The effects of a combination of cognitive interventions and loving-kindness meditations (C-METTA) on guilt, shame and PTSD symptoms: results from a pilot randomized controlled trial

Background: Trauma-related guilt and shame are crucial for the development and maintenance of PTSD (posttraumatic stress disorder). We developed an intervention combining cognitive techniques with loving-kindness meditations (C-METTA) that specifically target these emotions. C-METTA is an intervention of six weekly individual treatment sessions followed by a four-week practice phase.Objective: This study examined C-METTA in a proof-of-concept study within a randomized wait-list controlled trial.Method: We randomly assigned 32 trauma-exposed patients with a DSM-5 diagnosis to C-METTA or a wait-list condition (WL). Primary outcomes were clinician-rated PTSD symptoms (CAPS-5) and trauma-related guilt and shame. Secondary outcomes included psychopathology, self-criticism, well-being, and self-compassion. Outcomes were assessed before the intervention phase and after the practice phase.Results: Mixed-design analyses showed greater reductions in C-METTA versus WL in clinician-rated PTSD symptoms (d = -1.09), guilt (d = -2.85), shame (d = -2.14), psychopathology and self-criticism.Conclusion: Our findings support positive outcomes of C-METTA and might contribute to improved care for patients with stress-related disorders. The study was registered in the German Clinical Trials Register (DRKS00023470).

A preliminary study on the effect of trauma-focused therapies on sexual dysfunctions in women with PTSD after childhood abuse

BACKGROUND

Posttraumatic stress disorder (PTSD) is often associated with female sexual dysfunctions (FSD). However, little is known about the impact of therapies for PTSD on FSD according to DSM-5 criteria.

AIM/OBJECTIVE

To examine if sexual functioning diagnosed according to DSM-5 criteria improves after treatment for PTSD in women with a PTSD diagnosis after interpersonal child abuse.

METHOD

FSD according to DSM-5 criteria were assessed with the structured clinical interview SISEX in N = 152 female participants (mean age = 36.5 years) of a large randomized controlled trial three months into treatment and after 15 months of receiving either dialectical behavior therapy for PTSD or cognitive processing therapy. Number of fulfilled FSD criteria and diagnostic status were compared from pre-to post-treatment using Poisson and negative binomial regression analyses and the McNemar test. The effect of treatment type on reduction of FSD symptoms and the association between reduction in PTSD symptoms and reduction in FSD symptoms were assessed.

RESULTS

From pre-to post-treatment, the number of fulfilled criteria for each FSD decreased (Incident rate ratios between 0.60 and 0.71, p between <. 001 and <0 .05). Less women met criteria for genito-pelvic pain/penetration disorder at post-treatment compared to pre-treatment (11.8 % vs. 6.6 %, p < .05). No difference was found between treatments in reduction of FSD symptoms. Reduction of PTSD symptoms was associated with greater decrease in FSD symptoms.

CONCLUSIONS

Our results suggest a positive association between effective PTSD treatments and improvements in sexual functioning of women with PTSD after child abuse.

Sexual Dysfunctions in Women with Posttraumatic Stress Disorder Following Childhood Sexual Abuse: Prevalence Rates According to DSM-5 and Clinical Correlates

Many women with posttraumatic stress disorder (PTSD) after child sexual abuse (CSA) suffer from sexual problems. However, little is known about the frequency of female sexual dysfunctions (FSD) as defined by DSM-5 among women with PTSD due to CSA. Furthermore, factors related to FSD in this patient population are understudied. To assess prevalence rates and clinical correlates of FSD according to DSM-5 criteria in women with PTSD after CSA, a structured clinical interview for sexual dysfunctions according to DSM-5 criteria was administered in a sample of 137 women with PTSD after CSA. Participants also completed measures for PTSD, depression symptoms, and borderline personality disorder symptoms. The association between FSD, severity of abuse, PTSD-, depression-, borderline symptom severity, and age was examined. In a second step, the association between FSD and PTSD-clusters was assessed. Diagnostic criteria of female sexual interest/arousal disorder (FSIAD) were met by 2.6% of women in our sample. 5.2% met criteria of female orgasmic disorder (FOD), and 11.8% those of genito-pelvic pain/penetration disorder (GPPPD). PTSD symptom severity predicted number of fulfilled criteria of FSIAD and FOD, the cluster "negative alterations in cognition and mood," was associated with more fulfilled criteria in FSIAD and FOD. The majority of women reported sexual problems, but diagnostic criteria of FSD were met by only a small number of participants. PTSD symptoms, especially the cluster "negative alterations in cognition and mood," seem to be related to female sexual functioning after CSA.

Is adherence to dialectic behaviour therapy for post-traumatic stress disorder (PTSD) and cognitive processing therapy related to treatment outcome in PTSD after childhood abuse?

Background: Literature on the association between therapist adherence and treatment success in the treatment of post-traumatic stress disorder (PTSD) is scarce, and the results are mixed.Objective: To examine the relationship between therapist adherence to dialectical behaviour therapy for PTSD (DBT-PTSD) and cognitive processing therapy (CPT) on treatment outcome in women with PTSD and emotion regulation difficulties after interpersonal childhood abuse.Method: Videotaped therapy sessions from 160 female participants of a large randomized controlled trial [Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse. JAMA Psychiatry, 77(12), 1235. jamapsychiatry.2020.2148] were rated. Adherence to CPT and DBT-PTSD was assessed using two specifically developed rating scales.Results: Higher therapist adherence was associated with a greater reduction of clinician-rated PTSD symptom severity. This effect was more pronounced in the CPT group than in the DBT-PTSD group. Adherence was also related to a greater reduction of self-rated PTSD symptoms, borderline symptoms, and dissociation intensity.Conclusion: Our results indicate that higher therapist adherence can lead to better treatment outcomes in PTSD treatments, especially in CPT.

Does treatment specific-, disorder specific- or general therapeutic competence predict symptom reduction in posttraumatic stress disorder?

Background: Literature on the association between therapist competence and treatment success in posttraumatic stress disorder (PTSD) treatments is scarce and results are mixed.Aims/Objective: The relationship between different types of therapeutic competence, therapeutic alliance, and PTSD symptom reduction in patients treated with Dialectical Behaviour Therapy for PTSD (DBT-PTSD) or Cognitive Processing Therapy (CPT) was assessed. Competence types were PTSD-specific competence, treatment specific competence, and general competence in cognitive behaviour therapy (CBT).Method: Videotaped therapy sessions from N = 160 women with PTSD and emotion regulation difficulties after child abuse participating in a large randomised controlled trial (Bohus et al., 2020) were rated. Three therapeutic competence-types were assessed using specifically developed rating scales. Alliance was assessed via patient ratings with the Helping Alliance Questionnaire (HAQ). PTSD symptoms were assessed at pre- and post-treatment via clinician rating with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and via self-rating with the PTSD-Checklist for DSM-5 (PCL-5).Results: No significant association between competence and clinician or self-rated PTSD symptoms was found. PTSD specific competence predicted clinician rated PTSD symptom severity on a trend level. Alliance predicted both clinician and self-rated PTSD symptom reduction.Conclusion: Our results provide a starting point for future research on different competence types and their association with PTSD treatment gains. Therapists were highly trained and received weekly supervision, hence a restricted competence range is a possible explanation for non-existing associations between competence and PTSD symptom reduction in our sample. More research in naturalistic settings, such as dissemination studies, is needed.

Neurostructural associations with traumatic experiences during child- and adulthood

Adverse experiences can lead to severe mental health problems, such as posttraumatic stress disorder (PTSD), throughout the lifespan. In individuals with PTSD, both global and local brain volume reductions have been reported-especially in the amygdala and hippocampus-while the literature on childhood maltreatment suggests a strong dependency on the timing of adverse events. In the present study, we pooled data from two studies to contrast the effects of reported trauma exposure during neurodevelopmentally sensitive periods in early life with trauma exposure during adulthood. A total of 155 women were allocated into one of six age-matched groups according to the timing of traumatization (childhood vs adulthood) and psychopathology (PTSD vs trauma-exposed healthy vs trauma-naïve healthy). Volumes of the amygdala and hippocampus were compared between these groups. Six additional exploratory regions of interest (ROI) were included based on a recent meta-analysis. Amygdala volume was strongly dependent on the timing of traumatization: Smaller amygdala volumes were observed in participants with childhood trauma and PTSD compared to the healthy control groups. In contrast, larger amygdala volumes were observed in both groups with trauma exposure during adulthood compared to the trauma-naïve control group. Hippocampal volume comparisons revealed no statistically significant differences, although the descriptive pattern was similar to that found for the amygdala. The remaining exploratory ROIs showed significant group effects, but no timing effects. The timing might be an important moderator for adversity effects on amygdala volume, potentially reflecting neurodevelopmental factors. Albeit confounded by characteristics like trauma type and multiplicity, these findings pertain to typical childhood and adulthood trauma as often observed in clinical practice and speak against a simple association between traumatic stress and amygdala volume.

K-METTA: Kognitive Techniken und Metta-Meditationen zur Reduktion traumabezogener Schuld- und Schamgefühle – Darstellung der Intervention anhand von zwei Fallbeispielen

<b><i>Hintergrund:</i></b> Angst- und Ohnmachtsgefühle wurden lange als zentrale Emotionen der PTBS betrachtet. Neuere For­schungsergebnisse legen jedoch nahe, dass insbesondere nach interpersonellen Gewalterfahrungen Schuld- und Schamgefühle eine entscheidende Rolle für die Entstehung und Aufrechterhaltung einer PTBS spielen. Metta-Meditationen (deutsch: Liebende Güte) zielen darauf ab, sich selbst und anderen Menschen bedingungsloses Wohlwollen und Freundlichkeit entgegenzubringen. Durch das Praktizieren von Metta lässt sich Selbstkritik reduzieren und das Gefühl der sozialen Verbundenheit stärken. <b><i>Methoden:</i></b> K-METTA ist eine Intervention (6 Sitzungen) zur Reduktion traumabezogener Schuld- und Schamgefühle, bei der kognitive Techniken mit Metta-Meditationen kombiniert werden. Hierbei werden in den Sitzungen 1 und 2 zunächst den Schuldgefühlen zugrunde liegende Kognitionen im sokratischen Dialog hinterfragt. Der Schwerpunkt der Sitzungen 3–6 liegt, neben der Vertiefung der kognitiven Interventionen, auf Metta-Meditationen. Hierbei üben Patient*innen, gute Wünsche an sich selbst und andere zu richten. <b><i>Fallberichte:</i></b> Die Behandlung von zwei Patientinnen, die Opfer von sexueller Gewalt geworden sind, wird exemplarisch dargestellt. Deskriptive prä-post Vergleiche zeigen eine Reduktion traumabezogener Schuld- und Schamgefühle sowie der PTBS-Symptomatik und weiterer psychischer Symptome. <b><i>Schlussfolgerung:</i></b> Gezielte Interventionen zur Verringerung traumabezogener Schuld- und Schamgefühle können dazu beitragen, die Wirksamkeit traumatherapeutischer Behandlungen zu verbessern. Hierfür erscheint eine Kombinationsbehandlung aus kognitiven Techniken und Metta-Meditationen vielversprechend.

Scales for assessing therapeutic adherence and competence in dialectical behaviour therapy for PTSD: development and analysis of psychometric properties

BACKGROUND

The assessment of therapeutic adherence and competence is essential to understand mechanisms that contribute to treatment outcome. Nevertheless, their assessment is often neglected in psychotherapy research.

AIMS/OBJECTIVE

To develop an adherence and a treatment-specific competence rating scale for Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD), and to examine their psychometric properties. Global cognitive behavioural therapeutic competence and disorder-specific therapeutic competence were assessed using already existing scales to confirm their psychometric properties in our sample of patients with PTSD and emotion regulation difficulties.

METHOD

Two rating scales were developed using an inductive procedure. 155 videotaped therapy sessions from a multicenter randomised controlled trial were rated by trained raters using these scales, 40 randomly chosen videotapes involving eleven therapists and fourteen patients were doubly rated by two raters.

RESULTS

Both the adherence scale (Patient-level ICC = .98; α_s= .65; α _p= .75) and the treatment-specific competence scale (Patient-level ICC = .98; α_s= .78; α _p= .82) for DBT-PTSD showed excellent interrater - and good reliability on the patient level. Content validity, including relevance and appropriateness of all items, was confirmed by experts in DBT-PTSD for the new treatment-specific competence scale.

CONCLUSION

Our results indicate that both scales are reliable instruments. They will be useful to examine possible effects of adherence and treatment-specific competence on DBT-PTSD treatment outcome.

Women with abuse-related PTSD sleep more fitfully but just as long as healthy controls: an actigraphic study

STUDY OBJECTIVES

Subjective reports of sleep impairments are common in individuals with posttraumatic stress disorder (PTSD), but objective assessments of sleep have yielded mixed results.

METHODS

We investigated sleep via actigraphy and e-diary on 6 consecutive nights in a group of 117 women with PTSD after childhood abuse (CA; PTSD group), a group of 31 mentally healthy women with a history of CA (healthy trauma controls, HTC group) and a group of 36 non-traumatized mentally healthy women (healthy controls, HC group).

RESULTS

The PTSD group reported lower sleep quality, more nights with nightmares, and shorter sleep duration than both HTC and HC. Actigraphic measures showed more and longer sleep interruptions in the PTSD group compared to HTC and HC, but no difference in sleep duration. While the PTSD group underestimated their sleep duration, both HTC and HC overestimated their sleep duration. HTC did not differ from HC regarding sleep impairments.

CONCLUSIONS

Sleep in women with PTSD after CA seems to be more fragmented but not shorter compared to sleep patterns of mentally healthy control subjects. The results suggest a stronger effect of PTSD psychopathology on sleep compared to the effect of trauma per se.

Treating adults with a dual diagnosis of borderline personality disorder and posttraumatic stress disorder related to childhood abuse: Results from a randomized clinical trial

OBJECTIVE

About half of individuals seeking treatment for borderline personality disorder (BPD) present with co-occurring posttraumatic stress disorder (PTSD). However, therapies that have been proven efficacious for simultaneously treating the full spectrum of core symptoms in patients with a dual diagnosis of BPD + PTSD are lacking.

METHOD

This is a subgroup analysis from a randomized controlled trial (registration number DRKS00005578) which compared the efficacy of two treatment programs, dialectical behavior therapy for PTSD (DBT-PTSD) versus cognitive processing therapy (CPT). Specifically, the present analysis was carried out in 93 women with a dual diagnosis of BPD + PTSD (Diagnostic and Statistical Manual for Mental Disorders; DSM-5). Outcome evaluations included the Clinician-Administered PTSD Scale, the Borderline Symptom List, and validated scales assessing dissociation, depression, and global functioning. The primary analysis was based on the intent-to-treat population, using mixed models.

RESULTS

Both PTSD and BPD symptoms significantly decreased in both treatment groups. For PTSD symptoms, pre-post effect sizes were d = 1.20, 95% confidence interval (CI): [0.80-1.58] in the DBT-PTSD group and d = 0.90, 95% CI: [0.57-1.22] in the CPT group; for BPD symptoms, they were d = 1.17, 95% CI: [0.77-1.55], and d = 0.50, 95% CI: [0.20-0.79], respectively. Between-group comparisons significantly favored DBT-PTSD for improvement in symptoms of PTSD, BPD, and dissociation. Between-group differences regarding depression and global functioning were not significant.

CONCLUSION

Both DBT-PTSD and CPT emerged as promising treatment options for simultaneously addressing the full spectrum of core symptoms in patients diagnosed with BPD + PTSD. Differential efficacy was in favor of DBT-PTSD as participants randomized to the DBT-PTSD arm improved more with respect to both their BPD and PTSD symptoms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

[Burn-On Instead of Burn-Out: Self-Care and Functional Coping Strategies Protect Psychotherapists from Psychological Stress During the Corona Pandemic]

BACKGROUND AND OBJECTIVES

Due to the Corona pandemic, psychotherapists are confronted with new professional challenges. Regarding the patient care to be provided, the question of risk and protective factors for maintaining well-being during the pandemic appears relevant to prevent negative long-term consequences such as burnout. This is the first study investigating the influence of coping and self-care strategies on the psychological distress of psychotherapists in Germany during the Corona pandemic.

METHODS

From April to June 2020, 155 psychotherapists completed an online questionnaire. Additionally, to job related changes, stress level, symptoms of burnout and well-being were assessed. Furthermore, the influence of active and passive coping strategies as well as of different areas of self-care (e. g., professional support, cognitive awareness for work-related stress and work-life balance) on psychological burden was examined.

RESULTS

Psychotherapists worked an average of 1,22 hours less per week during the pandemic than before. On average, 38% of treatments were delivered via video therapy. Avoidant coping strategies were associated with increased stress levels, which predicted higher burnout scores and lower well-being. In contrast, a good work-life balance, a good daily balance at work and active coping had a positive effect. Contrary to expectation, cognitive awareness for work-related stress was related to lower well-being.

DISCUSSION

Work-life balance can serve as a preventive strategy to reduce stress during the Corona pandemic and thereby reduce the risk for burnout and improve well-being. Avoidant coping strategies, on the other hand, are a risk factor for increased stress levels during pandemic and promote burnout and lower well-being.

CONCLUSION

This study contributes to our knowledge regarding preventive measures to prevent stress and to maintain the well-being of psychotherapist in order to contribute to ongoing high quality patient care during the pandemic.

Which Trauma Treatment Suits me? Identification of Patients' Treatment Preferences for Posttraumatic Stress Disorder (PTSD)

Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes.

Die Cognitive Processing Therapy zur Behandlung Geflüchteter mit einer Posttraumatischen Belastungsstörung: Eine Machbarkeitsstudie

<b><i>Hintergrund:</i></b> Metaanalysen zeigen die Wirksamkeit traumafokussierter Verfahren für Geflüchtete. Für die Cognitive Processing Therapy (CPT) liegt bei dieser Population in Deutschland bisher keine empirische Machbarkeitsprüfung vor. <b><i>Patient</i></b>*<b><i>innen und Methoden:</i></b> Im Rahmen einer Machbarkeitsstudie erhielten 16 Geflüchtete mit einer Posttraumatischen Belastungsstörung (PTBS) unter klinischen Routinebedingungen drei diagnostische Vorgespräche, fünf probatorische Sitzungen, zwölf Doppelsitzungen (100 Minuten) CPT sowie bis zu vier optionale Krisensitzungen. Vor und nach der Therapie wurde die PTBS-Symptomatik erhoben. Qualitative Nachbefragungen mit Patient*innen und Therapeut*innen wurden durchgeführt. <b><i>Ergebnisse:</i></b> Insgesamt neun von 16 Patient*innen brachen die Therapie vorzeitig ab. Innerhalb der Completer-Stichprobe (Per-protocol-Analyse) zeigten sich mittelgroße, aber nicht signifikante Effekte auf die PTBS-Symptomatik (<i>d</i> = 0,75; M[CAPS_prä] = 39,33 [SD = 10,89]; M[CAPS_post] = 22,50 [SD = 15,16]). Patient*innen und Therapeut*innen berichteten eine Reihe von Hürden in der Therapiedurchführung. <b><i>Diskussionen:</i></b> Die vorliegende Machbarkeitsstudie verzeichnete eine für die CPT ungewöhnlich hohe Abbruchquote. Diese lässt sich möglicherweise auf die mangelnde Passung des Verfahrens für Patient*innen mit geringer Schreib- und Lesekompetenz oder hoher psychosozialer Belastung zurückführen. Implikationen für die Behandlung Geflüchteter bezüglich der Wahl des Behandlungsverfahrens, der Motivationsklärung und der Rahmenbedingungen werden diskutiert. <b><i>Schlussfolgerungen:</i></b> Während breite empirische Evidenz für traumafokussierte Verfahren bei Geflüchteten vorliegt, ist die Standard-CPT möglicherweise nur für Subgruppen dieser Population geeignet. Eine Vereinfachung der CPT-Materialien und eine vorherige Motivationsklärung erscheinen notwendig.

Preferences and Ratings of Partner Traits in Female Survivors of Childhood Abuse With PTSD and Healthy Controls

There is growing empirical evidence for an association between childhood abuse (CA) and intimate partner violence (IPV) in adulthood. We tested whether revictimized survivors of severe to extreme severities of child sexual abuse (CSA) and severe severities of child physical abuse (CPA) differed from nonvictimized healthy controls in their trait preferences in intimate partners and their current mate choice. In a sample of 52 revictimized female patients with posttraumatic stress disorder (PTSD) after CSA/CPA and 52 female healthy controls, the validated Intimate Partner Preferences Questionnaire (IPPQ) was used to assess (a) the desirability of tenderness, dominance, and aggression traits in potential partners, and (b) the presence of these traits in their current intimate partners. Factors potentially associated with partner preference and mate choice, for example, chronicity of traumatic events and lower self-esteem, were explored. Our results showed that, in general, revictimized PTSD patients did not have a preference for dominant or aggressive partners. However, revictimized women displayed a significantly larger discrepancy than did healthy controls between their preferences for tenderness traits and their ratings of the presence of tenderness traits in their current partners. Our results indicated that revictimized patients had lower self-esteem values; however, these values were associated with higher demands for tenderness traits. Furthermore, our results revealed that compared with patients who experienced early-onset childhood abuse (CA), those who experienced later onset CA were more accepting of dominant traits in potential partners. Women who had experienced IPV rated their current partners to be overly dominant. A higher tolerance of dominance traits might increase the risk of IPV in a specific subgroup of abused women (women with a later onset of abuse experiences and experiences of IPV).

Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial

IMPORTANCE

Childhood abuse significantly increases the risk of developing posttraumatic stress disorder (PTSD), often accompanied by symptoms of borderline personality disorder (BPD) and other co-occurring mental disorders. Despite the high prevalence, systematic evaluations of evidence-based treatments for PTSD after childhood abuse are sparse.

OBJECTIVE

To compare the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD), a new, specifically designed, phase-based treatment program, against that of cognitive processing therapy (CPT), one of the best empirically supported treatments for PTSD.

DESIGN, SETTING, AND PARTICIPANTS

From January 2014 to October 2016, women who sought treatment were included in a multicenter randomized clinical trial with blinded outcome assessments at 3 German university outpatient clinics. The participants were prospectively observed for 15 months. Women with childhood abuse-associated PTSD who additionally met 3 or more DSM-5 criteria for BPD, including affective instability, were included. Data analysis took place from October 2018 to December 2019.

INTERVENTIONS

Participants received equal dosages and frequencies of DBT-PTSD or CPT, up to 45 individual sessions within 1 year and 3 additional sessions during the following 3 months.

MAIN OUTCOMES AND MEASURES

The predefined primary outcome was the course of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from randomization to month 15. Intent-to-treat analyses based on dimensional CAPS-5 scores were complemented by categorical outcome measures assessing symptomatic remission, reliable improvement, and reliable recovery.

RESULTS

Of 955 consecutive individuals assessed for eligibility, 193 were randomized (DBT-PTSD, 98; CPT, 95; mean [SD] age, 36.3 [11.1] years) and included in the intent-to-treat analyses. Analysis revealed significantly improved CAPS-5 scores in both groups (effect sizes: DBT-PTSD: d, 1.35; CPT: d, 0.98) and a small but statistically significant superiority of DBT-PTSD (group difference: 4.82 [95% CI, 0.67-8.96]; P = .02; d, 0.33). Compared with the CPT group, participants in the DBT-PTSD group were less likely to drop out early (37 [39.0%] vs 25 [25.5%]; P = .046) and had higher rates of symptomatic remission (35 [40.7%] vs 52 [58.4%]; P = .02), reliable improvement (53 [55.8%] vs 73 [74.5%]; P = .006), and reliable recovery (34 [38.6%] vs 52 [57.1%]; P = .01).

CONCLUSIONS AND RELEVANCE

These findings support the efficacy of DBT-PTSD and CPT in the treatment of women with childhood abuse-associated complex PTSD. Results pertaining to the primary outcomes favored DBT-PTSD. The study shows that even severe childhood abuse-associated PTSD with emotion dysregulation can be treated efficaciously.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00005578.

Life within a limited radius: Investigating activity space in women with a history of child abuse using global positioning system tracking

Early experiences of childhood sexual or physical abuse are often associated with functional impairments, reduced well-being and interpersonal problems in adulthood. Prior studies have addressed whether the traumatic experience itself or adult psychopathology is linked to these limitations. To approach this question, individuals with posttraumatic stress disorder (PTSD) and healthy individuals with and without a history of child abuse were investigated. We used global positioning system (GPS) tracking to study temporal and spatial limitations in the participants’ real-life activity space over the course of one week. The sample consisted of 228 female participants: 150 women with PTSD and emotional instability with a history of child abuse, 35 mentally healthy women with a history of child abuse (healthy trauma controls, HTC) and 43 mentally healthy women without any traumatic experiences in their past (healthy controls, HC). Both traumatized groups—i.e. the PTSD and the HTC group—had smaller movement radii than the HC group on the weekends, but neither spent significantly less time away from home than HC. Some differences between PTSD and HC in movement radius seem to be related to correlates of PTSD psychopathology, like depression and physical health. Yet group differences between HTC and HC in movement radius remained even when contextual and individual health variables were included in the model, indicating specific effects of traumatic experiences on activity space. Experiences of child abuse could limit activity space later in life, regardless of whether PTSD develops.

Influence of Severity of Type and Timing of Retrospectively Reported Childhood Maltreatment on Female Amygdala and Hippocampal Volume

Deleterious effects of adverse childhood experiences (ACE) on human brain volume are widely reported. First evidence points to differential effects of ACE on brain volume in terms of timing of ACE. Upcoming studies additionally point towards the impact of different types (i.e., neglect and abuse) of ACE in terms of timing. The current study aimed to investigate the correlation between retrospectively reported severity of type (i.e., the extent to which subjects were exposed to abuse and/or neglect, respectively) and timing of ACE on female brain volume in a sample of prolonged traumatized subjects. A female sample with ACE (N = 68) underwent structural magnetic resonance imaging and a structured interview exploring the severity of ACE from age 3 up to 17 using the “Maltreatment and Abuse Chronology of Exposure” (MACE). Random forest regression with conditional interference trees was applied to assess the impact of ACE severity as well as the severity of ACE type, (i.e. to what extent individuals were exposed to neglect and/or abuse) at certain ages on pre-defined regions of interest such as the amygdala, hippocampus, and anterior cingulate (ACC) volume. Analyses revealed differential type and timing-specific effects of ACE on stress sensitive brain structures: Amygdala and hippocampal volume were affected by ACE severity during a period covering preadolescence and early adolescence. Crucially, this effect was driven by the severity of neglect.

Dwelling on verbal but not pictorial threat cues: An eye-tracking study with adult survivors of childhood interpersonal violence

OBJECTIVE

Previous studies have found evidence of an attentional bias for trauma-related stimuli in posttraumatic stress disorder (PTSD) using eye-tracking (ET) technlogy. However, it is unclear whether findings for PTSD after traumatic events in adulthood can be transferred to PTSD after interpersonal trauma in childhood. The latter is often accompanied by more complex symptom features, including, for example, affective dysregulation and has not yet been studied using ET. The aim of this study was to explore which components of attention are biased in adult victims of childhood trauma with PTSD compared to those without PTSD.

METHOD

Female participants with (n = 27) or without (n = 27) PTSD who had experienced interpersonal violence in childhood or adolescence watched different trauma-related stimuli (Experiment 1: words, Experiment 2: facial expressions). We analyzed whether trauma-related stimuli were primarily detected (vigilance bias) and/or dwelled on longer (maintenance bias) compared to stimuli of other emotional qualities.

RESULTS

For trauma-related words, there was evidence of a maintenance bias but not of a vigilance bias. For trauma-related facial expressions, there was no evidence of any bias.

CONCLUSIONS

At present, an attentional bias to trauma-related stimuli cannot be considered as robust in PTSD following trauma in childhood compared to that of PTSD following trauma in adulthood. The findings are discussed with respect to difficulties attributing effects specifically to PTSD in this highly comorbid though understudied population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

A research programme to evaluate DBT-PTSD, a modular treatment approach for Complex PTSD after childhood abuse

BACKGROUND

Posttraumatic stress disorder (PTSD) after childhood abuse (CA) is often related to severe co-occurring psychopathology, such as symptoms of borderline personality disorder (BPD). The ICD-11 has included Complex PTSD as a new diagnosis, which is defined by PTSD symptoms plus disturbances in emotion regulation, self-concept, and interpersonal relationships. Unfortunately, the empirical database on psychosocial treatments for survivors of CA is quite limited. Furthermore, the few existing studies often have either excluded subjects with self-harm behaviour and suicidal ideation - which is common behaviour in subjects suffering from Complex PTSD. Thus, researchers are still trying to identify efficacious treatment programmes for this group of patients.We have designed DBT-PTSD to meet the specific needs of patients with Complex PTSD. The treatment programme is based on the rules and principles of dialectical behavioural therapy (DBT), and adds interventions derived from cognitive behavioural therapy, acceptance and commitment therapy and compassion-focused therapy. DBT-PTSD can be provided as a comprehensive residential programme or as an outpatient programme. The effects of the residential programme were evaluated in a randomised controlled trial. Data revealed significant reduction of posttraumatic symptoms, with large between-group effect sizes when compared to a treatment-as-usual wait list condition (Cohen's d = 1.5).The first aim of this project on hand is to evaluate the efficacy of the outpatient DBT-PTSD programme. The second aim is to identify the major therapeutic variables mediating treatment efficacy. The third aim is to study neural mechanisms and treatment sensitivity of two frequent sequelae of PTSD after CA: intrusions and dissociation.

METHODS

To address these questions, we include female patients who experienced CA and who fulfil DSM-5 criteria for PTSD plus borderline features, including criteria for severe emotion dysregulation. The study is funded by the German Federal Ministry of Education and Research, and started in 2014. Participants are randomised to outpatient psychotherapy with either DBT-PTSD or Cognitive Processing Therapy. Formal power analysis revealed a minimum of 180 patients to be recruited. The primary outcome is the change on the Clinician-Administered PTSD Scale for DSM-5.

DISCUSSION

The expected results will be a major step forward in establishing empirically supported psychological treatments for survivors of CA suffering from Complex PTSD.

TRIAL REGISTRATION

German Clinical Trials Register: registration number DRKS00005578, date of registration 19 December 2013.

Generalisation of fear in PTSD related to prolonged childhood maltreatment: an experimental study

BACKGROUND

Fear responses are particularly intense and persistent in post-traumatic stress disorder (PTSD), and can be evoked by unspecific cues that resemble the original traumatic event. Overgeneralisation of fear might be one of the underlying mechanisms. We investigated the generalisation and discrimination of fear in individuals with and without PTSD related to prolonged childhood maltreatment.

METHODS

Sixty trauma-exposed women with (N = 30) and without (N = 30) PTSD and 30 healthy control participants (HC) underwent a fear conditioning and generalisation paradigm. In a contingency learning procedure, one of two circles of different sizes was associated with an electrical shock (danger cue), while the other circle represented a safety cue. During generalisation testing, online risk ratings, reaction times and fear-potentiated startle were measured in response to safety and danger cues as well as to eight generalisation stimuli, i.e. circles of parametrically varying size creating a continuum of similarity between the danger and safety cue.

RESULTS

The increase in reaction times from the safety cue across the different generalisation classes to the danger cue was less pronounced in PTSD compared with HC. Moreover, PTSD participants expected higher risk of an aversive event independent of stimulus types and task.

CONCLUSIONS

Alterations in generalisation constitute one part of fear memory alterations in PTSD. Neither the accuracy of a risk judgement nor the strength of the induced fear was affected. Instead, processing times as an index of uncertainty during risk judgements suggested a reduced differentiation between safety and threat in PTSD.

Detecting implicit cues of aggressiveness in male faces in revictimized female PTSD patients and healthy controls

Victimized women are thought to have impairments in identifying risk and to have dysfunctional reactions to threatening situations, which increase the risk for revictimization. To investigate possible deficits in revictimized women, we used a method examining women's perceptions of an implicit facial cue of aggressiveness - the facial Width-to-Height Ratio (fWHR). We tested whether revictimized women show impairments in detecting aggressiveness in male faces by neglecting cues of fWHR and choosing a smaller preferred distance to men. Fifty-two revictimized PTSD patients and 52 healthy controls provided ratings of aggressiveness and attractiveness for 65 photographed men and chose their preferred distance towards 11 pictured men. Multiple regression analyses indicated that revictimized women do not show impairments in perceiving and reacting to cues of aggression accurately. Hierarchical linear models, however, indicated that revictimized women rated all men as less aggressive. Revictimized women with histories of intimate partner violence (IPV) rated men with larger fWHRs and higher values of actual aggression to be more attractive than did revictimized women without IPV histories. A reduced appraisal of threat signals as threatening and an attraction to wider-faced and more aggressive men might increase the risk for revictimization.

Psychometric Properties and Factor Structure of the German Version of the Clinician-Administered PTSD Scale for DSM-5

The Clinician-Administered PTSD Scale (CAPS) is a widely used diagnostic interview for posttraumatic stress disorder (PTSD). Following fundamental modifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the CAPS had to be revised. This study examined the psychometric properties (internal consistency, interrater reliability, convergent and discriminant validity, and structural validity) of the German version of the CAPS-5 in a trauma-exposed sample (n = 223 with PTSD; n =51 without PTSD). The results demonstrated high internal consistency (αs = .65-.93) and high interrater reliability (ICCs = .81-.89). With regard to convergent and discriminant validity, we found high correlations between the CAPS severity score and both the Posttraumatic Diagnostic Scale sum score (r = .87) and the Beck Depression Inventory total score (r = .72). Regarding the underlying factor structure, the hybrid model demonstrated the best fit, followed by the anhedonia model. However, we encountered some nonpositive estimates for the correlations of the latent variables (factors) for both models. The model with the best fit without methodological problems was the externalizing behaviors model, but the results also supported the DSM-5 model. Overall, the results demonstrate that the German version of the CAPS-5 is a psychometrically sound measure.

Dialectical behaviour therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study in an outpatient treatment setting

Background: Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD), which is tailored to treat adults with PTSD and co-occurring emotion regulation difficulties, has already demonstrated its efficacy, acceptance and safety in an inpatient treatment setting. It combines elements of DBT with trauma-focused cognitive behavioural interventions. Objective: To investigate the feasibility, acceptance and safety of DBT-PTSD in an outpatient treatment setting by therapists who were novice to the treatment, we treated 21 female patients suffering from PTSD following childhood sexual abuse (CSA) plus difficulties in emotion regulation in an uncontrolled clinical trial. Method: The Clinician Administered PTSD Symptom Scale (CAPS), the Davidson Trauma Scale (DTS), the Borderline Section of the International Personality Disorder Examination (IPDE) and the Borderline Symptom List (BSL-23) were used as primary outcomes. For secondary outcomes, depression and dissociation were assessed. Assessments were administered at pretreatment, post-treatment and six-week follow-up. Results: Improvement was significant for PTSD as well as for borderline personality symptomatology, with large pretreatment to follow-up effect sizes for completers based on the CAPS (Cohens d = 1.30), DTS (d = 1.50), IPDE (d = 1.60) and BSL-23 (d = 1.20). Conclusion: The outcome suggests that outpatient DBT-PTSD can safely be used to reduce PTSD symptoms and comorbid psychopathology in adults who have experienced CSA.

Disorder- and Treatment-Specific Therapeutic Competence Scales for Posttraumatic Stress Disorder Intervention: Development and Psychometric Properties

Although the assessment of therapeutic competence in psychotherapy research is essential for examining its possible associations with treatment outcomes, it is often neglected due to high costs and a lack of valid instruments. This study aimed to develop two therapeutic competence scales that assess disorder-specific and treatment-specific therapeutic competence, and to examine these scales' psychometric properties along with those of the already established Cognitive Therapy Scale (CTS) in a posttraumatic stress disorder (PTSD) sample. Using an inductive procedure, two rating scales for assessing disorder-specific and treatment-specific competence were constructed. The psychometric properties of these scales and those of the CTS were assessed in a sample of 30 videotaped sessions of eight patients from a multicenter study in which PTSD related to child abuse was treated using cognitive processing therapy. Two raters assessed therapeutic competence in 30 videotaped psychotherapy sessions. Interrater reliability, internal consistency, and content validity were determined. The scales (all items and total scores) demonstrated good to excellent interrater reliability, intraclass correlation coefficients (ICCs) = .67 to .97, and internal consistency, Cronbach's α = .73 to .92. The PTSD experts' ratings confirmed good internal validity. We found statistically significant associations with therapeutic adherence, r = .62 to .85; p < .001; and therapeutic alliance, r = .47, p < .001. These preliminary data imply that the two newly developed competence scales and the CTS can be reliably used to assess different types of therapeutic competence in PTSD samples and may be useful as possible predictors of treatment outcomes.

Mindfulness-Based Stress Reduction (MBSR) as a Standalone Intervention for Posttraumatic Stress Disorder after Mixed Traumatic Events: A Mixed-Methods Feasibility Study

Objectives: There is promising evidence that mindfulness-based interventions are effective in reducing the symptoms of posttraumatic stress disorder (PTSD). However, until now, studies have often lacked a full clinical PTSD assessment, and interventions are often administered in addition to other interventions. This study examined the feasibility of mindfulness-based stress reduction (MBSR) as a standalone intervention in patients with PTSD who have experienced mixed traumatic events. Method: Fourteen patients participated in 8 weeks of MBSR. The patients were assessed prior to treatment, post-treatment and at a 1-month follow-up through self-ratings (e.g., the Davidson Trauma Scale) and the Clinician-Administered PTSD Scale to determine the effects of the intervention. Furthermore, after the intervention, the patients participated in qualitative interviews regarding their experiences with MBSR and their ideas for future improvements. Results: Nine patients finished the program, and these patients considered the exercises to be applicable and helpful. In the Clinician-Administered PTSD Scale, we found large effects regarding the reduction of PTSD symptoms among completers (Cohen's d = 1.2). In the Davidson Trauma Scale, the effect sizes were somewhat lower (Cohen's d = 0.6) but nevertheless confirmed the efficacy of MBSR in reducing PTSD symptoms. In the qualitative interviews, the patients reported an augmentation of wellbeing and improvement regarding the handling of difficult situations and more distance from the traumatic event. Conclusion: Despite the large effects, the high dropout rates and the results of the post-treatment interviews suggest that the intervention should be better adapted to the needs of PTSD patients, e.g., by giving more information regarding the exercises and by including shorter exercises to manage acute distress.

Cognitive restructuring and imagery modification for posttraumatic stress disorder (CRIM-PTSD): A pilot study

BACKGROUND AND OBJECTIVES

Cognitive restructuring and imagery modification for PTSD (CRIM-PTSD) is a new short intervention. It consists of the cognitive restructuring of core trauma-related dysfunctional beliefs about the self and the use of imagery to encourage more functional beliefs. A randomized controlled trial showed that CRIM was effective for reducing posttraumatic stress disorder (PTSD) in survivors of childhood sexual abuse (CSA) when it focused on the feeling of being contaminated. For this study, CRIM was adapted to treat PTSD symptoms more generally and after various types of trauma by addressing the patients' negative self-concept.

METHODS

Ten patients with PTSD received two assessment sessions, two treatment sessions, and a booster session. The Clinician-Administered PTSD Scale (CAPS) was administered prior to and four weeks after treatment. Self-ratings, e.g., the Posttraumatic Diagnostic Scale (PDS) and the Posttraumatic Cognitions Inventory (PTCI), were administered at baseline, immediately posttreatment, and four weeks after treatment.

RESULTS

The participants showed significant improvements in both clinician-rated (d = 2.55; p < 0.01) and self-reported PTSD symptoms (d = 1.47; p < 0.01). One month after treatment, 9 patients no longer fully met the diagnostic criteria for PTSD.

LIMITATIONS

The results are limited by the small sample size and the lack of a control group.

CONCLUSIONS

This pilot study suggests that addressing the negative self-concept of PTSD patients using a combination of cognitive techniques and imagery modification can effectively reduce PTSD symptoms. Further research is needed to assess the treatment's effects and stability in a randomized controlled trial.

When Decisions Should Be Shared

Background. Shared decision making (SDM) is often advocated as an ideal for making medical decisions. Until now, however, opinions regarding which treatment situations warrant SDM have not been systematically investigated. The purpose of this study was to examine social norms regarding medical decision making, using a factorial survey design. Methods. The factorial survey applied in this study consisted of 7 situational factors (e.g., the reason for consultation), each with 2 to 3 levels (e.g., prevention and severe disease). These factors were turned into various descriptions of treatment situations. A total of 101 physicians, 115 patients, and 113 members of self-help groups participated in the study. Each participant assessed 10 vignettes using a 5-point scale to indicate who they thought should make the decision in each specific situation. Results. Most assessments across the 3 groups called for a shared decision (39%). Ordered logistic regression analysis demonstrated that, according to study participants, all 7 situational factors (reason for consultation, time frame of negative outcomes, time pressure, number of therapeutic options, side effects, scientific evidence of efficacy, and desire to participate) significantly affected how decisions regarding treatment should be made. The strongest factor was the patient’s desire to participate in decision making (odds ratio = 1.84; P ≤ 0.001), followed by the reason for consultation (odds ratio = 0.69; P ≤ 0.001). Conclusions. This study reveals that there is a general desire for SDM in a variety of treatment situations. Furthermore, based on the responses of our participants, our findings also lay the framework in determining which treatment situations warrant SDM.

Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality

BACKGROUND

Childhood interpersonal violence is a major risk factor for developing Posttraumatic Stress Disorder (PTSD), other axis-I disorders or Borderline Personality Disorder (BPD). Individuals with a history of childhood sexual abuse (CSA) and childhood physical abuse (CPA) who meet the criteria of any axis-I disorder usually also exhibit general psychopathologic symptoms and impairments in quality of life and sexuality. The present study investigates whether women with a history of potentially traumatic CSA/CPA without any axis-I disorder or BPD show subthreshold symptoms of PTSD-specific and general psychopathology and impairments in global functioning, quality of life, and sexuality.

METHODS

Data were obtained from N = 92 female participants: n = 31 participants with a history of potentially traumatic CSA/CPA (defined as fulfilling PTSD criterion A) without any axis-I disorder or BPD; n = 31 participants with PTSD related to CSA/CPA; and n = 30 healthy controls without any traumatic experiences. All three groups were matched for age and education. Those with a history of CSA/CPA with and without PTSD were further matched with regard to severity of physical and sexual abuse.

RESULTS

While women with a history of potentially traumatic CSA/CPA without axis-I disorder or BPD clearly differed from the PTSD-group in the collected measures, they did not differ from healthy controls (e.g., GAF:87, BSI:0.3, BDI-II:4.5). They showed neither PTSD-specific nor general subthreshold symptoms nor any measurable restrictions in quality of life or sexual satisfaction.

CONCLUSIONS

Women with a history of potentially traumatic childhood interpersonal violence without axis-I disorder or BPD show a high level of functioning and a low level of pathological impairment that are comparable to the level of healthy controls. Further studies are needed to identify what helped these women survive these potentially traumatic experiences without developing any mental disorders.

TRIAL REGISTRATION

German Clinical Trials Registration ID: DRKS00006095. Registered 21 May 2014.

Trying to optimise the German version of the OPTION scale regarding the dyadic aspect of shared decision making

OBJECTIVES

The OPTION scale ("observing patient involvement in decision making") assesses the extent to which clinicians involve patients in decisions across a range of situations in clinical practice. It so far just covers physician behavior. We intended to modify the scoring of the OPTION scale to incorporate active patient behavior in consultations.

METHODS

Modification was done on scoring level, attempting a dyadic, relationship-centred approach in that high ratings can be evoked also by the behaviour of active patients. The German version of the OPTION scale was compared with a modified version by analysing video recordings of primary care consultations dealing with cardiovascular prevention. Fifteen general practitioners provided 40 videotaped consultations. Videos were analysed by two rater pairs and two experts in shared decision making (SDM).

RESULTS

Reliability measures of the modified version were lower than those of the original scale. Significant associations of the dichotomised scale with the expert SDM rating as well as with physicians' expertise in SDM were only found for the modified OPTION scale. Receiver Operating Characteristic (ROC) analyses confirmed a valid differentiation between the presence of SDM (yes/no) on total score level, even though the cut-off point was quite low. Standard deviations of the single items in the modified version were higher compared to the original OPTION scale, while the means of total scores were similar.

CONCLUSIONS

The original OPTION scale is physician-centered and neglects the activity and a possible self-involvement of the patient. Our modified instruction was able to capture the dyadic element partially. The development of a separate dyadic instrument might be more promising.

Reliability and validity of the German version of the OPTION scale

OBJECTIVE

To examine the psychometric properties of the German version of the 'observing patient involvement' scale (OPTION) by analysing video recordings of primary care consultations dealing with counselling in cardiovascular prevention.

DESIGN

Cross-sectional assessment of physician-patient interaction by two rater pairs and two experts in shared decision making (SDM).

SETTING

Primary care.

PARTICIPANTS

Fifteen general practitioners provided 40 videographed consultations.

MEASUREMENTS

Video ratings using the OPTION instrument.

RESULTS

Mean differences on item level between the four raters were quite large. Most items were skewed towards minimal levels of shared decision making. Measures of inter-rater association showed low to moderate associations on item level and high associations on total score level. Cronbach-α of the whole scale based on the data of all four raters is 0.90 and therefore on a high level. An oblique factor analysis revealed two factors, but both factors were highly correlated so we can confirm a one-dimensional structure of the instrument. ROC analyses between the rater total scores and dichotomized expert ratings (SDM yes/no) revealed a good discriminability of the OPTION total score. Physicians with more expertise in shared decision making received higher OPTION ratings.

CONCLUSIONS

The German version of the OPTION scale is reliable at total score level. Some items need further revision in the direction of more concrete, observable behaviour. We were only able to perform a quasi-validation of the scale. Validity issues need further research efforts.

Shared decision making in medicine: the influence of situational treatment factors

OBJECTIVE

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

METHODS

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

RESULTS

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

CONCLUSION

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

PRACTICE IMPLICATIONS

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.

Decision making preferences in the medical encounter--a factorial survey design

BACKGROUND

Up to now it has not been systematically investigated in which kind of clinical situations a consultation style based on shared decision making (SDM) is preferred by patients and physicians. We suggest the factorial survey design to address this problem.This method, which so far has hardly been used in health service research, allows to vary relevant factors describing clinical situations as variables systematically in an experimental random design and to investigate their importance in large samples.

METHODS/DESIGN

To identify situational factors for the survey we first performed a literature search which was followed by a qualitative interview study with patients, physicians and health care experts. As a result, 7 factors (e.g. "Reason for consultation" and "Number of therapeutic options") with 2 to 3 levels (e.g. "One therapeutic option" and "More than one therapeutic option") will be included in the study. For the survey the factor levels will be randomly combined to short stories describing different treatment situations.A randomized sample of all possible short stories will be given to at least 300 subjects (100 GPs, 100 patients and 100 members of self-help groups) who will be asked to rate how the decision should be made. Main outcome measure is the preference for participation in the decision making process in the given clinical situation.Data analysis will estimate the effects of the factors on the rating and also examine differences between groups.

DISCUSSION

The results will reveal the effects of situational variations on participation preferences. Thus, our findings will contribute to the understanding of normative values in the medical decision making process and will improve future implementation of SDM and decision aids.