Clinician's Trauma Update Online Newsletter
(CTU-Online)

Editor: Paula P. Schnurr, Ph.D.
Associate Editors: Susan Stevens, Psy.D.
Editorial Manager: Elizabeth Forshay, M.S.W.

CTU-Online includes brief updates on the latest clinically relevant research. Issues include an ID number so you can find the article in the PILOTS database and a link to the abstract or full article, if you have access through your library privileges. If not, see below.*

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CTU-Online, 2(2), April 2008 Printable PDF

CTU-Online, 2(2), April 2008

Treatment

Dismantling Cognitive Processing Therapy

Most treatments include multiple therapeutic techniques, so when a treatment is effective, the exact mechanism may be hard to determine. Do patients need all components? Are some components more effective than others? Questions like this are addressed by dismantling designs in which a treatment is compared to treatments that consist of its components. A new study recently examined the components of Cognitive Processing Therapy (CPT). The investigators randomly assigned 150 women with PTSD to receive CPT or one of its two components only: Cognitive Therapy or Written Exposure. Treatment was delivered 2 hours per week for 6 weeks. At the end of treatment, all patients improved substantially. There were no differences among treatments according to measures collected only at pretreatment, posttreatment, and 6-month follow-up, including the Clinician-Administered PTSD Scale.  Analyses of data from weekly self-reports of PTSD symptoms and depression revealed important differences between treatments in the rate of change. Patients assigned to Cognitive Therapy alone improved faster than patients assigned to Written Exposure, which suggests that administering the cognitive component could be an especially efficient treatment strategy. Yet the findings also suggest that even Written Exposure can be helpful in circumstances where it is not possible to deliver CPT. This study adds extremely valuable information to our understanding of how to optimize the benefits of the treatments we deliver.

Read the Article
Resick. P.A., Galovski, T.E., Uhlmansiek, M.O., Scher, C.D., Clum, G.A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of Cognitive Processing Therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76, 243-258. PILOTS ID 30597.

Study fails to find benefit of anticonvulsant treatment for PTSD

A team led by investigators at the Tuscaloosa VAMC recently reported the results of a randomized clinical trial of divalproex for treating PTSD in military veterans. Divalproex is an anticonvulsant that increases brain levels of GABA (g-aminobutyric acid), an amino acid that is linked to neural systems involved in the fear response and is thought to play a role in the pathophysiology of PTSD. Although SSRIs—selective-serotonin reuptake inhibitors—are the front-line medication for treating PTSD, clinicians may prescribe anticonvulsants such as divalproex for patients who do not respond adequately to SSRIs. The investigators randomized 85 military veterans with chronic PTSD, most of whom were male combat veterans, to receive 8 weeks either placebo or divalproex administered twice per day according to a flexible dosing schedule. Eighty percent completed treatment, and 82 of the 85 patients provided enough outcome data to be included in the analysis. There were no differences between the divalproex and placebo groups in PTSD, depression, anxiety, or other measures, even when the analyses were restricted to veterans who completed treatment. The investigators speculate that the chronic nature of the sample may have contributed to the lack of differences and suggest that the findings may not generalize to less chronic and treatment refractory patients. One further caveat is that the investigators used a method of handling missing data known as last-endpoint-carried-forward, which can lead to inaccurate estimation of a treatment’s effects. It appears that the jury is still out on the effectiveness of divalproex and other anticonvulsants for treating PTSD.

Read the Article
Davis, L.L., Davidson, J.R.T., Ward, L.C., Bartolucci, A., Bowden, C.L., & Petty, F. (2008). Divalproex in the treatment of posttraumatic stress disorder: A randomized, double-blind, placebo-controlled trial in a veteran population.Journal of Clinical Psychopharmacology, 28, 84-88. PILOTS ID 30463.

Novice raters perceive exposure therapy to be more distressing than cognitive therapy for PTSD

Evidence continues to mount about the efficacy of exposure therapy for treating PTSD, yet exposure is still an underused treatment. In an effort to understand factors that hinder more widespread use, a recent study explored beliefs people might have about exposure therapy before knowing much about the procedure.  Seventy-eight college students in Australia were asked to read a profile of a fictitious female rape patient and explanations of exposure therapy and cognitive therapy. The students then rated their perceptions of how distressing each type of therapy would be to the patient. As the researchers predicted, the students rated the description of exposure therapy to be more distressing than cognitive therapy. This finding adds support to the idea that some people may have preexisting beliefs about exposure that could create a negative bias about the therapy. The authors use these results to suggest that therapists also might have negative beliefs about the impact of exposure therapy upon their patients and thus avoid using the treatment. However, the student data many not generalize to actual therapists. College students and therapists differ greatly in knowledge and expertise, and the students’ perceptions were limited by the descriptions provided by the researchers. It would be helpful to know what therapists think and how their thoughts guide their treatment decisions.

Read the Article
Devilly, G.J., & Huther, A. (2008). Perceived distress and endorsement for cognitive- or exposure-based treatments following trauma. Australian Psychologist, 43, 7-14. PILOTS ID 30550.

Assessment

Unexpected effects of PTSD compensation seeking

Some critics have raised concerns about the VA claims process, arguing that the system creates incentives for veterans to exaggerate symptoms (see the article by Freeman et al., 2008, in this issue) or drop out of treatment once they have successfully pursued a claim. Prior research by investigators at the Minneapolis VA Medical Center had indicated that veterans who were awarded compensation increased treatment from pre-claim levels, but that veterans whose claims were denied decreased their use of treatment. Now another study from this group reports on the post-claim period, specifically on the effects of continuing to seek compensation to either increase an award or appeal one that was denied. Study participants were 50 compensation-seeking veterans (16 seeking an increase and 34 appealing a denial), and 51 non-compensation seeking veterans (44 with an awarded claim and 7 choosing not to appeal). The investigators predicted that symptoms would improve among veterans who were no longer seeking compensation, reasoning that if these veterans were exaggerating to support a claim, such exaggeration would no longer be necessary. However, symptom change was unrelated to compensation seeking status. The most surprising finding was that treatment engagement from preclaim to postnotification increased among non-compensation seeking veterans, but did not change among veterans who continued to seek compensation. These findings contradict the view that veterans exaggerate symptoms and engage in treatment to enhance the success of a claim. More studies like this are needed to further our understanding of the VA PTSD claims process and settle questions with evidence rather than beliefs only.

Read the Article
Sayer, N.A., Spoont, M., Nelson, D.B., Clothier, B., & Murdoch, M. (2008). Changes in psychiatric status and service use associated with continued compensation seeking after claim determinations for posttraumatic stress disorder. Journal of Traumatic Stress, 21, 40-48. PILOTS ID 81730.

Symptom exaggeration in veterans with PTSD

The issue of symptom exaggeration in veterans with PTSD has been hotly debated. Several interpretations have been offered. One view is that veterans exaggerate symptoms to bolster compensation claims. Another view is that the elevations on validity scales (e.g., of the MMPI) reflect a response style, or genuine distress. Whatever the explanation—several may be correct—the concerns remain and research continues. Investigators at the Little Rock VA Medical Center recently reported on symptom exaggeration in 74 veterans with chronic PTSD who were inpatients at a residential PTSD program. Most of the veterans had served in Vietnam and 80% were seeking initial PTSD disability compensation or an increase in existing compensation. The investigators administered several measures often used in forensic assessments, including the MMPI-2, Structured Interview for Reported Symptoms, Structured Inventory of Malingered Symptomatology, and Miller Forensic Assessment Test. Just over half of the veterans (53%) met criteria for clear symptom exaggeration. These veterans had greater clinician-rated PTSD severity but did not differ from veterans who showed no evidence of symptom exaggeration on compensation status, demographic factors, depression, and a measure of dishonesty. The investigators point out that the study was not designed to explain the basis for symptom exaggeration. Whatever the reason for the high rate of exaggeration, it is important to remember that the veterans in this study represent a select subgroup that differs in many respects from the majority of veterans with PTSD.

Read the Article
Freeman, T., Powell, M., & Kimbrell, T. (2008). Measuring symptom exaggeration in veterans with chronic posttraumatic stress disorder. Psychiatry Research, 158, 374-380. PILOTS ID 30499.

Common screening measures are useful for clinical assessment of active duty military personnel

Efforts continue in the goal to accurately assess the psychological problems of military personnel who seek mental health care while actively deployed in OIF/OEF. There has been an unprecedented stream of publications based on assessments of active duty personnel who are taking part in research studies, but few reports about the assessment of those who seek mental health treatment. A recent study examined the intake questionnaires of 296 servicemembers who sought care at a mental health clinic at a US military hospital in Kuwait. The 10-page intake questionnaire included well-validated measures of PTSD, depression, and alcohol use. Most of the patients in this study received some sort of mental health diagnosis. The most common disorders included adjustment disorder (34%), depressive disorders (32%), anxiety disorders other than PTSD (13%), and PTSD (12%). Although 73% of the patients presenting for treatment were men, there was a relatively high percentage of women (27%), compared to the overall percentage of women in the military. Although the investigators did not formally evaluate staff opinions about the screening measures, informal feedback indicated that staff found the measures to be easily implemented and useful. This study demonstrates the feasibility of using screening measures in a clinical setting and highlights the issues military clinicians are likely to face when treating OIF/OEF patients.

Read the Article
Felker, B., Hawkins, E., Dobie, D., Gutierrez, J., & McFall, M. (2008). Characteristics of deployed Operation Iraqi Freedom military personnel who seek mental health care. Military Medicine, 173, 155-158. PILOTS ID 81653.

Etiology

Genes may affect the risk of PTSD following child abuse

There is increasing evidence that a person’s genetic makeup contributes to the development of PTSD following traumatic exposure. Researchers have estimated that genetic factors account for between 30-40% of the risk. Tests of specific genes have led to a variety of findings, some of which indicate that that the effects of particular genes are influenced by an individual’s experiences, creating what is known as a gene X environment interaction. Investigators at Emory University have now examined the interaction between traumatic exposure and FKBP5, a gene that regulates aspects of the hypothalamic-pituitary-adrenal axis (HPA). The HPA axis mediates the stress response and is dysregulated in PTSD, making FKBP5 a good candidate to study. The investigators sampled 900 male and female medical outpatients at a large urban hospital and administered measures of traumatic exposure, PTSD, and depression along with genetic tests. As expected, the number of types of child abuse and of other traumas were each related to higher PTSD symptom severity. FKBP5 interacted with child abuse, but not other trauma, to increase risk of PTSD. Among patients who had experienced child abuse, those who had specific variants of the gene had an increased risk of PTSD. The same variants did not increase risk of depression following abuse. Also, the patients with the high-risk profile had enhanced sensitivity to the dexamethasone suppression test, which is used to assess the responsiveness of the HPA axis. The study illustrates the complexity of how genes affect the risk of PTSD and suggests promising avenues for future investigations of risk and resilience.

Read the Article
Binder, E.B., Bradley, R.G., Liu, W., Epstein, M.P., Deveau, T.C., Mercer, K.B., Tang, Y., Gillespie, C.F., Heim, C.M., Nemeroff, C.B., Schwartz, A.C., Cubells, J.F. & Ressler, K.J. (2008). Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. Journal of the American Medical Association, 299, 1291-1305. PILOTS ID 30476.

Comorbidity

PTSD can lead to worsened attachment patterns in former POWs over time

Insecure attachment patterns have been implicated as risk factors for the development of PTSD. A study of Israeli veterans from the 1973 Yom Kippur War now suggests that adult attachment patterns may be affected by PTSD. The investigators assessed PTSD symptoms and attachment in 209 Israeli veterans (103 former POWs and 106 veterans who served in the War but were not POWs), studying the group first in 1991 and then 12 years later in 2003. As expected, POWs reported more PTSD symptoms relative to the other veterans, and these symptoms increased between the two assessments periods. Avoidant and anxious attachment patterns also worsened over time. Notably, initial PTSD symptoms predicted an increase of insecure attachment, but initial insecure attachment did not predict an increase of PTSD symptoms. The possibility that PTSD can modify attachment style challenges our traditional conceptualization of attachment, which has been interpreted as a more fixed rather than malleable relational construct. Even though in this study PTSD seemed to worsen attachment patterns that were already insecure rather than change whole orientations from secure to insecure, the novel finding deepens our understanding of how relational systems may evolve in adulthood. It may be helpful to specifically target relational functioning when treating PTSD in patients who have insecure attachment patterns.

Read the Article
Solomon, Z., Dekel, R., & Mikulincer, M. (2008). Complex trauma of war captivity: A prospective study of attachment and posttraumatic stress disorder. Psychological Medicine 1-8. PILOTS ID 30552.

Alexithymia is related to poor health in sexually traumatized female veterans:

The existence of negative health outcomes in women who have been sexually traumatized is firmly established. Several mediators have been proposed to explain this link, including PTSD and risky health practices, such as smoking, substance abuse, and unhealthy eating. The authors of a recent study examined the issue further by looking at how the difficulty in identifying one’s emotions might be related to poor health and contribute to increased use of health services. A 25-page survey asking about psychological functioning, healthcare utilization, perceptions of health, and health risk behaviors was sent to 1,500 female veterans who had received care from a Women Veterans Health Care Clinic. A total of 456 women returned completed anonymous surveys. Having trouble identifying feelings was more strongly related than PTSD, depression, or trauma exposure to physical health complaints. Although the authors do not deny that sexual trauma survivors experience physical health problems, they speculate that alexithymia contributes to the increased rates of physical symptoms experienced by these women. Of course, the correlational nature of the data prevents the authors from making causal interpretations, but the data suggest that alexithymia may adversely affect the health of women who have been sexually traumatized.

Read the Article
Polusny, M.A., Dickinson, K.A., Murdoch, M., & Thuras, P. (2008). The role of cumulative sexual trauma and difficulties identifying feelings in understanding female veterans' physical health outcomes. General Hospital Psychiatry, 30, 162-70. PILOTS ID 30429.

CTU-Online, 2(2), April 2008 Printable PDF

*Articles authored by National Center for PTSD staff are available in full text. For other articles we provide a link to where you might be able to access the full text.

**PROBLEMS ACCESSING FULL TEXT? VA clinicians might have privileges through their university affiliation. However, VA firewalls sometimes block the permissions to access reference materials. If you cannot access the Full Text version of any article, we suggest you contact your local librarian or web/internet technical person.

If you usually have access to full text from the journal in which an article is published, but are not seeing it from the link provided, try accessing it directly through your university library system. Many online services have password access that only works through a user's library system.

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CTU-Online is published by the Executive Division of the National Center for Posttraumatic Stress Disorder in White River Junction, VT. We welcome feedback from readers about content and format. Please feel free to email us at ncptsd@va.gov.