Enhancement of PTSD Treatment With Computerized Executive Function Training
Condition: Posttraumatic Stress Disorder
MeSH terms: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
Study type: Interventional

Summary: 
      This study focuses on helping Iraq and Afghanistan Veterans with posttraumatic stress
      disorder (PTSD) benefit fully from therapy by first enhancing their thinking abilities. PTSD
      has been associated with thinking problems, including difficulty planning/organizing,
      thinking flexibly, and inhibiting distracting emotional information. There is some evidence
      that computerized training programs are helpful for improving thinking. Therefore, this study
      tests whether computerized cognitive training will in fact improve individuals' thinking
      abilities and if this will in turn improve PTSD treatment outcomes and lead to more
      individuals completing treatment and showing greater improvements in emotional symptoms and
      quality of life than standard therapy (when paired with a word training condition).
    

Detailed description: 
      PTSD affects approximately 14% of OEF/OIF Veterans and leads to considerable personal and
      societal costs (e.g., increased morbidity, reduced work productivity, poorer relationships).
      Although cognitive behavioral therapy (CBT) is one of the most effective treatments for PTSD,
      a substantial portion (approximately 50%) of individuals drop out prematurely, do not respond
      to treatment, or relapse.

      Treatment engagement is worse for OEF/OIF Veterans, who attend fewer sessions and have higher
      dropout rates than civilians and Veterans from other eras. One likely barrier to treatment
      engagement and effectiveness is the executive functioning problems present in individuals
      with PTSD. Executive functions (EFs) are the set of higher-level cognitive skills that
      organize and integrate lower-level cognitive processes in order to perform complex,
      goal-directed tasks. PTSD has been associated with EF deficits, including impairments in
      inhibitory control, working memory, and cognitive flexibly, as well as dysfunction in a
      network of brain regions that support EFs (e.g., prefrontal cortex [PFC], cingulate).

      EFs are essential for CBT in order to engage the cognitive skills involved in treatment
      (e.g., self-monitoring, inhibiting distorted thoughts, and flexibly generating/evaluating
      alternative thoughts). This is particularly true for Cognitive Processing Therapy (CPT), a
      frontline CBT treatment for PTSD, which involves identifying and challenging maladaptive
      trauma-related thoughts to alter their impact on emotions and behavior. Thus, EF deficits may
      lead to reduced CPT engagement and responsivity. In fact, worse EF at baseline has been
      associated with poorer response to CBT in several disorders (e.g., generalized anxiety
      disorder, obsessive compulsive disorder, and schizophrenia). Further, a study of brain
      functioning during an EF task demonstrated that dysfunction in EF-related brain regions
      including PFC and cingulate cortex at baseline predicted nonresponse to CBT for PTSD.
      Directly targeting EF prior to CPT via cognitive training would strengthen executive networks
      and likely boost treatment effectiveness, allowing Veterans to fully engage in and benefit
      more from components of CPT (e.g., cognitive restructuring). Evidence suggests that
      computerized cognitive training improves EF and functioning in EF-related brain regions,
      increases mental health treatment completion rates, and goal of the proposed study is to
      examine whether administering computerized EF training (CEFT) immediately prior to CPT will
      improve executive functioning and enhance treatment adherence, completion rates, and
      psychological and functional outcomes in OEF/OIF Veterans with PTSD.

      Objective (neuropsychological) and subjective (self- report) measures of EF will be collected
      to determine if CEFT enhances EF and if this in turn mediates the relationship between
      treatment condition and PTSD symptom improvement. Functional neuroimaging during EF tasks
      will also be collected at baseline to determine whether functioning within an EF network
      predicts treatment response, above and beyond traditional paper-and-pencil measures of EF.
      Veterans will be randomized to either 12 weeks of CEFT-CPT or a placebo word training
      condition plus CPT.

      Assessments will be administered at baseline, immediately after CEFT or word training (prior
      to CPT), and after CPT completion. The proposed research aims to reduce barriers to treatment
      engagement and has potential to significantly enhance current treatments for PTSD by
      combining cognitive and psychotherapeutic approaches. Targeting EF directly and independently
      represents a logical, innovative, and empirically-informed method for augmenting existing
      treatments for PTSD in order to optimize outcomes. Findings from the proposed study will not
      only directly inform clinical practice, but also have the potential to significantly improve
      the quality of Veterans' lives, reduce societal costs and burden, improve access to care, and
      reveal ways to better match individuals with treatments they are most likely to benefit from.
    

Intervention name(s): Computerized executive function training plus CPT (CEFT-CPT); Word game training plus CPT (WT-CPT)
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants randomized to the CEFT-CPT arm will receive 6 weeks of computerized executive function training and then 6 weeks of standard Cognitive Processing Therapy for PTSD (total of 12 sessions); Participants randomized to the WT-CPT arm will receive 6 weeks of computerized word game training and then 6 weeks of standard Cognitive Processing Therapy for PTSD (total of 12 sessions)
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Outcomes Assessor)
Primary purpose: Treatment
Keywords: PTSD; treatment; posttraumatic stress disorder; therapy; cognition; thinking; executive function; computer; training