Journal of Anxiety Disorders 28 (2014) 237–240
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder夽 D. Lloyd a,∗ , R.D.V. Nixon a,b , T. Varker a , P. Elliott a , D. Perry c , R.A. Bryant d , M. Creamer a , D. Forbes a,∗ a
Australian Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Vic, Australia School of Psychology, Flinders University, SA, Australia c Veterans and Veterans’ Families Counselling Service, Australia d School of Psychology, University of New South Wales, NSW, Australia b
a r t i c l e
i n f o
Article history: Received 11 June 2013 Received in revised form 5 December 2013 Accepted 14 December 2013 Keywords: PTSD Trauma Cognitive Processing Therapy Veterans Treatment Predictors
a b s t r a c t This paper examines clinical predictors of posttraumatic stress disorder (PTSD) treatment outcomes following Cognitive Processing Therapy (CPT) in Australian military veterans. Fifty nine treatment seeking veterans were enrolled in a randomized controlled trial comparing 12 sessions of CPT (n = 30) with usual treatment (n = 29) at three community-based veterans counseling centers. PTSD and key co-morbidities (depression, anxiety, anger and alcohol use) were measured. Growth curve modeling was used to examine factors which influenced PTSD severity post-treatment. For the CPT condition, baseline anger was the only co-morbidity predictive of change in PTSD severity over time. Participants with higher anger scores showed less of a decrease in PTSD severity over time. Higher anxiety in participants in treatment as usual was significantly associated with better treatment gains. This research suggests that veterans experiencing high levels of anger might benefit from targeted anger reduction strategies to increase the effectiveness of CPT treatment for PTSD. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
1. Introduction Posttraumatic stress disorder (PTSD) is a common psychiatric sequel of exposure to a traumatic event. Reported rates of PTSD are as high as 10–30% among returnees from recent military conflicts (Thomas et al., 2010). Fortunately we have effective treatments for PTSD. The two most established trauma focused cognitivebehavioral (TFCBT) treatments indicated in international treatment guidelines are prolonged exposure (PE) (Foa & Rothbaum, 1998) and Cognitive Processing Therapy (CPT) (Resick, Monson, & Chard, 2007). Despite the increasing evidence base surrounding these treatments, they are not equally effective for all sufferers. Between 40 and 60% of participants in research trials of effective treatments retain PTSD diagnosis at follow-up e.g. Forbes et al. (2012) and Monson et al. (2006). Understanding the factors that moderate and
夽 Funding for this study was provided by the Australian Department of Veterans Affairs Applied Research Program, June 2007. ∗ Corresponding authors at: Level 3, Alan Gilbert Building, 161 Barry Street, Vic 3052, Australia. Tel.: +61 3 9035 5599. E-mail address: [email protected] (D. Lloyd).
mediate PTSD treatment effects will enable more informed treatment planning, targeting of treatments to maximize improvement for responders, and improved approaches for those who are otherwise not responding. One of these factors is comorbidity, which is present in approximately 80% of PTSD cases. The most common comorbidities are depression, other anxiety problems, anger and substance abuse (Toole, Catts, Outram, Pierse, & Cockburn, 2009). Cognitively oriented trauma focused treatments such as PE and CPT require emotional engagement with traumatic memories. Leading theories suggest that comorbidities influence treatment outcomes by disrupting or inhibiting emotional engagement with the traumatic material which is required in treatments such as PE and CPT. Only a small number of studies have examined this issue to date, even fewer using data drawn from randomized controlled trials (RCTs). Analyses drawn from RCT data allows for more intervention specific interpretation of the findings. As yet no studies have examined comorbid factors influencing outcomes for veterans with PTSD using RCT generated data. Less rigorous studies using cohort study design in veterans have found that anger (Forbes, Creamer, Hawthorne, Allen, & McHugh, 2003; Forbes et al., 2005), anger and guilt (Stapleton, Taylor, & Asmundson, 2006) and alcohol (Seidel,
0887-6185/$ – see front matter. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.janxdis.2013.12.002
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D. Lloyd et al. / Journal of Anxiety Disorders 28 (2014) 237–240
Gusman, & Abueg, 1994), as well as the interaction between them (Forbes et al., 2008), negatively impacted on recovery following treatment. This research examined the influence of comorbidity on treatment outcome in a RCT of CPT in veterans with military related PTSD. As CPT gains momentum it is increasingly important to better understand factors associated with variability in treatment response, particularly in the context of comorbidity, to aid the tailoring and refinement of treatment delivery. This investigation needs to also understand the specificity of treatment predictors to frontline treatments as distinct from being predictors of treatment response generally.
control. Individual 60-min therapy sessions were delivered twice a week according to the Military Version Manual (Resick et al., 2007). Adherence to the manual was checked by rating audio recordings and found to be comparable to other studies in achieving adherence to protocol of 92%. For the TAU condition, the content of each session was recorded in written form but not prescribed to ensure the delivery of representative ‘usual treatment’. The TAU intervention depended on the orientation of the therapist and included elements of psychoeducation, supportive counseling, non-trauma focused symptom management interventions, some CBT and elements of exposure. Drop-out and attendance rates were equivalent for both groups.
2. Methods
2.6. Data analysis
A detailed description of the methods is provided in Forbes et al. (2012).
An analysis of treatment outcomes was reported in a previous paper (Forbes et al., 2012), which employed growth curve modeling (GCM) to investigate the trajectory of change over time in CAPS severity scores, and the relationship with group membership (CPT versus TAU). In this paper, a regression analysis was undertaken to identify comorbidity predictors of the PTSD treatment outcomes. Growth curve modeling against a square root trajectory was used (see Forbes et al. for a full description). The intercept and slope terms derived for the CPT and TAU groups, respectively, were regressed on to the clinical predictor variables. The significance of the coefficients indicates the strength of relationship between the trajectory parameters and these measures.
2.1. Participants Fifty nine veterans presenting for treatment at three community based Veterans and Veterans’ Families Counseling Services (VVCS) offices in Australia were recruited. Vietnam era veterans comprised 66% (n = 39) of the sample, Timor 14% (n = 8), Iraq or Afghanistan 5% (n = 3) and 15% (n = 9) other conflicts. Exclusion criterion included current uncontrolled psychosis, current suicidal ideation or significant cognitive impairment. Stable use of psychotropic medications was permitted. 2.2. Measures
3. Results
PTSD symptoms and diagnosis were assessed using the Clinician Administered PTSD Scale (CAPS; Blake et al., 1995). Comorbidity was measured using the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996), the State Trait Anxiety Inventory (state scale) (STAI; Spielberger, Gorsuch, & Lushene, 1970), the Dimensions of Anger Reactions Scale (DAR7; Forbes et al., 2004) and the Alcohol Use Disorders Identification Test (AUDIT; Babor, de la Fuente, Saunders, & Grant, 1989).
Initial intent-to-treat analyses as reported in Forbes et al. (2012) found significantly greater improvement for participants receiving CPT over TAU at post-treatment and 3-month follow-up. CPT also produced greater improvements in anxiety and depression than usual treatment. Here, the predictors of treatment outcomes are examined. Table 1 reports the mean CAPS severity and comorbidity scores for the whole sample, the CPT group and the TAU group at intake. At baseline the two groups did not differ on any comorbidity variables. The standardized coefficients and p-values resulting from regressing the intercept and slope on the clinical comorbidity predictors are presented in Table 2. For the CPT group, only anger was significantly predictive of change in CAPS scores over time following treatment (p < .001), with higher anger associated with poorer treatment response (p < .05). For the TAU group only anxiety was predictive of changes in CAPS severity over time, with higher anxiety associated with better treatment response.
2.3. Procedure After complete description of the study to the participants, written informed consent was obtained (approved by Department of Veterans’ Affairs Human Research Ethics Committee, 2007). Eligible participants (n = 59) were randomized to CPT (n = 30) or treatment as usual (TAU) (n = 29). Follow-up assessments were independently conducted at treatment completion and at 3months post-treatment. 2.4. Therapists Treatment was delivered in the community-based mental health services of the Veterans and Veterans Families Counseling Service (VVCS) by staff who were ongoing employees of the service, randomized to provide either CPT (n = 9) or TAU (n = 9). They received a 2-day CPT workshop followed by weekly 1-h group consultations by teleconference with the CPT expert trainer (R.N). Therapists providing TAU received a trial briefing but no training or supervision. 2.5. Treatments CPT is a 12-session manualized treatment for PTSD. It comprises cognitive restructuring and written exposure elements and aims to address key posttraumatic themes such as safety, trust, power and
4. Discussion This is the first study to examine comorbidity as a predictor of treatment outcome in veterans receiving CPT treatment. The analysis found that of depression, anxiety, alcohol and anger, only anger predicted response to CPT treatment, with more severe anger being associated with reduced treatment gains. This finding is consistent with findings from cohort studies examining male veterans with PTSD (Forbes et al., 2008). It has been suggested that anger may serve to inhibit anxiety following a trauma, especially when effortful avoidance is unsuccessful (Riggs, Dancu, Gershuny, & Greenberg, 1992). This raises the possibility that CPT may not have been as successful with the veterans with elevated anger because they were not able to engage in anxiety-related concerns because the anger inhibited emotional engagement. A related interpretation is that veterans’ fear of anger expression (rather than anger itself) may have attenuated responsivity to PTSD treatment (see Forbes et al., 2008). That
D. Lloyd et al. / Journal of Anxiety Disorders 28 (2014) 237–240
239
Table 1 Imputed means and standard deviations for outcome measures by condition at three time points. Outcome measure
Condition
Pre-treatment
Post-treatment
Follow-up
M
SD
M
SD
M
SD
CAPS
CPT TAU Total
75.53 64.55 70.14
16.35 19.46 18.63
48.03 57.73 52.80
27.89 20.01 24.62
45.30 52.55 48.86
28.15 18.93 14.14
BDI-II
CPT TAU Total
26.33 24.78 25.58
11.38 11.99 11.60
15.91 20.83 18.28
11.97 11.83 12.06
14.77 19.11 16.86
12.86 10.15 11.74
STAI-State
CPT TAU Total
55.97 50.29 53.22
13.52 9.94 12.17
44.59 48.31 46.52
13.12 12.75 12.95
43.59 47.26 45.36
11.49 16.17 13.94
DAR7
CPT TAU Total
31.23 28.75 30.03
14.31 11.36 12.92
23.88 26.48 25.14
15.64 13.98 14.79
17.66 21.68 19.60
12.89 12.54 12.77
AUDIT
CPT TAU Total
12.03 10.56 11.32
8.60 9.28 8.89
6.80 7.06 6.92
5.65 5.83 5.69
6.66 8.48 7.54
4.90 5.76 5.36
Note: CPT, Cognitive Processing Therapy; TAU, treatment as usual; CAPS, Clinician-Administered Posttraumatic Stress Disorder Scale; BDI-II, Beck Depression Inventory; STAI-State, State Trait Anxiety Inventory-State Scale; DAR7, Dimensions of Anger Reactions 7-item scale; AUDIT, Alcohol Use Disorders Identification Test.
Table 2 Comorbidity predictors of CAPS severity. Group
Measure
p
B
p
CPT (n = 30)
Anger Anxiety Depression Alcohol
0.272 0.192 0.510 0.335
.107 .342 .048 .177
0.515 −0.301 −0.112 −0.137
.001 .114 .663 .581
TAU (n = 29)
Anger Anxiety Depression Alcohol
0.549 −0.275 0.682 −0.323
.083 .393 .020 .278
−0.001 0.568 −0.451 0.059
.997 .023 .089 .799
Intercept
Slope
B
Note: B represents standardized coefficients resulting from regressing the intercept and slope on the clinical comorbidity predictors.
is, veterans may have been reluctant to engage fully in accessing trauma-related memories because of concern that such memories and cognitions would trigger anger and aggression, posing a risk of harm to self or others. This interpretation is supported by a growing number of studies demonstrating the link between PTSD and aggression and violence in veterans (Elbogen et al., 2010; MacManus et al., 2012). The finding that anger predicted poor treatment response in our sample, which is not found in female CPT recipients studied by Rizvi, Vogt, and Resick (2009), may reflect a gender effect. Examining different types of anger or anger expressions, and the relationship between anger, fear and anxiety is necessary to understand the mechanisms by which anger (and fear of anger, or avoidance of anxiety) affects treatment outcomes from CPT treatment, and to better understand why TAU outcomes were related to anxiety but not anger. This study suggests that there would be value in assessing and addressing anger prior to treatment, or early in the CPT process. If problematic anger is present, anger could be addressed early in the cognitive component of CPT. There may be value in considering CPT-C (cognitive component only) for clients who may be limited in their engagement with trauma accounts for fear of experiencing emotions including anger. Another approach would be to offer brief behavioral interventions before CPT to provide veterans with the confidence to fully engage with treatment. These suggestions require empirical investigation. This study has some limitations. The sample size was modest which limited the analysis of other factors and dropout rates. The majority of the sample (66%) were Vietnam era veterans, suggesting the need for caution when generalizing the findings to younger
veteran populations. We also did not employ within-session or between-session ratings of anger or anxiety, which would have clarified at which point these factors may influence treatment response.
5. Conclusions This study is the first to examine predictors of outcomes for veterans with PTSD drawn from RCT data and the first to examine comorbid predictors of outcome for CPT in a male sample. Findings suggest that anger is interacting in a specific way with CPT, and that clinicians should carefully assess anger in clients presenting with PTSD. This study points to anger in military related PTSD as an important focus for future research.
Conflict of interest None for any author. The Australian Centre for Posttraumatic Mental Health is partially funded by the Australian Government, Department of Veterans Affairs.
References Babor, T., de la Fuente, J., Saunders, J., & Grant, M. (1989). The Alcohol Use Disorders Identification Test: guidelines for use in primary health care. World Health Organisation, Geneva: Division of Mental Health. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory (2nd ed.). San Antonio, TX: The Psychological Corporation.
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Blake, D. D., Weathers, F., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician administered PTSD scale. Journal of Traumatic Stress, 8(1), 75–90. http://dx.doi.org/10.1002/jts.2490080106 Elbogen, E. B., Wagner, H. R., Fuller, S. R., Calhoun, P. S., Kinneer, P. M., Beckham, J. C., & Mid-Atlantic Mental Illness Research, Educational, and Clinical Center Workgroup. (2010). Correlates of anger and hostility in Iraq and Afghanistan war veterans. American Journal of Psychiatry, 167(9), 1051–1058. http://dx.doi.org/10.1176/appi.ajp.2010.09050739 Foa, E. B., & Rothbaum, B. O. (1998). Treating the trauma of rape: cognitive-behavioral therapy for PTSD. New York: Guilford Press. Forbes, D., Bennett, N., Biddle, D., Crompton, D., McHugh, T., Elliott, P., et al. (2005). Clinical presentations and treatment outcomes of peacekeeper veterans with PTSD: preliminary findings. American Journal of Psychiatry, 162(11), 2188–2190. http://dx.doi.org/10.1176/appi.ajp.162.11.2188 Forbes, D., Creamer, M., Hawthorne, G., Allen, N., & McHugh, T. (2003). Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 191(2), 93–99. http://dx.doi.org/10.1097/00005053-200302000-00005 Forbes, D., Hawthorne, G., Elliott, P., McHugh, T., Biddle, D., Creamer, M., et al. (2004). A concise measure of anger in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 17(3), 249–256. http://dx.doi.org/ 10.1023/B:JOTS.0000029268.22161.bd Forbes, D., Lloyd, D., Nixon, R. D., Elliott, P., Varker, T., Perry, D., et al. (2012). A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. Journal of Anxiety Disorders, 26(3), 442–452. http://dx.doi.org/10.1016/j.janxdis.2012.01.006 Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., & Hopwood, M. (2008). Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 142–149. http://dx. doi.org/10.1002/jts.20315 MacManus, D., Dean, K., Al Bakir, M., Iversen, A. C., Hull, L., Fahy, T., et al. (2012). Violent behaviour in UK military personnel returning home after deployment. Psychological Medicine, 42(8), 1663–1673. http://dx.doi.org/ 10.1017/s0033291711002327
Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898–907. http://dx.doi.org/10.1037/0022-006X.74.5.898 O’Toole, B. I., Catts, S. V., Outram, S., Pierse, K. R., & Cockburn, J. (2009). The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. American Journal of Epidemiology, 170(3), 318–330. http://dx.doi.org/10.1093/ aje/kwp146 Resick, P. A., Monson, C. M., & Chard, K. M. (2007). Cognitive processing therapy: veteran/military version. Washington, DC: Department of Veterans Affairs. Riggs, D. S., Dancu, C. V., Gershuny, B. S., Greenberg, D., et al. (1992). Anger and posttraumatic stress disorder in female crime victims. Journal of Traumatic Stress, 5(4), 613–625. http://dx.doi.org/10.1002/jts.2490050410 Rizvi, S. L., Vogt, D. S., & Resick, P. A. (2009). Cognitive and affective predictors of treatment outcome in Cognitive Processing Therapy and Prolonged Exposure for posttraumatic stress disorder. Behavior Research and Therapy, 47(9), 737–743. http://dx.doi.org/10.1016/j.brat.2009.06.003 (Research Support, N.I.H., Extramural) Seidel, R. W., Gusman, F. D., & Abueg, F. R. (1994). Theoretical and practical foundations of an inpatient post-traumatic stress disorder and alcoholism treatment program. Psychotherapy, 31(1), 67–78. http://dx.doi.org/10.1037/ 0033-3204.31.1.67 Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the state-trait anxiety inventory. Palo Alto, CA: Consulting Psychologists Press. Stapleton, J. A., Taylor, S., & Asmundson, G. J. G. (2006). Effects of three PTSD treatments on anger and guilt: exposure therapy, eye movement desensitization and reprocessing, and relaxation training. Journal of Traumatic Stress, 19(1), 19–28. http://dx.doi.org/10.1016/S0005-7967(01)00024-9 Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623. http://dx.doi.org/10.1001/archgenpsychiatry.2010.54
Contents lists available at ScienceDirect
Journal of Anxiety Disorders
Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder夽 D. Lloyd a,∗ , R.D.V. Nixon a,b , T. Varker a , P. Elliott a , D. Perry c , R.A. Bryant d , M. Creamer a , D. Forbes a,∗ a
Australian Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Vic, Australia School of Psychology, Flinders University, SA, Australia c Veterans and Veterans’ Families Counselling Service, Australia d School of Psychology, University of New South Wales, NSW, Australia b
a r t i c l e
i n f o
Article history: Received 11 June 2013 Received in revised form 5 December 2013 Accepted 14 December 2013 Keywords: PTSD Trauma Cognitive Processing Therapy Veterans Treatment Predictors
a b s t r a c t This paper examines clinical predictors of posttraumatic stress disorder (PTSD) treatment outcomes following Cognitive Processing Therapy (CPT) in Australian military veterans. Fifty nine treatment seeking veterans were enrolled in a randomized controlled trial comparing 12 sessions of CPT (n = 30) with usual treatment (n = 29) at three community-based veterans counseling centers. PTSD and key co-morbidities (depression, anxiety, anger and alcohol use) were measured. Growth curve modeling was used to examine factors which influenced PTSD severity post-treatment. For the CPT condition, baseline anger was the only co-morbidity predictive of change in PTSD severity over time. Participants with higher anger scores showed less of a decrease in PTSD severity over time. Higher anxiety in participants in treatment as usual was significantly associated with better treatment gains. This research suggests that veterans experiencing high levels of anger might benefit from targeted anger reduction strategies to increase the effectiveness of CPT treatment for PTSD. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
1. Introduction Posttraumatic stress disorder (PTSD) is a common psychiatric sequel of exposure to a traumatic event. Reported rates of PTSD are as high as 10–30% among returnees from recent military conflicts (Thomas et al., 2010). Fortunately we have effective treatments for PTSD. The two most established trauma focused cognitivebehavioral (TFCBT) treatments indicated in international treatment guidelines are prolonged exposure (PE) (Foa & Rothbaum, 1998) and Cognitive Processing Therapy (CPT) (Resick, Monson, & Chard, 2007). Despite the increasing evidence base surrounding these treatments, they are not equally effective for all sufferers. Between 40 and 60% of participants in research trials of effective treatments retain PTSD diagnosis at follow-up e.g. Forbes et al. (2012) and Monson et al. (2006). Understanding the factors that moderate and
夽 Funding for this study was provided by the Australian Department of Veterans Affairs Applied Research Program, June 2007. ∗ Corresponding authors at: Level 3, Alan Gilbert Building, 161 Barry Street, Vic 3052, Australia. Tel.: +61 3 9035 5599. E-mail address: [email protected] (D. Lloyd).
mediate PTSD treatment effects will enable more informed treatment planning, targeting of treatments to maximize improvement for responders, and improved approaches for those who are otherwise not responding. One of these factors is comorbidity, which is present in approximately 80% of PTSD cases. The most common comorbidities are depression, other anxiety problems, anger and substance abuse (Toole, Catts, Outram, Pierse, & Cockburn, 2009). Cognitively oriented trauma focused treatments such as PE and CPT require emotional engagement with traumatic memories. Leading theories suggest that comorbidities influence treatment outcomes by disrupting or inhibiting emotional engagement with the traumatic material which is required in treatments such as PE and CPT. Only a small number of studies have examined this issue to date, even fewer using data drawn from randomized controlled trials (RCTs). Analyses drawn from RCT data allows for more intervention specific interpretation of the findings. As yet no studies have examined comorbid factors influencing outcomes for veterans with PTSD using RCT generated data. Less rigorous studies using cohort study design in veterans have found that anger (Forbes, Creamer, Hawthorne, Allen, & McHugh, 2003; Forbes et al., 2005), anger and guilt (Stapleton, Taylor, & Asmundson, 2006) and alcohol (Seidel,
0887-6185/$ – see front matter. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.janxdis.2013.12.002
238
D. Lloyd et al. / Journal of Anxiety Disorders 28 (2014) 237–240
Gusman, & Abueg, 1994), as well as the interaction between them (Forbes et al., 2008), negatively impacted on recovery following treatment. This research examined the influence of comorbidity on treatment outcome in a RCT of CPT in veterans with military related PTSD. As CPT gains momentum it is increasingly important to better understand factors associated with variability in treatment response, particularly in the context of comorbidity, to aid the tailoring and refinement of treatment delivery. This investigation needs to also understand the specificity of treatment predictors to frontline treatments as distinct from being predictors of treatment response generally.
control. Individual 60-min therapy sessions were delivered twice a week according to the Military Version Manual (Resick et al., 2007). Adherence to the manual was checked by rating audio recordings and found to be comparable to other studies in achieving adherence to protocol of 92%. For the TAU condition, the content of each session was recorded in written form but not prescribed to ensure the delivery of representative ‘usual treatment’. The TAU intervention depended on the orientation of the therapist and included elements of psychoeducation, supportive counseling, non-trauma focused symptom management interventions, some CBT and elements of exposure. Drop-out and attendance rates were equivalent for both groups.
2. Methods
2.6. Data analysis
A detailed description of the methods is provided in Forbes et al. (2012).
An analysis of treatment outcomes was reported in a previous paper (Forbes et al., 2012), which employed growth curve modeling (GCM) to investigate the trajectory of change over time in CAPS severity scores, and the relationship with group membership (CPT versus TAU). In this paper, a regression analysis was undertaken to identify comorbidity predictors of the PTSD treatment outcomes. Growth curve modeling against a square root trajectory was used (see Forbes et al. for a full description). The intercept and slope terms derived for the CPT and TAU groups, respectively, were regressed on to the clinical predictor variables. The significance of the coefficients indicates the strength of relationship between the trajectory parameters and these measures.
2.1. Participants Fifty nine veterans presenting for treatment at three community based Veterans and Veterans’ Families Counseling Services (VVCS) offices in Australia were recruited. Vietnam era veterans comprised 66% (n = 39) of the sample, Timor 14% (n = 8), Iraq or Afghanistan 5% (n = 3) and 15% (n = 9) other conflicts. Exclusion criterion included current uncontrolled psychosis, current suicidal ideation or significant cognitive impairment. Stable use of psychotropic medications was permitted. 2.2. Measures
3. Results
PTSD symptoms and diagnosis were assessed using the Clinician Administered PTSD Scale (CAPS; Blake et al., 1995). Comorbidity was measured using the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996), the State Trait Anxiety Inventory (state scale) (STAI; Spielberger, Gorsuch, & Lushene, 1970), the Dimensions of Anger Reactions Scale (DAR7; Forbes et al., 2004) and the Alcohol Use Disorders Identification Test (AUDIT; Babor, de la Fuente, Saunders, & Grant, 1989).
Initial intent-to-treat analyses as reported in Forbes et al. (2012) found significantly greater improvement for participants receiving CPT over TAU at post-treatment and 3-month follow-up. CPT also produced greater improvements in anxiety and depression than usual treatment. Here, the predictors of treatment outcomes are examined. Table 1 reports the mean CAPS severity and comorbidity scores for the whole sample, the CPT group and the TAU group at intake. At baseline the two groups did not differ on any comorbidity variables. The standardized coefficients and p-values resulting from regressing the intercept and slope on the clinical comorbidity predictors are presented in Table 2. For the CPT group, only anger was significantly predictive of change in CAPS scores over time following treatment (p < .001), with higher anger associated with poorer treatment response (p < .05). For the TAU group only anxiety was predictive of changes in CAPS severity over time, with higher anxiety associated with better treatment response.
2.3. Procedure After complete description of the study to the participants, written informed consent was obtained (approved by Department of Veterans’ Affairs Human Research Ethics Committee, 2007). Eligible participants (n = 59) were randomized to CPT (n = 30) or treatment as usual (TAU) (n = 29). Follow-up assessments were independently conducted at treatment completion and at 3months post-treatment. 2.4. Therapists Treatment was delivered in the community-based mental health services of the Veterans and Veterans Families Counseling Service (VVCS) by staff who were ongoing employees of the service, randomized to provide either CPT (n = 9) or TAU (n = 9). They received a 2-day CPT workshop followed by weekly 1-h group consultations by teleconference with the CPT expert trainer (R.N). Therapists providing TAU received a trial briefing but no training or supervision. 2.5. Treatments CPT is a 12-session manualized treatment for PTSD. It comprises cognitive restructuring and written exposure elements and aims to address key posttraumatic themes such as safety, trust, power and
4. Discussion This is the first study to examine comorbidity as a predictor of treatment outcome in veterans receiving CPT treatment. The analysis found that of depression, anxiety, alcohol and anger, only anger predicted response to CPT treatment, with more severe anger being associated with reduced treatment gains. This finding is consistent with findings from cohort studies examining male veterans with PTSD (Forbes et al., 2008). It has been suggested that anger may serve to inhibit anxiety following a trauma, especially when effortful avoidance is unsuccessful (Riggs, Dancu, Gershuny, & Greenberg, 1992). This raises the possibility that CPT may not have been as successful with the veterans with elevated anger because they were not able to engage in anxiety-related concerns because the anger inhibited emotional engagement. A related interpretation is that veterans’ fear of anger expression (rather than anger itself) may have attenuated responsivity to PTSD treatment (see Forbes et al., 2008). That
D. Lloyd et al. / Journal of Anxiety Disorders 28 (2014) 237–240
239
Table 1 Imputed means and standard deviations for outcome measures by condition at three time points. Outcome measure
Condition
Pre-treatment
Post-treatment
Follow-up
M
SD
M
SD
M
SD
CAPS
CPT TAU Total
75.53 64.55 70.14
16.35 19.46 18.63
48.03 57.73 52.80
27.89 20.01 24.62
45.30 52.55 48.86
28.15 18.93 14.14
BDI-II
CPT TAU Total
26.33 24.78 25.58
11.38 11.99 11.60
15.91 20.83 18.28
11.97 11.83 12.06
14.77 19.11 16.86
12.86 10.15 11.74
STAI-State
CPT TAU Total
55.97 50.29 53.22
13.52 9.94 12.17
44.59 48.31 46.52
13.12 12.75 12.95
43.59 47.26 45.36
11.49 16.17 13.94
DAR7
CPT TAU Total
31.23 28.75 30.03
14.31 11.36 12.92
23.88 26.48 25.14
15.64 13.98 14.79
17.66 21.68 19.60
12.89 12.54 12.77
AUDIT
CPT TAU Total
12.03 10.56 11.32
8.60 9.28 8.89
6.80 7.06 6.92
5.65 5.83 5.69
6.66 8.48 7.54
4.90 5.76 5.36
Note: CPT, Cognitive Processing Therapy; TAU, treatment as usual; CAPS, Clinician-Administered Posttraumatic Stress Disorder Scale; BDI-II, Beck Depression Inventory; STAI-State, State Trait Anxiety Inventory-State Scale; DAR7, Dimensions of Anger Reactions 7-item scale; AUDIT, Alcohol Use Disorders Identification Test.
Table 2 Comorbidity predictors of CAPS severity. Group
Measure
p
B
p
CPT (n = 30)
Anger Anxiety Depression Alcohol
0.272 0.192 0.510 0.335
.107 .342 .048 .177
0.515 −0.301 −0.112 −0.137
.001 .114 .663 .581
TAU (n = 29)
Anger Anxiety Depression Alcohol
0.549 −0.275 0.682 −0.323
.083 .393 .020 .278
−0.001 0.568 −0.451 0.059
.997 .023 .089 .799
Intercept
Slope
B
Note: B represents standardized coefficients resulting from regressing the intercept and slope on the clinical comorbidity predictors.
is, veterans may have been reluctant to engage fully in accessing trauma-related memories because of concern that such memories and cognitions would trigger anger and aggression, posing a risk of harm to self or others. This interpretation is supported by a growing number of studies demonstrating the link between PTSD and aggression and violence in veterans (Elbogen et al., 2010; MacManus et al., 2012). The finding that anger predicted poor treatment response in our sample, which is not found in female CPT recipients studied by Rizvi, Vogt, and Resick (2009), may reflect a gender effect. Examining different types of anger or anger expressions, and the relationship between anger, fear and anxiety is necessary to understand the mechanisms by which anger (and fear of anger, or avoidance of anxiety) affects treatment outcomes from CPT treatment, and to better understand why TAU outcomes were related to anxiety but not anger. This study suggests that there would be value in assessing and addressing anger prior to treatment, or early in the CPT process. If problematic anger is present, anger could be addressed early in the cognitive component of CPT. There may be value in considering CPT-C (cognitive component only) for clients who may be limited in their engagement with trauma accounts for fear of experiencing emotions including anger. Another approach would be to offer brief behavioral interventions before CPT to provide veterans with the confidence to fully engage with treatment. These suggestions require empirical investigation. This study has some limitations. The sample size was modest which limited the analysis of other factors and dropout rates. The majority of the sample (66%) were Vietnam era veterans, suggesting the need for caution when generalizing the findings to younger
veteran populations. We also did not employ within-session or between-session ratings of anger or anxiety, which would have clarified at which point these factors may influence treatment response.
5. Conclusions This study is the first to examine predictors of outcomes for veterans with PTSD drawn from RCT data and the first to examine comorbid predictors of outcome for CPT in a male sample. Findings suggest that anger is interacting in a specific way with CPT, and that clinicians should carefully assess anger in clients presenting with PTSD. This study points to anger in military related PTSD as an important focus for future research.
Conflict of interest None for any author. The Australian Centre for Posttraumatic Mental Health is partially funded by the Australian Government, Department of Veterans Affairs.
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