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Background: Posttraumatic stress disorder (PTSD) is associated with suicidal ideation (SI) and SI tends to improve over the course of evidence-based psychotherapy for PTSD. However, it remains unclear which PTSD clusters and symptoms are central to changes in SI throughout treatment.Objective: To use (1) network analysis to identify the PTSD clusters and symptoms most uniquely related to SI (at baseline and post-treatment); and (2) cross-lagged analyses to examine whether these PTSD clusters and symptoms prospectively predicted decreases in SI over the course of cognitive processing therapy (CPT).Method: Participants were 188 individuals with PTSD receiving CPT as part of an implementation-effectiveness trial. At each session, DSM-IV PTSD clusters and symptoms were assessed using the PTSD Checklist and SI was assessed using the Outcome Questionnaire-45.Results: Multi-staged cross-sectional network analyses indicated that at baseline and post-treatment the avoidance and reexperiencing clusters were uniquely associated with SI. Within these clusters, the symptoms uniquely associated with SI were recurrent thoughts and dreams of trauma, restricted range of affect, and sense of foreshortened future at baseline; and sense of foreshortened future, restricted range of affect, recurrent dreams of trauma, feelings of detachment from others, memory impairment, avoidance of reminders of trauma, and psychological cue reactivity at post-treatment. Multilevel cross-lagged analyses indicated that the avoidance cluster and the restricted range of affect and sense of foreshortened future symptoms, uniquely predicted next-session decreases in SI.Conclusions: These findings suggest that reductions in SI within treatment may be due to direct targeting of avoidance, affect, and future-related cognitions. Further research remains necessary to determine whether the present findings extend to DSM-5 PTSD clusters and symptoms.

Background: Symptom accommodation by family members (FMs) of individuals with posttraumatic stress disorder (PTSD) includes FMs’ participation in patients’ avoidance/safety behaviours and constraining self-expression to minimise conflict, potentially maintaining patients’ symptoms. The Significant Others’ Responses to Trauma Scale (SORTS) is the only existing measure of accommodation in PTSD but has not been rigorously psychometrically tested.Objective: We aimed to conduct further psychometric analyses to determine the factor structure and overall performance of the SORTS. Method: We conducted exploratory and confirmatory factor analyses using a sample of N = 715 FMs (85.7% female, 62.1% White, 86.7% romantic partners of individuals with elevated PTSD symptoms).Results: After dropping cross-loading items, results indicated good fit for a higher-order model of accommodation with two factors: an anger-related accommodation factor encompassed items related largely to minimising conflict, and an anxiety-related accommodation factor encompassed items related primarily to changes to the FM’s activities. Accommodation was positively related to PTSD severity and negatively related to relationship satisfaction, although the factors showed somewhat distinct associations. Item Response Theory analyses indicated that the scale provided good information and robust coverage of different accommodation levels.Conclusions: SORTS data should be analysed as both a single score as well as two factors to explore the factors’ potential differential performance across treatment and relationship outcomes.

ABSTRACTBackground: Military personnel and veterans are at heightened risk for exposure to traumatic events and posttraumatic stress disorder (PTSD), as well as intimate relationship problems associated with PTSD.Objective: The purpose of this study was to evaluate the relative efficacy of CBCT and PE in improving intimate relationship functioning in active duty military personnel or veterans and their intimate partners; both conditions were hypothesized to significantly improve PTSD. Method: In this study, 32 military service members or veterans with PTSD and their intimate partners were randomized to receive either Cognitive–Behavioral Conjoint Therapy for PTSD (n = 15; CBCT; [Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: Harnessing the healing power of relationships. Guilford]), a trauma-focused couple therapy, or Prolonged Exposure (n = 17; PE; [Foa, E. B., Hembree, E. A., Dancu, C. V., Peterson, A. L., Cigrang, J. A., & Riggs, D. S. (2008). Prolonged exposure treatment for combat-related stress disorders – provider’s treatment manual [unpublished]. Department of Psychiatry, University of Pennsylvania]), a front-line evidence-based individual treatment for PTSD.Results: There were significant challenges with recruitment and a significant difference in dropout from treatment for the two therapies (65% for PE; 27% for CBCT). Treatment dropout was differentially related to pre-treatment relationship functioning; those with below average relationship functioning had higher dropout in PE compared with CBCT, whereas those with above average relationship functioning did not show differential dropout. In general, CBCT led to relational improvements, but this was not consistently found in PE. Clinician- and self-reported PTSD symptoms improved with both treatments.Conclusions: This study is the first to test a couple or family therapy against a well-established, front-line recommended treatment for PTSD, with expected superiority of CBCT over PE on relationship outcomes. Lessons learned in trial design, including considerations of equipoise, and the effects of differential dropout on trial analyses are discussed. This trial provides further support for the efficacy of CBCT in the treatment of PTSD and enhancement of intimate relationships.

Abstract Background Research suggests that interpersonal dysfunction may be central to borderline personality disorder (BPD), and that the relationships of people with BPD are particularly impaired. Further, the significant others of people with BPD exhibit elevated psychological problems but little access to mental healthcare. Despite this, most BPD interventions are delivered individually and do not routinely incorporate significant others. This manuscript presents the first case series of Sage, a 12-session manualized intervention for people with borderline personality disorder (BPD) and their intimate partners with three targets: a) BPD severity, b) relationship conflict, and c) intimate partner mental health. Findings Five couples of people with BPD with frequent suicidal/self-injurious behavior or high suicidal ideation and their intimate partners received Sage. Measures of Sage targets as well as tertiary outcomes were administered at pre-, mid-, and post-intervention. Four out of five dyads completed Sage, with high intervention satisfaction ratings. Improvements were generally demonstrated in BPD severity, suicidal ideation, and suicidal behavior/self-injury. Half of dyads exhibited improvements in conflict, and additional improvements in mental health outcomes for dyad members were demonstrated. One dyad exhibited poor outcomes and speculations regarding this are offered. Conclusions Findings provide proof of concept of Sage as an intervention that can improve BPD and other mental health outcomes in those with BPD and their intimate partners. Incorporating intimate partners into BPD treatment may optimize and expedite its outcomes. However, further testing is needed. Trial registration This project was pre-registered at Clinicaltrials.gov (Identifier: [NCT04737252]).

Although the association between post-traumatic stress disorder (PTSD) and social support is well documented, few studies have tested the causal pathways explaining this association at several points in the acute post-trauma recovery period or examined whether the association varies for different sources of social support. To address these gaps, 151 community individuals (mean age = 37.20 years, 69.5% women) exposed to trauma within the previous 6 months were recruited to complete measures of PTSD and social support from intimate partners, friends, and relatives four times in 1 year. In line with recent recommendations for research on social support and PTSD symptoms, random intercept cross-lagged panel modeling (RI-CLPM) was used to examine dynamic changes between PTSD severity and social support over time. The pattern of RI-CLPM cross-lagged coefficients indicated that positive deviations from one’s expected stable level of total social support (across all sources) sped up the recovery of PTSD symptoms at the end of the post-trauma year, and more severe PTSD symptoms than expected based on one’s expected stable level of PTSD started eroding social support midway through the assessment year. When specific sources of social support were analyzed separately, the association between within-person increases in social support from friends at any given time point accelerated the recovery from PTSD across the entire year. Among participants with intimate partners (n = 53), intimate partner support did not predict PTSD symptoms, but more severe PTSD symptoms at any given time point predicted less support at the following time point. Results from this longitudinal study provide additional support for the bidirectional relationship between PTSD and social support over time and suggest that perceived social support from friends may be especially helpful during trauma recovery.

Abstract Many healthcare workers on the frontlines of the COVID-19 pandemic are experiencing clinical levels of mental health symptoms. Evidence-based interventions to address these symptoms are urgently needed. RESTORE (Recovering from Extreme Stressors Through Online Resources and E-health) is an online guided transdiagnostic intervention including cognitive-behavioral interventions. It was specifically designed to improve symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) associated with COVID-19-related traumatic and extreme stressors. The aims of the present study were to assess the feasibility, acceptability, and initial efficacy of RESTORE in healthcare workers on the frontline of the COVID-19 pandemic. We conducted an initial uncontrolled trial of RESTORE in 21 healthcare workers who were exposed to COVID-19-related traumatic or extremely stressful experiences in the context of their work and who screened positive for clinical levels of anxiety, depression, and/or PTSD symptoms. RESTORE was found to be feasible and safe, and led to statistically significant and large effect size improvements in anxiety, depression, and PTSD symptoms over the course of the intervention through follow-up. RESTORE has the potential to become a widely disseminable evidence-based intervention to address mental health symptoms associated with mass traumas. Clinical Trials Registration: This trial was registered with ClinicalTrials.gov ID: NCT04873622

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that can result from experiencing traumatic events. Accurate diagnosis and optimal treatment strategies can be difficult to achieve, due to the heterogeneous etiology and symptomology of PTSD, and overlap with other psychiatric disorders. Advancing our understanding of PTSD pathophysiology is therefore critical. While functional connectivity alterations have shown promise for elucidating the neurobiological mechanisms of PTSD, previous findings have been inconsistent. Eleven patients with PTSD in our first cohort (PTSD-A) and 11 trauma-exposed controls (TEC) underwent functional magnetic resonance imaging. First, we investigated the intrinsic connectivity within known resting state networks (eg, default mode, salience, and central executive networks) previously implicated in functional abnormalities with PTSD symptoms. Second, the overall topology of network structure was compared between PTSD-A and TEC using graph theory. Finally, we used a novel combination of graph theory analysis and scaled subprofile modeling (SSM) to identify a disease-related, covarying pattern of brain network organization. No significant group differences were found in intrinsic connectivity of known resting state networks and graph theory metrics (clustering coefficients, characteristic path length, smallworldness, global and local efficiencies, and degree centrality). The graph theory/SSM analysis revealed a topographical pattern of altered degree centrality differentiating PTSD-A from TEC. This PTSD-related network pattern expression was additionally investigated in a separate cohort of 33 subjects who were scanned with a different MRI scanner (22 patients with PTSD or PTSD-B, and 11 healthy trauma-naïve controls or TNC). Across all participant groups, pattern expression scores were significantly lower in the TEC group, while PTSD-A, PTSD-B, and TNC subject profiles did not differ from each other. Expression level of the pattern was correlated with symptom severity in the PTSD-B group. This method offers potential in developing objective biomarkers associated with PTSD. Possible interpretations and clinical implications will be discussed.

Background: Consultation is an implementation strategy that improves delivery and clinical outcomes for Cognitive Processing Therapy (CPT), an evidence-based practice (EBP) for posttraumatic stress disorder (PTSD). However, little is known about the specific components of consultation that influence the fidelity of treatment delivery or clinical outcomes. Methods: The current study examined whether specific activities performed during CPT consultation meetings were associated with better fidelity to the CPT protocol among 60 newly trained therapists or improved clinical outcomes among 135 clients treated by these therapists. Consultation activities that fall under three broad categories (discussion of the application of CPT to individual cases, review/feedback on fidelity, and technical difficulties) were measured by consultant checklists for each consultation session. Treatment fidelity (adherence to the protocol and competence of delivery) was rated by trained observers for a random sample of therapists’ CPT sessions following consultation. The self-reported PTSD Checklist-IV assessed PTSD symptom change. Results: Multilevel regression analyses indicated that higher therapist consultation attendance predicted a greater decrease in their clients’ PTSD symptoms and that attendance was not associated with observer-rated treatment fidelity. Discussion of the application of specific CPT strategies was the only consultation activity that was significantly associated with greater improvement in PTSD symptoms. Lastly, no consultation activities were significantly associated with treatment fidelity. Conclusions: Our findings suggest that specific consultation strategies such as emphasizing the discussion of the application of specific CPT strategies to individual cases during consultation meetings may be effective in improving the clinical outcomes of CPT.

Couple HOPES (Helping Overcome PTSD and Enhance Satisfaction) is a guided, online couple intervention adapted from Cognitive-Behavioral Conjoint Therapy for posttraumatic stress disorder (PTSD). It was created to overcome a range of barriers to accessing evidence-based treatments for PTSD and the intimate relationship problems associated with it. This manuscript describes initial outcomes of the intervention in a series of 10 couples. Participants were military, veteran and first responders with probable PTSD and their intimate partners. Couples completed the program and measurements of PTSD, relationship satisfaction, and secondary outcomes at pre-, mid-, and post-intervention. Mean satisfaction for the program was high and it was completed by seven of ten couples. Participants with PTSD evidenced significant and large pre- to post-intervention effect size improvements in PTSD symptoms (g = 0.80) and perceived health (g = 1.13). They also exhibited non-significant but medium effect size pre- to post-intervention improvements in quality of life (g = 0.62), and depression (g = 0.53), and small effect size pre- to post-intervention improvements in argumentativeness (g = 0.43), anger (g = 0.31), and anxiety (g = 0.31). Partners reported significant and moderate pre- to post-intervention effect size improvements in relationship satisfaction (g = 0.68), and medium but not significant effect size improvements in accommodation of PTSD (g = 0.56). Results provide initial support for the feasibility, acceptability, and efficacy of Couple HOPES for improving PTSD and relationship satisfaction. However, more testing in larger samples, including with randomized controlled designs, is needed.

Healing from trauma occurs in a relational context, and the impacts of traumatic experiences that result in post-traumatic stress disorder (PTSD) go beyond the diagnosis itself. To fully understand a treatment for PTSD, understanding its impact on interpersonal, relational, and growth outcomes yields a more fulsome picture of the effects of the treatment. The current paper examines these secondary outcomes of a pilot trial of Cognitive Behavioral Conjoint Therapy (CBCT) for PTSD with MDMA. Six romantic dyads, where one partner had PTSD, undertook a course of treatment combining CBCT for PTSD with two MDMA psychotherapy sessions. Outcomes were assessed at mid-treatment, post-treatment, and 3- and 6-month follow-up. Both partners reported improvements in post-traumatic growth, relational support, and social intimacy. Partners reported reduced behavioral accommodation and conflict in the relationship, and patients with PTSD reported improved psychosocial functioning and empathic concern. These improvements were maintained throughout the follow-up period. These findings suggest that CBCT for PTSD with MDMA has significant effect on relational and growth outcomes in this pilot sample. Improvements in these domains is central to a holistic recovery from traumatic experiences, and lends support to the utility of treating PTSD dyadically.

Background: Couple HOPES (Helping Overcome PTSD and Enhance Satisfaction) was created to help overcome a range of barriers to accessing psychotherapy for posttraumatic stress disorder (PTSD) and commonly associated intimate relationship problems. Objective: Couple HOPES is a guided, online self-help intervention adapted from Cognitive-Behavioural Conjoint Therapy for PTSD that aims to improve PTSD and enhance relationship satisfaction. Method/Results: This paper describes the processes and principles used to develop the Couple HOPES intervention platform as well as the coaching model and manual used to promote engagement and adherence to the intervention. Conclusions: Current research and future directions in testing Couple HOPES are outlined.

Background: Frontline healthcare workers, recovered COVID+ patients who had severe illness, and close others of COVID+ patients who have recovered or died are at risk for clinical levels of mental health symptoms in the context of the COVID-19 pandemic. RESTORE (Recovering from Extreme Stressors Through Online Resources and E-health) was specifically designed for this context. RESTORE is a transdiagnostic guided online intervention adapted from evidence-based cognitive-behavioural therapies. Objectives: RESTORE was designed to address depression, anxiety, and posttraumatic stress disorder symptoms associated with exposure to COVID-19-related traumatic and extreme stressors, and to overcome multiple barriers to accessing psychotherapies. Method: This paper describes the intervention components and platform, as well as the principles used to develop RESTORE. Current research and future directions in developing and testing RESTORE are outlined. Results: Preliminary data from an initial uncontrolled trial evaluating RESTORE in frontline healthcare workers is highly promising. Conclusion: We believe RESTORE has great potential to provide accessible, evidence-based psychological intervention to those in great need.

Background: Physical health concerns (e.g. chronic pain, fatigue) are common among clients with posttraumatic stress disorder (PTSD). Prior research has indicated that clients report improved physical functioning and fewer physical health symptoms after receiving Cognitive Processing Therapy (CPT) for PTSD. However, less is known about the impact of physical functioning on the clients’ PTSD symptom improvement in CPT. Objective: The current study examined the patterns of change of and between physical functioning and PTSD symptoms over the course of CPT among a diverse military, veteran, and community sample. Method: We collected clients’ (N = 188) physical functioning and PTSD symptom severity prior to and during CPT using the 12-Item Short Form Health Survey and the PTSD Checklist. We used multilevel modelling to 1) evaluate the impact of baseline physical functioning on the PTSD symptom trajectory, 2) examine the trajectory of physical functioning, and 3) assess the dynamics between physical functioning and PTSD symptoms over the course of CPT. Results: Our multilevel analyses indicated that 1) physical functioning significantly improved for those with low levels of functioning prior to treatment, 2) poorer baseline physical functioning predicted slower improvements in PTSD symptoms, and 3) poorer physical functioning in one session predicted less PTSD symptom improvement by the next session. Conclusions: Our findings demonstrate that while physical functioning can interfere with PTSD symptom improvement, physical functioning can also improve over the course of CPT. In light of the interconnected nature of physical health and PTSD symptoms, clinicians may need to attend to lower levels of physical functioning when providing CPT or other trauma-focused therapies. Future research to determine whether specific treatment adaptations may benefit such clients is needed.

Cognitive-behavioural conjoint therapy (CBCT) for PTSD has been shown to improve PTSD, relationship adjustment, and the health and well-being of partners. MDMA (3,4-methylenedioxymethamphetamine) has been used to facilitate an individual therapy for PTSD. This study was an initial test of the safety, tolerability, and efficacy of MDMA-facilitated CBCT. Six couples with varying levels of baseline relationship satisfaction in which one partner was diagnosed with PTSD participated in a condensed version of the 15-session CBCT protocol delivered over 7 weeks. There were two sessions in which both members of the couple were administered MDMA. All couples completed the treatment protocol, and there were no serious adverse events in either partner. There were significant improvements in clinician-assessed, patient-rated, and partner-rated PTSD symptoms (pre- to post-treatment/follow-up effect sizes ranged from d = 1.85–3.59), as well as patient depression, sleep, emotion regulation, and trauma-related beliefs. In addition, there were significant improvements in patient and partner-rated relationship adjustment and happiness (d =.64–2.79). These results are contextualized in relation to prior results from individual MDMA-facilitated psychotherapy and CBCT for PTSD alone. MDMA holds promise as a facilitator of CBCT to achieve more robust and broad effects on individual and relational functioning in those with PTSD and their partners.

BackgroundIn the aftermath of disaster, a large proportion of people will develop psychosocial difficulties that impair recovery, but for which presentations do not meet threshold criteria for disorder. Although these adjustment problems can cause high distress and impairment, and often have a trajectory towards mental health disorder, few evidence-based interventions are available to facilitate recovery.ObjectiveThis paper describes the development and pilot testing of an internationally developed, brief, and scalable psychosocial intervention that targets distress and poor adjustment following disaster and trauma.MethodThe Skills fOr Life Adjustment and Resilience (SOLAR) program was developed by an international collaboration of trauma and disaster mental health experts through an iterative expert consensus process. The resulting five session, skills-based intervention, deliverable by community-based or frontline health or disaster workers with little or no formal mental health training (known as coaches), was piloted with 15 Australian bushfire survivors using a pre-post with follow up, mixed-methods design study.ResultsFindings from this pilot demonstrated that the SOLAR program was safe and feasible for non-mental health frontline workers (coaches) to deliver locally after two days of training. Participants' attendance rates and feedback about the program indicated that the program was acceptable. Pre-post quantitative analysis demonstrated reductions in psychological distress, posttraumatic stress symptoms, and impairment.ConclusionsThis study provides preliminary evidence that the delivery of the SOLAR program after disaster by trained, frontline workers with little or no mental health experience is feasible, acceptable, safe, and beneficial in reducing psychological symptoms and impairment among disaster survivors. Randomized controlled trials of the SOLAR program are required to advance evidence of its efficacy.

Abstract Background Posttraumatic stress disorder (PTSD) is associated with abnormal hippocampal activity; however, the functional connectivity (FC) of the hippocampus with other brain regions in PTSD and its relations with symptoms warrants further attention. We investigated subregional hippocampal FC in PTSD during a resting state compared with a trauma-exposed control (TEC) group. Based on extant research, we targeted the FCs of the anterior and posterior hippocampal subregions with the amygdala, medial prefrontal cortex (mPFC), and the posterior cingulate (PCC). Methods Resting-state functional magnetic resonance images were acquired from 11 individuals with PTSD and 13 trauma-exposed controls. Anterior and posterior hippocampal FC was compared between groups. Within the PTSD and TEC groups, subregional hippocampal FC was correlated with scores on the Clinician-Administered PTSD Scale (CAPS) at time of scan and 4 months post-scan. Results Those with PTSD had significantly greater FC compared with the TEC group between the left posterior hippocampus and the bilateral PCC (g’s > .96). Direct contrasts of the Fisher z-transformed coefficients indicated that the correlations between CAPS scores 4 months post scan and the FC between the left hippocampal head and the right PCC (z = − 2.07, p = .039) as well as the FC between the right hippocampal tail and the right mPFC (z = − 2.19, p = .029) were significantly greater in the PTSD group compared to the TEC group. Conclusions These results support between-group differences in posterior hippocampal FC and different relations with PTSD future symptoms, underscoring associations with the anterior and posterior hippocampus. These findings enrich our understanding of PTSD pathophysiology and provide support for future investigations of imaging biomarkers predictive of disease progression.

Interpersonal difficulties are common among veterans with posttraumatic stress disorder (PTSD) and are associated with poorer treatment response. Treatment outcomes for PTSD, including relationship functioning, improve when partners are included and engaged in the therapy process. Cognitive-behavioral conjoint therapy for PTSD (CBCT) is a manualized 15-session intervention designed for couples in which one partner has PTSD. CBCT was developed specifically to treat PTSD, engage a partner in treatment, and improve interpersonal functioning. However, recent research suggests that an abbreviated CBCT protocol may lead to sufficient gains in PTSD and relationship functioning, and yield lower dropout rates. Likewise, many veterans report a preference for receiving psychological treatments through clinical videoteleconferencing (CVT) rather than traditional face-to-face modalities that require travel to VA clinics. This manuscript describes the development and implementation of a novel randomized controlled trial (RCT) that examines the efficacy of an abbreviated 8-session version of CBCT (“brief CBCT,” or B-CBCT), and compares the efficacy of this intervention delivered via CVT to traditional in-person platforms. Veterans and their partners were randomized to receive B-CBCT in a traditional Veterans Affairs office-based setting (B-CBCT-Office), CBCT through CVT with the veteran and partner at home (B-CBCT-Home), or an in office-delivered, couple-based psychoeducation control condition (PTSD Family Education). This study is the first RCT designed to investigate the delivery of B-CBCT specifically to veterans with PTSD and their partners, as well as to examine the delivery of B-CBCT over a CVT modality; findings could increase access to care to veterans with PTSD and their partners. Keywords: Cognitive behavioral conjoint therapy, Videoconferencing, Veterans, Home-based care, Couple therapy, Randomized controlled trial