The Posttraumatic Stress Disorder Checklist (PCL-5; Weathers et al., 2013) was recently revised to reflect the changed diagnostic criteria for posttraumatic stress disorder (PTSD) in the fifth ...edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). We investigated the psychometric properties of PCL-5 scores in a large cohort (N = 912) of military service members seeking PTSD treatment while stationed in garrison. We examined the internal consistency, convergent and discriminant validity, and DSM-5 factor structure of PCL-5 scores, their sensitivity to clinical change relative to PTSD Symptom Scale-Interview (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993) scores, and their diagnostic utility for predicting a PTSD diagnosis based on various measures and scoring rules. PCL-5 scores exhibited high internal consistency. There was strong agreement between the order of hypothesized and observed correlations among PCL-5 and criterion measure scores. The best-fitting structural model was a 7-factor hybrid model (Armour et al., 2015), which demonstrated closer fit than all other models evaluated, including the DSM-5 model. The PCL-5's sensitivity to clinical change, pre- to posttreatment, was comparable with that of the PSS-I. Optimally efficient cut scores for predicting PTSD diagnosis were consistent with prior research with service members (Hoge, Riviere, Wilk, Herrell, & Weathers, 2014). The results indicate that the PCL-5 is a psychometrically sound measure of DSM-5 PTSD symptoms that is useful for identifying provisional PTSD diagnostic status, quantifying PTSD symptom severity, and detecting clinical change over time in PTSD symptoms among service members seeking treatment.
Abstract
Study Objectives
To examine sleep disorder symptom reports at baseline and posttreatment in a sample of active duty U.S. Army Soldiers receiving treatment for posttraumatic stress disorder ...(PTSD). Explore sleep-related predictors of outcomes.
Methods
Sleep was evaluated in 128 participants in a parent randomized clinical trial comparing Spaced formats of Prolonged Exposure (PE) or Present Centered Therapy and a Massed format of PE. In the current study, Spaced formats were combined and evaluated separately from Massed.
Results
At baseline, the average sleep duration was < 5 h per night on weekdays/workdays and < 6 h per night on weekends/off days. The majority of participants reported clinically significant insomnia, clinically significant nightmares, and probable sleep apnea and approximately half reported excessive daytime sleepiness at baseline. Insomnia and nightmares improved significantly from baseline to posttreatment in all groups, but many patients reported clinically significant insomnia (>70%) and nightmares (>38%) posttreatment. Excessive daytime sleepiness significantly improved only in the Massed group, but 40% continued to report clinically significant levels at posttreatment. Short sleep (Spaced only), clinically significant insomnia and nightmares, excessive daytime sleepiness, and probable sleep apnea (Massed only) at baseline predicted higher PTSD symptoms across treatment course. Short weekends/off days sleep predicted lower PTSD symptom improvement in the Spaced treatments.
Conclusions
Various sleep disorder symptoms were high at baseline, were largely unchanged with PTSD treatment, and were related to worse PTSD treatment outcomes. Studies are needed with objective sleep assessments and targeted sleep disorders treatments in PTSD patients.
Clinical Trial Registration
NCT01049516.
Cognitive Processing Therapy (CPT) is an evidence-based therapy recommended for posttraumatic stress disorder (PTSD). However, rates of improvement and remission are lower in veterans and active duty ...military compared to civilians. Although CPT was developed as a 12-session therapy, varying the number of sessions based on patient response has improved outcomes in a civilian study. This paper describes outcomes of a clinical trial of variable-length CPT among an active duty sample. Aims were to determine if service members would benefit from varying the dose of treatment and identify predictors of treatment length needed to reach good end-state (PTSD Checklist-5 ≤ 19). This was a within-subjects trial in which all participants received CPT (N = 127). Predictor variables included demographic, symptom, and trauma-related variables; internalizing/externalizing personality traits; and readiness for change. Varying treatment length resulted in more patients achieving good end-state. Best predictors of nonresponse or needing longer treatment were pretreatment depression and PTSD severity, internalizing temperament, being in precontemplation stage of readiness for change, and African American race. Controlling for differences in demographics and initial PTSD symptom severity, the outcomes using a variable-length CPT protocol were superior to the outcomes of a prior study using a fixed, 12-session CPT protocol.
NCT023818.
•Varying the length of CPT resulted in some active duty members stopping treatment early or improving with more sessions.•Thirteen percent achieved good end-state in less than 12 sessions, 9% in exactly 12 sessions, and 12% with more sessions.•Pretreatment depression, internalizing temperament, and PTSD severity predicted nonresponse or needing longer treatment.•Other predictors were being in the precontemplation stage of readiness to change or African American race.•Compared to a prior 12-session study, variable-length CPT resulted in more patients achieving reliable clinical change.
Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel.
To examine the effects of massed prolonged exposure therapy (massed therapy), ...spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity.
Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016.
Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks).
Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% 2.3 points on PSS-I, with 1-sided α = .05); and efficacy of spaced therapy vs PCT at posttreatment.
Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 SD, 7.3 years; 44 women 12.0%; mean baseline PSS-I score, 25.49 6.36), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 95% CI,0.72 to 6.68; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 95% CI, -2.48 to 2.27; P = .93).
Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings.
clinicaltrials.gov Identifier: NCT01049516.
Cognitive processing therapy (CPT), an evidence-based treatment for posttraumatic stress disorder (PTSD), has not been tested as an individual treatment among active-duty military. Group CPT may be ...an efficient way to deliver treatment.
To determine the effects of CPT on PTSD and co-occurring symptoms and whether they differ when administered in an individual or a group format.
In this randomized clinical trial, 268 active-duty servicemembers consented to assessment at an army medical center from March 8, 2012, to September 23, 2014, and were randomized to group or individual CPT. Inclusion criteria were PTSD after military deployment and stable medication therapy. Exclusion criteria consisted of suicidal or homicidal intent or psychosis. Data collection was completed on June 15, 2015. Analysis was based on intention to treat.
Participants received CPT (the version excluding written accounts) in 90-minute group sessions of 8 to 10 participants (15 cohorts total; 133 participants) or 60-minute individual sessions (135 participants) twice weekly for 6 weeks. The 12 group and individual sessions were conducted concurrently.
Primary measures were scores on the Posttraumatic Symptom Scale-Interview Version (PSS-I) and the stressor-specific Posttraumatic Stress Disorder Checklist (PCL-S); secondary measures were scores on the Beck Depression Inventory-II (BDI-II) and the Beck Scale for Suicidal Ideation (BSSI). Assessments were completed by independent evaluators masked to treatment condition at baseline and 2 weeks and 6 months after treatment.
Among the 268 participants (244 men 91.0%; 24 women 9.0%; mean SD age, 33.2 7.4 years), improvement in PTSD severity at posttreatment was greater when CPT was administered individually compared with the group format (mean SE difference on the PSS-I, -3.7 1.4; Cohen d = 0.6; P = .006). Significant improvements were maintained with the individual (mean SE PSS-I, -7.8 1.0; Cohen d = 1.3; mean SE PCL-S, -12.6 1.4; Cohen d = 1.2) and group (mean SE PSS-I, -4.0 0.97; Cohen d = 0.7; mean SE PCL-S, -6.3 1.4; Cohen d = 0.6) formats, with no differences in remission or severity of PTSD at the 6-month follow-up. Symptoms of depression and suicidal ideation did not differ significantly between formats.
Individual treatment resulted in greater improvement in PTSD severity than group treatment. Depression and suicidal ideation improved equally with both formats. However, even among those receiving individual CPT, approximately 50% still had PTSD and clinically significant symptoms. In the military population, improving existing treatments such as CPT or developing new treatments is needed.
clinicaltrials.gov identifier: NCT02173561.
The global outbreak of COVID‐19 has required mental health providers to rapidly rethink and adapt how they provide care. Cognitive processing therapy (CPT) is a trauma‐focused, evidence‐based ...treatment for posttraumatic stress disorder that is effective when delivered in‐person or via telehealth. Given current limitations on the provision of in‐person mental health treatment during the COVID‐19 pandemic, this article presents guidelines and treatment considerations when implementing CPT via telehealth. Based on lessons learned from prior studies and clinical delivery of CPT via telehealth, recommendations are made with regard to overall strategies for adapting CPT to a telehealth format, including how to conduct routine assessments and ensure treatment fidelity.
Objective: To determine whether group therapy improves symptoms of posttraumatic stress disorder (PTSD), this randomized clinical trial compared efficacy of group cognitive processing therapy ...(cognitive only version; CPT-C) with group present-centered therapy (PCT) for active duty military personnel. Method: Patients attended 90-min groups twice weekly for 6 weeks at Fort Hood, Texas. Independent assessments were administered at baseline, weekly before sessions, and 2 weeks, 6 months, and 12 months posttreatment. A total of 108 service members (100 men, 8 women) were randomized. Inclusion criteria included PTSD following military deployment and medication stability. Exclusion criteria included suicidal/homicidal intent or other severe mental disorders requiring immediate treatment. Follow-up assessments were administered regardless of treatment completion. Primary outcome measures were the PTSD Checklist (Stressor Specific Version; PCL-S) and Beck Depression Inventory-II. The Posttraumatic Stress Symptom Interview (PSS-1) was a secondary measure. Results: Both treatments resulted in large reductions in PTSD severity, but improvement was greater in CPT-C. CPT-C also reduced depression, with gains remaining during follow-up. In PCT, depression only improved between baseline and before Session 1. There were few adverse events associated with either treatment. Conclusions: Both CPT-C and PCT were tolerated well and reduced PTSD symptoms in group format, but only CPT-C improved depression. This study has public policy implications because of the number of active military needing PTSD treatment, and demonstrates that group format of treatment of PTSD results in significant improvement and is well tolerated. Group therapy may an important format in settings in which therapists are limited.
What is the public health significance of this article?
This study comparing two forms of group therapy for posttraumatic stress disorder (PTSD) has public policy implications because of the number of active duty military needing PTSD treatment, and demonstrates that group format of treatment of PTSD results in significant improvement and is well tolerated. Group therapy may be an important format in settings in which therapists are limited.
We examined the frequency of trauma types reported in a cohort of service members seeking treatment for posttraumatic stress disorder (PTSD) and compared symptom profiles between types. In this ...observational study, 999 service members (9.2% women; Mage = 32.91 years; 55.6% White) were evaluated using a standardized assessment procedure to determine eligibility for clinical trials. Participants were evaluated for DSM‐IV‐TR‐defined PTSD using the PTSD Symptom Scale–Interview; all participants reported a Criterion A event. Independent evaluators rated descriptions of Criterion A events as belonging to trauma types at a high degree of reliability, κ = 0.80. Aggregated non‐life‐threat primary trauma types were more frequently endorsed than aggregated life‐threat types, 95% CI 17.10%, 29.20%. Participants who endorsed moral injury–self traumas had a higher level of reexperiencing (d = 0.39), guilt (hindsight bias, d = 1.06; wrongdoing, d = 0.93), and self‐blame (d = 0.58) symptoms, relative to those who reported life threat–self. Participants who experienced traumatic loss had greater reexperiencing (d = 0.39), avoidance (d = 0.22), guilt (responsibility, d = 0.39), and greater peri‐ and posttraumatic sadness (d = 0.84 and d = 0.70, respectively) symptoms, relative to those who endorsed life threat–self. Relative to life threat–self, moral injury–others was associated with greater peri‐ (d = 0.36) and posttraumatic (d = 0.33) betrayal/humiliation symptoms, and endorsement of aftermath of violence was associated with greater peri‐ (d = 0.84) and posttraumatic sadness (d = 0.57) symptoms. War zone traumas were heterogeneous, and non‐life‐threat traumas were associated with distinct symptoms and problems.
Resumen
Spanish s by the Asociación Chilena de Estrés Traumático (ACET)
TIPOS DIFERENTES DE TRAUMA EN MIEMBROS DEL SERVICIO MILITAR QUE BUSCAN TRATAMIENTO POR TRASTORNO DE ESTRÉS POSTRAUMÁTICO
TIPOS DE TRAUMA EN MIEMBROS DEL SERVICIO QUE BUSCAN TRATAMIENTO
Examinamos la frecuencia de tipos de trauma reportados en una cohorte de miembros del servicio que buscaban tratamiento por trastorno de estrés Postraumático (TEPT), y comparamos el perfil de síntomas entre los tipos de trauma. En este estudio observacional, 999 miembros del servicio (9.2% mujeres; Media de edad = 32,91 años; 55,6% blancos) fueron evaluados usando un procedimiento de evaluación estandarizado para determinar la elegibilidad para los estudios clínicos. Los participantes fueron evaluados según criterios DSM‐IV‐TR para TEPT usando la Entrevista de Escala de Síntomas para TEPT; todos los participantes reportaron un evento del Criterio A. Evaluadores independientes clasificaron la descripción de los eventos del Criterio A como pertenecientes a los tipos de trauma con un alto grado de fiabilidad (ĸ = 0.80). Los tipos de trauma primarios agregados sin amenaza vital fueron endosados con mayor frecuencia que los tipos agregados con amenaza vital, IC 95% 17.10%, 29,20%. Los participantes que endosaron traumas por daño moral auto‐infringido tuvieron mayores síntomas de re‐experimentación (d = 0,39), sentimientos de culpa (sesgo retrospectivo, d = 1,06; hacerlo mal, d = 0,93), y autoinculpación (d = 0,58) en relación con aquellos que reportaron amenaza vital personal. Los participantes que experimentaron pérdidas traumáticas tuvieron mayores síntomas de re‐experimentación (d = 0,39), evitación (d = 0,22), sentimientos de culpa (responsabilidad, d = 0,39) y mayor tristeza peri y postraumática (d = 0,84 y 0,70 respectivamente), en relación con aquellos que reportaron amenaza vital personal. En relación con amenaza vital, de daño moral a otros estuvo más asociado con mayores niveles de síntomas de traición/ humillación peri (d = 0,36) y postraumáticos (d = 0,33), y el endosamiento de las consecuencias de la violencia estuvo asociado con más síntomas de tristeza peri (d = 0,84) y postraumática (d = 0,57). Los traumas de guerra fueron heterogéneos y los traumas sin amenaza de vida estuvieron asociados con problemas y síntomas distintivos.
抽象
Traditional and Simplified Chinese s by AsianSTSS
Distinct Trauma Types in Military Service Members Seeking Treatment for Posttraumatic Stress Disorder
Traditional Chinese
標題: 尋求治療創傷後壓力症的軍隊成員不同的創傷類型
撮要: 我們透過尋求治療創傷後壓力症(PTSD)的軍隊成員, 檢視創傷類型的頻率, 並比較不同創傷類型的症狀剖象。這項觀察研究的樣本為999名軍隊成員(9.2% 女性; Mage = 32.91 歲; 55.6% 白人)。我們採用標準化評估步驟, 找出樣本是否合適接受臨床試驗, 然後以「PTSD症狀量表會談版」評估樣本是否患有DSM‐IV‐TR介定的 PTSD。所有樣本都曾經歷標準A (Criterion A)事件。獨立的評估員把標準A事件歸類為有高水平倚賴性的創傷類型(κ = 0.80)。相比起整體生命威脅的創傷類型, 較多樣本有整體非生命威脅的主要創傷類型, 95% CI 17.10%, 29.20%。與有「生命威脅—個人」創傷類型的樣本相比, 有「道德創傷—個人」創傷類型的樣本, 有較高水平的再體驗(d = 0.39)、內疚 (事後聰明偏向, d = 1.06; 犯錯, d = 0.93)、和自責(d = 0.58)症狀。與有「生命威脅—個人」的樣本相比, 曾經歷創傷性損失的樣本有較高水平的再體驗(d = 0.39)、迴避(d = 0.22) 、內疚(責任, d = 0.39), 亦有較大程度的創傷當下和創傷後悲傷 (分別為d = 0.84 和d = 0.70)。與有「生命威脅—個人」的樣本相比, 有「道德創傷—他人」的創傷類型跟創傷當下(d = 0.36)和創傷後(d = 0.33)的背叛༏受辱症狀水平較高有關;受暴力影響跟有較高水平的創傷當下(d = 0.84)和創傷後(d = 0.57)悲傷有關。戰爭創傷具異質性;非生命威脅的創傷跟不同的症狀問題有關。
Simplified Chinese
标题: 寻求治疗创伤后压力症的军队成员不同的创伤类型
撮要: 我们透过寻求治疗创伤后压力症(PTSD)的军队成员, 检视创伤类型的频率, 并比较不同创伤类型的症状剖象。这项观察研究的样本为999名军队成员(9.2% 女性; Mage = 32.91 岁; 55.6% 白人)。我们采用标准化评估步骤, 找出样本是否合适接受临床试验, 然后以「PTSD症状量表会谈版」评估样本是否患有DSM‐IV‐TR介定的 PTSD。所有样本都曾经历标准A (Criterion A)事件。独立的评估员把标准A事件归类为有高水平倚赖性的创伤类型(κ = 0.80)。相比起整体生命威胁的创伤类型, 较多样本有整体非生命威胁的主要创伤类型, 95% CI 17.10%, 29.20%。与有「生命威胁—个人」创伤类型的样本相比, 有「道德创伤—个人」创伤类型的样本, 有较高水平的再体验(d = 0.39)、内疚 (事后聪明偏向, d = 1.06; 犯错, d = 0.93)、和自责(d = 0.58)症状。与有「生命威胁—个人」的样本相比, 曾经历创伤性损失的样本有较高水平的再体验(d = 0.39)、回避(d = 0.22) 、内疚(责任, d = 0.39), 亦有较大程度的创伤当下和创伤后悲伤 (分别为d = 0.84 和d = 0.70)。与有「生命威胁—个人」的样本相比, 有「道德创伤—他人」的创伤类型跟创伤当下(d = 0.36)和创伤后(d = 0.33)的背叛༏受辱症状水平较高有关;受暴力影响跟有较高水平的创伤当下(d = 0.84)和创伤后(d = 0.57)悲伤有关。战争创伤具异质性;非生命威胁的创伤跟不同的症状问题有关。
Objective: Survivors of intimate partner violence (IPV) report significant trauma histories, high rates of posttraumatic stress disorder (PTSD), head injuries and comorbid disorders, and multiple ...barriers to treatment that often preclude the regular attendance and engagement required in typical therapy protocols. The significant challenges faced by IPV survivors needing treatment may be ameliorated by condensing effective treatments for PTSD, such as cognitive processing therapy (CPT), in an accelerated delivery timeline. Method: Using a multiple subject, single case design of six matched pairs of 12 female IPV survivors, we preliminarily tested the relative effectiveness of individual massed CPT delivered over 5 days (mCPT) as compared with standard CPT (sCPT) delivery in women IPV survivors. Assessments included full psychiatric diagnostic interviews, clinical interviews assessing trauma history and head injury prior to treatment, symptom monitoring during treatment, and full repeat assessments at 1 month and 3 months following treatment. Results: No treatment group effect was found for PTSD severity between mCPT and sCPT among intention-to-treat, F(1, 10) = .01, p = .93. Both mCPT and sCPT were associated with significant improvement in PTSD, F(2, 20) = 45.05, p < .001, ds = 1.32-2.38). Conclusion: Overall, findings indicate mCPT appears effective in reducing psychological symptoms for women IPV survivors and suggest that condensed treatment is both palatable and feasible. Accelerated treatment delivery in this population may provide a necessary lifeline for women with IPV-related PTSD.
Clinical Impact StatementFindings in this pilot study of women survivors of intimate partner violence indicated Cognitive Processing Therapy administered in 5 days appears to be a promising approach for treating PTSD in this clinically complex sample. Massed treatment may be a particularly viable option for women who have a small window of opportunity to safely access treatment. PTSD is a painful and debilitating mental health condition. Shortening the time to recovery equals more days lived without PTSD. That might be the most important outcome of all.
Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources ...for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence‐based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military‐affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military‐affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM‐5 (PCL‐5) and the nine‐item Patient Health Questionnaire (PHQ‐9) in a community setting. Participants (N = 502) included military‐affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL‐5, military‐affiliated: d = −0.91, civilian: d = ‐1.18; and PHQ‐9, military‐affiliated: d = ‐0.65, civilian: d = ‐0.88, following treatment. However, military‐affiliated patients demonstrated smaller posttreatment reductions on the PCL‐5, Mdiff = 5.75, p = .003, and PHQ‐9, Mdiff = 1.71, p = .011, compared to civilians. Results demonstrate that military‐affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.
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