Evaluating changes in negative posttrauma cognition as a mechanism of PTSD severity changes in two separate intensive treatment programs for veterans

Abstract

Background A wealth of evidence has illustrated that reductions in negative posttrauma cognitions (NPCs) predict improvement in posttraumatic stress disorder (PTSD) symptoms during treatment. Yet, the specific temporal arrangement of changes in these constructs is less well understood. This study examined the temporal association between NPC changes and PTSD symptom changes in two distinct intensive PTSD treatment samples. Methods Data from 502 veterans who completed a 3-week CPT-based intensive PTSD treatment program was used to test the extent to which lagged NPC measurement predicted the next occurring PTSD severity measurement using linear mixed effects regression models. PTSD severity was assessed every other day during treatment. NPCs were assessed at three treatment timepoints. A second sample of 229 veterans who completed a 2-week CPT-based intensive PTSD treatment program was used to replicate these findings. Results Across both intensive PTSD treatment programs, NPCs generally increased from intake the end of the first treatment week, which was followed by gradual decreases in NPCs throughout the rest of both programs. Change in NPCs during both the 3-week (b = .21, p < .001, R2 = .38) and the 2-week programs (b = 0.20, p < .001, R2 = .24) were significant predictors of change in PTSD symptom severity. However, the reverse was true as well, with change in PTSD severity predicting latter change in NPCs during both the 3-week (b = 1.51, p < .001, R2 = .37) and 2-week (b = 1.37, p < .001, R2 = .33) programs, further raising questions about temporality of the association between NPCs and PTSD symptom severity during treatment. Conclusions The present study demonstrated that changes in NPCs may not temporally precede changes in PTSD symptom severity in PTSD treatment samples. Instead, we observed earlier PTSD symptom changes and a bidirectional association between the two constructs across both samples. Clinically, the study supports the continued focus on NPCs as an important treatment target as they are an important indicator of successful PTSD treatment, even if they may not be a direct mechanism of treatment-based changes in PTSD severity. Future research should attempt to identify alternative mechanisms of change in CPT.

Examining trauma cognition change trajectories among initial PTSD treatment non-optimal responders: a potential avenue to guide subsequent treatment selection

“…Another limitation is the relatively small number of repeated NPC assessments, especially compared to other studies that have evaluated PTSD severity trajectories, which may have limited the number of NPC change trajectories that could be identified. Since PTSD symptom changes were not examined longitudinally, it was not possible to assess timing or potential mechanistic roles, although there are several published studies that have addressed the temporality of changes in NPC and PTSD symptoms (Held et al, 2022 ; Lee et al, 2021 ). Finally, NPCs were measured in the present moment, whereas PTSD and depression symptoms were rated over the past one and two weeks, respectively.…”

The use of practice assignments in cognitive processing therapy to promote cognitive and emotional change: A case study

“…However, other studies have failed to find a clear directional relationship between changes in negative posttraumatic cognitions in CPT and change in PTSD symptom severity (Held et al, 2022;Lee et al, 2021),…”

“…However, other studies have failed to find a clear directional relationship between changes in negative posttraumatic cognitions in CPT and change in PTSD symptom severity (Held et al, 2022; Lee et al, 2021), suggesting that cognitions and PTSD symptoms may change at the same time, or that perhaps there is a bidirectional relationship between changes in cognitions and PTSD symptom improvement. Additionally, there is strong evidence that cognitive change also may be a mechanism of improvement in exposure therapies, which have a different theoretical rationale than CPT, and limitations in research methods make it difficult to determine with certainty the actual mechanism of change in CPT or other trauma‐focused treatments (Alpert et al, 2023).…”