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Background: Self-stigma refers to the internalisation of negative societal views and stereotypes. Self-stigma has been well-characterised in the context of mental disorders such as schizophrenia but has received little attention in relation to post-traumatic stress disorder (PTSD). Objective: This work aimed to determine the prevalence of self-stigma in a sample of adults with PTSD and to establish factors associated with the internalisation of stigma in this population. Method: Participants were 194 adults (mean age 46.07 (SD = 12.39); 64.4% female; 96.6% white Caucasian; residing in the UK), who self-reported a diagnosis of PTSD and currently screened positive for the disorder according to the PTSD Checklist for DSM-5 (PCL-5). Structured interviews and validated self-report questionnaires were used to ascertain clinical and sociodemographic information for analysis. Results: The prevalence of self-stigma measured by the Internalized Stigma of Mental Illness Scale (ISMIS) was 41.2% (95% CI 34.24–48.22). There was no evidence of an association between self-stigma and gender (β = −2.975 (95% CI −7.046–1.097) p = .151), age (β = 0.007 (95% CI −0.152–0.165) p = .953), sexual trauma (β = 0.904 (95% CI −3.668–5.476) p = .697), military trauma (β = −0.571 (95% CI −4.027–7.287) p = .571). Self-stigma was associated with lower income and higher levels of anxiety (β = 5.722 (95% CI 2.922–8.522) p =

Background: An increasing body of research highlights reconsolidation-based therapies as emerging treatments for post-traumatic stress disorder (PTSD). The Rewind Technique is a non-pharmacological reconsolidation-based therapy with promising early results, which now requires evaluation through an RCT. Objectives: This is a preliminary efficacy RCT to determine if the Rewind Technique is likely to be a good candidate to test against usual care in a future pragmatic efficacy RCT. Methods: 40 participants will be randomised to receive either the Rewind Technique immediately, or after an 8 week wait. The primary outcome will be PTSD symptom severity as measured by the Clinician-Administered PTSD Scale for DSM5 (CAPS-5) at 8 and 16 weeks post-randomisation. Secondary outcome measures include the PTSD Checklist (PCL-5), International Trauma Questionnaire (ITQ), Patient Health Questionnaire (PHQ-9), the General Anxiety Disorder-7 (GAD-7), Insomnia Severity Index, the Euro-Qol-5D (EQ5D-5 L), the prominence of re-experiencing specific symptoms (CAPS-5) and an intervention acceptability questionnaire to measure tolerability of the intervention. Conclusions: This study will be the first RCT to assess the Rewind Technique. Using a cross-over methodology we hope to rigorously assess the efficacy and tolerability of Rewind using pragmatic inclusion criteria. Potential challenges include participant recruitment and retention. Trial registration: ISRCTN91345822

Background: Pharmacological-assisted psychotherapies, using conventional and novel drug agents, are increasingly being used both in clinical and experimental research settings, respectively. Objective: To determine the efficacy of conventional and novel pharmacological-assisted psychotherapies in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised-controlled trials were undertaken; 21 studies were included. Results: MDMA-assisted therapy was found to statistically superior to active and inactive placebo-assisted therapy in reduction of PTSD symptoms (standardised mean difference −1.09, 95% CI −1.60 to −0.58). There was no evidence of superiority over placebo for any other intervention. Conclusions: MDMA-assisted therapy demonstrated an impressive effect size; however, it is difficult to have confidence at this stage in this intervention due to the small numbers of participants included, and more research in this area is needed. There was no evidence to support the efficacy of any other drug-assisted interventions.

Background: Pharmacological approaches are widely used for post-traumatic stress disorder (PTSD) despite uncertainty over efficacy. Objectives: To determine the efficacy of all pharmacological approaches, including monotherapy, augmentation and head-to-head approaches (drug versus drug, drug versus psychotherapy), in reducing PTSD symptom severity. Method: A systematic review and meta-analysis of randomised controlled trials were undertaken; 115 studies were included. Results: Selective serotonin reuptake inhibitors (SSRIs) were found to be statistically superior to placebo in reduction of PTSD symptoms but the effect size was small (standardised mean difference −0.28, 95% CI −0.39 to −0.17). For individual monotherapy agents compared to placebo in two or more studies, we found small statistically significant evidence for the antidepressants fluoxetine, paroxetine, sertraline, venlafaxine and the antipsychotic quetiapine. For pharmacological augmentation, we found small statistically significant evidence for prazosin and risperidone. Conclusions: Some medications have a small positive effect on reducing PTSD symptom severity and can be considered as potential monotherapy treatments; these include fluoxetine, paroxetine, sertraline, venlafaxine and quetiapine. Two medications, prazosin and risperidone, also have a small positive effect when used to augment pharmacological monotherapy. There was no evidence of superiority for one intervention over another in the small number of head-to-head comparison studies.

Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates. Objective: To ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity. Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression. Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14–18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated. Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.

Background: Psychological therapies are the recommended first-line treatment for post-traumatic stress disorder (PTSD). Previous systematic reviews have grouped theoretically similar interventions to determine differences between broadly distinct approaches. Consequently, we know little regarding the relative efficacy of the specific manualized therapies commonly applied to the treatment of PTSD. Objective: To determine the effect sizes of manualized therapies for PTSD. Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results: 114 randomized-controlled trials (RCTs) of 8171 participants were included. There was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T), as well as Eye Movement Desensitization and Reprocessing (EMDR), had a clinically important effect. The manualized CBT-Ts with the strongest evidence of effect were Cognitive Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus; guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging evidence for a number of other therapies. Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBT-Ts considered by the review CPT, CT and PE should be the treatments of choice. The findings should guide evidence informed shared decision-making between patient and clinician.

Objective Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap. Method We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission. Results Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome. Conclusion Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials.

Background Non-pharmacological and non-psychological approaches to the treatment of post-traumatic stress disorder (PTSD) have often been excluded from systematic reviews and meta-analyses. Consequently, we know little regarding their efficacy. Objective To determine the effect sizes of non-pharmacological and non-psychological treatment approaches for PTSD. Method We undertook a systematic review and meta-analyses following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results 30 randomised controlled trials (RCTs) of a range of heterogeneous non-psychological and non-pharmacological interventions (28 in adults, two in children and adolescents) were included. There was emerging evidence for six different approaches (acupuncture, neurofeedback, saikokeishikankyoto (a herbal preparation), somatic experiencing, transcranial magnetic stimulation, and yoga). Conclusions Given the level of evidence available, it would be premature to offer non-pharmacological and non-psychological interventions routinely, but those with evidence of efficacy provide alternatives for people who do not respond to, do not tolerate or do not want more conventional evidence-based interventions. This review should stimulate further research in this area.

Background Sleep disturbance has been described as a ‘hallmark’ symptom of posttraumatic stress disorder (PTSD). Although there are robust findings of self-reported sleep disturbance in PTSD, evidence of sleep disturbance measured using actigraphy is less certain. Objective To conduct a systematic review and meta-analysis to determine whether there are any significant differences between individuals with and without PTSD in actigraph-derived sleep measures. Method Case-control studies comparing participants with current PTSD to those without PTSD were eligible for inclusion. Sleep parameters of interest were: (1) total sleep time; (2) sleep onset latency; (3) wake after sleep onset (WASO); and (4) sleep efficiency. Data were meta-analysed as standardised mean differences (SMDs) and potential sources of heterogeneity were explored through meta-regression. Six actigraphy studies with 405 participants were included. Results There was no evidence of a statistically significant difference between those with and without PTSD in total sleep time (SMD 0.09, 95%CI −0.23 to 0.42); WASO (SMD 0.18, 95%CI −0.06 to 0.43); sleep latency (SMD 0.32, 95%CI −0.04 to 0.69); or sleep efficiency (SMD −0.28, 95%CI −0.78 to 0.21). Conclusions Further high-quality research is required to determine whether there is a true difference in sleep between those with and without PTSD.

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments. Objective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD). Method: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout. Results: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD −1.22, −1.78 to −0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD −0.35, −0.11 to −0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD −0.83, −1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.