Distress variability during exposure therapy and its relationship with PTSD symptom decline.

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.

Effectiveness of Narrative Exposure Therapy for Treatment of PTSD Following Childhood Trauma: A Single-Case Series Design.

BACKGROUND: Narrative exposure therapy (NET) has shown promising outcomes for treating posttraumatic stress disorder (PTSD) in refugees and veterans. Its effectiveness in patients with PTSD following childhood trauma is, however, still unknown. AIMS: We investigated whether NET is an effective treatment for patients with PTSD following childhood trauma. METHOD: We studied treatment outcomes of nine adult patients in an outpatient setting. An AB single-case series design was used with a baseline of 4 weeks prior to treatment. Participants filled in weekly online questionnaires to assess their PTSD symptoms (using the Posttraumatic Diagnostic Scale [PDS]) and their experienced quality of life (using the Manchester Short Assessment of Quality of Life [MANSA]). Data were analysed visually and using a mixed-effect model. RESULTS: Results revealed no significant reduction of PTSD symptoms during NET treatment, nor an increase in quality of life, as compared to baseline. CONCLUSIONS: The results of our study do not underscore the effectiveness of NET treatment for patients with PTSD following childhood trauma. Further research is needed to study the effectiveness of NET in this population.

Working alliance in exposure-based treatments of posttraumatic stress disorder related to childhood abuse.

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).

Impact of three variants of prolonged exposure therapy on comorbid diagnoses in patients with childhood abuse-related PTSD.

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.

Psychometric evaluation of the Dutch International Trauma Questionnaire for the 11th revision of the International Classification of Diseases posttraumatic stress disorder and complex posttraumatic stress disorder.

BACKGROUND: The International Trauma Questionnaire (ITQ) is a recent self-report measure to assess the severity and probable posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as defined by the 11th revision of the International Classification of Diseases. Few studies have examined the psychometric properties of full and short ITQ versions in depth. Therefore, we aimed to evaluate the psychometric properties of the Dutch-translated 28-item ITQ and the 12-item version. METHOD: Data were used from existing clinical studies and routine clinical assessments for the 28-item (n = 956) and 12-item (N = 4,944) ITQ versions in trauma-exposed treatment-seeking individuals in the Netherlands. Internal consistency and factor validity were assessed, and rates of probable PTSD and CPTSD were estimated. In addition, convergent and discriminant validity were examined by correlations with similar and dissimilar measures. RESULTS: Both versions of the ITQ showed good internal consistency and convergent validity. Confirmatory factor analysis showed that both a first-order correlated six-factor model and a two-factor second-order model were a good representation of the latent structure for the ITQ-12. The ITQ-12 resulted in higher CPTSD rates compared to the ITQ-28 (47% vs. 36.3%), while a similar number of patients met the criteria for either PTSD or CPTSD (70.6% vs. 76.4%). CONCLUSION: Internal consistency and convergent validity for the ITQ-12 and ITQ-28 were supported. The factorial validity was good for the ITQ-12 and acceptable for the ITQ-28. The discrepancy in CPTSD rates between the ITQ-12 and ITQ-28 calls for further testing of scoring methods against diagnostic clinical interviews for CPTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exposure-based treatments for childhood abuse-related post-traumatic stress disorder in adults: a health-economic evaluation.

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.

This is the first study to compare cost-effectiveness of three exposure-based treatments in patients with CA-PTSD alongside a randomized controlled clinical trial (N = 149).The three exposure-based treatments did not differ in terms of outcomes and costs.Findings underline that any of these treatments can be implemented, and we endorse shared decision making to meet patient treatment preference.

Changes in trauma-related cognitions predict subsequent symptom improvement during prolonged exposure in patients with childhood abuse-related PTSD.

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.

Temporal Relationship Between Change in Subjective Distress and PTSD Symptom Decrease During Prolonged Exposure Therapy for Posttraumatic Stress Disorder.

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.

Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial.

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 (t135 = -2.85, p = .005, d = .49) but not clinician-assessed symptoms (t135 = -1.65, p = .10) and faster initial symptom reduction than STAIR+PE for self-reported (t135 = -4.11, p < .001, d = .71) and clinician-assessed symptoms (t135 = -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.

Antecedentes: No está claro si los tratamientos basados en la evidencia para el TEPT son tan efectivos en pacientes con TEPT relacionado con abuso infantil (TEPT-AI).Objetivo: Nuestro objetivo fue investigar la efectividad de tres variantes de la terapia de exposición prolongada.Método: Reclutamos adultos con TEPT-AI. Los participantes fueron asignados aleatoriamente a Exposición Prolongada (EP; 16 sesiones en 16 semanas), Exposición Prolongada intensificada (EPi; 12 sesiones en 4 semanas seguidas de dos sesiones de refuerzo) o un tratamiento basado en fases, en el que 8 sesiones de EP fueron precedidas por 8 sesiones de Entrenamiento de Habilidades en Regulación Afectiva e Interpersonal (STAIR+EP; 16 sesiones en 16 semanas). Las evaluaciones se llevaron a cabo en la semana 0 (línea de base), semana 4, semana 8, semana 16 (postratamiento) y en un seguimiento de 6 y 12 meses. El resultado primario fue la gravedad de los síntomas de TEPT calificada por el médico.Resultados: Asignamos aleatoriamente 149 pacientes a EP (48), EPi (51) o STAIR+EP (50). Todos los tratamientos dieron como resultado grandes mejoras en los síntomas de TEPT evaluados por el médico y autoinformados, desde el inicio hasta el seguimiento de 1 año (d de Cohen > 1.6), sin diferencias significativas entre los tratamientos. La EPi condujo a una reducción más rápida de los síntomas iniciales que la EP para los síntomas de TEPT autoinformados (t135 = −2.85, p =.005, d =.49) pero no los síntomas evaluados por el médico (t135 = −1.65, p =.10) y una reducción más rápida de síntomas iniciales que STAIR+EP para los síntomas autoinformados (t135 = −4.11, p <.001, d =.71) y evaluados por el médico (t135 = −2.77, p =.006, d de Cohen =.48) STAIR+EP no dio como resultado una mejora significativamente mayor desde el inicio hasta el seguimiento de 1 año en los resultados secundarios de regulación emocional, problemas interpersonales y autoestima en comparación con la EP y la EPi. Las tasas de abandono no difirieron significativamente entre las condiciones.Conclusiones: Las variantes de la terapia de exposición se toleran bien y conducen a grandes mejoras en pacientes con TEPT-AI. La intensificación del tratamiento puede conducir a una mejora más rápida, pero no a mejores resultados en general.

Personalization of Treatment for Patients with Childhood-Abuse-Related Posttraumatic Stress Disorder.

BACKGROUND: Differences in effectiveness among treatments for posttraumatic stress disorder (PTSD) are typically small. Given the variation between patients in treatment response, personalization offers a new way to improve treatment outcomes. The aim of this study was to identify predictors of psychotherapy outcome in PTSD and to combine these into a personalized advantage index (PAI). METHODS: We used data from a recent randomized controlled trial comparing prolonged exposure (PE; n = 48), intensified PE (iPE; n = 51), and skills training (STAIR), followed by PE (n = 50) in 149 patients with childhood-abuse-related PTSD (CA-PTSD). Outcome measures were clinician-assessed and self-reported PTSD symptoms. Predictors were identified in the exposure therapies (PE and iPE) and STAIR+PE separately using random forests and subsequent bootstrap procedures. Next, these predictors were used to calculate PAI and to retrospectively determine optimal and suboptimal treatment in a leave-one-out cross-validation approach. RESULTS: More depressive symptoms, less social support, more axis-1 diagnoses, and higher severity of childhood sexual abuse were predictors of worse treatment outcomes in PE and iPE. More emotion regulation difficulties, lower general health status, and higher baseline PTSD symptoms were predictors of worse treatment outcomes in STAIR+PE. Randomization to optimal treatment based on these predictors resulted in more improvement than suboptimal treatment in clinician assessed (Cohens' d = 0.55) and self-reported PTSD symptoms (Cohens' d = 0.47). CONCLUSION: Personalization based on PAI is a promising tool to improve therapy outcomes in patients with CA-PTSD. Further studies are needed to replicate findings in prospective studies.

Does complex PTSD predict or moderate treatment outcomes of three variants of exposure therapy?

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.

Effectiveness of enhanced cognitive behavior therapy for eating disorders: A randomized controlled trial.

OBJECTIVE: Enhanced cognitive behavior therapy (CBT-E) is a transdiagnostic treatment suitable for the full range of eating disorders (EDs). Although the effectiveness of CBT(-E) is clear, it is not being used as widely in clinical practice as guidelines recommend. The aim of the present study was to compare the effectiveness of CBT-E with treatment as usual (TAU), which was largely based on CBT principles. METHOD: We conducted a randomized controlled trial on a total of 143 adult patients with an ED who received either CBT-E or TAU. The primary outcome was recovery from the ED. Secondary outcome measures were levels of ED psychopathology, anxiety, and depressive symptoms. Self-esteem, perfectionism, and interpersonal problems were repeatedly measured to examine possible moderating effects. We explored differences in duration and intensity between conditions. RESULTS: After 80 weeks, there were no differences between conditions in decrease in ED psychopathology, or symptoms of anxiety and depression. However, in the first six weeks of treatment there was a larger decrease in ED psychopathology in the CBT-E condition. Moreover, when the internationally most widely used definition of recovery was applied, the recovery rate at 20 weeks of CBT-E was significantly higher (57.7%) than of TAU (36.0%). At 80 weeks, this difference was no longer significant (CBT-E 60.9%; TAU 43.6%). Furthermore, CBT-E was more effective in improving self-esteem and was also the less intensive and shorter treatment. DISCUSSION: With broader use of CBT-E, the efficiency, accessibility and effectivity (on self-esteem) of treatment for EDs could be improved.

E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial.

BACKGROUND: Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied. OBJECTIVE: This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider's confidence to have a conversation about suicidal behavior with undergraduate psychology students. METHODS: The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program's effects on guideline adherence, self-evaluated knowledge, and provider's confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1. RESULTS: Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider's confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05). CONCLUSIONS: An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

Development and psychometric evaluation of the Transdiagnostic Decision Tool: matched care for patients with a mental disorder in need of highly specialised care.

BACKGROUND: Early identification of patients with mental health problems in need of highly specialised care could enhance the timely provision of appropriate care and improve the clinical and cost-effectiveness of treatment strategies. Recent research on the development and psychometric evaluation of diagnosis-specific decision-support algorithms suggested that the treatment allocation of patients to highly specialised mental healthcare settings may be guided by a core set of transdiagnostic patient factors. AIMS: To develop and psychometrically evaluate a transdiagnostic decision tool to facilitate the uniform assessment of highly specialised mental healthcare need in heterogeneous patient groups. METHOD: The Transdiagnostic Decision Tool was developed based on an analysis of transdiagnostic items of earlier developed diagnosis-specific decision tools. The Transdiagnostic Decision Tool was psychometrically evaluated in 505 patients with a somatic symptom disorder or post-traumatic stress disorder. Feasibility, interrater reliability, convergent validity and criterion validity were assessed. In order to evaluate convergent validity, the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the ICEpop CAPability measure for Adults (ICECAP-A) were administered. RESULTS: The six-item clinician-administered Transdiagnostic Decision Tool demonstrated excellent feasibility and acceptable interrater reliability. Spearman's rank correlations between the Transdiagnostic Decision Tool and ICECAP-A (-0.335), EQ-5D-5L index (-0.386) and EQ-5D-visual analogue scale (-0.348) supported convergent validity. The area under the curve was 0.81 and a cut-off value of ≥3 was found to represent the optimal cut-off value. CONCLUSIONS: The Transdiagnostic Decision Tool demonstrated solid psychometric properties and showed promise as a measure for the early detection of patients in need of highly specialised mental healthcare.

Eating disorders and posttraumatic stress disorder.

PURPOSE OF REVIEW: Childhood maltreatment is associated with all types of eating disorders. We provide a systematic review of the recent literature on comorbid posttraumatic stress disorder (PTSD) in patients with eating disorders, and focus on prevalence, relationship with symptom severity, operating mechanisms and treatment. RECENT FINDINGS: The prevalence of comorbid PTSD in patients with eating disorders ranges from 9 to 24%, with research suggesting that comorbid PTSD is associated with more severe eating disorder symptoms. Maladaptive emotional regulation strategies may mediate the relationship between PTSD and eating disorders. Two pilot studies provide preliminary evidence that concurrent cognitive behavior therapy (CBT) for PTSD and eating disorders may be beneficial and that repetitive transcranial magnetic stimulation (rTMS) could be helpful in the treatment of PTSD in some eating disorder patients. SUMMARY: PTSD is a common comorbidity in patients with eating disorders and impacts the severity of their eating disorder symptoms. However, there is little research into concurrent treatments for PTSD and eating disorders. Difficulties in emotional regulation may be a common mechanism in both disorders.

Longitudinal course of suicidal ideation and predictors of its persistence - A NESDA study.

BACKGROUND: Prior research indicates that the factors that trigger suicidal ideation may differ from those that maintain it, but studies into the maintenance of suicidal ideation remain scarce. Our aim was to assess the longitudinal course of suicidal ideation, and to identify predictors of persistent suicidal ideation. METHODS: We used data from the Netherlands Study of Depression and Anxiety (NESDA). We performed a linear mixed-effects growth model analysis (n = 230 with current suicidal ideation at baseline) to assess the course of suicidal ideation over time (baseline through 2-, 4-, 6- and 9-year follow-up). We used logistic regression analysis (n = 195) to test whether factors previously associated with the incidence of suicidal ideation in the literature (insomnia, hopelessness, loneliness, borderline personality traits, childhood trauma, negative life events) also predict persistence of suicidal ideation (i.e., reporting ideation at two consecutive assessment points, 6- and 9-years). We controlled for socio-demographics, clinical diagnosis and severity, medication use, and suicide attempt history. RESULTS: Suicidal ideation decreased over time, and this decrease became slower with increasing time, with the majority of symptom reductions occurring in the first two years of follow-up. More severe insomnia and hopelessness were associated with increased odds of persistent suicidal ideation, and hopelessness was a significant mediator of the relationship between insomnia and persistent suicidal ideation. LIMITATIONS: Findings may not generalize to those with more severe suicidal ideation due to dropout of those with the worst clinical profile. CONCLUSIONS: Targeting insomnia and hopelessness in treatment may be particularly important to prevent the persistence of suicidal ideation.

Enhanced cognitive behavioural therapy for patients with eating disorders: a systematic review.

PURPOSE OF REVIEW: The aim of this study was to provide an update of the most recent (since January 2014) enhanced cognitive behavioural therapy (CBT-E) effectiveness studies (randomized controlled trials and open trials) on bulimia nervosa, binge eating disorder and transdiagnostic samples. RECENT FINDINGS: Out of 451 screened studies, seven effectiveness studies (five randomized and two open trials) were included in this review: of these, three had a bulimia nervosa sample and four a transdiagnostic sample (all conducted in an outpatient setting). Substantial differences in posttreatment remission rates were found (range: 22.2-67.6%) due, in part, to differences in samples and operationalization of clinical significant change. SUMMARY: There is robust evidence that CBT-E is an effective treatment for patients with an eating disorder. However, more studies on differential effects and working mechanisms are required to establish the specificity of CBT-E.

Attentional bias modification in Dutch veterans with posttraumatic stress disorder--a case series with a personalized treatment version.

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.

Attentional bias and attentional control in Posttraumatic Stress Disorder.

Extensive evidence exists for an association between attentional bias (AB; attentional vigilance or avoidance) and anxiety. Recent studies in healthy participants suggest that attentional control (AC) may facilitate inhibition of automatic attentional processes associated with anxiety. To investigate relationships among AC, trauma-related AB, symptom severity and trait anxiety in patients with Posttraumatic Stress Disorder (PTSD), participants (N = 91) completed self-report measures of AC, posttraumatic stress symptoms (PTSS) and trait anxiety. AB was measured with a pictorial version of the Dot Probe Test. AC moderated the relationship between PTSS and AB (threat avoidance). Patients high in PTSS and low in AC showed attentional avoidance. No association between PTSS and AB in patients with medium or high levels of AC was found. A similar pattern of results was observed for the relationship between trait anxiety, AC and AB. These results suggest that a low ability to control attention is a risk factor for AB in PTSD. This first clinical study corroborates the accumulating evidence from analog studies that individual differences in top-down attentional control are of considerable importance in the expression of AB in anxious psychopathology.

Attentional bias modification in posttraumatic stress disorder: a randomized controlled trial.

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.