Adding physical activity to intensive trauma-focused treatment for post-traumatic stress disorder: results of a randomized controlled trial

IntroductionThis randomized controlled trial examined the effectiveness of physical activity added to an intensive trauma-focused treatment (TFT) for post-traumatic stress disorder (PTSD) in comparison to adding non-physical control activities.MethodsA total of 119 patients with PTSD were randomly assigned to a physical activity condition (PA; n = 59) or a non-physical activity control condition (nPA; n = 60). The 8-day intensive TFT programme consisted of daily prolonged exposure, EMDR therapy, and psychoeducation, which was complemented with physical activities versus controlled mixtures of guided (creative) tasks. As a primary outcome, the change in clinician and self-reported PTSD symptoms from pre-to post-treatment and at 6 months follow-up were measured.ResultsIntent-to-treat linear mixed-effects models showed no significant differences between the PA and nPA conditions on change in PTSD severity. Clinician and self-reported PTSD symptoms significantly decreased for both conditions, with large effect sizes (e.g., CAPS-5 dpre-post = 2.28). At post-treatment, 80.0% in the PA, and 82.7% in the nPA condition no longer met the diagnostic criteria for PTSD. Regarding the loss of Complex PTSD diagnoses this was 92.5% and 95.0%, respectively.ConclusionEither with additional physical or non-physical activities, intensive TFT is very effective for the treatment of (Complex) PTSD, as reflected by large effect sizes and loss of diagnostic status in both groups.Clinical trial registrationTrialregister.nl Identifier: Trial NL9120

Do Traumatic Events Have More Impact on the Development of Dental Anxiety Than Negative, Non-traumatic Events?

The importance of exposure to traumatic events for the development of dental anxiety has not been investigated. The aim of the present study was to test the hypotheses that individuals who reported having been exposed to a traumatic event [that is, fulfilling Criterion A of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), for post-traumatic stress disorder (PTSD)] as the cause of their dental anxiety would report significantly higher levels of dental anxiety, typical trauma-related (PTSD) symptoms, and greater disturbance of memories involving these events than those who reported being exposed to non-traumatic events. Patients of a specialized dental fear clinic (n = 90) were divided into those who reported a traumatic event that initiated their dental trait anxiety and those who did not. The two groups did not differ in their severity of dental anxiety and number of PTSD symptoms, but the memories of those who had been exposed to traumatic events were significantly more vivid than the memories of those in the reference group. Length of time since the event took place did not play a role. Hence, traumatic events are remembered more vividly, but do not seem to initiate more severe forms of dental anxiety than other events

Somatoform Dissociative Symptoms Have No Impact on the Outcome of Trauma-Focused Treatment for Severe PTSD

For patients with complex or other severe forms of PTSD, particularly in cases with dissociative symptoms, different treatment approaches have been suggested. However, the influence of somatoform dissociation on the effectiveness of trauma-focused treatment has hardly ever been studied. This study aims to test the hypotheses that (1) PTSD patients reporting a low level and those reporting a high level of somatoform dissociative symptoms would both benefit from an intensive trauma-focused treatment, and that (2) somatoform dissociative symptoms would alleviate. Participants were 220 patients with severe PTSD, enrolled in an intensive treatment program combining EMDR therapy and prolonged exposure therapy, without a preceding stabilization phase. Trauma history was diversified, and comorbidity was high. PTSD symptoms (CAPS-5 and PCL-5) and somatoform dissociative symptoms (SDQ-5 and SDQ-20) were assessed at pre-treatment, post-treatment and at six months after completion of treatment. The course of both PTSD and somatoform dissociative symptoms was compared for individuals reporting low and for those reporting high levels of somatoform dissociative symptoms. Large effect sizes were observed regarding PTSD symptoms reduction for patients with both low and high levels of somatoform dissociation. Somatoform dissociation did not impact improvement in terms of PTSD symptom reduction. The severity of somatoform dissociative symptoms decreased significantly in both groups. This decrease was greater for those with a positive screen for a dissociative disorder. These results add further support to the notion that the presence of strong somatoform dissociative symptoms in patients with PTSD does not necessarily call for a different treatment approach. Clinical implications are discussed

The impact of brief intensive trauma-focused treatment for PTSD on symptoms of borderline personality disorder

Objective: To investigate the effects of a brief, intensive, direct trauma-focused treatment programme for individuals with PTSD on BPD symptom severity. Methods: Individuals (n = 72) with severe PTSD (87.5% had one or more comorbidities; 52.8% fulfilled the criteria for the dissociative subtype of PTSD) due to multiple traumas (e.g. 90.3% sexual abuse) participated in an intensive eight-day trauma-focused treatment programme consisting of eye movement desensitization and reprocessing (EMDR) and prolonged exposure (PE) therapy, physical activity, and psychoeducation. Treatment did not include any form of stabilization (e.g. emotion regulation training) prior to trauma-focused therapy. Assessments took place at pre- and post-treatment (Borderline Symptom List, BSL-23; PTSD symptom severity, Clinician Administered PTSD Scale for DSM-5, CAPS-5), and across the eight treatment days (PTSD Checklist, PCL-5). Results: Treatment resulted in significant decreases of BPD symptoms (Cohen’s d = 0.70). Of the 35 patients with a positive screen for BPD at pre-treatment, 32.7% lost their positive screen at post-treatment. No adverse events nor dropouts occurred during the study time frame, and none of the patients experienced symptom deterioration in response to treatment. Conclusion: The results suggest that an intensive trauma-focused treatment is a feasible and safe treatment for PTSD patients with clinically elevated symptoms of BPD, and that BPD symptoms decrease along with the PTSD symptoms

Do emotion regulation difficulties affect outcome of intensive trauma-focused treatment of patients with severe PTSD?

Background: There is ongoing debate as to whether emotion regulation problems should be improved first in order to profit from trauma-focused treatment, or will diminish after successful trauma processing. Objective: To enhance our understanding about the importance of emotion regulation difficulties in relation to treatment outcomes of trauma-focused therapy of adult patients with severe PTSD, whereby we made a distinction between people who reported sexual abuse before the age of 12, those who were 12 years or older at the onset of the abuse, individuals who met the criteria for the dissociative subtype of PTSD, and those who did not. Methods: Sixty-two patients with severe PTSD were treated using an intensive eight-day treatment programme, combining two first-line trauma-focused treatments for PTSD (i.e. prolonged exposure and EMDR therapy) without preceding interventions that targeted emotion regulation difficulties. PTSD symptom scores (CAPS-5) and emotion regulation difficulties (DERS) were assessed at pre-treatment, post-treatment, and six month follow-up. Results: PTSD severity and emotion regulation difficulties significantly decreased following trauma-focused treatment. While PTSD severity scores significantly increased from post-treatment until six month follow-up, emotion regulation difficulties did not. Treatment response and relapse was not predicted by emotion-regulation difficulties. Survivors of childhood sexual abuse before the age of 12 and those who were sexually abused later in life improved equally well with regard to emotion regulation difficulties. Individuals who fulfilled criteria of the dissociative subtype of PTSD showed a similar decrease on emotion regulation difficulties during treatment than those who did not. Conclusion: The results support the notion that the severity of emotion regulation difficulties is not associated with worse trauma-focused treatment outcomes for PTSD nor with relapse after completing treatment. Further, emotion regulation difficulties improved after trauma-focused treatment, even for individuals who had been exposed to early childhood sexual trauma and individuals with dissociative subtype

Does EMDR Therapy Have an Effect on Memories of Emotional Abuse, Neglect and Other Types of Adverse Events in Patients with a Personality Disorder? Preliminary Data

Background: Little is known about the effectiveness of trauma-focused therapies for memories of events not meeting the A-criterion of post-traumatic stress disorder (PTSD). Objective: Determining the effect of EMDR therapy on memories of emotional abuse, neglect and other types of adverse events in patients with a personality disorder (PD). Method: We conducted a secondary analysis of the data from our study, which aimed to determine the effectiveness of five sessions of EMDR therapy in 49 patients with a PD. Patients were divided into three different groups depending on their most prevalent type of adverse event. Data were analyzed with Generalized Estimating Equations. Results: Of all patients, 49% reported emotional neglect, 22.4% emotional abuse and 26.5% other types. Only one patient reported memories that predominantly fulfilled the A-criterion of PTSD. After five sessions of EMDR therapy, medium to large treatment effects for memories related to neglect (ds between 0.52 and 0.79), medium treatment effects for memories involving emotional abuse (ds between 0.18 and 0.59) and other types of adverse events were found (ds between 0.18 and 0.53). No significant differences in symptom reduction associated with the application of EMDR therapy among memories involving these three different types of adverse events could be revealed. Conclusions: The results support the notion that EMDR therapy is not only an effective therapy for memories related to A-criteria-worthy events, but that it also has a symptom-reducing effect on memories involving other types of adverse events. This suggests that EMDR might be a valuable addition to the treatment of PD without PTS

The role of dissociation-related beliefs about memory in trauma-focused treatment

OBJECTIVE: Dysfunctional cognitions play a central role in the development of post-traumatic stress disorder (PTSD). However the role of specific dissociation-related beliefs about memory has not been previously investigated. This study aimed to investigate the role of dissociation-related beliefs about memory in trauma-focused treatment. It was hypothesized that patients with the dissociative subtype of PTSD would show higher levels of dissociation-related beliefs, dissociation-related beliefs about memory would decrease after trauma-focused treatment, and higher pre-treatment dissociation-related beliefs would be associated with fewer changes in PTSD symptoms.METHOD: Post-traumatic symptoms, dissociative symptoms, and dissociation-related beliefs about memory were assessed in a sample of patients diagnosed with PTSD ( n = 111) or the dissociative subtype of PTSD ( n  = 61). They underwent intensive trauma-focused treatment consisting of four or eight consecutive treatment days. On each treatment day, patients received 90 min of individual prolonged exposure (PE) in the morning and 90 min of individual eye movement desensitization and reprocessing (EMDR) therapy in the afternoon. The relationship between dissociation-related beliefs about memory and the effects of trauma-focused treatment was investigated. RESULTS: Dissociation-related beliefs about memory were significantly associated with PTSD and its dissociative symptoms. In addition, consistent with our hypothesis, patients with the dissociative subtype of PTSD scored significantly higher on dissociation-related beliefs about memory pre-treatment than those without the dissociative subtype. Additionally, the severity of these beliefs decreased significantly after trauma-related treatment. Contrary to our hypothesis, elevated dissociation-related beliefs did not negatively influence treatment outcome.CONCLUSION: The results of the current study suggest that dissociation-related beliefs do not influence the outcome of trauma-focused treatment, and that trauma-focused treatment does not need to be altered specifically for patients experiencing more dissociation-related beliefs about memory because these beliefs decrease in association with treatment.</p

Health–economic Benefits of Treating Trauma in Psychosis

Background: Co-occurrence of posttraumatic stress disorder (PTSD) in psychosis (estimated as 12%) raises personal suffering and societal costs. Health–economic studies on PTSD treatments in patients with a diagnosis of a psychotic disorder have not yet been conducted, but are needed for guideline development and implementation. This study aims to analyse the cost-effectiveness of guideline PTSD therapies in patients with a psychotic disorder. Methods: This health–economic evaluation alongside a randomized controlled trial included 155 patients with a psychotic disorder in care as usual (CAU), with comorbid PTSD. Participants received eye movement desensitization and reprocessing (EMDR) (n = 55), prolonged exposure (PE) (n = 53) or waiting list (WL) (n = 47) with masked assessments at baseline (T0) and at the two-month (post-treatment, T2) and six-month follow-up (T6). Costs were calculated using the TiC-P interview for assessing healthcare consumption and productivity losses. Incremental cost-effectiveness ratios and economic acceptability were calculated for quality-adjusted life years (EQ-5D-3L-based QALYs) and PTSD ‘Loss of diagnosis’ (LoD, CAPS). Results: Compared to WL, costs were lower in EMDR (-€1410) and PE (-€501) per patient per six months. In addition, EMDR (robust SE 0.024, t = 2.14, p = .035) and PE (robust SE 0.024, t = 2.14, p = .035) yielded a 0.052 and 0.051 incremental QALY gain, respectively, as well as 26% greater probability for LoD following EMDR (robust SE = 0.096, z = 2.66, p = .008) and 22% following PE (robust SE 0.098, z = 2.28, p = .023). Acceptability curves indicate high probabilities of PTSD treatments being the better economic choice. Sensitivity analyses corroborated these outcomes. Conclusion: Adding PTSD treatment to CAU for individuals with psychosis and PTSD seem to yield better health and less PTSD at lower costs, which argues for implementation

Effects of propranolol on fear of dental extraction: Study protocol for a randomized controlled trial

Background: Undergoing an extraction has been shown to pose a significantly increased risk for the development of chronic apprehension for dental surgical procedures, disproportionate forms of dental anxiety (that is, dental phobia), and symptoms of post-traumatic stress. Evidence suggests that intrusive emotional memories of these events both induce and maintain these forms of anxiety. Addressing these problems effectively requires an intervention that durably reduces both the intrusiveness of key fear-related memories and state anxiety during surgery. Moreover, evidence suggests that propranolol is capable of inhibiting "memory reconsolidation" (that is, it blocks the process of storing a recently retrieved fear memory). Hence, the purpose of this trial is to determine the anxiolytic and fear memory reconsolidation inhibiting effects of the ß-adrenoreceptor antagonist propranolol on patients with high levels of fear in anticipation of a dental extraction. Methods/Design: This trial is designed as a multicenter, randomized, placebo-controlled, two-group, parallel, double-blind trial of 34 participants. Consecutive patients who have been referred by their dentist to the departments of oral and maxillofacial surgery of a University hospital or a secondary referral hospital in the Netherlands for at least two tooth and/or molar removals and with self-reported high to extreme fear in anticipation of a dental extraction will be recruited. The intervention is the administration of two 40 mg propranolol capsules 1 hour prior to a dental extraction, followed by one 40 mg capsule directly postoperatively. Placebo capsules will be used as a comparator. The primary outcome will be dental trait anxiety score reduction from baseline to 4-weeks follow-up. The secondary outcomes will be self-reported anxiety during surgery, physiological parameters (heart rate and blood pressure) during recall of the crucial fear-related memory, self-reported vividness, and emotional charge of the crucial fear-related memory. Discussion: This randomized trial is the first to test the efficacy of 120 mg of perioperative propranolol versus placebo in reducing short-term ("state") anxiety during dental extraction, fear memory reconsolidation, and lasting dental ("trait") anxiety in a clinical population. If the results show a reduction in anxiety, this would offer support for routinely prescribing propranolol in patients who are fearful of undergoing dental extractions. Trial registration: ClinicalTrials.gov identifier: NCT02268357 , registered on 7 October 2014. The Netherlands National Trial Register identifier: NTR5364 , registered on 16 August 2015