Elna Yadin

Randomized Trial of Prolonged Exposure for Posttraumatic Stress Disorder With and Without Cognitive Restructuring: Outcome at Academic and Community Clinics

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.

Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial.

OBJECTIVE To examine the efficacy and maintenance of developmentally adapted prolonged exposure therapy for adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas. METHOD Thirty-eight adolescents (12 to 18 years old) were randomly assigned to receive PE-A or TLDP-A. RESULTS Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6- and 17-month follow-ups. CONCLUSIONS Brief individual therapy is effective in decreasing posttraumatic distress and behavioral trauma-focused components enhance efficacy. CLINICAL TRIAL REGISTRY INFORMATION: Prolonged Exposure Therapy Versus Active Psychotherapy in Treating Post-Traumatic Stress Disorder in Adolescents, URL: http://clinicaltrials.gov, unique identifier: NCT00183690.

Computer assisted analysis of 2-DG autoradiographs.

A computerized image processing system is described that assists the neurobiologists in analyzing data from 2-DG autoradiography by providing for: (1) Rapid fine-scale digitization of gray levels using a TV camera (2) The recognition of and verification of subtle differences in optical density with the aid of color windows (3) the superimposition of the autoradiographic image upon the histological image, so that the activity seen in the autoradiograph can be accurately assigned to anatomically defined structures (4) The production of numerical data suitable for statistical analysis and line drawings suitable for black on white publication (5) The relating of local gray level to a norm for the image as a whole, so as to remove the variability introduced by variations in section thickness, in the amount of 2-DG seen by the brain during incorporation, in level of anesthesia, etc. If the localized darkening in autoradiographic images is being used as an index of localized functional activity rather than as a measure of metabolism, normalization obviates the need to obtain arterial blood samples. These routines permit anatomically accurate numerical analysis of autoradiographs without any constraints on the experimental situation.

Unilaterally activated systems in rats self-stimulating at sites in the medial forebrain bundle, medial prefrontal cortex, or locus coeruleus

Rats with electrodes in either the posterior medial forebrain bundle (MFB), the anterior MFB, the medial prefrontal cortex, or the locus coeruleus self-stimulated during a 45 min period following the injection of [14C]2-deoxyglucose. They were then sacrificed and their brains prepared for autoradiography. The autoradiographs were analyzed for unilaterally activated neural systems, using a computerized image analyzing system to compare the darkness of neural structures on the stimulated side with the darkness of the same structures on the unstimulated side. There was extensive overlap in the neural structures unilaterally activated by stimulation in the anterior and posterior MFB; but there was no overlap between the structures activated by MFB stimulation and the structures activated by stimulation at either of the extradiencephalic sites; nor did the forebrain, diencephalic, and midbrain sites have any readily apparent bilateral effects in common. If there is a substrate common to MFB self-stimulation and extradiencephalic self-stimulation, its activation is not revealed by 2-deoxyglucose autoradiography.

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder

Background: Postraumatic stress disorder (PTSD) is associated with significant health risk, illness, and functional impairment, e.g., Green and Kimerling [2004: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Phychological Association] Kimerling et al. [2000: Trauma and Health: J Trauma Stress 13:115–128]. Methods: These analyses examined whether negative health perceptions and general social functioning change with treatment of chronic PTSD among women from a randomized controlled study comparing prolonged exposure (PE; n=48) or PE combined with cognitive restructuring (PE/CR; n=40) to waitlist (n=19; Foa et al., 2005: J Consult Clin Psychol 73:953–964]. Results: Self‐ reported physical health difficulties were significantly reduced in the PE and PE/CR conditions compared to the waitlist condition. These reductions did not demonstrate significant change during the 12 month follow‐up period. Self‐reported discomfort associated with physical health difficulties did not demonstrate significant change over treatment. No difference was detected between the active treatment and waitlist conditions. Both the PE and PE/CR groups reported improved social functioning at post treatment compared to the waitlist. Additional improvement in general social functioning was found between 3 and 12 month follow‐up assessments. Changes in PTSD and depressive symptoms over treatment accounted for 29% of the variance in reduction of reported health problems and 30% of the variance in improvement of general social functioning. Importantly, only changes in PTSD symptoms significantly contribute to the model predicting change in physical health problems with depression associated only at a trend level. However, collinearity between PTSD and depression makes interpretation difficult. Conclusions: Negative health perceptions and general social function improve with PE. Changes in depression and PTSD with treatment are related to these changes. Depression and Anxiety, 2009.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

Importance Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel. Objective To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity. Design, Setting, and Participants Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016. Interventions Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non–trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks). Main Outcomes and Measures Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale–Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided &agr; = .05]); and efficacy of spaced therapy vs PCT at posttreatment. Results Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, −∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, −∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, −2.48 to 2.27]; P = .93). Conclusions and Relevance Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings. Trial Registration clinicaltrials.gov Identifier: NCT01049516

Understanding Trauma: Cognitive Behavioral Treatments for Posttraumatic Stress Disorder

INTRODUCTION AND DIAGNOSIS OF POSTTRAUMATIC STRESS DISORDER The impact of traumatic events and the behavioral sequelae associated with them has been recognized for over 100 years under a variety of different labels, including compensation neurosis, nervous shock, hysteria, and war neurosis. The introduction of posttraumatic stress disorder (PTSD) into the third edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM–III in 1980 (APA, 1980) and its placement among the anxiety disorders reflects the perception that anxiety is a core component of an individuals reaction to a traumatic experience. Accordingly, PTSD is an anxiety disorder that develops in some individuals after a traumatic event defined by the DSM–IV (APA, 1994) as (1) experiencing, witnessing, or being confronted with an event that involves actual or threatened death or injury, or a threat to their physical integrity or that of others, and (2) responding to the event with intense fear, helplessness, or horror. In addition to experiencing or witnessing a traumatic event, a diagnosis of PTSD requires the individual to meet the following three symptom criteria: (1) At least one reexperiencing symptom, such as distressing recollections of the trauma, distressing dreams of the event, reliving the experience through flashbacks, psychological distress at exposure to internal or external reminders of the event, or physiological reactivity to those trauma reminders. (2) At least three symptoms of persistent avoidance such as making an effort to avoid trauma-related thoughts or feelings, making an effort to avoid trauma-related activities or situations, amnesia for important aspects of the event, diminished interest in activities, detachment from others, restricted range of affect, or a sense of a foreshortened future.

A pilot and feasibility randomised controlled study of Prolonged Exposure Treatment and supportive counselling for post-traumatic stress disorder in adolescents: a third world, task-shifting, community-based sample

BackgroundThere is a dearth of empirical evidence on the effectiveness of pharmacological and nonpharmacological treatments for adolescents with post-traumatic stress disorder (PTSD) in developing country settings. The primary aim of this study was to demonstrate that Prolonged Exposure Treatment for Adolescents (PE-A) and supportive counselling (SC) are implementable by nurses in a South African context. A secondary aim was to perform a preliminary analysis of the effectiveness of registered nurses delivering either PE-A or SC treatment to adolescents with PTSD. It is hypothesised that PE-A will be superior to SC in terms of improvements in PTSD symptoms and depression.MethodA pilot, single-blind, randomised clinical trial of 11 adolescents with PTSD. Nurses previously naïve to Prolonged Exposure (PE) Treatment and SC provided these treatments at the adolescents’ high schools. Data collection lasted from March 2013 to October 2014. Participants received twelve 60–90-min sessions of PE (n = 6) or SC (n = 5). All outcomes were assessed before treatment, at mid-treatment, immediately after treatment completion and at 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed with the Child PTSD Symptom Scale–Interview (CPSS-I) (range, 0–51; higher scores indicate greater severity). The secondary outcome, depression severity, was assessed with the Beck Depression Inventory (BDI) (range, 0–41; higher scores indicate greater severity).ResultsData were analysed as intention to treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvement on the CPSS-I as well as on the BDI. There was a significant difference between the PE-A and SC groups in maintaining PTSD and depression at the 12-month post-treatment assessment, with the participants in the PE-A group maintaining their gains both on PTSD and depression measures.ConclusionThe treatment was adequately implemented by the nurses and well-tolerated by the participants. Preliminary results suggest that the delivery of either intervention led to a significant improvement in PTSD and depression symptoms immediately post treatment. The important difference was that improvement gains in PTSD and depression in the PE-A group were maintained at 12-month follow-up. The results of this pilot and feasibility study are discussed.Trial registrationPan African Clinical Trials Registry: PACTR201511001345372, registered on 11 November 2015.

Adolescents’ Experience of Stigma When Accessing School-Based PTSD Interventions:

This qualitative investigation, nested within a randomized controlled trial (RCT), describes the experiences of adolescent participants accessing psychotherapy for posttraumatic stress disorder (PTSD) in a school-based setting. Supervised nurses provided the psychotherapeutic interventions. Twelve participants who took part in the RCT were invited, and 10 agreed to share their experiences through recorded face-to-face, semistructured, in-depth interviews and treatment-specific focus groups. Basic thematic analysis was applied using Atlas.ti software. Adolescents described a mixed range of perceived poor, ambivalent, and good support experiences when accessing treatment, and were particularly motivated when they had access to a caring adult. During the trial, adolescents used calculated disclosure strategies to reduce their vulnerability to marginalization and stigma. School-based therapy was well received but could be improved if sessions were offered after school hours. This study provides suggestions for improvement and scale-up of school-based PTSD interventions for adolescents.

Adolescent and nurse perspectives of psychotherapeutic interventions for PTSD delivered through task-shifting in a low resource setting

Background This investigation compared the perceived effectiveness of supportive counselling (SC) and prolonged exposure for adolescents (PE-A) by treatment users (adolescents with PTSD) and non-specialist treatment providers (supervised nurses). Method Adolescent participants and nurse providers were purposively recruited to share their experiences of trial participation through face to face semi-structured in-depth interviews and treatment-specific focus groups (all recorded). Twelve adolescent participant transcripts (ten interviews and two focus groups) and three nurse provider transcripts were doubly transcribed. Thematic content analysis was applied using Atlas.ti software. Two emerging themes are presented in this paper: 1) Perceptions of the intervention and 2) Usefulness of the intervention. Results Regardless of treatment arm, adolescents experienced warm counselling relationships and described the process of extending trust to the counselor. Adolescents in the PE-A arm provided clear descriptions of session structure and treatment rationale compared with adolescents receiving SC. The most helpful tools were breathing retraining and imaginal exposure for PE-A and creation of distraction strategies during non-directive SC. Adolescents in both arms continued to use the techniques acquired during treatment and reported symptom improvement. Participants who received SC acknowledged ongoing reexperiencing. Nurses perceived SC to be an immediately transferable skill, but feedback on their preference for one intervention over the other was inconclusive. Conclusion Both PTSD treatment strategies, implemented by non-specialists, were perceived as helpful. Overall, adolescents reported warm therapeutic relationships and a reduction in PTSD symptoms. Nurses stated that they would require institutional support to ensure delivery of these interventions in a scalable and sustainable manner.