Idan M. Aderka

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.

Sudden Gains during Psychological Treatments of Anxiety and Depression: A Meta-Analysis.

OBJECTIVE The present study quantitatively reviewed the literature on sudden gains in psychological treatments for anxiety and depression. The authors examined the short- and long-term effects of sudden gains on treatment outcome as well as moderators of these effects. METHOD The authors conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. The meta-analysis was based on 16 studies and included 1,104 participants receiving psychological treatment for major depressive disorder or an anxiety disorder. RESULTS Effect size estimates suggest that sudden gains had a moderate effect on primary outcome measures at posttreatment (Hedgess g = 0.62) and follow-up (Hedgess g = 0.56). These effect sizes were robust and unrelated to publication year or number of treatment sessions. The effect size of sudden gains in cognitive-behavioral therapy was higher (Hedgess g = 0.75) than in other treatments (Hedgess g = 0.23). CONCLUSIONS These results suggest that sudden gains are associated with short-term and long-term improvements in depression and anxiety, especially in cognitive-behavioral therapy.

Functional impairment in social anxiety disorder

The present study examined functional impairment among treatment seekers with social anxiety disorder (SAD). We investigated the effects of diagnostic subtypes of SAD and comorbidity with mood and anxiety disorders on impairment. In addition, we used cluster analysis procedures to empirically identify subgroups of individuals with distinct patterns of impairment. Participants were 216 treatment-seeking individuals with SAD. Clinical interviews were undertaken to determine diagnoses of anxiety disorders and major depressive disorder, and a battery of self-report measures was administered to index symptoms of social anxiety, depression and extent of impairment. Results indicated that individuals with the generalized subtype of SAD had greater impairment in all three life domains compared to individuals with the nongeneralized subtype. Comorbidity with mood disorders was associated with greater impairment than SAD alone, but comorbidity with anxiety disorders was not. Four distinct impairment profiles emerged from the cluster analysis: primary work/studies impairment, primary social life impairment, both work/studies and social impairment, and impairment in all domains. Findings from this study suggest that SAD is associated with substantial impairment across multiple domains, and that individuals with SAD present diverse impairment profiles. These profiles may inform subtyping of the disorder as well as therapeutic interventions.

Treating Prolonged Grief Disorder: A Randomized Clinical Trial

IMPORTANCE Prolonged grief disorder (PGD) is a potentially disabling condition that affects approximately 10% of bereaved people. Grief-focused cognitive behavior therapy (CBT) has been shown to be effective in treating PGD. Although treatments for PGD have focused on exposure therapy, much debate remains about whether exposure therapy is optimal for PGD. OBJECTIVE To determine the relative efficacies of CBT with exposure therapy (CBT/exposure) or CBT alone for PGD. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of 80 patients with PGD attending the outpatient University of New South Wales Traumatic Stress Clinic from September 17, 2007, through June 7, 2010. INTERVENTIONS All patients received 10 weekly 2-hour group therapy sessions that consisted of CBT techniques. Patients also received 4 individual sessions, in which they were randomized to receive exposure therapy for memories of the death or supportive counseling. MAIN OUTCOMES AND MEASURES Measures of PGD by clinical interview and self-reported measures of depression, cognitive appraisals, and functioning at the 6-month follow-up. RESULTS Intention-to-treat analyses at follow-up indicated a significant quadratic time×treatment condition interaction effect (B [SE], 0.49 [0.16]; t120.16=3.08 [95% CI, 0.18-0.81]; P=.003), indicating that CBT/exposure led to greater PGD reductions than CBT alone. At follow-up, CBT/exposure led to greater reductions in depression (B [SE], 0.35 [0.12]; t112.65=2.83 [95% CI, 0.11-0.60]; P=.005), negative appraisals (B [SE], 0.68 [0.25]; t109.98=2.66 [95% CI, 0.17-1.18]; P=.009), and functional impairment (B [SE], 0.24 [0.08]; t111.40=3.01 [95% CI, 0.08-0.40]; P=.003) than CBT alone. In terms of treatment completers, fewer patients in the CBT/exposure condition at follow-up (14.8%) met criteria for PGD than those in the CBT condition (37.9%) (odds ratio, 3.51; 95% CI, 0.96-12.89; χ2=3.81; P=.04). CONCLUSIONS AND RELEVANCE Including exposure therapy that promotes emotional processing of memories of the death is an important component to achieve optimal reductions in PGD severity. Facilitating emotional responses to the death may promote greater changes in appraisals about the loss, which are associated with symptom reduction. Promotion of emotional processing techniques in therapies to treat patients with PGD is needed. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12609000229279.

Social rank and affiliation in social anxiety disorder.

The present study examined the interpersonal lives of individuals with social anxiety disorder (SAD). According to evolutionary and interpersonal theories, we construed the interpersonal world using the social rank and the affiliation psychological systems. Two studies assessed measures of social rank, affiliation, social anxiety and depression among a population of treatment-seeking individuals with SAD. In study 1, individuals with SAD without major depressive disorder (MDD; n=42) were compared to healthy controls (n=47). In study 2, individuals with SAD and MDD (n=45) were compared to individuals with other anxiety disorders and MDD (n=31). Results indicated that SAD was related to perceiving oneself as having low social rank, being inferior, and behaving submissively, as well as to low perceived intimacy and closeness among peer relations, friendships and romantic relations. SAD was distinctly associated with these perceptions above and beyond the symptomatic (study 1) and the syndrome-level (study 2) effects of depression. These findings were further supported by a path analysis of the SAD participants from both studies. Our findings highlight the need to address both social rank and affiliation issues in the assessment and treatment of SAD.

Factors affecting treatment efficacy in social phobia: the use of video feedback and individual vs. group formats

This meta-analysis assessed two potential moderators of treatment efficacy in social phobia: video feedback, and treatment format (i.e., individual vs. group). Eighteen recent (2000-2006) trials including a total of 511 participants were sampled. Effect sizes (Cohens ds) were calculated for each trial while correcting for measurement error. The Q statistic was used to test (a) heterogeneity across trials and (b) potential moderators. Results indicated that use of video feedback was not a moderator of treatment efficacy and did not significantly affect effect sizes. In contrast, treatment format was a moderator of treatment efficacy such that individual treatments reported larger effect sizes and lower attrition rates compared with group treatments. The results suggest that individual treatments in social phobia may be superior to group treatments irrespective of treatment type.

The Child PTSD Symptom Scale: Psychometric Properties in Female Adolescent Sexual Assault Survivors

Traumatic experiences are common among youths and can lead to posttraumatic stress disorder (PTSD). In order to identify traumatized children who need PTSD treatment, instruments that can accurately and efficiently evaluate pediatric PTSD are needed. One such measure is the Child PTSD Symptom Scale (CPSS), which has been found to be a reliable and valid measure of PTSD symptom severity in school-age children exposed to natural disasters (Foa, Johnson, Feeny, & Treadwell, 2001). However, the psychometric properties of the CPSS are not known in youths who have experienced other types of trauma. The current study aims to fill this gap by examining the psychometric properties of the interview (CPSS-I) and self-report (CPSS-SR) administrations of the CPSS in a sample of 91 female youths with sexual abuse-related PTSD, a population that is targeted in many treatment studies. Scores on both the CPSS-I and CPSS-SR demonstrated good to excellent internal consistency. One-week test-retest reliability assessed for CPSS-SR scores was excellent (r=.86); interrater reliability of CPSS-I scores was also excellent (r=.87). Symptom-based diagnostic agreement between the CPSS-SR and CPSS-I was excellent at 85.5%; scores on both the CPSS-SR and CPSS-I also demonstrated good convergent validity (74.5-76.5% agreement) with the PTSD module of The Schedule of Affective Disorders and Schizophrenia for School-Age Children--Revised for DSM--IV (K-SADS; Kaufman, Birmaher, Brent, & Rao, 1997). The strong psychometric properties of the CPSS render it a valuable instrument for PTSD screening as well as for assessing symptom severity.

Longitudinal associations between post-traumatic distress and depressive symptoms following a traumatic event: a test of three models

BACKGROUND Symptoms of post-traumatic stress disorder (PTSD) and depression are highly co-morbid following a traumatic event. Nevertheless, decisive evidence regarding the direction of the relationship between these clinical entities is missing. METHOD The aim of the present study was to examine the nature of this relationship by comparing a synchronous change model (PTSD and depression are time synchronous, possibly stemming from a third common factor) with a demoralization model (i.e. PTSD symptoms causing depression) and a depressogenic model (i.e. depressive symptoms causing PTSD symptoms). Israeli adult victims of single-event traumas (n=156) were assessed on measures of PTSD and depression at 2, 4 and 12 weeks post-event. RESULTS A cross-lagged structural equation modeling (SEM) analysis provided results consistent with the synchronous change model and the depressogenic model. CONCLUSIONS Depressive symptoms may play an important role in the development of post-traumatic symptoms.

Age of onset in obsessive–compulsive disorder: admixture analysis with a large sample

BACKGROUND Research into age of onset in obsessive-compulsive disorder (OCD) has indicated significant differences between patients with early and late onset of the disorder. However, multiple criteria have been used arbitrarily for differentiating between early- and late-onset OCD, rendering inconsistent results that are difficult to interpret. METHOD In the current study, admixture analysis was conducted in a sample of 377 OC patients to determine the number of underlying populations of age of onset and associated demographic and clinical characteristics. Various measures of anxiety, depression, co-morbidity, autism, OCD, tics and attention deficit hyperactivity disorder (ADHD) symptoms were administered. RESULTS A bimodal age of onset was established and the best-fitting cut-off score between early and late age of onset was 20 years (early age of onset ≤19 years). Patients with early age of onset were more likely to be single. Early age of onset patients demonstrated higher levels of OCD severity and increased symptoms on all OCD dimensions along with increased ADHD symptoms and higher rates of bipolar disorder. CONCLUSIONS It is suggested that 20 years is the recommended cut-off age for the determination of early versus late age of onset in OCD. Early age of onset is associated with a generally graver OCD clinical picture and increased ADHD symptoms and bipolar disorder rates, which may be related to greater functional implications of the disorder. We propose that age of onset could be an important marker for the subtyping of OCD.

Direction of Influence Between Posttraumatic and Depressive Symptoms during Prolonged Exposure Therapy among Children and Adolescents

OBJECTIVE Our objective in the present study was to examine the temporal sequencing of posttraumatic and depressive symptoms during prolonged exposure therapy for posttraumatic stress disorder (PTSD) among children and adolescents. METHOD Participants were 73 children and adolescents (56.2% female) between the ages of 8 and 18. Participants completed self-report measures of posttraumatic stress and depression prior to every session. Measures included the Child PTSD Symptom Scale, Beck Depression Inventory, and Childrens Depression Inventory. RESULTS Multilevel mediational analyses indicated reciprocal relations during treatment: Changes in posttraumatic symptoms led to changes in depressive symptoms and vice versa. Posttraumatic symptoms accounted for 64.1% of the changes in depression, whereas depressive symptoms accounted for 11.0% of the changes in posttraumatic stress. CONCLUSIONS Prolonged exposure therapy may work primarily by reducing posttraumatic stress, which in turn reduces depression.