Homework Completion,Patient Characteristics,and Symptom Change in Cognitive Processing Therapy for PTSD

We evaluated the impact of homework completion on change in PTSD symptoms in the context of two randomized controlled trials of Cognitive Processing Therapy for PTSD (CPT). Female participants (n = 140) diagnosed with PTSD attended at least one CPT session and were assigned homework at each session. The frequency of homework completion was assessed at the beginning of each session and PTSD symptoms were assessed every other session. Piecewise growth models were used to examine the relationship between homework completion and symptom change. CPT version (with vs without the written trauma account) did not moderate associations between homework engagement and outcomes. Greater pretreatment PTSD symptoms predicted more Session 1 homework completion, but PTSD symptoms did not predict homework completion at other timepoints. More homework completion after Sessions 2 and 3 was associated with less change in PTSD from Session 2 to Session 4, but larger pre-to-post treatment changes in PTSD. Homework completion after Sessions 2 and 3 was associated with greater symptom change among patients who had fewer years of education. More homework completion after Sessions 8 and 9 was associated with larger subsequent decreases in PTSD. Average homework completion was not associated with client characteristics. In the second half of treatment, homework engagement was associated with less dropout. The results suggest that efforts to increase engagement in homework may facilitate symptom change.     

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants’ written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.     

PTSD Severity and Cognitive Reactions to Trauma Among a College Sample

ABSTRACT

Two hundred twenty-one undergraduate education students were assessed to determine trauma history and cognitive responses to traumatic events. Participants completed a demographic questionnaire, the Cognitive Distortions Scale, and the PTSD Symptom Scale (for those reporting a trauma history). The most common types of traumatic events were domestic violence, natural disasters, and severe transportation accidents. Differences in cognitive distortions of individuals with and without a trauma history also were assessed. Individuals with a trauma history were significantly higher on Preoccupation with Danger and Self-Blame subscales. Number of previous traumatic events and the subscale of Preoccupation of Danger significantly predicted PTSD severity.     

Adapting Cognitive Processing Therapy to Treat Co-Occurring Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: A Case Study

This case study aims to provide evidence for the effectiveness of adapting a particular manualized cognitive behavioral therapy intervention to treat co-occurring posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). This study presents the treatment of a woman who experienced co-occurring mTBI and PTSD following a motor vehicle accident, a dual diagnosis that was established through a flexible assessment approach involving interviews as well as standardized psychological, neuropsychological, and neurobehavioral testing. Treatment planning led to a-priori adaptation of Cognitive Processing Therapy (CPT) to treat both her PTSD symptoms and the sequelae associated with her mTBI. The therapist maintained fidelity to the manualized structure and content of CPT protocol, adapting portions of the treatment to add specific emphasis on issues of identity confusion and role loss in service of addressing these common functional impairments that can accompany mTBI. Discussion focuses on application of CPT for future treatment of comorbid PTSD and TBI amidst complicating factors, including role losses and medical and safety issues. This case study is especially relevant due to the prevalence of co-occurring PTSD and TBI across a variety of populations.     

Motivation-Adaptive Skills-Trauma Resolution (MASTR) Therapy for Adolescents with Conduct Problems

Summary

Trauma is proposed as a key to understanding the development and persistence of adolescent conduct problems, in conjunction with other contributing factors. A trauma-focused individual therapy approach is presented as one example of how this population might be more effectively treated. This approach features motivational interviewing, self-control training (cognitive-behavioral therapy), and trauma resolution (eye movement desensitization and reprocessing). This paper reports on an open trial of six adolescents with school and conduct problems who received school-based Motivation-Adaptive Skills-Trauma Resolution (MASTR) treatment. Reductions in post-traumatic stress, related symptoms, and problem behaviors, along with improved school performance, indicate the value of further study of this treatment approach.     

Adapting Cognitive Processing Therapy for PTSD for People With Disabilities: A Case Study With a U.S. Veteran

Many veterans receiving treatment for PTSD in the VA health care system are also living with a disability and utilize assistive technologies for communication and/or mobility. While evidence-based treatments for PTSD have been disseminated in VA hospitals nationwide, clinicians may have concerns about implementing these treatments with people with disabilities or question how to adapt evidence-based protocols to facilitate successful outcomes. This clinical case study details the treatment of a 48-year-old male U.S. veteran with a diagnosis of military-related PTSD and significant functional and communicative complexities characteristic of locked-in syndrome. The study implemented an adapted protocol of Cognitive Processing Therapy (CPT), a first-line evidence-based psychotherapy for PTSD with unknown application to people with disabilities. CPT protocol structure, length, and delivery was adapted to accommodate the veteran’s assistive devices and functional abilities. The veteran experienced a clinically significant reduction in PTSD symptoms over the course of treatment, suggesting successful application of the adapted protocol. In addition to symptom reduction, the veteran reported advances in his ability to tolerate emotional distress while engaged in goal-directed behavior and improved interpersonal functioning. Results suggest that CPT can be adapted and effective in instances where the presence of disability and multiple assistive technologies impact standard treatment implementation. This information is valuable in its potential ability to make evidence-based psychotherapies more accessible and disability-sensitive. Clinical recommendations for using and adapting CPT for people with disabilities are provided.     

Therapeutic response to Cognitive Processing Therapy in White and Black female veterans with military sexual trauma-related PTSD

Cognitive Processing Therapy (CPT) is an evidence-based treatment (EBT) for posttraumatic stress disorder (PTSD) which has been validated for female veterans with military-related PTSD. Existing trials have enrolled predominantly White veterans with some studies documenting higher rates of early termination from EBTs among Black females when compared to White females. Data from a previously published randomized clinical trial were used to evaluate the effectiveness of CPT for Black female veterans with military sexual trauma (MST)-related PTSD. Reductions in PTSD symptom severity, number of sessions attended, and early termination rates were compared between Black (n = 20) and White (n = 16) female veterans. A hierarchical linear modeling approach was used, with PTSD symptom severity over the course of treatment and follow-up entered as a level-1 variable and race (Black or White) entered as a level-2 predictor. Piecewise growth curves analyses revealed that both Black and White female veterans experienced significant reductions in PTSD symptom severity over the course of treatment and gains were maintained up to 6 months post-treatment. Race was not found to be a significant predictor of change in the slope of PTSD symptom severity over the course of CPT treatment. Additionally, number of sessions attended and rates of early termination did not significantly differ based on race. Results suggest that CPT was a well-tolerated and effective psychotherapeutic treatment for this sample regardless of racial self-identification.     

Development and Validation of the Screen for Adolescent Violence Exposure (SAVE)

Empirical evidence was provided on the utility of the Screen for Adolescent Violence Exposure (SAVE) in assessing adolescent exposure to school, home, and community violence. The SAVE was empirically developed on 1,250 inner-city adolescents, and obtained excellent reliability and validity. Both exploratory and confirmatory factor analyses identified three factors: Traumatic Violence, Indirect Violence, and Physical/Verbal Abuse. The SAVE demonstrated utility in classifying high- and low-violence participants, and correlated significantly with both objective crime data and theoretically relevant constructs (anger, posttraumatic stress symptoms, and internalizing/externalizing problems). Thus, the SAVE provides measurement of the stressor criterion associated with posttraumatic stress disorder, and allows quantification of severity of violence exposure by setting.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Cognitive Processing Therapy Versus Supportive Counseling for Acute Stress Disorder Following Assault: A Randomized Pilot Trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N = 30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.     

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

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.     

Exposure Therapy Beliefs and Utilization for Treatment of PTSD: A Survey of Licensed Mental Health Providers

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82–1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55–2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master’s degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.     

Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling

Post-traumatic stress disorder (PTSD) is of great interest to public health, due to the high burden it places on both the individual and society. We meta-analyzed randomized-controlled trials to examine the effectiveness of early trauma-focused cognitive-behavioral treatment (TFCBT) for preventing chronic PTSD. Systematic bibliographic research was undertaken to find relevant literature from on-line databases (Pubmed, PsycINFO, Psyndex, Medline). Using a mixed-effect approach, we calculated effect sizes (ES) for the PTSD diagnoses (main outcome) as well as PTSD and depressive symptoms (secondary outcomes), respectively. Calculations of ES from pre-intervention to first follow-up assessment were based on 10 studies. A moderate effect (ES = 0.54) was found for the main outcome, whereas ES for secondary outcomes were predominantly small (ES = 0.27–0.45). The ES for the main outcome decreased to small (ES = 0.34) from first follow-up to long-term follow-up assessment. The mean dropout rate was 16.7% pre- to post-treatment. There was evidence for the impact of moderators on different outcomes (e.g., the number of sessions on PTSD symptoms). Future studies should include survivors of other trauma types (e.g., burn injuries) rather than predominantly survivors of accidents and physical assault, and should compare early TFCBT with other interventions that previously demonstrated effectiveness.     

Cognitive Behavioral Treatment of PTSD with Comorbid Panic Attacks

Many individuals that experience traumatic events such as sexual and physical assault develop posttraumatic stress disorder (PTSD). More recently, research has indicated that a significant proportion of PTSD sufferers may also have comorbid panic attacks. Although there are several effective treatments that focus on alleviating PTSD symptoms, until now there were no treatments that focused on also treating comorbid panic attacks. Multiple channel exposure therapy (M-CET) is the first treatment developed to specifically treat comorbid PTSD and panic attacks. It is also unique in that it has been used to treat women who have multiple trauma histories as well as a wide range of different types of traumatic event exposure in a group format. This treatment is described in a session by session format and special considerations in implementing the treatment are discussed.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

A Preliminary Investigation of the Relationship Between Emotion Dysregulation and Partner Violence Perpetration Among Individuals with PTSD and Alcohol Dependence

This study examines the link between emotion dysregulation and intimate partner violence (IPV) among 77 individuals with posttraumatic stress disorder (PTSD) and alcohol dependence. Participants were recruited from a residential substance abuse treatment program as part of the eligibility screening for an institutional review board approved clinical trial examining the efficacy of an exposure-based intervention in individuals dually diagnosed with alcohol dependence and PTSD. Participants reported on PTSD symptoms, alcohol use disorder symptoms, emotion dysregulation, and physical and verbal aggression in their intimate relationships during the past year. Findings demonstrated that difficulties with emotion regulation are associated with physical and verbal IPV perpetration in a clinical sample. Although facets of emotion regulation emerged as significant predictors of IPV in the models, alcohol and PTSD symptom severity did not emerge as predictors of IPV. These findings suggest targeted emotion regulation skills training could benefit substance abusers who engage in IPV and that emotion dysregulation might be an important target for future research aimed at understanding elevated rates of IPV perpetration in mental health samples.     

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12–16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 – 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.     

Initial Evaluation of an Integrated Treatment for Comorbid PTSD and Smoking Using a Nonconcurrent,Multiple-Baseline Design

The present study examined an integrated treatment for comorbid posttraumatic stress disorder (PTSD) and smoking entitled “Smoke-Free to Overcome PTSD: An Integrated Treatment” (STOP IT program). A nonconcurrent multiple-baseline design was used with six community-recruited adult smokers with PTSD to investigate both patient acceptance of the treatment and its initial efficacy on both PTSD and smoking. Potential order effects of exposure-based and affect management components were also examined. A gold-standard assessment strategy that included the Clinician Administered PTSD Scale (Blake et al., 1995) and biochemical verification of self-reported smoking status was employed to measure primary targets of treatment. Results suggested that the STOP IT program was well tolerated. There were clinically significant improvements in PTSD outcomes, but only temporary reductions in smoking. Participants’ relatively low posttreatment smoking levels increased by the follow-up assessment, although not to baseline levels. Treatment component order did not appear to affect treatment outcomes, but those who were assigned to the exposure-focused writing prior to affect management training condition appeared more likely to discontinue treatment before beginning exposure. These preliminary data support the safety, acceptability, and potential efficacy of the STOP IT program. Future investigation of the STOP IT program should include testing the incremental efficacy of increasing the dose of smoking-focused intervention, as well as randomized controlled tests of the treatment that employ gold standards for treatment outcome research.