Rates of Subthreshold PTSD Among U.S. Military Veterans and Service Members: A Literature Review

The current study’s goal was to provide a comprehensive review of current subthreshold posttraumatic stress disorder (PTSD) rates among U.S. military veterans and service members. PubMed, PsycInfo, ProQuest, Web of Knowledge, Google Scholar, and any relevant articles’ reference lists identified studies of subthreshold PTSD in the U.S. military. Search terms included PTSD in combination with partial, subthreshold or sub-threshold, subsyndromal or sub-syndromal, subclinical or sub-clinical, and military or veteran. Sixteen articles met criteria for review. Current subthreshold PTSD rates ranged from 2.3% to 22.3%, with a weighted mean rate of 7.6%. Definitional variation within and across the “below threshold” terms produced some variability in rates reported. Few studies consistently reported on impairment and comorbidity in the subthreshold PTSD population. Variability of current subthreshold PTSD rates may be due to methodological issues such as sampling methods, sample sizes, and how below threshold PTSD was assessed and defined. Based on our findings, we provide a number of recommendations that can be used to inform future research of subthreshold PTSD among U.S. military veterans and service members. These recommendations include having a standardized term and definition, determining how to more properly assess subthreshold PTSD symptomatology, clarifying subthreshold PTSD diagnostic stability, and identifying appropriate sampling methods.     

Modification of Cognitive-Behavioral Techniques in the Treatment of a Five Year-Old Girl with Social Phobia

Social phobia is a debilitating anxiety disorder that often goes undetected in young children, but can be effectively treated with cognitive-behavioral interventions. For children and adolescents, treatment usually includes education, social skills training, cognitive restructuring, relaxation training, and exposure. However, for very young children who present with social phobia, it is necessary to adapt treatment to the developmental level of the child. A case illustration demonstrates the way in which cognitive behavioral treatment (CBT) was modified for the treatment of a five year-old girl with social phobia. Several modifications were made, including utilizing novel exposure techniques and emphasizing parent management training in order to promote generalization of treatment gains outside of session.     

The Effect of Concurrent Depression on PTSD Outcomes in Trauma-Focused Psychotherapy: A Meta-Analysis of Randomized Controlled Trials

The co-occurrence of depression with posttraumatic stress disorder (PTSD) is common and associated with greater severity and impairment than PTSD alone, but the effects on PTSD treatment outcomes are unclear. This study investigated the impact of baseline depression on PTSD symptom change and dropout in a meta-analysis of 44 randomized controlled trials (N = 4,866) of trauma-focused psychotherapies for PTSD. Analyses included 107 active (k = 71) and control (k = 36) conditions. Baseline depression was indexed within samples as (a) continuous symptom severity (e.g., Beck Depression Inventory), standardized across depression measures and (b) proportion of patients with comorbid depressive disorder diagnosis. Among active conditions reporting continuous depression scores (k = 62), greater depression severity predicted smaller PTSD treatment effect sizes (ß = -.36, p = .002), but not dropout (ß = .25, p = .18). Categorical depressive diagnosis rates (k = 29)—reported less frequently—were not associated with treatment effects or dropout in active conditions. Greater depression severity may reflect a risk factor for attenuated response in PTSD psychotherapies, potentially demanding complementary strategies within trauma-focused interventions. Variability between trials in baseline depression symptoms may suggest the need to consider this sample characteristic when comparing treatment outcomes across studies.     

Unique Ethical Concerns in Clinical Trials Comparing Psychosocial and Psychopharmalogical Interventions

In recent years, there has been a particular emphasis placed on conducting randomized controlled trials (RCTs) that compare the relative efficacy of psychosocial and pharmacological interventions. This article addresses relevant ethical considerations in the conduct of these treatment trials, with a focus on RCTs with children. Ethical concerns, including therapeutic misconception, treatment preference, therapeutic equipoise, structure of treatments, and balancing risks versus benefits, are introduced through a clinical scenario and discussed as they relate to psychotherapy versus medication RCTs. In each case, suggestions are made for researchers seeking to minimize the impact of these ethical concerns on research participants.     

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.     

Providing a treatment rationale for PTSD: Does what we say matter?

Little is understood about the factors that influence a woman's preference for a particular type of treatment after an assault. Furthermore, it remains unclear the extent to which providing detailed information such as the mechanism underlying a treatment or its side effects can affect a client's treatment preference for psychotherapy or pharmacotherapy. The current study of 324 women with varying degrees of trauma exposure and posttraumatic stress symptoms experimentally manipulated the content of treatment rationales for two common PTSD treatments: sertraline (SER) and prolonged exposure (PE). Specifically, both information regarding the hypothesized mechanism of the treatment and treatment side effects were manipulated. In general, personal reactions were more positive and credibility was stronger for psychotherapy than pharmacotherapy. This preference for the psychotherapy persisted regardless of specific information presented in the treatment rationale. For those reporting heightened hyperarousal and those of minority status, there was an increased likelihood of more positive reactions to sertraline. The results highlight assessment of treatment-related beliefs and preferences early on in the therapeutic process. Ultimately, understanding the factors that shape treatment preferences may contribute to the development of personalized treatment strategies that integrate preferences and attitudes about treatment as a way of bolstering adherence and outcome.     

The effects of positive patient testimonials on PTSD treatment choice

Despite the existence of effective treatment options for PTSD, these treatments are failing to reach those that stand to benefit from PTSD treatment. Understanding the processes underlying an individual's treatment seeking behavior holds the potential for reducing treatment-seeking barriers. The current study investigates the effects that positive treatment testimonials have on decisions regarding PTSD treatment. An undergraduate (N = 439) and a trauma-exposed community (N = 203) sample were provided with videotaped treatment rationales for prolonged exposure (PE) and sertraline treatments of PTSD. Half of each sample also viewed testimonials, detailing a fictional patient's treatment experience. All participants then chose among treatment options and rated the credibility of – and personal reactions toward – those options. Among treatment naïve undergraduates, testimonials increased the proportion choosing PE alone; and among treatment naïve members of the trauma-exposed community sample, testimonials increased the proportion choosing a combined PE plus sertraline treatment. These effects were not observed for those with prior history of either psychotherapeutic or pharmacological treatment. Major barriers exist that prevent individuals with PTSD from seeking treatment. For a critical unreached treatment sample, those who are treatment naïve, positive patient testimonials offer a mechanism in which to make effective treatments more appealing and accessible.