Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes?

Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%–95.1%) and posttreatment (69.1–71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.     

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self‐reported and clinician‐assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty‐six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present‐centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed‐effects model analysis revealed a significant interaction between groups (p = .05, d = ?0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self‐reported, but not clinician‐assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre‐ and posttreatment effect sizes were mostly moderate to large (d = 0.30–1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self‐reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.     

Examination of the World Health Organization Disability Assessment System as a Measure of Disability Severity Among Veterans Receiving Cognitive Processing Therapy

Cognitive processing therapy (CPT) is effective for reducing posttraumatic stress disorder (PTSD) and depression among military veterans. However, studies have not examined whether CPT is associated with reductions in disability severity. The current study examines the association between disability severity and PTSD and depression among U.S. veterans who are receiving CPT. Veterans completed measures at pre‐ and posttreatment and received CPT through a Veterans Affairs PTSD outpatient (n = 155) or residential (n = 177) program. The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 was used to assess disability severity. The WHODAS 2.0 scores were positively correlated with clinician‐ and veteran‐rated PTSD and veteran‐rated depression at pre‐ and posttreatment (r = .22 to. 60). Compared with outpatients, veterans in residential treatment had worse scores on the WHODAS Mobility scale ( = .03), but on no other WHODAS 2.0 scales. Pre‐ to posttreatment reductions were found on all WHODAS 2.0 subscales ( = .03 to .15). Reductions in PTSD and depression were positively associated with improvements on the WHODAS 2.0 Summary scale and most subscales (r = .22 to. 52). Findings suggest that the WHODAS 2.0 is a promising disability severity measure for veterans in PTSD treatment. Findings also suggest that CPT may help veterans to achieve reductions in disability severity.     

Comparing Response to Cognitive Processing Therapy in Military Veterans With Subthreshold and Threshold Posttraumatic Stress Disorder

Research suggests that subthreshold posttraumatic stress disorder (PTSD) symptomatology is associated with increased risk for psychological and functional impairment, including increased risk for suicidal ideation. However, it does not appear that any studies to date have investigated whether subthreshold PTSD can effectively be treated with evidence‐based, trauma‐focused treatment. Accordingly, we tested response to cognitive processing therapy (CPT) in 2 groups of military veterans receiving care at a VA outpatient specialty clinic, 1 with subthreshold PTSD at pretreatment (n = 51) and the other with full, diagnostic PTSD (n = 483). Multilevel analysis revealed that both groups experienced a significant decrease in PTSD symptoms over the course of therapy (the full and subthreshold PTSD groups experienced an average decrease of 1.79 and 1.52 points, respectively, on the PTSD Checklist with each increment of time, which was coded from 0 at pretreatment to 13 at posttreatment). After controlling for pretreatment symptom severity, a between‐groups difference was not found. These results suggest that CPT is an effective form of treatment among military veterans, and that its effectiveness does not differ between subthreshold and threshold groups.     

Imagery rehearsal therapy for posttraumatic nightmares in U.S. veterans

Imagery rehearsal therapy (IRT) may help reduce residual nightmares and posttraumatic stress disorder (PTSD) symptoms in veterans after trauma-focused PTSD treatment. Fifteen male U.S. veterans with PTSD and trauma-related nightmares, who had not previously completed trauma-focused PTSD treatment, attended 6 IRT group sessions. No benefits were observed immediately posttreatment. At 3- and 6-month follow-up, however, trauma-related nightmare frequency (nights/week) decreased (p < .01). The number of trauma-related nightmares/week (p < .01), number of total nightmares/week (p < .05), and PTSD symptoms (p < .05) also decreased at 3 months. The overall F test for time was significant (p < .05) for nightmare severity and fear of sleep. No effects were found on measures of the impact of nightmares, sleep quality, or depression. Clinical and research implications are discussed.     

Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism?

This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.     

Using Interpretation Bias Modification to Reduce Anger in Veterans with Posttraumatic Stress Disorder: A Pilot Study

Difficulty controlling anger is the most commonly reported reintegration concern among veterans with posttraumatic stress disorder (PTSD). One of the mechanisms associated with problematic anger is a tendency to interpret ambiguous interpersonal situations as hostile, known as the hostile interpretation bias (HIB). A computer-based interpretation bias modification (IBM) intervention has been shown to successfully reduce HIB and anger but has not been tested in veterans with PTSD. The current study was a pilot trial of this IBM intervention modified to address problematic anger among veterans with PTSD. Veterans with PTSD and a high level of anger (N = 7) completed eight sessions of IBM treatment over the course of 4 weeks. Participants completed self-report questionnaires at pre- and posttreatment assessment visits, as well as a treatment acceptability interview at posttreatment. Veterans experienced large reductions in hostile interpretation bias and anger from pre- to posttreatment, ds = 1.03–1.96, although these estimates may be unstable due to the small sample size. The feasibility for recruitment, retention, and treatment completion were high. Questionnaire and interview data demonstrated that most participants were satisfied with the treatment and found it helpful and easy to use. Overall, IBM for anger was feasible and acceptable to veterans with PTSD and was associated with reductions in hostile interpretations and self-reported anger outcomes. Further research examining this approach is warranted.     

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Recent studies have called attention to the need for enhancing treatment outcome in trauma‐focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic‐related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA‐positive and 276 OSA‐negative veterans were identified. Generalized estimating equations were used to compare between‐group differences in weekly self‐reported PTSD symptomatology. The OSA‐positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = −0.657). Additionally, OSA‐positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA‐positive veterans without access to CPAP (B = −0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence‐based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.     

Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive–behavioral treatment for posttraumatic stress disorder (PTSD) and a front‐line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy–cognitive therapy only (CPT‐C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT‐C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT‐C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self‐ and clinician‐reported PTSD and self‐reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment‐wise α correction was applied, this effect did not remain significant.     

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, β = .32, and less patient avoidance of engaging with the therapist, β = .35. When using the last available PTSD score, less fear, β = .23, and avoidance, β = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, β = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients’ cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.     

Cognitive–Behavioral Group Treatment for Driving‐Related Anger,Aggression, and Risky Driving in Combat Veterans: A Pilot Study

The present study examined the preliminary effects of an 8‐session group cognitive–behavioral treatment (CBT) designed to reduce driving‐related anger, aggression, and risky driving behaviors in veterans. Participants (N = 9) with self‐reported aggressive and risky driving problems completed self‐report measures at pretreatment, posttreatment, and 1‐month follow‐up. Of those completing the treatment, 89% demonstrated reliable change in driving‐related aggression and 67% evidenced reliable change in driving‐related anger. Similar changes were found for secondary treatment targets.     

Social Support Moderates the Association Between Posttraumatic Stress Disorder Treatment Duration and Treatment Outcomes in Telemedicine-Based Treatment Among Rural Veterans

For patients participating in trauma-focused psychotherapies for posttraumatic stress disorder (PTSD), such as cognitive processing therapy (CPT), pretreatment characteristics may moderate treatment effectiveness. For instance, preexisting supportive relationships may encourage skill utilization or provide contrasts to maladaptive cognitive biases highlighted in trauma-focused treatments for PTSD. Such pretreatment characteristics are important to study in rural individuals, who may experience barriers to initiating and completing treatment. The aim of this study was to examine whether pretreatment social support, measured using the Medical Outcomes Study Social Support Survey, would moderate the association between CPT duration (i.e., number of sessions attended) and change in PTSD symptoms, using data from a pragmatic randomized controlled trial of a telemedicine-based collaborative care intervention for rural veterans (N = 225). Social support moderated the association between CPT duration and PTSD symptom change, B = −0.016, SE = −.006; 95% CI [−0.028, −0.005], such that increased duration was associated with more PTSD symptom change only at average or higher levels of support. This effect was found for overall and emotional support but not tangible support. Additionally, on average, among participants who attended eight or more CPT sessions, only those at or above 1 standard deviation above the mean social support score demonstrated a reliable change in PTSD symptoms. The results indicate that the link between CPT treatment duration and treatment outcomes may be stronger for veterans with higher levels of pretreatment social support.     

The Moderating Effect of State Anger on Treatment Outcome in Female Adolescents With PTSD*

Trauma experienced in childhood and adolescence negatively affects the development of adaptive regulation of emotions and is associated with greater symptoms of anger. Prior research has suggested that high levels of anger may impede the outcome of treatment in adults with posttraumatic stress disorder (PTSD). The current study investigated whether high levels of anger resulted in poorer treatment outcomes in adolescent girls with PTSD. Participants included 61 female adolescent survivors of sexual abuse or assault who were randomized to either prolonged exposure for adolescents (PE‐A) or client‐centered therapy (CCT) for traumatized children for 8–14 weekly sessions. Participants were followed for 12 months posttreatment. High levels of state anger at baseline were associated with less improvement in PTSD symptoms in the CCT group than the PE‐A group (d = 0.62). The moderating effects of state anger on improvement in PTSD symptoms was significant with emotion regulation difficulties, which may underlie anger symptoms (d = 0.58) in the model. The results of this study suggessted that high state anger was less of an impediment to treatment of PTSD for those receiving PE‐A than those receiving less differentiated approaches such as CCT.     

Feasibility,acceptability, and preliminary efficacy of cognitive processing therapy in Japanese patients with posttraumatic stress disorder

Cognitive processing therapy (CPT) is one of the most widely tested evidence-based treatments for posttraumatic stress disorder (PTSD). However, most studies on CPT have been conducted in Western cultural settings. This open-label, single-arm trial investigated the feasibility, acceptability, and preliminary efficacy of CPT for treating Japanese patients with PTSD. A total of 25 outpatients underwent 12 CPT sessions. The primary outcome was the assessment of PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV); secondary outcomes included the assessment of subjective PTSD severity, depressive and anxiety symptoms, trauma-related cognitions, and subjective quality of life. All outcomes were evaluated at pretreatment (i.e., baseline), posttreatment, and 6- and 12-month follow-ups. On average, participants attended 13 sessions of CPT (SD = 1.38), with a completion rate of 96.0%. One serious adverse event (hospitalization) occurred. Significant within-subjects standardized mean differences in CAPS-IV scores were found from baseline to treatment completion, g = −2.28, 95% CI [−3.00, −1.56]; 6-month follow-up, g = −2.95, 95% CI [−3.79, −2.12]; and 12-month follow-up, g = −2.15, 95% CI [−2.89, −1.41]. Moderate-to-large effects, gs = −0.77 to −2.45, were found on secondary outcomes. These findings support the feasibility, acceptability, and preliminary efficacy of CPT in a Japanese clinical setting.     

The Impact of Depression Severity on Treatment Outcomes Among Older Male Combat Veterans with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) and depression are highly comorbid within the veteran population. Research studies have yielded divergent findings regarding the effect of depression on PTSD treatment outcomes. The present study investigated the influence of pretreatment depression severity on PTSD and depression symptom trajectories among 85 older (i.e., ≥ 60 years) male veterans with military-related PTSD who received either prolonged exposure or relaxation training as part of a randomized controlled trial. Participants were categorized as having no/mild depression (n = 23) or moderate/severe depression (n = 62). The PTSD Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) were completed at pretreatment, each of 12 therapy sessions, posttreatment, and 6-month follow-up, for a total of up to 15 data points per participant. Multilevel modeling (MLM) was used to evaluate the impact of pretreatment depression severity on piecewise symptom trajectories (i.e., active treatment and follow-up periods) over time and to determine whether treatment condition moderated the trajectories. The final MLM results showed significant main effects of depression severity on PCL-S scores, B = 10.84, p = .043 and PHQ-9 scores, B = 7.09, p = .001, over time. No significant interactions emerged for either the PCL-S or PHQ-9, indicating that although older veterans with more severe depression endorsed higher PTSD and depression scores across time, the symptom trajectories were not moderated by depression severity, treatment condition, or their interaction.     

A pilot study of behavioral activation for veterans with posttraumatic stress disorder

A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA) therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment at a Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of 16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed 15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showed significant pre- to posttreatment improvement and was associated with a moderate effect size. A number of participants also were improved on measures of depression and quality of life, but changes did not reach statistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD.     

Residual Symptoms of Posttraumatic Stress Disorder and Alcohol Use Disorder Following Integrated Exposure Treatment Versus Coping Skills Treatment

Although some studies have demonstrated residual symptoms in patients who have participated in posttraumatic stress disorder (PTSD) treatment, no studies to date have assessed residual PTSD symptoms following treatment for comorbid alcohol use disorder (AUD) and PTSD (PTSD/AUD). We examined residual symptoms of PTSD and AUD in 73 veterans with PTSD/AUD who completed a posttreatment assessment after being randomized to receive either Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) or Seeking Safety (SS). We used logistic regression to identify differences (a) in residual PTSD and AUD symptoms among participants randomized to COPE versus SS and (b) among those with versus without a posttreatment PTSD/AUD diagnosis within both treatment conditions. Participants randomized to SS were more likely to report persistent avoidance, inability to experience positive emotions, hypervigilance, difficulty concentrating, and difficulty sleeping, ORs = 3.74–6.21. There were no differences between COPE and SS regarding the likelihood of persistent AUD symptoms. Participants without a posttreatment PTSD diagnosis had lower conditional probabilities of most symptoms, although exaggerated startle, OR = 0.71, and irritability/aggression, OR = 0.58, were most likely to persist. Participants without a posttreatment AUD diagnosis had lower conditional probabilities of most symptoms, although withdrawal, OR = 0.21; unsuccessful quit attempts, OR = 0.04; and higher intake, OR = 0.01, were most likely to persist. Findings indicate hyperarousal may warrant additional intervention following PTSD treatment. Residual AUD symptoms may relate to the enduring nature of some AUD symptoms rather than a lack of treatment efficacy.     

The effect of childhood sexual assault history on outpatient cognitive processing therapy for military sexual trauma‐related posttraumatic stress disorder: A preliminary investigation

History of childhood sexual assault (CSA) may result in poorer emotion regulation and interpersonal functioning, potentially affecting the tolerability and effectiveness of evidence‐based treatments (EBTs) for posttraumatic stress disorder (PTSD). Survivors of military sexual trauma (MST) have an increased incidence of CSA; however, research examining the role of CSA in EBTs for veterans with MST‐related PTSD is limited. Data from 32 (9 male; 23 female) veterans with MST‐related PTSD were used from a previously conducted randomized clinical trial examining the efficacy of an outpatient PTSD EBT (i.e., cognitive processing therapy [CPT]). Self‐rated PTSD symptom severity was assessed at pretreatment, during treatment, and up to 6 months following treatment completion. Number of CPT sessions attended and treatment completion were also examined. Using a hierarchical linear modelling approach, results indicated both veterans with and without a history of CSA were found to benefit from CPT, and history of CSA did not significantly predict treatment response. Additionally, number of sessions attended and treatment completion did not significantly vary based on history of CSA. These preliminary findings provide support for the tolerability and efficacy of outpatient CPT in veterans with MST‐related PTSD regardless of CSA history.     

Effects of Cognitive–Behavioral Conjoint Therapy for PTSD on Partners’ Psychological Functioning

A number of studies have documented that posttraumatic stress disorder (PTSD) symptoms in “one” partner are negatively associated with their intimate partner's psychological functioning. The present study investigated intimate partners’ mental health outcomes (i.e., depression, anxiety, and anger) in a sample of 40 partners of individuals with PTSD within a randomized waitlist controlled trial of cognitive–behavioral conjoint therapy for PTSD (Monson & Fredman, 2012 ). There were no significant differences between active treatment and waitlist in intimate partners’ psychological functioning at posttreatment. Subgroup analyses, however, of partners exhibiting clinical levels of distress at pretreatment on several measures showed reliable and clinically significant improvements in their psychological functioning at posttreatment and no evidence of worsening. Results suggest that cognitive–behavioral conjoint therapy for PTSD may have additional benefits for partners presenting with psychological distress.     

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale–Interview Version and PTSD Checklist for DSM‐5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent‐to‐treat, mixed‐effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges’ gs = ?0.33 to ?1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges’ gs = ?0.78 to ?0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co‐occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.