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Cognitive processing therapy (CPT) is an effective treatment for posttraumatic stress disorder (PTSD); however, some patients do not improve to the same extent as others. It is important to understand potential factors that can be modified for better patient outcomes. This clinical trial implemented a three‐arm, equipoise‐stratified randomization design to allow for the accommodation of patient preference before randomization to one of three CPT treatment modalities: in‐home, in‐office, or telehealth. This study examined whether satisfaction with the modality, perceived stigma, expectations of therapy, and credibility of the therapist differed between modalities and whether these factors impacted treatment outcomes. We hypothesized that the contributions of these variables would depend upon whether participants opted out of any treatment arms and that these factors would predict treatment outcomes. Participants who endorsed less perceived stigma demonstrated larger reductions in PTSD symptom severity than those with similar levels of perceived stigma in the telehealth and in‐office conditions, η2 =.12–.18. Participants who endorsed lower satisfaction with their treatment modality and were assigned to the in‐home condition experienced larger PTSD symptom reductions than those with similar dissatisfaction in the telehealth and in‐office conditions, η2 =.20. The results show the robustness of evidence‐based therapies for PTSD given that dissatisfaction did not impede treatment success. In addition, they demonstrate that it is important for clinicians to address stigma before initiating evidence‐based therapies for PTSD. Strategies to address these factors are discussed. [ABSTRACT FROM AUTHOR]

Insomnia and nightmares are common in patients with posttraumatic stress disorder (PTSD). They are associated with worse psychological and physical health and worse PTSD treatment outcomes. In addition, they are resistant to PTSD treatments, which do not typically address sleep disorders. Cognitive behavioral therapy for insomnia and nightmares (CBT‐I&N) and cognitive processing therapy (CPT) for PTSD are first‐line treatments, but limited evidence exists guiding the treatment of individuals with all three disorders. The current study randomized U.S. military personnel (N = 93) to one of three conditions: CBT‐I&N delivered before CPT, CBT‐I&N delivered after CPT, or CPT alone; all groups received 18 sessions. Across groups, participants demonstrated significantly improved PTSD symptoms. Because the study was terminated prematurely due to challenges with recruitment and retention, it was underpowered to answer the initially intended research questions. Nonetheless, statistical findings and relevant clinically meaningful changes were observed. Compared to participants who received CPT alone, those who received CBT‐I&N and CPT, regardless of sequencing, demonstrated larger improvements in PTSD symptoms, d = −0.36; insomnia, d = −0.77; sleep efficiency, d = 0.62; and nightmares, d = −.53. Compared to participants who received CBT‐I&N delivered before CPT, those who received CBT‐I&N delivered after CPT demonstrated larger improvements in PTSD symptoms, d = 0.48, and sleep efficiency, d = −0.44. This pilot study suggests that treating comorbid insomnia, nightmares, and PTSD symptoms results in clinically meaningful advantages in improvement for all three concerns compared to treating PTSD alone. [ABSTRACT FROM AUTHOR]

Objective: To explore whether the association between change in headache management self‐efficacy and posttraumatic headache–related disability is partially mediated by a change in anxiety symptom severity. Background: Many cognitive–behavioral therapy treatments for headache emphasize stress management, which includes anxiety management strategies; however, little is currently known about mechanisms of change in posttraumatic headache–related disability. Increasing our understanding of mechanisms could lead to improvements in treatments for these debilitating headaches. Methods: This study is a secondary analysis of veterans (N = 193) recruited to participate in a randomized clinical trial of cognitive–behavioral therapy, cognitive processing therapy, or treatment as usual for persistent posttraumatic headache. The direct relationship between headache management self‐efficacy and headache‐related disability, along with partial mediation through change in anxiety symptoms was tested. Results: The mediated latent change direct, mediated, and total pathways were statistically significant. The path analysis supported a significant direct pathway between headache management self‐efficacy and headache‐related disability (b = −0.45, p < 0.001; 95% confidence interval [CI: −0.58, −0.33]). The total effect of change of headache management self‐efficacy scores on change in Headache Impact Test‐6 scores was significant with a moderate‐to‐strong effect (b = −0.57, p = 0.001; 95% CI [−0.73, −0.41]). There was also an indirect effect through anxiety symptom severity change (b = −0.12, p = 0.003; 95% CI [−0.20, −0.04]). Conclusions: In this study, most of the improvements in headache‐related disability were related to increased headache management self‐efficacy with mediation occurring through change in anxiety. This indicates that headache management self‐efficacy is a likely mechanism of change of posttraumatic headache–related disability with decreases in anxiety explaining part of the improvement in headache‐related disability. [ABSTRACT FROM AUTHOR]

Objective: Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. Methods: Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist–Stressor‐Specific Version, the PTSD Symptom Scale‐Interview, and the 2012 American College of Rheumatology FM questionnaire. Results: Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%. Conclusion: The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM. [ABSTRACT FROM AUTHOR]

Prolonged exposure therapy (PE) is an efficacious treatment for active duty service members and veterans with posttraumatic stress disorder (PTSD). However, PE is sometimes associated with high dropout rates, limited tolerability, and temporary symptom exacerbation during treatment. Stellate ganglion blocks (SGBs) are an emerging treatment that has the potential to enhance outcomes for PTSD when combined with trauma‐focused psychotherapy. To date, no study of which we are aware has examined the potential additive benefits of SGB injections when administered in conjunction with trauma‐focused behavioral treatment for PTSD. Thus, we conducted a nonrandomized clinical trial to evaluate the use of an SGB combined with massed PE therapy for combat‐related PTSD. Participants (N = 12) were treated with 10 daily 90‐min PE sessions delivered over 2 weeks and received a single SGB injection between Sessions 1 and 2. PE sessions lasted 90 min each. Participants reported a mean posttreatment PTSD symptom reduction of 32 points on the PTSD Checklist for DSM‐5 (PCL‐5), Hedges' gs = 1.28–2.80. Most participants (90.9%) demonstrated clinically significant change on the PCL‐5 (i.e., ≥10 points) by the final treatment session and 50.0% no longer met the diagnostic criteria for PTSD per the Clinician‐Administered PTSD Scale for DSM‐5 at 1‐month follow‐up. Adverse events for the combined treatment were consistent with those previously reported for standalone SGB and PE. This combined treatment approach provides promising results for improving the tolerability of trauma‐focused therapies, reducing symptom severity, and increasing PTSD remission rates. [ABSTRACT FROM AUTHOR]

This study examined the impact of a history of head injury (HHI) on posttraumatic stress disorder (PTSD) and depression symptoms in active duty military personnel following group and individual cognitive processing therapy (CPT). Data for these secondary analyses were drawn from a clinical trial comparing group and individual CPT. Service members (N = 268, 91.0% male) were randomized to 12 sessions of group (n = 133) or individual (n = 135) CPT. Most participants (57.1%) endorsed a deployment‐related HHI, 92.8% of whom reported currently experiencing symptoms (CES) related to the head injury (i.e., HHI/CES). Patients classified as non‐HHI/CES demonstrated large, significant improvements in PTSD symptom severity in both individual and group therapy, ds = 1.1, p <.001. Patients with HHI/CES status showed similar significant improvements when randomized to individual CPT, d = 1.4, p <.001, but did not demonstrate significant improvements when randomized to group CPT, d = 0.4, p =.060. For participants classified as HHI/CES, individual CPT was significantly superior to group CPT, d = 0.98, p =.003. Symptoms of depression improved following treatment, with no significant differences by treatment delivery format or HHI/CES status. The findings of this clinical trial subgroup study demonstrate evidence that group CPT is less effective than individual CPT for service members classified as HHI/CES. The results suggest that HHI/CES status may be important to consider in selecting patients for group or individual CPT; additional research is needed to confirm the clinical implications of these findings. [ABSTRACT FROM AUTHOR]

The theoretical framework of behavioral economics, a metatheory that integrates operant learning and economic theory, has only recently been applied to posttraumatic stress disorder (PTSD). A behavioral economic theory of PTSD reflects an expansion of prior behavioral conceptualization of PTSD, which described PTSD in terms of respondent and operant conditioning. In the behavioral economic framework of PTSD, negatively reinforced avoidance behavior is overvalued, in part due to deficits in environmental reward, and may be conceptualized as a form of reinforcer pathology (i.e., excessive preference for and valuation of an immediate reinforcer). We investigated cross‐sectional relationships between PTSD severity and several constructs rooted in this behavioral economic framework, including future orientation, reward availability, and delay discounting in a sample of 110 military personnel/veterans (87.2% male) who had served combat deployments following September 11, 2001. Total PTSD severity was inversely related to environmental reward availability, β = −.49, ΔR2 = 0.24, p <.001; hedonic reward availability, β = −.32, ΔR2 = 0.10, p =.001; and future orientation, β = −.20, ΔR2 = 0.04, p =.032, but not delay discounting, r = −.05, p =.633. An examination of individual symptom clusters did not suggest that avoidance symptoms were uniquely associated with these behavioral economic constructs. The findings offer support for a behavioral economic model of PTSD in which there is a lack of positive reinforcement as well as a myopic focus on the present. [ABSTRACT FROM AUTHOR]

Introduction: Pragmatic clinical trials (PCTs) can overcome implementation challenges for bringing evidence‐based therapies to people living with pain and co‐occurring conditions, providing actionable information for patients, providers, health systems, and policy makers. All studies, including those conducted within health systems that have a history of advancing equitable care, should make efforts to address justice and equity. Methods: Drawing from collective experience within pragmatic pain clinical trials networks, and synthesizing relevant literature, our multidisciplinary working group examined challenges related to integrating justice and equity into pragmatic pain management research conducted in large, integrated health systems. Our analysis draws from military and veteran health system contexts but offers strategies to consider throughout the lifecycle of pragmatic research more widely. Results: We found that PCTs present a unique opportunity to address major influences on health inequities by occupying a space between research, healthcare delivery, and the complexities of everyday life. We highlight key challenges that require attention to support complementary advancement of justice and equity via pragmatic research, offering several strategies that can be pursued. Conclusions: Efforts are needed to engage diverse stakeholders broadly and creatively in PCTs, such as through dedicated health equity working groups and other collaborative relationships with stakeholders, to support robust and inclusive approaches to research design and implementation across study settings. These considerations, while essential to pain management research, offer important opportunities toward achieving more equitable healthcare and health systems to benefit people living with pain and co‐occurring conditions. [ABSTRACT FROM AUTHOR]

Cognitive-behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) has demonstrated efficacy for improving PTSD and comorbid symptoms and relationship adjustment. To enhance treatment efficiency and scalability, we developed a 2-day, abbreviated, intensive, multicouple group version of CBCT for PTSD (AIM-CBCT for PTSD). Prior work demonstrated that AIMCBCT for PTSDwasassociated with reductions in PTSD and comorbid symptoms in a sample of 24 post-9/11 active duty military or veteran couples who received the treatment in a retreat format over a single weekend. The current study investigated secondary outcomes regarding trauma-related cognitions, psychosocial impairment, and insomnia. For trauma-related cognitions, reductions were nonsignificant and small at 1-month follow-up, ds = -0.14 to -0.32. However, by 3-month follow-up, there were significant, medium effect size reductions in total trauma-related cognitions, d = -0.68, and negative views of self and others, ds =-0.64 and -0.57, respectively, relative to baseline. There was also a nonsignificant, small-to-medium effect-size reduction in self-blame, d = -0.43, p = .053, by 3-month follow-up. For psychosocial impairment, there were significant and medium-to-large and large effect size reductions by 1- and 3-month follow-ups, ds = -0.73 and -0.81, respectively. There were nonsignificant, small effect size reductions in insomnia at both 1- and 3-month follow-ups relative to baseline, ds = -0.30 and -0.34, respectively. These findings suggest that AIM-CBCT for PTSD is associated with reductions inmaladaptive posttraumatic cognitions and psychosocial impairment but that adjunctive interventions may be needed to address insomnia. [ABSTRACT FROM AUTHOR]

Objective: To characterize the relationship between head trauma types (blast injury, blunt injury, combined blast+blunt injury) with subsequent headache presentations and functioning. Background: Posttraumatic headaches (PTHs), the most common sequelae of traumatic brain injury (TBI), are painful and disabling. More than 400,000 veterans report having experienced a TBI, and understanding the predictors of PTHs may guide treatment developments. Methods: This study used a nested‐cohort design analyzing baseline data from a randomized clinical trial of cognitive behavioral therapy for PTH (N = 190). Participants had PTH (from blast and/or blunt head trauma) and symptoms of posttraumatic stress disorder (PTSD). The Structured Diagnostic Interview for Headache‐Revised and Ohio State University Traumatic Brain Injury Identification Method were used to phenotype headaches and head injury histories, respectively. Results: Individuals with persistent PTHs after a combined blast and blunt head trauma were more likely (OR =3.45; 95% CI [1.41, 8.4]) to experience chronic (vs. episodic) PTHs compared with the blunt trauma only group (23/33, 70% vs. 26/65, 40%, respectively); and they were more likely (OR =2.51; 95% CI [1.07, 5.9]) to experience chronic PTH compared with the blast trauma only group (44/92, 48%). There were no differences between head injury type on headache‐related disability, depression symptoms, or severity of PTSD symptoms. Conclusion: The combination of blast and blunt injuries was associated with headache chronicity, but not headache disability. Considering the refractory nature of chronic headaches, the potential added and synergistic effects of distinct head injuries warrant further study. [ABSTRACT FROM AUTHOR]

Copyright of Family Process is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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. [ABSTRACT FROM AUTHOR]

Objective: To examine whether treating posttraumatic stress disorder (PTSD) reduces anger and aggression and if changes in PTSD symptoms are associated with changes in anger and aggression. Method: Active duty service members (n = 374) seeking PTSD treatment in two randomized clinical trials completed a pretreatment assessment, 12 treatment sessions, and a posttreatment assessment. Outcomes included the Revised Conflict Tactics Scale and state anger subscale of the State‐Trait Anger Expression Inventory. Results: Treatment groups were analyzed together. There were small to moderate pretreatment to posttreatment reductions in anger (standardized mean difference [SMD] = −0.25), psychological aggression (SMD = −0.43), and physical aggression (SMD = −0.25). The majority of participants continued to endorse anger and aggression at posttreatment. Changes in PTSD symptoms were mildly to moderately associated with changes in anger and aggression. Conclusions: PTSD treatments reduced anger and aggression with effects similar to anger and aggression treatments; innovative psychotherapies are needed. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Previous research in US Army Soldiers shows rates of mental health concerns as two to four times higher on anonymous surveys than on postdeployment health assessments. In this study, Soldiers presenting for health reassessment completed two questionnaires on suicide risk factors: one linked to the health assessment and one anonymous. About 5.1% of respondents reported suicide ideation on the anonymous questionnaire, 3.0% on the linked questionnaire, and 0.9% on the health reassessment. About 56.4% who reported suicide ideation anonymously told nobody of their thoughts. Current screening procedures identify only one in seven Soldiers experiencing suicide ideation and highlight the need for alternative risk-detection strategies. [ABSTRACT FROM AUTHOR]

Copyright of Journal of Traumatic Stress is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Between 44% and 87% of active duty service members and veterans who deployed following the September 11, 2001, terrorist attacks know someone who was killed or seriously injured in combat. Considering the high frequency and known impact of traumatic loss, it is important to understand if and how traumatic loss may impede posttraumatic stress disorder (PTSD) treatment progress in military personnel. Additionally, experiencing a traumatic loss elevates the risk of developing prolonged grief disorder (PGD), which is associated with higher levels of PTSD symptoms, more functional impairment, and more lifetime suicide attempts among military personnel. Given what is known about the association between PGD and PTSD in treatment‐seeking service members and veterans, it is also important to understand whether grief‐related symptom severity negatively impacts PTSD treatment response. The current study examined associations among traumatic loss, complicated grief, depressive symptoms, and PTSD treatment response among military personnel (N = 127) who participated in variable‐length cognitive processing therapy (CPT). There was no direct, F(2, 125) = 0.77, p = .465, or indirect, β = .02, p = .677, association between a traumatic loss index event and PTSD treatment response compared with other trauma types. Prior assessments of depressive symptom severity were directly related to PTSD at later assessments across two models, ps < .001–p = .021 Participants with a traumatic loss index trauma demonstrated significant reductions in complicated grief, depressive symptoms, and PTSD following CPT, ps < .001, ds = −0.61–−0.83. Implications, study limitations, and suggestions for future research are presented. [ABSTRACT FROM AUTHOR]