Does attachment predict the outcome of cognitive processing therapy for posttraumatic stress disorder in adolescent patients with interpersonal traumatization?

The attachment has emerged as a significant predictor of psychotherapy outcome. However, studies on trauma-focused treatments and adolescent samples are sparse. We analyzed the data of 43 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related posttraumatic stress disorder (PTSD) who were undergoing developmentally adapted cognitive processing therapy (D-CPT) within a multicenter, randomized clinical trial (German Clinical Trials Register; identifier: DRKS00004787). Besides clinician-rated posttraumatic stress symptoms (PTSS), attachment-related (AR) anxiety and AR avoidance were assessed using self-reports before and after treatment as well as at three-month and six-month follow-ups. Baseline attachment did not predict any changes in PTSS severity. Averaging across all assessment points, overall higher posttraumatic avoidance was associated with greater baseline AR avoidance in D-CPT. In terms of change in attachment during the trial, a greater reduction of attachment insecurities was associated with a greater reduction of PTSS severity. Results are compared with those of the control group, a wait-list condition with treatment advice (WL/TA; N = 42). AR anxiety was more often a significant variable in the models in WL/TA, whereas AR avoidance was in D-CPT. Our study does furnish initial insights into the role of attachment during trauma-focused treatment with abused adolescents and young adults.Trial registration: German Clinical Trials Register identifier: DRKS00004787.

Get secure soon: attachment in abused adolescents and young adults before and after trauma-focused cognitive processing therapy.

Severe posttraumatic stress symptoms (PTSS) are connected to a variety of health-related and interpersonal problems, among them are the insecure attachment orientations. However, psychotherapy seems to improve not only PTSS but also attachment insecurities. In a large multicenter, randomized clinical trial, the attachment characteristics and PTSS of 85 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related PTSS were assessed at study entry, at the end of treatment, and 3 months after the end of treatment. Participants were randomized either to a developmentally adapted cognitive processing therapy (D-CPT) or to a wait-list with treatment advice (WL/TA). The purpose of the study was to analyze the association between PTSS and attachment at study entry as well as changes in attachment during the trial. We found that attachment-related avoidance (AR avoidance) was positively associated with PTSS from both self-reports and clinician ratings, whereas attachment-related anxiety (AR anxiety) was only related to self-reported PTSS (Pearson correlation coefficients between 0.37 and 0.46). Changes in AR anxiety occurred in both conditions at some point during the study (baseline to 3-month follow-up effect size was d = 0.60 for D-CPT and d = 0.44 for WL/TA) whereas for AR avoidance, only participants in D-CPT improved significantly (baseline to 3-month follow-up effect size was d = 0.75). The results indicate that PTSS and attachment are connected. Positive changes in attachment insecurities brought about by trauma-focused psychotherapy seem possible.Trial registration: German Clinical Trials Register (DRKS); Germanctr.de; identifier: DRKS00004787; date of registration: 18 March 2013.

Reliability, Validity and Responsiveness of the EQ-5D-5L in Assessing and Valuing Health Status in Adolescents and Young Adults with Posttraumatic Stress Disorder: a Randomized Controlled Trail.

To validate the EQ-5D-5L health-related quality of life (HrQoL) questionnaire in adolescents and young adults with posttraumatic stress disorder (PTSD) after sexual and/or physical abuse. We used data from a randomized controlled trial of 87 participants with PTSD aged 14-21 years. The discriminative ability was evaluated by comparing participants scores on the descriptive system of the EQ-5D-5L with general population scores. Furthermore, the discriminative ability between subgroups of participants with different disease severity levels was estimated. Correlations between the EQ-5D index and clinical parameters were used to measure construct validity. Test-retest reliability was measured by intraclass correlation coefficients (ICC) between baseline, posttreatment and 3-month follow-up scores of participants with stable symptoms. Finally, the responsiveness of the EQ-5D was calculated by mean differences, effect sizes and receiver operating characteristic (ROC) analyses for participants with improved symptoms. Participants reported significantly more problems on the dimensions "mobility", "usual activities", "pain/discomfort" and "anxiety/depression" than the general population. The EQ-5D-5L was able to discriminate between different disease severity levels. The EQ-5D index and clinical scales were significantly correlated with absolute values of correlation coefficients varying between 0.21 and 0.59. Furthermore, ICCs between 0.65 and 0.91 indicated good test-retest reliability for the EQ-5D index. The ICCs for the EQ-VAS between baseline and 3-month follow-up, and posttreatment and 3-month follow-up were statistically significant with 0.71 and 0.87, respectively, whereas the ICC between baseline and posttreatment was 0.08 and not statistically significant. Effect sizes to measure the responsiveness ranged between -0.008 and 0.40 for the EQ-5D index and - 0.32 and 0.40 for the EQ-VAS. Furthermore, the area under the curve in ROC analyses was between 0.40 and 0.64 for the EQ-5D index and 0.60 and 0.70 for the EQ-VAS. Discriminative ability, test-retest reliability and construct validity of the EQ-5D-5L were good, whereas the responsiveness was rather weak. Nevertheless, the EQ-5D-5L can be used to measure HrQoL in adolescents and young adults with PTSD. German Clinical Trials Register identifier: DRKS00004787; date of registration: 18th March 2013; https://www.drks.de.

Long term efficacy of developmentally adapted cognitive processing therapy in youth with abuse related PTSD - Follow-up of a randomized control trial.

BACKGROUND: Adolescents and young adults with abuse-related post traumatic stress disorder (PTSD) have been shown to benefit from Developmentally Adapted Cognitive Processing Therapy (D-CPT), yet long-term efficacy of D-CPT has not yet been studied. OBJECTIVE: To assess the long-term efficacy of D-CPT in a sample of adolescents and young adults (age 14-21 years) with childhood abuse related PTSD. PARTICIPANTS AND SETTING: Patients of a previously conducted multicenter randomized controlled trial which showed the efficacy of D-CPT compared to a waitlist with treatment advice (WL/TA) were invited for follow-up assessments at 6 and 12 months after the end of treatment. METHODS: Primary outcome was the PTSD symptom severity, assessed with the Clinician-administered PTSD Scale for Children and Adolescents (CAPS-CA). Secondary outcomes were self-reported PTSD severity, depression, borderline symptom severity, behavior problems, and dissociation. RESULTS: Of the 44 participants who received D-CPT, 28 (63 %) responded and were assessed at 6-month follow-up. At 12-month follow-up, 22 participants (50 %) responded. The majority of participants in the WL/TA group received D-CPT after the end of the trial and were hence not available for follow-up assessment. In the D-CPT group, treatment gains were maintained at 6- and 12-month follow-up in the CAPS-CA as well as in all secondary outcomes. CONCLUSIONS: The positive effects of D-CPT were stable in adolescents and young adults with abuse-related PTSD indicating that they can benefit in the long term from a treatment with D-CPT.

Young people's trauma-related cognitions before and after cognitive processing therapy for post-traumatic stress disorder.

OBJECTIVES: Cognitive processing therapy (CPT) is a psychotherapy for post-traumatic stress disorder (PTSD) with a broad evidence base. Change in trauma-related cognitions is considered its primary working mechanism. When trying to integrate a traumatic event into existing cognitive schemas, the adaptive mechanism is changing the schema (accommodation). However, PTSD patients frequently either change their schemas too much (over-accommodation), or cognitively distort the event (assimilation). We aimed to test the hypothesized connections between the three types of cognition and symptom load. DESIGN: This study adds to the literature using 'impact statements', essays on their trauma-related thoughts written by patients at the beginning and end of CPT, to investigate cognitive change and its relationship to symptomatic outcome. METHODS: We analysed statements written by 31 adolescents and young adults who received developmentally adapted CPT (a longer treatment where CPT is the core component) in a randomized controlled trial. RESULTS: As expected, post-CPT statements contained more accommodated and fewer over-accommodated and assimilated clauses than pre-CPT statements. Correlations between cognition frequencies and concurrent symptom load were as expected for assimilation, and, in part, over-accommodation and accommodation. Decreased PTSD and depressive symptoms were correlated with increased accommodated thoughts. For over-accommodation and assimilation, however, expected correlations could not be shown. CONCLUSIONS: Our results support the notion that cognitive change is an important mechanism of change in CPT in a sample of younger, non-English-speaking clients.

Response of young patients with probable ICD-11 complex PTSD to treatment with developmentally adapted cognitive processing therapy.

Background: ICD-11 features Complex Posttraumatic Stress Disorder (CPTSD) as a new diagnosis. To date, very few studies have investigated CPTSD in young patients, and there is a need for evidence on effective treatment. Objective: The present study evaluates the applicability of developmentally adapted cognitive processing therapy (D-CPT) for CPTSD in young patients in a secondary analysis of the treatment condition of a randomized controlled trial (RCT) investigating the efficacy of D-CPT. Methods: The D-CPT treatment group in the original study included 44 patients (14-21 years) with DSM-IV PTSD after childhood abuse. We used the ICD-11 algorithm to divide the sample into a probable CPTSD and a non-CPTSD group. We performed multilevel models for interviewer-rated and self-rated PTSD symptoms with fixed effects of group (CPTSD, non-CPTSD) and time (up to 12 months follow-up) and their interaction. Treatment response rates for both groups were calculated. Results: Nineteen (43.2%) patients fulfilled criteria for probable ICD-11 CPTSD while 25 (56.8%) did not. Both CPTSD and non-CPTSD groups showed symptom reduction over time. The CPTSD group reported higher symptom severity before and after treatment. Linear improvement and treatment response rates were similar for both groups. D-CPT reduced symptoms of disturbances in self-regulation in both groups. Discussion: Both, patients with and without probable ICD-11 CPTSD seemed to benefit from D-CPT and the treatment also reduced disturbances in self-regulation. Conclusion: This study presents initial evidence of the applicability of D-CPT in clinical practice for young patients with CPTSD. It remains debatable whether CPTSD implies different treatment needs as opposed to PTSD.

Antecedentes: La CIE-11 presenta al Trastorno de Estrés Postraumático Complejo (TEPTC) como un nuevo diagnóstico. Hasta la fecha, muy pocos estudios han investigado el TEPTC en pacientes jóvenes y existe la necesidad de evidencia sobre un tratamiento efectivo.Objetivo: El presente estudio evalúa la aplicabilidad de la Terapia de Procesamiento Cognitivo adaptada según el desarrollo (TPC-D) para el TEPTC en pacientes jóvenes en un análisis secundario de la condición de tratamiento de un ensayo clínico controlado y aleatorizado (ECA) que investiga la eficacia de la TPC-D.Métodos: El grupo de tratamiento de la TPC-D en el estudio original incluyó 44 pacientes (14-21 años) diagnosticados con TEPT según el DSM-IV después del abuso infantil. Utilizamos el algoritmo de la CIE-11 para dividir la muestra en un grupo de TEPTC probable y otro grupo sin TEPTC. Realizamos modelos multinivel para los síntomas de TEPT, calificados por un entrevistador y por auto-reportes, con efectos fijos de grupo (TEPTC, sin TEPTC), de tiempo (hasta 12 meses de seguimiento) y su interacción. Se calcularon las tasas de respuesta al tratamiento para ambos grupos.Resultados: 19 pacientes (43.2%) cumplieron los criterios de TEPTC probable, según la CIE11, mientras que 25 pacientes (56.8%) no lo hicieron. Tanto el grupo de TEPTC probable como el grupo sin TEPTC mostraron una reducción de síntomas con el tiempo. El grupo de TEPTC reportó una mayor severidad de síntomas antes y después del tratamiento. Las tasas de mejoría lineal y de respuesta al tratamiento fueron similares en ambos grupos. La TPC-D redujo los síntomas de alteraciones en la autorregulación en ambos grupos.Discusión: Tanto los pacientes con y sin TEPTC probable según la CIE-11 parecían beneficiarse de la CPT-D y el tratamiento también redujo las alteraciones en la autorregulación.Conclusión: Este estudio presenta evidencia inicial sobre la aplicabilidad de la TPC-D en la práctica clínica en pacientes jóvenes con TEPTC. Sigue siendo debatible si el TEPTC requiere diferentes necesidades de tratamiento en contraposición al TEPT.

Health-Related Quality of Life and Costs of Posttraumatic Stress Disorder in Adolescents and Young Adults in Germany.

BACKGROUND: Posttraumatic stress disorder (PTSD) is one of the psychopathological consequences of sexual and/or physical abuse. The economic burden is assumed to be high, whereas health-related quality of life and education is negatively affected. This study aims to determine health care costs, health-related quality of life, and educational interruption in adolescents and young adults with PTSD after sexual and/or physical abuse in Germany. METHODS: This analysis used data of 87 participants aged 14-21 years of a randomized controlled trial. Health care utilization, health-related quality of life (EQ-5D-5L), sick leave days, productivity, and delay or failure to achieve educational aims were assessed. Health care costs from a payer perspective were calculated using unit costs for the year 2014. RESULTS: Mean health care costs for a six-month period were 5,243€ (SE 868€). In particular, costs of inpatient stays in psychiatric hospitals, general hospitals and rehabilitation as well as child welfare institutions were high. In addition, health-related quality of life was lower due to anxiety/depression, resulting in a mean EQ-5D index and EQ-VAS score of 0.70 and 61.0, respectively. Furthermore, participants reported on average 27 sick leave days, a productivity loss of 61%, and a delay in education attainment as well as having been unable to achieve educational aims. CONCLUSION: PTSD in adolescents and young adults is associated with a high economic burden. Health-related quality of life was substantially reduced. Furthermore, delay and productivity losses in education were observed. CLINICAL TRIAL REGISTRATION: German Clinical Trials Register identifier: DRKS00004787; date of registration: 18th March 2013; https://www.drks.de.

Effect of Developmentally Adapted Cognitive Processing Therapy for Youth With Symptoms of Posttraumatic Stress Disorder After Childhood Sexual and Physical Abuse: A Randomized Clinical Trial.

Importance: Despite the high prevalence, evidence-based treatments for abuse-related posttraumatic stress disorder (PTSD) in adolescents have rarely been studied. Objective: To examine whether developmentally adapted cognitive processing therapy (D-CPT) is more effective than a wait-list condition with treatment advice (WL/TA) among adolescents with PTSD related to childhood abuse. Design, Setting, and Participants: This rater-blinded, multicenter, randomized clinical trial (stratified by center) enrolled treatment-seeking adolescents and young adults (aged 14-21 years) with childhood abuse-related PTSD at 3 university outpatient clinics in Germany from July 2013 to June 2015, with the last follow-up interview conducted by May 2016. Of 194 patients, 88 were eligible for randomization. Interventions: Participants received D-CPT or WL/TA. Cognitive processing therapy was enhanced by a motivational and alliance-building phase, by including emotion regulation and consideration of typical developmental tasks, and by higher session frequency in the trauma-focused core CPT phase. In WL/TA, participants received treatment advice with respective recommendations of clinicians and were offered D-CPT after 7 months. Main Outcomes and Measures: All outcomes were assessed before treatment (baseline), approximately 8 weeks after the start of treatment, after the end of treatment (posttreatment), and at the 3-month follow-up. The primary outcome, PTSD symptom severity, was assessed in clinical interview (Clinician-Administered PTSD Scale for Children and Adolescents for DSM-IV [CAPS-CA]). Secondary outcomes were self-reported PTSD severity, depression, borderline symptoms, behavior problems, and dissociation. Results: The 88 participants (75 [85%] female) had a mean age of 18.1 years (95% CI, 17.6-18.6 years). In the intention-to-treat analysis, the 44 participants receiving D-CPT (39 [89%] female) demonstrated greater improvement than the 44 WL/TA participants (36 [82%] female) in terms of PTSD severity (mean CAPS-CA scores, 24.7 [95% CI, 16.6-32.7] vs 47.5 [95% CI, 37.9-57.1]; Hedges g = 0.90). This difference was maintained through the follow-up (mean CAPS-CA scores, 25.9 [95% CI, 16.2-35.6] vs 47.3 [95% CI, 37.8-56.8]; Hedges g = 0.80). Treatment success was greatest during the trauma-focused core phase. The D-CPT participants also showed greater and stable improvement in all secondary outcomes, with between-groups effect sizes ranging from 0.65 to 1.08 at the posttreatment assessment (eg, for borderline symptoms, 14.1 [95% CI, 8.0-20.2] vs 32.0 [95% CI, 23.8-40.2]; Hedges g = 0.91). Conclusions and Relevance: Adolescents and young adults with abuse-related PTSD benefited more from D-CPT than from WL/TA. Treatment success was stable at the follow-up and generalized to borderline symptoms and other comorbidities. Trial Registration: German Clinical Trials Register identifier: DRKS00004787.

Treating prolonged grief disorder with prolonged grief-specific cognitive behavioral therapy: study protocol for a randomized controlled trial.

BACKGROUND: Prolonged grief disorder (PGD) has emerged as a well-defined and relatively common mental disorder that will be included in the upcoming revision of the International Classification of Diseases. Recent trials with grief-specific, mostly cognitive behavioral interventions for patients with a clinically relevant diagnosis of PGD showed large effect sizes. However, a small trial suggested that non-specific behavioral activation might suffice to improve PGD. So, more evidence for the relative efficacy of grief-specific treatments is needed, as is more research on the predictors of treatment success. The purpose of the proposed trial is to evaluate a newly developed and successfully pilot-tested, prolonged grief-specific, integrative cognitive behavioral therapy (PG-CBT) compared to an active yet unspecific treatment, present-centered therapy (PCT). METHODS: In a multicenter, randomized controlled trial with 204 adults with a primary diagnosis of PGD, PG-CBT is compared to PCT, assuming the superiority of PG-CBT. Both treatments consist of 20 to 24 individual sessions, with an overall treatment length of about 6 months. The primary outcome, grief symptom severity, is assessed by blinded interviewers 12 months after randomization. Secondary outcomes are grief symptom severity at post treatment, in addition to self-reported overall mental health symptoms, depressive and somatoform symptoms at post treatment and 12 months post randomization. Possible moderators and mediators of treatment success are also explored. DISCUSSION: The trial is designed to avoid bias as much as possible (stratified randomization performed independently, blinded outcome assessment, intention-to-treat-analysis, balanced treatment dose, continuous supervision, control for allegiance effects) thereby enhancing internal validity. At the same time, some aspects of the trial will ensure clinical relevance (recruiting at outpatient clinics that are part of routine health care and keeping exclusion criteria to a minimum). Since the trial is powered adequately for the primary outcome, all secondary analyses including moderator analyses are exploratory by nature. The results will extend the knowledge on efficacious treatment of PGD and its predictors. TRIAL REGISTRATION: German Clinical Trials Register, ID: DRKS00012317 . Registered on 6 September 2017.