Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program

Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) is tailored for adults with PTSD from childhood sexual abuse (CSA). It uses principles from DBT and trauma-focused cognitive-behavioral approaches. To evaluate acceptance and safety, the authors treated 29 women with chronic CSA-related PTSD plus at least one other comorbid diagnosis. The Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Revised, Beck Depression Inventory, and State Trait Anxiety Inventory were administered prior to, at the end of, and 6 weeks after 3 months of intensive residential treatment. An effect size of 1.22 on the PDS was found between baseline and follow-up. Effect sizes for secondary outcomes ranged from medium to large. The results suggest that DBT-PTSD has promise for reducing severe and chronic PTSD after CSA.     

Posttraumatic Stress,Somatization, and Quality of Life Among Ivorian Refugees

The present study examined the relationship between peritraumatic reactions, posttraumatic stress disorder (PTSD) symptoms, somatization, and quality of life (QoL) in a sample of refugees, two years after the 2011 Ivory Coast sociopolitical crisis. Participants were 101 Ivorian adult refugees (mean age = 31.61 years, SD = 7.84; 45.5% women) who completed several questionnaires relating to peritraumatic reactions, PTSD symptoms, somatization, and QoL. Most participants (86.1%) scored above the cutoff for probable PTSD. Peritraumatic dissociation and peritraumatic distress were significantly associated with PTSD symptoms, (r = .64, p < .001) and (r = .60, p < .001), respectively, and somatization, (r = .21, p = .038) and (r = .35, p < .001), respectively, as well as with QoL, (r = –.20, p = .045) and (r = –.21, p = .037), respectively. Similarly, QoL was significantly negatively correlated with PTSD symptoms (r = −.33, p < .001) and somatization (r = −.39, p < .001). In multivariate analyses, somatization was the strongest predictor of QoL (β = −.31, p = .003). Finally, somatization statistically mediated the association between peritraumatic distress and QoL. These findings suggest that PTSD may be frequent among Ivorian refugees, and that somatization may be an important feature of the traumatic experiences. Targeting somatization in conjunction with trauma‐centered therapy may improve outcomes in sub‐Saharan Africans with PTSD.     

Depression Suppresses Treatment Response for Traumatic Loss–Related Posttraumatic Stress Disorder in Active Duty Military Personnel

There are multiple well‐established evidence‐based treatments for posttraumatic stress disorder (PTSD). However, recent clinical trials have shown that combat‐related PTSD in military populations is less responsive to evidence‐based treatments than PTSD in most civilian populations. Traumatic death of a close friend or colleague is a common deployment‐related experience for active duty military personnel. When compared with research on trauma and PTSD in general, research on traumatic loss suggests that it is related to higher prevalence and severity of PTSD symptoms. Experiencing a traumatic loss is also related to the development of prolonged grief disorder, which is highly comorbid with depression. This study examined the association between having traumatic loss–related PTSD and treatment response to cognitive processing therapy in active duty military personnel. Participants included 213 active duty service members recruited across two randomized clinical trials. Results showed that service members with primary traumatic loss–related PTSD (n = 44) recovered less from depressive symptoms than those who reported different primary traumatic events (n = 169), B = ?4.40. Tests of mediation found that less depression recovery suppressed recovery from PTSD symptoms in individuals with traumatic loss–related PTSD, B = 3.75. These findings suggest that evidence‐based treatments for PTSD should better accommodate loss and grief in military populations.     

Convergent validity of measures of Post-Traumatic Stress Disorder in a mixed military and civilian population

The authors evaluated the validity of the Post-Traumatic Stress Disorder (PTSD) subscale of the Minnesota Multiphasic Personality Inventory (MMPI), the Impact of Event Scale (IES) and the Symptom Check List 90 (SCL-90) as continuous and dichotomous measures of PTSD in a mixed military and civilian group of 70 subjects in the United Kingdom. The MMPI-PTSD and the IES are designed specifically as measures of PTSD and the Global Symptom Index of the SCL-90 is a general measure of neurosis. All measures produced significant positive correlations with scores from the Clinician Administered Post-Traumatic Stress Disorder Scale (CAPS-1) and with each other. The IES was the most useful dichotomous measure. The optimum cut-off score for the IES producing the highest Positive Predictive Value and the lowest Apparent Total Misclassification Error Rate has been determined.     

Anxiety, depressive, and posttraumatic stress symptoms in mothers of children with type 1 diabetes

This study investigated the prevalence of mothers' anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms triggered by their child's type 1 diabetes and identified individual diabetes-related traumatic stressors. Sixty mothers of children who had been diagnosed with diabetes within the past 5 years were interviewed using the Structured Clinical Interview (SCID) DSM-IV-PTSD module, and completed the Posttraumatic Stress Diagnostic Scale (PDS) and the Hospital Anxiety and Depression Scale (HADS). Fifteen percent of participants met criteria for partial and 10% for full PTSD. Fifty-five percent of participants identified hearing about their child's diagnosis as the traumatic stressor. Forty percent of participants reported moderate to severe symptoms of state-anxiety and 17% moderate to severe symptoms of depression. This study highlights the significant emotional impact this diagnosis in children can have on mothers, and identifies a population with clinical needs.     

Comparing Effectiveness of CPT to CPT‐C Among U.S. Veterans in an Interdisciplinary Residential PTSD/TBI Treatment Program

Cognitive processing therapy (CPT) is a leading cognitive–behavioral treatment for posttraumatic stress disorder (PTSD) and a front‐line intervention according to the U.S. Department of Veterans Affairs treatment guidelines. The original CPT protocol entails the creation of a written trauma account and use of cognitive therapy. Cognitive processing therapy–cognitive therapy only (CPT‐C) does not involve a written account and in a previous study resulted in faster symptom improvement and fewer dropouts than standard CPT. This study sought to replicate these findings by comparing the effectiveness of CPT to CPT‐C in a sample of 86 U.S. male veterans receiving treatment in a PTSD residential program for individuals with a history of traumatic brain injury. CPT and CPT‐C were delivered in a combined individual and group format as part of a comprehensive, interdisciplinary treatment program. Outcomes were self‐ and clinician‐reported PTSD and self‐reported depression symptoms. Multilevel analysis revealed no significant difference for PTSD symptoms, but did show a greater decrease in depression at posttreatment (d = 0.63) for those receiving CPT. When an experiment‐wise α correction was applied, this effect did not remain significant.     

Psychometric Properties of the Child PTSD Symptom Scale in Latino Children

The Child PTSD Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001 ) is a self‐report measure of posttraumatic stress disorder symptoms (PTSD) in children and adolescents. Despite widespread use of this measure, no study to our knowledge has examined its psychometric properties in Latino children. This study examined the factor structure, internal consistency, and convergent validity of the measure utilizing a sample of 161 Latino students (M = 11.42 years, SD = 0.70) at high risk of exposure to community violence. Confirmatory factor analyses suggested that a 3‐factor model consistent with the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000 ) provided the best fit to the data. Internal consistency of the total scale and subscales was high when completed in English or Spanish. All Child PTSD Symptom Scale scores were positively correlated with violence exposure. As additional evidence of convergent validity, scores evidenced stronger correlations with internalizing symptoms than with externalizing symptoms. Results supported the use of the Child PTSD Symptom Scale as a measure of PTSD severity in Latino children, but additional research is needed to determine appropriate clinical cutoffs for Latino youths exposed to chronic levels of violence. Implications for clinical practice and future research are discussed.     

Quality of Life in Ethiopia's Street Youth at a Rehabilitation Center and the Association With Trauma

Quality of life (QOL) tends to be lower among the homeless than the general population, and traumatic events experienced on the streets have a negative impact on QOL. Low‐income countries face a high number of street youth, yet little research has been performed so far on QOL, trauma, and posttraumatic stress disorder (PTSD) among this group. This study aimed at examining the QOL of a sample of Ethiopian street youth within a rehabilitation program and at exploring whether the street youth have experienced traumatic events and show posttraumatic stress symptoms. We interviewed 84 street youths with the World Health Organization Quality of Life Questionnaire (WHOQOL‐BREF) and the Diagnostic Interview for Children and Adolescents (DICA). Mean QOL scores differed significantly between the groups assessed at the beginning and at the end of the program (Cohen's d = 0.48). Eighty‐three percent of the Ethiopian street youths had experienced traumatic events, and 25.0% met criteria for PTSD according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. QOL did not differ between those with and without PTSD symptoms. These findings show the high rate of traumatic events among Ethiopian street youth and the importance for rehabilitation programs that focus on improving QOL. The results of the study may have cultural limitations.     

A study of the validity of a screening instrument for traumatic stress in earthquake survivors in Turkey

The validity of a Traumatic Stress Symptom Checklist (TSSC), which was developed as part of a Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES), was examined in 130 survivors of the recent earthquake in Turkey. Data were obtained on the TSSC, which consists of 17 DSM-IV posttraumatic stress disorder (PTSD) items and 6 symptoms of depression. The Clinician-Administered PTSD Scale and the Major Depressive Episode module of the Semistructured Clinical Interview for DSM-IV were used for comparison with the TSSC. The results indicated that the TSSC has high internal consistency and satisfactory sensitivity and specificity in predicting the diagnosis of PTSD and major depression. The SITSES appeared to be a useful instrument in screening earthquake survivors for PTSD, major depression, illness severity, and risk factors associated with traumatic stress responses.     

Fear and avoidance of internal experiences among patients with substance use disorders and PTSD: the centrality of anxiety sensitivity

This study evaluated anxiety sensitivity, cognitive avoidance, and alexithymia and their relationship to posttraumatic stress disorder (PTSD) and alcohol use indices concurrently and prospectively in an outpatient substance abuse treatment sample that screened positive for PTSD (N=58). Anxiety sensitivity accounted for substantial variance in the PTSD clusters, reexperiencing, avoidance, and hyperarousal, both concurrently and prospectively. Cognitive avoidance accounted for additional variance with concurrent PTSD avoidance symptoms. Anxiety sensitivity and cognitive avoidance were largely not associated with alcohol use indices. Alexithymia was largely redundant with cognitive avoidance and was, therefore, not included in the regression analyses. Theoretical and treatment implications of these findings are discussed in the context of individuals with dually diagnosed PTSD and substance abuse disorders.     

Associations Between Trauma‐Related Rumination and Symptoms of Posttraumatic Stress and Depression in Treatment‐Seeking Female Veterans

Trauma‐related rumination is a cognitive style characterized by repetitive negative thinking about the causes, consequences, and implications of a traumatic experience. Frequent trauma‐related rumination has been linked to posttraumatic stress disorder (PTSD) and depression in civilian samples but has yet to be examined among military veterans. This study extended previous research by examining trauma‐related rumination in female veterans who presented to a Veterans Affairs women's trauma recovery clinic (N = 91). The study had two main aims: (a) to examine associations between trauma‐related rumination and specific PTSD symptoms, adjusting for the overlap between trauma‐related rumination and other relevant cognitive factors, such as intrusive trauma memories and self‐blame cognitions; and (b) to assess associations between trauma‐related rumination, PTSD, and depression, adjusting for symptom comorbidity. At intake, patients completed a semistructured interview and self‐report questionnaires. Primary diagnoses were confirmed via medical record review. Trauma‐related rumination was common, with more than 80% of patients reporting at least sometimes engaging in this cognitive style in the past week. After adjusting for other relevant cognitive factors, trauma‐related rumination was significantly associated with several specific PTSD symptoms, r_ps = .33–.48. Additionally, the severity of trauma‐related rumination was associated with overall PTSD symptom severity, even after adjusting for comorbid depression symptoms, r_p² = .35. In contrast, the association between trauma‐related rumination and depressive symptom severity was not significant after adjusting for comorbid PTSD symptoms, r_p² = .008. These results highlight trauma‐related rumination as a unique contributing factor to the complex clinical presentation for a subset of trauma‐exposed veterans.     

Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions?

In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self‐reported PTSD severity on the PTSD Symptom Scale–Self‐Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.     

Cognitive Predictors and Risk Factors of PTSD Following Stillbirth: A Short‐Term Longitudinal Study

This short‐term longitudinal study investigated cognitive predictors and risk factors of posttraumatic stress disorder (PTSD) in mothers following stillbirth. After a stillbirth at ≥ 24 weeks gestational age, 65 women completed structured clinical interviews and questionnaires assessing PTSD symptoms, cognitive predictors (appraisals, dysfunctional strategies), and risk factors (perceived social support, trauma history, obstetric history) at 3 and 6 months. PTSD symptoms decreased between 3 and 6 months (Cohen's d ranged .34–.52). Regression analyses also revealed a specific positive relationship between Rumination and concurrent frequency of PTSD symptoms (β = .45). Negative Self‐View and Negative World‐View related positively and Self‐Blame related negatively to concurrent number of PTSD symptoms (β = .48, .44, ?.45, respectively). Suppression and Distraction predicted a decrease and Numbing predicted an increase in time‐lagged number of PTSD symptoms (β = ?.33, ?.28, .30, respectively). Risk factors for PTSD symptoms were younger age (β = ?.25), lower income (β = ?.29), fewer previous pregnancies (β = ?.31), and poorer perceived social support (β = ?.26). Interventions addressing negative appraisals, dysfunctional strategies, and social support are recommended for mothers with PTSD following stillbirth. Knowledge of cognitive predictors and risk factors of PTSD may inform the development of a screening instrument.     

CBT for Vietnamese Refugees with Treatment-Resistant PTSD and Panic Attacks: A Pilot Study

We examined the feasibility, acceptability, and therapeutic efficacy of a culturally adapted cognitive-behavior therapy (CBT) for twelve Vietnamese refugees with treatment-resistant posttraumatic stress disorder (PTSD) and panic attacks. These patients were treated in two separate cohorts of six with staggered onset of treatment. Repeated measures Group x Time ANOVAs and between-group comparisons indicated significant improvements, with large effect sizes (Cohen's d) for all outcome measures: Harvard Trauma Questionnaire (HTQ; d = 2.5); Anxiety Sensitivity Index (ASI: d = 4.3); Hopkins Symptom Checklist-25 (HSCL-25), anxiety subscale (d = 2.2); and Hopkins Symptom Checklist-25, depression subscale (d = 2.0) scores. Likewise, the severity of (culturally related) headache-and orthostasis-cued panic attacks improved significantly across treatment     

Complex Posttraumatic Stress Disorder in Patients Exposed to Emotional Neglect and Traumatic Events: Latent Class Analysis

The inclusion of a complex posttraumatic stress disorder (CPTSD) diagnosis in the 11th revision of the International Classification of Diseases reflects growing evidence that a subgroup of individuals with PTSD also suffer from disturbances in emotion regulation, interpersonal skills, and self‐concept, which together are termed “disturbances in self‐organization” (DSO). Although CPTSD is assumed to result from exposure to complex traumatic events, emotional neglect may be an important contributor. This study investigated the presence of CPTSD, defined by endorsement of PTSD and DSO symptoms in a clinical postwar generation sample. The sample consisted of 218 patients who had been exposed to emotional neglect in childhood, a subgroup of whom had also been exposed to potentially traumatic events. Using items from the Harvard Trauma Questionnaire and the Brief Symptom Inventory, a latent class analysis revealed two classes: high endorsement of almost all CPTSD symptoms (n = 83; 38.1%) and low endorsement of all CPTSD symptoms (n = 135; 61.9%). Contrary to our hypothesis, no DSO‐only class was found. The R3step method showed gender and number of traumatic events to be significant predictors of class membership. Compared to the low endorsement class, individuals in the CPTSD class were more likely to be female, p = .013, and to report a higher number of traumatic experiences, p < .001. The potential intermediary role of emotional neglect in the development of DSO and CPTSD is discussed.     

Comparing the diagnosis of PTSD when assessing worst versus multiple traumatic events in a chronically mentally ill sample

Despite interest in the nature of the traumatic event required to meet Criterion A for posttraumatic stress disorder (PTSD) as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), little attention has been paid to the diagnostic ramifications of linking PTSD symptoms to a single traumatic event in the context of multiple trauma exposures. In this study, 67 dually diagnosed clients with at least 2 potential Criterion A traumatic events completed the Posttraumatic Stress Diagnostic Scale twice, in counterbalanced order: once regarding their worst event and once regarding all events. When responding regarding their worst trauma, 53.7% met probable PTSD criteria. This rose to 67.2% when considering all traumas. Although preliminary, these results suggest that linking PTSD symptoms to a single traumatic event excludes a meaningful number of cases who are otherwise indistinguishable based on symptom profile.     

A Meta‐Analysis of the Association Between Appraisals of Trauma and Posttraumatic Stress in Children and Adolescents

Cognitive models of posttraumatic stress disorder (PTSD) place an emphasis on the role of negative appraisals of traumatic events. It is suggested that the way in which the event is appraised determines the extent to which posttraumatic stress symptoms will be experienced. Therefore, a strong relationship between trauma appraisals and symptoms of PTSD might be expected. However, this relationship is not as firmly established in the child and adolescent literature. A systematic literature review of this relationship returned 467 publications, of which 11 met full eligibility criteria. A random effects meta‐analysis revealed a large effect size for the relationship between appraisals and PTSD symptoms in children and adolescents, r = .63, 95% CI [.58, .68], Z = 17.32, p < .001, with significant heterogeneity present. A sensitivity analysis suggested that this relationship was not contingent on 1 specific measure of appraisals. Results were consistent with the cognitive behavioral theory of PTSD, demonstrating that appraisals of trauma are strongly related to posttraumatic stress in children and adolescents. However, this relationship was not observed in a sample of 4‐ to 6‐year‐olds, indicating that further research is required to explicate cognitive processing of trauma in very young children.     

Traumatic Stress Symptomatology After Child Maltreatment and Single Traumatic Events: Different Profiles

The sequelae of child maltreatment tend to extend current posttraumatic stress disorder (PTSD) symptoms. This study examined this assumption, hypothesizing that (a) PTSD and trauma‐related symptoms are more severe after single trauma than after child maltreatment; (b) symptoms unrelated to trauma are more severe after child maltreatment than after single trauma; and (c) a comorbid association of clinical PTSD with trauma‐related symptoms is more prevalent after single trauma, whereas a comorbid association of clinical PTSD with trauma unrelated symptoms is more prevalent after child maltreatment. The Trauma Symptom Checklist for Children (TSCC) assessed PTSD and trauma‐related symptoms in 256 children (83 children exposed to single trauma, 173 to child maltreatment). The Strengths and Difficulties Questionnaire (SDQ) assessed trauma‐unrelated symptoms. Single‐trauma children reported significantly more severe PTSD and trauma‐related symptoms. Significantly more severe trauma unrelated symptoms were reported after child maltreatment. A significant relation was found between clinical PTSD and more severe trauma‐related symptoms in both samples. Likelihood of children meeting PTSD symptoms after trauma seems to decrease when traumatization becomes more complex. Findings support our assumption that symptomatology of maltreated children extends current PTSD symptoms.     

Comorbidity of 9/11‐Related PTSD and Depression in the World Trade Center Health Registry 10–11 Years Postdisaster

Many studies report elevated prevalence of posttraumatic stress disorder (PTSD) and depression among persons exposed to the September 11, 2001 (9/11) disaster compared to those unexposed; few have evaluated long‐term PTSD with comorbid depression. We examined prevalence and risk factors for probable PTSD, probable depression, and both conditions 10–11 years post‐9/11 among 29,486 World Trade Center Health Registry enrollees who completed surveys at Wave 1 (2003–2004), Wave 2 (2006–2007), and Wave 3 (2011–2012). Enrollees reporting physician diagnosed pre‐9/11 PTSD or depression were excluded. PTSD was defined as scoring ≥ 44 on the PTSD Checklist and depression as scoring ≥ 10 on the 8‐item Patient Health Questionnaire. We examined 4 groups: comorbid PTSD and depression, PTSD only, depression only, and neither. Among enrollees, 15.2% reported symptoms indicative of PTSD at Wave 3, 14.9% of depression, and 10.1% of both. Comorbid PTSD and depression was associated with high 9/11 exposures, low social integration, health‐related unemployment, and experiencing ≥ 1 traumatic life event post‐9/11. Comorbid persons experienced poorer outcomes on all PTSD‐related impairment measures, life satisfaction, overall health, and unmet mental health care need compared to those with only a single condition. These findings highlight the importance of ongoing screening and treatment for both conditions, particularly among those at risk for mental health comorbidity.     

Psychosocial research in traumatic stress: An update

This report presents an update of psychosocial research in the traumatic stress field, presenting an overview of recent studies in several areas: the epidemiology of traumatic events and of PTSD in the general adult population, other diagnoses associated with trauma exposure and PTSD, the course and longevity of PTSD symptomatology, and risk factors for the diagnosis. Other areas of increasing interest and focus are briefly noted.Based on a keynote presentation at the Third European Conference on Traumatic Stress, Bergen, Norway, June 1993.