Psychosocial treatments for posttraumatic stress disorder: a critical review

Good moments to stimulate the brain - A randomized controlled double-blinded study on anodal transcranial direct current stimulation of the ventromedial prefrontal cortex on two different time points in a two-day fear conditioning paradigm

It is assumed that extinction learning is a suitable model for understanding the mechanisms underlying exposure therapy. Furthermore, there is evidence that non-invasive brain stimulation (NIBS) can elevate extinction learning by enhancing frontal brain activity and therefore NIBS can augment symptom reduction during exposure therapy in phobias. But, the underlying processes are still not well established. Open questions arise from NIBS time points and electrode placement, among others. Therefore, we investigated in a 2-day fear conditioning experiment, whether anodal transcranial direct current stimulation (tDCS) of the ventromedial prefrontal cortex (vmPFC) modulates either fear memory consolidation or dampened fear reaction during fear extinction. Sixty-six healthy participants were randomly assigned either to a group that received tDCS after fear acquisition (and before fear memory consolidation), to a group that received tDCS directly before fear extinction, or to a control group that never received active stimulation (sham). Differential skin conductance response (SCR) to CS+ vs. CS- was significantly decreased in both tDCS-groups compared to sham group. Our region of interest, the vmPFC, was stimulated best focally with a lateral anode position and a cathode on the contralateral side. But this comes along with a slightly lateral stimulation of vmPFC depending on whether anode is placed left or right. To avoid unintended effects of stimulated sides the two electrode montages (anode left or right) were mirror-inverted which led to differential effects in SCR and electrocortical (mainly late positive potential [LPP]) data in our exploratory analyses. Results indicated that tDCS-timing is relevant for fear reactions via disturbed fear memory consolidation as well as fear expression, and this depends on whether vmPFC is stimulated with either left- or right-sided anode electrode montage. Electrocortical data can shed more light on the underlying neural correlates and exaggerated LPP seems to be associated with disturbed fear memory consolidation and dampened SCR to CS+ vs. CS-, but solely in the right anode electrode montage. Further open questions addressing where and when to stimulate the prefrontal brain in the course of augmenting fear extinction are raised.

Pre-treatment amygdala activation and habituation predict symptom change in post-traumatic stress disorder

Trauma-focused psychotherapy approaches are the first-line treatment option for post-traumatic stress disorder (PTSD); however, up to a third of patients remain symptomatic even after completion of the treatment. Predicting which patients will respond to a given treatment option would support personalized treatments and improve the efficiency of healthcare systems. Although previous neuroimaging studies have examined possible pre-treatment predictors of response to treatment, the findings have been somewhat inconsistent, and no other study has examined habituation to stimuli as a predictor. In this study, 16 treatment-seeking adults (MAge = 43.63, n = 10 women) with a primary diagnosis of PTSD passively viewed pictures of emotional facial expressions during functional magnetic resonance imaging (fMRI). After scanning, participants rated facial expressions on both valence and arousal. Participants then completed eight weekly sessions of prolonged exposure (PE) therapy. PTSD symptom severity was measured before and after treatment. Overall, participants showed symptomatic improvement with PE. Consistent with hypotheses, lesser activation in the amygdala and greater activation in the ventromedial prefrontal cortex during the presentation of fearful vs. happy facial expressions, as well as a greater decline in amygdala activation across blocks of fearful facial expressions at baseline, were associated with greater reduction of PTSD symptoms. Given that the repeated presentation of emotional material underlies PE, changes in brain responses with repeated stimulus presentations warrant further studies as potential predictors of response to exposure therapies.

Functional correlates of subliminal stimulation in Posttraumatic Stress Disorder: Systematic review and meta-analysis

Patients with Post-traumatic stress disorder (PTSD) exposed to traumatic reminders show hyperreactivity in brain areas (e.g., amygdala) belonging or related to the Innate Alarm System (IAS), allowing the rapid processing of salient stimuli. Evidence that IAS is activated by subliminal trauma-reminders could shed a new light on the factors precipitating and perpetuating PTSD symptomatology. Thus, we systematically reviewed studies investigating neuroimaging correlates of subliminal stimulation in PTSD. Twenty-three studies were selected from the MEDLINE and Scopus® databases for a qualitative synthesis, 5 of which allowed a further meta-analysis of fMRI data. The intensity of IAS responses to subliminal trauma-related reminders ranged from a minimum in healthy controls to a maximum in the PTSD patients with the most severe (e.g., dissociative) symptoms or the least responsiveness to treatment. Comparisons with other disorders (e.g., phobias) revealed contrasting results. Our findings demonstrate the hyperactivation of areas belonging or related to IAS in response to unconscious threats that should be integrated in diagnostic as well as in therapeutic protocols.

Constant installation of present orientation and safety (CIPOS) - subjective and physiological effects of an ultrashort-term intervention combining both stabilizing and confrontational elements

Objectives

Constant Installation of Present Orientation and Safety (CIPOS) is a Eye Movements Desensitization and Reprocessing (EMDR)-derived technique, which is often used to prepare for the treatment of post-traumatic stress disorder (PTSD). It differs from the latter by involving cyclically recurring exercises in reorientation to the present, interspersed between brief periods of exposure to the traumatic material.While EMDR is well established as a therapeutic method, the efficacy and mechanisms of action of CIPOS have not been investigated so far. In this pilot study, an experimental setting was used to record the subjective and physiological effects of the CIPOS intervention compared to a control condition with pure mental exposition.

Methods

The study was performed on 30 healthy volunteers aged from 20 to 30 years. Distress was induced using audio files of subjectively stressful situations. Subjective distress was measured via the Subjective Units of Distress Scale (SUD), while physiological indicators (noise-induced startle reflex, skin conductance level) were used as measures for objective stress. For each condition, pre- and post-intervention comparisons were calculated.

Results

In both groups, startle reflex potentiation and mean skin conductance level significantly decreased. In the group with CIPOS intervention, but not in the control group, a significant decrease in the SUD value was found.

Conclusion and significance

The results show that the CIPOS technique is as effective as pure mental exposition in reducing physiological stress. In addition, a superiority in reducing subjective distress (indicating a simplified reassessment of the stressful material) was found compared to pure mental exposition. Possible explanations of these effects are discussed.

rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review

Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.

Adjunct treatment with ketamine enhances the therapeutic effects of extinction learning after chronic unpredictable stress

Post-traumatic stress disorder (PTSD) is a debilitating illness characterized by dysfunction in the medial prefrontal cortex (mPFC). Although both pharmacological and cognitive behavioral interventions have shown some promise at alleviating symptoms, high attrition and persistence of treatment-resistant symptoms pose significant challenges that remain unresolved. Specifically, prolonged exposure therapy, a gold standard intervention to treat PTSD, has high dropout rates resulting in many patients receiving less than a fully effective course of treatment. Administering pharmacological treatments together with behavioral psychotherapies like prolonged exposure may offer an important avenue for enhancing therapeutic efficacy sooner, thus reducing the duration of treatment and mitigating the impact of attrition. In this study, using extinction learning as a rat model of exposure therapy, we hypothesized that administering ketamine as an adjunct treatment together with extinction will enhance the efficacy of extinction in reversing stress-induced deficits in set shifting, a measure of cognitive flexibility. Results showed that combining a sub-effective dose of ketamine with a shortened, sub-effective extinction protocol fully reversed stress-induced cognitive set-shifting deficits in both male and female rats. These effects may be due to shared molecular mechanisms between extinction and ketamine, such as increased neuronal plasticity in common circuitry (e.g., hippocampus-mPFC), or increased BDNF signaling. This work suggests that fast-acting drugs, such as ketamine, can be effectively used in combination with behavioral interventions to reduce treatment duration and potentially mitigate the impact of attrition. Future work is needed to delineate other pharmacotherapies that may complement the effects of extinction via shared or independent mechanisms.

Predictors of response to cognitive-behavioral therapy in patients with posttraumatic stress disorder: a systematic review

ABSTRACT Objective Posttraumatic stress disorder (PTSD) is a highly prevalent and disabling disorder. Even when treated with the first-line intervention, cognitive-behavioral therapy (CBT), 45% of the patients continue suffering from this disorder. Therefore, knowing the factors that could foresee who will respond to CBT would be of great value to the treatment of these patients. Thus, we have systematically reviewed the literature to identify the variables that could predict response to CBT in patients suffering from PTSD. Methods Following the PRISMA 2020 guidelines, we searched the electronic databases ISI Web of Science, Scopus, PsycINFO, MEDLINE, and PTSDpubs until November 2021. Two authors have independently conducted study selection and data extraction. Studies that examined possible predictors of response to therapy on a sample of adults (18-65 years), both genders, with and without comorbidities were considered eligible. The characteristics of the studies were synthesized in a table. The risk of bias was assessed by the Cochrane risk of bias quality assessment tool. Results Twenty-eight studies comprising 15 variables were selected. Among those, eight showed a low risk of bias, 19 showed some concerns, and one showed a high potential risk of bias. The therapeutic relationship was the only variable considered to be a predictor of a good response to therapy. All other variables showed conflicting results. Conclusions The most promising variable, although scientifically weak, is the therapeutic relationship. Additional randomized clinical trials should be conducted to clarify the role of this variable as a predictor of response to CBT in patients with PTSD.

Early Interventions to Prevent Post-Traumatic Stress Disorder in Youth after Exposure to a Potentially Traumatic Event: A Scoping Review

The worldwide occurrence of potentially traumatic events (PTEs) in the life of children is highly frequent. We aimed to identify studies on early mental health interventions implemented within three months of the child/adolescent’s exposure to a PTE, with the aim of reducing acute post-traumatic symptoms, decreasing long term PTSD, and improving the child’s adjustment after a PTE exposure. The search was performed in PubMed and EMBASE databases resulting in twenty-seven articles meeting our inclusion criteria. Most non-pharmacological interventions evaluated had in common two complementary components: psychoeducation content for both children and parents normalizing early post-traumatic responses while identifying post-traumatic symptoms; and coping strategies to deal with post-traumatic symptoms. Most of these interventions studied yielded positive results on outcomes with a decrease in post-traumatic, anxiety, and depressive symptoms. However, negative results were noted when traumatic events were still ongoing (war, political violence) as well as when there was no or little parental involvement. This study informs areas for future PTSD prevention research and raises awareness of the importance of psychoeducation and coping skills building in both youth and their parents in the aftermath of a traumatic event, to strengthen family support and prevent the occurrence of enduring post-traumatic symptoms.

A cognitive behavioural therapy (CBT) approach for working with strong feelings of guilt after traumatic events

This article outlines a cognitive behavioural therapy (CBT) approach to treating feelings of guilt and aims to be a practical ‘how to’ guide for therapists. The therapeutic techniques were developed in the context of working with clients with a diagnosis of post-traumatic stress disorder (PTSD); however, the ideas can also be used when working with clients who do not meet a diagnosis of PTSD but have experienced trauma or adversity and feel guilty. The techniques in this article are therefore widely applicable: to veterans, refugees, survivors of abuse, the bereaved, and healthcare professionals affected by COVID-19, amongst others. We consider how to assess and formulate feelings of guilt and suggest multiple cognitive and imagery strategies which can be used to reduce feelings of guilt. When working with clients with a diagnosis of PTSD, it is important to establish whether the guilt was first experienced during the traumatic event (peri-traumatically) or after the traumatic event (post-traumatically). If the guilt is peri-traumatic, following cognitive work, this new information may then need to be integrated into the traumatic memory during reliving.

Key learning aims

(1)

Cannabis in the management of PTSD: a systematic review

Introduction

Existing reviews exploring cannabis effectiveness have numerous limitations including narrow search strategies. We systematically explored cannabis effects on PTSD symptoms, quality of life (QOL), and return to work (RTW). We also investigated harm outcomes such as adverse effects and dropouts due to adverse effects, inefficacy, and all-cause dropout rates.

Methods

Our search in MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, CENTRAL, and PubMed databases, yielded 1 eligible RCT and 10 observational studies (n = 4672). Risk of bias (RoB) was assessed with the Cochrane risk of bias tool and ROBINS-I.

Results

Evidence from the included studies was mainly based on non-randomized studies with no comparators. Results from unpooled, high RoB studies showed that cannabis was associated with a reduction in overall PTSD symptoms and improved QOL. Dry mouth, headaches, and psychoactive effects such as agitation and euphoria were the commonly reported adverse effects. In most studies, cannabis was well tolerated, but small proportions of patients experienced a worsening of PTSD symptoms.

Conclusion

Evidence in the current study primarily stems from low quality and high RoB observational studies. Further RCTs investigating cannabis effects on PTSD treatment should be conducted with larger sample sizes and explore a broader range of patient-important outcomes.

Experiences of Military Veterans in a Therapeutic Horseback Riding Program

Posttraumatic stress disorder commonly occurs among U.S. military veterans. Therapeutic horseback riding (THR) has emerged as an adjunct therapy. We explored 20 veterans' perceived benefits, drawbacks and views of a 6-week THR program. Participants had confirmed diagnoses of posttraumatic stress disorder, traumatic brain injury, or both. Veterans rode the same horse weekly, the same day, at the same time. Data were collected as part of a randomized clinical trial testing the effects of THR on Post-Traumatic Stress Disorder. Veterans responded to an open-ended questionnaire. Content analysis was used for data analysis. Benefits were "Connection to the Horse," "Relaxing," "180 Degree Change," and "Meeting New People." Drawbacks were "None," "Struggle to Get There," "Pain," "Too Short," and "It is Structured." Overall perceptions were "I Absolutely Loved It," "Feel Again," "The Horse," "The People," and "No Worries." Participants viewed THR as positive. Findings may elucidate why THR may be clinically beneficial.

Analytic Process and Linguistic Style: Exploring Analysts' Treatment Notes in the Light of Linguistic Measures of the Referential Process

This paper presents a comparison between a clinical evaluation and a computerized linguistic analysis of the treatment notes of the first two years of an analysis conducted four sessions a week with the patient lying on a couch. Clinical notes had been written as part of the analyst's standard practice after every session, some years prior to the planning of this study. The notes describe the analytic interchange and the analyst's internal thoughts. The linguistic analysis focuses on two analytically relevant linguistic variables: Referential Activity (RA), a measure of the degree of connection between emotional processing and language, and Reflection, the use of words referring to thoughts. The examination of the linguistic measures point to overlooked parts of sessions which may be clinically significant. In particular, the examination of the clinical material during the nodal points of the first summer break, where significant changes in the linguistic measures were seen, provided clinical understanding of the analytic work that was not explicitly noted at the time of treatment. This method has the potential to be utilized in ongoing treatments and to improve the supervisory process.

Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence

Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

The mechanisms of effect of a physiotherapist-delivered integrated psychological and exercise intervention for acute whiplash-associated disorders: secondary mediation analysis of a randomized controlled trial

Supplemental Digital Content is Available in the Text. Stress mediated the effect of a physiotherapist-delivered integrated intervention on multiple health outcomes and pain-related coping mediated the effect on pain self-efficacy only. Changes in depressive and posttraumatic stress symptoms were also mechanisms of effect.

Introduction:

Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work.

Objective:

To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes.

Methods:

Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3).

Results:

Reductions in stress mediated the effect of the integrated intervention on disability (β = −0.12, confidence interval [CI] = −0.21 to −0.06), pain self-efficacy (β = 0.09, CI = 0.02–0.18), pain (β = −0.12, CI = −0.21 to −0.06), and health-related quality of life (β = 0.11, CI = 0.04–0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01–0.12). Similar patterns were found in Models 2 and 3.

Conclusions:

Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.

Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers During the COVID-19 Pandemic

The outbreak of the coronavirus disease 2019 (COVID-19) and its rapid global spread have created unprecedented challenges to health care systems. Significant and sustained efforts have focused on mobilization of personal protective equipment, intensive care beds, and medical equipment, while substantially less attention has focused on preserving the psychological health of the medical workforce tasked with addressing the challenges of the pandemic. And yet, similar to battlefield conditions, health care workers are being confronted with ongoing uncertainty about resources, capacities, and risks; as well as exposure to suffering, death, and threats to their own safety. These conditions are engendering high levels of fear and anxiety in the shortterm, and place individuals at risk for persistent stressexposure syndromes, subclinical mental health symptoms, and professional burnout in the longterm. Given the potentially wide-ranging mental health impact of COVID-19, protecting health care workers from adverse psychological effects of the pandemic is critical. Therefore, we present an overview of the potential psychological stress responses to the COVID-19 crisis in medical providers and describe preemptive resilience-promoting strategies at the organizational and personal level. We then describe a rapidly deployable Psychological Resilience Intervention founded on a peersupport model (Battle Buddies) developed by the United States Army. This intervention—the product of a multidisciplinary collaboration between the Departments of Anesthesiology and Psychiatry & Behavioral Sciences at the University of Minnesota Medical Center—also incorporates evidence-informed “stress inoculation” methods developed for managing psychological stress exposure in providers deployed to disasters. Our multilevel, resource-efficient, and scalable approach places 2 key tools directly in the hands of providers: (1) apeersupport Battle Buddy; and (2) adesignated mental health consultant who can facilitate training in stress inoculation methods, provide additional support, or coordinate referral for external professional consultation. In parallel, we have instituted a voluntary research data-collection component that will enable us to evaluate the intervention’s effectiveness while also identifying the most salient resilience factors for future iterations. It is our hope that these elements will provide guidance to other organizations seeking to protect the well-being of their medical workforce during the pandemic. Given the remarkable adaptability of human beings, we believe that, by promoting resilience, our diverse health care workforce can emerge from this monumental challenge with new skills, closer relationships, and greater confidence in the power of community.

Treating patients with driving phobia by virtual reality exposure therapy - a pilot study

OBJECTIVES

Virtual reality exposure therapy (VRET) is a promising treatment for patients with fear of driving. The present pilot study is the first one focusing on behavioral effects of VRET on patients with fear of driving as measured by a post-treatment driving test in real traffic.

METHODS

The therapy followed a standardized manual including psychotherapeutic and medical examination, two preparative psychotherapy sessions, five virtual reality exposure sessions, a final behavioral avoidance test (BAT) in real traffic, a closing session, and two follow-up phone assessments after six and twelve weeks. VRE was conducted in a driving simulator with a fully equipped mockup. The exposure scenarios were individually tailored to the patients' anxiety hierarchy. A total of 14 patients were treated. Parameters on the verbal, behavioral and physiological level were assessed.

RESULTS

The treatment was helpful to overcome driving fear and avoidance. In the final BAT, all patients mastered driving tasks they had avoided before, 71% showed an adequate driving behavior as assessed by the driving instructor, and 93% could maintain their treatment success until the second follow-up phone call. Further analyses suggest that treatment reduces avoidance behavior as well as symptoms of posttraumatic stress disorder as measured by standardized questionnaires (Avoidance and Fusion Questionnaire: p < .10, PTSD Symptom Scale-Self Report: p < .05).

CONCLUSIONS

VRET in driving simulation is very promising to treat driving fear. Further research with randomized controlled trials is needed to verify efficacy. Moreover, simulators with lower configuration stages should be tested for a broad availability in psychotherapy.

Eye Movement Desensitization Reprocessing for Children and Adolescents With Posttraumatic Stress Disorder: A Systematic Narrative Review

There is currently a limited number of studies into the efficacy of eye movement desensitization reprocessing (EMDR) therapy with children and adolescents with posttraumatic stress disorder (PTSD). The current study utilizes a systematic narrative review of methodologies and findings of previous literature reviews and meta-analyses as well as analyzing randomized control trials (RCTs) conducted from 2002 to 2018. Following initial scoping of the extent of studies, two systematic literature searches were conducted, firstly for literature reviews and secondly for recent RCTs. Nine databases were utilized. Eight reviews and seven RCTs were identified and analyzed for quality of methodology and outcome as measured by impact on PTSD symptoms. EMDR was found to be efficacious in reducing children's PTSD symptoms compared to waitlist conditions, with similar outcomes to cognitive behavior therapy (CBT). EMDR was effective with both single-event trauma as well as cumulative trauma such as sexual abuse. EMDR was equally effective with girls and boys as well as children from different cultures. EMDR achieved medium to large effect sizes. Reductions in PTSD were maintained at 2-, 3-, 6-, and 12-month follow-up. In conclusion, EMDR was consistently found to be an efficacious treatment for children with PTSD. Recommendations are made for future practice and research.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual psychological debriefing is not an effective intervention at preventing post-traumatic stress disorder (PTSD). Over the past 20 years, other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of psychological interventions aimed at preventing PTSD in individuals exposed to a traumatic event but not identified as experiencing any specific psychological difficulties, in comparison with control conditions (e.g. usual care, waiting list and no treatment) and other psychological interventions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and ProQuest's Published International Literature On Traumatic Stress (PILOTS) database to 3 March 2018. An earlier search of CENTRAL and the Ovid databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). We handsearched reference lists of relevant guidelines, systematic reviews and included study reports. Identified studies were shared with key experts in the field.We conducted an update search (15 March 2019) and placed any new trials in the 'awaiting classification' section. These will be incorporated into the next version of this review, as appropriate.

SELECTION CRITERIA

We searched for randomised controlled trials of any multiple session (two or more sessions) early psychological intervention or treatment designed to prevent symptoms of PTSD. We excluded single session individual/group psychological interventions. Comparator interventions included waiting list/usual care and active control condition. We included studies of adults who experienced a traumatic event which met the criterion A1 according to the Diagnostic and Statistical Manual (DSM-IV) for PTSD.

DATA COLLECTION AND ANALYSIS

We entered data into Review Manager 5 software. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data with a fixed-effect meta-analysis, except where there was heterogeneity, in which case we used a random-effects model. Two review authors independently assessed the included studies for risk of bias and discussed any conflicts with a third review author.

MAIN RESULTS

This is an update of a previous review.We included 27 studies with 3963 participants. The meta-analysis included 21 studies of 2721 participants. Seventeen studies compared multiple session early psychological intervention versus treatment as usual and four studies compared a multiple session early psychological intervention with active control condition.Low-certainty evidence indicated that multiple session early psychological interventions may be more effective than usual care in reducing PTSD diagnosis at three to six months' follow-up (RR 0.62, 95% CI 0.41 to 0.93; I2 = 34%; studies = 5; participants = 758). However, there was no statistically significant difference post-treatment (RR 1.06, 95% CI 0.85 to 1.32; I2 = 0%; studies = 5; participants = 556; very low-certainty evidence) or at seven to 12 months (RR 0.94, 95% CI 0.20 to 4.49; studies = 1; participants = 132; very low-certainty evidence). Meta-analysis indicated that there was no statistical difference in dropouts compared with usual care (RR 1.34, 95% CI 0.91 to 1.95; I2 = 34%; studies = 11; participants = 1154; low-certainty evidence) .At the primary endpoint of three to six months, low-certainty evidence indicated no statistical difference between groups in reducing severity of PTSD (SMD -0.10, 95% CI -0.22 to 0.02; I2 = 34%; studies = 15; participants = 1921), depression (SMD -0.04, 95% CI -0.19 to 0.10; I2 = 6%; studies = 7; participants = 1009) or anxiety symptoms (SMD -0.05, 95% CI -0.19 to 0.10; I2 = 2%; studies = 6; participants = 945).No studies comparing an intervention and active control reported outcomes for PTSD diagnosis. Low-certainty evidence showed that interventions may be associated with a higher dropout rate than active control condition (RR 1.61, 95% CI 1.11 to 2.34; studies = 2; participants = 425). At three to six months, low-certainty evidence indicated no statistical difference between interventions in terms of severity of PTSD symptoms (SMD -0.02, 95% CI -0.31 to 0.26; I2 = 43%; studies = 4; participants = 465), depression (SMD 0.04, 95% CI -0.16 to 0.23; I2 = 0%; studies = 2; participants = 409), anxiety (SMD 0.00, 95% CI -0.19 to 0.19; I2 = 0%; studies = 2; participants = 414) or quality of life (MD -0.03, 95% CI -0.06 to 0.00; studies = 1; participants = 239).None of the included studies reported on adverse events or use of health-related resources.

AUTHORS' CONCLUSIONS

While the review found some beneficial effects of multiple session early psychological interventions in the prevention of PTSD, the certainty of the evidence was low due to the high risk of bias in the included trials. The clear practice implication of this is that, at present, multiple session interventions aimed at everyone exposed to traumatic events cannot be recommended. There are a number of ongoing studies, demonstrating that this is a fast moving field of research. Future updates of this review will integrate the results of these new studies.

Is and Ought: Descriptive and Prescriptive Cognitions in Military-Related Moral Injury

Debate exists regarding the most appropriate way to address moral injuries that stem from involvement in war and other military conflicts. In recent years, some researchers have suggested that existing treatments for trauma may be inadequate to address moral injury and have thus proposed novel interventions to help mitigate these concerns. In response, advocates of more traditional approaches have argued that standard trauma interventions are generally sufficient for moral injury, and investment in new interventions may be premature. This conceptual article draws from research findings and current theories of moral injury to demonstrate that there is merit on both sides of this debate, and further clarifying the types of cognitions involved in moral injury can guide effective treatment planning. In particular, the most recent diagnostic criteria for posttraumatic stress disorder is used to distinguish the objectively falsifiable descriptive cognitions often associated with trauma from the subjectively determined prescriptive cognitions that characterize moral injury. Scenarios from war zone deployments have been used to highlight the relevance of this distinction for moral injury, and a general treatment framework that shows how existing and novel interventions may complement one another is presented. Research suggestions for assessing descriptive and prescriptive cognitions in moral injury and empirically validating this treatment framework are discussed.

Comparing the Effectiveness of EMDR and TF-CBT for Children and Adolescents: a Meta-Analysis

Efficacy of EMDR and TF-CBT for posttraumatic stress symptoms (PTSS) was explored through meta-analysis. A comprehensive search yielded 494 studies of children and adolescents with PTSS who received treatment with these evidence-based therapeutic modalities. Thirty total studies were included in the meta-analysis. The overall Cohen's d was small (-0.359) and statistically significant (p < 0.05), indicating EMDR and TF-CBT are effective in treating PTSS. Major findings posit TF-CBT is marginally more effective than EMDR; those with sub-clinical PTSS responded more favorably in treatment than those with PTSD; and greater reductions in PTSS were observed with presence of comorbidity in diagnosis. Assessment of publication bias with Classic fail-safe N revealed it would take 457 nonsignificant studies to nullify these findings.

Case conceptualization from a process-based and modular perspective: Rationale and application to mood and anxiety disorders

This article presents the theoretical, clinical, and practical arguments supporting a process-based transdiagnostic approach to psychotherapy. A working definition of "psychological process" is provided, as well as a tri-dimensional categorization of psychological processes potentially involved in psychopathology. Guidelines are proposed to select psychological interventions based on the active psychopathological processes evidenced in a given case. We also provide a rationale to organize treatment as a set of modules, each addressing a specific psychopathological process. Next, we review the main processes that may be active in mood and anxiety disorders, and that are accessible to clinicians in regular practice. For each process, we propose a validated assessment questionnaire. Finally, we offer a free-access web-based instrument that allows clients to fill in these questionnaires via an internet survey, and that provides therapists with a tool to easily decode and interpret the questionnaire results and to present them to the clients.

Efficacy of EMDR Therapy for Children With PTSD: A Review of the Literature

The rationale is synthesized for the urgency of empirical studies demonstrating the efficacy of eye movement desensitization and reprocessing (EMDR) therapy for children and adolescents with posttraumatic stress disorder (PTSD), symptoms of PTSD, or other trauma-related symptoms. This literature review examined 15 studies (including nine randomized clinical trials) that tested the efficacy of EMDR therapy for the treatment of children and adolescents with these symptoms. All studies found that EMDR therapy produced significant reductions in PTSD symptoms at posttreatment and also in other trauma-related symptoms, when measured. A methodological analysis identified limitations in most studies, reducing the value of these findings. Despite these shortcomings, the methodological strength of the identified studies has increased over time. The review also summarized three meta-analyses. The need for additional rigorous research is apparent, and in order to profit from experiences of the past, the article provides some guidelines for clinicians seeking to conduct future research in their agencies.

First-line therapy for post-traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

BACKGROUND

Despite evidence supporting cognitive behavioural therapy (CBT)-based interventions as the most effective approach for treating post-traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)-based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

AIMS

Existing research exploring effective therapeutic interventions for PTSD includes trauma-focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT-based techniques over CBT-based techniques for the treatment of PTSD.

RESULTS

The evidence reviewed provided examples supporting PDT-based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

CONCLUSION/IMPLICATIONS

The need to routinely observe evidence-based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT-based interventions for the treatment of PTSD are identified.

A Case Study of the Effects of Posttraumatic Stress Disorder on Operational Fire Service Personnel Within the Lancashire Fire and Rescue Service

BACKGROUND

Lancashire Fire and Rescue Service (LFRS), the subject of this evaluative research document employs 1400 people. 80% of employees are operational firefighters and officers whom operate across a range of duty systems and support functions, providing prevention, protection and emergency response to the communities of Lancashire.

METHODS

The overarching purpose of this epidemiological study is to assess the prevalence of post-traumatic stress disorder (PTSD) amongst operational LFRS personnel and to analyse the effects upon those who may be suffering from it, whether brought about by a single traumatic event or by repeated exposure to traumatic occurrences over a period of time. A combination of primary and secondary research was carried out. Primary data was collated using two recognised clinical questionnaires and statistical analysis was conducted with the aid of the software package SPSS.

RESULTS

The findings and statistical analysis showed that out of the 100 people surveyed, 30% of respondents had signs of probable distress. Of this quota, 4% showed symptoms of PTSD. The study considers how an organisation can recognise and manage PTSD and provides recommendations to assist in better recognising and managing the associated risks.

CONCLUSION

Based upon the findings, the authors conclude that the level of PTSD within LFRS is slightly lower than those found in other studies undertaken within the Fire and Rescue Service sector. The paper provides recommendations for future studies and a series of actions for consideration by LFRS senior management to improve PTSD support services for employees.

Moral injury process and its psychological consequences among Israeli combat veterans

OBJECTIVES

We aim to examine the link between exposure to potentially morally injurious events (PMIEs) and posttraumatic stress disorder symptoms (PTSS). We also aim to explore the mediating roles of depressive attributions, trauma-related guilt and shame, and self-disgust in the relationship between PMIEs and PTSS among combat veterans.

METHOD

A volunteers' sample of 191 Israeli combat veterans responded to self-report questionnaires in a cross-sectional design study.

RESULTS

More than one-fifth of the sample reported experiencing PMIEs but only betrayal based experience was related to PTSS. Importantly, betrayal based experience was associated with depressive attributions which increased the level of trauma-related distressing guilt, intrinsic shame and self-disgust, which in turn were associated with high levels of PTSS.

CONCLUSIONS

PMIEs, and especially betrayal based experiences, are related to PTSS among Israeli veterans. Depressive attributions, trauma-related distressing guilt, intrinsic shame, and self-disgust might serve as possible mechanisms for the links between PMIEs and PTSS.

Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans

BACKGROUND

Large numbers of post-deployment U.S. veterans are diagnosed with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI), leading to an urgent need for effective interventions to reduce symptoms and increase veterans' coping. PTSD includes anxiety, flashbacks, and emotional numbing. The symptoms increase health care costs for stress-related illnesses and can make veterans' civilian life difficult.

METHODS

We used a randomized wait-list controlled design with repeated measures of U.S. military veterans to address our specific aim to test the efficacy of a 6-week therapeutic horseback riding (THR) program for decreasing PTSD symptoms and increasing coping self-efficacy, emotion regulation, social and emotional loneliness. Fifty-seven participants were recruited and 29 enrolled in the randomized trial. They were randomly assigned to either the horse riding group (n = 15) or a wait-list control group (n = 14). The wait-list control group experienced a 6-week waiting period, while the horse riding group began THR. The wait-list control group began riding after 6 weeks of participating in the control group. Demographic and health history information was obtained from all the participants. PTSD symptoms were measured using the standardized PTSD Checklist-Military Version (PCL-M). The PCL-M as well as other instruments including, The Coping Self Efficacy Scale (CSES), The Difficulties in Emotion Regulation Scale (DERS) and The Social and Emotional Loneliness Scale for Adults-short version (SELSA) were used to access different aspects of individual well-being and the PTSD symptoms.

RESULTS

Participants had a statistically significant decrease in PTSD scores after 3 weeks of THR (P ≤ 0.01) as well as a statistically and clinically significant decrease after 6 weeks of THR (P ≤ 0.01). Logistic regression showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks and 87.5% likelihood at 6 weeks. Under the generalized linear model(GLM), our ANOVA findings for the coping self-efficacy, emotion regulation, and social and emotional loneliness did not reach statistical significance. The results for coping self-efficacy and emotion regulation trended in the predicted direction. Results for emotional loneliness were opposite the predicted direction. Logistic regression provided validation that outcome effects were caused by riding longer.

CONCLUSION

The findings suggest that THR may be a clinically effective intervention for alleviating PTSD symptoms in military veterans.

Activity in the Ventral Medial Prefrontal Cortex Is Necessary for the Therapeutic Effects of Extinction in Rats

Poor response and high relapse rates remain problematic in the treatment of stress-related psychiatric disorders such as depression and post-traumatic stress disorder. Although mechanisms of pharmacotherapies are intensely studied, little is known about mechanisms of behavioral therapy that could inform improved treatments. We have previously demonstrated the therapeutic effects of extinction learning as a behavioral intervention modeling exposure therapy in rats. In the present study, we tested the hypothesis that activity in the ventral medial prefrontal cortex (vmPFC) during extinction is necessary for its therapeutic effects. The inhibitory Gi-coupled designer receptor exclusively activated by designer drug CaMKIIα-hM4Di was expressed in vmPFC before administering chronic unpredictable stress (CUS). vmPFC projection neurons were then inhibited during extinction treatment by administering clozapine-N-oxide. Coping behavior and cognitive flexibility were assessed 24 h later on the shock-probe defensive burying test and attentional set-shifting test, respectively. Replicating previous results, extinction reversed the CUS-induced deficits in coping behavior and cognitive flexibility. Inhibiting vmPFC during extinction blocked these therapeutic effects. Further, increasing vmPFC activity with the excitatory Gq-coupled designer receptor exclusively activated by designer drug hM3Dq 24 h before testing was sufficient to reverse the CUS-induced deficits. CUS reduced mPFC responsivity, assessed by measuring afferent-evoked field potentials in the mPFC, and this reduction was reversed by extinction treatment 24 h before testing. These results demonstrate the necessity of vmPFC activity in the therapeutic effects of extinction as a model of exposure therapy, and suggest that increased vmPFC activity induced by extinction is sufficient to produce lasting plastic changes that underlie its beneficial effects.SIGNIFICANCE STATEMENT Stress-related psychiatric disorders remain poorly treated. Psychotherapies can be effective, but their mechanisms remain unknown, hindering progress toward improved treatment. We used a rat model of behavioral therapy to identify potential targets for enhancing treatment. Fear extinction as a therapeutic behavioral intervention reversed stress-induced cognitive dysfunction and passive coping in rats, modeling components of stress-related psychiatric disease. Extinction also reversed stress-induced attenuation of mPFC responsivity. The therapeutic effects were prevented by blocking activity of glutamatergic neurons in the mPFC during extinction, and were mimicked by inducing activity in lieu of extinction. Thus, activity and plasticity in the mPFC underlie the beneficial effects of extinction on cognitive flexibility and coping behavior compromised by stress, and could be targets to enhance behavioral therapy.

Reconsolidation of Traumatic Memories for PTSD: A randomized controlled trial of 74 male veterans

Design: A randomized waitlist-controlled design (n = 74) examined the efficacy of Reconsolidation of Traumatic Memories (RTM) among male veterans with current-month flashbacks and nightmares. Volunteers were randomly assigned to immediate treatment (three 120-minute sessions of RTM), or to a 3-week waiting condition before receiving the RTM treatment. Blinded psychometricians evaluated the symptoms at intake, 2 weeks, and 6 weeks post. Wait-listed participants were re-evaluated and then treated. Sixty-five volunteers completed the treatment. Results: Of those treated, 46 (71%) lost DSM diagnosis for post-traumatic stress disorder (PTSD) by one of the following definitions: 42 persons (65%) were in complete remission (PTSD Symptom Scale Interview (PSS-I) ≤ 20 and DSM criteria not met). Four others (6%) lost the DSM diagnosis or were otherwise sub-clinical by dichotomous criteria (PSS-I < 20 and absence of flashbacks and nightmares) but non-ambiguous on the PTSD Checklist Military Version measures. Within-group RTM effect sizes (Hedges' g) for PSS-I score changes ranged from 1.45 to 2.3. The between-group comparison between the treatment group and the untreated controls was significant (p < .001) with an effect size equivalent to two standard deviations (g = 2.13; 95% CI [1.56, 2.70]). Patient satisfaction with the intervention was high. Conclusions: RTM shows promise as a brief, cost-effective intervention for PTSD characterized primarily by intrusive symptoms. Clinical or methodological significance of this article: The article provides evidence to support a fast (5 hours or fewer) robust intervention for PTSD characterized by intrusive symptoms including current-month flashbacks, nightmares, and accompanied by sympathetic arousal in response to trauma narratives. The intervention is well tolerated and has demonstrated efficacy up to one year.

The predictive value of dorsal cingulate activity and fractional anisotropy on long-term PTSD symptom severity

BACKGROUND

Posttraumatic stress disorder (PTSD) can be treated with trauma-focused therapy, although only about 50% of the patients recover on the short-term. In order to improve response rates it is important to identify who will and will not recover from trauma-focused therapy. Although previous studies reported dorsal anterior cingulate cortex (ACC) activity, as well as dorsal cingulum bundle white matter microstructure integrity as markers for the persistence of PTSD symptoms on the short-term, it remains unclear whether these markers also predict long-term PTSD symptom severity.

METHODS

PTSD patients (n = 57) were investigated with clinical interviews and an MRI protocol before the start of treatment. Clinical interviews were repeated after 6-8 months of treatment (short-term follow-up), and on average 4 years later (long-term follow-up). Twenty-eight PTSD patients returned for the long-term follow-up. Dorsal ACC activity in response to negative images, and fractional anisotropy (FA) of the dorsal cingulum were the neural markers investigated.

RESULTS

In this long-term follow-up sample (n = 28), dorsal ACC activity and dorsal cingulum FA values significantly predicted CAPS scores on short- and long-term follow-up. The results remained significant after controlling for baseline CAPS score, early trauma, and comorbidity.

CONCLUSION

This study confirms the importance of the cingulate cortex activation and white matter integrity not only for short-term treatment outcome, but also for PTSD long-term symptom severity. Future treatments should target ACC function in particular during treatment in order to improve response rates.

Factors Affecting Resilience and Development of Posttraumatic Stress Disorder in Critical Care Nurses

BACKGROUND

Job stress and cumulative exposure to traumatic events experienced by critical care nurses can lead to psychological distress and the development of burnout syndrome and posttraumatic stress disorder. Resilience can mitigate symptoms associated with these conditions.

OBJECTIVE

To identify factors that affect resilience and to determine if the factors have direct or indirect effects on resilience in development of posttraumatic stress disorder.

METHODS

Data from 744 respondents to a survey mailed to 3500 critical care nurses who were members of the American Association of Critical-Care Nurses were analyzed. Mplus was used to analyze a mediation model.

RESULTS

Nurses who worked in any type of intensive care unit other than the medical unit and had high scores for resilience were 18% to 50% less likely to experience post-traumatic stress disorder than were nurses with low scores. Nurses with a graduate degree in nursing were 18% more likely to experience posttraumatic stress disorder than were nurses with a bachelor's degree.

CONCLUSION

Because of their effects on resilience, working in a medical intensive care unit and having a graduate degree may influence the development of posttraumatic stress disorder. Future research is needed to better understand the impact of resilience on health care organizations, development of preventive therapies and treatment of posttraumatic stress disorder for critical care nurses, and the most appropriate mechanism to disseminate and implement strategies to address posttraumatic stress disorder.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.

Fidelity to the Cognitive Processing Therapy Protocol: Evaluation of Critical Elements

The contributions of individual therapy elements to the overall efficacy of evidence-based practices for the treatment of posttraumatic stress disorder (PTSD) are not well-understood. This study first examined the extent to which theoretically important treatment components of Cognitive Processing Therapy (CPT; i.e., skill in Socratic questioning; prioritizing assimilation; attention to practice assignments; emphasis on expression of natural affect) were successfully administered across the course of therapy for 68 PTSD-positive survivors of interpersonal trauma. Therapist fidelity in the administration of these four elements was evaluated in 533 taped CPT sessions of study participants included in one of two randomized controlled CPT treatment trials. Second, we examined therapist fidelity to these components as a predictor of session-to-session PTSD and depression symptom change. Third, follow-up analyses examined the influence of high therapist competence for these four components across an entire course of therapy on symptom change from pre- to posttreatment. Results showed consistently high adherence and more variable competence for these four treatment components. There were no significant effects of therapist fidelity on session-to-session symptom change. However, results showed that overall high therapist competence for "skill in Socratic questioning" and "prioritizing assimilation before overaccommodation" were related to greater client improvement in PTSD severity, but "attention to practice assignments" and "emphasis on expression of natural affect" were not. Overall competence ratings for the four components were not significantly associated with improvement in depressive symptoms. Findings contribute to increased understanding of the relationship between the key treatment components of CPT and symptom change.

Combat-Related Multifaceted Trauma-Focused Group Therapy: A Pilot Study

The efficacy of combat-related trauma-focused group therapy (TFGT) was tested using a unique technique that combines principles from prolonged exposure, cognitive processing therapy, and art therapy. Eighty Israeli male veterans exposed to traumatic events participated in the study. They were divided into eight therapeutic groups led by four pairs of trained therapists. Posttraumatic stress disorder and depression symptoms and levels of functioning were taken at pretherapy, end of therapy, and 6 months posttherapy. Analyses found that therapy helped in reducing posttraumatic and depressive symptoms at the end of therapy and at 6 months follow-up. It also showed that patients' functioning had significantly improved by the end of therapy and at 6 months follow-up. A significant clinical change in each parameter over time was also observed. In conclusion, the study provides preliminary evidence that combat-related TFGT may be efficacious in reducing psychological suffering and enhancing actual functioning. Follow-up randomized controlled trials to determine treatment efficacy are needed.

Benefits of a Psychodynamic Group Therapy (PGT) Model for Treating Veterans With PTSD

OBJECTIVE

To examine the effectiveness of a treatment model of psychodynamic group therapy (PGT) for combat Veterans with posttraumatic stress disorder (PTSD).

METHOD

A total of 158 male Veterans with PTSD (mean age = 30.09 years) were assigned to 15 treatment groups of 7-13 patients each. PGT was a 1-year therapy, 1.5 hour, once-a-week sessions administered in the following stages: group building activities, differentiation of group members, intimacy building, and termination. Levels of PTSD and depression symptoms, functioning, and hope were assessed at pretreatment baseline, posttreatment, and 12-month follow-up.

RESULTS

Multilevel modeling analyses indicate that our group therapy is associated with reductions in PTSD and depressive symptoms at posttreatment, and that these effects were maintained at 12-month follow-up. The results also showed significantly improved patients' functioning by the end of therapy and at the 12-month follow-up point, and that the patients' hope level had increased.

CONCLUSION

The findings show that our model of psychodynamic group therapy is associated with mental improvements in Veterans with PTSD. However, further randomized controlled trials are recommended to establish the advantages of our therapeutic method compared to other modes of therapy.

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Impact of perinatal asphyxia on parental mental health and bonding with the infant: a questionnaire survey of Swiss parents

OBJECTIVE

To compare current mental health symptoms and infant bonding in parents whose infants survived perinatal asphyxia in the last 2 years with control parents and to investigate which sociodemographic, obstetric and neonatal variables correlated with parental mental health and infant bonding in the asphyxia group.

DESIGN

Cross-sectional questionnaire survey of parents whose children were registered in the Swiss national Asphyxia and Cooling register and of control parents (Post-traumatic Diagnostic Scale, Hospital Anxiety and Depression Scale, Mother-to-Infant Bonding Scale).

RESULTS

The response rate for the asphyxia group was 46.5%. Compared with controls, mothers and fathers in the asphyxia group had a higher frequency of post-traumatic stress disorder (PTSD) symptoms (p<0.001). More mothers (n=28, 56%) had a symptom diagnosis of either full or partial PTSD than controls (n=54, 39%) (p=0.032). Similarly, more fathers (n=31, 51%) had a symptom diagnosis of either partial or full PTSD than controls (n=19, 33%) (p=0.034). Mothers reported poorer bonding with the infant (p=0.043) than controls. Having a trauma in the past was linked to more psychological distress in mothers (r=0.31 (95% CI 0.04 to 0.54)) and fathers (r=0.35 (95% CI 0.05 to 0.59)). For mothers, previous pregnancy was linked to poorer bonding (r=0.41 (95% CI 0.13 to 0.63)). In fathers, therapeutic hypothermia of the infant was related to less frequent PTSD symptoms (r=-0.37 (95% CI -0.61 to -0.06)) and past psychological difficulties (r=0.37 (95% CI 0.07 to 0.60)) to more psychological distress. A lower Apgar score was linked to poorer bonding (r=-0.38 (95% CI -0.64 to -0.05)).

CONCLUSIONS

Parents of infants hospitalised for perinatal asphyxia are more at risk of developing PTSD than control parents.

Therapeutic Effects of Extinction Learning as a Model of Exposure Therapy in Rats

Current treatments for stress-related psychiatric disorders, such as depression and posttraumatic stress disorder (PTSD), are inadequate. Cognitive behavioral psychotherapies, including exposure therapy, are an alternative to pharmacotherapy, but the neurobiological mechanisms are unknown. Preclinical models demonstrating therapeutic effects of behavioral interventions are required to investigate such mechanisms. Exposure therapy bears similarity to extinction learning. Thus, we investigated the therapeutic effects of extinction learning as a behavioral intervention to model exposure therapy in rats, testing its effectiveness in reversing chronic stress-induced deficits in cognitive flexibility and coping behavior that resemble dimensions of depression and PTSD. Rats were fear-conditioned by pairing a tone with footshock, and then exposed to chronic unpredictable stress (CUS) that induces deficits in cognitive set-shifting and active coping behavior. They then received an extinction learning session as a therapeutic intervention by repeated exposure to the tone with no shock. Effects on cognitive flexibility and coping behavior were assessed 24 h later on the attentional set-shifting test or shock-probe defensive burying test, respectively. Extinction reversed the CUS-induced deficits in cognitive flexibility and coping behavior, and increased phosphorylation of ribosomal protein S6 in the medial prefrontal cortex (mPFC) of stress-compromised rats, suggesting a role for activity-dependent protein synthesis in the therapeutic effect. Inhibiting protein synthesis by microinjecting anisomycin into mPFC blocked the therapeutic effect of extinction on cognitive flexibility. These results demonstrate the utility of extinction as a model by which to study mechanisms underlying exposure therapy, and suggest these mechanisms involve protein synthesis in the mPFC, the further study of which may identify novel therapeutic targets.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.