MIO the least frequently, these were associated with worse mental and behavioral health problems. The agreement between participants and assessors regarding the worst part of the event was poor. CONCLUSION: Because of discrepancies between participant and assessor typologies, clinical researchers should use participants' ratings, and these should trump assessor judgment. Differences in pretreatment behavioral and mental health problems across some participant-endorsed trauma types partially support the validity of the participant ratings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial.

STUDY OBJECTIVES: Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment. METHODS: In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment. RESULTS: Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment. CONCLUSIONS: Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561. CITATION: Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview-Short Form Among U.S. Active Duty Military Service Members and Veterans.

We assessed the interrater reliability, convergent validity, and discriminant validity of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF) in a sample of 1,944 active duty service members and veterans seeking services for posttraumatic stress disorder (PTSD) and related conditions. The SITBI-SF demonstrated high interrater reliability and good convergent and discriminant validity. The measurement properties of the SITBI-SF were comparable across service members and veterans. Approximately 8% of participants who denied a history of suicidal ideation on the SITBI-SF reported suicidal ideation on a separate self-report questionnaire (i.e., discordant responders). Discordant responders reported significantly higher levels of PTSD symptoms than those who denied suicidal ideation on both response formats. Findings suggest that the SITBI-SF is a reliable and valid interview-based measure of suicide-related thoughts and behaviors for use with military service members and veterans. Suicide risk assessment might be optimized if the SITBI-SF interview is combined with a self-report measure of related constructs.

Hyperarousal symptoms linger after successful PTSD treatment in active duty military.

OBJECTIVE: Evidence-based psychotherapies are efficacious at reducing posttraumatic stress disorder (PTSD) symptoms, but military and veteran samples improve less than civilians. The objective of this secondary analysis of two clinical trials of cognitive processing therapy (CPT) was to determine if hyperarousal symptoms were more resistant to change compared with other PTSD symptom clusters in active duty service members. METHOD: Service members completed the PTSD Checklist for the DSM-5 (PCL-5) pre- and post-CPT. Symptoms were coded present if rated 2 (moderate) or higher on a 0-4 scale. Cutoffs for reliable and clinically significant change classified 21%, 18%, and 61% of participants as recovered, improved, and suboptimal responders, respectively. Data analyses focused on the posttreatment status of symptoms that were present at baseline to determine their persistence as a function of treatment outcome. Generalized linear mixed effects models with items treated as a repeated measure estimated the proportions who continued to endorse each symptom and compared hyperarousal symptoms with symptoms in other clusters. RESULTS: Among improved participants, the average hyperarousal symptom was present in 69% compared with 49% for symptoms in other clusters (p < .0001). Among recovered patients, hyperarousal symptoms were present for 26%, while symptoms in the reexperiencing (2%), avoidance (3%), and negative alterations (4%) clusters were almost nonexistent (p < .0001). CONCLUSIONS: Even among service members who recovered from PTSD after CPT, a significant minority continue to report hyperarousal symptoms while other symptoms remit. Hyperarousal symptoms may require additional treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Veteran Suicide: Missed Opportunities for Suicide Prevention Within Concealed Pistol License Curriculum.

INTRODUCTION: Veteran suicide is a growing topic for public health concern. Despite enhancements from the Department of Veterans Health Administration, clinicians continue to struggle to identify and engage veterans at risk for suicide. MATERIALS AND METHODS: Examining suicide prevention efforts, epidemiology, risk factors, and barriers to care; Substance Abuse and Mental Health Services Administration and the U.S. Department of Veterans Affairs Governor's Challenges identified lethal means as one of 3 priority areas to focus on in during this agenda. RESULTS: The writers identified gaps within the current literature as an area for future research on lethal means within the veteran population and opportunity for intervention with concealed pistol license curriculum. CONCLUSION: This article ends with recommendations for further research on veteran suicides, acquisition of concealed pistol licenses, and advocacy for legislative change to require suicide prevention resources and education to be included in the training curriculum for concealed pistol license holders.

Prevalence of Fibromyalgia Syndrome in Active-Duty Military Personnel.

OBJECTIVE: Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. METHODS: Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist-Stressor-Specific Version, the PTSD Symptom Scale-Interview, and the 2012 American College of Rheumatology FM questionnaire. RESULTS: Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%. CONCLUSION: The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM.

Treatment responder status and time to response as a function of hazardous drinking among active-duty military receiving variable-length cognitive processing therapy for posttraumatic stress disorder.

OBJECTIVE: A common concern is whether individuals with posttraumatic stress disorder (PTSD) and hazardous drinking will respond to PTSD treatment or need a higher dose. In a sample of active-duty military, we examined the impact of hazardous drinking on cognitive processing therapy (CPT) outcomes and whether number of sessions to reach good end-state or dropout differed by drinking status. METHOD: Participants included 127 service members participating in a clinical trial of variable-length CPT. The Quick Drinking Screen was used to characterize drinking. Participants were categorized as treatment responders when they reached good end-state (<20 on the PTSD Checklist for DSM-5) or nonresponders if they completed 24 sessions or 18 weeks of treatment without good end-state. Survival analyses were used to compare time to dropout or good end-state between those with and without hazardous drinking. RESULTS: Those with hazardous drinking were as likely as those without to reach good end-state and no more likely to drop out. There were no differences in number of sessions to reach good end-state or dropout. On a gold-standard assessment, those with hazardous drinking evidenced more PTSD symptom reduction than those without. The overall proportion of participants with hazardous drinking decreased (30.7% to 18.6%), as did mean number of drinks per drinking day and drinks on the heaviest drinking day among those initially drinking hazardously. CONCLUSIONS: Results support using CPT for military personnel with PTSD and hazardous drinking and indicate that those with hazardous drinking can benefit from PTSD treatment without additional treatment sessions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The impact of prior head injury on outcomes following group and individual cognitive processing therapy among military personnel.

This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment-related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non-HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p < .001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p < .001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p = .060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p = .003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings.

Perceptions and experiences of web-prolonged exposure for posttraumatic stress disorder: A mixed-methods study.

OBJECTIVE: Web-based prolonged exposure therapy (Web-PE) has potential to increase the reach of effective posttraumatic stress disorder (PTSD) treatment. While there is initial support for the efficacy of Web-PE, no studies have examined the perceptions and experiences of participants receiving PE in this novel, Web based format. METHOD: We used a mixed-methods convergent design to examine and integrate quantitative and qualitative data of participant perceptions and experiences of Web-PE. Treatment-seeking active duty military personnel or veterans (N = 29) who received Web-PE completed posttreatment surveys about perceptions of Web-PE and a brief qualitative interview. Thematic coding was used to identify qualitative themes, which were integrated with quantitative data in a joint display. RESULTS: Although many were initially skeptical of experiencing benefit, participants reported that Web-PE was helpful. They appreciated the flexibility of online therapy and reported that self-motivation was important for engagement. Web-PE therapists were well-regarded, although additional therapist support and technical improvements to the Web-PE program were suggested. Scores on the perceptions of Web-PE survey, PTSD survey, and other quantitative data corroborated the qualitative themes. CONCLUSION: Perceptions and experience of Web-PE are favorable and help to highlight the strengths (e.g., flexibility) and challenges (e.g., requiring self-motivation) associated with Web-treatment for PTSD. The results of this study may inform further development of Web-PE or other Web-based treatment programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Testing the role of aerobic exercise in the treatment of posttraumatic stress disorder (PTSD) symptoms in U.S. active duty military personnel: a pilot study.

The purpose of this pilot study was to determine if the efficacy of imaginal exposure for symptoms of posttraumatic stress disorder (PTSD) could be improved by adding aerobic exercise. We hypothesized that aerobic exercise would enhance the efficacy of exposure therapy. Active duty service members with clinically significant symptoms of posttraumatic stress (PTSD Checklist-Stressor-Specific Version, [PCL-S], ≥25) were randomized into one of four conditions: exercise only; imaginal exposure only; imaginal exposure plus exercise; no exercise/no exposure therapy (control). Participants (N = 72) were primarily male, Army, noncommissioned officers ranging in age from 22 to 52. PTSD symptom severity decreased over time (p < .0001); however, there were no significant differences between the experimental conditions. The prediction that imaginal exposure augmented with aerobic exercise would be superior to either imaginal exposure alone or aerobic exercise alone was not supported, suggesting that engaging in exercise and imaginal exposure simultaneously may not be any better than engaging in either activity alone. A better understanding of individually administered and combined exercise and exposure therapy interventions for PTSD is warranted.

Secondary individual outcomes following multicouple group therapy for posttraumatic stress disorder: An uncontrolled pilot study with military dyads.

Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIM-CBCT for PTSD wasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds = -0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions in maladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia.

Temporal-dimensional examination of the Scale for Suicidal Ideation in a cohort of service members in treatment for PTSD.

OBJECTIVE: Failing to account for temporal dynamics can hinder our understanding of suicidal ideation and the potential mechanisms underlying increased risk for suicide death and suicide attempts associated with posttraumatic stress disorder (PTSD). To address these limitations, this study used an analytic approach based on Dynamical Systems Theory to describe temporal patterns associated with multiple dimensions of suicidal ideation in a treatment-seeking sample of military personnel diagnosed with PTSD. METHOD: We performed a secondary analysis of archived data from 742 active-duty military personnel (90% male, 57% white, mean age = 33 ± 7.4 years) enrolled in three clinical trials to examine the dimensional measurement properties of the first 5 items of the Scale for Suicidal Ideation (SSI). RESULTS: Findings indicated two change dynamics for suicidal ideation: homeostatic (i.e., the tendency for suicidal ideation to return to a stable point) and cyclical (i.e., the tendency for suicidal ideation to switch back and forth between higher and lower values). Cycling was the dominant dynamic and was related to variables other from suicidal ideation. CONCLUSION: The cyclic nature of suicidal ideation suggests that assessment timing and context could influence observed associations with other variables. Analytic approaches and clinical methods that do not account for the temporal dynamics of suicide risk could miss these properties, thereby hindering efforts to identify mechanisms underlying the relationship between PTSD and suicidal thoughts and behaviors and limiting opportunities for proactive and timely intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Efficacy of individual and group cognitive processing therapy for military personnel with and without child abuse histories.

Objective: Many clinicians question whether patients with a history of childhood trauma will benefit from trauma-focused treatment. In this secondary analysis, we examined whether reports of childhood abuse moderated the efficacy of cognitive processing therapy (CPT) for active-duty military with posttraumatic stress disorder (PTSD). Methods: Service members (N = 254, mean age 33.11 years, 91% male, 41% Caucasian) were randomized to receive individual or group CPT (n = 106 endorsing and n = 148 not endorsing history of childhood abuse). Outcomes included baseline cognitive-emotional characteristics [Posttraumatic Cognitions Inventory (PTCI), Trauma-Related Guilt Inventory (TRGI), Cognitive Emotion Regulation Questionnaire-Short Form (CERQ)], treatment completion, and symptom outcome (PTSD Checklist, Beck Depression Inventory-II). We predicted participants endorsing childhood abuse would have higher scores on the PTCI, TRGI, and CERQ at baseline, but be noninferior on treatment completion and change in PTSD and depression symptoms. We also predicted those endorsing childhood abuse would do better in individual CPT than those not endorsing abuse. Results: Those endorsing childhood abuse primarily experienced physical abuse. There were no baseline differences between service members with and without a history of childhood abuse (all p ≥ .07). Collapsed across treatment arms, treatment completion and symptom reduction were within the noninferiority margins for those endorsing versus not endorsing childhood abuse. History of abuse did not moderate response to individual versus group CPT. Conclusions: In this primarily male, primarily physically abused sample, active-duty military personnel with PTSD who endorsed childhood abuse benefitted as much as those who did not endorse abuse. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy.

Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.