Complex trauma disorders - Understanding and treatment : A clinical trial of stabilizing group treatment for patients with PTSD and Dissociative Disorders

Victims of childhood trauma and abuse predominantly experience many forms of trauma and multiple traumatic incidents throughout the life-span often termed complex trauma. Victims of complex trauma are at risk of developing a range of mental health difficulties, including posttraumatic stress symptoms, interpersonal difficulties, problems with emotional regulation, and dissociative reactions. However, our understanding of these aforementioned mental health difficulties and how best to treat them is unclear and debated. Thus, this thesis has three main aims; 1) Broaden our understanding of trauma-related difficulties by testing a new theoretical model of dissociation, 2) Investigate the efficacy of stabilizing group treatment for patients with PTSD related to childhood abuse, and 3) Investigate the efficacy of stabilizing group treatment for patients with dissociative disorders. A clinical research project was conducted at Modum Bad’s Trauma Clinic. In paper I, the predictions of the 4-D model of dissociation were tested in a sample of 142 patients with PTSD, either with (n=46) or without (n=96) comorbid dissociative disorders. In paper II the efficacy of stabilizing group treatment for patients with PTSD related to childhood abuse (N= 89) was investigated in a delayed-treatment design. In paper III, the efficacy of group treatment for patients with complex dissociative disorders (N = 59) was investigated in a similar design, the first randomized trial ever conducted with this patient group. Paper I showed general support for the 4-D model as a promising theoretical framework for understanding trauma-related reactions. Paper II and paper III both showed significant treatment gains However, we did not find significantly better outcomes related to group participation in either sample, although some indications of positive long-term effects were found in paper III. Based on these results, stabilizing-group treatment should not be the first choice for treatment of PTSD related to childhood abuse. Further clinical research is needed to establish evidence-based treatment for dissociative disorders

Psychometric properties of the International Trauma Questionnaire (ITQ) examined in a Norwegian trauma-exposed clinical sample

Background The International Trauma Questionnaire (ITQ) is a self-report measure for post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD), corresponding to the diagnostic criteria in the International Classification of Diseases, 11th Revision (ICD-11). A 12-item version of the ITQ based on samples from English-speaking countries has been presented, and the wider generalizability to other languages needs to be examined. Objective The current study examines the psychometric properties of scores from a longer, preliminary 22-item version of the ITQ and the current reduced 12-item version by means of generalizability theory (G-theory) and confirmatory factor analysis (CFA). Method The 22-item version of the ITQ was translated into Norwegian and administered to patients in two trauma treatment trials (total N = 202). A generalizability study was used to investigate the psychometric properties of scores reflecting CPTSD. G-theory was also used to investigate alternative measurement designs to optimize the sufficient number of items that provide acceptable generalizability and dependability of scores. Model fit to the theoretical factor structure was then examined by CFA, both for the 22-item version and for the 12-item version of the ITQ. Results The two subscales negative self-concept and relational disturbances had acceptable generalizability coefficients. We found substantial measurement error related to affective dysregulation, mainly attributable to affective hyperactivation. A latent factor structure model with two separate affective dysregulation factors: hyperactivation and deactivation, represented the data well in the 22-item version. The proposed confirmatory structure model for the 12-item short form did not converge in the CFA. Conclusion This study supports the applicability of the ITQ in a non-English-speaking country and provides support for the validity of the Norwegian translation. Further research is needed to improve the psychometric properties of the affective dysregulation subscale

Stabilizing group treatment for childhood-abuse related PTSD: a randomized controlled trial

Background: Patients with PTSD related to childhood-abuse often experience additional problems such as emotional dysregulation and interpersonal difficulties. Psychotherapy focused on stabilization of symptoms, emotion-regulation, and skills training has been suggested as a treatment for this patient population, either as preparation for further treatment or as a stand-alone intervention. Objective: The present study tests the efficacy of treatment using a group-protocol for stabilizing treatment delivered adjunct with conventional individual therapy. Methods: In a delayed-treatment design with switching replication, a clinically representative sample of 89 patients with PTSD and histories of childhood abuse were randomly assigned to either 20-week stabilizing group treatment or a corresponding waiting-period, both adjunct with conventional individual therapy. After the waiting-period, patients in the control condition were offered group treatment. The primary outcome was psychosocial functioning, measured with interview – assessed Global Assessment of Functioning (GAF), while secondary outcome was self-reported PTSD symptoms. These were measured before treatment, after treatment and at 6 months follow up. The trial was preregistered at Clinical Trials (NCT02450617). Results: We found large within-group effect sizes in both conditions on GAF and moderate effects on PTSD symptoms. Linear mixed-models did not indicate significant differences in treatment trajectories between conditions. Conclusion: Stabilizing group treatment focused on emotional-regulation and skills-training does not improve outcomes beyond individual-treatment alone, and should not be recommended as first-line treatment for this patient-grou

Group treatment for Complex Dissociative Disorders: A randomized controlled trial

This manuscript was published in BMC Psychiatry 16th of May 2022: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-03970-8 Patients with complex dissociative disorders report high levels of childhood- abuse experiences, clinical comorbidity, functional impairment, and treatment utilization. Although a few naturalistic studies indicate that these patients can benefit from psychotherapy, no randomized controlled trials have been reported with this patient-group. In the current study, 59 patients with Dissociative Identity Disorder (DID) or Other Specified Dissociative Disorders (OSDD) were randomized to 20 sessions of stabilizing group – treatment, conjoint with individual therapy, or individual therapy alone, in a delayed-treatment design. The treatment is based on the manual Coping with Trauma-Related Dissociation (Boon, Steele, & Hart, 2011). The primary outcome was Global Assessment of Functioning (GAF), while secondary outcomes were PTSD and dissociative symptoms, general psychopathology, interpersonal difficulties, and self-destructive behavior. Results indicate medium to large effects on psychosocial functioning and small to insignificant effects on reduction of symptoms and self-destructive behavior. Mixed effect models showed no condition x time interaction, indicating no immediate differences in treatment outcome, but some indication of positive effects in the six months follow-up period

Group treatment for complex dissociative disorders: a randomized clinical trial

Background Patients with complex dissociative disorders (CDD) report high levels of childhood- abuse experiences, clinical comorbidity, functional impairment, and treatment utilization. Although a few naturalistic studies indicate that these patients can benefit from psychotherapy, no randomized controlled trials have been reported with this patient-group. The current study evaluates a structured protocolled group treatment delivered in a naturalistic clinical setting to patients with CDD, as an add-on to individual treatment. Methods Fifty nine patients with CDD were randomized to 20 sessions of stabilizing group–treatment, conjoint with individual therapy, or individual therapy alone, in a delayed-treatment design. The treatment was based on the manual Coping with Trauma-Related Dissociation. The primary outcome was Global Assessment of Functioning (GAF), while secondary outcomes were PTSD and dissociative symptoms, general psychopathology, and interpersonal difficulties. Results Mixed effect models showed no condition x time interaction during the delayed treatment period, indicating no immediate differences between conditions in the primary outcome. Similar results were observed for secondary outcomes. Within-group effects were non-significant in both conditions from baseline to end of treatment, but significant improvements in psychosocial function, PTSD symptoms, and general psychopathology were observed over a 6-months follow-up period. Conclusion In the first randomized controlled trial for the treatment of complex dissociative disorders, stabilizing group treatment did not produce immediate superior outcomes. Treatment was shown to be associated with improvements in psychological functioning. Trial registration Clinical Trials ( NCT02450617 )

Implementation of evidence-based treatment for PTSD in Norway: clinical outcomes and impact of probable complex PTSD

Background: Posttraumatic stress disorder (PTSD) is a long-lasting and debilitating psychological disorder that affects a large portion of the population. Treatments such as Cognitive therapy for PTSD (CT-PTSD) and Eye movement desensitization and reprocessing (EMDR) have been shown to be effective and cost-efficient in clinical trials, but uptake and evidence of positive outcomes in real-world clinical services are limited. Implementation efforts have been hampered by providers’ concerns about the feasibility of trauma-focused treatments in more complex presentations (i.e. Complex PTSD). Objective: To evaluate the effectiveness of CT-PTSD and EMDR in a real-world setting, as implemented in Norwegian outpatient mental health clinics for adults, and investigate the impact of probable Complex PTSD status on treatment outcomes. Methods: Clinicians from 15 different outpatient clinics received training and supervision in EMDR or CT-PTSD as part of a national implementation project. 104 clinicians recruited and treated 196 participants with PTSD. Symptoms of PTSD, depression and anxiety were assessed session-by-session and used to estimate pre-post effect sizes. Mixed-models were employed to investigate the impact of complex PTSD. Results: Both EMDR and CT-PTSD were associated with significant reductions in PTSD symptoms, with large effect sizes. Probable Complex PTSD was associated with higher levels of symptoms before and after treatment but did not significantly impact the effectiveness of treatment. Conclusion: The use of evidence-based treatments for PTSD in routine clinical service is associated with good treatment outcomes, also for patients with Complex PTSD

Trauma-related altered states of consciousness in post-traumatic stress disorder patients with or without comorbid dissociative disorders

Background: The four-dimensional (‘4-D’) model has been proposed as a theoretical framework to understand and delineate trauma-related dissociative experiences, categorizing symptoms into trauma-related altered states of consciousness (TRASC) and normal waking consciousness (NWC), which occur along four dimensions: time, thought, body and emotion. Objective: The main aim of the present study was to evaluate the validity of this model in patients with post-traumatic stress disorder (PTSD), with and without comorbid dissociative disorders. Method: The predictions of the 4-D model were tested in 142 patients with PTSD, with (N = 46) and without (N = 96) comorbid dissociative disorders. Results: As predicted by the 4-D model, experiences of TRASC were less frequent and more specifically related to other measures of dissociation, dissociative disorder comorbidity and a history of childhood sexual abuse compared to experiences of NWC. The predicted lower intercorrelation of TRASC was not supported. Conclusion: The 4-D model represents a promising framework for understanding dissociation across trauma-related disorders

Individual-level associations between implementation leadership, climate, and anticipated outcomes: a time-lagged mediation analysis.

BackgroundLeaders can improve implementation outcomes by developing an organizational climate conducive to the implementation of evidence-based practices (EBP). This study tested the lagged associations between individual-level perceptions of implementation leadership, implementation climate, and three anticipated implementation outcomes, that is EBP acceptability, appropriateness, and feasibility.MethodsScreening tools and treatment methods for posttraumatic stress disorder were implemented in 43 Norwegian mental health services. A sample of 494 child and adult mental health care professionals (M = 43 years, 78% female) completed surveys addressing perceptions of first-level leaders' (n = 47) implementation leadership and their clinics' implementation climate. Single-level structural equation models estimating both direct, indirect, and total effects were used to investigate whether perceived implementation climate mediated the association between perceived implementation leadership and perceived acceptability, appropriateness, and feasibility of screening tools and treatment methods.ResultsRegarding the treatment methods, implementation leadership was associated with therapists' perceptions of acceptability, appropriateness, and feasibility. Implementation climate also mediated between implementation leadership and the outcomes. Regarding the screening tools, implementation leadership was not associated with the outcomes. However, implementation climate mediated between implementation leadership and therapists' perceptions of acceptability and feasibility, but not appropriateness. Analyses with the implementation climate subscales showed stronger associations for therapists' perceptions of the treatment methods than of screening tools.ConclusionsLeaders may promote positive implementation outcomes, both directly and through implementation climate. With regard to the effect sizes and explained variance, results indicated that both implementation leadership and implementation climate were more strongly associated with the therapists' perceptions of the treatment methods, implemented by one group of therapists, than the screening tools, implemented by all therapists. This may imply that implementation leadership and climate may have stronger effects for smaller implementation teams within a larger system than for system-wide implementations or when the clinical interventions being implemented are more complex rather than simple ones.Trial registrationClinicalTrials NCT03719651, 25 October 2018

Testing the leadership and organizational change for implementation (LOCI) intervention in Norwegian mental health clinics: a stepped-wedge cluster randomized design study protocol

Abstract Background Alignment across levels of leadership within an organization is needed for successful implementation of evidence-based practice. The leadership and organizational change for implementation (LOCI) intervention is a multi-faceted multilevel implementation strategy focusing on enhancing first-level general and implementation leadership while also engaging with organization upper management to develop an organizational climate for implementation. The aim of the project is to evaluate the effectiveness of LOCI in supporting the implementation of evidence-based treatment for PTSD in child- and adult-specialized mental health clinics in health trusts in Norway. Methods The study design is a stepped-wedge cluster randomized trial with enrollment of clinics in three cohorts. Executives, clinic leaders, and therapists will be asked to complete surveys assessing leadership and implementation climate. Surveys will be completed at baseline, 4, 8, 12, 16, and 20 months. Results from surveys will be shared with executives and clinic leaders to inform the subsequent creation of tailored leadership and climate development plans for enhanced implementation. Patients will complete surveys measuring traumatic events and post-traumatic stress symptoms during the therapy process. Therapy sessions will be audio or video recorded and scored for fidelity as part of training. Discussion This study aims to provide knowledge on how to improve leadership and organizational climate to enhance effective implementation of evidence-based treatments in mental health services. Trial registration The study has been registrated in ClinicalTrials with ID NCT03719651