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.

Prevalence of prolonged grief disorder in a sample of female refugees.

BACKGROUND: Prolonged Grief Disorder (PGD) is a distinct syndrome that follows bereavement. It is different from other mental disorders and is characterized by symptoms such as yearning for the bereaved, or intense emotional pain or distress. Violent loss is one major risk factor for the development of PGD. OBJECTIVES: PGD has been studied in different populations, mostly in small samples, with only a few of them being representative. Although research highlighted that traumatic experiences paired with challenges related to migration make refugees particularly vulnerable to PGD, PGD has only rarely been studied in refugees. Thus, this article a) examines the prevalence of PGD in female refugees in Germany according to the criteria proposed by Prigerson and colleagues in 2009, and b) associates PGD with other common psychopathology (e.g. anxiety, depression, somatization and trauma). METHOD: A total of 106 female refugees were assessed for bereavement and PGD. Of these 106 individuals, 85 were interviewed using the Prolonged Grief Disorder Scale (PG-13). Symptoms of anxiety and depression were assessed by the Hopkins Symptom Checklist-25 (HSCL-25), somatization was assessed by the Somatization Subscale of the Symptom-Checklist-90 (SCL-90), and the number of witnessed and experienced trauma was assessed by the Posttraumatic Diagnostic Scale (PDS/HTQ). RESULTS: Ninety of the 106 participants had experienced bereavement, and among those, 9.41% met criteria for PGD. The most frequent PGD symptoms were bitterness, longing or yearning for the bereaved, and lack of acceptance of the loss. Furthermore, grief symptoms were significantly associated with symptoms of depression, anxiety, somatization, and the number of experienced traumatic events. CONCLUSION: The PGD prevalence rate found corresponds with previous studies, demonstrating that prevalence rates for PGD are especially high in refugees. High prevalence rates of bereavement as well as PGD highlight the need for assessment and specifically tailored treatment of PGD in refugees. PGD goes along with significant psychopathology, which further emphasizes the need for treatment.

Near-death experiences, attacks by family members, and absence of health care in their home countries affect the quality of life of refugee women in Germany: a multi-region, cross-sectional, gender-sensitive study.

BACKGROUND: The year 2016 has marked the highest number of displaced people worldwide on record. A large number of these refugees are women, yet little is known about their specific situation and the hurdles they have to face during their journey. Herein, we investigated whether sociodemographic characteristics and traumatic experiences in the home country and during the flight affected the quality of life of refugee women arriving in Germany in 2015-2016. METHODS: Six hundred sixty-three women from six countries (Afghanistan, Syria, Iran, Iraq, Somalia, and Eritrea) living in shared reception facilities in five distinct German regions were interviewed by native speakers using a structured questionnaire. Sociodemographic data and information about reasons for fleeing, traumatic experiences, symptoms, quality of life, and expectations towards their future were elicited. All information was stored in a central database in Berlin. Descriptive analyses, correlations, and multivariate analyses were performed. RESULTS: The most frequent reasons cited for fleeing were war, terror, and threat to one's life or the life of a family member. Eighty-seven percent of women resorted to smugglers to make the journey to Europe, and this significantly correlated to residence in a war zone (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.4-4.6, p = 0.003) and homelessness prior to fleeing (OR = 2.1, 95% CI = 1-4.3, p = 0.04). Overall the described quality of life by the women was moderate (overall mean = 3.23, range of 1-5) and slightly worse than that of European populations (overall mean = 3.68, p < 0.0001). The main reasons correlating with lower quality of life were older age, having had a near-death experience, having been attacked by a family member, and absence of health care in case of illness. CONCLUSIONS: Refugee women experience multiple traumatic experiences before and/or during their journey, some of which are gender-specific. These experiences affect the quality of life in their current country of residence and might impact their integration. We encourage the early investigation of these traumatic experiences to rapidly identify women at higher risk and to improve health care for somatic and mental illness.

Adherence Rating Scale for Cognitive Processing Therapy - Cognitive Only: Analysis of Psychometric Properties.

BACKGROUND: The assessment of therapeutic adherence is essential for accurately interpreting treatment outcomes in psychotherapy research. However, such assessments are often neglected. AIMS: To fill this gap, we aimed to develop and test a scale that assessed therapeutic adherence to Cognitive Processing Therapy - Cognitive Only (CPT), which was adapted for a treatment study targeting patients with post-traumatic stress disorder and co-occurring borderline personality symptoms. METHOD: Two independent, trained raters assessed 30 randomly selected treatment sessions involving seven therapists and eight patients who were treated in a multicentre randomized controlled trial. RESULTS: The inter-rater reliability for all items and the total score yielded good to excellent results (intraclass correlation coefficient [ICC] = 0.70 to 1.00). Cronbach's α was .56 for the adherence scale. Regarding content validity, three experts confirmed the relevance and appropriateness of each item. CONCLUSION: The adherence rating scale for the adapted version of CPT is a reliable instrument that can be helpful for interpreting treatment effects, analysing possible relationships between therapeutic adherence and treatment outcomes and teaching therapeutic skills.

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.

Traumatic Life Events and Association With Depression, Anxiety, and Somatization Symptoms in Female Refugees.

Importance: Different types of traumatic life events have varying impacts on symptoms of depression, anxiety, and somatization. For women from areas of the world experiencing war and humanitarian crises, who have experienced cumulative trauma exposure during war and forced migration, it is not known whether cumulative trauma or particular events have the greatest impact on symptoms. Objective: To examine which traumatic life events are associated with depression, anxiety, and somatization symptoms, compared with the cumulative amount, in a sample of female refugees. Design, Setting, and Participants: For this cross-sectional study, data were collected in 2016 as a part of The Study on Female Refugees. The current analysis was conducted in 2022 to 2023. This multicenter study covered 5 provinces in Germany. Participants were recruited at reception centers for refugees. Women volunteered to participate and to be interviewed after information seminars at the different centers. Exposure: Traumatic life events experienced by refugees from areas of the world experiencing war and humanitarian crises. Main Outcomes and Measures: Demographic variables (age, country of origin, religion, education, relationship status, and children), traumatic and adverse life events, and self-reported depression, anxiety, and somatization symptoms were measured. Random forest regressions simultaneously examined the importance of these variables on symptom scores. Follow-up exploratory mediation models tested potential associative pathways between the identified variables of importance. Results: For the final sample of 620 refugee women (mean [SD] age, 32.34 [10.35] years), family violence was most associated with depression (mean [SD] variable of importance [VIM], 2.93 [0.09]), anxiety (mean [SD] VIM, 4.15 [0.11]), and somatization (mean [SD] VIM, 3.99 [0.15]), even though it was less common than other traumatic experiences, including war, accidents, hunger, or lack of housing. Other factors, such as childhood sexual abuse, injury, near-death experiences, and lack of access to health care, were also important. Follow-up analyses showed partial mediation effects between these factors in their association with symptoms, supporting the unique importance of family violence in understanding mental health. Conclusions and Relevance: The findings of this cross-sectional study of refugee women who experienced multiple severe traumas related to war in their home countries and danger encountered during their migration suggest that family violence was key to their current mental health problems. Culturally sensitive assessment and treatment need to place special emphasis on these family dynamics.

Which Trauma Treatment Suits me? Identification of Patients' Treatment Preferences for Posttraumatic Stress Disorder (PTSD).

Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes.

The Relationship of Acculturation, Traumatic Events and Depression in Female Refugees.

Recent research has identified significant correlations between traumatic events and depression in refugees. However, few studies have addressed the role of acculturation strategies in this relationship. This study explored the relationship between cultural orientation, traumatic events and depression in female refugees from Syria, Afghanistan, Eritrea, Iran, Iraq, and Somalia living in Germany. We expected acculturation strategies to moderate the effect of traumatic experiences on depression. The sample included 98 female refugees in Germany. The depression scale of the Hopkins Symptom Checklist (HSCL) represented the dependent measure. The trauma checklists derived from the Post-traumatic Diagnostic Scale (PDS) and the Harvard Trauma Questionnaire (HTQ) as well as the Frankfurt Acculturation Scale (FRACC) were used as independent measures for traumatic events and orientation toward the host culture as well as orientation toward the culture of origin, respectively. A moderation analysis was conducted to examine whether the relationship between the number of traumatic events and depression was influenced by the women's orientation toward the culture of origin and the host culture. We identified a significant model explaining 26.85% of the variance in depressive symptoms (Cohen's f2 = 0.37). The number of traumatic events and the orientation toward the host culture exerted significant effects on depressive symptoms. The moderating effect was not significant, indicating that the effect of the number of traumatic events was not influenced by cultural orientation. Based on our results, orientation toward the host culture as well as traumatic experiences exert independent effects on depressive symptoms in refugees.

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

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

Meta-analysis of the Long-Term Treatment Effects of Psychological Interventions in Youth with PTSD Symptoms.

To date, the long-term effectiveness of psychological treatments in reducing post-traumatic stress disorder symptoms in children and adolescents has not been investigated extensively. This meta-analysis quantifies the long-term effects of psychological interventions in children and adolescents with PTSD symptoms and examines the period-dependent follow-up (FU) effects based on 47 studies. The mean FU effect sizes (ESs) for PTSD symptoms ranged from medium (between treatment ESs for controlled studies) to large (within treatment ESs for uncontrolled studies; pooled analysis including all studies). These effects were comparable to the post-treatment ESs, which suggests that the treatment effects remained stable. ESs did not differ depending on the length of the FU period (6 months). In randomized controlled trials (RCTs), as well as trials conducted with treatment as usual or active control groups, the long-term treatment effects for the reduction of PTSD symptoms were small. These results demonstrate the long-term effectiveness of psychological interventions in the treatment of PTSD in youth. However, more studies should include a FU assessment. Further research should focus on RCTs with long-term assessments, report comorbid symptoms and investigate the influence of potential moderators. Research is also warranted to determine how to improve the long-term effects of treatments for PTSD in youth.

Psychological Treatments for Symptoms of Posttraumatic Stress Disorder in Children, Adolescents, and Young Adults: A Meta-Analysis.

Meta-analyses of the treatment of posttraumatic stress disorder (PTSD) in childhood and adolescence are restricted to specific trauma, selected interventions, and methodologically rigorous studies. This large meta-analysis quantifies the effects of psychological treatments for PTSD symptoms in children and adolescents. An extensive literature search yielded a total of 13,040 articles; 135 studies with 150 treatment conditions (N = 9562 participants) met the inclusion criteria (psychological interventions with children and/or adolescents with PTSD symptoms that report quantitative measures of symptom change). The mean effect sizes (ESs) for PTSD symptoms ranged from large to small, depending on the control condition. Cognitive behavioral therapy (CBT) yielded the highest ESs. Age and caretaker involvement were identified as moderators. CBT, especially when conducted in individual treatment with the inclusion of parents, is a highly effective treatment for trauma symptoms. Psychological treatments need to be modified to address younger patients' specific needs.

Reliability, factor structure, and validity of the German version of the Trauma Symptom Checklist for Children in a sample of adolescents.

BACKGROUND: The Trauma Symptom Checklist for Children (TSC-C) is the most widely used self-report scale to assess trauma-related symptoms in children and adolescents on six clinical scales. The purpose of the present study was to develop a German version of the TSC-C and to investigate its psychometric properties, such as factor structure, reliability, and validity, in a sample of German adolescents. METHOD: A normative sample of N=583 and a clinical sample of N=41 adolescents with a history of physical or sexual abuse aged between 13 and 21 years participated in the study. RESULTS: The Confirmatory Factor Analysis on the six-factor model (anger, anxiety, depression, dissociation, posttraumatic stress, and sexual concerns with the subdimensions preoccupation and distress) revealed acceptable to good fit statistics in the normative sample. One item had to be excluded from the German version of the TSC-C because the factor loading was too low. All clinical scales presented acceptable to good reliability, with Cronbach's α's ranging from .80 to .86 in the normative sample and from .72 to .87 in the clinical sample. Concurrent validity was also demonstrated by the high correlations between the TSC-C scales and instruments measuring similar psychopathology. TSC-C scores reliably differentiated between adolescents with trauma history and those without trauma history, indicating discriminative validity. CONCLUSIONS: In conclusion, the German version of the TSC-C is a reliable and valid instrument for assessing trauma-related symptoms on six different scales in adolescents aged between 13 and 21 years.

Therapeutic adherence and competence scales for Developmentally Adapted Cognitive Processing Therapy for adolescents with PTSD.

Background : The assessment of therapeutic adherence and competence is often neglected in psychotherapy research, particularly in children and adolescents; however, both variables are crucial for the interpretation of treatment effects. Objective : Our aim was to develop, adapt, and pilot two scales to assess therapeutic adherence and competence in a recent innovative program, Developmentally Adapted Cognitive Processing Therapy (D-CPT), for adolescents suffering from posttraumatic stress disorder (PTSD) after childhood abuse. Method : Two independent raters assessed 30 randomly selected sessions involving 12 D-CPT patients (age 13-20 years, M age=16.75, 91.67% female) treated by 11 therapists within the pilot phase of a multicenter study. Results : Three experts confirmed the relevance and appropriateness of each item. All items and total scores for adherence (intraclass correlation coefficients [ICC]=0.76-1.00) and competence (ICC=0.78-0.98) yielded good to excellent inter-rater reliability. Cronbach's alpha was 0.59 for the adherence scale and 0.96 for the competence scale. Conclusions : The scales reliably assess adherence and competence in D-CPT for adolescent PTSD patients. The ratings can be helpful in the interpretation of treatment effects, the assessment of mediator variables, and the identification and training of therapeutic skills that are central to achieving good treatment outcomes. Both adherence and competence will be assessed as possible predictor variables for treatment success in future D-CPT trials.

Psychological treatments for fibromyalgia: a meta-analysis.

The aims of the present analysis were to investigate the short- and long-term efficacies and treatment moderators of psychological interventions for fibromyalgia. A literature search using PubMed, PsychINFO, the Cochrane Library, and manual searches identified 23 eligible studies including 30 psychological treatment conditions and 1396 patients. Meta-analytic integration resulted in a significant but small effect size for short-term pain reduction (Hedges's g=0.37, 95% confidence interval (CI): 0.27-0.48) and a small-to-medium effect size for long-term pain reduction over an average follow-up phase of 7.4 months (Hedges's g=0.47, 95% CI: 0.3-0.65) for any psychological intervention. Psychological treatments also proved effective in reducing sleep problems (Hedges's g=0.46, 95% CI: 0.28-0.64), depression (Hedges's g=0.33, 95% CI: 0.20-0.45), functional status (Hedges's g=0.42, 95% CI: 0.25-0.58), and catastrophizing (Hedges's g=0.33, 95% CI: 0.17-0.49). These effects remained stable at follow-up. Moderator analyses revealed cognitive-behavioral treatment to be significantly better than other psychological treatments in short-term pain reduction (Hedges's g=0.60, 95% CI: 0.46-0.76). Higher treatment dose was associated with better outcome. Publication-bias analyses demonstrated that the effect sizes were robust. The results suggest that the effects of psychological treatments for fibromyalgia are relatively small but robust and comparable to those reported for other pain and drug treatments used for this disorder. Cognitive-behavioral therapy was associated with the greatest effect sizes.