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Kooistra MJ, Hoeboer CM, Oprel DAC, Schoorl M, van der Does W, van Minnen A, de Kleine RA. Distress variability during exposure therapy and its relationship with PTSD symptom decline. J Behav Ther Exp Psychiatry 2024; 85:101983. [PMID: 39133979 DOI: 10.1016/j.jbtep.2024.101983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 07/12/2024] [Accepted: 08/02/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND AND OBJECTIVES Inhibitory Learning Theory (ILT) framework implies that in-session distress variability may promote extinction learning and thereby enhance exposure therapy efficacy. Thus far, research has mainly focused on in-session distress reduction. The aim of the current study was to assess whether in-session distress variability predicts next session PTSD symptom decline in PTSD patients receiving prolonged exposure (PE). METHODS Eighty-six patients with PTSD received 14 to 16 sessions of PE. Using dynamic panel models, we assessed the temporal relation (i.e., within-persons) between in-session distress variability and PTSD symptom decline. Moreover, we assessed the averaged relation (i.e., between-persons) between in-session distress variability and PTSD symptom decline. RESULTS Temporal analyses showed that in-session distress variability did not precede PTSD symptom improvement. Averaged analyses showed that distress variability was related to PTSD symptom improvement. LIMITATION The operationalization of distress variability appeared to deviate from its theoretical conceptualization. CONCLUSIONS In absence of distress reduction, distress variability can vary. However, our findings suggest that in-session distress variability does not drive symptom reduction during PE. In contrast, averaged over participants, distress variability was related to symptom improvement, suggesting that those with a more variable distress pattern across sessions show better treatment response. More empirical work is needed to shed light on the effect of distress variability during exposure sessions on treatment outcome and to offer grounds for clinical recommendations.
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Affiliation(s)
- Marike J Kooistra
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Chris M Hoeboer
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands.
| | - Danielle A C Oprel
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Maartje Schoorl
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Willem van der Does
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Agnes van Minnen
- PSYTREC, Prof. dr. Bronkhorststraat 2, 3723 MB, Bilthoven, the Netherlands; Radboud University, Behavioural Science Institute, Nijmegen, the Netherlands.
| | - Rianne A de Kleine
- Leiden University, Department of Clinical Psychology, Institute of Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
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Hoeboer C, Wienen L, Smiddy M, van der Werff S, Maric M, Tjoa E, Timmers L, Schoorl M. Effectiveness of Narrative Exposure Therapy for Treatment of PTSD Following Childhood Trauma: A Single-Case Series Design. Clin Psychol Psychother 2024; 31:e3044. [PMID: 39210631 DOI: 10.1002/cpp.3044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 07/31/2024] [Accepted: 08/03/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Narrative exposure therapy (NET) has shown promising outcomes for treating posttraumatic stress disorder (PTSD) in refugees and veterans. Its effectiveness in patients with PTSD following childhood trauma is, however, still unknown. AIMS We investigated whether NET is an effective treatment for patients with PTSD following childhood trauma. METHOD We studied treatment outcomes of nine adult patients in an outpatient setting. An AB single-case series design was used with a baseline of 4 weeks prior to treatment. Participants filled in weekly online questionnaires to assess their PTSD symptoms (using the Posttraumatic Diagnostic Scale [PDS]) and their experienced quality of life (using the Manchester Short Assessment of Quality of Life [MANSA]). Data were analysed visually and using a mixed-effect model. RESULTS Results revealed no significant reduction of PTSD symptoms during NET treatment, nor an increase in quality of life, as compared to baseline. CONCLUSIONS The results of our study do not underscore the effectiveness of NET treatment for patients with PTSD following childhood trauma. Further research is needed to study the effectiveness of NET in this population.
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Affiliation(s)
- Chris Hoeboer
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- Department of Psychiatry, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- PsyQ, Parnassiagroep, The Hague, The Netherlands
| | - Laura Wienen
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Mary Smiddy
- PsyQ, Parnassiagroep, The Hague, The Netherlands
| | - Steven van der Werff
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Leids Universitair Behandel- en Expertise Centrum, Leiden University, Leiden, The Netherlands
| | - Marija Maric
- Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, The Netherlands
| | - Edith Tjoa
- PsyQ, Parnassiagroep, The Hague, The Netherlands
| | | | - Maartje Schoorl
- PsyQ, Parnassiagroep, The Hague, The Netherlands
- Leids Universitair Behandel- en Expertise Centrum, Leiden University, Leiden, The Netherlands
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Canty AR, Windsor TD, Nixon RDV. Using experience sampling methodology (ESM) to improve our understanding of day-to-day intrusion frequency and related distress in survivors of trauma. J Behav Ther Exp Psychiatry 2024; 82:101921. [PMID: 37944379 DOI: 10.1016/j.jbtep.2023.101921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Cognitive models of posttraumatic stress disorder (PTSD) suggest that appraisals of traumatic sequelae and subsequent distress drive the development and maintenance of PTSD. Posttraumatic research has relied heavily on macro-longitudinal designs, with weeks or months between assessments of trauma-related cognitions and symptoms. The present study uses experience sampling methodology (ESM) better understand the day-to-day experiences of trauma exposed individuals. METHODS One-hundred trauma exposed adults reported their posttraumatic symptoms, interpretations, and behaviours four times a day over a 10-day ESM period. RESULTS As anticipated, within-person fluctuations in negative appraisals of intrusions and maladaptive coping strategies (e.g., thought suppression) were significantly positively associated with intrusion frequency and related distress. In all cases, the associations for negative appraisals and maladaptive coping were stronger with intrusion related distress than intrusion frequency. LIMITATIONS The observed contemporaneous associations only demonstrate that variables reliably fluctuated together and cannot indicate causality. CONCLUSIONS The findings demonstrate that day-to-day fluctuations in trauma related perceptions and sequelae are significant and should be explored alongside broader individual differences to advance our understanding of the development, maintenance, and treatment of PTSD.
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Affiliation(s)
- Alexandra R Canty
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, Australia.
| | - Tim D Windsor
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, Australia; Flinders University Institute for Mental Health and Wellbeing, Adelaide, Australia
| | - Reginald D V Nixon
- College of Education, Psychology, and Social Work, Flinders University, Adelaide, Australia; Flinders University Institute for Mental Health and Wellbeing, Adelaide, Australia.
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Contractor AA, Blumenthal H, Rosenfield D, Shea MT, Taylor DJ, Fentem A, Vingren JL. Study protocol and rationale for a pilot randomized clinical trial comparing processing of positive memories technique with supportive counseling for PTSD. Contemp Clin Trials 2024; 138:107455. [PMID: 38253251 PMCID: PMC11338315 DOI: 10.1016/j.cct.2024.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Research indicates that positive memories have a role in posttraumatic stress disorder's (PTSD) symptomatology and treatment. Following treatment development guidelines, a novel PTSD intervention - Processing of Positive Memories Technique (PPMT) - was developed and subsequently examined for its effects and feasibility in pilot studies. Extending this research, the proposed pilot randomized clinical trial with PPMT and Supportive Counseling (SC) arms will examine PPMT's effects on PTSD severity and biomarkers of stress systems' dysregulation (awakening salivary alpha amylase [sAA] and cortisol concentrations); examine mechanistic targets (affect) underlying PPMT's effects; and refine PPMT. We hypothesize that the PPMT arm will report greater decreases in PTSD severity and greater decreases in awakening sAA/cortisol ratio compared to the SC arm; and that improved affect (more positive affect and less negative affect) will mediate associations between intervention arm and changes in PTSD severity. METHODS We will recruit 70 individuals aged 18-65 years with PTSD. They will be randomized to 5 weekly therapy sessions of PPMT or SC, and will be assessed at baseline, weekly during treatment, 1-week post-treatment, and 3-months post-treatment. Primary outcomes are past-week PTSD severity, past-week positive and negative affect levels, and feedback data on PPMT's feasibility, format, and content. The secondary outcome is the awakening sAA/cortisol ratio. Statistical analyses include mixed-effect models and within-subjects cross-lag longitudinal mediation analyses. CONCLUSION Study results will advance knowledge of trauma interventions by examining effects and feasibility of a novel PTSD intervention, and by elucidating potential mechanisms underlying PPMT's effects. Clinical Trials #: NCT05523453.
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Affiliation(s)
- Ateka A Contractor
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America.
| | - Heidemarie Blumenthal
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Expressway Tower, Dallas, TX, 75275, United States of America
| | - M Tracie Shea
- Box G-BH, Brown University, Providence, RI 02912, United States of America
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, 1503 W University Blvd, Tuscon, AZ 85721, United States of America
| | - Andrea Fentem
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - Jakob L Vingren
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton TX 76203, United States of America
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Cisler JM, Dunsmoor JE, Fonzo GA, Nemeroff CB. Latent-state and model-based learning in PTSD. Trends Neurosci 2024; 47:150-162. [PMID: 38212163 PMCID: PMC10923154 DOI: 10.1016/j.tins.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024]
Abstract
Post-traumatic stress disorder (PTSD) is characterized by altered emotional and behavioral responding following a traumatic event. In this article, we review the concepts of latent-state and model-based learning (i.e., learning and inferring abstract task representations) and discuss their relevance for clinical and neuroscience models of PTSD. Recent data demonstrate evidence for brain and behavioral biases in these learning processes in PTSD. These new data potentially recast excessive fear towards trauma cues as a problem in learning and updating abstract task representations, as opposed to traditional conceptualizations focused on stimulus-specific learning. Biases in latent-state and model-based learning may also be a common mechanism targeted in common therapies for PTSD. We highlight key knowledge gaps that need to be addressed to further elaborate how latent-state learning and its associated neurocircuitry mechanisms function in PTSD and how to optimize treatments to target these processes.
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Affiliation(s)
- Josh M Cisler
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, Austin, TX, USA; Institute for Early Life Adversity Research, University of Texas at Austin, Austin, TX, USA.
| | - Joseph E Dunsmoor
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, Austin, TX, USA; Institute for Early Life Adversity Research, University of Texas at Austin, Austin, TX, USA
| | - Gregory A Fonzo
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, Austin, TX, USA; Institute for Early Life Adversity Research, University of Texas at Austin, Austin, TX, USA
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, Austin, TX, USA; Institute for Early Life Adversity Research, University of Texas at Austin, Austin, TX, USA
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Alpert E, Shotwell Tabke C, Cole TA, Lee DJ, Sloan DM. A systematic review of literature examining mediators and mechanisms of change in empirically supported treatments for posttraumatic stress disorder. Clin Psychol Rev 2023; 103:102300. [PMID: 37320986 DOI: 10.1016/j.cpr.2023.102300] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/27/2023] [Indexed: 06/17/2023]
Abstract
Despite the availability of empirically supported treatments (ESTs) for posttraumatic stress disorder (PTSD), relatively little is known regarding these treatments' mechanisms of change. This systematic review moves beyond previous reviews by summarizing the findings and reviewing the methodological quality of literature that specifically examined mediators/mechanisms of change in ESTs for PTSD. Studies were included if they were written in English, empirical, peer-reviewed, claimed to study mediators/mechanisms of a recommended PTSD treatment, measured the mediator/mechanism during or before and after treatment, and included a posttreatment PTSD or global outcome (e.g., functioning). PsycINFO and PubMed were searched on October 7, 2022. Two coders screened and coded studies. Sixty-two eligible studies were identified. The most consistent mediator/mechanism was reduction in negative posttraumatic cognitions, followed by between-session extinction and decreased depression. Only 47% of studies measured the mediator/mechanism before the outcome and measured the mediator/mechanism and outcome at least three times, and 32% also used growth curve modeling to establish temporal precedence of change in the mediator/mechanism and outcome. Many of the mediators/mechanisms examined had weak or no empirical support. Results highlight the need for improved methodological rigor in treatment mediator and mechanism research. Implications for clinical care and research are discussed. PROSPERO ID: 248088.
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Affiliation(s)
- Elizabeth Alpert
- National Center for PTSD, United States of America; VA Boston Healthcare System, United States of America; Boston University Chobanian & Avedisian School of Medicine, United States of America.
| | - Chelsea Shotwell Tabke
- National Center for PTSD, United States of America; VA Boston Healthcare System, United States of America; Boston University Chobanian & Avedisian School of Medicine, United States of America
| | - Travis A Cole
- National Center for PTSD, United States of America; VA Boston Healthcare System, United States of America
| | - Daniel J Lee
- National Center for PTSD, United States of America; VA Boston Healthcare System, United States of America; Boston University Chobanian & Avedisian School of Medicine, United States of America
| | - Denise M Sloan
- National Center for PTSD, United States of America; VA Boston Healthcare System, United States of America; Boston University Chobanian & Avedisian School of Medicine, United States of America
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Kooistra MJ, Hoeboer CM, Oprel DAC, Schoorl M, van der Does W, Ter Heide JJ, van Minnen A, de Kleine RA. Changes in trauma-related cognitions predict subsequent symptom improvement during prolonged exposure in patients with childhood abuse-related PTSD. Behav Res Ther 2023; 163:104284. [PMID: 36870242 DOI: 10.1016/j.brat.2023.104284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/10/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023]
Abstract
Change in negative posttraumatic cognitions is a proposed mechanism through which Prolonged Exposure (PE) leads to symptom reduction of posttraumatic stress disorder (PTSD). A strong case for posttraumatic cognitions as a change mechanism in PTSD treatment can be made by establishing temporal precedence of change in cognitions. The current study examines the temporal relationship between change in posttraumatic cognitions and PTSD symptoms during PE, using the Posttraumatic Cognitions Inventory. Patients with DSM-5 defined PTSD following childhood abuse (N = 83) received a maximum of 14-16 sessions of PE. Clinician-rated PTSD symptom severity and posttraumatic cognitions were assessed at baseline, week 4, 8, and 16 (post-treatment). Using time-lagged mixed effect regression models, we found that posttraumatic cognitions predicted subsequent PTSD symptom improvement. Notably, when using the items of an abbreviated version of the PTCI (PTCI-9), we found a mutual relationship between posttraumatic cognitions and PTSD symptom improvement. Crucially, the effect of change in cognitions on PTSD symptom change was greater than the reverse effect. The current findings corroborate change in posttraumatic cognitions as a change process during PE, but cognitions and symptoms cannot be completely separated. The PTCI-9 is a short instrument that appears suitable to track cognitive change over time.
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Affiliation(s)
- Marike J Kooistra
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Chris M Hoeboer
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands.
| | - Danielle A C Oprel
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
| | - Maartje Schoorl
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | - Willem van der Does
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands; Leiden University Treatment Center (LUBEC), Leiden, the Netherlands.
| | | | - Agnes van Minnen
- PSYTREC, Bronkhorststraat 2, 3723 MB, Bilthoven, the Netherlands; Radboud University, Behavioural Science Institute, Nijmegen, the Netherlands.
| | - Rianne A de Kleine
- Leiden University, Department of Clinical Psychology, Wassenaarseweg 52, 2333 AK, Leiden, the Netherlands; Parnassia Groep, PsyQ, Lijnbaan 4, 2512 VA, The Hague, the Netherlands.
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