Moving beyond symptom reduction: A meta-analysis on the effect of exposure therapy for PTSD on quality of life

OBJECTIVES

Quality of life (QOL) is a multidimensional construct including emotional well-being, life satisfaction, and physical health. Individuals with posttraumatic stress disorder (PTSD) consistently report low QOL, highlighting the importance of assessing the effectiveness of first-line PTSD treatments (e.g., exposure-based therapies) on QOL. This meta-analysis examined the efficacy of exposure therapy for PTSD on QOL compared to control conditions (e.g., waitlist, medication, treatment-as-usual) at posttreatment and follow-up (ranging from 1 month to 2 years).

METHODS

Building on a previous meta-analysis of exposure-based therapy for PTSD, we searched PsycINFO and Medline in December 2021, July 2022, and March 2023 to include randomized controlled trials of exposure-based treatments for adult PTSD assessing QOL. We screened 295 abstracts for initial eligibility; 20 articles met inclusion criteria and were included (N = 2729 participants). Risk of bias was evaluated using the Cochrane Risk of Bias tool 2.0.

RESULTS

At posttreatment, exposure-based therapies showed a medium effect on QOL relative to control conditions (k = 25, g = 0.67). This effect was not observed at follow-up for the small subset of studies with follow-up data (k = 8, g = 0.16). At posttreatment, effect size varied significantly as a function of the control condition (p < .0001). There were no differences in QOL effects across exposure therapies at posttreatment or follow-up (p = .09).

CONCLUSION

Exposure therapy was associated with greater improvement in QOL compared to control conditions at posttreatment. Exposure was not superior to control conditions at follow-up, and the longer-term impact of exposure on QOL is unclear. The implications of these findings are discussed, along with the need for more PTSD treatment studies to examine QOL outcomes at posttreatment and follow-up.

Differential relations between breathing retraining, in vivo exposure, and imaginal exposure homework completion and treatment outcomes in veterans receiving prolonged exposure for PTSD

OBJECTIVES

Limited research exists that outlines the predictive relevance of the treatment components of prolonged exposure (PE) for post-traumatic stress disorder (PTSD) on PTSD and depression symptom outcomes. The goal of the present study was to investigate relations between participant completion of breathing retraining, in vivo exposure, and imaginal exposure exercises and symptom outcomes.

METHODS

A total of 58 participants completed a trial of PE as part of a larger trial on peer involvement and treatment adherence. Diagnostic and self-report measures were completed throughout treatment. Participants also recorded weekly completion of breathing retraining, in vivo exposure, and imaginal exposure exercises. Pearson correlations and hierarchical regression analyses were used to investigate relations between average weekly treatment component completion and treatment outcomes, controlling for relevant variables.

RESULTS

Although breathing retraining and in vivo exposures were associated with PTSD outcomes in the correlational findings, use of breathing retraining, in vivo exposures, and imaginal exposures were not reliably associated with PTSD symptom outcomes when controlling for other variables in the regression analysis. However, when investigating changes in comorbid symptoms of depression, greater use of breathing retraining was associated with decreased symptoms of depression at posttreatment.

CONCLUSIONS

Present findings demonstrate the differential relations between participation in various PE treatment components and posttreatment symptom outcomes. The importance of breathing retraining in addressing comorbid depressive symptoms is discussed, with emphasis on potentially increasing relaxation and positive activities more broadly to encourage further treatment benefits.

Changes in trauma appraisal during brief internet-based exposure and cognitive restructuring treatment for Arabic-speaking people with PTSD

Background: Maladaptive trauma appraisal plays an important role in the development and maintenance of posttraumatic stress disorder (PTSD). While studies have demonstrated the effectiveness of exposure and cognitive treatments for PTSD symptomatology, the effect of such treatments on specific trauma appraisals is still not well understood.Objective: The study investigated the effect of an exposure and a cognitive restructuring internet-based treatment on specific trauma appraisals in Arabic-speaking participants with PTSD.Method: 334 participants received either an exposure (n = 167) or a cognitive restructuring (n = 167) internet-based treatment. PTSD symptom severity (PCL-5) and specific trauma appraisals (TAQ) were assessed at pre- and post-treatment. Changes in specific trauma appraisals within and between the two treatments were analyzed using multi-group change modelling. Associations between changes in PTSD symptom severity and changes in trauma appraisals were evaluated using Pearson product-moment correlation. For both treatments, participants with versus without reliable improvement were compared regarding changes in specific trauma appraisals using Welch tests. Analyses were performed on 100 multiple imputed datasets.Results: Both treatments yielded significant changes in shame, self-blame, fear, anger, and alienation (all ps < .001). Changes in betrayal were only significant in the cognitive restructuring treatment (p < .001). There was no evidence of differences between treatments for any specific trauma appraisal. Changes in PTSD symptom severity were significantly associated with changes in trauma appraisals (all ps < .001). In both treatments, participants who experienced reliable improvement in PTSD symptom severity showed significantly larger pre- to post-treatment changes in specific trauma appraisals compared to those without reliable improvement. Again, differences in betrayal were only significant in the cognitive restructuring treatment.Conclusions: The findings indicate that both treatments are effective in reducing trauma appraisals in Arabic-speaking people with PTSD. Changes in trauma appraisal seem to be associated with changes in PTSD symptomatology.Trial registration: German Clinical Trials Register identifier: DRKS00010245.

Reclaiming hope: Subjective nearness to death as a moderator between posttraumatic stress symptoms and hope among older adults

Perceiving one's remaining time until death, can serve as a source of resilience when faced with adversity in the second half of life. The current work is based on a prospective study and examines whether subjective nearness-to-death (SNtD) moderates the association between posttraumatic-stress symptoms (PTSS) and hope among adults in the second half of life. The first wave was conducted after the end of a military conflict in the south of Israel, and included 170 participants (M = 66.61, SD = 9.16; age range 51-91), 115 of whom also participated in Wave 2. Participants filled out self-reported questionnaires regarding background information, PTSS, SNtD and hope. A moderation effect was found, revealing that high levels of PTSS predicted lower levels of hope among those who felt close to their death, but not among those who felt far from their death. We suggest that one's evaluation of little time remaining to live, especially in old age, may be a significant factor exacerbating the negative consequences of PTSS on hope. The importance of the results to the research field is discussed.

Corticotropin-releasing factor signaling and its potential role in the prefrontal cortex-dependent regulation of anxiety

A large body of literature has highlighted the significance of the corticotropin-releasing factor (CRF) system in the regulation of neuropsychiatric diseases. Anxiety disorders are among the most common neuropsychiatric disorders. An increasing number of studies have demonstrated that the CRF family mediates and regulates the development and maintenance of anxiety. Thus, the CRF family is considered to be a potential target for the treatment of anxiety disorders. The prefrontal cortex (PFC) plays a role in the occurrence and development of anxiety, and both CRF and CRF-R1 are widely expressed in the PFC. This paper begins by reviewing CRF-related signaling pathways and their different roles in anxiety and related processes. Then, the role of the CRF system in other neuropsychiatric diseases is reviewed and the potential role of PFC CRF signaling in the regulation of anxiety disorders is discussed. Although other signaling pathways are potentially involved in the process of anxiety, CRF in the PFC primarily modulates anxiety disorders through the activation of corticotropin-releasing factor type1 receptors (CRF-R1) and the excitation of the cAMP/PKA signaling pathway. Moreover, the main signaling pathways of CRF involved in sex differentiation in the PFC appear to be different. In summary, this review suggests that the CRF system in the PFC plays a critical role in the occurrence of anxiety. Thus, CRF signaling is of great significance as a potential target for the treatment of stress-related disorders in the future.

Comparative effectiveness of psychotherapies in adults with posttraumatic stress disorder: a network meta-analysis of randomised controlled trials

BACKGROUND

Evidence on the long-term comparative effectiveness of posttraumatic stress disorder (PTSD) psychotherapies in adults remains unknown. Therefore, we performed an extensive network meta-analysis of randomised controlled trials (RCTs) to determine the comparative effectiveness of psychotherapies for people diagnosed with PTSD.

METHODS

A comprehensive search was conducted in Cochrane library, Embase, Medline-OVID, PubMed, Scopus, and Psych-Info until March 2021. Studies on the effectiveness of cognitive processing therapy (CPT), cognitive therapy (CT), eye movement desensitisation reprocessing (EMDR), narrative exposure therapy (NET), prolonged exposure (PE), cognitive behavioural therapy (CBT), present-centred therapy (PCT), brief eclectic psychotherapies (BEP), psychodynamic therapy (PDT) or combination therapies compared to no treatment (NT) or treatment as usual (TAU) in adults with PTSD were included. Frequentist and Bayesian approaches were used for analysis in R-software.

RESULTS

We included 98 RCTs with 5567 participants from 18 897 studies. CPT, EMDR, CT, NET, PE, CBT, and PCT were significant to reduce PTSD symptoms (SMD range: -1.53 to -0.75; Certainty: very low to high) at immediate post-treatment and ranked accordingly. Longitudinal analysis found EMDR (1.02) and CPT (0.85) as the significant therapies with large effect size in short-term and long-term follow-up, respectively. NET and CPT showed higher proportion of loss of PTSD diagnosis (RR range: 5.51-3.45) while there were no significant psychotherapies for retention rate compared to NT.

CONCLUSIONS

Our findings provide evidence for improving current guidelines and informing clinical decision-making for PTSD management. However, the best PTSD treatment plan should be tailored to patients' needs, characteristics, and clinician expertise.

REGISTRATION

PROSPERO CRD42020162143.

β-adrenoceptors of the infra-limbic cortex mediate corticosterone-induced enhancement of acquisition and consolidation of fear memory extinction in rats

The extinction of auditory fear conditioning (AFC) refers to reducing the fear responses induced following repeated presentation of a conditioned stimulus (tone) in the absence of an unconditioned stimulus (electric foot shock). Glucocorticoid receptors (GRs) play an important role in extinction, but the underlying neurobiological mechanisms are unclear. This study aimed to investigate the interaction between glucocorticoids and β-adrenoceptors of the infra-limbic cortex (IL) in regulating the acquisition and consolidation of fear memory extinction in rats. Male rats were trained to AFC and received three trial tones (30 s, 4 kHz, 80 dB) co-terminated with a footshock (0.8 mA, 1 s; unconditioned stimulus). Extinction trials were conducted over 3 days after training (Ext 1-3). In experiment 1, rats received clenbuterol (0.25 mg/kg/2 ml, IP) as a β₂-adrenoceptor agonist or propranolol (2.5 mg/kg/2 ml, IP) as a β-adrenoceptors antagonist before Ext 1 and immediately after Ext 1 and Ext 2 followed by systemic injection of corticosterone (3 mg/kg/2 ml, IP). In Experiment 2, separate groups of rats received a bilateral intra-IL injection of clenbuterol (50 ng/0.5 µl/side) or propranolol (500 ng/0.5 µl/side) followed by a systemic injection of corticosterone (3 mg/kg/2 ml) before Ext 1 and immediately after Ext 1 and Ext 2. Results indicated that systemic and intra-IL injections of clenbuterol and propranolol inhibited and increased the facilitative effects of corticosterone on fear memory extinction, respectively. These findings show that activating β-adrenergic receptors in the IL mediates glucocorticoid effects on the acquisition and consolidation of auditory-conditioned fear memory extinction.

An Education Intervention to Improve Knowledge of Post-Traumatic Stress Disorder Symptoms and Treatments Among U.S. Women Service Members and Veterans

INTRODUCTION

Due to decades of prolonged combat operations, post-traumatic stress disorder (PTSD) is widely discussed and generally well conceptualized. The objective of this study was to determine if an educational program on the signs and symptoms of PTSD and an explanation of the current treatments utilized by the Veterans Administration is effective in increasing the knowledge levels of women service members and veterans, leading to seeking treatment.

MATERIALS AND METHODS

The design of this study was a quantitative pretest/posttest interventional study. The educational program was conducted at a Senior Citizen Center. The population was a purposive sample of 44 women service members and veterans from a military base in New Jersey. A 25-item PTSD Knowledge Questionnaire developed for the earlier Web-Based Post-traumatic Stress Disorder Education for Military Family Members (2012) study was used as the pretest and posttest.

RESULTS

The knowledge level of PTSD among women service members and veterans who participated in this study was significantly higher after completing the educational program with 43% indicating that they would seek mental health care.

CONCLUSIONS

Women service members and veterans were ill-informed on the signs, symptoms, and treatment options of PTSD. If the results of this survey are an indicator of the knowledge level of women service members in broader populations, there is a need to restructure how those who are at risk of developing PTSD are educated. Through better educational programs, women and men could seek care with increasingly favorable long-term outcomes.

Framework for Accurate Classification of Self-Reported Stress From Multisession Functional MRI Data of Veterans With Posttraumatic Stress

Background: Posttraumatic stress disorder (PTSD) is a significant burden among combat Veterans returning from the wars in Iraq and Afghanistan. While empirically supported treatments have demonstrated reductions in PTSD symptomatology, there remains a need to improve treatment effectiveness. Functional magnetic resonance imaging (fMRI) neurofeedback has emerged as a possible treatment to ameliorate PTSD symptom severity. Virtual reality (VR) approaches have also shown promise in increasing treatment compliance and outcomes. To facilitate fMRI neurofeedback-associated therapies, it would be advantageous to accurately classify internal brain stress levels while Veterans are exposed to trauma-associated VR imagery. Methods: Across 2 sessions, we used fMRI to collect neural responses to trauma-associated VR-like stimuli among male combat Veterans with PTSD symptoms (N = 8). Veterans reported their self-perceived stress level on a scale from 1 to 8 every 15 s throughout the fMRI sessions. In our proposed framework, we precisely sample the fMRI data on cortical gray matter, blurring the data along the gray-matter manifold to reduce noise and dimensionality while preserving maximum neural information. Then, we independently applied 3 machine learning (ML) algorithms to this fMRI data collected across 2 sessions, separately for each Veteran, to build individualized ML models that predicted their internal brain states (self-reported stress responses). Results: We accurately classified the 8-class self-reported stress responses with a mean (± standard error) root mean square error of 0.6 (± 0.1) across all Veterans using the best ML approach. Conclusions: The findings demonstrate the predictive ability of ML algorithms applied to whole-brain cortical fMRI data collected during individual Veteran sessions. The framework we have developed to preprocess whole-brain cortical fMRI data and train ML models across sessions would provide a valuable tool to enable individualized real-time fMRI neurofeedback during VR-like exposure therapy for PTSD.

Conceptual Framework for Rape Survivors Diagnosed with PTSD in the North West Province of South Africa

The lack of a conceptual framework that can be utilized to manage rape survivors diagnosed with Post-Traumatic Stress Disorders presents a challenge in the North-West province. The study aims to provide a conceptual framework for managing rape survivors with PTSD in the province of the North-West using Practice-Oriented Theory and Donabedian's Structure Process Outcome Model Features. The research was conducted using an explanatory, sequential and mixed-methods approach. Additionally, used was the descriptive and explorative programme evaluation design. The results of the study demonstrated the significance of PTSD assessment before management interventions for rape survivors. The study findings outlined and designed a framework to assess and manage PTSD among rape survivors consulting at Thuthuzela Care Centre and those referred to hospitals for further management. The Practice-Oriented theory by Dickoff, James and Wiedenbach, and the Structure Process Outcome model by Donabedian served as points of reference for the development of the conceptual framework. The study is limited to North-West provincial healthcare facilities and Thuthuzela care centres (TCCs), however, it highlights the lack of a conceptual framework pertaining to the psychological management of PTSD rape survivors in the province and South Africa.

Technology-enhanced in vivo exposures in Prolonged Exposure for PTSD: A pilot randomized controlled trial

In vivo exposures (IVEs) are a key component of exposure-based treatments, during which patients approach fear-provoking, yet safe, situations in "real life." This pilot study assessed the use of a wearable technology (Bio Ware) during IVEs to enhance Prolonged Exposure (PE) therapy for PTSD. Bio Ware provides a clinician dashboard with real-time physiological and subjective data for clinicians to use for virtually guided IVEs. Participants (N = 40) were randomized to a Guided group that received standard PE and virtual, clinician-guided IVEs with the Bio Ware device, or a Non-Guided group that received standard PE and used the Bio Ware device on their own for IVEs. Multilevel linear models with bootstrapping were completed on the intent-to-treat (ITT; N = 39) and per-protocol samples (PP; n = 23), defined as completing at least eight sessions of PE and using the Bio Ware system during ≥ 1 IVEs. In the PP sample, there were significant effects of treatment condition (b = -14.55, SE = 1.47, 95% CI [-17.58, -11.78], p < .001) and time (b = -1.98, SE = 0.25, 95% CI [-2.47, -1.48], p < .001). While both groups showed reductions in PTSD symptoms, the Guided group evidenced significantly greater reductions than the Non-Guided group. These findings demonstrate the feasibility and safety of leveraging Bio Ware for virtual, clinician-guided IVEs during PE therapy for PTSD and suggest that virtual, clinician-guided exposures may enhance treatment outcomes. CLINICAL TRIAL REGISTRATION: NCT04471207.

Current Treatments of Post-traumatic Stress Disorder and Amygdala Ablation as a Potential Cutting-Edge Therapy in Its Refractory Cases

Post-traumatic stress disorder (PTSD)is a very common psychiatric disorder occurring in an individual of any age, gender, or race who underwent trauma, with women being twice more at risk than men. It is generally seen more in American Indians, United States Latinos, and African American ethnic groups. A patient is diagnosed with PTSD if the symptoms of intrusion, avoidance, changes in cognition and emotions, arousal, and mood reactivity changes persist for more than a month and cause the individual severe difficulty in their everyday cognitive and psychological functioning. The psychological treatment includes numerous therapies including trauma-focused therapies such as cognitive behavioral therapy, cognitive processing therapy, prolonged exposure therapy, eye movement desensitization and reprocessing, and non-trauma-focused therapies such as relaxation techniques, interpersonal therapy, and mindfulness. Various pharmacological measures have also been tried with mixed results such as selective serotonin reuptake inhibitors, benzodiazepines, adrenergic drugs, atypical antipsychotics, and mood stabilizers like lithium and valproate. As numerous studies have proven, PTSD is linked with right-side stimulation of the amygdala. The purpose of this article is to highlight the use of extremely selective laser ablation of the amygdala-hippocampal unit as a successful surgical intervention for medically unresponsive PTSD and as a revolutionary solution and prospective cutting-edge therapy in the near future.

Factors Predicting Family Violence Revictimization Among Army Families With Child Maltreatment

The Army Family Advocacy Program (Army FAP) strives to prevent family violence and intervene to reduce the deleterious effects of exposure to family violence. This paper examines the individual, family, community, and treatment factors associated with family violence revictimization. Case files of 134 families with substantiated child maltreatment and associated Army FAP interventions that closed in 2013 were coded across risk and protective factors and intervention characteristics and were matched to Army Central Registry files to identify revictimization rates through 2017. Revictimization, experienced by 23% of families, was predicted by community risk and reduced by intervention dose. With the high rates of relocations, housing or neighborhood issues, and the isolation military families experience and the relationship of these concerns to repeated family violence, identifying the impact of community risk is particularly important. Similarly, research that elucidates the effective treatment components is needed.

Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology

Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.

The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among children and adolescents who have experienced traumatic events. Exposure therapy (ET) has been shown to be effective in treating PTSD in adults. However, its efficacy remains uncertain in children and adolescents.

AIMS

To evaluate the efficacy and acceptability of ET in children and adolescents with PTSD.

METHOD

We searched PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, ProQuest, LILACS, and international trial registries for randomized controlled trials (RCTs) assessed ET in children and adolescents (aged ≤18 years) with PTSD up to August 31, 2020. The primary outcomes were efficacy (the endpoint score from PTSD symptom severity rating scales) and acceptability (all-cause discontinuation), secondary outcomes included efficacy at follow-up (score from PTSD scales at the longest point of follow-up), depressive symptoms (end-point score on depressive symptom severity rating scales) and quality of life/social functioning (end-point score on quality of life/social functioning rating scales). This study was registered with PROSPERO (CRD42020150859).

RESULT

A total of 6 RCTs (278 patients) were included. The results showed that ET was statistically more efficacious than control groups (standardized mean differences [SMD]: - 0.47, 95% confidence interval [CI]: - 0.91 to - 0.03). In subgroup analysis, exposure therapy was more efficacious for patients with single type of trauma (SMD: - 1.04, 95%CI: - 1.43 to - 0.65). Patients with an average age of 14 years and older, ET was more effective than the control groups (SMD: - 1.04, 95%CI: - 1.43 to - 0.65), and the intervention using prolonged exposure therapy (PE) (SMD: - 1.04, 95%CI: - 1.43 to - 0.65) was superior than control groups. Results for secondary outcomes of efficacy at follow-up (SMD: - 0.64, 95%CI: - 1.17 to - 0.10) and depressive symptoms (SMD: - 0.58, 95%CI: - 0.93 to - 0.22) were similar to the previous findings for efficacy outcome. No statistically significant effects for acceptability and quality of life/social functioning were found.

CONCLUSION

ET showed superiority in efficacy at post-treatment/follow-up and depressive symptoms improvement in children and adolescents with PTSD. Patients with single type of trauma may benefit more from ET. And ET is more effective in patients 14 years or older. Moreover, PE could be a better choice.

The Computations of a Traumatized Mind: A Latent Cause Model of Posttraumatic Stress Disorder

In cognitive psychology, a recent perspective based on the notion of latent cause (LC) has offered new insight on how learning and memory work. Here I explore the implications of this novel perspective to understand posttraumatic stress disorder (PTSD). The proposal is that, because of a propensity to interpret events as manifestations of multiple LCs (a propensity facilitated by experiencing traumas in childhood), PTSD patients form an LC associated with the trauma and that this LC is responsible for typical symptoms of the illness (specifically, intrusive symptoms and associated fear). Later, after the trauma, some patients develop a second LC, now associated with the presence of trauma-related cues combined with absence of danger. Development of the latter LC would interfere with extinction and explain why, for some patients, exposure to trauma-related cues (even when supported by interventions such as exposure protocols) fails to provide much improvement. This proposal has potential clinical implications, raising the possibility that some patients might benefit from exposure to mildly painful aspects of the trauma in conjunction with trauma-related cues.

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.

A brief intervention for PTSD versus treatment as usual: Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Although existing treatment methods are effective in alleviating PTSD symptoms, several barriers to care exist, such as waiting times, avoidant tendencies, shame and stigma, potentially leading to fewer people seeking therapy or premature dropouts. A potential solution to battling these barriers is Brain Working Recursive Therapy (BWRT), a single-session exposure-oriented intervention for PTSD. Although not yet subjected to empirical investigation, clinical experiences suggest an often immediate and long-lasting effect following the intervention related to patient's symptomatology and functional abilities.

METHODS

The current study protocol outlines a plan to conduct the first non-inferiority randomized controlled trial aimed to explore the efficacy of BWRT compared to treatment as usual (TAU), operationalized as any evidence-based trauma treatment method administered in Norwegian out-patient clinics. Eighty-two participants will be allocated at a 1:1 ratio to one of the following treatment conditions: (1) BWRT or (2) treatment as usual. Participants will be compared on several variables, including changes in PTSD symptoms (primary objective), and changes in perceived quality of life, rumination, functional and cognitive ability (secondary objective). Data collection will take place baseline (T1), within three weeks post treatment (T2) and at 6-month follow-up (T3).

DISCUSSION

Should BWRT prove to be non-inferior to treatment as usual, this brief intervention may be an important contribution to future psychological treatment for PTSD, by making trauma treatment more accessible and battling current barriers to care.

TRIAL REGISTRATION

191548, 24.05.2021. ClinicalTrials.gov PRS: Release Confirmation.

Neuromodulation of Visual Cortex Reduces the Intensity of Intrusive Memories

Aversive events can be reexperienced as involuntary and spontaneous mental images of the event. Given that the vividness of retrieved mental images is coupled with elevated visual activation, we tested whether neuromodulation of the visual cortex would reduce the frequency and negative emotional intensity of intrusive memories. Intrusive memories of a viewed trauma film and their accompanied emotional intensity were recorded throughout 5 days. Functional connectivity, measured with resting-state functional magnetic resonance imaging prior to film viewing, was used as predictive marker for intrusions-related negative emotional intensity. Results indicated that an interaction between the visual network and emotion processing areas predicted intrusions’ emotional intensity. To test the causal influence of early visual cortex activity on intrusions’ emotional intensity, participants’ memory of the film was reactivated by brief reminders 1 day following film viewing, followed by inhibitory 1 Hz repetitive transcranial magnetic stimulation (rTMS) over early visual cortex. Results showed that visual cortex inhibitory stimulation reduced the emotional intensity of later intrusions, while leaving intrusion frequency and explicit visual memory intact. Current findings suggest that early visual areas constitute a central node influencing the emotional intensity of intrusive memories for negative events. Potential neuroscience-driven intervention targets designed to downregulate the emotional intensity of intrusive memories are discussed.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Lost in Transition? Evidence-Based Treatments for Adolescents and Young Adults with Posttraumatic Stress Disorder and Results of an Uncontrolled Feasibility Trial Evaluating Cognitive Processing Therapy

Posttraumatic stress disorder (PTSD) is not uncommon among adolescents and young adults (AYAs). Left untreated, transition to adulthood might be especially challenging and/or prolonged for AYAs. However, it is unclear whether AYAs are adequately represented in current PTSD treatment research and whether they benefit to the same degree as younger or older individuals. In the first part of the paper, we reflect on developmental considerations in the treatment of AYAs and give an overview of current age-specific results in PTSD treatment research. Furthermore, we review individual trauma-focused evidence-based treatments that were examined in AYAs over the last 10 years. In the second part, we present data from an uncontrolled feasibility trial evaluating cognitive processing therapy (CPT) with some age-adapted modifications and an exposure component (written accounts). We treated 17 AYAs (aged 14 to 21) suffering from posttraumatic stress symptoms (PTSS). At posttreatment, participants had improved significantly with respect to clinician-rated PTSS severity (d = 1.32). Treatment gains were maintained throughout the 6-week and 6-month follow-ups. Results indicated that CPT, with only minor adaptations, was feasible and safe in AYAs. The recommendations for future research focus on the inclusion of young adults in trials with adolescents, more refined age reporting in clinical trials, and the encouragement of dismantling studies in youth. To conclude, clinical recommendations for caregiver involvement and the addressing of developmental tasks, motivational issues and emotion regulation problems are discussed.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

Effect of trauma-related stress after alcohol consumption on perceived likelihood of negative consequences and willingness to drive

BACKGROUND

Alcohol-related motor vehicle crashes are a major preventable cause of death in the United States. One potential factor that may modulate the influence of alcohol on driving-related cognitions and decision-making is trauma-related stress. Indeed, in addition to compelling research indicating that both acute trauma-related stress and acute alcohol consumption may independently affect driving-related risky decision-making, there is reason to believe that the combination of these antecedents may have an exacerbating effect.

METHODS

The current study evaluated the influence of induction of acute trauma-related stress (via script-driven imagery) after alcohol consumption (0.06% Breath Alcohol Concentration [BrAC]) on driving-related cognitions - perceived likelihood of negative consequences and willingness to drive - among 25 trauma-exposed (currently symptomatic) adult drinkers from the community (M = 24.08; 36.0% female).

RESULTS

Participants who were acutely exposed to trauma-related stress after alcohol consumption evidenced lower perceived likelihood of being pulled over by a police officer (ηp2 = 0.38, large effect size) and lower perceived likelihood of getting in an accident (ηp2 = 0.17, medium-to-large effect size) relative to participants exposed to a neutral cue; conversely, participants exposed to trauma-related stress after alcohol consumption evidenced greater willingness to drive (d = 1.16, large effect size) than participants exposed to a neutral cue.

CONCLUSIONS

Generally, findings suggest that individuals with a trauma history that are acutely exposed to trauma-related stressors (e.g., reminders of their traumatic experience) may be particularly vulnerable to poorer driving-related decision-making after alcohol consumption. Results provide a meaningful target for the development of intoxicated driving prevention and intervention efforts geared specifically for individuals with trauma history.

Validation and Construct Validity of the Posttraumatic Avoidance Behaviour Questionnaire in a Sample of Trauma-Exposed Black Women

Engaging in posttraumatic avoidance behaviors after a traumatic incident is associated with posttraumatic stress disorder (PTSD) outcomes. Given the inherent limitations in the scope of the two-item assessment of posttraumatic avoidance used in commonly administered measures of PTSD symptoms, the 25-item Posttraumatic Avoidance Behaviour Questionnaire (PABQ) was developed to assess a range of avoidance behaviors, including avoidance of visual and sensory reminders, trauma-related thoughts, and agoraphobia, as well as avoidance related to the home, sleep, and social interaction. However, the PABQ's utility is limited by its lack of (a) construct validity and (b) validation in diverse samples. To address these limitations, we examined the psychometric properties of PABQ scores in a sample of trauma-exposed Black women (N = 601, M age = 41 years). Confirmatory factor analyses indicated that the original seven-factor model fit the data well when Item 8 was excluded, χ² (231, N = 602) = 497.86, RMSEA = .04, 90% CI [.04, .05], CFI = .99, TLI = .989, WRMR = .939, but reliability estimates were variable (i.e., Cronbach's αs = .70-.91). In addition, we found support for convergent validity, clinical validity, and incremental validity. These results provide evidence for the psychometric strengths of the PABQ in minority samples and suggest that it is a valid assessment of posttraumatic avoidance in Black women.

Trauma-focused cognitive behavioural therapy and exercise for chronic whiplash with comorbid posttraumatic stress disorder: a randomised controlled trial

ABSTRACT

Many people with chronic whiplash-associated disorders (WAD) have also symptoms of posttraumatic stress disorder (PTSD), but this is rarely considered in usual predominantly exercise-based interventions. We aimed to investigate the effectiveness of combined trauma-focused cognitive behavioural therapy (TF-CBT) and exercise compared with supportive therapy (ST) and exercise for people with chronic WAD and PTSD. A randomised controlled multicentre trial with concealed allocation, assessor blinding, and blinded analysis was conducted. One hundred three participants with chronic WAD (>3 months and <5 years, grade II) and PTSD were randomised to TF-CBT and exercise (n = 53) or ST and exercise (n = 50). Both interventions comprised 10 weeks of TF-CBT or ST, followed by 6 weeks of exercise. Outcomes were measured at baseline, 10, 16 weeks, 6, and 12 months after randomisation. Analysis was intention to treat using linear mixed models. There was no difference between the interventions on the primary outcome of neck pain-related disability at any time point. At 16 weeks, the treatment effect on the 0 to 100 Neck Disability Index was 0.59 (95% confidence interval [CI] 5.51 to -4.33), at 6 months 1.18 (95% CI 6.15 to -3.78), and at 12 months 1.85 (95% CI 6.81 to -3.11). In addition, there was no difference between the interventions for most secondary outcomes at any time. Exceptions were in favour of TF-CBT and exercise, where improvements in PTSD symptoms were found at 16 weeks. From 16 weeks onwards, both groups achieved a clinically important improvement in neck pain-related disability. However, both groups remained moderately disabled.

Virtual Reality Exposure Simulation for Student Veteran Social Anxiety and PTSD: A Case Study

Exposure based exercises are a common element of many gold standard treatments for anxiety disorders and post-traumatic stress disorder and virtual reality simulations have been evaluated as a platform for providing clients with opportunities for repeated exposure during treatment. Although research on virtual reality exposure therapy (VRET) indicates effectiveness and high levels of user satisfaction, VRETs require a participant to complete exposure exercises in-offices with specialized equipment. The current exploratory case method study evaluates the experience and outcomes of one student veteran with social anxiety disorder and PTSD completing twelve sessions of VRET exposure using a mobile phone simulation of a virtual grocery store. The participant reported decreases in psychological symptoms, improvements in neurological connectivity, and better sleep quality upon completing the trial. Results suggest that VRET using a mobile application is feasible and warrants further research to evaluate effectiveness more fully. Implications include the use of a mobile based virtual reality simulation for intervening in social anxiety for student veterans.

COVID-19 Stress and Mental Health of Students in Locked-Down Colleges

The impact of the COVID-19 pandemic on the mental health of students in locked-down colleges remains obscure. This study aimed to explore influencing factors for the psychological impact of COVID-19 on Wuhan college students, post-traumatic stress symptoms in particular, so as to inform evidence-based strategy development to ameliorate such adverse impacts. An online survey was conducted from 26 to 29 April 2020, and 4355 students enrolled in Wuhan universities and colleges participated. Post-Traumatic Stress Disorder via the Impact of Event-Scale-Revised was assessed. COVID-19 disproportionately affected older male Master’s and doctoral students living in Wuhan. The overall prevalence of PTSD was 16.3%. The three-level socio-interpersonal model of PTSD was empirically validated, and college students faced individual level risks such as infection with COVID-19, close relationship level risks such as family support (infection suspicion of family members, the loss of loved ones, and the family income decrease) and online course difficulties (little interaction, disturbing learning environment, and difficulty in adaption), and distant level risks such as excessive collection of personal information, estrangement of family relatives, and harassment and insult from strangers. The findings suggest the severity of the psychological impact of COVID-19. Mental health services reducing PTSD should be provided. Students who have lost loved ones and suffered family financial loss should be given particular care.

Virtual Trauma Interventions for the Treatment of Post-traumatic Stress Disorders: A Scoping Review

Some post-traumatic stress disorder (PTSD) patients do not benefit from imaginal exposure therapy. One possible approach to reach such patients are virtual trauma interventions. Herein, a qualitative scoping review was conducted. Different types of virtual trauma exposure interventions were identified. For each type of virtual trauma exposure interventions it was examined in detail: (1) which in sensu trauma exposure approach serves as therapeutic framework, how it was transferred into virtual reality, and if it was manualized; (2) which hardware and software were used; (3) whether the influence of spatial and social presence on the efficacy of virtual trauma interventions have been measured, and (4) whether the efficacy of virtual trauma interventions for PTSD patients having imagination difficulties was evaluated. These research questions were analyzed qualitatively. Accordingly, an extensive literature search was conducted using the databases Web of Science, PsycINFO, LIVIVO, PTSDpubs, and PubMed for scientific articles published between January 2013 and July 2020. Only studies aimed to reduce PTSD symptoms using virtual trauma interventions were included. The literature search was not limited to a specific study design, treatment/intervention method, or a minimum sample size. Eighteen studies were identified, which reported three different virtual trauma intervention approaches, namely, virtual reality exposure therapy (VRET), multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), and action-centered exposure therapy (ACET). Seven randomized controlled trials (RCTs), two pilot studies, and one case study were focused on VRET; while two RCTs, one pilot study, and three case studies focused on 3MDR, and two case studies on ACET. Regarding the first research question (1), the results show that VRET is based on prolonged exposure, aiming for a virtual re-creation of the patient's traumatic recounting. Several treatment protocols exist for VRET. 3MDR is based on eye movement desensitization and reprocessing, aiming to reduce the patient's avoidance behavior. In 3MDR patients walk toward individualized trauma-related symbolic images in a cave automatic virtual environment (CAVE). One treatment protocol exists for 3MDR. ACET is based on the inhibitory learning theory, aiming for active interactions with a virtual trauma-associated environment to alter the anxiety structure through new secondary inhibitory learning. One treatment protocol exists for ACET. For the second research question (2), the results indicate that all VRET studies used head-mounted displays (HMDs) with a virtual version of the Iraq/Afghanistan or the World Trade Center attacks, while 3MDR studies utilized two different versions of a CAVE with personalized trauma-related images, and the ACET studies used HMDs with virtual street scenarios. For the third research question (3), the results demonstrate that the influence of spatial or social presence on the efficacy of virtual trauma interventions was not examined in any of the included studies. Similarly, for the fourth research question (4), the results show that empirical evidence for the efficacy of virtual trauma interventions on PTSD patients having imagination difficulties was lacking. Therefore, such empirical studies are needed to fill these research gaps.

Racial discrimination and posttraumatic stress: examining emotion dysregulation as a mediator in an African American community sample

Background: African Americans experience more severe and chronic posttraumatic stress disorder (PTSD) symptoms compared to other racial groups, and thus it is important to examine factors that are relevant for the aetiology of PTSD in this population. Although racial discrimination has been implicated as an exacerbating factor in the development and maintenance of PTSD, relatively less is known about mechanisms through which this process may occur. Objective: The purpose of this study was to examine one such mechanism, emotion dysregulation, in two independent samples of African American adults. Method: Trauma-exposed participants were recruited in a large, urban community hospital setting (initial sample n = 1,841; replication sample n = 294). In the initial sample, participants completed a unidimensional measure of emotion dysregulation and self-reported PTSD symptoms based on the DSM-IV. In the replication sample, participants completed a multidimensional measure of emotion dysregulation and a diagnostic interview of PTSD symptoms based on the DSM-5. Mediation analyses were used to test our hypotheses. Results: Across both samples, results indicated that racial discrimination was indirectly associated with PTSD symptoms through emotion dysregulation (even when trauma load was added as a covariate). Conclusions: Taken together, these results provide strong evidence that the association between racial discrimination and PTSD symptoms may be partially explained by the association between racial discrimination and worse emotion dysregulation. These findings elucidate the impact of racist incidents on mental health and identify modifiable emotion regulatory processes that can be intervened upon to enhance the psychological and social wellbeing of African Americans.

Efficacy of an Early Cognitive-Behavioral Intervention for Acute Stress Disorder in Mexican Earthquake Victims

Acute stress disorder (ASD) refers to the symptoms associated with posttraumatic stress disorder (PTSD) within the first four weeks following the traumatic event. Recent theoretical models suggest that early detection of ASD provides an opportunity to implement early interventions to prevent the development of PTSD or ameliorate its symptomatology. The aim of the present study was the evaluation of the efficacy of an ASD treatment for earthquake victims, which would serve as an early intervention for PTSD. A single-case (n = 1) quasi-experimental design was used, with pre and post-assessments, as well as one, three and six-month follow-ups, with direct treatment replications. Fourteen participants completed the treatment and the follow-up measurements. The results obtained using a single-case analysis showed significant clinical improvement and clinically significant change when employing a clinical significance analysis and the reliable index of change. Statistical analyses of the dataset displayed statistically significant differences between the pre and post-assessments and the follow-up measures, as well as large effect sizes in all clinical measures. These results suggest that the treatment was an efficacious early intervention for PTSD during the months following the traumatic event, although some relevant study limitations are discussed in the text.

Re-engaging Dropouts of Prolonged Exposure for PTSD Delivered via Home-Based Telemedicine or In Person: Satisfaction with Veteran-to-Veteran Support

This paper describes feasibility of and patient and peer satisfaction with a Veteran-to-Veteran peer support program purposefully integrated into prolonged exposure (PE) for post-traumatic stress disorder (PTSD) to address barriers contributing to dropout from both in person and telemedicine delivered PE. Specifically, patients who had dropped out of PE were offered the opportunity to return to treatment, this time with a peer who themselves had completed PE, who would join them during a limited number of PE in vivo exposure homework trials. About half of the Veterans who dropped out indicated willingness to return to treatment, noting the peer as central to this decision, and about a third actually returned to treatment. Participants reported high satisfaction with the program, as did peers. Peers reported that their own symptoms were not exacerbated by engaging in exposure homework with the patients. While in the military, service members are trained to leverage the power of the group toward mission-specific tasks; and this training appears relevant to PTSD treatment in the present context.

Efficacy of Psychological Intervention for Children with Concurrent Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are common conditions following motor vehicle accidents (MVAs). Mild TBI and PTSD not only share similar features but may also coexist and interact. Nonetheless, research on psychotherapeutic interventions for PTSD in patients with a history of mTBI, particularly regarding pediatric populations, is limited. The present study compared the efficacy of the prolonged exposure treatment protocol for children and adolescents (PE-A) with PTSD and mTBI (n = 16) versus PTSD alone (n = 21); treatment commenced at least 3 months following an MVA. Emotional status and cognitive functioning were assessed pre- and postintervention using questionnaires and standardized neuropsychological tests. Participants from both groups benefitted from the intervention, as reflected in their emotional status via increased ratings of well-being and decreased ratings of PTSD, anxiety, depression, and postconcussive symptoms, η² = .21-.50. Ratings of cognitive function also improved for cognitive flexibility, η² = .30; executive function in everyday life, η² = .27; and attention and inhibition, η² = .16. Parental PTSD was the strongest predictor of improvement after intervention, sr² = .35. Thus, it appears that PE-A is an effective intervention for children with MVA-related PTSD regardless of its comorbidity with mTBI.

Cannabinoids as therapeutics for PTSD

Post-traumatic stress disorder (PTSD) is a complex disorder that involves dysregulation of multiple neurobiological systems. The traumatic stressor plays a causal role in producing psychological dysfunction and the pattern of findings suggests that the hypothalamic-pituitary-adrenal (HPA) axis, which is instrumental for stress adaptation, is critically dysfunctional in PTSD. Given the lack of understanding of the basic mechanisms and underlying pathways that cause the disorder and its heterogeneity, PTSD poses challenges for treatment. Targeting the endocannabinoid (ECB) system to treat mental disorders, and PTSD in particular, has been the focus of research and interest in recent years. The ECB system modulates multiple functions, and drugs enhancing ECB signaling have shown promise as potential therapeutic agents in stress effects and other psychiatric and medical conditions. In this review, we focus on the interaction between the ECB-HPA systems in animal models for PTSD and in patients with PTSD. We summarize evidence supporting the use of cannabinoids in preventing and treating PTSD in preclinical and clinical studies. As the HPA system plays a key role in the mediation of the stress response and the pathophysiology of PTSD, we describe preclinical studies suggesting that enhancing ECB signaling is consistent with decreasing PTSD symptoms and dysfunction of the HPA axis. Overall, we suggest that a pharmacological treatment targeted at one system (e.g., HPA) may not be very effective because of the heterogeneity of the disorder. There are abnormalities across different neurotransmitter systems in the pathophysiology of PTSD and none of these systems function uniformly among all patients with PTSD. Hence, conceptually, enhancing ECB signaling may be a more effective avenue for pharmacological treatment.

A review on how stress modulates fear conditioning: Let's not forget the role of sex and sex hormones

Stress and fear are two fields of research that have evolved simultaneously. It was not until the eighties that these domains converged in order to better characterize the impact of stress on fear memory formation. Here, we reviewed the effects of stress occurring before fear acquisition on the main phases of fear conditioning protocols (acquisition training, extinction training, extinction retention test), with a specific focus on sex and sex hormones. We also paid close attention to methodological aspects in order to better understand and characterize discrepant findings across studies. In men, stress appears to potentiate fear acquisition at a physiological level but induces lower activations of fear-related brain regions. In women, results are inconsistent. Although some studies have shown that stress lowers physiological fear responses and heightens brain activations in women during fear acquisition, many studies report no significant effects. Irrespective of sex, pre-acquisition stress seems to induce fear extinction learning resistance. Overall, few studies have taken into account sex hormones, despite their impact on both the fear and stress brain networks. As methodological variability makes it complex to draw strong conclusions, several methodological aspects are discussed with the aim of orienting future research.

Comparative Efficiency of EMDR and Prolonged Exposure in Treating Posttraumatic Stress Disorder: A Randomized Trial

The comparative treatment efficiency of eye movement desensitization and reprocessing (EMDR) therapy and prolonged exposure (PE) therapy for the treatment of posttraumatic stress disorder (PTSD) was tested for 20 participants diagnosed with PTSD. Efficiency was operationalized as the total exposure time to traumatic memories during and between sessions; the number of trauma memories processed over the course of therapy; how many sessions were required to resolve the primary trauma; and lower subjective units of disturbance (SUD) levels after the initial treatment session. Participants were randomized to each condition and received 12 90-minute sessions of therapy over 6 weeks. Symptoms were assessed by treatment-blind assessors at posttreatment, and at 3 and 6 months follow-up. Results demonstrated a significant decrease in symptoms posttreatment for PTSD (d = .64), depression (d = .46), anxiety (d = .52) and stress (d = .57) for both groups, which was maintained at 3 months. At 6 months there was a small increase in symptoms compared to the 3-month time point on the Clinician-Administered PTSD Scale (CAPS) but no significant change in any self-report symptoms EMDR was significantly more efficient than PE. EMDR participants had less total exposure time to traumatic memories when homework hours were included (d = .66), reported lower SUD scores after the first session (d = .45), required fewer sessions for the target memory to decrease to near zero distress levels (d = .84), and processed more traumatic memories.

Oestradiol, threat conditioning and extinction, post-traumatic stress disorder, and prolonged exposure therapy: A common link

The accumulating evidence regarding the impact of estradiol on learning and memory synergized studies to examine its influence on enhancing animal's ability to quell fear and anxiety. In this review, we first provide a foundational platform regarding the impact of oestradiol on cellular mechanisms of learning and memory and we review recent advances from rodent and human data showing that oestrogen enhances extinction learning across species. We then propose clinical application to these data. We discuss the potential role of oestradiol variance on the aetiology, maintenance and treatment for post-traumatic stress disorder. Specifically, we argue that the use of oestradiol as an adjunct to prolonged exposure (PE) therapy for PTSD may provide a new treatment approach for enhancing the efficacy of PE in women with PTSD. This could advance our understanding of the mechanisms of PTSD and help tailor sex-specific treatments for this disorder.

Demographic and mental health correlates of childhood emotional abuse and neglect in a Hong Kong sample

BACKGROUND

Adverse childhood experiences are an important public health issue. It is well documented that they are associated with many health problems. Nevertheless, little is known about childhood emotional abuse and neglect (CEA and CEN) among Hong Kong people.

OBJECTIVE

This study aimed to explore the demographic and mental health correlates of CEA and CEN in a Hong Kong sample.

METHODS

A total of N = 418 Hong Kong adults completed an online survey that included questions regarding demographic information and measures of adverse childhood experiences, depression, anxiety, borderline personality disorder, post-traumatic stress disorder and somatoform dissociation.

RESULTS

The rates of CEA and CEN were 43.3 % and 44.5 % respectively in this convenience sample. Both CEA and CEN were associated with poor socioeconomic status. They were also associated with psychiatric service usage and all five types of mental health problems. Both CEA and CEN increased the chance of having mental health problems even after taking into account the effects of other forms of childhood abuse and neglect.

CONCLUSIONS

This study is the first to show that CEA and CEN are significantly associated with poor socioeconomic status and mental health problems in the Hong Kong context. Implications are discussed. Further studies are needed.

Concurrent Treatment for PTSD and Prolonged Grief Disorder: Review of Outcomes for Exposure- and Nonexposure-Based Treatments

This review gives an overview of treatments used to concurrently reduce symptoms of posttraumatic stress disorder (PTSD) and prolonged grief disorder (PGD). For purposes of this review, emphasis is placed on locating and comparing literature on exposure- and nonexposure-based treatments. Across 14 studies, the overall findings suggest that treatments are generally effective in treating PTSD and PGD concurrently and that treatments incorporating exposure-based components performed similarly to those without exposure-based components. However, methodological limitations preclude the ability to draw firm conclusions about the added impact of exposure-based components in traumatic grief treatment. Future directions for research on concurrent treatments for PTSD and PGD are discussed.

The importance of using reflective practice when working with refugees, asylum seekers and survivors of torture within IAPT

There is a very high prevalence of post-traumatic stress disorder (PTSD) within refugee populations and survivors of torture. Refugees, asylum seekers and survivors of torture who access IAPT (Improving Access to Psychological Therapies) can present with unique clinical challenges for cognitive behavioural therapy (CBT) therapists. The use of reflective practice can be beneficial particularly when there is added complexity in the client's clinical presentation. The aim of this paper is to provide an overview of how reflective practice can improve clinical work with this patient group and to identify some of the challenges that refugees, asylum seekers and survivors of torture may present with during therapy. The paper sets out how the use of the critical incident analysis model and clinical supervision can assist to develop reflective practice skills and improve the clinical practice of IAPT CBT therapists who work with diverse populations.

Extinction learning with social support depends on protein synthesis in prefrontal cortex but not hippocampus

Extinction of contextual fear conditioning (CFC) in the presence of a familiar nonfearful conspecific (social support), such as that of others tasks, can occur regardless of whether the original memory is retrieved during the extinction training. Extinction with social support is blocked by the protein synthesis inhibitors anisomycin and rapamycin and by the inhibitor of gene expression 5,6-dichloro-1-β-d-ribofuranosylbenzimidazole infused immediately after extinction training into the ventromedial prefrontal cortex (vmPFC) but unlike regular CFC extinction not in the CA1 region of the dorsal hippocampus. So social support generates a form of learning that differs from extinction acquired without social support in terms of the brain structures involved. This finding may lead to a better understanding of the brain mechanisms involved in the social support of memories and in therapies for disorders related to dysfunctional fear memories. Thus, here we show that the consolidation of extinction memory with social support relies on vmPFC rather than hippocampus gene expression and ribosomal- and mammalian target of rapamycin-dependent protein synthesis. These results provide additional knowledge about the cellular mechanisms and brain structures involved on the effect of social support in changing behavior and fear extinction memory.

The clinical applications and practical relevance of human conditioning paradigms for posttraumatic stress disorder

The classical conditioning paradigm of fear learning has spawned a number of experimental variations for the explanation of posttraumatic stress disorder (PTSD) etiology. These paradigms include extinction learning and recall, fear inhibition, fear generalization, and conditioned avoidance. As such, each of these paradigms have significant applications for understanding the development, maintenance, treatment, and relapse of the fear-related features of PTSD. In the present review, we describe each of these conditioning-based paradigms with reference to the clinical applications, and supported by case examples from patients with severe PTSD symptoms. We also review the neurobiological models of conditioning and extinction in animals, psychiatrically healthy humans, and PTSD patients, and discuss the current balance of evidence suggesting a number of biological, behavioral, and cognitive mechanisms/moderators of the conditioning and extinction process in experimental and clinical contexts.

PTSD and the influence of context: The self as a social mirror

The principal accepted models of posttraumatic stress disorder (PTSD) are based on both memory processing and biological/brain changes occurring when one's life or well-being is threatened. It is our thesis that these models would be greatly informed by community studies indicating that PTSD is predicted to a greater extent by earlier life experience and experiences that occur distant from the threatening event. These findings suggest posttraumatic responding is best conceptualized through the lens of the self-in-context, as opposed to imprinting that results from a given event at a given time. Moreover, studies of non-Western populations often do not express trauma as PTSD, or at least not primarily as PTSD, which argues against specific neural or memory encoding processes, but rather for a more plastic neural process that is shaped by experience and how the self develops in its cultural context, as a product of a broad array of experiences. We posit that fear and emotional conditioning as well as the ways traumas are encoded in memory are only partial explanatory mechanisms for trauma responding, and that issues of safety and harm, which are long term and developmental, are the common and principal underpinnings of the occurrence of posttraumatic distress, including PTSD.

Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: task-shifting randomised controlled trial

BACKGROUND

Empirical evidence on the effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed.AimsTo evaluate the comparative effectiveness of prolonged exposure and supportive counselling in adolescents with PTSD.

METHOD

Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment (trial registration in the Pan African Clinical Trials Registry: PACTR201511001345372). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale at pre-treatment, post-treatment, and at 3- and 6-month follow-up.

RESULTS

Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving supportive counselling (between group differences at post-intervention, mean 12.49, 95% CI 6.82-18.17, P<0.001; d = 1.22). A similar effect size was maintained at 3-month (d = 0.85) and 6-month (d = 1.02) follow-up assessments.

CONCLUSIONS

Adolescents with PTSD experienced greater benefit from prolonged exposure treatment when provided by non-specialist health workers (nurses) in a community setting.Declaration of interestNone.

Prolonged exposure therapy and supportive counselling for posttraumatic stress disorder in adolescents in a community-based sample, including experiences of stakeholders: study protocol for a comparative randomized controlled trial using task-shifting

BACKGROUND

There is a dearth of empirical evidence on the effectiveness of pharmacological and non-pharmacological treatments for adolescents with posttraumatic stress disorder (PTSD) in developing countries. The primary aim of the study is to examine the effects of prolonged exposure therapy compared with supportive counseling for adolescents with PTSD delivered by nurses trained as counselors.

METHODS/DESIGN

A single-blind randomized clinical trial comprising 90 adolescents with PTSD using a permuted block design will be utilized. Nurses previously naïve to prolonged exposure and supportive counselling will be trained to provide these treatments at the adolescents' high schools. Data collection will last from March 2014 to December 2017 and annually thereafter, dependent on the availability of funding. Participants will receive seven to fourteen 60 min sessions of prolonged exposure treatment (n = 45) or supportive counselling (n = 45). All assessments will be conducted before treatment, at mid-treatment, immediately after treatment completion, at 3-, 6-, and 12-month follow-up, and annually thereafter. It is hypothesized that PE-A will be superior to SC in reducing PTSD symptoms at post-treatment as measured by the CPSS-I administered by an independent evaluator. It is further hypothesized that PE-A treatment gains will be maintained at 3-, 6- and 12-month follow-ups and annually thereafter.

DISCUSSION

While early indications are that PE-A is an effective treatment for PTSD in adolescents, this study will help determine the effectiveness of PE-A in a South African, community setting (school-based) when task-shifted to nurses, as compared to SC.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR201511001345372 , retrospectively registered 11 November 2015.

Tolerance of negative emotion moderates the amplification of mental contamination following an evoking task: A randomized experimental study

BACKGROUND AND OBJECTIVES

Contamination is a near universal feeling, with mental contamination representing a contamination feeling in the absence of direct physical contact with a source. Extant research indicates that tolerance of negative emotion is important for understanding emotional reactions to images, thoughts, and memories, all of which are common sources of mental contamination. Extending research linking distress tolerance to mental contamination, this study examined if individual differences in the tolerance of negative emotion moderates the amplification of mental contamination following an evoking task.

METHOD

Unselected participants completed a self-report measure of tolerance of negative emotion during an online session. They later attended an in-person session and were randomized to an experimental scenario group: betrayal (n = 49) or control (n = 49). Participants imagined themselves in a scenario, with the betrayal scenario designed to evoke mental contamination. Mental contamination was assessed by self-report before and after the scenario.

RESULTS

The betrayal, but not control, scenario caused an increase in mental contamination. Tolerance for negative emotion moderated the effect of group on mental contamination. Group differences in mental contamination evidenced at low, but not high, distress tolerance.

LIMITATIONS

A novel experimental manipulation and an unselected sample were used. Future research could assess tolerance of negative emotion using a behavioral task.

CONCLUSIONS

These results indicate that tolerance of negative emotion may be important for understanding when individuals experience mental contamination.

A Novel, Integrated Cognitive-Behavioral Therapy for Co-Occurring Posttraumatic Stress and Substance Use Disorders: A Case Study

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are complex psychiatric conditions that commonly co-occur. No preferred, evidence-based treatments for PTSD/SUD comorbidity are presently available. Promising integrated treatments have combined prolonged exposure therapy with cognitive-behavioral relapse prevention therapy for SUD. We describe a case study that showcases a novel, integrated cognitive-behavioral treatment approach for PTSD/SUD, entitled Treatment of Integrated Posttraumatic Stress and Substance Use (TIPSS). The TIPSS program integrates cognitive processing therapy with cognitive-behavioral therapy for SUD for the treatment of co-occurring PTSD/SUD. The present case report, based upon a woman with PTSD comorbid with both cocaine and alcohol dependence, demonstrates that TIPSS has the potential to effectively reduce PTSD symptoms as well as substance use.

An open trial of individualized face-to-face cognitive behavior therapy for psychological distress in parents of children after end of treatment for childhood cancer including a cognitive behavioral conceptualization

OBJECTIVE

A subgroup of parents of children who have been treated for childhood cancer report high levels of psychological distress. To date there is no empirically supported psychological treatment targeting cancer-related psychological distress in this population. The aim of the current study was to test the feasibility and preliminarily evaluate the effect of individualized face-to-face cognitive behavior therapy (CBT) for parents of children after the end of treatment for childhood cancer. A secondary aim was to present a cognitive behavioral conceptualization of cancer-related distress for these parents.

METHODS

An open trial was conducted where 15 parents of children who had completed successful treatment for cancer three months to five years earlier and who reported psychological distress related to a child's previous cancer disease were provided CBT at a maximum of 15 sessions. Participants were assessed at baseline, post-intervention, and three-month follow-up using self-reported psychological distress (including posttraumatic stress symptoms (PTSS), depression, and anxiety) and the diagnostic Mini-International Neuropsychiatric Interview. Feasibility outcomes relating to recruitment, data collection, and delivery of the treatment were also examined. Individual case formulations for each participant guided the intervention and these were aggregated and presented in a conceptualization detailing core symptoms and their suggested maintenance mechanisms.

RESULTS

A total of 93% of the participants completed the treatment and all of them completed the follow-up assessment. From baseline to post-assessment, parents reported significant improvements in PTSS, depression, and anxiety with medium to large effect sizes (Cohen's d = 0.65-0.92). Results were maintained or improved at a three-month follow-up. At baseline, seven (47%) participants fulfilled the diagnostic criteria for major depressive disorder and four (29%) fulfilled the criteria for posttraumatic stress disorder, compared to none at a post-assessment and a follow-up assessment. The resulting cognitive behavioral conceptualization suggests traumatic stress and depression as the core features of distress, and avoidance and inactivity is suggested as the core maintenance mechanisms.

CONCLUSION

The treatment was feasible and acceptable to the participants. Significant improvements in distress were observed during the study. Overall, results suggest that the psychological treatment for parents of children after end of treatment for childhood cancer used in the current study is promising and should be tested and evaluated in future studies.