Skip to main content Accessibility help

The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel

  • Lily A. Brown (a1), Joshua D. Clapp (a2), Joshua J. Kemp (a3), Jeffrey S. Yarvis (a4), Katherine A. Dondanville (a5), Brett T. Litz (a6), Jim Mintz (a5), John D. Roache (a5), Stacey Young-McCaughan (a5), Alan L. Peterson (a7), Edna B. Foa (a8) and For the STRONG STAR Consortium (a1) (a2) (a3) (a4) (a5) (a6) (a7) (a8)...



Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT).


Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership.


Five classes, namely rapid responder (7–17%), steep linear responder (14–22%), gradual responder (30–34%), non-responder (27–33%), and symptom exacerbation (7–13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT.


Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.


Corresponding author

Author for correspondence: Lily A. Brown, E-mail:


Hide All
Aderka, IM, Appelbaum-Namdar, E, Shafran, N and Gilboa-Schechtman, E (2011) Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 79, 441446.
Akaike, H (1987) Factor analysis and AIC. Psychometrika 52, 317332.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th Edn. text rev. Washington, DC: American Psychiatric Association.
Asparouhov, T and Muthen, B (2014) Auxiliary variables in mixture modeling: using the BCH method in Mplus to estimate a distal outcome model and an arbitrary second model. Mplus web notes: No. 21. Retrieved from
Bakk, Z and Vermunt, JK (2016) Robustness of stepwise latent class modeling with continuous distal outcomes. Structural Equation Modeling: A Multidisciplinary Journal 23, 2031.
Beck, AT, Steer, RA and Brown, GK (1996) Manual for the Beck Depression Inventory-II. San Antonio, Texas: The Psychological Corporation.
Brady, F, Warnock-Parkes, E, Barker, C and Ehlers, A (2015) Early in-session predictors of response to trauma-focused cognitive therapy for posttraumatic stress disorder. Behaviour Research and Therapy 75, 4047.
Brown, LA, Zandberg, LJ and Foa, EB (in press). Mechanisms of change in prolonged exposure therapy for PTSD: implications for clinical practice. Journal of Psychotherapy Integration.
Clapp, JD, Kemp, JJ, Cox, KS and Tuerk, PW (2016) Patterns of change in response to prolonged exposure: implications for treatment outcome. Depression and Anxiety, 33, 807815.
Clark, SL and Muthen, B (2009) Relating latent class analysis results to variables not included in the analysis. Retrieved from
Cusack, K, Jonas, DE, Forneris, CA, Wines, C, Sonis, J, Middleton, JC, Feltner, C, Brownley, KA, Olmsted, KR, Greenblatt, A, Weil, A and Gaynes, BN (2016) Psychological treatments for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Clinical Psychology Review 43, 128141.
Doane, LS, Feeny, NC and Zoellner, LA (2010) A preliminary investigation of sudden gains in exposure therapy for PTSD. Behaviour Research and Therapy 48, 555560.
Eftekhari, A, Ruzek, JI, Crowley, JJ, Rosen, CS, Greenbaum, MA and Karlin, BE (2013) Effectiveness of national implementation of prolonged exposure therapy in veterans affairs care. JAMA Psychiatry 70, 949955.
Foa, EB and Tolin, DF (2000) Comparison of the PTSD symptom scale-interview version and the clinician-administered PTSD scale. Journal of Traumatic Stress 13, 181191.
Foa, EB, Riggs, DS, Dancu, CV and Rothbaum, BO (1993) Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress 6, 459473.
Foa, EB, Tolin, DF, Ehlers, A, Clark, DM and Orsillo, SM (1999) The posttraumatic cognitions inventory (PTCI): development and validation. Psychological Assessment 11, 303314.
Foa, EB, Zoellner, LA, Feeny, NC, Hembree, EA and Alvarez-Conrad, J (2002) Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical Psychology 70, 10221028.
Foa, EB, McLean, CP, Capaldi, S and Rosenfield, D (2013) Prolonged exposure vs supportive counseling for sexual abuse-related PTSD in adolescent girls: a randomized clinical trial. Journal of the American Medical Association 310, 26502657.
Foa, EB, McLean, CP, Zang, Y, Rosenfield, D, Yadin, E, Yarvis, JS, Mintz, J, Young-McCaughan, S, Borah, EV, Dondanville, KA, Fina, BA, Hall-Clark, BN, Lichner, T, Litz, BT, Roache, J, Wright, EC, Peterson AL for the STRONG STAR Consortium (2018) Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present centered therapy on PTSD severity in military personnel: a randomized clinical trial. Journal of the American Medical Association 319, 354364.
Goodman, LA (2002) Latent class analysis: the empirical study of latent types, latent variables, and latent structures. In Hagenaars, JA and McCutcheon, AL (eds), Applied Latent Class Analysis. Cambridge, United Kingdom: Cambridge University Press, pp. 355.
Howell, DC (2010) Statistical methods for psychology, 7th Edn. Belmont, CA: Wadsworth.
Jacobson, NS and Truax, P (1991) Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59, 1219.
Joesch, JM, Golinelli, D, Sherbourne, CD, Sullivan, G, Stein, MB, Craske, MG and Roy-Byrne, PP (2013) Trajectories of change in anxiety severity and impairment during and after treatment with evidence-based treatment for multiple anxiety disorders in primary care. Depression and Anxiety 30, 10991106.
Jun, JJ, Zoellner, LA and Feeny, NC (2013) Sudden gains in prolonged exposure and sertraline for chronic PTSD. Depression and Anxiety 30, 607613.
Karlin, BE, Ruzek, JI, Chard, KM, Eftekhari, A, Monson, CM, Hembree, EA, Resick, PA and Foa, EB (2010) Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration. Journal of Trauamatic Stress 23, 663673.
Kelly, KA, Rizvi, SL, Monson, CM and Resick, PA (2009) The impact of sudden gains in cognitive behavioral therapy for posttraumatic stress disorder. Journal of Traumatic Stress 22, 287293.
Larsen, SE, Wiltsey Stirman, S, Smith, BN and Resick, PA (2016) Symptom exacerbations in trauma-focused treatments: associations with treatment outcome and non-completion. Behaviour Research and Therapy 77, 6877.
Loerinc, AG, Meuret, AE, Twohig, MP, Rosenfield, D, Bluett, EJ and Craske, MG (2015) Response rates for CBT for anxiety disorders: need for standardized criteria. Clinical Psychology Review 42, 7282.
Lubke, G and Muthén, BO (2007) Performance of factor mixture models as a function of model size, covariate effects, and class-specific parameters. Structural Equation Modeling: A Multidisciplinary Journal 14, 2647.
Muthén, LK and Muthén, BO (2012) Mplus User's Guide, 7th Edn. Los Angeles, CA: Muthén & Muthén.
Nishith, P, Resick, PA and Griffin, MG (2002) Pattern of change in prolonged exposure and cognitive-processing therapy for female rape victims with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 70, 880886.
Nylund, KL, Asparouhov, T and Muthén, BO (2007) Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Structural Equation Modeling: A Multidisciplinary Journal, 14, 535569.
Orinstein, AJ, Urcelay, GP and Miller, RR (2010) Expanding the intertrial interval during extinction: response cessation and recovery. Behavior Therapy 41, 1429.
Raftery, AE (1995) Bayesian model selection in social research. Sociological Methodology 25, 111163.
Ramaswamy, V, Desarbo, WS, Reibstein, DJ and Robinson, WT (1993) An empirical pooling approach for estimating marketing mix elasticities with PIMS data. Marketing Science 12, 103124.
Schnurr, PP, Friedman, MJ, Engel, CC, Foa, EB, Shea, MT, Chow, BK, Resick, PA, Thurston, V, Orsillo, SM, Haug, R, Turner, C and Bernardy, N (2007) Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. Journal of the American Medical Association 297, 820830.
Schumm, JA, Walter, KH and Chard, K (2013) Latent class differences explain variability in PTSD symptom changes during cognitive processing therapy for veterans. Psychological Trauma: Theory, Research, Practice, and Policy 5, 536544.
Suris, A, Link-Malcolm, J, Chard, K, Ahn, C and North, C (2013) A randomized clinical trial of cognitive processing therapy for veterans with PTSD related to military sexual trauma. Journal of Traumatic Stress 26, 2837.
Urcelay, GP, Wheeler, DS and Miller, RR (2009) Spacing extinction trials alleviates renewal and spontaneous recovery. Learning and Behavior 37, 6073.
U.S. Department of Veterans Affairs (2008) Uniform Mental Health Services in VA Medical Centers and Clinics (VHA Handbook 1160.01). Washington, DC: Author.
Weathers, F, Litz, BT, Herman, DS, Huska, JA and Keane, TM (1993, October). The PTSD Checklist (PCL): Reliability, validity and diagnostic utility. Paper presented at the 9th Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed