Trajectories of Response to Treatment for Posttraumatic Stress Disorder

Research on the predictors of response to cognitive-behavioral treatments for PTSD has often produced inconsistent or ambiguous results. We argue this is in part due to the use of statistical techniques that explore relationships among the entire sample of participants rather than homogeneous subgroups. Using 2 large randomized controlled trials of Cognitive Processing Therapy (CPT), CPT components, and Prolonged Exposure, we employed growth mixture modeling to identify distinct trajectories of treatment response and to determine the predictors of those trajectories. We determined that the participants’ trajectories could be best represented by 2 latent classes, which we subsequently labeled responders (87% of the sample) and nonresponders (13% of the sample). Notably, there was not a separate class for partial responders. Assignment to the nonresponder class was associated with receiving the written accounts (WA) component of CPT, a pretreatment diagnosis of major depression (MDD), and more pretreatment hyperarousal symptoms. Thus, it appears that some individuals do not benefit from merely writing about their trauma and processing it with the therapist; they may also need to engage in cognitive restructuring to successfully ameliorate their symptoms. Additionally, those who meet criteria for MDD or have high levels of hyperarousal at the onset of treatment might require additional treatment or support.     

Treatment of Posttraumatic Stress Disorder Following an Armed Robbery: A Case Study Testing the Transportability of Trauma-Focused Cognitive-Behavioural Therapy to Urban Africans

John, an urban African male who developed posttraumatic stress disorder (PTSD) following an armed robbery at the petrol station where he worked, was treated with 12 sessions of Trauma-focused cognitive behaviour therapy. Intervention involved a combination of psychoeducation, prolonged imaginal exposure, cognitive restructuring and behavioural assignments. This article is a systematic case study of his treatment which included a comprehensive narrative and tracking of progress by means of the Posttraumatic Diagnostic Scale. John responded well to the treatment, finding it acceptable and credible and remained free of PTSD symptoms at 15 months follow up. It is argued, based on the principles of Elliott's Hermeneutic Single Case Efficacy Design, that there is evidence from within the narrative that it was the treatment that led to remission of symptoms. This case study demonstrates the cognitive, emotional and behavioural processes underlying John's PTSD, which fits with those extensively described in the research literature, and that this evidence-based treatment developed in a westernised context is transportable to work with urban Africans.     

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.     

Phase-based Emotionally Focused Couple Therapy for Adults With Complex Posttraumatic Stress Disorder

Complex posttraumatic stress disorder (complex PTSD) presents unique challenges to treatment beyond that of posttraumatic stress disorder (PTSD). The expert consensus best practice for treatment of complex PTSD is a phase-based or sequenced approach that has typically been offered in individual or group therapy modalities. Emotionally focused couple therapy (EFCT) shows promise as a couple-based treatment for PTSD, but the standard protocol may inadequately incorporate best practice guidelines of phase-based treatment for complex PTSD. Integration of phase-based treatment of complex PTSD within an EFCT format is proposed, giving direction to EFCT providers on incorporating best practice guidelines into their work with survivors.     

Violence Exposure and Psychopathology in Urban Youth: The Mediating Role of Posttraumatic Stress

Understanding the mechanisms underlying the development of violence exposure sequelae is essential to providing effective treatments for traumatized youth. This longitudinal study examined the mediating role of posttraumatic stress in the relationship between violence exposure and psychopathology, and compared the mediated models by gender. Urban adolescents (n=1,358) were surveyed using the Social and Health Assessment. The proposed relationships were examined using Structural Equation Modeling. Posttraumatic stress fully mediated the relationships between victimization and depression and anxiety in girls, and partially so in boys. In addition, posttraumatic stress partially mediated the relationships between violence exposure and commission of violence in boys. Current findings support the longitudinal effects of violence exposure on adolescent mental health. Posttraumatic stress represents a unique mechanism for the development of psychopathology in girls and is also related to negative outcomes in boys. These findings have direct implications for prevention and rehabilitation efforts among violence exposed youth.     

Cognitive Behavioral Therapy and the Treatment of Posttraumatic Stress Disorder: Where Counseling and Neuroscience Meet

There is increasing evidence to support the biological basis of mental disorders. Subsequently, understanding the neurobiological context from which mental distress arises can help counselors appropriately apply cognitive behavioral therapy and other well‐researched cognitive interventions. The purpose of this article is to describe the neurobiological context underlying the formation and treatment of posttraumatic stress disorders, a mental disorder frequently encountered by counselors, from a cognitive therapy framework.     

Spirituality and Trauma: The Role of Clergy in the Treatment of Posttraumatic Stress Disorder

An increased awareness of the spiritual aspects of health and illness has recently led to changes in psychiatry residency training as well as hospital accreditation requirements. The spiritual impact of trauma has been an area of particular interest, as trauma evokes certain existential questions and crises. It is estimated that from 5–11% of trauma survivors will go on to develop posttraumatic stress disorder (PTSD). Given the spiritual challenges of the experience of trauma, patients with PTSD could benefit from spiritual assessment and intervention as part of their overall treatment plan, and clergy can be utilized to perform this. The literature exploring the spiritual impact of trauma and the use of clergy in the treatment of trauma survivors is reviewed. The methods used by three chaplains in a residential treatment program for PTSD at one facility are described and discussed. Both the literature and the experiences of the clergy suggest that exploration of trauma-related existential conflicts in patients with PTSD is beneficial. However, there is a notable dearth of controlled scientific studies evaluating the effectiveness of spiritual interventions with this treatment population. The need for controlled studies to verify the usefulness of spiritual assessment and intervention in patients with PTSD is noted, and a more rigorous analysis of how clergy can best serve this treatment population is encouraged.     

Posttraumatic Stress Disorder and Marital Adjustment: The Mediating Role of Forgiveness

The study assessed the effects of war captivity on posttraumatic stress symptoms and marital adjustment among Prisoners of War (POWs) from the Yom Kippur War. It was hypothesized that men's perception of level of forgiveness mediates the relation between posttraumatic symptoms and marital adjustment. The sample consisted of 157 Israeli veterans divided into 3 groups: 21 POWs with Posttraumatic Stress Disorder (PTSD), 58 former POWs without PTSD, and 70 control veterans. The findings indicated that former POWs with PTSD reported lower levels of marital satisfaction and forgiveness than veterans in the other 2 groups. In addition, men's perception of level of forgiveness mediated the relationship between their posttraumatic symptoms and their marital adjustment. The theoretical and clinical implications of these results are discussed.     

Breast Cancer as Trauma: Posttraumatic Stress and Posttraumatic Growth

Diagnosis and treatment of cancer has been associated with both posttraumatic stress disorder (PTSD) symptoms and posttraumatic growth (PTG). This cross-sectional study sought to assess the frequency, common predictors, and interrelationships of PTSD symptoms and PTG in breast cancer survivors (n = 65). In this sample, symptoms of PTSD and reports of PTG were common and were not significantly related to one another. Greater social constraints on talking about breast cancer and perception of cancer as a traumatic stressor were associated with greater PTSD symptomatology. Younger age and perception of cancer as a traumatic stressor were associated with greater PTG. Findings suggest the central role of subjective appraisal in adjustment to cancer. Psychosocial interventions should be sensitive to the potential for PTG, both in treatment design and in assessment of outcomes.     

The Relationship between Personality Disorder Features and Symptom Improvement at an Inpatient Treatment Program for Posttraumatic Stress Disorder

This study examined the association between personality disorder (PD) features and symptom improvement among adult survivors of childhood trauma in an inpatient program for posttraumatic stress disorder (PTSD). Participants completed questionnaires at admission, discharge, and six months following discharge. Multiple regression analyses were used to assess the combined effects of personality features on symptom improvement. Results indicated that improvement in trauma-related symptoms was not related to PD features. By contrast, the PD features were associated with change in other Axis I symptoms often comorbid with PTSD. Overall, results suggested that PD features do not impede improvement in trauma-related symptoms; however, specific accommodations might be needed to address comorbid disorders among individuals with PTSD.     

Direct and Mediating Effects of an Anxiety Sensitivity Intervention on Posttraumatic Stress Disorder Symptoms in Trauma-Exposed Individuals

Anxiety sensitivity (AS), or fear of anxious arousal, is a higher-order cognitive risk-factor for posttraumatic stress disorder (PTSD) composed of lower-order physical, cognitive, and social concerns regarding anxiety symptoms. Brief and effective interventions have been developed targeting AS and its constituent components. However, there is limited evidence as to whether an intervention aimed at targeting AS would result in reductions in PTS symptoms and whether the effects on PTS symptoms would be mediated by reductions in AS. Furthermore, there is no evidence whether these mediation effects would be because of the global or more specific components of AS. The direct and indirect effects of an AS intervention on PTS symptoms were examined in a sample of 82 trauma-exposed individuals (M age = 18.84 years, SD = 1.50) selected based on elevated AS levels (i.e., 1 SD above the mean) and assigned to either a treatment (n = 40) or an active control (n = 42) condition. Results indicated that the intervention led to reductions in Month 1 PTS symptoms, controlling for baseline PTS symptoms. Furthermore, this effect was mediated by changes in global AS and AS social concerns, occurring from intervention to Week 1. These findings provide an initial support for an AS intervention in amelioration of PTS symptoms and demonstrate that it is primarily reductions in the higher-order component of AS contributing to PTS symptom reduction.     

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.     

Parent and Child Agreement for Acute Stress Disorder,Post-Traumatic Stress Disorder and other Psychopathology in a Prospective Study of Children and Adolescents Exposed to Single-Event Trauma

Examining parent-child agreement for Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) in children and adolescents is essential for informing the assessment of trauma-exposed children, yet no studies have examined this relationship using appropriate statistical techniques. Parent-child agreement for these disorders was examined by structured interview in a prospective study of assault and motor vehicle accident (MVA) child survivors, assessed at 2–4 weeks and 6 months post-trauma. Children were significantly more likely to meet criteria for ASD, as well as other ASD and PTSD symptom clusters, based on their own report than on their parent’s report. Parent-child agreement for ASD was poor (Cohen’s κ = −.04), but fair for PTSD (Cohen’s κ = .21). Agreement ranged widely for other emotional disorders (Cohen’s κ = −.07–.64), with generalised anxiety disorder found to have superior parent-child agreement (when assessed by phi coefficients) relative to ASD and PTSD. The findings support the need to directly interview children and adolescents, particularly for the early screening of posttraumatic stress, and suggest that other anxiety disorders may have a clearer presentation post-trauma.     

The Forensic Examination of Posttraumatic Stress Disorder

Abstract

The diagnosis of posttraumatic stress disorder (PTSD) has achieved a major level of significance in our judicial system. The forensic examination of PTSD is identified as a specialized assessment that is non-biased and non-prejudicial. This article attempts to provide a standard methodology to offer an objective and neutral forensic assessment and diagnosis of PTSD that will stand up to legal scrutiny by identifying problems in diagnosing PTSD and establishing a six-step methodology for the differential diagnosis of the disorder. Procedures for providing a forensic examination of PTSD and details of the author's methods of providing a forensic examination are presented.     

A Novel,Integrated Cognitive-Behavioral Therapy for Co-Occurring Posttraumatic Stress and Substance Use Disorders: A Case Study

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No preferred, evidence-based treatments for PTSD/SUD comorbidity are presently available. Promising integrated treatments have combined prolonged exposure therapy with cognitive-behavioral relapse prevention therapy for SUD. We describe a case study that showcases a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS). The TIPSS program integrates cognitive processing therapy with cognitive-behavioral therapy for SUD for the treatment of co-occurring PTSD/SUD. The present case report, based upon a woman with PTSD comorbid with both cocaine and alcohol dependence, demonstrates that TIPSS has the potential to effectively reduce PTSD symptoms as well as substance use.     

Course of Treatment During a Cohort-Based Inpatient Program for Posttraumatic Stress Disorder

This study examined one group of veterans with post-traumatic stress disorder (PTSD) over the course of a four month inpatient treatment program. The aim of the study was to examine treatment process factors that may contribute to the generally poor outcome reported in previous studies. Group members made weekly ratings in the domains of PTSD symptoms, morale, interpersonal relationships, and physical problems. Results contrasted with clinical assumptions usually made regarding the treatment process in these programs. Despite an appearance of cohesion among group members, variation of scores on functional domains was explained largely by individual differences. Progress through the program showed a strongly linear pattern, with no phase effects. Somatic complaints did not increase during the phase when traumatic material was explored. Degree of improvement or worsening was best predicted by level of PTSD symptoms at admission, indicating that more symptomatic veterans did worse in the program. Additional factors of race, combat exposure, childhood abuse, and application for disability had no effect on the process variables measured.     

Treatment Adherence Among War Veterans with Posttraumatic Stress Disorder: A Concept Analysis

Aim: This study was made to analyze the concept of treatment adherence among war veterans who suffer posttraumatic stress disorder.

Methods: This concept analysis was done using Walker and Avant’s concept analysis model. Online English and Persian databases were searched using keywords such as “posttraumatic stress disorder,” “mental disorder,” “compliance,” and “adherence.” Finally, 11 eligible documents were included in the analysis. The retrieved articles were perused word-by-word, line-by-line, and paragraph-by-paragraph in order to arrive at an in-depth understanding about their contents. Then, the obtained excerpts from the articles, which were relevant to the study subject matter, were coded. The codes were then grouped into the antecedents, consequences, and attributes of the concept.

Findings: In total, 122 primary codes, 19 subcategories, 8 main categories, and 4 main themes were extracted. The main antecedents of the treatment adherence concept are patients’ personal health background and the attributes of posttraumatic stress disorder and its treatments while its main outcome is the changes in the quality of life. Moreover, the main attribute of adherent veterans is that they take responsibility for their own health and subsequently attempt to plan for health promotion.

Conclusion: The concept of treatment adherence among war veterans who suffer from PTSD is a complex and relative concept which depends on patients’ personal health background as well as the attributes of the afflicting disorder and its treatments. The concept is manifested by patient’s attempts to plan for receiving or parting with treatments and can result in changes in health-related quality of life.     

Neuroimaging and Occupational Therapy: Bridging the Gap to Advance Rehabilitation in Developmental Coordination Disorder

Developmental coordination disorder (DCD) is a neurodevelopmental disorder characterized by poor motor skills that interfere with a child's ability to perform everyday activities. Little is known about the neural mechanisms that implicate DCD, making it difficult to understand why children with DCD struggle to learn motor skills and selecting the best intervention to optimize function. Neuroimaging studies that utilize magnetic resonance imaging techniques have the capacity to play a critical role in helping to guide clinicians to optimize functional outcomes of children with DCD using evidence-based rehabilitation interventions. The authors' goal is to describe how neuroimaging research can be applied to occupational therapy and rehabilitation sciences by highlighting projects that are at the forefront of the field and elucidate future directions.     

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.     

Virtual Reality Exposure for Veterans with Posttraumatic Stress Disorder

Abstract

Two open trials of Virtual Reality based exposure therapy (VRE) to desensitize Vietnam veterans with Posttraumatic Stress Disorder (PTSD) to some of their traumatic memories are described. A total of 21 patients were exposed to one of two virtual Vietnam computer-generated environments in which their individual traumatic experiences were simulated in response to their recounting these events. Although two patients experienced significant increases in symptoms during VRE, all patients' PTSD symptoms were below baseline by the 3-month post-treatment assessment. When the data from the two open trials was combined, clinically meaningful and statistically significant reductions in PTSD symptoms were found. These changes were long lasting as evidenced by the 6-month follow-up assessments. Two case examples are provided and future applications of this treatment are discussed.