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O'Doherty L, Whelan M, Carter GJ, Brown K, Tarzia L, Hegarty K, Feder G, Brown SJ. Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood. Cochrane Database Syst Rev 2023; 10:CD013456. [PMID: 37795783 PMCID: PMC10552071 DOI: 10.1002/14651858.cd013456.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults. OBJECTIVES To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood. SEARCH METHODS In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches. SELECTION CRITERIA Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD). AUTHORS' CONCLUSIONS Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.
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Affiliation(s)
- Lorna O'Doherty
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
- Department of General Practice, The University of Melbourne, Melbourne, Australia
| | - Maxine Whelan
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Grace J Carter
- Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Katherine Brown
- Department of Psychology and Sports Science, University of Hertfordshire, Hatfield, UK
| | - Laura Tarzia
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Kelsey Hegarty
- Department of General Practice, The University of Melbourne, Melbourne, Australia
- The Royal Women's Hospital, Victoria, Australia
| | - Gene Feder
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah J Brown
- Faculty of Arts, Business and Law, Law School, USC: University of the Sunshine Coast, Sippy Downs, Australia
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Tan L, Strudwick J, Deady M, Bryant R, Harvey SB. Mind-body exercise interventions for prevention of post-traumatic stress disorder in trauma-exposed populations: a systematic review and meta-analysis. BMJ Open 2023; 13:e064758. [PMID: 37438059 PMCID: PMC10347470 DOI: 10.1136/bmjopen-2022-064758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE Mind-body exercise (MBE) interventions, such as yoga, are increasingly recognised as an adjunct treatment for trauma-related mental disorders but less is known about their efficacy as a preventative intervention. We aimed to systematically review if, and what type of, MBE interventions are effective at preventing the development of post-traumatic stress disorder (PTSD) or acute stress disorder (ASD) in trauma-exposed populations. DESIGN Systematic review and meta-analysis. METHODS A systematic search of MEDLINE, PsycINFO, EMBASE and CENTRAL databases was conducted to identify controlled trials of MBE interventions aimed at preventing the development of PTSD or ASD in high-risk populations. Risk of bias was assessed using the revised Cochrane risk-of-bias and ROBINS-I tools. Pooled effect sizes using Hedges' g and 95% CIs were calculated using random effects modelling for the main meta-analysis and planned subgroup and sensitivity analyses. RESULTS Six studies (N analysed=399) were included in the final meta-analysis. Overall, there was a small effect for MBE interventions in preventing the development of PTSD (g=-0.25, 95% CI -0.56 to 0.06) among those with previous or ongoing exposure to trauma. Although a prespecified subgroup analyses comparing the different types of MBE intervention were conducted, meaningful conclusions could not be drawn due to the small number of studies. None of the included studies assessed ASD symptoms. CONCLUSION Limited evidence was found for MBE interventions in reducing PTSD symptomology in the short term. Findings must be interpreted with caution due to the small number of studies and possible publication bias. PROSPERO REGISTRATION NUMBER CRD42020180375.
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Affiliation(s)
- Leona Tan
- School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
- Black Dog Institute, Randwick, New South Wales, Australia
| | | | - Mark Deady
- Black Dog Institute, Randwick, New South Wales, Australia
| | - Richard Bryant
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
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Analysis of the bidirectional relationships between posttraumatic stress and depression symptoms with physical health functioning in post-9/11 veteran men and women deployed to a war zone. J Psychosom Res 2022; 162:111034. [PMID: 36099750 DOI: 10.1016/j.jpsychores.2022.111034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Many war-zone deployed post-9/11 veterans report negative mental health symptoms related to their military service, which can have consequences for physical health symptoms and the impact of physical health on functioning. The current study examined the longitudinal, bidirectional relationships between mental health symptoms and physical health functioning in veteran men and women, allowing for exploration of gender differences. METHODS A sample of 1032 post-9/11 veterans (women: n = 554; men: n = 478) who recently returned from a war-zone deployment completed self-report measures of posttraumatic stress disorder (PTSD) symptoms, depression symptoms, and physical health functioning at 3 time points spanning approximately 7 years. Gender-stratified longitudinal cross-lagged panel analyses were used to examine bidirectional relationships. RESULTS PTSD symptom severity was negatively associated with physical health functioning across time. For women, associations were reciprocal, such that those reporting poorer physical health functioning reported more severe PTSD symptoms at later time points. Men with greater PTSD symptom severity reported poorer physical health functioning at later time points, but there was no evidence of bidirectionality. Men and women with more severe depression symptoms reported worse later physical health functioning, which further exacerbated depression symptoms across time. CONCLUSIONS Findings showed that individual differences in mental health symptoms both set the stage for and were impacted by physical health functioning in post-9/11 veterans. Although additional research is needed, the current study suggests that healthcare approaches that consider the whole person, such as through integration of mental and physical health treatments, may be particularly relevant for post-9/11 veterans.
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Jarnecke AM, Saraiya TC, Brown DG, Richardson J, Killeen T, Back SE. Examining the role of social support in treatment for co-occurring substance use disorder and posttraumatic stress disorder. Addict Behav Rep 2022; 15:100427. [PMID: 35480064 PMCID: PMC9036141 DOI: 10.1016/j.abrep.2022.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/14/2022] [Accepted: 04/09/2022] [Indexed: 12/01/2022] Open
Abstract
Objective Social support may be a critical mechanism in the treatment of co-occurring substance use disorder (SUD) and posttraumatic stress disorder (PTSD). However, no studies have examined how social support changes as a function of treatment or predicts treatment outcome in a Veteran population with co-occurring SUD and PTSD. Method The current study is a secondary analysis that examined social support over the course of treatment for co-occurring SUD and PTSD (N = 81). Analyses were conducted to examine if a) social support predicts change in substance use and PTSD symptoms, respectively, over the course of treatment and during follow-up, and b) substance use and PTSD symptoms, respectively, predicts change in social support over treatment and during follow-up. Results The findings revealed that between-person social support moderated decreases in substance use (B = -0.17, SE = 0.07, p = 0.017) and PTSD symptom severity (B = -0.12, SE = 0.05, p = 0.009) during treatment but not during follow-up. Within-person substance use and PTSD symptom severity predicted social support but substance use and PTSD symptoms did not moderate changes in social support during treatment or follow-up. Conclusions The findings highlight the critical role of social support during treatment in enhancing outcomes for individuals with co-occurring SUD and PTSD.
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Affiliation(s)
- Amber M Jarnecke
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Tanya C Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Delisa G Brown
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - James Richardson
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Therese Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.,Ralph H. Johnson VA Medical Center, Charleston, SC, United States
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Lumley MA, Yamin JB, Pester BD, Krohner S, Urbanik CP. Trauma matters: psychological interventions for comorbid psychosocial trauma and chronic pain. Pain 2022; 163:599-603. [PMID: 34338244 PMCID: PMC8799778 DOI: 10.1097/j.pain.0000000000002425] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, MI, United States
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Scoglio AAJ, Reilly ED, Girouard C, Quigley KS, Carnes S, Kelly MM. Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review. TRAUMA, VIOLENCE & ABUSE 2022; 23:356-371. [PMID: 32812513 DOI: 10.1177/1524838020946800] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.
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Affiliation(s)
- Arielle A J Scoglio
- Social and Community Reintegration Research Program, ENRM VA Medical Center, Bedford, MA, USA
- Institute of Health Equity and Social Justice Research, Northeastern University, Boston, MA, USA
| | - Erin D Reilly
- Social and Community Reintegration Research Program, ENRM VA Medical Center, Bedford, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Caitlin Girouard
- Social and Community Reintegration Research Program, ENRM VA Medical Center, Bedford, MA, USA
| | - Karen S Quigley
- Social and Community Reintegration Research Program, ENRM VA Medical Center, Bedford, MA, USA
- Center for Healthcare Organizational and Implementation Research, ENRM VA Medical Center, Bedford, MA, USA
- Department of Psychology, Northeastern University, Boston, MA, USA
| | | | - Megan M Kelly
- Social and Community Reintegration Research Program, ENRM VA Medical Center, Bedford, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
- VISN 1 New England Mental Illness Research, Education, and Clinical Center, ENRM VA Medical Center, Bedford, MA, USA
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Faustino B. Minding my brain: Fourteen neuroscience-based principles to enhance psychotherapy responsiveness. Clin Psychol Psychother 2022; 29:1254-1275. [PMID: 35112428 DOI: 10.1002/cpp.2719] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/21/2021] [Accepted: 01/28/2022] [Indexed: 11/12/2022]
Abstract
Intersections between psychotherapy and neurosciences are at its dawn. The quest to understand the neural underpinnings of psychological processes has led several generations of scientists to explore neural correlates between mind, brain, and behavior. Neuroscience methods and research has given psychology new perspectives and insights about the structure and function of complex neural pathways, that underly human functioning (cognition, emotion, motivation, and interpersonal behavior). By translating neuroscientific findings into psychotherapeutic principles of change, it is possible to promote responsiveness towards brain dysfunction that underlies patients' psychological malfunctioning. In psychotherapy, responsiveness is a core aspect of the therapeutic change process, especially to adapt psychological interventions to patients' motivational stages and preferences, coping styles, neurobehavioral modes, and emotional needs. Within a transtheoretical and translational approach, contemporary neuroscientific findings are revised, discussed, and used to attempt to build-on fourteen theoretical brain-based principles that may be applied to psychotherapy. Translating these empirical findings into practical principles, clinical strategies and tasks is expected to enhance psychotherapy responsiveness grounded on a science-based knowledge of brain functioning.
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Affiliation(s)
- Bruno Faustino
- Faculdade de Psicologia da Universidade de Lisboa, Portugal.,HEI-Lab, Lusófona University, Lisbon, Portugal
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8
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Park JE, Choi KS, Han YR, Kim JE, Song J, Yu JC, Yun JA. An Open Pilot Trial of Written Exposure Therapy for Patients With Post-Traumatic Stress Disorder in Korea. Psychiatry Investig 2021; 18:728-735. [PMID: 34333897 PMCID: PMC8390941 DOI: 10.30773/pi.2021.0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/23/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Written exposure therapy (WET) is exposure therapy for post-traumatic stress disorder (PTSD). Compared to evidencebased treatments for PTSD, WET requires only five sessions, has a shorter session time, and no between-session assignments. The current study examined the efficacy of WET among Korean patients with PTSD due to various traumatic events on PTSD symptoms, depressive symptoms, and global functioning levels. METHODS The study recruited 41 patients with a current primary diagnosis of PTSD in psychiatric outpatient clinics. Assessments were conducted at baseline, and at 6, 12, and 24 weeks following the first treatment session. RESULTS In total, 25 patients started WET. Findings showed a significant reduction in the rate of PTSD diagnosis and symptom severity scores. Fourteen of 23 (60.9%) patients at 6 weeks, 15 of 22 (68.2%) patients at 12 weeks, and 14 of 18 (77.8%) patients at 24 weeks no longer met the diagnosis of PTSD. Depressive symptoms and global function scores also improved after WET. The dropout rate was 8% (n=2). CONCLUSION This study suggests the feasibility of implementing WET among various types of patients with PTSD in Korea and other Asian countries.
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Affiliation(s)
- Ju-Eun Park
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea
| | - Kyeong-Sook Choi
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea.,Department of Neuropsychiatry, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Yu-Ri Han
- Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jeong-Eun Kim
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea
| | - Jay Song
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea
| | - Je-Chun Yu
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea.,Department of Neuropsychiatry, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Ji-Ae Yun
- Department of Neuropsychiatry, Daejeon Eulji Medical Center, Daejeon, Republic of Korea.,Department of Neuropsychiatry, Eulji University School of Medicine, Daejeon, Republic of Korea
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Simon N, Robertson L, Lewis C, Roberts NP, Bethell A, Dawson S, Bisson JI. Internet-based cognitive and behavioural therapies for post-traumatic stress disorder (PTSD) in adults. Cochrane Database Syst Rev 2021; 5:CD011710. [PMID: 34015141 PMCID: PMC8136365 DOI: 10.1002/14651858.cd011710.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Therapist-delivered trauma-focused psychological therapies are effective for post-traumatic stress disorder (PTSD) and have become the accepted first-line treatments. Despite the established evidence-base for these therapies, they are not always widely available or accessible. Many barriers limit treatment uptake, such as the number of qualified therapists available to deliver the interventions; cost; and compliance issues, such as time off work, childcare, and transportation, associated with the need to attend weekly appointments. Delivering Internet-based cognitive and behavioural therapy (I-C/BT) is an effective and acceptable alternative to therapist-delivered treatments for anxiety and depression. OBJECTIVES To assess the effects of I-C/BT for PTSD in adults. SEARCH METHODS We searched MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials to June 2020. We also searched online clinical trial registries and reference lists of included studies and contacted the authors of included studies and other researchers in the field to identify additional and ongoing studies. SELECTION CRITERIA We searched for RCTs of I-C/BT compared to face-to-face or Internet-based psychological treatment, psychoeducation, wait list, or care as usual. We included studies of adults (aged over 16 years), in which at least 70% of the participants met the diagnostic criteria for PTSD, according to the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD). DATA COLLECTION AND ANALYSIS Two review authors independently assessed abstracts, extracted data, and entered data into Review Manager 5. The primary outcomes were severity of PTSD symptoms and dropouts. Secondary outcomes included diagnosis of PTSD after treatment, severity of depressive and anxiety symptoms, cost-effectiveness, adverse events, treatment acceptability, and quality of life. We analysed categorical outcomes as risk ratios (RRs), and continuous outcomes as mean differences (MD) or standardised mean differences (SMDs), with 95% confidence intervals (CI). We pooled data using a fixed-effect meta-analysis, except where heterogeneity was present, in which case we used a random-effects model. We independently assessed the included studies for risk of bias and we evaluated the certainty of available evidence using the GRADE approach; we discussed any conflicts with at least one other review author, with the aim of reaching a unanimous decision. MAIN RESULTS We included 13 studies with 808 participants. Ten studies compared I-C/BT delivered with therapist guidance to a wait list control. Two studies compared guided I-C/BT with I-non-C/BT. One study compared guided I-C/BT with face-to-face non-C/BT. There was substantial heterogeneity among the included studies. I-C/BT compared with face-to-face non-CBT Very low-certainty evidence based on one small study suggested face-to-face non-CBT may be more effective than I-C/BT at reducing PTSD symptoms post-treatment (MD 10.90, 95% CI 6.57 to 15.23; studies = 1, participants = 40). There may be no evidence of a difference in dropout rates between treatments (RR 2.49, 95% CI 0.91 to 6.77; studies = 1, participants = 40; very low-certainty evidence). The study did not measure diagnosis of PTSD, severity of depressive or anxiety symptoms, cost-effectiveness, or adverse events. I-C/BT compared with wait list Very low-certainty evidence showed that, compared with wait list, I-C/BT may be associated with a clinically important reduction in PTSD post-treatment (SMD -0.61, 95% CI -0.93 to -0.29; studies = 10, participants = 608). There may be no evidence of a difference in dropout rates between the I-C/BT and wait list groups (RR 1.25, 95% CI 0.97 to 1.60; studies = 9, participants = 634; low-certainty evidence). I-C/BT may be no more effective than wait list at reducing the risk of a diagnosis of PTSD after treatment (RR 0.53, 95% CI 0.28 to 1.00; studies = 1, participants = 62; very low-certainty evidence). I-C/BT may be associated with a clinically important reduction in symptoms of depression post-treatment (SMD -0.51, 95% CI -0.97 to -0.06; studies = 7, participants = 473; very low-certainty evidence). Very low-certainty evidence also suggested that I-C/BT may be associated with a clinically important reduction in symptoms of anxiety post-treatment (SMD -0.61, 95% CI -0.89 to -0.33; studies = 5, participants = 345). There were no data regarding cost-effectiveness. Data regarding adverse events were uncertain, as only one study reported an absence of adverse events. I-C/BT compared with I-non-C/BT There may be no evidence of a difference in PTSD symptoms post-treatment between the I-C/BT and I-non-C/BT groups (SMD -0.08, 95% CI -0.52 to 0.35; studies = 2, participants = 82; very low-certainty evidence). There may be no evidence of a difference between dropout rates from the I-C/BT and I-non-C/BT groups (RR 2.14, 95% CI 0.97 to 4.73; studies = 2, participants = 132; I² = 0%; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment depressive symptoms between the I-C/BT and I-non-C/BT groups (SMD -0.12, 95% CI -0.78 to 0.54; studies = 2, participants = 84; very low-certainty evidence). Two studies found no evidence of a difference in post-treatment symptoms of anxiety between the I-C/BT and I-non-C/BT groups (SMD 0.08, 95% CI -0.78 to 0.95; studies = 2, participants = 74; very low-certainty evidence). There were no data regarding cost-effectiveness. Data regarding adverse effects were uncertain, as it was not discernible whether adverse effects reported were attributable to the intervention. AUTHORS' CONCLUSIONS While the review found some beneficial effects of I-C/BT for PTSD, the certainty of the evidence was very low due to the small number of included trials. This review update found many planned and ongoing studies, which is encouraging since further work is required to establish non-inferiority to current first-line interventions, explore mechanisms of change, establish optimal levels of guidance, explore cost-effectiveness, measure adverse events, and determine predictors of efficacy and dropout.
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Affiliation(s)
- Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Catrin Lewis
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Neil P Roberts
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
- Psychology & Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Andrew Bethell
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
- Changing Minds UK, Warrington, UK
| | - Sarah Dawson
- Cochrane Common Mental Disorders, University of York, York, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
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Bernardi J, Engelbrecht A, Jobson L. The impact of culture on cognitive appraisals: Implications for the development, maintenance, and treatment of posttraumatic stress disorder. CLIN PSYCHOL-UK 2020. [DOI: 10.1111/cp.12161] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jessica Bernardi
- Monash Institute of Cognitive and Clinical Neuroscience, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia,
| | - Alberta Engelbrecht
- Monash Institute of Cognitive and Clinical Neuroscience, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia,
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK,
| | - Laura Jobson
- Monash Institute of Cognitive and Clinical Neuroscience, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia,
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A Pilot Study of Racial and Ethnic Differences in Mental Health Outcomes During the First 6 Weeks of Trauma-Focused Treatment. Community Ment Health J 2020; 56:1592-1602. [PMID: 32285373 DOI: 10.1007/s10597-020-00620-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
The objective of this research was to investigate the relationship between race/ethnicity, intervention type, and mental health outcomes at 6 weeks into treatment in a low-income, diverse community-based sample of adults seeking treatment for traumatic stress. Adult patients (N = 163) received either prolonged exposure (PE) or present centered therapy (PCT). Results suggest significant within group differences with moderate to large effect sizes after six sessions of PE or PCT by race/ethnicity. Logistic regression analyses indicated that after adjusting for significant sociodemographic covariates, at the 6-week time-point the White group had increased likelihood of: probable PTSD compared to the Latinx group; probable anxiety compared to the Black group, Latinx group, and Other group; and probable depression compared to the Other group. Covariate adjusted models also found that at 6 weeks individuals in the PCT group had significantly greater odds of probable PTSD compared to those in the PE group. Implications for behavioral healthcare in a community-based setting are discussed.
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12
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Reich K, Nemeth LS, Mueller M, Sternke LM, Acierno R. Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods. J Psychosoc Nurs Ment Health Serv 2020; 59:31-40. [PMID: 33095268 DOI: 10.3928/02793695-20201015-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/28/2020] [Indexed: 12/21/2022]
Abstract
The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31-40.].
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13
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Graham B, Garcia NM, Bergman HE, Feeny NC, Zoellner LA. Prolonged Exposure and Sertraline Treatments for Posttraumatic Stress Disorder Also Improve Multiple Indicators of Social Functioning. J Trauma Stress 2020; 33:488-499. [PMID: 32662191 PMCID: PMC7719061 DOI: 10.1002/jts.22570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/23/2020] [Accepted: 04/29/2020] [Indexed: 11/07/2022]
Abstract
Trauma survivors with posttraumatic stress disorder (PTSD) frequently also suffer from difficulties in social functioning that range across emotional, cognitive, and environmental domains. A detailed evaluation of the differential impacts of effective PTSD treatments on social functioning is needed. Men and women (N = 200) with chronic PTSD received 10 weeks of prolonged exposure (PE) or sertraline in a randomized clinical trial and were followed for 24 months. A secondary data analysis examined changes in social functioning with regard to fear of intimacy; receipt of social support; and distress, avoidance, and negative cognitions in social situations. Effects were examined between treatments over time, controlling for baseline functioning. There were large, durable improvements across all indices. Compared to sertraline, PE was more efficient at reducing fear of intimacy and distress from negative social cognitions by posttreatment, ds = 0.94-1.14. Patients who received sertraline continued to improve over the course of follow-up, ds = 0.54-1.17. The differential speed of therapeutic effects may argue for more direct mechanisms in cognitive behavioral interventions versus cascade effects in serotonin reuptake inhibitors. Notably, both treatments produced substantial social benefits for trauma survivors with social functioning difficulties, and effect sizes were comparable to typical reductions in PTSD, depression, and anxiety.
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Affiliation(s)
- Belinda Graham
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Natalia M. Garcia
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Hannah E. Bergman
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Norah C. Feeny
- Department of Psychological Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lori A. Zoellner
- Department of Psychology, University of Washington, Seattle, Washington, USA
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14
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Scherrer JF, Salas J, Schneider FD, Friedman MJ, van den Berk-Clark C, Chard KM, Norman SB, Lustman PJ, Tuerk P, Schnurr PP, Cohen BE. PTSD improvement and incident cardiovascular disease in more than 1000 veterans. J Psychosom Res 2020; 134:110128. [PMID: 32403058 PMCID: PMC7274904 DOI: 10.1016/j.jpsychores.2020.110128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) is associated with increased risk for cardiovascular disease (CVD). Whether clinically meaningful PTSD improvement is associated with lowering CVD risk is unknown. METHODS Eligible patients (n = 1079), were 30-70 years old, diagnosed with PTSD and used Veterans Health Affairs PTSD specialty clinics. Patients had a PTSD Checklist score (PCL) ≥ 50 between Fiscal Year (FY) 2008 and FY2012 and a second PCL score within 12 months and at least 8 weeks after the first PCL ≥ 50. Clinically meaningful PTSD improvement was defined by ≥20 point PCL decrease between the first and second PCL score. Patients were free of CVD diagnoses for 1 year prior to index. Index date was 12 months following the first PCL. Follow-up continued to FY2015. Cox proportional hazard models estimated the association between clinically meaningful PTSD improvement and incident CVD and incident ischemic heart disease (IHD). Sensitivity analysis stratified by age group (30-49 vs. 50-70 years) and depression. Confounding was controlled using propensity scores and inverse probability of exposure weighting. RESULTS Patients were 48.9 ± 10.9 years of age on average, 83.3% male, 60.1% white, and 29.5% black. After controlling for confounding, patients with vs. without PTSD improvement did not differ in CVD risk (HR = 1.08; 95%CI: 0.72-1.63). Results did not change after stratifying by age group or depression status. Results were similar for incident IHD. CONCLUSIONS Over a 2-7 year follow-up, we did not find an association between clinically meaningful PTSD improvement and incident CVD. Additional research is needed using longer follow-up.
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Affiliation(s)
- Jeffrey F. Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104,Harry S. Truman Veterans Administration Medical Center. Columbia, MO.,Corresponding author at: Family and Community Medicine, Saint Louis University School of Medicine, 1402 N. Grand Blvd, St. Louis, MO. 63104,
| | - Joanne Salas
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104,Harry S. Truman Veterans Administration Medical Center. Columbia, MO
| | - F. David Schneider
- Department of Family and Community Medicine, University of Texas Southwestern, Dallas TX
| | - Matthew J. Friedman
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Carissa van den Berk-Clark
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis MO. 63104
| | - Kathleen M. Chard
- Trauma Recovery Center Cincinnati VAMC and Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, OH
| | - Sonya B. Norman
- National Center for PTSD and Department of Psychiatry, University of California San Diego
| | - Patrick J. Lustman
- Department of Psychiatry, Washington University School of Medicine, St. Louis MO.,The Bell Street Clinic Opioid Addiction Treatment Program, VA St. Louis Health Care System, St. Louis MO
| | - Peter Tuerk
- Sheila C. Johnson Center for Clinical Services, Department of Human Services, University of Virginia, Charlottesville, VA
| | - Paula P. Schnurr
- National Center for PTSD and Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Beth E. Cohen
- Department of Medicine, University of California San Francisco School of Medicine and San Francisco VAMC, CA
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15
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Badour CL, Cox KS, Goodnight JR, Flores J, Tuerk PW, Rauch SA. Sexual Desire among Veterans Receiving Prolonged Exposure Therapy for PTSD: Does Successful PTSD Treatment Also Yield Improvements in Sexual Desire? Psychiatry 2020; 83:70-83. [PMID: 31577915 PMCID: PMC7083685 DOI: 10.1080/00332747.2019.1672439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: People with posttraumatic stress disorder (PTSD) commonly report difficulties with sexual desire and other aspects of sexual functioning, but it is currently unknown if people who respond to psychotherapy for PTSD also report improvements in sexual desire. Method: One hundred and eighty-seven veterans with PTSD received prolonged exposure (PE) therapy at two outpatient PTSD specialty clinics and completed measures of PTSD symptoms (the PTSD Checklist - Military Version) and sexual desire (item 21 of the Beck Depression Inventory - Second Edition) repeatedly throughout the course of treatment. Results: The results of a conditional generalized mixed ordinal regression model showed a significant interaction between weeks in treatment and PTSD treatment response in predicting change in sexual desire across the course of treatment. Specifically, PTSD treatment responders reported improvement in sexual desire over the course of treatment, whereas nonresponders did not show changes in sexual desire over time. However, the effect of PTSD treatment response was no longer significant when accounting for severity of depression at the start of treatment. Participants reporting more severe depression at the start of treatment reported less improvement in sexual desire, regardless of PTSD symptom response. Conclusions: People with PTSD who respond to PE also report improvements in sexual desire over time, indicating that response to PE is associated with improved sexual desire, but the effect is complicated by the presence of co-occurring depression symptomatology.
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Affiliation(s)
| | - Keith S. Cox
- University of North Carolina, Asheville, Department of Psychology
| | | | | | | | - Sheila A.M. Rauch
- Emory University, Department of Psychiatry and Behavioral Sciences,VA Atlanta Healthcare System, Mental Health Service Line
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16
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Simon N, McGillivray L, Roberts NP, Barawi K, Lewis CE, Bisson JI. Acceptability of internet-based cognitive behavioural therapy (i-CBT) for post-traumatic stress disorder (PTSD): a systematic review. Eur J Psychotraumatol 2019; 10:1646092. [PMID: 31497259 PMCID: PMC6719262 DOI: 10.1080/20008198.2019.1646092] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/28/2022] Open
Abstract
Background: Internet-delivered Cognitive Behavioural Therapy (i-CBT) offers potential as an alternative, accessible, clinically and cost-effective treatment for post-traumatic stress disorder (PTSD), but little is known about its acceptability. Objective: To review the available evidence to understand the acceptability of i-CBT for PTSD. Method: We undertook a mixed-methods systematic review according to Cochrane Collaboration Guidelines, of randomised controlled trials (RCTs) of i-CBT for adults with PTSD. We examined included studies for measures of acceptability, and possible proxy indicators of acceptability, including dropout rates, which were meta-analysed as risk ratios (RRs). Results: Ten studies with 720 participants were included. We found i-CBT to be acceptable according to specific acceptability measures, and suggestions for acceptability according to some proxy measures of i-CBT programme usage. There was, however, evidence of greater dropout from i-CBT than waitlist (RR 1.39, CI 1.03-1.88; 8 studies; participants = 585) and no evidence of a difference in dropout between i-CBT and i-non-CBT (RR 2.14, CI 0.97-4.73; participants = 132; 2 studies). Conclusion: i-CBT appears a potentially acceptable intervention for adults with PTSD. We identified clinical and research questions, including the status of proxy indicators, and call for standardised, consistent treatment acceptability measurement.
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Affiliation(s)
- Natalie Simon
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Leah McGillivray
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Neil P Roberts
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK.,Psychology and Psychological Therapies Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Kali Barawi
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Catrin E Lewis
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | - Jonathan I Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
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17
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Abraham TH, Marchant-Miros K, McCarther MB, Craske MG, Curran GM, Kearney LK, Greene C, Lindsay JA, Cucciare MA. Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach. JMIR Ment Health 2018; 5:e10277. [PMID: 30135051 PMCID: PMC6125613 DOI: 10.2196/10277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A national priority at the US Department of Veterans Affairs (VA) is to increase the availability and accessibility of evidence-based psychotherapies (EBPs) across all VA medical facilities. Yet many veterans, particularly those who use remote outpatient VA clinics, still do not receive much needed evidence-based treatment. Strategies are needed for supporting mental health providers at rural VA community-based outpatient clinics (CBOCs) as they translate their clinical training to routine practice. The Coordinated Anxiety Learning Management (CALM) program is a computer-delivered program that supports the delivery of cognitive behavioral therapy (CBT) by providers in outpatient settings to patients with depression and anxiety, including posttraumatic stress disorder. OBJECTIVE The objectives of our study were to (1) adapt an existing computer-based program to rural VA CBOCs through feedback from key stakeholder focus groups; (2) develop a prototype of the adapted program; and (3) determine the adapted program's acceptability and feasibility. Mental health stakeholders included VA leaders (n=4) in the implementation of EBPs, VA experts (n=4) in CBT, VA CBOC mental health providers (n=8), and veterans (n=8) diagnosed with a mental health condition treated using the CALM program and receiving treatment in a VA CBOC. METHODS An iterative approach comprising 3 waves of focus group discussions was used to develop a modified prototype of CALM. Following each wave of focus group discussions, template analysis was used to rapidly communicate stakeholder recommendations and feedback to the design team. The original program was first adapted through a process of data collection, design modification, and product development. Next, a prototype was developed. Finally, the redesigned program was tested for acceptability and feasibility through a live demonstration. RESULTS Key stakeholders suggested modifications to the original CALM program that altered its modules' appearance by incorporating veteran-centric content. These modifications likely have no impact on the integrity of the original CALM program, but have altered its content to reflect better the demographic characteristics and experiences of rural veterans. Feedback from stakeholder groups indicates that changes will help VA patients identify with the program content, potentially enhancing their treatment engagement. CONCLUSIONS The development model was effective for economically gathering actionable recommendations from stakeholders to adapt a computer-based program, and it can result in the development of an acceptable and feasible computer-delivered intervention. Results have implications for developing computer-based programs targeting behavior change more broadly and enhancing engagement in EBP.
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Affiliation(s)
- Traci H Abraham
- South Central Mental Illness Research, Education, and Clinical Center, US Department of Veterans Affairs, Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Kathy Marchant-Miros
- South Central Mental Illness Research, Education, and Clinical Center, US Department of Veterans Affairs, Little Rock, AR, United States
| | - Michael B McCarther
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Michelle G Craske
- Department of Psychology, University of California, Los Angles, Los Angeles, CA, United States.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Geoffrey M Curran
- South Central Mental Illness Research, Education, and Clinical Center, US Department of Veterans Affairs, Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Lisa K Kearney
- US Department of Veterans Affairs Center for Integrated Healthcare, Buffalo, NY, United States.,Department of Psychiatry, The University of Texas Health Science Center, San Antonio, TX, United States
| | - Carolyn Greene
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Office of Mental Health and Suicide Prevention, US Department of Veterans Affairs, Washington, DC, United States
| | - Jan A Lindsay
- Houston Veterans Affairs Health Services Research & Development Service Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, United States.,Menninger Department of Psychiatry & Behavioral Sciences, Houston, TX, United States
| | - Michael A Cucciare
- South Central Mental Illness Research, Education, and Clinical Center, US Department of Veterans Affairs, Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
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18
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Janeček M, Dabrowska J. Oxytocin facilitates adaptive fear and attenuates anxiety responses in animal models and human studies-potential interaction with the corticotropin-releasing factor (CRF) system in the bed nucleus of the stria terminalis (BNST). Cell Tissue Res 2018; 375:143-172. [PMID: 30054732 DOI: 10.1007/s00441-018-2889-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/04/2018] [Indexed: 01/28/2023]
Abstract
Despite its relatively well-understood role as a reproductive and pro-social peptide, oxytocin (OT) tells a more convoluted story in terms of its modulation of fear and anxiety. This nuanced story has been obscured by a great deal of research into the therapeutic applications of exogenous OT, driving more than 400 ongoing clinical trials. Drawing from animal models and human studies, we review the complex evidence concerning OT's role in fear learning and anxiety, clarifying the existing confusion about modulation of fear versus anxiety. We discuss animal models and human studies demonstrating the prevailing role of OT in strengthening fear memory to a discrete signal or cue, which allows accurate and rapid threat detection that facilitates survival. We also review ostensibly contrasting behavioral studies that nonetheless provide compelling evidence of OT attenuating sustained contextual fear and anxiety-like behavior, arguing that these OT effects on the modulation of fear vs. anxiety are not mutually exclusive. To disambiguate how endogenous OT modulates fear and anxiety, an understudied area compared to exogenous OT, we survey behavioral studies utilizing OT receptor (OTR) antagonists. Based on emerging evidence about the role of OTR in rat dorsolateral bed nucleus of stria terminalis (BNST) and elsewhere, we postulate that OT plays a critical role in facilitating accurate discrimination between stimuli representing threat and safety. Supported by human studies, we demonstrate that OT uniquely facilitates adaptive fear but reduces maladaptive anxiety. Last, we explore the limited literature on endogenous OT and its interaction with corticotropin-releasing factor (CRF) with a special emphasis on the dorsolateral BNST, which may hold the key to the neurobiology of phasic fear and sustained anxiety.
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Affiliation(s)
- Michael Janeček
- Department of Cellular and Molecular Pharmacology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA
| | - Joanna Dabrowska
- Department of Cellular and Molecular Pharmacology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA. .,Department of Neuroscience, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA.
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19
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Harned MS, Wilks CR, Schmidt SC, Coyle TN. Improving functional outcomes in women with borderline personality disorder and PTSD by changing PTSD severity and post-traumatic cognitions. Behav Res Ther 2018; 103:53-61. [PMID: 29448136 PMCID: PMC5837954 DOI: 10.1016/j.brat.2018.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 01/27/2018] [Accepted: 02/05/2018] [Indexed: 10/18/2022]
Abstract
Although functional impairment typically improves during evidence-based psychotherapies (EBPs) for borderline personality disorder (BPD), functional levels often remain suboptimal after treatment. The present pilot study evaluated whether and how integrating PTSD treatment into an EBP for BPD would improve functional outcomes. Participants were 26 women with BPD, PTSD, and recent suicidal and/or self-injurious behavior who were randomized to receive one year of Dialectical Behavior Therapy (DBT) or DBT with the DBT Prolonged Exposure (DBT PE) protocol for PTSD. Five domains of functioning were assessed at 4-month intervals during treatment and at 3-months post-treatment. DBT + DBT PE was superior to DBT in improving global social adjustment, health-related quality of life, and achieving good global functioning, but not interpersonal problems or quality of life. Results of time-lagged mixed effects models indicated that, across both treatments, reductions in PTSD severity significantly predicted subsequent improvement in global social adjustment, global functioning, and health-related quality of life, whereas reductions in post-traumatic cognitions significantly predicted later improvement in all functional outcomes except global social adjustment. These findings provide preliminary evidence supporting the role of change in PTSD severity and trauma-related cognitions as active mechanisms in improving functional outcomes among individuals with BPD and PTSD.
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20
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Nollett C, Lewis C, Kitchiner N, Roberts N, Addison K, Brookes-Howell L, Cosgrove S, Cullen K, Ehlers A, Heke S, Kelson M, Lovell K, Madden K, McEwan K, McNamara R, Phillips C, Pickles T, Simon N, Bisson J. Pragmatic RAndomised controlled trial of a trauma-focused guided self-help Programme versus InDividual trauma-focused cognitive Behavioural therapy for post-traumatic stress disorder (RAPID): trial protocol. BMC Psychiatry 2018; 18:77. [PMID: 29580220 PMCID: PMC5870753 DOI: 10.1186/s12888-018-1665-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/14/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is good evidence that trauma-focused therapies for Post-Traumatic Stress Disorder are effective. However, they are not always feasible to deliver due a shortage of trained therapists and demands on the patient. An online trauma-focused Guided Self-Help (GSH) programme which could overcome these barriers has shown promise in a pilot study. This study will be the first to evaluate GSH against standard face-to-face therapy to assess its suitability for use in the NHS. METHODS The study is a large-scale multi-centre pragmatic randomised controlled non-inferiority trial, with assessors masked to treatment allocation. One hundred and ninety-two participants will be randomly allocated to receive either face-to-face trauma-focused cognitive behaviour therapy (TFCBT) or trauma-focused online guided self-help (GSH). The primary outcome will be the severity of symptoms of PTSD over the previous week as measured by the Clinician Administered PTSD Scale for DSM5 (CAPS-5) at 16 weeks post-randomisation. Secondary outcome measures include PTSD symptoms over the previous month as measured by the CAPS-5 at 52 weeks plus the Impact of Event Scale - revised (IES-R), Work and Social Adjustment Scale (WSAS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Test (AUDIT-O), Multidimensional Scale for Perceived Social Support (MSPSS), short Post-Traumatic Cognitions Inventory (PTCI), Insomnia Severity Index (ISI) and General Self Efficacy Scale (GSES) measured at 16 and 52 weeks post-randomisation. Changes in health-related quality of life will be measured by the EQ-5D and the level of healthcare resource utilisation for health economic analysis will be determined by an amended version of the Client Socio-Demographic and Service Receipt Inventory European Version. The Client Satisfaction Questionnaire (CSQ) will be collected at 16 weeks post-randomisation to evaluate treatment satisfaction. DISCUSSION This study will be the first to compare online GSH with usual face-to-face therapy for PTSD. The strengths are that it will test a rigorously developed intervention in a real world setting to inform NHS commissioning. The potential challenges of delivering such a pragmatic study may include participant recruitment, retention and adherence, therapist retention, and fidelity of intervention delivery. TRIAL REGISTRATION ISRCTN13697710 registered on 20/12/2016.
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Affiliation(s)
- Claire Nollett
- Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Catrin Lewis
- 0000 0001 0807 5670grid.5600.3Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK
| | - Neil Kitchiner
- 0000 0001 0807 5670grid.5600.3Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK ,0000 0001 0807 5670grid.5600.3Cardiff & Vale University Health Board, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK
| | - Neil Roberts
- 0000 0001 0807 5670grid.5600.3Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK ,0000 0001 0807 5670grid.5600.3Cardiff & Vale University Health Board, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK
| | - Katy Addison
- 0000 0001 0807 5670grid.5600.3Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Lucy Brookes-Howell
- 0000 0001 0807 5670grid.5600.3Centre for Trials Research, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Sarah Cosgrove
- Independent Public and Patient Involvement (PPI) representative, Cardiff, UK
| | - Katherine Cullen
- 0000 0001 0658 8800grid.4827.9Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Anke Ehlers
- grid.470387.fDepartment of Experimental Psychology, Oxford Centre for Anxiety Disorders and Trauma, Paradise Square, Oxford, OX1 1TW UK
| | - Sarah Heke
- grid.439501.aGrenfell Emotional Health and Wellbeing service, Central and Northwest London (CNWL) NHS Trust, St Charles Hospital, Exmoor Street, London, UK ,0000 0004 0581 2008grid.451052.7Formerly at Institute of Psychotrauma, East London Foundation NHS Trust, 86 Old Montague Street, London, E1 8NN UK
| | - Mark Kelson
- 0000 0004 1936 8024grid.8391.3Department of Mathematics, Laver Building, University of Exeter, Exeter, EX4 4QRE UK
| | - Karina Lovell
- 0000000121662407grid.5379.8Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Room 6.322a, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
| | - Kim Madden
- 0000 0001 0807 5670grid.5600.3Centre for Trials Research, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Kirsten McEwan
- 0000 0001 2232 4004grid.57686.3aDepartment of Psychology, University of Derby, Kedleston Road, Derby, DE22 1GB UK
| | - Rachel McNamara
- 0000 0001 0807 5670grid.5600.3Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Ceri Phillips
- 0000 0001 0658 8800grid.4827.9Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Timothy Pickles
- 0000 0001 0807 5670grid.5600.3Centre for Trials Research, Cardiff University, 4th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Natalie Simon
- 0000 0001 0807 5670grid.5600.3Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ UK
| | - Jonathan Bisson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Haydn Ellis Building, Maindy Road, Cardiff, CF24 4HQ, UK.
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Comorbid Posttraumatic Stress Disorder and Traumatic Brain Injury: Generalization of Prolonged-Exposure PTSD Treatment Outcomes to Postconcussive Symptoms, Cognition, and Self-Efficacy in Veterans and Active Duty Service Members. J Head Trauma Rehabil 2018; 33:E53-E63. [DOI: 10.1097/htr.0000000000000344] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury. J Head Trauma Rehabil 2018; 32:34-45. [PMID: 27323217 DOI: 10.1097/htr.0000000000000242] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties. SETTING VA Polytrauma Rehabilitation Centers. PARTICIPANTS Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data. DESIGN Prospective, longitudinal cohort. MAIN MEASURES Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning. RESULTS In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability. CONCLUSION Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.
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Chan AHL, Wong SYS, Chien WT. A prospective cohort study of community functioning among psychiatric outpatients. Psychiatry Res 2018; 259:125-134. [PMID: 29040948 DOI: 10.1016/j.psychres.2017.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 08/05/2017] [Accepted: 10/07/2017] [Indexed: 11/15/2022]
Abstract
The present study analyzed the community functioning among Chinese people with common mental disorders and their relationships with different factors under the framework of Model of Human Occupation. The research team followed up a stratified random sample of 238 patients in three public psychiatric specialist outpatient clinics in Hong Kong in one year. The patients completed assessments at baseline and 12-month follow-up in four areas of community functioning (i.e., self-care, independent living skills, social skills, and work skills), self-esteem, self-efficacy, physical functioning, behavioral regulation, mental states, family expressed emotion, and perceived social stigma. The data showed that after 12 months, the patients had positive changes in self-care, work skills, and behavioral regulation. Those patients who had higher levels of self-esteem at baseline and reduced their negative reactions to stigma were more likely to improve social skills, while those patients who perceived less discrimination at baseline and enhanced their self-esteem would have a higher likelihood of making improvement in work skills. The findings implied that the rehabilitation services for people with common mental disorders might target on the enhancement of self-esteem and reduction of discrimination experience to facilitate their improvement in social skills and work skills.
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Affiliation(s)
- Alan H L Chan
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong.
| | - Samuel Y S Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
| | - Wai-Tong Chien
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
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Milligan-Saville JS, Paterson HM, Harkness EL, Marsh AM, Dobson M, Kemp RI, Bryant RA, Harvey SB. The Amplification of Common Somatic Symptoms by Posttraumatic Stress Disorder in Firefighters. J Trauma Stress 2017; 30:142-148. [PMID: 28273379 DOI: 10.1002/jts.22166] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/22/2016] [Accepted: 11/30/2016] [Indexed: 01/07/2023]
Abstract
Posttraumatic stress disorder (PTSD) in emergency service personnel and other trauma-exposed populations is known to be associated with a variety of physical health problems. However, little attention has been paid to the health of ageing emergency service personnel, who may be forced into early medical retirement because of a combination of these issues. Currently employed (N = 274) Australian firefighters completed a cross-sectional survey using validated, self-report measures of PTSD and somatic symptoms. Analyses examined the association between probable PTSD and a range of common somatic symptoms, and whether any association differed depending on the age of the firefighters. Firefighters with PTSD reported greater levels of neurological (p = .024), gastrointestinal (p = .015), and cardiorespiratory (p = .027) symptoms compared to those without PTSD. After adjusting for sex, age, and rank, linear regression analysis demonstrated that PTSD was significantly associated with increased total somatic symptom severity (p = .024), with PTSD accounting for 9.8% of the variance in levels of somatic symptoms. There was no interaction between age and the association between PTSD and somatic symptom severity. These results suggest that PTSD is associated with a significant increase in a wide range of somatic symptoms among firefighters, regardless of age. The implications for the identification and treatment of PTSD are discussed.
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Affiliation(s)
| | | | | | - Annabel M Marsh
- School of Psychology, University of Sydney, Sydney, Australia
| | - Mark Dobson
- Fire and Rescue New South Wales, Sydney, Australia
| | - Richard I Kemp
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Samuel B Harvey
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Black Dog Institute, Sydney, Australia.,St. George Hospital, Kogarah, Australia
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Wang SJ, Bytyçi A, Izeti S, Kallaba M, Rushiti F, Montgomery E, Modvig J. A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: a pilot randomized controlled trial in Kosovo. Confl Health 2017; 10:34. [PMID: 28191034 PMCID: PMC5297130 DOI: 10.1186/s13031-016-0100-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 10/06/2016] [Indexed: 11/16/2022] Open
Abstract
Background Some evidence showed that multidisciplinary rehabilitation in Western countries is effective for treating war-related trauma, but it remains unclear whether this approach is applicable to civilians living in resource-poor countries affected by war. In 2012–14, Danish Institute against Torture (DIGNITY) conducted a randomized controlled trial (RCT), in partnership with Kosova Rehabilitation Centre for Torture Victims (KRCT), to examine the effects of multidisciplinary intervention among victims of torture and war in Kosovo. Methods A single-center, randomized, parallel-arm, single-masked, waiting-list controlled trial was implemented in northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group, which received integrated treatments plus a once-daily multivitamin, or the waiting list group, which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-min sessions of cognitive behavioral therapy (CBT), based on an adapted prolonged exposure therapy manual, an individual 20-min breathing exercise with an emWave biofeedback device, and 90-min group physiotherapy. The waiting list group also received the same treatment after the intervention group had completed their sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Outcomes measures consisted of 4 subtypes: mental, emotional, physical health, functioning and social outcomes, i.e. PTSD, depression, anxiety, chronic pain, anger and hatred expression, body mass index, handgrip strength, standing balance, income, employment rate and disability score. Results Over 1/3 of PTSD cases were successfully treated. Inconsistent patterns with mental health and chronic pain outcomes were observed while there was a definite impact of intervention on functioning and social outcomes, i.e. the employment rate, which increased nearly 15 %, and the monthly wage, which rose 45–137 %. There was also a noticeable improvement in handgrip strength and disability score; the feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance. Conclusions The impact of bio-psycho-social intervention is likely sensitive to the context of post-war economy in Kosovo and the treatment goals. The potential for improving the emotional well-being and employment outcome in victims was demonstrated. A larger scale RCT in a similar setting is needed, with close monitoring of treatment integrity and data reliability. Trial registration Clinicaltrials.gov (NCT01696578).
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Affiliation(s)
- Shr-Jie Wang
- Danish Institute against Torture (DIGNITY), Copenhagen, Denmark
| | - Ardiana Bytyçi
- Kosova Rehabilitation Centre for Torture Victims (KRCT), Pristina, Kosovo ; Department of Psychology, University of Pristina, Pristina, Kosovo
| | - Selvi Izeti
- Kosova Rehabilitation Centre for Torture Victims (KRCT), Pristina, Kosovo ; Department of Psychology, University of Pristina, Pristina, Kosovo
| | - Melita Kallaba
- Kosova Rehabilitation Centre for Torture Victims (KRCT), Pristina, Kosovo
| | - Feride Rushiti
- Kosova Rehabilitation Centre for Torture Victims (KRCT), Pristina, Kosovo
| | | | - Jens Modvig
- Danish Institute against Torture (DIGNITY), Copenhagen, Denmark
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26
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Zandberg L, Kaczkurkin AN, McLean CP, Rescorla L, Yadin E, Foa EB. Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems. J Trauma Stress 2016; 29:507-514. [PMID: 27859619 PMCID: PMC7367099 DOI: 10.1002/jts.22138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/20/2016] [Accepted: 08/21/2016] [Indexed: 11/07/2022]
Abstract
The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.
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Affiliation(s)
- Laurie Zandberg
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Antonia N. Kaczkurkin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carmen P. McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie Rescorla
- Department of Psychology, Bryn Mawr College, Bryn Mawr, Pennsylvania, USA
| | - Elna Yadin
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edna B. Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Strom TQ, Wolf GK, Crawford E, Blahnik M, Kretzmer T. Implementing Prolonged Exposure for Veterans With Comorbid PTSD and Traumatic Brain Injury: Two Case Studies. COGNITIVE AND BEHAVIORAL PRACTICE 2016. [DOI: 10.1016/j.cbpra.2015.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Fear memory is the best-studied form of memory. It was thoroughly investigated in the past 60 years mostly using two classical conditioning procedures (contextual fear conditioning and fear conditioning to a tone) and one instrumental procedure (one-trial inhibitory avoidance). Fear memory is formed in the hippocampus (contextual conditioning and inhibitory avoidance), in the basolateral amygdala (inhibitory avoidance), and in the lateral amygdala (conditioning to a tone). The circuitry involves, in addition, the pre- and infralimbic ventromedial prefrontal cortex, the central amygdala subnuclei, and the dentate gyrus. Fear learning models, notably inhibitory avoidance, have also been very useful for the analysis of the biochemical mechanisms of memory consolidation as a whole. These studies have capitalized on in vitro observations on long-term potentiation and other kinds of plasticity. The effect of a very large number of drugs on fear learning has been intensively studied, often as a prelude to the investigation of effects on anxiety. The extinction of fear learning involves to an extent a reversal of the flow of information in the mentioned structures and is used in the therapy of posttraumatic stress disorder and fear memories in general.
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Affiliation(s)
- Ivan Izquierdo
- National Institute of Translational Neuroscience, National Research Council of Brazil, and Memory Center, Brain Institute, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cristiane R. G. Furini
- National Institute of Translational Neuroscience, National Research Council of Brazil, and Memory Center, Brain Institute, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jociane C. Myskiw
- National Institute of Translational Neuroscience, National Research Council of Brazil, and Memory Center, Brain Institute, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Bourn LE, Sexton MB, Raggio GA, Porter KE, Rauch SAM. Posttraumatic stress disorder and somatic complaints: Contrasting Vietnam and OIF/OEF Veterans' experiences. J Psychosom Res 2016; 82:35-40. [PMID: 26944397 DOI: 10.1016/j.jpsychores.2016.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 01/25/2016] [Accepted: 01/28/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To replicate and expand upon the relationship of somatic symptoms and posttraumatic stress disorder (PTSD) by comparing symptoms among service eras in US Veterans. METHOD Data were collected from 226 Vietnam and 132 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans who were referred to a Veterans Affairs (VA) hospital PTSD outpatient clinic between 2005 and 2013. Veterans were administered self-report inventories and a clinical interview to measure somatic symptoms and PTSD severity. A subset of Veterans (n=185) screening positive for PTSD were administered the Clinician Administered PTSD Scale (CAPS) to measure PTSD severity. Multiple moderated linear regressions were used to examine the influence of service era on the relationship between somatic and PTSD symptoms. RESULTS There were no significant differences between service eras in pain severity, pain interference, and total somatic symptoms reported. Vietnam Veterans were more likely to report limb/join pain (p<.05), fainting (p<.01), and shortness of breath (p<.001), whereas OIF/OEF Veterans were more likely to complain of headaches (p<.001). A significant interaction effect occurred between service era and dizziness (p<.05) and chest pain (p<.01), with OIF/OEF Veterans reporting higher levels of these symptoms significantly more likely than Vietnam Veterans to also experience more severe PTSD. CONCLUSION Findings are consistent with previous research demonstrating the relationship of somatic symptoms and PTSD across service eras but provide additional data concerning similarities and differences of somatic symptoms between eras. Potential explanations for observed service era differences in somatic symptoms are discussed.
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Affiliation(s)
- Laura E Bourn
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States; University of Michigan Medical School Department of Psychiatry, Ann Arbor, MI, United States
| | - Minden B Sexton
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States; University of Michigan Medical School Department of Psychiatry, Ann Arbor, MI, United States
| | - Greer A Raggio
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States; University of Michigan Medical School Department of Psychiatry, Ann Arbor, MI, United States
| | - Katherine E Porter
- VA Ann Arbor Healthcare System, Ann Arbor, MI, United States; University of Michigan Medical School Department of Psychiatry, Ann Arbor, MI, United States
| | - Sheila A M Rauch
- Emory University School of Medicine, Atlanta, GA, United States; Atlanta VA Medical Center, Atlanta, GA, United States
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30
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Botella C, Serrano B, Baños RM, Garcia-Palacios A. Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability. Neuropsychiatr Dis Treat 2015; 11:2533-45. [PMID: 26491332 PMCID: PMC4599639 DOI: 10.2147/ndt.s89542] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance. OBJECTIVE In addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT. METHOD We performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols. RESULTS Results showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD. CONCLUSION The main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatment.
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Wolf GK, Kretzmer T, Crawford E, Thors C, Wagner HR, Strom TQ, Eftekhari A, Klenk M, Hayward L, Vanderploeg RD. Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury. J Trauma Stress 2015. [PMID: 26201688 DOI: 10.1002/jts.22029] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self-report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory-II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = -3.00, 95% CI [-3.22, -2.78]; t(210) = -13.5; p < .001, and in depressive symptoms, B = -1.46, 95% CI [-1.64, -1.28]; t(192) = -8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.
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Affiliation(s)
- Gregory K Wolf
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - Tracy Kretzmer
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - Eric Crawford
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Christina Thors
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA
| | - H Ryan Wagner
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Thad Q Strom
- Mental Health Services for Minneapolis, Department of Veterans Affairs Medical Center, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Afsoon Eftekhari
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto HCS, Menlo Park, California, USA
| | - Megan Klenk
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Laura Hayward
- Department of Psychology, Syracuse VA Medical Center, Syracuse, New York, USA
| | - Rodney D Vanderploeg
- Mental Health & Behavioral Sciences, James A. Haley Veterans Affairs Medical Center, Tampa, Florida, USA.,Departments of Psychiatry and Neurosciences, and Psychology, University of South Florida, Tampa, Florida, USA
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Pelton D, Wangelin B, Tuerk P. Utilizing Telehealth to Support Treatment of Acute Stress Disorder in a Theater of War: Prolonged Exposure via Clinical Videoconferencing. Telemed J E Health 2015; 21:382-7. [DOI: 10.1089/tmj.2014.0111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Dan Pelton
- U.S. Army Individual Ready Reserve
- Anxiety-Solutions, LLC, McLean, Virginia
| | - Bethany Wangelin
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
| | - Peter Tuerk
- Mental Health Service Line, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina
- Department of Psychiatry and Behavioral Sciences, Military Sciences Division, Medical University of South Carolina, Charleston, South Carolina
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Crawford EF, Elbogen EB, Wagner HR, Kudler H, Calhoun PS, Brancu M, Straits-Troster KA. Surveying treatment preferences in U.S. Iraq-Afghanistan Veterans with PTSD symptoms: a step toward veteran-centered care. J Trauma Stress 2015; 28:118-26. [PMID: 25820339 DOI: 10.1002/jts.21993] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = -0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help-seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help-seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.
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Affiliation(s)
- Eric F Crawford
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA; Duke University Medical Center, Department of Psychiatry & Behavioral Sciences, Durham, North Carolina, USA
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van Minnen A, Zoellner LA, Harned MS, Mills K. Changes in comorbid conditions after prolonged exposure for PTSD: a literature review. Curr Psychiatry Rep 2015; 17:549. [PMID: 25736701 PMCID: PMC4348535 DOI: 10.1007/s11920-015-0549-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Prolonged exposure (PE) is an effective psychological treatment for patients who suffer from PTSD. The majority of PTSD patients have comorbid psychiatric disorders, and some clinicians are hesitant to use PE with comorbid patients because they believe that comorbid conditions may worsen during PE. In this article, we reviewed the evidence for this question: what are the effects of PE on comorbid symptoms and associated symptomatic features? We reviewed findings from 18 randomized controlled trials of PE that assessed the most common comorbid conditions (major depression, anxiety disorders, substance use disorders, personality disorders, and psychotic disorders) and additional symptomatic features (suicidality, dissociation, negative cognitions, negative emotions, and general health and work/social functioning). Although systematic research is not available for all comorbid populations, the existing research indicates that comorbid disorders and additional symptomatic features either decline along with the PTSD symptoms or do not change as a result of PE. Therefore, among the populations that have been studied to date, there is no empirical basis for excluding PTSD patients from PE due to fear of increases in comorbid conditions or additional symptomatic features. Limitations of the existing research and recommendations for future research are also discussed.
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Affiliation(s)
- Agnes van Minnen
- Behavioural Science Institute, Radboud University Nijmegen, NijCare, Pro Persona, Tarweweg 2, 6524 AM, Nijmegen, The Netherlands,
| | - Lori A. Zoellner
- Department of Psychology, University of Washington, Seattle, WA USA
| | | | - Katherine Mills
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Somatic symptoms and health-related quality of life among treatment-seeking Canadian Forces personnel with PTSD. Psychiatry Res 2014; 218:148-52. [PMID: 24745465 DOI: 10.1016/j.psychres.2014.03.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 01/06/2014] [Accepted: 03/29/2014] [Indexed: 11/21/2022]
Abstract
This study examined the association between somatic complaints and health-related quality of life (HR-QoL) in treatment-seeking Canadian military personnel with military-related Posttraumatic Stress Disorder (PTSD). Current and former Canadian Forces (CF) members attending the Parkwood Hospital Operational Stress Injury Clinic in London, Ontario (N=291) were administered self-report questionnaires assessing number and severity of somatic complaints, PTSD and depressive symptom severity, and mental and physical health-related quality of life (HR-QoL) prior to commencing treatment. Regression analyses were used to identify the role of somatic complaints on physical and mental HR-QoL, after controlling for PTSD symptom cluster and depressive symptom severity. Somatic symptom severity accounted for only a small amount of the variance in mental HR-QoL after accounting for PTSD symptom cluster and depressive symptom severity, but accounted for a larger proportion of the variance in physical HR-QoL after accounting for PTSD cluster and depressive symptom severity. Understanding the role of somatization in the symptom-presentation of military personnel with PTSD may provide additional avenues for treatment with this population.
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36
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Porter KE, Pope EB, Mayer R, Rauch SAM. PTSD and pain: exploring the impact of posttraumatic cognitions in veterans seeking treatment for PTSD. PAIN MEDICINE 2014; 14:1797-805. [PMID: 24238355 DOI: 10.1111/pme.12260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Previous research has demonstrated a significant relationship between posttraumatic stress disorder (PTSD) and pain. While several models attempt to explain this relationship, significant questions remain regarding factors that may play a role in this interaction. The purpose of this study was to determine whether posttraumatic cognitions mediate the relationship between PTSD and pain. DESIGN The sample comprised 136 veterans who presented to the VA Ann Arbor Health Care System seeking evaluation and treatment in the PTSD clinic. Participants completed the Clinician-Administered PTSD Scale, the Posttraumatic Cognitions Inventory, and Brief Pain Inventory-Short Form, along with other assessments as part of their evaluation. RESULTS This study showed that the majority of patients (86.8%) reported some problems with pain. Further, the findings indicate that there is a significant relationship between PTSD severity and pain severity. Posttraumatic cognitions were not related to the level of pain experienced, but they were related to pain interference in this population. CONCLUSIONS In particular, negative cognitions regarding the self were associated with the level of pain-related interference, and partially mediated the relationship between PTSD and pain. The clinical implications of these findings are discussed.
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Affiliation(s)
- Katherine E Porter
- Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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McLean CP, Foa EB. The use of prolonged exposure therapy to help patients with post-traumatic stress disorder. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/cpr.13.96] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Ford JD, Chang R, Levine J, Zhang W. Randomized clinical trial comparing affect regulation and supportive group therapies for victimization-related PTSD with incarcerated women. Behav Ther 2013; 44:262-76. [PMID: 23611076 DOI: 10.1016/j.beth.2012.10.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 10/11/2012] [Accepted: 10/26/2012] [Indexed: 11/16/2022]
Abstract
Traumatic victimization and associated problems with posttraumatic stress disorder (PTSD) and affect dysregulation are prevalent among incarcerated women, but there is limited evidence to support psychotherapeutic interventions for these problems in this underserved population. A group psychotherapy designed to enhance affect regulation without trauma memory processing-Trauma Affect Regulation: Guide for Education and Therapy (TARGET)-was compared to a supportive group therapy (SGT) in a randomized clinical trial with 72 incarcerated women with full or partial PTSD. Both interventions achieved statistically significant reductions in PTSD and associated symptom severity and increased self-efficacy. Dropout rates for both interventions were low (<5%). TARGET was more effective than SGT in increasing sense of forgiveness toward others who have caused harm in the past. Group therapy that teaches affect regulation may enhance incarcerated women's ability to achieve affective resolution (forgiveness) while also reducing their victimization-related PTSD and associated symptoms. Experiential-focused supportive group therapy also may reduce victimization-related PTSD and associated symptoms. Both group therapy approaches warrant further study with this vulnerable population.
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Affiliation(s)
- Julian D Ford
- UCHC Department of Psychiatry MC1410, 263 Farmington Ave., Farmington, CT 06030, USA.
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Wachen JS, Shipherd JC, Suvak M, Vogt D, King LA, King DW. Posttraumatic stress symptomatology as a mediator of the relationship between warzone exposure and physical health symptoms in men and women. J Trauma Stress 2013; 26:319-28. [PMID: 23695839 DOI: 10.1002/jts.21818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The mediating role of posttraumatic stress symptomatology (PSS) on the association between warzone exposure and physical health symptoms in 7 bodily systems (cardiovascular, dermatological, gastrointestinal, genitourinary, musculoskeletal, neurological, and pulmonary) was examined. We also examined if mediation effects varied as a function of sex. A sample of 317 U.S. Gulf war veterans was assessed for warzone exposure, PSS, and physical health symptoms 10 years after deployment. PSS was significantly associated with postdeployment physical health in all symptom categories when accounting for predeployment health (with effect sizes ranging from a 1.27-1.64 increase in the likelihood of postdeployment physical health symptoms with a 1 standard deviation increase in the PSS symptoms). PSS severity mediated the relationship between warzone exposure and postdeployment symptoms in all physical health domains (with percent mediation ranging 44%-75%). A significant Warzone Exposure × PSS interaction emerged for 5 outcomes such that the effect of PSS on physical health was stronger for veterans reporting lower warzone exposure. No significant interactions with sex emerged. These findings suggest the important influence of PSS on physical health symptoms for both men and women.
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Affiliation(s)
- Jennifer Schuster Wachen
- VA Boston Healthcare System, National Center for PTSD, Women's Health Sciences Division, Boston, MA 02130, USA.
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Shipherd JC, Clum G, Suvak M, Resick PA. Treatment-related reductions in PTSD and changes in physical health symptoms in women. J Behav Med 2013; 37:423-33. [PMID: 23471544 DOI: 10.1007/s10865-013-9500-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 02/19/2013] [Indexed: 10/27/2022]
Abstract
This study examined the relationship between change in posttraumatic stress disorder (PTSD) symptoms over the course of PTSD treatment and the association with changes in general physical health symptoms. Both positive health habits (e.g., exercise) and negative (e.g., smoking), were examined to determine if they accounted for the association between changes in PTSD severity over time and changes in physical health. Participants were 150 women seeking treatment for PTSD. Latent growth curve modeling indicated a substantial relationship (R (2) = 34%) between changes in PTSD and changes in physical health that occurred during and shortly following treatment for PTSD. However, there was no evidence to suggest that changes in health behaviors accounted for this relationship. Thus, PTSD treatment can have beneficial effects on self-reported physical health symptoms, even without direct treatment focus on health per se, and is not accounted for by shifts in health behavior.
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Affiliation(s)
- Jillian C Shipherd
- Women's Health Sciences Division (116B-3), VA Boston Healthcare System, National Center for PTSD, 150 South Huntington Ave., Boston, MA, 02130, USA,
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Abstract
Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.
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Affiliation(s)
- Madhulika A Gupta
- Department of Psychiatry, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
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Pérez LG, Abrams MP, López-Martínez AE, Asmundson GJG. Trauma exposure and health: the role of depressive and hyperarousal symptoms. J Trauma Stress 2012. [PMID: 23184401 DOI: 10.1002/jts.21762] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Posttraumatic stress disorder (PTSD) and depressive symptoms have been theorized to mediate the relationship between trauma exposure and physical health symptoms. Although empirical evidence supports this premise, studies conducted to date have employed statistical mediation analyses that are now broadly criticized. Furthermore, the mediating roles of both PTSD and depressive symptoms have seldom been examined concurrently, and it remains unclear which PTSD symptom clusters uniquely mediate this relationship. The aim of the present study was to examine the mediating role of reexperiencing, avoidance/numbing, hyperarousal, and depressive symptoms in the relationship between trauma exposure and physical health symptoms. Participants were 516 Spanish female undergraduate students. Physical health symptoms were compared between those who reported trauma exposure (n = 266) and those who did not (n = 250). Data from trauma-exposed participants were analyzed using regression models with bootstrapping to test mediation. Results of the analyses showed that the trauma-exposed group reported significantly more physical health symptoms (r(2) = .035). Hyperarousal and depressive symptoms uniquely mediated the relationship between trauma exposure and physical health symptoms. Our findings clarify some of the mechanisms by which negative health consequences occur subsequent to trauma exposure.
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Affiliation(s)
- Lydia Goméz Pérez
- Anxiety and Illness Behaviours Laboratory, Department of Psychology, University of Regina, Regina, Saskatchewan, Canada.
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Ramage AE, Laird AR, Eickhoff SB, Acheson A, Peterson AL, Williamson DE, Telch MJ, Fox PT. A coordinate-based meta-analytic model of trauma processing in posttraumatic stress disorder. Hum Brain Mapp 2012; 34:3392-9. [PMID: 22936519 DOI: 10.1002/hbm.22155] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 06/01/2012] [Accepted: 06/02/2012] [Indexed: 01/29/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) has a well-defined set of symptoms that can be elicited during traumatic imagery tasks. For this reason, trauma imagery tasks are often employed in functional neuroimaging studies. Here, coordinate-based meta-analysis (CBM) was used to pool eight studies applying traumatic imagery tasks to identify sites of task-induced activation in 170 PTSD patients and 104 healthy controls. In this way, right anterior cingulate (ACC), right posterior cingulate (PCC), and left precuneus (Pcun) were identified as regions uniquely active in PTSD patients relative to healthy controls. To further characterize these regions, their normal interactions, and their typical functional roles, meta-analytic connectivity modeling (MACM) with behavioral filtering was applied. MACM indicated that the PCC and Pcun regions were frequently co-active and associated with processing of cognitive information, particularly in explicit memory tasks. Emotional processing was particularly associated with co-activity of the ACC and PCC, as mediated by the thalamus. By narrowing the regions of interest to those commonly active across multiple studies (using CBM) and developing a priori hypotheses about directed probabilistic dependencies amongst these regions, this proposed model-when applied in the context of graphical and causal modeling-should improve model fit and thereby increase statistical power for detecting differences between subject groups and between treatments in neuroimaging studies of PTSD.
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Affiliation(s)
- Amy E Ramage
- Research Imaging Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Ford JD, Steinberg KL, Zhang W. A randomized clinical trial comparing affect regulation and social problem-solving psychotherapies for mothers with victimization-related PTSD. Behav Ther 2011; 42:560-78. [PMID: 22035986 DOI: 10.1016/j.beth.2010.12.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 12/27/2010] [Accepted: 12/31/2010] [Indexed: 11/17/2022]
Abstract
Addressing affect dysregulation may provide a complementary alternative or adjunctive approach to the empirically supported trauma memory processing models of cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). A CBT designed to enhance affect regulation without trauma memory processing--trauma affect regulation: guide for education and therapy (TARGET)--was compared to present centered therapy (PCT) and wait-list (WL) conditions in a randomized clinical trial with 146 primarily low-income and ethnoracial minority mothers with PTSD. TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Drop-out rates (~25%) were comparable in TARGET and PCT, similar to those previously reported for trauma memory processing CBTs. Symptom worsening was rare (2-8%) and transient. Affect regulation-based CBT without trauma memory processing warrants further research as a potentially efficacious therapy for victimization-related PTSD.
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Pietrzak RH, Goldstein RB, Southwick SM, Grant BF. Medical comorbidity of full and partial posttraumatic stress disorder in US adults: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Psychosom Med 2011; 73:697-707. [PMID: 21949429 PMCID: PMC3188699 DOI: 10.1097/psy.0b013e3182303775] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study examined associations between lifetime trauma exposures, PTSD and partial PTSD, and past-year medical conditions in a nationally representative sample of US adults. METHODS Face-to-face interviews were conducted with 34,653 participants in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression analyses evaluated associations of trauma exposure, PTSD, and partial PTSD with respondent-reported medical diagnoses. RESULTS After adjustment for sociodemographic characteristics and comorbid Axis I and II disorders, respondents with full PTSD were more likely than traumatized respondents without full or partial PTSD (comparison group) to report diagnoses of diabetes mellitus, noncirrhotic liver disease, angina pectoris, tachycardia, hypercholesterolemia, other heart disease, stomach ulcer, human immunodeficiency virus seropositivity, gastritis, and arthritis (odds ratios [ORs] = 1.2-2.5). Respondents with partial PTSD were more likely than the comparison group to report past-year diagnoses of stomach ulcer, angina pectoris, tachycardia, and arthritis (ORs = 1.3-1.6). Men with full and partial PTSD were more likely than controls to report diagnoses of hypertension (both ORs = 1.6), and both men and women with PTSD (OR = 1.8 and OR = 1.6, respectively) and men with partial PTSD (OR = 2.0) were more likely to report gastritis. The total number of lifetime traumatic event types was associated with many assessed medical conditions (ORs = 1.04-1.16), reducing the magnitudes and rendering some of the associations between PTSD status and medical conditions nonsignificant. CONCLUSIONS Greater lifetime trauma exposure and PTSD are associated with numerous medical conditions, many of which are stress-related and chronic, in US adults. Partial PTSD is associated with intermediate odds of some of these conditions.
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Affiliation(s)
- Robert H Pietrzak
- National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, 950 Campbell Ave 151/E, West Haven, CT 06516, USA.
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Yuan C, Wang Z, Inslicht SS, McCaslin SE, Metzler TJ, Henn-Haase C, Apfel BA, Tong H, Neylan TC, Fang Y, Marmar CR. Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry Res 2011; 188:45-50. [PMID: 21095622 PMCID: PMC3071439 DOI: 10.1016/j.psychres.2010.10.034] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 08/16/2010] [Accepted: 10/31/2010] [Indexed: 12/01/2022]
Abstract
Although police officers are frequently exposed to potentially traumatic incidents, only a minority will develop chronic posttraumatic stress disorder (PTSD). Identifying and understanding protective factors could inform the development of preventive interventions; however, few studies have examined this. In the present prospective study, 233 police officers were assessed during academy training and again following 2 years of police service. Caucasian race, less previous trauma exposure, and less critical incident exposure during police service as well as greater sense of self-worth, beliefs of greater benevolence of the world, greater social support and better social adjustment, all assessed during academy training, were associated with lower PTSD symptoms after 2 years of service. Positive personality attributes assessed during training with the NEO Five-Factor Personality Inventory were not associated with lower PTSD symptoms. In a hierarchical linear regression model, only Caucasian race, lower critical incident exposure during police service, greater assumptions of benevolence of the world and better social adjustment during training remained predictive of lower PTSD symptoms after 2 years of police service. These results suggest that positive world assumptions and better social functioning during training may protect police officers from critical incident related PTSD.
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Affiliation(s)
- Chengmei Yuan
- Division of Mood Disorder, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China, Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States
| | - Zhen Wang
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States, Department of Clinical Psychology, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sabra S. Inslicht
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States
| | - Shannon E. McCaslin
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States
| | - Thomas J. Metzler
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States
| | - Clare Henn-Haase
- Department of Psychiatry, New York University, New York, NY, United States
| | - Brigitte A. Apfel
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States,Corresponding author: Brigitte Apfel, MD, Department of Psychiatry, Veterans Administration Medical Center, 4150 Clement St. (116P), San Francisco, CA 94121, Tel: (415) 221 4810, Fax: (415) 751-2297,
| | - Huiqi Tong
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States
| | - Thomas C. Neylan
- Department of Psychiatry, San Francisco VA Medical Center, San Francisco, CA, United States, Department of Psychiatry, University of California, San Francisco, CA, United States
| | - Yiru Fang
- Division of Mood Disorder, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Co-corresponding author: Yiru Fang, MD, Division of Mood Disorder, Shanghai Mental Health Center, Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai, 200030, China, Tel: (8621) 3428 9888, Fax: (8621) 6438 7986,
| | - Charles R. Marmar
- Department of Psychiatry, New York University, New York, NY, United States
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Rasmusson AM, Schnurr PP, Zukowska Z, Scioli E, Forman DE. Adaptation to extreme stress: post-traumatic stress disorder, neuropeptide Y and metabolic syndrome. Exp Biol Med (Maywood) 2010; 235:1150-62. [PMID: 20881319 DOI: 10.1258/ebm.2010.009334] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The prevalence rates of obesity and metabolic syndrome are on the rise in the United States. Epidemiological surveys suggest that the rates of these medical conditions are especially high among persons with psychiatric disorders, including post-traumatic stress disorder (PTSD). A variety of factors are thought to contribute to the risk for metabolic syndrome, including excessive caloric intake, decreased activity and energy expenditure, use of certain medications, stress and genetic influences. Recent research demonstrates that stress, acting through the neuropeptide Y (NPY) and glucocorticoid systems, potentiates the development of obesity and other aspects of metabolic syndrome in mice fed a high caloric, fat and sugar diet. Alterations in the NPY and glucocorticoid systems also impact behavioral adaptation to stress, as indicated by studies in animals and persons exposed to severe, life-threatening or traumatic stress. The following review examines the biology of the NPY and neuroactive steroid systems as physiological links between metabolic syndrome and PTSD, a paradigmatic neuropsychiatric stress disorder. Hopefully, understanding the function of these systems from both a translational and systems biology point of view in relation to stress will enable development of more effective methods for preventing and treating the negative physical and mental health consequences of stress.
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Impairment of contextual conditioned fear extinction after microinjection of alpha-1-adrenergic blocker prazosin into the medial prefrontal cortex. Behav Brain Res 2010; 211:89-95. [DOI: 10.1016/j.bbr.2010.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 03/01/2010] [Accepted: 03/05/2010] [Indexed: 11/22/2022]
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Hassija CM, Gray MJ. Are cognitive techniques and interventions necessary? A case for the utility of cognitive approaches in the treatment of PTSD. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2010. [DOI: 10.1111/j.1468-2850.2010.01201.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Galovski TE, Monson C, Bruce SE, Resick PA. Does cognitive-behavioral therapy for PTSD improve perceived health and sleep impairment? J Trauma Stress 2009; 22:197-204. [PMID: 19466746 PMCID: PMC2765684 DOI: 10.1002/jts.20418] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There is a paucity of empirical study about the effects of evidence-based psychotherapy for posttraumatic stress disorder (PTSD) on concurrent health concerns including sleep impairment. This study compares the differential effects of cognitive processing therapy (CPT) and prolonged exposure (PE) on health-related concerns and sleep impairment within a PTSD sample of female, adult rape survivors (N = 108). Results showed that participants in both treatments reported lower health-related concerns over treatment and follow-up, but there were relatively more improvements in the CPT condition. Examination of sleep quality indicated significant improvement in both CPT and PE across treatment and follow-up and no significant differences between treatments. These results are discussed with regard to the different mechanisms thought to underlie the treatments and future innovations in PTSD treatment.
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Affiliation(s)
- Tara E Galovski
- Department of Psychology, Center for Trauma Recovery, University of Missouri-St. Louis, St. Louis, MO 63121-4499, USA.
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