Publications by authors named "Patricia A Resick"

183 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

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.

Behav Ther 2021 05 12;52(3):656-672. Epub 2020 Sep 12.

Duke University Medical Center.

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.
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http://dx.doi.org/10.1016/j.beth.2020.08.005DOI Listing
May 2021

Variable-length Cognitive Processing Therapy for posttraumatic stress disorder in active duty military: Outcomes and predictors.

Behav Res Ther 2021 06 25;141:103846. Epub 2021 Mar 25.

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

Cognitive Processing Therapy (CPT) is an evidence-based therapy recommended for posttraumatic stress disorder (PTSD). However, rates of improvement and remission are lower in veterans and active duty military compared to civilians. Although CPT was developed as a 12-session therapy, varying the number of sessions based on patient response has improved outcomes in a civilian study. This paper describes outcomes of a clinical trial of variable-length CPT among an active duty sample. Aims were to determine if service members would benefit from varying the dose of treatment and identify predictors of treatment length needed to reach good end-state (PTSD Checklist-5 ≤ 19). This was a within-subjects trial in which all participants received CPT (N = 127). Predictor variables included demographic, symptom, and trauma-related variables; internalizing/externalizing personality traits; and readiness for change. Varying treatment length resulted in more patients achieving good end-state. Best predictors of nonresponse or needing longer treatment were pretreatment depression and PTSD severity, internalizing temperament, being in precontemplation stage of readiness for change, and African American race. Controlling for differences in demographics and initial PTSD symptom severity, the outcomes using a variable-length CPT protocol were superior to the outcomes of a prior study using a fixed, 12-session CPT protocol. CLINICALTRIALS.GOV IDENTIFIER: NCT023818.
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http://dx.doi.org/10.1016/j.brat.2021.103846DOI Listing
June 2021

Cognitive Processing Therapy for Substance-Involved Sexual Assault: Does an Account Help or Hinder Recovery?

J Trauma Stress 2021 Apr 5. Epub 2021 Apr 5.

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

Sexual assault (SA) often occurs in the context of substances, which can impair the trauma memory and contribute to negative cognitions like self-blame. Although these factors may affect posttraumatic stress disorder (PTSD) treatment, outcomes for substance-involved SA have not been evaluated or compared with other types of SA. As such, we conducted a secondary analysis of a dismantling trial for cognitive processing therapy (CPT), focusing on 58 women with an index trauma of SA that occurred since age 14. Women who experienced a substance-involved SA (n = 21) were compared with those who experienced a non-substance-involved SA (n = 37). Participants were randomized to CPT, CPT with written account (CPT+A), or written account only (WA). Regressions controlling for pretreatment symptom levels revealed no differences by SA type in PTSD severity at posttreatment. At 6-month follow-up, substance-involved SA was associated with more severe residual PTSD severity than non-substance-involved SA, with no significant differences by treatment condition. Among participants in the substance-involved SA group, the largest effect for reduced PTSD symptom severity from pretreatment to follow-up emerged in the CPT condition, d = -2.02, with reductions also observed in the CPT+A, d = -0.92, and WA groups, d = -1.23. Although more research in larger samples is needed, these preliminary findings suggest that following substance-involved SA, a cognitive treatment approach without a trauma account may facilitate lasting change in PTSD symptoms. We encourage replications to better understand the relative value of cognitive and exposure-based treatment for PTSD following substance-involved SAs.
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http://dx.doi.org/10.1002/jts.22674DOI Listing
April 2021

Cognitive Processing Therapy for Substance-Involved Sexual Assault: Does an Account Help or Hinder Recovery?

J Trauma Stress 2021 Apr 5. Epub 2021 Apr 5.

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

Sexual assault (SA) often occurs in the context of substances, which can impair the trauma memory and contribute to negative cognitions like self-blame. Although these factors may affect posttraumatic stress disorder (PTSD) treatment, outcomes for substance-involved SA have not been evaluated or compared with other types of SA. As such, we conducted a secondary analysis of a dismantling trial for cognitive processing therapy (CPT), focusing on 58 women with an index trauma of SA that occurred since age 14. Women who experienced a substance-involved SA (n = 21) were compared with those who experienced a non-substance-involved SA (n = 37). Participants were randomized to CPT, CPT with written account (CPT+A), or written account only (WA). Regressions controlling for pretreatment symptom levels revealed no differences by SA type in PTSD severity at posttreatment. At 6-month follow-up, substance-involved SA was associated with more severe residual PTSD severity than non-substance-involved SA, with no significant differences by treatment condition. Among participants in the substance-involved SA group, the largest effect for reduced PTSD symptom severity from pretreatment to follow-up emerged in the CPT condition, d = -2.02, with reductions also observed in the CPT+A, d = -0.92, and WA groups, d = -1.23. Although more research in larger samples is needed, these preliminary findings suggest that following substance-involved SA, a cognitive treatment approach without a trauma account may facilitate lasting change in PTSD symptoms. We encourage replications to better understand the relative value of cognitive and exposure-based treatment for PTSD following substance-involved SAs.
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http://dx.doi.org/10.1002/jts.22674DOI Listing
April 2021

Treatment Outcomes for Adolescents Versus Adults Receiving Cognitive Processing Therapy for Posttraumatic Stress Disorder During Community Training.

J Trauma Stress 2021 Mar 14. Epub 2021 Mar 14.

Duke University Medical Center, Durham, North Carolina, USA.

Cognitive processing therapy (CPT) is a gold-standard treatment for adults with posttraumatic stress disorder (PTSD). However, adolescents may also benefit from CPT, particularly when existing evidence-based treatments for adolescents are unavailable or not a good fit. In this program evaluation study, community-based therapists participating in training delivered a modular version of CPT to 32 adolescents (age range: 14-17 years) and 174 adults recruited at their sites (overall sample: 81.1% female, 59.7% White, 31.6% Black, 21.6% Hispanic, 2.9% American Indian/Alaskan Native, 1.9% Asian, and 9.7% other race). The same protocol was used for adolescents as adults. Treatment outcomes, including treatment completion status, number of sessions needed, and PTSD and depression symptom change, were compared between groups. In total, 47.1% of adults versus 71.9% of adolescents completed treatment. Among completers, there was no between-group difference in the number of attended sessions, RR = 1.04, 95% CI [0.88, 1.23], p = .576. Overall, in the full intent-to-treat sample (i.e., completers and noncompleters), large symptom reductions were observed for PTSD, b = -3.27, SE = 0.17, p < .001, d = 1.22; and depression, b = -0.82, SE = 0.07, p < .001, d = 0.84. There were no differences in the rate of change for adolescents versus adults regarding PTSD, b = -0.15, SE = 0.48, p = .759; or depression, b = -0.20, SE = 0.14, p = .181. These findings suggest that CPT is a viable treatment option for adolescents, who benefited from treatment and completed treatment at a high rate.
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http://dx.doi.org/10.1002/jts.22668DOI Listing
March 2021

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

Contemp Clin Trials Commun 2021 Mar 6;21:100699. Epub 2021 Jan 6.

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

Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in PTH unique from other types of headaches. The treatments under study differed in clinical focus and dose (i.e., number of treatment sessions), but the trial was designed to balance the treatments as well as possible. Finally, while the primary endpoints for pain research can vary from assessments of pain intensity to objective and subjective functional measures, this trial of PTH interventions chose carefully to establish clinically relevant endpoints and to maximize the opportunity to detect significant differences between groups with two primary outcomes. All these issues are discussed in this manuscript.
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http://dx.doi.org/10.1016/j.conctc.2021.100699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7806520PMC
March 2021

Estimated Intelligence Moderates Cognitive Processing Therapy Outcome for Posttraumatic Stress Symptoms.

Behav Ther 2021 01 2;52(1):162-169. Epub 2020 Apr 2.

National Center for PTSD at VA Boston Healthcare System; Boston University School of Medicine.

Although patient intelligence may be an important determinant of the degree to which individuals may comprehend, comply with, and ultimately benefit from trauma-focused treatment, no prior studies have examined the impact of patient intelligence on benefit from psychotherapies for PTSD. We investigated the degree to which educational achievement, often used as a proxy for intelligence, and estimated full scale intelligence quotient (FSIQ) scores themselves moderated treatment outcomes for two effective psychotherapies for PTSD: Cognitive Processing Therapy (CPT) and Written Exposure Therapy (WET). Participants, 126 treatment-seeking adults with PTSD (52% male; mean age = 43.9, SD = 14.6), were equally randomized to CPT and WET; PTSD symptom severity was measured at baseline and 6-, 12-, 24-, 36-, and 60-weeks following the first treatment session. Multilevel models revealed that participants with higher FSIQ scores experienced significantly greater PTSD symptom reduction through the 24-week assessment in CPT but not WET; this effect did not persist through the 60-week assessment. Educational achievement did not moderate symptom change through either 24- or 60-weeks. Individuals with higher FSIQ who are treated with CPT may experience greater symptom improvement in the early stages of recovery.
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http://dx.doi.org/10.1016/j.beth.2020.03.008DOI Listing
January 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 effect of reducing posttraumatic stress disorder symptoms on cardiovascular risk: Design and methodology of a randomized clinical trial.

Contemp Clin Trials 2021 Mar 8;102:106269. Epub 2021 Jan 8.

Duke University Medical Center, Durham, NC, USA. Electronic address:

Posttraumatic stress disorder (PTSD) has been associated with accelerated progression of coronary heart disease (CHD). However, the underlying pathophysiological pathway has remained elusive and it is unclear whether there is a direct link between PTSD and CHD risk. This paper describes the methods of a randomized controlled trial developed to examine how changes in PTSD symptoms affect CHD disease pathways. One hundred twenty participants with current PTSD and who are free of known CHD will be randomized to receive either an evidence-based treatment for PTSD (Cognitive Processing Therapy; CPT) or a waitlist control (WL). Before and after CPT/WL, participants undergo assessment of CHD risk biomarkers reflecting autonomic nervous system dysregulation, systemic inflammation, and vascular endothelial dysfunction. The primary hypothesis is that individuals who show improvement in PTSD symptoms will show improvement in CHD risk biomarkers, whereas individuals who fail to improve or show worsening PTSD symptoms will have no change or worsening in CHD biomarkers. This study is expected to provide knowledge of the role of both the direct impact of PTSD symptoms on CHD risk pathways and the role of these systems as candidate mechanisms underlying the relationship between PTSD and CHD risk. Further, results will provide guidance on the utility of cognitive therapy as a tool to mitigate the accelerated progression of CHD in PTSD. Clinical Trials Registration: https://clinicaltrials.gov/ct2/show/NCT02736929; Unique identifier: NCT02736929.
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http://dx.doi.org/10.1016/j.cct.2021.106269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009821PMC
March 2021

Interpersonal violence and head injury: The effects on treatment for PTSD.

Psychol Trauma 2021 Mar 3;13(3):376-384. Epub 2020 Dec 3.

Duke University Medical Center.

This study sought to understand the extent and influence of head injuries (HIs) on recovery from posttraumatic stress disorder (PTSD) in a sample of treatment-seeking survivors of interpersonal violence, including intimate partner violence (IPV). Three randomized controlled clinical trials (RCTs) investigating the efficacy of cognitive processing therapy were combined to form a repository resulting in 306 participants (92% women) diagnosed with PTSD. Participants were an average age of 36.83 years old ( = 12.15), and 56% were White and 40% were Black. RCTs were conducted at the same location, with the same procedures and overlapping staff. PTSD was diagnosed via the Clinician-Administered PTSD Scale, depression was measured by the Beck Depression Inventory-II, and trauma history and injuries were assessed via the clinician-administered Trauma Interview. Most of the sample (74.9%) reported HI during at least 1 interpersonal assault. Higher rates of HI were reported in those who endorsed IPV (84.5%; = .001). To assess the influence of HI on outcomes, the sample was grouped into 3 conditions: HI (at least 1 significant head injury during trauma), NHI (denied head injuries, but reported serious nonhead injuries), and NI (denied any injury). All injury groups improved on PTSD and depressive symptoms with no moderation of group. Most individuals exposed to violence experienced at least 1 head injury, with higher rates in those assaulted by an intimate partner. The experience of HI did not negatively impact recovery from PTSD, including with participants histories of multiple head injuries. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000976DOI Listing
March 2021

Interpersonal violence and head injury: The effects on treatment for PTSD.

Psychol Trauma 2021 Mar 3;13(3):376-384. Epub 2020 Dec 3.

Duke University Medical Center.

This study sought to understand the extent and influence of head injuries (HIs) on recovery from posttraumatic stress disorder (PTSD) in a sample of treatment-seeking survivors of interpersonal violence, including intimate partner violence (IPV). Three randomized controlled clinical trials (RCTs) investigating the efficacy of cognitive processing therapy were combined to form a repository resulting in 306 participants (92% women) diagnosed with PTSD. Participants were an average age of 36.83 years old ( = 12.15), and 56% were White and 40% were Black. RCTs were conducted at the same location, with the same procedures and overlapping staff. PTSD was diagnosed via the Clinician-Administered PTSD Scale, depression was measured by the Beck Depression Inventory-II, and trauma history and injuries were assessed via the clinician-administered Trauma Interview. Most of the sample (74.9%) reported HI during at least 1 interpersonal assault. Higher rates of HI were reported in those who endorsed IPV (84.5%; = .001). To assess the influence of HI on outcomes, the sample was grouped into 3 conditions: HI (at least 1 significant head injury during trauma), NHI (denied head injuries, but reported serious nonhead injuries), and NI (denied any injury). All injury groups improved on PTSD and depressive symptoms with no moderation of group. Most individuals exposed to violence experienced at least 1 head injury, with higher rates in those assaulted by an intimate partner. The experience of HI did not negatively impact recovery from PTSD, including with participants histories of multiple head injuries. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000976DOI Listing
March 2021

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

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

Cephalalgia 2020 10 31;40(11):1155-1167. Epub 2020 Aug 31.

Department of Anaesthesia, Massachusetts General Hospital, Boston, MA, USA.

Background: Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion.

Method: A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury.

Result: 127 participants (66%; 95% CI: 59-72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt;  = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for  = 1.3, 95% CI = -27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = -6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = -2.7, 15.6).

Conclusions: Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months.

Clinicaltrials.gov Identifier: NCT02419131.
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http://dx.doi.org/10.1177/0333102420953109DOI Listing
October 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

Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial.

JAMA Psychiatry 2020 Dec;77(12):1235-1245

Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.

Importance: Childhood abuse significantly increases the risk of developing posttraumatic stress disorder (PTSD), often accompanied by symptoms of borderline personality disorder (BPD) and other co-occurring mental disorders. Despite the high prevalence, systematic evaluations of evidence-based treatments for PTSD after childhood abuse are sparse.

Objective: To compare the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD), a new, specifically designed, phase-based treatment program, against that of cognitive processing therapy (CPT), one of the best empirically supported treatments for PTSD.

Design, Setting, And Participants: From January 2014 to October 2016, women who sought treatment were included in a multicenter randomized clinical trial with blinded outcome assessments at 3 German university outpatient clinics. The participants were prospectively observed for 15 months. Women with childhood abuse-associated PTSD who additionally met 3 or more DSM-5 criteria for BPD, including affective instability, were included. Data analysis took place from October 2018 to December 2019.

Interventions: Participants received equal dosages and frequencies of DBT-PTSD or CPT, up to 45 individual sessions within 1 year and 3 additional sessions during the following 3 months.

Main Outcomes And Measures: The predefined primary outcome was the course of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from randomization to month 15. Intent-to-treat analyses based on dimensional CAPS-5 scores were complemented by categorical outcome measures assessing symptomatic remission, reliable improvement, and reliable recovery.

Results: Of 955 consecutive individuals assessed for eligibility, 193 were randomized (DBT-PTSD, 98; CPT, 95; mean [SD] age, 36.3 [11.1] years) and included in the intent-to-treat analyses. Analysis revealed significantly improved CAPS-5 scores in both groups (effect sizes: DBT-PTSD: d, 1.35; CPT: d, 0.98) and a small but statistically significant superiority of DBT-PTSD (group difference: 4.82 [95% CI, 0.67-8.96]; P = .02; d, 0.33). Compared with the CPT group, participants in the DBT-PTSD group were less likely to drop out early (37 [39.0%] vs 25 [25.5%]; P = .046) and had higher rates of symptomatic remission (35 [40.7%] vs 52 [58.4%]; P = .02), reliable improvement (53 [55.8%] vs 73 [74.5%]; P = .006), and reliable recovery (34 [38.6%] vs 52 [57.1%]; P = .01).

Conclusions And Relevance: These findings support the efficacy of DBT-PTSD and CPT in the treatment of women with childhood abuse-associated complex PTSD. Results pertaining to the primary outcomes favored DBT-PTSD. The study shows that even severe childhood abuse-associated PTSD with emotion dysregulation can be treated efficaciously.

Trial Registration: German Clinical Trials Register: DRKS00005578.
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http://dx.doi.org/10.1001/jamapsychiatry.2020.2148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376475PMC
December 2020

Associations between PTSD-Related extinction retention deficits in women and plasma steroids that modulate brain GABA and NMDA receptor activity.

Neurobiol Stress 2020 Nov 15;13:100225. Epub 2020 May 15.

National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, 02130, USA.

Several studies have demonstrated poor retention of extinction learning among individuals with posttraumatic stress disorder (PTSD). Gonadal hormone signaling in brain appears to influence the retention of extinction learning differently in women with and without PTSD. Women with PTSD, compared to trauma-exposed women without PTSD, show relative deficits in extinction retention during the mid-luteal phase (mLP) of the menstrual cycle, compared to the early follicular phase (eFP). A PTSD-related reduction in conversion of progesterone to its GABAergic metabolites allopregnanolone (Allo) and pregnanolone (PA) may contribute to these findings. The current study in trauma-exposed women with (n = 9) and without (n = 9) PTSD investigated associations between extinction retention and plasma Allo + PA levels, as well as the ratio of Allo + PA to 5α-dihydroprogesterone (5α-DHP), the immediate steroid precursor for Allo. The study also investigated the relationship between extinction retention and the ratio of Allo + PA to dehydroepiandrosterone (DHEA), an adrenally-derived GABA receptor antagonist. Study participants completed differential fear-conditioning during both the eFP and mLP of the menstrual cycle. Analyses revealed a strong positive relationship between resting plasma Allo + PA levels and extinction retention during the mLP in the women with, but not without, PTSD (e.g., diagnosis X Allo + PA interaction controlling for early extinction: β = -.0008,  = .003). A similar pattern emerged for the Allo + PA to 5α-DHP ratio (β = -.165,  = .071), consistent with a PTSD-related block in production of Allo and PA at the enzyme 3α-hydroxysteroid dehydrogenase. The ratio of Allo + PA to DHEA appeared to influence extinction retention only during the eFP when Allo + PA and DHEA levels are comparable and thus may compete for effects on GABA receptor function. This study aligns with male rodent PTSD models linking experimental reductions in brain Allo levels to deficits in extinction retention and suggests that targeting PTSD-related deficits in GABAergic neurosteroid synthesis may be therapeutic.
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http://dx.doi.org/10.1016/j.ynstr.2020.100225DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256058PMC
November 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

Cognitive Processing Therapy for Posttraumatic Stress Disorder via Telehealth: Practical Considerations During the COVID-19 Pandemic.

J Trauma Stress 2020 08 11;33(4):371-379. Epub 2020 Jun 11.

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

The global outbreak of COVID-19 has required mental health providers to rapidly rethink and adapt how they provide care. Cognitive processing therapy (CPT) is a trauma-focused, evidence-based treatment for posttraumatic stress disorder that is effective when delivered in-person or via telehealth. Given current limitations on the provision of in-person mental health treatment during the COVID-19 pandemic, this article presents guidelines and treatment considerations when implementing CPT via telehealth. Based on lessons learned from prior studies and clinical delivery of CPT via telehealth, recommendations are made with regard to overall strategies for adapting CPT to a telehealth format, including how to conduct routine assessments and ensure treatment fidelity.
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http://dx.doi.org/10.1002/jts.22544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272815PMC
August 2020

Baseline Cognitive Performance and Treatment Outcomes From Cognitive-Behavioral Therapies for Posttraumatic Stress Disorder: A Naturalistic Study.

J Neuropsychiatry Clin Neurosci 2020 17;32(3):286-293. Epub 2020 Jan 17.

Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Goetter); the Department of Psychiatry, Massachusetts General Hospital, Boston (Tanev, Federico, Greenberg, Orr, Goetter, Pitman); and the Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, N.C. (Resick).

Objective: Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD.

Methods: This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively).

Results: Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD.

Conclusions: These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.
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http://dx.doi.org/10.1176/appi.neuropsych.19020032DOI Listing
May 2021

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

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

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

Testing a variable-length Cognitive Processing Therapy intervention for posttraumatic stress disorder in active duty military: Design and methodology of a clinical trial.

Contemp Clin Trials Commun 2019 Sep 23;15:100381. Epub 2019 May 23.

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

Combat-related trauma exposures have been associated with increased risk for posttraumatic stress disorder (PTSD) and comorbid mental health conditions. Cognitive Processing Therapy (CPT) is a 12-session manualized cognitive-behavioral therapy that has emerged as one of the leading evidence-based treatments for combat-related PTSD among military personnel and veterans. However, rates of remission have been less in both veterans and active duty military personnel compared to civilians, suggesting that studies are needed to identify strategies to improve upon outcomes in veterans of military combat. There is existing evidence that varying the number of sessions in the CPT protocol based on patient response to treatment improves outcomes in civilians. This paper describes the rationale, design, and methodology of a clinical trial examining a variable-length CPT intervention in a treatment-seeking active duty sample with PTSD to determine if some service members would benefit from a longer or shorter dose of treatment, and to identify predictors of length of treatment response to reach good end-state functioning. In addition to individual demographic and trauma-related variables, the trial is designed to evaluate factors related to internalizing/externalizing personality traits, neuropsychological measures of cognitive functioning, and biological markers as predictors of treatment response. This study attempts to develop a personalized approach to achieving positive treatment outcomes for service members suffering from PTSD. Determining predictors of treatment response can help to develop an adaptable treatment regimen that returns the greatest number of service members to full functioning in the shortest amount of time.
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http://dx.doi.org/10.1016/j.conctc.2019.100381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542750PMC
September 2019

Salience Network Disruption in U.S. Army Soldiers With Posttraumatic Stress Disorder.

Chronic Stress (Thousand Oaks) 2019 Jan-Dec;3. Epub 2019 May 15.

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

Background: Better understanding of the neurobiology of posttraumatic stress disorder (PTSD) may be critical to developing novel, effective therapeutics. Here, we conducted a data-driven investigation using a well-established, graph-based topological measure of nodal strength to determine the extent of functional dysconnectivity in a cohort of active duty US Army soldiers with PTSD compared to controls.

Methods: 102 participants with (n=50) or without PTSD (n=52) completed functional magnetic resonance imaging (MRI) at rest and during symptom provocation using subject-specific script imagery. Vertex/voxel global brain connectivity with global signal regression (GBCr), a measure of nodal strength, was calculated as the average of its functional connectivity with all other vertices/voxels in the brain gray matter.

Results: In contrast to during resting-state, where there were no group differences, we found a significantly higher GBCr during symptom provocation, in PTSD participants compared to controls, in areas within the right hemisphere, including anterior insula, caudal-ventrolateral prefrontal, and rostral-ventrolateral parietal cortices. Overall, these clusters overlapped with the ventral and dorsal salience networks. analysis showed increased GBCr in these salience clusters during symptom provocation compared to resting-state. In addition, resting-state GBCr in the salience clusters predicted GBCr during symptom provocation in PTSD participants but not in controls.

Conclusion: In PTSD, increased connectivity within the salience network has been previously hypothesized, based primarily on seed-based connectivity findings. The current results strongly support this hypothesis using whole-brain network measure in a fully data-driven approach. It remains to be seen in future studies whether these identified salience disturbances would normalize following treatment.
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http://dx.doi.org/10.1177/2470547019850467DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529942PMC
May 2019

Corrigendum to "Design of VA Cooperative Study #591: CERV-PTSD, Comparative Effectiveness Research in Veterans with PTSD" [Contemp. Clin. Trials 41 (2015) 75-84].

Contemp Clin Trials 2019 May 5;80:61. Epub 2019 Apr 5.

VA Cooperative Studies Program Coordinating Center, Palo Alto, CA, USA; Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA.

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http://dx.doi.org/10.1016/j.cct.2019.04.003DOI Listing
May 2019