Innovations for Addressing Posttraumatic Stress and Co-occurring Conditions

Dear Colleagues,

Posttraumatic stress disorder (PTSD) is associated with high rates of psychological comorbidities. Individuals with PTSD also present for treatment with factors that may interfere with their recovery, such as ongoing risks of re-exposure to trauma, substance use disorders, self-injury/suicidality, and interpersonal relationship distress. There is a need to better understand how cognitive behavioral therapies (CBT), considered the gold standard in PTSD treatment, can effectively and efficiently address these co-occurring concerns.

This Special Issue aims to identify papers on novel interventions or innovations in treatment that address PTSD and co-occurring concerns. Papers may present data on treatments that address PTSD and comorbidities such as substance use disorders, insomnia, personality disorders, eating disorders, severe mental illness, and depression. We also welcome papers on treatments and treatment innovations that address PTSD and clinically relevant issues such as support with return to work, chronic pain, racial trauma, dissociation, safety concerns, high risk of re-exposure to trauma, gender-based violence, interpersonal relationships and family distress, and traumatic brain injury/concussion, among others. We are in search of papers with both original data from treatment trials and basic science research that could have implications for treatments, as well as review papers. Of importance, these papers should describe the application of their findings to diverse populations and how diversity, equity, and inclusion are factored into treatment development or innovations.

Dr. Naomi Ennis
Dr. Candice M. Monson
Guest Editors

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• comorbidities
• posttraumatic stress disorder
• CBT
• substance use disorders
• personality disorders
• insomnia
• eating disorders
• ongoing risk

Title: Helping Opioid Use Disorder and PTSD with Exposure (HOPE): An open-label pilot study
Authors: Tanya C Saraiya; Sonali Singal; Tamina Daruvala; Priya Johal; Chloe Rosenkranz; Denise A Hien; Katherine L Mills; Kathleen T Brady; Sudie E Back
Affiliation: Department of Clinical Psychology & Center of Alcohol & Substance Use Studies, Graduate School of Applied and Professional Psychology
Abstract: Opioid use disorder (OUD) and posttraumatic stress disorder (PTSD) highly co-occur. There are no behavioral treatments designed for this specific comorbidity or designed to be paired with medications for OUD. This study pilot tested Helping Opioid Use with Exposure (HOPE), a behavioral treatment adapted from Concurrent Treatment for PTSD and Substance Use Disorders Using Prolonged Exposure, among N=6 individuals with OUD/PTSD and stabilized on medications for OUD. HOPE was delivered weekly for 10-12 sessions and follow-up outcomes were assessed 2-4 weeks later. Primary outcomes include weekly measures of: PTSD symptoms, substance use (self-reported and biospecimens), and client satisfaction.

Title: Associations Among Individual Mental Health Concerns and Intimate Relationship Adjustment in Veterans of the Wars in Afghanistan and Iraq
Author: Azubuike
Highlights: PTSD, veterans, depression, alcohol, relationship adjustment

Title: Changes in Trauma-related Cognitions During Therapeuatic and Natural Recovery for Recent Sexual Assault Survivors
Authors: Beth Lehinger, Molly Joseph, Antoine Lebeaut, Debra Kaysen, & Michele Bedard-Gilligan
Affiliation: Department of Psychiatry and Behavioral Sciences，University of Washington
Abstract: Almost 30% of women will experience a sexual assault during their time in college (Mellins et al., 2017), increasing risk for both PTSD and alcohol misuse (Dworkin et al., 2017). Interventions delivered in the initial weeks following assault are effective at decreasing the development of long-term reactions (Dworkin et al., 2018). Cognitive therapies teach strategies to shift unhelpful trauma-related thinking patterns, which then leads to change in associated emotions, distress, and behaviors (Resick et al., 2016). Thus, trauma-related beliefs are a potentially important mechanism of recovery for PTSD and other trauma related disorders, but little is known about how trauma-related cognitions change in the early aftermath of a sexual assault. In this study, we explored trajectories of trauma-related cognitions in a sample of 57 female identifying participants who experienced a sexual assault in the last 10 weeks, met criteria for PTSD and high risk drinking, and were enrolled in an RCT comparing a single session + 4 coaching call cognitive intervention to symptom monitoring only (Bedard-Gilligan et al., 2021; Bedard-Gilligan et al, under review). Cognitions, assessed using Posttraumatic Cognitions Inventory (PTCI; Foa et al., 1999), PTSD, and alcohol use were assessed at baseline, weekly for five weeks and at 3-month follow-up. Preliminary analyses showed that negative trauma-related beliefs showed a steeper decrease over time for participants receiving the intervention compared to symptom monitoring only (p < .001). In addition, trauma-related cognitions showed strong (r = .71) relationships with PTSD symptoms, and a small to moderate relationship with heavy drinking (r = .23) across all timepoints. Additional analyses will look specifically at PTCI subscales (world, self, self-blame) and will further examine the relationships between changes in PTCI scores and prediction of 3 month outcomes (PTSD, alcohol use) for both therapeutic and natural recovery groups. Findings of this study can help further understand the importance of addressing maladaptive cognitive patterns in the early aftermath of a sexual assault and can help us understand the role cognitions play in both PTSD and alcohol misuse following sexual assault.

Title: Examination of Provider Perspectives of an Efficient, Exposure-based Integrated Intervention for PTSD and Substance Use Tailored to Recent Sexual Assault Survivors
Authors: Christine Hahn, Emily Tilstra-Ferrell, Angela Moreland, Kathleen Brady, Sudie Back
Affiliation: Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
Abstract: Despite the high co-occurrence of posttraumatic stress disorder (PTSD) and substance use (SU) among sexual assault (SA) survivors, there is a dearth of evidence-based integrated treatment options tailored for this population. The current study examined provider perceptions and suggestions for refining Skills Training and Exposure for PTSD and Substance Misuse (STEPS), an efficient, 5-session integrated intervention tailored for SA survivors. Thematic analyses of data collected during four focus groups with providers across diverse settings (SA, PTSD, and SU service providers; n=27) indicated strengths, potential barriers, implementation considerations, and suggested content/adaptations when developing integrated interventions for PTSD-SU tailored to SA survivors.

Title: Differential effects of hazardous drinking on posttraumatic stress disorder outcomes across two prolonged exposure treatment formats
Author: Straud
Highlights: *Data collection is complete but not analyzed. Highlights are listed as hypotheses. -Are there differences in PTSD response between nonhazardous and hazardous drinkers engaged in PE? -Does drinking improve following PE for PTSD among hazardous drinkers? -Is there a differential effect between two PE formats on PTSD and drinking?

Title: Treating Racial Trauma: Methodology of a randomized controlled trial of the Racial Stress and Trauma Treatment Protocol
Authors: Monnica Williams; Muna Osman; Sophia Gran-Ruaz
Affiliation: University of Ottawa
Abstract: Cumulative experiences of racism lead to stress and trauma. Racial trauma is associated with compromised functioning across psychological, social, and physical health domains. This is further complicated by any comorbidity with other mental health conditions. Many clinicians are not trained in identifying, diagnosing, and treating racial trauma. Given the pervasive nature of racism, limited clinician knowledge and experiences, as well as the impact of this condition, there is an urgent need for an effective treatment. The newly developed Racial Stress and Trauma Treatment Protocol (RSTTP) shows significant promise. This manuscript describes the methodology of an innovation randomized controlled trial to compare the efficacy of the RSTTP for Black individuals suffering from racial trauma compared to a control treatment-as-usual condition in reducing the severity of racial trauma and depression symptoms, as well as improved functioning. Methodological considerations in trial design, research population, and treatment protocol are explored.

Title: Examining longitudinal within- and between-person risk and strength-based factors associated with depression symptoms among sexual minority men (SMM) using multilevel modeling
Authors: Yusuf Ghauri; Graham Berlin; Shayna Skakoon-Sparling; Adhm Zahran; Allison Kirschbaum; David J. Brennan; Barry Adam; Trevor A. Hart
Affiliation: Toronto Metropolitan University
Abstract: SMM have elevated rates of childhood abuse, discrimination, and depression symptoms. Integrating a risk and strength-based approach, we examined predictors of depression symptoms among SMM across three time points, disaggregating between- and within-person effects of minority stressors (internalized homonegativity, heterosexist discrimination) and strength-based factors (hope, self-esteem, social support) using multilevel modeling. Stressors were associated with greater depression symptoms whereas strength-based factors were associated with lesser depression symptoms. Social support buffered against the harmful effects of discrimination. Our findings highlight within-person factors associated with depression and represent potential targets of psychosocial interventions, which affect change at the within-person level.

Title: Integrating Cognitive Processing Therapy and Relapse Prevention for Adults with Co-occurring PTSD and Alcohol Use Disorder: Treatment Overview and Case Series
Authors: Anka A. Vujanovic; Amber M. Jarnecke; Fiorela Ruiz; Kayla Hall; Kat Roberts; Sudie E. Back
Affiliation: Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
Abstract: Alcohol use disorder (AUD) commonly co-occurs with posttraumatic stress disorder (PTSD) and this complex comorbidity is challenging to treat. Trauma-focused treatment delivered alongside evidence-based treatment for AUD is recommended for treating co-occurring PTSD/AUD. While one integrated trauma-focused treatment with a strong evidence base currently exists for PTSD/AUD, it uses prolonged exposure therapy to address the PTSD and may not be appropriate for all patients (e.g., those with insufficient memory of the trauma). Additional integrated, trauma-focused treatments are needed to effectively address the complex needs of individuals with PTSD/AUD. Cognitive processing therapy (CPT) is a leading evidence-based cognitive-behavioral treatment for PTSD that shows strong preliminary evidence for effectively treating PTSD when it co-occurs with AUD; however, CPT is designed to target PTSD symptoms and not AUD symptoms. Thus, adapting CPT to address co-occurring AUD in an integrated fashion is needed and may represent an additional treatment option for diverse patient needs. The current study presents a brief overview of a novel, integrated trauma-focused treatment that combines CPT with relapse prevention (RP) for AUD (i.e., CPT-RP) in 12, 90-minute individual sessions. A multi-site randomized clinical trial is ongoing. We present a case series of N = 4 patients (n = 3 women, n = 1 man; Mage = 42.75, SD = 20.16) with comorbid PTSD/AUD who completed this new treatment. The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5) were used to assess PTSD symptoms; the Timeline Follow-back (TLFB) assessed amount and frequency of drinking (e.g., percent days drinking, PDD); and the Patient Health Questionnaire-9 (PHQ-9) measured depressive symptoms. Difference scores were calculated to examine change in symptoms or alcohol use from pre- (i.e., baseline assessment) to post-treatment (i.e., session 12). The Client Satisfaction Questionnaire assessed acceptability of the CPT-RP treatment. The results demonstrate that participants evidenced pre- to post-treatment reductions in PTSD symptoms (ΔMCAPS-5 = 10.00, SD = 12.83; ΔMPCL-5 = 21.25, SD = 12.26), frequency of alcohol use (ΔMPDD = 37.92, SD = 6.29), and depressive symptoms (ΔMPHQ-9 = 5.50, SD = 5.45). All participants decreased their drinking frequency. Based on previously established criteria, two of the four participants met for clinically significant change in PTSD symptoms on the CAPS-5 and three of four participants met criteria for clinically significant change in PTSD symptoms on the PCL-5. Two of four participants met criteria for clinically significant change in depressive symptoms on the PHQ-9. Further, CPT-RP demonstrated high acceptability ratings across participants (MCSQ = 31.75, SD = 0.50). Overall, the preliminary findings suggest that CPT-RP may be an effective and promising new behavioral treatment for co-occurring PTSD and AUD.

Title: An Initial Examination of Couple Therapy for PTSD Outcomes Among Black/African Americans: Findings from an Uncontrolled Trial with Military Dyads
Authors: Steffany J. Fredman; Alyssa A. Gamaldo; August I. C. Jenkins; Brittany N. Hall-Clark; Yunying Le; Jacqueline A. Mogle; Candice M. Monson; Charlene E. Gamaldo; Roland J. Thorpe, Jr.; Tabatha H. Bloun
Affiliation: Human Development and Family Studies - HDFS
Abstract: Black/African Americans experience high rates of posttraumatic stress disorder (PTSD), which is frequently chronic and undertreated in this population. Intimate relationships are a salient resource for Black/African Americans’ psychological well-being. As part of efforts to advance health equity, this study serves as an initial, proof-of-concept investigation of patient outcomes among Black/African American adults who received a disorder-specific couple therapy for PTSD. Participants were a subsample of seven Black/African American adults (mean age = 40.56 years, SD = 10.18; 85.7% male) who participated in an uncontrolled trial of an abbreviated, intensive, multi-couple group version of cognitive-behavioral conjoint therapy for PTSD with 24 military dyads. Treatment was delivered over 2 days in a weekend retreat format. Assessments were administered at baseline, 1-month postretreat, and 3 months postretreat. There were large and significant decreases in patients’ PTSD symptoms based on clinicians’ and patients’ ratings (ds -1.37 and -1.36, respectively) by 3-month follow-up relative to baseline. There were also large and significant decreases in patients’ self-reported depressive, anxiety, and anger symptoms (ds -1.39 to -1.93), as well as large, nonsignificant decreases in patients’ self-reported insomnia (d = -0.85; p = .083). Patients reported moderate, nonsignificant increases in relationship satisfaction (d = 0.68; p = .146) and large, nonsignificant increases in joint dyadic coping (d = 0.90; p = .069). Findings offer preliminary evidence that treating PTSD within a couple context is a relevant strategy to reduce PTSD and comorbid symptoms among partnered Black/African Americans and a promising approach to enhance relationships.

Title: Overcoming Implementation Barriers of Concurrent Treatment for Eating Disorders and Posttraumatic Stress Disorder: Two Novel and Feasible Approaches
Authors: Kathryn Trottier
Affiliation: University Health Network Department of Psychiatry Toronto, Canada
Abstract: Eating disorders (ED) and posttraumatic stress disorder (PTSD) frequently co-occur and share a functional relationship. Evidence suggests benefits of integrated/concurrent treatment; however, implementation is hindered by clinician training burden and challenges of delivering two treatments simultaneously. This paper explores two novel and feasible approaches to addressing ED-PTSD. The first involves a clinician-guided workbook delivered during ED treatment. It involves psychoeducation, addresses dissociation, and encourages approach (versus avoidance) practices. The second involves integrating Written Exposure Therapy and Cognitive-Behavioral Therapy-Ten for ED. Both approaches have a low training burden and are feasible in routine clinical practice making concurrent treatment available to those who need it.