Search

Background and Objectives: Inhibitory Learning Theory (ILT) framework implies that in-session distress variability may promote extinction learning and thereby enhance exposure therapy efficacy. Thus far, research has mainly focused on in-session distress reduction. The aim of the current study was to assess whether in-session distress variability predicts next session PTSD symptom decline in PTSD patients receiving prolonged exposure (PE)., Methods: Eighty-six patients with PTSD received 14 to 16 sessions of PE. Using dynamic panel models, we assessed the temporal relation (i.e., within-persons) between in-session distress variability and PTSD symptom decline. Moreover, we assessed the averaged relation (i.e., between-persons) between in-session distress variability and PTSD symptom decline., Results: Temporal analyses showed that in-session distress variability did not precede PTSD symptom improvement. Averaged analyses showed that distress variability was related to PTSD symptom improvement., Limitation: The operationalization of distress variability appeared to deviate from its theoretical conceptualization., Conclusions: In absence of distress reduction, distress variability can vary. However, our findings suggest that in-session distress variability does not drive symptom reduction during PE. In contrast, averaged over participants, distress variability was related to symptom improvement, suggesting that those with a more variable distress pattern across sessions show better treatment response. More empirical work is needed to shed light on the effect of distress variability during exposure sessions on treatment outcome and to offer grounds for clinical recommendations., Competing Interests: Declaration of competing interest There are no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Working alliance is considered an important determinant of outcome of psychotherapy. Patients with posttraumatic stress disorder (PTSD) following childhood abuse (CA-PTSD) may have challenges in building interpersonal relationships, including working alliance. Phase-based treatment provides an opportunity to strengthen alliance prior to trauma-focused treatment. This study aimed to compare the development of working alliance among patients with CA-PTSD in three variants of prolonged exposure (PE) therapy: standard PE, intensive PE (iPE), and skill training in affective and interpersonal regulation + prolonged exposure (STAIR + PE). We also examined the effect of alliance on treatment outcome and dropout., Method: Self-reported PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (Blevins et al., 2015) and patient-rated Working Alliance Inventory (Tracey & Kokotovic, 1989) were assessed in a clinical trial. We analyzed data from 138 adult patients (76.1% female; 42% non-Western). Analyses were performed using mixed-effects models., Results: Patients established a satisfactory alliance early in treatment, which increased over time. For PE and STAIR + PE, a larger decrease in PTSD symptom severity was related to a higher alliance in the subsequent session, but not the other way around. In STAIR + PE, a higher alliance in Phase 1 was related to lower PTSD symptoms in Phase 2. In all conditions, a higher initial working alliance was related to a lower chance of treatment dropout., Conclusion: In the treatment of CA-PTSD, all three variants of prolonged exposure foster positive development of the working alliance. Across conditions, working alliance did not precede symptom decline. Therapists should strive for a strong alliance at the beginning of treatment as this reduces the likelihood of dropout. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Recent studies indicated that Prolonged Exposure (PE) is safe and effective for posttraumatic stress disorder (PTSD). It is unclear whether PE also leads to a reduction in comorbid diagnoses. Data from a large randomized controlled trial ( N  = 149) on the effects of three variants of PE for PTSD were used. We examined the treatment effects on co-morbid diagnoses of depressive, anxiety, obsessive compulsive, substance abuse, psychotic, eating and personality disorders in a sample of patients with PTSD related to childhood abuse. Outcomes were assessed with clinical interviews at baseline, post-treatment and at 6- and 12-month follow-up. All variants of PE led to a decrease from baseline to post-treatment in diagnoses of depressive, anxiety, substance use and personality disorders. Improvements were sustained during follow-up. We found an additional decrease in the number of patients that fulfilled the diagnostic criteria of a depressive disorder between 6- and 12-month follow-up. No significant changes were observed for the presence of OCD, psychotic and eating disorders. Findings suggest that it is effective to treat PTSD related to childhood abuse with trauma-focused treatments since our 14-to-16 weeks PE for PTSD resulted in reductions in comorbid diagnoses of depressive, anxiety, substance use and personality disorders.

Change in negative posttraumatic cognitions is a proposed mechanism through which Prolonged Exposure (PE) leads to symptom reduction of posttraumatic stress disorder (PTSD). A strong case for posttraumatic cognitions as a change mechanism in PTSD treatment can be made by establishing temporal precedence of change in cognitions. The current study examines the temporal relationship between change in posttraumatic cognitions and PTSD symptoms during PE, using the Posttraumatic Cognitions Inventory. Patients with DSM-5 defined PTSD following childhood abuse (N = 83) received a maximum of 14-16 sessions of PE. Clinician-rated PTSD symptom severity and posttraumatic cognitions were assessed at baseline, week 4, 8, and 16 (post-treatment). Using time-lagged mixed effect regression models, we found that posttraumatic cognitions predicted subsequent PTSD symptom improvement. Notably, when using the items of an abbreviated version of the PTCI (PTCI-9), we found a mutual relationship between posttraumatic cognitions and PTSD symptom improvement. Crucially, the effect of change in cognitions on PTSD symptom change was greater than the reverse effect. The current findings corroborate change in posttraumatic cognitions as a change process during PE, but cognitions and symptoms cannot be completely separated. The PTCI-9 is a short instrument that appears suitable to track cognitive change over time., Competing Interests: Declaration of competing interest None., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Prolonged exposure (PE) is an effective treatment for post-traumatic stress disorder (PTSD). Objective: This study aimed to analyse the cost-effectiveness of three exposure-based treatments in patients with childhood abuse-related PTSD. Method: A net-benefit analysis was conducted alongside a pragmatic randomized controlled trial with participants ( N  = 149) randomized to three conditions: PE ( n =  48), intensified PE (i-PE, n  = 51), and phase-based PE [Skills Training in Affective and Interpersonal Regulation (STAIR) + PE, n  = 50]. Assessments took place at baseline (T0), post-treatment (T3), 6 month follow-up (T4), and 12 month follow-up (T5). Costs stemming from healthcare utilization and productivity losses were estimated using the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness. Quality-adjusted life-years (QALYs) were based on the 5-level EuroQoL 5 Dimensions (EQ-5D-5L) using the Dutch tariff. Missing values of costs and utilities were multiply imputed. To compare i-PE to PE and STAIR + PE to PE, pair-wise unequal-variance t -tests were conducted. Net-benefit analysis was used to relate costs to QALYs and to draw acceptability curves. Results: Intervention costs did not differ across the three treatment conditions. Total medical costs, productivity losses, total societal costs, and EQ-5D-5L-based QALYs did not differ between treatment conditions either (all p  > .10). At the relevant €50,000/QALY threshold, the probability of one treatment being more cost-effective than another was 32%, 28%, and 40% for PE, i-PE, and STAIR-PE, respectively. Conclusion: Three equally effective treatments were compared and no differences in cost-effectiveness between treatments were found. Therefore, we advocate the implementation and adoption of any of the treatments and endorse shared decision making.

There is growing evidence that change in distress is an indicator of change during Prolonged Exposure (PE) for posttraumatic stress disorder (PTSD). However, temporal sequencing studies investigating whether change in distress precedes PTSD symptom decline are lacking. These studies are essential since the timeline between indicators of change and treatment outcome is a key assumption for mediation. The aim of the present study was to assess the temporal relationship between within- and between-session change in subjective distress and PTSD symptom decrease. We analyzed session data from 86 patients with PTSD. Data were analyzed using dynamic panel models. We distinguished temporal effects (within-persons) from averaged effects (between-persons). Results regarding the temporal effect showed that within-session change in subjective distress preceded PTSD symptom improvement while the reversed effect was absent. Averaged within-session change in subjective distress was also related to PTSD symptom improvement. Results regarding the temporal effect of between-session change in subjective distress showed that it did not precede PTSD symptom improvement. Averaged between-session change in subjective distress was related to PTSD symptom improvement. This study provides evidence for within- but not between-session change in subjective distress as indicator of change during PE. We also found that the way of modeling potential indicators of change affects results and implications. We recommend future studies to analyze mediators during treatment using temporal rather than averaged effects., Competing Interests: Conflict of Interest Statement The authors declare that there are no conflicts of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Background: One reason for the inclusion of Complex Posttraumatic Stress Disorder (CPTSD) in the 11th revision of the International Classification of Diseases (ICD-11) was its suspected relevance for treatment indications. We investigated whether CPTSD predicted and moderated treatment outcomes of Prolonged Exposure (PE), intensified PE (iPE) and Skills Training in Affective and Interpersonal Regulation followed by PE (STAIR + PE). We expected that CPTSD would predict worse treatment outcomes across treatments. Secondly, we expected that CPTSD would lead to better treatment effect in STAIR + PE compared to PE and iPE., Methods: We analyzed 149 patients with childhood-abuse related PTSD from a randomized clinical trial. CPTSD diagnosis and symptom severity were measured with the International Trauma Questionnaire. The main outcome was change in clinician-assessed PTSD symptoms. Assessments took place at baseline, week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. Analyses were based on an intention-to-treat sample using mixed effect models., Results: More than half (54 %) of the patients met criteria for CPTSD at baseline. CPTSD was related to more severe PTSD symptoms and higher comorbidity at baseline. CPTSD neither predicted nor moderated treatment outcome., Limitations: Inclusion was limited to patients with PTSD related to childhood abuse. Replication is needed in different samples., Conclusions: CPTSD is associated with more severe PTSD and with higher comorbidity. CPTSD did not predict treatment outcome and did not indicate differential treatment outcome of STAIR + PE compared to PE and iPE., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background : It is unclear whether the evidence-based treatments for PTSD are as effective in patients with CA-PTSD. Objective : We aimed to investigate the effectiveness of three variants of prolonged exposure therapy. Method : We recruited adults with CA-PTSD. Participants were randomly assigned to Prolonged Exposure (PE; 16 sessions in 16 weeks), intensified Prolonged Exposure (iPE; 12 sessions in 4 weeks followed by 2 booster sessions) or a phase-based treatment, in which 8 sessions of PE were preceded by 8 sessions of Skills Training in Affective and Interpersonal Regulation (STAIR+PE; 16 sessions in 16 weeks). Assessments took place in week 0 (baseline), week 4, week 8, week 16 (post-treatment) and at a 6-and 12-month follow-up. The primary outcome was clinician-rated PTSD symptom severity. Results : We randomly assigned 149 patients to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up (Cohen's d > 1.6), with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms ( t 135  = -2.85, p = .005, d = .49) but not clinician-assessed symptoms (t 135  = -1.65, p = .10) and faster initial symptom reduction than STAIR+PE for self-reported ( t 135  = -4.11, p < .001, d = .71) and clinician-assessed symptoms ( t 135  = -2.77, p = .006, Cohen's d = .48) STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions. Conclusions : Variants of exposure therapy are tolerated well and lead to large improvements in patients with CA-PTSD. Intensifying treatment may lead to faster improvement but not to overall better outcomes. The trial is registered at the clinical trial registry, number NCT03194113, https://clinicaltrials.gov/ct2/show/NCT03194113., Competing Interests: Dr. van Minnen reports personal fees from Royalties and fees, outside the submitted work; Dr. Cloitre reports personal fees from Royalites and fees British Psychological Society San Francisco University Department of Psychiatry during the conduct of the study; Drs. Oprel, Drs. Hoeboer, Dr. Schoorl, Dr. van der Does, Drs. Wigard and Dr. de Kleine report no financial relationships with commercial interests., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Childhood abuse related posttraumatic stress disorder (CA-PTSD) is associated with a high burden of disease and with treatment response rates that leave room for improvement. One of the treatments for PTSD, prolonged exposure (PE), is effective but has high drop-out rates and remission rates are relatively low. An intensified form of PE (iPE) was associated with good response and low drop-out rates in PTSD and has not yet been tested in a controlled trial in CA-PTSD. Phase-based treatment (PBT), in which PE is preceded by skills training may improve overall outcomes in this population. We will assess the effectiveness and cost-effectiveness of standard PE, iPE and PBT in patients with CA-PTSD., Methods/design: Multi-center randomized controlled trial. Treatment conditions are: prolonged exposure (PE; maximum of 16 sessions in 16 weeks); intensified PE (iPE; maximum of 12 sessions in four weeks and two booster sessions); phase-based treatment (PBT; maximum of eight sessions skills training followed by eight sessions PE in 16 weeks)., Primary Outcome: Clinician-rated PTSD symptom severity., Secondary Outcomes: loss of PTSD diagnosis, self-reported PTSD symptom severity, comorbid symptom severity and quality of life. Moreover, we will examine cost-effectiveness and moderators and mediators of treatment outcome., Target Population: adults with CA-PTSD (N = 150). Assessments in weeks 0, 4, 8, 16, 26 and 52., Discussion: Given that no consensus yet exists about the treatment guidelines for patients with CA-PTSD, the present study may have important implications for the treatment of CA-PTSD., Trail Registration: Registered at C.C.M.O. on Sept 7, 2016 (NL57984.058.16); retrospectively registered at June 21, 2017 at clinicaltrials.gov identifier: NCT03194113 .

Beneficial effects of attentional bias modification have been claimed for a number of anxiety disorders, but study results are variable. A recent trial in patients with posttraumatic stress disorder (PTSD) showed no therapeutic effects. The use of personally relevant and verbal stimuli might increase the efficacy of attentional bias modification. In an A-B case series design, we hypothesized that individualized attentional bias modification would lead to reduction of attentional bias and a decrease in PTSD symptoms. Six Dutch male war veterans (mean age 39.33 years) who had developed PTSD after peacekeeping missions underwent the treatment. No therapeutic effects were observed. Inter- and intraindividual attentional bias scores varied widely and did not respond to attentional bias modification as hypothesized. This study provides no evidence that individualized attentional bias modification is an effective treatment for PTSD., (Copyright © 2014 International Society for Traumatic Stress Studies.)

Background: Attentional bias modification (ABM) is a new treatment for anxiety disorders. Three randomized controlled clinical trials have shown positive effects of ABM in social anxiety disorder and generalized anxiety disorder. This study investigated the efficacy of ABM in outpatients with chronic posttraumatic stress disorder (PTSD)., Methods: Randomized controlled double-blind trial (n = 102). ABM and control treatment consisted of eight 20-min sessions over the course of 3 weeks. Symptoms and attentional bias were assessed before and after treatment and at 3-week follow-up., Results: ABM and the control treatment were equally effective in reducing the symptoms of PTSD. The effect sizes of the improvement (from before to after treatment) were 0.66 for ABM and 0.46 for the control treatment, which is comparable to the effect sizes of pill-placebos in pharmacotherapy trials of chronic PTSD. Both treatments did not affect attentional bias. The acceptability and tolerability of ABM was moderate., Conclusions: This version of ABM is not an effective treatment of PTSD., (Copyright © 2012 S. Karger AG, Basel.)