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Lewis C, Roberts NP, Andrew M, Starling E, Bisson JI. Psychological therapies for post-traumatic stress disorder in adults: systematic review and meta-analysis. Eur J Psychotraumatol 2020; 11:1729633. [PMID: 32284821 PMCID: PMC7144187 DOI: 10.1080/20008198.2020.1729633] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/23/2019] [Accepted: 01/24/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Psychological therapies are the recommended first-line treatment for post-traumatic stress disorder (PTSD). Previous systematic reviews have grouped theoretically similar interventions to determine differences between broadly distinct approaches. Consequently, we know little regarding the relative efficacy of the specific manualized therapies commonly applied to the treatment of PTSD. Objective: To determine the effect sizes of manualized therapies for PTSD. Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: 114 randomized-controlled trials (RCTs) of 8171 participants were included. There was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T), as well as Eye Movement Desensitization and Reprocessing (EMDR), had a clinically important effect. The manualized CBT-Ts with the strongest evidence of effect were Cognitive Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus; guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging evidence for a number of other therapies. Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBT-Ts considered by the review CPT, CT and PE should be the treatments of choice. The findings should guide evidence informed shared decision-making between patient and clinician.
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Affiliation(s)
- Catrin Lewis
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P. Roberts
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
- Directorate of Psychology and Psychological Therapies, Cardiff & Vale University Health Board, Cardiff, UK
| | - Martin Andrew
- Cardiff Traumatic Stress Service, Cardiff & Vale University Health Board, Cardiff, UK
| | - Elise Starling
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I. Bisson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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152
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Badour CL, Dutton CE, Wright JJ, Jones AC, Feldner MT. Shame Proneness, Negative Cognitions, and Posttraumatic Stress Among Women with a History Sexual Trauma. JOURNAL OF AGGRESSION, MALTREATMENT & TRAUMA 2020; 29:699-713. [PMID: 33716493 PMCID: PMC7954215 DOI: 10.1080/10926771.2020.1725211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/07/2019] [Accepted: 12/16/2019] [Indexed: 06/12/2023]
Abstract
While fear and anger have been extensively studied as emotions involved in posttraumatic stress disorder, shame is an important emotion to examine in those who have experienced a traumatic event, as it is often associated with treatment avoidance and treatment resistance. Compared to guilt, which is associated with having participated in something that violates social/cultural norms or expectations, shame is associated with a negative perception of the self. The current paper sought to examine the role of shame proneness and guilt proneness, as it relates to posttraumatic cognitions and posttraumatic stress symptoms (PTSS) among women reporting a history of sexual trauma. Seventy-two community-recruited women with a history of sexual trauma completed self-report measures of shame and guilt proneness and negative posttraumatic cognitions as well as a semi-structured interview assessing PTSS. There was an indirect effect of shame proneness on PTSS, through its positive association with negative cognitions about the self but not others or the world. Guilt proneness was not significantly related to PTSS or negative posttraumatic cognitions. The current paper outlines the importance of these findings and future directions for continuing to better understand the relations between shame and posttraumatic stress disorder symptoms and treatment.
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153
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Fortney JC, Heagerty PJ, Bauer AM, Cerimele JM, Kaysen D, Pfeiffer PN, Zielinski MJ, Pyne JM, Bowen D, Russo J, Ferro L, Moore D, Nolan JP, Fee FC, Heral T, Freyholtz-London J, McDonald B, Mullins J, Hafer E, Solberg L, Unützer J. Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics. Contemp Clin Trials 2020; 90:105873. [PMID: 31678410 DOI: 10.1016/j.cct.2019.105873] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. INTERVENTIONS Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. METHODS Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. RESULTS A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. DISCUSSION We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul N Pfeiffer
- University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Melissa J Zielinski
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Pyne
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, AR, USA
| | - Deb Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Danna Moore
- Social and Economic Sciences Research Center at Washington State University, Pullman, WA, USA
| | | | - Florence C Fee
- NHMH - No Health without Mental Health, San Francisco, CA, Arlington, VA, USA
| | | | | | - Bernadette McDonald
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jeremey Mullins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin Hafer
- Community Health Plan of Washington, Seattle, WA, USA
| | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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154
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Egberts MR, Engelhard IM, Schoot RVD, Bakker A, Geenen R, van der Heijden PGM, Van Loey NEE. Mothers' emotions after pediatric burn injury: Longitudinal associations with posttraumatic stress and depressive symptoms 18 months postburn. J Affect Disord 2020; 263:463-471. [PMID: 31969279 DOI: 10.1016/j.jad.2019.11.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/30/2019] [Accepted: 11/29/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Various emotions are implicated in posttraumatic stress disorder (PTSD). Longitudinal studies examining temporal associations between emotions and posttraumatic stress may reveal who is at risk of chronic psychological problems. This study examined the longitudinal relationships of mothers' trauma-related emotions with posttraumatic stress and depressive symptoms after pediatric burn injury. METHODS Data from two cohort studies were used (n = 296). Mothers reported the intensity of burn-related emotions within the first month (T1) and 12 months postburn (T2). The Impact of Event Scale (IES) and the Hospital and Anxiety Depression Scale (HADS-D; depression subscale) were administered at T1 and 18 months postburn (T3). RESULTS Based on two exploratory factor analyses, emotion variables were combined into acute and long-term basic emotions (fear, sadness, horror, anger) and self-conscious emotions (guilt, shame). The path model showed a positive relationship between acute and long-term basic emotions. Higher long-term basic emotions were related to persistence of posttraumatic stress and depressive symptoms. Acute self-conscious emotions showed associations with posttraumatic stress and depressive symptoms at T1 and were longitudinally related to depressive, but not posttraumatic stress, symptoms. LIMITATIONS The posttraumatic stress measure was not based on DSM-5 PTSD criteria and results require replication using these criteria. CONCLUSIONS This study suggests that mothers' acute self-conscious and long-term basic emotions in relation to their child's burn injury are involved in the development of posttraumatic stress and depressive symptoms. Clinically, assessing and monitoring parents' early posttraumatic stress, depressive symptoms and burn-related emotions may be useful to identify parents at risk.
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Affiliation(s)
- Marthe R Egberts
- Association of Dutch Burn Centres, Beverwijk, the Netherlands; Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands; Department of Methods and Statistics, Utrecht University, Utrecht, the Netherlands.
| | - Iris M Engelhard
- Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
| | - Rens van de Schoot
- Department of Methods and Statistics, Utrecht University, Utrecht, the Netherlands; Optentia Research Program, Faculty of Humanities, North-West University, Vanderbijlpark, South Africa
| | - Anne Bakker
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, research institute(s), Amsterdam, the Netherlands
| | - Rinie Geenen
- Department of Psychology, Utrecht University, Utrecht, the Netherlands
| | - Peter G M van der Heijden
- Department of Methods and Statistics, Utrecht University, Utrecht, the Netherlands; S3RI, University of Southampton, Southampton, United Kingdom
| | - Nancy E E Van Loey
- Association of Dutch Burn Centres, Beverwijk, the Netherlands; Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands
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155
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LeBlanc NJ, Toner ER, O’Day EB, Moore CW, Marques L, Robinaugh DJ, McNally RJ. Shame, guilt, and pride after loss: Exploring the relationship between moral emotions and psychopathology in bereaved adults. J Affect Disord 2020; 263:405-412. [PMID: 31969271 PMCID: PMC7307182 DOI: 10.1016/j.jad.2019.11.164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/20/2019] [Accepted: 11/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Self-blame following bereavement has been implicated in the development of post-loss psychopathology. However, prior studies have not distinguished between the emotions of shame versus guilt. This study examined the cross-sectional associations among bereavement-related shame, bereavement-related guilt, and two mental disorders that commonly arise after bereavement: complicated grief and depression. In addition, exploratory analyses examined the associations between bereavement-related pride and post-loss psychopathology. METHODS Participants included 92 bereaved adults who experienced the death of a family member at least one year prior to the study. Participants completed self-report measures of complicated grief symptoms, depression symptoms, shame, guilt, and pride. RESULTS Shame and guilt were positively correlated with complicated grief and depression symptoms. When controlling for their shared variance, only shame remained a significant predictor of post-loss psychopathology. Follow-up analyses indicated that the effect of guilt on psychopathology depended on the level of shame, and vice versa. At low shame, guilt predicted psychopathology; however guilt did not predict psychopathology at moderate to high shame. At low to moderate guilt, shame predicted psychopathology; however shame did not predict psychopathology at high guilt. Pride negatively predicted depression symptoms, but not complicated grief symptoms, when we controlled for shame and guilt. LIMITATIONS Limitations include the cross-sectional design and modest sample size. CONCLUSIONS Our analyses identify shame as the more pathogenic moral emotion for bereaved adults. However, whereas guilt in the absence of shame is often considered adaptive, we found that guilt predicted greater psychological distress at low levels of shame in this sample.
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Affiliation(s)
- Nicole J. LeBlanc
- Department of Psychology, Harvard University,Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital
| | - Emma R. Toner
- Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital
| | | | - Cynthia W. Moore
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital,Department of Psychiatry, Harvard Medical School
| | - Luana Marques
- Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital,Department of Psychiatry, Harvard Medical School,Community Psychiatry Program for Research in Implementation and Dissemination of Evidence-Based Treatments, Massachusetts General Hospital
| | - Donald J. Robinaugh
- Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital,Department of Psychiatry, Harvard Medical School
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156
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A randomized clinical trial investigating perceived burdensomeness as a mediator of brief intervention effects on posttraumatic stress symptoms. J Affect Disord 2020; 262:344-349. [PMID: 31740111 PMCID: PMC6917918 DOI: 10.1016/j.jad.2019.11.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 09/25/2019] [Accepted: 11/09/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a prevalent and impairing condition that often involves difficulties with interpersonal functioning. Targeting interpersonal difficulties may be a promising alternative approach to reducing PTSD symptoms, particularly given the relatively low rates of treatment engagement and efficacy for first-line treatments for PTSD. Recent research has identified perceived burdensomeness (i.e., feelings of being a burden on others) and thwarted belongingness (i.e., feeling isolated and as if one does not belong) as two specific interpersonal factors related to increased PTSD symptoms. Thus, the current study tested whether a brief, computerized intervention would reduce PTSD symptoms via reductions in perceived burdensomeness and thwarted belongingness, vs. a repeated contact control condition. METHOD Hypotheses were tested among 250 trauma-exposed participants who were randomized to receive one of two active computerized interventions designed to target interpersonal factors (i.e., perceived burdensomeness or thwarted belongingness) or anxiety sensitivity, or participate in a repeated contact control condition, as part of a larger randomized clinical trial. Participants were then followed over six-months. RESULTS Results indicated a direct effect of the active interventions on PTSD symptoms at month-one, that was not detected at months three or six. However, there was a significant indirect effect of condition at all-time points, such that reductions in perceived burdensomeness mediated condition effects on PTSD symptoms. CONCLUSIONS Findings identify perceived burdensomeness as a potential etiological factor in the maintenance of PTSD symptoms, and suggest that targeting perceived burdensomeness may be an effective approach to reducing PTSD symptoms.
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157
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Blais RK, Livingston WS, Fargo JD. Higher depression severity mediates the association of assault military sexual trauma and sexual function in partnered female service members/veterans. J Affect Disord 2020; 261:238-244. [PMID: 31655379 DOI: 10.1016/j.jad.2019.09.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/16/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Military sexual trauma (MST), and assault as opposed to harassment-only MST in particular, is associated with lower sexual function among female service members/veterans (SM/Vs). Recent research revealed that higher posttraumatic stress disorder (PTSD) symptom clusters of anhedonia and dysphoric arousal mediated the association of assault MST and sexual function. Such clusters represent the depressive symptoms of PTSD, and theories of sexual function suggest that depression worsens sexual function. The impact of depression on the association of MST and sexual function has yet to be tested. METHOD Using path analysis, the study examined whether depression severity mediated the association of MST and sexual function after accounting for demographics and mediators of PTSD-related anhedonia and dysphoric arousal. Female SM/Vs (N = 697) completed measures of MST (history, severity), depression, PTSD-related anhedonia and dysphoric arousal, sexual function, and a demographic inventory. RESULTS One hundred twenty-two (17.50%) indicated that they did not experience MST, 336 (48.21%) reported that they experienced harassment-only MST, and 239 (34.29%) reported assault MST. Fit indices evidenced strong model fit, χ2(12, N = 697)=18.85, p=.09, CFI=1.00, TLI=0.99, SRMR=0.02, and RMSEA=0.03. The indirect effect of depression severity was significant (p<.001). LIMITATIONS Use of cross-sectional data in a convenience sample of female SM/Vs. CONCLUSIONS Even after accounting for established covariates and mediators of assault MST and sexual function, depression accounted for a significant amount of variance in this association. Treatment of poor sexual function must address depressive symptoms. As medications for depression can exacerbate sexual issues, psychotherapy may be the most effective treatment strategy.
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158
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Alexander KS, Nalloor R, Bunting KM, Vazdarjanova A. Investigating Individual Pre-trauma Susceptibility to a PTSD-Like Phenotype in Animals. Front Syst Neurosci 2020; 13:85. [PMID: 31992972 PMCID: PMC6971052 DOI: 10.3389/fnsys.2019.00085] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
Post-Traumatic Stress Disorder (PTSD) is a complex condition that develops after experiencing a severe emotional trauma, with or without physical trauma. There is no known cure and evidence-based treatments, which are effective in reducing symptoms, have low retention rates. It is therefore important, in addition to seeking new therapeutics, to identify ways to reduce the likelihood of developing PTSD. The fact that some, but not all, individuals exposed to the same traumatic event develop PTSD suggests that there is individual susceptibility. Investigating susceptibility and underlying factors will be better guided if there is a coherent framework for such investigations. In this review, we propose that susceptibility is a dynamic state that is comprised of susceptibility factors (before trauma) and sequalae factors (during or after trauma, but before PTSD diagnosis). We define key features of susceptibility and sequalae factors as: (1) they are detectable before trauma (susceptibility factors) or during/shortly after trauma (sequalae factors), (2) they can be manipulated, and (3) manipulation of these factors alters the likelihood of developing PTSD, thus affecting resilience. In this review we stress the importance of investigating susceptibility to PTSD with appropriate animal models, because prospective human studies are expensive and manipulation of susceptibility and sequalae factors for study purposes may not always be feasible. This review also provides a brief overview of a subset of animal models that study PTSD-related behaviors and related alterations in endocrine and brain systems that focus on individual differences, peri- and post-trauma. Attention is drawn to the RISP model (Revealing Individual Susceptibility to a PTSD-like Phenotype) which assesses susceptibility before trauma. Using the RISP model and expression of plasticity-associated immediate early genes, Arc and Homer1a, we have identified impaired hippocampal function as a potential susceptibility factor. We further discuss other putative susceptibility factors and approaches to mitigate them. We assert that this knowledge will guide successful strategies for interventions before, during or shortly after trauma that can decrease the probability of developing PTSD.
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Affiliation(s)
- Khadijah S Alexander
- VA Research Service, Charlie Norwood VA Medical Center, Augusta, GA, United States.,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
| | - Rebecca Nalloor
- VA Research Service, Charlie Norwood VA Medical Center, Augusta, GA, United States.,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
| | - Kristopher M Bunting
- VA Research Service, Charlie Norwood VA Medical Center, Augusta, GA, United States.,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
| | - Almira Vazdarjanova
- VA Research Service, Charlie Norwood VA Medical Center, Augusta, GA, United States.,Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, United States
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159
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Comparing the effectiveness of eye movement desensitization reprocessing and cognitive behavioral therapy in reducing post traumatic stress disorder. HEALTH PSYCHOLOGY REPORT 2020. [DOI: 10.5114/hpr.2019.92305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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160
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Gallagher MW, Long LJ, Richardson A, D’Souza J, Boswell JF, Farchione TJ, Barlow DH. Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols. Behav Ther 2020; 51:190-202. [PMID: 32005336 PMCID: PMC7000132 DOI: 10.1016/j.beth.2019.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 01/13/2023]
Abstract
Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.
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161
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Lewis C, Roberts NP, Gibson S, Bisson JI. Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. Eur J Psychotraumatol 2020; 11:1709709. [PMID: 32284816 PMCID: PMC7144189 DOI: 10.1080/20008198.2019.1709709] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.
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Affiliation(s)
- Catrin Lewis
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P Roberts
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK.,Psychology and Psychological Therapies, Cardiff & Vale University Health Board, Cardiff, UK.,Cardiff University Traumatic Stress Service, Cardiff & Vale University Health Board, Cardiff, UK
| | - Samuel Gibson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I Bisson
- National Centre for Mental Health (NCMH), Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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162
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Bedard-Gilligan M, Masters NT, Ojalehto H, Simpson TL, Stappenbeck C, Kaysen D. Refinement and Pilot Testing of a Brief, Early Intervention for PTSD and Alcohol Use Following Sexual Assault. COGNITIVE AND BEHAVIORAL PRACTICE 2019; 27:470-486. [PMID: 34168421 DOI: 10.1016/j.cbpra.2019.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Experiencing a sexual assault can have long-lasting negative consequences including development of posttraumatic stress disorder (PTSD) and alcohol misuse. Intervention provided in the initial weeks following assault can reduce the development of these chronic problems. This study describes the iterative treatment development process for refining a brief intervention targeting PTSD and alcohol misuse for women with recent sexual assault experiences. Experts, treatment providers, and patients provided feedback on the intervention materials and guided the refinement process. Based on principles of cognitive change, the final intervention consists of one in-person session and four coaching calls targeting beliefs about the assault and about drinking behavior. Initial feasibility and acceptability data are presented for patients enrolled in an open trial (N = 6). The intervention was rated as helpful, not distressing, and interesting by patients and all patients completed the entire treatment protocol. A large decrease in PTSD symptoms pre- to post-intervention was observed. A small effect on decreasing alcohol consequences also emerged, although drinks consumed per week showed a slight increase, not a decrease, over the course of the intervention. Applications of this intervention and next steps for testing efficacy are presented.
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Affiliation(s)
| | | | | | - Tracy L Simpson
- University of Washington and Center of Excellence in Substance Addiction, Treatment, and Education, VA Puget Sound, Seattle
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163
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Rehder K, Lusk J, Chen JI. Deaths of Despair: Conceptual and Clinical Implications. COGNITIVE AND BEHAVIORAL PRACTICE 2019; 28:40-52. [PMID: 34168422 DOI: 10.1016/j.cbpra.2019.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Since the late 1990s, mortality rates for middle-aged (45-55), White non-Hispanic (WNH) Americans began to rise while rates declined for all other demographic and age groups. Coinciding with the rise in mortality, rates of death due to suicide, drug- and alcohol-related overdoses, and alcohol-related liver diseases increased as well for this demographic. Research suggests these causes of death (i.e., suicide, poisoning, alcohol-related liver disease) are driving the overall mortality rate for middle-aged WNHs and have been described as "deaths of despair" in the literature. In the current paper, we describe the social and clinical features of "deaths of despair," explore theoretical models of psychopathology (e.g., depression, posttraumatic stress disorder) that may inform our understanding of mechanisms of risk for negative mental health outcomes, and propose an initial conceptual model of "deaths of despair" to identify intervention targets. We then review an applied case example demonstrating how this model could be used for clinical application. We conclude our paper by describing how current cognitive-behavioral interventions may address these mechanisms of "despair."
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Affiliation(s)
- Kristoffer Rehder
- Pacific University, Salem Vet Center Information, HSR&D Center to Improve Veteran Involvement in Care and Oregon Health & Science University
| | - Jaimie Lusk
- Pacific University, Salem Vet Center Information, HSR&D Center to Improve Veteran Involvement in Care and Oregon Health & Science University
| | - Jason I Chen
- Pacific University, Salem Vet Center Information, HSR&D Center to Improve Veteran Involvement in Care and Oregon Health & Science University
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164
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Sapoznikow A, Walsh Z, Tupper KW, Erowid E, Erowid F. The influence of context on ayahuasca experiences: An analysis of experience reports. JOURNAL OF PSYCHEDELIC STUDIES 2019. [DOI: 10.1556/2054.2019.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background and aims
Ayahuasca is a psychedelic decoction prepared from two (or more) plants containing monoamine oxidase inhibitors, N, N-dimethyltryptamine, and other chemicals. Ayahuasca has apparently been used for centuries in the Amazon basin of South America, and in recent years has increasingly been used internationally in diverse contexts. This study aims to elucidate differences between cross-cultural ceremonial and psychonautic contexts of ayahuasca use.
Methods
This study systematically examines subjective differences across contexts for contemporary ayahuasca-drinking practices. User reports of ayahuasca experiences were subjected to textual analysis to compare use in cross-culturalceremonial contexts that attempt to include elements of traditional Amazonian practices, with psychonautic use that does not formally integrate traditional ceremonial aspects. The experience reports were collected from an online database.
Results
The use of ayahuasca in a cross-cultural ceremonial context is associated with prominence of affective and motivational features, whereas psychonautic use was associated with an emphasis on cognitive processes.
Conclusions
The beneficial effects of ayahuasca may operate via affective processing and integration and as such, cross-cultural ceremonial use may have advantages relative to psychonautic use. Findings are considered in light of the importance of context on experiences with ayahuasca and other psychedelic substances.
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Affiliation(s)
- Avery Sapoznikow
- 1 Department of Psychology, University of British Columbia, Okanagan, Kelowna, Canada
| | - Zachary Walsh
- 1 Department of Psychology, University of British Columbia, Okanagan, Kelowna, Canada
| | - Kenneth W. Tupper
- 2 School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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165
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Holmes SC, Johnson CM, Suvak MK, Sijercic I, Monson CM, Wiltsey Stirman S. Examining patterns of dose response for clients who do and do not complete cognitive processing therapy. J Anxiety Disord 2019; 68:102120. [PMID: 31585686 PMCID: PMC10408992 DOI: 10.1016/j.janxdis.2019.102120] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/30/2019] [Accepted: 08/02/2019] [Indexed: 12/11/2022]
Abstract
Trauma-focused therapies, including Cognitive Processing Therapy (CPT; Resick et al., 2016), are effective at reducing clients' PTSD symptoms. A limitation to these treatments, however, is client completion of them. The current study examined temporal patterns of treatment non-completion and the relationships among non-completion, PTSD, and overall mental health functioning outcomes, among clients in a randomized controlled CPT implementation trial. Two models of symptom change were tested: 1) dose-effect model (i.e., clients uniformly improve with additional sessions at a negatively accelerating rate); and 2) the good-enough level model (i.e., clients remain in therapy until they have achieved sufficient improvement, thus clients who attend fewer sessions improve at quicker rates). Results indicated that 42% of clients did not complete treatment, with most discontinuing between sessions two and five. Data did not fit the dose-effect or good-enough level model. Rather, clients who improved at a greater rate in their PTSD symptoms and overall mental health functioning attended more sessions. The average client had the best outcomes when they completed all 12 sessions. Identifying clients who may be at risk for discontinuing treatment, and making a concerted effort toward retaining them, is imperative to reduce non-completion rates and ultimately improve client outcomes.
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Affiliation(s)
- Samantha C Holmes
- Yale School of Medicine, Department of Psychiatry, United States; University of Akron, Department of Psychology, United States
| | - Clara M Johnson
- National Center for PTSD, Dissemination and Training Division, United States
| | | | - Iris Sijercic
- Ryerson University, Department of Psychology, Canada
| | | | - Shannon Wiltsey Stirman
- National Center for PTSD, Dissemination and Training Division, United States; Stanford University, Department of Psychiatry and Behavioral Sciences, United States.
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166
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Ironson G, Fitch C, Banerjee N, Hylton E, Ivardic I, Safren SA, O'Cleirigh C. Posttraumatic cognitions, childhood sexual abuse characteristics, and posttraumatic stress disorder in men who have sex with men. CHILD ABUSE & NEGLECT 2019; 98:104187. [PMID: 31655249 DOI: 10.1016/j.chiabu.2019.104187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 08/23/2019] [Accepted: 09/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND High rates of experience of childhood sexual abuse (CSA) among in men who have sex with men (MSM) place this population at increased risk for posttraumatic stress disorder (PTSD). OBJECTIVE This study explores how specific characteristics of CSA relate to posttraumatic cognitions (PTCs) and explores the role that specific PTCs play in the relationship between CSA and PTSD in MSM. METHODS Two-hundred and ninety MSM completed a CSA interview, the Davidson Trauma Scale, and the Posttraumatic Cognitions Inventory. RESULTS Controlling for sociodemographic factors, CSA involving physical injury and CSA with intense fear were associated with higher levels of PTCs about the self and world, but not with self-blame. We did not find significant associations for CSA involving a family member, CSA with penetration, or duration or frequency of CSA with any subscale on the PTCI. Experiencing CSA for the first time during adolescence was associated with higher self-blame. Analyses revealed that physical injury and intense fear each had indirect effects on PTSD symptoms through negative cognitions about the self and world. First CSA episode during adolescence had an indirect effect on PTSD symptoms through self-blame. CSAs accounted for 16.7% and PTCs accounted for 31.7% of the variance in PTSD, underlining the importance of PTCs. CONCLUSIONS Assessing for physical injury, intense fear, and age at first CSA are particularly relevant to PTCs and of critical importance to advancing assessment and treatment strategies for PTSD in MSM.
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Affiliation(s)
- Gail Ironson
- Department of Psychology, University of Miami, Coral Gables, FL, United States; Department of Psychiatry, University of Miami, Coral Gables, FL, United States.
| | - Calvin Fitch
- Department of Psychology, University of Miami, Coral Gables, FL, United States; Department of Psychiatry, Harvard Medical School/Massachusetts General Hospital, Boston, MA, United States
| | - Nikhil Banerjee
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Emily Hylton
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Ivan Ivardic
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Steven A Safren
- Department of Psychology, University of Miami, Coral Gables, FL, United States
| | - Conall O'Cleirigh
- Department of Psychiatry, Harvard Medical School/Massachusetts General Hospital, Boston, MA, United States; Fenway Health, The Fenway Institute, Boston, MA, United States
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167
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DeRubeis RJ. The history, current status, and possible future of precision mental health. Behav Res Ther 2019; 123:103506. [DOI: 10.1016/j.brat.2019.103506] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/14/2019] [Accepted: 10/25/2019] [Indexed: 01/20/2023]
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168
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Jacoby VM, Hale W, Dillon K, Dondanville KA, Wachen JS, Yarvis JS, Litz BT, Mintz J, Young-McCaughan S, Peterson AL, Resick PA. Depression Suppresses Treatment Response for Traumatic Loss-Related Posttraumatic Stress Disorder in Active Duty Military Personnel. J Trauma Stress 2019; 32:774-783. [PMID: 31461575 PMCID: PMC6800580 DOI: 10.1002/jts.22441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/06/2019] [Accepted: 04/17/2019] [Indexed: 11/10/2022]
Abstract
There are multiple well-established evidence-based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat-related PTSD in military populations is less responsive to evidence-based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment-related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss-related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss-related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = -4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss-related PTSD, B = 3.75. These findings suggest that evidence-based treatments for PTSD should better accommodate loss and grief in military populations.
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Affiliation(s)
- Vanessa M. Jacoby
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Willie Hale
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | - Kirsten Dillon
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Katherine A. Dondanville
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jennifer Schuster Wachen
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, C.R. Darnall Army Medical Center, Fort Hood, Texas
| | - Brett T. Litz
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts,Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
| | - Jim Mintz
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas,Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Stacey Young-McCaughan
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Alan L. Peterson
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas,Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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169
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Straud CL, Siev J, Messer S, Zalta AK. Examining military population and trauma type as moderators of treatment outcome for first-line psychotherapies for PTSD: A meta-analysis. J Anxiety Disord 2019; 67:102133. [PMID: 31472332 PMCID: PMC6739153 DOI: 10.1016/j.janxdis.2019.102133] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/31/2019] [Accepted: 08/17/2019] [Indexed: 11/20/2022]
Abstract
There is conflicting evidence as to whether military populations (i.e., veteran and active-duty military service members) demonstrate a poorer response to psychotherapy for posttraumatic stress disorder (PTSD) compared to civilians. Existing research may be complicated by the fact that treatment outcomes differences could be due to the type of trauma exposure (e.g., combat) or population differences (e.g., military culture). This meta-analysis evaluated PTSD treatment outcomes as a function of trauma type (combat v. assault v. mixed) and population (military v. civilian). Unlike previous meta-analyses, we focused exclusively on manualized, first-line psychotherapies for PTSD as defined by expert treatment guidelines. Treatment outcomes were large across trauma types and population; yet differences were observed between trauma and population subgroups. Military populations demonstrated poorer treatment outcomes compared to civilians. The combat and assault trauma subgroups had worse treatment outcomes compared to the mixed trauma subgroup, but differences were not observed between assault and combat subgroups. Higher attrition rates predicted poorer treatment outcomes, but did not vary between military populations and civilians. Overall, manualized, first-line psychotherapies for PTSD should continue to be used for civilians and military populations with various trauma types. However, greater emphasis should be placed on enhancing PTSD psychotherapies for military populations and on treatment retention across populations based on findings from this meta-analysis.
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Affiliation(s)
- Casey L Straud
- University of Texas Health Science Center at San Antonio, San Antonio, TX, United States.
| | | | - Stephen Messer
- Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Alyson K Zalta
- University of California, Irvine, Irvine, CA, United States
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170
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Lambert HK, McLaughlin KA. Impaired hippocampus-dependent associative learning as a mechanism underlying PTSD: A meta-analysis. Neurosci Biobehav Rev 2019; 107:729-749. [PMID: 31545990 DOI: 10.1016/j.neubiorev.2019.09.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/10/2019] [Accepted: 09/13/2019] [Indexed: 12/19/2022]
Abstract
Smaller hippocampal volume is associated with increased risk for PTSD following trauma, but the hippocampal functions involved remain unknown. We propose a conceptual model that identifies broad impairment in hippocampus-dependent associative learning as a vulnerability factor for PTSD. Associative learning of foreground cues and background context is required to form an integrated representation of an event. People with poor associative learning may have difficulty remembering who or what was present during a trauma, where the trauma occurred, or the sequence of events, which may contribute to PTSD symptoms. We argue that associative learning difficulties in PTSD exist for cues and context, regardless of the emotional nature of the information. This contrasts with PTSD models that focus exclusively on threat-processing or contextual-processing. In a meta-analysis, people with PTSD exhibited poor associative learning of multiple information types compared to those without PTSD. Differences were of medium effect size and similar magnitude for neutral and negative/trauma-related stimuli. We provide evidence for associative learning difficulties as a neurocognitive pathway that may contribute to PTSD.
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Affiliation(s)
- Hilary K Lambert
- Department of Psychology, University of Washington, 119A Guthrie Hall, Box 351525, Seattle, WA, 98195-1525, USA.
| | - Katie A McLaughlin
- Department of Psychology, Harvard University, William James Hall, 33 Kirkland Street, Cambridge, MA 02138, USA.
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171
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Proença CR, Markowitz JC, Prado EA, Braga R, Coimbra BM, Mello TF, Maciel MR, Pupo M, Póvoa J, Mello AF, Mello MF. Attrition in Interpersonal Psychotherapy Among Women With Post-traumatic Stress Disorder Following Sexual Assault. Front Psychol 2019; 10:2120. [PMID: 31572281 PMCID: PMC6753915 DOI: 10.3389/fpsyg.2019.02120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/02/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An estimated 16.9% of adult Brazilian women experience sexual assault in their lifetime. Almost half of women who suffer such trauma develop post-traumatic stress disorder (PTSD). Markowitz et al. (2015) found that an affect-focused non-exposure therapy, Interpersonal Psychotherapy (IPT), adapted to treat PTSD (IPT-PTSD) had similar efficacy to and lower dropout rates than Prolonged Exposure (PE), the "gold standard," most studied exposure therapy for PTSD. OBJECTIVE To assess attrition rates in IPT of sexually assaulted women recently diagnosed with PTSD. METHODS The current study derives from a two-arm, randomized controlled clinical trial of sexually assaulted women with PTSD who received 14 weeks of standardized treatment with either IPT-PTSD or sertraline. Sample: The 32 patients in the IPT treatment arm were analyzed. RESULTS Overall attrition was 29%. One patient was withdrawn because of suicidal risk; four dropped out pre-treatment, and five dropped out during IPT-PTSD. If the excluded patient is considered a dropout, the rate increases to 31%. DISCUSSION This is the first formal study of IPT for PTSD specifically due to sexual assault. IPT attrition approximated dropout rates in PE studies, which are often around 30%, and to the sertraline group in our study (34.5%). Further research should compare IPT and PE among sexually assaulted women to clarify our hypothesis that IPT could be an attractive alternative approach for this patient group.
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Affiliation(s)
- Cecília R. Proença
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - John C. Markowitz
- New York State Psychiatric Institute, Columbia University, New York, NY, United States
| | - Euthymia A. Prado
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Rosaly Braga
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Bruno M. Coimbra
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Thays F. Mello
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Mariana R. Maciel
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Mariana Pupo
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Juliana Póvoa
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Andrea F. Mello
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Marcelo F. Mello
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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172
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O'Cleirigh C, Safren SA, Taylor SW, Goshe BM, Bedoya CA, Marquez SM, Boroughs MS, Shipherd JC. Cognitive Behavioral Therapy for Trauma and Self-Care (CBT-TSC) in Men Who have Sex with Men with a History of Childhood Sexual Abuse: A Randomized Controlled Trial. AIDS Behav 2019; 23:2421-2431. [PMID: 30993478 PMCID: PMC7271561 DOI: 10.1007/s10461-019-02482-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
To address childhood sexual abuse (CSA) related distress and HIV risk in men who have sex with men (MSM) using cognitive-behavioral therapy for trauma and self-care (CBT-TSC), which is a novel intervention integrating HIV risk reduction with modified cognitive and behavioral therapy strategies for post-traumatic stress. We compared CBT-TSC to HIV voluntary counseling and testing (VCT)-only in an initial 2-arm RCT in 43 HIV-negative MSM at with a history of CSA and HIV risk. Serodiscordant condomless anal/vaginal sex (CAS; CAS with HIV-postive or HIV unknown status partners) and posttraumatic stress disorder (PTSD) symptoms (Davidson Trauma Scale: total score and avoidance, intrusions, hyperarousal subscales) were outcomes immediately post-treatment, and at 6- and 9-month follow-up. At post-treatment, CBT-TSC had decreased odds (approximately 60%) of any CAS and greater reductions in CAS compared to VCT-only. Additionally, the CBT-TSC condition experienced greater reductions in total PTSD and avoidance symptoms. At the follow-up visits, CBT-TSC condition had significant reductions in the odds of any CAS and reductions in CAS. However, for PTSD symptoms, only the avoidance subscale remained significantly different compared to VCT-only. CBT-TSC is a potentially efficacious approach to address HIV risk in MSM with a CSA history, with replication and extension in a larger trial needed. This proof-of-concept trial is the first to integrate the treatment of a commonly occurring mental-health syndemic problem in MSM with a health psychology approach to self-care in MSM.Trial Registration Clinicaltrials.gov NCT01266122.
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Affiliation(s)
- Conall O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 7th Floor, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
- The Fenway Institute of Fenway Health, Boston, MA, USA.
| | - Steven A Safren
- The Fenway Institute of Fenway Health, Boston, MA, USA
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - S Wade Taylor
- The Fenway Institute of Fenway Health, Boston, MA, USA
- School of Social Work, Boston University, Boston, MA, USA
| | - Brett M Goshe
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 7th Floor, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - C Andres Bedoya
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 7th Floor, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Samantha M Marquez
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, 7th Floor, Boston, MA, 02114, USA
- The Fenway Institute of Fenway Health, Boston, MA, USA
| | | | - Jillian C Shipherd
- VA Boston Healthcare System, Boston, MA, USA
- Women's Health Sciences Division, National Center for PTSD, Boston, MA, USA
- Department of Veterans Affairs, LGBT Health Program, Washington, DC, USA
- Boston University School of Medicine, Boston, MA, USA
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173
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Kinney AR, Eakman AM, Lassell R, Wood W. Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review. Mil Med Res 2019; 6:28. [PMID: 31462305 PMCID: PMC6714435 DOI: 10.1186/s40779-019-0217-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Evidence-based treatments for service-related health conditions such as posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) are not effective for all veterans. Equine-assisted interventions are emerging as an additional treatment modality, but little is known regarding the safe and effective delivery of these interventions. This study aimed to describe the following features of the body of literature concerning equine-assisted interventions among veterans: 1) veterans who have participated in equine-assisted interventions; 2) specific characteristics of equine-assisted interventions in veterans; and 3) the specific characteristics of research on equine-assisted interventions in veterans. METHODS We conducted a systematic mapping review of peer-reviewed literature reporting on equine-assisted interventions among veterans between 1980 and 2017. Searches of nine databases yielded 3336 unique records, six of which met the inclusion criteria and were reviewed. Data relevant to the study aims were extracted and analyzed. RESULTS Equine-assisted interventions among veterans disproportionately targeted psychosocial outcomes and yielded promising results. The detailed methods of EAI varied in the reported studies, ranging from communicating with the horse to mounted exercises. There was also great diversity in outcome measurement. The state of theoretical development regarding the mechanisms by which equine-assisted interventions benefit the veteran population is currently underdeveloped. Studies provided insufficient detail with respect to the description of the intervention, reasons for attrition, and the dose-response relationship. CONCLUSIONS Scientific development of equine-assisted interventions targeting psychosocial outcomes among veterans is warranted to establish their efficacy. Targeted outcomes should be expanded, including outcomes more closely aligned with the nature of polytraumatic injuries. Future research must also emphasize the theoretical development of equine-assisted interventions for veterans and thoroughly describe the participants, components of the intervention, factors contributing to attrition, and optimal dose-response relationships.
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Affiliation(s)
- Adam R. Kinney
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
| | - Aaron M. Eakman
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
| | - Rebecca Lassell
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
- Temple Grandin Equine Center, Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523 USA
| | - Wendy Wood
- Temple Grandin Equine Center, Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523 USA
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174
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Beck JG, Dodson TS, Pickover AM, Woodward MJ, Lipinski AJ, Tran HN. The effects of shame on subsequent reactions to a trauma analog. J Anxiety Disord 2019; 66:102108. [PMID: 31387013 DOI: 10.1016/j.janxdis.2019.102108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/07/2019] [Accepted: 06/21/2019] [Indexed: 11/25/2022]
Abstract
The current study examined the effects of experimentally-induced shame on subsequent reactions to a trauma analog. Participants were 88 college-aged women randomly assigned to a shame prime condition or to a control (neutral) condition. Participants then were presented with an analog trauma audiotape depicting dating violence. Participants reported intrusive thoughts relating to the trauma analog in the two days following the procedure. Negative (shame, guilt) and positive (pride, positive affect) emotions were monitored throughout the procedure. Results indicated that the shame prime successfully increased shame in the Shame condition alone. After the trauma analog, increases in shame were noted in both conditions. In contrast, guilt reduced in the Shame condition, while this emotion increased in the Control condition, contrary to hypothesis. Shame and guilt were somewhat volatile for participants in the Shame condition in the two days following the lab procedure, while individuals in the Control condition reported steadily decreasing levels of these emotions. No between-condition differences were noted in the frequency of intrusions in the two days following the laboratory procedure, contrary to hypothesis. Results are discussed in light of our current understanding of shame and its role in PTSD, with suggestions to guide future research.
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Affiliation(s)
- J Gayle Beck
- Department of Psychology, The University of Memphis, United States.
| | - Thomas S Dodson
- Department of Psychology, The University of Memphis, United States
| | | | - Matthew J Woodward
- Department of Psychological Sciences, Western Kentucky University, United States
| | | | - Han N Tran
- Department of Psychology, The University of Memphis, United States
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175
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Zang Y, Su YJ, McLean CP, Foa EB. Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions? J Trauma Stress 2019; 32:577-585. [PMID: 31265187 DOI: 10.1002/jts.22412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/20/2019] [Accepted: 01/30/2019] [Indexed: 11/09/2022]
Abstract
In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.
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Affiliation(s)
- Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi-Jen Su
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Graduate Institute of Behavioral Sciences, Chang Gung University, Taoyuan, Taiwan, ROC.,Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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McLean CP, Zandberg L, Brown L, Zang Y, Benhamou K, Dondanville KA, Yarvis JS, Litz BT, Mintz J, Young-McCaughan S, Peterson AL, Foa EB. Guilt in the Treatment of Posttraumatic Stress Disorder Among Active Duty Military Personnel. J Trauma Stress 2019; 32:616-624. [PMID: 31356703 DOI: 10.1002/jts.22416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 11/09/2022]
Abstract
The current study examined the role of trauma-related guilt on posttraumatic stress disorder (PTSD) symptom change during prolonged exposure therapy (PE) as well as the efficacy of PE in reducing three dimensions of guilt (responsibility, wrongdoing, and lack of justification) during treatment. Participants were 331 active duty U.S. military personnel seeking treatment for PTSD who were randomized to one of four groups: massed PE (10 sessions delivered over 2 weeks), spaced PE (10 sessions delivered over 8 weeks), present-centered therapy (PCT; 10 sessions delivered over 8 weeks), or minimal contact control (MCC; weekly therapist phone check-in for 4 weeks). The results showed that baseline guilt did not predict reductions in PTSD symptoms for spaced PE or for PCT, ps = .178-.387, ds = -0.02-0.07. Treatment condition (massed PE vs. MCC; spaced PE vs. PCT) did not moderate reductions in guilt for spaced PE versus PCT. Guilt decreased significantly over treatment in all groups, p < .001 to p = .038, ds = -0.19 to -0.42, except concerning justification in the spaced PE and PCT groups, p = .140, d = -0.10. The findings suggest that guilt may be reduced significantly following active PTSD treatment and attention control and that PTSD recovery is not impacted by baseline levels of trauma-related guilt in military personnel with PTSD, although reported levels of guilt were low to moderate in this sample.
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Affiliation(s)
- Carmen P McLean
- National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laurie Zandberg
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lily Brown
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yinyin Zang
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathy Benhamou
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine A Dondanville
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jeffrey S Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
| | - Brett T Litz
- Massachusetts Veterans Epidemiological Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jim Mintz
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Stacey Young-McCaughan
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Alan L Peterson
- Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.,South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, USA
| | - Edna B Foa
- Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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178
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Yabuki Y, Fukunaga K. Clinical Therapeutic Strategy and Neuronal Mechanism Underlying Post-Traumatic Stress Disorder (PTSD). Int J Mol Sci 2019; 20:ijms20153614. [PMID: 31344835 PMCID: PMC6695947 DOI: 10.3390/ijms20153614] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 12/15/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) is characterized by an exaggerated response to contextual memory and impaired fear extinction, with or without mild cognitive impairment, learning deficits, and nightmares. PTSD is often developed by traumatic events, such as war, terrorist attack, natural calamities, etc. Clinical and animal studies suggest that aberrant susceptibility of emotion- and fear-related neurocircuits, including the amygdala, prefrontal cortex (PFC), and hippocampus may contribute to the development and retention of PTSD symptoms. Psychological and pharmacological therapy, such as cognitive behavioral therapy (CBT), and treatment with anti-depressive agents and/or antipsychotics significantly attenuate PTSD symptoms. However, more effective therapeutics are required for improvement of quality of life in PTSD patients. Previous studies have reported that ω3 long-chain polyunsaturated fatty acid (LCPUFA) supplements can suppress the development of PTSD symptoms. Fatty acid binding proteins (FABPs) are essential for LCPUFA intracellular trafficking. In this review, we have introduced Fabp3 null mice as an animal model of PTSD with impaired fear extinction. Moreover, we have addressed the neuronal circuits and novel therapeutic strategies for PTSD symptoms.
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Affiliation(s)
- Yasushi Yabuki
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai 980-8578, Japan
| | - Kohji Fukunaga
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai 980-8578, Japan.
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179
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Bhardwaj V, Angkaw AC, Franceschetti M, Rao R, Baker DG. Direct and indirect relationships among posttraumatic stress disorder, depression, hostility, anger, and verbal and physical aggression in returning veterans. Aggress Behav 2019; 45:417-426. [PMID: 30835866 DOI: 10.1002/ab.21827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/04/2019] [Accepted: 02/21/2019] [Indexed: 12/27/2022]
Abstract
Hostility, anger, and aggression are conceptually related but unique constructs found to occur more often among veterans with posttraumatic stress disorder (PTSD) than among civilians or veterans without PTSD. However, the pathways between PTSD, depression, hostility, anger, and aggression have not been comprehensively characterized. Therefore, drawing on a sample of returning Operation Enduring Freedom/Operation Iraqi Freedom combat veterans ( N = 175; 95% male; mean age 30 years), this study sought to examine the direct and indirect relationships among PTSD, depression, hostility, anger, and four types of aggression: verbal, and physical toward self, others, and objects. Functional modeling of direct effects was done using multiple least-squares regression and bootstrapped mediation analyses were carried out to test indirect effects. Results indicate that PTSD is not the overall direct contributor to different forms of aggression, supporting the mediating role of depression and trait anger. Depression symptoms explain part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward self and trait anger explains part of the relationships between PTSD and verbal aggression, physical aggression toward objects, and physical aggression toward others. Our findings support the importance of assessing for anger, depression, and different types of aggression among veterans presenting for PTSD treatment to develop individualized treatment plans that may benefit from early incorporation of interventions.
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Affiliation(s)
- Vinnu Bhardwaj
- Qualcomm InstituteUniversity of CaliforniaSan Diego CA
- Department of ECEUniversity of CaliforniaSan Diego CA
| | - Abigail C. Angkaw
- Veterans Affairs San Diego Healthcare SystemSan Diego CA
- Department of PsychiatryUniversity of CaliforniaSan Diego CA
| | - Massimo Franceschetti
- Qualcomm InstituteUniversity of CaliforniaSan Diego CA
- Department of ECEUniversity of CaliforniaSan Diego CA
| | - Ramesh Rao
- Qualcomm InstituteUniversity of CaliforniaSan Diego CA
- Department of ECEUniversity of CaliforniaSan Diego CA
| | - Dewleen G. Baker
- Veterans Affairs San Diego Healthcare SystemSan Diego CA
- VA Center of Excellence for Stress and Mental HealthSan Diego CA
- Department of PsychiatryUniversity of CaliforniaSan Diego CA
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180
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Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members. Behav Res Ther 2019; 118:7-17. [DOI: 10.1016/j.brat.2019.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/12/2019] [Accepted: 03/04/2019] [Indexed: 11/18/2022]
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181
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Holder N, Holliday R, Wiblin J, LePage JP, Surís A. Predictors of dropout from a randomized clinical trial of cognitive processing therapy for female veterans with military sexual trauma-related PTSD. Psychiatry Res 2019; 276:87-93. [PMID: 31030005 DOI: 10.1016/j.psychres.2019.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 04/19/2019] [Accepted: 04/21/2019] [Indexed: 12/30/2022]
Abstract
Many veterans do not complete evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD). Veterans with military sexual trauma (MST)-related PTSD were shown to have higher than average rates of dropout from PTSD treatment in a national study of EBT implementation. Although predictors of dropout from EBTs have been identified, these factors are largely unmodifiable (e.g., age, service era). The purpose of the present study was to identify dynamic psychosocial predictors of dropout among female veterans from cognitive processing therapy (CPT). Data were utilized from 56 female veterans who participated in a randomized clinical trial investigating the effectiveness of CPT for MST-related PTSD. Dropout was defined continuously (i.e., number of sessions attended) and dichotomously (i.e., attending six or more sessions). Potential predictors included sociodemographic factors, psychotherapist fidelity, PTSD-related service connection, psychiatric symptom severity (i.e., PTSD, depression), trauma-related negative cognitions (about self, self-blame, world), and treatment expectations. Higher trauma-related negative cognitions about self-blame and lower trauma-related negative cognitions about self were protective against dropout. The current study generated testable hypotheses for further research on dynamic predictors of dropout from CPT in female veterans with MST-related PTSD. With replication, results may assist with identifying pre-treatment strategies to reduce dropout in this clinical population.
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Affiliation(s)
- Nicholas Holder
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA.
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, 1700N Wheeling St (G-3-116M), Aurora, CO 80045, USA; University of Colorado Anschutz Medical Campus, Building 500, Mail Stop F546, 13001 East 17th Place, Aurora, CO 80045, USA
| | - Jessica Wiblin
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - James P LePage
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Alina Surís
- Veterans Affairs North Texas Health Care System, Research Service (151), 4500 S. Lancaster Rd., Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
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182
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Marques L, Valentine SE, Kaysen D, Mackintosh MA, Dixon De Silva LE, Ahles EM, Youn SJ, Shtasel DL, Simon NM, Wiltsey-Stirman S. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. J Consult Clin Psychol 2019; 87:357-369. [PMID: 30883163 DOI: 10.1037/ccp0000384] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes. METHOD Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications. RESULTS Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms. CONCLUSIONS The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Luana Marques
- Department of Psychiatry, Massachusetts General Hospital
| | | | - Debra Kaysen
- Department of Global Health, University of Washington
| | | | | | - Emily M Ahles
- Department of Psychiatry, Massachusetts General Hospital
| | - Soo Jeong Youn
- Department of Psychiatry, Massachusetts General Hospital
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183
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Bernardi J, Dahiya M, Jobson L. Culturally modified cognitive processing therapy for Karen refugees with posttraumatic stress disorder: A pilot study. Clin Psychol Psychother 2019; 26:531-539. [PMID: 31069863 DOI: 10.1002/cpp.2373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 04/23/2019] [Accepted: 05/04/2019] [Indexed: 11/08/2022]
Abstract
Karen refugees, many originating from Myanmar, have suffered one of the longest civil wars in history and have thus witnessed and experienced substantial trauma. Refugees from Myanmar are currently one of the largest refugee groups being resettled in Western countries. This study investigated the feasibility and acceptability of a modified cognitive processing therapy (CPT) group program for Karen refugees with posttraumatic stress disorder (PTSD; N =7). It was found that the CPT program was well accepted, with high satisfaction and no drop-outs. At posttreatment all participants no longer met PTSD diagnostic criteria and had a reliable improvement in PTSD symptoms when compared with pretreatment scores. At 3-month follow-up four participants (57% of sample) did not meet PTSD diagnostic criteria and three participants (43%) had a reliable improvement in PTSD symptoms when compared with pretreatment scores. However, at follow-up four participants (57% of the sample) had a reliable worsening in PTSD symptoms when compared with their posttreatment PTSD symptom levels. Although the study found that the modified CPT was acceptable and feasible, future research is needed to develop and enhance strategies to ensure that refugees benefit from empirically supported treatments.
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Affiliation(s)
- Jessica Bernardi
- Monash Institute of Cognitive and Clinical Neurosciences and School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Mini Dahiya
- Action on Disability within Ethnic Communities Inc., Melbourne, Australia
| | - Laura Jobson
- Monash Institute of Cognitive and Clinical Neurosciences and School of Psychological Sciences, Monash University, Melbourne, Australia
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184
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Mathersul DC, Tang JS, Schulz-Heik RJ, Avery TJ, Seppälä EM, Bayley PJ. Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans. BMJ Open 2019; 9:e027150. [PMID: 30948610 PMCID: PMC6500221 DOI: 10.1136/bmjopen-2018-027150] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/11/2018] [Accepted: 12/18/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while these treatments show clinically meaningful symptom improvement, the majority of those who begin treatment retain a diagnosis of PTSD post-treatment. Perhaps for this reason, many individuals with PTSD have sought more holistic, mind-body, complementary and integrative health (CIH) interventions. However, there remains a paucity of high-quality, active controlled efficacy studies of CIH interventions for PTSD, which precludes their formal recommendation. METHODS AND ANALYSES We present the protocol for an ongoing non-inferiority parallel group randomised controlled trial (RCT) comparing the efficacy of a breathing meditation intervention (Sudarshan Kriya Yoga [SKY]) to a recommended evidence-based psychotherapy (CPT) for PTSD among veterans. Assessors are blinded to treatment group. The primary outcome measure is the PTSD Checklist-Civilian Version and a combination of clinical, self-report, experimental and physiological outcome measures assess treatment-related changes across each of the four PTSD symptom clusters (re-experiencing, avoidance, negative cognitions or mood and hyperarousal/reactivity). Once the RCT is completed, analyses will use both an intent-to-treat (using the 'last observation carried forward' for missing data) and a per-protocol or 'treatment completers' procedure, which is the most rigorous approach to non-inferiority designs. ETHICS AND DISSEMINATION To the best of our knowledge, this is this first non-inferiority RCT of SKY versus CPT for PTSD among veterans. The protocol is approved by the Stanford University Institutional Review Board. All participants provided written informed consent prior to participation. Results from this RCT will inform future studies including larger multi-site efficacy RCTs of SKY for PTSD and other mental health conditions, as well as exploration of cost-effectiveness and evaluation of implementation issues. Results will also inform evidence-based formal recommendations regarding CIH interventions for PTSD. TRIAL REGISTRATION NUMBER NCT02366403; Pre-results.
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Affiliation(s)
- Danielle C Mathersul
- War Related Illness and Injury Study Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Julia S Tang
- War Related Illness and Injury Study Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - R Jay Schulz-Heik
- War Related Illness and Injury Study Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Timothy J Avery
- War Related Illness and Injury Study Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Emma M Seppälä
- Center for Compassion and Altruism Research and Education, Stanford University School of Medicine, Stanford, California, USA
- Yale Center for Emotional Intelligence, Yale University, New Haven, Connecticut, USA
| | - Peter J Bayley
- War Related Illness and Injury Study Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
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185
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Zoellner LA, Roy-Byrne PP, Mavissakalian M, Feeny NC. Doubly Randomized Preference Trial of Prolonged Exposure Versus Sertraline for Treatment of PTSD. Am J Psychiatry 2019; 176:287-296. [PMID: 30336702 DOI: 10.1176/appi.ajp.2018.17090995] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The authors examined the effect of patient treatment preference on the differential effectiveness of prolonged exposure and sertraline for the treatment of posttraumatic stress disorder (PTSD). METHOD In a doubly randomized preference trial, 200 patients with PTSD viewed standardized treatment rationales prior to randomization. Patients were first randomized to choice of treatment or no choice. Those assigned to no choice were then randomized to prolonged exposure or sertraline. Acute treatment was 10 weeks, with 24-month follow-up. Interviewer-rated PTSD symptom severity was the main outcome measure, and depression, anxiety, and functioning were assessed as additional outcomes. RESULTS Patients preferred prolonged exposure over sertraline (number needed to benefit [NNTB]=4.5). Using intent-to-treat analyses (N=200), both prolonged exposure and sertraline showed large gains that were maintained over 24 months. Although no differential effect was observed on interviewer-rated PTSD severity, there was a significant benefit of prolonged exposure over sertraline on interview-rated loss of PTSD diagnosis (NNTB=7.0), responder status (NNTB=5.7), and self-reported PTSD, depression, and anxiety symptoms and functioning (effect sizes, 0.35-0.44). Patients who received their preferred treatment were more likely to be adherent, lose their PTSD diagnosis (NNTB=3.4), achieve responder status (NNTB=3.4), and have lower self-reported PTSD, depression, and anxiety symptoms (effect sizes, 0.40-0.72). CONCLUSIONS Prolonged exposure and sertraline confer significant benefits for PTSD, with some evidence of an advantage for prolonged exposure. Giving patients with PTSD their preferred treatment also confers important benefits, including enhancing adherence.
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Affiliation(s)
- Lori A Zoellner
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Peter P Roy-Byrne
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Matig Mavissakalian
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
| | - Norah C Feeny
- From the Department of Psychology and the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle; and the Department of Psychiatry and the Department of Psychology, Case Western Reserve University, Cleveland
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186
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Philippi CL, Dahl G, Jany M, Bruce SE. Impact Statement Coding of Self-Related Thought in Women With Posttraumatic Stress Disorder. J Trauma Stress 2019; 32:269-276. [PMID: 30892743 PMCID: PMC6506228 DOI: 10.1002/jts.22386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/25/2018] [Accepted: 12/09/2018] [Indexed: 11/11/2022]
Abstract
Clinical and empirical studies have documented significant alterations in self-related thought in posttraumatic stress disorder (PTSD). To our knowledge, however, few studies have examined self-referential cognition by analyzing survivors' written impact statements in individuals whose PTSD is due to interpersonal trauma. In the current study, we performed a linguistic analysis of impact statements (i.e., descriptions of how the trauma has affected the survivors' views of themselves, others, and the world) collected at the start of therapy from women with PTSD that was due to interpersonal trauma, with the goal of determining whether PTSD symptom clusters were associated with altered self-referential thought. We found that higher levels of PTSD-related hyperarousal symptoms were significantly associated with diminished self-related word use, after controlling for depression severity, f2 = .31. Similarly, diminished negative self-related word use was associated with higher levels of hyperarousal symptoms, f2 = .47. Our findings align with previous research that has provided evidence for a diminished sense of self in PTSD. These results may help inform targeted interventions aimed at improving social-affective functions in PTSD and other psychiatric conditions.
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Affiliation(s)
- Carissa L. Philippi
- Department of Psychological Sciences, University of Missouri–St. Louis, St. Louis, Missouri, USA
| | - Gregory Dahl
- Department of Psychological Sciences, University of Missouri–St. Louis, St. Louis, Missouri, USA
| | - Miranda Jany
- Department of Psychological Sciences, University of Missouri–St. Louis, St. Louis, Missouri, USA
| | - Steven E. Bruce
- Department of Psychological Sciences, University of Missouri–St. Louis, St. Louis, Missouri, USA,Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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187
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Tran HN, Lipinski AJ, Peter SC, Dodson TS, Majeed R, Savage UC, Beck JG. The Association Between Posttraumatic Negative Self-Conscious Cognitions and Emotions and Maladaptive Behaviors: Does Time Since Trauma Exposure Matter? J Trauma Stress 2019; 32:249-259. [PMID: 30913339 DOI: 10.1002/jts.22388] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 11/05/2022]
Abstract
Negative beliefs about the self, self-blame, guilt, and shame have been consistently linked to emotional problems, such as posttraumatic stress disorder and depression, following trauma exposure. To expand understanding of the potential role of negative self-conscious cognitions and emotions in other forms of posttrauma maladjustments, such as maladaptive behaviors, the current study examined the associations between these cognitions and emotions with dissociation, alcohol use, and avoidant problem-solving. As a secondary goal, the influence of time since trauma exposure was considered given recent data suggesting that some posttraumatic responses require lengthier time following trauma to become salient. Multiple-group analysis was conducted in two groups of female survivors of intimate partner violence (IPV): women whose IPV experiences occurred within 3 months prior to assessment (early posttrauma phase [EPP]; n = 67) and those whose experiences occurred 12 months or more prior to assessment (chronic posttrauma phase [CPP]; n = 145). The results suggested model invariance. Posttraumatic negative self-conscious cognitions and emotions were significantly correlated with dissociation (EPP group: β = .61, p < .001 and CPP group: β = .48, p < .001), alcohol use (EPP group: β = .31, p = .014 and CPP group: β = .30, p < .001), and avoidant problem-solving (EPP group: β = .58, p < .001 and CPP group: β = .56, p < .001). The findings highlight the importance of negative self-conscious cognitions and emotions in posttrauma maladjustment and support intervening in these domains shortly after trauma exposure.
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Affiliation(s)
- Han N Tran
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
| | | | - Samuel C Peter
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
| | - Thomas S Dodson
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
| | - Rimsha Majeed
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
| | - Ulysses C Savage
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
| | - J Gayle Beck
- Department of Psychology, The University of Memphis, Memphis, Tennessee, USA
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188
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Trauma-informed care and practice for eating disorders: personal and professional perspectives of lived experiences. Eat Weight Disord 2019; 24:329-338. [PMID: 30565188 DOI: 10.1007/s40519-018-0628-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Learning about the life stories of patients who have experienced a severe eating disorder (ED), but also traumas that led to PTSD, dissociative disorders, and other comorbidities, has great value to clinicians in their efforts to deliver trauma-informed care (TIC). Many investigators have been researching and writing about these issues for years, and strong scientific evidence has emerged, indicating that trauma is a significant risk factor for the development of EDs, particularly in its bulimic forms. PURPOSE Peer-reviewed literature contains scarce input from people with "lived experiences". Hearing and "sitting with" such individuals are extremely useful in clinical practice and research. Further, encouraging patients to put words to their pain has recognized therapeutic effects. These lived experiences are often demonstrative of key elements of what professionals need to know about evaluating and treating patients with EDs and co-occurring trauma-related disorders. METHOD/RESULTS The principal author invited two courageous recovered ED advocates and writers (June Alexander and Jenni Schaefer), who have gone public about their ED-PTSD experiences, to recount their life stories and treatment experiences (both positive and negative). Dr. Brewerton then offers his professional perspectives on the course of their treatment experiences put in the context of ongoing relevant clinical research. CONCLUSION Their and other patients' experiences have great power to guide professionals toward trauma-informed care, more integrated practice, and theoretically improved outcomes. LEVEL OF EVIDENCE Level V.
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189
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Larsen SE. Hypersexual Behavior as a Symptom of PTSD: Using Cognitive Processing Therapy in a Veteran with Military Sexual Trauma-Related PTSD. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:987-993. [PMID: 30783872 DOI: 10.1007/s10508-018-1378-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/08/2018] [Accepted: 12/13/2018] [Indexed: 06/09/2023]
Abstract
Hypersexual behavior is a construct that is well recognized yet vaguely conceptualized, leading to some arguments that it may be comprised of multiple etiologies. Childhood sexual abuse is often acknowledged as a common experience among those with sexually addictive behaviors, yet the intersection between PTSD and sexual addiction has not been fully explored. This case illustrates the use of Cognitive Processing Therapy, an empirically supported treatment for PTSD, as a means to treat both PTSD symptoms and hypersexual behaviors in a veteran who had experienced military sexual trauma. Treatment led to a meaningful decrease in both types of symptoms, even in the absence of a structured treatment approach for sexual addiction. It is argued that differential diagnosis, including functional analysis of hypersexual behaviors, is crucial in treatment planning. Further, attention to trauma and PTSD is important in veterans and others for whom PTSD is part of the etiology of hypersexual behavior; trauma-focused CBT therapies can provide a useful treatment approach in these cases.
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Affiliation(s)
- Sadie E Larsen
- Clement J. Zablocki VA Medical Center, Milwaukee, WI, USA.
- Department of Psychiatry, Medical College of Wisconsin, 1155 North Mayfair Road, Milwaukee, WI, 53226, USA.
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190
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Evidenced-Based Treatment of Posttraumatic Stress Disorder: An Updated Review of Validated Psychotherapeutic and Pharmacological Approaches. Harv Rev Psychiatry 2019; 26:99-115. [PMID: 29734225 DOI: 10.1097/hrp.0000000000000186] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Evaluate psychotherapeutic and pharmacologic approaches to treating patients with posttraumatic stress disorder. ABSTRACT A strong evidence base exists for psychological and pharmacological interventions for the treatment of posttraumatic stress disorder (PTSD). The published literature investigating the effectiveness of these treatments in reducing the symptoms and impairments associated with PTSD has expanded substantially in recent years. This review provides a concise overview of the empirical literature examining these treatment approaches. Evidence-based, trauma-focused therapies are recommended as first-line interventions, with the most support for cognitive- and exposure-based approaches. Prolonged exposure and cognitive processing therapy are the two most cited and rigorously investigated. Various other evidence-supported protocols are discussed. Pharmacotherapies can be used when evidence-based psychotherapies are not available or are ineffective, or on the basis of patient preference. Pharmacotherapy with the most support for PTSD includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Evidence supports the implementation of these interventions across genders, populations, and settings. Given that little research directly compares the effectiveness of different PTSD interventions and their mechanisms of action, it remains uncertain how to best select and tailor treatments to optimize individual outcomes. Future directions and novel, ongoing research are discussed.
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191
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Wagner AC, Mithoefer MC, Mithoefer AT, Monson CM. Combining Cognitive-Behavioral Conjoint Therapy for PTSD with 3,4-Methylenedioxymethamphetamine (MDMA): A Case Example. J Psychoactive Drugs 2019; 51:166-173. [PMID: 30890035 DOI: 10.1080/02791072.2019.1589028] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Treatments for posttraumatic stress disorder (PTSD) have evolved significantly in the past 35 years. From what was historically viewed as a pervasive, intractable condition have emerged multiple evidence-based intervention options. These treatments, predominantly cognitive behavioral in orientation, provide significant symptom improvement in 50-60% of recipients. The treatment of PTSD with MDMA-assisted psychotherapy using a supportive, non-directive approach has yielded promising results. It is unknown, however, how different therapeutic modalities could impact or improve outcomes. Therefore, to capitalize on the strengths of both approaches, Cognitive Behavioral Conjoint Therapy for PTSD (CBCT) was combined with MDMA in a small pilot trial. The current article provides a case study of one couple involved in the trial, chosen to provide a demographically representative example of the study participants and a case with a severe trauma history, to offer a detailed account of the methodology and choices made to integrate CBCT and MDMA, as well as an account of their experience through the treatment and their treatment gains. This article offers a description of the combination of CBCT for PTSD and MDMA, and demonstrates that it can produce reductions in PTSD symptoms and improvements in relationship satisfaction.
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Affiliation(s)
- Anne C Wagner
- a Department of Psychology , Ryerson University , Toronto , Canada.,b Remedy , Toronto , Canada
| | | | | | - Candice M Monson
- a Department of Psychology , Ryerson University , Toronto , Canada
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192
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López CM, Hahn CK, Gilmore AK, Danielson CK. Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV. COGNITIVE AND BEHAVIORAL PRACTICE 2019; 27:70-83. [PMID: 32742160 DOI: 10.1016/j.cbpra.2019.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This Treatment Development Report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically-supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.
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Affiliation(s)
- Cristina M López
- College of Nursing, Medical University of South Carolina; 99 Jonathan Lucas MSC 160, Charleston, SC 29425.,National Crime Victims Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina; 67 President Street, MSC 861, Charleston, SC 29425
| | - Christine K Hahn
- National Crime Victims Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina; 67 President Street, MSC 861, Charleston, SC 29425
| | - Amanda K Gilmore
- College of Nursing, Medical University of South Carolina; 99 Jonathan Lucas MSC 160, Charleston, SC 29425
| | - Carla Kmett Danielson
- National Crime Victims Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina; 67 President Street, MSC 861, Charleston, SC 29425
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193
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Pearson CR, Kaysen D, Huh D, Bedard-Gilligan M. Randomized Control Trial of Culturally Adapted Cognitive Processing Therapy for PTSD Substance Misuse and HIV Sexual Risk Behavior for Native American Women. AIDS Behav 2019; 23:695-706. [PMID: 30607757 PMCID: PMC6407746 DOI: 10.1007/s10461-018-02382-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
An overlooked sequela of HIV risk is trauma exposure, yet few HIV interventions address trauma exposure, mental health, and substance misuse. In a two-arm randomized controlled trial 73 Native American women were randomized to a culturally-adapted Cognitive Processing Therapy (CPT) or 6-weeks waitlist. Outcomes assessed: PTSD symptom severity, alcohol use frequency, substance abuse or dependence diagnosis, and high-risk sexual behavior defined as vaginal/anal intercourse (a) under the influence of alcohol and/or illicit substances, (b) with a partner who was concurrently sexually active with someone else, and/or (c) with more than one partner in the past 6 weeks. Among immediate intervention participants, compared to waitlist participants, there were large reductions in PTSD symptom severity, high-risk sexual behavior, and a medium-to-large reduction in the frequency of alcohol use. CPT appears to improve mental health and risk behaviors, suggesting that addressing PTSD may be one way of improving HIV-risk related outcomes.
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194
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Kozel FA, Van Trees K, Larson V, Phillips S, Hashimie J, Gadbois B, Johnson S, Gallinati J, Barrett B, Toyinbo P, Weisman M, Centorino M, Gibson CA, Catalano G. One hertz versus ten hertz repetitive TMS treatment of PTSD: A randomized clinical trial. Psychiatry Res 2019; 273:153-162. [PMID: 30641346 DOI: 10.1016/j.psychres.2019.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/19/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023]
Abstract
The purpose of this trial was to test whether right prefrontal cortex 1 Hz versus 10 Hz rTMS provides a significantly greater improvement in PTSD symptoms and/or function. Veterans 18 to 50 years of age suffering from PTSD were randomized to right prefrontal 1 Hz rTMS [2400 pulses/session] versus right prefrontal 10 Hz rTMS [2400 pulses/session]. The treatments were performed 5 days a week for 6 weeks with a 3-week taper using the NeuroStar system. There were one month and three months post treatment follow-up evaluations. Forty-four participants were enrolled with 17 being randomized to 1 Hz rTMS and 18 to 10 Hz rTMS. Both groups had significant improvement in PTSD and depression scores from baseline to the end of acute treatment. The 10 Hz group but not the 1 Hz group demonstrated significant improvement in function. Although both groups demonstrated significant improvement in PTSD and depression symptoms, a significant advantage for either the 1 Hz or 10 Hz frequency group on any of the scales acquired was not demonstrated. Further work is required with larger samples sizes to test whether low or high frequency is superior or if individual differences would indicate the more effective frequency.
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Affiliation(s)
- F Andrew Kozel
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA.
| | - Kimberly Van Trees
- Nursing Services, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Valerie Larson
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Sean Phillips
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Jaffrey Hashimie
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Brian Gadbois
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Suzanne Johnson
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Jessica Gallinati
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Blake Barrett
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; VISN 8 Patient Safety Center of Inquiry, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Peter Toyinbo
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA
| | - Mark Weisman
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Michael Centorino
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Carri-Ann Gibson
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Glenn Catalano
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
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195
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Doran JM, O'Shea M, Harpaz-Rotem I. In Their Own Words: Clinician Experiences and Challenges in Administering Evidence-Based Treatments for PTSD in the Veterans Health Administration. Psychiatr Q 2019; 90:11-27. [PMID: 30209719 DOI: 10.1007/s11126-018-9604-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The aim of the present study was to increase the understanding of clinician experiences with administering two evidence-based psychotherapies (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). The study assessed clinician perceptions through the use of two, one-hour focus groups and employed a rigorous data analysis approach, Consensual Qualitative Research. Clinicians who work in an outpatient PTSD clinic at a New England VA, and who routinely administer EPBs for PTSD, participated in the study. Results were categorized into seven domains by the coding team, including 1) EBP Strengths, 2) EBP Weaknesses, 3) Challenges Specific to the Veteran Population, 4) Perceived EBP Effectiveness, 5) Active Ingredients for Treating PTSD, 6) Treatment Structure and Process, and 7) Suggested Changes/Improvements to EBPs. These domains are discussed in detail, with several core ideas falling under each domain. Operational definitions and representative quotes are provided. Overall, clinicians provided a balanced perspective and identified both strengths and weaknesses of the EBPs for PTSD. They identified several challenges in applying these treatments to veteran populations, and shared their beliefs about treatment effectiveness, how they use these treatments in their clinical practice, and how they would change the treatments if given an opportunity to do so. In this way, the study offers a small but important step in attempting to address the science-practice gap related to EBP for PTSD implementation efforts in the VA.
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Affiliation(s)
- Jennifer M Doran
- VA National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - McKenna O'Shea
- VA National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Ilan Harpaz-Rotem
- VA National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Northeast Program Evaluation Center, VA Connecticut Healthcare System, West Haven, CT, USA
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196
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Alcohol Use Problems, Posttraumatic Stress Disorder, and Suicide Risk Among Trauma-Exposed Firefighters. J Nerv Ment Dis 2019; 207:192-198. [PMID: 30724832 DOI: 10.1097/nmd.0000000000000947] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Alcohol use problems are associated with suicidal desire and may provide an avenue to suicidal ideation and behavior. However, the influence of posttraumatic stress disorder (PTSD) on the nature of the relationship between alcohol use problems and suicide risk is not well understood. In particular, the potential for PTSD to moderate the association between alcohol use problems and suicide risk remains unexplored. The present study investigated the main and interactive effects of alcohol use problems (Alcohol Use Disorders Identification Test) and PTSD symptoms (PTSD Checklist for DSM-5) on suicide risk (Suicide Behaviors Questionnaire-Revised) in a sample of 632 trauma-exposed firefighters (93.5% men; Mage = 38.44 years, SD = 8.59). Hierarchical logistic regression analyses evaluated whether the main and interactive effects of PTSD symptom severity and alcohol use disorders were significantly related to suicide risk, above and beyond age and cumulative trauma. The main effects of PTSD symptom severity (odds ratio, 1.76; p < 0.001) and alcohol use problems (odds ratio, 1.37; p = 0.391) significantly positively predicted suicide risk; however, PTSD symptoms did not moderate an association between alcohol use problems and suicide risk after accounting for these main effects (p > 0.05). A secondary, exploratory aim demonstrated that all PTSD symptom clusters significantly positively predicted suicide risk (p's < 0.001), although none of these clusters interacted with alcohol use problems to predict suicide risk (p's > 0.05). Theoretical and clinical implications are discussed as they relate to the importance of screening for PTSD and alcohol use disorder among firefighter populations.
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197
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Abstract
Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.
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Affiliation(s)
- Sara L Johansen
- Stanford University School of Medicine, Stanford, CA 94305-5119, USA
| | - Thalia K Robakis
- Stanford University School of Medicine, Stanford, CA 94305-5119, USA
| | | | - Natalie L Rasgon
- Stanford University School of Medicine, Stanford, CA 94305-5119, USA
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198
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Tuerk PW, Rauch SAM, Rothbaum BO. Effect size matters: a key neglected indicator of comparative trial quality. Lancet Psychiatry 2019; 6:e4. [PMID: 30686400 DOI: 10.1016/s2215-0366(18)30505-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Peter W Tuerk
- Department of Human Services, University of Virginia, Charlottesville, VA 22904, USA.
| | - Sheila A M Rauch
- Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
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199
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Goodnight JRM, Ragsdale KA, Rauch SAM, Rothbaum BO. Psychotherapy for PTSD: An evidence-based guide to a theranostic approach to treatment. Prog Neuropsychopharmacol Biol Psychiatry 2019; 88:418-426. [PMID: 29786514 DOI: 10.1016/j.pnpbp.2018.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/25/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is often a clinically complex disorder, frequently presenting with comorbid clinical conditions. Individuals with PTSD may also present with high-risk symptoms such as substance misuse and suicidal ideation. The clinical complexity of PTSD has precluded some clinicians from providing gold-standard trauma-focused treatment due to concern of iatrogenic effects. However, evidence to date suggests that trauma-focused treatments are safe and effective for PTSD even when higher-risk comorbidity presents. Occasionally, while some patients present with clinical concerns that may benefit from modifications to standard recommended treatment protocols, research suggests there are few absolute contraindications to trauma-focused treatment. The present manuscript provides a review of evidence-based assessment and treatment recommendations for PTSD. A clinical decision-making guide for PTSD across areas of clinical complexity is provided.
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Affiliation(s)
- Jessica R M Goodnight
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States
| | - Katie A Ragsdale
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States
| | - Sheila A M Rauch
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States; VA Atlanta Healthcare System, United States
| | - Barbara O Rothbaum
- Emory Healthcare Veterans Program, Emory University School of Medicine, Department of Psychiatry, 12 Executive Park Drive Northeast, 3rd Floor, Atlanta, GA 30329, United States.
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200
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Lenz AS, Luo Y. Differential Estimation of Treatment Effect Between Clinician-Administered and Self-Reported PTSD Assessments. JOURNAL OF COUNSELING AND DEVELOPMENT 2019. [DOI: 10.1002/jcad.12230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A. Stephen Lenz
- Department of Counseling and Educational Psychology, Texas A&M University-Corpus Christi
| | - Ye Luo
- Department of Counseling and Educational Psychology, Texas A&M University-Corpus Christi
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