Implementing Approach-Bias Modification as Add-On to Varieties of Clinical Treatment for Alcohol Use Disorders: Results of a Multicenter RCT.

INTRODUCTION: Abstinence rates after inpatient treatment for alcohol use disorder (AUD) are modest (1-year rate around 50%). One promising approach is to re-train the automatically activated action tendency to approach alcohol-related stimuli (alcohol-approach bias) in AUD patients, as add-on to regular treatment. As efficacy has been demonstrated in well-controlled randomized controlled trials, the important next step is to add alcohol-approach-bias modification (alcohol-ApBM) to varieties of existing treatments for AUD. Therefore, this prospective, multicenter implementation-RCT examined whether adding alcohol-ApBM to regular treatments (various abstinence-oriented treatments including both individual and group-based interventions) would significantly increase abstinence rates compared to receiving regular treatment only, in a variety of naturalistic settings with different therapeutic approaches. METHODS: A total of 1,586 AUD inpatients from 9 German rehabilitation clinics were randomly assigned to receive either ApBM in addition to regular treatment or not. Training satisfaction of patients and therapists was measured after training. Success rates were determined at 3, 6, and 12 months post-treatment. RESULTS: Return rates of the post-treatment assessments varied greatly between clinics, often being low (18-76%). Nevertheless, ApBM significantly increased success rates after 3 months. After 6 and 12 months, the differences were not significant. ApBM was evaluated mostly positively by patients and therapists. DISCUSSION/CONCLUSION: ApBM was an effective add-on to regular treatment of AUD at 3 months follow-up, across a variety of AUD treatment settings. However, low return rates for the clinical outcomes reduced the effect size of ApBM considerably. The application of ApBM proved feasible in varying clinical settings, offering the opportunity to modify automatic processes and to promote abstinence.

Hostile and threatening interpretation biases in adolescent inpatients are specific to callous-unemotional traits and social anxiety.

Psychopathological syndromes, such as disruptive behavior and anxiety disorders in adolescence, are characterized by distorted cognitions and problematic behavior. Biased interpretations of ambiguous social situations can elicit both aggressive and avoidance behavior. Yet, it is not well understood whether different interpretation biases are specific to different syndromes, or whether they can co-occur. We assessed both hostile and threatening interpretation biases in identical social situations, and proposed that they are uniquely related to callous-unemotional (CU) traits and social anxiety, respectively. We also explored the role of gender and age herein. The sample consisted of 390 inpatients between 10 and 18 years of age with a variety of psychiatric disorders. Hostile and threatening interpretations were assessed with the Ambiguous Social Scenario Task (ASST) consisting of 10 written vignettes. Both CU-traits and social anxiety were assessed with self-report questionnaires. Results showed that, overall, CU-traits were related to more hostile interpretations, whereas social anxiety was related to more threatening interpretations. In addition, in boys, hostile and threatening interpretations correlated significantly positive with each other. Age was not related to interpretation biases. Together, these results generally support the content-specificity of interpretation biases in concepts relevant to disruptive behavior disorders and anxiety disorders, and indicate that different interpretation biases can co-occur specifically in boys.

The longitudinal link between popularity, likeability, fear of negative evaluation and social avoidance across adolescence.

This study investigated the longitudinal bidirectional associations between likeability, popularity, fear of negative evaluation, and social avoidance, to aid in preventing the negative consequences and persistent trajectories of low social status and heightened social anxiety. In total, 1741 adolescents in grades 7-9 participated at 3 yearly waves. A self-report questionnaire measured fear of negative evaluation. Peer nominations assessed likeability, popularity, and social avoidance. Lower popularity predicted more avoidance, and vice versa. More avoidance was related to lower likeability over time. Being less popular and/or more liked by peers, increased fear of negative evaluation. Support for a transactional model between social anxiety and social status was found, but distinguishing different social status and social anxiety components is necessary.

Facing Uncertainty: Interpretation of Ambiguous Emotional Faces in Childhood Social Anxiety Disorder.

OBJECTIVE: The current study examined whether children with a social anxiety disorder (SAD) demonstrate divergent facial emotion processing and a disorder-specific negative interpretation bias in the processing of facial emotional expressions. This study aimed to overcome previous study limitations by including both a nonsocially anxious control group and a healthy control group to examine whether childhood SAD is characterized by a general emotion labeling deficit, and/or by a negative interpretation bias, indicated by systematic misclassifications, or a lower threshold for recognizing threatening emotions. METHOD: Participants were 132 children aged 7-12 years (Mage = 9.15; 45.5% female). Children with SAD (n = 42) were compared to children with other, nonsocial, anxiety disorders (n = 40) and healthy control children (n = 50) on a novel facial emotion recognition task. Children judged ambiguous happy/neutral, angry/neutral and fear/neutral faces that were morphed at different intensities (10%, 30%, 50%, 70%). RESULTS: Children with SAD did not differ from other groups in their accuracy of identifying emotions. They did not show systematic misclassifications or a heightened sensitivity to negative, threatening faces either. Rather, children with nonsocial anxiety disorders showed a generally heightened sensitivity to emotional faces. CONCLUSIONS: The current study does not provide evidence for a general deficit in labeling of emotional faces in childhood SAD. Childhood SAD was not characterized by an interpretation bias in processing emotional faces. Children with nonsocial anxiety disorders may benefit from assistance in accurately interpreting the degree of emotionality in interpersonal situations.

Evaluations of three different types of smiles in relation to social anxiety and psychopathic traits.

Research has identified three different types of smiles - the reward, affiliation and dominance smile - which serve expressions of happiness, connectedness, and superiority, respectively. Examining their explicit and implicit evaluations by considering a perceivers' level of social anxiety and psychopathy may enhance our understanding of these smiles' theorised meanings, and their role in problematic social behaviour. Female participants (N=122) filled in questionnaires on social anxiety, psychopathic tendencies (i.e. the affective-interpersonal deficit and antisocial lifestyle) and callous-unemotional (CU) traits. In order to measure explicit and implicit evaluations of the three smiles, angry and neutral facial expressions, an Explicit Valence Rating Task and an Approach-Avoidance Task were administered. Results indicated that all smiles were explicitly evaluated as positive. No differences in implicit evaluations between the smile types were found. Social anxiety was not associated with either explicit or implicit smile evaluations. In contrast, CU-traits were negatively associated with explicit evaluations of reward and dominance smiles. These findings support the assumptions of non-biased explicit information processing in social anxiety, and flattened emotional sensitivity in CU-traits. The importance of a multimethod approach to enhance the understanding of the effects of smile types on perceivers is discussed.

The Role of Perseverative Cognition for Both Mental and Somatic Disorders in a Naturalistic Psychiatric Patient Sample.

OBJECTIVE: Perseverative cognition (PC) is the repeated or long-term activation of the cognitive representation of psychological stressors and is associated with prolonged stress including somatic and mental consequences. Hence, PC might represent a cognitive process linking mental and somatic pathology, but current research on this link is limited by investigating healthy samples, markers of somatic disease, and single disorders. The present study explored the importance of PC for different mental and somatic disorders in psychiatric patients. METHODS: Data from 260 naturalistic psychiatric outpatients were used. Psychiatric diagnoses were based on structured clinical interviews. Somatic diseases were assessed using a well-validated questionnaire and were clustered into (cardio)vascular and immune/endocrine diseases. PC was operationalized using the Perseverative Thinking Questionnaire (PTQ). RESULTS: Multiple regression complemented with relative importance analyses showed that the PTQ total and subscale scores were associated with the presence of mood disorders, addiction, and anxiety. Unexpectedly, no relatively important associations were found between the PTQ and autism spectrum disorder, attention-deficit/hyperactivity disorder, or somatic disease. CONCLUSIONS: Our data complement previous work linking PC to stress-related mental disorders but question its immediate role in neurodevelopmental and somatic disorders. Targeting PC in the treatment of mood disorders and perhaps also in addiction seems promising.

A randomized controlled trial of cognitive control training (CCT) as an add-on treatment for late-life depression: a study protocol.

BACKGROUND: Already a major health concern, late-life depression (LLD) is expected to form an increasing problem in the aging population. Moreover, despite current treatments, LLD is associated with a poor long-term prognosis and high rate of chronicity. Treatment provision and treatment accordingly warrant improvement, where add-on treatments might contribute to the efficacy of conventional therapies. Although it is known that impaired cognitive control contributes to LDD, it is not targeted sufficiently by current interventions. Research on cognitive control training (CCT) shows promising results on depressive symptoms, cognitive performance, and overall functioning. However, further research is needed to determine the long-term effects of CCT on LLD, its cost-effectiveness, and mechanisms of change. METHODS: In the current multicenter randomized controlled trial (RCT) with a between-subjects design participants aged 60 years and over with a current LLD receiving treatment as usual (TAU) are randomized to add-on CCT or placebo training. Randomization is stratified by depression severity. Participants will receive eight online CCT or placebo sessions spread across four consecutive weeks. They will complete a post-training assessment after 1 month and three follow-up assessments scheduled three, six and 12 months after completing the training. We expect CCT and TAU to be more (cost-)effective in reducing depressive symptoms than placebo training and TAU. Additionally, we will be looking at secondary clinical, cognitive and global functioning outcomes and likely mechanisms of change (e.g., improved cognitive functioning, reduced rumination, and improved inhibition of negative stimuli). DISCUSSION: The proposed RCT aims to contribute to the clinical and scientific knowledge on the long-term effects of CCT as an add-on treatment for LLD. Cost-effectiveness is particularly relevant considering the expected volume of the target demographic. The study will be a pragmatic trial with few inclusion restrictions, providing information on feasibility of web-based trainings in clinical settings. The outcomes are potentially generalizable to guidelines for treatment of LLD. TRIAL REGISTRATION: This trial is registered in the Netherlands Trial Register (code: NL7639 ). Registered 3 april 2019.

Addiction-Focused Eye Movement Desensitization and Reprocessing Therapy as an Adjunct to Regular Outpatient Treatment for Alcohol Use Disorder: Results From a Randomized Clinical Trial.

BACKGROUND: This study examined the feasibility, safety, and efficacy of addiction-focused eye movement desensitization and reprocessing (AF-EMDR) treatment, as an add-on intervention to treatment as usual (TAU). METHODS: Adult outpatients with alcohol use disorder (AUD) (N = 109) who already received or had just started with TAU (Community Reinforcement Approach) were recruited at 6 outpatient addiction care facilities. They were randomly assigned to either TAU + 7 weekly 90-minute sessions of AF-EMDR (N = 55) or TAU-only (N = 54). Assessments were made at baseline, after AF-EMDR therapy (+ 8 weeks in the TAU-only group), and at 1- and 6-month follow-up. The primary outcomes were changes in drinking behavior as reported by the participant and biomarker indices. RESULTS: Data were analyzed as intent-to-treat with linear mixed models. Additionally, sensitivity analyses were performed. No group or interaction effects were found for any of the outcome variables. Only limited change over time was seen with regard to indices of personal and societal recovery and in some secondary indices of clinical recovery (craving, desire thinking, and rumination). Reliable Change Index calculations showed that more TAU-only participants showed clinical improvement with regard to alcohol consumption while a somewhat higher proportion of participants in the TAU + AF-EMDR group experienced less craving. The acceptability, safety, and feasibility of the treatments received in both groups were comparable. CONCLUSIONS: There was no add-on effect of AF-EMDR on TAU with regard to drinking behavior in outpatients with an AUD. Possible explanations are discussed. Future studies should first establish proof of principle regarding the potential of AF-EMDR therapy to disrupt operant learning and habits relevant in addiction.

Cognitive Remediation Therapy Does Not Enhance Treatment Effect in Obsessive-Compulsive Disorder and Anorexia Nervosa: A Randomized Controlled Trial.

BACKGROUND: Guideline-recommended therapies are moderately successful in the treatment of obsessive-compulsive disorder (OCD) and anorexia nervosa (AN), leaving room for improvement. Cognitive inflexibility, a common trait in both disorders, is likely to prevent patients from engaging in treatment and from fully benefiting from existing therapies. Cognitive remediation therapy (CRT) is a practical augmentation intervention aimed at ameliorating this impairing cognitive style prior to disorder-specific therapy. OBJECTIVE: To compare the effectiveness of CRT and a control treatment that was not aimed at enhancing flexibility, named specialized attention therapy (SAT), as add-ons to treatment as usual (TAU). METHODS: In a randomized controlled multicenter clinical trial, 71 adult patients with OCD and 61 with AN were randomized to ten twice-weekly sessions with either CRT or SAT, followed by TAU. Patients were evaluated at baseline, post-CRT/SAT, and after 6 and 12 months, with outcomes being quantified using the Yale-Brown Obsessive Compulsive Scale for OCD and the Eating Disorder Examination Questionnaire for AN. RESULTS: Across study groups, most importantly CRT+TAU was not superior to control treatment (SAT)+TAU in reducing OCD and AN pathology. Contrary to expectations, SAT+TAU may have been more effective than CRT+TAU in patients being treated for OCD. CONCLUSIONS: CRT did not enhance the effect of TAU for OCD and AN more than SAT. Unexpectedly, SAT, the control condition, may have had an augmentation effect on TAU in OCD patients. Although this latter finding may have been due to chance, the effect of SAT delivered as a pretreatment add-on intervention for adults with OCD and AN merits future efforts at replication.

Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials.

The purpose of this meta-analysis was to provide updated pooled effect sizes of evidence-based psychotherapies and medications for generalized anxiety disorder (GAD) and to investigate potential moderators of outcomes. Seventy-nine randomized controlled trials (RCT) including 11,002 participants with a diagnosis of GAD were included in a meta-analysis that tested the efficacy of psychotherapies or medications for GAD. Psychotherapy showed a medium to large effect size (g = 0.76) and medication showed a small effect size (g = 0.38) on GAD outcomes. Psychotherapy also showed a medium effect on depression outcomes (g = 0.64) as did medications (g = 0.59). Younger age was associated with a larger effect size for psychotherapy (p < 0.05). There was evidence of publication bias in psychotherapy studies. This analysis found a medium to large effect for empirically supported psychotherapy interventions on GAD outcomes and a small effect for medications on GAD outcomes. Both groups showed a medium effect on depression outcomes. Because medication studies had more placebo control conditions than inactive conditions compared to psychotherapy studies, effect sizes between the domains should not be compared directly. Patient age should be further investigated as a potential moderator in psychotherapy outcomes in GAD.

The processing of task-irrelevant emotion and colour in the Approach-Avoidance Task.

When processing information about human faces, we have to integrate different sources of information like skin colour and emotional expression. In 3 experiments, we investigated how these features are processed in a top-down manner when task instructions determine the relevance of features, and in a bottom-up manner when the stimulus features themselves determine process priority. In Experiment 1, participants learned to respond with approach-avoidance movements to faces that presented both emotion and colour features (e.g. happy faces printed in greyscale). For each participant, only one of these two features was task-relevant while the other one could be ignored. In contrast to our predictions, we found better learning of task-irrelevant colour when emotion was task-relevant than vice versa. Experiment 2 showed that the learning of task-irrelevant emotional information was improved in general when participants' awareness was increased by adding NoGo-trials. Experiment 3 replicated these results for faces and emotional words. We conclude that during the processing of faces, both bottom-up and top-down processes are involved, such that task instructions and feature characteristics play a role. Ecologically significant features like emotions are not necessarily processed with high priority. The findings are discussed in the light of theories of attention and cognitive biases.

Effect of cognitive bias modification-memory on depressive symptoms and autobiographical memory bias: two independent studies in high-ruminating and dysphoric samples.

Memory bias is a risk factor for depression. In two independent studies, the efficacy of one CBM-Memory session on negative memory bias and depressive symptoms was tested in vulnerable samples. We compared positive to neutral (control) CBM-Memory trainings in highly-ruminating individuals (N = 101) and individuals with elevated depressive symptoms (N = 100). In both studies, participants studied positive, neutral, and negative Swahili words paired with their translations. In five study-test blocks, they were then prompted to retrieve either only the positive or neutral translations. Immediately following the training and one week later, we tested cued recall of all translations and autobiographical memory bias; and also measured mood, depressive symptoms, and rumination. Retrieval practice resulted in training-congruent recall both immediately after and one week after the training. Overall, there was no differential decrease in symptoms or difference in autobiographical memory bias between the training conditions. In the dysphoric but not in the high-ruminating sample, the positive training resulted in positive autobiographical bias only in dysphoric individuals with positive pre-existing bias. We conclude that one session of positive retrieval-based CBM-Memory may not be enough to yield symptom change and affect autobiographical memory bias in vulnerable individuals.

Content-Specific Interpretation Bias in Children with Varying Levels of Anxiety: The Role of Gender and Age.

The current study examined whether children varying in their levels of social anxiety, separation anxiety and spider fear exhibit a negative interpretation bias specific for their fears. Furthermore, age and gender were assessed as moderators of this relation. Children (N = 603) of the age of 7-12 years were asked to solve ambiguous scenarios reflecting social threat, separation threat or spider threat. Children's levels of anxiety were assessed with self-report questionnaires. Results indicated that children scoring higher on self-reported social anxiety, separation anxiety or spider fear, displayed a negative interpretation bias for the threat-scenarios pertaining to their specific anxiety or fear, even after controlling for comorbidity with other anxiety subtypes. Contrary to our hypotheses, we did not find moderating effects of age or gender. These results indicate that even in a community sample, content-specificity of negative interpretation biases is present.

Modification of Automatic Alcohol-Approach Tendencies in Alcohol-Dependent Patients with Mild or Major Neurocognitive Disorder.

BACKGROUND: To examine the applicability of an alcohol-avoidance training procedure in patients with alcohol dependence and alcohol-induced neurocognitive disorders (NDs), we trained 2 groups that differed in the degree of cognitive impairment: One group fulfilled the DSM-5 criteria for alcohol-induced mild ND, and 1 group was diagnosed with Korsakoff's syndrome (KS) (alcohol-induced major ND, confabulatory/amnesic subtype; DSM-5). The intervention is assumed to match the preserved cognitive capacity for implicit learning in both groups. METHODS: Fifty-one inpatients with a mild ND and 54 inpatients with KS were trained. Six training sessions (including pre- and posttests) of a computerized implicit alcohol approach-avoidance task were applied. Neurocognitive variables were available from the standard assessment procedure of the clinic. RESULTS: Training of alcohol-avoidance tendencies is feasible in a population with alcohol-related NDs. The alcohol-approach bias decreased for both groups in each session. Better learning results over time were obtained in participants with a larger baseline alcohol-approach tendency. Learning effects were positively related to age and implicit (nondeclarative) memory functioning. No relation between training effects and executive or explicit memory functions was found. CONCLUSIONS: Training of an alcohol-avoidance tendency can be successfully applied in patients with alcohol dependence including those with alcohol-induced NDs.

Mindfulness-based cognitive therapy for patients with chronic, treatment-resistant depression: A pragmatic randomized controlled trial.

BACKGROUND: Chronic and treatment-resistant depressions pose serious problems in mental health care. Mindfulness-based cognitive therapy (MBCT) is an effective treatment for remitted and currently depressed patients. It is, however, unknown whether MBCT is effective for chronic, treatment-resistant depressed patients. METHOD: A pragmatic, multicenter, randomized-controlled trial was conducted comparing treatment-as-usual (TAU) with MBCT + TAU in 106 chronically depressed outpatients who previously received pharmacotherapy (≥4 weeks) and psychological treatment (≥10 sessions). RESULTS: Based on the intention-to-treat (ITT) analysis, participants in the MBCT + TAU condition did not have significantly fewer depressive symptoms than those in the TAU condition (-3.23 [-6.99 to 0.54], d = 0.35, P = 0.09) at posttreatment. However, compared to TAU, the MBCT + TAU group reported significantly higher remission rates (χ2 (2) = 4.25, φ = 0.22, P = 0.04), lower levels of rumination (-3.85 [-7.55 to -0.15], d = 0.39, P = 0.04), a higher quality of life (4.42 [0.03-8.81], d = 0.42, P = 0.048), more mindfulness skills (11.25 [6.09-16.40], d = 0.73, P < 0.001), and more self-compassion (2.91 [1.17-4.65], d = 0.64, P = 0.001). The percentage of non-completers in the MBCT + TAU condition was relatively high (n = 12, 24.5%). Per-protocol analyses revealed that those who completed MBCT + TAU had significantly fewer depressive symptoms at posttreatment compared to participants receiving TAU (-4.24 [-8.38 to -0.11], d = 0.45, P = 0.04). CONCLUSION: Although the ITT analysis did not reveal a significant reduction in depressive symptoms of MBCT + TAU over TAU, MBCT + TAU seems to have beneficial effects for chronic, treatment-resistant depressed patients in terms of remission rates, rumination, quality of life, mindfulness skills, and self-compassion. Additionally, patients who completed MBCT showed significant reductions in depressive symptoms. Reasons for non-completion should be further investigated.

Retraining of automatic action tendencies in individuals with obesity: A randomized controlled trial.

Obesity is a major health concern, characterized by an automatically activated tendency to (over)-eat. Recent research suggests that an effective way to counteract automatic approach tendencies in unhealthy consumption behavior might be approach bias modification. Therefore, we investigated an approach-avoidance training for unhealthy food cues in 189 patients with obesity of a psychosomatic inpatient clinic who were participating in a nutrition advice program. Patients in the active training group were trained to make avoidance movements (pushing a joystick) in response to unhealthy food pictures and approach movements (pulling the joystick) in response to positive pictures, while the control group received sham training (approaching and avoiding both picture types). Approach-avoidance bias, body mass index, eating pathology and food-specific implicit associations were assessed before and after the training. In line with our hypothesis, approach-avoidance bias improved in the active training group after the training, in comparison to the sham training group. Moreover, this effect generalized to new, untrained stimuli. However, no effects of the training were found in a food-specific Single-Target Implicit Association Test, or on eating pathology questionnaires or body mass index. While the training results are promising, the effect of approach-avoidance bias modification on relevant behavior in obesity has yet to be established before it may be implemented as an add-on treatment.

Learning to avoid spiders: fear predicts performance, not competence.

We used an immersive virtual environment to examine avoidance learning in spider-fearful participants. In 3 experiments, participants were asked to repeatedly lift one of 3 virtual boxes, under which either a toy car or a spider appeared and then approached the participant. Participants were not told that the probability of encountering a spider differed across boxes. When the difference was large (Exps. 1 and 2), spider-fearfuls learned to avoid spiders by lifting the few-spiders-box more often and the many-spiders-box less often than non-fearful controls did. However, they hardly managed to do so when the probability differences were small (Exp. 3), and they did not escape from threat more quickly (Exp. 2). In contrast to the observed performance differences, spider-fearfuls and non-fearfuls showed equal competence, that is comparable post-experimental knowledge about the probability to encounter spiders under the 3 boxes. The limitations and implications of the present study are discussed.

The Role of Self-reports and Behavioral Measures of Interpretation Biases in Children with Varying Levels of Anxiety.

We investigated the role of self-reports and behavioral measures of interpretation biases and their content-specificity in children with varying levels of spider fear and/or social anxiety. In total, 141 selected children from a community sample completed an interpretation bias task with scenarios that were related to either spider threat or social threat. Specific interpretation biases were found; only spider-related interpretation bias and self-reported spider fear predicted unique variance in avoidance behavior on the Behavior Avoidance Task for spiders. Likewise, only social-threat related interpretation bias and self-reported social anxiety predicted anxiety during the Social Speech Task. These findings support the hypothesis that fearful children display cognitive biases that are specific to particular fear-relevant stimuli. Clinically, this insight might be used to improve treatments for anxious children by targeting content-specific interpretation biases related to individual disorders.

Do health-related factors predict major depression? A longitudinal epidemiologic study.

Major depressive disorder (MDD) is a leading cause of global disease burden. Hence, examining the role of risk and protective factors for MDD is an important target in psychological research. Various studies showed that obesity, smoking, and alcohol consumption are related to depressive symptoms. In contrast, physical activity has been found to be a protective factor. The present population-based study tested whether these health-related factors are prospectively associated with incidence of MDD. Data were taken from the Dresden Predictor Study, which was designed to investigate risk and protective factors of mental health in young women. It included two assessments approximately 17 months apart. Results of single logistic regression analyses showed that being overweight, being a smoker, and being in a high-risk drinking group at baseline were predictive of developing MDD at follow-up. Engaging in regular physical activity and having good physical health were found to be protective factors of MDD. However, being in a medium-risk drinking group was not predictive of incidence of MDD, and irregular physical activity was not a protective factor. This is the first prospective, longitudinal study to show that obesity, smoking, and high-risk drinking are predictive of new onsets of MDD and that physical health is a protective factor. These data provide promising avenues for future research.

Intensive prolonged exposure treatment for adolescent complex posttraumatic stress disorder: a single-trial design.

BACKGROUND: The current study evaluated the effectiveness and safety of intensive prolonged exposure (PE) targeting adolescent patients with complex posttraumatic stress disorder (PTSD) and comorbid disorders following multiple interpersonal trauma. METHODS: Ten adolescents meeting full diagnostic criteria for PTSD were recruited from a specialized outpatient mental health clinic and offered a standardized intensive PE. The intensive PE consisted of three daily 90-min exposure sessions delivered on five consecutive weekdays, followed by 3 weekly 90-min booster sessions. In a single-trial design, the participants were randomly allocated to one of five baseline lengths (4-8 weeks) before starting the intensive PE. Before, during, and after intensive PE completion, self-reported PTSD symptom severity was assessed weekly as a primary outcome (a total of 21 measurements). Furthermore, clinician-administered PTSD diagnostic status and symptom severity (primary outcome), as well as self-reported comorbid symptoms (secondary outcomes), were assessed at four single time points (baseline-to-6-month follow-up). RESULTS: Time-series analyses showed that self-reported PTSD symptom severity significantly declined following treatment (p = .002). Pre-postgroup analyses demonstrated significant reductions of clinician-administered PTSD symptom severity and self-reported comorbidity that persisted during the 3- and 6-month follow-ups (all ps < .05), where 80% of adolescents had reached diagnostic remission of PTSD. There was neither treatment dropout nor any adverse events. CONCLUSIONS: The results of this first proof of concept trial suggest that intensive PE can be effective and safe in an adolescent population with complex PTSD, although the gains achieved need to be confirmed in a randomized controlled trial.