Kristen H. Walter

Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD

OBJECTIVE Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. DESIGN The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. RESULTS Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. CONCLUSION This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.

Treatment adherence in cognitive processing therapy for combat-related PTSD with history of mild TBI.

OBJECTIVE This retrospective study examined treatment adherence in Cognitive Processing Therapy (CPT) for combat-related posttraumatic stress disorder (PTSD) in Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) with and without history of mild traumatic brain injury (mTBI). METHOD Medical record review of consecutive referrals to an outpatient PTSD clinic identified veterans diagnosed with combat-related PTSD who began treatment with CPT. The sample (N = 136) was grouped according to positive (n = 44) and negative (n = 92) mTBI history. Groups were compared in terms of presenting symptoms and treatment adherence. RESULTS The groups were not different on a pretreatment measure of depression, but self-reported and clinician-rated PTSD symptoms were higher in veterans with history of mTBI. The treatment completion rate was greater than 61% in both groups. The number of sessions attended averaged 9.6 for the PTSD group and 7.9 for the mTBI/PTSD group (p = .05). IMPLICATIONS Given the lack of marked group differences in treatment adherence, these initial findings suggest that standard CPT for PTSD may be a tolerable treatment for OEF/OIF veterans with a history of PTSD and mTBI as well as veterans with PTSD alone.

Relationship between posttraumatic stress disorder and postconcussive symptom improvement after completion of a posttraumatic stress disorder/traumatic brain injury residential treatment program.

OBJECTIVE Research has demonstrated that veterans with a history of traumatic brain injury (TBI) may experience persistent symptoms following injury. These symptoms are frequently maintained or exacerbated by psychiatric symptoms, including posttraumatic stress disorder (PTSD). Studies suggest that decreasing PTSD symptoms may also reduce postconcussive symptoms. This study examined whether (a) PTSD and postconcussive symptoms decreased over the course of residential PTSD/TBI treatment and (b) a reduction in PTSD symptoms was associated with a reduction in postconcussive symptoms. METHOD Twenty-eight veterans who met diagnostic criteria for PTSD and had a history of TBI were included in the study. Veterans received 8 weeks of treatment in a residential PTSD/TBI program and completed self-report measures of PTSD and postconcussive symptoms at pre- and posttreatment. RESULTS Results indicated that PTSD and postconcussive symptoms significantly decreased over the course of treatment. Furthermore, the decreases in PTSD and postconcussive symptoms were significantly positively related. CONCLUSIONS The reduction in PTSD symptoms is positively associated with a reduction in postconcussive symptoms following residential treatment in a PTSD/TBI program. These findings suggest that PTSD and postconcussive symptoms are interdependent and mutually influence one another.

More than symptom reduction: changes in executive function over the course of PTSD treatment.

Persons with posttraumatic stress disorder (PTSD) have neuropsychological impairments in multiple cognitive domains, though particularly in executive function. This exploratory study examined whether these cognitive impairments were alleviated following trauma-focused treatment. Fifteen women underwent neuropsychological testing within a week of treatment onset and approximately 3 months later. Results suggest medium-sized improvement in multiple aspects of executive function, including tests of cognitive flexibility/set-shifting and organization/planning. If replicated in larger samples, such findings raise the possibility that treatment may alleviate neuropsychological impairment in persons with PTSD and thus reduce risk for poor outcome.

Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy.

OBJECTIVE Although cognitive processing therapy (CPT) has strong empirical support as a treatment for posttraumatic stress disorder (PTSD), studies have not directly examined the proposed change mechanisms that underlie CPT-that change in trauma-related cognitions produces change in PTSD and depression symptoms. To improve the understanding of underlying mechanisms of psychotherapeutic change, this study investigated longitudinal association between trauma-related cognitions, PTSD, and depression among veterans receiving CPT during a 7-week residential PTSD treatment program. METHOD All 195 veterans met DSM-IV-TR diagnosis for PTSD. The sample was 53% male with a mean age of 48 years. Self-reported race was 50% White and 45% African American. The Posttraumatic Cognitions Inventory was used to assess trauma-related cognitions. The PTSD Checklist and Beck Depression Inventory-II were used to assess PTSD and depression, respectively. Cross-lagged panel models were used to test the longitudinal associations between trauma-related cognitions, PTSD, and depression. Measures were administered at three time points: pre-, mid-, and posttreatment. RESULTS Change in posttraumatic cognitions (self-blame; negative beliefs about the self) preceded change in PTSD. In addition, (a) change in negative beliefs about the self preceded change in depression, (b) change in depression preceded change in self-blame cognitions, and (c) change in depression preceded change in PTSD. CONCLUSION Findings support the hypothesized underlying mechanisms of CPT in showing that change in trauma-related cognitions precedes change in PTSD symptoms. Results suggest that reduction of depression may be important in influencing reduction of PTSD among veterans in residential PTSD treatment.

The Impact of Personality Disorders on Treatment Outcome for Veterans in a Posttraumatic Stress Disorder Residential Treatment Program

This study evaluated the effect of comorbid personality disorders on treatment outcome for male and female Veterans with posttraumatic stress disorder (PTSD). One hundred and sixty-six Veterans participated in a PTSD Residential Rehabilitation Program, which included cognitive processing therapy (CPT) provided in a combined individual and group format. Sixty-six percent of participants met criteria at pre-treatment for at least one personality disorder. No difference was found between participants with and without personality disorders on pre-treatment demographic variables, self-reported PTSD symptoms, or clinician-assessed PTSD symptoms. However, differences were found between the groups on self-reported depression symptoms. When controlling for pre-treatment self-reported depression symptoms, results indicated that both groups had significant reductions on PTSD outcome measures, regardless of the presence of a personality disorder. Additionally, a comparable number of participants with and without personality disorders no longer met criteria for PTSD following treatment. Findings suggest that Veterans with personality disorders can benefit from a CPT-based PTSD residential program.

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.

Cognitive function during acute cold exposure with or without sleep deprivation lasting 53 hours.

INTRODUCTION Cold exposure and sleep deprivation are independently associated with transient cognitive impairment, including difficulty in attention, reaction time, and executive function. The possible interactive effects of cold exposure and sleep deprivation on cognition have not previously been examined. METHODS Six apparently healthy young adult men participated in a within-subjects design with two counterbalanced 53-h protocols: 2-h cold exposure (10 degrees C) blocks every 24 h with normal sleep (Cold), and the same cold exposure in addition to 53 h of complete sleep deprivation (Cold + Sdep). Computerized cognitive tasks of attention, reaction time, and executive function were completed every 4 h during Cold + Sdep, and every 4 waking hours during Cold. RESULTS Cold was associated with a decline in attention over time (b = -0.06). Cold + Sdep was associated with greater attentional decline than Cold (b = -0.13), a significantly reduced speeded/reaction time performance (b = 0.02; b = -0.13), and a trend toward reduced cognitive inhibition over time (b = -0.10). DISCUSSION Findings suggest an additive effect of sleep deprivation to cold exposure in attention and reaction time, and a trend toward this pattern in aspects of executive functioning. These findings raise concern for errors when careful attention and speeded cognitive flexibility are necessary and optimal sleep and protection from the environment is not possible. Mechanisms are not entirely clear, but may be related to transient cerebrovascular or neurochemical changes, or direct physiological effects. Further work is needed to clarify mechanisms for the additive cognitive decline associated with cold exposure and sleep deprivation.

Cognitive processing therapy for veterans with posttraumatic stress disorder: a comparison between outpatient and residential treatment.

OBJECTIVE Across the Veterans Affairs (VA) Healthcare System, outpatient and residential posttraumatic stress disorder (PTSD) treatment programs are available to veterans of all ages and both genders; however, no research to date has compared these treatment options. This study compared veterans who received outpatient (n = 514) to those who received residential treatment (n = 478) within a VA specialty clinic on demographic and pretreatment symptom variables. Further, the study examined pre- to posttreatment symptom trajectories across the treatment programs. METHOD All 992 veterans met diagnostic criteria for PTSD and attended at least 1 session of cognitive processing therapy (CPT) in either the outpatient or residential program. Bivariate analyses were utilized to investigate differences between samples on demographic variables and severity of pretreatment symptoms. Multilevel modeling (MLM) was used to investigate the change in symptomatology between the 2 samples from pre- to posttreatment. RESULTS Analyses indicated that the samples differed on all demographic and pretreatment symptom variables, with residential patients reporting higher scores on all assessment measures. MLM results demonstrated that symptom scores improved for all veterans across time, with outpatients consistently reporting fewer symptoms at both time points. The time by program interaction was significant for PTSD-related symptom trajectories, but not for the depression-related symptom trajectory. CONCLUSION This is the 1st study to compare pretreatment characteristics and treatment outcome between veterans receiving outpatient and residential PTSD treatment. Findings may help clinicians select appropriate care for their patients by identifying relevant pretreatment characteristics and generally informing expectations of 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.