Christine Knaevelsrud

Posttraumatic stress disorder in older adults: an overview of characteristics and treatment approaches.

Posttraumatic stress disorder (PTSD) is a common and disabling condition following a traumatic event. Despite its high prevalence rates, relatively little is known about the manifestation and course of the disorder in older adults. Moreover, there has been little evaluation of the efficacy of psychotherapeutic treatment approaches for older patients.

Internet-based interventions for posttraumatic stress: A meta-analysis of randomized controlled trials.

Posttraumatic stress disorder (PTSD) is a prevalent and highly distressing affliction, but access to trauma-focused psychotherapy is limited. Internet-based interventions (IBIs) could improve the delivery of and access to specialized mental health care. Currently, no meta-analytical evidence is available on IBIs for PTSD. We conducted a meta-analysis of 20 randomized controlled studies, including 21 comparisons, in order to summarize the current state of efficacy for the treatment of PTSD and to identify moderator variables. Studies tested internet-based cognitive behavioral therapy (CBT) and expressive writing (EW) against active or passive comparison conditions, including subclinical and clinical samples. Results show that at post-assessment CBT-IBIs are significantly more efficacious than passive controls, resulting in medium to large effects on the PTSD sum and all sub-symptom scores (0.66<g<0.83), but both EW and CBT are not superior to active controls. EW differed from controls only at follow-up in reducing intrusions and hyperarousal, but based on merely two studies. Subgroup analyses reveal that for CBT none of the program components such as provision of therapeutic support, reminders, or number of sessions serves as a moderator. Overall, results for CBT-IBIs are promising, but the number of includable studies for subgroup analyses was low, limiting statistical power. Future research is necessary to systematically investigate the impact of treatment components and test against active controls with optimal power.

Post‐Traumatic Growth and Optimism as Outcomes of an Internet‐Based Intervention for Complicated Grief

This explorative study examines the effects of an internet‐based cognitive‐behavioural therapy for complicated grief on post‐traumatic growth and optimism. The study is part of a larger randomized controlled trial described in Wagner, Knaevelsrud, and Maercker (2006). The patients were randomly assigned to either a treatment group (n = 26) or a waiting list control condition (n = 25). The internet‐based intervention consisted of exposure to bereavement cues, cognitive reappraisal exercises, and a module on integration and restoration. A short form of the Post‐traumatic Growth Inventory (PTGI), the Life Orientation Test‐Revised (LOT‐R), and measures of complicated grief and psychopathological outcomes were administered. Results indicate that post‐traumatic growth increased in the treatment group. No treatment effect was found for optimism. These findings contribute to the growing literature on personal growth in psychotherapy.

Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms

BACKGROUND Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment. METHOD In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD. RESULTS In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [chi2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022]. CONCLUSIONS These findings provide evidence of mutual maintenance between pain and PTSD.

Long-Term Effects of an Internet-Based Treatment for Posttraumatic Stress

Abstract Advances in communication technology offer additional strategies for providing psychological treatment. Previous trials of Internet-based treatment approaches reported significant reductions in posttraumatic stress and related symptoms in response to Internet-based treatments relative to control groups. However, empirical data on the long-term effects of those approaches are sparse. In order to evaluate the long-term effect of an Internet-based intervention, the authors conducted an 18-month follow-up of an Internet-based cognitive behavioural therapy for posttraumatic stress. Severity of posttraumatic stress symptoms was the primary outcome. Additional measures were depression, anxiety, mental and physical health, and health care utilization during the follow-up period. Treatment group participants (n = 34) were assessed 1.5 years after completing treatment. Results indicated that reductions in symptoms of posttraumatic stress symptoms, depression, and anxiety found at posttreatment were sustained during the 18-month follow-up period. Preliminary evidence on long-term effects of Internet-based health care as shown in this study is promising. However, research with larger and clinically more diverse samples is needed to fully assess the clinical impact and potential of Internet-based health care provision.

Efficacy of an Internet-based intervention for posttraumatic stress disorder in Iraq: A pilot study

In the past 20 years, war and human rights violations have led to high rates of exposure to traumatic events among the Iraqi population. Due to the ongoing violence, many physicians and mental health professionals have left Iraq in recent years. The Internet offers new possibilities for the psychological treatment of posttraumatic stress disorder (PTSD) in conflict areas. A therapist-supported cognitive-behavioral treatment manual that has been evaluated in Western countries was translated into Arabic and culturally adapted. The treatment was conducted via the Internet by Arabic-speaking therapists and was evaluated in an uncontrolled pilot study with 15 participants. Main outcome measures were PTSD (Posttraumatic Diagnostic Scale (PDS)), depression, anxiety (Hopkins Symptom Check List-25 (HSCL-25)), and quality of life (EUROHIS). The intervention resulted in a highly significant decrease in symptoms of PTSD, depression, and anxiety. Quality of life was higher at posttreatment. All treatment effect sizes were in the large range, indicating a significant improvement in mental health symptoms and quality of life. Preliminary clinical evidence indicates that new technologies can be used to provide humanitarian aid in the form of e-mental health services, even in areas that remain highly unstable.

Web-Based Psychotherapy for Posttraumatic Stress Disorder in War-Traumatized Arab Patients: Randomized Controlled Trial

Background In recent years, armed conflicts in the Middle East have resulted in high rates of exposure to traumatic events. Despite the increasing demand of mental health care provision, ongoing violence limits conventional approaches of mental health care provision. Internet-based interventions for posttraumatic stress disorder (PTSD) have proved feasible and effective in Western countries, but their applicability and efficacy in war and conflict regions remains unknown. Objective This study investigated the efficacy of a cognitive behavioral Internet-based intervention for war-traumatized Arab patients, with focus on Iraq. Methods A total of 159 individuals with PTSD participated in a parallel group randomized trial. Participants were randomly allocated by a computer-generated sequence to a treatment group (n=79) or a waiting list control group (n=80). The treatment group received 2 weekly 45-minute cognitive behavioral interventions via Internet over a 5-week period (10 sessions in total). The primary outcome was recovery from posttraumatic stress symptoms. Results Posttraumatic stress symptoms were significantly reduced from baseline to posttreatment (intention-to-treat analysis) in the treatment group relative to the control group (F1,157=44.29, P<.001, d=0.92). Treatment effects were sustained at 3-month follow-up. Completer analysis indicated that 29 of 47 patients (62%) in the treatment group had recovered from posttraumatic stress symptoms at posttreatment (reliable change and Posttraumatic Stress Diagnostic Scale score <20) versus 1 patient (2%) in the control group (OR 74.19, 95% CI 9.93-585.8, P<.001) indicating that the chance of recovering was 74.19 times higher in the treatment than in the control group. Conclusions The results indicate, even in unstable and insecure settings with ongoing exposure to human rights violations through war and dictatorships, people with posttraumatic stress symptoms benefit from a cognitive behavioral treatment provided entirely through the Internet. This method of delivery could improve patients’ access to humanitarian aid in the form of e-mental health services. Trial Registration Australian New Zealand Clinical Trial Registry, ACTRN12611001019998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347505 (Archived by WebCite at http://www.webcitation.org/6Wto4HCdH).

Posttraumatic Growth, Optimism and Openness as Outcomes of a Cognitive-behavioural Intervention for Posttraumatic Stress Reactions

The aim of this study was to examine the effect of an Internet-based CBT intervention on posttraumatic growth, openness and optimism. Ninety-six participants suffering from posttraumatic stress reactions were randomly assigned to either the treatment or a waiting-list control condition. We assessed posttraumatic stress reactions, depression and anxiety, posttraumatic growth, optimism and openness to new experiences. We found significant changes in posttraumatic growth in the treatment group. In addition regression analysis revealed that symptom improvements in posttraumatic stress reactions significantly predicted posttraumatic growth post-treatment. Our findings indicate the potential of psychotherapy to stimulate posttraumatic growth.

Loneliness among older veterans in the United States: results from the National Health and Resilience in Veterans Study.

OBJECTIVES This study examined the current prevalence, and demographic, military, health, and psychosocial correlates of loneliness in a contemporary nationally representative sample of older U.S. veterans. METHODS Two thousand twenty-five veterans aged 60 years and older participated in the National Health and Resilience in Veterans Study. Loneliness was assessed using a questionnaire adapted from the Revised UCLA Loneliness Scale. A broad range of demographic, military, health, and psychosocial variables was also assessed. RESULTS 44% of veterans reported feeling lonely at least some of the time (10.4% reported often feeling lonely). Greater age, disability in activities of daily living, lifetime traumas, perceived stress, and current depressive and post-traumatic stress disorder symptoms were positively associated with loneliness, and being married/cohabitating, higher income, greater subjective cognitive functioning, social support, secure attachment, dispositional gratitude, and frequency of attending religious services were negatively associated with loneliness. The largest magnitude associations were observed for perceived social support, secure attachment style, and depressive symptoms. CONCLUSIONS Loneliness is prevalent among older veterans in the United States, and associated with several health and psychosocial variables. These results suggest that multifactorial interventions that emphasize bolstering of social support and reduction of depressive symptoms may help mitigate loneliness in the rapidly growing population of older veterans.

Online working alliance predicts treatment outcome for posttraumatic stress symptoms in Arab war-traumatized patients.

Previous studies have shown that Internet‐based interventions for posttraumatic stress disorder are feasible. However, little is known about how therapeutic process factors impact online interventions in war and conflict regions.