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

Impact of three variants of prolonged exposure therapy on comorbid diagnoses in patients with childhood abuse-related PTSD

Recent studies indicated that Prolonged Exposure (PE) is safe and effective for posttraumatic stress disorder (PTSD). It is unclear whether PE also leads to a reduction in comorbid diagnoses. Data from a large randomized controlled trial (N = 149) on the effects of three variants of PE for PTSD were used. We examined the treatment effects on co-morbid diagnoses of depressive, anxiety, obsessive compulsive, substance abuse, psychotic, eating and personality disorders in a sample of patients with PTSD related to childhood abuse. Outcomes were assessed with clinical interviews at baseline, post-treatment and at 6- and 12-month follow-up. All variants of PE led to a decrease from baseline to post-treatment in diagnoses of depressive, anxiety, substance use and personality disorders. Improvements were sustained during follow-up. We found an additional decrease in the number of patients that fulfilled the diagnostic criteria of a depressive disorder between 6- and 12-month follow-up. No significant changes were observed for the presence of OCD, psychotic and eating disorders. Findings suggest that it is effective to treat PTSD related to childhood abuse with trauma-focused treatments since our 14-to-16 weeks PE for PTSD resulted in reductions in comorbid diagnoses of depressive, anxiety, substance use and personality disorders.

Changes in trauma-related cognitions predict subsequent symptom improvement during prolonged exposure in patients with childhood abuse-related PTSD

Change in negative posttraumatic cognitions is a proposed mechanism through which Prolonged Exposure (PE) leads to symptom reduction of posttraumatic stress disorder (PTSD). A strong case for posttraumatic cognitions as a change mechanism in PTSD treatment can be made by establishing temporal precedence of change in cognitions. The current study examines the temporal relationship between change in posttraumatic cognitions and PTSD symptoms during PE, using the Posttraumatic Cognitions Inventory. Patients with DSM-5 defined PTSD following childhood abuse (N = 83) received a maximum of 14-16 sessions of PE. Clinician-rated PTSD symptom severity and posttraumatic cognitions were assessed at baseline, week 4, 8, and 16 (post-treatment). Using time-lagged mixed effect regression models, we found that posttraumatic cognitions predicted subsequent PTSD symptom improvement. Notably, when using the items of an abbreviated version of the PTCI (PTCI-9), we found a mutual relationship between posttraumatic cognitions and PTSD symptom improvement. Crucially, the effect of change in cognitions on PTSD symptom change was greater than the reverse effect. The current findings corroborate change in posttraumatic cognitions as a change process during PE, but cognitions and symptoms cannot be completely separated. The PTCI-9 is a short instrument that appears suitable to track cognitive change over time.

Temporal Relationship Between Change in Subjective Distress and PTSD Symptom Decrease During Prolonged Exposure Therapy for Posttraumatic Stress Disorder

There is growing evidence that change in distress is an indicator of change during Prolonged Exposure (PE) for posttraumatic stress disorder (PTSD). However, temporal sequencing studies investigating whether change in distress precedes PTSD symptom decline are lacking. These studies are essential since the timeline between indicators of change and treatment outcome is a key assumption for mediation. The aim of the present study was to assess the temporal relationship between within- and between-session change in subjective distress and PTSD symptom decrease. We analyzed session data from 86 patients with PTSD. Data were analyzed using dynamic panel models. We distinguished temporal effects (within-persons) from averaged effects (between-persons). Results regarding the temporal effect showed that within-session change in subjective distress preceded PTSD symptom improvement while the reversed effect was absent. Averaged within-session change in subjective distress was also related to PTSD symptom improvement. Results regarding the temporal effect of between-session change in subjective distress showed that it did not precede PTSD symptom improvement. Averaged between-session change in subjective distress was related to PTSD symptom improvement. This study provides evidence for within- but not between-session change in subjective distress as indicator of change during PE. We also found that the way of modeling potential indicators of change affects results and implications. We recommend future studies to analyze mediators during treatment using temporal rather than averaged effects.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial

Background

Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study’s aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated.

Methods

The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains.

Discussion

This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome.

Trial registration

Netherlands Trial Register NL6965, registered 25/04/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05712-9.

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.

Does complex PTSD predict or moderate treatment outcomes of three variants of exposure therapy?

BACKGROUND

One reason for the inclusion of Complex Posttraumatic Stress Disorder (CPTSD) in the 11th revision of the International Classification of Diseases (ICD-11) was its suspected relevance for treatment indications. We investigated whether CPTSD predicted and moderated treatment outcomes of Prolonged Exposure (PE), intensified PE (iPE) and Skills Training in Affective and Interpersonal Regulation followed by PE (STAIR + PE). We expected that CPTSD would predict worse treatment outcomes across treatments. Secondly, we expected that CPTSD would lead to better treatment effect in STAIR + PE compared to PE and iPE.

METHODS

We analyzed 149 patients with childhood-abuse related PTSD from a randomized clinical trial. CPTSD diagnosis and symptom severity were measured with the International Trauma Questionnaire. The main outcome was change in clinician-assessed PTSD symptoms. Assessments took place at baseline, week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. Analyses were based on an intention-to-treat sample using mixed effect models.

RESULTS

More than half (54 %) of the patients met criteria for CPTSD at baseline. CPTSD was related to more severe PTSD symptoms and higher comorbidity at baseline. CPTSD neither predicted nor moderated treatment outcome.

LIMITATIONS

Inclusion was limited to patients with PTSD related to childhood abuse. Replication is needed in different samples.

CONCLUSIONS

CPTSD is associated with more severe PTSD and with higher comorbidity. CPTSD did not predict treatment outcome and did not indicate differential treatment outcome of STAIR + PE compared to PE and iPE.

Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial

Background: It is unclear whether the evidence-based treatments for PTSD are as effective in patients with CA-PTSD. Objective: We aimed to investigate the effectiveness of three variants of prolonged exposure therapy. Method: We recruited adults with CA-PTSD. Participants were randomly assigned to Prolonged Exposure (PE; 16 sessions in 16 weeks), intensified Prolonged Exposure (iPE; 12 sessions in 4 weeks followed by 2 booster sessions) or a phase-based treatment, in which 8 sessions of PE were preceded by 8 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR+PE; 16 sessions in 16 weeks). Assessments took place in week 0 (baseline), week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. The primary outcome was clinician-rated PTSD symptom severity. Results: We randomly assigned 149 patients to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up (Cohen's d > 1.6), with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms (t₁₃₅ = -2.85, p = .005, d = .49) but not clinician-assessed symptoms (t₁₃₅ = -1.65, p = .10) and faster initial symptom reduction than STAIR+PE for self-reported (t₁₃₅ = -4.11, p < .001, d = .71) and clinician-assessed symptoms (t₁₃₅ = -2.77, p = .006, Cohen's d = .48) STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions. Conclusions: Variants of exposure therapy are tolerated well and lead to large improvements in patients with CA-PTSD. Intensifying treatment may lead to faster improvement but not to overall better outcomes. The trial is registered at the clinical trial registry, number NCT03194113, https://clinicaltrials.gov/ct2/show/NCT03194113.

Pathways to aggression and violence in psychosis without longstanding antisocial behavior: A review and proposed psychosocial model for integrative clinical interventions

There is a need for a clearer understanding of the factors associated with increased risk of aggression and violence (AV) among people with psychosis and other severe mental illness (SMI) to guide effective prevention and intervention. The current article (1) reviews the literature regarding psychosocial factors associated with AV among individuals with psychosis and other SMI who do not have longstanding antisocial behaviors, (2) proposes an integrative psychosocial model of AV that can be practically applied, and (3) proposes appropriate evidence-based clinical interventions to reduce AV and facilitate recovery. We propose that increased risk for AV among people with psychosis is driven by anger, which is affected by a range of factors including victimization and situational stressors, social rejection or experiences of discrimination, anxious arousal, and hostile attribution bias related to psychosis. The cumulative effect of these systems is exacerbated by co-occurring substance misuse and increased impulsivity, particularly negative urgency. In consideration of the current psychosocial model and existing evidence-based interventions for AV in individuals with psychosis, we propose that trauma-informed interventions that integrate skills training in emotion regulation, social and interpersonal situations, cognitive restructuring and remediation, and modified prolonged exposure may demonstrate the most promise for this population.

Do emotion regulation difficulties affect outcome of intensive trauma-focused treatment of patients with severe PTSD?

Background: There is ongoing debate as to whether emotion regulation problems should be improved first in order to profit from trauma-focused treatment, or will diminish after successful trauma processing. Objective: To enhance our understanding about the importance of emotion regulation difficulties in relation to treatment outcomes of trauma-focused therapy of adult patients with severe PTSD, whereby we made a distinction between people who reported sexual abuse before the age of 12, those who were 12 years or older at the onset of the abuse, individuals who met the criteria for the dissociative subtype of PTSD, and those who did not. Methods: Sixty-two patients with severe PTSD were treated using an intensive eight-day treatment programme, combining two first-line trauma-focused treatments for PTSD (i.e. prolonged exposure and EMDR therapy) without preceding interventions that targeted emotion regulation difficulties. PTSD symptom scores (CAPS-5) and emotion regulation difficulties (DERS) were assessed at pre-treatment, post-treatment, and six month follow-up. Results: PTSD severity and emotion regulation difficulties significantly decreased following trauma-focused treatment. While PTSD severity scores significantly increased from post-treatment until six month follow-up, emotion regulation difficulties did not. Treatment response and relapse was not predicted by emotion-regulation difficulties. Survivors of childhood sexual abuse before the age of 12 and those who were sexually abused later in life improved equally well with regard to emotion regulation difficulties. Individuals who fulfilled criteria of the dissociative subtype of PTSD showed a similar decrease on emotion regulation difficulties during treatment than those who did not. Conclusion: The results support the notion that the severity of emotion regulation difficulties is not associated with worse trauma-focused treatment outcomes for PTSD nor with relapse after completing treatment. Further, emotion regulation difficulties improved after trauma-focused treatment, even for individuals who had been exposed to early childhood sexual trauma and individuals with dissociative subtype.