Temporal Relationship Between Change in Subjective Distress and PTSD Symptom Decrease During Prolonged Exposure Therapy for Posttraumatic Stress Disorder

There is growing evidence that change in distress is an indicator of change during Prolonged Exposure (PE) for posttraumatic stress disorder (PTSD). However, temporal sequencing studies investigating whether change in distress precedes PTSD symptom decline are lacking. These studies are essential since the timeline between indicators of change and treatment outcome is a key assumption for mediation. The aim of the present study was to assess the temporal relationship between within- and between-session change in subjective distress and PTSD symptom decrease. We analyzed session data from 86 patients with PTSD. Data were analyzed using dynamic panel models. We distinguished temporal effects (within-persons) from averaged effects (between-persons). Results regarding the temporal effect showed that within-session change in subjective distress preceded PTSD symptom improvement while the reversed effect was absent. Averaged within-session change in subjective distress was also related to PTSD symptom improvement. Results regarding the temporal effect of between-session change in subjective distress showed that it did not precede PTSD symptom improvement. Averaged between-session change in subjective distress was related to PTSD symptom improvement. This study provides evidence for within- but not between-session change in subjective distress as indicator of change during PE. We also found that the way of modeling potential indicators of change affects results and implications. We recommend future studies to analyze mediators during treatment using temporal rather than averaged effects.     

Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl

The alpha-2 adrenergic receptor antagonist, yohimbine, can facilitate fear extinction in animals and humans. One potential mechanism is increased noradrenergic activity and associated arousal in the presence of conditioned stimuli. Accordingly, yohimbine might augment prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD), where heightened exposure-oriented arousal is a theorized driver and empirical predictor of treatment success. A double-blind placebo-controlled randomized trial (NCT 01031979) piloted yohimbine augmentation in 26 males with combat-related PTSD. Participants were given one-time dose of yohimbine or placebo prior to the first imaginal exposure. Subsequently, both arms completed standard PE. The primary outcome was trauma-cued heart-rate reactivity a week after the drug/exposure visit, a highly specified, objective measure sensitive to incremental change. Secondary outcomes included arousal during the drug/exposure visit and slope of distress, PTSD, and depression over the course of PE. Consistent with hypothesis, yohimbine led to higher objective and subjective arousal during the drug/exposure visit and to lower trauma-cued heart-rate reactivity one-week later. One dose of yohimbine also led to greater between-session habituation and more rapid improvement on depression, but not PTSD, over the course of care. Results of this controlled pilot indicate support for continued investigation of yohimbine-augmented exposure therapy for PTSD.     

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.     

Posttraumatic Stress Disorder and Chronic Pain Arising from Motor Vehicle Accidents: Efficacy of Interoceptive Exposure Plus Trauma-Related Exposure Therapy

Preliminary data are presented on the pattern of treatment response of combining interoceptive exposure (IE) with trauma-related exposure therapy (TRE) in five female patients with posttraumatic stress disorder (PTSD) and comorbid chronic musculoskeletal pain originating from motor vehicle accidents. Treatment consisted of four sessions of IE followed by eight sessions of TRE. Four participants reported a reduction in PTSD symptoms after completing treatment, and three no longer met diagnostic criteria for PTSD. Although both interventions were associated with reductions in PTSD symptoms, TRE was associated with greater reductions in PTSD symptoms than IE and was particularly effective at reducing avoidance. IE was associated with larger reductions in anxiety sensitivity than TRE. Pain symptoms lessened slightly during IE and then worsened following TRE. Anxiety decreased after completing treatment, whereas panic and depressive symptoms responded less so. Three individuals completed a 3-month follow-up assessment. There was no change in their PTSD diagnostic status, and all experienced a slight loss of pre–post gains, particularly involving the return of pain. Clinical and research implications are discussed.     

Brief Imaginal Exposure for PTSD: Trajectories of Change in Distress

Preliminary evidence shows that brief, condensed imaginal exposure only interventions can be effective in the treatment of PTSD, but we need to understand its mechanisms of action. Consistent with extinction learning and retrieval processes, the present study examined whether a pattern of between-session distress reduction observed during standard prolonged exposure (PE) therapy would be observed and predict outcome. Sixty-three patients with PTSD were enrolled in two clinical trials using our treatment protocol consisting of six daily 50-min sessions focusing on imaginal exposure and processing only. Individual patient trajectories of distress reduction were examined over the course of the five imaginal exposure sessions (Sessions 2-6). Overall, significant linear distress reduction was observed for anticipatory (d = 1.18), peak (d = 1.83), and ending imaginal exposure distress (d = 1.21). Consistent with extinction learning, the steeper slope of peak distress (d = 1.03) and end distress (d = 0.68) across imaginal exposure sessions strongly predicted decreases in PTSD symptoms. Distress reduction across sessions was predicted by higher baseline avoidance and hyperarousal but not reexperiencing symptoms. This condensed format of daily 50-min sessions without in vivo exposure may be operating via similar extinction learning processes as longer protocols. Our clinical observations suggest that the brief daily format may offer the advantage of allowing each session to build on the previous one to promote meaningful shifts in the retrieval of the trauma memory. Brief imaginal exposure and processing may be a viable option for PTSD patients in settings where brief interventions are needed. Understanding potential change processes and baseline predictors of change brings us closer toward precision medicine in treating PTSD.     

A preliminary investigation of sudden gains in exposure therapy for PTSD

The purpose of the current study was to examine sudden gains in those receiving treatment for PTSD and whether these rapid changes were related to overall symptom reduction in a small sample of female assault survivors with PTSD undergoing prolonged exposure (PE) therapy. Sudden gains were found to occur in 52% of the sample. Among those who experienced a sudden gain, the average magnitude (12.4 points) accounted for 61% of overall symptom reduction. Importantly, treatment outcome was better for those who experienced sudden gains than those who did not. The experience of a sudden gain may result in patients becoming more fully engaged with treatment, and recognition of them may result in identifying potential process-related predictors of treatment response.     

Sudden Gains in Two Trauma-Focused Treatments for Posttraumatic Stress Disorder

In the current study, we examined the degree to which sudden gains (large, rapid, and stable symptom reduction in a one-session interval) predicted treatment outcome in adults randomized to two different trauma-focused treatments. Adults diagnosed with PTSD were randomized to either written exposure therapy (WET; n = 63), a brief, exposure-based treatment for posttraumatic stress disorder (PTSD), or the more time-intensive Cognitive Processing Therapy (CPT; n = 63). Findings showed that 20.6% of participants who received WET and 17.5% of participants who received CPT experienced sudden gains. Sudden gains occurred earlier in WET (M session = 2.69, SD = 0.75) than in CPT (M session = 5.64, SD = 3.01). However, there were no treatment condition differences in the magnitude of the sudden gains. Treatment outcomes were significantly better for those who experienced sudden gains compared with those who did not, regardless of treatment assignment. Exploratory analyses of participants’ trauma narratives revealed that expressing more negative emotion predicted the occurrence of sudden gains in both treatment conditions. Negative beliefs about the self and others did not predict sudden gains. The findings are discussed in terms of how they may help identify individual early response patterns that predict outcomes in trauma-focused treatments.     

Physiological arousal and attention in veterans with posttraumatic stress disorder

Psychophysiological reactivity has been well documented in WWII, Korean Conflict, and Vietnam veterans with posttraumatic stress disorder (PTSD). In addition, these individuals have demonstrated cognitive impairments within the domains of attention, concentration, new learning, and memory. However, there has been no research examining the impact of physiological arousal on attention in individuals with PTSD. This study documents the level of physiological arousal and associated disruption of attentional abilities in 28 Persian Gulf War veterans (18 without PTSD or other psychopathology and 10 with PTSD). This population represents a group of combat trauma victims who experienced a relatively acute onset of PTSD, thus providing a unique opportunity to compare prior psychophysiological and cognitive results with a group of veterans who manifested a recent onset of PTSD. Results indicated relatively comparable psychophysiological reactivity and arousal between Persian Gulf War veterans with PTSD and Persian Gulf War veterans without PTSD. Furthermore, attentional processes of veterans with PTSD were not more disrupted than in comparison soldiers. Results suggest that the intensity and chronicity of the disorder may impact physiological arousal and disruption of cognitive functioning. Following Persian Gulf War veterans with PTSD over time may reveal that psychophysiological arousal becomes more pronounced with chronicity, perhaps as memory networks become strengthened and/or neuroendocrine systems become increasingly disrupted.     

Trauma in Resettled Iraqi Refugees: Differences between Those Seeking Psychological Treatment and Those Not Seeking Psychological Treatment

Psychological distress experienced by resettling refugees has been well documented, with posttraumatic stress disorder (PTSD) and depression being prevalent outcomes. This study examined psychological and physiological measures of trauma exposure in 2 groups of Iraqi refugees resettled in Australia, those seeking psychological treatment (n = 25) versus those not seeking treatment (n = 22). Data from a group of healthy sex- and age-matched controls (n = 32) were collected to facilitate norm comparisons for physiological arousal. Continuous recording of electrocardiogram data examined resting heart rate (HR). Refugees seeking treatment had significantly higher levels of PTSD symptomology and depression levels compared to non-treatment-seeking refugees; however, there was no difference in the number of trauma events endorsed. Finally, resting HR was significantly higher in both refugee groups compared with healthy controls; however, there was no difference between the refugee groups. Clinical consideration of this excessive trauma exposure and elevated autonomic arousal is warranted.     

Regional brain electrical activity in posttraumatic stress disorder after motor vehicle accident

This study examined whether patients with posttraumatic stress disorder (PTSD) related to motor vehicle accidents (MVAs) would show an abnormal pattern of electroencephalographic (EEG) alpha asymmetries, which has been proposed for particular types of anxiety. Patients with PTSD (n = 22) or subsyndromal PTSD (n = 21), traumatized controls without PTSD (non-PTSD with MVA; n = 21), and healthy controls without MVA (n = 23) underwent measurement of EEG activity during baseline and exposure to a neutral, a positive, a negative, and an accident-related picture. Differences in brain asymmetry between groups were observed only during exposure to trauma-related material. PTSD and subsyndromal PTSD patients showed a pattern of enhanced right anterior and posterior activation, whereas non-PTSD with MVA participants showed the opposite pattern. Furthermore, posterior asymmetry in nontraumatized healthy controls varied with gender, with female participants showing a pattern of higher right posterior activation. The results support the hypothesis that symptomatic MVA survivors are characterized by a pattern of right hemisphere activation that is associated with anxious arousal and symptoms of PTSD during processing of trauma-specific information.     

Written exposure as an intervention for PTSD: A randomized clinical trial with motor vehicle accident survivors

The present study examined the efficacy of a brief, written exposure therapy (WET) for posttraumatic stress disorder (PTSD). Participants were 46 adults with a current primary diagnosis of motor vehicle accident-related PTSD. Participants were randomly assigned to either WET or a waitlist (WL) condition. Independent assessments took place at baseline and 6-, 18-, and 30-weeks post baseline (WL condition not assessed at 30 weeks). Participants assigned to WET showed significant reductions in PTSD symptom severity at 6- and 18-week post-baseline, relative to WL participants, with large between-group effect sizes. In addition, significantly fewer WET participants met diagnostic criteria for PTSD at both the 6- and 18-week post-baseline assessments, relative to WL participants. Treatment gains were maintained for the WET participants at the 30-week post baseline assessment. Notably, only 9% of participants dropped out of WET and the WET participants reported a high degree of satisfaction with the treatment. These findings suggest that a brief, written exposure treatment may efficaciously treat PTSD. Future research should examine whether WET is efficacious with other PTSD samples, as well as compare the efficacy of WET with that of evidence-based treatments for PTSD.     

Post-Traumatic Stress Disorder as a Consequence of a Toxic Spill in Northern California

This study examined the development of post-traumatic stress disorder (PTSD) and associated features in residents of Dunsmuir, California, following a toxic spill. Classification of PTSD was based on a cutoff score from the Impact of Event Scale. It was predicted that greater exposure to the spill would increase the risk of PTSD and associated symptoms among spill residents; that those classified with PTSD would report more symptoms than would those without PTSD and controls; and that litigants would be classified with PTSD more than would nonlitigants. Results suggest that spill residents classified with PTSD had greater levels of tension, depression, anxiety, anger, fatigue, and confusion than did spill residents without PTSD and control residents with and without PTSD. Spill residents with PTSD reported more memory problems and sleep disorders than did those without PTSD and control residents with and without PTSD. Measures of physiological arousal showed that spill residents had higher systolic blood pressure several hours after a stressful interview than did control residents without PTSD. Pulse rates several hours after a stressful interview were higher for spill residents with and without PTSD than for control residents with PTSD. Results suggest that exposed residents are at risk for developing PTSD and associated symptoms.     

Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone

Cambodian refugees with posttraumatic stress disorder (PTSD) represent a cohort in severe need of treatment, but little information is available to guide treatment choices. We selected a sample of pharmacotherapy-refractory individuals to test the efficacy of combination treatment with sertraline and cognitive-behavior therapy (CBT) for treating PTSD. Participants in this pilot study were ten Khmer-speaking women who had been at a mean age of 22-26 years during the Pol Pot period (1975-1979). These patients were randomly assigned to either sertraline alone or combined treatment. We found that combined treatment offered additional benefit in the range of medium to large effect sizes for PTSD and associated symptoms. Our findings indicate that substantial gains can be achieved by adding CBT to pharmacotherapy for PTSD, and that a program of CBT emphasizing information, exposure, and cognitive-restructuring can be successfully modified for Khmer-speaking refugees.     

Young Children’s Physiological Reactivity during Memory Recall: Associations with Posttraumatic Stress and Parent Physiological Synchrony

Autonomic reactivity is implicated in stress response and social engagement – both key components of posttraumatic stress disorder (PTSD) – but few studies have examined autonomic reactivity in pediatric samples, and no known studies have examined physiological synchrony among children with PTSD and caregivers. In a sample of 247 young children (94 girls, 153 boys), most (85%) of whom had exposure to trauma and 40% who met criteria for PTSD, we examined children’s patterns of respiratory sinus arrhythmia (RSA) at baseline and in response to a memory recall task, as well as correspondence between parents’ and children’s RSA. Children with PTSD demonstrated significantly higher reactivity than other groups during their recollection of a traumatic memory, but not during other memory tasks. Regarding synchrony, caregivers’ and children’s RSA were more significantly and positively correlated during the trauma recall task among children who had had exposure to a potentially traumatic event but did not meet PTSD criteria, suggesting physiological synchrony may be protective in contexts of trauma. Overall, findings demonstrate physiological reactivity differences among young children with PTSD. While more work is needed to understand the meaning of parent-child physiological synchrony, these data suggest that children’s psychopathology is associated with physiological synchrony processes among young children with exposure to trauma.     

心理咨询中的突然获益：工作同盟及初始症状的影响

对82位当事人在咨询中的症状改变过程进行纵向研究,检验突然获益模式（Sudden Gain, SG）的发生及其与咨询效果的联系,并探索初始症状水平、工作同盟对SG的影响。结果表明,24.93%的当事人经历了SG,咨询效果显著好于其他当事人;SG组与对照组在初始症状水平和总体工作同盟水平上差异显著。结论：SG出现于本土心理咨询中,经历SG的当事人取得了更好的咨询效果,工作同盟与初始症状水平与SG的发生相关。     

Prolonged exposure therapy for chronic combat-related PTSD: a case report of five veterans

Prolonged exposure (PE) therapy has been found efficient in reducing posttraumatic stress disorder (PTSD) symptoms mostly among rape victims, but has not been explored in combat-related PTSD. Five patients with severe chronic PTSD, unresponsive to previous treatment (medication and supportive therapy) are described. Patients were evaluated with the PTSD Symptom Scale-Interview, and Beck Depression Inventory, before and after 10-15 sessions of PE therapy. All five patients showed marked improvement with PE, with a mean decrease of 48% in PTSD Symptom Scale-Interview score and 69% in Beck Depression Inventory score. Moreover, four patients maintained treatment gains or kept improving 6-18 months after the treatment. The results suggest that PE was effective in reducing combat-related chronic PTSD symptoms.     

The relationship of affiliative arousal to dopamine release

Higher levels of affiliation motivation after exposure to affiliative films are significantly related to higher dopamine concentrations in saliva in one study of 61 college students of both sexes, and in plasma in another study of 47 adults of both sexes. Individuals high in dispositionaln Affiliation, if they also reported high life stress, showed high gains in dopamine concentration in plasma after exposure to an affiliative film significantly more often than other individuals. Since aroused affiliation motivation was not associated with higher concentrations of norepinephrine, epinephrine, or cortisol in either study, it appears likely that dopamine is especially associated with arousal of affiliation motivation, just as norepinephrine has been found to be associated with arousal of power motivation. Thus, different motives may be subserved by different hormones, making it unlikely that all motives lead to the same state of physiological arousal.This research was carried out when all the authors were connected with the Department of Psychology and Social Relations at Harvard University. We acknowledge with thanks the support of the John D. and Catherine T. MacArthur Foundation through a grant to the senior author.     

PTSD arousal and depression symptoms associated with increased right-sided parietal EEG asymmetry

Researchers have proposed that depression and particular types of anxiety are associated with unique patterns of regional brain activation. The authors examined the relationship among posttraumatic stress disorder (PTSD), anxiety, and depressive symptoms and frontal, temporal, and parietal EEG alpha asymmetry in female Vietnam War nurse veterans. The results indicate that PTSD arousal symptoms are associated with increased right-sided parietal activation. However, the combination of arousal, depression, and their interaction explain more than twice the variance in parietal asymmetry compared with arousal alone. The results support the contention that the association between anxiety and right-sided posterior activation is specific to the anxious arousal subtype. These findings underscore the importance of isolating, both theoretically and statistically, emotional subcomponents in studies of regional brain activation.     

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.     

Chronic PTSD Treated With Metacognitive Therapy: An Open Trial

This paper reports on an open trial of metacognitive therapy (MCT) for chronic PTSD. MCT does not require imaginal reliving, prolonged exposure, or challenging of thoughts about trauma. It is based on an information-processing model of factors that impede normal and in-built recovery processes. It is targeted at modifying maladaptive styles of worry/rumination and attention so that emotional processing can proceed spontaneously. Eleven out of 13 patients with a mean duration of PTSD of 19.5 months completed treatment. Therapists followed the treatment manual by Wells and Sembi (2004b). Self-report measures of PTSD symptoms, anxiety and depression, and assessor ratings of PTSD were administered at pre- and posttreatment, and at 3- and 6-month follow-up. Treatment appeared to result in large and significant improvements on all measures of PTSD and general measures of anxiety and depression. Statistically significant treatment gains were maintained at 3- and 6-month follow-up. Jacobson's criteria for recovery showed that 90% of patients were recovered at posttreatment. At 6-month follow-up approximately 89% were recovered or reliably improved. Results suggest that MCT could be highly effective and extend evidence of its applicability to more treatment-resistant chronic PTSD cases. Comparisons against other active interventions are now clearly indicated.