An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors

Abstract Introduction: Torture is associated with adverse health consequences, with especially high rates of PTSD, depression and chronic pain. Despite increased awareness of the relationship between pain and posttraumatic symptoms, and the accompanying need for effective treatment strategies, few studies have examined an integrated treatment of comorbid PTSD and pain. Methods: In this study, using an A-B case series design with three and six month follow-up, six refugee torture survivors with comorbid PTSD, depression and chronic pain received 20 sessions of Narrative Exposure Therapy (NET) and 10 sessions of physiotherapy. Outcome variables included symptoms of PTSD and depression, pain intensity, physical functioning and quality of life. Symptoms of PTSD and pain were also rated after each treatment session. Results: Two patients achieved clinically significant reduction in symptoms of PTSD. Only one patient achieved clinically significant change in depressive symptoms, and two experienced clinically significant reduction in pain intensity. Clinical descriptions of the course of treatment for all patients are provided. Discussion and Conclusions: Despite its limitations, the study suggests that some torture survivors who suffer high symptom loads may benefit from a combined treatment of NET and physiotherapy. Appreciating individual differences and how they affect treatment can provide valuable insight and inform clinicians working with torture survivors. Directions for future research regarding the improvement of rehabilitation strategies of torture survivors are discussed, and highlighted through descriptions from the six therapy cases

Painful memories: Challenges in trauma-focused therapy for torture survivors with PTSD and chronic pain: – a narrative review

Introduction: PTSD and chronic pain are disorders that researchers increasingly acknowledge to be risk factors that overlap and their comorbidity is associated with poorer treatment outcomes. This review focuses on torture survivors due to the high prevalence of comorbidity in this group, as well as how PTSD and chronic pain might develop, interact and mutually maintain each other. Methods: A narrative review of empirical studies and theoretical models regarding chronic pain and PTSD in torture survivors, informed by studies conducted in other contexts. Results and discussion: An overview of PTSD and chronic pain studies of torture survivors is presented. Treatment studies for torture survivors with PTSD are scarce and have been discouraging. Studies in other patient populations and theoretical models of maintaining factors within the cognitive-behavioral paradigm are presented, and focused around how interactions between PTSD and chronic pain might mitigate treatment of both disorders. Mutually maintaining factors between chronic pain and PTSD are presented as potential barriers to healing, and clinical implications involve suggestions for clinicians with intention to overcome these barriers in trauma-focused treatment of torture survivors. The knowledge base on how chronic pain and PTSD interact within the context of torture is still very limited. Torture is a potent risk factor in itself for both chronic pain and PTSD. Studies point to complex interactions between pain and PTSD across different trauma-exposed populations, especially when the trauma includes pain. Moreover, the coping strategies that are available and might function as some form of protection during torture [e.g. dissociation, withdrawal], might conversely function to exacerbate symptoms when the survivor is in a safe rehabilitation context. Observations combined with CPPC literature and recent developments in learning theory challenge clinical practice accordingly. Additionally, the limited knowledge base prevents us from providing clear-cut sugges- tions, particularly as the majority of scientific enquiry regarding chronic pain and PTSD has been conducted in other populations outside of the torture survivors group. Furthermore, cultural factors, specific needs and characteristics in this group, the human rights perspective and the socio-political context all need to be acknowledged. Trauma-focused treatment does not appear to specifically target all the mechanisms that are supposedly interacting in maintaining chronic pain and PTSD. Interdisciplinary rehabilitation and close collaboration between physiotherapists and trauma-focused therapists are warranted

Modified prolonged exposure therapy as Early Intervention after Rape (The EIR-study): study protocol for a multicenter randomized add-on superiority trial

Background Sexual assault and rape are the traumatic life events with the highest probability for posttraumatic stress disorder (PTSD), which can have devastating consequences for those aficted by the condition. Studies indicate that modifed prolonged exposure (mPE) therapy may be efective in preventing the development of PTSD in recently traumatized individuals, and especially for people who have experienced sexual assault. If a brief, manualized early intervention can prevent or reduce post-traumatic symptoms in women who have recently experienced rape, healthcare services targeted for these populations (i.e., sexual assault centers, SACs) should consider implementing such interventions as part of routine care. Methods/design This is a multicenter randomized controlled add-on superiority trial that enrolls patients attending sexual assault centers within 72 h after rape or attempted rape. The objective is to assess whether mPE shortly after rape can prevent the development of post-traumatic stress symptoms. Patients will be randomized to either mPE plus treatment as usual (TAU) or TAU alone. The primary outcome is the development of post-traumatic stress symptoms 3 months after trauma. Secondary outcomes will be symptoms of depression, sleep difculties, pelvic foor hyperactivity, and sexual dysfunction. The frst 22 subjects will constitute an internal pilot trial to test acceptance of the intervention and feasibility of the assessment battery. Discussion This study will guide further research and clinical initiatives for implementing strategies for preventing post-traumatic stress symptoms after rape and provide new knowledge about which women may beneft the most from such initiatives and for revising existing treatment guidelines within this area

PTSD relapse in Veterans of Iraq and Afghanistan: A systematic review

This systematic review examines studies published between 2003, the initial invasion of Iraq, and 2018 related to the long-term treatment outcomes for Veterans of Iraq and Afghanistan suffering from combat-related posttraumatic stress disorder (PTSD). More specifically this review attempts to estimate the rate at which Veterans experience the return of symptoms after completing treatment. The review was conducted by the authors in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The literature search identified eight eligible studies, which met the predefined inclusion criteria. Of the included studies a majority were deemed to be at a high risk of attrition bias. In addition, few studies comprehensively reported relevant relapse or recurrence related outcome statistics. The implications of the available evidence base on long-term treatment outcomes are discussed. Recommendations for future studies on relapse and recurrence of PTSD symptoms among Veterans of Iraq and Afghanistan are also presented

Challenges with benchmarking of MDMA-assisted psychotherapy

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New treatments for mental disorders should be routinely compared to psychotherapy in trials conducted for regulatory purposes

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Psychotherapy and psychedelic drugs - Authors’ reply

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An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors

INTRODUCTION: Torture is associated with adverse health consequences, with especially high rates of PTSD, depression and chronic pain. Despite increased awareness of the relationship between pain and posttraumaticsymptoms, and the accompanying need for effective treatment strategies, few studies have examined an integrated treatment of comorbid PTSD and pain. METHODS: In this study, using an A-B case series design with three and six month follow-up, six refugee torture survivors with comorbid PTSD, depression and chronic pain received 20 sessions of Narrative Exposure Therapy (NET) and 10 sessions of physiotherapy. Outcome variables included symptoms of PTSD and depression, pain intensity, physical functioning and quality of life. Symptoms of PTSD and pain were also rated after each treatment session. RESULTS: Two patients achieved clinically significant reduction in symptoms of PTSD. Only one patient achieved clinically significant change in depressive symptoms, and two experienced clinically significant reduction in pain intensity. Clinical descriptions of the course of treatment for all patients are provided. DISCUSSION AND CONCLUSIONS: Despite its limitations, the study suggests that some torture survivors who suffer high symptom loads may benefit from a combined treatment of NET and physiotherapy. Appreciating individual differences and how they affect treatment can provide valuable insight and inform clinicians working with torture survivors. Directions for future researchregarding the improvement of rehabilitation strategies of torture survivors are discussed, and highlighted through descriptions from the six therapy cases