Personalizing Cognitive Processing Therapy With a Case Formulation Approach to Intentionally Target Impairment in Psychosocial Functioning Associated With PTSD

Posttraumatic stress disorder (PTSD) is common and complicated. Recent estimates suggest that over 610,000 US Veterans treated by the Veterans Health Administration (VHA) suffer from posttraumatic stress disorder (PTSD), a disorder that can be chronic and debilitating. The heterogeneity of the 20 symptoms of PTSD; comorbidity with disorders such as depression, panic, and substance use; high rates of concurrent and lingering effects of physical injury, and suicidality all contribute to complex clinical presentations and can exact a significant toll on functioning, quality of life, and well-being decades after exposure to the trauma. The complex and enduring challenges inherent in PTSD and their effect on patients' functioning pose significant hurdles for patients and clinicians.

Impairments in psychosocial functioning are an important, but less well-attended, facet of PTSD. While significant impairment in functioning is clearly a requirement for the diagnosis of PTSD as indicated by Criterion G of the diagnostic criteria for PTSD, resolution of functional impairment is not considered to be a primary therapeutic target in evidence-based PTSD treatment protocols. Improvements in domains of functioning and, more broadly, quality of life and well-being, are most typically considered secondary outcomes in RCTs, if they are reported at all. This seeming lack of attention to impairments in functioning stands in stark contrast to patients' reports of the meaningfulness of these impairments in their lives. In fact, it is often precisely these types of impairments that drive patients suffering from PTSD to seek treatment, arguably more so than the 20 core symptoms of the disorder.

Researchers and providers alike recognize the importance of well-being and seek to maximize functional recovery. It has theoretically been difficult to directly target impairment in functioning (PTSD Criterion G) in manualized therapies, perhaps because "functional impairment" is quite variable across patients in breadth and scope. Including explicit and manualized instruction on "treating functional impairment" is impossible and is likely the reason that no single PTSD psychotherapy exists that is specifically designed to "treat" functional recovery. Trauma-focused EBPs instead are specifically designed to directly target the core symptoms of PTSD. Functional impairment is targeted indirectly through relief in the core symptoms. For example, improvement in occupational functioning may be achieved through decreases in avoidance, mood or anger symptoms that might be interfering with job performance. Gains in functioning (e.g. improving marital relations or workplace functioning) and large effects in well-being and quality of life have historically been difficult to operationalize and are often considered more longterm therapeutic goals, perhaps beyond the scope of brief therapies. However, given the importance of functioning to patients with PTSD, intentionally and thoughtfully building on the success of the skills acquired in evidence-based psychotherapies (EBPs) and expanding those skills to specifically target functional outcomes warrants further exploration.

Cognitive Processing Therapy (CPT) is effective at reducing PTSD symptoms and is widely used. CPT is one of the therapies with the most accumulated empirical support to date. Recent meta-analyses indicate that CPT has the largest effect size of existing evidence-based treatments for PTSD in soldiers and Veterans and across trauma populations (mean ES = 1.69). The effectiveness of CPT extends across patient populations suffering from a range of comorbid conditions including TBI, chronic child abuse histories, comorbid psychiatric and substance use disorders, and ongoing peritraumatic situations. CPT has been designated a first-line treatment in a number of clinical guidelines, including the VHA / Department of Defense (DoD) PTSD Clinical Practice Guidelines. Since 2007, VHA has dedicated substantial resources and effort to the historic, large-scale dissemination of CPT via the Mental Health Dissemination Initiative. To date, over 4,150 VHA providers have been trained in CPT and at least 20,774 Veterans have begun CPT in the last year. Yet the impact of CPT on both PTSD symptoms and psychosocial functioning can be improved.

Veterans with PTSD present to treatment with challenges in psychosocial functioning and other clinical complexities; the failure of manualized treatments for PTSD to provide guidance on how to address these concerns is negatively impacting outcomes. Nearly all (87%) Veterans with PTSD presenting to VHA primary care have at least one comorbid psychiatric condition and, on average, Veterans with PTSD had 2.95 comorbid mental health diagnoses and over 50% reported suicidal ideation. Across trauma populations, PTSD is associated with severe impairments in social and occupational functioning, exerting a more deleterious effect than most mental health diagnoses. Clinical presentations in Veterans suffering from PTSD are further complicated by a host of psychosocial stressors, impairments in major domains of functioning, and comorbid physical conditions. Veterans are more likely to be homeless, be under- or unemployed, and have poor physical health status as compared to non-Veterans. Prior work suggests that unaddressed difficulties in these domains contributes to suboptimal outcomes and premature dropout from CPT among Veterans. The investigators posit that frontline treatments for PTSD must be expanded to directly and intentionally target functional impairments and improve holistic outcomes.