Cognition and Psychotherapy in PTSD
Condition: Posttraumatic Stress Disorder (PTSD)
MeSH terms: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
Study type: Observational

Summary: 
      Posttraumatic stress disorder (PTSD) is prevalent among combat Veterans and is a substantial
      public health burden. Several psychotherapies, including cognitive processing therapy (CPT)
      and prolonged exposure therapy, have been recommended as efficacious for the treatment of
      PTSD and are being disseminated nationally in the VA Healthcare System. Yet many individuals
      show limited benefit from such treatments. Accumulating evidence indicates that episodic
      memory deficits may be one factor limiting psychotherapy treatment efficacy in PTSD. The
      proposed study will determine whether verbal memory is a specific predictor of CPT outcomes
      in PTSD, including both symptom reductions and functional outcomes. The study will also
      determine the pathways by which memory functioning affects treatment outcomes by examining
      relationships between memory functioning, treatment engagement, recall of treatment content,
      and illness course. More specifically, analyses will examine whether memory for treatment
      content affects the relationship between memory functioning and treatment outcomes.
    

Detailed description: 
      Accumulating evidence indicates that memory dysfunction: 1) is prominent in PTSD; and 2)
      adversely affects psychotherapy outcomes. Identifying mechanisms underlying the relationship
      between memory dysfunction and poor treatment outcomes is crucial to provide empirical
      guidance regarding appropriate rehabilitation targets to reduce the impact of cognitive
      dysfunction on therapy outcomes.

      In this study, the investigators aim to examine the specific effects of verbal memory on both
      PTSD symptoms and functional outcomes during CPT (Aim 1); identify the pathways by which
      cognitive dysfunction affects psychotherapy treatment response, with a focus on memory for
      treatment content and treatment adherence (Aim 2).

      To achieve these aims, the investigators will enroll 105 Veterans with PTSD, who will
      complete a standard course of cognitive processing therapy (CPT) and complete longitudinal
      assessments of PTSD symptoms, functional status, treatment adherence, and memory for
      treatment content. This study does not randomize participants to treatment since all
      participants will be initiating CPT.

      Recruitment. Participants will primarily be drawn from clinical referrals for PTSD therapy at
      the Corporal Michael J. Crescenz VA Medical Center (CMC VAMC) or its Community Based
      Outpatient Clinics (CBOCs).

      Procedures. Participants will provide written informed consent and undergo intake screening.
      Major assessments will be conducted with participants at study entry (baseline), after
      session 6, and after session 12 (critical endpoint assessment) of CPT.

      Baseline Visit (180-240 mins). Baseline procedures (before starting CPT) include diagnostic
      interviews, questionnaires assessing mood and functioning, a neurocognitive assessment, and
      additional memory measures. Participants will complete structured interview assessments for
      psychiatric conditions including PTSD, stressful life events, sociodemographics and medical
      history, and traumatic brain injury. Self-report assessments of mood, functional status
      (e.g., social adjustment), combat exposure, and behavioral functioning will also be
      administered. The neurocognitive assessment will include conventional neuropsychological
      tests and tests drawn from the Penn Computerized Neurocognitive Battery to assess multiple
      cognitive domains including memory, attention, speed of information processing, executive
      functioning, social cognition, and an IQ estimate. Additional experimental measures of memory
      processes from cognitive science will also be administered.

      Psychotherapy. After the baseline visit, participants will begin a standard course of CPT (12
      sessions) following standardized protocols (Resick et al, 2008) with the investigators' study
      therapists, who will all have extensive, formalized training in CPT and be supervised by an
      expert in CPT. Therapists will be blinded to scores on cognitive measures. After the initial
      CPT session, participants will complete questionnaires of treatment expectancy and
      self-efficacy (10 mins). At every following CPT visit, patients will complete brief
      questionnaires of adherence and application of treatment, depression symptoms, and suicide
      risk.

      Mid-Treatment Assessments (20-30 mins). At CPT sessions 4, 6, 8, and 12 (end), participants
      will complete measures of memory for treatment content, treatment expectancy, and brief
      re-assessments of PTSD, mood, and functioning.

      End of Treatment Assessment (120-180 mins). At the end of treatment, a final visit will
      consist of questionnaires and interviews to assess symptoms of PTSD, mood, functioning,
      cognitive functioning and memory for treatment content.

      Although not a clinical trial, the investigators will examine individual change in symptoms
      at treatment end. Participants who drop out and are not able to be re-engaged will be
      contacted by study staff and asked to participate in a final assessment. After this visit is
      complete (or if the participant refuses), Veterans will be offered additional treatment at
      CMC VAMC as appropriate, with a warm handoff from study staff to the clinical team. Treatment
      non-responders, defined as participants displaying less than a 10-point reduction in CAPS
      Scores at follow-up, will also be referred for further treatment.
    

Intervention name(s): Cognitive Processing Therapy
Intervention type(s): Behavioral
Intervention description(s): Cognitive Processing Therapy is an evidence-based psychotherapy for PTSD.
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Veterans
      
Keywords: Posttraumatic Stress Disorder; Psychotherapy; Neuropsychology