Sara Freedman

Early PTSD Symptom Trajectories: Persistence, Recovery, and Response to Treatment: Results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS)

Context Uncovering heterogeneities in the progression of early PTSD symptoms can improve our understanding of the disorders pathogenesis and prophylaxis. Objectives To describe discrete symptom trajectories and examine their relevance for preventive interventions. Design Latent Growth Mixture Modeling (LGMM) of data from a randomized controlled study of early treatment. LGMM identifies latent longitudinal trajectories by exploring discrete mixture distributions underlying observable data. Setting Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity. Participants Adult survivors of potentially traumatic events consecutively admitted to the hospitals emergency department (ED) were assessed ten days and one-, five-, nine- and fifteen months after ED admission. Participants with data at ten days and at least two additional assessments (nu200a=u200a957) were included; 125 received cognitive behavioral therapy (CBT) between one and nine months. Approach We used LGMM to identify latent parameters of symptom progression and tested the effect of CBT on these parameters. CBT consisted of 12 weekly sessions of either cognitive therapy (nu200a=u200a41) or prolonged exposure (PE, nu200a=u200a49), starting 29.8±5.7 days after ED admission, or delayed PE (nu200a=u200a35) starting at 151.8±42.4 days. CBT effectively reduced PTSD symptoms in the entire sample. Main Outcome Measure Latent trajectories of PTSD symptoms; effects of CBT on these trajectories. Results Three trajectories were identified: Rapid Remitting (rapid decrease in symptoms from 1- to 5-months; 56% of the sample), Slow Remitting (progressive decrease in symptoms over 15 months; 27%) and Non-Remitting (persistently elevated symptoms; 17%). CBT accelerated the recovery of the Slow Remitting class but did not affect the other classes. Conclusions The early course of PTSD symptoms is characterized by distinct and diverging response patterns that are centrally relevant to understanding the disorder and preventing its occurrence. Studies of the pathogenesis of PTSD may benefit from using clustered symptom trajectories as their dependent variables.

Social relationship satisfaction and PTSD: which is the chicken and which is the egg?

Background Impaired social relationships are linked with higher levels of posttraumatic stress disorder (PTSD), but the associations underlying dynamics are unknown. PTSD may impair social relationships, and, vice versa, poorer relationship quality may interfere with the recovery from PTSD. Objective This work longitudinally evaluates the simultaneous progression of PTSD symptoms and social relationship satisfaction (SRS) in a large cohort of recent trauma survivors. It also explores the effect of cognitive behavior therapy (CBT) on the association between the two. Method Consecutive emergency department trauma admissions with qualifying PTSD symptoms (n=501) were assessed 3 weeks and 5 months after trauma admission. The World Health Organization Quality of Life evaluated SRS and the Clinician Administered PTSD Scale evaluated PTSD symptom severity. Ninety-eight survivors received CBT between measurement sessions. We used Structural Equation Modeling to evaluate cross-lagged effects between the SRS and PTSD symptoms. Results The cross-lagged effect of SRS on PTSD was statistically significant (β=−0.12, p=0.01) among survivors who did not receive treatment whilst the effect of PTDS on SRS was nil (β=−0.02, p=0.67). Both relationships were non-significant among survivors who received CBT. Discussion SRS and PTSD are highly associated, and this study shows that changes in SRS in the early aftermath of traumatic events contribute to changes in PTSD, rather than vice versa. SRS impacts natural recovery, but not effective treatment. This study suggests that being satisfied with ones relationships might be considered as an important factor in natural recovery from trauma, as well as in intervention.

Early intervention for preventing posttraumatic stress disorder: an Internet-based virtual reality treatment

Background Posttraumatic stress disorder (PTSD) develops in approximately 20% of people exposed to a traumatic event, and studies have shown that cognitive-behavioral therapy (CBT) is effective as a treatment for chronic PTSD. It has also been shown to prevent PTSD when delivered early after a traumatic event. However, studies have shown that uptake of early treatment is generally low, and therefore, the need to provide interventions through other mediums has been identified. The use of technology may overcome barriers to treatment. Objective This paper describes a randomized controlled trial that will examine an early CBT intervention for PTSD. The treatment incorporates virtual reality (VR) as a method for delivering exposure-based elements of the treatment. The intervention is Internet based, such that the therapist and patient will “meet” in a secure online site. This site will also include multi-media components of the treatment (such as videos, audios, VR) that can be accessed by the patient between sessions. Method Two hundred patients arriving to a Level 1 emergency department following a motor vehicle accident will be randomly assigned to either treatment or control groups. Inclusion criteria are age 18–65, PTSD symptoms 2 weeks posttrauma related to current trauma, no suicidality, no psychosis. Patients will be assessed by telephone by a team blind to the study group, on four occasions: before and after treatment, and 6 and 12 months posttreatment. The primary outcome is PTSD symptoms at follow up. Secondary outcomes include depression and cost effectiveness. Analyses will be on an intention-to-treat basis. Discussion The results will provide more insight into the effects of preventive interventions, in general, and Internet-based early interventions, in particular, on PTSD, in an injured population, during the acute phase after trauma. We will discuss possible strengths and limitations.

Prospective Studies of the Recently Traumatized

Reactions to traumatic events, their course, and their presumed etiology have been studied throughout this century (e.g., Rivers, 1918; Fraser & Wilson, 1918; Grinker et al., 1946), although it is only since these were included in an official nosology that their natural course has been studied systematically. Seventeen years following the inclusion of post-traumatic stress disorder (PTSD) in the psychiatric literature, it seems worthwhile to assess what has been learned from more systematic research and which questions still remain to be answered. This chapter reviews longitudinal studies to date, outlines some of the gaps that remain in our knowledge, and suggests a possible way forward for future research.

Shared trauma reality in war: Mental health therapists' experience

Introduction Shared traumatic reality occurs when therapists are doubly exposed to a traumatic event, both through their clients’ experience, along with their own direct exposure. Studies have shown that a shared traumatic reality can lead to both positive and negative outcomes for therapists. Most studies have examined these reactions sometime after the end of the traumatic event, and less is known about reactions that occur during a traumatic event. In addition, most studies have assumed, rather than examined, indirect exposure. In this study, we extend this literature by examining direct and indirect exposure of therapists during a war situation, and their psychological reactions. Method Over a period of two months in 2014, 70% of the Israeli population was exposed to rocket fire. Geographical areas differed in terms of amount of exposure, and its potential danger. 151 therapists living throughout Israel were assessed via an Internet based survey in the middle of the war, and were assessed for the effects on their professional and personal lives, degree of burnout, ways of coping and symptoms levels of PTSD and psychological distress. Results These indicate that significant differences in direct exposure occurred depending on place of residence. PTSD levels were related to higher direct exposure, as well as prior trauma exposure, but not to indirect exposure. Indirect exposure, as measured by increased workload, was related to increased distress and emotional exhaustion. Discussion These data shed light on the effects of direct and indirect exposure to a shared traumatic experience of war amongst therapists. The data support previous studies showing a greater effect of direct exposure on PTSD. Since indirect exposure appears to negatively impact burnout and psychological distress, rather than PTSD, this study shows that symptoms other than PTSD should be the result of in a shared traumatic reality.

Posttraumatic Stress Disorder, Parenting, and Marital Adjustment among a Civilian Population

While psychopathology in general is linked to poorer marital and parental satisfaction, there is a paucity of data regarding these interactions in parents with Posttraumatic stress disorder (PTSD). The current study addresses this issue among a civilian population. Two hundred trauma-exposed parents, mean age of 37.2, 62% mothers, were assessed using self-report questionnaires, for background variables, PTSD symptoms using the Posttraumatic Stress Diagnostic Scale (PDS), depression symptoms (Beck Depression Inventory, BDI), marital satisfaction (Dyadic Adjustment Scale, DAS-7), parenting behavior (Alabama Parenting Questionnaire, APQ-9), and parenting satisfaction (Parenting Satisfaction Questionnaire). We hypothesized that positive parenting behavior and parenting satisfaction would be negatively correlated with PTSD symptom levels, and that this relationship would be mediated by marital satisfaction; the independent effects of depression on marital and parenting functioning were also examined. Data was analyzed using structural equation modeling (SEM). Results indicated that PTSD was related to poorer parenting behavior (B = 0.089, p = 0.033), depression had a negative impact on parenting satisfaction (B = 0.983, p = 0.003), and marital satisfaction (B = −0.672, p = 0.004), and marital satisfaction fully mediated the relationship between depression and parenting. The findings demonstrated that the effects of PTSD can cast a pall not only over the individual but over the entire family. Interventions are needed to address these issues.

Posttraumatic growth and recovery from addiction

ABSTRACT Background: It is well documented that individuals coping with adverse events report both negative outcomes, such as posttraumatic stress symptoms, as well as positive changes, described as posttraumatic growth. Positive changes are also reported in people who have recovered from substance abuse. It seems plausible from the literature that both of these types of positive changes have elements in common. To date, no published studies have examined positive outcomes among people who have recovered from addiction. Objectives: In this study, posttraumatic growth in individuals who were formerly addicted to alcohol or substances, termed ‘addiction-related growth,’ was examined. Addiction-related growth refers to the growth that an individual undergoes as a result of the addiction itself, and the recovery from the addiction. A successful recovery from addiction is associated with positive changes, particularly regarding spirituality and meaning-making, and the construct of addiction-related growth may explain why. Method: This cross-sectional study examined growth among 104 individuals who had recovered from addiction who were recruited from addiction treatment programmes, between February and July 2012. Questionnaires assessed demographics and substance abuse use and treatment, posttraumatic growth (PTGI); social support (Perceived Social Support Questionnaire); and help-seeking (Willingness to Seek Help Scale). Data was analysed using an analysis of variance (ANOVA), Pearson correlations, and multiple regression. Results: Results indicated that addiction-related growth is a phenomenon that accurately captures the positive changes experienced as a result of an individual’s struggle with addiction and recovery. This growth was found to be associated with participation in 12-steps programmes, and to be predicted by levels of perceived social support. Conclusions: The results show that recovery from addiction is associated with addiction-related growth. These positive changes, along with the importance of communal social support, resemble the changes that take place as a result of processes described in 12-steps programmes.

Correction: Shared trauma reality in war: Mental health therapists' experience

[This corrects the article DOI: 10.1371/journal.pone.0191949.].

Differential effect of exposure‐based therapy and cognitive therapy on post‐traumatic stress disorder symptom clusters: A randomized controlled trial

A question remains regarding differential effects of exposure-based versus non-exposure-based therapies on specific post-traumatic stress disorder (PTSD) symptom clusters. Traumatized emergency room patients were randomized to receive prolonged exposure (PE) or cognitive therapy (CT) without exposure. PE/CT had no differential effect on individual symptom clusters, and change in total PTSD score remained significant even after controlling for the reductions in all three symptom clusters. In addition, baseline levels of PTSD avoidance/intrusion/hyperarousal did not moderate the effects of PE and CT on total PTSD symptom scores. Taken together, these findings challenge the notion that PE and CT are specifically, and differentially, useful in treating one particular PTSD symptom cluster.nnnPRACTITIONER POINTSnDespite their different theoretical backgrounds and techniques, the notion that PE and CT (without exposure) target different PTSD symptoms was not confirmed in this study. Thus, both interventions may in fact be equally effective for treating intrusion, avoidance and hyperarousal symptoms. Baseline levels of avoidance, intrusion and hyperarousal may not be good a priori indicators for PTSD treatment selection. The effect of PE and CT on PTSD as a whole does not seem to depend on a reduction in any specific symptom cluster. These findings indicate that exposure and non-exposure interventions may lead to similar results in terms of reductions in specific PTSD symptoms. It is quite possible that individual PTSD clusters may respond to therapy in an inter-related fashion, with one cluster affecting the other.

Distress Levels among Parents of Active Duty Soldiers during Wartime

Objective: Military service is a highly stressful period both for the soldiers serving and for their parents. Surprisingly, parents’ experience has been mostly ignored in the research. This study’s goal is to shed light on the experience and distress levels of parents of active duty combat soldiers during Operation Protective Edge, a military operation carried out by the Israel Defense Forces during July and August of 2014. Methods: During the advanced stages of the operation, 69 parents of Israeli male combat soldiers (55 mothers and 14 fathers) completed an online survey measuring symptoms of Posttraumatic Stress Disorder (PTSD-Checklist-5) and distress (Brief Symptom Inventory-18). Participants were recruited using a convenience sample, by posting ads on the public Facebook pages of the researchers and of the groups dedicated to parents of Israeli soldiers. Results: Parents’ depression and anxiety symptom levels were higher than depression and anxiety symptom levels of the adult community norms in Israel. General distress rates of parents were similar to those presented by adults in southern Israel who were exposed for 7 years to the ongoing threat of daily rocket fire from Gaza, and higher than rates of a non-threatened Israeli population. Finally, 20.2% of the parents presented PTSD-like symptoms, a higher percentage than the probable PTSD diagnosis rates that were found in the general population in Israel during previous terror waves. Conclusion: This study provides preliminary evidence of soldiers’ parents’ distress and indicates the need for a better understanding of the impact of military service on soldiers’ parents.