Maria Böttche

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.

Integrative testimonial therapy: an Internet-based, therapist-assisted therapy for German elderly survivors of the World War II with posttraumatic stress symptoms.

Abstract Trauma-focused cognitive behavioral treatments are known to be effective for posttraumatic stress disorder (PTSD) in adults. However, evidence for effective treatments for older persons with PTSD, particularly elderly war trauma survivors, is scarce. In an open trial, 30 survivors of World War II aged 65 to 85 years (mean, 71.73 years; SD, 4.8; n = 17 women) with PTSD symptoms were treated with a Web-based, therapist-assisted cognitive-behavioral/narrative therapy for 6 weeks. Intent-to-treat analyses revealed a significant decrease in PTSD severity scores (Cohen’s d = 0.43) and significant improvements on secondary clinical outcomes of quality of life, self-efficacy, and posttraumatic growth from pretreatment to posttreatment. All improvements were maintained at a 3-month follow-up. The attrition rate was low (13.3%), with participants who completed the trial reporting high working alliance and treatment satisfaction. Results of this study suggest that integrative testimonial therapy is a well accepted and potentially effective treatment for older war trauma survivors experiencing PTSD symptoms.

Impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees: results of a longitudinal study

Background: A significant proportion of trauma survivors experience an additional critical life event in the aftermath. These renewed experiences of traumatic and stressful life events may lead to an increase in trauma-related mental health symptoms. Method: In a longitudinal study, the effects of renewed experiences of a trauma or stressful life event were examined. For this purpose, refugees seeking asylum in Germany were assessed for posttraumatic stress symptoms (PTS), Posttraumatic Stress Diagnostic Scale (PDS), anxiety, and depression (Hopkins Symptom Checklist [HSCL-25]) before treatment start as well as after 6 and 12 months during treatment (N=46). Stressful life events and traumatic events were recorded monthly. If a new event happened, PDS and HSCL were additionally assessed directly afterwards. Mann–Whitney U-tests were performed to calculate the differences between the group that experienced an additional critical event (stressful vs. trauma) during treatment (n=23) and the group that did not (n=23), as well as differences within the critical event group between the stressful life event group (n=13) and the trauma group (n=10). Results: Refugees improved significantly during the 12-month period of our study, but remained severely distressed. In a comparison of refugees with a new stressful life event or trauma, significant increases in PTS, anxiety, and depressive symptoms were found directly after the experience, compared to the group without a renewed event during the 12 months of treatment. With regard to the different critical life events (stressful vs. trauma), no significant differences were found regarding overall PTS, anxiety, and depression symptoms. Only avoidance symptoms increased significantly in the group experiencing a stressful life event. Conclusion: Although all clinicians should be aware of possible PTS symptom reactivation, especially those working with refugees and asylum seekers, who often experience new critical life events, should understand symptom fluctuation and address it in treatment. Highlights of the article Within a longitudinal design, refugees currently in treatment are compared concerning symptom course after new traumatic or stressful events. New stressful life events and traumatic events increase posttraumatic, anxious, and depressive symptoms in the first 6 months after the events. Stressful and traumatic events overall did not show differential symptom exacerbations. Only avoidance symptoms were an exception; stressful life events were associated with an increase in PTS avoidance symptoms. Because reducing avoidance is the pivotal mechanism of psychotherapy with PTSD patients, clinicians should anticipate PTS symptom reactivation when patients are re-exposed to significant stressful stimuli, especially with asylum seekers and refugees, who often experience new stressful events.

Predictors of outcome of an Internet-based cognitive-behavioural therapy for post-traumatic stress disorder in older adults

OBJECTIVES The aim of this study was to evaluate the role of resource-oriented variables such as self-efficacy, locus of control (LOC) and post-traumatic growth (PTG) in predicting treatment response in older adults with post-traumatic stress. METHODS Fifty-eight older adults with subsyndromal or greater severity of war-associated post-traumatic stress disorder (PTSD) symptoms completed a randomized controlled Internet-based cognitive-behavioural therapy (CBT) with immediate and delayed treatment groups. Assessments of PTSD severity and resource-oriented variables of self-efficacy, LOC and PTG were conducted at baseline, post-treatment and at a 6-month follow-up. RESULTS Results revealed that pre-treatment scores on measures of internal LOC and PTG predicted PTSD symptom severity at post-treatment, even after controlling for initial PTSD. At a 6-month follow-up, internal LOC continued to predict PTSD symptom severity. In addition, repeated-measures analyses of variance revealed that, relative to older adults with low internal LOC and PTG, older adults with high internal LOC and PTG, respectively, did not differ with respect to initial PTSD severity, but they showed a more pronounced response to treatment. CONCLUSION These findings suggest that greater locus of control and post-traumatic growth is associated with greater improvement in PTSD symptoms following Internet-based CBT. Assessment of these constructs may be useful in identifying trauma survivors who are most likely to respond to CBT. PRACTITIONER POINTS Greater internal locus of control and post-traumatic growth is associated with greater improvement in PTSD symptoms following Internet-based CBT. Older adults with initial high internal locus of control and post-traumatic growth, respectively, did not differ with respect to initial PTSD severity, but they showed a more pronounced response to treatment. It could be assumed that patients with initial functional appraisals could benefit easier and faster from a trauma-focused cognitive-behavioural therapy compared to individuals with lower internal locus of control and post-traumatic growth.

Die therapeutische Beziehung in internetbasierten Therapieverfahren

There has been an increased use of modern information and communication technology in healthcare services in recent years; however, little is yet known about the nature of the therapeutic alliance in internet-based interventions. This review aims to give a systematic overview of controlled evaluation studies with a focus on the nature and impact of the therapeutic alliance in internet-based interventions available to date. The results of internet-based randomized controlled trials indicate that a positive therapeutic alliance can be established regardless of the medium of communication. The therapeutic alliance was rated equally satisfying as in conventional face-to-face therapy.ZusammenfassungDie moderne Informations- und Kommunikationstechnologie hat in den letzten Jahren verstärkt Einzug in den Bereich der psychosozialen Gesundheitsversorgung gehalten. Die Qualität der therapeutischen Beziehung in einem medienvermittelten therapeutischen Kontakt ist bisher unzureichend geklärt. Ziel dieses Reviews ist es, einen systematischen Überblick vorliegender kontrollierter Evaluationsstudien zu geben, die die Qualität und Relevanz der therapeutischen Beziehung in internetbasierten Interventionen untersuchen. Die Ergebnisse deuten darauf hin, dass unabhängig vom Kommunikationsmedium eine stabile therapeutische Beziehung in internetbasierten randomisiert-kontrollierten Studien hergestellt werden kann. Diese wird vergleichbar positiv bewertet wie herkömmliche Face-to-Face-Therapien.SummaryThere has been an increased use of modern information and communication technology in healthcare services in recent years; however, little is yet known about the nature of the therapeutic alliance in internet-based interventions. This review aims to give a systematic overview of controlled evaluation studies with a focus on the nature and impact of the therapeutic alliance in internet-based interventions available to date. The results of internet-based randomized controlled trials indicate that a positive therapeutic alliance can be established regardless of the medium of communication. The therapeutic alliance was rated equally satisfying as in conventional face-to-face therapy.

Construction of a questionnaire for readiness to reconcile in victims of human rights violations

Background Post-conflict reconciliation is supposed to have a positive impact on survivors of war and conflict. However, knowledge is limited as validated questionnaires to assess individual readiness to reconcile in the context of human rights violations are still missing. Objectives This study aimed to develop and pilot-test a questionnaire to assess individual readiness to reconcile in victims of human rights violations. Methods The questionnaire was developed and pilot-tested in a sample of 60 adult Kurdish refugees from Turkey. In addition to the questionnaire, trauma exposure, Posttraumatic Stress Disorder (PTSD), depression, anxiety, perceived emotional closeness to the Kurdish people as well as the participants’ ability to differentiate between perpetrators and the people in general were assessed in structured interviews, and their associations with readiness to reconcile were analyzed. Results Factor and item analysis resulted in an 18-item questionnaire with three subscales (openness to interactions; absence of feelings of revenge; openness to conflict resolution). Cronbachs α for the subscales ranged from 0.74 to 0.90, explaining 61% of the total variance. The ability to differentiate between perpetrators and people in general and perceived emotional closeness were the best predictors for readiness to reconcile. The level of trauma exposure was not linked to readiness to reconcile. Although readiness to reconcile was negatively related to PTSD, depression and anxiety, none of these associations reached statistical significance. Conclusions The questionnaire appears to be a reliable measure with good psychometric properties. Further validations in different samples are needed.

Typologies of posttraumatic stress disorder in treatment-seeking older adults.

BACKGROUND While it is well known that posttraumatic stress disorder (PTSD) is characterized by heterogeneous symptom clusters, little is known about predominant typologies of PTSD symptoms in older adults. METHODS Latent profile analyses (LPAs) were employed to evaluate predominant typologies of PTSD symptoms in a sample of 164 treatment-seeking older adults with childhood war-related trauma. Multinomial logistic regressions were conducted to evaluate predictors of class membership. RESULTS LPAs revealed that a 3-class solution best fit the data. These included an Intermediate Disturbance class (50.0%) and two Pervasive Disturbance classes, which differed with respect to severity of avoidance symptoms (Pervasive Disturbance-Low Avoidance: 33.5%, Pervasive Disturbance-High Avoidance: 16.5%). A greater number of traumatic events predicted membership in the Pervasive Disturbance classes. The Pervasive Disturbance-Low Avoidance class had a higher level of education than the Pervasive Disturbance-High Avoidance class. Compared to the Intermediate Disturbance class, the Pervasive Disturbance classes had the highest levels of depression, anxiety and somatization symptoms. CONCLUSION These results suggest that PTSD in treatment-seeking older adults may be characterized by three predominant typologies, which are differentiated by overall severity and avoidance symptoms, lifetime trauma burden, education level, and comorbid depression, anxiety, and somatization symptoms. These results underscore the importance of considering heterogeneity in the phenotypic presentation of PTSD in assessment and treatment approaches for this disorder in older adults.

Schreibtherapie nach traumatischen Belastungen: Therapieansätze und Wirkmechanismen

The (written) disclosure of information, thoughts and emotions of individually significant tops is associated with positive effects on well-being and the psychological health. The applicability of expressive writing as a psychotherapeutic intervention for stress reactions after stressful/traumatic life events were also intensely discussed in the clinical context. However, structural and content-related variation of the initial writing paradigm resulted in significantly different effects on general psychological health and posttraumatic stress symptoms.This overview provides current findings to application and efficacy of expressive writing respectively writing therapy for posttraumatic stress disorder. Mechanisms of expressive writing (inhibition, habituation, construction of a coherent narrative, emotion regulation, social integration) are analyzed with regard to their relevance concerning PTSD. Finally, potentials for application in the clinical practice are discussed.

Multidisciplinary treatment for traumatized refugees in a naturalistic setting: symptom courses and predictors

ABSTRACT Background: Multidisciplinary treatment approaches are commonly used in specialized psychosocial centres for the treatment of traumatized refugees, but empirical evidence for their efficacy is inconsistent. Objective: In order to obtain more evidence on the development of mental health and well-being of traumatized refugees who receive multidisciplinary treatment, symptom courses of posttraumatic stress disorder (PTSD), anxiety, depression and somatoform symptoms as well as in the subjective quality of life were investigated in the course of a multidisciplinary treatment. In addition, it was analysed if sociodemographic variables were predictors for possible changes in symptomatology and quality of life. Method: N = 76 patients of the outpatient clinic of a psychosocial centre for traumatized refugees receiving regular multidisciplinary treatment were surveyed using standardized questionnaires at three measurement points (at the beginning of treatment, and after an average of 7 and 14 months of treatment) in a single-group design. Results: Multilevel analysis showed significant improvements of symptoms of PTSD (p < .001), depression (p < .001), anxiety (p < .001), and somatoform symptoms (p = .002) as well as of the subjective quality of life (p < .001) over time. Among the tested predictors (gender, age, country of origin), age was a significant predictor for the course of somatoform symptoms (p < .05). Younger patients showed greater improvements in symptomatology over time than older ones. Conclusions: The results suggest that the received multidisciplinary treatment had a positive effect on trauma-related symptoms as well as on quality of life of traumatized refugees. There was no indication that sociodemographic characteristics predicted the symptom courses of the patients, except for somatoform symptoms. Younger patients benefitted more from multidisciplinary treatment than older ones.

Efficacy and Feasibility of a Therapist-Guided Internet-Based Intervention for Older Persons with Childhood Traumatization: A Randomized Controlled Trial

OBJECTIVE Although cognitive-behavioral treatment approaches for post-traumatic stress disorder (PTSD) exist, only a small proportion of older adults seeks psychological treatment. Alternative treatment approaches are thus needed to fill the gap between provision and use of psychological interventions. This study aimed to investigate the efficacy and feasibility of an Internet-based, therapist-guided cognitive-behavioral therapy (Internet-based CBT) for older individuals with PTSD symptoms. METHODS Patients with clinically meaningful (i.e., subsyndromal or greater) PTSD symptoms were randomly assigned to a 6-week treatment group of therapist-guided Internet-based CBT (N = 47; treatment group) or a wait-list group (N = 47; WL). The treatment group was assessed pre- and post-treatment as well as at 3-, 6- and 12-month follow-ups. RESULTS Linear mixed-effects analyses showed a significant interaction between group (treatment versus WL) and time (pre versus post) for PTSD symptoms with a moderate between-group effect size in favor of the treatment group (d = 0.42). Effects in the treatment group were maintained up to the 12-month follow-up. Findings indicate a significant interaction (group × time) for quality of life (d = 0.39) and self-efficacy (d = 0.38). With regard to the feasibility, attrition rate was very low in both groups (treatment group: 12.8%, WL: 6.4%) and working alliance was very high. CONCLUSIONS Results suggest that therapist-guided Internet-based CBT is associated with a substantial reduction in PTSD symptoms, and increase in resource-related variables in older adults with (subsyndromal) PTSD. This Internet-based intervention may offer a promising option in a stepped-care approach for older trauma-affected persons who may otherwise not pursue mental health treatment.