The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans

Systematic Review of Dispositional Mindfulness and Posttraumatic Stress Disorder Symptomology: A Targeted Examination of Avoidance

High rates of nonresponse to evidence-based treatment for posttraumatic stress disorder (PTSD) have fueled the search for improved intervention. Evidence suggests that improvements in dispositional mindfulness (i.e., tendency to attend to the present with nonjudgment and nonreactivity) may help reduce PTSD symptoms. While some research suggests that transdiagnostic mindfulness-based interventions particularly target avoidance symptoms, the association between dispositional mindfulness and avoidance has yet to be systematically examined. To address this gap, we examined peer-reviewed studies that reported quantitative associations between avoidance and dispositional mindfulness among trauma-exposed adults, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Sixteen studies were identified for final review from PsycINFO and PubMed databases. Results suggest that mindfulness has a weak relationship with effortful avoidance. This weak relationship may be obscured in studies where effortful avoidance is measured among other symptoms (e.g., anhedonia). Mindfulness appeared to have stronger associations with symptoms of hyperarousal and negative alterations in cognition and mood. An important clinical implication is that high effortful avoidance may manifest among patients who report strong mindfulness skills. It may be helpful for clinicians to carefully assess how mindfulness is being used to cope.

Open Trial of a Brief Imagery-Based Stabilization Psychotherapy for Adults with Acute Posttraumatic Stress Disorder

PURPOSE

Early intervention after trauma is needed for reduction in clinical distress and prevention of chronic posttraumatic stress disorder (PTSD). This study describes findings from an open pilot trial of a brief stabilization psychotherapy based on imagery techniques for adults with acute PTSD (i.e., within 3 months of onset).

MATERIALS AND METHODS

Four sessions of 60-minute individual psychotherapy were conducted on 18 participants with PTSD within 3 months after accidents, 15 of whom completed the treatment. The clinician-administered PTSD scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Hamilton Depression and Anxiety Rating Scales, and self-questionnaires were administered at pre-treatment, post-treatment, and 6-month follow-up.

RESULTS

Eight (53.3%) of the 15 patients at post-treatment and 8 of the 9 patients at 6-month follow-up did not meet the DSM-5 criteria for PTSD. Reliable change of PTSD symptoms after treatment was observed in 6 of 15 (45.0%) patients at post-treatment and in 4 of 9 (45.0%) patients after 6 months. There was a significant decrease in PTSD, depression, anxiety, and impaired quality of life scores after treatment, and these gains were maintained after 6 months. No cases of exacerbated PTSD symptoms were observed among completers and non-completers.

CONCLUSION

Our findings suggest that brief stabilization sessions are safe treatment options for acute PTSD (KCT0001918).

Self-reported mental health in hospitalized patients with COVID-19: A 1-year follow-up

OBJECTIVES

This study aimed to longitudinally follow self-reported symptoms of depression, anxiety, post-traumatic stress disorder, and fatigue during the first year after hospitalization because of COVID-19.

DESIGN

The study was an observational longitudinal study.

METHODS AND PARTICIPANTS

Between July 2020, and February 2021, 211 patients aged ≥ 18 years, hospitalized ≥ 5 days at 5 hospitals in Region Västra Götaland, who had COVID-19, and were non-contagious (at study enrolment) were included in the baseline assessment. Of these, 168 (79.6%) patients completed mental health questionnaires at a 3-month follow-up, and 172 (83.1%) at a 12-month follow-up. A total of 120 (56.9%) participants who completed at least 1 questionnaire at both the 3- and 12-month follow-ups were analysed; the majority were male (n = 78, 65.0%).

RESULTS

There was an improvement in all patients from 3 to 12 months on the fatigue subscales "reduced activity" (p = 0.02) and "physical fatigue" (p = 0.04). No other significant mental health improvements were found. At 12 months, 34 (28.4%) were classified as having anxiety symptoms, 29 (24.1%) as having depression symptoms, and 40 (33.3%) had symptoms of probable post-traumatic stress disorder.

CONCLUSIONS

Participants in the present study did not report full mental health recovery 1 year after hospitalization for COVID-19.

Long-term PTSD prevalence and associated adverse psychological, functional, and economic outcomes: a 12-15 year follow-up of adults with suspected serious injury

Background: An increasing number of longitudinal studies investigates long-term PTSD, related outcomes and potential gender differences herein. However, a knowledge gap exists when it comes to studies following individual civilian trauma beyond a decade post-trauma.Objective: To investigate the long-term PTSD prevalence, associated adverse psychological, functional and economic outcomes related to (suspected) serious injury of 12-15 years ago in Dutch adults, as well as potential gender differences herein.Method: N = 194 trauma-exposed adults (34% women) admitted to an emergency department following suspected serious injury completed a follow-up assessment 12-15 years (M = 14.30, SD = 1.00) post-trauma. Participants completed assessments of clinician-rated PTSD symptom severity, as well as self-report questionnaires on psychological, functional and economic outcomes.Results: Nine participants (4.8%) fulfilled the DSM-5 diagnostic criteria for PTSD related to the index trauma of 12-15 years ago. Results showed that PTSD symptom severity (CAPS-5) was significantly associated with more severe symptoms of anxiety (HADS) and depression (QIDS), lower well-being (WHO-5) and (health-related) quality of life (WHOQOL; EQ-5D-5L), but not with alcohol use (AUDIT), productivity loss at work (iPCQ) and health care use (iMCQ). No significant gender differences in the long-term PTSD prevalence nor in its related psychological, functional and economic outcomes were found.Conclusions: Our findings underscore the long-term presence of PTSD and associated adverse psychological and functional outcomes in a proportion of adults who experienced (suspected) serious injury over a decade ago. PTSD is already widely recognized for its substantial impact in the aftermath of a trauma. The current study emphasizes the potential long-term consequences of individual civilian trauma, highlighting the importance of accurate screening and prevention for PTSD.

A guided single session intervention to reduce intrusive memories of work-related trauma: a randomised controlled trial with healthcare workers in the COVID-19 pandemic

BACKGROUND

Intrusive memories of psychologically traumatic events bring distress both sub-clinically and clinically. This parallel-group, two-arm randomised controlled trial evaluated the effect of a brief behavioural intervention on reducing intrusive memories in frontline healthcare workers exposed to traumatic events during the COVID-19 pandemic.

METHODS

Participants with at least two intrusive memories of work-related trauma in the week before recruitment were randomised 1:1 to an imagery-competing task intervention (n = 73) or attention-based control task (n = 71). The number of intrusive memories was assessed at baseline and 5 weeks after the guided session (primary endpoint).

RESULTS

The intervention significantly reduced intrusive memory frequency compared with control [intervention Mdn = 1.0 (IQR = 0-3), control Mdn = 5.0 (IQR = 1-17); p < 0.0001, IRR = 0.30; 95% CI = 0.17-0.53] and led to fewer post-traumatic stress-related symptoms at 1, 3 and 6 month follow-ups (secondary endpoints). Participants and statisticians were blinded to allocation. Adverse events data were acquired throughout the trial, demonstrating safety. There was high adherence and low attrition.

CONCLUSIONS

This brief, single-symptom, repeatable digital intervention for subclinical-to-clinical samples after trauma allows scalability, taking a preventing-to-treating approach after trauma.

TRIAL REGISTRATION

2020-07-06, ClinicalTrials.gov identifier: NCT04460014.

Changes in emotion regulation difficulties and PTSD symptom severity in an intensive treatment program for PTSD

BACKGROUND

Greater difficulties in emotion regulation (ER) and decreased use of adaptive ER strategies have been associated with higher levels of posttraumatic stress disorder (PTSD) symptoms. To date, limited research has explored whether ER improves with PTSD treatment or whether such improvements are linked with improvements in PTSD symptoms.

METHODS

Veterans and service members with PTSD (N = 223) participated in a 2-week intensive treatment program (ITP) based in Cognitive Processing Therapy (CPT). ER was measured using the Difficulties in Emotion Regulation Short Form (DERS-SF) at baseline and on days 4 and 9 of treatment. PTSD symptoms were reported on the PTSD Symptom Checklist for DSM-5 (PCL-5) at baseline, on days 3, 5, 6, and 8 of treatment, and at post-treatment.

RESULTS

DERS-SF scores decreased during treatment (Mchange = 5.12, d = 0.38). Baseline DERS-SF did not predict overall PCL-5 scores across timepoints (p = .377). However, scores on the DERS-SF over time were significantly associated with PCL-5 improvement over the course of treatment (p < .001, R2b = 0.07). Finally, improvements in all subscales of the DERS-SF across time except clarity were significantly associated with improvement in PCL-5 over time.

LIMITATIONS

Additional treatment components in the ITP beyond CPT may have contributed to ER improvements. Conclusions are also limited by the use of self-report data.

CONCLUSIONS

An intensive CPT-based treatment program for veterans and service members can lead to improved ER in two weeks. ER improvements are associated with PTSD symptom severity during the ITP.

Childhood-related PTSD: the role of cognitions in EMDR and imagery rescripting

Background: The relationship between trauma-related negative cognitions and post-traumatic stress disorder (PTSD) symptoms has been studied frequently. Several studies found a mediating effect of trauma-related negative cognitions on symptom reduction in studies on different psychotherapeutic treatments, however, this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR).Objective: To analyse the role of trauma-related negative cognitions in the treatment of PTSD due to childhood trauma with EMDR and ImRs.Method: N = 155 patients with PTSD due to childhood trauma aged between 18 and 65 (M = 38.54) participated in a randomized clinical trial and were treated with either EMDR or ImRs in Australia, Germany, and the Netherlands between October 2014 and June 2019. We analysed the relationship between PTSD symptoms (Clinician-administered PTSD Scale for DSM-5, CAPS-5 and Impact of Event Scale revised; IES-R, completed twice for index trauma and for all other traumas) and trauma-related negative cognitions (Post-Traumatic Cognitions Inventory, PTCI) using Granger Causality analyses with linear mixed models on person-centered variables. Assessments were conducted pre-treatment, post-treatment (12 sessions in 6 weeks), eight weeks post-treatment, and one year after the pre-treatment assessment.Results: Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectional) as measured by the CAPS and the IES-R for index trauma. For the IES-R related to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. On the level of PTCI subscales only changes in cognitions about oneself preceeded changes in PTSD symptoms.Conclusions: The results support the idea of a general role of trauma-related negative cognitions in the treatment of PTSD. The analyses should be replicated with a higher frequency of assessments.

Long-term effects of dialectical behaviour therapy for posttraumatic stress disorder and cognitive processing therapy 9 months after treatment termination

Background: The complexity of posttraumatic stress disorder (PTSD) symptoms related to childhood abuse (CA) present challenges for effective psychotherapeutic treatment. Consequently, there is great interest in the long-term effectiveness of psychological treatments for this population.Objective: This study aims to investigate the long-term outcomes of Dialectical Behaviour Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT) 9 months after treatment termination.Method: This is a long-term analysis from a randomised-controlled trial of DBT-PTSD versus CPT (registration number DRKS00005578). Initially, 193 individuals with CA-related PTSD were randomly allocated to receive either DBT-PTSD (n = 98) or CPT (n = 95). The primary outcome the Clinician-administered PTSD-Scale for DSM-5 (CAPS-5) was administred at baseline, treatment completion (15 months post-randomization) and at the 9-month follow-up. Secondary outcomes included self-reported PTSD severity (PCL-5), dissociation (DSS), severity of borderline symptoms (BSL-23), and psychosocial functioning (GAF).Results: No significant changes were observed in the primary (CAPS) and all other outcomes from post-intervention to 9-months follow-up in both the DBT-PTSD (CAPS: Mpost  = 15.60, Mfollow-up  = 14.93) and CPT group (CAPS: Mpost = 18.80, Mfollow-up = 17.41). Between-group analyses at 9-months follow-up were significantly in favour of DBT-PTSD compared to CPT with small to medium effect sizes on all outcomes ranging from d = 0.35 on the CAPS to d = 0.57 on the BSL-23 and GAF.Conclusions: Our results indicate that treatment effects of psychotherapy addressing complex presentations of PTSD persist 9 months after treatment termination. In addition, the superiority of DBT-PTSD as compared to CPT found at treatment termination, was confirmed at 9-months follow-up.Trial registration: German Clinical Trials Register identifier: DRKS00005578..

The effect of a reduction in irrational beliefs on Posttraumatic Stress Disorder (PTSD), depression, and anxiety symptoms in a group treatment for post-9/11 Veterans

Previous research has indicated that a Rational Emotive Behavior Therapy (REBT)-Informed Group focused on changing irrational beliefs to address comorbid depression and anxiety (as well as anger and guilt) in a combat Veteran population diagnosed with Posttraumatic Stress Disorder (PTSD) demonstrated significant reductions in depression and PTSD symptoms at posttreatment. However, mechanisms of change associated with improvement have not been evaluated. REBT theory suggests that a decline in irrational beliefs predicts a decrease in PTSD, depression, and anxiety symptoms. This study aimed to test this tenet of REBT theory in a naturalistic treatment setting. Participants (N = 86) were post-9/11 combat Veterans, engaged in the REBT-Informed Group between October 2016 and February 2020. Results of hierarchical multiple regression analyses indicated that a reduction in irrational beliefs predicted notable decreases in PTSD, depression, and anxiety symptoms controlling for several covariates. This study extends previous research demonstrating the success of the REBT-Informed Group with combat Veterans and gives support to REBT theory regarding the effect of a decline in irrational beliefs. Future directions include replication of findings with Veterans who experienced military sexual trauma (MST), pre-9/11 Veterans, those at other military or Veterans Affairs (VA) medical centers, and civilians to determine generalizability.

Post-treatment alterations in white matter integrity in PTSD: Effects on symptoms and functional connectivity a secondary analysis of an RCT

Post-traumatic stress disorder (PTSD) has been linked to altered communication within the limbic system, including reduced structural connectivity in the uncinate fasciculus (UNC; i.e., decreased fractional anisotropy; FA) and reduced resting-state functional connectivity (RSFC) between the hippocampus and ventromedial prefrontal cortex (vmPFC). Previous research has demonstrated attenuation of PTSD symptoms and alterations in RSFC following exposure-based psychotherapy. However, the relationship between changes in structural and functional connectivity patterns and PTSD symptoms following treatment remains unclear. To investigate this, we conducted a secondary analysis of data from a randomized clinical trial of intensive exposure therapy, evaluating alterations in UNC FA, hippocampus-vmPFC RSFC, and PTSD symptoms before (pre-treatment), 7 days after (post-treatment), and 30 days after (follow-up) the completion of therapy. Our results showed that post-treatment changes in RSFC were positively correlated with post-treatment and follow-up changes in UNC FA and that post-treatment changes in UNC FA were positively correlated with post-treatment and follow-up changes in PTSD symptoms. These findings suggest that early changes in functional connectivity are associated with sustained changes in anatomical connectivity, which in turn are linked to reduced PTSD symptom severity.

Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine

BACKGROUND AND OBJECTIVES

There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine.

METHODS

This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38).

RESULTS

Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study.

DISCUSSION AND CONCLUSIONS

Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling.

SCIENTIFIC SIGNIFICANCE

This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.

Examining Rates of Traumatic Events and Posttraumatic Stress Disorder Symptoms Among Autistic Adults

Background

Autistic adults experience high rates of traumatic events and posttraumatic stress disorder (PTSD) symptoms. However, less is known about how autistic adults experience (i.e., by directly experiencing, witnessing, and/or learning about) distinct types of traumatic events (e.g., social, nonsocial traumas). Little research has considered whether the four-factor structure of PTSD symptom domains (e.g., avoidance, intrusions, hypervigilance, negative mood/cognition) can be applied for autistic adults. Lastly, understanding how demographic factors (e.g., gender, race/ethnicity) relate to rates of traumatic events and symptoms among autistic adults is critical for understanding disparities relating to PTSD. Therefore, the current study aims to examine self-reported traumatic events and PTSD symptoms, and identify associations with demographic factors, among autistic adults.

Methods

Participants included 276 autistic adults and a nationally representative sample of 361 nonautistic adults who completed online measures, including the Life Events Checklist for DSM-5, Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), Autism-Spectrum Quotient-Short, and Patient Health Questionnaire-4. Analyses focused on evaluating group differences in traumatic events and symptoms and considered associations with demographic factors.

Results

Autistic adults reported significantly higher rates of directly experiencing, witnessing, and learning about traumatic events than nonautistic adults, including more interpersonal events (e.g., physical assault, sexual assault) and fewer transportation accidents than nonautistic adults. Autistic adults also reported significantly higher levels of all PTSD symptom clusters than nonautistic adults. A confirmatory factor analysis and follow-up invariance analyses of the PCL-5 revealed that the four-factor Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) PTSD symptom subscale structure was equivalent across groups of autistic and nonautistic adults.

Conclusion

Autistic adults experienced more traumatic events and PTSD symptoms overall, particularly more interpersonal traumas and hyperarousal and negative mood/cognition symptoms than nonautistic adults. Future research should examine outcomes of trauma exposure, identify protective factors, and examine efficacy of trauma-focused treatments for autistic individuals, in partnership with autistic adults.

An Item Response Theory Analysis of the Clinician-Administered PTSD Scale for DSM-5 Among Veterans

We used item response theory (IRT) analysis to examine Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) item performance using data from three large samples of veterans (total N = 808) using both binary and ordinal rating methods. Relative to binary ratings, ordinal ratings provided good coverage from well below to well above average within each symptom cluster. However, coverage varied by cluster, and item difficulties were unevenly distributed within each cluster, with numerous instances of redundancy. For both binary and ordinal scores, flashbacks, dissociative amnesia, and self-destructive behavior items showed a pattern of high difficulty but relatively poor discrimination. Results indicate that CAPS-5 ordinal ratings provide good severity coverage and that most items accurately differentiated between participants by severity. Observed uneven distribution and redundancy in item difficulty suggest there is opportunity to create an abbreviated version of the CAPS-5 for determining PTSD symptom severity, but not DSM-5 PTSD diagnosis, without sacrificing precision.

Examination of PTSD symptom networks over the course of cognitive processing therapy

OBJECTIVES

Cognitive processing therapy (CPT) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, little is known about how interrelationships between PTSD symptoms change over the course of treatment. The current study examined baseline, midtreatment, and posttreatment PTSD symptom networks during CPT for PTSD.

METHOD

Adults with PTSD (n = 107) received 12 sessions of CPT as part of a randomized trial. Self-reported PTSD symptoms were assessed at pretreatment, midtreatment, and posttreatment, and network analysis was used to examine the interrelationships between symptoms at these three timepoints. Linear regression was conducted to examine whether any baseline symptoms or midpoint symptoms predicted overall treatment change.

RESULTS

In the baseline PTSD network, feelings of detachment and feeling upset at reminders of the trauma were central to the symptom network. These symptoms were no longer central at midtreatment, possibly suggesting that CPT quickly reduces the importance of these symptoms. These findings were consistent with regression results that, after accounting for multiple comparisons, high baseline scores of feeling upset at trauma reminders predicted later treatment change. At the conclusion of treatment, strong negative emotions were the most central symptom and may be most important in maintaining or lowering other PTSD symptoms at the conclusion of treatment.

CONCLUSIONS

Though replication is necessary, these findings offer insights into identifying which symptoms may be most predictive of treatment outcomes and the course by which CPT reduces PTSD symptoms. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Disentangling subjective symptom complaints and objective cognitive performance in veterans: Impact of posttraumatic stress disorder and lifetime traumatic brain injury burden

Self-reported histories of mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) symptoms are prevalent among post-9/11 veterans. Both are associated with subjective and often overlapping symptom complaints, but variably with objective neuropsychological test performances. These outcomes are seldom explored in relation to lifetime mTBI burden. This cross-sectional study examined associations of PTSD and lifetime mTBI with subjective (persistent symptoms after concussion and cognitive complaints) and objective (performances across five cognitive domains) measures among 46 veterans. Within this sample, 20 veterans had Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) confirmed PTSD (PTSD+), whereas 26 demographically-similar participants did not meet criteria (PTSD-). The Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) yielded total mTBI scores ranging from 0 to 8. Regressions showed PTSD was associated with increased subjective symptoms/cognitive complaints, along with reduced verbal fluency, visuospatial memory, and processing speed performances. Lifetime mTBI burden was associated with subjective symptoms, but not with objective cognitive test performance, after controlling for PTSD. No significant interactions were observed. Exploratory correlations suggested that all PTSD symptom clusters were generally associated with the subjective and objective measures. However, fewer significant associations emerged within the PTSD+/- groups separately, with each group yielding somewhat different patterns of relationships. PTSD and increasing mTBI burden are consistently associated with negative subjective symptoms, including cognitive complaints. Each condition likely explains some degree of unique variance in symptom reporting. PTSD is associated with poorer objective cognition on some tasks, including processing speed, executive functioning, and learning/memory. Implications are explored.

Assessment of PTSD and Trauma Symptoms With the MMPI-3 in College Students: Validity and Incremental Utility of the Anxiety Related Experiences (ARX) Scale

Post Traumatic Stress Disorder (PTSD) is heterogeneous in nature, which complicates diagnostic efforts and makes accurate assessment tools critical. The MMPI family of instruments are widely used broadband measures of psychopathology, including trauma symptomology. The MMPI-3's Anxiety Related Experiences scale (ARX) is an expansion of the MMPI-2-RF Anxiety (AXY) scale which has historically represented the MMPI family's best measure of trauma symptoms. This study expands research on ARX in 2 samples of college students (n = 332 [PCL-5 Criterion] & n = 58 [CAPS-5 Criterion]) by examining ARX's incremental, criterion, and classification validity. ARX incrementally predicted PCL-5 total and cluster scores beyond that accounted for by AXY (R2Δ = .01-.09). ARX accounted for the most unique variance, beyond RCd and RC7, in CAPS-5 interview ratings of intrusion symptoms (R2Δ = .16). ARX was strongly related to trauma symptomology broadly (r = .42-.58) and demonstrated strong screening ability at T65 (sensitivity = .37-.40; specificity = .91-.92) and stronger diagnostic screening at T75 (sensitivity = .31; specificity = .93). We discuss clinical considerations when using ARX for assessing PTSD.

Imagery rescripting: The value of an added positive emotion component

BACKGROUND AND OBJECTIVES

Imagery Rescripting (ImRs) aims to reduce trauma-related negative emotions and intrusions. Positive emotions during ImRs may aid coping with the consequences of trauma, but protocols vary in the extent to which they explicitly target such positive emotions. We used a multiple-day design with a trauma film paradigm to investigate whether adding an explicit positive emotion component to ImRs improved intervention effects in a non-clinical sample. In addition, we explored potentially differential effects on high, medium, and low arousal positive affect.

METHODS

Participants (n = 105) were randomly assigned to either a standard ImRs condition, to an ImRs condition with an added explicit positive emotion component targeting joy (ImRs+), or to a non-intervention control (NIC) condition. Participants watched a trauma film on day 1, received the condition-specific intervention on day 2, and completed additional post-assessments of positive and negative affect on day 3. In addition, participants recorded intrusions from the trauma film from day 1 until day 3.

RESULTS

Compared to standard ImRs and NIC, ImRs + significantly increased positive affect. Exploratory analyses showed that this increase concerned medium and high, but not low arousal positive affect. No significant between-group differences were found for negative affect and intrusion-related outcomes.

LIMITATIONS

Floor effects for intrusions and negative affect limited our ability to fully investigate the potential benefits of targeting positive affect.

CONCLUSIONS

Adding a positive emotion component to ImRs reliably improved positive affect. More research is needed to determine whether explicitly targeting positive affect improves efficacy of ImRs for intrusion-related outcomes.

Non-fear emotions in changes in posttraumatic stress disorder symptoms during treatment

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) is not only associated with fear but also with other emotions. The present study aimed to examine if changes in shame, guilt, anger, and disgust predicted changes in PTSD symptoms during treatment, while also testing if PTSD symptoms, in turn, predicted changes in these emotions.

METHODS

Participants (N = 155) with childhood-related PTSD received a maximum of 12 sessions of eye movement desensitization and reprocessing or imagery rescripting. The data was analyzed using Granger causality models across 12 treatment sessions and 6 assessment sessions (up until one year after the start of treatment). Differences between the two treatments were explored.

RESULTS

Across treatment sessions, shame, and disgust showed a reciprocal relationship with PTSD symptoms, while changes in guilt preceded PTSD symptoms. Across assessments, anger was reciprocally related to PTSD, suggesting that anger might play a more important role in the longer term.

LIMITATIONS

The individual emotion items were not yet validated, and the CAPS was not administered at all assessments.

CONCLUSIONS

These findings partly differ from earlier studies that suggested a unidirectional relationship in which changes in emotions preceded changes in PTSD symptoms during treatment. This is in line with the idea that non-fear emotions do play an important role in the treatment of PTSD and constitute an important focus of treatment and further research.

Executive functioning in posttraumatic stress disorder: Understanding how inhibition, switching, and test modality affect reaction times

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been linked to deficits in executive functioning, but the literature suggests these associations are inconsistent. Results vary depending on the task used, test modality, and the specific subdomain being measured, such as inhibitory control (interference resolution, response inhibition) or set shifting (task switching, rule switching). Notably, deficits are more consistently observed in computerized tasks that measure precise reaction times (RTs) than in classic paper-and-pencil measures, but few studies have parsed specific executive functioning deficits in PTSD using detailed analyses of RT data.

METHOD

The present study used a cued-switching Stroop Task to examine both interference resolution and task switching in 28 veterans with PTSD and 28 age-matched controls. Each trial required attending to a randomly presented cue and responding to the specified target while ignoring irrelevant or opposing information. Analyses of RT distributions estimated both Gaussian (normal) and ex-Gaussian (exponential) parameters.

RESULTS

Veterans with PTSD had slower and more variable RTs than the controls on trials that required ignoring conflicting information (interference resolution, d' = .68). These effects were confined to the normal distribution, not to excessively slow responses (as estimated by ex-Gaussian parameters). Veterans with PTSD also showed modestly slower RTs on trials that required switching between cues, but Bayesian evidence for this was weak, and measures by ex-Gaussian parameters were not significant.

CONCLUSIONS

These results highlight the importance of examining executive functioning in PTSD with a more nuanced approach, as clarity around these deficits may have important implications for future intervention and rehabilitation strategies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Meta-Analysis of Interpersonal and Psychodynamic Psychotherapies for Posttraumatic Stress Disorder

OBJECTIVE

Established trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD) have remission rates of approximately 30%-40%. Alternatively, interpersonal psychotherapy (IPT) and psychodynamic psychotherapy (PDT) focus on disrupted attachment, mentalization, and social connection in PTSD and may help some patients. The authors conducted a meta-analysis on these interpersonal and affect-oriented approaches to treating PTSD.

METHODS

Building on a prior meta-analysis, the authors searched for randomized controlled trials (RCTs) comparing IPT or PDT with other established PTSD treatments or control conditions for adults diagnosed as having PTSD. Random-effects meta-analyses were conducted to assess outcome effect sizes and dropout rates. RCTs were rated via the Randomized Controlled Trial Psychotherapy Quality Rating Scale.

RESULTS

Ten RCTs (eight of IPT) comparing IPT or PDT with control (k=7) or active treatment (k=4) conditions were identified, nine of which were of adequate quality. IPT (k=5) and PDT (k=2), when analyzed together, were superior to control conditions overall (g=-1.14, p=0.011 [as was IPT alone: g=-0.88, p=0.034]) and to waitlist (g=-1.49) and treatment-as-usual (g=-0.70) groups. Effect sizes, however, may have been inflated by outliers or publication bias. IPT (k=3) and PDT (k=1), when analyzed together, were equally efficacious compared with other active PTSD treatments (primarily exposure-based psychotherapies), as was IPT alone, and had lower dropout rates (relative risk=0.63, p=0.049 for IPT and PDT analyzed together; relative risk=0.61, p=0.098 for IPT alone).

CONCLUSIONS

Affect-focused therapies hold promise in the treatment of PTSD. IPT has demonstrated efficacy in multiple trials, whereas the evidence base for PDT is sparse.

Assessing shared psychological constructs as risk factors in comorbid PTSD-AUD combat-exposed male veterans

PTSD and AUD are frequently comorbid post-trauma outcomes. Much remains unknown about shared risk factors as PTSD and AUD work tends to be conducted in isolation. We examined how self-report measures of distress tolerance (DT), experiential avoidance (EA), and drinking motives (DM) differed across diagnostic groups in white, male combat-exposed veterans (n = 77). A MANOVA indicated a significant difference in constructs by group, F (5, 210) = 4.7, p = <.001. Follow-up ANOVAs indicated DM subscales (Coping: F (3,82) = 21.3; Social: F (3,82) = 13.1; Enhancement: F (3,82) = 10.4; ps = <.001) and EA (F (3,73) = 7.8, p < .001) differed by groups but not DT. Post hoc comparisons indicated that mean scores of the comorbid and AUD-only groups were significantly higher than controls for all DM subscales (all ps < .01). EA scores were significantly higher for the comorbid as compared to control (p < .001) and PTS-only (p = .007) groups. Findings support shared psychological factors in a comorbid PTSD-AUD population.

Validation of the PCL-5 in Dutch trauma-exposed adults

BACKGROUND

The PTSD Checklist for DSM-5 (PCL-5) is an internationally widely used self-report questionnaire that can be used to screen for probable diagnosis of posttraumatic stress disorder (PTSD). Information on the psychometric properties of the Dutch PCL-5 is currently lacking.

OBJECTIVE

We aimed to validate the Dutch PCL-5 in a sample of Dutch adults with prior (suspected) serious injury and establish the optimal cut-off for probable PTSD diagnosis herein.

METHODS

Data for the current study were collected as part of a long-term follow-up measurement of the TraumaTIPS cohort, where adults admitted to an emergency department following (suspected) serious injury completed a follow-up measurement 12-15 years post-trauma. Of N = 333 eligible participants, n = 192 (57.7%) consented and completed the PCL-5 alongside self-report instruments measuring depression (QIDS), PTSD (IES-R), and quality of life (WHO-QOL and EQ-6D). In total, n = 185 participants also completed a clinician administered interview for PTSD (CAPS-5). Most participants were men (66%) and on average 54 years old (SD = 12.41). We evaluated the diagnostic utility of the PCL-5 using Youden index and tested reliability and convergent validity.

RESULTS

The PCL-5 demonstrated excellent diagnostic accuracy with a cut-off point of 16 resulting in an optimal Youden index (0.90) for screening purposes with a high sensitivity (1.00) and specificity (0.90). A cut-off of 22 yielded a slightly lower Youden index (0.84) but better positive predictive value (0.50 instead of 0.33) than the cut-off of 16. A cut-off of 29 resulted in the most accurate prevalence estimates. The PCL-5 showed a high internal consistency (Cronbach's α = 0.94), excellent inter-item and item-total correlations and good convergent validity (r > .5 for CAPS-5, IES-R and QIDS).

CONCLUSIONS

The PCL-5 is a reliable and valid measurement for PTSD symptoms and probable diagnosis and shows excellent screening abilities in Dutch adults with prior (suspected) serious injury, with a lower optimal cut-off compared to previously found in clinical populations. We recommend a cut-off of 22 for screening purposes and a cut-off of 29 for prevalence estimates in Dutch trauma-exposed adults.

Investigating the bed nucleus of the stria terminalis as a predictor of posttraumatic stress disorder in Black Americans and the moderating effects of racial discrimination

Altered functioning of the bed nucleus of the stria terminalis (BNST) may play a critical role in the etiology of posttraumatic stress disorder (PTSD). Chronic stressors such as racial discrimination and lifetime trauma are associated with an increased risk for PTSD, but it is unknown whether they influence the relationship between BNST functioning and PTSD. We investigated acute post-trauma BNST resting-state functional connectivity (rsFC) as a predictor of future PTSD symptoms in Black trauma survivors. We also examined whether racial discrimination and lifetime trauma moderated the relationship between BNST rsFC and PTSD symptoms. Black adults (N = 95; 54.7% female; mean age = 34.04) were recruited from an emergency department after experiencing a traumatic injury (72.6% were motor vehicle accidents). Two-weeks post-injury, participants underwent a resting-state fMRI scan and completed questionnaires evaluating their PTSD symptoms as well as lifetime exposure to racial discrimination and trauma. Six-months post-injury, PTSD symptoms were reassessed. Whole brain seed-to-voxel analyses were conducted to examine BNST rsFC patterns. Greater rsFC between the BNST and the posterior cingulate cortex, precuneus, left angular gyrus, and hippocampus prospectively predicted six-month PTSD symptoms after adjusting for sex, age, education, and baseline PTSD symptoms. Acute BNST rsFC was a stronger predictor of PTSD symptoms in individuals who experienced more racial discrimination and lifetime trauma. Thus, in the acute aftermath of a traumatic event, the BNST could be a key biomarker of risk for PTSD in Black Americans, particularly for individuals with a greater history of racial discrimination or previous trauma exposure.

Evidence for Locus Coeruleus-Norepinephrine System Abnormality in Military Posttraumatic Stress Disorder Revealed by Neuromelanin-Sensitive Magnetic Resonance Imaging

BACKGROUND

The complex neurobiology of posttraumatic stress disorder (PTSD) calls for the characterization of specific disruptions in brain functions that require targeted treatment. One such alteration could be an overactive locus coeruleus (LC)-norepinephrine system, which may be linked to hyperarousal symptoms, a characteristic and burdensome aspect of the disorder.

METHODS

Study participants were Canadian Armed Forces veterans with PTSD related to deployment to combat zones (n = 34) and age- and sex-matched healthy control participants (n = 32). Clinical measures included the Clinician-Administered PTSD Scale for DSM-5, and neuroimaging measures included a neuromelanin-sensitive magnetic resonance imaging scan to measure the LC signal. Robust linear regression analyses related the LC signal to clinical measures.

RESULTS

Compared with control participants, the LC signal was significantly elevated in the PTSD group (t62 = 2.64, p = .010), and this group difference was most pronounced in the caudal LC (t56 = 2.70, Cohen's d = 0.72). The caudal LC signal was also positively correlated with the severity of Clinician-Administered PTSD Scale for DSM-5 hyperarousal symptoms in the PTSD group (t26 = 2.16, p = .040).

CONCLUSIONS

These findings are consistent with a growing body of evidence indicative of elevated LC-norepinephrine system function in PTSD. Furthermore, they indicate the promise of neuromelanin-sensitive magnetic resonance imaging as a noninvasive method to probe the LC-norepinephrine system that has the potential to support subtyping and treatment of PTSD or other neuropsychiatric conditions.

Comparison of autonomic reactivity to trauma and nightmare imagery: A Pilot Study

Study Objectives

Trauma-related nightmares (TRNs) are a hallmark symptom of PTSD and are highly correlated with PTSD severity and poor sleep quality. Given the salience and arousal associated with TRNs, they might be an effective target for imaginal exposures during Prolonged Exposure (PE) therapy. As a first step in this line of research, the current study compared participants' emotional reactivity during recollection of TRNs to their recollection of the index traumatic event.

Methods

Seventeen trauma-exposed participants with clinical or sub-clinical PTSD who reported frequent TRNs engaged in script-driven imagery using scripts depicting their index trauma and their most trauma-like TRN. Heart rate (HRR), skin conductance (SCR), corrugator EMG (EMGR) responses, and emotional ratings were recorded.

Results

HRR, SCR, and EMGR did not differ significantly between trauma-related and TRN scripts. Bayesian analyses confirmed support for the null hypothesis, indicating no differences. With the exception of "Sadness," for which TRNs elicited significantly lower ratings than trauma scripts, individual emotion ratings showed no significant differences, suggesting likely parity between the emotionality of trauma-related and TRN recollections.

Conclusions

Together, TRN content elicited psychophysiological reactivity similar to that of the index trauma in this pilot study. Upon replication, studies testing TRNs as potential targets for imaginal exposures during PE may be warranted.

Comorbidity of binge eating disorder and other psychiatric disorders: a systematic review

OBJECTIVE

Binge eating disorder (BED), although relatively recently recognized as a distinct clinical syndrome, is the most common eating disorder. BED can occur as a separate phenomenon or in combination with other mental disorders, adding to the overall burden of the illness. Due to the relatively short history of recognizing BED as a distinct disorder, this review aimed to summarize the current knowledge on the co-occurrence of BED with other psychiatric disorders.

METHOD

This review adhered to the PRISMA guidelines. Multiple databases, such as MEDLINE, MEDLINE Complete, and Academic Search Ultimate, were used to identify relevant studies. Of the 3766 articles initially identified, 63 articles published within the last 13 years were included in this review. This systematic review has been registered through INPLASY (INPLASY202370075).

RESULTS

The most frequently observed comorbidities associated with BED were mood disorders, anxiety disorders and substance use disorders. They were also related to more severe BED presentations. Other psychiatric conditions frequently associated with BED include reaction to severe stress and adjustment disorders, impulse control disorder, ADHD, personality disorders, behavioral disorders, disorders of bodily distress or bodily experience, and psychotic disorders. Additionally, BED was linked to suicidality and sleep disorders.

DISCUSSION

The findings highlight the interconnected nature of BED with various psychiatric conditions and related factors, shedding light on the complexity and broader impact of BED on mental health and the need for appropriate screening and appropriately targeted clinical interventions.

The assessment of reliability generalisation of clinician-administered PTSD scale for DSM-5 (CAPS-5): a meta-analysis

Background

The CAPS-5 is a reliable instrument for assessing PTSD symptoms, demonstrating strong consistency, validity, and reliability after a traumatic event. However, further research is warranted to explore the divergent validity of the CAPS-5 and its adaptation to diverse cultural contexts.

Objective

In this meta-analysis, we endeavoured to comprehensively evaluate the reliability generalization of the CAPS-5 across diverse populations and clinical contexts.

Methods

A reliability generalization meta-analysis on the psychometric properties of CAPS-5 was conducted, encompassing 15 studies. The original versions' psychometric properties were systematically retrieved from databases including PubMed, PsychNet, Medline, CHAHL, ScienceDirect, Scopus, Web of Science, and Google Scholar, with a focus on studies published between 2013 and 2023. Two independent investigators evaluated study quality using QUADAS-2 and COSMIN RB, pre-registering the protocol in the Prospero database for transparency and minimizing bias risk.

Results

Meta-analysis reveals CAPS-5 global reliability (α = 0.92, 95% CI [0.90, 0.94]), z = 99.44, p < 0.05 across 15 studies, supporting consistent internal consistency. Subscale analysis shows variability in Reexperiencing (α = 0.82), Avoidance (α = 0.68), Cognition and Mood (α = 0.82), and Hyperarousal (α = 0.74), with an overall estimate of 0.77 (95% CI [0.70;0.83]). Language-dependent analysis highlights reliability variations (α range: 0.83 to 0.92) across Brazilian-Portuguese, Dutch, English, French, German, Korean, and Portuguese. Test-retest reliability demonstrates stability (r = 0.82, 95% CI [0.79; 0.85]), with overall convergent validity (r = 0.59, 95% CI [0.50;0.68]).

Conclusion

The meta-analysis affirms CAPS-5's robust global and subscale reliability across studies and languages, with stable test-retest results. Moderator analysis finds no significant impact, yet substantial residual heterogeneity remains unexplained. Our findings contribute intricate insights into the psychometric properties of this instrument, offering a more complete understanding of its utility in PTSD assessment.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023483748.

"I Felt Dirty in a Way a Shower Wouldn't Fix": A Qualitative Examination of Sexual Trauma-Related Mental Contamination

Trauma-related mental contamination (MC) is a distressing sense of dirtiness that arises absent a contaminant following a traumatic event. Existing work has linked MC to more severe posttraumatic stress disorder symptoms among individuals with sexual trauma histories and has begun to characterize some aspects of the experience of trauma-related MC. However, a more nuanced understanding of how individuals experience and respond to trauma-related MC is lacking. The present study explored lived experiences of trauma-related MC among a sample of 34 women with sexual trauma histories using semi-structured qualitative interviews. Women were asked about MC across several domains, including somatic locations where trauma-related MC is experienced; triggers for trauma-related MC; and engagement in MC-related coping strategies, including washing behaviors. Women reported experiencing trauma-related MC in various bodily locations (internal, external, and both). Both overtly trauma-related triggers (e.g., trauma-relevant people or words, sexual contact) and non-trauma-related triggers (e.g., sweating, being around other people) were mentioned. Women also reported experiencing a variety of emotions alongside trauma-related MC (e.g., disgust, shame, anger) and using a range of strategies to cope with trauma-related MC, including washing behaviors, distraction, and substance use. Findings suggest that triggers for and responses to trauma-related MC are heterogeneous. Future work should explore the role of context in individuals' experiences of and responses to trauma-related MC, as well as whether experiences of trauma-related MC may differ by gender or across settings. Increased understanding of trauma-related MC may inform efforts to more readily and effectively identify and target MC in clinical practice.

Semantic structures facilitate threat memory integration throughout the medial temporal lobe and medial prefrontal cortex

Emotional experiences can profoundly impact our conceptual model of the world, modifying how we represent and remember a host of information even indirectly associated with that experienced in the past. Yet, how a new emotional experience infiltrates and spreads across pre-existing semantic knowledge structures (e.g., categories) is unknown. We used a modified aversive sensory preconditioning paradigm in fMRI (n = 35) to investigate whether threat memories integrate with a pre-established category to alter the representation of the entire category. We observed selective but transient changes in the representation of conceptually related items in the amygdala, medial prefrontal cortex, and occipitotemporal cortex following threat conditioning to a simple cue (geometric shape) pre-associated with a different, but related, set of category exemplars. These representational changes persisted beyond 24 h in the hippocampus and perirhinal cortex. Reactivation of the semantic category during threat conditioning, combined with activation of the hippocampus or medial prefrontal cortex, was predictive of subsequent amygdala reactivity toward novel category members at test. This provides evidence for online integration of emotional experiences into semantic categories, which then promotes threat generalization. Behaviorally, threat conditioning by proxy selectively and retroactively enhanced recognition memory and increased the perceived typicality of the semantic category indirectly associated with threat. These findings detail a complex route through which new emotional learning generalizes by modifying semantic structures built up over time and stored in memory as conceptual knowledge.

Post-ICU Care: Why, What, When and How? ISCCM Position Statement

How to cite this article: Ramakrishnan N, Abraham BK, Barokar R, Chanchalani G, Jagathkar G, Shetty RM, et al. Post-ICU Care: Why, What, When and How? ISCCM Position Statement. Indian J Crit Care Med 2024;28(S2):S279-S287.

Advancing the Measurement of Trauma-Related Shame Among Women With Histories of Interpersonal Trauma

Shame is a predominant emotion for many interpersonal trauma (IPT) survivors and is associated with more severe posttraumatic stress disorder (PTSD) symptoms. Measurement challenges have led to difficulties in understanding the impact of trauma-related shame. The Trauma-Related Shame Inventory (TRSI) was developed to address this limitation, yet additional psychometric support is needed. The present study evaluated and provided psychometric support for the TRSI among women with IPT histories, although recommendations for improvement are discussed. The impact of trauma-related shame, relative to trait shame and trauma-related guilt, on PTSD symptoms was also studied, with results suggesting that trauma-related shame had the strongest association.

Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial

Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment.Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs).Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12-18 sessions) or ImRs + GST (12-18 ImRs + 52-58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5.Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97-2.87; dImRs + GST = 2.44, 95%CI = 1.99-2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = -0.33-0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months.Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment.Trial registration: ClinicalTrials.gov identifier: NCT03833531.

Probing the neurocardiac circuit in trauma and posttraumatic stress

The neurocardiac circuit is integral to physiological regulation of threat and trauma-related responses. However, few direct investigations of brain-behavior associations with replicable physiological markers of PTSD have been conducted. The current study probed the neurocardiac circuit by examining associations among its core regions in the brain (e.g., insula, hypothalamus) and the periphery (heart rate [HR], high frequency heart rate variability [HF-HRV], and blood pressure [BP]). We sought to characterize these associations and to determine whether there were differences by PTSD status. Participants were N = 315 (64.1 % female) trauma-exposed adults enrolled from emergency departments as part of the prospective AURORA study. Participants completed a deep phenotyping session (e.g., fear conditioning, magnetic resonance imaging) two weeks after emergency department admission. Voxelwise analyses revealed several significant interactions between PTSD severity 8-weeks posttrauma and psychophysiological recordings on hypothalamic connectivity to the prefrontal cortex (PFC), insula, superior temporal sulcus, and temporoparietaloccipital junction. Among those with PTSD, diastolic BP was directly correlated with right insula-hypothalamic connectivity, whereas the reverse was found for those without PTSD. PTSD status moderated the association between systolic BP, HR, and HF-HRV and hypothalamic connectivity in the same direction. While preliminary, our findings may suggest that individuals with higher PTSD severity exhibit compensatory neural mechanisms to down-regulate autonomic imbalance. Additional study is warranted to determine how underlying mechanisms (e.g., inflammation) may disrupt the neurocardiac circuit and increase cardiometabolic disease risk in PTSD.

MDMA-assisted brief cognitive behavioral conjoint therapy for PTSD: Study protocol for a pilot study

Background

Posttraumatic Stress Disorder (PTSD) impacts both individual and relational functioning. Veteran couples are at increased risk of relationship distress due to military stressors such as deployment, family reintegration, and traumatic stress. Although both Cognitive-Behavioral Conjoint Therapy (CBCT) and its brief version (bCBCT) consistently have large effects on reducing PTSD symptoms, these treatments have more variable effects on relational outcomes. Given the impact of relationship functioning on the overall health of veterans, improving the effect of PTSD treatments on relationship functioning is an essential area of research. One promising path is the role of MDMA (3,4-methylenedioxymethamphetamine)-assisted therapy in augmenting the relational impact of established therapeutic interventions such as bCBCT.

Method/Design

This is a single site, open-label study assessing the preliminary efficacy, safety, and acceptability of MDMA-assisted therapy in combination with bCBCT in 8 veterans with PTSD and their intimate partners (N = 16). Therapy teams trained in bCBCT and MDMA-assisted therapy will deliver bCBCT combined with two MDMA sessions and two couple emotion focused integration sessions. PTSD symptom severity and relationship functioning outcomes will be evaluated.

Conclusion

This is the first study to examine the efficacy of MDMA-assisted bCBCT for improving PTSD and relationship functioning among a sample of U.S. military veterans and their partners. This project could provide an opportunity to pilot a scalable model of treating PTSD within the Veterans Affairs healthcare system and leverage the benefits of MDMA for veterans with PTSD, as well as the downstream benefits to their partner on both individual and relationship functioning. ClinicalTrials.gov Identifier: NCT05979844.

Posttraumatic stress and probable post traumatic stress disorder as it relates to smoking behavior and beliefs among trauma exposed hispanic persons who smoke

There has been little scientific effort to evaluate the associations between cigarette smoking and cessation-related constructs and exposure to traumatic events, posttraumatic stress, and Posttraumatic Stress Disorder (PTSD) symptoms among Hispanic persons who smoke in the United States (US). Such trauma-related factors may pose unique difficulties for Hispanic persons who smoke and possess a desire to quit. As such, the present investigation sought to fill this gap in the literature and examine posttraumatic stress and probable PTSD in terms of their relations with several clinically significant smoking constructs among trauma-exposed Hispanic persons who smoke from the United States. Participants included 228 Spanish-speaking Hispanic persons who endorsed prior traumatic event exposure and smoked combustible cigarettes daily (58.3% female, Mage= 32.1 years, SD = 9.65). Results indicated that posttraumatic stress symptoms were related to increased cigarette dependence, perceived barriers for smoking cessation, and more severe problems when trying to quit with effect sizes ranging from small to moderate in adjusted models. Additionally, Hispanic persons who smoke with probable PTSD compared to those without probable PTSD showcased a statistically effect for perceived barriers for cessation (p < .008) and a severity of problems when trying to quit (p < .001). No effect was evident for cigarette dependence after alpha correction. Overall, the present study offers novel empirical evidence related to the role of posttraumatic stress symptoms and PTSD among Hispanic persons who smoke in the US. Such findings highlight the need to expand this line of research to better understand the role of posttraumatic stress and PTSD among Hispanic persons who smoke which can inform smoking cessation treatments for Hispanic persons who smoke experiencing trauma-related symptomology.

Are rescue workers still at risk? A meta-regression analysis of the worldwide prevalence of post-traumatic stress disorder and risk factors

Rescue workers (policemen, firefighters, emergency medical staff, etc.) experience intense stress due to rescuing and helping victims of accidents, terrorist attacks, violent crimes, and natural disasters. Overexposure and ineffective coping with such stressful events may lead to developing Post-Traumatic Stress Disorder (PTSD). Meta-regression procedures were applied to examine moderators such as the sample sex composition, age, working experience, occupation, country, or type of PTSD evaluation. The 9.8% PTSD prevalence found here was virtually the same compared with earlier findings from 10 years ago. There was a large heterogeneity, however, associated with geographical location and the instrument used to evaluate PTSD. The main findings revealed that rescue workers are a high-risk group with increased levels of Post-traumatic Stress Disorder (PTSD). Moreover, PTSD prevalence could depend on a great extent on geographical and cultural factors, and on the type of PTSD evaluation.

Ketamine-enhanced prolonged exposure therapy in veterans with PTSD: A randomized controlled trial protocol

BACKGROUND

The 2023 VA/DoD Clinical Practice Guideline for the Management of PTSD recommends individual, manualized trauma-focused such as Prolonged Exposure (PE) over pharmacologic interventions for the primary treatment of PTSD. Unfortunately, clinical trials of trauma-based therapies in the military and veteran population showed that 30% to 50% of patients did not demonstrate clinically meaningful symptom change. Ketamine, an FDA-approved anesthetic with potent non-competitive glutamatergic N-methyl-d-aspartate antagonistic properties, has demonstrated to enhance the recall of extinction learning and decrease fear renewal without interference of extinction training in preclinical studies.

METHODS

We plan to conduct a single site RCT comparing three ketamine treatment vs. active placebo (midazolam) adjunct to PE therapy among Veterans with PTSD. Pharmacological phase will start simultaneously with PE session 1. Infusions will be administered 24 h. prior to PE session for the first 3 weeks. After PE is completed (session 10), patients will be assessed during a 3-month follow-up period at various time points. We estimate that out of 100 veterans, 80 will reach time point for primary outcome measure and will be considered for primary analysis. Secondary outcomes include severity of depression and anxiety scores, safety and tolerability of ketamine-enhanced PE therapy, cognitive performance during treatment and early improvement during PE related to the rate of dropouts during PE therapy.

DISCUSSION

Results of the proposed RCT could provide scientific foundation to distinguish the essential components of this approach, enhance the methodology, elucidate the mechanisms involved, and identify sub-PTSD populations that most likely benefit from this intervention.

Characterizing 1991 Gulf War women veterans from the Boston Biorepository and Integrative Network for Gulf War Illness: Demographics, exposures, neuroimaging and cognitive outcomes

Objective: Gulf War Illness (GWI) is a debilitating multisymptom condition that affects nearly a third of 1990-91 Gulf War (GW) veterans. Symptoms include pain, fatigue, gastrointestinal issues, and cognitive decrements. Our work has shown that GWI rates and potential causes for symptoms vary between men and women veterans. Studies have documented neuropsychological and neuroimaging findings mostly in men or combined sex datasets. Data are lacking for women veterans due to lack of power and repositories of women veteran samples. Methods: We characterized GW women veterans in terms of demographics, exposures, neuropsychological and neuroimaging outcomes from the newly collated Boston, Biorepository and Integrative Network (BBRAIN) for GWI. Results: BBRAIN women veterans are highly educated with an average age of 54 years. 81% met GWI criteria, 25% met criteria for current PTSD, 78% were white, and 81% served in the Army. Exposure to combined acetylcholinesterase inhibitors (AChEi) including skin pesticides, fogs/sprays and/or pyridostigmine bromide (PB) anti-nerve gas pill exposure resulted in slower processing speed on attentional tasks and a trend for executive impairment compared with non-exposed women. Brain imaging outcomes showed lower gray matter volumes and smaller caudate in exposed women. Conclusions: Although subtle and limited findings were present in this group of women veterans, it suggests that continued follow-up of GW women veterans is warranted. Future research should continue to evaluate differences between men and women in GW veteran samples. The BBRAIN women sub-repository is recruiting and these data are available to the research community for studies of women veterans.

Examining the clinical validity of the global psychotrauma screen in refugees

Introduction

The Global Psychotrauma Screen (GPS) is a brief transdiagnostic screener that covers a broad range of trauma-related disorders as well as risk factors known to influence the course of symptoms.

Methods

We analyzed data from African war refugees in Australia (n = 70), including the GPS, the Structured Clinical Interview for DSM-5 Disorders (SCID-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and the Brief Resilience Scale (BRS).

Results

Using the Youden's J Index to examine the clinical validity of the GPS subscales measuring PTSD, dissociation, depression, and generalized anxiety disorder (GAD), we found that a PTSD subscale score of 3 or higher, and a depression and dissociation subscale score of 1 or higher, was optimally efficient for detecting a probable diagnosis (Youden's J = 0.76, J = 0.72, and J = 0.90, respectively) with high sensitivity and specificity. We were unable to test the GPS clinical validity for GAD due to the low GAD occurrence. The GPS resilience item was not related to the total score (r = 0.02), indicating low convergent validity for resilience. Risk factors, including current stressors and childhood trauma history, were related to more severe GPS symptom scores, while lack of resilience, social support, and history of mental illness were not.

Conclusion

We conclude that the GPS may be a useful screening tool for PTSD, depression, and the dissociative subtype in refugees.

Naltrexone augmented with prazosin for alcohol use disorder: results from a randomized controlled proof-of-concept trial

AIMS

We conducted a proof-of-concept randomized controlled trial of the mu-opioid receptor antagonist, naltrexone, augmented with the alpha-1 adrenergic receptor antagonist, prazosin, for alcohol use disorder in veterans. We sought a signal that the naltrexone plus prazosin combination regimen would be superior to naltrexone alone.

METHODS

Thirty-one actively drinking veterans with alcohol use disorder were randomized 1:1:1:1 to naltrexone plus prazosin (NAL-PRAZ [n = 8]), naltrexone plus placebo (NAL-PLAC [n = 7]), prazosin plus placebo (PRAZ-PLAC [n = 7]), or placebo plus placebo (PLAC-PLAC [n = 9]) for 6 weeks. Prazosin was titrated over 2 weeks to a target dose of 4 mg QAM, 4 mg QPM, and 8 mg QHS. Naltrexone was administered at 50 mg QD. Primary outcomes were the Penn Alcohol Craving Scale (PACS), % drinking days (PDD), and % heavy drinking days (PHDD).

RESULTS

In the NAL-PRAZ condition, % reductions from baseline for all three primary outcome measures exceeded 50% and were at least twice as large as % reductions in the NAL-PLAC condition (PACS: 57% vs. 26%; PDD: 51% vs. 22%; PHDD: 69% vs. 15%) and in the other two comparator conditions. Standardized effect sizes between NAL-PRAZ and NAL-PLAC for each primary outcome measure were >0.8. All but one participant assigned to the two prazosin containing conditions achieved the target prazosin dose of 16 mg/day and maintained that dose for the duration of the trial.

CONCLUSION

These results suggest that prazosin augmentation of naltrexone enhances naltrexone benefit for alcohol use disorder. These results strengthen rationale for an adequately powered definitive randomized controlled trial.

Prefrontal metabolite alterations in individuals with posttraumatic stress disorder: a 7T magnetic resonance spectroscopy study

Background

Evidence from animal and human studies suggests glutamatergic dysfunction in posttraumatic stress disorder (PTSD). The purpose of this study was to investigate glutamate abnormalities in the dorsolateral prefrontal cortex (DLFPC) of individuals with PTSD using 7T MRS, which has better spectral resolution and signal-to-noise ratio than lower field strengths, thus allowing for better spectral quality and higher sensitivity. We hypothesized that individuals with PTSD would have lower glutamate levels compared to trauma-exposed individuals without PTSD and individuals without trauma exposure. Additionally, we explored potential alterations in other neurometabolites and the relationship between glutamate and psychiatric symptoms.

Methods

Individuals with PTSD (n=27), trauma-exposed individuals without PTSD (n=27), and individuals without trauma exposure (n=26) underwent 7T MRS to measure glutamate and other neurometabolites in the left DLPFC. The severities of PTSD, depression, anxiety, and dissociation symptoms were assessed.

Results

We found that glutamate was lower in the PTSD and trauma-exposed groups compared to the group without trauma exposure. Furthermore, N-acetylaspartate (NAA) was lower and lactate was higher in the PTSD group compared to the group without trauma exposure. Glutamate was negatively correlated with depression symptom severity in the PTSD group. Glutamate was not correlated with PTSD symptom severity.

Conclusion

In this first 7T MRS study of PTSD, we observed altered concentrations of glutamate, NAA, and lactate. Our findings provide evidence for multiple possible pathological processes in individuals with PTSD. High-field MRS offers insight into the neurometabolic alterations associated with PTSD and is a powerful tool to probe trauma- and stress-related neurotransmission and metabolism in vivo.

Efficacy of digital mental health interventions for PTSD symptoms: A systematic review of meta-analyses

BACKGROUND

The present systematic review aimed to synthesize the results of meta-analyses which examine the effects of digital mental health interventions (DMHIs) on post-traumatic stress disorder (PTSD) symptoms, and investigate whether intervention characteristics (i.e., technique, timeframe, and therapeutic guidance) and methodological characteristics including outcome measures and sample inclusion criteria (age, gender, socioeconomic status, country, comorbidity) moderate the efficacy of digital interventions.

METHODS

A systematic search of various sources (ECSCOhost PsycInfo, PubMed, Web of Science, Scopus, EBSCOhost ERIC, Google Scholar, ProQuest Dissertations & Theses) including five peer-reviewed journals was conducted to identify relevant meta-analyses up to December 2023, and 11 meta-analyses were included in the final review.

RESULTS

Overall, our review elucidates that DMHIs are appropriate for alleviating PTSD symptoms in adults, with more consistent evidence supporting the efficacy of cognitive behavioral therapy (CBT)-based, compared to non-CBT-based, interventions when compared to control conditions. However, we found inconclusive evidence that the efficacy of DMHIs varied according to intervention timeframe, therapeutic guidance, or sample characteristics.

LIMITATIONS

A relatively limited number of different populations was sampled across meta-analyses. Further, while our review focused on PTSD symptoms to indicate the efficacy of digital interventions, other indices of effectiveness were not examined.

CONCLUSION

Our findings indicate the clinical utility of DMHIs for managing PTSD symptoms particularly when CBT-based intervention techniques are employed.

Light Therapy in Post-Traumatic Stress Disorder: A Systematic Review of Interventional Studies

Background: Due to limitations in treatment strategies for post-traumatic stress disorders (PTSD), therapeutic options such as light therapy (LT) have garnered some interest in recent years. We aimed to review the effectiveness of LT in patients with PTSD. Methods: Using PubMed, PsycINFO, Web of Science, the Cochrane database, ClinicalTrials.gov, and PTSDpubs, we systematically searched for papers assessing the effect of LT in PTSD. We evaluated the risk of bias of included studies using the Cochrane handbook, and synthesized our findings following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA 2020). Results: From 140 initial papers, we included four randomized controlled trials (RCTs) and one single-arm study. The study sample size ranged between 15 and 82, the mean age (standard deviation) varied between 31.4 (8.8) and 44.9 (11.8) years, and LT was applied for four or six weeks. The risk of bias was low in three studies, and of some concern in the two other trials. Most studies reported no significant differences between LT and placebo regarding effects on subjective (sleep quality and insomnia severity) and objective sleep parameters. LT was associated with a significant improvement in PTSD symptom severity in the single-arm study and two RCTs, as well as a greater retention of extinction learning. Results on depression and anxiety were discrepant. Conclusions: This review revealed that relevant studies are scarce, with promising findings concerning PTSD symptoms, but inconsistencies for the other parameters. Further research projects are needed to better explore this topic.

Enhancing Agency in Posttraumatic Stress Disorder Therapies Through Sensorimotor Technologies

Posttraumatic stress disorder (PTSD) is a significant public health concern, with only a third of patients recovering within a year of treatment. While PTSD often disrupts the sense of body ownership and sense of agency (SA), attention to the SA in trauma has been lacking. This perspective paper explores the loss of the SA in PTSD and its relevance in the development of symptoms. Trauma is viewed as a breakdown of the SA, related to a freeze response, with peritraumatic dissociation increasing the risk of PTSD. Drawing from embodied cognition, we propose an enactive perspective of PTSD, suggesting therapies that restore the SA through direct engagement with the body and environment. We discuss the potential of agency-based therapies and innovative technologies such as gesture sonification, which translates body movements into sounds to enhance the SA. Gesture sonification offers a screen-free, noninvasive approach that could complement existing trauma-focused therapies. We emphasize the need for interdisciplinary collaboration and clinical research to further explore these approaches in preventing and treating PTSD.

Healing Trauma While Staying at Home: Using Telehealth to Conduct a Brief Treatment Program for Posttraumatic Stress Disorder

Studies suggest that a three-session brief treatment program (Brief Relaxation, Education, and Trauma Healing [BREATHE]) can help treat posttraumatic stress disorder (PTSD) and symptoms of trauma; however, the program has not been examined via telehealth. Thus, the current study evaluated the feasibility of BREATHE delivered via telehealth. The intervention included breathing retraining and psychoeducation about PTSD and trauma. Thirty participants from the community with confirmed PTSD diagnoses participated in this telehealth program. Treatment retention was high, and participants showed decreased PTSD symptoms, posttraumatic cognitions, depression, anxiety, overall psychiatric symptoms, and internalized stigma and increased resiliency at posttreatment and 3-month follow up. Results suggest that a telehealth brief treatment program for PTSD is feasible and effective for individuals with PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(7), 36-46.].

Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program

Negative posttraumatic cognitions (NPCs) have been linked to symptoms of PTSD and are an important target of cognitive behavioral treatments for PTSD, including Cognitive Processing Therapy (CPT). Yet to be explored are the different change trajectories of NPCs during CPT. Knowledge of such change trajectories could elucidate common NPC change processes within CPT and their relationship to PTSD symptom severity. We examined NPC change trajectories in a group of 443 veterans who completed a 2-week intensive CPT program. We identified four NPC trajectory groups termed start high end high, start high end moderate, start moderate end low, and start low end low. Most of the groups showed an increase in NPCs at the midpoint of treatment before ultimately decreasing. As predicted, baseline PTSD symptom severity predicted change trajectory group membership. Also, NPC change trajectories were associated with PTSD severity at the end of treatment such that individuals in smaller NPC change groups had higher PTSD symptoms at the end of treatment, and vice versa. Clinicians can use this knowledge to make predictions of a particular client's NPC change trajectory and set expectations for what progress in treatment may look like, including normalizing increases in NPCs from the start of treatment.

Deep brain stimulation of the amygdala for treatment-resistant combat post-traumatic stress disorder: Long-term results

Deep brain stimulation (DBS) holds promise for neuropsychiatric conditions where imbalance in network activity contributes to symptoms. Treatment-resistant Combat post-traumatic stress disorder (TR-PTSD) is a highly morbid condition and 50% of PTSD sufferers fail to recover despite psychotherapy or pharmacotherapy. Reminder-triggered symptoms may arise from inadequate top-down ventromedial prefrontal cortex (vmPFC) control of amygdala reactivity. Here, we report long-term data on two TR-PTSD participants from an investigation utilizing high-frequency amygdala DBS. The two combat veterans were implanted bilaterally with quadripolar electrodes targeting the basolateral amygdala. Following a randomized staggered onset, patients received stimulation with adjustments based on PTSD symptom severity for four years while psychiatric and neuropsychiatric symptoms, neuropsychological performance, and electroencephalography were systematically monitored. Evaluation of vmPFC-Amygdala network engagement was assessed with 18FDG positron emission tomography (PET). CAPS-IV scores varied over time, but improved 55% from 119 at baseline to 53 at 4-year study endpoint in participant 1; and 44%, from 68 to 38 in participant 2. Thereafter, during 5 and 1.5 years of subsequent clinical care respectively, long-term bilateral amygdala DBS was associated with additional, clinically significant symptomatic and functional improvement. There were no serious stimulation-related adverse psychiatric, neuropsychiatric, neuropsychological, neurological, or neurosurgical effects. In one subject, symptomatic improvement was associated with an intensity-dependent reduction in amygdala theta frequency power. In our two participants, FDG-PET findings were inconclusive regarding the hypothesized mechanism of suppression of amygdala hyperactivity. Our findings encourage further research to confirm and extend our preliminary observations.

Spatiotemporal dynamics of hippocampal-cortical networks underlying the unique phenomenological properties of trauma-related intrusive memories

Trauma-related intrusive memories (TR-IMs) possess unique phenomenological properties that contribute to adverse post-traumatic outcomes, positioning them as critical intervention targets. However, transdiagnostic treatments for TR-IMs are scarce, as their underlying mechanisms have been investigated separate from their unique phenomenological properties. Extant models of more general episodic memory highlight dynamic hippocampal-cortical interactions that vary along the anterior-posterior axis of the hippocampus (HPC) to support different cognitive-affective and sensory-perceptual features of memory. Extending this work into the unique properties of TR-IMs, we conducted a study of eighty-four trauma-exposed adults who completed daily ecological momentary assessments of TR-IM properties followed by resting-state functional magnetic resonance imaging (rs-fMRI). Spatiotemporal dynamics of anterior and posterior hippocampal (a/pHPC)-cortical networks were assessed using co-activation pattern analysis to investigate their associations with different properties of TR-IMs. Emotional intensity of TR-IMs was inversely associated with the frequency and persistence of an aHPC-default mode network co-activation pattern. Conversely, sensory features of TR-IMs were associated with more frequent co-activation of the HPC with sensory cortices and the ventral attention network, and the reliving of TR-IMs in the "here-and-now" was associated with more persistent co-activation of the pHPC and the visual cortex. Notably, no associations were found between HPC-cortical network dynamics and conventional symptom measures, including TR-IM frequency or retrospective recall, underscoring the utility of ecological assessments of memory properties in identifying their neural substrates. These findings provide novel insights into the neural correlates of the unique features of TR-IMs that are critical for the development of individualized, transdiagnostic treatments for this pervasive, difficult-to-treat symptom.

Adaptation and validation study of the Indonesian version of the Global Psychotrauma Screen in an undergraduate student population

BACKGROUND

The high incidence of potentially traumatic events (PTEs) in Indonesia warrants early identification of those with probable trauma-related disorders in order to tailor prevention and intervention for trauma-related symptoms.

OBJECTIVES

This study aims to adapt and validate a novel brief transdiagnostic screener, the Global Psychotrauma Screen (GPS), in Indonesian undergraduate students.

METHODS

An online survey was administered among Indonesian undergraduate students (N = 322). Exploratory factor analysis, reliability analyses, clinical validity analyses, and correlational analyses were performed to evaluate the construct validity, reliability, clinical validity, and convergent-divergent validity of the Indonesian GPS. Hierarchical multiple regression was conducted to assess the relationship between risk factors and trauma-related symptoms. The relationship between four categories of trauma-related symptom severity and social/work functioning was measured using Analysis of Covariance.

RESULTS

Exploratory factor analysis yielded a single-factor solution. The Indonesian GPS demonstrated good internal consistency, test-retest correlation, and absolute agreement, indicating good reliability. The Indonesian GPS also had an acceptable area under the curve, sensitivity, and specificity for a probable diagnosis of Post-Traumatic Stress Disorder (PTSD), Complex-PTSD (CPTSD), depression, and generalized anxiety disorder (GAD). We also established evidence for the convergent and divergent validity of GPS. The GPS risk factors (low psychological resilience, other stressful events, history of mental illness, and low social support) contributed to predicting trauma-related symptoms after controlling for gender, age, employment status, and faculty background. Additionally, in comparison to participants from the mild and low categories of GPS symptoms scores, participants from the severe and moderate category reported impaired lowered social/work functioning.

CONCLUSION

The current findings indicate that the Indonesian GPS is a valid and reliable transdiagnostic trauma screener for Indonesian undergraduate students. This first comprehensive validation of the GPS in Indonesia calls for more research in Lower-middle Income Countries (LMICs) as a way towards prevention and early intervention for trauma-related symptoms.

Pharmacotherapy for sleep disturbances in post-traumatic stress disorder (PTSD): A network meta-analysis

BACKGROUND

Sleep disturbances are an important symptom dimension of post-traumatic-stress-disorder (PTSD). There is no meta-analytic evidence examining the effects of all types of pharmacotherapy on sleep outcomes among patients with PTSD.

METHODS

Medline/Embase/PsychInfo/CENTRAL/clinicaltrials.gov/ICTRP, reference lists of published reviews and all included studies were searched for Randomised Controlled Trials (RCTs) examining any pharmacotherapy vs. placebo or any other drug among patients with PTSD.

PRIMARY OUTCOMES

total sleep time, nightmares, sleep quality.

SECONDARY OUTCOMES

sleep onset latency, number of nocturnal awakenings, time spent awake following sleep onset, dropouts due to sleep-related adverse-effects, insomnia/somnolence/vivid-dreams as adverse-effects. Pairwise and network meta-analyses were performed.

RESULTS

99 RCTs with 10,481 participants were included. Prazosin may be the most effective treatment for insomnia (SMD = -0.88, 95%CI = [-1.22;-0.54], nightmares (SMD = -0.44, 95%CI = [-0.84;-0.04]) and poor sleep quality (SMD = -0.55, 95%CI = [-1.01;-0.10]). Evidence is scarce and indicates lack of efficacy for SSRIs, Mirtazapine, z-drugs and benzodiazepines, which are widely used in daily practice. Risperidone and Quetiapine carry a high risk of causing somnolence without having a clear therapeutic benefit. Hydroxyzine, Trazodone, Nabilone, Paroxetine and MDMA-assisted psychotherapy may be promising options, but more research is needed.

CONCLUSIONS

Underpowered individual comparisons and very-low to moderate confidence in effect estimates hinder the generalisability of the results. More RCTs, specifically reporting on sleep-related outcomes, are urgently needed.