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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.
Treatment Adherence in Cognitive Processing Therapy for Combat-Related
PTSD With History of Mild TBI
Jeremy J. Davis
Cincinnati VA Medical Center, Cincinnati, Ohio and University
of Utah School of Medicine
Kristen H. Walter
Cincinnati VA Medical Center, Cincinnati, Ohio
Kathleen M. Chard
Cincinnati VA Medical Center, Cincinnati, Ohio and University
of Cincinnati Medical School
R. Bruce Parkinson and Wes S. Houston
Cincinnati VA Medical Center, Cincinnati, Ohio
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
(N136) was grouped according to positive (n44) and negative (n92) 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.
Keywords: posttraumatic stress disorder, mild traumatic brain injury, cognitive processing therapy,
Impact and Implications
Although the co-occurrence of mTBI and PTSD is not uncommon in
OEF/OIF veterans, the optimal empirically supported treatment for PTSD
in the cases remains an area of ongoing research. This study of CPT for
PTSD in veterans with and without history of mTBI extend previous
clinical trials demonstrating the efficacy of CPT by examining its utility
under standard clinical conditions. OEF/OIF veterans with a history of
PTSD and mTBI did not demonstrate marked differences in treatment
adherence from veterans with PTSD alone. These preliminary findings
indicate that standard CPT for PTSD may be a tolerable approach for
veterans with PTSD and history of mTBI. If supported by additional
research, these preliminary findings indicate that standard CPT might
useful among veterans regardless of mTBI history.
Posttraumatic stress disorder (PTSD) and mild traumatic brain
injury (mTBI) are commonly encountered by clinicians treating
veterans of Operation Enduring Freedom (OEF) and Operation
Iraqi Freedom (OIF) in both mental health and general medical
settings (Department of Defense [DOD], 2007; Seal, Bertenthal,
Miner, Sen, & Marmar, 2007; Tanielian & Jaycox, 2008). A
number of studies have explored the relationship of mTBI sequelae
and physical and mental health outcomes in OEF/OIF veterans. In
a well-known postdeployment survey of infantry soldiers, Hoge
and colleagues (2008) found that respondents with a history of
mTBI were more likely to report poor health, increased medical
visits and missed workdays, and greater somatic and cognitive
complaints compared to those who sustained other injuries. When
PTSD was included in logistic regression analyses, the association
between mTBI and negative health outcomes was greatly reduced,
which suggested that PTSD might mediate health outcomes. An
independent investigation of postdeployment National Guard and
reserve personnel found PTSD to mediate health and psychosocial
outcomes (Pietrzak, Johnson, Goldstein, Malley, & Southwick,
2009). Similarly, Schneiderman, Braver, and Kang (2008) exam-
ined the prevalence of mTBI, PTSD, and postconcussive symp-
toms in OEF/OIF veterans and found a greater association between
PTSD and postconcussive symptoms than history of mTBI after
removal of overlapping symptoms. In yet another study, self-
Jeremy J. Davis, Mental Health Care Line, Cincinnati VA Medical
Center, Cincinnati, Ohio, and Division of Physical Medicine and Rehabil-
itation, University of Utah School of Medicine; Kristen H. Walter, Trauma
Recovery Center, Cincinnati VA Medical Center; Kathleen M. Chard,
Trauma Recovery Center, Cincinnati VA Medical Center, and Department
of Psychiatry, University of Cincinnati Medical School; R. Bruce Parkin-
son and Wes S. Houston, Mental Health Care Line, Cincinnati VA Medical
Correspondence concerning this article should be addressed to Kathleen
M. Chard, 3200 Vine Street, Cincinnati, OH 45220. E-mail: kathleen
Rehabilitation Psychology © 2013 American Psychological Association
2013, Vol. 58, No. 1, 36– 42 0090-5550/13/$12.00 DOI: 10.1037/a0031525
reported postconcussive symptoms varied by TBI severity until
PTSD symptoms were entered as a covariate (Belanger, Kretzmer,
Vanderploeg, & French, 2010). Thus, emotional complaints (e.g.,
self-reported PTSD symptoms) appeared to be more strongly re-
lated to postconcussive symptom endorsement than TBI severity.
These findings are consistent with evidence from research in
civilian samples that has found postconcussive symptoms to be
nonspecific (Gunstad & Suhr, 2002; Meares et al., 2011) and
endorsed by a range of participants from healthy controls (Garden,
Sullivan, & Lange, 2010; Iverson & Lange, 2003; Iverson, Lange,
Brooks, & Rennison, 2010) to individuals with depression (Tra-
han, Ross, & Trahan, 2001) and chronic pain (Iverson & Mc-
Cracken, 1997). Additional research has identified relationships
between postconcussive symptom endorsement and factors unre-
lated to the injury, including premorbid emotional status (Greiff-
enstein & Baker, 2001), personality characteristics (Garden et al.,
2010), assessment method (Villemure, Nolin, & Le Sage, 2011),
combat stress (Cooper et al., 2011), and symptom exaggeration
(Lange, Iverson, Brooks, & Rennison, 2010). It has been proposed
that persistent postconcussive symptoms may also be iatrogenic
phenomena in some patients (i.e., that diagnosis threat, diagnostic
misinformation, or treatment context might contribute to symptom
maintenance; Howe, 2009). The interaction between PTSD and
history of mTBI has been described as “mutually exacerbating”
(King, 2008, p. 3). Extending the notion of mutual symptom
exacerbation in PTSD and mTBI, Brenner, Vanderploeg, and
Terrio (2009) proposed a model of cumulative disadvantage for
understanding the complex clinical presentation and increased risk
of poor outcomes when the conditions co-occur. According to this
model, stressors due to a range of problems from emotional and
psychosocial issues to vocational and financial difficulties exert a
cumulative effect that may result in increases in the severity and
persistence of symptoms. Brenner and colleagues recommended
treatment aimed at symptom reduction to lower the burden load,
regardless of etiology.
Numerous studies and meta-analytic reviews have provided
strong evidence of symptom resolution following mTBI with full
recovery being the expectation in three months (Belanger, Curtiss,
Demery, Lebowitz, & Vanderploeg, 2005; Binder, Rohling, &
Larrabee, 1997; Carroll et al., 2004; Dikmen, Machamer, Winn, &
Temkin, 1995; Frencham, Fox, & Maybery, 2005; Iverson, 2005;
McCrea et al., 2003; Schretlen & Shapiro, 2003). The meta-
analytic findings have been challenged on methodological grounds
(Iverson, 2010; Pertab, James, & Bigler, 2009), and some studies
have reported statistically significant group differences on mea-
sures of cognitive and emotional functioning more than 3 months
post-mTBI after controlling for performance validity (Konrad et
al., 2011; Meyers & Rohling, 2004). There is a growing appreci-
ation of the potential for negative outcomes in cases in which a
subsequent mTBI occurs before complete resolution of the initial
injury (i.e., second impact syndrome; Cantu, 1998) and when
athletes sustain multiple concussions over the course of a career in
boxing or football (DeKosky, Ikonomovic, & Gandy, 2010). In
cases involving a single uncomplicated mTBI (i.e., without find-
ings on neuroimaging), a recent review (McCrea et al., 2009)
concluded that complete symptom resolution “within days to
weeks in the overwhelming majority of cases” (p. 1381) is the
expectation. The authors noted a need for further research to
examine competing claims regarding mTBI recovery and stressed
the importance of a biopsychosocial treatment model with “atten-
tion to the diagnosis and treatment of psychological disorders in
the context of mTBI” (p. 1384). Given the possibility that psycho-
social factors might complicate recovery from mTBI and the
increased prevalence of PTSD among veterans, treatment aimed at
reducing PTSD would appear a useful therapeutic target.
Researchers and clinical collaborators within the Veterans
Health Administration (VHA) and DOD have developed guide-
lines for assessment and treatment of PTSD and TBI (VHA, 2005,
2007; VHA & DOD, 2004, 2009). With regard to psychothera-
peutic intervention for PTSD, prolonged exposure (PE) and cog-
nitive processing therapy (CPT) have been endorsed as best prac-
tice models (Foa, Keane, Friedman, & Cohen, 2008; VHA &
DOD, 2004). Both of these treatments have been extensively
examined through clinical research, including randomized con-
trolled trials, with civilian samples and to a lesser extent, with
veterans (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011;
Chard, Schumm, Owens, & Cottingham, 2010; Foa et al., 1999;
Monson et al., 2006; Resick, Nishith, Weaver, Astin, & Feuer,
2002; Schnurr et al., 2007). However, evidence-based treatments
for TBI and PTSD have typically been developed independently of
one another (Chard, 2005; Gordon et al., 2006; Monson et al.,
2006), and research that examines psychotherapeutic interventions
for PTSD in patients with a history of TBI is limited (Soo & Tate,
2007; Stein & McAllister, 2009; Vasterling, Verfaellie, & Sulli-
van, 2009).
The research addressing PTSD in the context of TBI primarily
involves case studies and randomized clinical trials in civilian
samples. For example, McGrath (1997) reported a case study in
which a cognitive– behavioral intervention was implemented for
PTSD following a motor vehicle accident that resulted in mTBI.
Therapeutic gains included improved work performance and re-
ductions in intrusive thoughts, angry outbursts, self-reported anx-
iety, and self-reported depressive symptoms. Williams, Evans, and
Wilson (2003) described two cases in which cognitive– behavioral
therapy was used to treat PTSD during intensive neurorehabilita-
tion for TBI. Both patients showed symptom reductions following
treatment, but residual anxiety symptoms persisted. Bryant and
colleagues (2003) compared cognitive– behavioral and supportive
interventions for acute stress disorder in individuals with a history
of mTBI. At posttreatment, 58% of participants in the supportive
group continued to meet criteria for PTSD, and 8% of the
cognitive– behavioral group continued to meet criteria. Tiersky et
al. (2005) examined the efficacy of cognitive remediation in con-
junction with psychotherapy in patients with history of mild to
moderate TBI. Compared to waitlist controls, participants in the
treatment group showed posttreatment reductions in overall symp-
tom severity and on specific measures of anxiety and depression.
One recent study examined psychotherapy for PTSD in veterans
with a history of TBI. Chard et al. (2011) reported that veterans in
a residential TBI/PTSD program receiving a modified version of
CPT (i.e., CPT-C, which does not involve written trauma narra-
tives) demonstrated reductions in clinician-assessed PTSD symp-
toms and self-reported symptoms of PTSD and depression.
Although these findings provide initial support for cognitive–
behavioral interventions for PTSD in the context of TBI, there
remains a paucity of studies of veterans with a history of mTBI.
Veterans presenting with PTSD and history of mTBI may repre-
sent a unique clinical group that is distinct from veterans with
PTSD alone, and it remains an empirical question whether veterans
with PTSD and history of mTBI will participate in standard
outpatient intervention (Vasterling et al., 2009). The goals of the
present study were to describe the symptom presentation and
treatment adherence of veterans with and without a history of
mTBI who underwent unmodified CPT for PTSD in an outpatient
clinic. It was hypothesized that veterans with a history of mTBI
and PTSD would report greater symptoms, consistent with previ-
ous research. Exploratory analyses were also conducted to exam-
ine whether mTBI affected engagement in PTSD treatment.
Review of medical records from consecutive referrals to an
outpatient PTSD program at a Midwestern VA Medical Center
revealed 1,128 cases of which 285 were OEF/OIF veterans diag-
nosed with combat-related PTSD. One hundred twenty-five cases
did not undergo CPT and 160 cases initiated treatment with CPT.
Twenty-four cases were excluded from this group for several
reasons including ongoing treatment (n14), subthreshold PTSD
(n8; defined as endorsing 2 symptoms of avoidance or 1
symptom of hyperarousal, but otherwise meeting criteria for
PTSD), and history of moderate-severe TBI (n2) resulting in
the pretreatment sample (N136). The two cases with a history
of moderate-severe TBI were excluded because they were insuf-
ficient to serve as a separate group. Participants who initiated CPT
did not differ from those OEF/OIF veterans did not initiate CPT in
age, t(283) 0.13, p.90; ethnicity (i.e., Caucasian vs. not
(1, N282) 0.88, p.35; education, t(185)
0.06, p.95; or service area (i.e., Iraq, Afghanistan, or both),
(2, N285) 0.67, p.71.
All 136 participants met diagnostic criteria for PTSD based on
a combat-related trauma as assessed by the Clinician-Administered
PTSD Scale (CAPS; Blake et al., 1990). Among the participants,
44 (32%) had a documented history of mTBI, based on informa-
tion gleaned from medical records. OEF/OIF veterans undergo a
standardized screening procedure for TBI as they enter the VA
system. Individuals with positive screening results are evaluated
further in polytrauma clinics, so this information is often readily
available in the medical record. According to VHA and DOD
guidelines (2009), mTBI is defined as a brain injury caused by
external force that leads to an alteration of consciousness (i.e.,
looking or feeling dazed or confused), loss of consciousness (0 –30
min), and/or posttraumatic amnesia (0 –24 hr).
PTSD. The Clinician-Administered PTSD Scale (CAPS;
Blake et al., 1990) is a structured clinical interview that follows
PTSD diagnostic criteria outlined in the DSM–IV–TR (American
Psychiatric Association, 2000). Each criterion of PTSD is rated for
frequency and severity; these ratings are summed to obtain a total
PTSD severity score (Blanchard et al., 1995), for which a cut-off
of 45 was used for diagnosis. The CAPS has demonstrated excel-
lent psychometric properties (Weathers, Keane, & Davidson,
The PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, &
Keane, 1993) is a commonly used 17-item self-report measure for
assessing PTSD with established psychometric properties. Items
are rated on a 5-point Likert-type scale ranging from 1 (not at all)
to5(extremely) and summed to yield a total score. A total score
cut-off of 50 is suggested for diagnosis. Among samples of vet-
erans, the PCL is shown to have excellent internal and test–retest
reliability, along with strong convergent and discriminant validity
(Weathers et al., 1993).
Depression. The Beck Depression Inventory-II (BDI-II;
Beck, Steer, & Brown, 1996) is a widely used 21-item self-report
measure of depressive symptoms with well-established psycho-
metric properties. Each item is rated on a 4-point Likert-type scale
ranging from 0 to 3, for a maximum score of 63 (higher scores
indicate greater severity of depression symptoms). The BDI-II has
demonstrated excellent internal and test–retest reliability, in addi-
tion to strong convergent validity (Beck et al., 1996).
Treatment Completion and Number of Sessions. Treatment
completion was determined by chart review of session notes. If
participants had completed the 12-session protocol or were early
responders to treatment (e.g., reduced symptoms/impairment
maintained prior to completing the protocol) and the clinician
indicated treatment was completed, then participants were consid-
ered completers. Furthermore, participants who received more
than 12 sessions, in keeping with the guidelines outlined in the
CPT protocol, were included if treatment completion was indicated
in the notes by the clinician. If participants did not return to
treatment, required different services during the course of treat-
ment, or were dismissed due to noncompliance, these participants
were considered noncompleters. The number of sessions attended
was also determined by chart review and refers to the total number
of CPT sessions attended.
This retrospective chart review was approved by a university
institutional review board and the VA Research and Development
Committee. Medical records were reviewed from consecutive in-
take assessments at an outpatient PTSD program between Septem-
ber 2001 and December 2008. Relevant information from the
medical record was compiled into a database, including demo-
graphic and treatment variables.
Participants in the study received individual CPT, as designed
for a military population (Resick, Monson, & Chard, 2007). CPT
was provided by a licensed clinician (nurse practitioner, social
worker, psychiatrist, or psychologist) or trainee (psychiatry resi-
dent or psychology intern) supervised by a licensed clinician. All
therapists were trained by one of the developers of CPT (Kathleen
M. Chard), who provided weekly group supervision. CPT is a
manualized treatment that consists of 12 60-min individual ses-
sions. All sessions were in-person and provided at a VA PTSD
specialty clinic. The therapy consists of three stages, including an
initial phase that explores the impact/meaning of the trauma, the
connection between thoughts and emotions, and begins the process
of identifying “stuck points.” The second stage involves the writ-
ing of traumatic accounts designed to activate and normalize the
natural emotions related to the trauma and to help the patient begin
to examine their stuck points. The final phase of treatment focuses
on challenging stuck points and replacing them with more bal-
anced thoughts. Stuck points related to safety, trust, power/control,
esteem, and intimacy as well as overgeneralized stuck points
related to self, others, and the world are examined and allow the
participant to scrutinize the logic behind their reasoning and to
identify more healthy alternatives to their thoughts. Specifically,
cognitive techniques are used using challenging questions, patterns
of problematic thinking, and challenging beliefs worksheets. In
addition, Socratic Dialogue is used throughout therapy to facilitate
further evaluation of beliefs. During the final session, the individ-
ual is again asked to discuss the impact of the event to allow them
to see concrete changes in their thinking from the start to the
completion of the treatment.
Veterans with and without history of mTBI were compared on
demographic and treatment variables using chi-square and inde-
pendent samples ttest analyses. The PTSD and mTBI/PTSD
groups were not significantly different in terms of age, ethnicity,
education, marital status, service connected disability rating, or
psychiatric comorbidity (see Table 1). In terms of pretreatment
scores on outcome measures, the groups did not differ significantly
on the BDI-II, t(119) ⫽⫺1.00, p.32, d.18, but were
significantly different on the CAPS, t(132) ⫽⫺2.19, p.03, d
.40, and PCL, t(119) ⫽⫺2.05, p.04, d.39, with the mTBI
group reporting more symptoms (see Table 2). The dropout rate
did not differ significantly between PTSD and mTBI/PTSD
(1, N136) 0.004, p.95. The mean number of
CPT sessions attended was slightly higher for PTSD (M 9.6;
SD 4.9) than mTBI/PTSD (M 7.9; SD 4.9) groups, which
trended toward significance, t(134) 1.95, p.05, d.17. On
post hoc analysis, the achieved power for this comparison was
0.26. Given the sample size, a medium effect (specifically, d
0.52) would be minimally detected at 1 ⫺␤⫽0.80. To further
explore these findings, analyses were conducted to determine if
differences were present on early treatment drop-out (i.e., 4 or
fewer sessions; when the trauma account is assigned in CPT). The
rate of early drop-out trended toward significance,
(1, N
136) 3.84, p.05, ⌽⫽.05, with 20.7% of the PTSD and
36.4% of the mTBI/PTSD groups discontinuing treatment at or
before Session 4 of CPT. Considering the sample size, a small
effect (specifically, w0.24) would be minimally detected at 1 -
This retrospective study examined pretreatment characteristics
and CPT treatment adherence for veterans with PTSD, with and
without a history of mTBI. The sample was grouped according to
history of mTBI, and groups were compared on treatment adher-
ence variables (e.g., number of sessions, treatment drop-out) and
on three psychological measures administered at pretreatment—
the PCL, CAPS, and BDI-II. The hypothesis regarding symptom
presentation was supported as veterans with PTSD and history of
mTBI reported more symptoms than veterans with only PTSD on
both self-report and clinician-administered measures of PTSD.
This finding is consistent with prior studies suggesting greater
symptom report among individuals with mTBI history (Belanger et
al., 2010; Hoge et al., 2008; Schneiderman et al., 2008). The
observation of differences in both self-reported and clinician-
assessed symptoms of PTSD also suggests that the cumulative
disadvantage model proposed by Brenner and colleagues (2009)
may be helpful in conceptualizing these cases. Although the his-
tory of mTBI does not offer a neurologic explanation for increased
symptom report, as another psychosocial stressor it may increase
emotional difficulty.
Findings related to treatment adherence were mixed. The mTBI/
PTSD and PTSD groups demonstrated similar drop-out rates, but
the PTSD group attended almost two more sessions on average
than the mTBI/PTSD group. Although the difference in session
attendance was not statistically significant, post hoc power analy-
sis showed the present study to be underpowered for the observed
effect size. The finding of similar drop-out rates with an almost
significant difference in session attendance raises the possibility
that participants in the mTBI/PTSD dropped out more quickly than
those in the PTSD group. Further analyses showed that the data
trended toward this pattern in that the mTBI/PTSD group had
slightly higher rates of dropping out of treatment at or before the
Session 4 of CPT. This is an interesting trend as it suggests the
possibility that veterans with PTSD and a history of mTBI may
be more likely to drop out early in CPT treatment, specifically
before significant trauma processing and challenging of trauma-
related stuck points were undertaken. However, this analysis was
also inadequately powered, so results should be interpreted with
caution. Further, weekly assessment of PTSD symptoms was not
Table 1
Demographic Characteristics by Group
Characteristic nPTSD nmTBI/PTSD Tor
Age, M(SD) 92 30.1 (7.6) 44 30.3 (8.2) 0.16 .88
Caucasian, % 92 91.3 44 88.6 0.25 .62
Years education, M(SD) 92 13.1 (1.4) 44 13.1 (1.6) 0.02 .99
Married, % 92 52.2 44 65.9 2.29 .13
OIF, % 92 89.1 44 84.1 1.56 .46
Axis I comorbidity, % 92 72.8 44 79.5 0.72 .40
Service connected, % 92 39.1 44 40.9 0.04 .84
Note. PTSD posttraumatic stress disorder; mTBI mild traumatic brain injury; OIF percentage of
participants who served in Operation Iraqi Freedom; Service connected percentage of participants with
service-connected disability.
routinely conducted during this time frame, so it is not possible to
determine whether individuals who did not complete the full
protocol were early responders to treatment. Although it is implau-
sible that all individuals who dropped out were early responders to
treatment by Session 4. Given the potential clinical utility of early
identification of individuals who are likely to drop out of treat-
ment, this topic would benefit from further study. It is important to
note that the available data are not indicative of marked group
differences in treatment adherence, which may mitigate the con-
cern that patients with a history of mTBI might be more difficult
to treat with cognitive– behavioral interventions (Vasterling et al.,
This study has several strengths including the fact that these data
were collected in a clinical population seeking care at a VA
hospital, which adds to the external validity of the findings. In
addition, the sampling procedure (i.e., consecutive referrals) did
not impose stringent exclusionary criteria that would limit the
generalizability of randomized clinical trials. As a result, these
findings may be more readily generalized to the typical patients
and service providers found in VA clinics. Finally, the use of
standardized measures commonly used in PTSD treatment out-
come studies allows for further comparison to existing treatment
outcome studies using CPT. Despite these strengths, this study has
several limitations, for example, reliance on self-reported symp-
toms in establishing the history of mTBI. The assessment proce-
dure used in TBI/polytrauma clinics relies almost entirely on
self-report, and corroboration of these reports is often impossible.
The conditions of combat often preclude the collection of data at
the time of injury, records which do exist are often unavailable,
and the veterans themselves are routinely the only sources of
information about events that occurred months to years in the past.
A related consideration is that data relevant to describing TBI
sequelae (e.g., time since injury and findings of neuropsycholog-
ical evaluation) were not consistently available for this sample.
Posttreatment data were limited, which precluded prepost compar-
isons and examination of hypotheses related to differential treat-
ment gains by groups. Finally, symptom validity was not exam-
ined, so the degree to which the results may have been influenced
by response bias remains unknown.
Future research might examine pre- and posttreatment data to
examine whether therapeutic gains vary by groups. It might also be
of benefit to investigate the influence of cognitive ability on
treatment outcome by including neuropsychological data. To the
extent possible, it will also be important to consider symptom
validity in future research to explore its role in treatment nonre-
sponse. Increased understanding of the best clinical practices for
veterans with PTSD and history of mTBI is important given the
frequency of this presentation among OEF/OIF veterans.
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Table 2
Pretreatment Symptoms and Treatment Characteristics
CAPS, M(SD) 91 67.9 (15.0) 43 74.1 (15.9) 2.10 .03
PCL, M(SD) 77 57.1 (10.5) 44 61.32 (11.3) 2.05 .04
BDI-II, M(SD) 78 27.8 (9.3) 43 29.6 (10.6) 1.00 .32
Sessions attended, M(SD) 92 9.6 (4.9) 44 7.9 (4.9) 1.95 .05
Drop-out rate, % 92 38.0 44 38.6 0.01 .95
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Revision received November 8, 2012
Accepted December 3, 2012
... The definition of the term "dropout" has varied depending on the nature of the study, which may potentially account for some of the differences in rates of treatment dropout across studies (e.g., Goetter et al., 2015;Imel et al., 2013;Najavits, 2015;Steenkamp & Litz, 2013). For example, some studies define treatment dropout from a clinical perspective, such as when a client discontinues treatment before achieving their agreed-upon PTSD treatment goals (e.g., Davis et al., 2013;Schumm et al., 2017;Zayfert et al., 2005). Other studies define treatment dropout as a function of dosage (i.e., occurring when clients fail to attend a predetermined number of sessions; e.g., Eftekhari et al., 2013;Hundt et al., 2018;Maieritsch et al., 2016). ...
... • No differences in demographic, TBI, intellectual functioning, or memory variables between treatment completers and treatment dropouts • Treatment dropouts had more severe PTSD symptoms and postconcussive symptoms at baseline • Treatment dropouts performed more poorly than treatment completers on tests of executive functioning at baseline, including a test of novel problem-solving (WCST-64) and a test of cognitive flexibility (D-KEFS Trail Making number-letter switching). However, only the WCST-64 remained a significant predictor of dropout when controlling for baseline PTSD and postconcussive symptoms Davis et al. (2013) OEF/OIF/OND entire sample ...
... Moreover, the findings are mixed regarding the impact of certain psychological factors. For example, some studies have found that both greater PTSD symptom severity (Crocker et al., 2018;Garcia et al., 2011;Grubaugh et al., 2016;Kozel et al., 2018;Smith et al., 2015) and overall distress (Lamkin et al., 2019) were associated with treatment dropout among OEF/OIF/OND veterans, whereas other studies have found no differences in pretreatment assessment measures when comparing OEF/OIF/OND veterans to other veteran cohorts Davis et al., 2013;Eftekhari et al., 2013;Yoder et al., 2012). Consequently, it has been suggested that pretreatment PTSD symptom severity not be used to predict the risk of individual patient dropout . ...
Full-text available
Although treatment effectiveness among evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) has been well established, treatment dropout among veterans continues to be a concern within these treatments. Due to the uniqueness of the Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veteran cohort, this article reviewed the literature examining factors contributing to treatment dropout from EBPs for PTSD among OEF/OIF/OND veterans. We conducted a systematic review of the published literature using PsycINFO, PubMed, and PTSDpubs with a restriction on year of publication beginning in 2007, following the first VA national initiative to roll-out EBPs for PTSD, through May 1st, 2020. Articles were retained if treatment dropout for EBPs was examined among OEF/OIF/OND veterans with PTSD, which yielded a total of 26 manuscripts. Common themes associated with treatment dropout were identified, including demographic, psychological, cognitive, practical, and treatment-related factors. Specifically, younger age, concurrent substance use, and practical concerns (e.g., balancing multiple life roles) emerged as factors that consistently contributed to treatment dropout. Other findings were mixed (e.g., pretreatment symptom severity and presence of traumatic brain injury). While factors contributing to dropout are complex and interact uniquely for each veteran, improved understanding of these factors in combination with innovative strategies for treating OEF/OIF/OND veterans utilizing EBPs is needed to enhance treatment engagement, retention, and outcomes. Implications for these factors are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... A study comparing the effectiveness of CPT for veterans with and without TBI showed no difference in symptom reduction, suggesting that those with TBI benefit as much from CPT as those without (Ragsdale & Voss Horrell, 2016). In a medical record review of veterans with PTSD with or without mild TBI, there was also no difference in dropout from CPT (Davis et al., 2013). Although those with TBI completed, on average, two fewer sessions than those with PTSD only, the difference was not statistically significant (Davis et al., 2013). ...
... In a medical record review of veterans with PTSD with or without mild TBI, there was also no difference in dropout from CPT (Davis et al., 2013). Although those with TBI completed, on average, two fewer sessions than those with PTSD only, the difference was not statistically significant (Davis et al., 2013). In a Clinician Concerns About CPT 21 randomized clinical trial, researchers compared CPT to CPT plus compensatory cognitive training in a sample of Iraq/Afghanistan veterans with PTSD and mild to moderate TBI (Jak et al., 2019). ...
Cognitive processing therapy (CPT) is recommended for the treatment of posttraumatic stress disorder (PTSD) but is infrequently delivered. Many clinicians have concerns about CPT that impact usage. Common concerns include (a) CPT’s effectiveness in “real-world” settings, (b) whether CPT can be individualized, (c) the possibility of making clients worse, (d) CPT’s effectiveness for clients with comorbidities, (e) CPT’s effectiveness for clients with childhood trauma, (f) the appropriateness of CPT for moral injury, (g) delivering CPT to culturally diverse populations, (h) initiating CPT without first stabilizing clients with preparatory treatment, (i) the effects of CPT’s structure on rapport, (j) whether and when CPT should be stopped, and (k) whether clients will maintain their gains long term. To inform clinical decision making, findings from the psychological literature are presented for each concern. The evidence provides support for CPT’s safety, tolerability, acceptability, and effectiveness across populations and settings, as well as for delivery of CPT without preparatory treatment and across a range of secondary outcomes. Although symptom exacerbations occur, evidence suggests they are typically temporary and occur at similar rates as in control conditions. Findings highlight the role of fidelity in symptom outcome. The evidence may aid providers in making informed decisions about training in or delivering CPT.
... This assumption is often not met in clinical conditions. Participant factors including employment flexibility, socioeconomic status, transportation availability, and even underlying physical, mental, or emotional health may affect the ability a participant to receive planned therapy [23][24][25][26][27]. When the aWLC method is applied in clinical situations, we expect the Stage I durations for the control group will be both more variable and longer than the current simulation study implies. ...
Full-text available
Wait-list control clinical trials are popular among psychologists and rehabilitation specialists partly because all participants receive the intervention. In 2 arm wait-list control trials, individuals randomized to the treatment group receive immediate treatment whereas individuals randomized to the control group wait a fixed amount of time before intervention is initiated. For interventions that have varying durations, careful consideration must be given to the period that participants in the control group have a delay until treatment begins, as incongruent wait times compared to the intervention durations of the treatment group may introduce confounding into the evaluation of the treatment differences. To alleviate this issue, we propose to adaptively assign wait times to individuals randomized to the control group based on the intervention duration of those in the treatment group. Simulations demonstrate the that our method not only results in similar timing distributions between participants in the treatment and control groups, but also allows participants in the control group to initiate treatment earlier than the traditional design. The latter characteristic may reduce dropout and result in more efficient study enrollment.
... When present, these factors should be addressed in treatment to enhance recovery. While evidence suggests that individuals with comorbid PTSD and TBI respond similarly to evidence-based treatments for PTSD as those without TBI (e.g., Davis et al., 2013;Sripada et al., 2013), few studies have addressed treating PTSD and TBI concurrently and none in a brief or intensive fashion. ...
Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are pervasive consequences of the post-9/11 conflicts. Treatment of PTSD and mTBI has historically occurred separately and sequentially, which does not reflect the overlapping etiology of symptoms and may attenuate or delay recovery. This paper describes an integrated 2-week treatment program using prolonged exposure and cognitive symptom management and rehabilitation therapy to comprehensively treat PTSD and cognitive complaints attributed to mTBI, regardless of etiology. To minimize potential iatrogenic effects of treating presumed mTBI-related symptoms, a central focus of the program was to instill expectations of full recovery. Thirty patients with full or subclinical PTSD and self-reported TBI history completed the PTSD+TBI treatment program. Results indicated that self-reported PTSD, depression, and neurobehavioral symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that PTSD complicated by mTBI history can be effectively treated within a 2-week intensive outpatient program.
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.
Trauma‐focused psychotherapies are increasingly offered in community‐based mental health centers, but little is known about treatment dropout in these settings. The current study explored dropout at different stages of treatment in a treatment‐seeking sample of 1,186 adults who experienced interpersonal violence and were offered trauma‐focused and non–trauma‐focused therapies. A total of 31.6% of participants dropped out before treatment initiation, 28.0% dropped out after treatment initiation and completed a mean of 4.02 (SD = 2.41) sessions, and 40.4% completed a full course of PTSD treatment. Being unemployed, p < .001, and scoring lower on measures of environment factors, p = .045, were significant predictors of pretreatment dropout. Being female, p < .001; Latinx, p = .032; and scoring higher on a measure of social relationships, p = .024, were independent predictors of postinitiation dropout. Individuals who completed nine sessions of treatment displayed significantly lower levels of posttraumatic stress disorder, depression, and anxiety symptoms. The present study provides preliminary evidence that survivors of interpersonal violence who seek therapy tend to drop out early during treatment, and most who complete treatment attain symptom reduction.
Background: Treatment dropout has been problematic with evidence-based treatments for posttraumatic stress disorder (PTSD), including cognitive processing therapy (CPT). This study sought to evaluate whether CPT group contributed to symptom improvement among treatment completers and non-completers. Methods: Sixty-one Iraq and Afghanistan combat Veterans self-selected CPT group or treatment as usual (TAU) forming a convenience sample. Defining treatment completion as attending at least nine sessions: 18 completed treatment, 20 dropped-out (DOs); 20 completed TAU, 3 lost to TAU follow-up. Results: Multiple Regression revealed significant pre-post-treatment improvement, the Clinician-Administered PTSD Scale (CAPS-IV, F(5, 40.1) = 2.53, p = 0.0436). Reviewing DOs' last available PTSD Checklist-Military Version scores before leaving treatment, six achieved clinically significant improvement of >10 points; seven a clinically reliable change of 5-10 points. Conclusion: These findings highlight that CPT group may be effective at reducing trauma-related symptoms among treatment completers and dropouts and point to the utility of a clinical definition of good treatment end-state.
A substantial number of individuals who undergo cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) drop out before receiving a full course of treatment. Therapeutic alliance, defined as the working relationship between the therapist and client, is a dynamic process within therapy that may change over time. Research suggests that therapeutic alliance is associated with dropout in various treatments. However, no studies have yet examined the association between therapeutic alliance and dropout in CPT, and few studies have examined therapeutic alliance longitudinally over the course of treatment. Examining alliance in CPT through different methods may increase clinicians’ understanding of how to tailor interventions to prevent treatment dropout. The present study examined the association between therapeutic alliance and treatment dropout among 169 participants in a randomized implementation effectiveness trial. In total, 33.1% of clients dropped out over the course of CPT, and nearly half of these individuals dropped out during the first six sessions. Continuous‐time survival analysis results indicated that mean ratings of alliance significantly predicted treatment dropout, Wald χ2(1, N = 167) = 4.08, Exp(β) = .64, p = .043, whereas initial alliance, late alliance, and change in alliance over treatment did not. These findings suggest that overall therapeutic alliance is an important predictor of dropout from CPT.
Post-traumatic stress disorder (PTSD) is a complex disorder that involves dysregulation of multiple neurobiological systems. The traumatic stressor plays a causal role in producing psychological dysfunction and the pattern of findings suggests that the hypothalamic–pituitary–adrenal (HPA) axis, which is instrumental for stress adaptation, is critically dysfunctional in PTSD. Given the lack of understanding of the basic mechanisms and underlying pathways that cause the disorder and its heterogeneity, PTSD poses challenges for treatment. Targeting the endocannabinoid (ECB) system to treat mental disorders, and PTSD in particular, has been the focus of research and interest in recent years. The ECB system modulates multiple functions, and drugs enhancing ECB signaling have shown promise as potential therapeutic agents in stress effects and other psychiatric and medical conditions. In this review, we focus on the interaction between the ECB-HPA systems in animal models for PTSD and in patients with PTSD. We summarize evidence supporting the use of cannabinoids in preventing and treating PTSD in preclinical and clinical studies. As the HPA system plays a key role in the mediation of the stress response and the pathophysiology of PTSD, we describe preclinical studies suggesting that enhancing ECB signaling is consistent with decreasing PTSD symptoms and dysfunction of the HPA axis. Overall, we suggest that a pharmacological treatment targeted at one system (e.g., HPA) may not be very effective because of the heterogeneity of the disorder. There are abnormalities across different neurotransmitter systems in the pathophysiology of PTSD and none of these systems function uniformly among all patients with PTSD. Hence, conceptually, enhancing ECB signaling may be a more effective avenue for pharmacological treatment.
Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are common conditions following motor vehicle accidents (MVAs). Mild TBI and PTSD not only share similar features but may also coexist and interact. Nonetheless, research on psychotherapeutic interventions for PTSD in patients with a history of mTBI, particularly regarding pediatric populations, is limited. The present study compared the efficacy of the prolonged exposure treatment protocol for children and adolescents (PE-A) with PTSD and mTBI (n = 16) versus PTSD alone (n = 21); treatment commenced at least 3 months following an MVA. Emotional status and cognitive functioning were assessed pre- and postintervention using questionnaires and standardized neuropsychological tests. Participants from both groups benefitted from the intervention, as reflected in their emotional status via increased ratings of well-being and decreased ratings of PTSD, anxiety, depression, and postconcussive symptoms, η2 = .21-.50. Ratings of cognitive function also improved for cognitive flexibility, η2 = .30; executive function in everyday life, η2 = .27; and attention and inhibition, η2 = .16. Parental PTSD was the strongest predictor of improvement after intervention, sr2 = .35. Thus, it appears that PE-A is an effective intervention for children with MVA-related PTSD regardless of its comorbidity with mTBI.
Full-text available
The Clinician-Administered PTSD Scale (CAPS) is a structured interview for assessing posttraumatic stress disorder (PTSD) diagnostic status and symptom severity. In the 10 years since it was developed, the CAPS has become a standard criterion measure in the field of traumatic stress and has now been used in more than 200 studies. In this paper, we first trace the history of the CAPS and provide an update on recent developments. Then we review the empirical literature, summarizing and evaluating the findings regarding the psychometric properties of the CAPS. The research evidence indicates that the CAPS has excellent reliability, yielding consistent scores across items, raters, and testing occasions. There is also strong evidence of validity: The CAPS has excellent convergent and discriminant validity, diagnostic utility, and sensitivity to clinical change. Finally, we address several concerns about the CAPS and offer recommendations for optimizing the CAPS for various clinical research applications. Depression and Anxiety 13:132–156, 2001 © 2001 Wiley-Liss, Inc.
This is the protocol for a review and there is no abstract. The objectives are as follows: To determine whether psychological treatment for anxiety (with or without pharmacological treatment) in people with TBI is superior to: • no psychological treatment for anxiety with no pharmacological treatment for anxiety and, • no psychological treatment for anxiety with pharmacological treatment for anxiety. In addition, different psychological treatments for anxiety in people with TBI will be compared to determined which psychological treatment is superior.
Ninety-six female assault victims with chronic posttraumatic stress disorder (PTSD) were randomly assigned to 4 treatment conditions: prolonged exposure (PE), stress inoculation training (SIT), combined treatment (PE-SIT). or wait-list control (WL). Treatment consisted of 9 twice-weekly. individual sessions, Independent evaluations were conducted at pretreatment; posttreatment: and 3-, 6-, and 12-month follow-ups. All 3 active treatments reduced severity of PTSD and depression compared with WL but did not differ significantly from each other, and these gains were maintained throughout the follow-up period. However, in the intent-to-treat sample. PE was superior to SIT and PE-SIT on posttreatment anxiety and global social adjustment at follow-up and had larger effect sizes on PTSD severity, depression, and anxiety. SIT and PE-SIT did not differ significantly from each other on any outcome measure.
A case of post-traumatic stress disorder and minor head injury following a road traffic accident is reported. Significant, persisting, and disabling cognitive deficits were reported by the patient and confirmed on neuropsychological testing. A magnetic resonance imaging scan showed no evidence of cerebral damage. A cognitive behavioural treatment approach to the problem is described. The relative contribution of emotional and organic factors to the cognitive and behavioural sequelae of head injury is discussed.
Neuropsychological outcome at 1 year postinjury was examined prospectively in representative groups of 436 adult head-injured participants and 121 general-trauma control participants. A comprehensive battery of neuropsychological measures was administered. The head-injured group performed significantly worse than the trauma controls on most measures (p < .01). However, the magnitude and pervasiveness of the impairments depended on the severity of the head injury. This study provides information about expected ranges of impairment as a function of different severity levels and appropriate comparison values. The findings raise important questions about clinically held beliefs of differential sensitivity of neuropsychological measures. Furthermore, the substantial variability in outcome observed underscores the importance of examining factors that seem to exacerbate or mitigate the effects of brain damage.