Complex PTSD: what is the clinical utility of the diagnosis?

Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications

BACKGROUND

Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post-traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD-ED) have protracted treatment courses and poorer prognoses.

AIM

To summarise the knowledge base on cPTSD-ED with specific emphasis on disturbances in self-organisation (DSO) in relation to therapeutic alliance (TA) processes.

METHOD

Expert opinions based on current relevant literature are critically examined.

RESULTS

Preliminary insights on change and alliance processes suggest that neglecting to address emotional-relational processes in the conceptualisation and treatment of cPTSD-ED impedes treatment progress.

CONCLUSION

We hypothesise that the DSO construct inherent in cPTSD-ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for.

Psychometric properties of International Trauma Questionnaire (ITQ) and symptom structure of complex post-traumatic stress disorder among Chinese patients with MDD

AIMS

To assess the validity and internal reliability of the International Trauma Questionnaire (ITQ) among patients diagnosed with major depressive disorder (MDD) and to explore the network structure of Complex post-traumatic stress disorder (CPTSD) among MDD patients in China.

METHODS

Eligible individuals were recruited from a large tertiary hospital in Guangdong Province. Trained researchers conducted in-person interviews and administered self-report questionnaires, including demographics, medical information, and psychological assessments. Confirmatory factor analyses (CFA) and network analysis were performed, with calculations of Average Variance Extracted (AVE), Cronbach's α, and composite reliability.

RESULTS

A total of 113 patients with MDD participated in this study. The correlated six-factor one-order model was a good representation of the latent structure of ITQ (χ2= 60.114, df = 39, P = 0.017, SRMR = 0.070, RMSEA = 0.050, TLI = 0.952, CFI = 0.972, BIC = 175.508). All ITQ subscales possessed acceptable convergent validity and internal reliability, except for affective dysregulation and re-experiencing. The square root of AVE for affective dysregulation was lower than its correlations with other clusters. Network analysis revealed that node C4 ('I feel worthless'), as a core symptom, was significantly associated with the development of CPTSD.

CONCLUSIONS

The clinical applicability of the ITQ was demonstrated by its overall validity and reliability among patients with MDD. However, the affective dysregulation and re-experiencing clusters still need to be revised and enhanced. Timely screening, recognition, and diagnosis are critical due to the worse clinical outcomes seen in comorbid patients.

How effective are mood stabilizers in treating bipolar patients comorbid with cPTSD? Results from an observational study

BACKGROUND

Multiple traumatic experiences, particularly in childhood, may predict and be a risk factor for the development of complex post-traumatic stress disorder (cPTSD). Unfortunately, individuals with bipolar disorder (BP) are more likely to have suffered traumatic events than the general population. Consequently, cPTSD could be comorbid with BD, and this may negatively affect psychopathological manifestations. To date, no one has explored whether such comorbidity also affects the response to treatment with mood stabilizers in BD patients.

RESULTS

Here, a cross-sectional study was carried out by comparing the response to treatment, measured by the Alda scale, in a cohort of 344 patients diagnosed with BD type I and II, screened for the presence (or absence) of cPTSD using the International Trauma Questionnaire. The main result that emerged from the present study is the poorer response to mood stabilizers in BD patients with comorbid cPTSD compared with BD patients without cPTSD.

CONCLUSIONS

The results collected suggest the need for an add-on therapy focused on trauma in BD patients. This could represent an area of future interest in clinical research, capable of leading to more precise and quicker diagnoses as well as suggesting better tailored and more effective treatments.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

MDMA-Based Psychotherapy in Treatment-Resistant Post-Traumatic Stress Disorder (PTSD): A Brief Narrative Overview of Current Evidence

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that causes significant dysfunction in individuals. Currently, there are many approved pharmacotherapy and psychotherapy treatment options for PTSD, but unfortunately, half of the patients do not respond to traditional therapies. In this article, we review clinical trials and research on 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy in PTSD patients, its pharmacokinetics, and current treatment guidelines for PTSD. Our findings are based on the results of the efficacy of MDMA-assisted psychotherapy from six phase II randomized controlled trials. MDMA-assisted psychotherapy for PTSD has received the "breakthrough therapy" designation from the FDA. MDMA can reduce PTSD symptoms even in treatment-resistant cases by increasing certain neurohormones, i.e., dopamine, serotonin, norepinephrine, and oxytocin. It also modulates activities in the brain regions involved in fear and anxiety. Future research is needed to show whether the advantages outweigh the disadvantages and whether its use can be integrated into available treatment options for PTSD.

Assessment tools for complex post traumatic stress disorder: a systematic review

Appropriate screening tools are required to accurately detect complex post traumatic stress disorder (CPTSD). This systematic review aimed to assess and compare measurement tools. A literature search using key words 'complex post traumatic stress disorder', 'PTSD', and 'assessment' was undertaken on Embase and PsychINFO during February 2022 by two reviewers. Inclusion criteria included full text papers between 2002-2022 which evaluated CPTSD using assessment tools. Exclusion criteria included reviews, editorials, meta-analyses, or conference abstracts. Twenty-two papers met selection criteria. Thirteen studies used the International Trauma Questionnaire (ITQ). Two studies each evaluated CPTSD with the International Trauma Interview (ITI) or Symptoms of Trauma Scale (SOTS). The Developmental Trauma Inventory (DTI), Cameron Complex Trauma Interview (CCTI), Complex PTSD Item Set additional to the Clinician Administered PTSD Scale (COPISAC), Complex Trauma Questionnaire (ComplexTQ), and Scale 8 of the Minnesota Multiphasic Personality Inventory Scale (MMPI) were used by a single study each. The ITQ was the most thoroughly investigated, validated across different populations, and is a convenient questionnaire for screening within the clinical setting. Where self-report measures are inappropriate, the ITI, SOTS, and COPISAC are interview tools which detect CPTSD. However, they require further validation and should be used alongside clinical history and examination.

Deep brain stimulation of the subgenual cingulum and uncinate fasciculus for the treatment of posttraumatic stress disorder

Deep brain stimulation (DBS) has been investigated for neuropsychiatric disorders. In this phase 1 trial, we treated four posttraumatic stress disorder (PTSD) patients with DBS delivered to the subgenual cingulum and the uncinate fasciculus. In addition to validated clinical scales, patients underwent neuroimaging studies and psychophysiological assessments of fear conditioning, extinction, and recall. We show that the procedure is safe and potentially effective (55% reduction in Clinical Administered PTSD Scale scores). Posttreatment imaging data revealed metabolic activity changes in PTSD neurocircuits. During psychophysiological assessments, patients with PTSD had higher skin conductance responses when tested for recall compared to healthy controls. After DBS, this objectively measured variable was significantly reduced. Last, we found that a ratio between recall of extinguished and nonextinguished conditioned responses had a strong correlation with clinical outcome. As this variable was recorded at baseline, it may comprise a potential biomarker of treatment response.

The Self-Administered Version of the Structured Interview for Disorders of Extreme Stress (SIDES-SR) in a Clinical and Non-Clinical Portuguese Sample

Disorders of Extreme Stress Not Otherwise Specified (DESNOS) refers to a constellation of symptoms deriving from chronic interpersonal trauma, inflicted by caregivers or in the context of intimate relationships. The Structured Interview for Disorders of Extreme Stress-Self-Report (SIDES-SR) was designed for the assessment of DESNOS. This study aimed to validate the Portuguese version of the SIDES-SR in the community (N = 814; M_age = 40.09, SD = 14.25, 39.2% male, 60.8% female) and clinical (N = 310; M_age = 42.49, SD = 12.47, 57.7% male, 42.3% female) samples. It had three objectives: (1) to validate the SIDES-SR rationally derived domains in the community sample; (2) to characterise the reliability of the SIDES-SR scales in both samples; and (3) to explore mean differences in the SIDES-SR results in both samples. The Portuguese SIDES-SR confirmed the six clinical domains of DESNOS and demonstrated acceptable internal consistency levels, similar to those obtained in prior research. Highly significant differences and large and very large effect sizes between the community and clinical samples were found for all the SIDES-SR domains. DESNOS symptomatology was shown to be more frequent in females and the clinical sample reported a higher frequency of traumatic events in life, specifically interpersonal trauma. The results support the relevance of the SIDES-SR for clinical practice in the assessment of the DESNOS diagnosis.

Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys

Patient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys - 17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) - carried out as part of the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.

Can developmental trauma disorder be distinguished from posttraumatic stress disorder? A symptom-level person-centred empirical approach

BACKGROUND

Developmental Trauma Disorder (DTD) is a proposed childhood psychiatric diagnosis for psychopathological and developmental sequela of victimization and attachment trauma extending beyond posttraumatic stress disorder (PTSD).

OBJECTIVE

To determine whether a sub-group of trauma-impacted children is characterized by symptoms of DTD that extend beyond, or co-occur with, the symptoms of PTSD.

METHOD

Person-centred Latent Class Analyses (LCA) were done with data from 507 children (ages 7-18 years, (M = 12.11, SD = 2/92); 49% female) referred to the study by mental health or paediatric clinicians.

RESULTS

A four class solution was optimal (LMR = 398.264, p < .001; Entropy = .93): (1) combined DTD + PTSD (n = 150); (2) predominant DTD (n = 156); (3) predominant PTSD (n = 54); (4) minimal symptoms (n = 147). Consistent with prior research, the DTD + PTSD class was most likely to have experienced traumatic emotional abuse and neglect (X² (3) = 16.916 and 28.016, respectively, p < .001), and had the most psychiatric comorbidity (F(3, 502) = 3.204, p < .05). Predominant DTD class members were most likely to meet criteria for Oppositional Defiant Disorder (ODD) (X²(3) = 84.66, p < .001).

CONCLUSION

Symptoms of DTD may occur with, or separately from, PTSD symptoms. Children with high DTD|+PTSD symptoms had extensive psychiatric comorbidity, while those with high DTD symptoms and minimal PTSD symptoms were highly likely to meet criteria for ODD. In clinical and research assessment and treatment of children with complex psychiatric comorbidity or disruptive behaviour problems, symptoms of DTD should be considered, both along with, and in the absence of, PTSD symptoms.