The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse

Impact of comorbid personality disorders on psychotherapy for post-traumatic stress disorder: systematic review and meta-analysis

Background: Although personality disorders are common in PTSD patients, it remains unclear to what extent this comorbidity affects PTSD treatment outcome. Objective: This constitutes the first meta-analysis investigating whether patients with and without comorbid personality disorders can equally benefit from psychotherapy for PTSD. Method: A systematic literature search was conducted in PubMed, EMBASE, PsychINFO and Cochrane databases from inception through 31 January 2020, to identify clinical trials examining psychotherapies for PTSD in PTSD patients with and without comorbid personality disorders (PROSPERO reference CRD42020156472). Results: Of the 1830 studies identified, 12 studies reporting on 918 patients were included. Effect sizes were synthesized using a random-effects model. Patients with comorbid personality disorders did not have significantly higher baseline PTSD severity (Hedges' g = 0.23, 95%CI -0.09-0.55, p = .140), nor were at higher risk for dropout from PTSD treatment (RR = 1.19, 95%CI 0.83-1.72, p = .297). Whilst pre- to post-treatment PTSD symptom improvements were large in patients with comorbid PDs (Hedges' g = 1.31, 95%CI 0.89-1.74, p < .001) as well as in patients without comorbid PDs (Hedges' g = 1.57, 95%CI 1.08-2.07, p < .001), personality disorders were associated with a significantly smaller symptom improvement at post-treatment (Hedges' g = 0.22, 95%CI 0.05-0.38, p = .010). Conclusion: Although the presence of personality disorders does not preclude a good treatment response, patients with comorbid personality disorders might benefit less from PTSD treatment than patients without comorbid personality disorders.

Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy

Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.

Psychodynamic and systemic group treatment for women with a history of childhood sexual abuse: five-year follow-up of a randomized controlled trial

Background: Childhood sexual abuse (CSA) is a significant trauma that may have lifelong impact. Due to the long-term negative personal and societal consequences of CSA, it is crucial to find treatments with enduring outcomes. Objective: The aim of this study was to determine the relative long-term efficacy of psychodynamic and systemic group therapy for adult women exposed to CSA. Method: A prospective randomized controlled trial was conducted with outcomes assessed at pre- and post-treatment, and 1 and 5 years post-treatment. All analyses were intention-to-treat. One hundred and six women with sequelae from childhood sexual abuse were treated with psychodynamic or systemic group therapy. Primary outcome was Global Severity Index (GSI) of SCL-90-R. Secondary outcomes included symptoms of PTSD and depression and psycho-social functioning. Results: Treatment was completed by 81% of participants; 64% completed the 1-year follow-up and 60% completed the 5-year follow-up. Completion rates did not differ between treatments. Significant reduction in symptoms measured on GSI and improvement of psychosocial functioning was found for both interventions at all measurement points after treatment (ES range = 0.68-1.19). However, different trajectories were observed: while outcome at end of treatment was significantly better in the systemic group, no differences in gains were observed at the 1- and 5-year follow-ups when controlling for baseline differences. Conclusions: The findings add to the evidence base for psychodynamic and systemic group therapy, but the result also underscores the importance of taking post-treatment trajectories into account in evidence-based research, in the continued efforts to improve treatment for this population.

A Brief History of Group Therapy as a Field and the Representation of Women in Its Development

This article explores the place of women in the specialization of group psychotherapy, particularly their representation in journal publications, both in topical coverage related to women as well as in editorial participation and leadership. We first present a brief history of group psychotherapy to provide overall context. Next, we present major cross-cutting themes related to women and group work that emerged from our review of nine peer-reviewed journals deemed most relevant to our investigation. We end with observations and a call for greater inclusion of women in the group psychotherapy literature.

Psychotherapy for posttraumatic stress disorder in patients with borderline personality disorder: a systematic review and meta-analysis of its efficacy and safety

Background: Posttraumatic stress disorder (PTSD) is common in patients with personality disorders. This comorbidity is accompanied by a lower quality of life, and a higher risk of suicide attempts than patients with only one of these diagnoses. Objective: The aim of this systematic review and meta-analysis was to evaluate the scientific evidence of the efficacy of PTSD treatments for this population. Method: A literature search was performed from 1946 through June 2020. Standardized mean effect sizes of psychotherapy for PTSD were computed. Results: The literature search revealed that psychotherapy was the only intervention that was systematically explored. Fourteen studies were included. In 12 of these studies solely patients with borderline personality disorder participated. Analysis of the four RCTs showed a significant, moderate to high standardized effect size for reducing PTSD symptom severity (Hedges' g = 0.54), with effects being maintained at least 3 months (Hedges' g = 0.82). Effect sizes for all studies were also significant, with moderate to high standardized values for symptoms of PTSD (Hedges' g = 1.04). PTSD improvements were again maintained at 3-month follow-up and beyond (Hedges' g = 0.98). In addition, a significant decrease in symptoms of depression, anxiety, borderline symptoms, and PTSD in patients with borderline personality disorder could be revealed for all studies (Hedges' g 0.48-1.04). No increase in self-injurious behaviour, suicide attempts, or hospitalization was observed, while the mean weighted dropout rate during PTSD treatment was 17%. Conclusions: Psychotherapy for PTSD is efficacious and safe for patients with borderline personality disorder and should not be withheld from these vulnerable individuals.

Interventions for adults with a history of complex traumatic events: the INCiTE mixed-methods systematic review

BACKGROUND

People with a history of complex traumatic events typically experience trauma and stressor disorders and additional mental comorbidities. It is not known if existing evidence-based treatments are effective and acceptable for this group of people.

OBJECTIVE

To identify candidate psychological and non-pharmacological treatments for future research.

DESIGN

Mixed-methods systematic review.

PARTICIPANTS

Adults aged ≥ 18 years with a history of complex traumatic events.

INTERVENTIONS

Psychological interventions versus control or active control; pharmacological interventions versus placebo.

MAIN OUTCOME MEASURES

Post-traumatic stress disorder symptoms, common mental health problems and attrition.

DATA SOURCES

Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 onwards); Cochrane Central Register of Controlled Trials (CENTRAL) (from inception); EMBASE (1974 to 2017 week 16); International Pharmaceutical Abstracts (1970 onwards); MEDLINE and MEDLINE Epub Ahead of Print and In-Process & Other Non-Indexed Citations (1946 to present); Published International Literature on Traumatic Stress (PILOTS) (1987 onwards); PsycINFO (1806 to April week 2 2017); and Science Citation Index (1900 onwards). Searches were conducted between April and August 2017.

REVIEW METHODS

Eligible studies were singly screened and disagreements were resolved at consensus meetings. The risk of bias was assessed using the Cochrane risk-of-bias tool and a bespoke version of a quality appraisal checklist used by the National Institute for Health and Care Excellence. A meta-analysis was conducted across all populations for each intervention category and for population subgroups. Moderators of effectiveness were assessed using metaregression and a component network meta-analysis. A qualitative synthesis was undertaken to summarise the acceptability of interventions with the relevance of findings assessed by the GRADE-CERQual checklist.

RESULTS

One hundred and four randomised controlled trials and nine non-randomised controlled trials were included. For the qualitative acceptability review, 4324 records were identified and nine studies were included. The population subgroups were veterans, childhood sexual abuse victims, war affected, refugees and domestic violence victims. Psychological interventions were superior to the control post treatment for reducing post-traumatic stress disorder symptoms (standardised mean difference -0.90, 95% confidence interval -1.14 to -0.66; number of trials = 39) and also for associated symptoms of depression, but not anxiety. Trauma-focused therapies were the most effective interventions across all populations for post-traumatic stress disorder and depression. Multicomponent and trauma-focused interventions were effective for negative self-concept. Phase-based approaches were also superior to the control for post-traumatic stress disorder and depression and showed the most benefit for managing emotional dysregulation and interpersonal problems. Only antipsychotic medication was effective for reducing post-traumatic stress disorder symptoms; medications were not effective for mental comorbidities. Eight qualitative studies were included. Interventions were more acceptable if service users could identify benefits and if they were delivered in ways that accommodated their personal and social needs.

LIMITATIONS

Assessments about long-term effectiveness of interventions were not possible. Studies that included outcomes related to comorbid psychiatric states, such as borderline personality disorder, and populations from prisons and humanitarian crises were under-represented.

CONCLUSIONS

Evidence-based psychological interventions are effective and acceptable post treatment for reducing post-traumatic stress disorder symptoms and depression and anxiety in people with complex trauma. These interventions were less effective in veterans and had less of an impact on symptoms associated with complex post-traumatic stress disorder.

FUTURE WORK

Definitive trials of phase-based versus non-phase-based interventions with long-term follow-up for post-traumatic stress disorder and associated mental comorbidities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017055523.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 43. See the NIHR Journals Library website for further project information.

Multiple and interpersonal trauma are risk factors for both post-traumatic stress disorder and borderline personality disorder: A systematic review on the traumatic backgrounds and clinical characteristics of comorbid post-traumatic stress disorder/borderline personality disorder groups versus single-disorder groups

BACKGROUND

Both borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are associated with exposure to traumatic events and are highly comorbid. No review to date has addressed the clinical presentations and traumatic backgrounds associated with these disorders although this work is essential for the development of effective interventions.

OBJECTIVES

To systematically explore similarities and differences in traumatic history and clinical presentation in comorbid BPD and PTSD as compared to PTSD or BPD alone.

METHOD

The Web of Science, Cochrane Library, PsycINFO, MEDLINE, and PILOTS databases were searched systematically. Eligible studies included adult populations, compared comorbid BPD/PTSD to a single disorder, and published in English.

RESULTS

A total of 10,147 cases across 33 studies were included: 2,057 comorbid BPD/PTSD, 2,648 BPD only, and 5,442 PTSD only. The comorbid group overall reported greater exposure to multiple and interpersonal trauma and elevated emotion dysregulation compared to both single-disorder groups. In terms of methodological quality, most papers achieved a Fair rating with improvements required in minimizing bias through recruiting adequate and representative samples, and reporting on traumatic exposure.

CONCLUSION

Multiple and interpersonal trauma might have a unique role in the development of comorbid BPD/PTSD features, particularly so for emotion dysregulation. Future research is required to unravel the unique characteristics of interpersonal trauma that can generate BPD and PTSD symptoms.

PRACTITIONER POINTS

Practitioners should routinely assess for interpersonal trauma considering its impact. Tackling emotion regulation difficulties might promote recovery from both PTSD and BPD symptoms. Presence of self -injury might be used to discriminate between PTSD and BPD and offer suitable interventions.

Feasibility of EMDR for posttraumatic stress disorder in patients with personality disorders: a pilot study

Background: Trauma and posttraumatic stress disorder (PTSD) are prevalent in patients with personality disorders. Despite the established efficacy of eye movement desensitisation and reprocessing (EMDR) for PTSD, EMDR has barely been examined in patients with comorbid PTSD and personality disorders. Objective: The aim of this study was to explore what changes occur in symptom severity of PTSD, dissociative symptoms, insomnia, non-suicidal self-injurious behaviour and auditory verbal hallucinations in patients with personality disorders during treatment with EMDR. Method: This uncontrolled open feasibility study on EMDR for PTSD was an addition to treatment-as-usual for personality disorders. The outcome measures were the severity of PTSD symptoms, dissociation, insomnia, non-suicidal self-injury, and auditory verbal hallucinations. Results: Forty-seven participants (22 with a borderline personality disorder, 25 with other personality disorders) were included. A significant reduction in the severity of symptoms of PTSD, dissociation and insomnia was observed after EMDR treatment (median of four sessions), and 40% of the participants scored below the threshold for PTSD diagnosis. No differences in efficacy were found between patients with borderline personality disorder and other personality disorders. EMDR treatment was completed by 68% of the participants. Conclusions: The addition of EMDR techniques to treatment, as usual, may be beneficial in the treatment of PTSD in patients with personality disorders in order to reduce symptoms of PTSD, dissociation and insomnia. Although one-third of these patients did not complete the additional EMDR treatment, no severe complications (e.g. suicidal behaviour or hospitalisation) occurred. Controlled studies are needed to further investigate the validity of these findings.

The influence of trauma and patient characteristics on provider burnout in VA post-traumatic stress disorder specialty programmes

OBJECTIVE

Prolonged exposure (PE) and cognitive processing therapy (CPT) - post-traumatic stress disorder (PTSD) treatments now available at the Veterans Health Administration (VHA) - expose the provider to graphic traumatic material. Little is known about the impact of traumatic material on VHA providers. The purpose of this study was to examine the relationship between trauma content, patient characteristics, and burnout among VHA PTSD Clinical Team (PCT) providers. It was hypothesized that trauma content and patient characteristics would significantly predict burnout in this population.

DESIGN

This cross-sectional study consisted of 137 participants. The sample was mostly female (67%), Caucasian (non-Hispanic; 81%), and married (70%) with a mean age of 44.3 years (SD = 11.3).

METHODS

Participants completed an electronic survey that assessed demographics, patient characteristics (i.e., anger, personality disorder, malingering), trauma content characteristics (e.g., killing of women and children) as well as burnout as measured by the Maslach Burnout Inventory-General Survey (MBI-GS; Maslach et al., 1996, Burnout inventory manual. Palo Alto: Consulting Psychologist Press).

RESULTS

Over half of the study population reported being bothered by trauma content; however, trauma content did not predict burnout. Treating patients with personality disorders and suspected malingering predicted burnout in PCT providers. High numbers (77%) reported perceiving that emotional exhaustion impacted the quality of care they provided.

CONCLUSION

These findings suggest an important role of burnout assessment, prevention, and treatment strategies at the VHA.

PRACTITIONER POINTS

This paper addresses the impact of provider burnout on perceived quality of care. This paper also addresses potential predictors of burnout in PCT settings. This paper outlines potential remedies to provider burnout in the VHA.

Correlations Between Sexual Abuse Histories, Perceived Danger, and PTSD Among Intimate Partner Violence Victims

Intimate partner violence (IPV), childhood abuse, and sexual assault in adulthood are profound public health concerns, particularly for women. Exposure to trauma can contribute to long-standing health problems and escalated medical costs. Unfortunately, these experiences are often intertwined. Sexual assault often occurs in intimate relationships in which there is concurrent IPV; likewise, many victims of IPV have experienced childhood abuse. The prevalent intersections of these struggles can lead to posttraumatic stress disorder (PTSD) symptoms. This article examines the contributions of childhood abuse histories and sexual assault to PTSD symptoms among women experiencing IPV. Findings suggest childhood abuse experiences account for more variance in PTSD symptoms than adult sexual assault. Clinical implications are discussed.

A Review of Interpersonal-Psychodynamic Group Psychotherapy Outcomes for Adult Survivors of Childhood Sexual Abuse

This article discusses the use of interpersonal-psychodynamic group treatments for survivors of childhood sexual abuse. Empirically based interpersonal-psychodynamic group outcome studies are reviewed according to efficacy and effectiveness models of treatment outcome research. To facilitate the evaluation and comparison of clinically significant change across studies, effect size indicators were calculated when descriptive data were reported. Findings suggest that interpersonal-psychodynamic group therapy is an effective treatment approach for many survivors of childhood sexual abuse. Implications for future research are considered.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

Comorbidity between post-traumatic stress disorder and borderline personality disorder: a review

BACKGROUND

Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD.

METHODS

A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were 'post-traumatic stress disorder', 'borderline personality disorder', 'PTSD', 'complex PTSD' and 'BPD'.

RESULTS

Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of 'complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD.

CONCLUSIONS

These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.

Evidence-based treatment for adult women with child abuse-related Complex PTSD: a quantitative review

INTRODUCTION

Effective first-line treatments for posttraumatic stress disorder (PTSD) are well established, but their generalizability to child abuse (CA)-related Complex PTSD is largely unknown.

METHOD

A quantitative review of the literature was performed, identifying seven studies, with treatments specifically targeting CA-related PTSD or Complex PTSD, which were meta-analyzed, including variables such as effect size, drop-out, recovery, and improvement rates.

RESULTS

Only six studies with one or more cognitive behavior therapy (CBT) treatment conditions and one with a present centered therapy condition could be meta-analyzed. RESULTS indicate that CA-related PTSD patients profit with large effect sizes and modest recovery and improvement rates. Treatments which include exposure showed greater effect sizes especially in completers' analyses, although no differential results were found in recovery and improvement rates. However, results in the subgroup of CA-related Complex PTSD studies were least favorable. Within the Complex PTSD subgroup, no superior effect size was found for exposure, and affect management resulted in more favorable recovery and improvement rates and less drop-out, as compared to exposure, especially in intention-to-treat analyses.

CONCLUSION

Limited evidence suggests that predominantly CBT treatments are effective, but do not suffice to achieve satisfactory end states, especially in Complex PTSD populations. Moreover, we propose that future research should focus on direct comparisons between types of treatment for Complex PTSD patients, thereby increasing generalizability of results.

Trauma reactivation under the influence of propranolol: an examination of clinical predictors

BACKGROUND

In two recent studies conducted by our group, a treatment combining propranolol with a brief reactivation session subsequently reduced posttraumatic stress disorder (PTSD) symptom severity and diagnosis, as well as reducing psychophysiological responses during trauma-related script-driven imagery. One likely explanation for those results is that memory reconsolidation was blocked by propranolol.

OBJECTIVE

We explored the influence of various predictors on treatment outcome (i.e., PTSD severity), and whether the treated individuals improved in other important domains of functioning associated with PTSD.

METHOD

Thirty-three patients with longstanding PTSD participated in a 6-week open-label trial consisting of actively recalling one's trauma under the influence of propranolol, once a week.

RESULTS

Treated patients reported a better quality of life, less comorbid depressive symptoms, less negative emotions in their daily life and during trauma recollections. Women were also found to improve more than men. Type of trauma (childhood vs. adulthood), time elapsed since trauma, borderline personality traits, depressive symptoms severity, Axis I comorbidity, and age did not influence treatment outcome.

CONCLUSION

These results must await publication of a randomized-controlled trial to further delineate effectiveness with this novel treatment approach.

Clinical phenomenology of childhood abuse-related complex PTSD in a population of female patients: patterns of personality disturbance

OBJECTIVE

Complex posttraumatic stress disorder (PTSD) involves a variety of personality disturbances presumed to result from repeated interpersonal trauma such as child abuse. As Complex PTSD patients are a heterogeneous population, we searched for clinically relevant personality-based subtypes.

METHOD

This study used a cluster analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Axis II features within a sample of 71 female outpatients with systematically assessed child abuse-related Complex PTSD.

RESULTS

Two main subtypes were found: adaptive and nonadaptive. The latter was further differentiated into withdrawn, alienated, suffering, and aggressive subtypes, characterized by different levels of introversion and disinhibition. Among the nonadaptive subtypes, the severity of Complex PTSD symptoms was lowest in the withdrawn (introverted only) subtype. The subtypes differed in their level of dissociation and depression but did not differ regarding PTSD symptoms, trauma history, or parental bonding characteristics.

CONCLUSION

Confirming earlier findings, our study found personality-based Complex PTSD subtypes, which could implicate differential treatment needs and results.

The impact of endorsing Spitzer's proposed criteria for PTSD in the forthcoming DSM-V on male and female Veterans

This study explored differences between Spitzer's proposed model of posttraumatic stress disorder (PTSD) and the current DSM-IV diagnostic classification scheme in 353 Veterans. The majority of Veterans (89%) diagnosed with PTSD as specified in the DSM-IV also met Spitzer's proposed criteria. Veterans who met both DSM-IV and Spitzer's proposed criteria had significantly higher Clinician Administered PTSD Scale severity scores than Veterans only meeting DSM-IV criteria. Logistic regression indicated that being African American and having no comorbid diagnosis of major depressive disorder or history of a substance use disorder were found to predict those Veterans who met current, but not proposed criteria. These findings have important implications regarding proposed changes to the diagnostic classification criteria for PTSD in the forthcoming DSM-V.

Integrative multidisciplinary treatment in the public sector: a pilot study

Integrative Multidisciplinary Treatment (IMT) emphasizes factors common to evidence-based treatments for borderline personality disorder (BPD) and is suitable for implementation in a public sector setting staffed by clinicians with diverse theoretical backgrounds. Preliminary results suggested decreases in psychiatric disturbance, depression, suicidality, hospitalizations, and emergency room visits, and increases in quality of relationships and quality of life. Results generalized across patients with and without BPD, with two exceptions: hospitalizations and suicidality.

Stabilizing group treatment for Complex Posttraumatic Stress Disorder related to childhood abuse based on psycho-education and cognitive behavioral therapy: a pilot study

OBJECTIVE

This study tests a Stabilizing Group Treatment protocol, designed for the management of the long-term sequelae of child abuse, that is, Complex Posttraumatic Stress Disorder (Complex PTSD). Evidence-based treatment for this subgroup of PTSD patients is largely lacking. This stabilizing treatment aims at improving Complex PTSD using psycho-education and cognitive behavioral interventions.

METHOD

Thirty-six patients with a history of childhood abuse, Complex PTSD and severe co-morbidity entered a 20-week treatment with pre-, post-, and follow-up-assessments.

RESULTS

Improvement was found for PTSD and borderline symptoms. Post-treatment 64% and after 6 months 78% of patients no longer met criteria for Complex PTSD.

CONCLUSIONS

This open study indicates both the feasibility of investigating treatment outcome and the initial efficacy of stabilizing group treatment in severely ill patients with Complex PTSD related to childhood abuse.

Borderline personality characteristics and treatment outcome in cognitive-behavioral treatments for PTSD in female rape victims

Many studies report that comorbid borderline personality pathology is associated with poorer outcomes in the treatment of Axis I disorders. Given the high rates of comorbidity between borderline personality pathology and posttraumatic stress disorder (PTSD), it is essential to determine whether borderline symptomatology affects PTSD treatment outcome. This study examined the effects of borderline personality characteristics (BPC) on 131 female rape victims receiving cognitive-behavioral treatment for PTSD. Higher BPC scores were associated with greater pretreatment PTSD severity; however, individuals with higher levels of BPC were just as likely to complete treatment and also as likely to show significant treatment response on several outcome measures. There were no significant interactions between type of treatment and BPC on the outcome variables. Findings suggest that women with borderline pathology may be able to benefit significantly from cognitive-behavioral treatment for PTSD.

Efficacy of a group intervention for adult women survivors of sexual abuse

This study evaluates the effects of a group intervention for women sexually abused in childhood or adulthood. The sample consisted of 41 women involved in a group intervention based on a feminist approach offered by help centers for sexual assault victims in Quebec and 11 women in a wait-list comparison group. Results reveal that the group intervention reduced psychological distress and consequences associated with sexual abuse and that gains were maintained at three-month follow- up. Analyses of potential factors related to differential gains indicated that abuse-related variables and concurrent individual interventions were not linked to outcomes. Exploratory analyses suggested that women experiencing severe physical partner violence showed greater gains with respect to self-blame/stigmatization, sexual anxiety, and anxiety related to assertiveness.

Group therapy for women sexually abused as children: mental health before and after group therapy

Forty-five female outpatients sexually abused in childhood were offered a 2-year phase-divided group therapy. Before and after treatment and at 12 months follow-up, they answered questionnaires designed to elicit responses concerning psychological symptoms (Symptom Checklist; SCL-90) and sense of coherence (SOC). Symptoms for posttraumatic stress disorder (PTSD) were assessed before and after treatment. Inpatient days and sick listing days were assessed during 2 years before and 2 years after treatment. The psychological and PTSD symptoms were significantly reduced after treatment, and the SOC was increased as well. Inpatient days were decreased, and sick listing days increased but not significantly. Compared to a similar short-term focused therapy group and a waiting-list group there were no significant differences between the groups. Trauma-focused group therapy for women who were sexually abused in childhood seems to have promising effects on mental health, both concerning long-term and short-term approaches.

[Evaluation of a group intervention using a feminist approach for women experiencing sexual abuse]

OBJECTIVE

The present study evaluates a group intervention using a feminist approach for women experiencing sexual abuse in childhood or adulthood in order to measure changes associated with participation in a group intervention and verifies whether effects are maintained over time. The present study relates effects of the group intervention in terms of psychological distress, depression symptoms, post-traumatic stress symptoms and feelings of guilt and helplessness.

METHOD

The sample consists of 26 women participating in a group intervention offered by sexual assault centers in Quebec (CALACS - Centre d'aide et de lutte contre les agressions à caractère sexuel).

RESULTS

Results show significant differences between pretest and post-test scores obtained one week following the end of the group intervention and gains are maintained at follow-up 3 months later.

CONCLUSION

The findings suggest that participation in the group intervention is associated with a reduction of psychological distress, depression symptoms, post-traumatic stress symptoms and feelings of guilt and helplessness in adult women reporting sexual abuse.

Psychotherapy approaches for adult survivors of childhood sexual abuse: an integrative review of outcomes research

This review synthesized results of 26 outcomes research studies and two meta-analyses that evaluated abuse-focused psychotherapy techniques for survivors of childhood sexual abuse. Different therapeutic approaches delivered in individual, group, or combination formats were evaluated with pre/post test, quasi-experimental, or randomized control designs. Accumulated research findings suggest that abuse-focused psychotherapy for adults sexually abused as children is generally beneficial in reducing psychiatric distress, depression, and trauma-specific symptoms. No one therapeutic approach was demonstrated to be superior. There was little evidence about the effectiveness of individual versus group therapy or the optimal treatment duration.

Treatment of complex posttraumatic self-dysregulation

The authors describe a three-phase sequential integrative model for the psychotherapy of complex posttraumatic self-dysregulation: Phase 1 (alliance formation and stabilization), Phase 2 (trauma processing), and Phase 3 (functional reintegration). The technical precautions designed to maximize safety, trauma processing, and reintegration regardless of the specific treatment approach are discussed. Existing and emerging treatment models that address posttraumatic dysregulation of consciousness, bodily functioning, emotion, and interpersonal attachments are also described. The authors conclude with suggestions for further clinical innovation and research evaluation of therapeutic models that can enhance the treatment of PTSD by addressing complex posttraumatic self-dysregulation.

An experiential approach to the inpatient anger management group

Groups that target aggression on the inpatient milieu usually use psycho-educational and cognitive-behavioral techniques. In contrast, this article presents an experiential approach that targets the moment-by-moment experience within the inpatient group. It makes unique use of group-closing relaxation exercises that facilitate cohesion, consolidate the affectively charged material generated during the session, and reorganize patients' emotional/cognitive understanding of themselves and the world around them. These groups also give patients the opportunity to negotiate the affective residue associated with past aggressive acts, and the opportunity to examine the personal meaning and underlying assumptions behind ongoing group interactions. We describe several techniques or modes of intervention. The authors also use case examples to illustrate the theory, technique, and impact the approach can have on its members.

Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse

Fifty-eight women with posttraumatic stress disorder (PTSD) related to childhood abuse were randomly assigned to a 2-phase cognitive-behavioral treatment or a minimal attention wait list. Phase 1 of treatment included 8 weekly sessions of skills training in affect and interpersonal regulation; Phase 2 included 8 sessions of modified prolonged exposure. Compared with those on wait list, participants in active treatment showed significant improvement in affect regulation problems, interpersonal skills deficits, and PTSD symptoms. Gains were maintained at 3- and 9-month follow-up. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the value of establishing a strong therapeutic relationship and emotion regulation skills before exposure work among chronic PTSD populations.