Transdiagnostic mechanisms of change and cognitive-behavioral treatments for PTSD

Negative posttraumatic cognitions and cognitive emotion regulation strategies as predictors of PTSD symptom change during an intensive outpatient program for PTSD

Negative posttraumatic cognitions (NPCs) and cognitive emotion regulation (CER) strategies have both been proposed as predictors of change in evidence-based cognitive behavioral therapies for posttraumatic stress disorder (PTSD). However, they are rarely studied simultaneously, with only one study examining these predictors in a randomized clinical trial of prolonged exposure therapy. It remains to be tested how these variables predict improvements in PTSD severity in real world clinical settings or different delivery formats. Data from 487 military service members and veterans that participated in a 2-week nonrandomized, uncontrolled cognitive processing therapy-based intensive treatment program (ITP) for PTSD were used to evaluate NPCs and CER strategies as predictors of improvements in PTSD severity. Results showed that, in a model with both predictors, decreases in self-focused NPCs, world-focused NPCs, and catastrophizing (CER strategy) were associated with reductions in PTSD severity during treatment and at follow-up. However, these effects were small (R2 ranging from .005 to.04) relative to reductions in depression severity (R2 = .40). Although NPCs and CER strategies significantly predicted reductions in PTSD severity, their overall impact was relatively small in this nonrandomized, uncontrolled ITP. Future research should continue to investigate these and other predictors in a variety of treatment settings.

Multidimensional Emotional Disorder Inventory: reliability and validity in a Colombian non-clinical sample

BACKGROUND

Contemporary diagnostic frameworks in the realm of mental health have garnered criticism due to their categorical paradigm. Given the propensity of emotional disorders to manifest overlapping features, these frameworks fall short in comprehensively encapsulating their intricate nature. As a strategic response, Brown and Barlow introduced an innovative composite approach, amalgamating dimensions and categorical classifications, to adress this concern. Their strategic implementation hinged on the Multidimensional Emotional Disorder Inventory (MEDI), a transdiagnostic self-report instrument.

OBJECTIVE

this study undertakes the task of refining and validating the applicability of the MEDI within a non-clinical sample of Colombian university students (n = 808).

METHODS

This study employed Exploratory Structural Equation Modeling (ESEM) to explore the structure of the measure.

RESULTS

ESEM suggested that the 8-dimension model with 48 items was the best-fitting solution, aligning with most dimensions identified by the original MEDI validation. Reliability was adequate for almost all dimensions (α: 0.69 - 0.92). An 8-dimension model with 48 items emerged as the most fitting solution, aligning with most dimensions identified by the original MEDI validation.

CONCLUSION

The ensuing validation and contextual adaptation of the MEDI for use in the Colombian population augments the transdiagnostic evaluation of emotional disorders, with potential implications for enhanced stratification of targeted therapeutic interventions. By optimizing the assessment of both dimensional and cross-diagnostic paradigms, the MEDI portends a noteworthy impact in realms encompassing both academic inquiry and clinical practice.

BPD Compass: Using a dimensional model of psychopathology to treat co-occurring borderline personality disorder and posttraumatic stress symptoms

BPD Compass is a transdiagnostic psychotherapy that includes cognitive, behavioral, and mindfulness skills targeting the personality dimensions of negative affectivity, disinhibition, and antagonism. Given considerable symptom comorbidity and overlap in etiology between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD), this study investigated whether BPD Compass holds promise as an integrated approach to simultaneously treating co-occurring BPD features and PTSD symptoms. Participants included 84 trauma-exposed adults who participated in a two-phase clinical trial (Phase 1: randomized controlled trial of BPD Compass vs. waitlist [n = 43]; Phase 2: open trial of BPD Compass [n = 41]). Compared to waitlist, BPD Compass led to medium-to-large-sized, significant improvements in BPD features, βs = -.57 -.44, and facets of neuroticism, βs < -.55--.73, as well as small, nonsignificant improvements in self-reported, β = -.20, and clinician-rated PTSD symptom severity, β = -.19. During treatment, within-person improvements in PTSD symptoms predicted subsequent improvements in BPD features, β = .13, but not vice versa, β = .07. Within-person PTSD symptom reduction also predicted subsequent improvement in all personality dimensions, whereas only within-person improvement in despondence, β = .12, affective dysregulation, β = .11, and dissociative tendencies, β = .12, predicted PTSD symptom reductions. Findings offer preliminary support for the potential of BPD Compass to target BPD features and aspects of neuroticism and agreeableness among trauma-exposed adults. Moreover, PTSD symptom change predicting subsequent improvement in BPD features runs counter to current stage-based treatment models that emphasize BPD feature stabilization before engaging in trauma-focused therapy.

The promise of compassion-based therapy as a novel intervention for adolescent PTSD

In this review, we summarize current evidence for compassion-based approaches for PTSD and the potential for their application to the adolescent PTSD population. Exposure to traumatic events is common in adolescence and PTSD remains a public health crisis. Accessibility, willingness, and engagement are significant barriers to established treatments for PTSD, with attrition rates as high as 50 %. Compassion-based therapies provide potential solutions to treatment obstacles by providing a non-threatening, transdiagnostic option unburdened by aspects of current trauma treatment which may be associated with treatment resistance (e.g., exposure, trauma narrative, induction of fear). Compassion-based approaches are intuitive for trauma treatment, as compassion activates the self-soothing system, thereby disarming the fear system and promoting affect regulation. Compassion-based treatments demonstrate reductions across a substantial range of PTSD symptoms in adults, however, in adolescents extant literature is sparse, with cross-sectional studies suggesting self-compassion is inversely associated with trauma-related psychopathology. Understanding the impact of compassion-based approaches on adolescent PTSD is warranted as the adolescent developmental period may be a particularly opportune time for this approach. Evaluation of the impact of compassion-based treatment on adolescent PTSD in clinical populations via randomized-controlled studies and comparison of its relative efficacy to current evidence-based practices is warranted.

MDMA-Based Psychotherapy in Treatment-Resistant Post-Traumatic Stress Disorder (PTSD): A Brief Narrative Overview of Current Evidence

Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that causes significant dysfunction in individuals. Currently, there are many approved pharmacotherapy and psychotherapy treatment options for PTSD, but unfortunately, half of the patients do not respond to traditional therapies. In this article, we review clinical trials and research on 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy in PTSD patients, its pharmacokinetics, and current treatment guidelines for PTSD. Our findings are based on the results of the efficacy of MDMA-assisted psychotherapy from six phase II randomized controlled trials. MDMA-assisted psychotherapy for PTSD has received the "breakthrough therapy" designation from the FDA. MDMA can reduce PTSD symptoms even in treatment-resistant cases by increasing certain neurohormones, i.e., dopamine, serotonin, norepinephrine, and oxytocin. It also modulates activities in the brain regions involved in fear and anxiety. Future research is needed to show whether the advantages outweigh the disadvantages and whether its use can be integrated into available treatment options for PTSD.

Toward Cognitive-Behavioral Therapy for Sexual Minority Women: Voices From Stakeholders and Community Members

Sexual minority women (SMW) experience an elevated risk of mental health problems compared to heterosexual women. However, knowledge gaps remain regarding whether cognitive-behavioral therapy (CBT) interventions meet SMW's mental health needs. Further, virtually no studies have integrated stakeholder (i.e., researchers with content expertise in SMW's health and clinical providers who work with SMW) and community member (i.e., SMW) perspectives to identify CBT approaches that address SMW-specific issues. This study used qualitative data gathered from 39 SMW who reported depression, anxiety, suicidality, and heavy drinking in the past 3 months and 16 content experts and clinical providers to obtain information relevant to enhancing CBT for SMW. In addition, we used thematic analysis to identify themes related to the adaptation and delivery of CBT for SMW. Building on prior literature, this study's findings revealed seven considerations for delivering mental health services to SMW: (1) attending to SMW's diverse gender identities and expressions; (2) focusing on SMW's nonbinary stressors; (3) formulating SMW's gender-based stressors within a feminist framework; (4) applying intersectionality frameworks; (5) incorporating issues of diversity, multiculturalism, and social justice; (6) addressing the role of trauma exposure; and (7) addressing the role of alcohol use in SMW's lives. These considerations are reviewed in terms of their implications for clinical practice, with a focus on enhancing applications of existing CBT interventions, to best respond to the unique needs of this population.

A systematic review of literature examining mediators and mechanisms of change in empirically supported treatments for posttraumatic stress disorder

Despite the availability of empirically supported treatments (ESTs) for posttraumatic stress disorder (PTSD), relatively little is known regarding these treatments' mechanisms of change. This systematic review moves beyond previous reviews by summarizing the findings and reviewing the methodological quality of literature that specifically examined mediators/mechanisms of change in ESTs for PTSD. Studies were included if they were written in English, empirical, peer-reviewed, claimed to study mediators/mechanisms of a recommended PTSD treatment, measured the mediator/mechanism during or before and after treatment, and included a posttreatment PTSD or global outcome (e.g., functioning). PsycINFO and PubMed were searched on October 7, 2022. Two coders screened and coded studies. Sixty-two eligible studies were identified. The most consistent mediator/mechanism was reduction in negative posttraumatic cognitions, followed by between-session extinction and decreased depression. Only 47% of studies measured the mediator/mechanism before the outcome and measured the mediator/mechanism and outcome at least three times, and 32% also used growth curve modeling to establish temporal precedence of change in the mediator/mechanism and outcome. Many of the mediators/mechanisms examined had weak or no empirical support. Results highlight the need for improved methodological rigor in treatment mediator and mechanism research. Implications for clinical care and research are discussed. PROSPERO ID: 248088.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

Assessing the impact of the Royal Canadian Mounted Police (RCMP) protocol and Emotional Resilience Skills Training (ERST) among diverse public safety personnel

BACKGROUND

Public safety personnel (PSP; e.g., border services personnel, correctional workers, firefighters, paramedics, police, public safety communicators) are frequently exposed to potentially psychologically traumatic events. Such events contribute to substantial and growing challenges from posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder.

METHODS

The current protocol paper describes the PSP PTSI Study (i.e., design, measures, materials, hypotheses, planned analyses, expected implications, and limitations), which was originally designed to evaluate an evidence-informed, proactive system of mental health assessment and training among Royal Canadian Mounted Police for delivery among diverse PSP (i.e., firefighters, municipal police, paramedics, public safety communicators). Specifically, the PSP PTSI Study will: (1) adapt, implement, and assess the impact of a system for ongoing (i.e., annual, monthly, daily) evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; and, (4) assess the impact of providing diverse PSP with a tailored version of the Emotional Resilience Skills Training originally developed for the Royal Canadian Mounted Police in mitigating PTSIs based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Participants are assessed pre- and post-training, and then at a follow-up 1-year after training. The assessments include clinical interviews, self-report surveys including brief daily and monthly assessments, and daily biometric data. The current protocol paper also describes participant recruitment and developments to date.

DISCUSSION

The PSP PTSI Study is an opportunity to implement, test, and improve a set of evidence-based tools and training as part of an evidence-informed solution to protect PSP mental health. The current protocol paper provides details to inform and support translation of the PSP PTSI Study results as well as informing and supporting replication efforts by other researchers.

TRIAL REGISTRATION

Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022-Prospectively registered.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05530642. Registered 1 September 2022-Retrospectively registered. The subsequent PSP PTSI Study results are expected to benefit the mental health of all participants and, ultimately, all PSP.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

A Preliminary Evaluation of the Unified Protocol among Trauma-Exposed Adults with and without PTSD

The purpose of this study was to evaluate whether the Unified Protocol (UP)-a mechanistically transdiagnostic psychological treatment-provides benefit to individuals with a range of trauma histories, psychological difficulties, and diagnostic comorbidity. Using data from a sequential multiple-assignment randomized trial (SMART), this exploratory analysis included a sample of 69 community-recruited adults seeking outpatient mental health treatment. We examined reductions in anxiety and depressive symptoms and changes in aversive and avoidant reactions to intense emotions-the UP's putative mechanism-first by comparing individuals with and without trauma histories and then specifically among participants with PTSD. Findings suggest that the UP may lead to similar improvements in clinical diagnostic severity, anxiety, and depression among patients with trauma exposure as those without trauma exposure. Roughly half of participants with PTSD demonstrated reductions in PTSD clinical severity, anxiety, depression, and distress aversion, suggesting the UP may be an efficacious treatment for people with PTSD and comorbid conditions.

Cognitive-Affective Transdiagnostic Factors Associated With Vulnerability to Alcohol and Prescription Opioid Use in the Context of Pain

The use of alcohol and prescription opioids is common among people in pain and poses significant public health burdens. This review identifies factors associated with motivation to use alcohol and prescription opioids in the context of pain. Pain-relevant, cognitive-affective, transdiagnostic vulnerability factors-expectancies/motives, pain catastrophizing, pain-related anxiety, distress intolerance, anxiety sensitivity, and perceived interrelations-were selected from theoretical conceptualizations of pain and substance use. Searches conducted in PubMed, PsycINFO, and Embase returned 25 studies that examined associations between identified variables of interest and the use of alcohol and prescription opioids in the context of pain. Consistent with a larger literature on pain and substance use, the studies included in this review demonstrated that people with chronic pain are motivated to use alcohol and opioids in response to negative affect and hold expectancies/motives for coping with pain. Vulnerabilities that engender difficulty managing aversive internal states (distress intolerance and anxiety sensitivity) and maladaptive responses to pain (pain-related anxiety and pain catastrophizing) also were implicated in motivation for alcohol and opioid use. Although one study found that pain-related anxiety was associated with co-use of alcohol and opioids, no studies examined simultaneous use. Future research directions that can explicate causal associations, identify patterns of alcohol and opioid co-use, clarify the role of pain in cessation processes, and inform treatment development are discussed.

A Pilot Study of the Efficacy of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Treating Posttraumatic Psychopathology: A Randomized Controlled Trial

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is an intervention that targets common mechanisms that maintain symptoms across multiple disorders. The UP has been shown to be effective across many disorders, including generalized anxiety disorder, major depressive episode (MDE), and panic disorder, that commonly codevelop following trauma exposure. The present study represented the first randomized controlled trial of the UP in the treatment of trauma-related psychopathology, including posttraumatic stress disorder (PTSD), depression, and anxiety symptoms. Adults (N = 43) who developed posttraumatic psychopathology that included PTSD, MDE, or an anxiety disorder after sustaining a severe injury were randomly assigned to receive 10-14 weekly, 60-min sessions of UP (n = 22) or usual care (n = 21). The primary treatment outcome was PTSD symptom severity, with secondary outcomes of depression and anxiety symptom severity and loss of diagnosis for any trauma-related psychiatric disorder. Assessments were conducted at intake, posttreatment, and 6-month follow-up. Posttreatment, participants who received the UP showed significantly larger reductions in PTSD, Hedges' g = 1.27; anxiety, Hedges' g = 1.20; and depression symptom severity, Hedges' g = 1.40, compared to those receiving usual care. These treatment effects were maintained at 6-month follow-up for PTSD, anxiety, and depressive symptom severity. Statistically significant posttreatment loss of PTSD, MDE, and agoraphobia diagnoses was observed for participants who received the UP but not usual care. This study provides preliminary evidence that the UP may be an effective non-trauma-focused treatment for PTSD and other trauma-related psychopathology.

Comparison of cannabidiol to citalopram in targeting fear memory in female mice

Background

Cannabidiol (CBD) and selective serotonin reuptake inhibitors (SSRIs) are currently used to treat post-traumatic stress disorder (PTSD). However, these drugs are commonly studied after dosing just prior to extinction training, and there are gaps in our understanding of how they affect fear memory formation, their comparative effects on various types of memory, and of sexual dimorphisms in effects. Also, more studies involving female subjects are needed to balance the gender-inequality in the literature. Therefore, the purpose of this study was to directly compare the effects of CBD to citalopram in affecting the formation of auditory cued, contextual, and generalized fear memory, and to evaluate how extinction of these different memories was altered by pre-acquisition treatment in female mice. We also evaluated the impact of the estrous cycle on each of these.

Methods

Auditory-cued trace fear conditioning was conducted shortly after dosing female C57BL/6 mice, with either CBD or citalopram (10 mg/kg each), by pairing auditory tones with mild foot shocks. Auditory-cued, contextual, and generalized fear memory was assessed by measuring freezing responses, with an automated fear conditioning system, 24 h after conditioning. Each memory type was then evaluated every 24 h, over a 4-day period in total, to create an extinction profile. Freezing outcomes were statistically compared by ANOVA with Tukey HSD post hoc analysis, N = 12 mice per experimental group. Evaluation of sexual dimorphism was by comparison to historical data from male mice.

Results

Auditory cue-associated fear memory was not affected with CBD or citalopram; however, contextual memory was reduced with CBD by 11%, p < 0.05, but not citalopram, and generalized fear memory was reduced with CBD and citalopram, 20% and 22%, respectively, p < 0.05. Extinction learning was enhanced with CBD and citalopram, but, there was considerable memory-type variability between drug effects, with freezing levels reduced at the end of training by 9 to 17% for CBD, and 10 to 12% with citalopram. The estrous cycle did not affect any outcomes.

Conclusions

Both drugs are potent modifiers of fear memory formation; however, there is considerable divergence in their targeting of different memory types which, overall, could support the use of CBD as an alternative to SSRIs for treating PTSD in females, but not males. A limitation of the study was that it compared data from experiments done at different times to evaluate sexual dimorphism. Overall, this suggests that more research is necessary to guide any therapeutic approach involving CBD.

A combined individual and group-based stabilization and skill training intervention versus treatment as usual for patients with long lasting posttraumatic reactions receiving outpatient treatment in specialized mental health care - a study protocol for a randomized controlled trial

BACKGROUND

Suffering linked to previous interpersonal trauma is common among patients in mental health care. Diagnostic labels may vary, but the clinical picture is often characterized by long-lasting and complex psychological and somatic symptoms, subjective distress and reduced quality of health and life. A substantial proportion of patients do not recover after individual treatment in ordinary specialized mental healthcare settings, despite the proven usefulness of individual trauma-specific treatments. The therapeutic factors that arise in group settings, such as normalization, shame reduction and corrective relational experiences, may be particularly useful for trauma survivors. However, evidence in support of group treatment for trauma survivors is scarce. This study aims to test whether combining a novel group intervention to individual treatment is superior to conventional individual out-patient treatment in an ordinary community mental health hospital.

METHODS

In a single-site, non-blinded, randomized controlled trial (RCT), the effect of a combined group-based stabilization and skill-training (SST) intervention added to individual treatment will be compared to conventional treatment (treatment as usual, TAU) alone. Participants (N = 160) with ongoing and long-lasting reactions related to known adverse life events from the past will be recruited among patients at general outpatient clinics in a community mental health centre at St. Olav's University Hospital, Trondheim, Norway. Following baseline assessment and randomization, participants will complete follow-up measures at 4, 8, 13 and 19 months post-baseline. The primary outcome is personal recovery (The questionnaire about the process of recovery , QPR). Secondary outcomes include (1) self-reported symptoms of posttraumatic stress, general mental and somatic health symptoms, well-being, functional impairment and client satisfaction, (2) immunological and endocrine response measured in blood samples and (3) national registry data on occupational status, use of mental health services and pharmacological treatment. Additionally, mechanisms of change via posttraumatic cognitions will be examined.

DISCUSSION

The addition of a group-based intervention to individual treatment for trauma survivors might prove to be an efficient way to meet the need of long-lasting high-intensity treatment in a large group of patients in mental health care, thereby reducing their suffering and increasing their psychosocial functioning.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03887559. Registered on 25 March 2019.

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.

Mechanisms of change in psychological interventions for posttraumatic stress symptoms: A systematic review with recommendations

Psychological interventions can alleviate posttraumatic stress symptoms (PTSS). However, further development of treatment approaches calls for understanding the mechanisms of change through which diverse interventions affect PTSS. We systematically searched the literature for controlled studies of mechanisms of change in psychological interventions for PTSS. We aimed to detect all empirically studied mechanisms and evaluate the level of evidence for their role in the alleviation of PTSS. We identified 34 studies, of which nine were among children. We found evidence for improvements in maladaptive posttraumatic cognitions as a general mechanism of change involved in diverse interventions, among both adults and children. We also found some preliminary evidence for increases in mindfulness as a mechanism of change in mindfulness- and spiritually-oriented interventions among adults. We found scant, mixed empirical evidence for other mechanisms of change. Notably, studies on changes in traumatic memories as a mechanism of change were lacking, despite clinical emphasis on their importance. A major limitation across reviewed studies was that most could not establish temporal order of changes in mechanisms and PTSS. Including thorough analyses of mechanisms of change beyond cognitions in all future trials and improving the reporting of findings would aid the development and implementation of even more effective interventions.

Randomized clinical trial of capnometry-assisted respiratory training in veterans with posttraumatic stress disorder hyperarousal

OBJECTIVE

To investigate whether capnometry-assisted antihyperventilation respiratory training, successful in treating panic, and sleep hygiene instructions would reduce posttraumatic stress disorder (PTSD) hyperarousal symptoms in U.S. military veterans.

METHOD

We conducted a parallel, nonblinded clinical trial and randomized 80 veterans with PTSD hyperarousal into treatment or wait list. Primary treatment outcomes from baseline to 1st follow-up were analyzed using mixed modeling. Baseline physiological measures were compared between the PTSD hyperarousal group and a no-PTSD group (n = 68).

RESULTS

Baseline respiration rate but not partial-pressure of end-tidal carbon dioxide (PCO₂) was higher in the PTSD hyperarousal group than in the no-PTSD group during 3 min of quiet sitting, indicating no difference in baseline hyperventilation. There was no significant effect of the intervention on PTSD hyperarousal symptoms or hyperventilation compared to wait list, but treatment did lower respiratory rate.

CONCLUSION

This intervention did not reduce PTSD hyperarousal symptoms, perhaps due to differences between underlying mechanisms of PTSD hyperarousal and panic disorder or to differences between veteran and civilian populations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Dealing with complexity and comorbidity: Opportunity for transdiagnostic treatment for PTSD

Purpose of Review

This review synthesizes literature on transdiagnostic treatments for PTSD and trauma-related psychopathology over the last three years and discusses their across diverse contexts.

Recent Findings

Global and domestic studies suggest that a transdiagnostic approach has the potential to address many challenges providers encounter when treating traumatized populations. Existing research shows that transdiagnostic approaches (including the Unified Protocol, Common Elements Treatment Approach, and Modular Approach to Therapy for Children) are effective across low and high resourced settings, populations, and with comorbid mental health symptoms. Moreover, transdiagnostic approaches offer flexibility in treatment delivery, adaptability across contexts, and parsimonious training to treatment providers. They also provide a standalone alternative for unable or unwilling individuals to engage in traditional single diagnosis trauma-focused treatment, or those presenting with complex presentations that might otherwise require sequential courses of targeted interventions.

Summary

The promise of transdiagnostic treatment for trauma-populations is strong. Research is needed to examine patient and therapist perceptions of these approaches for optimally addressing PTSD and related symptoms, the extent to which they offer comparable, or perhaps better, outcomes than existing single diagnosis PTSD treatments, and their sustainability overtime. Considerations of adaptations to transdiagnostic treatment manuals across settings are also needed.

The effects of exercise on transdiagnostic treatment targets: A meta-analytic review

BACKGROUND

The present study meta-analytically reviewed the effects of exercise on four transdiagnostic treatment targets: anxiety sensitivity (AS), distress tolerance (DT), stress reactivity (SR), and general self-efficacy (GSE).

METHODS

We conducted systematic searches of peer-reviewed studies in bibliographical databases (Cochrane Library, psychINFO, PubMed) before April 1, 2018. Only randomized controlled trials (RCT) evaluating the effect of exercise on AS, DT, SR, or GSE using at least one validated outcome instrument in a sample of adolescents (≥13 years old) or adults were selected. We employed a meta-analysis of effects using random-effects pooling modeling for each treatment target.

RESULTS

The systematic search yielded 28 RCTs meeting eligibility criteria. Exercise interventions had a large effect on reducing AS (six studies, Hedges's g = 0.72, p = .001), a medium effect on increasing GSE (eight studies, Hedges's g = 0.59, p < .001), and a small effect on reducing SR (ten studies, Hedges's g = 0.32, p < .001). Evidence from four studies suggested that exercise interventions had a small but non-significant effect on increasing DT (Hedges's g = 0.21, p = .26).

CONCLUSIONS

This meta-analysis provides preliminary evidence exercise can engage certain transdiagnostic targets. Further research is required to optimize exercise intervention parameters to achieve the strongest effects on these important mechanistic variables.

The unique and interactive effects of anxiety sensitivity and emotion dysregulation in relation to posttraumatic stress, depressive, and anxiety symptoms among trauma-exposed firefighters

BACKGROUND

Firefighters are chronically exposed to traumatic events. Relatedly, past work has documented high rates of psychiatric problems, such as posttraumatic stress symptoms and depression, among firefighters. Less is known regarding anxiety symptoms among firefighters. Moreover, little work has examined risk/maintenance factors related to these symptoms among firefighters. Doing so may be important to developing interventions tailored to trauma-exposed firefighters. The current study examined symptoms of posttraumatic stress, depression, panic disorder, and social anxiety among trauma-exposed firefighters.

PROCEDURE

Using structural equation modeling, the main and interactive effects of anxiety sensitivity and emotion dysregulation were examined in relation to these symptom outcomes. Participants included 787 male urban firefighters reporting at least one past traumatic event.

RESULTS

There was a statistically significant main effect of anxiety sensitivity on each outcome. Emotion dysregulation exerted a statistically significant main effect on posttraumatic stress, depression, and social anxiety symptoms. Interactive effects of anxiety sensitivity and emotion dysregulation did not reach statistical significance but examination of effect sizes suggests that interactive effects may be present for posttraumatic stress symptoms (R² = 0.011), depression (R² = 0.008), and panic (R² = 0.016) such that emotion dysregulation is more strongly related to outcomes when anxiety sensitivity levels are relatively lower. All effects were evident after controlling for trauma severity and history of armed forces service.

CONCLUSION

Overall, results suggest that anxiety sensitivity and emotion dysregulation represent unique risk/maintenance factors related to a broad range of emotional symptoms among trauma-exposed firefighters. These findings replicate patterns found among the general population and extend the findings to potentially vulnerable firefighters.