Identifying Trajectories and Predictors of Response to Psychotherapy for Post-Traumatic Stress Disorder in Adults: A Systematic Review of Literature

Client characteristics and early working alliance development: A person-centered research approach

OBJECTIVE

Certain client characteristics are associated with early working alliance difficulties in psychotherapy. However, there is limited quantitative evidence on whether combinations of these characteristics (e.g., intersectional identities, prior treatment experiences) are related to alliance development. The present study leveraged a person-centered research approach to examine profiles of early alliance development and differences in the latent class structure of client characteristics among alliance development profiles.

METHOD

Individual psychotherapy clients (N = 2,579) rated the working alliance for their first four sessions and self-reported demographics, treatment history, and psychological distress. Therapists provided their assessment of clients' primary presenting concerns at baseline.

RESULTS

Latent profile analysis revealed three profiles of working alliance development: high and stable, moderate and increasing, and low and stable. Follow-up person-centered analyses (multigroup confirmatory latent class analysis) indicated that clients in the alliance profiles differed in their combinations of clinical and demographic characteristics. For example, women of color with high baseline distress and a history of prior psychotherapy were over-represented in the low and stable alliance profile.

CONCLUSION

These results are consistent with recommendations to holistically consider how clients' characteristics and experiences shape psychotherapy processes. Results also highlight the utility of person-centered quantitative methods in psychotherapy research.

Examining Rates of Traumatic Events and Posttraumatic Stress Disorder Symptoms Among Autistic Adults

Background

Autistic adults experience high rates of traumatic events and posttraumatic stress disorder (PTSD) symptoms. However, less is known about how autistic adults experience (i.e., by directly experiencing, witnessing, and/or learning about) distinct types of traumatic events (e.g., social, nonsocial traumas). Little research has considered whether the four-factor structure of PTSD symptom domains (e.g., avoidance, intrusions, hypervigilance, negative mood/cognition) can be applied for autistic adults. Lastly, understanding how demographic factors (e.g., gender, race/ethnicity) relate to rates of traumatic events and symptoms among autistic adults is critical for understanding disparities relating to PTSD. Therefore, the current study aims to examine self-reported traumatic events and PTSD symptoms, and identify associations with demographic factors, among autistic adults.

Methods

Participants included 276 autistic adults and a nationally representative sample of 361 nonautistic adults who completed online measures, including the Life Events Checklist for DSM-5, Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5), Autism-Spectrum Quotient-Short, and Patient Health Questionnaire-4. Analyses focused on evaluating group differences in traumatic events and symptoms and considered associations with demographic factors.

Results

Autistic adults reported significantly higher rates of directly experiencing, witnessing, and learning about traumatic events than nonautistic adults, including more interpersonal events (e.g., physical assault, sexual assault) and fewer transportation accidents than nonautistic adults. Autistic adults also reported significantly higher levels of all PTSD symptom clusters than nonautistic adults. A confirmatory factor analysis and follow-up invariance analyses of the PCL-5 revealed that the four-factor Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) PTSD symptom subscale structure was equivalent across groups of autistic and nonautistic adults.

Conclusion

Autistic adults experienced more traumatic events and PTSD symptoms overall, particularly more interpersonal traumas and hyperarousal and negative mood/cognition symptoms than nonautistic adults. Future research should examine outcomes of trauma exposure, identify protective factors, and examine efficacy of trauma-focused treatments for autistic individuals, in partnership with autistic adults.

Posttraumatic cognition change trajectories in veterans with PTSD who completed an intensive Cognitive Processing Therapy treatment program

Negative posttraumatic cognitions (NPCs) have been linked to symptoms of PTSD and are an important target of cognitive behavioral treatments for PTSD, including Cognitive Processing Therapy (CPT). Yet to be explored are the different change trajectories of NPCs during CPT. Knowledge of such change trajectories could elucidate common NPC change processes within CPT and their relationship to PTSD symptom severity. We examined NPC change trajectories in a group of 443 veterans who completed a 2-week intensive CPT program. We identified four NPC trajectory groups termed start high end high, start high end moderate, start moderate end low, and start low end low. Most of the groups showed an increase in NPCs at the midpoint of treatment before ultimately decreasing. As predicted, baseline PTSD symptom severity predicted change trajectory group membership. Also, NPC change trajectories were associated with PTSD severity at the end of treatment such that individuals in smaller NPC change groups had higher PTSD symptoms at the end of treatment, and vice versa. Clinicians can use this knowledge to make predictions of a particular client's NPC change trajectory and set expectations for what progress in treatment may look like, including normalizing increases in NPCs from the start of treatment.

COULD FAMILY WELL-BEING MODERATE THE RELATIONSHIP BETWEEN ADVERSE CHILDHOOD EXPERIENCES AND SOMATOFORM DISSOCIATION? A PRELIMINARY INVESTIGATION

The impacts of adverse childhood experiences (ACEs) have been well documented. One possible consequence of ACEs is dissociation, which is a major feature of post-traumatic psychopathology and is also associated with considerable impairment and health care costs. Although ACEs are known to be associated with both psychoform and somatoform dissociation, much less is known about the mechanisms behind this relationship. Little is known about whether social and interpersonal factors such as family environments would moderate the relationship between ACEs and somatoform dissociation. This paper discusses the importance of having a positive and healthy family environment in trauma recovery. We then report the findings of a preliminary study in which we examined whether the association between ACEs and somatoform dissociation would be moderated by family well-being in a convenience sample of Hong Kong adults (N = 359). The number of ACEs was positively associated with somatoform dissociative symptoms, but this association was moderated by the level of family well-being. The number of ACEs was associated with somatoform dissociation only when the family well-being scores were low. These moderating effects were medium. The findings point to the potential importance of using family education and intervention programs to prevent and treat trauma-related dissociative symptoms, but further investigation is needed.

Identification of potential biomarkers and therapeutic targets related to post-traumatic stress disorder due to traumatic brain injury

BACKGROUND

Post-traumatic stress disorder (PTSD), a disease state that has an unclear pathogenesis, imposes a substantial burden on individuals and society. Traumatic brain injury (TBI) is one of the most significant triggers of PTSD. Identifying biomarkers associated with TBI-related PTSD will help researchers to uncover the underlying mechanism that drives disease development. Furthermore, it remains to be confirmed whether different types of traumas share a common mechanism of action.

METHODS

For this study, we screened the eligible data sets from the Gene Expression Omnibus (GEO) database, obtained differentially expressed genes (DEGs) through analysis, conducted functional enrichment analysis on the DEGs in order to understand their molecular mechanisms, constructed a PPI network, used various algorithms to obtain hub genes, and finally evaluated, validated, and analyzed the diagnostic performance of the hub genes.

RESULTS

A total of 430 upregulated and 992 down-regulated differentially expressed genes were extracted from the TBI data set. A total of 1919 upregulated and 851 down-regulated differentially expressed genes were extracted from the PTSD data set. Functional enrichment analysis revealed that the differentially expressed genes had biological functions linked to molecular regulation, cell signaling transduction, cell metabolic regulation, and immune response. After constructing a PPI network and introducing algorithm analysis, the upregulated hub genes were identified as VNN1, SERPINB2, and ETFDH, and the down-regulated hub genes were identified as FLT3LG, DYRK1A, DCN, and FKBP8. In addition, by comparing the data with patients with other types of trauma, it was revealed that PTSD showed different molecular processes that are under the influence of different trauma characteristics and responses.

CONCLUSIONS

By exploring the role of different types of traumas during the pathogenesis of PTSD, its possible molecular mechanisms have been revealed, providing vital information for understanding the complex pathways associated with TBI-related PTSD. The data in this study has important implications for the design and development of new diagnostic and therapeutic methods needed to treat and manage PTSD.

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

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

Trajectories of parental posttraumatic stress disorder and children's mental health following Super Typhoon Lekima: The mediating role of feeling of safety

INTRODUCTION

Several studies have examined the impact of parents' posttraumatic stress disorder (PTSD) on their children's mental health, but few have evaluated the role of parents' specific PTSD trajectories. The aim of this study was to assess the mechanisms underlying distinct trajectories of parental PTSD that affect children's PTSD and depression through the feeling of safety.

METHODS

The final sample comprised 242 dyads of parents and their children who experienced Super Typhoon Lekima in 2019. All participants were surveyed at three time points after the typhoon: 3 months (T1), 15 months (T2), and 27 months (T3). Parental PTSD symptoms at three time points and children's PTSD, depression, and feeling of safety at T3 were analyzed.

RESULTS

Four parental PTSD trajectories were identified: recovery, resilience, delayed, and coping. Compared with the resilient group, children of parents with delayed PTSD trajectories reported higher levels of depression at T3, while children of parents in the coping group were more likely to experience severe PTSD at T3. Children of parents in the recovery group, with a reduced feeling of safety, exhibited more severe depression and PTSD at T3, whereas children of parents in the delayed group were at an increased risk of PTSD at T3.

CONCLUSIONS

These findings highlight the heterogeneity of parental PTSD trajectories following natural disasters and their distinct effects on children's PTSD and depression. Furthermore, feeling of safety emerges as a crucial mechanism in this process.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring trajectories in transdiagnostic behavior therapy

Transdiagnostic treatments have been designed to target common processes for clusters of disorders. One such treatment, transdiagnostic behavior therapy (TBT), targets avoidance across emotional disorders, including posttraumatic stress disorder (PTSD), depressive disorders, and anxiety disorders, and has demonstrated efficacy in randomized controlled trials. The current study was designed to examine whether distinct treatment trajectories would emerge in a sample of 112 veterans receiving TBT and whether diagnostic comorbidity, baseline levels of several transdiagnostic risk factors, or treatment engagement influence trajectory membership. Growth mixture modeling revealed three distinct trajectories across depression, ds = 0.55-1.09; PTSD ds = -0.07-1.43; and panic disorder symptoms, ds = -0.13-1.09. Notably, for PTSD and panic disorder symptoms, separate classes for responders and nonresponders emerged among participants with high baseline symptom levels. Findings for the risk factors suggested that PTSD and panic nonresponders evidenced significantly higher behavioral avoidance at baseline and reduced engagement in treatment procedures and homework completion compared to responders. Together, the findings provide additional support for the use of TBT in the treatment of emotional disorders, including PTSD. Potential adaptations are discussed for patients with significantly elevated behavioral avoidance to improve treatment engagement and related outcomes.

Dr. Smartphone, can you support my trauma? An informatics analysis study of App Store apps for trauma- and stressor-related disorders

Background

Psychological trauma is prevalent in developed countries, with prevalence rates and treatment needs exceeding health system capacity. As telemedicine and out-of-patient care are promoted, there has been an expansion of digital apps to compliment therapeutic stages in psychological trauma. To date there are no reviews that have compared these apps and their clinical utility. This study aims to identify the availability of trauma- and stressor-related mhealth apps, assess their functionality, and review their therapeutic abilities.

Methodology

The authors conducted a systematic search using an iPhone 13 Pro in the Australian IOS App Store to extract trauma- and stressor-related apps that resulted from the search criteria. A cross-adaptation of the Mobile App Rating Scale (MARS) and the Comprehensive App Evaluation Model (CAEM) were used as a framework to produce the mTrauma App Evaluation Conceptual Model and Informatics Framework. App content descriptors were analysed based on their general characteristics, usability, therapeutic focus, clinical utility, data integration. Following an applicability in concordance with psychological trauma-informed delivery.

Results

A total of 234 apps resulting from the search strategy were screened, with 81 apps that met the inclusion criteria. The majority of apps were marketed to 4+ to 17+ years of age, categorised as 'health and fitness', with the highest target markets observed for adolescents, children, parents, clinicians, and clients. A total of 43 apps (53.1%) contained a trauma-informed specified section, and 37 (45.7%) incorporated a section useful to support trauma-related symptoms. A significant number of apps there was an absence of therapeutic utility (in 32 apps (39.5%)). Most apps were supporting post-traumatic stress disorder-informed, cognitive behavioural therapy and eye movement desensitisation and reprocessing. Provision of psychoeducation, courses, guided sessions, trainings, self-reflection/journaling, symptom management and progress tracking were highly present.

Conclusions

Trauma-informed mobile apps are available in the App Store, expanding in its target market reach and usability, with an increase of creative psychotherapies being introduced alongside conventional modalities. However, based on the app descriptors, the scarcity of evidenced-based testimonials and therapeutic applicability remains questionable for clinical validity. Although mhealth tools are marketed as trauma-related, current available apps employ a multifunctional approach to general psychological symptomatology, through to associated comorbid conditions and emphasizes on passive activity. For higher uptake on user engagement, clinical application and validity, trauma-apps require curated specification to fulfil its role as complimentary psychological treatment.

Building strong therapeutic relationships quickly: The effect of the perceived working alliance on veterans' intensive PTSD treatment outcomes

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2 × individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1 × group CPT/day and 1 × individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD (ps = .012 and .002, respectively) and depression symptoms (ps = .009 and .007, respectively) and negative posttrauma cognitions (ps = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Treating posttraumatic stress disorder at home in a single week using 1-week virtual massed cognitive processing therapy

Posttraumatic stress disorder (PTSD) treatments are increasingly delivered in massed formats and have shown comparable results to standard, weekly treatment. To date, massed cognitive processing therapy (CPT), delivered daily, has been delivered primarily in combination with adjunctive services and among veteran populations, but it has not been rigorously evaluated as a standalone intervention. The present study evaluated 1-week massed CPT delivered virtually (i.e., via telehealth) to a community sample of trauma-exposed individuals (N = 24). Using a single-arm open-label design, participants received CPT twice per day for 5 days. The results indicated that most participants completed treatment (n = 23, 95.8%), and no adverse events were reported. Participants exhibited large reductions in clinician-rated, d = 2.01, and self-reported PTSD symptoms, d = 2.55, as well as self-reported depressive symptoms, d = 1.46. On average, participants reported a 5-point PTSD symptom reduction and 1-point reduction in depressive symptoms for each treatment day. Reductions in PTSD and depressive symptoms were maintained at 3-month follow-up. Overall, 1-week massed CPT delivered virtually was shown to be feasible and to result in rapid symptom reductions that were sustained over time. Virtual massed CPT has the potential to increase access to effective treatments and help trauma survivors restore aspects of their lives in short amounts of time.

Enhancing exposure therapy for posttraumatic stress disorder (PTSD): a randomized clinical trial of virtual reality and imaginal exposure with a cognitive enhancer

Posttraumatic stress disorder (PTSD) is a significant public health issue. Yet, there are limited treatment options and no data to suggest which treatment will work for whom. We tested the efficacy of virtual reality exposure (VRE) or prolonged imaginal exposure (PE), augmented with D-cycloserine (DCS) for combat-related PTSD. As an exploratory aim, we examined whether brain-derived neurotrophic factor (BDNF) and fatty acid amide hydrolase (FAAH) moderated treatment response. Military personnel with PTSD (n = 192) were recruited into a multisite double-blind randomized controlled trial to receive nine weeks of VRE or PE, with DCS or placebo. Primary outcome was the improvement in symptom severity. Randomization was stratified by comorbid depression (MDD) and site. Participants in both VRE and PE showed similar meaningful clinical improvement with no difference between the treatment groups. A significant interaction (p = 0.45) suggested VRE was more effective for depressed participants (CAPS difference M = 3.51 [95% CI 1.17-5.86], p = 0.004, ES = 0.14) while PE was more effective for nondepressed participants (M = -8.87 [95% CI -11.33 to -6.40], p < 0.001, ES = -0.44). The main effect of DCS vs. placebo was not significant. Augmentation by MDD interaction (p = 0.073) suggested that depressed participants improved more on placebo (M = -8.43 [95% CI -10.98 to -5.88], p < 0.001, ES = -0.42); DCS and placebo were equally effective for nondepressed participants. There was an apparent moderating effect of BDNF Val66Met polymorphism on DCS augmentation (ES = 0.67). Met66 allele carriers improved more on DCS (ES = -0.25). FAAH 385 A carriers improved more than non-carriers (ES = 0.33), particularly those with MDD (ES = 0.62). This study provides a step toward precision therapeutics for PTSD by demonstrating that comorbid MDD and genetic markers may help guide treatment selection.ClinicalTrials.gov Identifier: NCT01352637.

Effect of patient characteristics on posttraumatic stress disorder treatment retention among veterans: A systematic review

To identify baseline patient characteristics (i.e., demographic and psychological factors, military background) associated with better posttraumatic stress disorder (PTSD) treatment retention among veterans, we conducted a systematic review. After an electronic database search for studies of PTSD treatment in veterans, two reviewers independently screened the literature for eligibility, abstracted study-level information, and assessed risk of bias. As most studies used multivariate models to assess multiple potential predictors of retention simultaneously, the results were described narratively. The GRADE approach, adapted for prognostic literature, was used to assess the overall quality of evidence (QoE). In total, 19 studies reported in 25 publications met the inclusion criteria (n = 6 good quality, n = 9 fair quality, n = 4 poor quality). Definitions of treatment completion and dropout varied, and some studies lumped different therapy approaches together. Older age and higher treatment expectations were associated with better retention (moderate QoE). In 5 of 6 studies, baseline PTSD severity was not associated with retention, and the remaining study reported an association between better retention and more severe PTSD symptoms; the presence of more co-occurring psychiatric disorders was associated with better retention (moderate QoE). QoE was low or insufficient to support conclusions for any other characteristics due to inconsistent results, imprecision, potential publication bias, possible study population overlap, study limitations, or lack of studies. More research is needed regarding the associations between modifiable factors (e.g., motivation, barriers, expectations) and retention, and consistent definitions of treatment completion and minimally adequate treatment should be adopted throughout the field.

Brain Responses to a Self-Compassion Induction in Trauma Survivors With and Without Post-traumatic Stress Disorder

Self-compassion (SC) is a mechanism of symptom improvement in post-traumatic stress disorder (PTSD), however, the underlying neurobiological processes are not well understood. High levels of self-compassion are associated with reduced activation of the threat response system. Physiological threat responses to trauma reminders and increased arousal are key symptoms which are maintained by negative appraisals of the self and self-blame. Moreover, PTSD has been consistently associated with functional changes implicated in the brain's saliency and the default mode networks. In this paper, we explore how trauma exposed individuals respond to a validated self-compassion exercise. We distinguish three groups using the PTSD checklist; those with full PTSD, those without PTSD, and those with subsyndromal PTSD. Subsyndromal PTSD is a clinically relevant subgroup in which individuals meet the criteria for reexperiencing along with one of either avoidance or hyperarousal. We use electroencephalography (EEG) alpha-asymmetry and EEG microstate analysis to characterize brain activity time series during the self-compassion exercise in the three groups. We contextualize our results with concurrently recorded autonomic measures of physiological arousal (heart rate and skin conductance), parasympathetic activation (heart rate variability) and self-reported changes in state mood and self-perception. We find that in all three groups directing self-compassion toward oneself activates the negative self and elicits a threat response during the SC exercise and that individuals with subsyndromal PTSD who have high levels of hyperarousal have the highest threat response. We find impaired activation of the EEG microstate associated with the saliency, attention and self-referential processing brain networks, distinguishes the three PTSD groups. Our findings provide evidence for potential neural biomarkers for quantitatively differentiating PTSD subgroups.

Medication-Enhanced Psychotherapy for Posttraumatic Stress Disorder: Recent Findings on Oxytocin's Involvement in the Neurobiology and Treatment of Posttraumatic Stress Disorder

Background

Traumatic experiences may result in Posttraumatic Stress Disorder (PTSD), which is characterized as an exaggerated fear response that cannot be extinguished over time or in safe environments. What are beneficial psychotherapeutic treatment options for PTSD patients? Can oxytocin (OXT), which is involved in the stress response, and safety learning, ameliorate PTSD symptomatology and enhance psychotherapeutic effects? Here, we will review recent studies regarding OXT's potential to enhance psychotherapeutic therapies for PTSD treatment.

Method

We conducted a literature review on the neurobiological underpinnings of PTSD especially focusing on OXT's involvement in the biology and memory formation of PTSD. Furthermore, we researched successful psychotherapeutic treatments for PTSD patients and discuss how OXT may facilitate observed psychotherapeutic effects.

Results

For a relevant proportion of PTSD patients, existing psychotherapies are not beneficial. OXT may be a promising candidate to enhance psychotherapeutic effects, because it dampens responses to stressful events and allows for a faster recovery after stress. On a neural basis, OXT modulates processes that are involved in stress, arousal and memory. OXT effectively counteracts memory impairments caused by stress and facilitates social support seeking which is a key resilience factor for PTSD and which is beneficial in psychotherapeutic settings.

Conclusion

OXT has many characteristics that are promising to positively influence psychotherapy for PTSD patients. It potentially reduces intrusions, but preserves memory of the event itself. Introducing OXT into psychotherapeutic settings may result in better treatment outcomes for PTSD patients. Future research should directly investigate OXT's effects on PTSD, especially in psychotherapeutic settings.

Personalization of Treatment for Patients with Childhood-Abuse-Related Posttraumatic Stress Disorder

BACKGROUND

Differences in effectiveness among treatments for posttraumatic stress disorder (PTSD) are typically small. Given the variation between patients in treatment response, personalization offers a new way to improve treatment outcomes. The aim of this study was to identify predictors of psychotherapy outcome in PTSD and to combine these into a personalized advantage index (PAI).

METHODS

We used data from a recent randomized controlled trial comparing prolonged exposure (PE; n = 48), intensified PE (iPE; n = 51), and skills training (STAIR), followed by PE (n = 50) in 149 patients with childhood-abuse-related PTSD (CA-PTSD). Outcome measures were clinician-assessed and self-reported PTSD symptoms. Predictors were identified in the exposure therapies (PE and iPE) and STAIR+PE separately using random forests and subsequent bootstrap procedures. Next, these predictors were used to calculate PAI and to retrospectively determine optimal and suboptimal treatment in a leave-one-out cross-validation approach.

RESULTS

More depressive symptoms, less social support, more axis-1 diagnoses, and higher severity of childhood sexual abuse were predictors of worse treatment outcomes in PE and iPE. More emotion regulation difficulties, lower general health status, and higher baseline PTSD symptoms were predictors of worse treatment outcomes in STAIR+PE. Randomization to optimal treatment based on these predictors resulted in more improvement than suboptimal treatment in clinician assessed (Cohens' d = 0.55) and self-reported PTSD symptoms (Cohens' d = 0.47).

CONCLUSION

Personalization based on PAI is a promising tool to improve therapy outcomes in patients with CA-PTSD. Further studies are needed to replicate findings in prospective studies.

Treatment response trajectories in a three-week CPT-Based intensive treatment for veterans with PTSD

Response to weekly evidence-based PTSD treatments varies. Little is known about response trajectories and predictors in intensive PTSD treatments. This study sought to identify different trajectories of symptom change among veterans who completed a 3-week CPT-based intensive PTSD treatment program and examined potential predictors of trajectory group membership. Four hundred fifty-two veterans completed the program. Demographics, PTSD and depression severity, negative posttrauma cognitions, and alcohol use were assessed at intake and evaluated as possible predictors of group membership. Group based trajectory modeling was used to determine distinct groups based on PTSD symptom trajectory over the course of treatment, as well as predictors of group membership. Four distinct treatment trajectories were identified: Fast responders (15.3%), steady responders (32.0%), partial responders (38.4%), and minimal responders (14.4%). Fast and steady responders reported substantial symptom reductions and dropped below the "probable PTSD" threshold, with fast responders achieving improvements after just one week of treatment. Partial responders experienced clinically significant reductions but remained above the "probable PTSD" threshold. Minimal responders reported the highest baseline PTSD symptoms and changed the least throughout treatment. Negative posttrauma cognitions as well as self-reported and clinician-rated PTSD symptom severity assessed at intake successfully predicted trajectory membership. The identified trajectories closely resemble findings in the limited existing literature on intensive PTSD treatment trajectories. Results suggest that some individuals may improve with even shorter interventions and others might benefit from additional treatment sessions. Overall, findings support the importance of evaluating individual- and group-level treatment responses.

Differential Effects of Comorbid Psychiatric Disorders on Treatment Outcome in Posttraumatic Stress Disorder from Childhood Trauma

Patients with posttraumatic stress disorder (PTSD) frequently have comorbid diagnoses such as major depressive disorder (MDD) and anxiety disorders (AD). Studies into the impact of these comorbidities on the outcome of PTSD treatment have yielded mixed results. The different treatments investigated in these studies might explain the varied outcome. The purpose of this study was to examine the impact of these comorbidities on the outcome of two specific PTSD treatments. MDD and AD were analyzed as predictors and moderators in a trial comparing 12 sessions of either eye movement desensitization and reprocessing (EMDR) or imagery rescripting (IR) in 155 adult patients with PTSD from childhood trauma. The primary outcome was reduction of PTSD symptoms (clinician-administered PTSD Scale for DSM-5, CAPS-5) assessed at eight-week follow-up and a secondary outcome was self-report PTSD symptoms (Impact of Event Scale, IES-R). MDD was not a predictor of treatment outcome but did have a significant moderator effect. Patients with MDD showed a better outcome if they were treated with IR, whereas patients without MDD improved more in the EMDR condition. No impact of AD emerged. It seems essential to consider comorbid MDD when planning PTSD treatment to improve treatment outcomes. More research is needed to replicate our findings and focus on different kinds of PTSD treatments and other comorbidities.

Overcoming Adversity and Stress Injury Support (OASIS): Evaluation of Residential Treatment Outcomes for U.S. Service Members with Posttraumatic Stress Disorder

Research on residential posttraumatic stress disorder (PTSD) treatment has predominantly focused on the U.S. veteran population, whereas limited research exists regarding active duty service members. The present study evaluated outcomes among service members who received treatment in the Department of Defense's only residential PTSD program, Overcoming Adversity and Stress Injury Support (OASIS). Over a 5-year period, 289 male service members with combat-related PTSD received treatment in the program. Service members completed an initial assessment and weekly PTSD and depression self-report measures during the 10-week program. Multilevel modeling results demonstrated statistically significant reductions in PTSD. On average, participants reported a 0.76-point reduction on the PTSD Checklist, B = -0.76, p < .001, for each additional week of treatment. Pretreatment symptom scores and fitness-for-duty status predicted PTSD symptoms across time. Weekly changes in depression symptoms were not statistically significant; however, a significant Time × Pretreatment Depression Severity interaction emerged. Service members with higher baseline levels of depression severity showed larger reductions in depression symptom severity than those with lower levels, B = -0.02, p = .020, although a sizeable minority continued to retain symptoms at diagnostic levels. Depression symptom change was not related to any other treatment- or service-related variables. Differing trajectories were found between service members whose symptoms improved over the course of residential treatment and those who did not. The results indicate that there were larger improvements in PTSD than depression symptoms and highlight the need to optimize care provision for service members with severe PTSD or comorbid symptoms.

Neural correlates of treatment effect and prediction of treatment outcome in patients with PTSD and comorbid personality disorder: study design

BACKGROUND

Neural alterations related to treatment outcome in patients with both post-traumatic stress disorder (PTSD) and comorbid personality disorder are unknown. Here we describe the protocol for a neuroimaging study of treatment of patients with PTSD and comorbid borderline (BPD) or cluster C (CPD) personality disorder traits. Our specific aims are to 1) investigate treatment-induced neural alterations, 2) predict treatment outcome using structural and functional magnetic resonance imaging (MRI) and 3) study neural alterations associated with BPD and CPD in PTSD patients. We hypothesize that 1) all treatment conditions are associated with normalization of limbic and prefrontal brain activity and hyperconnectivity in resting-state brain networks, with additional normalization of task-related activation in emotion regulation brain areas in the patients who receive trauma-focused therapy and personality disorder treatment; 2) Baseline task-related activation, together with structural brain measures and clinical variables predict treatment outcome; 3) dysfunction in task-related activation and resting-state connectivity of emotion regulation areas is comparable in PTSD patients with BPD or CPD, with a hypoconnected central executive network in patients with PTSD+BPD.

METHODS

We aim to include pre- and post-treatment 3 T-MRI scans in 40 patients with PTSD and (sub) clinical comorbid BPD or CPD. With an expected attrition rate of 50%, at least 80 patients will be scanned before treatment. MRI scans for 30 matched healthy controls will additionally be acquired. Patients with PTSD and BPD were randomized to either EMDR-only or EMDR combined with Dialectical Behaviour Therapy. Patients with PTSD and CPD were randomized to Imaginary Rescripting (ImRs) or to ImRs combined with Schema Focused Therapy. The scan protocol consists of a T1-weighted structural scan, resting state fMRI, task-based fMRI during an emotional face task and multi-shell diffusion weighted images. For data analysis, multivariate mixed-models, regression analyses and machine learning models will be used.

DISCUSSION

This study is one of the first to use neuroimaging measures to predict and better understand treatment response in patients with PTSD and comorbid personality disorders. A heterogeneous, naturalistic sample will be included, ensuring generalizability to a broad group of treatment seeking PTSD patients.

TRIAL REGISTRATION

Clinical Trials, NCT03833453 & NCT03833531 . Retrospectively registered, February 2019.

[Deliberate Renunciation of Coercion in the Case of Persistent Self-Destructive Behavior]

The clinical course of borderline personality disorder with persistent suicidal communication and self-destruction is often characterized by freedom-restricting interventions, long-term hospitalization, and a lack of commitment for disorder-oriented treatment. We present the course of a 31-year-old man who was offered the free choice between disorder-oriented treatment or discharge from in-patient treatment. The clinical decision to offer the choice to the patient was based on the judgment of given capacity of self-determination except for short periods of acute crisis. Deliberate refraining from the use of coercive interventions and demanding responsibility for change from the patient paved the way for psychotherapeutic treatment and the reactivation of his own skills.