Comparing phase-based treatment, prolonged exposure, and skills-training for Complex Posttraumatic Stress Disorder: A randomized controlled trial

Predicting treatment outcome for complex posttraumatic stress disorder using the personalized advantage index

ABSTRACTBackground: Ample studies have demonstrated the effectiveness of psychotherapy for posttraumatic stress disorder (PTSD). However, large individual variation in treatment outcome remains unsolved and treatment options for complex posttraumatic stress disorder (CPTSD) are debated. There is a need for exploring methods for matching patients with treatment they will most likely benefit from.Objective: To develop a personalized advantage index (PAI) based on relevant clinical and demographic predictors of outcome from exposure therapy and skills-training for CPTSD.Method: Data from a previous randomized controlled trial (RCT) in 92 patients with a CPTSD diagnosis was used to compare Prolonged Exposure (PE; n = 32) and Skills Training in Affective and Interpersonal Regulation (STAIR; n = 60). Outcome measures were clinician-assessed and self-reported PTSD symptoms. Predictors of outcome in PE and STAIR were identified separately from sixty-one candidate variables using random forest and bootstrap procedures. Relevant predictors were then used to calculate PAI and retrospectively identify optimal versus suboptimal treatment in a leave-one-out cross-validation approach.Results: In PE, somatoform dissociation, depression, suicidal ideation, and reduced physical health predicted worse outcome. In STAIR, interpersonal problems, total PTSD symptom severity, intrusions, elevated guilt, and psychoticism predicted worse outcome, while being a witness to trauma predicted better outcome. Allocation to optimal treatment according to the PAI was associated with large improvements in clinician-assessed (Cohen's d = 0.83) and moderate improvement in self-rated (Cohen's d = 0.60) PTSD symptoms as compared to allocation to suboptimal teatment.Conclusions: Using the PAI in personalizing psychological treatment for CPTSD is a promising approach to improve treatment benefits. Further research on larger samples and external validation of the PAI is needed.

Associations among child maltreatment, non-suicidal self-injury and internet addiction in adolescents: Longitudinal mediation of symptoms of complex posttraumatic stress disorder

BACKGROUNDS

Non-suicidal self-injury (NSSI) and internet addiction are behavioral problems influenced by environmental factors, with child maltreatment emerging as an important risk factor. Complex posttraumatic stress disorder (CPTSD) is closely associated with child maltreatment.

OBJECTIVE

This study aimed to explore the longitudinal associations among child maltreatment, NSSI and internet addiction, focusing on the mediating role of CPTSD symptoms.

PARTICIPANTS AND SETTING

This study collected three-wave data from 454 Chinese adolescents with a six-month interval. Child maltreatment was assessed at T1, while CPTSD symptoms, NSSI and internet addiction were assessed at both T2 and T3.

METHODS

Path analysis was utilized to examine both direct and indirect effects of child maltreatment on NSSI and internet addiction, mediated by two clusters of CPTSD symptoms: posttraumatic stress disorder (PTSD) and disturbance in self-organization (DSO).

RESULTS

CPTSD symptoms partially mediated the relationship between child maltreatment and the two behavioral problems, with DSO symptoms being the primary contributors to this mediating effect. Specifically, affective dysregulation and negative self-concept in DSO were key mediators for internet addiction and NSSI respectively.

CONCLUSIONS

Among adolescents with child maltreatment, CPTSD symptoms, especially DSO symptoms, exert a significant influence on behavioral problems. This study underscores the need to integrate CPTSD symptoms into evidence-based interventions targeting maladaptive behaviors in maltreated youth.

Mental Health and Personality Functioning of People With Probable Personality Disorder Who Have Coexisting Complex Post Traumatic Stress Disorder

This paper examines the prevalence and comorbidity of complex post-traumatic stress disorder (CPTSD) and borderline personality disorder (BPD) among individuals with probable personality disorder, using baseline data from the Structured Psychological Support clinical trial. The clinical characteristics and personality functioning of participants are summarised and compared between those meeting criteria for BPD, CPTSD, both or neither condition. Among 292 participants, 97% reported significant trauma exposure, and over half met the criteria for CPTSD. Those with CPTSD exhibited higher levels of social dysfunction and depression compared with those with BPD, despite both groups showing elevated emotion dysregulation and anxiety. Comorbidity of CPTSD and BPD was high, with 50% of the sample meeting criteria for both conditions. Participants with comorbid CPTSD and BPD displayed poorer baseline scores across all measures of mental health and functioning than those who met criteria for BPD alone. No statistically significant differences were found in suicidal behaviour or treatment-seeking between groups. There were no significant differences in International Classification of Diseases-11 personality trait domains between participants with CPTSD and BPD, but people with comorbid CPTSD and BPD displayed higher levels of trait negative affectivity than those with BPD alone. The findings highlight the need for trauma-informed assessments in clinical settings and a better understanding of the impact of CPTSD on treatment outcomes for people with personality disorder, including how existing treatments may need to be modified to better meet the needs of people with these highly comorbid conditions. TRIAL REGISTRATION: Current controlled trials ISRCTN13918289 (registered 11/11/2022).

Developing an extended process model of emotion regulation in PTSD

Emotion regulation is a topic of growing interest in the field of post-traumatic stress disorder (PTSD). Despite the field's concentrated efforts in this area, the research has not matched advancements in the general emotion regulation literature, which have proposed more holistic models to understanding to how individuals identify and respond to emotions. In looking at emotion regulation in PTSD, this paper reviews the current state of the literature using the Extended Process Model proposed by Gross (2015). Considering emotion perception, beliefs, emotion regulation strategies (in terms of choice, flexibility of use, and repertoire of strategies available), and tactics, it discusses how these constructs help us understand the pathogenesis of PTSD and identifies areas in need of further research, including assessing the role of culture and improving measurement of emotion regulation constructs. Clinical implications of the emotion regulation literature for PTSD treatment are discussed.

Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications

BACKGROUND

Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post-traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD-ED) have protracted treatment courses and poorer prognoses.

AIM

To summarise the knowledge base on cPTSD-ED with specific emphasis on disturbances in self-organisation (DSO) in relation to therapeutic alliance (TA) processes.

METHOD

Expert opinions based on current relevant literature are critically examined.

RESULTS

Preliminary insights on change and alliance processes suggest that neglecting to address emotional-relational processes in the conceptualisation and treatment of cPTSD-ED impedes treatment progress.

CONCLUSION

We hypothesise that the DSO construct inherent in cPTSD-ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for.

A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder

Background: While there are well-established treatments for post-traumatic stress disorder (PTSD), these interventions appear to be less effective for individuals with comorbid borderline personality disorder (BPD) symptoms. Dialectical Behavior Therapy (DBT) for PTSD and DBT Prolonged Exposure (PE) are both effective interventions for treating these patients, but a comprehensive analysis evaluating the efficacy of these two interventions is lacking.Objective: To determine the effect sizes of PTSD-specific DBT treatments.Methods: We conducted a systematic review and pre-registered meta-analysis of the DBT literature for treating PTSD (osf.io/62rfq). Eligible trials and treatment evaluations published before September 2023 were searched in SCOPUS, PubMed, and the Cochrane Library databases. Thirteen articles were identified, and data were extracted for primary (PTSD symptoms) and secondary outcomes (BPD, depression, dissociation, non-suicidal self-injury [NSSI]). Treatment effects were calculated for randomised controlled trials, controlled clinical trials, and pre-post evaluations.Results: Overall, the studies involved 663 participants. Compared with control groups, PTSD-specific DBT treatments showed moderate effects in reducing PTSD symptom severity g = -0.69 (95% CI -1.03 to -0.34, p < .001) and depression g = -0.62 (95% CI -1.13 to -0.12, p = .016). Moreover, the pre-post changes showed an overall effect size for dissociative symptoms of g = -0.72 (95% CI -1.05 to -0.40, p < .001), for BPD-associated symptoms of g = -0.82 (95% CI -1.06 to -0.59, p < .001), and for NSSI frequency (g = -0.70, 95% CI -1.12 to -0.28, p = .001).Conclusions: Based on the results of our meta-analysis, DBT-PTSD and DBT PE were effective in reducing PTSD symptom severity and comorbid depressive symptoms. Further research on stage-based treatments should focus on systematically assessing NSSI, BPD symptoms, and suicidality.

State of the Science: Prolonged exposure therapy for the treatment of posttraumatic stress disorder

Prolonged exposure therapy (PE) is a well-established first-line treatment for posttraumatic stress disorder (PTSD) that is based on emotional processing theory. PE has been rigorously evaluated and tested in a large number of clinical trials in many countries covering a wide range of trauma populations. In this review, we summarize the evidence base supporting the efficacy of PE across populations, including adults with sexual assault-related PTSD and mixed trauma-related PTSD, military populations, and adolescents. We highlight important strengths and gaps in the research on PE with individuals from marginalized communities. We discuss the efficacy of PE on associated psychopathology and in the presence of the most commonly comorbid conditions, either alone or integrated with other treatments. In addition, we provide an overview of research examining strategies to augment PE. Much of this work remains preliminary, but numerous trials have tested PE in combination with other psychological or pharmacological approaches, interventions to facilitate extinction learning, and behavioral approaches, in the hopes of further increasing the efficiency and efficacy of PE. There are now several trials testing PE in novel formats that may have advantages over standard in-person PE, such as lower dropout and increased scalability. We examine this recent work on new models of delivering PE, including massed treatment, telehealth, and brief adaptations for primary care, all of which have the potential to increase access to PE. Finally, we highlight several promising areas for future research.