Prolonged grief disorder in an inpatient psychiatric sample: psychometric properties of a new clinical interview and preliminary prevalence.

BACKGROUND: Prolonged Grief Disorder (PGD) was newly included in the ICD-11 and DSM-5-TR. It is not yet part of the standard assessments in many healthcare systems, including psychiatric wards. Because disordered grief is associated with suicidality, sleep problems and substance use disorders, an investigation into PGD in psychiatric inpatients is warranted. METHOD: We interviewed N = 101 psychiatric inpatients who were admitted to the open psychiatric wards and the day hospital of a German psychiatric hospital and who had lost a person close to them. Assessments comprised clinical interviews and self-report instruments covering PGD and other mental disorders. We specifically developed the International Interview for Prolonged Grief Disorder according to ICD-11 (I-PGD-11) for the study and examined its psychometric properties. RESULTS: The prevalence rate of PGD among bereaved patients according to ICD-11 was 16.83% and according to DSM-5-TR 10.89%. The I-PGD-11 showed good psychometric properties (Mc Donald's ω = 0.89, ICC = 0.985). Being female, having lost a child or spouse, and unnatural or surprising circumstances of the death were associated with higher PGD scores. TRIAL REGISTRATION: Approval was obtained by the ethics committee of the of the Goethe University Frankfurt (2021-62, 2023-17) and the Chamber of Hessian Physicians (2021-2730-evBO). The study was preregistered ( https://doi.org/10.17605/OSF.IO/K98MF ). LIMITATIONS: We only assessed inpatients of one psychiatric clinic in Germany, limiting the generalizability of our findings. CONCLUSION: The present study underlines the importance of exploring loss and grief in psychiatric inpatients and including PGD in the assessments. Given that a significant minority of psychiatric inpatients has prolonged grief symptoms, more research into inpatient treatment programs is needed.

Associations between olfactory reference disorder and social phobia - results of an internet-based study.

Despite the similar clinical features of Olfactory Reference Disorder (ORD) and Social Phobia (SP), or studies showing elevated comorbidity of the two disorders, and the conceptualization of ORD as a form of SP in the East Asian culture, to our knowledge, the relationship between ORD and SP has not been investigated. This study examined the association of ORD according to the 11th revision of the International Classification of Diseases (ICD-11) and SP in 225 German university / college students who completed self-ratings with regard to socio-demographic data and symptoms of SP and ORD within an anonymous internet-based survey. Symptoms of SP were assessed with the Social Phobia Inventory (SPIN). Symptoms of ORD according to the ICD-11 were assessed with the Olfactory Reference Disorder Questionnaire (ORDQ), developed for this study. In our sample, 86.6% of the participants who met the self-rated features for ORD also met the self-rated criteria for current SP. ORD severity scores were significantly related to SP. Participants with and without self-reported ORD differed significantly in their SP total scores. SP severity was also significantly correlated with poorer insight of ORD-related beliefs, greater ORD-related avoidance of intimate relationships and higher levels of shame and fear of rejection due to body odor. These preliminary findings indicate that ORD could be closely related to SP and highlight the need for future research on the relationship of ORD and SP in order to gain a better understanding of the development, maintenance, treatment and classification of ORD.

A preliminary study on the effect of trauma-focused therapies on sexual dysfunctions in women with PTSD after childhood abuse.

BACKGROUND: Posttraumatic stress disorder (PTSD) is often associated with female sexual dysfunctions (FSD). However, little is known about the impact of therapies for PTSD on FSD according to DSM-5 criteria. AIM/OBJECTIVE: To examine if sexual functioning diagnosed according to DSM-5 criteria improves after treatment for PTSD in women with a PTSD diagnosis after interpersonal child abuse. METHOD: FSD according to DSM-5 criteria were assessed with the structured clinical interview SISEX in N = 152 female participants (mean age = 36.5 years) of a large randomized controlled trial three months into treatment and after 15 months of receiving either dialectical behavior therapy for PTSD or cognitive processing therapy. Number of fulfilled FSD criteria and diagnostic status were compared from pre-to post-treatment using Poisson and negative binomial regression analyses and the McNemar test. The effect of treatment type on reduction of FSD symptoms and the association between reduction in PTSD symptoms and reduction in FSD symptoms were assessed. RESULTS: From pre-to post-treatment, the number of fulfilled criteria for each FSD decreased (Incident rate ratios between 0.60 and 0.71, p between <. 001 and <0 .05). Less women met criteria for genito-pelvic pain/penetration disorder at post-treatment compared to pre-treatment (11.8 % vs. 6.6 %, p < .05). No difference was found between treatments in reduction of FSD symptoms. Reduction of PTSD symptoms was associated with greater decrease in FSD symptoms. CONCLUSIONS: Our results suggest a positive association between effective PTSD treatments and improvements in sexual functioning of women with PTSD after child abuse.

Is adherence to dialectic behaviour therapy for post-traumatic stress disorder (PTSD) and cognitive processing therapy related to treatment outcome in PTSD after childhood abuse?

Background: Literature on the association between therapist adherence and treatment success in the treatment of post-traumatic stress disorder (PTSD) is scarce, and the results are mixed.Objective: To examine the relationship between therapist adherence to dialectical behaviour therapy for PTSD (DBT-PTSD) and cognitive processing therapy (CPT) on treatment outcome in women with PTSD and emotion regulation difficulties after interpersonal childhood abuse.Method: Videotaped therapy sessions from 160 female participants of a large randomized controlled trial [Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse. JAMA Psychiatry, 77(12), 1235. jamapsychiatry.2020.2148] were rated. Adherence to CPT and DBT-PTSD was assessed using two specifically developed rating scales.Results: Higher therapist adherence was associated with a greater reduction of clinician-rated PTSD symptom severity. This effect was more pronounced in the CPT group than in the DBT-PTSD group. Adherence was also related to a greater reduction of self-rated PTSD symptoms, borderline symptoms, and dissociation intensity.Conclusion: Our results indicate that higher therapist adherence can lead to better treatment outcomes in PTSD treatments, especially in CPT.

Higher therapist adherence to cognitive processing therapy was associated with higher treatment gains in women with post-traumatic stress disorder (PTSD) after childhood abuse.Adherence was related to higher reductions in symptom severity of PTSD, borderline symptoms, and dissociation intensity.Adherence to dialectical behaviour therapy for PTSD did not show a strong association with treatment outcome.

Associations between sleep problems and posttraumatic stress symptoms, social functioning, and quality of life in refugees with posttraumatic stress disorder.

Many patients with posttraumatic stress disorder (PTSD) suffer from sleep problems, leading to impairments in social functioning and quality of life. Refugees are at high risk for sleep problems due to stressful life circumstances and a high PTSD prevalence. However, limited data on the frequency of sleep problems in refugees with diagnosed PTSD exist. This study examined the frequency of sleep problems in refugees with PTSD and their associations with symptoms of PTSD. Additionally, we investigated the contribution of sleep problems to social functioning and quality of life. Participants (N = 70) were refugees from different countries of origin currently living in Germany. All participants met the criteria for PTSD and completed measures of PTSD symptom severity, subjective sleep problems, social impairment, and quality of life. There was a very high frequency of sleep problems in the sample (100%), and sleep problems were significantly associated with both clinician-rated, r = .47, and self-rated, r = .30, PTSD symptom severity after controlling for overlapping items. Contrary to expectations, sleep problems did not predict social impairment, d = 0.16, nor quality of life, d = 0.13, beyond the effect of other PTSD symptoms. The findings highlight the widespread frequency of sleep problems among refugees. Future studies should assess the causal nature of the association between sleep problems and measures of psychosocial functioning in more detail and examine its dynamic change over time.

Does treatment specific-, disorder specific- or general therapeutic competence predict symptom reduction in posttraumatic stress disorder?

Background: Literature on the association between therapist competence and treatment success in posttraumatic stress disorder (PTSD) treatments is scarce and results are mixed.Aims/Objective: The relationship between different types of therapeutic competence, therapeutic alliance, and PTSD symptom reduction in patients treated with Dialectical Behaviour Therapy for PTSD (DBT-PTSD) or Cognitive Processing Therapy (CPT) was assessed. Competence types were PTSD-specific competence, treatment specific competence, and general competence in cognitive behaviour therapy (CBT).Method: Videotaped therapy sessions from N = 160 women with PTSD and emotion regulation difficulties after child abuse participating in a large randomised controlled trial (Bohus et al., 2020) were rated. Three therapeutic competence-types were assessed using specifically developed rating scales. Alliance was assessed via patient ratings with the Helping Alliance Questionnaire (HAQ). PTSD symptoms were assessed at pre- and post-treatment via clinician rating with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and via self-rating with the PTSD-Checklist for DSM-5 (PCL-5).Results: No significant association between competence and clinician or self-rated PTSD symptoms was found. PTSD specific competence predicted clinician rated PTSD symptom severity on a trend level. Alliance predicted both clinician and self-rated PTSD symptom reduction.Conclusion: Our results provide a starting point for future research on different competence types and their association with PTSD treatment gains. Therapists were highly trained and received weekly supervision, hence a restricted competence range is a possible explanation for non-existing associations between competence and PTSD symptom reduction in our sample. More research in naturalistic settings, such as dissemination studies, is needed.

Three different types of therapeutic competence and their association to treatment gains in women with posttraumatic stress disorder after child abuse were assessed.Therapist competence was high in all three domains of competence.No association was found between any of the competence types and reduction in posttraumatic stress disorder symptoms.

Sexual Dysfunctions in Women with Posttraumatic Stress Disorder Following Childhood Sexual Abuse: Prevalence Rates According to DSM-5 and Clinical Correlates.

Many women with posttraumatic stress disorder (PTSD) after child sexual abuse (CSA) suffer from sexual problems. However, little is known about the frequency of female sexual dysfunctions (FSD) as defined by DSM-5 among women with PTSD due to CSA. Furthermore, factors related to FSD in this patient population are understudied. To assess prevalence rates and clinical correlates of FSD according to DSM-5 criteria in women with PTSD after CSA, a structured clinical interview for sexual dysfunctions according to DSM-5 criteria was administered in a sample of 137 women with PTSD after CSA. Participants also completed measures for PTSD, depression symptoms, and borderline personality disorder symptoms. The association between FSD, severity of abuse, PTSD-, depression-, borderline symptom severity, and age was examined. In a second step, the association between FSD and PTSD-clusters was assessed. Diagnostic criteria of female sexual interest/arousal disorder (FSIAD) were met by 2.6% of women in our sample. 5.2% met criteria of female orgasmic disorder (FOD), and 11.8% those of genito-pelvic pain/penetration disorder (GPPPD). PTSD symptom severity predicted number of fulfilled criteria of FSIAD and FOD, the cluster "negative alterations in cognition and mood," was associated with more fulfilled criteria in FSIAD and FOD. The majority of women reported sexual problems, but diagnostic criteria of FSD were met by only a small number of participants. PTSD symptoms, especially the cluster "negative alterations in cognition and mood," seem to be related to female sexual functioning after CSA.

Effect of therapeutic competence, adherence, and alliance on treatment outcome in youth with PTSD treated with developmentally adapted cognitive processing therapy.

BACKGROUND: Developmentally adapted cognitive processing therapy (D-CPT) is an effective treatment for posttraumatic stress disorder (PTSD) in adolescents and young adults. It is unclear if therapeutic adherence and competence in D-CPT are associated with higher PTSD treatment gains. OBJECTIVE: To assess if higher therapeutic adherence and competence in D-CPT are associated with higher symptom reduction of PTSD in adolescents and young adults, while controlling for therapeutic alliance. PARTICIPANTS AND SETTING: Participants were 38 patients (aged 14-21 years; M = 17.61 years, SD = 2.42 years) of a multicenter randomized controlled trial in which the efficacy of D-CPT was compared to a waitlist with treatment advice. METHODS: Videotaped therapy sessions were rated using validated ratings scales to assess adherence and competence. Therapeutic alliance was assessed via weekly patient ratings. We used hierarchical linear modelling to assess the relationship of adherence and competence on PTSD symptoms being measured by both clinician and patient while controlling for alliance. RESULTS: Neither adherence nor competence were related to treatment outcomes in clinician or patient rated PTSD symptom severity. Higher alliance was associated with a lower symptom severity at 12 months posttreatment in both clinician and patient rated PTSD symptoms. CONCLUSIONS: In this study of young adults with PTSD, who were treated with D-CPT by well-trained therapists, therapeutic adherence and competence were not related to treatment outcome. This might be explained by a lack of range in therapist adherence and competence. Therapeutic alliance had a positive effect on PTSD symptom severity.

Climate for evidence-based mental health care implementation in Germany: psychometric investigation of the Implementation Climate Scale (ICS).

Organizational implementation climate is an important construct in implementation research to describe to what extent implementation is expected, supported, and rewarded. Efforts in bridging the research-practice gap by implementing evidence-based practice (EBP) can benefit from consideration of implementation climate. The Implementation Climate Scale (ICS) is a psychometrically strong measure assessing employees' perceptions of the implementation climate. The present cross-sectional study aimed at providing a German translation and investigating its psychometric properties. The translation followed standard procedures for adapting psychometric instruments. German psychotherapists (N = 425) recruited online completed the ICS, the Evidence Based Practice Attitudes Scale (EBPAS-36D) and the Intention Scale for Providers (ISP). We conducted standard item and reliability analyses. Factorial validity was assessed by comparing an independent cluster model of Confirmatory Factorial Analysis (ICM-CFA), a Bifactor CFA, a Second-order CFA and an (Bifactor) Exploratory Structural Equation Model (ESEM). Measurement invariance was tested using multiple-group CFA and ESEM, convergent validity with correlation analysis between the ICS and the ISP subjective norms subscale (ISP-D-SN). The mean item difficulty was pi = .47, mean inter-item correlation r = .34, and mean item-total correlation ritc = .55. The total scale (ω = 0.91) and the subscales (ω = .79-.92) showed acceptable to high internal consistencies. The model fit indices were comparable and acceptable (Second-order CFA: RMSEA [90% CI] = .077 [.069; .085], SRMR = .078, CFI = .93). Multiple-group CFA and ESEM indicated scalar measurement invariance across gender and presence of a psychotherapy license. Psychotherapists in training reported higher educational support for EBP than licensed psychotherapists (T = 2.09, p = .037, d = 0.25). The expected high correlation between the ICS and the ISP-D-SN was found (r = .59, p < .001). Results for the German ICS confirm good psychometric properties including validity.

Differentiated processing of emotional cues in adolescents and young adults with ICD-11 PTSD and complex PTSD after child abuse.

BACKGROUND: The recent update of the International Classification of Diseases 11th revision (ICD-11) introduced the diagnosis of complex posttraumatic stress disorder (CPTSD) as a distinct entity from posttraumatic stress disorder (PTSD). Because psychophysiological alterations are a core diagnostic feature of PTSD and CPTSD, the aim of the current study was to examine potential distinctive patterns in cortical and cardiac responses to emotional words in adolescent and young adult patients with PTSD and CPTSD. METHOD: Event-related potentials and heart rate responses were studied in 81 adolescent and young adult participants, of which 17 individuals were diagnosed with ICD-11 PTSD and 32 individuals with CPTSD, each after childhood sexual and/or physical abuse. Thirty-two individuals served as healthy controls. The paradigm consisted of a passive reading task with neutral, positive, physically threatening, and socially threatening words. RESULTS: Differentiated early processing of emotional words was indicated by differences on P1 and left EPN components. Additionally, PTSD and CPTSD patients presented with specific patterns of heart rate responses to emotional words. In CPTSD patients, heart rate reactions to emotional words were more variable than in PTSD patients. CONCLUSIONS: These findings provide early evidence of differentiated cortical and cardiac response patterns in adolescent and young adult patients with CPTSD and PTSD, supporting a nosological distinction between PTSD and complex PTSD. However, due to small and unequal sample sizes, findings presented in the current study are preliminary and require future research.

Neurostructural associations with traumatic experiences during child- and adulthood.

Adverse experiences can lead to severe mental health problems, such as posttraumatic stress disorder (PTSD), throughout the lifespan. In individuals with PTSD, both global and local brain volume reductions have been reported-especially in the amygdala and hippocampus-while the literature on childhood maltreatment suggests a strong dependency on the timing of adverse events. In the present study, we pooled data from two studies to contrast the effects of reported trauma exposure during neurodevelopmentally sensitive periods in early life with trauma exposure during adulthood. A total of 155 women were allocated into one of six age-matched groups according to the timing of traumatization (childhood vs adulthood) and psychopathology (PTSD vs trauma-exposed healthy vs trauma-naïve healthy). Volumes of the amygdala and hippocampus were compared between these groups. Six additional exploratory regions of interest (ROI) were included based on a recent meta-analysis. Amygdala volume was strongly dependent on the timing of traumatization: Smaller amygdala volumes were observed in participants with childhood trauma and PTSD compared to the healthy control groups. In contrast, larger amygdala volumes were observed in both groups with trauma exposure during adulthood compared to the trauma-naïve control group. Hippocampal volume comparisons revealed no statistically significant differences, although the descriptive pattern was similar to that found for the amygdala. The remaining exploratory ROIs showed significant group effects, but no timing effects. The timing might be an important moderator for adversity effects on amygdala volume, potentially reflecting neurodevelopmental factors. Albeit confounded by characteristics like trauma type and multiplicity, these findings pertain to typical childhood and adulthood trauma as often observed in clinical practice and speak against a simple association between traumatic stress and amygdala volume.

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.

Introduction and evaluation of a therapeutic adherence and competence scale for grief-focused cognitive behavioural therapy.

Background: There is no therapeutic competence and adherence scale for grief-focused cognitive behavioural therapy (grief-focused CBT). However, given the growing body of evidence for the efficacy of grief-focused CBT, such a scale is needed both to ensure the internal validity of clinical trials and to facilitate psychotherapy process research. Objective: To develop and undertake a psychometric evaluation of a therapeutic adherence and competence scale for grief-focused CBT. Method: The scale was developed in two steps. (I) Five experts on the treatment of prolonged grief disorder provided feedback on the relevance and appropriateness of the items. The scale was revised to reflect their feedback. The final therapeutic adherence and competence scale for grief (TACs-G) consisted of 15 adherence and 16 competence items. (II) Psychometric evaluation of the TACs-G was based on the rating of 48 randomly selected PG-CBT sessions by two independent raters. The videos were recorded in the context of a randomized controlled trial (RCT; DRKS00012317.) ICC was used to calculate inter-rater reliability and TACs-G stability over time (re-evaluation of 10 sessions after 12 months). Results: The five experts confirmed the relevance and appropriateness of the items. Interrater reliability was found to be high for the total adherence and competence scores (ICC = 0.889 and 0.782, respectively) and moderate to excellent for individual items (ICC = 0.509-1.00). The TACs-G stability over time was found to be strong for both adherence (ICC = 0.970) and competence total scores (ICC = 0.965). Conclusions: The TACs-G for CBT is a reliable instrument that can be used not only to ensure internal validity but is also suited for psychotherapy process studies. Additionally, it provides a valuable database for targeted feedback in training settings. HIGHLIGHTS: This is the first study to report on the development and psychometrical evaluation of a grief-focused adherence and competence scale.Although an increasing number of clinical trials do report the efficacy of grief-focused cognitive-behavioural therapy, none of these studies used a standardized adherence and competence scale to control internal validity.In the present study, we introduced a therapeutic adherence and competence scale for grief (TACs-G) that can be applied efficiently across different research settings (e.g. manipulation check, dissemination), and report results of good to excellent psychometric properties.The scale itself could prove useful beyond the research setting as it could possibly serve as a basis for feedback in training settings.

How to Treat Childhood Sexual Abuse Related PTSD Accompanied by Risky Sexual Behavior: A Case Study on the Use of Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD).

Childhood and adolescent sexual abuse (CSA) is a traumatic experience associated with a variety of short- and long-term negative consequences. Theoretical models assume that an abuse related and learned distorted image of sexuality might lead CSA survivors to feel obligated to provide sex or engage in unwanted sexual practices in order to gain affection or prevent abandonment. Dialectical behavioral therapy for posttraumatic stress disorder (DBT-PTSD) is tailored to people with PTSD and comorbid emotion regulation deficits. This case study presents the results of an outpatient DBT-PTSD treatment of an adult patient with posttraumatic stress disorder following sexual and physical abuse. DBT-PTSD was used to treat the patient's complex psychopathological problems and to decrease her risky sexual behavior, which manifested itself in highly dangerous sexual practices with her partner. The treatment took place over a period of 18 months, with a total of 72 sessions. At the end of the treatment, the patient no longer met criteria for PTSD as indicated by large reductions in the assessments used. Furthermore, she managed to distance herself from risky sexual practices and to remain in a satisfying relationship.

Same name, same content? Evaluation of DSM-5-TR and ICD-11 prolonged grief criteria.

OBJECTIVE: Investigating the concordance of prolonged grief disorder (PGD) criteria that have been recently introduced to the 5th text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) and the International Classification of Diseases 11th Revision (ICD-11). METHOD: N = 193 treatment-seeking bereaved adults were assessed with the prolonged grief disorder 13 + 9 interview. Data were examined in terms of (a) diagnostic rates for PGDDSM-5-TR and PGDICD-11, including increases of the PGDICD-11 accessory symptom threshold (PGDICD-11-X+) and time criterion (PGDICD-11-12 months), (b) dimensionality, (c) the frequency with which single PGD symptoms occur, and (d) concurrent validity in terms of psychological symptoms and loss-related characteristics. RESULTS: The diagnostic rate of PGDDSM-5-TR (52%) was significantly lower than that of PGDICD-11 (76%) and agreement between the two criteria sets was moderate, κ = 0.51, 95% CI [0.47-0.55]. Increasing the PGDICD-11 accessory symptom threshold did not improve the diagnostic agreement. In contrast, increasing the ICD-11 time criterion led to almost perfect agreement between PGDICD-11-12 months and PGDDSM-5-TR, κ = 0.91, 95% CI [0.89-0.93]. Confirmatory factor analysis results indicated a one-factor model fit best for both PGDDSM-5-TR and PGDICD-11. Emotional pain symptoms (e.g., guilt) were predominantly reported by patients with a PGDICD-11 diagnosis, while attachment disturbance symptoms (e.g., identity disruption) were reported more often by patients with a PGDDSM-5-TR diagnosis. CONCLUSIONS: Despite methodological limitations of this study, results indicate discordance in PGDDSM-5-TR and PGDICD-11 regarding diagnostic rates and single symptom occurrence, while the factor structure is similar. Changes in the ICD-11 time criterion could reduce these differences. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Scales for assessing therapeutic adherence and competence in dialectical behaviour therapy for PTSD: development and analysis of psychometric properties.

Background: The assessment of therapeutic adherence and competence is essential to understand mechanisms that contribute to treatment outcome. Nevertheless, their assessment is often neglected in psychotherapy research. Aims/Objective: To develop an adherence and a treatment-specific competence rating scale for Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD), and to examine their psychometric properties. Global cognitive behavioural therapeutic competence and disorder-specific therapeutic competence were assessed using already existing scales to confirm their psychometric properties in our sample of patients with PTSD and emotion regulation difficulties. Method: Two rating scales were developed using an inductive procedure. 155 videotaped therapy sessions from a multicenter randomised controlled trial were rated by trained raters using these scales, 40 randomly chosen videotapes involving eleven therapists and fourteen patients were doubly rated by two raters. Results: Both the adherence scale (Patient-level ICC = .98; αs = .65; α p = .75) and the treatment-specific competence scale (Patient-level ICC = .98; αs = .78; α p = .82) for DBT-PTSD showed excellent interrater - and good reliability on the patient level. Content validity, including relevance and appropriateness of all items, was confirmed by experts in DBT-PTSD for the new treatment-specific competence scale. Conclusion: Our results indicate that both scales are reliable instruments. They will be useful to examine possible effects of adherence and treatment-specific competence on DBT-PTSD treatment outcome.

Antecedentes: La evaluación de la adherencia y la competencia terapéuticas es esencial para comprender las posibles intervenciones y los mecanismos que contribuyen al resultado del tratamiento. Sin embargo, su evaluación es a menudo descuidada en la investigación en psicoterapia. Objetivos: El objetivo del presente estudio fue desarrollar una escala de valoración de la adherencia y de la competencia específica del tratamiento para la Terapia Dialéctica Conductual para el Trastorno de Estrés Postraumático (DBT-PTSD, en sus siglas en inglés), y examinar sus propiedades psicométricas. Además, se evaluó la competencia terapéutica cognitivo-conductual global y la competencia terapéutica específica del trastorno utilizando escalas ya existentes para confirmar sus propiedades psicométricas en nuestra muestra de pacientes con TEPT y dificultades de regulación de las emociones. Método: Se desarrollaron dos escalas de calificación utilizando un procedimiento inductivo. 155 sesiones de terapia grabadas en video de un ensayo controlado aleatorizado multicéntrico fueron calificadas por evaluadores entrenados utilizando estas escalas, 40 videos elegidos al azar que involucraron a once terapeutas y catorce pacientes fueron doblemente evaluados por dos evaluadores. Resultados: Tanto la escala de adherencia (CCI a nivel de paciente = 0,98; αs = 0,65; α p = 0,75) como la escala de competencia específica para el tratamiento (CCI a nivel de paciente = 0,98; αs = 0,78; α p = 0,82) para la DBT-PTSD mostraron una excelente fiabilidad entre evaluadores y buena a nivel de paciente. La validez del contenido, incluyendo la relevancia y adecuación de todos los ítems, fue confirmada por expertos en DBT-PTSD para la nueva escala de competencia específica para el tratamiento. Conclusión: Nuestros resultados indican que ambas escalas son instrumentos fiables. Serán útiles para examinar los posibles efectos de la adherencia y de la competencia específica para el tratamiento en el resultado del tratamiento DBT-PTSD.

Interpersonal problems and cooperative behavior in patients suffering from prolonged grief disorder as compared to bereaved healthy controls.

OBJECTIVES: Interpersonal factors, such as impairments in social interaction or lack of social support, have an important share when it comes to the development, maintenance, and progression of various mental disorders. METHODS: Individuals suffering from prolonged grief disorder (PGD) and matched bereaved healthy controls (n = 54) underwent a thorough diagnostic procedure, further completed the Inventory of Interpersonal Problems (IIP-D-32), and participated in a finitely iterated prisoner's dilemma (FIPD). RESULTS: Individuals suffering from PGD reported significantly more interpersonal problems. Both groups behaved differently in the FIPD with healthy controls being more carefully, adapting their behavior more flexible, whereas PGD patients displayed a lower responsiveness, which may indicate an inability to adapt to changes in relationships. CONCLUSION: We conclude that interpersonal problems appear to be a relevant feature of PGD. Future studies need to clarify the causal relation behind this link, and should also include measures of attachment, social support, and disconnectedness.

Mental imagery in adolescent PTSD patients after child abuse: a comparison with matched healthy controls.

BACKGROUND: Intrusive mental imagery (MI) plays a crucial role in the maintenance of posttraumatic stress disorder (PTSD) in adults. Evidence on the characteristics of MI in adolescents suffering from PTSD is sparse. The aim of this study was to thoroughly assess MI in an adolescent sample suffering from PTSD after the experience of childhood sexual abuse and/or childhood physical abuse (CA). METHODS: Thirty-two adolescents with a primary diagnosis of PTSD after CA and 32 adolescents without any mental disorder and without a history of CA, matched for age and gender, completed questionnaires assessing the characteristics of negative and positive MI, as well as images of injury and death that lead to positive emotions (ID-images). RESULTS: The PTSD group reported significantly more frequent, more vivid, more distressing and more strongly autobiographically linked negative MI compared to the control group. Although positive MI was highly present in both groups (PTSD: 65.6%; controls: 71.9%), no significant differences emerged between the two groups regarding the distinct characteristics of positive MI. The frequency of the ID-images did not significantly differ between the two groups (PTSD: 21.9%; controls: 9.4%), although the ID-images were more vivid in the PTSD group. DISCUSSION: Negative MI appears to be crucial in adolescent PTSD, whilst positive MI are unexpectedly common in both the PTSD and the control group. The role of positive MI as well as that of ID-images remain unclear. Specific interventions for changing negative MI that are tailored to the developmental challenges in adolescents with PTSD should be developed. TRIAL REGISTRATION: Some of the PTSD patients in this study were also part of a randomized controlled trial on Developmentally adapted Cognitive Processing Therapy (D-CPT). This trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787 , 18 March 2013.

Suicidal ideation, self-injury, aggressive behavior and substance use during intensive trauma-focused treatment with exposure-based components in adolescent and young adult PTSD patients.

BACKGROUND: Multiple traumata such as child sexual and/or physical abuse often result in complex psychopathologies and a range of associated dysfunctional behaviors. Although evidence-based interventions exist, some therapists are concerned that trauma-focused psychotherapy with exposure-based elements may lead to the deterioration of associated dysfunctional behaviors in adolescents and young adults. Therefore, we examined the course of suicidal ideation, self-injury, aggressive behavior and substance use in a group of abuse-related posttraumatic stress disorder (PTSD) patients during phase-based, trauma-focused PTSD treatment. METHODS: Daily assessments from a randomized controlled trial (RCT) of Developmentally adapted Cognitive Processing Therapy (D-CPT) were analyzed to test for differences in the stated dysfunctional behaviors between the four treatment phases. We conducted multilevel modeling and repeated measure ANOVAs. RESULTS: We did not find any significant differences between the treatment phases concerning the stated dysfunctional behaviors, either at the level of urge or at the level of actual actions. On the contrary, in some primary outcomes (self-injury, aggressive behavior), as well as secondary outcomes (distress caused by trauma, joy), we observed significant improvements. DISCUSSION: Overall, during D-CPT, adolescents and young adults showed no deterioration in dysfunctional behaviors, while even showing improvements in some, suggesting that trauma-focused treatment preceded by skills building was not deleterious to this population. Hence, the dissemination of effective interventions such as D-CPT should be fostered, whilst the concerns of the therapists regarding exposure-based components need to be addressed during appropriate training. Nevertheless, further studies with momentary assessment, extended measurement methods, a control group and larger sample sizes are needed to confirm our preliminary findings. TRIAL REGISTRATION: The trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787, 18 March 2013, https://www.drks.de/DRKS00004787 .

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.