Therapist rotation: a novel approach for implementation of trauma-focused treatment in post-traumatic stress disorder

Efficacy of an Intensive Exposure Intervention for Individuals With Persistent Concussion Symptoms Following Concussion: A Concurrent Multiple Baseline Single-Case Experimental Design (SCED) Study

OBJECTIVE

After a concussion, 1 in 3 patients report persistent symptoms and experience long-term consequences interfering with daily functioning, known as persistent concussion symptoms (PCS). Evidence suggests PCS is (partly) maintained by anxious thoughts about brain functioning, recovery, and experienced symptoms, leading to avoidance behaviors, which may prevent patients from meeting life demands. We aimed to investigate the efficacy of a newly developed intensive exposure intervention for individuals with PCS after concussion aimed to tackle avoidance behavior.

SETTING

Participants took part in the intervention at the Maastricht University faculty.

PARTICIPANTS

Four participants who experienced PCS after concussion partook in the exploratory study. Participants' age ranged between 20 and 32 (mean = 26.5, SD = 5.9) years, with an average length of time after the concussion of 9.8 months.

DESIGN

A concurrent multiple-baseline single-case design was conducted. The baseline period (A phase) length was randomly determined across participants (3, 4, 5, or 6 weeks). The exposure intervention (B phase) was conducted by psychologists over a 4-week period and consisted of 3 stages: exploration (2 sessions), active exposure (12 sessions conducted over 1 week), and 2 booster sessions.

MAIN MEASURES

Participants answered daily questions on a visual analog scale related to symptom experience, satisfaction with daily functioning, and degree of avoidance of feared activities. Additional outcomes included symptom severity, catastrophizing, fear of mental activity, anxiety, depression, and societal participation.

RESULTS

Tau-U yielded significant effects ( P < .05) for all participants on all measures when comparing baseline and intervention phases. The pooled standardized mean difference was high for all measures (symptom experience = 0.93, satisfaction of daily functioning = 1.86, and activity avoidance = -2.05).

CONCLUSIONS

The results show efficacy of the newly developed intensive exposure treatment for PCS after concussion, which is based on the fear avoidance model. Replication in a larger heterogeneous sample is warranted and needed.

Making sense of change after Intensive Trauma Treatment: a mixed-methods study into adolescents' experience of efficacy

BACKGROUND

While evidence-based interventions are effective for children with post-traumatic stress disorder (PTSD), some adolescents may not respond sufficiently. Intensive trauma treatment (ITT) has shown promise for adults, but research on its efficacy for adolescents is limited. This study therefore aimed to explore the efficacy and subjective experience of change in adolescents participating in ITT.

METHODS

The present study employed a mixed-methods approach among a sample of adolescents with PTSD (N = 22; 90.1% female, age M = 17.0, SD = 1.72) who participated in an ITT program. Clinical data and narratives were combined to assess treatment efficacy and subjective experiences of change.

RESULTS

Quantitative analysis revealed a significant reduction in PTSD symptoms post-ITT, aligning with prior research. Qualitative analysis highlighted themes such as negative thoughts impacting treatment success, the importance of social support, and identity-related struggles.

CONCLUSIONS

The study contributes to understanding ITT efficacy and emphasizes the need for developmental sensitivity, systemic interventions, and continued research to enhance PTSD treatment for adolescents.

Exhausting, but necessary: the lived experience of participants in an intensive inpatient trauma treatment program

Background

Intensive inpatient treatment programs have shown robust results in the treatment of post-traumatic stress disorder (PTSD). How patients experience this treatment program and what changes they experience as a result of the treatment have, however, only scarcely been explored through qualitative studies.

Objective

This study aimed to explore the lived experience of participants in an intensive inpatient trauma treatment program. Our research questions were as follows: how do patients experience intensive trauma-focused treatment? How do they experience possible changes related to participating in the treatment program?

Methods

Six patients diagnosed with PTSD with significant comorbidities, who recently participated in an intensive 2-week (4 + 4 days) inpatient trauma treatment program with prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and therapist rotation (TR), were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach.

Results

Our analysis resulted in five main themes: (1) the need to feel safe; (2) the benefits of many and different therapeutic encounters; (3) variable experience with elements of treatment; (4) intensity; and (5) experienced change. Our results suggest that feeling safe within the framework of the treatment program facilitated the treatment process. Many and different therapeutic encounters, both through TR and with ward staff, contributed to experienced change. All participants described the intensity as facilitative to trauma processing. However, most participants also describe often feeling too overwhelmed to benefit from all elements of the treatment program.

Conclusions

Our findings suggest that participants experience the overall treatment program as beneficial and contributing to experienced change. Participants described the intensity of the program as exhausting, but necessary. Most did, however, report at times of being too overwhelmed to benefit from elements of the program. Consequently, our results prompt us to question the optimal level of intensity.

Trial registration

ClinicalTrials.gov identifier: NCT05342480. Date of registration: 2022-04-22.

The effects of an intensive outpatient treatment for PTSD

Introduction: Research has shown that combining different evidence-based PTSD treatments for patients with PTSD in an intensive inpatient format seems to be a promising approach to enhance efficiency and reduce generally high dropout rates.Objective: To assess the effectiveness of an intensive six-day outpatient trauma-focused treatment for patients with PTSD.Method: Data from 146 patients (89.7% female, mean age = 36.79, SD = 11.31) with PTSD due to multiple traumatization were included in the analyses. The treatment programme consisted of six days of treatment within two weeks, with two daily individual 90-minute trauma-focused sessions (prolonged exposure and eye movement desensitization and reprocessing), one hour of exercise, and one hour of psychoeducation. All participants experienced multiple traumas, and 85.6% reported one or more comorbid psychiatric disorders. PTSD symptoms and diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), and self-reported symptoms were assessed with the PTSD Checklist for DSM-5 (PCL-5).Results: A significant decline in PTSD symptoms (CAPS-5 and PCL-5) from pretreatment to one-month follow-up (Cohen's d = 1.13 and 1.59) was observed and retained at six-month follow-up (Cohen's d = 1.47 and 1.63). After one month, 52.4% of the patients no longer met the diagnostic criteria for PTSD (CAPS-5). The Reliable Change Index (RCI) shows that 73.9% of patients showed improvement on the CAPS-5 and 77.61% on the PCL-5. Additionally, 21.77% (CAPS-5) and 20.0% (PCL-5) showed no change, while 4.84% (CAPS-5) and 2.96% (PCL-5) showed symptom worsening.Discussion: The results show that an intensive outpatient trauma treatment programme, including two evidence-based trauma-focused treatments, exercise, and psychoeducation, is effective for patients suffering from PTSD as a result of multiple traumatization. Subsequent research should focus on more controlled studies comparing the treatment programme with other intensive trauma treatments and less frequent routine treatment.

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

The role of dissociation-related beliefs about memory in trauma-focused treatment

OBJECTIVE

Dysfunctional cognitions play a central role in the development of post-traumatic stress disorder (PTSD). However the role of specific dissociation-related beliefs about memory has not been previously investigated. This study aimed to investigate the role of dissociation-related beliefs about memory in trauma-focused treatment. It was hypothesized that patients with the dissociative subtype of PTSD would show higher levels of dissociation-related beliefs, dissociation-related beliefs about memory would decrease after trauma-focused treatment, and higher pre-treatment dissociation-related beliefs would be associated with fewer changes in PTSD symptoms.

METHOD

Post-traumatic symptoms, dissociative symptoms, and dissociation-related beliefs about memory were assessed in a sample of patients diagnosed with PTSD (n = 111) or the dissociative subtype of PTSD (n = 61). They underwent intensive trauma-focused treatment consisting of four or eight consecutive treatment days. On each treatment day, patients received 90 min of individual prolonged exposure (PE) in the morning and 90 min of individual eye movement desensitization and reprocessing (EMDR) therapy in the afternoon. The relationship between dissociation-related beliefs about memory and the effects of trauma-focused treatment was investigated.

RESULTS

Dissociation-related beliefs about memory were significantly associated with PTSD and its dissociative symptoms. In addition, consistent with our hypothesis, patients with the dissociative subtype of PTSD scored significantly higher on dissociation-related beliefs about memory pre-treatment than those without the dissociative subtype. Additionally, the severity of these beliefs decreased significantly after trauma-related treatment. Contrary to our hypothesis, elevated dissociation-related beliefs did not negatively influence treatment outcome.

CONCLUSION

The results of the current study suggest that dissociation-related beliefs do not influence the outcome of trauma-focused treatment, and that trauma-focused treatment does not need to be altered specifically for patients experiencing more dissociation-related beliefs about memory because these beliefs decrease in association with treatment.

Changes in comorbid depression following intensive trauma-focused treatment for PTSD and complex PTSD

BACKGROUND

The extent to which intensive trauma-focused treatment for individuals with post-traumatic stress disorder (PTSD) is also effective in treating comorbid major depressive disorder (MDD) remains unclear.

OBJECTIVE

The purpose of the present study was to test the hypothesis that brief intensive trauma-focused therapy for PTSD is associated with significant reductions in depressive symptoms and loss of diagnostic status of MDD.

METHODS

A total of 334 adult patients with PTSD (189 patients who were also diagnosed with MDD) underwent a brief intensive trauma-focused treatment programme consisting of EMDR therapy, prolonged exposure, physical activity, and psychoeducation. At pre-treatment, post-treatment and 6-month follow-up, severity and diagnostic status of PTSD and MDD were assessed. A linear mixed model was used to analyze changes in the severity of PTSD and depressive symptoms, whereas a generalized linear mixed model was used to determine changes in the MDD diagnostic status.

RESULTS

Treatment resulted in a significant and strong decrease of PTSD and MDD symptoms at post-treatment (d = 2.34 and 1.22, respectively), and at 6-month follow-up (d = 1.67 and 0.73, respectively). The proportion of patients fulfilling the diagnostic status of MDD changed from 57% at pre-treatment to 33% at the 6-month follow-up. Although the initial response to treatment did not differ between patients with and without comorbid MDD, for both groups a significant relapse in depressive symptoms was found after six months, which could be explained almost entirely by the presence of CPTSD at baseline.

CONCLUSIONS

The results support the notion that brief, intensive trauma-focused treatment is highly effective for individuals with PTSD and comorbid MDD. Because patients with CPTSD are vulnerable to relapse in depressive symptoms, this target group may require additional treatment.

The impact of intensive trauma-focused treatment on sexual functioning in individuals with PTSD

Background

Individuals with posttraumatic stress disorder (PTSD) often experience sexual disturbances.

Objective

To determine whether intensive trauma-focused treatment is associated with an improvement in sexual functioning (i.e., sexual satisfaction and sexual desire) in individuals with PTSD.

Method

In total, 227 patients with PTSD (68.7% women, mean age = 40.97) participated in an intensive eight-day trauma-focused treatment program consisting of prolonged exposure, eye movement and desensitization and reprocessing (EMDR) therapy, physical activity, and psychoeducation. Patients were assessed (i.e., Clinician Administered PTSD Scale and Sexual Functioning Questionnaire) pre- and post-treatment and at 6-months follow-up.

Results

Sexual satisfaction and sexual desire increased significantly associated with trauma-focused treatment from pre-treatment to 6-months follow-up, albeit the effect sizes were small (Cohen's d = 0.39 and 0.17, respectively). Although men reported greater overall sexual desire than women, sexual functioning improved after treatment in both men and women. Furthermore, those with remission of PTSD reported greater sexual functioning post-treatment and at 6-months follow-up, than those without remission. However, changes in PTSD symptoms associated with treatment were not predictive of the level of sexual satisfaction or sexual desire 6 months after treatment.

Conclusion

The results of this uncontrolled study suggest that intensive treatment for PTSD can have beneficial effects on sexual satisfaction and desire in both men and women; however, this may not necessarily be due to a decrease in PTSD symptoms.

Is it safe enough? A pilot feasibility study of an 8-day intensive treatment for severe PTSD

Intensive treatments for posttraumatic stress disorder (PTSD) are gaining increased research support. Treatment models targeting Complex PTSD and previously treatment-resistant PTSD have shown a good effect. A pilot study was performed to assess the feasibility of an 8-day intensive treatment program for severe PTSD in a Swedish public healthcare setting. Eleven participants completed treatment, and overall, the reduction in PTSD symptoms was considerable. Also, loss of diagnosis at 3-month follow-up was 100%. No adverse events occurred, and no elevation of suicidal intentions was reported. Symptom exacerbation could not be observed in the data and dropout due to the intensity of the treatment format did not occur. Based on these positive results, it is recommended that further research with larger samples is conducted. If found safe and effective, the 8-day treatment program could be an important addition to psychiatric healthcare.

Fully remote intensive trauma-focused treatment for PTSD and Complex PTSD

Background: It is unknown whether remotely delivered intensive trauma-focused therapy not only is an effective treatment for PTSD, but also for Complex PTSD. Objective: Testing the hypothesis that a brief, fully remotely administered intensive trauma-focused treatment programme for individuals with PTSD and Complex PTSD would be safe, and associated with a significant decline of the corresponding symptoms and diagnostic status. Method: The treatment sample consisted of 73 consecutive patients diagnosed with PTSD according to the CAPS-5. According to the ITQ (n = 70) 33 (47.1%) patients also fulfilled the diagnostic criteria of Complex PTSD. The 4-day treatment programme contained a combination of prolonged exposure, EMDR therapy, physical activities and psycho-education. Treatment response was measured using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the PTSD Checklist for DSM-5 (PCL-5), and the International Trauma Questionnaire (ITQ) for classifying Complex PTSD and indexing disturbances in self-organization (DSO). Results: Overall CAPS-5, PCL-5, and ITQ-DSO scores decreased significantly from pre- to post-treatment (Cohen's ds 2.12, 1.59, and 1.18, respectively), while the decrease was maintained to six months follow-up. At post-treatment, 60 patients (82.2%) no longer met the diagnostic criteria of PTSD, while the proportion of patients with Complex PTSD decreased from 47.1% to 10.1%. No drop out, and no personal adverse events occurred. Conclusions: The results support the notion that intensive, trauma-focused treatment is feasible, safe and associated with a large decrease in PTSD and Complex PTSD symptoms, even when it is brief, and applied fully remote. HIGHLIGHTS Second study to examine the effectiveness of a fully remote intensive trauma-focused treatment for PTSD and Complex PTSD.Significant decrease of DSO symptoms.Over 80 percent of the patients no longer met the diagnostic criteria of PTSD and Complex PTSD following treatment.

Effectiveness of a high-intensive trauma-focused, family-based therapy for youth exposed to family violence: study protocol for a randomized controlled trial

BACKGROUND

Family violence is a common problem with direct adverse effects on children as well as indirect effects through disruption of parenting and parent-child relationships. The complex interrelationships between family violence, parenting, and relationships make recovery from psychological responses difficult. In more than half of the families referred to mental health care after family violence, the violence continues. Also, the effect sizes of "golden standard" treatments are generally lower for complex trauma compared to other forms of trauma. In the treatment of complex trauma, trauma-focused therapies including cognitive restructuring and imaginal exposure are most effective, and intensifying therapy results in faster symptom reduction. Furthermore, there is promising evidence that adding a parental component to individual trauma treatment increases treatment success. In family-based intensive trauma treatment (FITT), these factors are addressed on an individual and family level in a short period of time to establish long-term effects on the reduction of trauma symptoms and recovery of security in the family. This randomized controlled multicentre study tests if FITT is an effective treatment for concurrent reduction of trauma symptoms of children, improvement of parenting functioning, and increasing emotional and physical security in children, through the improvement of parent-child relationships.

METHODS

The effectiveness of FITT will be tested by a RCT design. A total of 120 adolescents with a history of family violence and PTS symptoms will be randomized to (a) an intensive trauma treatment with a parent and systemic component (FITT), (b) an intensive trauma treatment without these components (ITT), and (c) treatment as usual (TAU, low-frequency trauma treatment with parent therapy and family sessions). Changes in children's trauma symptoms, child and parent functioning, and emotional and physical security in the family will be monitored before, during, after, and at 3 months follow-up.

DISCUSSION

Comparing these interventions with and without a high intensive frequency and parenting and family components can help to understand if and how these interventions work and can contribute to the ambition to recover from the impact of family violence and restore emotional and physical security for children and young people.

TRIAL REGISTRATION

Netherlands Trial Register Trial NL8592 . Registered on 4 May 2020.

Intensive outpatient treatment for PTSD: an open trial combining prolonged exposure therapy, EMDR, and physical activity

Background: Intensive outpatient treatment could be a promising option for patients with post-traumatic stress disorder (PTSD). Objective: The aim of the study was to test the effectiveness of an eight-day (two-week) intensive treatment for PTSD within a public health care setting (open trial design). Method: Eighty-nine patients were offered the choice between intensive treatment and spaced individual treatment, of which 34 (38.2%) chose the intensive format. Patients were assessed with self-report batteries and interviews at pre-treatment, start of treatment, post-treatment and three-month follow-up. Each day consisted of individual Prolonged Exposure therapy, Eye Movement Desensitization and Reprocessing therapy, group psychoeducation, and physical activity. Therapists rotated between patients. Results: Between 55 and 62% of the patients showed a clinically significant change (recovery) in symptoms of PTSD, and the effect sizes were large (d = 1.38-1.52). Patients also showed reduction in symptoms of depression and anxiety, along with improved well-being and interpersonal functioning. Changes in social and work functioning were more ambiguous. There were no dropouts, attendance was high, and patients were highly satisfied with the treatment. Conclusions: The intensive programme was an attractive and effective treatment option for patients with PTSD.

Intensive outpatient treatment for post-traumatic stress disorder: a thematic analysis of patient experience

BACKGROUND

Intensive treatments have shown encouraging results in the treatment of several psychological disorders, including post-traumatic stress disorder (PTSD). However, qualitative studies on patient experiences with intensive treatment for PTSD remain scarce.

OBJECTIVE

The aim of this study was to explore patient experiences with an intensive, outpatient treatment for PTSD and to discover important factors behind treatment feasibility.

METHOD

Eight participants were recruited from two groups of patients having completed the intensive treatment programme. Semi-structured qualitative interviews were conducted, and data sets were analysed using thematic analysis.

RESULTS

The main result indicated that patients experienced the treatment as very demanding, but still worth the effort in terms of reducing symptoms. The intensity was valued as useful. Participants emphasized the sense of unity with other participants as well as physical activity as important factors for completion of the treatment programme. The rotation of therapists was also highlighted as important for treatment efficacy.

CONCLUSIONS

This study provides insights into what the patients experienced and emphasized as important aspects of treatment and essential factors for completing treatment. The main conclusions were that all of the patients evaluated the treatment as demanding, but the reward of reduced symptoms made it worthwhile. The high frequency of therapy sessions and the therapist rotation were reported to counteract avoidance and increase the patients' commitment to therapy. Physical activity and unity in the group were highlighted as essential for treatment feasibility.

HIGHLIGHTS

• High treatment intensity enabled increased focus and adherence, and reduced avoidance.  Therapist rotation led to heightened intensity and new learning experiences.• Physical activity and sense of unity through group elements were reported as important factors for treatment feasibility.

Intensive clinical trauma treatment for children and adolescents with mild intellectual disability or borderline intellectual functioning: A pilot study

BACKGROUND

Children and adolescents with mild intellectual disability (MID) or borderline intellectual functioning (BIF) are at increased risk for posttraumatic stress disorder (PTSD) or trauma-related symptoms due to adverse childhood experiences (ACEs). Weekly provided treatment sessions and/or outpatient treatment may not be effective enough.

AIMS

Investigate feasibility, safety and potential effectiveness of an intensive clinical trauma treatment in children and adolescents with MID-BIF and trauma-related symptoms as a result of ACEs or PTSD.

METHODS AND PROCEDURES

Thirty-three participants between 6 and 17 years of age received intensive clinical treatment after experiencing multiple ACEs (most commonly physical abuse, emotional neglect or abuse, sexual abuse, domestic violence and bullying). Treatment lasted 8.4 days on average and consisted of a daily program of prolonged exposure, eye movement desensitisation and reprocessing and physical activation, embedded in a trauma-sensitive environment. Data were collected at intake, first day of treatment, last day of treatment and at follow-up.

OUTCOMES AND RESULTS

There was a significant reduction of trauma-related symptoms and emotional and behavioral problems after treatment. In addition, the number of participants fulfilling the DSM-5 criteria of PTSD decreased from 24 at intake to 8 at the end of treatment. There was no drop out and no adverse events were seen.

CONCLUSIONS AND IMPLICATIONS

The results of this pilot study suggest that an intensive clinical trauma treatment is a potentially effective and safe option for children and adolescents with MID-BIF.

Predicting Outcome in an Intensive Outpatient PTSD Treatment Program Using Daily Measures

It is useful to investigate factors that could predict treatment outcomes for PTSD. The current study aims to investigate the relationship between daily measured PTSD symptoms during an intensive six-day treatment program and overall post-treatment outcomes. The treatment program combines eye movement desensitization with reprocessing and prolonged exposure, as well as physical activity and psychoeducation. It was expected that for the entire duration of treatment, as well as the first half of the treatment, a greater decline in daily PTSD symptoms would be a predictor for a greater decline in PTSD symptoms at a four-week follow-up. Data from 109 PTSD-patients (87.2% female, mean age = 36.9, SD = 11.5) were used. PTSD symptoms were measured with the CAPS-5 and the self-reported PTSD checklist for DSM-5 (PCL-5). Daily PTSD symptoms were measured with an abbreviated version of the PCL-5 (8-item PCL). Latent growth curve models were used to describe changes in daily PTSD symptoms and predict treatment outcome. Results show that a greater decline in daily PTSD symptoms measured by the 8-item PCL predicts better treatment outcome (CAPS-5 and PCL-5), but that a patient’s PTSD symptoms on the first day of treatment has no predictive effect. A decline in PTSD symptoms only during the first half of treatment was also found to predict treatment outcomes. Future research should be focused on replicating the results of the current study.

Treating posttraumatic stress disorder in substance use disorder patients with co-occurring posttraumatic stress disorder: study protocol for a randomized controlled trial to compare the effectiveness of different types and timings of treatment

BACKGROUND

Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have high comorbidity. Although prior research indicated that PTSD can effectively be treated with Prolonged Exposure (PE) in these patients, reported effects are small and treatment dropout rates high. Eye Movement Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs) are other promising treatment options for PTSD, that have not yet been examined in this patient group. Furthermore, it is unclear whether PTSD treatment is most effective when offered simultaneous to or after SUD treatment.

METHODS

In this article, the Treatment Of PTSD and Addiction (TOPA) study is described: a Dutch randomized controlled trial (RCT) that studies the effectiveness of PTSD treatment as an add-on to regular SUD treatment in patients with SUD and co-occurring PTSD. Effects of PE, EMDR, ImRs, and a 3-month SUD treatment only condition will be compared, as well as simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment. The primary outcome measure is PTSD symptoms. Secondary outcomes are: treatment completion, psychological distress, substance use, interpersonal problems, emotion dysregulation, and trauma-related emotions guilt, shame, and anger.

DISCUSSION

This study is the first to compare effects of PE, EMDR, and ImRs in one study and to compare simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment as well. This RCT will provide more knowledge about the effectiveness of different treatment strategies for PTSD in patients with co-occurring SUD and will ultimately improve treatment outcomes for patients with this common co-morbidity worldwide.

TRIAL REGISTRATION

Netherlands Trial Register (NTR), Identifier: NL7885 . Registered 22 July 2019.

Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Therapeutic alliance is a key element of successful therapy. Despite being particularly relevant in people with posttraumatic stress disorder (PTSD), due to fear, mistrust and avoidance, there has not yet been a comprehensive systematic review of therapeutic alliance in this population. This review explored (a) variables which may predict alliance and (b) whether alliance predicts PTSD outcomes.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the review identified 34 eligible studies. Studies were subjected to a quality assessment. Predictors of alliance were considered in a narrative synthesis. Twelve studies were entered into a meta-analysis of the association between therapeutic alliance and PTSD outcomes.

RESULTS

There was some evidence for individual variables including attachment, coping styles and psychophysiological variables predicting the alliance. Therapy variables did not predict alliance. The therapeutic alliance was found to significantly predict PTSD outcomes, with an aggregated effect size of r = -.34, across both in-person and remote therapies.

LIMITATIONS

Included studies were restricted to peer-reviewed, English language studies. Quality of included studies was mostly rated weak to moderate, primarily reflecting issues with selection bias in this area of research.

CONCLUSIONS

This is the first review to demonstrate that therapeutic alliance is a consistent predictor of PTSD outcomes, in both in-person and remote therapies, and the effect appears at least as strong as in other populations. This is of relevance to clinicians working with traumatized populations. The review identified a need for further research to determine variables predicting alliance in therapy for PTSD.

Effectiveness of an intensive treatment programme combining prolonged exposure and EMDR therapy for adolescents suffering from severe post-traumatic stress disorder

Background: Following promising effects of an intensive trauma treatment for adults, the question arises whether adolescents who suffer from severe post-traumatic stress disorder (PTSD) can also profit from a similar treatment programme. Objective: To assess the effectiveness of an intensive trauma-focused treatment programme combining two evidence-based trauma-focused therapies and physical activities for adolescents suffering from severe PTSD. Method: Treatment consisted of daily sessions of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy supplemented with physical activity (13 days on average). All patients (N = 27; 96.3% women, mean age = 16.1 years; SD = 1.3) had been exposed to one or more (interpersonal) traumatic events. Twenty-two of them (81.5%) also fulfilled the diagnostic criteria of a comorbid psychiatric disorder (mean number of comorbid disorders = 2.22). The majority of patients were referred because previous treatment was difficult or complications were expected to occur. Severity of PTSD symptoms and presence of a PTSD diagnostic status were assessed using the Dutch version of the CAPS-CA IV at baseline, post-treatment and at 3-month follow-up. Results: CAPS-CA IV scores decreased significantly from pre- to post-treatment (Cohen's d = 1.39). Of all patients 81.5% (n = 22) showed a clinically meaningful response, of whom 63% (n = 17) no longer fulfilled the diagnostic criteria of PTSD at post-treatment as established with the CAPS-CA IV. The results were maintained at 3-month follow-up. During treatment, neither adverse events nor dropout occurred. Conclusions: The results suggest that an intensive trauma-focused treatment programme combining prolonged exposure, EMDR therapy, and physical activity can be an effective and safe treatment for adolescents suffering from severe PTSD and multiple comorbid psychiatric disorders.

Intensive outpatient treatment for PTSD: a pilot feasibility study combining prolonged exposure therapy, EMDR, physical activity, and psychoeducation

Background: Intensive treatment could be effective for patients with post-traumatic stress disorder (PTSD). Objective: The aim of the study was to test the feasibility of an 8-day (2-week) intensive outpatient treatment for PTSD. Method: Treatment each day consisted of individual Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and psychoeducation and physical activity in groups. Patients met different therapists from session to session. Results: Six patients started and completed treatment. Levels of attendance of sessions was high. Patients reported that they were satisfied with the treatment, describing it as emotionally taxing, but meaningful. Therapists also described several positive aspects of the treatment format. There were large reductions in PTSD symptoms. Conclusions: Given these promising, but preliminary findings on the programme's feasibility, future research should investigate this treatment format using larger samples and controlled designs.

Research and recovery: Can patient participation in research promote recovery for people with complex post-traumatic stress disorder, CPTSD?

BACKGROUND

A new diagnosis of complex post-traumatic stress disorder, CPTSD, has been agreed by the World Health Organization, WHO, and evidence is needed for what psychological treatment might be effective, particularly from those with experience of the disorder. We used a novel participatory approach to explore patient views and simultaneously studied the impact on the patient researchers of the research process itself. In this paper, we report on the latter section of the study how the involvement in research of patients with CPTSD affected their mental health. Symptoms of CPTSD may include emotional dysregulation, feelings of self-worthlessness and difficulties in relationships.

OBJECTIVE

The aim of this study section was to explore whether patients' mental health could be promoted through empowering them to participate in research on CPTSD.

DESIGN

The study had a qualitative, participatory design. The clinician who led the research (first author) held group meetings with patient researchers to explore the impact of the research process. The clinician also kept notes on the process in a reflective log.

SETTING AND PARTICIPANTS

Six patient researchers participated in research with other patients with lived experience of CPTSD in an NHS outpatient unit in a London hospital.

INTERVENTION STUDIED

The research process itself was analysed in group meetings with researchers which the clinician recorded and transcribed.

FINDINGS

Participation in research may promote increased self-confidence and social inclusion for those with CPTSD.

CONCLUSION

Involvement in research may be seen as an empowering intervention because patients felt it contributed to recovery.

Somatoform Dissociative Symptoms Have No Impact on the Outcome of Trauma-Focused Treatment for Severe PTSD

For patients with complex or other severe forms of PTSD, particularly in cases with dissociative symptoms, different treatment approaches have been suggested. However, the influence of somatoform dissociation on the effectiveness of trauma-focused treatment has hardly ever been studied. This study aims to test the hypotheses that (1) PTSD patients reporting a low level and those reporting a high level of somatoform dissociative symptoms would both benefit from an intensive trauma-focused treatment, and that (2) somatoform dissociative symptoms would alleviate. Participants were 220 patients with severe PTSD, enrolled in an intensive treatment program combining EMDR therapy and prolonged exposure therapy, without a preceding stabilization phase. Trauma history was diversified, and comorbidity was high. PTSD symptoms (CAPS-5 and PCL-5) and somatoform dissociative symptoms (SDQ-5 and SDQ-20) were assessed at pre-treatment, post-treatment and at six months after completion of treatment. The course of both PTSD and somatoform dissociative symptoms was compared for individuals reporting low and for those reporting high levels of somatoform dissociative symptoms. Large effect sizes were observed regarding PTSD symptoms reduction for patients with both low and high levels of somatoform dissociation. Somatoform dissociation did not impact improvement in terms of PTSD symptom reduction. The severity of somatoform dissociative symptoms decreased significantly in both groups. This decrease was greater for those with a positive screen for a dissociative disorder. These results add further support to the notion that the presence of strong somatoform dissociative symptoms in patients with PTSD does not necessarily call for a different treatment approach. Clinical implications are discussed.

Comparing Intensive Trauma-Focused Treatment Outcome on PTSD Symptom Severity in Older and Younger Adults

Objective: To examine the treatment outcome of an intensive trauma-focused treatment program for post-traumatic stress disorder (PTSD) in older and younger adults. Methods: A non-randomized outcome study was conducted with 62 consecutively admitted older PTSD patients (60–78 years) and 62 younger PTSD patients (19–58 years), matched on gender and availability of follow-up data. Patients participated in an intensive eight-day trauma-focused treatment program consisting of eye movement desensitization and reprocessing (EMDR), prolonged exposure (PE), physical activity, and group psycho-education. PTSD symptom severity (Clinician-Administered PTSD Scale-5 (CAPS-5)) was assessed, at pre- and post-treatment, and for a subsample (n = 31 older; n = 31 younger patients) at six-month follow-up. Results: A repeated-measures ANCOVA (centered CAPS pre-treatment score as covariate) indicated a significant decrease in CAPS-5-scores from pre- to post-treatment for the total sample (partial η² = 0.808). The treatment outcome was not significantly different across age groups (partial η² = 0.002). There were no significant differences in treatment response across age groups for the follow-up subsample (pre- to post-treatment partial η² < 0.001; post-treatment to follow-up partial η² = 0.006), and the large decrease in CAPS-5 scores from pre- to post-treatment (partial η² = 0.76) was maintained at follow-up (partial η² = 0.003). Conclusion: The results suggest that intensive trauma-focused treatment is applicable for older adults with PTSD with a large within-effect size comparable to younger participants. Further research on age-related features is needed to examine whether these results can be replicated in the oldest-old (>80).

Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth

Background: Home-based psychotherapy delivered via telehealth has not been investigated in the context of intensive trauma-focused treatment for individuals with severe or Complex posttraumatic stress disorder (PTSD). Objective: To examine the feasibility, safety and effectiveness of an intensive treatment programme containing prolonged exposure, EMDR therapy, physical activities and psycho-education, delivered via home-based telehealth. Method: The treatment was carried out within four consecutive days during the outbreak of the COVID-19 pandemic. The sample consisted of six (four female) patients suffering from severe or Complex PTSD resulting from exposure to multiple traumatic events, mostly during early childhood. Four of them fulfilled the diagnostic criteria of complex PTSD. Outcome measures were the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), the PTSD Checklist for DSM-5 (PCL-5), and the International Trauma Questionnaire (ITQ). Results: CAPS-5 and PCL-5 scores decreased significantly from pre- to post-treatment (Cohen's ds 1.04 and 0.93), and from post-treatment to follow-up (Cohen's ds 0.92 and 1.24). Four of the six patients lost their PTSD or Complex PTSD diagnostic status. No patient dropped out, no personal adverse events and no reliable symptom worsening occurred. Conclusions: The results suggest that intensive, trauma-focused treatment of severe or Complex PTSD delivered via home-based telehealth is feasible, safe and effective, and can be a viable alternative to face-to-face delivered intensive trauma-focused treatment.

A participatory study of patient views on psychotherapy for complex post-traumatic stress disorder, CPTSD

BACKGROUND

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse.

AIMS

This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach.

METHOD

Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment.

RESULTS

The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable.

CONCLUSIONS

The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed.

Sequence matters: Combining Prolonged Exposure and EMDR therapy for PTSD

OBJECTIVE

Investigating the influence of the sequence in which two evidence-based trauma-focused treatments are offered to PTSD-patients.

METHODS

PTSD-patients were treated using an intensive eight-day treatment program, combining Prolonged Exposure (PE) and EMDR therapy. Forty-four patients received a PE session in the morning and an EMDR session in the afternoon, while 62 patients received the reversed sequence (EMDR followed by PE). Outcome measures were PTSD symptom severity and subjective experiences.

RESULTS

Patients who received PE first and EMDR second showed a significantly greater reduction in PTSD symptoms. Patients preferred this sequence and valued the treatment sessions as significantly more helpful compared to patients in the EMDR-first condition.

CONCLUSION

The results of this explorative study are supportive of the notion that PE and EMDR therapy can be successfully combined, and that sequence matters. First applying PE sessions before EMDR sessions resulted in better treatment outcome, and better subjective patient's evaluations in terms of treatment helpfulness and preference.

Trauma-focused treatment outcome for complex PTSD patients: results of an intensive treatment programme

BACKGROUND

Complex PTSD (CPTSD) has been incorporated in the 11th edition of the International Classification of Diseases (ICD-11) as a mental health condition distinct from PTSD.

OBJECTIVE

The objective of the current study is to determine whether individuals classified as having CPTSD can benefit from an intensive trauma-focused treatment, resulting in decreased PTSD and CPTSD symptoms, and loss of diagnoses.

METHOD

Patients diagnosed with PTSD (N = 308) took part in an intensive 8-day treatment programme combining prolonged exposure, EMDR therapy, psycho-education, and physical activity. The treatment was not phase-based in that it did not contain a stabilization phase or skill training prior to therapy. CPTSD diagnosis was assessed by means of the International Trauma Questionnaire (ITQ) and PTSD diagnosis was assessed with both the ITQ and CAPS-5. Treatment response was measured with the CAPS-5, PCL-5, and ITQ.

RESULTS

Symptoms of both PTSD and CPTSD significantly decreased from pre- to post-treatment resulting in a significant loss of CAPS-5 based PTSD (74.0%) and ITQ-based PTSD and CPTSD diagnoses (85.0% and 87.7%, respectively). No adverse events occurred in terms of suicides, suicide attempts, or hospital admissions.

CONCLUSIONS

The results are supportive of the notion that the majority of patients classified as having CPTSD strongly benefit from an intensive trauma-focused treatment for their PTSD.

Do emotion regulation difficulties affect outcome of intensive trauma-focused treatment of patients with severe PTSD?

Background: There is ongoing debate as to whether emotion regulation problems should be improved first in order to profit from trauma-focused treatment, or will diminish after successful trauma processing. Objective: To enhance our understanding about the importance of emotion regulation difficulties in relation to treatment outcomes of trauma-focused therapy of adult patients with severe PTSD, whereby we made a distinction between people who reported sexual abuse before the age of 12, those who were 12 years or older at the onset of the abuse, individuals who met the criteria for the dissociative subtype of PTSD, and those who did not. Methods: Sixty-two patients with severe PTSD were treated using an intensive eight-day treatment programme, combining two first-line trauma-focused treatments for PTSD (i.e. prolonged exposure and EMDR therapy) without preceding interventions that targeted emotion regulation difficulties. PTSD symptom scores (CAPS-5) and emotion regulation difficulties (DERS) were assessed at pre-treatment, post-treatment, and six month follow-up. Results: PTSD severity and emotion regulation difficulties significantly decreased following trauma-focused treatment. While PTSD severity scores significantly increased from post-treatment until six month follow-up, emotion regulation difficulties did not. Treatment response and relapse was not predicted by emotion-regulation difficulties. Survivors of childhood sexual abuse before the age of 12 and those who were sexually abused later in life improved equally well with regard to emotion regulation difficulties. Individuals who fulfilled criteria of the dissociative subtype of PTSD showed a similar decrease on emotion regulation difficulties during treatment than those who did not. Conclusion: The results support the notion that the severity of emotion regulation difficulties is not associated with worse trauma-focused treatment outcomes for PTSD nor with relapse after completing treatment. Further, emotion regulation difficulties improved after trauma-focused treatment, even for individuals who had been exposed to early childhood sexual trauma and individuals with dissociative subtype.

A decennial review of psychotraumatology: what did we learn and where are we going?

On 6 December 2019 we start the 10th year of the European Journal of Psychotraumatogy (EJPT), a full Open Access journal on psychotrauma. This editorial is part of a special issue/collection celebrating the 10 years anniversary of the journal where we will acknowledge some of our most impactful articles of the past decade (also discussed below and marked with * in the reference list). In this editorial the editors present a decennial review of the field addressing a range of topics that are core to both the journal and to psychotraumatology as a discipline. These include neurobiological developments (genomics, neuroimaging and neuroendocrine research), forms of trauma exposure and impact across the lifespan, mass trauma and early interventions, work-related trauma, trauma in refugee populations, and the potential consequences of trauma such as PTSD or Complex PTSD, but also resilience. We address innovations in psychological, medication (enhanced) and technology-assisted treatments, mediators and moderators like social support and finally how new research methods help us to gain insights in symptom structures or to better predict symptom development or treatment success. We aimed to answer three questions 1. Where did we stand in 2010? 2. What did we learn in the past 10 years? 3. What are our knowledge gaps? We conclude with a number of recommendations concerning top priorities for the future direction of the field of psychotraumatology and correspondingly the journal.

Facts on psychotraumatology

Daily news is dominated by reports of traumatic events across the world. Is trauma indeed rather the norm than the exception? What are the facts? How can we better understand, prevent and treat the consequences of trauma? This past year the European Journal of Psychotraumatology (EJPT) has again tried to address these questions. With the gold Open Access model articles in the journal are being made immediately available without any barriers to access. In Europe, promising developments with regard to Open Science emerged in 2018, for instance, cOAlition S with their ambitious Plan S boosting the transition to full Open Access. In this editorial these and other developments in the journal, such as Registered Reports as a way to reduce Questionable Research Practices (QRPs), journal metrics, and the ESTSS EJPT award finalists for best paper of 2018 are being presented.