Intensive prolonged exposure treatment for adolescent complex posttraumatic stress disorder: a single-trial design

Heart Rate Variability Biofeedback as a Treatment for Military PTSD: A Meta-Analysis

INTRODUCTION

Emerging research has provided tentative support for the use of heart rate variability biofeedback (HRVB) as a treatment for several psychological disorders, with meta-analyses providing compelling evidence for HRVB as a promising treatment for anxiety, depression, and PTSD. Given the prevalence of PTSD in military veterans and the comparatively lower benefit and higher attrition rate of traditional psychological treatment for PTSD relative to civilian counterparts, it is important to examine complementary and alternative treatment approaches such as HRVB in this population. Although studies of HRVB for PTSD have been conducted with military veterans, they have involved relatively small sample sizes, limiting interpretation. To address this, the current article presents a comprehensive meta-analysis, consolidating existing literature to more accurately evaluate the efficacy of HRVB in reducing PTSD symptoms within military populations.

MATERIALS AND METHODS

This meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and our protocol was registered with PROSPERO to increase review transparency. A literature search of HRVB interventions was conducted using PubMed, PsycINFO, Military Database, PTSDPubs, and EBSCO's Psychological and Behavioral Sciences Collection.

RESULTS

Five studies met eligibility criteria, providing a combined sample size of 95 military services members. For all studies, effect sizes were negative, indicating a reduction in PTSD symptoms. Effect sizes ranged from -1.614 to -0.414, resulting in an overall moderate to large mean effect for HRVB (Hedges's g = -0.557; 95% confidence interval = -0.818 to -0.296; P < .001). Additionally, cumulative attrition was 5.8%, significantly lower than commonly reported rates for evidence-based treatments (16%-36%).

CONCLUSIONS

The present study is the first meta-analysis to examine HRVB as a treatment for military service members with PTSD. Results indicate that HRVB may be a viable treatment approach to reduce PTSD symptomatology. Low attrition rates, ease of accessibility, and favorable participant outlook serve as additional benefits for the use of HRVB.

State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.

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.

When one tool is not enough: An integrative psychotherapeutic approach to treating complex PTSD

Complex posttraumatic stress disorder (CPTSD) is a term representing the psychopathological implications of exposure to chronic, inter-personal trauma. These include the main symptoms of PTSD, as well as changes in identity, emotion regulation, and inter-personal relationships. Self-harm and dissociation (i.e., disintegration of mental processes) are also quite common in CPTSD. Considering this complex and often severe clinical picture, mental health professionals often find it difficult to effectively treat CPTSD. In this paper, we present an integrative approach to the treatment of CPTSD based on a combination of techniques from several psychotherapy approaches. The case described here illustrates the need for therapeutic flexibility and eclecticism when treating individuals exposed to chronic trauma. We show the advantages of flexible therapeutic attunement, which enables the therapist to respond to the changing need of the patient, as well as her fluid clinical picture and symptom manifestation. The case also illustrates how interventions taken from psychodynamic therapy, Dialectical behavior therapy, and Eye Movement Desensitization and Reprocessing may be applicable in various stages of treatment, alleviating the patient's distress in several psychological and physical domains.

Prolonged exposure treatment for post-traumatic stress disorder: Single case studies in a sample of adults with mild intellectual disabilities

BACKGROUND

Post-traumatic stress disorder (PTSD) is common in adults with intellectual disabilities. Often there are additional disorders such as substance use, mood and anxiety disorders. The current study focuses on the feasibility and initial efficacy of prolonged exposure (PE) for PTSD in adults with mild intellectual disabilities. The secondary effect of PE on additional mood, anxiety and substance use disorders is also examined.

METHODS

A single case experimental design (N = 12) with an A (baseline)-B (intervention) phase including a follow-up measurement after 3 months was conducted. Time series and single time points measurements were performed.

RESULTS

Six participants dropped-out. The results showed a significant decrease in PTSD symptoms and a significant decrease in additional symptoms (social avoidance, anxiety and stress), among participants who completed treatment.

CONCLUSION

PE appears to be a feasible and effective treatment for PTSD in some adults with mild intellectual disabilities. Suggestions emerge from this study to make standard PE treatment more appropriate for adults with mild intellectual disabilities. Further research is needed to reduce drop-out in trauma treatment. Some suggestions for this are made in this study. Treatment of PTSD with PE did not appear to affect comorbid mood disorders. Further research is needed.

Case report: Intensive online trauma treatment combining prolonged exposure and EMDR 2.0 in a patient with severe and chronic PTSD

Introduction

Short and intensive trauma treatment programs seem promising in treating post-traumatic stress disorder (PTSD). However, little is known about the effects performing these types of intensive treatment programs online.

Method

At the Altrecht Academic Anxiety Centre, an in person intensive trauma focused treatment of six days (three consecutive days in two weeks) was altered into a fully online treatment. A treatment day consisted of 90 minutes of prolonged exposure, 60 minutes of exercise, 90 minutes of Eye Movement Desensitization and Reprocessing (EMDR) 2.0 and 60 minutes of psychoeducation. Mary, a patient diagnosed with chronic and severe PTSD, chronic depressive disorder (single episode, moderate to severe), a panic disorder, and an other specified personality disorder was the first patient to take part in this intensive online trauma treatment.

Results

Mary reached full remission of PTSD. The PTSD symptoms (measured on both the clinician-administered PTSD scale for DSM-5, CAPS-5 and The PTSD Checklist for DSM-5, PCL-5) showed maximum improvement and were completely absent during one month and six month follow-up. Moreover, she no longer suffered from severe depressive symptoms and did not report any general psychiatric symptoms (measured with the Beck Depression Inventory version 2, BDI-II and the Brief Symptom Inventory, BSI).

Conclusion

In conclusion, the case-report demonstrates that intensive trauma treatment online was successful in this specific case, thereby being a 'proof of concept' that intensive trauma treatment online is feasible. It might be promising for patients with severe and chronic PTSD and comorbid psychiatric disorders. However, further research must show if the results of this specific case can be translated to other patients with severe and chronic PTSD and comorbid psychiatric disorders.

Massed v. standard prolonged exposure therapy for PTSD in military personnel and veterans: 12-month follow-up of a non-inferiority randomised controlled trial

BACKGROUND

The utilisation of massed therapy for treating posttraumatic stress disorder (PTSD) is gaining strength, especially prolonged exposure. However, it is unknown whether massed prolonged exposure (MPE) is non-inferior to standard prolonged exposure (SPE) protocols in the long term. The current study aimed to assess whether MPE was non-inferior to SPE at 12 months post-treatment, and to ascertain changes in secondary measure outcomes.

METHODS

A multi-site non-inferiority randomised controlled trial (RCT) compared SPE with MPE in 12 clinics. The primary outcome was PTSD symptom severity (CAPS-5) at 12 months post-treatment commencement. Secondary outcome measures included symptoms of depression, anxiety, anger, disability, and quality of life at 12 weeks and 12 months post-treatment commencement. Outcome assessors were blinded to treatment allocation. The intention-to-treat sample included 138 Australian military members and veterans and data were analysed for 134 participants (SPE = 71, MPE = 63).

RESULTS

Reductions in PTSD severity were maintained at 12 months and MPE remained non-inferior to SPE. Both treatment groups experienced a reduction in depression, anxiety, anger, and improvements in quality of life at 12 weeks and 12 months post-treatment commencement. Treatment effects for self-reported disability in the SPE group at 12 weeks were not maintained, with neither group registering significant effects at 12 months.

CONCLUSIONS

The emergence of massed protocols for PTSD is an important advancement. The current study provides RCT evidence for the longevity of MPE treatment gains at 12 months post-treatment commencement and demonstrated non-inferiority to SPE. Promisingly, both treatments also significantly reduced the severity of comorbid symptoms commonly occurring alongside PTSD.

Treatment of multiple traumatized adolescents by enhancing regulation skills and reducing trauma related symptoms: rationale, study design, and methods of randomized controlled trial (the Mars-study)

BACKGROUND

There is ongoing debate regarding the treatment of severe and multiple traumatized children and adolescents with post-traumatic stress disorder (PTSD). Many clinicians favor a phase-based treatment approach (i.e., a stabilization phase prior to trauma-focused therapy) over immediate trauma-focused psychological treatment, despite the lack of scientific evidence. Research on the effects of different treatment approaches is needed for children and adolescents with (symptoms of complex) PTSD resulting from repeated sexual and/or physical abuse during childhood.

OBJECTIVE

This paper describes the rationale, study design, and methods of the MARS-study, a two-arm randomized controlled trial (RCT) that aims to compare the results of phase-based treatment with those of immediate trauma-focused treatment and determine whether immediate trauma-focused treatment is not worse than phase-based treatment in reducing PTSD symptoms.

METHODS

Participants are individuals between 12 and 18 years who meet the diagnostic criteria for PTSD due to repeated sexual abuse, physical abuse, or domestic violence during childhood. Participants will be blindly allocated to either the phase-based or immediate trauma-focused treatment condition. In the phase-based treatment condition, participants receive 12 sessions of the Dutch version of Skill Training in Affective and Interpersonal Regulation (STAIR-A), followed by 12 sessions of EMDR therapy. In the immediate trauma-focused condition, the participants receive 12 sessions of EMDR therapy. The two groups are compared for several outcome variables before treatment, mid-treatment (only in the phase-based treatment condition), after 12 trauma-focused treatment sessions (post-treatment), and six months post-treatment (follow-up). The main parameter is the presence and severity of PTSD symptoms (Clinician-Administered PTSD Scale for Children and Adolescents, CAPS-CA). The secondary outcome variables are the severity of complex PTSD symptoms (Interpersonal Problems as measured by the Experiences in Close Relationship-Revised, ECR-RC; Emotion Regulation as measured by the Difficulties in Emotion Regulation Scale, DERS; Self Esteem as measured by the Rosenberg Self Esteem Scale, RSES), changes in anxiety and mood symptoms (Revised Anxiety and Depression Scale; RCADS), changes in posttraumatic cognitions (Child Posttraumatic Cognitions Inventory, CPTCI), changes in general psychopathology symptoms (Child Behavior Checklist, CBCL), and Quality of Life (Youth Outcome Questionnaire, Y-OQ-30). Furthermore, parental stress (Opvoedingsvragenlijst, OBVL) and patient-therapist relationship (Feedback Informed Treatment, FIT) will be measured, whereas PTSD symptoms will be monitored in each session during both treatment conditions (Children's Revised Impact of Event Scale, CRIES-13).

DISCUSSION

Treating (symptoms of complex) PTSD in children and adolescents with a history of repeated sexual and/or physical abuse during childhood is of great importance. However, there is a lack of consensus among trauma experts regarding the optimal treatment approach. The results of the current study may have important implications for selecting effective treatment options for clinicians working with children and adolescents who experience the effects of exposure to multiple interpersonal traumatic events during childhood.

TRIAL REGISTRATIONS

The study was registered on the "National Trial Register (NTR)" with the number NTR7024. This registry was obtained from the International Clinical Trial Registry Platform (ICTRP) and can be accessed through the ICTRP Search Portal ( https://trialsearch.who.int/ ).

Review: Adverse event monitoring and reporting in studies of pediatric psychosocial interventions: a systematic review

BACKGROUND

Adverse event monitoring in studies of psychotherapy is crucial to clinical decision-making, particularly for weighing of benefits and harms of treatment approaches. In this systematic review, we identified how adverse events are defined, measured, and reported in studies of psychosocial interventions for children with mental disorders.

METHOD

Medline, PsycINFO, Embase, ProQuest Dissertations and Theses Global, and the Cochrane Library were searched from January 2011-January 2023, and Google Scholar from January 2011-February 2023. English language experimental and quasi-experimental studies that evaluated the efficacy or effectiveness of psychosocial interventions for childhood mental disorders were included. Information on the definition, assessment, and report of adverse events was extracted using a checklist based on Good Clinical Practice guidelines.

RESULTS

In this review, 117 studies were included. Studies most commonly involved treating anxiety disorders or obsessive-compulsive disorder (32/117; 27%); 44% of the experimental interventions tested (52/117) were cognitive behavioral therapies. Adverse events were monitored in 36 studies (36/117; 31%) with a protocol used in 19 of these studies to guide monitoring (19/36; 53%). Twenty-seven different events were monitored across the studies with hospitalization the most frequently monitored (3/36; 8%). Event severity was fully assessed in 6 studies (17%) and partially assessed in 12 studies (33%). Only 4/36 studies (11%) included assessing events for cause.

CONCLUSIONS

To date, adverse events have been inconsistently defined, measured and reported in psychosocial intervention studies of childhood mental health disorders. Information on adverse events is an essential knowledge component for understanding the potential impacts and risks of therapeutic interventions.

Effectiveness of 'Tackle Your Tics', a brief, intensive group-based exposure therapy programme for children with tic disorders: study protocol of a randomised controlled trial

INTRODUCTION

This paper outlines the study protocol for the Dutch Tackle Your Tics study in youth with tic disorders. Tourette syndrome and chronic tic disorders are prevalent neurodevelopmental disorders, placing considerable burden on youth and their families. Behavioural treatment is the first-line, evidence-based intervention for tic disorders, but tic reduction and availability remain relatively low. Patient associations stress the need for more accessible high-quality treatments, also focusing on improving quality of life. Therefore, the brief, intensive group-based treatment Tackle Your Tics was developed.

METHODS AND ANALYSIS

Tackle Your Tics is a 4-day intensive and comprehensive group-based intervention for children and adolescents (9-17 years) with Tourette syndrome or a chronic tic disorder. The programme encompasses exposure and response prevention treatment and additional supporting components (coping strategies, relaxation exercises and parent support). To study the effectiveness of Tackle Your Tics and identify predictors/moderators at baseline, a single-blinded randomised controlled trial (n=104) is conducted, comparing Tackle Your Tics (n=52) with a waiting list condition lasting 3 months (n=52). Assessments are performed at similar time points for both groups: at baseline, after 4 weeks, and at 3 and 6 months of follow-up, on tic severity, quality of life and other psychosocial variables.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the medical ethical committee of the Amsterdam Medical Centre (METC nr NL66340.018.18, v3 June 2020). Findings will be presented on national and international conferences, peer-reviewed scientific journals, patient organisation meetings and public media. Patient representatives are fully integrated as part of the research team. If Tackle Your Tics proves to be effective, it can expand evidence-based treatment possibilities for children and adolescents with tic disorders. Identifying the psychosocial predictors/moderators for the effectiveness of this intervention can provide personalised treatment advice in the future.

TRIAL REGISTRATION NUMBER

NL8052.

A scoping review investigating the use of exposure for the treatment and targeted prevention of anxiety and related disorders in young people

Background

Cognitive Behavioural Therapy (CBT) is the gold standard intervention for anxiety and related mental health disorders among young people; however, the efficacy of individual elements of CBT (e.g., exposure to feared stimuli) have received little scrutiny.

Aims

This scoping review, informed by three stakeholder groups and a scientific advisory group, aimed to identify the nature and extent of the available research literature on the efficacy of exposure to feared stimuli, moderators of effectiveness in young people aged 14-24 years.

Method

Three international stakeholder groups composed of clinicians (N = 8), parents/carers (N = 5) and youth with lived experience of anxiety (N = 7) provided input into study design and results. Using the PRISMA extension for scoping reviews, a search of MEDLINE/Ovid, PsycINFO, PubMed, CINAHL, SCOPUS, EMBASE, ERIC, and Health Collection (informit) was conducted using terms related to anxiety, ages 14-24, and exposure.

Results

From 3508 unique abstracts, 64 papers were included for the review. While there was evidence for the efficacy of exposure as a treatment for youth anxiety disorders, fundamental gaps in knowledge of exposure in this age group were identified. Most studies examined post-traumatic stress disorder, obsessive-compulsive disorder, and specific phobias with no randomised clinical trials uniquely evaluating exposure for the treatment of DSM-5 anxiety disorders. Exposure was typically delivered accompanied by other anxiety management techniques. A multitude of optimisation strategies have been tested, yet only one of these effects (timing relative to sleep) showed preliminary evidence of replication.

Conclusions

A systematic and theoretically driven program of research investigating the efficacy of exposure in young people and factors that moderate its efficacy, along with methods to overcome barriers for delivery, is urgently needed.

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.

Behavioral and pharmacological interventions for the prevention and treatment of psychiatric disorders with children exposed to maltreatment

There is a well-established relation between exposure to child maltreatment and the onset and course of multiple, comorbid psychiatric disorders. Given the heterogeneous clinical presentations at the time services are initiated, interventions for children exposed to maltreatment need to be highly effective to curtail the lifelong burden and public health costs attributable to psychiatric disorders. The current review describes the most effective, well-researched, and widely-used behavioral and pharmacological interventions for preventing and treating a range of psychiatric disorders common in children exposed to maltreatment. Detailed descriptions of each intervention, including their target population, indicated age range, hypothesized mechanisms of action, and effectiveness demonstrated through randomized controlled trials research, are presented. Current limitations of these interventions are noted to guide specific directions for future research aiming to optimize both treatment effectiveness and efficiency with children and families exposed to maltreatment. Strategic and programmatic future research can continue the substantial progress that has been made in the prevention and treatment of psychiatric disorders for children exposed to maltreatment.

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.

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.

The Tern Programme Study protocol for an implementation trial of a flexible, long-term psychosocial intervention for complex posttraumatic stress in young people

BACKGROUND

Complex Trauma (CT) is a term used to refer to multiple or prolonged traumatic experiences. Such experiences are often first encountered during childhood and may impact key developmental periods. CT is a risk for a broad range of deleterious physical, psychological, social, and occupational outcomes. The diagnosis of Complex Posttraumatic Stress Disorder (C-PTSD) has been proposed to capture the symptomatology resulting from CT exposure.In Australia, there are few publicly funded services that target, and are purposely designed to support, the mental health needs of young people with symptoms of complex post-traumatic stress (C-PTSD). The Tern Programme has been designed as a purpose-built model of care for providing mental health support to young people with C-PTSD.

METHODS

This implementation trial will involve a longitudinal examination of Tern participants for a fixed 24-month period. Participants will be recruited from the young people referred to Tern at headspace centres in regional Australia where Tern operates. Eligible participants will have reported a history of complex trauma, and present with symptoms of C-PTSD. All participants will be invited to complete a series of surveys during their participation in the programme. Survey items will assess C-PTSD symptom change, quality of life and occupational functioning.The Tern model of care is delivered in a semi-structured format to accommodate a person-centred flexible approach. Fidelity will be monitored through the completion of a clinician post-session checklist and through group supervision.

DISCUSSION

This study will provide the first quantitative data on the new Tern model of care and evaluate mental health and functional outcomes of its participants. If effective, Tern may be suitable for replication in other Australian or international youth mental health services where complex post-traumatic stress is prevalent.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000079842p. Prospectively registered on 29 January 2021.

ABBREVIATIONS

CT = Complex Trauma; C-PTSD = Complex Posttraumatic Stress Disorder.

Tackle your Tics: pilot findings of a brief, intensive group-based exposure therapy program for children with tic disorders

Tourette syndrome (TS) and other chronic tic disorders (CTD) are prevalent neurodevelopmental disorders, which can have a huge burden on families and society. Behavioral treatment is a first-line intervention for tic disorders. Despite demonstrated efficacy, tic reduction and utilization rates of behavioral treatment remain relatively low. Patient associations point to an urgent need for easy-to-undergo treatments that focus both on tic reduction and improvement of quality of life. To enhance treatment outcome and overcome treatment barriers, this pilot study's aim was to investigate the feasibility and preliminary results of a brief, intensive group-based treatment. Tackle your Tics is a 4-day intensive and comprehensive group-based program for children and adolescents (9-17 years) with a tic disorder, consisting of exposure and response prevention (ERP) treatment and additional supporting components, such as coping strategies, relaxing activities and parent support. Assessments were performed pre- and post-treatment and at 2 months follow-up, to test outcomes on tic severity and quality of life, and explore premonitory urges, emotional and behavioral functioning and treatment satisfaction (N = 14, of whom 13 completed the treatment). Parents and children rated this treatment positive on a treatment satisfaction questionnaire. On tic severity (Yale Global Tic Severity Scale) and quality of life (Gilles de la Tourette Syndrome Quality of Life Scale for children and adolescents), improvements between pre-treatment and follow-up were found. Intensive ERP in group format is promising as a feasible treatment to improve both tic severity as well as quality of life. Larger controlled trials are needed to establish its effectiveness.

Feasibility and potential effectiveness of an intensive trauma-focused treatment programme for families with PTSD and mild intellectual disability

BACKGROUND

Persons with mild intellectual disabilities or borderline intellectual functioning (MID-BIF; IQ 50-85) have a higher risk of being exposed to traumatic events and developing posttraumatic stress disorder (PTSD). EMDR therapy has shown to be applicable, safe and potentially effective for the treatment of PTSD in individuals with MID-BIF. However, in traumatized multi-problem families with MID-BIF and (impending) out of home placement of children, standard PTSD treatment in an outpatient setting may not be appropriate.

OBJECTIVE

To evaluate the feasibility and potential effectiveness of KINGS-ID, a six-week clinical trauma-focused treatment programme consisting of intensive EMDR therapy with parents and children, and parental skills training followed by two weeks of parent support at home.

METHOD

Six families (nine parents of whom six had MID-BIF) and 10 children (all having MID-BIF) participated in the KINGS-ID programme. Seven parents and seven children had PTSD. Data were collected within a single case study design. For each family member data were collected during baseline (three measurements), treatment (seven weekly measurements), posttreatment (three measurements) and at follow-up (three measurements).

RESULTS

None of the family members dropped out. Within the first two treatment weeks all but one child and one parent no longer met PTSD symptom criteria. In both children and parents, trauma-related symptoms and daily life impairment significantly decreased following treatment and in parents a significant decrease in symptoms of general psychopathology and parental stress was found. Results were maintained at six-month follow-up.

CONCLUSIONS

The findings of the current study are promising given that the treatment programme seems to offer new perspectives for traumatized multi-problem families with MID-BIF.

Improving treatment for patients with childhood abuse related posttraumatic stress disorder (IMPACT study): protocol for a multicenter randomized trial comparing prolonged exposure with intensified prolonged exposure and phase-based treatment

BACKGROUND

Childhood abuse related posttraumatic stress disorder (CA-PTSD) is associated with a high burden of disease and with treatment response rates that leave room for improvement. One of the treatments for PTSD, prolonged exposure (PE), is effective but has high drop-out rates and remission rates are relatively low. An intensified form of PE (iPE) was associated with good response and low drop-out rates in PTSD and has not yet been tested in a controlled trial in CA-PTSD. Phase-based treatment (PBT), in which PE is preceded by skills training may improve overall outcomes in this population. We will assess the effectiveness and cost-effectiveness of standard PE, iPE and PBT in patients with CA-PTSD.

METHODS/DESIGN

Multi-center randomized controlled trial. Treatment conditions are: prolonged exposure (PE; maximum of 16 sessions in 16 weeks); intensified PE (iPE; maximum of 12 sessions in four weeks and two booster sessions); phase-based treatment (PBT; maximum of eight sessions skills training followed by eight sessions PE in 16 weeks).

PRIMARY OUTCOME

Clinician-rated PTSD symptom severity.

SECONDARY OUTCOMES

loss of PTSD diagnosis, self-reported PTSD symptom severity, comorbid symptom severity and quality of life. Moreover, we will examine cost-effectiveness and moderators and mediators of treatment outcome.

TARGET POPULATION

adults with CA-PTSD (N = 150). Assessments in weeks 0, 4, 8, 16, 26 and 52.

DISCUSSION

Given that no consensus yet exists about the treatment guidelines for patients with CA-PTSD, the present study may have important implications for the treatment of CA-PTSD.

TRAIL REGISTRATION

Registered at C.C.M.O. on Sept 7, 2016 (NL57984.058.16); retrospectively registered at June 21, 2017 at clinicaltrials.gov identifier: NCT03194113 .

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.