Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq

The American Psychological Association (APA) Practice Guidelines for the Treatment of Posttraumatic Stress Disorder (PTSD) concluded that there was strong evidence for cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and exposure therapy yet weak evidence for eye movement desensitization and reprocessing (EMDR). This is despite the findings from an associated systematic review which concluded that EMDR leads to loss of PTSD diagnosis and symptom reduction. Depression symptoms were also found to improve more with EMDR than control conditions. In that review, EMDR was marked down on strength of evidence (SOE) for symptom reduction for PTSD. However, there were several problems with the conclusions of that review. Firstly, in assessing the evidence in one of the studies, the reviewers chose an incorrect measure that skewed the data. We recalculated a meta-analysis with a more appropriate measure and found the SOE improved. The resulting effect size for EMDR on PTSD symptom reduction compared to a control condition was large for studies that meet the APA inclusion criteria (SMD = 1.28) and the heterogeneity was low (I2= 43%). Secondly, even if the original measure was chosen, we highlight inconsistencies with the way SOE was assessed for EMDR, CT, and CPT. Thirdly, we highlight two papers that were omitted from the analysis. One of these was omitted without any apparent reason. It found EMDR superior to a placebo control. The other study was published in 2015 and should have been part of APA guidelines since they were published in 2017. The inclusion of either study would have resulted in an improvement in SOE. Including both studies results in standard mean difference and confidence intervals that were better for EMDR than for CPT or CT. Therefore, the SOE should have been rated as moderate and EMDR assessed as at least equivalent to these CBT approaches in the APA guidelines. This would bring the APA guidelines in line with other recent practice guidelines from other countries. Less critical but also important, were several inaccuracies in assessing the risk of bias and the failure to consider studies supporting strong gains of EMDR at follow-up.

Treatment guidelines consistently identify cognitive behavioral interventions as among the most effective treatments for posttraumatic stress disorder (PTSD). This chapter reviews evidence-based cognitive behavioral therapies for PTSD, including exposure therapy (with an emphasis on prolonged exposure), cognitive therapy (with an emphasis on cognitive processing therapy), and stress inoculation training/ stress management. For each type of cognitive behavioral intervention, we review the relevant theory, treatment procedures, and key research studies. The chapter concludes with practice considerations covering factors related to treatment outcome, implementation, and adaptation of these evidence-based treatments. List of Abbreviations AHRQ Agency for Healthcare Research and Quality APA American Psychiatric Association BA Behavioral activation CPT-C Cognitive processing therapy – cognitive only CR Cognitive restructuring DCS D-Cycloserine EMDR Eye movement desensitization and reprocessing IOM Institute of Medicine ISTSS International Society for Traumatic Stress Studies ITT Intent to treat MST Military sexual trauma NHMRC Australian National Health and Medical Research Council NICE United Kingdom’s National Institute for Health and Care Excellence PCT Present-centered therapy PE Prolonged exposure PTSD Posttraumatic stress disorder RCT Randomized controlled trial SIT Stress inoculation training *Email: juliette.mott@va.gov Comprehensive Guide to Post-Traumatic Stress Disorder DOI 10.1007/978-3-319-08613-2_17-2 # Springer International Publishing Switzerland (outside the USA) 2015

Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis

Traumatic life events can result in severe psychiatric conditions among which posttraumatic stress disorder (PTSD) is the most prevalent. Due to high comorbidity with other psychiatric diagnoses, PTSD treatment is challenging. In older adults, the presentation of PTSD symptoms is especially complicated because of even higher comorbidity, higher rates with other mental disorders, and cognitive and somatic conditions. Eye movement desensitization and reprocessing (EMDR) is an evidence-based treatment for trauma in younger adults. There is limited empirical research on the treatment effects of EMDR in older adults. Moreover, the impact of successful EMDR treatment on the comorbid disorders, especially personality and cognitive dysfunctions, is unclear. In this case report, EMDR treatment effects for late-onset PTSD with comorbid borderline and avoidant personality disorders, as well as cognitive disorders and multiple somatic problems, will be presented in an older woman.

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.

BackgroundEye movement desensitization and reprocessing (EMDR) is an evidenced-based treatment for posttraumatic stress disorder (PTSD). Forensic mental health services provide assessment and treatment of people with mental illness and a history of criminal offending, or those who are at risk of offending. Forensic mental health services include high, medium, and low-security inpatient settings as well as prison in-reach and community outpatient services. There is a high prevalence of PTSD in forensic settings and posttraumatic experiences can arise in people who violently offend in the context of serious mental illness (SMI). Successful treatment of PTSD may reduce the risk of relapse and improve clinical outcomes for this population. This study aims to assess the efficacy, risk of harm, and acceptability of EMDR within forensic and rehabilitation mental health services, as compared to treatment as usual (routine care).MethodsThis is a single-blind, randomized controlled trial comparing EMDR therapy to the waiting list (routine care). Adult forensic mental health service users (n = 46) with SMI and meeting the criteria for PTSD will be included in the study. Participants will be randomized after baseline assessment to either treatment as usual plus waiting list for EMDR or to treatment as usual plus EMDR. The EMDR condition comprises nine sessions, around 60 min in length delivered weekly, the first of which is a case conceptualization session. The primary outcomes are clinician and participant-rated symptoms of PTSD, and adverse events. Secondary outcomes include psychotic symptoms, social functioning, level of disability, self-esteem, depressive symptoms, post-trauma cognitions, and broad domains of complex posttraumatic difficulties. A trained assessor blinded to the treatment condition will assess outcomes at baseline, 10 weeks, and 6 months. Additionally, grounded theory qualitative methods will be used to explore participant experience of EMDR for a subset of participants.DiscussionThis study will contribute to the currently limited evidence base for EMDR for PTSD in forensic settings. It is the first randomized clinical trial to assess the efficacy, risk of harm, and acceptability of EMDR for PTSD in people with SMI in either forensic, mental health inpatient, or custodial settings.Trial registrationAustralia and New Zealand Clinical Trials Network, ACTRN12618000683235. Registered prospectively on 24 April 2018.

Objective To explore the effect of the eye movement desensitization and reprocessing(EMDR) on military pilot's post-traumatic stress disorders (PTSD) and to provide evidence to the aviation medical service. Methods Forty-three pilots, who suffered from flight accident, were assessed with subjective units of discomfort scale (SUDs), validity of cognition (VOC), symptom checklist 90 (SCL-90) and the symptom questionnaire of PTSD. They were treated with EMDR, cognitive therapy, biofeedback therapy and mental supporting therapy. Results There were significant differences in memory imagoes, hint, body reaction of EMDR groups before and after treatment: SUDS (t=7.64, P<0. 01); VOC (t=6.87, P<0.01); SCL-90 (t=4.93, P<0.01)).Ridit analysis showed that there were differences (Hc = 9. 173, P<0.05) among the effects of each therapy. The EMDR was the most effective(R=0. 591)in the four groups of pilots. Conclusions EMDR is effective on pilot's post-traumatic disorders. Key words: Stress disorders, post-traumatic; Eye movement desensitization and reprocessing; Imagery; psychotherapy; Cognitive therapy; Biofeedback; psychology

Background: Posttraumatic stress disorder (PTSD) is a serious mental disorder, which is associated with emotional and cognitive functioning problems. Psychological interventions, such as trauma-focused cognitive behavioural therapy (tf-CBT) and eye movement desensitization and reprocessing (EMDR) are effective in reducing PTSD symptoms. Despite evidence showing that PTSD is associated with neurocognitive deficits, there is no systematic overview available on neurocognitive outcomes following treatment for PTSD. The current systematic review examined whether psychological treatments for PTSD improve neurocognitive functioning outcomes related to memory, attention, information processing, and executive functioning. Method: A literature search in PubMed, PsycINFO, PTSDpubs, and Cochrane Library was performed up to March 7, 2022, in collaboration with a medical information specialist. Eligible PTSD treatment studies examining neurocognitive outcomes (memory, attention, information processing and executive function) in patients with a DSM-IV or ICD diagnosis of PTSD were included. Results: Of the 3023 titles and abstracts identified, 9 articles met inclusion criteria, of which 5 randomized controlled trials (RCTs) and 4 non-randomized studies. Treatments included were cognitive behavioural therapy (CBT), cognitive processing therapy (CPT), brief eclectic psychotherapy (BEP), eye movement desensitization and reprocessing (EMDR), virtual reality graded exposure therapy (VR-GET), and resilience-oriented treatment (ROT). Conclusions: This systematic review showed that psychological treatments for PTSD do not affect most neurocognitive functions, with exception of the memory outcomes. Future research, high-quality studies are needed to provide evidence of the effect of psychological treatment in improving neurocognitive functioning in PTSD. HIGHLIGHTS This systematic review investigated the effects of psychological treatments on neurocognitive functioning in adults with PTSD. This review showed that most studies were very heterogeneous in design, method, and analysis. This review supports the evidence for psychological treatments for PTSD on improving memory outcomes.

Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Receiving VA Medical Care

Objectives To assess efficacy, comparative effectiveness, and harms of psychological and pharmacological treatments for adults with posttraumatic stress disorder (PTSD). Data sources MEDLINE®, Cochrane Library, PILOTS, International Pharmaceutical Abstracts, CINAHL®, PsycINFO®, Web of Science, Embase, U.S. Food and Drug Administration Web site, and reference lists of published literature (January 1980–May 2012). Review methods Two investigators independently selected, extracted data from, and rated risk of bias of relevant trials. We conducted quantitative analyses using random-effects models to estimate pooled effects. To estimate medications’ comparative effectiveness, we conducted a network meta-analysis using Bayesian methods. We graded strength of evidence (SOE) based on established guidance. Results We included 92 trials of patients, generally with severe PTSD and mean age of 30s to 40s. High SOE supports efficacy of exposure therapy for improving PTSD symptoms (Cohen’s d −1.27; 95% confidence interval, −1.54 to −1.00); number needed to treat (NNT) to achieve loss of diagnosis was 2 (moderate SOE). Evidence also supports efficacy of cognitive processing therapy (CPT), cognitive therapy (CT), cognitive behavioral therapy (CBT)-mixed therapies, eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy for improving PTSD symptoms and/or achieving loss of diagnosis (moderate SOE). Effect sizes for reducing PTSD symptoms were large (e.g., 28.9- to 32.2-point reduction in Clinician-Administered PTSD Scale [CAPS]; Cohen’s d ~ −1.0 or more compared with controls); NNTs were ≤ 4 to achieve loss of diagnosis for CPT, CT, CBT-mixed, and EMDR. Evidence supports the efficacy of fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine for improving PTSD symptoms (moderate SOE); effect sizes were small or medium (e.g., 4.9- to 15.5-point reduction in CAPS compared with placebo). Evidence for paroxetine and venlafaxine also supports their efficacy for inducing remission (NNTs ~8; moderate SOE). Evidence supports paroxetine’s efficacy for improving depression symptoms and functional impairment (moderate SOE) and venlafaxine’s efficacy for improving depression symptoms, quality of life, and functional impairment (moderate SOE). Risperidone may help PTSD symptoms (low SOE). Network meta-analysis of 28 trials (4,817 subjects) found paroxetine and topiramate to be more effective than most medications for reducing PTSD symptoms, but analysis was based largely on indirect evidence and limited to one outcome measure (low SOE). We found insufficient head-to-head evidence comparing efficacious treatments; insufficient evidence to verify whether any treatment approaches were more effective for victims of particular trauma types or to determine comparative risks of adverse effects. Conclusions Several psychological and pharmacological treatments have at least moderate SOE supporting their efficacy: exposure, CPT, CT, CBT-mixed therapies, EMDR, narrative exposure therapy, fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine.

Update on Posttraumatic Stress Disorder and Implications for Acute and Critical Care APRNs.

Although psychological trauma affects millions of Americans, few studies have examined treatment of posttraumatic stress disorder (PTSD) in real-world service environments. This study explored pharmacological treatment of PTSD among privately insured individuals. Data were from the MarketScan database, which compiles claims from private health insurance plans nationwide. Descriptive statistics and multivariate logistic regression were used to identify predictors of any use of a psychotropic medication and use of three medication classes: antidepressants, anxiolytics or sedative-hypnotics, and antipsychotics. Of 860,090 adult mental health care users in 2005, only 10,636 (1.2%) had a diagnosis of PTSD. Sixty percent of PTSD patients received any psychotropic medication: 74.3% of those received antidepressants, 73.7% received anxiolytics or sedative-hypnotics, and 21.3% received antipsychotics. Greater likelihood of any medication use was associated with greater use of mental health services and with several comorbid psychiatric disorders. Having a comorbid diagnosis of an indicated disorder was the most robust predictor of use of each of the three medication classes: major depressive disorder and dysthymia were most strongly associated with antidepressant use, schizophrenia and bipolar disorder were associated with antipsychotic use, and anxiety disorders were associated with use of anxiolytics or sedative-hypnotics. Psychotropic medications were frequently used in the treatment of PTSD among privately insured clients. Although use targeted specifically to PTSD and to comorbid disorders was common, substantial use appeared to be unrelated to diagnosis and may be targeted at specific symptoms rather than diagnosed illnesses. Further research is needed to determine symptom-specific responses to medications across diagnoses.

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.

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.

EMDR Treatment for Posttraumatic Stress Disorder, With Focus on Hippocampal Volumes: A Pilot Study