Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices

The International Trauma Interview (ITI): development of a semi-structured diagnostic interview and evaluation in a UK sample

Background: The International Trauma Interview (ITI) is a structured clinician-administered measure developed to assess posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as defined in the 11th version of the International Classification of Diseases (ICD-11). This study aimed to investigate a psychometric evaluation of the ITI and to finalise the English language version.Method: The latent structure, internal consistency, interrater agreement, and convergent and discriminant validity were evaluated with data from a convenience sample, drawn from an existing research cohort, of 131 trauma exposed participants from the United Kingdom reporting past diagnosis for PTSD or who had screened positively for traumatic stress symptoms. A range of self-report measures evaluating depression, panic, insomnia, dissociation, emotion dysregulation, negative cognitions about self, interpersonal functioning and general wellbeing were completed.Results: Confirmatory factor analysis supported an adjusted second-order two-factor model of PTSD and disturbances in self-organisation (DSO) symptoms, allowing affect dysregulation to also load onto the PTSD factor, over alternative models. The ITI scores showed acceptable internal consistency, and interrater reliability was strong. Findings for convergent and discriminant validity were mostly as predicted for PTSD and DSO domains. Correlations with the ITQ were good but coefficients for the level of agreement of PTSD diagnosis and CPTSD diagnosis between the ITI and the ITQ were weaker, and item level agreement was variable.Conclusion: Results provide support for the reliability and validity of the ITI as a measure of ICD-11 PTSD and CPTSD. Final revisions of the ITI are described.

Common Elements and Differences Among Treatment Approaches to Complex Post-Traumatic Stress Disorder: A Commentary on Five Case Studies

Treating people who have experienced deep and prolonged developmental trauma, that is, complex post-traumatic stress disorder (cPTSD), can be challenging given the complexity and severity of their presentations. The main features of complex post-traumatic stress disorder, that is, affective and behavioral dysregulation, altered self-experience and identity disturbances, relational difficulties, negative self-concepts, and negative pathogenic beliefs, are, at the same time, therapeutic goals and obstacles to treatment. Therefore, clinicians must be aware of these difficulties in order to identify them and be ready to treat them when they arise during therapy with the same client. For this reason, the clinical cases presented in this issue of the Journal of Clinical Psychology: In Session provide a very useful overview of how to deal with these manifestations from the perspective of different models of psychotherapy. This commentary, after briefly reviewing the clinical features and therapeutic difficulties of these clients, offers a critical summary of the commonalities and differences between the various approaches presented by the clinical cases in this special issue. The purpose is to help the reader navigate the key aspects of treating the pathogenetic processes involved in cPTSD and to identify the different therapeutic tools that may be applicable to the different clinical presentations.

Five hypothesized biological mechanisms linking adverse childhood experiences with anxiety, depression, and PTSD: A scoping review

Adults with symptoms of anxiety, depression, or PTSD and a history of adverse childhood experiences (ACEs) may experience more severe symptoms than those without ACEs. The identification of mechanisms linking ACEs to later mental health problems may provide salient treatment targets to improve outcomes. Several biological markers (cortisol, inflammation, allostatic load, DNA methylation, and telomere length) that are indicative of functional variation in stress response systems, have been hypothesized as potential mechanisms linking ACEs to later mental health outcomes. Much of the evidence supporting this hypothesis examines isolated pairwise associations between variables and it is unclear whether statistical tests of mediation support these conclusions. It is also unclear how much of the extant research has used theory to guide mediation analyses, which may be a salient factor in the recognition of a mechanism. This scoping review surveyed research conducting mediation analysis examining the indirect effect of any of these five biological markers on the relationship between ACEs and anxiety, depression, or PTSD. It further surveyed the use of theory in these analyses. Pubmed and seven electronic databases were searched: (1) APA PsychInfo (2) CINAHL Plus (3) Health Source: Nursing/Academic Edition (4) MEDLINE (5) Psychology and Behavioral Sciences Collection (6) Science and Technology Collection, and (7) SocINDEX. A total of 16 articles were identified. The majority of studies examined depression as an outcome and the statistical significance of indirect effects were mixed across mediators. Common theoretical models and frameworks were consistent with life course theory and evolutionary or developmental perspectives.

Mapping connections between complex post-traumatic stress disorder and psychotic-like experiences among adolescents: a Gaussian and Bayesian network study

BACKGROUND

Complex post-traumatic stress disorder (cPTSD) is a newly recognized condition characterized by core PTSD symptoms and disturbances in self-organization (DSO) that has been associated with psychotic-like experiences (PLEs). This study employs two psychopathology network approaches to identify which post-traumatic symptoms are related to PLEs in a sample of late adolescents. We propose that cPTSD symptoms play a crucial role in explaining the co-occurrence of trauma and PLEs.

METHODS

A sample of 1010 late adolescents provided measures of post-traumatic symptomatology and PLEs. We estimated the Gaussian graphical network structure of PTSD/cPTSD symptoms and PLEs and assessed their bridge centrality indices. Bayesian network analysis was then used to estimate a directed acyclic graph (DAG). Gender was set as a moderator in both Gaussian and Bayesian models.

RESULTS

Results show that affect dysregulation, a cPTSD domain, presented the highest bridge connection with the PLE cluster. Bayesian network analysis identified a pathway going from cPTSD items of worthlessness and relational dysregulation, to PLE items of paranoia and social anxiety. Additionally, we found relevant gender differences in network connectivity, with females showing higher connectivity compared to males.

CONCLUSIONS

Our findings highlight the central role of affect dysregulation and negative self-concept in linking cPTSD to PLE symptoms, with specific differences according to gender. These insights underscore the need for targeted, gender-sensitive approaches in the prevention and treatment of PLEs among adolescents, emphasizing early intervention and tailored treatment strategies.

"I know that all this is me" Pathways of change in complex dissociative disorder

OBJECTIVES

This qualitative study explored changes described by individuals with complex dissociative disorders (CDDs) 2 years after participating in a psychoeducative group. Few recent studies have examined the early changes from incomprehensible reactions to the integration of traumatic events.

METHODS

Interviews were conducted with 25 participants with CDD 2 years after completing a 20-week psychoeducative skills training group. Transcripts were analysed using an interpretive phenomenological framework.

RESULTS

Three pathways of change were identified: (1) the ability to be present in life, (2) ways of approaching internal conflicts and (3) the degree of ownership of the self. These pathways illustrate the initial steps towards integration, in which participants start recognizing and confronting previously avoided emotions and experiences. This allows them to better tolerate and accept more of themselves. Processes varied among the participants, with some achieving cohesive integration of challenging memories.

CONCLUSION

Traditionally, there has been little treatment optimism for individuals with CDD. This study highlights the potential for comprehensive change within 2 years. It contributes to the debate on whether focusing on coping strategies delays trauma memory integration, emphasizing the need for a balance between exposure and coping based on the patient's capacity.

Post-traumatic stress disorder: evolving conceptualization and evidence, and future research directions

The understanding of responses to traumatic events has been greatly influenced by the introduction of the diagnosis of post-traumatic stress disorder (PTSD). In this paper we review the initial versions of the diagnostic criteria for this condition and the associated epidemiological findings, including sociocultural differences. We consider evidence for post-traumatic reactions occurring in multiple contexts not previously defined as traumatic, and the implications that these observations have for the diagnosis. More recent developments such as the DSM-5 dissociative subtype and the ICD-11 diagnosis of complex PTSD are reviewed, adding to evidence that there are several distinct PTSD phenotypes. We describe the psychological foundations of PTSD, involving disturbances to memory as well as to identity. A broader focus on identity may be able to accommodate group and communal influences on the experience of trauma and PTSD, as well as the impact of resource loss. We then summarize current evidence concerning the biological foundations of PTSD, with a particular focus on genetic and neuroimaging studies. Whereas progress in prevention has been disappointing, there is now an extensive evidence supporting the efficacy of a variety of psychological treatments for established PTSD, including trauma-focused interventions - such as trauma-focused cognitive behavior therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) - and non-trauma-focused therapies, which also include some emerging identity-based approaches such as present-centered and compassion-focused therapies. Additionally, there are promising interventions that are neither psychological nor pharmacological, or that combine a pharmacological and a psychological approach, such as 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy. We review advances in the priority areas of adapting interventions in resource-limited settings and across cultural contexts, and of community-based approaches. We conclude by identifying future directions for work on trauma and mental health.

Attachment classification and early adversity predict perinatal partial hospital treatment response

BACKGROUND

Depression and anxiety are common in the perinatal period. While most of those affected respond well to treatment, a subpopulation is more resistant. Understanding more about individuals who do not respond well to available treatments may improve care for this group.

METHODS

We administered entry and exit self-report measures to 178 women who participated in a specialized partial hospitalization program for perinatal individuals. Baseline measures of anxiety, obsessive symptoms, sleep quality, early life adversity, and adult attachment security were examined as potential predictors of response to treatment.

RESULTS

While no individual baseline survey predicted treatment response, clustering patients on the basis of a combination of self-report adult attachment styles and early life adversity yielded four distinct groups. A cluster with high attachment anxiety, high attachment avoidance, and childhood history of verbal and emotional abuse was less responsive to treatment than the other groups.

CONCLUSIONS

Combining detailed information about self-report adult attachment style and early life adversity may improve prediction of treatment response in individuals with perinatal mood and anxiety disorders.

Can dissociative amnesia be a residual symptom of prolonged complex post-traumatic stress disorder?

BACKGROUND

Dissociative amnesia, a disorder characterized by impairments in multiple memory areas, is frequently associated with trauma. Complex post-traumatic stress disorder (CPTSD) is marked by mood dysregulation, negative self-concept, and impaired interpersonal relationships, in addition to the classic symptoms of post-traumatic stress disorder (PTSD). The relationship between CPTSD and dissociative amnesia, as well as whether CPTSD should be considered a dissociative subtype, remains uncertain in the literature. Individuals diagnosed with CPTSD tend to exhibit higher levels of dissociative symptoms than those diagnosed with PTSD.

CLINICAL PRESENTATION

We present the clinical report of a 42-year-old male who, after a car accident, exhibited core symptoms of PTSD along with symptoms of self-organization disorders. While these symptoms persisted, the patient developed dissociative amnesia years after the trauma. Neuroimaging studies, psychometric tests, reviewed hospital records, and clinical interviews were conducted to speculate on the differential diagnosis of organic psychiatric conditions and potential diagnoses. The possible relationship between dissociative amnesia and complex post-traumatic stress disorder was examined.

CONCLUSION

This case demonstrates the complexity of differentiating dissociative amnesia from organic conditions. Discussing the possible shared mechanisms between CPTSD and dissociative amnesia could contribute to a better understanding of both conditions.

Complex posttraumatic stress disorder (CPTSD) is uniquely linked to suicidality beyond posttraumatic stress disorder (PTSD) in adults with childhood maltreatment: A multinational study across four countries

BACKGROUND

Suicide is a leading cause of death worldwide, with childhood maltreatment identified as a significant risk factor for suicidal behavior in adulthood. The link between childhood maltreatment and suicidality is well-documented; however, the role of complex posttraumatic stress disorder (CPTSD), which includes an additional symptom cluster of disturbances in self-organization (DSO) compared to posttraumatic stress disorder (PTSD), remains underexplored. This study aimed to investigate the association between meeting the criteria for ICD-11 PTSD or CPTSD and suicidality in adults with a history of childhood maltreatment across culturally diverse samples.

METHODS

Data were collected across four sites: the United States, the United Kingdom, China, and Malaysia. The Childhood Trauma Questionnaire (CTQ), Suicidal Behaviors Questionnaire-Revised (SBQ-R), and International Trauma Questionnaire (ITQ) were used to assess childhood maltreatment, suicidality, and PTSD or CPTSD, respectively. Linear regressions were conducted to examine the associations, controlling for demographic variables (age, sex, ethnicity, educational level, and subjective socioeconomic status) as well as the severity of maltreatment (CTQ total scores).

RESULTS

Among the 1324 participants who experienced childhood maltreatment, meeting the criteria for CPTSD was significantly associated with higher suicidality compared to not meeting the criteria for either PTSD or CPTSD (B(SE) = 1.68 (0.30), p < .001), or only meeting the criteria for PTSD (B(SE) = 1.38 (0.43), p < .001). In contrast, meeting the criteria for PTSD alone was not significantly associated with suicidality (B(SE) = 0.35 (0.46), p = .45). These associations remained consistent across different cultural settings.

CONCLUSION

The study findings highlight the unique association of CPTSD with suicidality in adults with a history of childhood maltreatment, suggesting that the DSO symptom cluster of CPTSD, which distinguish it from PTSD, play a critical role in the development of suicidality in this population. Targeting these symptoms may be essential for effective intervention strategies. Screening for childhood maltreatment and CPTSD in individuals at risk of suicide is crucial for guiding treatment planning.

EMDR treatment in patients with personality disorders. Should we fear symptom exacerbation?

Background: Clinicians are often hesitant to use trauma-focused therapy for patients with personality disorders (PDs) because of concerns that the pathology may worsen.Objective: Exploring trajectories of change and individual exacerbations in psychological distress and suicidal thoughts in patients with a PD without comorbid posttraumatic stress disorder (PTSD) during EMDR therapy or waiting time.Method: In a randomized controlled trial, the effectiveness of five sessions of EMDR therapy was compared with a waitlist in 97 outpatients. Acute suicidal patients were not included in this study. Psychological distress and suicidality scores were measured on a weekly basis during the EMDR and waiting list (WL) periods and at 3-month follow-up. Data were analysed in a descriptive manner for individual patients, and hierarchical cluster analysis was used to identify patterns of change among clusters of patients. Mann-Whitney U and chi-squared tests were used to explore differences in specific patient characteristics between the found clusters of patients.Results: Patients generally improved, and no clusters of patients deteriorated during the EMDR therapy. Session-to-session exacerbations occurred in both the EMDR (psychological distress: 10.0%; suicidal thoughts: 28.0%) and WL group (psychological distress: 28.0%; suicidal thoughts: 43.5%). Two percent of patients in the EMDR group and 8.7% of patients in the WL condition showed an increase in psychological distress, whereas 2.0% of patients in the EMDR group and 10.9% of patients in the WL condition showed an increase in suicidal thoughts posttreatment compared to baseline.Conclusions: These results show that although individual exacerbations in psychological distress and suicidal thoughts occur, these were less likely to occur in response to EMDR therapy compared with no therapy. Continuation of therapy following exacerbation led to a decrease in psychological distress and suicidal thoughts in most patients.

EMDR-Teens-cPTSD: Efficacy of Eye Movement Desensitization and Reprocessing in Adolescents with Complex PTSD Secondary to Childhood Abuse: A Case Series

Background: Mental healthcare for children and adolescents with a history of childhood abuse constitutes a major public health issue. Indeed, abuse exposes children to severe and complex post-traumatic stress disorder (cPTSD) but also to neurodevelopmental and psychological repercussions impacting the developmental trajectory. Trauma-focused care is essential to avoid the chronicization of symptoms and disorders. Objective: The aim of this prospective case series study was to investigate the efficacy of eye movement desensitization and reprocessing (EMDR) on complex post-traumatic symptoms and associated psychiatric disorders in adolescents with a history of abuse. Method: Twenty-two adolescents, aged 12 to 17, who had been abused during childhood were included. All adolescents met ICD-11 criteria for complex PTSD. Subjective measures of PTSD and associated psychiatric disorders were taken before (T0) and after 3 months of EMDR therapy (T1). Results: The average PTSD symptom score on the CPTS-RI significantly decreased from 40.2 to 34.4 after EMDR, indicating improvement in post-traumatic symptoms. A significant decrease in the average depression score (CDI from 18.2 at T0 to 10.6 at T1), anxiety score (R-CMAS from 21.3 at T0 to 13.3 at T1), emotional regulation score (ALS from 29 at T0 to 10.8 at T1), insomnia score (ISI from 18.5 at T0 to T1 of 9.2 at T1), and harmful use of alcohol and drugs score (ADOSPA from 2.3 at T0 to 0.3 at T1) was observed after EMDR therapy, as well as an increase in quality of life (CBCL 4-16 score from 57.9 at T0 to 77.4 at T1). Conclusions: The results of this study are encouraging and suggest that EMDR may be effective in the symptom management reducing post-traumatic symptoms and certain comorbid disorders frequently seen in adolescents who have experienced childhood abuse. Further research is needed on adolescent populations suffering from cPTSD (e.g., randomized controlled trials with control groups and other therapies or evaluating the action of the different phases of the study).

Understanding Trauma in IPV: Distinguishing Complex PTSD, PTSD, and BPD in Victims and Offenders

This work aims to shed light on the differential diagnosis of complex post-traumatic stress disorder (cPTSD), post-traumatic stress disorder (PTSD), and borderline personality disorder (BPD) within the context of intimate partner violence (IPV), which represents a highly innovative field of clinical research. To this end, a critical review of the literature was conducted to identify and compare the clinical patterns and symptomatic overlaps among cPTSD, PTSD, and BPD, with an emphasis on their manifestation in both IPV victims and offenders. The results show that despite some symptomatic similarities, cPTSD, PTSD, and BPD have distinct clinical patterns of interpersonal violence. Specifically, disturbances in self-organization (DSO) are more commonly found in offenders, while the diagnosis of cPTSD seems more aligned with the psychological functioning of victims. In addition, cPTSD and specific characteristics of BPD, such as fear of rejection and instability of identity, constitute risk factors for IPV victimization. cPTSD is shown as a predisposing factor not only for IPV victims but also for offenders, while PTSD emerges as a consequential factor. The specific pathways linking PTSD, cPTSD, and BPD with IPV have significant implications for clinical practice. Further research is needed to understand these profiles and the mechanisms linking trauma-related features to IPV, which is crucial for implementing effective violence prevention programs.

Complex Posttraumatic Stress Disorder Links Trauma Exposure and Suicidal Behaviors Among Sexual Minority Populations: A New Target in Suicide Prevention?

Exposure to potentially traumatic events and posttraumatic stress are known risk factors for suicidal thoughts and behaviors (STB). Research suggests that sexual minorities are disproportionately exposed to traumatic events and experience greater STB than their heterosexual peers, although few studies have explored connections between these parallel disparities. Further, existing literature may implicate complex posttraumatic stress disorder (CPTSD) as a potential mechanism in the trauma-suicide connection among sexual minorities. This study uses a sample from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III; n = 1351) to test structural equation models for associations between trauma exposure, heterosexist discrimination, and CPTSD with suicide attempt status. We found CPTSD mediated associations between exposure to traumatic events and presence of a lifetime suicide attempt among sexual minority male and female samples. Discrimination demonstrated a synergistic effect on the association between trauma exposure and CPTSD, but, among males, CPTSD did not fully explain associations between discrimination and suicide attempts. Our findings suggest that CPTSD should be considered an important mechanism in the trauma-suicide connection for sexual minorities and may be a potentially important target for suicide prevention and that interventions should address the influence of discrimination on traumatic stress in this high-risk population.

[Effects of complex trauma disorder on the workplace: a scoping review]

BACKGROUND

The "International Classification of Diseases 11th Revision" (ICD-11) introduces complex post-traumatic stress disorder (CPTSD) as a separate diagnosis to account for the effects that persistent or repetitive trauma can have. In CPTSD, disorders of self-organization are added to the core symptoms of PTSD. It can be assumed that those affected are impaired in their professional lives as a result. The aim of this paper is to provide an overview of the effects of CPTSD on work-related functioning and to present possible consequences for therapeutic and rehabilitative treatment.

METHOD

A scoping review with a literature search in the MEDLINE, APA PsycArticles, and APA PsycInfo databases was conducted in February 2024.

RESULTS

Of 2378 studies on KPTBS, five studies were included, of which only three dealt more specifically with the impact on the world of work. Those affected appear to have a poorer prognosis for maintaining their ability to work and are therefore to be regarded as a socio-medical risk group with regard to long-term maintenance of participation in working life.

DISCUSSION

The current state of research on the effects of the CPTSD symptom complex on the world of work is surprisingly limited. In comparison, the results indicate that CPTSD has a greater negative impact on the ability to function in the world of work than PTSD and other mental disorders. It is still unclear which psychopathological mechanisms mediate the connection. Only basic findings on the psychopathology of CPTSD are available. Treatment approaches that address the disorders of self-organization in addition to PTSD symptoms appear necessary.

Skills training followed by either EMDR or narrative therapy for posttraumatic stress disorder in adult survivors of childhood abuse: a randomized controlled trial

Background: Individuals suffering from PTSD following childhood abuse represent a large subgroup of patients attending mental health services. The aim of phase-based treatment is to tailor treatment to the specific needs to childhood abuse survivors with PTSD with a Skills Training in Affective and Interpersonal Regulation (STAIR) phase, in which emotion dysregulation and interpersonal problems are targeted, and a trauma-focused phase.Objective: The purpose of this study was to compare STAIR + Eye Movement Desensitization and Reprocessing (EMDR) vs. STAIR + Narrative Therapy (NT) as treatments for PTSD following childhood-onset trauma in a routine clinical setting.Method: Sixty-eight adults were randomly assigned to STAIR/EMDR (8 STAIR-sessions followed by 12 EMDR-sessions) or STAIR/NT (8 STAIR-sessions followed by 12 NT-sessions). Assessments took place at pre-treatment, after each treatment phase and at 3 and 12 months post-intervention follow-up. Primary outcomes were interviewer-rated and self-reported symptom levels of PTSD. Secondary outcomes included symptom levels of depression and disturbances in emotion regulation and interpersonal skills.Results: Multilevel analyses in the intent-to-treat sample indicated that patients in both treatments improved substantially on PTSD symptom severity (CAPS: d = 0.81 to 1.29; PDS: d = 1.68 to 2.15), as well as on symptom levels of depression, anxiety, emotion regulation, dissociation and interpersonal skills. Effects increased or were maintained until 12-month follow-up. At mid-treatment, after STAIR, patients in both treatments improved moderately on PTSD symptom severity (PDS: d = 1.68 to 2.15), as well as on symptom levels of depression (BDI: d = .32 to .31). Symptoms of anxiety, emotion dysregulation, interpersonal problems and dissociation were not decreased after STAIR. There were no significant differences between the two conditions on any outcome.Conclusion: PTSD in adult survivors of childhood interpersonal trauma can effectively be treated by phase-based interventions using either EMDR or NT in the trauma-processing phase.Trial registration: ClinicalTrials.gov identifier: NCT01443182..

Healing wounded trees: clinicians' perspectives on treatment of complex posttraumatic stress disorder

While treatment guidelines agree on the first-line interventions for the treatment of posttraumatic stress disorder (PTSD), there is an ongoing debate between experts regarding the treatment of complex posttraumatic stress disorder (C-PTSD). As scientific research is slowly emerging, different treatment approaches are used in clinical practice This article aims to provide a set of treatment options for C-PTSD in adult survivors of repeated exposure to severe violence and abuse, both in childhood and later on in life. The developmental-contextual perspective on mental health forms the basis of this approach. This perspective is elaborated using the tree metaphor. Then, several treatment strategies are suggested. The presented strategies are a combination of the existing evidence-based approaches for the treatment of PTSD and personality disorders. They target psychological damage in survivors while taking their developmental trajectories and ecological environments into consideration. The treatment model presented is based on longstanding clinical practice and it may be a promising framework for treating C-PTSD. However, it still needs to be scientifically examined for acceptability and effectiveness.

Trauma-focused treatment of a client with Complex PTSD and comorbid pathology using EMDR therapy

OBJECTIVE

Complex post-traumatic stress disorder (CPTSD) is a classification within the International Classification of Diseases, 11th Revision (ICD-11) that, besides the DSM-5 symptom clusters of post-post-traumatic stress disorder (PTSD), includes the presence of negative self-concept, difficulties in regulating emotions and relationship skills. The purpose of the present study was to provide guidance on how to deliver Eye Movement Desensitization and Reprocessing (EMDR) therapy in the context of CPTSD, based on current clinical knowledge and the latest scientific research findings.

METHOD

This paper describes the treatment of a 52-year-old woman with CPTSD and borderline personality disorder for which immediate trauma-focused EMDR therapy was used.

RESULTS

First, a description of what EMDR therapy entails and some important treatment strategies that the therapist may employ to assist in trauma-focused treatment of clients with CPTSD using EMDR therapy are outlined.

CONCLUSION

The treatment results are in line with mounting evidence supporting the notion that EMDR therapy is a safe and potentially effective treatment alternative for individuals with CPTSD or personality problems.

[Posttraumatic stress disorder in children and adolescents: results of a cross-sectional study on the effects of the newly formulated PTSD and CPTSD diagnoses in the ICD-11]

BACKGROUND

ICD-11 presents narrowed criteria for posttraumatic stress disorder (PTSD) and introduces complex PTSD (CPTSD) with additional difficulties in self-organization (DSO). These changes can have significant effects on the frequency of the diagnosis. The aim of this study was to investigate which ICD-11 symptom clusters cause children and adolescents to miss the diagnosis and whether caregivers are more likely to attribute changes in DSO to developmental level or to the traumatic event, and how these attributions are in turn related to symptom severity.

METHODS

N = 88 German-speaking children and adolescents (age: 7-17 years) after traumatic events and N = 79 caregivers participated between September 2019 and November 2020 in a survey on PTSD symptom severity (CATS-2) and attribution of DSO symptoms (caregiver questionnaire).

RESULTS

The ICD-11 criteria (CATS‑2 and a developmentally adapted version) showed lower frequency rates for PTSD as compared to DSM‑5 and ICD-10. The ICD-11 clusters re-experiencing and hyperarousal were met the least often. Changes in DSO symptoms were predominantly rated as event-related. This attribution was associated with higher PTSD and DSO symptom severity in caregiver reports. The age-related attribution was associated with higher DSO-symptom severity, but not PTSD symptom severity in caregiver reports.

DISCUSSION

In the context of the diagnostic process and the revision of diagnostic instruments for ICD-11 (C)PTSD, development-specific symptoms should be taken into account. The trauma-related differentiation of DSO symptom changes as compared to development-related fluctuations is challenging and therefore requires several sources of information.

The effectiveness of two novel approaches to prevent intrusions: A pilot study comparing Tetris_dualtask and imagery rescripting to control

BACKGROUND AND OBJECTIVES

Post-traumatic stress disorder (PTSD) is a global health problem. Although effective treatments for it exist, early interventions that prevent PTSD from developing are lacking. The aim of this pilot analogue trauma study was to compare the effects of two potential early intervention strategies, namely Tetris_dualtask and imagery rescripting (IR) to a no-intervention control group on intrusion frequency and the vividness and emotionality of aversive film memory.

METHODS

Sixty healthy students were subjected to the trauma film paradigm and randomly allocated to either: Tetris_dualtask, IR or no-intervention. Main outcomes were the number of film-related intrusions at one week and vividness and emotionality ratings of the most aversive film memory. Secondary outcomes were PTSD-like symptoms, intrusion intensity, and explicit film memory.

RESULTS

The Tetris_dualtask group reported significant fewer intrusions compared to the no-intervention group; whereas the IR group did not. No effect was found on vividness and emotionality ratings, PTSD-like symptoms, intrusion intensity, and explicit memory.

LIMITATIONS

The sample size was small, and analogue trauma in healthy individuals was examined, thus generalizability may be limited. Also, to increase comparability between interventions, the duration of Tetris_dualtask and IR was standardized. As a result, the IR intervention was shorter compared to other studies, which might have decreased its efficacy.

CONCLUSIONS

The results of this pilot study suggest that playing Tetris during retrieval of traumatic images, might hold potential as an early intervention strategy to reduce intrusions in the early aftermath of trauma and adversity. However, future large-scale replication research is needed.

Case conceptualization in child welfare: an underused resource to improve child, family, and provider outcomes

Case conceptualization, formally known as case formulation, is one tool that assists in determining the best course of action for children and families experiencing family violence that has been under-utilized in child welfare. In this article we present a step-by-step case conceptualization process that considers the child welfare context. We then present a hypothetical case example of a 10-year-old child referred by a child welfare worker to evidence-based treatment for mental health and behavioural concerns. Mental health services are not helpful for the child and further consultation is enlisted. To more effectively guide intervention and treatment planning and ultimately improve outcomes for the child, we present case conceptualization as a process that incorporates relevant aspects of the child and family's history and circumstance. We conclude with a succinct case conceptualization and treatment plan to show how the prognosis of the child can be improved when case conceptualization is employed.

Responding to concerns related to the measurement of ICD-11 complex posttraumatic stress disorder using the International Trauma Questionnaire

BACKGROUND

A recent study in this journal by Frewen et al. (2023) provided a critical analysis of the most widely used measure of ICD-11 Complex Posttraumatic Stress Disorder (CPTSD), the International Trauma Questionnaire (ITQ). The article was a thoughtful review and gave voice to several widely held concerns about the nature of CPTSD as it is represented in ICD-11 and measured by the ITQ. The primary concern expressed by Frewen et al. was that the symptom profile of ICD-11 CPTSD, as represented in the ITQ, is too simple and fails to provide adequate coverage of the construct.

OBJECTIVE

Despite its quality, the article included several misunderstandings about the nature of ICD-11 CPTSD, and the function of the ITQ, that we wish to clarify.

PARTICIPANTS

Not applicable.

SETTING

Not applicable.

RESULTS

In this article, we provide a description of what ICD-11 PTSD and CPTSD are, a review of the process that led to their inclusion in ICD-11, how the ITQ was developed and refined to measure these constructs. We then provide responses to several of the most important concerns raised by Frewen et al. CONCLUSIONS: We highlight the clinical utility of the ICD-11 descriptions of PTSD and CPTSD and discuss how the ITQ can be used as part of a suite of clinical assessments to accurately describe and understand common experiences of psychological distress that often result from exposure to traumatic life events.

Expert international trauma clinicians’ views on the definition, composition and delivery of reintegration interventions for complex PTSD

Background: Research has previously distinguished between complex post-traumatic stress disorder (CPTSD) and PTSD, with the former including a range of disturbances in self-regulatory capacities in addition to difficulties associated with PTSD. Clinical guidelines have previously recommended a phase-based approach for the treatment of CPTSD, yet the final 'reintegration' phase of treatment has been overlooked in research, with limited evidence into its value and effectiveness, and inconsistencies in its definitions and understanding.Objective: We set out to define and determine the key principles of 'reintegration' and to specify the components and method of delivery of treatment.Method: Leading national and international clinical and academic experts in CPTSD were interviewed and asked about their views of how 'reintegration' should be defined, its role in the treatment of CPTSD, what it should be composed of, the key principles of its delivery, and how it should be evaluated. We analysed transcripts of the interviews following the principles of Codebook Thematic Analysis.Results: We conducted 16 interviews with leading national and international experts with at least 10 years' experience of treating people with CPTSD. Themes derived from our analysis demonstrated that while the definition and composition of reintegration varied greatly between experts, the key principles in its delivery were consistent across all experts.Conclusions: The results of this study lay the foundation for a framework of what reintegration is and how it can be used in, but also highlight the need for more research to be conducted on the role of reintegration in the treatment of CPTSD. Consensus for the definition and composition of reintegration is still yet to be reached. Possible measures for evaluating reintegration should also be explored in the future.

What are the predictive variables that increase the risk of developing a complex trauma? A meta-analysis

In 2018, Complex Post Traumatic Stress Disorder (CPTSD) was officially recognized as a distinct syndrome in the International Classification of Diseases, 11th Revision (ICD-11). This recognition aimed to differentiate between neurotic disorders secondary to stressful situations and somatoform disorders, and disorders specifically associated with stress. The inclusion of CPTSD in the ICD-11 marked the culmination of two decades of research focused on understanding its symptoms, treatments, and risk factors. However, despite the progress made, a comprehensive meta-analysis to elucidate the specific risk factors and impact on the development of CPTSD is still lacking. The objective of this article is to conduct such a meta-analysis. A total of 24 studies were selected for analysis, and the findings revealed several key risk factors associated with the development of CPTSD. The main risk factor identified is having experienced sexual abuse in childhood (k = 12; OR = 2.880). In addition, childhood physical abuse (k = 11; OR = 2.841), experiencing emotional neglect during childhood (k = 5; OR = 2.510), physical abuse throughout life (k = 8; OR = 2.149) and being a woman (k = 13; OR = 1.726) were also significant risk factors.

War-related stressors and ICD-11 (complex) post-traumatic stress disorders in Ukrainian students living in Kyiv during the Russian-Ukrainian war

We estimated the prevalence of war-related stressors (Harvard Trauma Questionnaire-R), risk of ICD-11 posttraumatic stress disorder (PTSD), and complex posttraumatic stress disorder (CPTSD; International Trauma Questionnaire-R) in N = 563 Ukrainian students living in Kyiv, an active war zone between December 2022 and January 2023. Among trauma survivors (n = 381), we used multinomial logistic regression to examine whether different war-related traumatic events and cumulative trauma increased risk for ICD-11-PTSD and CPTSD after controlling for other traumatic events, age, and gender. Nine of ten Ukrainian students (91.5%) reported at least one war-related stressor, one of five (20.8%) reported four or more stressors. War-related combat situations were reported most frequently (59.5%), followed by forced separation from family members (54.5%), lack of shelter (53.3%), and murder or violent death of a family member or friend (15.6%). Rates for probable ICD-11 PTSD and CPTSD were 12.4% and 11.2%, respectively. Sexual violence and cumulative trauma exposure significantly increased the risk of CPTSD compared to other traumatic events. The high proportions of ICD-11-PTSD and CPTSD underscore the psychological burden of Ukrainian students living in an active war zone and the need for trauma-focused interventions for war-affected populations.

Predicting optimal treatment outcomes in phase-based treatment and direct trauma-focused treatment among patients with posttraumatic stress disorder stemming from childhood abuse

Research over the last few decades has demonstrated the effectiveness of various treatments for posttraumatic stress disorder (PTSD). However, the question of which treatment works best remains, especially for patients with PTSD stemming from childhood abuse. Using the Personalized Advantage Index (PAI), we explored which patients benefit more from phase-based treatment and which benefit more from direct trauma-focused treatment. Data were obtained from a multicenter randomized controlled trial (RCT) comparing a phase-based treatment condition (i.e., eye-movement desensitization and reprocessing [EMDR] therapy preceded by Skills Training in Affect and Interpersonal Regulation [STAIR]; n = 57) and a direct trauma-focused treatment (EMDR only; n = 64) among individuals with PTSD related to childhood abuse. Machine learning techniques were used to examine all pretreatment variables included in the trial as potential predictors and moderators, with selected variables combined to build the PAI model. The utility of the PAI was tested by comparing actual posttreatment outcomes of individuals who received PAI-indicated treatment with those allocated to a non-PAI-indicated treatment. Although eight pretreatment variables between PTSD treatment outcome and treatment condition were selected as moderators, there was no significant difference between participants assigned to their PAI-indicated treatment and those randomized to a non-PAI-indicated treatment, d = 0.25, p = .213. Hence, the results of this study do not support the need for personalized medicine for patients with PTSD and a history of childhood abuse. Further research with larger sample sizes and external validation is warranted.

Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR): A New Modular Treatment for ICD-11 Complex Posttraumatic Stress Disorder (CPTSD)

ICD-11 Complex Posttraumatic Stress Disorder (CPTSD) is a relatively new condition; therefore, there is limited available evidence for its treatment. Prior to the recognition of CPTSD as a separate trauma condition, people who met criteria were often diagnosed with multiple co-morbid conditions such as PTSD, anxiety, depression, and emotional dysregulation difficulties. In the absence of a coherent evidence base, treatment tended to involve multiple treatments for these multiple conditions or lengthy phase-based interventions, often delivered in an integrative fashion, which was not standardized. In this paper, we present Enhanced Skills Training in Affective and Interpersonal Regulation (ESTAIR), a new flexible multi-modular approach for the treatment of CPTSD and its transdiagnostic symptoms. ESTAIR is consistent with trauma-informed and patient-centered care, which highlights the importance of patient choice in identification and sequencing in targeting CPTSD symptoms. Directions for future research are discussed.

Working with Survivors of Sex Trafficking: Mental Health Implications

Human trafficking is one of the largest criminal enterprises in the world, generating an estimated $150 billion in illegal profits annually. Sex trafficking is the most common form of human trafficking, and survivors experience significant physical, emotional, and sexual trauma that places them at increased risk of poor health outcomes. As sex trafficking continues to disproportionately impact the physical and mental health of individuals belonging to marginalized groups, a multidisciplinary approach to combat trafficking will require collaboration between health services, law enforcement, and social services. Therefore, medical professionals should be familiar with screening protocols for trafficking and evidence based, trauma-informed mental health treatment interventions.

Trauma Matters: Integrating Genetic and Environmental Components of PTSD

Trauma is ubiquitous, but only a subset of those who experience trauma will develop posttraumatic stress disorder (PTSD). In this review, it is argued that to determine who is at risk of developing PTSD, it is critical to examine the genetic etiology of the disorder and individual trauma profiles of those who are susceptible. First, the state of current PTSD genetic research is described, with a particular focus on studies that present evidence for trauma type specificity, or for differential genetic etiology according to gender or race. Next, approaches that leverage non-traditional phenotyping approaches are reviewed to identify PTSD-associated variants and biology, and the relative advantages and limitations inherent in these studies are reflected on. Finally, it is discussed how trauma might influence the heritability of PTSD, through type, risk factors, genetics, and associations with PTSD symptomology.

A Structural Analysis of Gender-Based Violence and Depression in the Lives of Sexual Minority Women and Trans People

This article explores structural mechanisms that are the context for violence and depression in the lives of sexual minority women and trans people in Ontario, Canada. The article draws on interviews with 14 people who reported experiences of depression in the previous year, foregrounding three representative narratives. Narrative and case study analysis reveal that violence is a repeated and cumulative experience over lifetimes, occurring across different interpersonal contexts and institutional encounters. A common theme across the narratives is that experiences of violence are connected to a broader context in which structural arrangements, cultural norms, and institutional processes create conditions where marginalized people are put in harm's way, perpetrators are empowered, and justice and access to help are elusive. As the violence experienced by these sexual minority women and trans people is rooted in structural and cultural oppression represented in poverty, racism, misogyny, homophobia, and transphobia, the prevention of violence and its consequences for these and other marginalized populations requires systemic transformation of the structures and systems that currently allow and perpetuate harm.

Long-term follow-up of a multimodal day clinic, group-based treatment program for patients with very high risk for complex posttraumatic stress disorder, and for patients with non-complex trauma-related disorders

Objective

The present study examined the follow-up of a multimodal day clinic group-based therapy program for patients with trauma-related disorders and investigated potential differences for patients with classic PTSD versus cPTSD.

Method

Sixty-six patients were contacted 6 and 12 months after discharge of our 8-week program and completed various questionnaires (Essen Trauma Inventory (ETI), Beck Depression Inventory-Revised (BDI-II), Screening scale of complex PTSD (SkPTBS), Patient Health Questionnaire (PHQ)-Somatization, as well as single items to therapy utilization and life events in the interim period). Due to organizational reasons a control group could not be included. Statistical analyses included repeated-measures ANOVA with cPTSD as between-subject factor.

Results

The reduction of depressive symptoms at discharge was persistent at 6 and 12 months follow-up. Somatization symptoms were increased at discharge, but were leveled out at 6 months follow-up. The same effect was found for cPTSD symptoms in those patients with non-complex trauma-related disorders: Their increase of cPTSD symptoms was flattened at 6 months follow-up. Patients with a very high risk for cPTSD showed a strong linear reduction of cPTSD symptoms from admission to discharge and 6 months follow-up. cPTSD patients had a higher symptom load compared to patients without cPTSD on all time points and scales.

Conclusion

Multimodal, day clinic trauma-focused treatment is associated with positive changes even after 6 and 12 months. Positive therapy outcomes (reduced depression, reduced cPTSD symptoms for patients with a very high risk for cPTSD) could be maintained. However, PTSD symptomatology was not significantly reduced. Increases in somatoform symptoms were leveled out and can therefore be regarded as side effects of treatment, which may be connected with actualization of trauma in the intensive psychotherapeutic treatment. Further analyses should be applied in larger samples and a control group.

Treating post-traumatic stress disorder in survivors of community and domestic violence using narrative exposure therapy: a case series in two public health centers in Rio de Janeiro/Brazil

Prevalence of violence in Brazil is high, which contributes to an increasing number of trauma-related disorders, especially post-traumatic stress disorder (PTSD). This study aims to present a case series of PTSD patients treated with narrative exposure therapy (NET) in two public health centers in Rio de Janeiro (Brazil). Health professionals were trained in a two-week workshop to deliver NET. Exposure to violence and other potentially traumatic events, as well as PTSD were assessed by interviewers before treatment and six months later in follow-up interviews conducted by blind assessors. Multiple traumatic events, including different types of childhood and sexual abuse, intimate partner violence and community violence were reported. Five patients were exposed to community violence, and one to domestic violence, during or after NET treatment. Treatment delivery was integrated into the routine of health centers. Eight patients completed NET and presented a substantial reduction in PTSD severity at six-month follow-up. NET is a feasible and effective treatment for PTSD patients exposed to ongoing violence, and can be integrated into established public health services.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

Prevalence of Different Approaches to Clinical Hypnosis: Bridging Research and Practice

A recent survey conducted by the Society of Clinical and Experimental Hypnosis Task Force for Efficacy Standards in Hypnosis Research found that clinicians reported using one or more of several different styles of hypnosis in their work. The most common of these was Ericksonian, used by over 2/3rds of clinicians, followed by hypnotic relaxation therapy and traditional hypnosis. Surprisingly, a little less than a 3rd of respondents indicated using the evidence-based practice of hypnotherapy. The present paper discusses these findings from the perspective of optimal survey methodology, examines areas of differences and overlap among response options, and considers the question of the evidence base for the practice of clinical hypnosis.

Early maladaptive schemas and ICD-11 CPTSD symptoms: Treatment considerations

OBJECTIVES

Early maladaptive schemas (EMS) can result from adverse interpersonal traumatic experiences. The ICD-11 updated the concept of disorders following traumatic experiences with the new disorder of complex post-traumatic stress disorder (CPTSD). There is now a need to develop and test interventions for CPTSD. An essential step in identifying interventions that are particularly relevant to the treatment of CPTSD is to explore psychological constructs associated more closely with CPTSD compared to PTSD. The current study explored the associations of EMS with PTSD and CPTSD.

DESIGN

The sample consisted of 603 adults (mean age = 41.65, SD = 13.8), recruited through social media and e-mails, and who responded to an online questionnaire.

METHODS

Participants completed measures of demographic, traumatic life events, EMS, PTSD and CPTSD symptoms.

RESULTS

Overall, results suggest that participants with CPTSD present with higher schema elevations across all schemas compared to those with PTSD or no diagnosis. Secondly, the schemas of emotional deprivation, abandonment/instability, social isolation/alienation, defectiveness/shame, enmeshment/undeveloped self, subjugation, emotional inhibition and insufficient self-control/self-discipline were significantly associated with the symptom clusters of CPTSD. Finally, results indicate that different schemas form significant associations with the individual symptom clusters of CPTSD.

CONCLUSIONS

Although results require replication in clinical samples, initial findings suggest that specific EMS may be important psychological correlates of CPTSD symptoms. Wider treatment considerations of these findings are discussed.

Shifting to Trauma-Informed Care in Inpatient Psychiatry: A Case Study of an Individual with Dissociative PTSD Undergoing EMDR Therapy

Caring for patients with personality disorders can be challenging due to risks associated with suicidal ideation, homicidal threats, splitting, and acting out with problematic behavior in psychiatric inpatient units. Limited resources on inpatient units further add to the stress and burden on staff. This case summarizes how trauma-informed care was implemented in an inpatient setting to produce marked improvement in a patient's treatment outcomes as well as better staff engagement and satisfaction. This culture change in the approach to care was not an easy process, as effortful planning and resources were required for key elements such as ongoing coaching, education, and regular staff debriefings. This case report signals the need for service providers to enable health systems to examine rules and exceptions from a cultural perspective of considering equity, diversity, and inclusion (EDI)-to allow openness to rational exceptions, even if they are unconventional.

Factors associated with posttraumatic growth: gratitude, PTSD and distress; one year into the COVID-19 pandemic in Lebanon

Almost one year since the COVID-19 was declared a global pandemic, mental distress remains elevated with high prevalence of post-traumatic stress disorder (PTSD). Yet studies suggest these challenging circumstances might be conducive of post-traumatic growth (PTG). This study aims to investigate the factors associated with growth after the original trauma. A sample of 252 Lebanese adults filled an online survey to determine levels of PTG, PTSD and gratitude using validated self-rating scales. Participants also subjectively evaluated the sources of their distress such as the COVID-19 pandemic, the Beirut port explosion and/or their deteriorating financials. The PTGi-SF evaluated dimensions of growth while the IES-R_22 measured the degree of distress post-trauma. The GQ-6 was used to measure the proneness to experience gratitude daily. Results indicated 41% of participants scored above the cutoff for PTSD symptomatology. Yet, PTSD was positively correlated, alongside gratitude and accumulated subjective distress, with higher levels of PTG. A forward linear regression taking PTG scores as the dependent variable further showed that more gratitude (Beta = 0.57), a higher impact of events (Beta = 0.16), and knowing anyone who died from COVID-19 (Beta = 3.93) were significantly associated with more growth. The study highlights elevated levels of PTSD symptoms in a context of a global pandemic worsened by financial and socio-political instabilities. It mostly identifies personal factors, including high initial symptomatology post-trauma and gratitude, related to the capacity for growth in spite of these accumulating hardships. As such, it advocates the need to investigate and bolster silver linings amidst unprecedented traumas.

Women-only versus mixed-gender groups in multimodal, day clinic treatment of trauma-related disorders

Background: In the German healthcare system benefits include inpatient and day clinic psychotherapy of trauma-related disorders, which are often provided in gender specific groups. Despite this widespread practice, the actual impact and potential outcome have been studied relatively scarcely and are still open to debate. The present study therefore examines whether the therapeutic relationships in the group vary depending on the group composition and whether this has an effect on therapy outcome. Methods: 66 patients (N = 55 women) were treated in our multimodal, day clinic groupbased treatment program and filled out symptom questionnaires (ETI, BDI-II, PHQ-15, Questionnaire on social support) at admission and discharge and the Group Questionnaire (GQ; including subscales positive bonding, positive working and negative relationships) at the end of each of the eight weeks of treatment. Patients took part in five women-only and six mixed-gender groups and underwent therapy in a closed group format, so that they began and ended therapy within the same group. All patients were diagnosed with trauma-related disorders, which included PTSD, cPTSD, depression, somatoform disorders and further mental diseases. Outcome data were examined using functional regression analysis and linear mixed models. Results: In women-only groups, positive bonding and positive working relationship were significantly higher than in mixed-gender groups. Negative relationship ratings were significantly lower in women-only groups, especially in the middle phase of treatment. However, no effect of an exclusively female group composition on treatment outcome was found, except for the higher increase of perceived social support for patients treated in women-only groups. Conclusions: Group relationships were considered more pleasant in women-only groups than in mixed-gender groups, but this had no effect on the symptom-based therapy outcome. To enhance feelings of safety and comfort, traumatized women should have the possibility to choose whether to be treated in a women-only or a mixed-gender group.

Imagery Rescripting as a stand-alone treatment for posttraumatic stress disorder related to childhood abuse: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) related to childhood abuse (CA) is associated with high symptom complexity. This study examined the efficacy of Imagery Rescripting (ImRs) as a stand-alone treatment versus a sequenced approach with Skills training in Affective and Interpersonal Regulation (STAIR) followed by ImRs for CA-related PTSD.

METHODS

Outpatients of two mental health clinics with CA-related PTSD (N = 61) were randomly assigned to ImRs (16 sessions; n = 21), STAIR/ImRs (8 STAIR-sessions followed by 16 ImRs-sessions; n = 20), or Waitlist (8 weeks; n = 20). Patients of the waitlist condition were also randomized to the two active conditions for comparison of STAIR/ImRs (total n for this condition = 31) and ImRs (total n for this condition = 30) and started treatment after waitlist completion. Assessments took place at pre-treatment, after each treatment phase and at 12-week post-intervention follow-up. PTSD symptoms and diagnosis were primary outcome measures, and depression, emotion regulation and interpersonal functioning were secondary outcomes.

RESULTS

ImRs showed greater reduction of PTSD severity (effect sizes [ES] 1.40-1.63) than STAIR (ES, 0.23-0.33) as compared to waitlist. When comparing STAIR/ImRs and ImRs directly, (i.e. including re-randomized Waitlist-patients), PTSD symptoms reduced significantly (within condition ES, 1.64-2.10) and improved further to 12-week follow-up (within-condition ES, 2.33-2.66), with no significant difference between both conditions (between-condition ES, 0.21-0.45). Loss of PTSD diagnosis was achieved by 70% in the ImRs condition and 86% in the STAIR/ImRs condition.

LIMITATIONS

The sample size was relatively small.

CONCLUSIONS

Results show that ImRs is an effective treatment for CA-related PTSD, whereby the current data do not convincingly show an additive effect of STAIR.

French cross-cultural adaptation and validation of the International Trauma Questionnaire (ITQ) in a French community sample

Aims: In 2018, the 11th version of the International Classification of Diseases (ICD-11) recognized a new diagnosis in addition to Posttraumatic Stress Disorder (PTSD), that of Complex Posttraumatic Stress Disorder (C-PTSD). A new measurement tool was developed to assess both disorders: the International Trauma Questionnaire. The objectives of this study were (a) to conduct a French translation of the tool, (b) to confirm the factorial structure of the tool, (c) to verify its convergent and divergent validity, (d) and finally to ensure its temporal stability.Method: The ITQ was translated into French using a committee approach, bringing together experts and bilingual individuals with a dual French-English culture. It was then completed by 750 people residing in France and having been exposed to potentially traumatic events, recruited from the general population. Other measures were also completed (HADS, ITEM, PCL-5, WHO-5, DERS).Results: Confirmatory factor analysis confirmed that the French version of the ITQ had the same factor structure as the original version. The scale showed satisfactory convergent and divergent validity, as well as good stability over time.Conclusion: Our study suggests that the French version of the ITQ is a good measurement tool for assessing PTSD and C-PTSD according to the ICD-11 diagnostic criteria.HIGHLIGHTS This study provides the first translation and validation of the International Trauma Questionnaire in the French population.Confirmatory factor analysis confirmed that the French version of the ITQ had the same factor structure as the original version.The French version of the ITQ showed good convergent and divergent validity, as well as good test-retest reliability.

The effectiveness of trauma-focused psychotherapy for complex post-traumatic stress disorder: A retrospective study

OBJECTIVE

We retrospectively evaluated the effectiveness of trauma-focused psychotherapy (TF-P) versus stabilization and waiting in a civilian cohort of patients with an 11th version of the international classification of disease (ICD-11) diagnosis of complex post-traumatic stress disorder (CPTSD).

METHODS

We identified patients with CPTSD treated at a specialist trauma service over a 3-year period by triangulating evidence from self-report questionnaires, file review, and expert-clinician opinion. Patients completed a phase-based treatment: stabilization consisting of symptom management and establishing safety, followed by waiting for treatment (phase 1); individual TF-P in the form of trauma-focused cognitive behavioral therapy (TF-CBT), or eye movement desensitization and reprocessing (EMDR) or TF-CBT plus EMDR (phase 2). Our primary outcome was PTSD symptoms during phase 2 versus phase 1. Secondary outcomes included depressive symptoms, functional impairment, and a proxy CPTSD measure. Exploratory analysis compared outcomes between treatments. Adverse outcomes were recorded.

RESULTS

Fifty-nine patients were included. Compared to receiving only phase 1, patients completing TF-P showed statistically significant reductions in PTSD [t(58) = -3.99, p < 0.001], depressive symptoms [t(58) = -4.41, p < 0.001], functional impairment [t(58) = -2.26, p = 0.028], and proxy scores for CPTSD [t(58) = 4.69, p < 0.001]. There were no significant differences in outcomes between different treatments offered during phase 2. Baseline depressive symptoms were associated with higher PTSD symptoms and functional impairment.

CONCLUSIONS

This study suggests that TF-P effectively improves symptoms of CPTSD. However, prospective research with validated measurements is necessary to evaluate current and new treatments and identify personal markers of treatment effectiveness for CPTSD.

Relative efficacy of psychological interventions following interpersonal trauma on anxiety, depression, substance use, and PTSD symptoms in young people: A meta-analysis

AIM

Interpersonal trauma exposures are associated with anxiety, depression, and substance use in youth populations (aged 12-25 years). This meta-analysis reports on the efficacy of psychological interventions on these symptom domains in addition to post-traumatic stress.

METHODS

Following PRISMA guidelines, a search of electronic databases was performed for randomized controlled trials (RCTs) assessing interventions for young people following interpersonal trauma exposure. Risk of bias was assessed using the Cochrane Risk of Bias tool. Data were analysed using random-effects meta-analyses.

RESULTS

Of the 4832 records screened, 78 studies were reviewed, and 10 RCTs, involving 679 participants (mean age 15.6 years), were analysed. There was a large pooled effect size for post-traumatic stress (7 studies, g = 1.43, 95% CI [0.37, 2.15], p = .002) and substance use (2 studies, g = 0.70, 95% CI [-0.11, 1.22], p < .001) and small effect sizes for anxiety (4 studies, g = 0.30, 95% CI [0.10, 0.49], p = .003), and trend-level effect for depression (10 studies, g = 0.27, 95% CI [0.00, 0.54], p = .052). Heterogeneity was significant for post-traumatic stress and moderate for depression.

CONCLUSIONS

High-quality RCTs of psychological interventions for anxiety, depression, substance use, and post-traumatic stress symptoms in young people exposed to interpersonal trauma are scarce. While available studies show either statistically significant or trend-level efficacy for psychological interventions in reducing these symptoms, wide confidence intervals, heterogeneity and small sample size mean that results need to be interpreted with caution.

Constant installation of present orientation and safety (CIPOS) - subjective and physiological effects of an ultrashort-term intervention combining both stabilizing and confrontational elements

Objectives

Constant Installation of Present Orientation and Safety (CIPOS) is a Eye Movements Desensitization and Reprocessing (EMDR)-derived technique, which is often used to prepare for the treatment of post-traumatic stress disorder (PTSD). It differs from the latter by involving cyclically recurring exercises in reorientation to the present, interspersed between brief periods of exposure to the traumatic material.While EMDR is well established as a therapeutic method, the efficacy and mechanisms of action of CIPOS have not been investigated so far. In this pilot study, an experimental setting was used to record the subjective and physiological effects of the CIPOS intervention compared to a control condition with pure mental exposition.

Methods

The study was performed on 30 healthy volunteers aged from 20 to 30 years. Distress was induced using audio files of subjectively stressful situations. Subjective distress was measured via the Subjective Units of Distress Scale (SUD), while physiological indicators (noise-induced startle reflex, skin conductance level) were used as measures for objective stress. For each condition, pre- and post-intervention comparisons were calculated.

Results

In both groups, startle reflex potentiation and mean skin conductance level significantly decreased. In the group with CIPOS intervention, but not in the control group, a significant decrease in the SUD value was found.

Conclusion and significance

The results show that the CIPOS technique is as effective as pure mental exposition in reducing physiological stress. In addition, a superiority in reducing subjective distress (indicating a simplified reassessment of the stressful material) was found compared to pure mental exposition. Possible explanations of these effects are discussed.

Early interventions for post-traumatic stress following musculoskeletal trauma: protocol for a systematic review and meta-analysis

INTRODUCTION

Post-traumatic stress symptoms (PTSS) can be triggered following exposure to a traumatic event, such as violence, disasters, serious accidents and injury. Little is known about which interventions provide the greatest benefit for PTSS. This systematic review aims to estimate the effects of early interventions on PTSS following musculoskeletal trauma.

METHODS/ANALYSIS

Development of this review protocol was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols checklist. This review will include randomised controlled trials and non-randomised controlled studies evaluating the effect of early (within 3 months of a traumatic event) non-pharmacological and non-surgical interventions on PTSS in adults (aged ≥18 years). MEDLINE, PsycINFO, Embase, CINAHL, Zetoc, PROSPERO, Web of Science, PubMed and Google Scholar, as well as key journals/grey literature, will be searched from inception to 31 July 2022. Only articles published in English will be considered. Two independent reviewers will search, screen studies, extract data and assess risk of bias using the Cochrane Risk of Bias tool V.2 (RoB 2) and the Risk Of Bias in Non-randomised Studies of Interventions (ROBINS-I), respectively. Mean difference or standardised mean difference (SMD) will be extracted with accompanying 95% CIs and p values where these are reported. Group effect size will be extracted and reported. Symptoms of PTSS will be ascertained using SMDs (continuous) and diagnosis of PTSS using risk ratio (dichotomous). If possible, study results will be pooled into a meta-analysis. A narrative synthesis of the results will be presented if heterogeneity is high. The overall quality of evidence and risk of bias will be assessed using the Grading of Recommendations Assessment, Development and Evaluation, RoB 2 and ROBINS-I guidelines, respectively.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review since data from published studies will be used. This review is expected to provide a better understanding of the effect of early intervention for PTSS following musculoskeletal trauma. Findings of this review will be disseminated in peer-reviewed publications and through national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42022333905.

Trauma exposure and co-occurring ICD-11 post-traumatic stress disorder and complex post-traumatic stress disorder in adults with lived experience of psychiatric disorder

OBJECTIVE

To establish factors associated with ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in a large sample of adults with lived experience of psychiatric disorder and examine the psychiatric burden associated with the two disorders.

METHODS

One thousand three hundred and five adults were recruited from the National Centre for Mental Health (NCMH) cohort. ICD-11 PTSD/CPTSD were assessed with the International Trauma Questionnaire (ITQ). Binary logistic regression was used to determine factors associated with both PTSD and CPTSD. One-way between-groups analysis of variance was conducted to examine the burden associated with the two disorders in terms of symptoms of anxiety, depression, and psychological wellbeing. For post-hoc pairwise comparisons, the Tukey HSD test was used, and the magnitude of between-group differences assessed using Cohen's d.

RESULTS

Probable ICD-11 CPTSD was more common than PTSD within the sample (PTSD 2.68%; CPTSD 12.72%). We found evidence that PTSD was associated with interpersonal trauma and household income under £20,000 a year. CPTSD was also associated with interpersonal trauma, higher rates of personality disorder, and lower rates of bipolar disorder. Those with probable-CPTSD had higher levels of current anxiety and depressive symptoms and lower psychological wellbeing in comparison to those with probable-PTSD and those with neither disorder.

CONCLUSIONS

CPTSD was more prevalent than PTSD in our sample of people with lived experience of psychiatric disorder. Our findings indicate a need for routine screening for trauma histories and PTSD/CPTSD in clinical settings and a greater focus on the need for interventions to treat CPTSD.

Long-term effectiveness of a prolonged exposure-based intensive outpatient program for veterans with posttraumatic stress disorder

Empirically-supported psychotherapies for posttraumatic stress disorder (PTSD) are highly effective and recommended as first-line treatments, yet dropout rates from standard outpatient therapy are high. Intensive outpatient programs (IOPs) that provide these therapies in condensed format with complementary interventions show promise, as they have demonstrated similar efficacy and higher retention rates. The current study examined initial and long-term outcomes up to 12-months following a 2-week PTSD IOP involving daily prolonged exposure therapy (PE) and adjunctive interventions for veterans and military service members. Participants (N = 376) demonstrated high retention (91%) and large effect size reductions in self-reported PTSD and depression symptoms after two weeks. Small increases in symptoms occurred after 3 months but these stabilized and large reductions compared to baseline were maintained up to 12 months. Piecewise multilevel modeling indicated that demographic variables did not predict PTSD or depression symptom trajectories. Higher PTSD and depression severity at intake predicted higher symptomatology across timepoints and larger relative gains during treatment. Greater alcohol use prior to treatment was associated with higher PTSD symptomatology but did not affect the magnitude of gains. A history of childhood sexual abuse was associated with greater reduction in depression symptoms over treatment, although this effect faded over follow-up. Together these findings underscore the long-term effectiveness of a PE-based IOP across a diverse range of veterans and service members.

Functional connectivity changes in the delta frequency band following trauma treatment in complex trauma and dissociative disorder patients

Objective

Phase-oriented trauma treatment is efficacious in the treatment of complex trauma and dissociative disorder patients. However, the neural correlates of this therapeutic effect are not yet well-understood. In the current study we investigated whether patients show a strengthening in functional network connectivity in the delta frequency band (1-3.5 Hz) over the course of phase-oriented inpatient trauma treatment while they performed an emotion regulation task. Further, we examined whether neural changes were associated with symptom reduction and improvement in emotion regulation skills.

Methods

Before and after 8 weeks of treatment, electroencephalography (EEG) was acquired in patients (n = 28) with a complex posttraumatic stress disorder (cPTSD) or complex dissociative disorder (CDD). They also completed clinical and emotion regulation questionnaires. To delimit data variability, patients participated as one dissociative part that is referred to as Apparently Normal Part (ANP). Patients' data were compared to a matched healthy control croup (n = 38), also measured twice.

Results

Prior to treatment, functional connectivity was significantly lower in patients compared to controls during cognitive reappraisal of unpleasant pictures and passive viewing of unpleasant and neutral pictures. These hypoconnected networks largely overlapped with networks typically activated during the recall of (emotional) autobiographical memories. Functional connectivity strength within these networks significantly increased following treatment and was comparable to controls. Patients showed symptom reduction across various clinical domains and improvement in the use of cognitive reappraisal as emotion regulation strategy. Treatment-related network normalizations were not related to changes in questionnaire data.

Conclusion

Phase-oriented treatment may strengthen connections between regions that are activated during autobiographical recall. These findings encourage further investigation of this circuitry as a therapeutic target in cPTSD and CDD patients.

Clinial trial registration

www.ClinicalTrials.gov, identifier: NCT02459340, https://www.kofam.ch/de/studienportal/suche/149284/studie/26681.