Posttraumatic stress disorder following high‐ and low‐ magnitude stressors in psychotherapeutic inpatients

High‐magnitude stressors and posttraumatic stress disorder (PTSD) are frequently in psychiatric patients. In contrast, the role of low‐magnitude stressors has rarely been studied. We assessed a consecutive series of 78 psychiatric inpatients taking part in our psychotherapy programme for potentially traumatic events and PTSD with a structured interview. All participants completed self‐report questionnaires on PTSD‐symptomatology, dissociative and general psychopathology (DES, SCL‐90). A distressing event was reported by 48 patients (61.5%) and 27 (34.6%) met the diagnostic criteria for PTSD. Of these, 16 reported a low‐magnitude stressor, while 11 had experienced a high‐magnitude stressor. There were no significant differences in PTSD symptoms, dissociative and general psychopathology between patients with PTSD due to a minor trauma and those with a major trauma. Our preliminary findings suggest that low‐magnitude stressors can also lead to PTSD. We discuss the possible implications with regard to psychotherapy. Copyright © 2000 John Wiley & Sons, Ltd.     

The active ingredient in EMDR: is it traditional exposure or dual focus of attention?

Very little is known about the mechanisms that underlie the therapeutic effectiveness of eye movement desensitization and reprocessing (EMDR). This study tested whether the content of participants' responses during EMDR is similar to that thought to be effective for traditional exposure treatments (reliving), or is more consistent with distancing, which would be expected given Shapiro's proposal of dual process of attention. The responses made by 44 participants with post‐traumatic stress disorder (PTSD) were examined during their first EMDR treatment session. An independent rater coded these responses according to whether they were consistent with reliving, distancing or focusing on material other than the primary trauma. The coding system was found to have satisfactory inter‐rater reliability. Greatest improvement on a measure of PTSD symptoms occurred when the participant processed the trauma in a more detached manner. Cross‐lagged panel correlations suggest that processing in a more detached manner was a consequence of the EMDR procedure rather than a measure that covaried with improvement. Copyright © 2006 John Wiley & Sons, Ltd.     

A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post‐traumatic stress disorder

A total of 105 patients with post‐traumatic stress disorder (PTSD) were randomly allocated to eye‐movement desensitization and reprocessing (EMDR) (n = 39) versus exposure plus cognitive restructuring (E + CR) (n = 37) versus waiting list (WL) (n = 29) in a primary care setting. EMDR and E + CR patients received a maximum of 10 treatment sessions over a 10‐week period. All patients were assessed by blind raters prior to randomization and at end of the 10‐week treatment or waiting list period. EMDR and E + CR patients were also assessed by therapists at the mid‐point of the 10‐week treatment period and on average at 15 months follow‐up. Patients were assessed on a variety of assessor‐rated and self‐report measures of PTSD symptomatology including the Clinician Administered PTSD Scale (CAPS), the Impact of Events Scale (IOE) and a self‐report version of the SI‐PTSD Checklist. Measures of anxiety and depression included the Montgomery Asberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAM‐A) and the Hospital Anxiety and Depression Scale (HADS). A measure of social function, the Sheehan Disability Scale was also used. Drop‐out rates between the three groups were 12 EMDR, 16 E + CR and five WL. Treatment end‐point analyses were conducted on the remaining 72 patients. Repeated measures analysis of variance of treatment outcome at 10 weeks revealed significant time, interaction and group effects for all the above measures. In general there were significant and substantial pre–post reductions for EMDR and E + CR groups but no change for the WL patients. Both treatments were effective over WL. The only indication of superiority of either active treatment, in relation to measures of clinically significant change, was a greater reduction in patient self‐reported depression ratings and improved social functioning for EMDR in comparison to E + CR at the end of the treatment period and for fewer number of treatment sessions for EMDR (mean 4.2) than E + CR (mean 6.4) patients. At 15 months follow‐up treatment gains were generally well‐maintained with the only difference, in favour of EMDR over E + CR, occurring in relation to assessor‐rated levels of clinically significant change in depression. However, exclusion of patients who had subsequent treatment during the follow‐up period diminished the proportion of patients achieving long‐term clinically significant change. In summary, at end of treatment and at follow‐up, both EMDR and E + CR are effective in the treatment of PTSD with only a slight advantage in favour of EMDR. Copyright © 2002 John Wiley & Sons, Ltd.     

A comparison of CBT and EMDR for sexually‐abused Iranian girls

Fourteen randomly assigned Iranian girls ages 12–13 years who had been sexually abused received up to 12 sessions of CBT or EMDR treatment. Assessment of post‐traumatic stress symptoms and problem behaviours was completed at pre‐treatment and 2 weeks post‐treatment. Both treatments showed large effect sizes on the post‐traumatic symptom outcomes, and a medium effect size on the behaviour outcome, all statistically significant. A non‐significant trend on self‐reported post‐traumatic stress symptoms favoured EMDR over CBT. Treatment efficiency was calculated by dividing change scores by number of sessions; EMDR was significantly more efficient, with large effect sizes on each outcome. Limitations include small N, single therapist for each treatment condition, no independent verification of treatment fidelity, and no long‐term follow‐up. These findings suggest that both CBT and EMDR can help girls to recover from the effects of sexual abuse, and that structured trauma treatments can be applied to children in Iran. Copyright © 2004 John Wiley & Sons, Ltd     

Treating complicated grief and posttraumatic stress in homicidally bereaved individuals: A randomized controlled trial

Homicidally bereaved individuals may experience symptoms of Complicated Grief (CG) and Posttraumatic Stress Disorder (PTSD). This Randomized Controlled Trial examined the effectiveness of an 8‐session treatment encompassing Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) to reduce self‐rated CG and PTSD symptoms in 85 Dutch adult homicidally bereaved men and women. We compared changes in symptoms of CG (assessed using the Inventory of Complicated Grief) and PTSD (assessed using the Impact of Event Scale) between an intervention group and a waitlist control group. The treatment was effective in reducing CG and PTSD symptoms, from pretreatment to posttreatment. It can be concluded that EMDR and CBT seem promising treatments for homicidally bereaved individuals for both men and women, and regardless of the time since the loss. Further research is needed to examine whether a combined treatment of EMDR and CBT together is of added value in situations where grief and trauma are intertwined over offering only one of the two treatment modalities.     

Demographic and Seizure Variables,But Not Hypnotizability or Dissociation,Differentiated Psychogenic from Organic Seizures

Abstract

Early detection and differential diagnosis of psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES) is a major clinical issue in comprehensive epilepsy centers. Using blind conditions with patients with PNES (N= 10) and ES (N= 31) before diagnosis, we tested the hypotheses that individuals with PNES would exhibit significantly greater dissociativity, hypnotizability, absorption, and history of early abuse than ES patients. Although PNES patients tended to show greater dissociative phenomena, only the last of our hypotheses was fully supported. Although absorption did not discriminate between the two diagnostic groups, it was significantly higher among those reporting early abuse. A logistic regression analysis using scores on dissociation, hypnotizability and absorption showed them to be poor predictors of diagnosis; however, other analyses revealed that female gender, reports of multiple trauma incidents lasting months or years, initial seizure onset in late teens or twenties, and daily seizure attacks significantly differentiated PNES from ES patients. Thus, demographic and seizure variables proved to be much better predictors of diagnosis than psychological dimensions often associated with PNES.     

Relationships between self‐consistency,trauma‐centred identity,and post‐traumatic adjustment

Background: Post‐traumatic stress disorder (PTSD) models suggest that trauma‐centred self‐change is motivated by self‐consistency. Aim: The objective of this study was to investigate the relationships between self‐consistency, trauma‐centred identity, and PTSD symptoms. Method: University students (n = 134) completed measures of trauma‐centred identity (Centrality of Events Scale), self‐consistency, and post‐traumatic stress symptoms (Impact of Events Scale—Revised, Centre for Epidemiological Studies—Depression Scale). Results: A significant positive correlation was found between trauma‐centred identity and post‐traumatic symptoms. However, self‐consistency was not related to post‐traumatic symptoms or trauma‐centred identity. Given the relationship between depressive symptoms and self‐consistency, the correlations were also conducted controlling for depression. When the effects of depressive symptoms were partialled out, both self‐consistency and trauma‐centred identity were positively correlated with intrusion symptoms. Discussion and Conclusion: The implications for PTSD models, which suggest self‐change is motivated by self‐consistency, are discussed and implications for clinical treatments are considered.     

Salivary cortisol levels and the cortisol response to dexamethasone before and after EMDR: a case report

Trauma survivors with posttraumatic stress disorder (PTSD) have been shown to have lower basal cortisol levels in the urine, plasma, and saliva than in trauma survivors without PTSD, nontraumatized mentally ill, or healthy subjects. We report on a case study in which we measured pre- and post-Eye Movement Desensitization and Reprocessing (EMDR) treatment salivary cortisol levels and salivary cortisol response to 0.50 mg of dexamethasone in a 41-year-old female with chronic PTSD symptoms. Our goal was to determine whether symptom improvement following trauma-focused treatment (EMDR) is associated with changes in basal salivary cortisol or in the cortisol response to dexamethasone administration. Our findings show moderate symptom improvement, an increase in basal cortisol levels, and a more attenuated cortisol hypersuppression in response to the dexamethasone suppression test following EMDR treatment. These results suggest the potential utility of including neuroendocrine measures in the assessment of treatment outcome in PTSD.     

Dissociative subtype of posttraumatic stress disorder in women in partial and residential levels of psychiatric care

ABSTRACT

The dissociative subtype of posttraumatic stress disorder (PTSD) is estimated to characterize about 12-30% of those with PTSD. Some research links this subtype with increased severity of PTSD symptoms compared to samples with “classic” PTSD. However, prevalence and severity rates reported in the literature have varied. One possible explanation for these discrepancies could be related to where the populations were sampled. Therefore, we investigated whether these differences are still observed when holding level of care constant. We collected data from 104 women at a partial and residential psychiatric hospital program focused on trauma-related disorders. Participants completed self-report questionnaires assessing trauma exposure, symptoms and provisional diagnosis of PTSD, trauma-related thoughts and beliefs, and feelings of shame. All participants reported a history of childhood and/or adulthood trauma exposure. Eighty-eight (85%) met criteria for PTSD, and of those, seventy-three (83%) met criteria for the dissociative subtype as assessed by the Dissociative Subtype of PTSD Scale. A series of independent t-tests revealed no significant differences between the “classic” and dissociative PTSD groups with respect to lifetime or childhood trauma exposure, posttraumatic cognitions, shame, or overall PTSD severity. Our results suggest that samples with classic PTSD and the dissociative subtype may not differ in some types of symptom severity when holding level of care constant. Importantly, however, we found at partial/residential level of care the majority of patients with PTSD were dissociative. Given the elevated prevalence rate in this sample, these findings support the need to assess dissociative symptoms, particularly in more acute psychiatric settings.     

Sex dependent influence of a functional polymorphism in steroid 5‐α‐reductase type 2 (SRD5A2) on post‐traumatic stress symptoms

A non‐synonymous, single nucleotide polymorphism (SNP) in the gene coding for steroid 5‐α‐reductase type 2 (SRD5A2) is associated with reduced conversion of testosterone to dihydrotestosterone (DHT). Because SRD5A2 participates in the regulation of testosterone and cortisol metabolism, hormones shown to be dysregulated in patients with PTSD, we examined whether the V89L variant (rs523349) influences risk for post‐traumatic stress disorder (PTSD). Study participants (N = 1,443) were traumatized African‐American patients of low socioeconomic status with high rates of lifetime trauma exposure recruited from the primary care clinics of a large, urban hospital. PTSD symptoms were measured with the post‐traumatic stress symptom scale (PSS). Subjects were genotyped for the V89L variant (rs523349) of SRD5A2. We initially found a significant sex‐dependent effect of genotype in male but not female subjects on symptoms. Associations with PTSD symptoms were confirmed using a separate internal replication sample with identical methods of data analysis, followed by pooled analysis of the combined samples (N = 1,443, sex × genotype interaction P < 0.002; males: n = 536, P < 0.001). These data support the hypothesis that functional variation within SRD5A2 influences, in a sex‐specific way, the severity of post‐traumatic stress symptoms and risk for diagnosis of PTSD. © 2013 Wiley Periodicals, Inc.     

Posttraumatic Stress Disorder in DSM‐5: New Criteria and Controversies

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5; American Psychiatric Association, 2013) featured extensive changes to the posttraumatic stress disorder (PTSD) diagnosis. PTSD was moved out of the anxiety disorders into a new class of “trauma‐ and stressor‐related disorders,” and the definition of what constitutes a traumatic experience was revised. Three new symptoms were added, existing ones were modified, and a new four‐cluster organization and diagnostic algorithm were introduced. Finally, a new dissociative subtype was added to the diagnosis. We review these changes, discuss some of the controversies surrounding them, and then introduce a new debate involving a radically different conceptualization of PTSD proposed for International Classification of Diseases, 11th edition.     

Integrating EMDR into Phase-Oriented Treatment for Trauma

ABSTRACT

Originally introduced a century ago by Pierre Janet, phase-oriented treatment has been independently proposed by many authors and is now widely considered by trauma specialists to be the treatment of choice for PTSD and other posttraumatic disorders. Much more recently, introduced by Francine Shapiro in 1989, Eye Movement Desensitization and Reprocessing (EMDR) has also become available for the treatment of PTSD and other trauma-based disorders. EMDR has become widely accepted by clinicians and has received strong support regarding its efficacy from a wide range of empirical studies. However, with a very few exceptions (highlighted in this paper), these two major approaches for treating trauma have developed largely independently. The present paper integrates the major EMDR developments with the different stages of the phase-oriented approach to assess if such an integration is conceptually and clinically useful. The EMDR developments integrated into the phases of trauma treatment include: Shapiro's prototypic protocol for PTSD and the protocols for other trauma-based disorders, safety protocols, Leeds' and Korn's work with Resource Development and Installation, and Kitchur's Strategic Developmental Model for EMDR. The usefulness of integrating phase-oriented treatment and EMDR is then assessed. These approaches were found to strongly complement each other in their clinical strengths and weaknesses, while sharing many underlying theoretical and structural elements.     

Comparison of two treatments for traumatic stress: a community-based study of EMDR and prolonged exposure.

This pilot study compared the efficacy of two treatments for postraumatic stress disorder (PTSD): Eye Movement Desensitization and Reprocessing (EMDR) and Prolonged Exposure (PE). Data were analyzed for 22 patients from a university-based clinic serving the outside community (predominantly rape and crime victims) who completed at least one active session of treatment after three preparatory sessions. Results showed both approaches produced a significant reduction in PTSD and depression symptoms, which were maintained at three-month follow-up. Successful treatment was faster with EMDR as a larger number of people (7 of 10) had a 70% reduction in PTSD symptoms after three active sessions compared to 2 of 12 with PE. EMDR appeared to be better tolerated as the dropout rate was significantly lower in those randomized to EMDR versus PE (0 of 10 vs. 3 of 10). However all patients who remained in treatment with PE had a reduction in PTSD scores. Finally, Subjective Units of Distress (SUDS) ratings decreased significantly during the initial session of EMDR, but changed little during PE. Postsession SUDS were significantly lower for EMDR than for PE. Suggestions for future research are discussed.     

Quantitative electroencephalography during rapid eye movement (REM) and non‐REM sleep in combat‐exposed veterans with and without post‐traumatic stress disorder

Sleep disturbances are a hallmark feature of post‐traumatic stress disorder (PTSD), and associated with poor clinical outcomes. Few studies have examined sleep quantitative electroencephalography (qEEG), a technique able to detect subtle differences that polysomnography does not capture. We hypothesized that greater high‐frequency qEEG would reflect ‘hyperarousal’ in combat veterans with PTSD (n = 16) compared to veterans without PTSD (n = 13). EEG power in traditional EEG frequency bands was computed for artifact‐free sleep epochs across an entire night. Correlations were performed between qEEG and ratings of PTSD symptoms and combat exposure. The groups did not differ significantly in whole‐night qEEG measures for either rapid eye movement (REM) or non‐REM (NREM) sleep. Non‐significant medium effect sizes suggest less REM beta (opposite to our hypothesis), less REM and NREM sigma and more NREM gamma in combat veterans with PTSD. Positive correlations were found between combat exposure and NREM beta (PTSD group only), and REM and NREM sigma (non‐PTSD group only). Results did not support global hyperarousal in PTSD as indexed by increased beta qEEG activity. The correlation of sigma activity with combat exposure in those without PTSD and the non‐significant trend towards less sigma activity during both REM and NREM sleep in combat veterans with PTSD suggests that differential information processing during sleep may characterize combat‐exposed military veterans with and without PTSD.     

Hypnosis and Traumatic Dissociation: Therapeutic Opportunities

ABSTRACT

Hypnosis and the related phenomenon of dissociation have long been linked to trauma. Evidence is reviewed regarding the relationship between trauma and dissociation, the prevalence of these dissociative symptoms in the acute aftermath of trauma, and their salience in predicting the development of later PTSD symptoms. The evidence reviewed regarding the prevalence of dissociative and other symptoms in the immediate aftermath of trauma formed the basis for including Acute Stress Disorder (ASD) as a new diagnosis in the DSM-IV. Dissociative amnesia is described as the key commonality between formally induced hypnosis and dissociative symptomatology, and controversy regarding traumatic amnesia is discussed. Finally principles of psychotherapy involving hypnosis and related techniques for dissociative and other post-traumatic symptoms are reviewed.     

Treatment of post‐traumatic stress disorder in children using cognitive behavioural writing therapy

Objectives: This study evaluated the effectiveness of Cognitive Behavioral Writing Therapy (CBWT) in 23 children (age 8–18 years) in the Netherlands, who experienced a range of single and recurrent traumatic experiences. CBWT uses exposure, cognitive restructuring and social sharing. Methods: At pre‐test, post‐test and follow‐up, post‐traumatic stress disorder (PTSD) symptoms, depressive symptoms, trauma‐related cognitions and general behavioural problems were assessed. Results: At post‐test there was a significant reduction of all symptoms, and this effect was maintained at 6 months follow‐up. The mean amount of treatment sessions needed was 5.5. Conclusions: This study shows that short‐term CBWT is a potentially effective intervention for clinically referred traumatized children. There is now a clear need of establishing the effectiveness of CBWT in a randomized, controlled trial. Practice implication: This first study indicates CBWT is a promising treatment, which can easily be used in clinical practice. Copyright © 2009 John Wiley & Sons, Ltd. Key practitioner massage:

• CWBT can easily be implemented in clinical practice.
• CWBT is suitable for a clinically representative group of children and adolescents with PTSD, who have experienced a wide range of single and recurrent traumatic experiences.
• CWBT is a short‐term potentially effective treatment.

     

Expressive writing and post‐traumatic stress disorder: Effects on trauma symptoms,mood states,and cortisol reactivity

Objectives. This study investigates the boundary conditions (feasibility, safety, and efficacy) of an expressive writing intervention for individuals with post‐traumatic stress disorder [PTSD]. Design. Randomized trial with baseline and 3‐month follow‐up measures of PTSD severity and symptoms, mood states, post‐traumatic growth, and (post‐only) cortisol reactivity to trauma‐related stress. Methods. Volunteers with a verified diagnosis of PTSD (N = 25) were randomly assigned to an experimental group (writing about their traumatic experience) or control group (writing about time management). Results. Expressive writing was acceptable to patients with PTSD and appeared safe to utilize. No changes in PTSD diagnosis or symptoms were observed, but significant improvements in mood and post‐traumatic growth were observed in the expressive writing group. Finally, expressive writing greatly attenuated neuroendocrine (cortisol) responses to trauma‐related memories. Conclusions. The present study provides insight into several boundary conditions of expressive writing. Writing did not decrease PTSD‐related symptom severity. Although patients continue to exhibit the core features of PTSD, their capacity to regulate those responses appears improved following expressive writing. Dysphoric mood decreased after writing and when exposed to traumatic memories, participants' physiological response is reduced and their recovery enhanced.     

Feigning post‐traumatic stress disorder on the PAI

Multiscale personality inventories have been used to detect dissimulation of PTSD. The Personality Assessment Inventory (PAI) is a self‐report inventory which has validity indicators that may be used to detect dishonest or biased self‐report. The accuracy of these validity indicators was tested by comparing non‐traumatized individuals instructed to fake PTSD with patients diagnosed as having PTSD and normal controls. Twenty‐five individuals completed the PAI with the instruction to feign PTSD. The PAI results of these participants were compared to a cohort of 19 patients diagnosed as suffering from PTSD and 21 controls. Eleven of the 25 individuals instructed to fake PTSD on the PAI produced a profile consistent with this diagnosis. However, more than half of the faked profiles were correctly identified as feigned by the validity indicators. Specificity of the validity indicators was very high. The results of this study indicate that the PAI can be one useful source of information for the clinician when assessing for the possible distortion of PTSD symptoms. Copyright © 2000 John Wiley & Sons, Ltd.     

Baseline resting heart rate variability predicts post‐traumatic stress disorder treatment outcomes in adults with co‐occurring substance use disorders and post‐traumatic stress

Post‐traumatic stress disorder (PTSD) symptoms are highly prevalent among individuals with substance use disorders (SUD), presenting a difficult‐to‐treat, complex comorbidity. Prognostic factors for treatment outcomes may characterize heterogeneity of the treated population and/or implicate mechanisms of action that are salient for improving treatments. High frequency heart rate variability (HF‐HRV) is a suggested biomarker for emotion regulation—the ability to generate appropriate emotional responses via the influence of the parasympathetic nervous system on the heart. This initial study investigated the utility of baseline resting HF‐HRV for predicting PTSD symptoms and substance use outcomes following treatment of 37 SUD participants with comorbid PTSD symptoms. Participants completed either standard cognitive‐ behavioral therapy (CBT) for SUD or a novel treatment of integrated post‐traumatic stress and substance use that combined CBT for SUD with cognitive processing therapy for PTSD. Analyses demonstrated that higher HF‐HRV predicted greater reduction in PTSD symptoms following both types of treatment. This suggests prognostic value of HF‐HRV as a predictor of PTSD treatment outcomes; those with poorer autonomic emotional regulation may not respond as well to psychotherapy in general. This hypothesis‐generating analysis identifies a putative biomarker that might have utility in treatment prediction.