Paula P. Schnurr

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population.

Trauma and health : physical health consequences of exposure to extreme stress

A Context for Understanding the Physical Health Consequences of Exposure to Extreme Stress Trauma, PTSD, and Health Status Costs and Health Care Utilization Associated With Traumatic Experiences Depression, Trauma, and Cardiovascular Health Coping and Health: A Comparison of the Stress and Trauma Literatures Psychoneuroimmunology and Trauma PTSD, Allostatic Load, and Medical Illness Somatization Trauma, PTSD, and Health Risk Behaviors Understanding Relationships Among Trauma, PTSD, and Health Outcomes

Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse.

The authors conducted a randomized clinical trial of individual psychotherapy for women with posttraumatic stress disorder (PTSD) related to childhood sexual abuse (n = 74), comparing cognitive-behavioral therapy (CBT) with a problem-solving therapy (present-centered therapy; PCT) and to a wait-list (WL). The authors hypothesized that CBT would be more effective than PCT and WL in decreasing PTSD and related symptoms. CBT participants were significantly more likely than PCT participants to no longer meet criteria for a PTSD diagnosis at follow-up assessments. CBT and PCT were superior to WL in decreasing PTSD symptoms and secondary measures. CBT had a significantly greater dropout rate than PCT and WL. Both CBT and PCT were associated with sustained symptom reduction in this sample.

Meta-Analysis of the Efficacy of Treatments for Posttraumatic Stress Disorder

OBJECTIVE Posttraumatic stress disorder (PTSD) is an important mental health issue in terms of the number of people affected and the morbidity and functional impairment associated with the disorder. The purpose of this study was to examine the efficacy of all treatments for PTSD. DATA SOURCES PubMed, MEDLINE, PILOTS, and PsycINFO databases were searched for randomized controlled clinical trials of any treatment for PTSD in adults published between January 1, 1980, and April 1, 2012, and written in the English language. The following search terms were used: post-traumatic stress disorders, posttraumatic stress disorder, PTSD, combat disorders, and stress disorders, post-traumatic. STUDY SELECTION Articles selected were those in which all subjects were adults with a diagnosis of PTSD based on DSM criteria and a valid PTSD symptom measure was reported. Other study characteristics were systematically collected. The sample consisted of 137 treatment comparisons drawn from 112 studies. RESULTS Effective psychotherapies included cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing (g = 1.63, 1.08, and 1.01, respectively). Effective pharmacotherapies included paroxetine, sertraline, fluoxetine, risperidone, topiramate, and venlafaxine (g = 0.74, 0.41, 0.43, 0.41, 1.20, and 0.48, respectively). For both psychotherapy and medication, studies with more women had larger effects and studies with more veterans had smaller effects. Psychotherapy studies with wait-list controls had larger effects than studies with active control comparisons. CONCLUSIONS Our findings suggest that patients and providers have a variety of options for choosing an effective treatment for PTSD. Substantial differences in study design and study participant characteristics make identification of a single best treatment difficult. Not all medications or psychotherapies are effective.

Understanding relationships among trauma, post-tramatic stress disorder, and health outcomes.

Since Selye first published his classic work, The Stress of Life, a great deal of research has investigated the relationship between stress and physical health. Most of this research has focused on stressors such as divorce, bereavement, and job loss, but some has examined the health effects associated with extreme stressors, including war, sexual victimization, disasters, and serious accidents. The evidence presented here shows that poor physical health should be recognized, along with mental health problems and impaired psychosocial functioning, as an outcome of traumatic exposure. PTSD and other clinically significant distress reactions are a key step in triggering the processes through which exposure affects health. These processes involve psychological, biological, behavioral, and attentional mechanisms that interact to strain the bodys ability to adapt, thereby increasing the likelihood of disease and illness behavior. However, by addressing the physical health consequences of traumatic exposure in treatment and treatment systems, the burden on individuals and society may be reduced.

Posttraumatic stress disorder and quality of life: Extension of findings to veterans of the wars in Iraq and Afghanistan

The wars in Iraq and Afghanistan-Operation Iraqi Freedom and Operation Enduring Freedom, or OEF/OIF-have created unique conditions for promoting the development of psychological difficulties such as posttraumatic stress disorder (PTSD). PTSD is an important outcome because it can affect quality of life, impairing psychosocial and occupational functioning and overall well-being. The literature on PTSD and quality of life in OEF/OIF Veterans is at an early stage, but the consistency of the evidence is striking. Our review indicates that the findings on PTSD and quality of life in OEF/OIF veterans are comparable to findings obtained from other war cohorts and from nonveterans as well. Even though the duration of PTSD in OEF/OIF Veterans is much shorter than in Vietnam Veterans, for example, those with PTSD in both cohorts are likely to experience poorer functioning and lower objective living conditions and satisfaction. The review ends with discussion of the implications of the evidence for research and clinical practice.

Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans.

This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD (κ(.5) = .58). Overall, the findings suggest that the PCL-5 is a psychometrically sound instrument that can be used effectively with veterans. Further, by determining a valid cutoff score using the CAPS-5, the PCL-5 can now be used to identify veterans with probable PTSD. However, findings also suggest the need for research to evaluate cluster structure of DSM-5. (PsycINFO Database Record

Combat exposure, posttraumatic stress disorder symptoms, and health behaviors as predictors of self-reported physical health in older veterans.

We used path analysis to model the effects of combat exposure, posttraumatic stress disorder (PTSD) symptoms, and health behaviors on physical health. Participants were 921 male military veterans from the Normative Aging Study. Their mean age at time of study was 65. Measures of combat exposure, PTSD symptoms, smoking, and alcohol problems were used to predict subsequent self-reported physical health status. Both combat exposure and PTSD were correlated with poorer health. In path analysis, combat exposure had only an indirect effect on health status, through PTSD, whereas PTSD had a direct effect. Smoking had a small effect on health status but did not mediate the effects of PTSD, and alcohol was unrelated to health status. We conclude that PTSD is an important predictor of physical health and encourage further investigation of health behaviors and other possible mediators of this relationship.

Change in posttraumatic stress disorder symptoms: do clinicians and patients agree?

This study assessed the longitudinal association between clinician and patient ratings of posttraumatic stress disorder (PTSD) symptoms over the course of 2 different randomized clinical trials of veterans with chronic PTSD. One trial, the Department of Veterans Affairs Cooperative Study 420 (CSP 420; N = 360) compared trauma-focused and present-centered group therapies, and the 2nd trial compared cognitive processing theory and a waitlist control condition (N = 60). Linear mixed effects modeling revealed significant associations between clinician ratings (Clinician-Administered PTSD Scale; CAPS; D. D. Blake et al., 1990) and patient ratings (Posttraumatic Stress Disorder Checklist; PCL; F. W. Weathers, B. T. Litz, J. A. Herman, J. A. Huska, & T. M. Keane, 1993) in total and symptom clusters of PTSD. Contrary to hypothesis, the amount of change on the CAPS ranged from .75 to .82 standard deviations for every 1 standard deviation change on the PCL. The CAPS and PCL were more closely associated in the trauma-focused vs. present-centered treatment condition in CSP 420, and especially regarding hyperarousal symptoms. When comparing categorization of clinically significant change on the CAPS and PCL, the authors found no differences in the percentages of agreement between clinicians and patients in improvement and exacerbation. The value of multimodal assessment of PTSD treatment outcomes is discussed.

Estimating population prevalence of posttraumatic stress disorder: An example using the PTSD checklist†

The PTSD Checklist (PCL) is among the most widely used self-report instruments for assessing PTSD. To determine PCLs performance on a population level, the authors combined data from published studies that compared the PCL with structured diagnostic interviews. Weighted average sensitivities and specificities were calculated for cutoff categories most often reported in the literature. Weighted average sensitivity decreased from .85 to .39 and specificity increased from .73 to .97 for cutoffs ranging from 30 to 60. The PCLs ability to accurately estimate PTSD prevalence varied as a function of cutoff and true PTSD prevalence. In populations with a true PTSD prevalence of 15% or less, cutoff values below 44 will substantially overestimate PTSD prevalence. Uncalibrated use of the PCL for prevalence estimation may lead to large errors.