Neurobiological Predictors and Mechanisms in Exposure Therapy for PTSD

Apr 11, 2018

Prolonged Exposure, or PE, is one of the most effective treatments for posttraumatic stress disorder. The therapy has helped many PTSD patients face thoughts, feelings and situations that they have avoided due to distress. Even with this effective therapy, however, many patients continue to suffer with PTSD symptoms following treatment.

In this study for the Consortium to Alleviate PTSD, a research team led by Sheila A.M. Rauch, PhD, of the Emory University School of Medicine and Atlanta VA Medical Center, will use neuroscience methods in an effort to learn how effective therapy for PTSD works on a biological level in order to learn how to make it work even better.

Neurobiological studies have found links between PTSD severity and the levels of certain compounds produced by the body. Dr. Rauch and her fellow CAP investigators want to know if changes in the levels of those substances can serve as biomarkers of response to therapy.

To help answer such questions, this study will work with active duty military personnel and veterans who enrolled in either of two studies utilizing PE that are part of the clinical trials network of the STRONG STAR Consortium and the Consortium to Alleviate PTSD.

Dr. Rauch and her colleagues will measure various neuroendocrine and neurosteroid substances before, during, and after the patients’ treatment periods to see how those substances change in response to therapy, potentially shedding light on components of PE that are most effective. They also will compare differences in biomarkers resulting from different ways of delivering PE. Substances to be measured include cortisol, allopregnanolone and related metabolites, and dehydroepiandrosterone.

Potential benefits

The ability to measure neurobiological processes in response to PTSD treatment will provide a guide for making improvements to treatment so that more patients will benefit. This study will inform our understanding of how therapy works (or does not work) and how we might improve treatments based on these biological responses.

Project Remission: Maximizing Outcomes with Intensive Treatments for Combat-Related PTSD

Dec 22, 2017

This study by the Consortium to Alleviate PTSD aims to maximize improvements and, if possible, treat patients with combat-related PTSD into remission so they can return to full fitness for military duty or successfully integrate into civilian life.

The need for tailored, intensive treatment programs

Effective treatment of combat-related PTSD requires tailored and enhanced approaches that work quickly in getting PTSD into remission. The leading exposure therapies, in which patients confront traumatic memories and environmental triggers rather than avoid them, show 80 percent success rates with civilian victims of assault, accidents, and similar traumas. But the rate of remission with service members and veterans has been lower and often is less than 50 percent of those studied.

Reasons for the lower success rate with combat PTSD include the fact that service members in combat zones are more likely to experience multiple types of trauma and repeated exposure to trauma. That may require extra time and attention to address multiple, varied traumatic memories and more trauma-related issues. Also, military culture may increase concerns about the stigma of mental health care, perhaps making service members reluctant to seek treatment in the first place, while work schedules may interfere with patients’ ability to complete treatment.

How the CAP IOP study works

With those challenges in mind, Alan Peterson, PhD, of The University of Texas Health Science Center at San Antonio and the South Texas Veterans Health Care System leads a study for the Consortium to Alleviate PTSD to evaluate two versions of intensive outpatient treatment programs for military service members and veterans with PTSD. Patients involved in this study will participate in a three-week, fulltime treatment program at a designated treatment center. The aim with this approach is to both maximize improvements and streamline the treatment length.

The study will compare two intensive, enhanced forms of Prolonged Exposure (PE), the PTSD treatment with the most scientific support for efficacy with civilians.

Rather than the traditional PE treatment of 10 therapy sessions delivered over a period of three to four months, participants will receive more sessions in a shorter time period, three weeks. They will be randomly placed into one of two treatment arms with different levels of therapy enhancement:

  • Massed-PE format, with 15 daily sessions over three weeks, or
  • Intensive Outpatient PE (IOP-PE) format, also with 15 daily sessions over three weeks, but with additional enhancements to better tailor the treatment to those with combat-related PTSD or otherwise help improve treatment outcomes.

The researchers hypothesize that both formats will result in improved outcomes over standard PE delivery and that IOP-PE will provide maximum benefit. Participants in this randomized clinical trial will include 100 active duty military service members recruited worldwide and 100 veterans, treated at military and Department of Veterans Affairs sites in South and Central Texas.

Potential benefits

If the intensive outpatient format is found to be highly effective at reducing PTSD symptoms, it will offer the military and VA a valuable option that would increase access to care, boost patient retention, and improve treatment outcomes. It also could enable creation of specialized PTSD treatment centers to which service members could travel from around the world for short-term, state-of-the-art care. This would make it possible for more service members to stay on active duty and for veterans to reintegrate more quickly into civilian life, potentially saving the nation millions of dollars in long-term disability payments to veterans.

Brief Treatment for PTSD: Enhancing Treatment Engagement and Retention

Feb 19, 2016

Although we have treatments for posttraumatic stress disorder (PTSD) that are known to be effective, too many military personnel avoid therapy or drop out prematurely, often citing a lack of time. Many also avoid talking about their trauma experience with others, yet this mental re-exposure to their trauma is a key component of effective treatments called “exposure therapies.”

One approach that could help many people overcome barriers to treatment is a form of narrative therapy called Written Exposure Therapy (WET). Patients in WET simply write about their trauma, gaining the benefit of exposure therapies. WET may be easier for patients to complete because it is short in duration, with no out-of-office homework assignments. Although some studies have found narrative therapy comparable to more standard therapies in reducing PTSD symptoms in civilians and veterans, it has not yet been studied with active duty military.

Comparing WET to a leading talk therapy

In this STRONG STAR-affiliated study, a team of investigators led by Denise Sloan, PhD, of the Department of Veterans Affairs’ National Center for PTSD and the Boston University School of Medicine, will measure the effectiveness of WET with active-duty service members in San Antonio and Killeen, Texas. The research team will examine whether WET is as effective at reducing PTSD symptoms as a gold-standard talk therapy for PTSD called Cognitive Processing Therapy, Cognitive-only version (CPT-C).

The study also will examine patient dropout rates. Researchers believe that WET, with its valuable exposure-based writing component, will be as effective as CPT-C in alleviating symptoms and helping patients recover from PTSD. They also believe that the shorter course of treatment and fewer time demands will lead to greater patient retention and overall treatment satisfaction. WET is delivered in five weekly sessions, with the first session lasting an hour and the remaining four lasting 40 minutes. CPT-C requires 12 one-hour sessions delivered twice weekly over six weeks.

Potential benefits

If proven effective, WET could provide an evidence-based form of PTSD treatment that is appealing and accessible to many service members who have avoided or discontinued other treatments. It requires a shorter treatment period and can be administered by peer counselors as well as psychotherapists, with less direct provider supervision required compared to more traditional therapies. These features of the treatment would help increase the number of patients who could be served in the busy military mental health care system as it strives to improve the emotional, mental, and physical health of thousands of service members suffering silently with PTSD.

In addition, the general public would benefit through improved force readiness and potentially reduced military costs of PTSD-related lost-work time and veteran disability benefits. Civilians with PTSD also may benefit from yet another effective treatment option.

Randomized Clinical Trial of Cognitive-Behavioral Therapy for Posttraumatic Headache

Dec 10, 2015

More than 100,000 military service members and veterans suffer from chronic headaches resulting from a traumatic brain injury (TBI) sustained during deployment. Although that population has seen a sharp increase in these posttraumatic headaches (PTHA), the condition is extraordinarily difficult to treat. There is very little evidence guiding its management.

Complicating things is the fact that those who have suffered a traumatic injury during deployment often have co-occurring symptoms of posttraumatic stress, which may worsen their headaches or make them more difficult to treat.

To better inform our understanding of how to help our suffering war veterans, principal investigator Donald McGeary of the University of Texas Health Science Center at San Antonio and co-principal investigator Donald Penzien of Wake Forest University have developed a study for the Consortium to Alleviate PTSD (CAP) addressing posttraumatic headache in war veterans with co-occurring symptoms of posttraumatic stress.

A key aim of the study will be to evaluate whether a leading psychological therapy for migraine headaches is effective with posttraumatic headaches. Investigators also seek to determine if treatment for PTHA likewise improves problems with PTSD, and whether treatment for PTSD simultaneously alleviates headaches.

To accomplish these aims, the study will have three arms, with participants placed randomly into one of three treatment conditions:

  • Treatment as usual, receiving standard care for PTHA through the South Texas Veterans Health Care System’s Polytrauma Rehabilitation Center in San Antonio;
  • A gold standard, manualized cognitive-behavioral intervention for headache; or
  • A gold-standard treatment for PTSD, called Cognitive Processing Therapy.

Expected benefit

Because posttraumatic headache is the most common and debilitating chronic symptom of deployment-related traumatic brain injury, this study, if successful, could lead to improved treatment for the more than 100,000 active military and veterans with chronic PTHA. That would mean relief for a variety of problems, including poor general health, missed work days, increased frequency of medical visits, and other physical and mental health symptoms. Cognitive behavioral therapy also costs considerably less to provide than other TBI treatments.

If the proposed study is successful and its hypotheses hold true, it will provide the first scientific evidence supporting the efficacy of any therapy—pharmacological or psychological—in directly treating posttraumatic headache. Consequently, it would offer clinicians and the service members and veterans they treat a safe, effective, medication-free intervention that specifically targets posttraumatic headache symptoms without risk of negative side effects. Cognitive-behavioral treatment could relieve wounded warriors’ suffering from a chronic and often debilitating condition in as little as 6 weeks, facilitating their rapid return to home and work activities and greatly enhancing their quality of life.

For the Defense Department, the dissemination of CBT for posttraumatic headache could potentially save millions of dollars in lost work time while ensuring its primary goals: the rapid care of affected service members and the continued strength of the military’s mission. The therapy’s relatively short duration and its lack of negative side effects enable its use in theater.

Individual PE vs. Couples’ Cognitive-Behavioral Therapy for Combat-Related PTSD

Aug 18, 2010

The military family plays a much more complex role in a soldier’s life than simply “keeping the home fires burning.” In fact, family members play a significant role in how service members adjust in the aftermath of their combat experiences. Studies of veterans from previous wars have found that the presence of adequate social support following combat is one of the strongest predictors of successful adjustment, and the absence of such support is associated with the persistence of posttraumatic stress disorder (PTSD). Families often represent the chief source of support, so developing programs to assist military families in adjusting to deployment and providing support to the returning combatant is vital.

Unfortunately, the individuals most in need of family support may be least able to obtain it. Symptoms of PTSD, such as emotional numbing, irritability, and anhedonia, or the inability to experience pleasure in normally pleasurable acts, can push loved ones away and cause relationships to deteriorate. Studies reveal that both veterans and their partners report significant marital and family problems associated with veterans’ PTSD symptoms, including lower relationship satisfaction, less cohesive relationships, less emotional expression and intimacy in their relationships, and more conflict in the relationships. Studies also have found elevated levels of anger, hostility, conflict, and violence in the families of veterans with PTSD.

The interdependence of individual and family adjustment can lead to a negatively spiraling process. As individual distress and PTSD symptoms worsen, family difficulties are likely to increase, and as family difficulties increase, so does stress upon the individual. But this process does not have to be only negative; it also can work in a positive direction. When families are able to provide a safe, stable environment for the returning service members, they can help to promote a more positive adjustment process, and when service members are able to reach out and reconnect with family members, it can strengthen the family structure.

Getting the family to help with treatment, and treatment to help the family

Several treatments have been proposed or developed to address the needs of families following trauma. Some focus on relieving family distress rather than focusing on a particular individual’s PTSD symptoms. Alternatively, other programs focus on the role of the partner and family members in helping the trauma survivor to recover from the symptoms arising from the trauma. These approaches are not mutually exclusive, and one recently developed program, Cognitive-Behavioral Couples Therapy (CBCT) for PTSD, includes techniques designed both to treat PTSD and to reduce relationship distress. This program has shown promising results in small, uncontrolled studies of combat veterans with chronic PTSD.

Now, under the direction of Candice Monson, PhD, of Canada’s Ryerson University, the STRONG STAR Consortium has designed a study to examine the efficacy of this treatment in a sample of active-duty military personnel who have recently returned from combat deployments. This randomized clinical trial compares traditional Prolonged Exposure therapy, which involves only the individual service member, to CBCT, which includes the service member’s partner. It also includes behavioral communication skills training in addition to psychoeducation and cognitive interventions based on Cognitive Processing Therapy. Because the CBCT protocol addresses both individual and couple-level distress, Dr. Monson expects to see greater improvement in couple functioning with this treatment as she explores the role that military spouses can play in PTSD treatment and recovery.