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The heterogeneity of the core symptoms of posttraumatic stress disorder (PTSD), high rates of comorbid mental and physical health conditions, and substantial impact of the disorder on functioning and well-being contribute to complex clinical presentations that can be challenging to treat. Despite these challenges, there are excellent manualized treatments for PTSD with significant empirical support. Although the success of frontline treatments for PTSD is evident, there remains room for improvement as indicated by suboptimal response and attrition rates. To address challenges to optimal therapy outcomes (COTOs), researchers have conducted numerous clinical trials designed to (a) enhance the core structure of treatment protocols to increase flexibility or (b) expand the protocols to address comorbid conditions that inhibit recovery. However, it is implausible to ever conduct the number of enhancement and expansion clinical trials necessary to test manual modifications for the universe of possible COTOs. This conceptual review describes the concept of a personalized model of therapy that leverages a case formulation approach to implementing an evidence-based treatment for PTSD. This personalized approach provides guidance for the clinician in assessing the patient's COTOs, monitoring them throughout treatment, and relying on the patient's idiosyncratic data to inform treatment decisions, including how and when to diverge from treatment when clinically indicated and ensuring a clear path to return to trauma-focused work when the COTO is stabilized. This personalized, case formulation approach to treating PTSD provides guidance for adopting a more flexible approach to treating clinically complex patients while ensuring fidelity to the protocol., (© 2024 International Society for Traumatic Stress Studies.)

Little is known about the impact of perceived neighborhood danger on military veterans' mental health, a population potentially at higher risk for this experience, or whether interpersonal social support and neighborhood cohesion can help buffer against poor mental health. This study examined: (1) the impact of perceived neighborhood danger on depression and posttraumatic stress disorder (PTSD) among veterans; (2) whether interpersonal social support and neighborhood cohesion can mitigate these effects; and (3) how prior trauma history may interact with these factors. Six moderation models were examined using data from 3049 veterans enrolled in the Longitudinal Investigation of Gender, Health, and Trauma study, a mail-based survey that oversampled for veterans in high crime neighborhoods. Most notably, results indicated that perceived neighborhood danger was associated with increased depression and PTSD (all p < .001). Interpersonal social support or neighborhood cohesion mitigated the effect of perceived neighborhood danger on veterans' depression, but, only for those without prior trauma (all p < .011). For trauma-exposed veterans, interpersonal social support was more effective in mitigating the effect of perceived neighborhood danger on depression than neighborhood cohesion (p = .006). Findings help inform interventions to improve the mental health of veterans living in high crime neighborhoods., (© 2023 Society for Community Research and Action. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

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., (© 2023 International Society for Traumatic Stress Studies.)

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., (© 2020 International Society for Traumatic Stress Studies.)

Trauma-related rumination is a cognitive style characterized by repetitive negative thinking about the causes, consequences, and implications of a traumatic experience. Frequent trauma-related rumination has been linked to posttraumatic stress disorder (PTSD) and depression in civilian samples but has yet to be examined among military veterans. This study extended previous research by examining trauma-related rumination in female veterans who presented to a Veterans Affairs women's trauma recovery clinic (N = 91). The study had two main aims: (a) to examine associations between trauma-related rumination and specific PTSD symptoms, adjusting for the overlap between trauma-related rumination and other relevant cognitive factors, such as intrusive trauma memories and self-blame cognitions; and (b) to assess associations between trauma-related rumination, PTSD, and depression, adjusting for symptom comorbidity. At intake, patients completed a semistructured interview and self-report questionnaires. Primary diagnoses were confirmed via medical record review. Trauma-related rumination was common, with more than 80% of patients reporting at least sometimes engaging in this cognitive style in the past week. After adjusting for other relevant cognitive factors, trauma-related rumination was significantly associated with several specific PTSD symptoms, r p s = .33-.48. Additionally, the severity of trauma-related rumination was associated with overall PTSD symptom severity, even after adjusting for comorbid depression symptoms, r p 2 = .35. In contrast, the association between trauma-related rumination and depressive symptom severity was not significant after adjusting for comorbid PTSD symptoms, r p 2 = .008. These results highlight trauma-related rumination as a unique contributing factor to the complex clinical presentation for a subset of trauma-exposed veterans., (Published 2019. This article is a U.S. government work and is in the public domain in the USA.)

Longitudinal research following discreet traumatic events reveals distinct symptom trajectories in untreated survivors of trauma. Trajectories within communities exposed to shared, prolonged violence involving subgroups differing in perspectives, and roles during the event have not been studied. This study examined trajectories of posttraumatic stress (PTS) and depressive symptoms secondary to exposure to violence during civil unrest in citizens (n = 311) and law enforcement (n = 255) over 1.5 years following exposure. Latent class growth modeling was used to examine trajectories of PTS and depressive symptoms. Four-class quadratic solutions for both PTS and depressive symptoms demonstrated best fit. Similar patterns emerged for such that most participants were classified as resistant (57% and 67%, respectively), followed by resilience (23.8% and 17.2%), chronic (12.6% and 12.0%), and worsening (6.1% and 4.4%). When all predictors were entered in a single model, race, and membership in citizen or law enforcement groups did not distinguish trajectories of recovery. Higher income and social support emerged as consistent protective factors against PTS and depressive symptoms, while trauma history emerged as a risk factor for PTS. Women were more at risk for depressive symptoms only. Implications for improving police/civilian relations in Ferguson, Missouri, and other communities are discussed., (© 2018 Society for Community Research and Action.)

There is little information available on the mental health effects of exposure to shared community violence such as the August 2014 violence that occurred in Ferguson, Missouri. This study sought to examine the relationship between proximity to community violence and mental health in both community members and police officers. We recruited 565 adults (community, n = 304, and police, n = 261) exposed to the violence in Ferguson to complete measures of proximity to violence, posttraumatic stress, depression, and anger. Using structural equation modeling, we assessed aspects of proximity to violence-connectedness, direct exposure, fear from exposure, media exposure, reactions to media, and life interruption-as correlates of posttraumatic stress disorder (PTSD) symptoms, depression, and anger. The final model yielded (n = 432), χ(2) (d = 12) = 7.4, p = .830; comparative fit index = 1.0, root mean square error of approximation = 0 [0, .04]. All aspects of proximity except direct exposure were associated with mental health outcomes. There was no moderation as a function of community versus police. Race moderated the relationship between life interruptions and negative outcomes; interruption was related to distress for White, but not Black community members. Based on group comparisons, community members reported more symptoms of PTSD and depression than law enforcement (ηp (2) = .06 and .02, respectively). Black community members reported more PTSD and depression than White community members (ηp (2) = .05 and .02, respectively). Overall, distress was high, and mental health interventions are likely indicated for some individuals exposed to the Ferguson events., (Copyright © 2016 International Society for Traumatic Stress Studies.)

This study examined responses to loud tones before and after cognitive-behavioral treatment for posttraumatic stress disorder (PTSD). Seventy-four women in a PTSD treatment outcome study for rape-related (n = 54) or physical assault-related PTSD (n = 20) were assessed in an auditory loud tone paradigm. Assessments were conducted before and after a 6-week period of cognitive-behavioral therapy. Physiologic responses to loud tones included heart rate (HR), skin conductance (SC), and eye-blink electromyogram (EMG). Groups were formed based upon treatment outcome and included a treatment responder group (no PTSD at posttreatment) and a nonresponder group (PTSD-positive at posttreatment). Treatment was successful for 53 of 74 women (72%) and unsuccessful for 21 women (28%). Responders and nonresponders were not significantly different from each other at pretreatment on the main outcome variables. Treatment responders showed a significant reduction in loud tone-related EMG, HR, and SC responses from pre- to posttreatment (partial η(2) = .24, .31, and .36, respectively; all p < .001) and the EMG and HR responses were significantly smaller than nonresponders at posttreatment (partial η(2) = .11, p = .004 and .19, p < .001, respectively). Successful cognitive-behavioral treatment of PTSD is associated with a quantifiable reduction in physiological responding to loud tones., (Copyright © 2012 International Society for Traumatic Stress Studies.)

This study assessed the relationship between sexual self-schema and posttraumatic functioning in a clinical sample of 112 female sexual assault survivors. Contrary to hypotheses, posttraumatic stress disorder and depressive symptom severity were unrelated to the valence of sexual self-schema. Yet, negative posttraumatic cognitions were related to sexual self-schemas. Specifically, less positive self-views were associated with more negative schema (r = -.35). In a multivariate analysis, the measure of negative views of the world and others was associated with more positive schema. Results indicate that intervening to improve survivors' postassault appraisals of the self may help to reduce the impact of interpersonal trauma on women's sexual functioning., (Copyright © 2011 International Society for Traumatic Stress Studies.)

There is a paucity of empirical study about the effects of evidence-based psychotherapy for posttraumatic stress disorder (PTSD) on concurrent health concerns including sleep impairment. This study compares the differential effects of cognitive processing therapy (CPT) and prolonged exposure (PE) on health-related concerns and sleep impairment within a PTSD sample of female, adult rape survivors (N = 108). Results showed that participants in both treatments reported lower health-related concerns over treatment and follow-up, but there were relatively more improvements in the CPT condition. Examination of sleep quality indicated significant improvement in both CPT and PE across treatment and follow-up and no significant differences between treatments. These results are discussed with regard to the different mechanisms thought to underlie the treatments and future innovations in PTSD treatment.