Primary Care Treatment Integrating Motivation and Exposure for PTSD Symptoms and Hazardous Alcohol Use: A Case Series

Symptoms of posttraumatic stress disorder (PTSD) and hazardous alcohol use are highly comorbid. Research on integrated interventions to address PTSD symptoms and hazardous alcohol use concurrently has demonstrated efficacy, yet integrated treatments are underutilized. Both patient (e.g., stigma, scheduling/logistics) and clinician (e.g., concern about symptom exacerbation and/or treatment dropout) barriers may impede utilization of integrated interventions among those with comorbid PTSD symptoms and hazardous alcohol use. Primary care behavioral health models (PCBH), in which embedded behavioral health providers deliver treatment to individuals with mild or moderate behavioral health symptoms in primary care, may help address treatment barriers by offering accessible behavioral health interventions in a destigmatizing setting. This paper presents two case examples from a randomized controlled trial testing the efficacy of an integrated intervention for PTSD symptoms and hazardous alcohol use developed for and delivered in primary care. Outcome data and session-by-session content for two participants are included, along with discussion of barriers encountered during the course of treatment. Clinician-suggested strategies for navigating barriers to facilitate utilization of integrated interventions for PTSD symptoms and hazardous alcohol use are also discussed.     

A Data-Driven Perspective: Response to Commentaries by Maguen and Burkman (2013) and Steenkamp et al. (2013)

We respond to commentary from Maguen and Burkman (2013-this issue) and Steenkamp et al. (2013-this issue) on our presentation of how to use PE to treat PTSD resulting from perceived perpetration (Smith et al., 2013-this issue). We focus our response on the distinction between moral injury, which can result in many potential mental health outcomes, with various treatment plans coming out of the patient's presentation, and treatment of PTSD resulting from trauma that may or may not include moral injury. We then focus on the strong evidence base that supports the use of PE for PTSD across trauma types and across many complicated patient presentations, including evidence within veteran populations. We respond to common misunderstandings of PE and Emotional Processing Theory that underlie this treatment model. Specifically, we discuss the flexibility that is inherent in the PE model, reassert that PE focuses on whatever emotion/s are present and provoked by direct confrontation of traumatic material (e.g., reminders, memories), and discuss that habituation is not the only process at work in PE. As such, shame and guilt related to moral injury can be effectively addressed, as noted in Smith et al. Finally, rather than developing a new and unproven model of treatment as the commentaries propose, we assert that given the strong evidence base for efficacy and effectiveness of PE for PTSD and the significant and ongoing investment in dissemination of PE, continued support for providers on how to effectively use PE with difficult patients is warranted.     

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.     

Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV

This treatment development report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.     

Organizational factors and mental health in community volunteers. The role of exposure,preparation, training,tasks assigned,and support

During disasters, aid organizations often respond using the resources of local volunteer members from the affected population who are not only inexperienced, but who additionally take on some of the more psychologically and physically difficult tasks in order to provide support for their community. Although not much empirical evidence exists to justify the claim, it is thought that preparation, training, and organizational support limit (or reduce) a volunteer's risk of developing later psychopathology. In this study, we examined the effects of preparation, training, and organizational support and assigned tasks on the mental health of 506 Indonesian Red Cross volunteers who participated in the response to a massive earthquake in Yogyakarta, Indonesia, in 2006. Controlling for exposure level, the volunteers were assessed for post-traumatic stress disorder (PTSD), anxiety, depression, and subjective health complaints (SHCs) 6, 12, and 18 months post-disaster. Results showed high levels of PTSD and SHCs up to 18 months post-disaster, while anxiety and depression levels remained in the normal range. Higher levels of exposure as well as certain tasks (e.g., provision of psychosocial support to beneficiaries, handling administration, or handing out food aid) made the volunteers more vulnerable. Sense of safety, expressed general need for support at 6 months, and a lack of perceived support from team leaders and the organization were also related to greater psychopathology at 18 months. The results highlight the importance of studying organizational factors. By incorporating these results into future volunteer management programs the negative effects of disaster work on volunteers can be ameliorated.     

Treatment of a Case Example With PTSD and Chronic Pain

This commentary reviews the case of GH, a survivor of a road traffic collision, who has chronic pain and posttraumatic stress disorder (PTSD). The case formulation, assessment strategy, and treatment plan are informed by the relevant experimental literature and empirically supported treatments using a cognitive behavioral perspective. Given this framework, the commentary includes a focus on the treatment of PTSD with an eye toward generalizing the therapeutic strategies to chronic pain problems. Psychoeducation, imaginal exposure to the traumatic event, in vivo exposure to avoided activities, and cognitive interventions including coping self-statements, correction of logical errors, decatastrophizing and developing alternative explanations are all included in the recommendations as part of a standard cognitive behavioral treatment for PTSD. Added to this standard PTSD protocol is the suggested use of interoceptive exposure to address GH’s feared bodily sensations. In the assessment domain, standard measures for pain and PTSD assessment are suggested along with tracking of depression and anxiety sensitivity. Some recognition of more recent approaches to cognitive behavioral therapy (e.g., Acceptance and Commitment Therapy) is given in considering potential obstacles to treatment.     

Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms

While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.     

A Clinician's Guide to PTSD Treatments for Returning Veterans

What options are available to mental health providers helping clients with posttraumatic stress disorder (PTSD)? In this paper we review many of the current pharmacological and psychological interventions available to help prevent and treat PTSD with an emphasis on combat-related traumas and Veteran populations. There is strong evidence supporting the use of several therapies including prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and cognitive processing therapies (CPT), with PE possessing the most empirical evidence in favor of its efficacy. There have been relatively fewer studies of non-exposure based modalities (e.g., psychodynamic, interpersonal, and dialectical behavior therapy perspectives), but there is no evidence that these treatments are less effective. Pharmacotherapy is promising (especially paroxetine, sertraline, and venlafaxine), but more research comparing the relative merits of medication vs. psychotherapy and the efficacy of combined treatments is needed. Given the recent influx of combat-related traumas due to ongoing conflicts in Iraq and Afghanistan, there is clearly an urgent need to conduct more randomized clinical trials research and effectiveness studies in military and Department of Veterans Affairs PTSD samples. Finally, we provide references to a number of PTSD treatment manuals and propose several recommendations to help guide clinicians' treatment selections.     

Treatment Effects for Common Outcomes of Child Sexual Abuse: A Current Meta-Analysis

The present meta-analysis examined the effects of psychosocial treatments at reducing deleterious outcomes of sexual abuse. The meta-analysis included a total of 35 published and unpublished studies written in English, focusing on youth under the age of 18, and evaluating the effectiveness of treatments for the most common negative outcomes of sexual abuse: PTSD symptoms, externalizing problems, and internalizing problems. Results revealed medium effect sizes for PTSD symptoms, externalizing problems, and internalizing problems following treatment for sexual abuse. This study also examined the potential moderating effects of treatment (e.g., modality, duration, inclusion of caregiver) and participant (e.g., age, gender, ethnicity) characteristics. Results indicated that longer interventions were associated with greater treatment gains while group and individual treatments were equally effective. These findings shed new light on treatment effectiveness and provide useful information regarding the conditions under which treatment may be most effective. Future directions for research in this area are discussed.     

11-M Victims 3 Years After Madrid Terrorist Attacks: Looking for Health Beyond Trauma

Although there is a growing body of evidence that health is the presence of well-being and not just the absence of a disease, research related to victims of terrorists attacks is mostly focused on the presence/absence of pathology (e.g. PTSD). The present study aims to apply the Complete State Model of Health to evaluate the mental health status of 69 direct victims of 11-M terrorist attack three years after the event. The results of Horn’s Parallel Analysis and CFA confirmed that the measures of positive mental health (well-being indicators) and illness (PTSD) loaded on separate but correlated factors. This is to say, the absence of PTSD in our sample was not equivalent to the presence of health. However, although positive health and illness indicators should be considered as two different factors, they were closely related. In fact, three well-being indicators were strongly associated with PTSD: positive affect, self-acceptance and positive relations. These findings suggest the need to work to ensure victims’ positive health.     

Prospective associations between changes in mental health symptoms and health-related quality of life in veterans seeking posttraumatic stress disorder residential treatment

Background and Objectives: This study examined prospective associations between changes in mental health symptoms (posttraumatic stress disorder [PTSD], depression) and health-related quality of life (physical health, psychological well-being) for veterans with PTSD. Design: This study focused on 139 patients who completed a residential treatment program for PTSD in the Veterans Health Administration. Methods: Patients completed the veteran-specific, 12-item Medical Outcomes Study Short Form, PTSD Checklist – Military version, and Beck Depression Inventory at pre-treatment, discharge, and a four-month follow-up. When accounting for demographic factors, combat exposure, and baseline scores on the respective outcome variables (e.g. mental health, physical health, PTSD, and depressive symptoms), a series of multivariate analyses were conducted for treatment-related changes in mental and physical health on the outcome measures. Results: Reductions in PTSD symptomatology during the treatment period were prospectively linked with better health-related outcomes at the four-month follow-up. In addition, improved physical health and psychological well-being during treatment were each similarly associated with better PTSD and depression outcomes in the months following treatment. Conclusions: Addressing concerns in mental and physical health might have synergistic effects across both domains, supporting the need for holistic models and integrated health care strategies for treating veterans with PTSD.     

Multiple channel exposure therapy for women with PTSD and comorbid panic attacks

Multiple channel exposure therapy (M-CET; Falsetti & Resnick, 2000) was developed to treat posttraumatic stress disorder (PTSD) with comorbid panic attacks and can be administered in a group format. In addition to being a cost-effective way to provide treatment, group treatment for those with PTSD has been proposed as potentially very beneficial for addressing feelings of shame related to the traumatic event as well as social isolation in general (Foy et al., 2000). Previous studies of M-CET indicate that it may be effective for the treatment of PTSD with comorbid panic attacks (Falsetti et al., 2001, 2003, 2005). The authors examine the relationship of PTSD and panic symptoms pre- and posttreatment and present 6-month follow-up data on the long-term effectiveness of M-CET.     

The Current State of Intervention Research for Posttraumatic Stress Disorder Within the Primary Care Setting

Posttraumatic Stress Disorder (PTSD) is common among primary care patients and is associated with significant functional impairment, physical health concerns, and mental health comorbidities. Significant barriers to receiving adequate treatment often exist for primary care patients with PTSD. Mental health professionals operating as part of the primary care team have the potential to provide effective brief intervention services. While good PTSD screening and assessment measures are available for the primary care setting, there are currently no empirically supported primary care-based brief interventions for PTSD. This article reviews early research on the development and testing of primary care-based PTSD treatments and also reviews other brief PTSD interventions (i.e., telehealth and early intervention) that could be adapted to the primary care setting. Cognitive and behavioral therapies currently have the strongest evidence base for establishing an empirically supported brief intervention for PTSD in primary care. Recommendations are made for future research and clinical practice.     

Predictors of PTSD Improvement with Cognitive/Exposure Group Interventions in Operation Enduring Freedom/Operation Iraqi Freedom Female Veterans

Predictors of successful PTSD outcome have been examined through individually delivered treatments. We examined predictors using a group protocol with cognitive, exposure, and skills modules. Assessments included self-report and interview (CAPS, SCID-I/II) measures at baseline, post, and six months; treatment was a 16-week, three-member group for 32 OEF/OIF women Veterans. A regression analysis showed major depressive disorder and no baseline psychiatric medication predicted PTSD improvement. PTSD improvement predicted fewer outpatient medical visits at follow-up. The results supported past research and challenged other findings (e.g., sexual assault predicts less improvement). An additional unique contribution was examining predictors in a group treatment format.     

Homelessness Is Traumatic: Abuse,Victimization, and Trauma Histories of Homeless Men

Homelessness is traumatic, and trauma-informed care is an emerging best practice. Using structured interviews with day shelter clients (N = 152), this study examined trauma among homeless men. The PTSD Checklist (PCL–C) was used to assess for posttraumatic stress disorder (PTSD). Participants’ pattern of PCL–C responses suggested that 23% to 30% screened positive for PTSD. Those with positive PTSD screens had been homeless longer and were more likely to have met time criteria for chronic homelessness. They were significantly more likely to be veterans and to report violent attacks, abuse histories, and mental health problems. Importantly, only 69% of those with positive PTSD screens acknowledged current mental health problems. These individuals were much less likely to report mental health counseling in the prior year.     

Be Fair,Your Employees Are Watching: A Relational Response Model of External Third‐Party Justice

There is growing theoretical recognition in the organizational justice literature that an organization's treatment of external parties (such as patients, community members, customers, and the general public) shapes its own employees’ attitudes and behavior toward it. However, the emerging third‐party justice literature has an inward focus, emphasizing perceptions of the treatment of other insiders (e.g., coworkers or team members). This inward focus overlooks meaningful “outward” employee concerns relating to how organizations treat external parties. We propose a relational response model to advance the third‐party justice literature asserting that the organization's fair treatment of external parties sends important relational signals to employees that shape their social exchange perceptions toward their employer. Supporting this proposition, in two multisource studies in separate healthcare organizations we found that patient‐directed justice had indirect effects on supervisory cooperative behavior ratings through organizational trust and organizational identification.     

儿童青少年创伤后应激障碍(PTSD)治疗的研究热点——基于美国文献的知识图谱分析

为了解近10年(2006~2016)来美国18岁及以下的儿童青少年创伤后应激障碍(PTSD)治疗研究的热点和重点,利用Bicomb 2.0软件和IBM SPSS Statistics 20.0软件,对ISI Web of Science数据库中查询到的363篇论文进行了知识图谱的可视化分析。结果表明,近10年来美国儿童青少年PTSD治疗研究可分为两个大的研究领域。领域一为儿童青少年PTSD的精神科和神经生物学相关的治疗,包括了两个小的研究热点:(1)儿童青少年PTSD精神科药物治疗相关的研究;(2)儿童青少年PTSD眼动脱敏再加工治疗等神经生物学机制的疗法。领域二为儿童青少年PTSD的心理学治疗,包括了两个小的研究热点:(1)家庭暴力导致的儿童青少年PTSD心理学治疗研究;(2)儿童青少年PTSD的认知行为治疗研究。其中关于儿童青少年PTSD的认知行为治疗研究是研究的热点和重点领域,但关于儿童青少年PTSD治疗效果的长期纵向研究还较为缺乏,未来研究者应加强对儿童青少年PTSD治疗效果的追踪研究,并开展心理治疗与药物治疗相结合的疗效研究。     

Psychological impact of remote combat/graphic media exposure among US Air Force intelligence personnel

Since 2001 there has been a significant increase in the use of intelligence, surveillance, and reconnaissance (ISR) analysis for tactical, operational, and strategic decision makers engaged in global operations. To meet this demand, US Air Force intelligence personnel participate in remote combat and graphic media exploitation operations (e.g., review of still imagery, video, and audio), the long-term psychological effects of which are not well understood. Research to date has focused primarily on outcomes related to how intelligence personnel work, versus the specifics of what they do. Military psychologists embedded in ISR units conducted studies to address this gap. Intelligence analysts participated in focus groups and surveys assessing the frequency of exposure, previous exposures to other potentially traumatic events, symptoms of PTSD, moral injury, and other psychosocial experiences. Results showed that exposure levels, albeit virtual, rivaled or exceeded those reported by a sample of special operations forces. Results also showed that specific types of exposures (e.g., witnessing US military casualties, civilian casualties, atrocities committed by the enemy) are related to increased posttraumatic stress and other sequelae that may not adequately be captured by standard posttraumatic stress disorder screening measures. The results contribute to the existing literature on posttraumatic stress, shed new light on the emerging construct of moral injury, and highlight challenges presented by remote combat and graphic media exploitation operations to force health sustainment and performance optimization. The authors provide directions for future research and recommendations for ongoing assessment, monitoring, and selection and training of ISR personnel.     

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.