Objectives: To examine (a) generalization of the effectiveness of prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in improving postconcussive symptoms (PCSs) and other outcomes in military service members and Veterans (VA) with histories of mild to severe traumatic brain injury (TBI), and (b) factors associated with PCS reduction. Setting: VA polytrauma medical center. Participants: Consecutive referrals for PTSD treatment of Active Duty (n = 17) or Veterans (n = 27) diagnosed with PTSD and TBI (N = 44). Main Outcome Measures: Neurobehavioral Symptom Inventory, Key Behaviors Change Inventory, Self-Efficacy for Symptom Management, Posttraumatic Stress Disorder Checklist, and Beck Depression Inventory, 2nd edition. Design: Post hoc analysis of archival clinical effectiveness program evaluation data. Interventions: PE for PTSD. Results: There were significant improvements on all outcome measures with large effect sizes (Cohen's d ranging from 0.68 to 2.02). Improvement on PCS (Cohen's d = 1.21) was associated with lower levels of VA service-connected disability and PE treatment completion. Conclusion: PE treatment-related improvements for participants with comorbid PTSD and TBI generalize from PTSD outcomes to PCS and other TBI-related outcomes. Positive outcomes were independent of TBI severity, treatment setting, or Veteran status, but dependent upon PE treatment completion and lower levels of VA service-connected disability.

In contrast to concerns that cognitive limitations and neurobehavioral symptoms (NBS) associated with traumatic brain injury (TBI) may inhibit treatment effectiveness, a recent study found prolonged exposure (PE) led to large reductions in posttraumatic stress disorder (PTSD) symptoms among Iraq-Afghanistan veterans with a range of TBI severity (article by Wolf, Kretzmer, Crawford, Thors, Wagner, Strom, Eftekhari, Klenk, Hayward, and Vanderploeg [J Trauma Stress 28:339-347, 2015]). We further examined this sample of 69 veterans to determine whether system, veteran, and therapist factors predicted clinically significant responses. Results of hierarchical, logistic regressions revealed that therapist training in PE and lower service connection were associated with increased odds of large decreases in PTSD symptoms after adjusting for the robust effect of PE sessions completed. Other patient-level factors including age, time since injury, and baseline NBS were unrelated to significant improvements. Findings emphasized the impact of PE dosage, indicated greater mastery of the protocol was beneficial, and showed that service connection could impede self-reported, clinically significant change during PE in this important cohort.

Initial studies suggest that prolonged exposure (PE) can be successfully implemented with veterans with comorbid posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). However, due to persistent TBI-related cognitive deficits associated with moderate to severe TBI, clinicians may have significant concerns about implementing these treatments and may have questions about how to adapt procedures to facilitate successful outcomes. The present article demonstrates the successful implementation of PE in instances where the presence of TBI-related neurobehavioral symptoms interfered with standard treatment implementation. Procedural modifications such as the inclusion of partners or multidisciplinary staff, incorporation of compensatory strategies, and titration of exposure exercises are demonstrated. Finally, clinical recommendations are provided to assist mental health practitioners with assessment and treatment planning.

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.

Objective: Preliminary examination of the effectiveness of prolonged exposure (PE) therapy for the treatment of posttraumatic stress disorder (PTSD) with Operation Enduring Freedom and Operation Iraqi Freedom Veterans who have experienced traumatic brain injury (TBI). Participants: Ten Veterans with a history of mild to moderate TBI and chronic PTSD. Setting: Outpatient Mental Health/PTSD clinics and polytrauma centers at 2 VA medical centers. Measures: Comprehensive evaluation that included clinical interview, neuropsychologic evaluation, and/or neuroimaging; Posttraumatic Stress Disorder Checklist and Beck Depression Inventory-Second Edition. Procedures: Standard implementation of the PE manual was used in all cases with slight adjustments to account for Veterans' residual cognitive deficits. Veterans completed between 8 and 18 sessions. Results: Veterans demonstrated significant reductions in total PTSD and depression symptoms from pre- to posttreatment. Within-group effect sizes were large. Conclusions: These findings suggest that PE can be safely and effectively implemented with Veterans with PTSD, a history of mild to moderate TBI, and current cognitive impairment.

Minnesota Multiphasic Personality Inventory (MMPI) clinical scales as well as 4 sets of MMPI items known to be sensitive to neurological dysfunction (closed head injury, cerebrovascular disorder) were administered to survivors of childhood physical and/or sexual abuse and to non-abused adults. As predicted, relative to the comparison group of psychiatric patients, the abused participants scored significantly higher on Scale 8 (Schizophrenia) and on all 4 sets of items associated with neurological dysfunction. The results suggest that early abuse/trauma is associated with cognitive disturbances and somatization. Findings appear to support the conceptualization of these psychophysical experiences as a central part of what is often called "complex posttraumatic stress disorder." Limitations and suggestions for further study are discussed.

This study integrated psychological and neuroscience research regarding the effects of childhood trauma in order to advance assessment with this population. Recently, researchers proposed new criteria for complex posttraumatic stress disorder (PTSD) on the basis of years of interdisciplinary research, identifying symptoms that have an empirical association with survivors of childhood trauma. The criteria reflect alterations in regulating affect, dissociation, executive functioning, somatization, and chronic characterological changes. These content areas are compatible with recent neuroscience research with this population and illustrate the interplay between mind brain interactions, chronic stress, and neurodevelopment. Prior research suggested that Scale 8 of the Minnesota Multiphasic Personality Inventory (MMPI) was most sensitive to neurological dysfunction. Therefore, can complex PTSD be detected by the MMPI? Item analyses were performed comparing abused and nonabused participants. Stage 1 of the analysis identified 11 items that differentiated groups. In Stage 2, the study attempted to construct a preliminary scale that correctly classified 81% of participants and 89% of those with a history of abuse. The content of identified items reflects problems with impulsivity, affect regulation, and disrupted cognitive processes. A theoretical explanation is provided in the Discussion section.