Predictors of treatment attendance in patients with posttraumatic stress disorder and comorbid personality disorders.

INTRODUCTION: High dropout and low treatment attendance rates among patients with posttraumatic stress disorder (PTSD) and personality disorders (PDs) continue to pose a significant challenge. Despite numerous studies focusing on enhancing treatment attendance, the identification of consistent and reliable predictors in patients with PTSD and comorbid PDs remains limited. OBJECTIVES: This study aims to investigate a wide range of potential predictors of treatment attendance, encompassing demographic, patient-severity, treatment, and therapist-related variables in patients with PTSD and comorbid borderline and/or cluster C PDs. METHODS: Utilizing data from 255 patients participating in two randomized controlled trials comparing trauma-focused treatment with or without concurrent PD treatment, candidate predictors were individually analyzed in univariate regression models. Significant predictors were then combined in a multiple ordinal regression model. RESULTS: In total, 40% of patients attended fewer trauma-focused treatment sessions than the minimum recommended in treatment guidelines. Out of the 38 candidate predictors examined, five significant, independent predictors of treatment attendance emerged in a multiple ordinal regression model. Higher baseline PTSD severity (OR = 1.04, p = .036), higher education level (OR = 1.22, p = .009) and a stronger patient-rated working alliance (OR = 1.72, p = .047) with the therapist predicted higher treatment attendance. Conversely, inadequate social support from friends (OR = 0.90, p = .042) and concurrent PD treatment and trauma-focused treatment (OR = 0.52, p = .022) were associated with lower treatment attendance. CONCLUSIONS: In conclusion, this constitutes the first study investigating predictors of treatment attendance in patients with PTSD and comorbid PDs. The results highlight the complexity of pinpointing reliable predictors. Nevertheless, the identification of five predictors provides valuable insights, aiding clinicians in customizing treatment strategies for individual patients and enhancing overall treatment attendance.

Study protocol: development and randomized controlled trial of a preventive blended care parenting intervention for parents with PTSD.

BACKGROUND: Children of parents with post-traumatic stress disorder (PTSD) are at increased risk of adverse psychological outcomes. An important risk mechanism is impaired parental functioning, including negative parenting behavior, perceived incompetence, and lack of social support. Several parenting interventions for trauma-exposed parents and parents with psychiatric disorders exist, but none have specifically targeted parents with PTSD. Our objective is to evaluate the effectiveness of a blended care preventive parenting intervention for parents with PTSD. METHODS: The intervention was adapted from an existing online intervention, KopOpOuders Self-Help. In co-creation with parents with PTSD and partners, the intervention was adapted into KopOpOuders-PTSD, by adding PTSD-specific content and three in-person-sessions with a mental health prevention professional. Effectiveness will be tested in a randomized controlled trial among N = 142 parents being treated for PTSD at Arkin Mental Health Care (control condition: treatment as usual, n = 71; intervention condition: treatment as usual + intervention, n = 71). Online questionnaires at pretest, posttest, and three-month follow-up and ecological momentary assessment at pretest and posttest will be used. Intervention effects on primary (parenting behavior) and secondary outcomes (perceived parenting competence, parental social support, parenting stress, child overall psychological problems and PTSD symptoms) will be analyzed using generalized linear mixed modeling. We will also analyze possible moderation effects of parental PTSD symptoms at pretest on primary and secondary outcomes. DISCUSSION: This study protocol describes the randomized controlled trial of KopOpOuders-PTSD, a blended care preventive parenting intervention for parents with PTSD. Findings can contribute to understanding of the effectiveness of parenting support in clinical practice for PTSD. TRIAL REGISTRATION: This protocol (Version 1) was registered on 11-02-2022 at ClinicalTrials.gov under identification number NCT05237999.

Towards a more comprehensive understanding of PTSD and parenting.

BACKGROUND: The impact of post-traumatic stress disorder (PTSD) on parenting and the parent-child relationship has been well-documented in the scientific literature. However, some conceptual and methodological challenges within this research field remain. PROCEDURE: We reflect on a number of challenges that we identified while examining the literature in preparation of an individual participant data meta-analysis on the relationships between PTSD and parenting. FINDINGS: We address 1) the presence of 'trauma-islands'; 2) the need for transdiagnostic theoretical frameworks for mechanisms between PTSD and parenting; 3) the lack of developmental perspectives; 4) the overuse of self-reported retrospective measures; 5) the need to study more diverse samples and cultural contexts; and 6) the lack of research on resilience and post-traumatic growth in parenting. Based on these reflections, we offer suggestions on strategies for responding to these challenges through: 1) welcoming open science; 2) working towards shared theoretical frameworks; 3) doing more longitudinal research 4) expanding the methodological palette; 5) centering lived experience; and 6) taking systemic inequality into account. CONCLUSION: With this commentary, we aim to open a discussion on next steps towards a more comprehensive understanding of the association between PTSD and parenting, and inspire collaborative research.

Self-rated personality disorder symptoms do not predict treatment outcome for posttraumatic stress disorder in routine clinical care.

OBJECTIVE: To test the hypothesis that self-rated personality disorder (PD) symptoms are a significant and clinically relevant predictor of treatment outcomes in a naturalistic treatment setting specialized in trauma-focused treatment using a single-group pretest-posttest design. METHOD: Treatment-seeking patients reporting clinical levels of posttraumatic stress disorder (PTSD) symptoms filled out questionnaires at intake and after treatment. The primary outcome was change in PTSD severity after treatment, measured by the PTSD Checklist for DSM-5 (PCL-5). PD symptoms were measured with the Structured Clinical Interview for DSM-5 Screening Personality Questionnaire (SCID-5-SPQ). Secondary outcomes were general mental health problems, treatment response, number of sessions and dropout. RESULTS: N = 1174 patients (59% female, baseline PCL-5 score M [SD] = 53.0 [10.8]) were included for the primary analysis. Regression analysis revealed that PD symptoms explained 0.4% of variance in PTSD symptom change (p = .066). After controlling for baseline PTSD symptoms, PD symptoms explained 0.0% of variance (p = .311). The fully adjusted model including baseline PTSD symptom severity, age, gender, cumulative exposure to potentially traumatic experiences, PD symptoms, and number of sessions together explained 5% of the observed variance in PTSD symptom change. Baseline PTSD severity was the only significant predictor and negatively predicted outcome. Sensitivity analyses with imputed data from N = 2694 cases yielded comparable results. Finally, secondary analyses showed that PD symptoms did not predict significant or clinically relevant changes in treatment response status, general mental health problems, dropout rates or number of sessions. CONCLUSION: The findings provide no evidence that self-rated PD symptoms predict treatment outcomes for patients suffering from clinical levels of PTSD symptoms in a naturalistic treatment setting specializing in trauma-focused treatment. Self-report screening for these symptoms to inform clinicians about expected effects of PTSD treatment is not supported by the evidence.

Associations between personality traits and suicidal ideation and suicide attempts in patients with personality disorders.

INTRODUCTION: People with personality disorders (PDs) have an elevated suicide risk. However, correlates of suicidal ideation (SI) and suicide attempts (SA) remain largely unknown in this population. A growing body of literature highlights the contribution of the Big Five personality traits in suicide-outcomes. Therefore, the present study investigates the association between the Big Five personality traits and SI and SA in people with PDs while applying the ideation-to-action framework. METHOD: Data were obtained from 105 treatment-seeking individuals diagnosed with PDs participating in the Trauma tO Personality Spectrum Study (TOPSS). Multinomial logistic regression analyses were used to analyze the association between the NEO Five-Factor Inventory and the three category suicide-outcome: non-suicidal, SI, and SA. RESULTS: After controlling for age, gender, a comorbid depressive disorder, the severity of borderline manifestations, and other personality traits from the Big Five taxonomy, significantly lower levels of extraversion were observed in participants with SI compared to non-suicidal participants (OR = 0.27, 95% CI 0.10-0.72) but not in SA participants. In contrast, higher levels of extraversion were associated with SA when compared to SI (OR = 3.52, 95% CI 1.33-9.32). Other Big Five traits were not independently associated with suicide-outcomes. CONCLUSIONS: Of the Big Five traits, the introversion-extraversion dimension most clearly distinguishes individuals with SI from non-suicidal individuals, as well as those with a SA in the past from those with SI only. Prospective studies are required to investigate if this personality trait can predict the progression from being non-suicidal to having SI and from having SI to performing an attempt.

A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design.

BACKGROUND: Comorbidity between Posttraumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD) is high. There is growing motivation among clinicians to offer PTSD treatments - such as Eye Movement Desensitization and Reprocessing (EMDR) - to patients with PTSD and comorbid BPD. However, a large subgroup with comorbid BPD does not sufficiently respond to PTSD treatment and is more likely to be excluded or to dropout from treatment. Dialectical Behaviour Therapy (DBT) for BPD is well established and although there is some evidence that DBT combined with DBT Prolonged Exposure (DBT + DBT PE) is twice as effective in reducing PTSD symptoms than DBT alone, the comparative efficacy of integrated PTSD-DBT and PTSD-only treatment has not been investigated yet. The current study will therefore evaluate the comparative clinical efficacy and cost-effectiveness of EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD. Moreover, it is not clear yet what treatment works best for which individual patient. The current study will therefore evaluate neurobiological predictors and mediators of the individual response to treatment. METHOD: A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of integrated EMDR-DBT (n = 63) and EMDR-only (n = 63) in treatment-seeking adult patients with PTSD and comorbid (sub)clinical BPD. In addition, neurobiological predictors and mediators of treatment outcome, such as hair cortisol, FKBP5 and BDNF protein levels and FKBP5 and BDNF methylation status, are measured through hair and blood samples. DISCUSSION: This is the first study to compare the clinical efficacy and cost-effectiveness of integrated EMDR-DBT and EMDR-only in patients with PTSD and comorbid (sub)clinical BPD, while simultaneously identifying individual predictors and mediators of treatment response. Results will reveal which treatment works best for which individual patient, thereby guiding individual treatment choices and personalizing psychiatry. TRIAL REGISTRATION: Clinical Trials, NCT03833453 . Retrospectively registered, 15 March 2019.

Brain activation during an emotional task in participants with PTSD and borderline and/or cluster C personality disorders.

INTRODUCTION: Although comorbidity of post-traumatic stress disorder (PTSD) with borderline personality disorder (BPD) and/or cluster C personality disorders (CPD) is common, neural correlates of this comorbidity are unknown. METHODS: We acquired functional MRI scans during an emotional face task in participants with PTSD + CPD (n = 34), PTSD + BPD (n = 24), PTSD + BPD + CPD (n = 18) and controls (n = 30). We used ANCOVAs and Bayesian analyses on specific ROIs in a fearful vs. scrambled faces contrast. We also investigated associations with clinical measures. RESULTS: There were no robust differences in brain activation between the groups with ANCOVAs. Transdiagnostically, we found a negative association between severity of dissociation and right insula and right dmPFC activation, and emotion regulation problems with right dmPFC activation. Bayesian analyses showed credible evidence for higher activation in all ROIs in the PTSD + BPD + CPD group compared to PTSD + BPD and PTSD + CPD. DISCUSSION: Our Bayesian and correlation analyses support new dimensional conceptualizations of personality disorders.

A network perspective on posttraumatic stress disorder and comorbid borderline personality disorder symptoms.

Background: Comorbidity between posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) is surrounded by diagnostic controversy and although various effective treatments exist, dropout and nonresponse are high.Objective: By estimating the network structure of comorbid PTSD and BPD symptoms, the current study illustrates how the network perspective offers tools to tackle these challenges.Method: The sample comprised of 154 patients with a PTSD diagnosis and BPD symptoms, assessed by clinician-administered interviews. A regularised partial correlation network was estimated using the GLASSO algorithm in R. Central symptoms and bridge symptoms were identified. The reliability and accuracy of network parameters were determined through bootstrapping analyses.Results: PTSD and BPD symptoms largely clustered into separate communities. Intrusive memories, physiological cue reactivity and loss of interest were the most central symptoms, whereas amnesia and suicidal behaviour were least central.Conclusions: Present findings suggest that PTSD and BPD are two distinct, albeit weakly connected disorders. Treatment of the most central symptoms could lead to an overall deactivation of the network, while isolated symptoms would need more specific attention during therapy. Further experimental, longitudinal research is needed to confirm these hypotheses.Trial registration: ClinicalTrials.gov identifier: NCT03833453.

A network analysis of PTSD and BPD symptoms.PTSD and BPD symptoms largely clustered into separate communities.Intrusive memories, loss of interest and physiological cue reactivity seem valuable treatment targets.

Valenced dual tasking in patients with posttraumatic stress disorder.

OBJECTIVE: Dual-tasking studies show that emotionality and vividness of aversive memory decrease by engaging in a working memory task and simultaneous recall of that memory. Adding positive valence to a dual task might be a promising innovation in the amelioration of lab-induced memory. However, studies aiming to translate these findings into autobiographical memory of a posttraumatic stress disorder (PTSD) population find conflicting results or show methodological flaws. The current study assesses the benefit of adding positive valence to a dual-tasking procedure in PTSD patients. METHOD: In a cross-over design PTSD patients (N = 33) recalled their traumatic memory and received the following three conditions in randomized order: rating positive pictures + exposure, rating neutral pictures + exposure, and exposure only. Each of the three conditions consisted of four sets of 1 min. In the first cycle, participants were exposed to each condition in a randomized order, which was then repeated in a second cycle. Before and after each condition, emotionality and vividness were rated on a visual analog scale (VAS), resulting in seven measurement timepoints in total. RESULTS: Firstly, repeated measures ANOVAs showed a time effect: memories were less emotional and vivid after our summed (three) interventions. Secondly, repeated measures ANCOVAs indicated no evidence for differences between the conditions. CONCLUSIONS: We did not find evidence for a benefit of adding positive valence to a dual-task procedure in PTSD patients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Stabilizing group treatment for complex posttraumatic stress disorder related to child abuse based on psychoeducation and cognitive behavioural therapy: a multisite randomized controlled trial.

BACKGROUND: Evidence-based treatments for complex posttraumatic stress disorder (PTSD) related to childhood abuse are scarce. This is the first randomized controlled trial to test the efficacy of psycho-educational and cognitive behavioural stabilizing group treatment in terms of both PTSD and complex PTSD symptom severity. METHODS: Seventy-one patients with complex PTSD and severe comorbidity (e.g., 74% axis II comorbidity) were randomly assigned to either a 20-week group treatment in addition to treatment as usual or to treatment as usual only. Primary outcome measures were the Davidson trauma scale (DTS) for PTSD and the structured interview for disorders of extreme stress (SIDES) for complex PTSD symptoms. Statistical analysis was conducted in the intention-to-treat (ITT) and in the completer sample. Subjects were considered responders when scoring at 20 weeks at least 1 standard deviation below pretest findings. RESULTS: The 16% attrition was relatively low. After 20 weeks, the experimental condition (large effect sizes) and control condition (medium effect sizes) both showed significant decreases on the DTS and SIDES, but differences between the conditions were not significant. The secondary responder analysis (ITT) revealed significantly more responders on the DTS (45 vs. 21%), but not on the SIDES (61 vs. 42%). CONCLUSIONS: Adding psycho-educational and cognitive behavioural stabilizing group treatment for complex PTSD related to child abuse to treatment as usual showed an equivocal outcome. Patients in both conditions improved substantially during stabilizing treatment, and while significant superiority on change scores was absent, responder analysis suggested clinical meaningfulness of adding group treatment.

Clinical phenomenology of childhood abuse-related complex PTSD in a population of female patients: patterns of personality disturbance.

OBJECTIVE: Complex posttraumatic stress disorder (PTSD) involves a variety of personality disturbances presumed to result from repeated interpersonal trauma such as child abuse. As Complex PTSD patients are a heterogeneous population, we searched for clinically relevant personality-based subtypes. METHOD: This study used a cluster analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Axis II features within a sample of 71 female outpatients with systematically assessed child abuse-related Complex PTSD. RESULTS: Two main subtypes were found: adaptive and nonadaptive. The latter was further differentiated into withdrawn, alienated, suffering, and aggressive subtypes, characterized by different levels of introversion and disinhibition. Among the nonadaptive subtypes, the severity of Complex PTSD symptoms was lowest in the withdrawn (introverted only) subtype. The subtypes differed in their level of dissociation and depression but did not differ regarding PTSD symptoms, trauma history, or parental bonding characteristics. CONCLUSION: Confirming earlier findings, our study found personality-based Complex PTSD subtypes, which could implicate differential treatment needs and results.

Cluster B versus Cluster C Personality Disorders: A Comparison of Comorbidity, Suicidality, Traumatization and Global Functioning.

A general clinical assumption states that cluster B personality disorders (PDs) represent a more severe form of PD than cluster C PDs. Consequently, most PD research is centered on cluster B PDs (especially borderline PD). Yet, prevalence ratings of cluster C PDs exceed those of cluster B PDs. In this explorative, cross-sectional study, we compared cluster B and C PD patients (N = 94) on a wide range of clinically-relevant severity measures, including comorbidity, suicidality, (childhood) traumatization and global functioning. Results showed that, although cluster B PD patients suffered more often from substance use disorders and lifetime suicide attempts, no difference could be established between groups for all other severity measures, including trauma variables. In our study, we additionally included a group of combined cluster B and C PDs, who were largely similar to both other groups. Although our study is insufficiently powered to claim a significant non-difference, these findings emphasize that high rates of comorbidity, suicidality, childhood traumatization and functional impairment apply to both cluster B and C patients. As such, our findings encourage more research into cluster C PDs, ultimately leading to more evidence-based treatments for this prevalent patient group. In addition, the high level of traumatization across groups calls for a routine trauma screening, especially since PD treatment may benefit from concurrent trauma treatment.

Associations Between Child Maltreatment, Inflammation, and Comorbid Metabolic Syndrome to Depressed Mood in a Multiethnic Urban Population: The HELIUS Study.

Background: Child maltreatment is a common negative experience and has potential long-lasting adverse consequences for mental and physical health, including increased risk for major depressive disorder (MDD) and metabolic syndrome. In addition, child maltreatment may increase the risk for comorbid physical health conditions to psychiatric conditions, with inflammation as an important mediator linking child maltreatment to poor adult health. However, it remains unresolved whether experiencing child maltreatment increases the risk for the development of comorbid metabolic syndrome to MDD. Therefore, we investigated whether child maltreatment increased the risk for comorbid metabolic syndrome to depressed mood. Subsequently, we examined whether C-reactive protein (CRP), as an inflammatory marker, mediated this association. In addition, we investigated whether effects differed between men and women. Methods: Associations were examined within cross-sectional data from the multiethnic HELIUS study (N = 21,617). Adult residents of Amsterdam, Netherlands, self-reported on child maltreatment (distinct and total number of types experienced before the age of 16 years) as well as current depressed mood (PHQ-9 score ≥ 10), and underwent physical examination to assess metabolic syndrome. The CRP levels were assessed in N = 5,998 participants. Logistic and linear regressions were applied for binary and continuous outcomes, respectively. All analyses were adjusted for relevant demographic, socioeconomic, and lifestyle characteristics, including ethnicity. Results: A higher number of maltreatment types as well as distinct types of emotional neglect, emotional abuse, and sexual abuse were significantly associated with a higher risk for current depressed mood. Child maltreatment was not significantly associated with the risk for metabolic syndrome in the whole cohort, nor within individuals with depressed mood. As child maltreatment was not significantly associated with the CRP levels, subsequent mediation analyses were not performed. No significant moderating effects by sex were observed. Conclusion: In this multiethnic urban cohort, child maltreatment was associated with a higher risk for depressed mood. Contrary to our expectations, child maltreatment was not significantly associated with an increased risk for metabolic syndrome, neither in the whole cohort nor as a comorbid condition in individuals with depressed mood. As the data were cross-sectional and came from a non-clinical adult population, longitudinal perspectives in relation to various stages of the investigated conditions were needed with more comprehensive assessments of inflammatory markers.

Impact of comorbid personality disorders on psychotherapy for post-traumatic stress disorder: systematic review and meta-analysis.

Background: Although personality disorders are common in PTSD patients, it remains unclear to what extent this comorbidity affects PTSD treatment outcome. Objective: This constitutes the first meta-analysis investigating whether patients with and without comorbid personality disorders can equally benefit from psychotherapy for PTSD. Method: A systematic literature search was conducted in PubMed, EMBASE, PsychINFO and Cochrane databases from inception through 31 January 2020, to identify clinical trials examining psychotherapies for PTSD in PTSD patients with and without comorbid personality disorders (PROSPERO reference CRD42020156472). Results: Of the 1830 studies identified, 12 studies reporting on 918 patients were included. Effect sizes were synthesized using a random-effects model. Patients with comorbid personality disorders did not have significantly higher baseline PTSD severity (Hedges' g = 0.23, 95%CI -0.09-0.55, p = .140), nor were at higher risk for dropout from PTSD treatment (RR = 1.19, 95%CI 0.83-1.72, p = .297). Whilst pre- to post-treatment PTSD symptom improvements were large in patients with comorbid PDs (Hedges' g = 1.31, 95%CI 0.89-1.74, p < .001) as well as in patients without comorbid PDs (Hedges' g = 1.57, 95%CI 1.08-2.07, p < .001), personality disorders were associated with a significantly smaller symptom improvement at post-treatment (Hedges' g = 0.22, 95%CI 0.05-0.38, p = .010). Conclusion: Although the presence of personality disorders does not preclude a good treatment response, patients with comorbid personality disorders might benefit less from PTSD treatment than patients without comorbid personality disorders.

Antecedentes: Aunque los trastornos de la personalidad son comunes en los pacientes con TEPT, sigue sin estar claro en qué medida afecta esta comorbilidad al resultado del tratamiento del TEPT.Objetivo: Este constituye el primer meta-análisis que investiga si los pacientes con ysin trastornos de la personalidad comórbidos pueden beneficiarse de la misma forma de la psicoterapia para el TEPT.Método: Se realizó una búsqueda sistemática de literatura en las bases de datos PubMed, EMBASE, PsycINFO yCochrane desde su creación hasta el 31 de enero de 2020, para identificar estudios clínicos que examinaron psicoterapias para el TEPT en pacientes con TEPT, con ysin trastornos de la personalidad comórbidos. (referencia PROSPERO CRD42020156472).Resultados: De los 1830 estudios identificados, se incluyeron 12 estudios, que reportaron 918 pacientes. Los tamaños de efecto fueron sintetizados usando un modelo de efectos aleatorios. Los pacientes con trastornos de la personalidad comórbidos no tuvieron una severidad del TEPT basal significativamente mayor (gde Hedges = 0.23, IC 95% ­0.09 ­ 0.55, p= .140), ni tuvieron un mayor riesgo de abandono del tratamiento del TEPT (RR=1.19, IC 95% 0.83 ­ 1.72, p= .297). Mientras que la mejoría de los síntomas de TEPT pre apost tratamiento fue grande en los pacientes con TP comórbidos (g de Hedges = 1.31, IC 95% 0.89 ­ 1.74, p< .001) así como también en pacientes sin TP comórbidos (g de Hedges = 1.57, IC 95% 1.08 ­ 2.07, p< .001), los trastornos de la personalidad se asociaron auna mejoría sintomática significativamentemás pequeña en el post-tratamiento (g de Hedges = 0.22, IC 95% 0.05 ­ 0.38, p= .010).Conclusión: Aunque la presencia de trastornos de la personalidad no impide una buena respuesta atratamiento, los pacientes con trastornos de la personalidad comórbidos podrían beneficiarse menos del tratamiento del TEPT que los pacientes sin trastornos de la personalidad comórbidos.

The Association Between Childhood Trauma and Attachment Functioning in Patients With Personality Disorders.

Attachment (mal)functioning and a history of childhood trauma (CT) are both considered psychological determinants of personality disorders (PDs). Their interaction, however, remains largely uninvestigated. In this study, the authors assessed adult and childhood attachment style in a sample of patients with diverse PDs (N = 75) and determined the relation with both occurrence and severity of CT. The authors found that the sample was characterized by severe attachment malfunctioning and high levels of CT. Using cross-tabulations and analysis of variance, the authors showed that patients with a fearful or dismissive attachment style experienced more severe CT than patients with a preoccupied attachment style. Patients reporting an affectionless control bonding style to either parent suffered frequent and severe CT. Although temporal causality cannot be determined, these findings stress the necessity to screen for CT in PDs and suggest that attachment-centered psychotherapy for these patients may benefit from preceding or concurrent trauma treatment.

Clinical Efficacy and Cost-Effectiveness of Imagery Rescripting Only Compared to Imagery Rescripting and Schema Therapy in Adult Patients With PTSD and Comorbid Cluster C Personality Disorder: Study Design of a Randomized Controlled Trial.

Background: Posttraumatic stress disorder (PTSD) is a serious and relatively common mental disorder causing a high burden of suffering. Whereas evidence-based treatments are available, dropout and non-response rates remain high. PTSD and Cluster C personality disorders (avoidant, dependent or obsessive-compulsive personality disorder; CPD) are highly comorbid and there is evidence for suboptimal treatment effects in this subgroup of patients. An integrated PTSD and CPD treatment may be needed to increase treatment efficacy. However, no studies directly comparing the efficacy of regular PTSD treatment and treatment tailored to PTSD and comorbid CPD are available. Whether integrated treatment is more effective than treatment focused on PTSD alone is important, since (1) no evidence-based guideline for PTSD and comorbid CPD treatment exists, and (2) treatment approaches to CPD are costly and time consuming. Present study design describes a randomized controlled trial (RCT) directly comparing trauma focused treatment with integrated trauma focused and personality focused treatment. Methods: An RCT with two parallel groups design will be used to compare the clinical efficacy and cost-effectiveness of "standalone" imagery rescripting (n = 63) with integrated imagery rescripting and schema therapy (n = 63). This trial is part of a larger research project on PTSD and personality disorders. Predictors, mediators and outcome variables are measured at regular intervals over the course of 18 months. The main outcome is PTSD severity at 12 months. Additionally, machine-learning techniques will be used to predict treatment outcome using biopsychosocial variables. Discussion: This study protocol outlines the first RCT aimed at directly comparing the clinical efficacy and cost-effectiveness of imagery rescripting and integrated imagery rescripting and schema therapy for treatment seeking adult patients with PTSD and comorbid cluster C personality pathology. Additionally, biopsychosocial variables will be used to predict treatment outcome. As such, the trial adds to the development of an empirically informed and individualized treatment indication process. Clinical Trial registration: ClinicalTrials.gov, NCT03833531.

Neural correlates of treatment effect and prediction of treatment outcome in patients with PTSD and comorbid personality disorder: study design.

BACKGROUND: Neural alterations related to treatment outcome in patients with both post-traumatic stress disorder (PTSD) and comorbid personality disorder are unknown. Here we describe the protocol for a neuroimaging study of treatment of patients with PTSD and comorbid borderline (BPD) or cluster C (CPD) personality disorder traits. Our specific aims are to 1) investigate treatment-induced neural alterations, 2) predict treatment outcome using structural and functional magnetic resonance imaging (MRI) and 3) study neural alterations associated with BPD and CPD in PTSD patients. We hypothesize that 1) all treatment conditions are associated with normalization of limbic and prefrontal brain activity and hyperconnectivity in resting-state brain networks, with additional normalization of task-related activation in emotion regulation brain areas in the patients who receive trauma-focused therapy and personality disorder treatment; 2) Baseline task-related activation, together with structural brain measures and clinical variables predict treatment outcome; 3) dysfunction in task-related activation and resting-state connectivity of emotion regulation areas is comparable in PTSD patients with BPD or CPD, with a hypoconnected central executive network in patients with PTSD+BPD. METHODS: We aim to include pre- and post-treatment 3 T-MRI scans in 40 patients with PTSD and (sub) clinical comorbid BPD or CPD. With an expected attrition rate of 50%, at least 80 patients will be scanned before treatment. MRI scans for 30 matched healthy controls will additionally be acquired. Patients with PTSD and BPD were randomized to either EMDR-only or EMDR combined with Dialectical Behaviour Therapy. Patients with PTSD and CPD were randomized to Imaginary Rescripting (ImRs) or to ImRs combined with Schema Focused Therapy. The scan protocol consists of a T1-weighted structural scan, resting state fMRI, task-based fMRI during an emotional face task and multi-shell diffusion weighted images. For data analysis, multivariate mixed-models, regression analyses and machine learning models will be used. DISCUSSION: This study is one of the first to use neuroimaging measures to predict and better understand treatment response in patients with PTSD and comorbid personality disorders. A heterogeneous, naturalistic sample will be included, ensuring generalizability to a broad group of treatment seeking PTSD patients. TRIAL REGISTRATION: Clinical Trials, NCT03833453 & NCT03833531 . Retrospectively registered, February 2019.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial.

BACKGROUND: Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study's aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated. METHODS: The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains. DISCUSSION: This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome. TRIAL REGISTRATION: Netherlands Trial Register NL6965, registered 25/04/2018.

Increased activation of the left hippocampus region in Complex PTSD during encoding and recognition of emotional words: a pilot study.

To gain insight into memory disturbances in Complex Posttraumatic Stress Disorder (Complex PTSD), we investigated declarative memory function and medial temporal lobe activity in patients and healthy non-traumatized controls. A case-control study was performed in nine patients with Complex PTSD and nine controls. All respondents performed a declarative memory task with neutral and emotional, negative words during functional magnetic resonance imaging. Memory performance of neutral words was impaired in Complex PTSD with a relative conservation of recall of negative words. Deep encoding of later remembered negative words, as well as correct recognition of negative words and false alarms, was associated with an enhanced Blood Oxygenation Level Dependent (BOLD) response in the left hippocampus extending into the parahippocampal gyrus of Complex PTSD patients compared with controls. Post-hoc volumetric comparisons did not reveal significant anatomical differences in the medial temporal lobe between Complex PTSD patients and controls. We conclude that in Complex PTSD preferential recall of negative words is associated with increased activation in the left hippocampus and parahippocampal gyrus during both successful and false recall. These findings support a model of an abnormally functioning hippocampus in Complex PTSD.