How to best understand theoretically the nature of the relationship between co-occurring PTSD and MDD (PTSD+MDD) is unclear. In a sample of 173 individuals with chronic PTSD, we examined whether the data were more consistent with current co-occurring MDD as a separate construct or as a marker of posttraumatic stress severity, and whether the relationship between PTSD and MDD is a function of shared symptom clusters and affect components. Results showed that the more severe depressive symptoms found in PTSD+MDD as compared to PTSD remained after controlling for PTSD symptom severity. Additionally, depressive symptom severity significantly predicted co-occurring MDD even when controlling for PTSD severity. In comparison to PTSD, PTSD+MDD had elevated dysphoria and re-experiencing – but not avoidance and hyperarousal – PTSD symptom cluster scores, higher levels of negative affect, and lower levels of positive affect. These findings provide support for PTSD and MDD as two distinct constructs with overlapping distress components.
This initial feasibility study examined the use of virtual reality exposure therapy (VRE) in the treatment of MST-related PTSD, with newly developed content tailored to MST. Participants included 15 veterans (26% male) with MST-related PTSD. Assessment of PTSD, depression, and psychophysiological indicators of distress occurred at pre-treatment, post-treatment, and 3-month follow-up. Treatment included 6-12 VRE sessions. There were significant reductions in pre- to post-treatment PTSD (CAPS severity: t(10) = 3.69, p = .004; PCL-5: t(10) = 3.79, p = .004) and depressive symptoms, (PHQ-9: t(8) = 2.83, p = .022), which were maintained at follow-up. There also was a significant pre- to post-treatment reduction in heart rate response to a trauma cue. Cohen's d effect sizes were large (CAPS: d = 1.11; PCL-5: d = 1.14, PHQ-9: d = .94), and the percentage of participants meeting PTSD criteria continued to decline from post-treatment (53%) to follow-up (33%). Findings indicate VRE can be safely delivered and is a promising treatment for MST-related PTSD.
These results suggest that memory reactivation prior to exposure therapy did not have an impact on clinical measures but may enhance the effect of exposure therapy at the physiological level.
High rates of drop-out from treatment of PTSD have challenged implementation. Care models that integrate PTSD focused psychotherapy and complementary interventions may provide benefit in retention and outcome. The first 80 veterans with chronic PTSD enrolled in a 2-week intensive outpatient program combining Prolonged Exposure (PE) and complementary interventions completed symptom and biological measures at baseline and posttreatment. We examined trajectories of symptom change, mediating and moderating effects of a range of patient characteristics. Of the 80 veterans, 77 completed (96.3%) treatment and pre- and posttreatment measures. Self-reported PTSD (p < .001), depression (p < .001) and neurological symptoms (p < .001) showed large reductions with treatment. For PTSD, 77% (n = 59) showed clinically significant reductions. Satisfaction with social function (p < .001) significantly increased. Black veterans and those with a primary military sexual trauma (MST) reported higher baseline severity than white or primary combat trauma veterans respectively but did not differ in their trajectories of treatment change. Greater cortisol response to the trauma potentiated startle paradigm at baseline predicted smaller reductions in PTSD over treatment while greater reductions in this response from baseline to post were associated with better outcomes. Intensive outpatient prolonged exposure combined with complementary interventions shows excellent retention and large, clinically significant reduction in PTSD and related symptoms in two weeks. This model of care is robust to complex presentations of patients with varying demographics and symptom presentations at baseline.
Over the past 10 years, our experiences delivering exposure therapy and teaching clinicians to deliver exposure therapy for PTSD have taught us some important lessons. We will focus on lessons learned as we have attended to clinicians’ experiences as they begin to implement and apply the therapy. Specifically, we highlight common therapist expectations including the beliefs that the exposure therapy requires a new set of clinical skills, therapists themselves will experience a high level of distress hearing about traumatic events, and clients will become overly distressed. We then discuss common clinical challenges in the delivery of exposure therapy and illustrate them with case examples. The challenges addressed include finding the appropriate level of therapist involvement in session, handling client distress during treatment, targeting in-session covert avoidance, and helping the client shift from being trauma-focused to being more present and future oriented. Clinicians training exposure therapists and therapists new to the implementation of exposure therapy for PTSD should find this practical discussion of common expectations and initial clinical challenges reassuring and clinically useful.
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