Toward staging differentiation for posttraumatic stress disorder treatment

What I was thinking/what I would do differently: Technology-enabled traumatic stress support

At the 39th meeting of the International Society of Traumatic Stress Studies, three leading researchers and clinicians in technology-enabled traumatic stress support were invited to reflect on their careers and contributions to the field. Dr. Brian P. Marx has led the development of large-scale technologies to screen, assess, and treat traumatic stress pathology across diverse etiologies and needs. Dr. Barbara O. Rothbaum, a pioneer in the development of virtual reality for exposure therapy, has demonstrated the efficacy and scalability of digital treatment for traumatic stress. Retired Col. Dr. Eric Vermetten has worked extensively on the intersection of basic mechanisms, novel psychological and biological treatment, and technology for scalable assessment and treatment, primarily in military and mass casualty contexts. The panelists were asked to reflect on their initial ambitions, concerns, unexpected challenges, and the influence of their work on new research trajectories. Their insights provide valuable lessons about the process and content of their work, and their pioneering efforts have significantly advanced the field of technology-enabled traumatic stress support.

Dissociative Subtype of Posttraumatic Stress Disorder and its Correlates Among Treatment-Seeking Refugees

The dissociative subtype of posttraumatic stress disorder (PTSD-DS) denotes a severe type of PTSD associated with complex trauma exposure and psychiatric comorbidity. Refugees may be at heightened risk of developing PTSD-DS, but research is lacking. This cross-sectional study aimed to examine PTSD-DS and its demographic, trauma-related, and clinical correlates among a convenience sample of refugee patients over 18 years old who were diagnosed with PTSD according to DSM-5. PTSD-DS (Clinician-Administered PTSD Scale for DSM-5), trauma exposure (Life Events Checklist for DSM-5) and general psychopathology (Brief Symptom Inventory) were assessed at intake. T-tests, chi-square tests, and logistical regression analysis were conducted. The final sample consisted of 552 participants (177 (32.1%) women; 375 (67.9%) men; average age 40.0 years (SD = 11.2)) who originated from 63 countries. Of those, 158 (28.6%) met criteria for PTSD-DS. Participants with PTSD-DS scored significantly higher on PTSD symptom severity (t(550)=-5.270, p < .001), number of traumatic event types (t(456)=-3.499, p < .001), and exposure to sexual assault (χ(1) = 6.471, p = .01) than those without PTSD-DS. The odds of having PTSD-DS increased by 14.1% with exposure to each additional traumatic event type (OR = 1.141, CI 0.033-1.260). In conclusion, around 29% of adult treatment-seeking refugees with PTSD met the criteria for PTSD-DS. Those exposed to multiple traumatic event types including sexual assault, regardless of sex, were especially at risk. Having PTSD-DS was associated with more severe PTSD. Prioritizing trauma-focused treatment for those with PTSD-DS is recommended.

Staging model of PTSD: a strategy for the implementation of precision medicine in military settings

Biomarkers have been of considerable interest in military medicine as a strategy to identify objective measures of resilience in the context of the cumulative trauma exposure of combat as well defining the emerging neurobiological dysregulation associated with post-traumatic stress disorder (PTSD). This body of work has been driven by the imperative of developing strategies to optimally manage the long-term health outcomes of personnel and finding novel treatment approaches. However, the challenge of defining the relevant phenotypes of PTSD and in the context of the multiplicity of biological systems of interest has hampered the identification of biomarkers that have clinical utility. One key strategy to improve the utility of precision medicine in military settings is to use a staging approach to define the relevant phenotypes. A staging model of PTSD captures the progression of the disorder and the transitions from being at risk to subsyndromal disorder and the path to chronic disorder.A staging approach addresses the longitudinal course of PTSD and the fluidity of the disorder across time. Staging describes how symptoms evolve into more stable diagnostic syndromes and the stepwise changes in clinical status which is key to the identification of phenotypes that can be tied to relevant biomarkers. When a population is exposed to a trauma, the individuals will be at different stages in the emergence of risk and the development of PTSD. The staging approach provides a method of capturing the matrix of phenotypes that need to be demarcated to study the role of multiple biomarkers. This paper forms part of the Special issue of BMJ Military Health dedicated to personalised digital technology for mental health in the armed forces.

Identifying psychological risk and resilience in high-risk military personnel

INTRODUCTION

Combat exposure has been associated with the emergence of post-traumatic stress disorder (PTSD) symptoms in military personnel; however, not all veterans are negatively impacted by their operational experience. In many instances, the absence of symptoms following operational service is attributed to resilience. This study explored the construct of resilience by examining the relationship between levels of deployment-related exposures and psychological symptoms, as well as identifying factors that may contribute to resilience and emerging risk.

METHOD

Participants were special forces personnel who completed self-report questionnaires 1 month before deployment and 4 months post deployment. Subgroups were created based on psychological reactivity to deployment exposures, representing risk, vulnerability and resilience. Regression analysis assessed the contribution of factors that were predictive of risk or resilience groups specifically.

RESULTS

Results showed the overall levels of psychological reactivity in this population post deployment were low; however, differences between risk and resilience subgroups were found. Subthreshold indicators of psychological reactivity, as well as deployment factors such as increased deployment frequency and time spent away from home, were found to contribute to differences between risk and resilient trajectories.

CONCLUSION

Findings reflect a military population with low psychological symptoms despite high trauma exposure. However, subtle underlying differences between subgroups suggest that the early identification of risk and emerging trajectories is possible. Risk and resilience in military populations needs to consider subthreshold indicators and individual differences over time.

Expert opinions on implementation of MDMA-assisted therapy in Europe: critical appraisal towards training, clinical practice, and regulation

Introduction: The positive results of MDMA from Phase 2 and 3 clinical trials in MDMA-assisted therapy (MDMA-AT) for the treatment of post-traumatic stress disorder (PTSD) call for a critical evaluation of its regulatory status within the European mental healthcare system. This is driven by the recent submission of MDMA-AT for FDA approval in the United States. Unless coordinated efforts in the European regulatory landscape start, there may be potential divergences in national regulatory strategies. Gaining insights from researchers and clinicians involved in the application of MDMA-AT may be useful in guiding the discussion of factors involved in its implementation.Method: A comprehensive invitation-only survey was sent to researchers and clinicians involved in MDMA-AT clinical trials and contributors to the scientific literature on MDMA-AT from around the globe. This study aimed to collect opinions on clinical practices, training, and regulation worldwide, examining the global best practices and pitfalls to outline strategies for possible European implementation of MDMA-AT.Results: The survey, which included responses from 68 experts, yielded a range of opinions where a large majority endorsed the need for training and standardization, emphasizing equity and access, stressing impediments in the national approval processes, and reflecting critically on anticipated spill-over effects of MDMA-AT in clinical settings.Conclusion: The experts highlight the need for science-informed policy development, active regulatory involvement, and international cooperation to incorporate MDMA-AT into the European mental healthcare system in general and the treatment of PTSD in particular. The study emphasizes the importance of ongoing research, open professional discourse, and collaborative engagement to facilitate MDMA-AT's ethical and effective implementation.

EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis

BACKGROUND

This systematic review and individual participant data meta-analysis (IPDMA) examined the overall effectiveness of eye movement desensitization and reprocessing (EMDR) in reducing posttraumatic stress disorder (PTSD) symptoms, achieving response and remission, and reducing treatment dropout among adults with PTSD compared to other psychological treatments. Additionally, we examined available participant-level moderators of the efficacy of EMDR.

METHODS

This study included randomized controlled trials. Eligible studies were identified by a systematic search in PubMed, Embase, PsyclNFO, PTSDpubs, and CENTRAL. The target population was adults with above-threshold baseline PTSD symptoms. Trials were eligible if at least 70% of study participants had been diagnosed with PTSD using a structured clinical interview. Primary outcomes included PTSD symptom severity, treatment response, and PTSD remission. Treatment dropout was a secondary outcome. The systematic search retrieved 15 eligible randomized controlled trials (RCTs); 8 of these 15 were able to be included in this IPDMA (346 patients). Comparator treatments included relaxation therapy, emotional freedom technique, trauma-focused cognitive behavioral psychotherapies, and REM-desensitization.

RESULTS

One-stage IPDMA found no significant difference between EMDR and other psychological treatments in reducing PTSD symptom severity (β = -0.24), achieving response (β = 0.86), attaining remission (β = 1.05), or reducing treatment dropout rates (β = -0.25). Moderator analyses found unemployed participants receiving EMDR had higher PTSD symptom severity at the post-test, and males were more likely to drop out of EMDR treatment than females.

CONCLUSION

The current study found no significant difference between EMDR and other psychological treatments. We found some indication of the moderating effects of gender and employment status.

Reduced pre-attentive threat versus nonthreat signal discrimination in clinically healthy military personnel with recurrent combat exposure history: A preliminary event-related potential (ERP) study

Evidence now suggests that traumatic-stress impacts brain functions even in the absence of acute-onset post-traumatic stress disorder (PTSD) symptoms. These neurophysiological changes have also been suggested to account for increased risks of PTSD symptoms later developing in the aftermath of subsequent trauma. However, surprisingly few studies have explicitly examined brain function dynamics in high-risk populations, such as combat exposed military personnel without diagnosable PTSD. To extend available research, facial expression sensitive N170 event-related potential (ERP) amplitudes were examined in a clinically healthy sample of active service military personnel with recurrent combat exposure history. Consistent with several established theories of delayed-onset PTSD vulnerability, higher N170 amplitudes to backward-masked fearful and neutral facial expressions correlated with higher levels of past combat exposure. Significantly elevated amplitudes to nonthreatening neutral facial expressions also resulted in an absence of normal threat-versus-nonthreat signal processing specificity. While a modest sample size and cross-sectional design are key limitations here, ongoing prospective-longitudinal follow-ups may shed further light on the precise aetiology and prognostic utility of these preliminary findings in the near future.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

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.

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.

Clinical staging across eating disorders: a scoping review protocol

INTRODUCTION

Clinical staging models in psychiatry assert that there are earlier, less severe or more malleable forms of illness that are distinguishable from later, more chronic forms of illness, and that these stages may have different prognostic and treatment implications. Previous reviews on clinical staging in eating disorders (EDs) suggest a staging heuristic could be useful for anorexia nervosa, but less research is available on how this applies to other EDs. An up-to-date review is required to synthesise new and heterogenous avenues of research. This scoping review aims to explore the extent and types of evidence in relation to illness staging for EDs and how these concepts are associated with treatment response and outcomes.

METHODS AND ANALYSIS

This protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for Scoping Reviews checklist and the Joanna Briggs Institute Reviewer's Manual. We will consider any documents providing evidence for clinical staging such as those which describe full or partial staging models, for all EDs, across various domains of assessment and functioning. Participants will include clinical or non-clinical population samples with full-syndrome EDs or disordered eating behaviour. PubMed, PsycINFO, MEDLINE and Web of Science databases will be systematically searched for relevant literature. Two authors will export documents and screen titles, abstracts and full texts. Data will be extracted into a charting form drafted by the authors. A narrative summary of the documents will be conducted in line with the study aims. Finally, clinical and research recommendations will be outlined.

ETHICS AND DISSEMINATION

Ethical approval will not be required to synthesise published and unpublished literature. The study will be published in a peer-reviewed journal and shared at conferences, via social media, and in other communications.

[Personalized psychotherapy of posttraumatic stress disorder : Overview on the selection of treatment methods and techniques using statistical procedures]

BACKGROUND

A relevant heterogeneity of treatment effects in posttraumatic stress disorder (PTSD) is discussed with respect to the debate about the necessity of phase-based treatment and in light of the new diagnosis of complex PTSD and has recently been proven; however, there has been little personalization in the treatment of PTSD. This article presents the current state of research on the personalized selection of specific psychotherapeutic methods for the treatment of PTSD based on patient characteristics using statistical methods.

METHODS

A systematic literature search was conducted in the PubMed (including Medline), Embase, Web of Science Core Collection, Google Scholar, PsycINFO and PSYNDEX databases to identify clinical trials and reviews examining personalized treatment for PTSD.

RESULTS

A total of 13 relevant publications were identified, of which 5 articles were predictor analyses in samples without control conditions and 7 articles showed analyses of randomized controlled trials (RCT) with a post hoc comparison of treatment effects in optimally and nonoptimally assigned patients. In addition, one article was a systematic review on the treatment of patients with comorbid borderline personality order and PTSD.

DISCUSSION

The available manuscripts indicate the importance and benefits of personalized treatment in PTSD. The relevant predictor variables identified for personalization should be used as a suggestion to investigate them in future prospective studies.

Molecular Toxicology and Pathophysiology of Comorbid Alcohol Use Disorder and Post-Traumatic Stress Disorder Associated with Traumatic Brain Injury

The increasing comorbidity of alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) associated with traumatic brain injury (TBI) is a serious medical, economic, and social issue. However, the molecular toxicology and pathophysiological mechanisms of comorbid AUD and PTSD are not well understood and the identification of the comorbidity state markers is significantly challenging. This review summarizes the main characteristics of comorbidity between AUD and PTSD (AUD/PTSD) and highlights the significance of a comprehensive understanding of the molecular toxicology and pathophysiological mechanisms of AUD/PTSD, particularly following TBI, with a focus on the role of metabolomics, inflammation, neuroendocrine, signal transduction pathways, and genetic regulation. Instead of a separate disease state, a comprehensive examination of comorbid AUD and PTSD is emphasized by considering additive and synergistic interactions between the two diseases. Finally, we propose several hypotheses of molecular mechanisms for AUD/PTSD and discuss potential future research directions that may provide new insights and translational application opportunities.

Unity or Anarchy? A Historical Search for the Psychological Consequences of Psychotrauma

The field of traumatic stress is often referred to as being in a state of controversy and lack of continuity. Throughout history, disputes repeatedly centered on defining the psychological consequences of severe adverse events and on their causes. Even to this day this is current. To understand these controversies, an extensive historical literature review is presented of how mental consequences of trauma have been described in history, of the circumstances in which this took place, and of the disputes that have influenced the conceptualization of these mental responses. We found psychotrauma always being surrounded by controversy. Significant heterogeneity in symptom expression has been described over the centuries to this day. Some symptoms appeared steadily over many decades, but often each time period showed its own core symptoms. At syndrome level, we found an acute condition, one with longer duration, and a complex condition. Also here, definitions varied over the decades. Finally, causes have always been debated, such as biological, psychological, socio-economic, cultural, political, or legal. To better reflect the described ongoing variation in symptomatology, a more flexible diagnostic approach is proposed with a combination of both staging and subtyping that offers room for a more flexible, symptom-oriented, and personalized perspective.