Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial.

BACKGROUND: Veterans with posttraumatic stress disorder (PTSD) tend to benefit less from evidence-based treatments than other PTSD populations. A novel virtual reality and motion-assisted exposure therapy, called 3MDR, provides treatment in an immersive, personalized and activating context. OBJECTIVE: To study the efficacy of 3MDR for veterans with treatment-resistant PTSD. METHOD: In a randomized controlled trial (n = 43) 3MDR was compared to a non-specific treatment component control group. Primary outcome was clinician-rated PTSD symptoms at baseline, after 3MDR, and at the 12-week and 16-week follow-up (primary end point). Intention-to-treat analyses of covariance and mixed models were applied to study differences between groups at the end point and over the course of intervention, controlling for baseline scores. RESULTS: The decrease in PTSD symptom severity from baseline to end point was significantly greater for 3MDR as compared to the control group, with a large effect size (F[1, 37] = 6.43, p = 0.016, d = 0.83). No significant between-group difference was detected in the course of PTSD symptoms during treatment when including all time points. The dropout rate was low (7%), and 45% of the patients in the 3MDR group improved clinically. The number needed to treat was 2.86. CONCLUSIONS: In this trial, 3MDR significantly decreased PTSD symptoms in veterans with, on average, a history of 4 unsuccessful treatments. The low dropout rate may be indicative of high engagement. However, a lack of significant differences on secondary outcomes limits conclusions that can be drawn on its efficacy and underlines the need for larger phase III trials. These data show emerging evidence for 3MDR and its potential to progress PTSD treatment for veterans (Dutch Trial Register Identifier: NL5126).

The dissociative post-traumatic stress disorder (PTSD) subtype: A treatment outcome cohort study in veterans with PTSD.

OBJECTIVES: Dissociation is a prevalent phenomenon among veterans with post-traumatic stress disorder (PTSD) that may interfere with the effectiveness of treatment. This study aimed to replicate findings of a dissociative PTSD subtype, to identify corresponding patterns in coping style, symptom type, and symptom severity, and to investigate its impact on post-traumatic symptom improvement. METHODS: Latent profile analysis (LPA) was applied to baseline data from 330 predominantly (97%) male treatment-seeking veterans (mean age 39.5 years) with a probable PTSD. Multinomial logistic models were used to identify predictors of dissociative PTSD. Eighty veterans with PTSD that commenced with psychotherapy were invited for a follow-up measure after 6 months. The majority (n = 64, 80% response rate) completed the follow-up measure. Changes in post-traumatic stress between baseline and follow-up were explored as a continuous distal outcome. RESULTS: Latent profile analysis revealed four distinct patient profiles: 'low' (12.9%), 'moderate' (33.2%), 'severe' (45.1%), and 'dissociative' (8.8%) PTSD. The dissociative PTSD profile was characterized by more severe pathology levels, though not post-traumatic reactions symptom severity. Veterans with dissociative PTSD benefitted equally from PTSD treatment as veterans with non-dissociative PTSD with similar symptom severity. CONCLUSIONS: Within a sample of veterans with PTSD, a subsample of severely dissociative veterans was identified, characterized by elevated severity levels on pathology dimensions. The dissociative PTSD subtype did not negatively impact PTSD treatment. PRACTITIONER POINTS: The present findings confirmed the existence of a distinct subgroup veterans that fit the description of dissociative PTSD. Patients with dissociative PTSD subtype symptoms uniquely differed from patients with non-dissociative PTSD in the severity of several psychopathology dimensions. Dissociative and non-dissociative PTSD patients with similar post-traumatic severity levels showed similar levels of improvement after PTSD treatment. The observational design and small sample size caution interpretation of the treatment outcome data. The IES-R questionnaire does not assess all PTSD DSM-IV diagnostic criteria (14 of 17), although it is considered a valid measure for an indication of PTSD.

Predicting post-traumatic stress disorder treatment response in refugees: Multilevel analysis.

OBJECTIVES: Given the recent peak in refugee numbers and refugees' high odds of developing post-traumatic stress disorder (PTSD), finding ways to alleviate PTSD in refugees is of vital importance. However, there are major differences in PTSD treatment response between refugees, the determinants of which are largely unknown. This study aimed at improving PTSD treatment for adult refugees by identifying PTSD treatment response predictors. DESIGN: A prospective longitudinal multilevel modelling design was used to predict PTSD severity scores over time. We analysed data from a randomized controlled trial with pre-, post-, and follow-up measurements of the safety and efficacy of eye movement desensitization and reprocessing and stabilization in asylum seekers and refugees suffering from PTSD. METHODS: Lack of refugee status, comorbid depression, demographic, trauma-related and treatment-related variables were analysed as potential predictors of PTSD treatment outcome. Treatment outcome data from 72 participants were used. RESULTS: The presence (B = 6.5, p = .03) and severity (B = 6.3, p < .01) of a pre-treatment depressive disorder predicted poor treatment response and explained 39% of the variance between individuals. CONCLUSIONS: Refugee patients who suffer from PTSD and severe comorbid depression benefit less from treatment aimed at alleviating PTSD. Results highlight the need for treatment adaptations for PTSD and comorbid severe depression in traumatized refugees, including testing whether initial targeting of severe depressive symptoms increases PTSD treatment effectiveness. PRACTITIONER POINTS: There are differences in post-traumatic stress disorder (PTSD) treatment response between traumatized refugees. Comorbid depressive disorder and depression severity predict poor PTSD response. Refugees with PTSD and severe depression may not benefit from PTSD treatment. Targeting comorbid severe depression before PTSD treatment is warranted. This study did not correct for multiple hypothesis testing. Comorbid depression may differentially impact alternative PTSD treatments.

Health trajectories of international humanitarian aid workers: growth mixture modelling findings from a prospective cohort study.

BACKGROUND: Most staff stay healthy during humanitarian work, although some worsen. Mean scores on health indicators may be masking individual participants struggling with health issues. AIMS: To investigate different field assignment-related health trajectories among international humanitarian aid workers (iHAWs) and explore the mechanisms used to stay healthy. METHOD: Growth mixture modelling analyses for five health indicators using pre-/post-assignment and follow-up data. RESULTS: Among 609 iHAWs three trajectories (profiles) were found for emotional exhaustion, work engagement, anxiety and depression. For post-traumatic stress disorder (PTSD) symptoms, four trajectories were identified. The 'healthy/normative' trajectory had the largest sample size for all health indicators (73-86%). A stable (moderate) 'ill health' trajectory was identified for all health indicators (7-17%), except anxiety. An 'improving' trajectory was found for PTSD and anxiety symptoms (5-14%). A minority of staff (4-15%) worsened on all health indicators. Deterioration continued for PTSD, depressive symptoms and work engagement 2 months post-assignment. A strong sense of coherence was associated with higher odds of belonging to the 'healthy' trajectory. Female biological sex was associated with higher odds of belonging to the 'worsening' depression and anxiety trajectories. Extended duration of field assignment was related to higher odds of belonging to the 'worsening' depressive symptoms trajectory. CONCLUSIONS: Most iHAWs stayed healthy during their assignment; a stable 'ill health' trajectory was identified for most health indicators. Sense of coherence is an important mechanism for understanding the health of all iHAWs in the different health trajectories, including the 'healthy' profile. These findings give new possibilities to develop activities to prevent worsening health and help strengthen iHAWs' ability to remain healthy under stress.

Symptom severity in PTSD and comorbid psychopathology: A latent profile analysis among traumatized veterans.

Individuals diagnosed with posttraumatic stress disorder (PTSD) show remarkably different symptom presentations. Identification of diagnostic profiles of PTSD may contribute to knowledge about treatment modifications to enhance treatment effectiveness. The present study aimed to identify symptom severity classes among 236 Dutch veterans based on a broad range of psychopathology outcomes, including PTSD, using Latent Profile Analysis (LPA). Moreover, multinomial logistic regression was used to test whether class membership could be predicted by the number and characteristics of traumatic event types, coping and personality dimensions. LPA identified three classes of individuals, defined as average, severe, and highly severe symptom severity classes, respectively. No qualitative differences in the symptom dimensions emerged between classes. Veterans with higher amounts of traumatic experiences and specifically with regard to lack of basic human needs, as well as those using more avoidant and problem-focused coping strategies and with more dysfunctional personality characteristics regarding neuroticism and agreeableness were significantly more often in the severe and/or highly severe symptom classes. In conclusion, general symptom severity was found to be an important diagnostic characteristic in this population. Integrated treatments targeting the broad spectrum of mental health problems may be of importance in treating patients that show low therapeutic recovery.

PTSD after childbirth: A predictive ethological model for symptom development.

BACKGROUND: Childbirth can be a traumatic experience occasionally leading to posttraumatic stress disorder (PTSD). This study aimed to assess childbirth-related PTSD risk-factors using an etiological model inspired by the transactional model of stress and coping. METHODS: 348 out of 505 (70%) Dutch women completed questionnaires during pregnancy, one week postpartum, and three months postpartum. A further 284 (56%) also completed questionnaires ten months postpartum. The model was tested using path analysis. RESULTS: Antenatal depressive symptoms (ß=.15, p<.05), state anxiety (ß=.17, p<.01), and perinatal psychoform (ß=.17, p<.01) and somatoform (ß=.17, p<.01) dissociation were identified as PTSD symptom risk factors three months postpartum. Antenatal depressive symptoms (ß=.31, p<.001) and perinatal somatoform dissociation (ß=.14, p<.05) predicted symptoms ten months postpartum. LIMITATIONS: Almost a third of our sample was lost at three months postpartum, and 44% at ten months. The sample size was relatively small. The present study did not control for prior PTSD. The PTSD A criterion was not considered an exclusion criteria for model testing, and the fit index of the ten months model was just below suggested cut-off values. CONCLUSIONS: Screening for high risk pregnant women should focus on antenatal depression, anxiety and dissociative tendencies. Hospital staff and midwives are advised to be vigilant for perinatal dissociation after intense negative emotions. To help regulate perinatal negative emotional responses, hospital staff and midwifes are recommended to provide information about birth procedures and be attentive to women's birth-related needs.

The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis.

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.