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Edna B Foa

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Papers by Edna B Foa

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

Behaviour research and therapy, 2016

The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV c... more The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model). Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout. Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted high...

Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members

Behaviour Research and Therapy, 2019

Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem.... more Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem. We reported rates and predictors of attendance and dropout in three clinical trials of evidence-based PTSD treatments in military service members (N = 557). Service members attended 81.0% of treatment sessions and 30.7% dropped out. Individually delivered treatment was associated with greater attendance rates (β = 0.23, p < .001) than group therapy; trauma-focused treatments were associated with higher dropout (β = 0.19, p < .001) than Present-Centered Therapy. Age was a significant predictor of session attendance (β = 0.17, p < .001) and drop out (β = −0.23, p < .001). History of traumatic brain injury (TBI) predicted lower attendance rates (β = −0.26, p < .001) and greater dropout (β = 0.19, p < .001). Regardless of treatment type or format, patients who did not drop out were more likely to experience clinically significant gains (d = 0.49, p < .001). Results demonstrate that dropout from PTSD treatments in these trials was significantly associated with treatment outcome and suggest that strategies are needed to mitigate dropout, particularly in group and traumafocused therapies, and among younger service members and those with TBI.

Motivation to Participate in PTSD Research-Reply

JAMA, Jun 19, 2018

Author Contributions: Drs Kitchlu and Harel had full access to all of the data in the study and t... more Author Contributions: Drs Kitchlu and Harel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kitchlu, Shapiro, Wald, Harel. Acquisition, analysis, or interpretation of data: Kitchlu, Shapiro, Amir, Garg, Kim, Harel. Drafting of the manuscript: Kitchlu, Amir, Wald, Harel. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kitchlu. Obtained funding: Wald. Administrative, technical, or material support: Kitchlu, Wald. Supervision: Kim, Wald, Harel.

Women's self-perceptions in the aftermath of trauma: The role of trauma-centrality and trauma-type

Psychological trauma : theory, research, practice and policy, Jan 16, 2018

Traumatic events tend to play a major role in the way we perceive ourselves. Whereas the links be... more Traumatic events tend to play a major role in the way we perceive ourselves. Whereas the links between posttraumatic stress disorder (PTSD) and self-perceptions are well examined, less is known regarding other factors that may be involved in the erosion of self-perceptions. We sought to examine the contribution of trauma-centrality and trauma-type to the erosion of self-perceptions following trauma. Our hypotheses were (a) trauma-centrality is significantly related to impairments in self-perceptions, (b) sexual assault (SA) is related to greater erosion in self-perceptions compared with motor vehicle accident (MVA) and to unexpected death (bereavement), and (c) the effects of trauma-centrality and trauma-type on self-perceptions remain significant when statistically controlling for levels of PTSD symptoms. Adult American women ( = 108: SA = 48, MVA = 38, bereavement = 22) were recruited via online labor market and completed self-report measures of trauma history, PTSD symptoms, trau...

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

JAMA, Jan 23, 2018

Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active du... more Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Outcomes were...

Implementation of Prolonged Exposure in the Army: Is Consultation Necessary for Effective Dissemination?

Public reporting burden for this collection of information is estimated to average 1 hour per res... more Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

Psychiatric Symptoms and Barriers to Care in HIV-Infected Individuals Who Are Lost to Care

Journal of the International Association of Providers of AIDS Care, 2017

Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and ... more Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and few have assessed barriers to care among people living with HIV (PLWH) who are lost to care (LTC). We examined psychiatric symptoms, barriers to HIV care, and immune functioning in PLWH who were retained in care (RIC; n = 21) or LTC (n = 21). Participants completed diagnostic interviews for posttraumatic stress disorder (PTSD) and other psychiatric disorders, self-report measures of HIV risk behaviors and psychiatric symptoms, and a blood draw to assess viral load. Compared to RIC participants, LTC participants met criteria for a greater number of psychiatric disorders and reported greater depressive symptoms and more barriers to HIV care. There were no group differences in PTSD severity, risk behaviors, or viral load, suggesting that LTC individuals experience greater psychiatric problems and perceive more barriers to care than RIC participants, but are not less likely to have achieved ...

Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder

Journal of affective disorders, Jan 15, 2017

Given the alarming rate of military suicides, it is critical to identify the factors that increas... more Given the alarming rate of military suicides, it is critical to identify the factors that increase risk of suicidal thoughts and behaviors among active duty military personnel. This study examined a predictive model of suicidal ideation among 366 treatment-seeking active duty military personnel with posttraumatic stress disorder (PTSD) following deployments to or near Iraq or Afghanistan. Structural equation modeling was employed to examine the relative contribution of combat exposure, social support, PTSD severity, depressive symptoms, guilt, and trauma-related cognitions on suicidal ideation. The final structural equation model had a highly satisfactory fit [χ(2) (2) =2.023, p=.364; RMSEA =.006; CFI =1; GFI =.998]. PTSD severity had an indirect effect on suicidal ideation via trauma-related cognitions. Depression had a direct positive effect on suicidal ideation; it also had an indirect effect via trauma-related cognitions and interpersonal support. Among participants who had made...

The impact of social support, unit cohesion, and trait resilience on PTSD in treatment-seeking military personnel with PTSD: The role of posttraumatic cognitions

Journal of Psychiatric Research, 2017

Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome

Journal of Consulting and Clinical Psychology, 2016

Objective-The present study examined predictors and moderators of treatment response among 165 ad... more Objective-The present study examined predictors and moderators of treatment response among 165 adults meeting DSM-IV criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD) who were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use. Method-Six domains of predictors/moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview; PSS-I) and AD (percent days drinking from the Timeline Follow-Back Interview) collected every four weeks throughout treatment. Multi-level modeling using the Fournier approach was employed to evaluate predictors and moderators of rates of symptom improvement and post-treatment outcomes. Results-Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, white race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of alcohol dependence. Conclusions-These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified subgroups of PTSD-AD patients.

Mechanisms of symptom reduction in a combined treatment for comorbid posttraumatic stress disorder and alcohol dependence

Journal of Consulting and Clinical Psychology, 2015

Objective-To examine the mechanisms of prolonged exposure (PE) and naltrexone (NAL) that underlie... more Objective-To examine the mechanisms of prolonged exposure (PE) and naltrexone (NAL) that underlie symptom reduction among individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). We hypothesized that: 1) reduction in negative cognitions mediates PTSD improvement during PE; and 2) reduction in alcohol craving mediates reduction in drinking frequency during NAL treatment; and (3) PTSD improvement mediates reduction in craving and alcohol use during PE. Method-Participants were 159 individuals meeting the DSM-IV diagnosis of PTSD and AD randomly assigned to one of four conditions: PE+NAL, PE+placebo (PBO), supportive counseling (SC)+NAL; and SC+PBO. All participants received supportive counseling. Results-Lagged multilevel mediational analyses indicated that: 1) a reciprocal relationship between cognitive change and PTSD improvement was observed in PE+NAL, PE+PBO, and SC +NAL but not in SC+PBO; 2) reduction in craving significantly mediated subsequent decrease in alcohol use in PE+NAL and SC+PBO, but not in PE+PBO and SC+NAL; and 3) PTSD improvement significantly mediated subsequent reduction of craving in PE+PBO, and mediated decrease in alcohol use in PE+NAL. Conclusions-The efficacy of combining PE and NAL for reducing alcohol use among those with comorbid PTSD/AD seems to be through reduction in both PTSD symptoms and craving. These findings shed light on the mechanism of PE and highlight the central role of PTSD in the maintenance of alcohol craving and use in patients with comorbid PTSD/AD.

Prolonged Exposure Therapy

Evidence Based Treatments for Trauma-Related Psychological Disorders, 2015

This is an incredible opportunity to undertake a four-day training in Prolonged Exposure (PE) the... more This is an incredible opportunity to undertake a four-day training in Prolonged Exposure (PE) therapy for PTSD from the international leader in this NICE recommended treatment. There is no other trainer in the world with higher credentials to teach this therapy. The efficacy and effectiveness of PE was investigated in over 30 random control trials, and up to 80 % of patients get significant reduction in PTSD symptoms. Participants will learn how to conduct the PE components via clear instructions, DVDs demonstrations and role-plays. Participants will also learn how to conduct therapy with the most difficult-to-treat cases, and how to overcome the problems that pull therapy off track. Places are restricted to only 50 so that every person gets a chance to learn the techniques thoroughly. Professor Foa of the University of Pennsylvania was named as one of TIME magazine's 100 most influential thinkers in 2010 and is the recipient of many awards including a Lifetime Achievement Award from the International Society for Traumatic Stress Studies, and from the Association of Behavioural and Cognitive Therapies. She is making a rare visit to the UK in 2015 and delegates are encouraged to book early for one of the limited places available.

Resilient but addicted: The impact of resilience on the relationship between smoking withdrawal and PTSD

Journal of psychiatric research, Jan 4, 2015

Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which ... more Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which is reflected in one's ability to cope with stress, has been shown to be associated with lower cigarette smoking and posttraumatic stress symptoms, but relationships among these three variables have not been examined. This study investigates the relationships of resilience and nicotine withdrawal with each other and in relation to PTSD symptoms. Participants were 118 cigarette smokers with PTSD seeking treatment for PTSD and nicotine use. Data were randomly cross-sectionally sampled from three time points: week 0, week 12, and week 27 of the study. Hierarchical multiple regression analyses revealed main effects of both resilience and nicotine withdrawal symptoms on PTSD severity, controlling for the sampled time point, negative affect, and expired carbon monoxide concentration. Consistent with prior research, PTSD severity was higher among individuals who were less resilient and for t...

Changes in PTSD and Depression During Prolonged Exposure and Client-Centered Therapy for PTSD in Adolescents

Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, Jan 9, 2015

Depressive symptoms are common among individuals with posttraumatic stress disorder (PTSD). Prolo... more Depressive symptoms are common among individuals with posttraumatic stress disorder (PTSD). Prolonged exposure therapy (PE) for PTSD has been found to alleviate both PTSD and depressive symptoms, but relatively little is known about the pattern of PTSD and depressive symptom change during treatment. This study aimed to investigate the relationship between changes in PTSD and depression during PE for adolescent (PE-A) and client-centered therapy (CCT). The moderating role of PE-A versus CCT and the possible differences across symptom clusters of PTSD were also examined. Participants were 61 female adolescents with sexual-assault-related PTSD randomized to PE-A (n = 31) or CCT (n = 30). Participants completed the Beck Depression Inventory and the Child PTSD Symptom Scale at pre-, mid-, and posttreatment and before each treatment session. Multilevel mediation analysis indicated a reciprocal but asymmetrical relationship between changes in PTSD and depression during treatment in the ove...

Change in obsessive-compulsive symptoms mediates subsequent change in depressive symptoms during exposure and response prevention

Behaviour Research and Therapy, 2015

Objective-The current study examines the temporal relationship between changes in obsessivecompul... more Objective-The current study examines the temporal relationship between changes in obsessivecompulsive symptoms and changes in depressive symptoms during exposure and response prevention (EX/RP) therapy for obsessive-compulsive disorder (OCD). Method-Participants were 40 adults (53% female) who received EX/RP in a randomized controlled trial comparing serotonin reuptake inhibitor (SRI) augmentation strategies. Participants completed clinician-administered assessments of OCD (Yale Brown Obsessive Compulsive Scale) and depressive symptoms (Hamilton Depression Rating Scale) every four weeks from baseline to 32-week follow-up. Results-Lagged multilevel mediational analyses indicated that change in OCD symptoms accounted for 65% of subsequent change in depressive symptoms. In contrast, change in depressive symptoms only partially mediated subsequent change in OCD symptoms, accounting for 20% of the variance in outcome. Conclusions-These data indicate that reductions in co-morbid depressive symptoms during EX/RP for OCD are largely driven by reductions in obsessive compulsive symptoms.

Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents

Behaviour Research and Therapy, 2015

Objective-To assess whether changes in negative trauma-related cognitions play an important role ... more Objective-To assess whether changes in negative trauma-related cognitions play an important role in reducing symptoms of posttraumatic stress disorder (PTSD) and depression during prolonged exposure therapy for adolescents (PE-A). Method-Secondary analysis of data from a randomized controlled trial comparing PEA with client-centered therapy (CCT) for PTSD. Participants were 61 adolescent female sexual assault survivors ages 13-18 who received 8-14 weekly sessions of PEA or CCT at a community rape crisis center. PTSD severity was assessed at baseline, mid-treatment, post-treatment, and 3-months post-treatment. Participants also completed self-report measures of negative posttraumatic cognitions and depressive symptoms at the same assessment points. Results-Cross lag panel mediation analyses showed that change in negative trauma-related cognitions mediated change in PTSD symptoms and depressive symptoms whereas change in PTSD and depressive symptoms did not mediate change in negative cognitions. Conclusion-Our findings support EPT and suggest that change in negative trauma-related cognitions is a mechanism of both PEA and CCT.

Six-Month Outcomes From a Randomized Trial Augmenting Serotonin Reuptake Inhibitors With Exposure and Response Prevention or Risperidone in Adults With Obsessive-Compulsive Disorder

The Journal of Clinical Psychiatry, 2014

Objective-To compare outcomes after six-month maintenance treatment of adults diagnosed with OCD ... more Objective-To compare outcomes after six-month maintenance treatment of adults diagnosed with OCD based on DSM IV criteria who responded to acute treatment with serotonin reuptake inhibitors (SRIs) augmented by exposure therapy (EX/RP) or risperidone. Method-A randomized trial was conducted at two academic sites from October 2006 through December 2012. In the Acute Phase, 100 patients on therapeutic SRI dose with at least moderate OCD severity were randomized to 8 weeks of EX/RP, risperidone, or pill placebo. Responders

Trauma Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of Childhood Sexual Abuse

Journal of Family Violence, 2014

This study examined the relationship between the characteristics of childhood sexual abuse (CSA) ... more This study examined the relationship between the characteristics of childhood sexual abuse (CSA) and the severity of consequent posttraumatic stress disorder (PTSD), depression, suicidal ideation, and substance use in a sample of 83 female adolescents aged 13-18 years seeking treatment for PTSD. Nearly two-thirds of the sample (60.7%, n = 51) reported the perpetrator of the CSA was a relative. A large portion (40.5%, n = 34) of the sample reported being victimized once, while almost a quarter of the sample reported chronic victimization (23.8%, n = 20). PTSD and depression scores were in the clinical range, whereas reported levels of suicidal ideation and substance use were low. The frequency of victimizations was associated with suicidal ideation. Contrary to expectation, CSA characteristics including trauma type, perpetrator relationship, and duration of abuse were unrelated to PTSD severity, depressive symptoms, or substance abuse. Keywords childhood sexual abuse; posttraumatic stress disorder; adolescent mental health Child sexual abuse (CSA) is defined as any forced or coerced sexual activity with a minor including noncontact abuse, sexual molestation, and rape (American Psychological Association, 2012). CSA is a serious public health problem that affects a substantial number of children in the United States each year. In the most comprehensive study of child abuse to date, the Fourth National Incidence Study of Child Abuse and Neglect, it was estimated that 135,300 children are sexually abused each year (National Center on Child Abuse and Neglect, 2010). Because many incidences of CSA are not reported, the actual incidence is thought to be significantly larger than this estimated figure (Watkins & Bentovim, 1992). The possible negative consequences of CSA are numerous. CSA has been identified as a risk factor for several mental health problems during adolescence including depression (e.g., Buzi, 2007), suicidality (e.g., Brent et al., 2002), low self-esteem (e.g.

Prolonged Exposure Versus Dynamic Therapy for Adolescent PTSD: A Pilot Randomized Controlled Trial

Journal of the American Academy of Child & Adolescent Psychiatry, 2010

Objective-To examine the efficacy and maintenance of developmentally adapted prolonged Exposure (... more Objective-To examine the efficacy and maintenance of developmentally adapted prolonged Exposure (PE-A) compared to active control Time Limited Dynamic Therapy (TLDP-A) for reducing post-traumatic and depressive symptoms in adolescent victims of single event traumas. Method-38 adolescents (age 12-18) were randomly assigned to receive either PEA or TLDP-A. Results-Both treatments resulted in decreased post-traumatic stress disorder and depression, and increased functioning. PEA exhibited greater reduction of PTSD and depression symptom severity, and greater increase in global functioning than did TDLP-A. At post-treatment, 68.4% of adolescents beginning treatment with PEA and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for PTSD. Treatment gains were maintained at 6 and 17 months follow-up.

Direction of influence between posttraumatic and depressive symptoms during prolonged exposure therapy among children and adolescents

Journal of Consulting and Clinical Psychology, 2011

Objective-The objective of the present study was to examine the temporal sequencing of posttrauma... more Objective-The objective of the present study was to examine the temporal sequencing of posttraumatic and depressive symptoms during prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) among children and adolescents. Method-Participants were 73 children and adolescents (56.2% female) between the ages of 8 and 18. Participants completed self report measures of posttraumatic stress and depression prior to every session. Measures included the Child PTSD Symptom Scale (CPSS), Beck Depression Inventory (BDI), and Children's Depression Inventory (CDI). Results-Multilevel mediational analyses indicated reciprocal relations during treatment: changes in posttraumatic symptoms led to changes in depressive symptoms and vice versa. Posttraumatic symptoms accounted for 64.1% of the changes in depression, whereas depressive symptoms accounted for 11.0% of the changes in posttraumatic stress. Conclusions-PE may work primarily by reducing posttraumatic stress which in turn reduces depression.

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

Behaviour research and therapy, 2016

The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV c... more The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model). Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout. Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted high...

Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members

Behaviour Research and Therapy, 2019

Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem.... more Dropout from first-line posttraumatic stress disorder (PTSD) treatments is a significant problem. We reported rates and predictors of attendance and dropout in three clinical trials of evidence-based PTSD treatments in military service members (N = 557). Service members attended 81.0% of treatment sessions and 30.7% dropped out. Individually delivered treatment was associated with greater attendance rates (β = 0.23, p < .001) than group therapy; trauma-focused treatments were associated with higher dropout (β = 0.19, p < .001) than Present-Centered Therapy. Age was a significant predictor of session attendance (β = 0.17, p < .001) and drop out (β = −0.23, p < .001). History of traumatic brain injury (TBI) predicted lower attendance rates (β = −0.26, p < .001) and greater dropout (β = 0.19, p < .001). Regardless of treatment type or format, patients who did not drop out were more likely to experience clinically significant gains (d = 0.49, p < .001). Results demonstrate that dropout from PTSD treatments in these trials was significantly associated with treatment outcome and suggest that strategies are needed to mitigate dropout, particularly in group and traumafocused therapies, and among younger service members and those with TBI.

Motivation to Participate in PTSD Research-Reply

JAMA, Jun 19, 2018

Author Contributions: Drs Kitchlu and Harel had full access to all of the data in the study and t... more Author Contributions: Drs Kitchlu and Harel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kitchlu, Shapiro, Wald, Harel. Acquisition, analysis, or interpretation of data: Kitchlu, Shapiro, Amir, Garg, Kim, Harel. Drafting of the manuscript: Kitchlu, Amir, Wald, Harel. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kitchlu. Obtained funding: Wald. Administrative, technical, or material support: Kitchlu, Wald. Supervision: Kim, Wald, Harel.

Women's self-perceptions in the aftermath of trauma: The role of trauma-centrality and trauma-type

Psychological trauma : theory, research, practice and policy, Jan 16, 2018

Traumatic events tend to play a major role in the way we perceive ourselves. Whereas the links be... more Traumatic events tend to play a major role in the way we perceive ourselves. Whereas the links between posttraumatic stress disorder (PTSD) and self-perceptions are well examined, less is known regarding other factors that may be involved in the erosion of self-perceptions. We sought to examine the contribution of trauma-centrality and trauma-type to the erosion of self-perceptions following trauma. Our hypotheses were (a) trauma-centrality is significantly related to impairments in self-perceptions, (b) sexual assault (SA) is related to greater erosion in self-perceptions compared with motor vehicle accident (MVA) and to unexpected death (bereavement), and (c) the effects of trauma-centrality and trauma-type on self-perceptions remain significant when statistically controlling for levels of PTSD symptoms. Adult American women ( = 108: SA = 48, MVA = 38, bereavement = 22) were recruited via online labor market and completed self-report measures of trauma history, PTSD symptoms, trau...

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

JAMA, Jan 23, 2018

Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active du... more Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Outcomes were...

Implementation of Prolonged Exposure in the Army: Is Consultation Necessary for Effective Dissemination?

Public reporting burden for this collection of information is estimated to average 1 hour per res... more Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing this collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

Psychiatric Symptoms and Barriers to Care in HIV-Infected Individuals Who Are Lost to Care

Journal of the International Association of Providers of AIDS Care, 2017

Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and ... more Past studies of barriers to HIV care have not comprehensively assessed psychiatric symptoms, and few have assessed barriers to care among people living with HIV (PLWH) who are lost to care (LTC). We examined psychiatric symptoms, barriers to HIV care, and immune functioning in PLWH who were retained in care (RIC; n = 21) or LTC (n = 21). Participants completed diagnostic interviews for posttraumatic stress disorder (PTSD) and other psychiatric disorders, self-report measures of HIV risk behaviors and psychiatric symptoms, and a blood draw to assess viral load. Compared to RIC participants, LTC participants met criteria for a greater number of psychiatric disorders and reported greater depressive symptoms and more barriers to HIV care. There were no group differences in PTSD severity, risk behaviors, or viral load, suggesting that LTC individuals experience greater psychiatric problems and perceive more barriers to care than RIC participants, but are not less likely to have achieved ...

Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder

Journal of affective disorders, Jan 15, 2017

Given the alarming rate of military suicides, it is critical to identify the factors that increas... more Given the alarming rate of military suicides, it is critical to identify the factors that increase risk of suicidal thoughts and behaviors among active duty military personnel. This study examined a predictive model of suicidal ideation among 366 treatment-seeking active duty military personnel with posttraumatic stress disorder (PTSD) following deployments to or near Iraq or Afghanistan. Structural equation modeling was employed to examine the relative contribution of combat exposure, social support, PTSD severity, depressive symptoms, guilt, and trauma-related cognitions on suicidal ideation. The final structural equation model had a highly satisfactory fit [χ(2) (2) =2.023, p=.364; RMSEA =.006; CFI =1; GFI =.998]. PTSD severity had an indirect effect on suicidal ideation via trauma-related cognitions. Depression had a direct positive effect on suicidal ideation; it also had an indirect effect via trauma-related cognitions and interpersonal support. Among participants who had made...

The impact of social support, unit cohesion, and trait resilience on PTSD in treatment-seeking military personnel with PTSD: The role of posttraumatic cognitions

Journal of Psychiatric Research, 2017

Concurrent treatment of posttraumatic stress disorder and alcohol dependence: Predictors and moderators of outcome

Journal of Consulting and Clinical Psychology, 2016

Objective-The present study examined predictors and moderators of treatment response among 165 ad... more Objective-The present study examined predictors and moderators of treatment response among 165 adults meeting DSM-IV criteria for comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD) who were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive counseling for alcohol use. Method-Six domains of predictors/moderators (23 variables) were evaluated using measures of PTSD (Posttraumatic Stress Symptom Scale Interview; PSS-I) and AD (percent days drinking from the Timeline Follow-Back Interview) collected every four weeks throughout treatment. Multi-level modeling using the Fournier approach was employed to evaluate predictors and moderators of rates of symptom improvement and post-treatment outcomes. Results-Combat trauma, sexual assault trauma, and higher baseline anxiety sensitivity predicted slower improvement and poorer PTSD outcome. Combat trauma, white race, and higher baseline drinking severity predicted poorer drinking outcome. PTSD severity moderated the efficacy of PE on PTSD outcomes, such that the benefit of PE over no-PE was greater for participants with higher baseline PTSD severity. Baseline depressive severity moderated the efficacy of PE on drinking outcomes, whereby the benefit of PE over no-PE was greater for participants with higher depressive symptoms. NAL effects were most beneficial for those with the longest duration of alcohol dependence. Conclusions-These results suggest that concurrent, trauma-focused treatment should be recommended for PTSD-AD patients who present with moderate or severe baseline PTSD and depressive symptoms. Future research should examine the mechanisms underlying poorer outcome among identified subgroups of PTSD-AD patients.

Mechanisms of symptom reduction in a combined treatment for comorbid posttraumatic stress disorder and alcohol dependence

Journal of Consulting and Clinical Psychology, 2015

Objective-To examine the mechanisms of prolonged exposure (PE) and naltrexone (NAL) that underlie... more Objective-To examine the mechanisms of prolonged exposure (PE) and naltrexone (NAL) that underlie symptom reduction among individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD). We hypothesized that: 1) reduction in negative cognitions mediates PTSD improvement during PE; and 2) reduction in alcohol craving mediates reduction in drinking frequency during NAL treatment; and (3) PTSD improvement mediates reduction in craving and alcohol use during PE. Method-Participants were 159 individuals meeting the DSM-IV diagnosis of PTSD and AD randomly assigned to one of four conditions: PE+NAL, PE+placebo (PBO), supportive counseling (SC)+NAL; and SC+PBO. All participants received supportive counseling. Results-Lagged multilevel mediational analyses indicated that: 1) a reciprocal relationship between cognitive change and PTSD improvement was observed in PE+NAL, PE+PBO, and SC +NAL but not in SC+PBO; 2) reduction in craving significantly mediated subsequent decrease in alcohol use in PE+NAL and SC+PBO, but not in PE+PBO and SC+NAL; and 3) PTSD improvement significantly mediated subsequent reduction of craving in PE+PBO, and mediated decrease in alcohol use in PE+NAL. Conclusions-The efficacy of combining PE and NAL for reducing alcohol use among those with comorbid PTSD/AD seems to be through reduction in both PTSD symptoms and craving. These findings shed light on the mechanism of PE and highlight the central role of PTSD in the maintenance of alcohol craving and use in patients with comorbid PTSD/AD.

Prolonged Exposure Therapy

Evidence Based Treatments for Trauma-Related Psychological Disorders, 2015

This is an incredible opportunity to undertake a four-day training in Prolonged Exposure (PE) the... more This is an incredible opportunity to undertake a four-day training in Prolonged Exposure (PE) therapy for PTSD from the international leader in this NICE recommended treatment. There is no other trainer in the world with higher credentials to teach this therapy. The efficacy and effectiveness of PE was investigated in over 30 random control trials, and up to 80 % of patients get significant reduction in PTSD symptoms. Participants will learn how to conduct the PE components via clear instructions, DVDs demonstrations and role-plays. Participants will also learn how to conduct therapy with the most difficult-to-treat cases, and how to overcome the problems that pull therapy off track. Places are restricted to only 50 so that every person gets a chance to learn the techniques thoroughly. Professor Foa of the University of Pennsylvania was named as one of TIME magazine's 100 most influential thinkers in 2010 and is the recipient of many awards including a Lifetime Achievement Award from the International Society for Traumatic Stress Studies, and from the Association of Behavioural and Cognitive Therapies. She is making a rare visit to the UK in 2015 and delegates are encouraged to book early for one of the limited places available.

Resilient but addicted: The impact of resilience on the relationship between smoking withdrawal and PTSD

Journal of psychiatric research, Jan 4, 2015

Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which ... more Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which is reflected in one's ability to cope with stress, has been shown to be associated with lower cigarette smoking and posttraumatic stress symptoms, but relationships among these three variables have not been examined. This study investigates the relationships of resilience and nicotine withdrawal with each other and in relation to PTSD symptoms. Participants were 118 cigarette smokers with PTSD seeking treatment for PTSD and nicotine use. Data were randomly cross-sectionally sampled from three time points: week 0, week 12, and week 27 of the study. Hierarchical multiple regression analyses revealed main effects of both resilience and nicotine withdrawal symptoms on PTSD severity, controlling for the sampled time point, negative affect, and expired carbon monoxide concentration. Consistent with prior research, PTSD severity was higher among individuals who were less resilient and for t...

Changes in PTSD and Depression During Prolonged Exposure and Client-Centered Therapy for PTSD in Adolescents

Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, Jan 9, 2015

Depressive symptoms are common among individuals with posttraumatic stress disorder (PTSD). Prolo... more Depressive symptoms are common among individuals with posttraumatic stress disorder (PTSD). Prolonged exposure therapy (PE) for PTSD has been found to alleviate both PTSD and depressive symptoms, but relatively little is known about the pattern of PTSD and depressive symptom change during treatment. This study aimed to investigate the relationship between changes in PTSD and depression during PE for adolescent (PE-A) and client-centered therapy (CCT). The moderating role of PE-A versus CCT and the possible differences across symptom clusters of PTSD were also examined. Participants were 61 female adolescents with sexual-assault-related PTSD randomized to PE-A (n = 31) or CCT (n = 30). Participants completed the Beck Depression Inventory and the Child PTSD Symptom Scale at pre-, mid-, and posttreatment and before each treatment session. Multilevel mediation analysis indicated a reciprocal but asymmetrical relationship between changes in PTSD and depression during treatment in the ove...

Change in obsessive-compulsive symptoms mediates subsequent change in depressive symptoms during exposure and response prevention

Behaviour Research and Therapy, 2015

Objective-The current study examines the temporal relationship between changes in obsessivecompul... more Objective-The current study examines the temporal relationship between changes in obsessivecompulsive symptoms and changes in depressive symptoms during exposure and response prevention (EX/RP) therapy for obsessive-compulsive disorder (OCD). Method-Participants were 40 adults (53% female) who received EX/RP in a randomized controlled trial comparing serotonin reuptake inhibitor (SRI) augmentation strategies. Participants completed clinician-administered assessments of OCD (Yale Brown Obsessive Compulsive Scale) and depressive symptoms (Hamilton Depression Rating Scale) every four weeks from baseline to 32-week follow-up. Results-Lagged multilevel mediational analyses indicated that change in OCD symptoms accounted for 65% of subsequent change in depressive symptoms. In contrast, change in depressive symptoms only partially mediated subsequent change in OCD symptoms, accounting for 20% of the variance in outcome. Conclusions-These data indicate that reductions in co-morbid depressive symptoms during EX/RP for OCD are largely driven by reductions in obsessive compulsive symptoms.

Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents

Behaviour Research and Therapy, 2015

Objective-To assess whether changes in negative trauma-related cognitions play an important role ... more Objective-To assess whether changes in negative trauma-related cognitions play an important role in reducing symptoms of posttraumatic stress disorder (PTSD) and depression during prolonged exposure therapy for adolescents (PE-A). Method-Secondary analysis of data from a randomized controlled trial comparing PEA with client-centered therapy (CCT) for PTSD. Participants were 61 adolescent female sexual assault survivors ages 13-18 who received 8-14 weekly sessions of PEA or CCT at a community rape crisis center. PTSD severity was assessed at baseline, mid-treatment, post-treatment, and 3-months post-treatment. Participants also completed self-report measures of negative posttraumatic cognitions and depressive symptoms at the same assessment points. Results-Cross lag panel mediation analyses showed that change in negative trauma-related cognitions mediated change in PTSD symptoms and depressive symptoms whereas change in PTSD and depressive symptoms did not mediate change in negative cognitions. Conclusion-Our findings support EPT and suggest that change in negative trauma-related cognitions is a mechanism of both PEA and CCT.

Six-Month Outcomes From a Randomized Trial Augmenting Serotonin Reuptake Inhibitors With Exposure and Response Prevention or Risperidone in Adults With Obsessive-Compulsive Disorder

The Journal of Clinical Psychiatry, 2014

Objective-To compare outcomes after six-month maintenance treatment of adults diagnosed with OCD ... more Objective-To compare outcomes after six-month maintenance treatment of adults diagnosed with OCD based on DSM IV criteria who responded to acute treatment with serotonin reuptake inhibitors (SRIs) augmented by exposure therapy (EX/RP) or risperidone. Method-A randomized trial was conducted at two academic sites from October 2006 through December 2012. In the Acute Phase, 100 patients on therapeutic SRI dose with at least moderate OCD severity were randomized to 8 weeks of EX/RP, risperidone, or pill placebo. Responders

Trauma Characteristics and Posttraumatic Stress Disorder among Adolescent Survivors of Childhood Sexual Abuse

Journal of Family Violence, 2014

This study examined the relationship between the characteristics of childhood sexual abuse (CSA) ... more This study examined the relationship between the characteristics of childhood sexual abuse (CSA) and the severity of consequent posttraumatic stress disorder (PTSD), depression, suicidal ideation, and substance use in a sample of 83 female adolescents aged 13-18 years seeking treatment for PTSD. Nearly two-thirds of the sample (60.7%, n = 51) reported the perpetrator of the CSA was a relative. A large portion (40.5%, n = 34) of the sample reported being victimized once, while almost a quarter of the sample reported chronic victimization (23.8%, n = 20). PTSD and depression scores were in the clinical range, whereas reported levels of suicidal ideation and substance use were low. The frequency of victimizations was associated with suicidal ideation. Contrary to expectation, CSA characteristics including trauma type, perpetrator relationship, and duration of abuse were unrelated to PTSD severity, depressive symptoms, or substance abuse. Keywords childhood sexual abuse; posttraumatic stress disorder; adolescent mental health Child sexual abuse (CSA) is defined as any forced or coerced sexual activity with a minor including noncontact abuse, sexual molestation, and rape (American Psychological Association, 2012). CSA is a serious public health problem that affects a substantial number of children in the United States each year. In the most comprehensive study of child abuse to date, the Fourth National Incidence Study of Child Abuse and Neglect, it was estimated that 135,300 children are sexually abused each year (National Center on Child Abuse and Neglect, 2010). Because many incidences of CSA are not reported, the actual incidence is thought to be significantly larger than this estimated figure (Watkins & Bentovim, 1992). The possible negative consequences of CSA are numerous. CSA has been identified as a risk factor for several mental health problems during adolescence including depression (e.g., Buzi, 2007), suicidality (e.g., Brent et al., 2002), low self-esteem (e.g.

Prolonged Exposure Versus Dynamic Therapy for Adolescent PTSD: A Pilot Randomized Controlled Trial

Journal of the American Academy of Child & Adolescent Psychiatry, 2010

Objective-To examine the efficacy and maintenance of developmentally adapted prolonged Exposure (... more Objective-To examine the efficacy and maintenance of developmentally adapted prolonged Exposure (PE-A) compared to active control Time Limited Dynamic Therapy (TLDP-A) for reducing post-traumatic and depressive symptoms in adolescent victims of single event traumas. Method-38 adolescents (age 12-18) were randomly assigned to receive either PEA or TLDP-A. Results-Both treatments resulted in decreased post-traumatic stress disorder and depression, and increased functioning. PEA exhibited greater reduction of PTSD and depression symptom severity, and greater increase in global functioning than did TDLP-A. At post-treatment, 68.4% of adolescents beginning treatment with PEA and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for PTSD. Treatment gains were maintained at 6 and 17 months follow-up.

Direction of influence between posttraumatic and depressive symptoms during prolonged exposure therapy among children and adolescents

Journal of Consulting and Clinical Psychology, 2011

Objective-The objective of the present study was to examine the temporal sequencing of posttrauma... more Objective-The objective of the present study was to examine the temporal sequencing of posttraumatic and depressive symptoms during prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) among children and adolescents. Method-Participants were 73 children and adolescents (56.2% female) between the ages of 8 and 18. Participants completed self report measures of posttraumatic stress and depression prior to every session. Measures included the Child PTSD Symptom Scale (CPSS), Beck Depression Inventory (BDI), and Children's Depression Inventory (CDI). Results-Multilevel mediational analyses indicated reciprocal relations during treatment: changes in posttraumatic symptoms led to changes in depressive symptoms and vice versa. Posttraumatic symptoms accounted for 64.1% of the changes in depression, whereas depressive symptoms accounted for 11.0% of the changes in posttraumatic stress. Conclusions-PE may work primarily by reducing posttraumatic stress which in turn reduces depression.