Psychology paper

Journal of Traumatic Stress, Vol. 24, No. 5, October 2011, pp. 591–595 ( C 2011) BRIEF REPORT A Resilience-Oriented Treatment for Posttraumatic Stress Disorder: Results of a Preliminary Randomized Clinical Trial Martha Kent Phoenix VA Healthcare System and Banner Behavioral Health Hospital, Scottsdale Mary C. Davis and Shannon L. Stark Arizona State University Laura A. Stewart Southwest Behavioral Health Services, Phoenix This preliminary randomized trial examined the effect of a resilience-oriented intervention for posttraumatic stress disorder (PTSD) versus a waitlist control on anxiety and depressive symptoms, positive emotional health, and cognitive performance in 39 veterans with a variety of traumatic exposures. From pre- to posttreatment, the intervention but not the control group showed improvements that were large in magnitude for affective symptoms and positive emotional health (ds=0.73–1.18), moderate in magnitude for memory (ds=0.50–0.54), and small-to-moderate in magnitude for executive function (ds=0.30–0.35). Findings suggest that treatment explicitly targeting resilience resources (e.g., positive emotional engagement, social connectedness) may provide broad bene ts, including alleviation of anxiety and depressive symptoms and improved positive emotional and cognitive function.

Individuals are motivated to approach rewards and avoid painful conditions. Attention to both motivational systems is highly adaptive. In the case of posttraumatic stress disorder (PTSD), however, individuals are oriented more toward avoid- ance of threat and attend less to the pursuit of positive, val- ued experiences (Kashdan, Breen, & Julian, 2010). At a neural level, the circuitry of fear and avoidance remains hyperactive long past trauma exposure and is relatively unmodulated by higher level cortical activity (Aupperle & Paulus, 2010; Walter, Palmieri, & Gunstad, 2010). Not surprisingly, most current psychological PTSD treatments focus primarily on extinguishing the fear re- sponse, most typically through exposure (Foa, Keane, Friedman, & Cohen, 2008). Martha Kent, Phoenix VA Healthcare System and Banner Behavioral Health Hospital, Scotts- dale; Mary C. Davis and Shannon L. Stark, Department of Psychology, Arizona State University, Tempe; Laura A. Stewart, Southwest Behavioral Health Services, Phoenix.

This work was supported by the Phoenix VA Health Care System and the Institute for Mental Health Research to Martha Kent. Contents do not represent views of the Department of Veterans Affairs or U. S. Government.

Correspondence concerning this article should be addressed to Martha Kent, Research De- partment, R151, Phoenix VA Health Care System, 650 E. Indian School Road, Phoenix, AZ 85012. E-mail: [email protected] C 2011 International Society for Traumatic Stress Studies. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.20685 In this study, we tested an alternative approach to PTSD treat- ment, one that emphasizes reengagement of the approach moti- vational system to create a positive hub of regulatory activity. A capacity-building approach is grounded in evidence from disparate literatures pointing to the value of positive resilience resources in ameliorating responses to trauma or stress. Strong social relation- ships and self-ef cacy are protective factors for children facing adversity (Masten, 2001). Likewise, positive emotions accelerate physiological recovery following stress-induced autonomic arousal (Tugade & Fredrickson, 2004), and even build intellectual and cognitive resources (Fredrickson, 2004).

This preliminary randomized trial of a resilience-oriented treat- ment attempted to bolster positive emotional engagement and so- cial bonds prior to revisiting past traumatic experiences in veterans with PTSD. The treatment was expected to have broad effects, improving symptoms, positive emotional health, and cognitive function compared to a waitlist control. METHOD Participants and Procedure Eligibility criteria included (a) being United States veterans from the Vietnam war era up through the Gulf war, and (b) scoring> 591 592Kent et al.

40 on the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1998). Exclusion criteria included (a) active suicidality, (b) active alcohol/substance abuse, (c) psychosis, and (d) life-threatening illness.

Of 47 individuals assessed for eligibility, 39 completed the preassessment and were randomly assigned stratifying by sex (n= 20 intervention,n=19 control). The sample was primarily male (67%), Caucasian (75.8 %), and unemployed (66%), and had attended at least some college (73%). Mean age was 54 years (SD= 8.34, range=34–66), and modal household income was $21,000– $24,999. The traumas indexed by the CAPS were combat (31%), childhood sexual abuse (21%), childhood physical abuse (18%), violent unexpected death of another (14%), sexual assault (6%), physical assault (5%), and accident (5%). The PTSD symptom duration averaged 12 years (range=1–41).

Study procedures were approved by the institutional review boards of the Phoenix Veterans Affairs Health Care System (VA) and Arizona State University and conducted at the VA. Individuals were recruited via posted yers at the VA and local veteran centers, screened by phone, consented, and administered the CAPS by a psychologist (MK) or a master’s-level clinician trained in the use of the CAPS according to the guidelines of the National Center for PTSD.

Pre and postassessment included completion of standardized questionnaires assessing mental health symptoms and positive emotional health, and neuropsychological testing. Because it was a group intervention, randomization was in waves. Participants in both conditions within a treatment wave completed questionnaire postassessments 1 week after and neuropsychological assessments within 5 weeks of the nal treatment session in meetings conducted at the VA.

The manualized intervention, delivered in 12 weekly 90-minute group sessions, initially fosters resilience resources (e.g., awareness of positive emotions; social connectedness) that individuals are en- couraged to draw on in later sessions when they revisit traumatic episodes or experience PTSD symptoms. Week 1 provides an intro- duction to the concept of resilience and the topics to be covered in the remainder of the treatment. Weeks 2 and 3 focus on increasing attention to bodily sensations as sources of vitality and engage- ment. Weeks 4–7 seek to build positive emotional experiences and social bonds, rst by drawing on childhood experiences and then expanding the focus to include current experiences. Weeks 8–10 involve revisiting stressors and traumas, tapping into the positive emotional resources and strong social bonds developed in earlier sessions. Finally, Weeks 11 and 12 focus on developing a plan to sustain change.

The intervention was implemented in two waves (Wave 1 was 10 intervention, 9 controls; Wave 2 was 10 intervention, 10 con- trols), with all treatment delivered by the same clinician (MK).

Average attendance was 9.75 group sessions (SD=2.24, range= 2–12). Measures The CAPS (Blake et al., 1998) provided a PTSD diagnostic and symptom score at enrollment. Pre- to-post change in mental health symptoms were assessed via the Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995) for PTSD symptoms; Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) for depressive symptoms, and the State-Trait Anxiety Inventory (STAI; Spiel- berger, Gorsuch, & Lushene, 1970) for anxiety levels. Internal consistencies at pre- and post-treatment were good for measures of PTSD (pre=.83; post=.96); depression (pre=.93; post= .95); anxiety (pre=.90; post=.95).

Pre- to-post change in positive emotional health was assessed with the Vitality and Social Functioning subscales of the RAND 36-item Health Survey-1.0 (Ware, Kosinski, & Keller, 1994), and by summing the Purpose in Life (e.g., “I have a sense of direction and purpose in life”), Positive Relations with Oth- ers (e.g., “Most people see me as loving and affectionate”), and Personal Growth (e.g., “Life has been a continuous process of learning, changing, and growth”) subscales of the Psychological Well-Being Scale (Ryff, 1989) to provide a rating of well-being. In- ternal consistency was adequate to good at pre- and post-treatment for Vitality (pre=.84; post=.75), Social Functioning (pre= .80; post=.68), and Well-being (pre=.90; post=.90).

Executive function was assessed with the Word Generation sub- test of the Neuropsychological Assessment Battery (Stern & White, 2003), and the Category Fluency, Category Switching, and Color- Word Switching subtests of the Delis-Kaplan Executive Function System (Delis, Kaplan, & Kramer, 2001). Repeatable Battery for the Assessment of Neuropsychological Status (Randolph, 1998) subtests assessed working memory (List Learning) and episodic memory (Story Memory, Story Recall, List Recall). Alternate ver- sions of all cognitive tests were employed at pre- and postassess- ment. Test-retest reliability from pre- to postasssessment ranged from .50 for Category Switching to .74 for Word Generation.

Data Analysis Botht-test and chi-square analyses were conducted to compare groups on demographic characteristics and pretreatment levels of all outcome measures. Pretreatment scores of three individuals who dropped out prior to study completion (one intervention, two control participants) were carried forward to posttreatment (i.e., intent-to-treat; see Figure 1).

To evaluate intervention effects, 2 (Group)×2(Time)re- peated measures analyses of variance (ANOVA) were performed for symptom, positive emotional health, executive function, and memory measures. Signi cant Group×Time effects were fol- lowed by within-groupt-tests. Cohen’sdvalues (Cohen, 1988) estimated the magnitude of within-group pre- to-post change, and Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. Resilience-Oriented Treatment for PTSD593 Assessed for eligibility (n= 47) Excluded ( n= 8) Not meeting inclusion criteria (n = 2) Declined to participate (n= 2) Other reasons ( n = 4) Analyzed ( n = 20) Excluded from analysis (n = 0); Pretreatment values carried forward to posttest for 1 dro p ou t Discontinued intervention and lost to posttest (n= 1) Allocated to intervention (n = 20) Received allocated intervention (n = 19) Did not receive allocated intervention ( n = 1; due to increased family obligations ) Discontinued intervention and lost to post test (n = 2 ) Allocated to waitlist ( n = 19) Received allocated waitlist (n = 17) Did not receive allocated waitlist (n = 2; 1 due to worsening mental health, 1 due to increased family obligations) Analyzed (n = 19) Excluded from analysis (n = 0); Pretreatment values carried forward to posttest for 2 dro pouts Allocation Analysis Posttest Randomized (n= 39 ) Enrollment Figure 1.CONSORT ow diagram.

between-group differences in pre- to-post change and were calculated as the difference between the two group means divided by the pooled standard deviation of the groups.

RESULTS At pretreatment, the groups were comparable on demographic characteristics (ps>.13) and CAPS score (interventionM= 74.79,SD=24.07; controlM=83.42,SD=18.13,t(37)= 1.25,ns). Groups also were comparable across dependent measures (ps>.43), suggesting that random assignment yielded groups that were equivalent at pretreatment.

Table 1 presents the pre- and posttreatment raw scores anddval- ues for symptoms, positive emotional health, executive function, and memory separately for the intervention and control groups.

Pre- to-post changes in symptom scores all varied by group, Group ×Timeps<.003. Within-group comparisons revealed that the intervention group improved on all measures pre- to posttreatment (ps<.02,ds=0.82–1.18), whereas waitlist controls remained unchanged (ps>.09). Differences between groups in the mag- nitude of symptom change pre- to posttreatment were large for PTSD, depression, and anxiety (ds>1.02). The proportion scor- ing in the severe range posttreatment was 30% for interventionversus 58% for control participants for PTSD (PDS>35), and 10% for intervention versus 63% for control participants for de- pression (BDI-II>28). The proportion of individuals scoring in the severe range at posttreatment differed between groups only for depression;χ 2(1,N=39)=11.97,p=.001.

Pre- to-post change in positive emotional functioning measures varied between groups, Group×Timeps<.05. Within-group comparisons indicated that the intervention group improved in well-being, vitality, and social functioning (ps<.05,ds=0.42 –0.73), whereas controls showed declines in well-being (p=.039, d=−0.32) and no change in vitality or social functioning. Effect sizes comparing group pre- to-post change were large for well- being and vitality (ds>0.96), and moderate-to-large for social functioning (d=0.68).

Pre- to-post change varied by group for three measures of ex- ecutive functioning: Word Generation, Category Fluency, and Color-Word Switching, Group×Timeps<.03. Within-group comparisons for the intervention group revealed that pre-to- post change was signi cant for Word Generation (p<.04, d=0.35), marginally signi cant for Category Fluency (p<.06, d=0.30), and nonsigni cant for Color-Word Switching (p> .10). For controls, Word Generation scores declined (p=0.011, d=−0.37), whereas other measures of executive function re- mained unchanged (ps>.08). The magnitude of group differences Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 594Kent et al. Ta b l e 1 .Pre- and Posttreatment Group Means, and Standard Deviations, and Treatment Effect Sizes Pretreatment Posttreatment Intervention (n=20) Control (n=19) Intervention (n=20) Control (n=19) MeasuresM SD M SD M SD M SDCohen’sd a PDS 35.90 9.49 37.53 9.77 23.00 12.23 36.90 9.65 1.40 BDI-II 26.05 10.04 29.16 16.16 15.65 8.71 29.90 15.16 1.25 ∗ STAI-State 53.05 10.64 54.53 12.84 44.05 11.32 56.63 10.58 1.02 ∗ Well-Being 78.95 14.62 75.95 18.95 88.50 14.85 69.95 18.55 1.30 ∗ SF-36 Social Role Functioning 36.25 18.54 30.92 29.28 45.63 25.42 26.32 17.63 0.68 ∗ SF-36 Vitality 33.31 14.28 34.80 16.66 43.44 13.49 31.97 14.83 0.96 ∗ Word Generation 10.00 5.21 10.32 4.80 11.75 4.82 8.63 4.45 1.10 Category Fluency 9.50 3.50 10.05 3.19 10.55 3.47 9.32 2.77 0.80 ∗ Category Switching 10.80 3.09 10.84 3.08 11.70 3.60 9.84 4.02 0.58 Color-Word Switching 8.60 3.93 9.58 3.78 9.80 2.98 8.74 3.11 0.77 ∗ List Learning 25.15 4.98 25.05 5.05 27.95 5.40 24.74 5.39 0.79 ∗ Story Memory 16.90 4.42 16.58 3.72 17.35 4.16 15.58 3.44 0.43 List Recall 3.75 2.15 4.21 2.10 4.95 2.24 4.37 1.98 0.67 ∗ Story Recall 8.25 1.83 8.53 2.01 9.35 1.84 8.42 2.34 0.66 ∗ Note.PDS=Posttraumatic Stress Diagnostic Scale; BDI-II=Beck Depression Inventory-II; STAI=State-Trait Anxiety Inventory. Cohen’sdre ects between-group differences in magnitude of pre- to-post change.

aSigni cance levels based on 2 (Group)×2 (Pre-, Post-) analyses of variance interactionFs (1,37).∗p<.05.

in pre- to-post change was large for both Word Generation and Category Fluency (ds>0.80).

Pre- to-post change varied by group for three memory mea- sures: List Learning, List Recall, and Story Recall, Group×Time ps<.05. Within-group comparisons revealed that all three scores improved signi cantly from pre- to post-treatment in the interven- tion group (ps<.03,ds=0.54–0.60), but not in controls (ps> .53,ds=−0.08–0.06). The magnitude of the difference between groups was moderate-to-large for Story Recall,List Learning, and List Recall (ds>0.66).

DISCUSSION The current ndings suggest that a PTSD intervention designed to enhance resilience capacities yields bene ts for veterans not only in symptoms, but also in positive emotional health and cogni- tive functioning, compared to a waitlist control. Large treatment- control differences emerged for mental health symptoms, compa- rable to those reported in trials of established treatments of PTSD (Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010). Thus, at- tention to both symptoms and positive aspects of health appear to be warranted in efforts to promote change in PTSD.

Most novel are the ndings for cognitive function. The treat- ment group showed modest improvement whereas controls showed modest declines in executive function. These ndings extendthose of a small, uncontrolled study that found moderate to-post- treatment improvement in executive function among women re- ceiving individual psychotherapy for PTSD (Walter et al., 2010).

The treatment group also showed moderate-to-large gains rela- tive to controls in two memory processes: encoding and reten- tion/retrieval. Encoding of new information is a process engaging prefrontal cortical areas that deliver information to the hippocam- pal medial temporal region, and is the most common memory impairment in PTSD (Vasterling & Bailey, 2005). Retention and retrieval, memory processes that engage frontal-temporal-polar re- gions, also showed signi cant improvement.

Several methodological limitations deserve comment. First, use of a small sample of veterans, a single clinician delivering treatment, and variability in session attendance constrains generalizability.

Second, individuals administering posttreatment cognitive tests were aware of treatment condition. Although the testing format is standardized, there remains potential bias in cognitive outcomes.

Third, no data are available to determine whether treatment gains persist over time. Finally, the contribution of nonspeci c factors to intervention effects cannot be evaluated due to use of a waitlist control.

Nevertheless, this study suggests that a capacity-building approach to PTSD is a tolerable treatment (i.e., one with low attrition) that may address multiple problems in PTSD, includ- ing decreased positive emotional health and cognitive dysfunction.

Journal of Traumatic StressDOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. Resilience-Oriented Treatment for PTSD595 Future work that attempts to replicate the current ndings, elab- orate potential treatment mechanisms, and compare a resilience approach with more established PTSD treatments is warranted. REFERENCES Aupperle, R. L., & Paulus, M. P. (2010). Neural systems underlying approach and avoidance in anxiety disorders.Dialogues in Clinical Neuroscience, 12, 517– 529.

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