Randomized controlled trial of multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) for male military veterans with treatment-resistant post-traumatic stress disorder

OBJECTIVE

To explore the potential efficacy of multi-modular motion-assisted memory desensitization and reprocessing (3MDR) in British military veterans with treatment-resistant service-related PTSD.

METHODS

Exploratory single-blind, randomized, parallel arm, cross-over controlled trial with nested process evaluation to assess fidelity, adherence and factors that influence outcome.

RESULTS

A total of 42 participants (all male) were randomized with 83% retention at 12 weeks and 86% at 26 weeks. The difference in mean Clinician-Administered PTSD Scale for DSM-5 scores between the immediate and delayed 3MDR arms was -9.38 (95% CI -17.33 to -1.44, P = 0.021) at 12 weeks and -3.59 (-14.39 to 7.20, P = 0.513) at 26 weeks when both groups had received 3MDR. The likely effect size of 3MDR was found to be 0.65. Improvements were maintained at 26-week follow-up. 3MDR was found to be acceptable to most, but not all, participants. Several factors that may impact efficacy and acceptability of 3MDR were identified.

CONCLUSION

3MDR is a promising new intervention for treatment-resistant PTSD with emerging evidence of effect.

Internet-delivered cognitive behavioural therapy for post-traumatic stress disorder: systematic review and meta-analysis

OBJECTIVE

To determine whether Internet-delivered cognitive behavioural therapy (i-CBT) is an effective treatment for those who meet diagnostic criteria for post-traumatic stress disorder (PTSD).

METHOD

A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measures were reduction in PTSD symptoms and drop-out. Categorical outcomes were meta-analysed as risk ratios (RRs) and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs).

RESULTS

Ten studies with 720 participants were included. Evidence showed that i-CBT may be associated with a clinically important reduction in post-treatment PTSD symptoms compared with wait list (SMD -0.60, 95% confidence interval -0.97 to -0.24; N = 560); however, only three studies reported follow-up data, and there was no evidence to support the maintenance of symptom improvement at follow-up of 3-6 months. There was no evidence of a difference in PTSD symptoms between i-CBT and Internet-delivered non-CBT post-treatment. There was evidence of greater treatment effect from trauma-focused i-CBT than i-CBT without a trauma focus, as well as evidence that treatment effect was increased by the provision of guidance.

CONCLUSIONS

While the review found some beneficial effects of i-CBT for PTSD post-treatment, the quality of the evidence was very low because of the small number of included trials and there was insufficient evidence to support the maintenance of improvement at follow-up of 3-6 months. Further work is required to establish non-inferiority to current first-line interventions; to determine long-term efficacy; to explore mechanisms of effect; and to establish optimal levels of guidance.

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD

OBJECTIVE

The purpose of this study was to finalize the development of the International Trauma Questionnaire (ITQ), a self-report diagnostic measure of post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD), as defined in the 11th version of the International Classification of Diseases (ICD-11).

METHOD

The optimal symptom indicators of PTSD and CPTSD were identified by applying item response theory (IRT) analysis to data from a trauma-exposed community sample (n = 1051) and a trauma-exposed clinical sample (n = 247) from the United Kingdom. The validity of the optimized 12-item ITQ was assessed with confirmatory factor analyses. Diagnostic rates were estimated and compared to previous validation studies.

RESULTS

The latent structure of the 12-item, optimized ITQ was consistent with prior findings, and diagnostic rates of PTSD and CPTSD were in line with previous estimates.

CONCLUSION

The ITQ is a brief, simply worded measure of the core features of PTSD and CPTSD. It is consistent with the organizing principles of the ICD-11 to maximize clinical utility and international applicability through a focus on a limited but central set of symptoms. The measure is freely available and can be found in the body of this paper.

Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire

OBJECTIVE

The 11th version of the International Classification of Diseases (ICD-11) has proposed two related trauma diagnoses: Post-traumatic stress disorder (PTSD) and Complex PTSD (CPTSD). Using a newly developed, disorder-specific measure of PTSD and CPTSD called the International Trauma Questionnaire (ITQ) the current study will (i) assess the factorial validity of ICD-11 PTSD and CPTSD; (ii) provide the first test of the discriminant validity of these constructs; and (iii) provide the first comparison of ICD-11, and Diagnostic and Statistical Manual, Fifth Edition (DSM-5), PTSD diagnostic rates using disorder-specific measures.

METHOD

ICD-11 and DSM-5 PTSD-specific measures were completed by a British clinical sample of trauma-exposed patients (N = 171). The structure and validity of ICD-11 PTSD and CPTSD were assessed by means of factor analysis and assessing relationships with criterion variables.

RESULTS

Diagnostic rates under ICD-11 were significantly lower than those under DSM-5. A two-factor second-order model reflecting the distinction between PTSD and CPTSD best represented the data from the ITQ; and the PTSD and CPTSD factors differentially predicted multiple psychological variables.

CONCLUSION

The factorial and discriminant validity of ICD-11 PTSD and CPTSD was supported, and ICD-11 produces fewer diagnostic cases than DSM-5.

Alternative models of disorders of traumatic stress based on the new ICD-11 proposals

OBJECTIVE

Although there is emerging evidence for the factorial validity of the distinction between post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) proposed in ICD-11, such evidence has been predominantly based on using selected items from individual scales that describe these factors. We have attempted to address this gap in the literature by testing a range of alternative models of disorders of traumatic stress using a broader range of symptoms and standardized measures.

METHOD

Participants in this cross-sectional study were a sample of individuals who were referred for psychological therapy to a National Health Service (NHS) trauma centre in Scotland (N = 195). Participants were recruited over a period of 18 months and completed measures of stressful life events, DSM-5 PTSD, emotion dysregulation, self-esteem and interpersonal difficulties.

RESULTS

Overall, results indicate that a structural model incorporating six first-order factors (re-experiencing, avoidance of traumatic reminders, sense of threat, affective dysregulation, negative self-concept and disturbances in relationships) and two second-order factors (PTSD and disturbances in self-organization [DSO]) was the best fitting. The model presented with good concurrent validity. Childhood trauma was found to be more strongly associated with DSO than with PTSD.

CONCLUSION

Our results are in support of the ICD-11 proposals for PTSD and CPTSD.

Experience of implementing an adult educational approach to treating anxiety disorders

This paper describes the background to the development and delivery of a self-help package for anxiety disorders. Evidence of effectiveness is summarized. The paper outlines the intervention and describes the experience of two mental health nurses, who set out to assess its acceptability, evaluate its outcomes in routine clinical practice and assess the feasibility of its delivery by mental health nurses. Acceptability of the intervention was high, judged by retention and attendance rates. The pilot study produced promising clinical outcomes, especially for people with depression secondary to anxiety. Clinical measures showed significant improvements from pre-course to 6-month follow-up in anxiety, psychological well-being and depression. The outcomes suggest that appropriately trained mental health nurses could deliver the intervention as a routine treatment. The paper concludes by discussing future plans, including a randomized controlled trial and implementation in primary care.

The prevalence and predictors of psychological distress in patients with early localized prostate cancer

OBJECTIVE

To determine the level of psychopathology, traumatic distress and quality of life in men with newly diagnosed clinically localized prostate cancer, the effect on these of a consultation in a combined-specialist early-prostate clinic, and predictors of psychopathology.

PATIENTS AND METHODS

Eighty-eight patients were recruited from the combined clinic; they completed a battery of questionnaires including the Hospital Anxiety and Depression Scale (HADS), the revised Impact of Event Scale (IES) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, before their first appointment. Two weeks later they completed the HADS, IES and a patient-satisfaction survey.

RESULTS

The overall level of psychopathology varied among the questionnaires used, from 0% on the HADS depression scale, 8% on the HADS anxiety scale and 14% on the IES. Anxiety and traumatic stress symptoms were commoner than depressive symptoms. The quality-of-life scores showed a relatively good level of functioning. Pre-morbid factors and disease status did not predict psychological distress. Younger age was mildly predictive of poorer psychological functioning. Anxiety symptoms reduced slightly after a joint clinic appointment, whereas depressive symptoms showed a slight increase.

CONCLUSION

This study suggests that men with early localized prostate cancer have low levels of psychopathology overall. However, some men experience distressing psychological symptoms and it is important that future research is conducted to help develop clear guidelines on the optimal methods of detecting and managing men with prostate cancer who have mental health difficulties.

Posttraumatic stress reactions after injury

BACKGROUND

Many individuals experience psychological distress after injury. It is unclear whether poor psychological outcome reflects pretrauma variables.

METHODS

In a prospective, cross-sectional study, 152 accident and emergency department patients with physical injuries and an acute stress reaction completed trauma and psychometric questionnaires, including the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

RESULTS

Although levels of pretrauma social, occupational, and familial functioning were high, and the modal Abbreviated Injury Scale score was 1, there were high levels of psychological distress at 3 weeks. Mean Hospital Anxiety and Depression Scale anxiety and depression scores were 11.8 (SD, 4.4) and 8.7 (SD, 4.4), respectively. The mean total Impact of Event Scale score was 46.0 (SD, 16.1). Stepwise linear regression analysis found unemployment and previous history of trauma to be associated with increased symptoms of traumatic stress.

CONCLUSION

Trauma patients with high levels of pretrauma functioning may develop acute psychological distress. Unemployment and previous trauma increase risk. Psychological wellbeing should be considered in routine injury assessments.

Follow-up study of British military hostages and their families held in Kuwait during the Gulf War

On 2 August 1990 Iraq invaded Kuwait and held hostage all its inhabitants. Amongst those forced to stay were 71 British servicemen and their families who were held hostage for up to four and a half months. This study investigated the mental health status of this group of individuals at 6 and 18 months after the final hostage was released. Participants completed the Impact of Event Scale and the 28-item version of the General Health Questionnaire at both 6 and 18 months. In addition they completed a questionnaire regarding background factors, the dimensions of the trauma and the effects of their hostage experience. The Impact of Event Scale scores changed little over time whereas the General Health Questionnaire scores reduced significantly (p = .001) over the 12-month period suggesting that despite ongoing intrusive and avoidance phenomena levels of psychological distress did reduce. Those variables most strongly associated with a poor psychological outcome were witnessing physical violence and perceived deterioration in physical and mental health. Poor outcome at 6 months was strongly correlated with poor outcome at 18 months.

Psychological sequelae of facial trauma

BACKGROUND

Facial trauma is common in accidents and assaults and can be accompanied by distressing psychological sequelae.

METHODS

Retrospective analysis of case notes followed by a prospective assessment of consecutive facial trauma victims was performed to determine the prevalence and detection rate of psychological sequelae.

RESULTS

Only 8 of 47 case notes (17%) contained any reference to mental state. Forty-three patients completed initial assessment and 7-week questionnaires. Twelve (27%) were suffering from posttraumatic stress disorder at 7 weeks. Factors significantly associated with poorer outcome were higher initial Hospital Anxiety and Depression Scale and Impact of Event Scale scores, assault injury fractures, and prediction of psychological sequelae by junior oral surgeons.

CONCLUSION

More than one-quarter of victims of facial trauma in this study developed posttraumatic stress disorder, documentation of which was poor. The study suggests that psychological sequelae can be predicted using simple measures such as a basic initial assessment by nonmedically qualified personnel.

Randomised controlled trial of psychological debriefing for victims of acute burn trauma

BACKGROUND

Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae.

METHOD

One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later.

RESULTS

Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome.

CONCLUSION

This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives.

Early psychological reactions in a group of individuals with pre-existing and enduring mental health difficulties following a major coach accident

BACKGROUND

The impact of major trauma on individuals with pre-existing and enduring mental health difficulties is poorly understood.

METHOD

Twenty individuals with pre-existing and enduring mental health difficulties were assessed with the Clinician Administered Post Traumatic Stress Disorder Scale, the 28-item version of the GHO, the Hospital Anxiety and Depression Scale, and the impact of Event Scale between four and eight weeks after their involvement in a major coach accident.

RESULTS

Ten (50%) individuals satisfied the full DSM-IV criteria for a diagnosis of PTSD. The questionnaire scores indicated a high level of psychological suffering among the group. On dividing the sample into those individuals with previous diagnosis of anxiety or depressive disorders and those with a previous diagnosis of chronic schizophrenia, the schizophrenia group displayed less marked psychological sequelae on all measures.

CONCLUSION

There was a high incidence of early psychological sequelae among the group as a whole. Some diagnoses (e.g. depression and anxiety) may predispose to psychological sequelae while others (e.g. chronic schizophrenia) may not.

Dealing with disasters: does psychological debriefing work?

The psychological aftermath of disaster causes significant long-term psychiatric disability and suffering to victims and rescuers alike. This paper examines the effectiveness of psychological debriefing (PD), an early intervention that is widely used and claimed to reduce long-term psychiatric morbidity in the wake of disaster. Numerous factors hamper the design of methodologically sound research in this field and there is a lack of controlled studies supporting the efficacy of PD. Further research is needed to demonstrate the effectiveness of any immediate psychological intervention before significant resources are allocated to their routine provision.

Taped imaginal exposure as a treatment for post-traumatic stress reactions

The efficacy of taped imaginal exposure as a treatment for Post-Traumatic Stress Reactions (PTSR) was assessed in eighteen consecutive outpatients, including Gulf War veterans. Detailed present-tense scripts of their personal traumatic experiences were prepared and in all but two cases audio-taped and listened to regularly. The severity of PTSR and standard questionnaire scores (including the IES, BDI, GHQ8 and the SCL 90) all showed statistically significant improvements post treatment and at three month follow-up. This case series confirms the potential efficacy of taped imaginal exposure in the treatment of full and partial forms of Post-Traumatic Stress Disorder (PTSD). The simplicity of its administration and acceptability to the individual suggest that it is worthy of more thorough research.

A comparison of carbohydrate deficient transferrin with other markers of alcohol misuse in male soldiers under the age of thirty

The paper describes a study of 58 consecutive male soldiers under 30 years old admitted to an alcohol treatment unit in London, and 51 age- and gender-matched controls to compare the efficacy of isoelectric focusing, a non-quantitative measure of carbohydrate deficient transferrin (CDT), with other markers of alcohol misuse. The Severity of Alcohol Dependence Questionnaire, the Michigan Alcohol Screening Test and the CAGE questions were all more sensitive in detecting alcohol misusers than the laboratory markers measured. At standard cut-off levels, the laboratory markers yielded low sensitivities even in those subjects who admitted to drinking over 80 g alcohol daily for at least 3 weeks immediately prior to the study. CDT was the most sensitive (31%), followed by mean cell volume (14%) and gamma glutamyl transferase (11%). The questionnaires and laboratory markers had good specificities.

Automatism and post-traumatic stress disorder

A soldier with post-traumatic stress disorder (PTSD) who committed a criminal act during a dissociative episode is described. This report and other published cases indicate that criminal acts can occur during dissociative episodes among people who suffer from PTSD. However, the evidence suggests that such incidents are rare and may be overemphasised. There often seems to be little relationship between the crimes committed by war veterans and their war experiences.