Hyperarousal Symptoms Linger After Successful PTSD Treatment in Active Duty Military

Clinical Impact Statement There are evidence-based psychotherapies (EBP) to help those with posttraumatic stress disorder (PTSD). Active duty service members respond differently to EBP than civilians. We examined if there were specific PTSD symptom clusters that were more likely to linger after cognitive processing therapy (CPT) in active duty service members who had served at least one combat deployment. Hyperarousal symptoms were more likely to persist than the other symptom clusters even in service members who responded optimally to CPT. Providers should be aware that hyperarousal symptoms may need treatment before or after CPT. Objective: Evidence-based psychotherapies are efficacious at reducing posttraumatic stress disorder (PTSD) symptoms, but military and veteran samples improve less than civilians. The objective of this secondary analysis of two clinical trials of cognitive processing therapy (CPT) was to determine if hyperarousal symptoms were more resistant to change compared with other PTSD symptom clusters in active duty service members. Method: Service members completed the PTSD Checklist for the DSM-5 (PCL-5) pre- and post-CPT. Symptoms were coded present if rated 2 (moderate) or higher on a 0-4 scale. Cutoffs for reliable and clinically significant change classified 21%, 18%, and 61% of participants as recovered, improved, and suboptimal responders, respectively. Data analyses focused on the posttreatment status of symptoms that were present at baseline to determine their persistence as a function of treatment outcome. Generalized linear mixed effects models with items treated as a repeated measure estimated the proportions who continued to endorse each symptom and compared hyperarousal symptoms with symptoms in other clusters. Results: Among improved participants, the average hyperarousal symptom was present in 69% compared with 49% for symptoms in other clusters (p < .0001). Among recovered patients, hyperarousal symptoms were present for 26%, while symptoms in the reexperiencing (2%), avoidance (3%), and negative alterations (4%) clusters were almost nonexistent (p < .0001). Conclusions: Even among service members who recovered from PTSD after CPT, a significant minority continue to report hyperarousal symptoms while other symptoms remit. Hyperarousal symptoms may require additional treatment.