A. van Minnen

Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.

The relationship between autobiographical memory specificity and depressed mood following a stressful life event: A prospective study

OBJECTIVES In the present prospective study, the relationship between autobiographical memory specificity and the emotional reactions to a stressful event was investigated. DESIGN AND METHODS The Autobiographical Memory Test (AMT) was administered to 74 women before they underwent an in vitro fertilization (IVF) treatment, which subsequently failed. Symptoms of emotional reactions - depression and anxiety - were measured both before and after the (failed) IVF treatment. RESULTS It was found that the number of reported specific memories at baseline was negatively related to depressive and anxiety symptoms after the treatment, even when initial depressive and anxiety symptoms and verbal fluency were controlled for. CONCLUSIONS Taken together, the findings indicate that a lack of autobiographical memory specificity predicts changes in depressive mood after a stressful event.

Treating PTSD in patients with psychosis: a within-group controlled feasibility study examining the efficacy and safety of evidence-based PE and EMDR protocols.

The present study uses a within-group controlled design to examine the efficacy and safety of two psychological approaches to posttraumatic stress disorder (PTSD) in 10 patients with a concurrent psychotic disorder. Patients were randomly assigned either to prolonged exposure (PE; N=5) or eye movement desensitization and reprocessing (EMDR; N=5). Before, during, and after treatment, a total of 20 weekly assessments of PTSD symptoms, hallucinations, and delusions were carried out. Twelve weekly assessments of adverse events took place during the treatment phase. PTSD diagnosis, level of social functioning, psychosis-prone thinking, and general psychopathology were assessed pretreatment, posttreatment, and at three-month follow-up. Throughout the treatment, adverse events were monitored at each session. An intention-to-treat analysis of the 10 patients starting treatment showed that the PTSD treatment protocols of PE and EMDR significantly reduced PTSD symptom severity; PE and EMDR were equally effective and safe. Eight of the 10 patients completed the full intervention period. Seven of the 10 patients (70%) no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events occurred, nor did patients show any worsening of hallucinations, delusions, psychosis proneness, general psychopathology, or social functioning. The results of this feasibility trial suggest that PTSD patients with comorbid psychotic disorders benefit from trauma-focused treatment approaches such as PE and EMDR.

Hospital vs. outreach treatment of patients with mental retardation and psychiatric disorders: a controlled study

The aim of this study was to investigate the effectiveness of specialized hospital treatment vs. outreach treatment of patients with mental retardation and serious mental illness. A total of 50 patients were randomly assigned to either the hospital treatment (n=25) or the outreach treatment group (n=25). The outcome measures included psychiatric symptoms, family burden, costs and hospital admissions. At most observation points (up to 28 weeks) and at all endpoints the two groups were equivalent with regard to psychiatric symptoms. The burden on carers did not increase significantly during the outreach treatment. Treatment costs were lower for the outreach treatment. Of the 25 patients who received outreach treatment, four had to be admitted to the specialized hospital. Aggressive behaviour, social competence and number of previous psychiatric hospitalizations were found to be predictors of treatment outcome. It is concluded that outreach treatment represents an effective and efficient alternative to hospital treatment for patients with mental retardation and psychiatric disorders.

Trauma-Focused Treatment in PTSD Patients With Psychosis: Symptom Exacerbation, Adverse Events, and Revictimization

OBJECTIVES Most clinicians refrain from trauma treatment for patients with psychosis because they fear symptom exacerbation and relapse. This study examined the negative side effects of trauma-focused (TF) treatment in patients with psychosis and posttraumatic stress disorder (PTSD). METHODS Analyses were conducted on data from a single-blind randomized controlled trial comparing TF treatment (N = 108; 8 sessions prolonged exposure or eye movement desensitization) and waiting list (WL; N = 47) among patients with a lifetime psychotic disorder and current chronic PTSD. Symptom exacerbation, adverse events, and revictimization were assessed posttreatment and at 6-month follow-up. Also investigated were symptom exacerbation after initiation of TF treatment and the relationship between symptom exacerbation and dropout. RESULTS Any symptom exacerbation (PTSD, paranoia, or depression) tended to occur more frequently in the WL condition. After the first TF treatment session, PTSD symptom exacerbation was uncommon. There was no increase of hallucinations, dissociation, or suicidality during the first 2 sessions. Paranoia decreased significantly during this period. Dropout was not associated with symptom exacerbation. Compared with the WL condition, fewer persons in the TF treatment condition reported an adverse event (OR = 0.48, P = .032). Surprisingly, participants receiving TF treatment were significantly less likely to be revictimized (OR = 0.40, P = .035). CONCLUSIONS In these participants, TF treatment did not result in symptom exacerbation or adverse events. Moreover, TF treatment was associated with significantly less exacerbation, less adverse events, and reduced revictimization compared with the WL condition. This suggests that conventional TF treatment protocols can be safely used in patients with psychosis without negative side effects.

Prolonged exposure and EMDR for PTSD v. a PTSD waiting-list condition: Effects on symptoms of psychosis, depression and social functioning in patients with chronic psychotic disorders

Background. In patients with psychotic disorders, the effects of psychological post-traumatic stress disorder (PTSD) treatment on symptoms of psychosis, depression and social functioning are largely unknown Method. In a single-blind randomized controlled trial (RCT) 155 outpatients in treatment for psychosis (61.3% schizophrenic disorder, 29% schizoaffective disorder) were randomized to eight sessions prolonged exposure (PE; n = 53) or eye movement desensitization and reprocessing (EMDR) (n = 55), or a waiting-list condition (WL, n = 47) for treatment of their co-morbid PTSD. Measures were performed on (1) psychosis: severity of delusions (PSYRATS-DRS), paranoid thoughts (GPTS), auditory verbal hallucinations (PSYRATS-AHRS), and remission from psychotic disorder (SCI-SR-PANSS); (2) depression (BDI-II); (3) social functioning (PSP). Outcomes were compared at baseline, post-treatment, 6-month follow-up and over all data points. Results. Both PE and EMDR were significantly associated with less severe paranoid thoughts post-treatment and at 6-month follow-up, and with more patients remitting from schizophrenia, at post-treatment (PE and EMDR) and over time (PE). Moreover, PE was significantly associated with a greater reduction of depression at post-treatment and at 6-month follow-up. Auditory verbal hallucinations and social functioning remained unchanged. Conclusions. In patients with chronic psychotic disorders PE and EMDR not only reduced PTSD symptoms, but also paranoid thoughts. Importantly, in PE and EMDR more patients accomplished the status of their psychotic disorder in remission. Clinically, these effects are highly relevant and provide empirical support to the notion that delivering PTSD treatment to patients with psychotic disorders and PTSD deserves increasing recognition and acceptance among clinicians.

Intensive EMDR to treat patients with complex posttraumatic stress disorder: A case series

There is mounting evidence suggesting that by increasing the frequency of treatment sessions, posttraumatic stress disorder (PTSD) treatment outcomes significantly improve. As part of an ongoing research project, this study examined the safety and effectiveness of intensive eye movement desensitization and reprocessing (EMDR) therapy in a group of seven (four female) patients suffering from complex PTSD and multiple comorbidities resulting from childhood sexual abuse, physical abuse, and/or work and combat-related trauma. Treatment was not preceded by a preparation phase and consisted of 2 × 4 consecutive days of EMDR therapy administered in morning and afternoon sessions of 90 minutes each, interspersed with intensive physical activity and psychoeducation. Outcome measures were the Clinician-Administered PTSD Scale (CAPS) and the PTSD Symptom Scale Self-report questionnaire (PSS-SR). During treatment, neither personal adverse events nor dropout occurred. CAPS scores decreased significantly from pre- to posttreatment, and four of the seven patients lost their PTSD diagnosis as established with the CAPS. The results were maintained at 3-month follow-up. Effect sizes (Cohen’s d) on the CAPS and PSS-SR were large: 3.2, 1.7 (prepost) and 2.3, 2.1 (prefollow-up), respectively. The results of this case series suggest that an intensive program using EMDR therapy is a potentially safe and effective treatment alternative for complex PTSD. The application of massed, consecutive days of treatments using EMDR therapy for patients suffering from PTSD, particularly those with multiple comorbidities, merits more clinical and research attention.

The Impact of Childhood Sexual Abuse on the Outcome of Intensive Trauma-focused Treatment for PTSD

ABSTRACT Background: It is assumed that PTSD patients with a history of childhood sexual abuse benefit less from trauma-focused treatment than those without such a history. Objective: To test whether the presence of a history of childhood sexual abuse has a negative effect on the outcome of intensive trauma-focused PTSD treatment. Method: PTSD patients, 83% of whom suffered from severe PTSD, took part in a therapy programme consisting of 2 × 4 consecutive days of Prolonged Exposure (PE) and EMDR therapy (eight of each). In between sessions, patients participated in sport activities and psycho-education sessions. No prior stabilization phase was implemented. PTSD symptom scores of clinician-administered and self-administered measures were analysed using the data of 165 consecutive patients. Pre-post differences were compared between four trauma groups; patients with a history of childhood sexual abuse before age 12 (CSA), adolescent sexual abuse (ASA; i.e. sexual abuse between 12 and 18 years of age), sexual abuse (SA) at age 18 and over, or no history of sexual abuse (NSA). Results: Large effect sizes were achieved for PTSD symptom reduction for all trauma groups (Cohen’s d = 1.52–2.09). For the Clinical Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES), no differences in treatment outcome were found between the trauma (age) groups. For the PTSD Symptom Scale Self Report (PSS-SR), there were no differences except for one small effect between CSA and NSA. Conclusions: The results do not support the hypothesis that the presence of a history of childhood sexual abuse has a detrimental impact on the outcome of first-line (intensive) trauma-focused treatments for PTSD.

THE IMPORTANCE OF THE SOCIAL ENVIRONMENT IN THE TREATMENT OF MENTALLY RETARDED ADULTS WITH PSYCHIATRIC DISORDERS: AN OUTREACH TREATMENT PROGRAMME

Due to their biological impairments, mentally retarded persons are for a large part dependent on their social environment (Edgerton, 1967; Helsel and Matson, 1988; Reiss, 1985; Reiss and Benson, 1985). Therefore, negative social-environmental conditions, such as frequent relocations (O’Connor, 1983; Reiss, 1985; Reiss and Benson, 1985), limited social support (Burchard et al., 1991; Reiss and Benson, 1985; Reiss and Trenn, 1984; Rosen and Burchard, 1990) and limited social integration (Burchard et al., 1991; Reiss and Benson, 1985; Rosen and Burchard, 1990), can play an important role in the development and continuance of psychopathology (Burchard et al., 1991; Carr and Durand, 1985; O’Connor, 1983; Reiss and Benson, 1985; Romer and Heller, 1983). Frequent relocations may cause disruption in social life (O’Connor, 1983; Reiss,

Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD

ABSTRACT Background: There is a widely-held belief in the trauma field that the presence of dissociative symptoms is associated with poor treatment response. However, previous research on the effect of dissociation in treatment outcomes pertained to specific patients and trauma populations. Objective: To test the hypothesis that the presence of the dissociative subtype of PTSD (DS) would have a detrimental effect on the outcome of an intensive trauma-focused treatment programme. Methods: PTSD symptom scores (Clinician Administered PTSD Scale [CAPS] and PTSD Symptom Scale Self-Report [PSS-SR]) were analysed using the data of 168 consecutive patients (70.6% female) who had been exposed to a wide variety of multiple traumas, including childhood sexual abuse, and of whom 98.2% were diagnosed with severe PTSD (CAPS > 65). Most of them suffered from multiple comorbidities and 38 (22.6%) met the criteria for DS. They took part in an intensive trauma-focused treatment programme for PTSD. Pre- and post-treatment differences were compared between patients with and without DS. Results: Large effect sizes were achieved for PTSD symptom reduction on CAPS and the PSS-SR, both for patients with DS and those without. Although patients with DS showed a significantly greater PTSD symptom severity at the beginning, and throughout, treatment, both groups showed equal reductions in PTSD symptoms. Of those who met the criteria for DS, 26 (68.4%) no longer fulfilled the criteria for this classification after treatment. Conclusion: The results provide no support for the notion that the presence of DS negatively impacts trauma-focused treatment outcomes. Accordingly, PTSD patients with DS should not be denied effective trauma-focused treatments.