An open trial of individualized face-to-face cognitive behavior therapy for psychological distress in parents of children after end of treatment for childhood cancer including a cognitive behavioral conceptualization

OBJECTIVE

A subgroup of parents of children who have been treated for childhood cancer report high levels of psychological distress. To date there is no empirically supported psychological treatment targeting cancer-related psychological distress in this population. The aim of the current study was to test the feasibility and preliminarily evaluate the effect of individualized face-to-face cognitive behavior therapy (CBT) for parents of children after the end of treatment for childhood cancer. A secondary aim was to present a cognitive behavioral conceptualization of cancer-related distress for these parents.

METHODS

An open trial was conducted where 15 parents of children who had completed successful treatment for cancer three months to five years earlier and who reported psychological distress related to a child's previous cancer disease were provided CBT at a maximum of 15 sessions. Participants were assessed at baseline, post-intervention, and three-month follow-up using self-reported psychological distress (including posttraumatic stress symptoms (PTSS), depression, and anxiety) and the diagnostic Mini-International Neuropsychiatric Interview. Feasibility outcomes relating to recruitment, data collection, and delivery of the treatment were also examined. Individual case formulations for each participant guided the intervention and these were aggregated and presented in a conceptualization detailing core symptoms and their suggested maintenance mechanisms.

RESULTS

A total of 93% of the participants completed the treatment and all of them completed the follow-up assessment. From baseline to post-assessment, parents reported significant improvements in PTSS, depression, and anxiety with medium to large effect sizes (Cohen's d = 0.65-0.92). Results were maintained or improved at a three-month follow-up. At baseline, seven (47%) participants fulfilled the diagnostic criteria for major depressive disorder and four (29%) fulfilled the criteria for posttraumatic stress disorder, compared to none at a post-assessment and a follow-up assessment. The resulting cognitive behavioral conceptualization suggests traumatic stress and depression as the core features of distress, and avoidance and inactivity is suggested as the core maintenance mechanisms.

CONCLUSION

The treatment was feasible and acceptable to the participants. Significant improvements in distress were observed during the study. Overall, results suggest that the psychological treatment for parents of children after end of treatment for childhood cancer used in the current study is promising and should be tested and evaluated in future studies.

What Therapies are Favored in the Treatment of the Psychological Sequelae of Trauma in Human Trafficking Victims?

Human trafficking is a major public health concern that brings about deleterious psychological consequences and sequelae. Although a number of risk and protective factors for the health consequences of human trafficking victims have been identified, there is a dearth of information in the area of treatment. Specifically, we found no articles comparing the different components of prevailing trauma treatment strategies, and the potential usefulness of these strategies in the treatment of human trafficking victims. To this end, we compared and contrasted the different therapeutic treatments typically implemented with victims of trauma (including domestic violence victims and torture victims), and discussed how the different components of these treatments may or may not be helpful for human trafficking victims. We assessed the impact of these treatments on the psychological consequences of trauma and, in particular on posttraumatic stress disorder. We also assessed the potential usefulness of these treatments with co-occurring problems such as substance use, psychosis, dissociation, and other mood and anxiety disorders. On the basis of the prevailing research, we highlighted cognitive therapies as being preferred in addressing the needs of human trafficking victims. Mental health providers who work with human trafficking victims should become aware of and practiced in the use of cognitive therapeutic approaches in treating this population. Efficacy and effectiveness studies are needed to validate our recommendations.

Internet-delivered cognitive behavioral therapy for posttraumatic stress disorder in international humanitarian aid workers: Study protocol

BACKGROUND

Humanitarian aid workers are likely to be exposed or witness complex emergencies. Posttraumatic stress disorder (PTSD) is one of the most widespread and most commonly studied mental health problems after exposure to adversities and trauma. However, face-to-face treatment has limited utilization in the resource-constrained settings where humanitarian aid workers often operate. Internet-delivered cognitive behavioral therapy (iCBT) is a treatment option with the potential to improve the access to evidence-based care for humanitarian aid workers. Until now, only a few studies have evaluated iCBT in the treatment of PTSD. No studies have yet explored the feasibility of iCBT for humanitarian aid workers with PTSD. The aim of this study is to investigate the participants' experiences and progress with the treatment, in order to determine whether TELLUS is acceptable for humanitarian aid workers.

METHODS AND DESIGN

A pilot feasibility study will be conducted with 20 humanitarian aid workers with a full or subclinical PTSD diagnosis according to DSM-IV criteria. The intervention used is TELLUS, which is a therapist-assisted Internet-delivered treatment program based on trauma-focused CBT components for individuals with PTSD. It contains eight text-based modules, where each module is expected to be completed within one week.

DISCUSSION

This study may set the ground for a large-scale randomized control trial that would test the effectiveness and cost-effectiveness of the program. The study may contribute to the better understanding of PTSD treatment and increase the availability of evidence-based treatments in resource-constrained settings.

Prolonged Exposure Therapy for Comorbid Psychogenic Nonepileptic Seizures and Posttraumatic Stress Disorder

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures but are not associated with epileptic discharges in the brain. Instead, these episodes, which tend to occur with alterations in consciousness and body movements, are thought to be the result of mechanisms of conversion and dissociation. Psychological trauma and PTSD are very prevalent among patients with PNES. PNES can be conceived of as an extreme avoidance mechanism that serves the function of modulating distress and, in some cases, eliminating the precipitant stressor. Avoidance is also an essential component of PTSD. In patients who carry a dual diagnosis of PNES and PTSD, it is sensible that an empirically validated treatment for PTSD such as prolonged exposure (PE) therapy which targets avoidance by promoting exposure might be a useful approach to treat these patients. In this report, we present the case of a 52-year-old male with a 7-year history of PNES. His seizures, which were characterized by intense body shaking and loud guttural outbursts, were occurring up to 15 times per day. Because of these symptoms, he lost his employment and was ostracized by his family. Upon completion of a course of intensive outpatient PE, he achieved full remission of all psychogenic symptoms. Except for three brief seizures, he has maintained his health for 2 years. This constitutes the first detailed report of PE therapy used to effectively treat comorbid PNES and posttraumatic stress symptoms.

Prazosin during threat discrimination boosts memory of the safe stimulus

The α-1 adrenoreceptor antagonist prazosin has shown promise in the treatment of post-traumatic stress disorder (PTSD) symptoms, but its mechanisms are not well understood. Here we administered prazosin or placebo prior to threat conditioning (day 1) and tested subsequent extinction (day 2) and reextinction (day 3) in healthy human participants. Prazosin did not affect threat conditioning but augmented stimulus discrimination during extinction and reextinction, via lower responding to the safe stimulus. These results suggest that prazosin during threat acquisition may have influenced encoding or consolidation of safety processing in particular, subsequently leading to enhanced discrimination between the safe and threatening stimuli.

Older Adults with PTSD: Brief State of Research and Evidence-Based Psychotherapy Case Illustration

Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals.

A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo

Background

Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo.

Methods

A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score.

Results

Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance.

Conclusions

The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability.

Trial registration

Clinicaltrials.gov (NCT01696578).

A pilot and feasibility randomised controlled study of Prolonged Exposure Treatment and supportive counselling for post-traumatic stress disorder in adolescents: a third world, task-shifting, community-based sample

BACKGROUND

There is a dearth of empirical evidence on the effectiveness of pharmacological and nonpharmacological treatments for adolescents with post-traumatic stress disorder (PTSD) in developing country settings. The primary aim of this study was to demonstrate that Prolonged Exposure Treatment for Adolescents (PE-A) and supportive counselling (SC) are implementable by nurses in a South African context. A secondary aim was to perform a preliminary analysis of the effectiveness of registered nurses delivering either PE-A or SC treatment to adolescents with PTSD. It is hypothesised that PE-A will be superior to SC in terms of improvements in PTSD symptoms and depression.

METHOD

A pilot, single-blind, randomised clinical trial of 11 adolescents with PTSD. Nurses previously naïve to Prolonged Exposure (PE) Treatment and SC provided these treatments at the adolescents' high schools. Data collection lasted from March 2013 to October 2014. Participants received twelve 60-90-min sessions of PE (n = 6) or SC (n = 5). All outcomes were assessed before treatment, at mid-treatment, immediately after treatment completion and at 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed with the Child PTSD Symptom Scale-Interview (CPSS-I) (range, 0-51; higher scores indicate greater severity). The secondary outcome, depression severity, was assessed with the Beck Depression Inventory (BDI) (range, 0-41; higher scores indicate greater severity).

RESULTS

Data were analysed as intention to treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvement on the CPSS-I as well as on the BDI. There was a significant difference between the PE-A and SC groups in maintaining PTSD and depression at the 12-month post-treatment assessment, with the participants in the PE-A group maintaining their gains both on PTSD and depression measures.

CONCLUSION

The treatment was adequately implemented by the nurses and well-tolerated by the participants. Preliminary results suggest that the delivery of either intervention led to a significant improvement in PTSD and depression symptoms immediately post treatment. The important difference was that improvement gains in PTSD and depression in the PE-A group were maintained at 12-month follow-up. The results of this pilot and feasibility study are discussed.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR201511001345372 , registered on 11 November 2015.

Integrated Exposure-Based Therapy for Co-Occurring Post Traumatic Stress Disorder (PTSD) and Substance Dependence: Predictors of Change in PTSD Symptom Severity

This paper examines factors associated with change in PTSD symptom severity among individuals randomised to receive an integrated exposure-based psychotherapy for PTSD and substance dependence–Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE). Outcomes examined include change in PTSD symptom severity as measured by the Clinician Administered PTSD Scale (CAPS), and the reliability and clinical significance of change in PTSD symptom severity. Factors examined include patient baseline characteristics, treatment characteristics, and events over follow-up. The mean difference in CAPS score was 38.24 (SE 4.81). Approximately half (49.1%) demonstrated a reliable and clinically significant improvement in PTSD symptom severity. No one was classified as having demonstrated clinically significant worsening of symptoms. Three independent predictors of reductions in PTSD symptom severity were identified: baseline PTSD symptom severity (β 0.77, SE 0.23, p = 0.001), number of traumas experienced prior to baseline (β −0.30, SE 0.15, p = 0.049), and number of sessions attended (β 2.05, SE 0.87, p = 0.024). The present study provides further evidence regarding the safety of the COPE treatment and factors associated with improvement in PTSD symptom severity. The identification of only a small number of predictors of the outcome points to the broad applicability of the COPE treatment to PTSD and substance use disorder (SUD) patients.

A Dynamic Model of Post-Traumatic Stress Disorder for Military Personnel and Veterans

Post-traumatic stress disorder (PTSD) stands out as a major mental illness; however, little is known about effective policies for mitigating the problem. The importance and complexity of PTSD raise critical questions: What are the trends in the population of PTSD patients among military personnel and veterans in the postwar era? What policies can help mitigate PTSD? To address these questions, we developed a system dynamics simulation model of the population of military personnel and veterans affected by PTSD. The model includes both military personnel and veterans in a “system of systems.” This is a novel aspect of our model, since many policies implemented at the military level will potentially influence (and may have side effects on) veterans and the Department of Veterans Affairs. The model is first validated by replicating the historical data on PTSD prevalence among military personnel and veterans from 2000 to 2014 (datasets from the Department of Defense, the Institute of Medicine, the Department of Veterans Affairs, and other sources). The model is then used for health policy analysis. Our results show that, in an optimistic scenario based on the status quo of deployment to intense/combat zones, estimated PTSD prevalence among veterans will be at least 10% during the next decade. The model postulates that during wars, resiliency-related policies are the most effective for decreasing PTSD. In a postwar period, current health policy interventions (e.g., screening and treatment) have marginal effects on mitigating the problem of PTSD, that is, the current screening and treatment policies must be revolutionized to have any noticeable effect. Furthermore, the simulation results show that it takes a long time, on the order of 40 years, to mitigate the psychiatric consequences of a war. Policy and financial implications of the findings are discussed.

Does Feeling Bad, Lead to Feeling Good? Arousal Patterns during Expressive Writing

Different psychotherapy theories describe process patterns of emotional arousal in contradictory ways. To control both treatment and therapist responsivity, this study sought to test dynamic patterns in the arousal of negative affect using a controlled experimental study of expressive writing. There were 261 participants (78% women; M = 21 years old; 56% White) who suffered unresolved traumas who were randomly assigned to an expressive writing task and asked to write about their deepest thoughts and feelings, or to a writing control. Participants wrote for 15 min on three consecutive days, completing the Positive Affect and Negative Affect Scale before and after each visit. Data across 6 time points were subjected to hierarchical linear modeling (HLM) and pattern analyses. Session-by-session (24 hr periods), the expressive writing group showed an overall linear decrease in negative affect (β = −2.273, p < .001). However, in pre- to post-session ratings (15 min periods), the expressive writing group also demonstrated increases in negative affect (β = 6.467, p < .001). Neither of these patterns were observed in the control group. Pattern analysis demonstrated 69.8% of cases in the expressive writing group perfectly or almost perfectly followed a predicted zig-zag pattern ( p < .01). No control cases showed this pattern. Findings demonstrate how the habituation/inhibition hypothesis (“it gets easier as one gets over it”) and the meaning-making hypothesis (“it gets worse before it gets better”) can both be supported, each at different scopes of analysis. Implications clarify the role of emotional arousal in change.

Psychological interventions for post-traumatic stress disorder in people living with HIV in Resource poor settings: a systematic review

OBJECTIVE

Post-traumatic stress disorder is pervasive in low- and middle-income countries. There is evidence to suggest that post-traumatic stress disorder is more common among people living with HIV than non-infected matched controls. We carried out a systematic review of interventions for adult post-traumatic stress disorder from resource poor settings with a focus on people living with HIV.

METHODS

We included all studies that investigated interventions for adult post-traumatic stress disorder from resource poor settings with a focus on interventions that were either randomised controlled trials or observational cohort studies carried out from 1980 to May 2015.

RESULTS

Of the 25 articles that were identified for full review, two independent reviewers identified seven studies that met our study inclusion criteria. All randomised controlled trials (RCT) (n = 6) used cognitive behavioural therapy-based interventions and focused on people living with HIV in resource poor settings. There was only one study focusing on the use of lay counsellors to address post-traumatic stress disorder but core competencies were not described. There were no intervention studies from Africa, only an observational cohort study from Rwanda.

CONCLUSION

Rigorously evaluated interventions for adult post-traumatic stress disorder in people living with HIV are rare. Most were undertaken in resource poor settings located in high-income countries. There is a need for research on the development and implementation of appropriate interventions for post-traumatic stress disorder in people living with HIV in low- and middle-income countries.

Internet-based cognitive behavioural therapy (iCBT) for posttraumatic stress disorder versus waitlist control: study protocol for a randomised controlled trial

BACKGROUND

This randomised controlled trial (RCT) with two parallel arms will evaluate the efficacy of an internet-delivered six-lesson 10-week cognitive behavioural therapy (iCBT) intervention for posttraumatic stress disorder (PTSD). It will also investigate the association between changes in PTSD symptoms, intolerance of uncertainty (IU) and emotion regulation.

METHODS/DESIGN

Patients with PTSD will be recruited via the research arm of a not-for-profit clinical and research unit in Australia and randomised to a treatment group or waitlist control group. The minimum sample size for each group (alpha 0.05, power 0.80 for a g of 0.47) was identified as 72, but 10 % more will be recruited to hedge against expected attrition. PTSD diagnosis will be determined using the PTSD module from the Mini International Neuropsychiatric Interview version 5.0.0. The PTSD Checklist - Civilian version (PCL-C) will be used to measure PTSD symptoms (the primary outcome measure), with the Intolerance of Uncertainty Scale 12-item version (IUS-12) and the Emotion Regulation Questionnaire (ERQ) used to measure intolerance of uncertainty and emotion regulation, respectively. The PCL-C will be administered to the treatment group before each lesson of the PTSD program and at 3-month follow-up. The IUS-12 and ERQ will be administered before lessons 1 and 4, at post-treatment and at 3-month follow-up. The waitlist control group will complete these measures at week 1, week 5 and week 11 of the waitlist period. PTSD program efficacy will be determined using intent-to-treat mixed models. Maintenance of gains will be assessed at 3-month follow-up. Mediation analyses using PROCESS will be used to examine the association between change in PTSD symptoms over treatment and change in each of IU and emotion regulation ability in separate analyses.

DISCUSSION

The current RCT seeks to replicate previous efficacy findings of iCBT for PTSD in a formally assessed PTSD sample from the general population. Findings may point to future lines of enquiry for the role of IU and emotion regulation in the mechanism of PTSD symptom change during CBT.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614001213639 , registered 18 November 2014. This trial protocol is written in compliance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.

The Efficacy of Exposure Therapy for Anxiety-Related Disorders and Its Underlying Mechanisms: The Case of OCD and PTSD

In this review we describe the intricate interrelationship among basic research, conceptualization of psychopathology, treatment development, treatment outcome research, and treatment mechanism research and how the interactions among these areas of study further our knowledge about psychopathology and its treatment. In describing the work of Edna Foa and her colleagues in anxiety disorders, we demonstrate how emotional processing theory of anxiety-related disorders and their treatment using exposure therapy have generated hypotheses about the psychopathology of posttraumatic stress disorder and obsessive-compulsive anxiety disorder that have informed the development and refinement of specific treatment protocols for these disorders: prolonged exposure and exposure and response (ritual) prevention. Further, we have shown that the next step after the development of theoretically driven treatment protocols is to evaluate their efficacy. Once evidence for a treatment's efficacy has accumulated, studies of the mechanisms involved in the reduction of the targeted psychopathology are conducted, which in turn inform the theory and further refine the treatments. We conclude our review with a discussion of how the knowledge derived from Foa and colleagues' programmatic research together with knowledge emerging from basic research on extinction learning can inform future research on the psychopathology of anxiety disorders and their treatments.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men. Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity. PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function. Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy. Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories. However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events. The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies. However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.

Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability

INTRODUCTION

The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance.

OBJECTIVE

In addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT.

METHOD

We performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols.

RESULTS

Results showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD.

CONCLUSION

The main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatment.

Prolonged exposure, paroxetine and the combination in the treatment of PTSD following a motor vehicle accident. A randomized clinical trial - The "TRAKT" study

BACKGROUND AND OBJECTIVE

Little is known about direct comparisons of the efficacy of trauma-focused psychotherapies and SSRIs. This is the first randomized clinical trial comparing the efficacy of prolonged exposure (PE), paroxetine (Ph) and their combination (Comb) in a sample of adults diagnosed with PTSD following motor vehicle accidents (MVA).

METHODS

A total of 228 people were randomly assigned to a twelve-week treatment of PE (N = 114), Ph (N = 57) or Comb (N = 57).

RESULTS

The ITT analyses showed that the remission rate of PTSD was significantly greater after PE (65.5%) compared with Ph (43.3%), whereas Comb (51.2%) did not differ from either. The differences in dropout rates were not significant between treatments (18.4% - PE; 12.2% - Ph; 22.8% - Comb), while the differences in numbers of refusers were significant (3.5% PE <31.6% Comb <47.4% Ph; p < .01). The changes in self-rated PTSD were significant for each treatment and without significant differences between treatments. Differences between clinician and self-rated outcomes can be explained by depressive symptoms influencing self-rating by the PDS. At a 12 month follow-up treatment results were maintained and different trajectories of functioning were identified.

LIMITATIONS

Larger samples would allow analyses of predictors of treatment response, dropout and refusal.

CONCLUSIONS

In this, largest to date study comparing PE, paroxetine and combination treatment in PTSD PE was more effective than Ph in achieving remission of PTSD. The additive effect of Comb over any monotherapy was not shown.

Are 60-minute prolonged exposure sessions with 20-minute imaginal exposure to traumatic memories sufficient to successfully treat PTSD? A randomized noninferiority clinical trial

The study aims to determine whether 60-minute sessions of prolonged exposure (PE) that include 20 minutes of imaginal exposure (IE) are noninferior to the standard 90-minute sessions that include 40 minutes of IE in treating posttraumatic stress disorder (PTSD) and to explore the relationship of treatment outcome to within- and between-session habituation and change in negative cognitions. Thirty-nine adult veterans with chronic PTSD were randomly assigned to 90-minute (n=19) or 60-minute (n=20) sessions of PE. PTSD symptoms were assessed by an unaware independent evaluator before and after treatment and at 6-month follow-up. Self-reports of depression and negative cognitions were assessed before and after treatment. Participants in both conditions showed significant reductions in PTSD symptoms. Sixty-minute sessions were found to be noninferior to 90-minute sessions in reducing PTSD symptoms, as the upper bound of the 95% confidence interval for the difference between conditions in the PTSD Symptom Scale-Interview (posttreatment: 6.00; follow-up: 6.77) was below the predefined noninferiority margin (7.00). Participants receiving shorter sessions showed less within- and between-session habituation than those receiving longer sessions, but no group differences in reductions in negative cognitions were found. The current findings indicate that the outcomes of 60-minute sessions of PE do not differ from those of 90-minute sessions. In addition, change in trauma-related cognitions and between-session habituation are both potential mechanisms of PE.

An unconditioned stimulus retrieval extinction procedure to prevent the return of fear memory

BACKGROUND

Conditioned fear memories can be updated by extinction during reconsolidation, and this effect is specific to the reactivated conditioned stimulus (CS). However, a traumatic event can be associated with several cues, and each cue can potentially trigger recollection of the event. We introduced a technique to target all diverse cues associated with an aversive event that causes fear.

METHODS

In human experiments, 161 subjects underwent modified fear conditioning, in which they were exposed to an unconditioned stimulus (US) or unreinforced CS to reactivate the memory and then underwent extinction, spontaneous recovery, and reinstatement. In animal experiments, 343 rats underwent contextual fear conditioning under a similar protocol as that used in the human experiments. We also explored the molecular alterations after US reactivation in rats.

RESULTS

Presentation of a lower intensity US before extinction disrupted the associations between the different CS and reactivated US in both humans and rats. This effect persisted for at least 6 months in humans and was selective to the reactivated US. This procedure was also effective for remote memories in both humans and rats. Compared with the CS, the US induced stronger endocytosis of alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid glutamate receptors 1 and 2 and stronger activation of protein kinase A, p70S6 kinase, and cyclic adenosine monophosphate response element binding protein in the dorsal hippocampus in rats.

CONCLUSIONS

These findings demonstrate that a modified US retrieval extinction strategy may have a potential impact on therapeutic approaches to prevent the return of fear.

A comparison of Narrative Exposure Therapy and Prolonged Exposure therapy for PTSD

The purpose of this review was to compare and contrast Prolonged Exposure (PE) and Narrative Exposure Therapy (NET). We examined the treatment manuals to describe the theoretical foundation, treatment components, and procedures, including the type, manner, and focus of exposure techniques and recording methods used. We examined extant clinical trials to investigate the range of treatment formats reported, populations studied, and clinical outcome data. Our search resulted in 32 studies on PE and 15 studies on NET. Consistent with prior reviews of PTSD treatment, it is evident that PE has a solid evidence base and its current status as a first line treatment for the populations studied to this date is warranted. We argue that NET may have advantages in treating complex traumatization seen in asylum seekers and refugees, and for this population NET should be considered a recommended treatment. NET and PE have several commonalities, and it is recommended that studies of these treatments include a broader range of populations and trauma types to expand the current knowledge on the treatment of PTSD.

Cultural adaptations of prolonged exposure therapy for treatment and prevention of posttraumatic stress disorder in african americans

Posttraumatic stress disorder (PTSD) is a highly disabling disorder, afflicting African Americans at disproportionately higher rates than the general population. When receiving treatment, African Americans may feel differently towards a European American clinician due to cultural mistrust. Furthermore, racism and discrimination experienced before or during the traumatic event may compound posttrauma reactions, impacting the severity of symptoms. Failure to adapt treatment approaches to encompass cultural differences and racism-related traumas may decrease treatment success for African American clients. Cognitive behavioral treatment approaches are highly effective, and Prolonged Exposure (PE) in particular has the most empirical support for the treatment of PTSD. This article discusses culturally-informed adaptations of PE that incorporates race-related trauma themes specific to the Black experience. These include adding more sessions at the front end to better establish rapport, asking directly about race-related themes during the assessment process, and deliberately bringing to the forefront race-related experiences and discrimination during treatment when indicated. Guidelines for assessment and the development of appropriate exposures are provided. Case examples are presented demonstrating adaptation of PE for a survivor of race-related trauma and for a woman who developed internalized racism following a sexual assault. Both individuals experienced improvement in their posttrauma reactions using culturally-informed adaptations to PE.

Mindfulness-based training attenuates insula response to an aversive interoceptive challenge

Neuroimaging studies of mindfulness training (MT) modulate anterior cingulate cortex (ACC) and insula among other brain regions, which are important for attentional control, emotional regulation and interoception. Inspiratory breathing load (IBL) is an experimental approach to examine how an individual responds to an aversive stimulus. Military personnel are at increased risk for cognitive, emotional and physiological compromise as a consequence of prolonged exposure to stressful environments and, therefore, may benefit from MT. This study investigated whether MT modulates neural processing of interoceptive distress in infantry marines scheduled to undergo pre-deployment training and deployment to Afghanistan. Marines were divided into two groups: individuals who received training as usual (control) and individuals who received an additional 20-h mindfulness-based mind fitness training (MMFT). All subjects completed an IBL task during functional magnetic resonance imaging at baseline and post-MMFT training. Marines who underwent MMFT relative to controls demonstrated a significant attenuation of right anterior insula and ACC during the experience of loaded breathing. These results support the hypothesis that MT changes brain activation such that individuals process more effectively an aversive interoceptive stimulus. Thus, MT may serve as a training technique to modulate the brain's response to negative interoceptive stimuli, which may help to improve resilience.

Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial

BACKGROUND

Post-traumatic stress disorder (PTSD) with co-occurring severe psychopathology such as borderline personality disorder (BPD) is a frequent sequel of childhood sexual abuse (CSA). CSA-related PTSD has been effectively treated through cognitive-behavioural treatments, but it remains unclear whether success can be achieved in patients with co-occurring BPD. The aim of the present study was to determine the efficacy of a newly developed modular treatment programme (DBT-PTSD) that combines principles of dialectical behaviour therapy (DBT) and trauma-focused interventions.

METHODS

Female patients (n = 74) with CSA-related PTSD were randomised to either a 12-week residential DBT-PTSD programme or a treatment-as-usual wait list. About half of the participants met the criteria for co-occurring BPD. Individuals with ongoing self-harm were not excluded. The primary outcomes were reduction of PTSD symptoms as assessed by the Clinician-Administered PTSD Scale (CAPS) and by the Posttraumatic Stress Diagnostic Scale (PDS). Hierarchical linear models were used to compare improvements across treatment groups. Assessments were carried out by blinded raters at admission, at end of treatment, and at 6 and 12 weeks post-treatment.

RESULTS

Under DBT-PTSD the mean change was significantly greater than in the control group on both the CAPS (33.16 vs. 2.08) and the PDS (0.70 vs. 0.14). Between-group effect sizes were large and highly significant. Neither a diagnosis of BPD nor the severity or the number of BPD symptoms was significantly related to treatment outcome. Safety analyses indicated no increase in dysfunctional behaviours during the trial.

CONCLUSION

DBT-PTSD is an efficacious treatment of CSA-related PTSD, even in the presence of severe co-occurring psychopathology such as BPD.

Animal models of fear relapse

Whereas fear memories are rapidly acquired and enduring over time, extinction memories are slow to form and are susceptible to disruption. Consequently, behavioral therapies that involve extinction learning (e.g., exposure therapy) often produce only temporary suppression of fear and anxiety. This review focuses on the factors that are known to influence the relapse of extinguished fear. Several phenomena associated with the return of fear after extinction are discussed, including renewal, spontaneous recovery, reacquisition, and reinstatement. Additionally, this review describes recent work, which has focused on the role of psychological stress in the relapse of extinguished fear. Recent developments in behavioral and pharmacological research are examined in light of treatment of pathological fear in humans.

Reenvisioning Clinical Science: Unifying the Discipline to Improve the Public Health

We present a vision of clinical science, based on a conceptual framework of intervention development endorsed by the Delaware Project. This framework is grounded in an updated stage model that incorporates basic science questions of mechanisms into every stage of clinical science research. The vision presented is intended to unify various aspects of clinical science toward the common goal of developing maximally potent and implementable interventions, while unveiling new avenues of science in which basic and applied goals are of equally high importance. Training in this integrated, translational model may help students learn how to conduct research in every domain of clinical science and at each stage of intervention development. This vision aims to propel the field to fulfill the public health goal of producing implementable and effective treatment and prevention interventions.

Cognitive-behavioral group therapy for youths with anxiety disorders in the community: effectiveness in low and middle income countries

BACKGROUND

Although cognitive-behavioral therapy (CBT) is established as a first line treatment for anxiety disorders in children and adolescents, there is little evidence about the effectiveness of CBT protocols in cases identified in the community in low and middle income countries (LaMICs).

AIMS

To evaluate the effectiveness of group CBT protocol for youths with anxiety disorders identified in a community sample in LaMICs.

METHOD

A total of 14 sessions of group CBT for youths and 2 concurrent sessions for parents based on Kendall's Coping Cat program were offered. Participants were selected from a cross-sectional community study; 45 subjects fulfilled inclusion criteria and 28 agreed to participate in the open clinical trial. Treatment effectiveness was evaluated with standard clinical, self- and parent-rated measures of anxiety, depression, externalizing symptoms and quality of life (QoL).

RESULTS

Twenty youths completed the protocol. All scales showed an improvement of anxiety and reduction in externalizing symptoms over time, with a moderate to large effect size (d = 0.59 to 2.06; p < .05), but not in depressive symptoms or QoL.

CONCLUSIONS

Consistent with previous evidence, group CBT is effective in treating anxiety disorders in youths. Results encourage further randomized clinical trials using CBT protocols adapted and developed to be used in LaMICs.

Experimental Exposure Therapy for Posttraumatic Nightmares

Nightmares are one of the most troubling features of posttraumatic stress disorder (PTSD), yet imagery rehearsal training (IRT) is currently the only empirically supported treatment for posttraumatic nightmares. Although IRT is effective, it is unknown whether IRT or the exposure, which is inherent in this procedure, causes the decrease in nightmares. This study will attempt to clarify this issue by using exposure therapy alone to treat a patient with PTSD. The participant is a 39-year-old male who experienced a single traumatic event. Data were collected on his sleep habits, as well as on the frequency and intensity of the nightmares. Results indicate that exposure-based nightmare treatment for PTSD sufferers should be considered in conjunction with standard treatment packages.

Systemic or intra-prelimbic cortex infusion of prazosin impairs fear memory reconsolidation

The alpha-1 adrenergic antagonist prazosin has been used to alleviate the symptoms of PTSD, but the mechanism remains unclear. One possibility is that prazosin may disrupt fear memory reconsolidation, leading to attenuation of fear responses. To test this hypothesis, we administered a single systemic injection of prazosin during the reconsolidation of olfactory fear conditioning in rats. We found that a post-retrieval injection of prazosin disrupted subsequent retrieval of fear. Similarly, intra-prelimbic cortex infusion of prazosin during the reconsolidation period also disrupted subsequent retrieval of fear. These findings suggest that fear memory undergoes reconsolidation through activation of alpha-1 adrenergic receptors in the prelimbic cortex.

The effects of positive patient testimonials on PTSD treatment choice

Despite the existence of effective treatment options for PTSD, these treatments are failing to reach those that stand to benefit from PTSD treatment. Understanding the processes underlying an individual's treatment seeking behavior holds the potential for reducing treatment-seeking barriers. The current study investigates the effects that positive treatment testimonials have on decisions regarding PTSD treatment. An undergraduate (N = 439) and a trauma-exposed community (N = 203) sample were provided with videotaped treatment rationales for prolonged exposure (PE) and sertraline treatments of PTSD. Half of each sample also viewed testimonials, detailing a fictional patient's treatment experience. All participants then chose among treatment options and rated the credibility of - and personal reactions toward - those options. Among treatment naïve undergraduates, testimonials increased the proportion choosing PE alone; and among treatment naïve members of the trauma-exposed community sample, testimonials increased the proportion choosing a combined PE plus sertraline treatment. These effects were not observed for those with prior history of either psychotherapeutic or pharmacological treatment. Major barriers exist that prevent individuals with PTSD from seeking treatment. For a critical unreached treatment sample, those who are treatment naïve, positive patient testimonials offer a mechanism in which to make effective treatments more appealing and accessible.

Psychological adaptation to life-threatening injury in dyads: the role of dysfunctional disclosure of trauma

BACKGROUND

CERTAIN MODES OF TRAUMA DISCLOSURE HAVE BEEN FOUND TO BE ASSOCIATED WITH MORE SEVERE SYMPTOMS OF POSTTRAUMATIC STRESS (PTS) IN DIFFERENT TRAUMA POPULATIONS: the reluctance to disclose trauma-related thoughts and feelings, a strong urge to talk about it, and physical as well as emotional reactions during disclosure. Although social-contextual influences gain more and more interest in trauma research, no study has yet investigated these "dysfunctional disclosure tendencies" and their association with PTS from an interpersonal perspective.

OBJECTIVE

(1) To replicate previous findings on dysfunctional disclosure tendencies in patients with life-threatening injury and their significant others and (2) to study interpersonal associations between dysfunctional disclosure style and PTS at a dyadic level.

METHOD

PTS symptom severity and self-reports on dysfunctional disclosure tendencies were assessed in N=70 dyads comprising one individual with severe traumatic brain injury and a significant other ("proxy") 3 months after injury.

RESULTS

Regression analyses predicting PTS symptom severity revealed dysfunctional disclosure tendencies to have incremental validity above and beyond sex, age, and trauma severity within the individual (both patient and proxy), with moderate effect sizes. The interaction between patient's and proxy's disclosure style explained additional portions of the variance in patients' PTS symptom severity.

CONCLUSIONS

Findings suggest that dysfunctional disclosure tendencies are related to poorer psychological adaptation to severe traumatic brain injury. This intrapersonal association may be exacerbated by dysfunctional disclosure tendencies on the part of a significant other. Although the results require replication in other trauma samples without brain injury to further generalize the findings beyond the observed population, the study contributes to the expanding literature on the crucial role of interpersonal relationships in trauma recovery.