Habituation of distress and craving during treatment as predictors of change in PTSD symptoms and substance use severity

Christal L. Badour, Julianne C. Flanagan, Daniel F. Gros, Therese Killeen, Irene Pericot-Valverde, Kristina J. Korte, Nicholas P. Allan, Sudie E. Back

Research output: Contribution to journalArticlepeer-review

16 Scopus citations


Objective: Increasing evidence supports the efficacy of trauma-focused exposure therapy in the treatment of posttraumatic stress disorder (PTSD) and co-occurring substance use disorders. Little is known, however, about the mechanisms of change in treatment for patients with PTSD and co-occurring substance use disorders. The aim of the present study was to examine whether within- and between-session habituation of distress and substance craving during imaginal exposure relates to treatment outcomes among U.S. military veterans with PTSD and a co-occurring substance use disorder (N = 54). Method: Veterans received Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure, a manualized integrated treatment combining prolonged exposure with cognitive-behavioral therapy for substance use disorders as part of a larger randomized clinical trial. Self-reported distress and craving ratings were collected during each imaginal exposure session. Results: Data were analyzed using a series of random intercept and slope multilevel linear and generalized linear models. Results revealed that between-session habituation of distress and craving was associated with greater improvement in PTSD symptoms during treatment. Between-session habituation of craving was also associated with a marginally greater reduction in frequency of substance use among participants still reporting use during treatment. Within-session habituation of distress was unrelated to treatment outcome. Conclusion: Together, these findings indicate that habituation in both distress and craving may be important in maximizing treatment outcome for patients with PTSD and comorbid substance use disorders.

Original languageEnglish
Pages (from-to)274-281
Number of pages8
JournalJournal of Consulting and Clinical Psychology
Issue number3
StatePublished - Mar 1 2017

Bibliographical note

Funding Information:
The authors would like to acknowledge support from the National Institute on Drug Abuse (NIDA), Grant DA030143 (to Sudie E. Back), the U.S. Department of Veteran Affairs Clinical Sciences Research and Development Career Development Award CX000845 (principal investigator, Daniel F. Gros), and resources at the Ralph H. Johnson Veterans Affairs Medical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of NIDA, the U.S. Department of Veterans Affairs, or the U.S. government.

Publisher Copyright:
© 2017 American Psychological Association.


  • PTSD
  • posttraumatic stress disorder
  • prolonged exposure
  • substance use disorders
  • veterans

ASJC Scopus subject areas

  • Clinical Psychology
  • Psychiatry and Mental health


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