Effectiveness of treating post-traumatic stress disorder in patients with co-occurring substance use disorder with prolonged exposure, eye movement desensitization and reprocessing or imagery rescripting: A randomized controlled trial.

Co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorder (SUD) is common and difficult to treat. Understanding which timing and type of PTSD treatment is most effective for treating PTSD in patients with SUD and PTSD is important to improve treatment outcomes. This study compared effectiveness of simultaneous versus sequential SUD-PTSD-treatment and compared Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and Imagery Rescripting (ImRs) head-to-head in patients with co-occurring SUD and PTSD. A single-blind 6-arm randomized controlled trial with 209 patients with co-occurring SUD and PTSD at two addiction treatment centers in the Netherlands, providing intra- and extramural care. Patients were allocated to simultaneous SUD+PE, SUD+EMDR or SUD+ImRs treatment or sequential SUD-PTSD-treatment (25% each). Next, sequential SUD+PTSD patients were randomly assigned to PE, EMDR, or ImRs (33% each). Data were collected at baseline, 3-month, 6-month, and 9-month follow-up. All analyses were intention-to-treat. Participants were randomized to receive 12 PTSD treatment sessions of simultaneous SUD+PE (n=53), simultaneous SUD+EMDR (n=50), simultaneous SUD+ImRs (n=55), sequential SUD+PE (n=17), sequential SUD+EMDR (n=17) or sequential SUD+ImRs (n=17). Standard protocols were used. Primary outcome was clinician-administered PTSD symptom severity. Secondary outcomes were treatment completion and SUD-severity. Additionally, loss of PTSD diagnosis and full remission of PTSD criteria were tested. Linear-Mixed-Models with a two-level structure (repeated measures, patients), were used to investigate treatment-effects. In the primary analyses including the 6-month and 9-month follow up, no significant differences in PTSD-severity were found between timing nor treatment-types. However, simultaneous treatment outperformed sequential treatment at 3-month follow-up and was preferred by most participants. ImRs was superior to PE and EMDR regarding PTSD-treatment completion. No between-group differences in SUD outcomes were found. EMDR and ImRs are effective alternatives to the more established PE. These findings indicate that delaying PTSD treatment until after SUD treatment is not necessary.

The efficacy of posttraumatic stress disorder (PTSD) treatments in psychosis has not been examined in a randomized clinical trial to our knowledge. Psychosis is an exclusion criterion in most PTSD trials. To examine the efficacy and safety of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy in patients with psychotic disorders and comorbid PTSD. A single-blind randomized clinical trial with 3 arms (N = 155), including PE therapy, EMDR therapy, and waiting list (WL) of 13 outpatient mental health services among patients with a lifetime psychotic disorder and current chronic PTSD. Baseline, posttreatment, and 6-month follow-up assessments were made. Participants were randomized to receive 8 weekly 90-minute sessions of PE (n = 53), EMDR (n = 55), or WL (n = 47). Standard protocols were used, and treatment was not preceded by stabilizing psychotherapeutic interventions. Clinician-rated severity of PTSD symptoms, PTSD diagnosis, and full remission (on the Clinician-Administered PTSD Scale) were primary outcomes. Self-reported PTSD symptoms and posttraumatic cognitions were secondary outcomes. Data were analyzed as intent to treat with linear mixed models and generalized estimating equations. Participants in the PE and EMDR conditions showed a greater reduction of PTSD symptoms than those in the WL condition. Between-group effect sizes were 0.78 (P < .001) in PE and 0.65 (P = .001) in EMDR. Participants in the PE condition (56.6%; odds ratio [OR], 3.41; P = .006) or the EMDR condition (60.0%; OR, 3.92; P < .001) were significantly more likely to achieve loss of diagnosis during treatment than those in the WL condition (27.7%). Participants in the PE condition (28.3%; OR, 5.79; P = .01), but not those in the EMDR condition (16.4%; OR, 2.87; P = .10), were more likely to gain full remission than those in the WL condition (6.4%). Treatment effects were maintained at the 6-month follow-up in PE and EMDR. Similar results were obtained regarding secondary outcomes. There were no differences in severe adverse events between conditions (2 in PE, 1 in EMDR, and 4 in WL). The PE therapy and EMDR therapy showed no difference in any of the outcomes and no difference in participant dropout (24.5% in PE and 20.0% in EMDR, P = .57). Standard PE and EMDR protocols are effective, safe, and feasible in patients with PTSD and severe psychotic disorders, including current symptoms. A priori exclusion of individuals with psychosis from evidence-based PTSD treatments may not be justifiable. isrctn.com Identifier: ISRCTN79584912.

Background: Trauma and posttraumatic stress disorder (PTSD) are prevalent in patients with personality disorders. Despite the established efficacy of eye movement desensitisation and reprocessing (EMDR) for PTSD, EMDR has barely been examined in patients with comorbid PTSD and personality disorders. Objective: The aim of this study was to explore what changes occur in symptom severity of PTSD, dissociative symptoms, insomnia, non-suicidal self-injurious behaviour and auditory verbal hallucinations in patients with personality disorders during treatment with EMDR. Method: This uncontrolled open feasibility study on EMDR for PTSD was an addition to treatment-as-usual for personality disorders. The outcome measures were the severity of PTSD symptoms, dissociation, insomnia, non-suicidal self-injury, and auditory verbal hallucinations. Results: Forty-seven participants (22 with a borderline personality disorder, 25 with other personality disorders) were included. A significant reduction in the severity of symptoms of PTSD, dissociation and insomnia was observed after EMDR treatment (median of four sessions), and 40% of the participants scored below the threshold for PTSD diagnosis. No differences in efficacy were found between patients with borderline personality disorder and other personality disorders. EMDR treatment was completed by 68% of the participants. Conclusions: The addition of EMDR techniques to treatment, as usual, may be beneficial in the treatment of PTSD in patients with personality disorders in order to reduce symptoms of PTSD, dissociation and insomnia. Although one-third of these patients did not complete the additional EMDR treatment, no severe complications (e.g. suicidal behaviour or hospitalisation) occurred. Controlled studies are needed to further investigate the validity of these findings.

PTSD and Combat-Related Injuries: Functional Neuroanatomy

Very few trials have investigated TFPIs for individuals with SMI and PTSD. Results from trials of TF-CBT are limited and inconclusive regarding its effectiveness on PTSD, or on psychotic symptoms or other symptoms of psychological distress. Only one trial evaluated EMDR and provided limited preliminary evidence favouring EMDR compared to waiting list. Comparing TF-CBT head-to-head with EMDR and brief psychoeducation respectively, showed no clear effect for either therapy. Both TF-CBT and EMDR do not appear to cause more (or less) adverse effects, compared to waiting list or usual care; these findings however, are mostly based on low to very low-quality evidence. Further larger scale trials are now needed to provide high-quality evidence to confirm or refute these preliminary findings, and to establish which intervention modalities and techniques are associated with improved outcomes, especially in the long term.

IntroductionThe lifetime prevalence of comorbid posttraumatic stress disorder (PTSD) in patients with bipolar disorder (BD) is approximately 20%. Guidelines for BD give adequate pharmacological treatment options when there is a ‘pure’ bipolar disorder but lack of treatment options when there is a comorbid disorder present.ObjectivesThe present study aimed to review the pharmacological treatment options for comorbid PTSD in patients with BD.MethodsLiterature research was conducted via PubMed, Embase and the Cochrane Library. Search terms included ‘bipolar disorder’, ‘posttraumatic stress disorder’, ‘PTSD’, ‘pharmacotherapy’ and ‘treatment’. Relevant studies were reviewed.ResultsNo randomized controlled trials have been conducted in patients with bipolar disorder and comorbid PTSD. Most studies included open-label studies and case-reports. No convincing scientific evidence for pharmacological treatment of comorbid PTSD in patients with BD was found. Selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of PTSD. However, SSRIs or other antidepressants are complicated due to potential induction of a manic episode or promote rapid cycling. Nevertheless, it is important to treat the bipolar patient with a mood stabilizer first before antidepressants are prescribed.ConclusionsThe findings of this study show that there is no convincing scientific evidence for the pharmacological treatment of comorbid PTSD in patients with bipolar disorder. Therefore, psychotherapy is preferable. When psychotherapy is not effective, pharmacotherapy can be considered. However, randomized controlled trials are needed to obtain scientific evidence for pharmacological treatment options.DisclosureNo significant relationships.

Meta-analysis of post-traumatic stress disorder and COVID-19 in patients discharged

Background: Prior exposure to traumatic events significantly increases the risk of developing substance use disorders (SUD), while having SUD, in turn, elevates the likelihood of encountering additional traumatic events. Despite this relationship, the consequences of trauma frequently go undetected and untreated in this population. The trauma-focused intervention eye movement desensitisation and reprocessing (EMDR), a first-line treatment for post-traumatic stress disorder (PTSD), has shown promising therapeutic potential in SUD patients. However, its underlying neurobiological mechanisms remain unclear. This study aims to investigate the efficacy of EMDR in SUD patients with comorbid psychological trauma. Additionally, potential mechanisms of action of the intervention will be explored. The primary hypothesis is that integrating EMDR into standard SUD treatment will enhance substance use prognosis. Methods: Sixty-four patients with SUD and trauma symptomatology will be randomised into two groups. One group will receive EMDR trauma-focused intervention in 6-8 sessions alongside treatment as usual (TAU) (n = 32), while the control group will receive TAU only (n = 32). The primary outcome will be the time to relapse, assessed at baseline, immediately after treatment, and at 1- and 3-months follow-up. Additional measures include post-traumatic, anxiety, depressive symptoms and biological markers (hair/salivary cortisol levels, eye blink conditioning, and resting-state fMRI). Survival analysis and linear mixed models will be used to assess treatment effects. The trial is registered on ClinicalTrials.gov (NCT05488691). Discussion: This study addresses a critical gap in scientific literature and clinical practice by evaluating the efficacy of EMDR, in patients with SUD and comorbid trauma symptoms, through a combination of clinical and biological markers. The findings could lead to integration of personalised, trauma-focused interventions into public health services for patients with SUD.

Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq

Background: Many patients with post-traumatic stress disorder (PTSD) due to childhood trauma (Ch-PTSD) also suffer from comorbid personality pathology. Little is known about the effectiveness of treatments for Ch-PTSD in reducing the comorbid personality pathology. Schema Modes are an operationalization of personality pathology according to schema therapy and can be measured with the Schema Mode Inventory (SMI). Therefore, we evaluated the effects of two treatments for adult patients with Ch-PTSD on Schema Modes. Method: Participants (n = 114) of the Imagery Rescripting and Eye Movement Desensitization and Reprocessing (IREM) Randomized Clinical Trial (Boterhoven de Haan, K. L., Lee, C. W., Fassbinder, E., Voncken, M. J., Meewisse, M., Van Es, S. M., Menninga, S., Kousemaker, M., & Arntz, A. (2017). Imagery rescripting and eye movement desensitization and reprocessing for treatment of adults with childhood trauma-related post-traumatic stress disorder: IREM study design. BMC Psychiatry, 17(1), 1–12, Boterhoven de Haan, K. L., Lee, C. W., Fassbinder, E., van Es, S. M., Menninga, S., Meewisse, M.-L., Rijkeboer, M., Kousemaker, M., & Arntz, A. (2020). Imagery rescripting and eye movement desensitization and reprocessing as treatment for adults with post-traumatic stress disorder from childhood trauma: Randomised clinical trial. The British Journal of Psychiatry, 217(5), 609–615) with Ch-PTSD who filled in the SMI next to other outcomes, were randomly allocated to a 12-session treatment of Imagery Rescripting (ImRs) or Eye Movement Desensitization and Reprocessing (EMDR). The SMI was collected at waitlist, pre-treatment, mid-treatment, posttreatment, and 8-week and 1-year follow-up. Results: For both treatments, patients reported large reductions in the Maladaptive Schema Modes and improvements in the Adaptive Schema Modes (Cohen’s d = .94–1.18) from pre-treatment to posttreatment, 8-week follow-up, and 1-year follow-up. No statistically significant differences were found between ImRs and EMDR regarding changes in Schema Modes over time. No significant changes were observed during the waitlist period. Conclusions: ImRs and EMDR showed improvements in Schema Modes when primarily targeting Ch-PTSD. The results indicate the possible value of both treatments in reducing comorbid personality pathology.

Background: Posttraumatic stress disorder (PTSD) is prevalent in people with acquired brain injury (ABI). Despite the established efficacy of eye movement desensitization and reprocessing (EMDR) for PTSD in general, evaluation studies on EMDR in ABI patients with PTSD are limited. Objective: The aim of this study is to explore clinical features, treatment characteristics, feasibility and first indications of efficacy of EMDR in adult ABI patients with PTSD. Method: This retrospective consecutive case series included ABI patients, who received at least one session of EMDR for PTSD between January 2013 and September 2020. PTSD symptoms were measured using the Impact of Event Scale (IES) pre- and post-treatment. Affective distress was measured using the Subjective Units of Distress (SUD) pre- and post-treatment of the first target. Results: Sixteen ABI patients (median age 46 years, 50% males), with predominantly moderate or severe TBI (50%) or stroke (25%) were included. Treatment duration was a median of seven sessions. Post-treatment IES scores were significantly lower than pre-treatment scores (p < .001). In 81% of the cases there was an individual statistically and clinically relevant change in IES score. Mean SUD scores of the first target were significantly lower at the end of treatment compared to scores at the start of treatment (p < .001). In 88% of the patients full desensitization to a SUD of 0–1 of the first target was accomplished. Only few adjustments to the standard EMDR protocol were necessary. Conclusions: Findings suggest that EMDR is a feasible, well tolerated and potentially effective treatment for PTSD in ABI patients. For clinical practice in working with ABI patients, it is advised to consider EMDR as a treatment option.

Clinical Characteristics and Health Service Use of Veterans With Comorbid Bipolar Disorder and PTSD

Post-traumatic stress disorder (PTSD) is a distressing condition, which is often treated with psychological therapies. Earlier versions of this review, and other meta-analyses, have found these to be effective, with trauma-focused treatments being more effective than non-trauma-focused treatments. This is an update of a Cochrane review first published in 2005 and updated in 2007. To assess the effects of psychological therapies for the treatment of adults with chronic post-traumatic stress disorder (PTSD). For this update, we searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR-Studies and CCDANCTR-References) all years to 12th April 2013. This register contains relevant randomised controlled trials from: The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). In addition, we handsearched the Journal of Traumatic Stress, contacted experts in the field, searched bibliographies of included studies, and performed citation searches of identified articles. Randomised controlled trials of individual trauma-focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), non-trauma-focused CBT (non-TFCBT), other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and present-centred therapy), group TFCBT, or group non-TFCBT, compared to one another or to a waitlist or usual care group for the treatment of chronic PTSD. The primary outcome measure was the severity of clinician-rated traumatic-stress symptoms. We extracted data and entered them into Review Manager 5 software. We contacted authors to obtain missing data. Two review authors independently performed 'Risk of bias' assessments.We pooled the data where appropriate, and analysed for summary effects. We include 70 studies involving a total of 4761 participants in the review. The first primary outcome for this review was reduction in the severity of PTSD symptoms, using a standardised measure rated by a clinician. For this outcome, individual TFCBT and EMDR were more effective than waitlist/usual care (standardised mean difference (SMD) -1.62; 95% CI -2.03 to -1.21; 28 studies; n = 1256 and SMD -1.17; 95% CI -2.04 to -0.30; 6 studies; n = 183 respectively). There was no statistically significant difference between individual TFCBT, EMDR and Stress Management (SM) immediately post-treatment although there was some evidence that individual TFCBT and EMDR were superior to non-TFCBT at follow-up, and that individual TFCBT, EMDR and non-TFCBT were more effective than other therapies. Non-TFCBT was more effective than waitlist/usual care and other therapies. Other therapies were superior to waitlist/usual care control as was group TFCBT. There was some evidence of greater drop-out (the second primary outcome for this review) in active treatment groups. Many of the studies were rated as being at 'high' or 'unclear' risk of bias in multiple domains, and there was considerable unexplained heterogeneity; in addition, we assessed the quality of the evidence for each comparison as very low. As such, the findings of this review should be interpreted with caution. The evidence for each of the comparisons made in this review was assessed as very low quality. This evidence showed that individual TFCBT and EMDR did better than waitlist/usual care in reducing clinician-assessed PTSD symptoms. There was evidence that individual TFCBT, EMDR and non-TFCBT are equally effective immediately post-treatment in the treatment of PTSD. There was some evidence that TFCBT and EMDR are superior to non-TFCBT between one to four months following treatment, and also that individual TFCBT, EMDR and non-TFCBT are more effective than other therapies. There was evidence of greater drop-out in active treatment groups. Although a substantial number of studies were included in the review, the conclusions are compromised by methodological issues evident in some. Sample sizes were small, and it is apparent that many of the studies were underpowered. There were limited follow-up data, which compromises conclusions regarding the long-term effects of psychological treatment.

Among the different therapeutic alternatives for post-traumatic stress disorder (PTSD), Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) Therapy have shown promising results in helping patients cope with PTSD symptoms. However, given the different theoretical and methodological substrate of TF-CBT and EMDR, a potentially different impact on the brain for the two interventions could be hypothesized, as well as an interaction between trauma-specific PTSD symptomatology and response to a given psychotherapy. In this study, we monitored psychological and spontaneous functional connectivity fMRI patterns in two groups of PTSD patients who suffered by the same traumatic event (i.e., natural disaster), before and after a cycle of psychotherapy sessions based on TF-CBT and EMDR. Thirty-seven (37) PTSD patients were enrolled from a larger sample of people exposed to a single, acute psychological stress (i.e., 2002 earthquake in San Giuliano di Puglia, Italy). Patients were randomly assigned to TF-CBT (n = 14) or EMDR (n = 17) psychotherapy. Clinical assessment was performed using the Clinician-Administered PTSD Scale (CAPS), the Davidson Trauma Scale (DTS) and the Work and Social Adjustment Scale (WSAS), both at baseline and after treatment. All patients underwent a fMRI data acquisition session before and after treatment, aimed at characterizing their functional connectivity (FC) profile at rest, as well as potential connectivity changes associated with the clinical impact of psychotherapy. Both EMDR and TF-CBT induced statistically significant changes in clinical scores, with no difference in the clinical impact of the two treatments. Specific changes in FC correlated with the improvement at the different clinical scores, and differently for EMDR and TF-CBT. However, a similarity in the connectivity changes associated with changes in CAPS in both groups was also observed. Specifically, changes at CAPS in the entire sample correlated with an (i) increase in connectivity between the bilateral superior medial frontal gyrus and right temporal pole, and a (ii) decrease in connectivity between left cuneus and left temporal pole. Results point to a similar, beneficial psychological impact of EMDR and TF-CBT for treatment of natural-disaster PTSD patients. Neuroimaging data suggest a similar neurophysiological substrate for clinical improvement following EMDR and TF-CBT, involving changes affecting bilateral temporal pole connectivity.

ABSTRACTObjectiveA significant proportion of patients with eating disorders (EDs) also meet criteria for posttraumatic stress disorder (PTSD). Guidelines recommend exposure‐based treatments for PTSD, including prolonged exposure (PE) and eye movement desensitisation and reprocessing (EMDR). Investigating therapist‐related factors could lead to improve their use when ED and PTSD co‐occur.MethodA cross‐sectional survey was conducted among 81 EDs therapists (88% female; M age = 40.4, SD = 10.4) in 2023 in the Netherlands. Hierarchical multiple regression analyses assessed predictors of excluding patients with EDs and comorbid PTSD from exposure‐based treatments for PTSD.ResultsTherapists held more favourable beliefs about EMDR (M = 10.5, SD = 7.5) than PE (M = 13.9, SD = 6.9), and were less likely to exclude patients with EDs and comorbid PTSD from EMDR (M = 15.5, SD = 9.3) than PE (M = 17.7, SD = 9.3) (t(80) = 3.47, p < 0.002). Beliefs about exposure‐based interventions predicted the likelihood of exclusion from both PE (β = 0.56, p < 0.002) and EMDR (β = 0.69, p < 0.002).ConclusionsTherapists' beliefs influence the use of exposure‐based treatments for PTSD in patients with EDs and comorbid PTSD. Addressing these beliefs in training, may support broader implementation.