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Schindler L, Stalder T, Kirschbaum C, Plessow F, Schönfeld S, Hoyer J, Trautmann S, Steudte-Schmiedgen S. Cognitive functioning in posttraumatic stress disorder before and after cognitive-behavioral therapy. J Anxiety Disord 2020; 74:102265. [PMID: 32623282 DOI: 10.1016/j.janxdis.2020.102265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 05/22/2020] [Accepted: 06/16/2020] [Indexed: 11/24/2022]
Abstract
Although substantial evidence suggests altered executive functioning and autobiographical memory in posttraumatic stress disorder (PTSD), the clinical significance of these findings remains unclear. Here, we investigated the effects of cognitive-behavioral therapy (CBT) on different aspects of cognitive functioning (working memory, interference susceptibility, conflict adaptation, autobiographical memory) in PTSD patients in a pre-post control group design with a nested cross-sectional element. Cross-sectional analyses at baseline were conducted on 58 PTSD patients, 39 traumatized (TC), and 45 non-traumatized controls (NTC). Intervention effects were investigated before and after 25 CBT sessions in 25 PTSD and 34 untreated NTC individuals assessed in parallel. At baseline, PTSD patients showed higher conflict adaptation than the NTC group and less autobiographical memory specificity than both control groups, suggesting particularly the latter to be a correlate of PTSD. No consistent evidence for treatment-induced improvements in cognitive functioning emerged on the group level or from associations between intra-individual clinical and cognitive changes. Analyses on the role of cognitive functioning on subsequent treatment effects revealed a predictive effect of backward digit span on CBT-induced reductions of depressiveness, but no other significant effects. Our findings highlight the need for further research to identify more relevant predictors of differential treatment response.
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Affiliation(s)
- Lena Schindler
- Faculty of Psychology, Technische Universität Dresden, Germany.
| | - Tobias Stalder
- Department Erziehungswissenschaften und Psychologie, Universität Siegen, Germany.
| | | | - Franziska Plessow
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| | - Sabine Schönfeld
- Faculty of Psychology, Technische Universität Dresden, Germany; Department of Psychology, Lund University, Sweden.
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany.
| | - Sebastian Trautmann
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany; Department of Psychology, Medical School Hamburg, Germany.
| | - Susann Steudte-Schmiedgen
- Faculty of Psychology, Technische Universität Dresden, Germany; Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Germany.
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Tanev KS, Federico LE, Terry DP, Clark EL, Iverson GL. Cognitive Impairment and Predicting Response to Treatment in an Intensive Clinical Program for Post-9/11 Veterans With Posttraumatic Stress Disorder. J Neuropsychiatry Clin Neurosci 2020; 31:337-345. [PMID: 31018812 DOI: 10.1176/appi.neuropsych.18090208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined whether objectively measured pretreatment cognitive impairment predicted worse response to treatment for posttraumatic stress disorder. Participants were 113 veterans and active duty service members who participated in a new multidisciplinary 2-week intensive clinical program that included individual trauma-focused cognitive-behavioral therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments (mean age: 39.7 years [SD=8.5]; 20% women). METHODS Prior to treatment, participants completed a brief computerized cognitive battery (CNS Vital Signs) and were operationalized as having cognitive impairment if they scored in the ≤5th percentile on two or more of five core cognitive domains. Participants completed measures of traumatic stress, depression, cognitive self-efficacy, and satisfaction with their ability to participate in social roles before and after treatment. RESULTS There were no significant correlations between pretreatment individual cognitive test scores and change in the clinical outcome measures. One-half of the study sample (49.6%) met criteria for cognitive impairment. In a mixed multivariate analysis of variance, the interaction between cognitive impairment and time was not significant (F=0.83, df=4, 108, p=0.51), indicating that the pre- to posttreatment changes in outcome scores were not significantly different for the cognitively impaired group compared with the cognitively intact group. The multivariate main effect for time was significant (F=36.75, df=4, 108, p<0.001). Follow-up univariate tests revealed significant improvement in traumatic stress, depression, cognitive self-efficacy, and satisfaction with social roles after treatment. CONCLUSIONS Cognitive impairment was not associated with worse response to treatment in veterans with severe and complex mental health problems. Veterans with and without cognitive impairment reported large improvements in symptoms and functioning after treatment.
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Affiliation(s)
- Kaloyan S Tanev
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Lydia E Federico
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Douglas P Terry
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Erika L Clark
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
| | - Grant L Iverson
- From Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston (Tanev, Federico, Terry, Clark, Iverson); the Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Tanev, Federico, Clark); and the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Harvard Medical School, Boston (Iverson, Terry)
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Tanev KS, Federico LE, Greenberg MS, Orr SP, Goetter EM, Resick PA, Pitman RK. Baseline Cognitive Performance and Treatment Outcomes From Cognitive-Behavioral Therapies for Posttraumatic Stress Disorder: A Naturalistic Study. J Neuropsychiatry Clin Neurosci 2020; 32:286-293. [PMID: 31948321 PMCID: PMC8887025 DOI: 10.1176/appi.neuropsych.19020032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. METHODS This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively). RESULTS Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD. CONCLUSIONS These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.
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Affiliation(s)
- Kaloyan S. Tanev
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Lydia E. Federico
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | | | - Scott P. Orr
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Elizabeth M. Goetter
- Home Base, a Red Sox Foundation and Massachusetts General Hospital Program, Boston,Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical School, Durham, N.C
| | - Roger K. Pitman
- Department of Psychiatry, Massachusetts General Hospital, Boston
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Metts AV, Keilp JG, Kishon R, Oquendo MA, Mann JJ, Miller JM. Neurocognitive performance predicts treatment outcome with cognitive behavioral therapy for major depressive disorder. Psychiatry Res 2018; 269:376-385. [PMID: 30173044 DOI: 10.1016/j.psychres.2018.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 12/20/2022]
Abstract
The current study examined the contribution of baseline neuropsychological functioning to the prediction of antidepressant outcome with cognitive behavioral therapy (CBT) for Major Depressive Disorder (MDD). We hypothesized that depressed participants who were more neurocognitively intact and had less rigid, negative thinking would respond better to CBT. Thirty-one MDD patients completed a comprehensive neuropsychological battery before initiation of CBT. A subgroup also completed a probabilistic reversal learning task. Depression severity was assessed with the Beck Depression Inventory (BDI); rigid, negative thinking was assessed with the Dysfunctional Attitudes Scale (DAS) and the Automatic Thoughts Questionnaire (ATQ) throughout treatment. Remitters were compared to non-remitters. Paradoxically, eventual remitters performed generally worse across the neuropsychological battery considered as a whole. Univariate testing showed a significant difference on only a single measure, the Continuous Performance Test d', when corrected for multiple comparisons. Baseline rigid, negative thinking did not predict treatment outcome. Results suggest that the structure of CBT may particularly benefit individuals with mild depression-related neurocognitive difficulties during a depressive episode. Further research is needed to examine these patient characteristics and their potential contribution to the mechanisms of CBT efficacy.
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Affiliation(s)
- Allison V Metts
- Department of Psychiatry, Columbia University, Molecular Imaging and Neuropathology Division, and New York State Psychiatric Institute, New York, NY, USA
| | - John G Keilp
- Department of Psychiatry, Columbia University, Molecular Imaging and Neuropathology Division, and New York State Psychiatric Institute, New York, NY, USA
| | - Ronit Kishon
- Department of Psychiatry, Columbia University, Depression Evaluation Service, and New York State Psychiatric Institute, New York, NY, USA
| | - Maria A Oquendo
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - J John Mann
- Department of Psychiatry, Columbia University, Molecular Imaging and Neuropathology Division, and New York State Psychiatric Institute, New York, NY, USA
| | - Jeffrey M Miller
- Department of Psychiatry, Columbia University, Molecular Imaging and Neuropathology Division, and New York State Psychiatric Institute, New York, NY, USA.
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