Increased tolerance of negative emotions predicts Veterans’ PTSD symptom reduction

Why do patients respond in different ways to PTSD treatment? One potential explanation is their ability to accept and manage negative emotions, also called distress tolerance. A study led by National Center for PTSD investigators examined whether increases in distress tol-erance were related to Veterans’ symptom change during PTSD treatment. Two samples of Veterans in a VA residential treatment program for PTSD (n = 53) or for PTSD and comorbid substance use disorders (n = 33) participated in the study. Both programs included Cogni-tive Processing Therapy and a variety of other interventions. Veterans completed the PTSD Checklist for DSM-IV, the Distress Tolerance Scale, and the Beck Depression Inventory-II. As expected, at the beginning of treatment, more severe PTSD was associated with lower distress tolerance. On average, both samples reported increases in distress tolerance and reductions in PTSD symptoms by the end of treatment. Veterans with the greatest increases in distress tolerance had the best PTSD treatment outcomes, even when controlling for baseline PTSD and depression symptoms, perhaps because greater ability to tolerate negative emotions facilitated engagement in treatment. Future studies can examine whether increased distress tolerance actually leads to changes in PTSD symptoms (or vice-versa), and whether distress tolerance could even protect against development of PTSD.

Read the article:

Banducci, A. N., Connolly, K. M., Vujanovic, A. A., Alvarez, J., & Bonn-Miller, M. O. (2017). The impact of changes in distress tolerance on PTSD symptom severity post-treatment among veterans in residential trauma treatment. Journal of Anxiety Disorders, 47, 99-105. PILOTS ID: 46813

Randomized trials offer growing support for tech-based PTSD interventions

Web and mobile interventions are becoming increasingly available to patients with PTSD. These interventions can vary widely in the degree to which clinicians are involved in deliv-ery. Two recent trials provide support for the efficacy of very different technology-based approaches to PTSD treatment: a mobile app that involves no clinician contact and a clini-cian-led online CBT program.

Investigators from the National Center for PTSD evaluated the effectiveness of PTSD Coach, a mobile app that includes psychoeducation, assessment, and self-management tools like relaxation and grounding. The trial enrolled 120 men and women (39 years old, on average) whose total score on the PTSD Checklist was 35 or more. Participants were randomized to use PTSD Coach (n = 62) or to a waitlist (n = 68) for 3 months. Those in the PTSD Coach condi-tion were instructed to download the app and use it however they would like. On average, they reported using PTSD Coach 1-2 days a week. Compared with waitlist participants, those who used PTSD Coach showed significantly greater improvements in self-reported PTSD and depression (d’s = .41-.45) and were more likely to achieve clinically significant change in PTSD symptoms.

Read the article: Issue 11(2) April 2017 Page 2

In a separate trial, a team led by investigators from Freie Universität Berlin in Germany randomized older adults with full or subthreshold PTSD to a 6-week online CBT intervention called Integrative Testimonial Therapy (n = 47) or waitlist (n = 47). All participants had experienced trauma as a child or adolescent during WWII; their average age was 71 years. Those in the online CBT condition completed writing assignments on a secure web platform and received online instructions and therapeutic feedback from clinicians on each assignment. Online CBT was associated with greater improvement in PTSD symptoms than waitlist (d = .42). Gains were maintained throughout a 1-year follow up period.

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Findings from these studies suggest that technology-based interventions—both with and without therapist facilitation—are more effective than no treatment. Notably, consistent results were found in a sample of middle-aged adults and a sample of older adults, suggesting that these treatments can benefit a range of ages. Future studies can help to determine whether there may be an optimal amount of clinician involvement for mobile and online interventions.

Knaevelsrud, C., Böttche, M., Pietrzak, R. H., Freyberger, H. J., & Kuwert, P. (2017). Efficacy and feasibility of a therapist-guided internet-based intervention for older persons with childhood traumatization: A randomized controlled trial. The American Journal of Geriatric Psychiatry. Advance online publication. PILOTS ID: 47282

Kuhn, E., Kanuri, N., Hoffman, J. E., Garvert, D. W., Ruzek, J. I., & Taylor, C. B. (2017). A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. Journal of Consulting and Clinical Psychology, 85, 267–273. PILOTS ID: 47101


Special issue focuses on innovative topics in PTSD

A special issue of Current Opinion in Psychology features a series of review articles that touch on some of the most important and timely issues in the field of PTSD. Topics range from recent advances in assessment, to special populations, to novel treatment delivery formats.

Read the overview:

Vujanovic, A. A., & Schnurr, P. P. (2017). Editorial overview: Advances in science and practice in traumatic stress. Current Opinion in Psychology. Advance online publication. PILOTS ID: 47358

Systematic review on PTSD dissociative subtype

A recent review by investigators at the University of Southern Denmark includes 11 studies that used either latent profile analysis or latent class analysis to investigate the dissociative subtype and identify potential risk factors.

Read the article:

Hansen, M., Ross, J., & Armour, C. (2017). Evidence of the dissociative PTSD subtype: A systematic literature review of latent class and profile analytic studies of PTSD. Journal of Affective Disorders, 213, 59–69. PILOTS ID: 47284

New adjunctive treatment addresses killing in war

Veterans who have killed in war are at risk for a number of negative mental health and functional outcomes, including PTSD. Investigators from the San Francisco VA Medical Center have developed a new treatment for individuals who report distress related to killing in war even after completing existing evidence-based treatments for PTSD. The pilot study enrolled 33 combat Veterans who had completed a trauma-focused therapy and continued to meet PTSD criteria and experience distress related to killing. Participants were randomized to the Impact of Killing (IOK) treatment or a waitlist control that allowed participants to continue treatment as usual including medication, case management, and supportive group therapy. IOK is a cognitive-behavioral intervention consisting of six to eight 60-90 minute individual sessions focused on the moral struggles of killing in war. Veterans in the IOK condition experienced improvement in self-reported PTSD and general psychiatric symptoms and greater reductions in some important maladaptive killing-related cognitions compared with the control group. These findings provide preliminary evidence that Veterans who experience distress related to killing and who do not fully respond to existing evidence-based therapies may experience additional gains by engaging in IOK. As previous research shows that patients may continue to improve by increasing the length of evidence-based treatments (see

December 2012-CTU Online), future studies comparing IOK to an extended dose of trauma-focused therapy would help to determine the importance of specifically focusing on killing.

Read the article:

Maguen, S., Burkman, K., Madden, E., Dinh, J., Bosch, J., Keyser, J., … Neylan, T. C. (2017). Impact of killing in war: A randomized controlled pilot trial. Journal of Clinical Psychology. Advance online publication. PILOTS ID: 47285

Randomized trial of CPT for acute stress disorder

Cognitive Processing Therapy is effective for people who have had chronic PTSD for years or even decades. A recent randomized trial by investigators at Flinders University in Australia suggests that CPT can also benefit patients at the opposite end of the spectrum, even before PTSD has even developed. The study included 47 women with DSM-IV acute stress disorder due to a sexual assault within the past month. Participants were randomized to a modified 6-session CPT (n = 25) or treatment as CTU-Online Issue 11(2) April 2017 Page 3

usual (TAU; n = 22), which included mostly non-CBT interventions such as supportive counseling or interpersonal therapy. Both groups improved after treatment, with average drops of more than 30 points on the Clinician Administered PTSD Scale. Gains were maintained over the 1-year follow up period (Cohen’s ds 0.76 to 1.45). CPT showed a slight advantage over TAU on most outcomes; at posttreatment, CPT participants were more likely to respond to treatment (>12 point reduction on the CAPS) and achieve PTSD remission (CAPS score <20). However, effect sizes were modest and differences were not statistically significant. One caveat is that not everyone with acute stress disorder goes on to develop PTSD, and some participants might have improved without intervention.

Read the article:

Nixon, R. D. V., Best, T., Wilksch, S. R., Angelakis, S., Beatty, L. J., & Weber, N. (2016). Cognitive Processing Therapy for the treatment of acute stress disorder following sexual assault: A randomised effectiveness study. Behaviour Change, 33, 232–250. PILOTS ID: 47286

Comparing refusal and dropout from pharmacotherapy vs. psychotherapy

Evidence-based treatments can only benefit those patients who are willing to engage in them. A meta-analysis led by researchers at Idaho State University investigated whether refusal and dropout differ between psychotherapy and pharmacotherapy. The meta-analysis included 186 studies, including 7 studies of PTSD, that were head-to-head comparisons of at least two of the following conditions: psychotherapy (primarily CBT), pharmacotherapy, their combination, or psychotherapy with pill placebo. On average, 8.2% of patients refused treatment and 22% of patients dropped out, with greater likelihood of refusal (OR = 1.76) and dropout (OR = 1.20) in pharmacotherapy than in psychotherapy. Patients with depression, social anxiety, panic, and anorexia/bulimia were more likely to refuse or drop out of pharmacotherapy than psychotherapy. In contrast, patients with PTSD were equally likely to refuse and drop out of pharmacotherapy as psychotherapy and their combination. PTSD patients were more likely to drop out of pharmacotherapy than psychotherapy plus placebo, although this finding was based on only one small study. Average refusal and dropout across PTSD studies were not reported, but a previous meta-analysis found that PTSD psychotherapy has low refusal (7.8%) and moderate dropout (27%) relative to other disorders (see the

October 2015 CTU-Online). Results suggest that PTSD patients may be equally likely to initially engage in and complete a full course of pharmacotherapy and psychotherapy.

Read the article:

Swift, J. K., Greenberg, R. P., Tompkins, K. A., & Parkin, S. R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54, 47–57. PILOTS ID: 47288


Tailored help-seeking advice post-screening does not improve outcomes

The utility of screening depends on multiple factors. Although the focus is often on the quality of screening itself, what happens post-screening is important to ensure that potential cases receive needed care. A group led by investigators at King’s Centre for Military Health Research in the United Kingdom recently evalu-ated the effectiveness of tailored advice after post-deployment screening for mental disorders to facilitate the transition to care. Military personnel completed a computerized self-assessment of PTSD, depression, anxiety, and alcohol use and were then ran-domized to receive general help-seeking advice only (n = 3,840) or to screening with tailored help-seeking advice (n = 6,350) 6-12 weeks post-deployment. Follow-up assessments occurred 10-24 months later. Among participants randomized to receive tailored advice, one-third declined to view the suggestions at all; those endorsing psychiatric symptoms were more likely to view the advice than those without symptoms. Only one-third of those individuals screening positively for psychiatric symptomology sought care at follow-up. There were no differences in prevalence of disorders assessed or help-seeking behavior between groups (tailored or general advice) at follow-up. Although these findings suggest tailored advice did not result in improved outcomes or treatment engagement, mounting evidence (see the

August 2016 CTU-Online), suggests other strategies such as collaborative primary care models including screening and ready access to medical and psychiatric care may be effective.

Read the article:

Rona, R. J., Burdett, H., Khondoker, M., Chesnokov, M., Green, K., Pernet, D., … Fear, N. T. (2017). Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: A cluster randomised controlled trial. The Lancet, 389, 1410-1423. PILOTS ID: 47287

Study shows importance of screening for TBI and PTSD after intimate partner violence

There has been significant recent attention to traumatic brain injury as a result of sports injuries and combat, but TBI also can result from interpersonal violence (IPV). A study led by research-ers from the National Center for PTSD examined the occurrence of IPV-related TBI history and its association with PTSD symptoms in a national sample of women Veterans. Of the 411 participants, 55% reported experiencing lifetime IPV. These 224 women com-pleted additional measures assessing probable IPV-related TBI history and current TBI and PTSD symptoms. Approximately 28% screened positive for IPV-related TBI history, and of those, just under half (44%) reported current TBI symptoms. Women with current TBI symptoms were nearly 6 times more likely than those with no IPV-related TBI history to have a probable PTSD diagnosis Page

(OR = 5.9). These results highlight a strong association between IPV-related TBI symptoms and PTSD among women Veterans. Clinicians should screen for both PTSD and TBI symptoms in women who report IPV in order to refer them to appropriate ser-vices. However, more work is needed to understand whether TBI resulting from IPV may differ in important ways from TBIs from other events with regard to symptom presentation or response to intervention.

Read the article:

Iverson, K. M., Dardis, C. M., & Pogoda, T. K. (2017). Traumatic brain injury and PTSD symptoms as a consequence of intimate partner violence. Comprehensive Psychiatry, 74, 80–87. PILOTS ID: 46692

A new adherence measure for an adapted CPT protocol

Evaluating adherence to manualized treatment protocols is critical for accurately interpreting outcomes in psychotherapy research. When treatments are adapted, it is important to devel-op adherence measures relevant to these adaptations. A group led by investigators at Goethe University in Germany has devel-oped the Adherence Rating Scale for CPT (ARS-CPT), designed specifically for an adapted CPT protocol addressing PTSD and borderline personality symptoms. This 10-item scale includes items from the original CPT Adherence Protocol as well as 6 items evaluating global therapeutic adherence (i.e., common factors including rapport building and time management). Validation data were collected from two independent raters who evaluated 30 randomly selected videotaped sessions of 7 therapists and 8 participants from a multicenter RCT evaluating CPT in women with co-occurring PTSD and borderline personality disorder. Interrater reliability was good to excellent across items (ICC = .70 to 1.00) with adequate internal consistency (Chronbach’s α = .56). Content validity, including relevance and appropriateness of each item, was acceptable, although less satisfactory than expected, perhaps due to the relatively small and homogeneous sample. Measures like the ARS-CPT not only help ensure treatment is pro-vided with consistency, but also can identify key components of a specific protocol, and highlight therapist training needs.


Articles authored by National Center for PTSD staff are available in full text. For other articles we



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