A trial of prolonged exposure therapy for outpatients with comorbid bipolar disorder and posttraumatic stress disorder (PTSD)

BACKGROUND

Bipolar disorder and posttraumatic stress disorder (PTSD) commonly co-occur, but no treatment guidelines exist for this population. Prolonged exposure (PE) is a well-established and efficacious treatment for PTSD, untested in patients with comorbid bipolar disorder. The current study evaluates the feasibility and preliminary efficacy of PE for patients with bipolar disorder and PTSD.

METHODS

Participants were enrolled in PE and completed assessments of PTSD symptoms, suicidality, state and trait anxiety, depression, and mania at baseline, Sessions 5 and 10, and at 6-months post-treatment.

RESULTS

32 patients enrolled in this study, with 75 % (24/32) completing all ten PE sessions and 50 % completing 6-month follow-up assessments. PTSD symptoms decreased from baseline to Session 10 and continued to decrease throughout the follow-up period. Suicidality, measured by implicit associations between self and death, showed a similar pattern of decrease over treatment and follow-up periods. Suicidal thinking and depressive symptoms decreased from baseline through Session 10 and rebounded slightly, remaining below baseline at 6-months follow-up. State and trait anxiety increased initially through Session 5 but then decreased and remained stable. Mania scores remained stable at all assessment periods.

LIMITATIONS

The study is limited by a small sample size and absence of a control condition. Criterion A trauma was not required, limiting generalizability, and there was significant attrition at follow-up.

CONCLUSIONS

These findings suggest that PE is a feasible and preliminarily efficacious treatment for patients with bipolar disorder and comorbid PTSD, and support the conduct of a fully powered efficacy of PE for this comorbidity.

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

122 PTSD Symptom Clusters as Predictors of Pain Interference in Burn Survivors

Introduction

Individuals who experience burns are at higher risk of developing post-traumatic stress disorder (PTSD) and chronic pain. There exists a synergistic relationship between PTSD and chronic pain in burn survivors. Theories exist about how aspects of each condition may perpetuate one another, or share underlying mechanisms. Both of these conditions are of relevance to pain-related disability. We sought to examine the role of individual PTSD symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two PTSD symptom clusters, pain intensity, and other covariates (burn size, hospital length of stay, age and gender).

Methods

Data were analyzed from the Burn Model System National Database. Inclusion criteria required participants to have a moderate to severe burn injury that required surgery for wound closure. Patient-reported outcome data: PTSD Checklist - Civilian, PROMIS-Pain Interference Short Form 4a, and a 0-10 average Pain Intensity item were analyzed at 6-months after injury. Hierarchical linear regression models were fit to examine the impact of PTSD symptom clusters on pain interference over and above that of pain intensity, and standardized betas were calculated (B).

Results

A total of 439 adult participants had complete responses on the measures of interest (e.g. PTSD symptoms, PROMIS-Pain Interference, and Pain Intensity) and were included in the analysis. Mean age, percent total body surface area burned, and hospital length of stay were 47 years, 18%, and 27 days, respectively. 69% were male and 82% were Caucasian. Results of a linear regression found that hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) PTSD symptom clusters were each significant predictors of pain-related disability, even when accounting for pain intensity (B = .64, p < .001). The covariates age, gender, days until discharge, and TBSA were all nonsignificant. The model accounted for 61% of the variance associated with pain-related disability.

Conclusions

Results highlight the importance of the emotional numbing and hyperarousal PTSD symptom clusters in explaining pain interference. Future evaluations parsing out the longitudinal relationships (i.e., beyond 6-months postburn) between PTSD symptom clusters, pain intensity, and pain interference, as well as evaluating other underlying mechanisms, are warranted.

Evaluating chronic suicide risk with the Personality Assessment Inventory: Development and initial validation of the Chronic Suicide Risk Index (S_Chron)

The current study sought to develop and validate a new measure of chronic suicide risk (the S_Chron) from the Personality Assessment Inventory in a mixed sample of psychiatric inpatients and outpatients. In an initial development sample (N=397), hierarchical logistic regression identified six PAI variables uniquely associated with multiple versus single/no prior suicide attempts after controlling for sample demographics: Negative Impression Management, Situational Stress, Mania - Grandiosity, Borderline - Negative Relationships, Borderline - Self-Harm, and Antisocial Behaviors. These indicators were then aggregated into a single index (S_Chron) and evaluated in terms of validity in an independent clinical sample (N=398). Results indicated the S_Chron effectively differentiated between groups with multiple versus single/no prior suicide attempts, even after controlling for the effects of the PAI Suicidal Ideation (SUI) and Suicide Potential (SPI) indices, with moderate to large effect sizes observed (range of Cohen's d's=0.30-0.91). Further, the S_Chron incremented all other PAI indices and SUI in predicting multiple suicide attempts. The potential clinical application and ways in which the S_Chron may augment other existing measures of suicide risk are discussed.

Changes in Positive Quality of Life over the Course of Psychotherapy

The objective of this study was to examine patients' reports of positive quality of life over the course of multiple forms of psychotherapy and disorders. Data from five studies using a common assessment battery were pooled to evaluate the magnitude of change in positive quality of life and explore the relation of change in positive quality of life to change in symptoms, and how these relations vary by disorder. Positive quality of life was measured at intake, termination, and during two post-treatment visits 6 and 12 months following termination. Results revealed that positive quality of life improves moderately over the course of psychotherapy and sustains the improvement through follow-up. Levels of positive quality of life and the degree of change in positive quality of life varied considerably by disorder. There also were moderate sized correlations between changes in positive quality of life and changes in symptomatic response and interpersonal functioning from intake to termination. Implications of the findings for clinical practice and future research are discussed.