Publications by authors named "Brett T Litz"

157 Publications

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

J Consult Clin Psychol 2021 May;89(5):476-482

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.

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). Service members ( = 254, mean age 33.11 years, 91% male, 41% Caucasian) were randomized to receive individual or group CPT ( = 106 endorsing and = 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. 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 ≥ .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. 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).
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http://dx.doi.org/10.1037/ccp0000641DOI Listing
May 2021

What the public should know about veterans returning from combat deployment to support reintegration: A qualitative analysis.

Am J Orthopsychiatry 2021 29;91(3):398-406. Epub 2021 Apr 29.

Massachusetts Veterans Epidemiological Research and Information Center.

Consensus reports have called for interventions to educate civilians about the reintegration challenges that veterans experience. The current study describes veterans' perspectives of what the public should know and what the public can do to help veterans reintegrate into civilian life. We conducted thematic analysis of written essays from a stratified random sample of 100 US veterans (half women, half deployed from National Guard or Reserves) from Afghanistan and Iraq military operations who had participated in the control writing condition from a randomized controlled trial of expressive writing to improve reintegration outcomes. Veterans described a military-civilian divide that makes reintegration difficult and recommended that the public help bridge this divide. The divide was attributable to the uniqueness of military culture and bonds, the personal changes associated with deployment, and the time it takes for veterans to reacclimate. Five themes captured what the public can do to foster veteran reintegration: to reintegration. Themes were present across groupings by gender, type of military service and screening status for posttraumatic stress disorder. Findings can inform interventions that target the public's understanding of and response to returning veteran. Consistent with an ecological model of reintegration, such interventions have the potential to foster successful reintegration. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/ort0000541DOI Listing
April 2021

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads.

Fam Process 2021 Apr 20. Epub 2021 Apr 20.

Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.
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http://dx.doi.org/10.1111/famp.12654DOI Listing
April 2021

A Closer Examination of Relational Outcomes from a Pilot Study of Abbreviated, Intensive, Multi-Couple Group Cognitive-Behavioral Conjoint Therapy for PTSD with Military Dyads.

Fam Process 2021 Apr 20. Epub 2021 Apr 20.

Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD) is associated with improvements in patients' PTSD symptoms, partners' psychological distress, and relationship satisfaction. However, little is known about whether CBCT for PTSD is associated with changes in other relationship domains that have theoretical and clinical relevance to the relational context of PTSD. The current study is a secondary analysis of relational outcomes from an uncontrolled, within-group trial designed to examine whether an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered in a retreat during a single weekend was associated with improvements in PTSD symptoms and relationship satisfaction. In this investigation, we examined whether AIM-CBCT for PTSD is also associated with improvements in ineffective arguing, supportive dyadic coping by partner, joint dyadic coping, and partners' accommodation of patients' PTSD symptoms. Participants were 24 couples who included a post-9/11 U.S. service member or veteran with PTSD. At 1- and 3-month follow-up, patients reported significant reductions in couples' ineffective arguing (ds = -.71 and -.78, respectively) and increases in supportive dyadic coping by partners relative to baseline (ds = .50 and .44, respectively). By 3-month follow-up, patients also reported significant increases in couples' joint dyadic coping (d = .57), and partners reported significant reductions in their accommodation of patients' PTSD symptoms (d = -.44). Findings suggest that AIM-CBCT for PTSD is associated with improvements in multiple relationship domains beyond relationship satisfaction but that these may be differentially salient for patients and partners.
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http://dx.doi.org/10.1111/famp.12654DOI Listing
April 2021

Adaptive disclosure, a combat-specific PTSD treatment, versus cognitive-processing therapy, in deployed marines and sailors: A randomized controlled non-inferiority trial.

Psychiatry Res 2021 03 24;297:113761. Epub 2021 Jan 24.

Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, San Diego, CA, United States; Department of Psychiatry, University of California San Diego, San Diego, CA, United States.

Adaptive Disclosure (AD) is a new emotion-focused psychotherapy for combat-related PTSD. As a second step in the evaluation process, we conducted a non-inferiority (NI) trial of AD, relative to Cognitive Processing Therapy - Cognitive Therapy version (CPT-C), an established first-line psychotherapy. Participants were 122 U.S. Marines and Sailors. The primary endpoint was PTSD symptom severity change from pre- to posttreatment, using the Clinician Administered PTSD Scale for DSM-IV. Secondary endpoints were depression (Patient Health Questionnaire-9; PHQ-9) and functioning (Veterans Rand Health Survey-12; VR-12). For cases with complete data, the mean difference in CAPS-IV change scores was 0.33 and the confidence interval (CI) did not include the predefined NI margin (95% CI =-10.10, 9.44). The mean difference in PHQ-9 change scores was -1.01 and the CI did not include the predefined margin (95% CI = -3.31, 1.28), as was the case for the VR-12 Physical Component and VR-12 Mental Component subscale scores (0.27; 95% CI = -4.50, 3.95, and -2.10; 95% CI = -7.03, 2.83, respectively). A series of intent-to-treat sensitivity analyses confirmed these results. The differential effect size for CAPS-IV was d = 0.01 (nonsignificant). As predicted, Adaptive Disclosure was found to be no less effective than a first-line psychotherapy.
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http://dx.doi.org/10.1016/j.psychres.2021.113761DOI Listing
March 2021

Parameters of Aggressive Behavior in a Treatment-Seeking Sample of Military Personnel: A Secondary Analysis of Three Randomized Controlled Trials of Evidence-Based PTSD Treatments.

Behav Ther 2021 01 30;52(1):136-148. Epub 2020 Mar 30.

VA Boston Healthcare System and Boston University School of Medicine.

Aggressive behavior is prevalent among veterans of post-9/11 conflicts who have posttraumatic stress disorder (PTSD). However, little is known about whether PTSD treatments reduce aggression or the direction of the association between changes in PTSD symptoms and aggression in the context of PTSD treatment. We combined data from three clinical trials of evidence-based PTSD treatment in service members (N = 592) to: (1) examine whether PTSD treatment reduces psychological (e.g., verbal behavior) and physical aggression, and; (2) explore temporal associations between aggressive behavior and PTSD. Both psychological (Estimate = -2.20, SE = 0.07) and physical aggression (Estimate = -0.36, SE = 0.05) were significantly reduced from baseline to posttreatment follow-up. Lagged PTSD symptom reduction was not associated with reduced reports of aggression; however, higher baseline PTSD scores were significantly associated with greater reductions in psychological aggression (exclusively; ß = -0.67, 95% CI = -1.05, -0.30, SE = -3.49). Findings reveal that service members receiving PTSD treatment report substantial collateral changes in psychological aggression over time, particularly for participants with greater PTSD symptom severity. Clinicians should consider cotherapies or alternative ways of targeting physical aggression among service members with PTSD and alternative approaches to reduce psychological aggression among service members with relatively low PTSD symptom severity when considering evidence-based PTSD treatments.
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http://dx.doi.org/10.1016/j.beth.2020.03.007DOI Listing
January 2021

The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder.

Psychol Trauma 2020 Nov 19. Epub 2020 Nov 19.

Department of Psychiatry and Behavioral Sciences.

Objective: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy.

Method: We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment.

Results: Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT.

Conclusions: Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000978DOI Listing
November 2020

The effects of web-prolonged exposure among military personnel and veterans with posttraumatic stress disorder.

Psychol Trauma 2020 Nov 19. Epub 2020 Nov 19.

Department of Psychiatry and Behavioral Sciences.

Objective: Web-based treatments address many of the logistical and stigma-related barriers to in-person behavioral health care. Prior studies of web-based treatments for posttraumatic stress disorder (PTSD) did not employ gold-standard treatments and have not compared to in-person therapy.

Method: We compared a web version of Prolonged Exposure Therapy, "Web-PE," to in-person Present-Centered Therapy (PCT) in a randomized controlled trial (RCT) with 40 military personnel with PTSD seeking treatment at Fort Hood, Texas. Due to recruitment challenges, we terminated the RCT and subsequently examined the effects of Web-PE in an uncontrolled open trial with 34 service members and veterans recruited nationwide. Both studies assessed PTSD, depressive symptoms, and health functioning at baseline and 1 and 3 months posttreatment; the RCT also included a 6-month assessment.

Results: Results of the RCT showed no differential impact for Web-PE and PCT, although more PCT participants achieved clinically significant change at one of the follow-up assessments. Both treatment conditions significantly reduced self-reported and blind independent interviewer-assessed symptoms of PTSD. Results of the open trial showed that Web-PE was associated with significant reductions in self-reported PTSD symptoms, with a much larger effect size than in the RCT.

Conclusions: Web-PE significantly reduced PTSD symptoms in both studies, although the reductions in PTSD symptoms were greater among open trial participants, who were specifically seeking a web-based treatment. Future research should evaluate Web-PE relative to another web-based treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000978DOI Listing
November 2020

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

J Trauma Stress 2021 02 19;34(1):210-220. Epub 2020 Oct 19.

Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA.

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale-Interview Version and PTSD Checklist for DSM-5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent-to-treat, mixed-effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges' gs = -0.33 to -1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges' g = -0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges' gs = -0.78 to -0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co-occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.
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http://dx.doi.org/10.1002/jts.22609DOI Listing
February 2021

A Nonrandomized Trial of Prolonged Exposure and Cognitive Processing Therapy for Combat-Related Posttraumatic Stress Disorder in a Deployed Setting.

Behav Ther 2020 11 13;51(6):882-894. Epub 2020 Jan 13.

University of Texas Health Science Center at San Antonio.

For many decades, the U.S. military's general operational guideline has been to limit the use of trauma-focused treatments for combat and operational stress reactions in military service members until they have returned from deployment. Recently, published clinical trials have documented that active-duty military personnel with combat-related posttraumatic stress disorder (PTSD) can be treated effectively in garrison. However, there are limited data on the treatment of combat and operational stress reactions or combat-related PTSD during military deployments. This prospective, nonrandomized trial evaluated the treatment of active-duty service members (N = 12) with combat and operational stress reactions or combat-related PTSD while deployed to Afghanistan or Iraq. Service members were treated by deployed military behavioral health providers using modified Prolonged Exposure (PE; n = 6) or modified Cognitive Processing Therapy (CPT; n = 6), with protocol modifications tailored to individual mission requirements. The PTSD Checklist-Military Version (PCL-M) total score was the primary outcome measure. Results indicated that both groups demonstrated clinically significant change in PTSD symptoms as indicated by a reduction of 10 points or greater on the PCL-M. Participants treated with modified PE had significant reductions in PTSD symptoms, t = -3.83, p = .01; g = -1.32, with a mean reduction of 18.17 points on the PCL-M. Participants treated with modified CPT had a mean PCL-M reduction of 10.00 points, but these reductions were not statistically significant, t = -1.49, p = .12; g = -0.51. These findings provide preliminary evidence that modified forms of PE and CPT can be implemented in deployed settings for the treatment of combat and operational stress reactions and combat-related PTSD.
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http://dx.doi.org/10.1016/j.beth.2020.01.003DOI Listing
November 2020

Manage Emotions to Reduce Aggression: A Pilot Study of a Brief Treatment to Help Veterans Reduce Impulsive Aggression.

J Nerv Ment Dis 2020 11;208(11):897-903

Hope and Healing Center & Institute, Houston.

Veterans with posttraumatic stress disorder (PTSD) report more aggression than civilians with PTSD. Because emotion regulation difficulties mediated the relationship between PTSD symptoms and impulsive aggression in veterans, we developed an intervention to increase emotion regulation skills. This pilot study tested the feasibility and acceptability of a three-session treatment, Manage Emotions to Reduce Aggression (MERA), and examined its effectiveness at reducing aggression and emotion dysregulation. Male combat veterans with PTSD and impulsive aggression completed assessments before and 4 weeks after MERA. Overt Aggression Scale measured frequency of aggression; Difficulties in Emotion Regulation Scale assessed emotion dysregulation. Most veterans (95%) who completed MERA and the posttreatment assessment (n = 20) reported MERA was helpful. Veterans in the intent-to-treat sample demonstrated a significant decrease in their frequency of aggression (Cohen's d = -0.55) and emotion dysregulation (Cohen's d = -0.55). MERA may be an innovative treatment that helps veterans reduce aggression.
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http://dx.doi.org/10.1097/NMD.0000000000001229DOI Listing
November 2020

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

Behav Ther 2020 09 27;51(5):700-714. Epub 2019 Nov 27.

The University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; The University of Texas at San Antonio.

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.
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http://dx.doi.org/10.1016/j.beth.2019.10.003DOI Listing
September 2020

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

Behav Ther 2020 09 27;51(5):700-714. Epub 2019 Nov 27.

The University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; The University of Texas at San Antonio.

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.
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http://dx.doi.org/10.1016/j.beth.2019.10.003DOI Listing
September 2020

PTSD Treatments for Veterans-Reply.

JAMA 2020 07;324(3):301-302

New York University School of Medicine, Center for Alcohol Use Disorder and Posttraumatic Stress Disorder, New York, New York.

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http://dx.doi.org/10.1001/jama.2020.7554DOI Listing
July 2020

Predictors of Cognitive Behavioral Therapy for Insomnia (CBTi) Outcomes in Active-Duty U.S. Army Personnel.

Behav Ther 2020 07 14;51(4):522-534. Epub 2020 Feb 14.

University of Arizona.

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged. The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active-duty service members who received in-person CBTi in a randomized clinical trial. Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI). Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.
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http://dx.doi.org/10.1016/j.beth.2020.02.001DOI Listing
July 2020

Response to Zalta and Held's "Commentary on the Special Issue on Moral Injury: Leveraging Existing Constructs to Test the Heuristic Model of Moral Injury".

Authors:
Brett T Litz

J Trauma Stress 2020 08 1;33(4):600-602. Epub 2020 Jun 1.

VA Boston Healthcare System, Boston University, Boston, Massachusetts, USA.

Zalta and Held (2020) generated some interesting and potentially useful principles to distinguish moral distress and moral injury, leveraging ideas from our introduction to the Journal of Traumatic Stress special issue on moral injury. In this response, I provide feedback and commentary about the principles generated by Zalta and Held. I also attempt to modify and expand the various principles to accommodate any moral emotion and all possible dimensions of response to exposure to potentially morally injurious experiences.
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http://dx.doi.org/10.1002/jts.22514DOI Listing
August 2020

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy.

Behav Ther 2020 05 28;51(3):386-400. Epub 2019 Jun 28.

Duke University Medical Center.

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.
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http://dx.doi.org/10.1016/j.beth.2019.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233479PMC
May 2020

Sleep problems in active duty military personnel seeking treatment for posttraumatic stress disorder: presence, change, and impact on outcomes.

Sleep 2020 10;43(10)

Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.

Study Objectives: To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder (PTSD). Explore sleep-related predictors of outcomes.

Methods: Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed.

Results: At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments.

Conclusions: Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients.

Clinical Trial Registration: NCT01049516.
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http://dx.doi.org/10.1093/sleep/zsaa065DOI Listing
October 2020

First-line Psychotherapies for Military-Related PTSD.

JAMA 2020 02;323(7):656-657

Center for Alcohol Use Disorder and Posttraumatic Stress Disorder, Steven and Alexandra Cohen Veterans Center for Posttraumatic Stress and Traumatic Brain Injury, New York University School of Medicine, New York.

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http://dx.doi.org/10.1001/jama.2019.20825DOI Listing
February 2020

A pilot randomized controlled trial of cognitive behavioral treatment for trauma-related nightmares in active duty military personnel.

J Clin Sleep Med 2020 01 26;16(1):29-40. Epub 2019 Nov 26.

Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas.

Study Objectives: The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares.

Methods: Forty participants were randomized to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, posttreatment/postcontrol, and 1-month follow-up.

Results: Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51). In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), posttraumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up. Participants generally endorsed medium to high ratings of treatment credibility and expectancy. The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians.

Conclusions: ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia. Participants considered ERRT-M to be credible. An adequately powered randomized clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control.

Clinical Trial Registration: Registry: ClinicalTrials.gov; Title: A Pilot Randomized Controlled Trial of Treatment for Trauma-Related Nightmares In Active Duty Military Personnel; Identifier: NCT02506595; URL: https://clinicaltrials.gov/ct2/show/NCT02506595.
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http://dx.doi.org/10.5664/jcsm.8116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7053000PMC
January 2020

Study design comparing written exposure therapy to cognitive processing therapy for PTSD among military service members: A noninferiority trial.

Contemp Clin Trials Commun 2020 Mar 10;17:100507. Epub 2019 Dec 10.

University of Texas Health Science Center at San Antonio, Department of Psychiatry, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.

Although there are a number of effective treatments for posttraumatic stress disorder (PTSD), there is a need to develop more efficient evidence-based PTSD treatments to address barriers to seeking and receiving treatment. Written exposure therapy (WET) is a potential alternative that is a 5-session treatment without any between-session assignments. WET has demonstrated efficacy, and low treatment dropout rates. However, prior studies with WET have primarily focused on civilian samples. Identifying efficient PTSD treatments for military service members is critical given the high prevalence of PTSD in this population. The current ongoing randomized clinical trial builds upon the existing literature by investigating whether WET is equally efficacious as Cognitive Processing Therapy (CPT) in a sample of 150 active duty military service members diagnosed with PTSD who are randomly assigned to either WET ( = 75) or CPT ( = 75). Participants are assessed at baseline and 10, 20, and 30 weeks after the first treatment session. The primary outcome measure is PTSD symptom severity assessed with the Clinician Administered PTSD Scale for . Given the prevalence of PTSD and the aforementioned limitations of currently available first-line PTSD treatments, the identification of a brief, efficacious treatment that is associated with reduced patient dropout would represent a significant public health development.
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http://dx.doi.org/10.1016/j.conctc.2019.100507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926127PMC
March 2020

The Inclusion of Mefloquine Exposure as a Common Data Element in Studies by the Consortium to Alleviate PTSD.

Mil Med 2020 02;185(1-2):17-18

Massachusetts Veterans Epidemiology Research and Information Center, MAVERIC, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130.

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http://dx.doi.org/10.1093/milmed/usz345DOI Listing
February 2020

Trauma-Related Cognitions and Cognitive Emotion Regulation as Mediators of PTSD Change Among Treatment-Seeking Active-Duty Military Personnel With PTSD.

Behav Ther 2019 11 5;50(6):1053-1062. Epub 2019 Apr 5.

University of Pennsylvania School of Medicine.

Trauma-related cognitions about the self and the world have been identified as a mediator of posttraumatic stress disorder (PTSD) change during prolonged exposure (PE) therapy. However, the extent to which negative cognitions mediate PTSD change in other PTSD treatments is unclear. In addition, previous studies have not tested alternate mediators of PTSD change during PE. In a sample of 216 treatment-seeking active-duty military personnel with PTSD, the present study examined the specificity of the negative cognition mediation effect in both PE and present-centered therapy (PCT). In addition, we examined another possible mediator, cognitive emotion regulation. Lagged mediational analyses indicated that negative cognitions about the self and world and the unhelpful cognitive emotion regulation strategy of catastrophizing each significantly mediated change in PTSD from baseline to 6-month follow-up. In a combined model, the mediating effect of catastrophizing was greater than negative cognitions about the world, and similar to negative cognitions about the self. Moderated mediation analyses revealed that the effect of catastrophizing was greater in PE than in PCT. Findings show that trauma-related cognitions and, to a greater degree, the emotion regulation strategy catastrophizing, both mediate PTSD change. Further research is needed to determine whether these mediating variables represent mechanisms of therapeutic change.
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http://dx.doi.org/10.1016/j.beth.2019.03.006DOI Listing
November 2019

Changes in anger and aggression after treatment for PTSD in active duty military.

J Clin Psychol 2020 03 16;76(3):493-507. Epub 2019 Nov 16.

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Objective: To examine whether treating posttraumatic stress disorder (PTSD) reduces anger and aggression and if changes in PTSD symptoms are associated with changes in anger and aggression.

Method: Active duty service members (n = 374) seeking PTSD treatment in two randomized clinical trials completed a pretreatment assessment, 12 treatment sessions, and a posttreatment assessment. Outcomes included the Revised Conflict Tactics Scale and state anger subscale of the State-Trait Anger Expression Inventory.

Results: Treatment groups were analyzed together. There were small to moderate pretreatment to posttreatment reductions in anger (standardized mean difference [SMD] = -0.25), psychological aggression (SMD = -0.43), and physical aggression (SMD = -0.25). The majority of participants continued to endorse anger and aggression at posttreatment. Changes in PTSD symptoms were mildly to moderately associated with changes in anger and aggression.

Conclusions: PTSD treatments reduced anger and aggression with effects similar to anger and aggression treatments; innovative psychotherapies are needed.
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http://dx.doi.org/10.1002/jclp.22878DOI Listing
March 2020

A resting-state network comparison of combat-related PTSD with combat-exposed and civilian controls.

Soc Cogn Affect Neurosci 2019 09;14(9):933-945

Research Imaging Institute, University of Texas Health Science Center, San Antonio, TX 78229, USA.

Resting-state functional connectivity (rsFC) is an emerging means of understanding the neurobiology of combat-related post-traumatic stress disorder (PTSD). However, most rsFC studies to date have limited focus to cognitively related intrinsic connectivity networks (ICNs), have not applied data-driven methodologies or have disregarded the effect of combat exposure. In this study, we predicted that group independent component analysis (GICA) would reveal group-wise differences in rsFC across 50 active duty service members with PTSD, 28 combat-exposed controls (CEC), and 25 civilian controls without trauma exposure (CC). Intranetwork connectivity differences were identified across 11 ICNs, yet combat-exposed groups were indistinguishable in PTSD vs CEC contrasts. Both PTSD and CEC demonstrated anatomically diffuse differences in the Auditory Vigilance and Sensorimotor networks compared to CC. However, intranetwork connectivity in a subset of three regions was associated with PTSD symptom severity among executive (left insula; ventral anterior cingulate) and right Fronto-Parietal (perigenual cingulate) networks. Furthermore, we found that increased temporal synchronization among visuospatial and sensorimotor networks was associated with worse avoidance symptoms in PTSD. Longitudinal neuroimaging studies in combat-exposed cohorts can further parse PTSD-related, combat stress-related or adaptive rsFC changes ensuing from combat.
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http://dx.doi.org/10.1093/scan/nsz072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6917024PMC
September 2019

Patterns and predictors of change in trauma-focused treatments for war-related posttraumatic stress disorder.

J Consult Clin Psychol 2019 Nov 26;87(11):1019-1029. Epub 2019 Sep 26.

University of Texas Health Science Center at San Antonio.

Objective: We evaluated patterns and predictors of change from three efficacy trials of trauma-focused cognitive-behavioral treatments (TF-CBT) among service members (N = 702; mean age = 32.88; 89.4% male; 79.8% non-Hispanic/Latino). Rates of clinically significant change were also compared with other trials.

Method: The trials were conducted in the same setting with identical measures. The primary outcome was symptom severity scores on the PTSD Symptom Scale-Interview Version (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993).

Results: Symptom change was best explained by baseline scores and individual slopes. TF-CBT was not associated with better slope change relative to Present-Centered Therapy, a comparison arm in 2 trials. Lower baseline scores (β = .33, p < .01) and higher ratings of treatment credibility (β = -.22, p < .01) and expectancy for change (β = -.16, p < .01) were associated with greater symptom change. Older service members also responded less well to treatment (β = .09, p < .05). Based on the Jacobson and Truax (1991) metric for clinically significant change, 31% of trial participants either recovered or improved.

Conclusions: Clinicians should individually tailor treatment for service members with high baseline symptoms, older patients, and those with low levels of credibility and expectancy for change. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ccp0000426DOI Listing
November 2019

Depression Suppresses Treatment Response for Traumatic Loss-Related Posttraumatic Stress Disorder in Active Duty Military Personnel.

J Trauma Stress 2019 10 28;32(5):774-783. Epub 2019 Aug 28.

Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.

There are multiple well-established evidence-based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat-related PTSD in military populations is less responsive to evidence-based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment-related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss-related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss-related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = -4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss-related PTSD, B = 3.75. These findings suggest that evidence-based treatments for PTSD should better accommodate loss and grief in military populations.
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http://dx.doi.org/10.1002/jts.22441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800580PMC
October 2019

Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel.

J Trauma Stress 2019 08 29;32(4):616-624. Epub 2019 Jul 29.

Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.
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http://dx.doi.org/10.1002/jts.22416DOI Listing
August 2019

Conceptualizing comorbid PTSD and depression among treatment-seeking, active duty military service members.

J Affect Disord 2019 09 30;256:541-549. Epub 2019 Jun 30.

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.

Background: Among active duty service members and veterans with PTSD, depression is the most commonly diagnosed comorbid psychiatric condition. More research is warranted to investigate the relationship between PTSD and depression to improve treatment approaches. Byllesby et al. (2017) used confirmatory factor analyses in a sample of trauma-exposed combat veterans with PTSD and found that only the general distress factor, and not any specific symptom cluster of PTSD, predicted depression. This study seeks to replicate Byllesby et al. (2017) in a sample of treatment-seeking active duty soldiers.

Methods: Confirmatory factor analyses, bifactor modeling, and structural equation modeling (SEM) were used with data gathered at pretreatment and posttreatment as part of a large randomized clinical trial.

Results: Confirmatory factor analyses and bifactor modeling demonstrated that PTSD symptom clusters, Negative Alterations in Cognition and Mood (NACM) and Alterations in Arousal and Reactivity (AAR), as well as the general distress factor significantly predicted depression at pretreatment and posttreatment.

Limitations: The current study was predominantly male, limiting the generalizability to female service members with PTSD. Also, self-report measures were used, which may introduce response-bias.

Conclusions: The current study did not replicate Byllesby et al. (2017). Results demonstrated that the relationship between PTSD and depression among active duty service members can be explained by both transdiagnostic factors and disorder-specific symptoms.
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http://dx.doi.org/10.1016/j.jad.2019.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750963PMC
September 2019

Conceptualizing comorbid PTSD and depression among treatment-seeking, active duty military service members.

J Affect Disord 2019 09 30;256:541-549. Epub 2019 Jun 30.

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.

Background: Among active duty service members and veterans with PTSD, depression is the most commonly diagnosed comorbid psychiatric condition. More research is warranted to investigate the relationship between PTSD and depression to improve treatment approaches. Byllesby et al. (2017) used confirmatory factor analyses in a sample of trauma-exposed combat veterans with PTSD and found that only the general distress factor, and not any specific symptom cluster of PTSD, predicted depression. This study seeks to replicate Byllesby et al. (2017) in a sample of treatment-seeking active duty soldiers.

Methods: Confirmatory factor analyses, bifactor modeling, and structural equation modeling (SEM) were used with data gathered at pretreatment and posttreatment as part of a large randomized clinical trial.

Results: Confirmatory factor analyses and bifactor modeling demonstrated that PTSD symptom clusters, Negative Alterations in Cognition and Mood (NACM) and Alterations in Arousal and Reactivity (AAR), as well as the general distress factor significantly predicted depression at pretreatment and posttreatment.

Limitations: The current study was predominantly male, limiting the generalizability to female service members with PTSD. Also, self-report measures were used, which may introduce response-bias.

Conclusions: The current study did not replicate Byllesby et al. (2017). Results demonstrated that the relationship between PTSD and depression among active duty service members can be explained by both transdiagnostic factors and disorder-specific symptoms.
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http://dx.doi.org/10.1016/j.jad.2019.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750963PMC
September 2019
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