Trauma-focused Psychotherapy Research Articles

Mining Clinical Data for Novel Posttraumatic Stress Disorder Medications

BackgroundDespite the prevalence and negative impact of posttraumatic stress disorder (PTSD), there are few medications approved by the U.S. Food and Drug Administration for treatment, and approved medications do not work well enough. We leveraged large-scale electronic health record data to identify existing medications that may be repurposed as PTSD treatments. MethodsWe constructed a mechanistic tree of all Food and Drug Administration–approved medications and used the tree-based scan statistic to identify medications associated with greater than expected levels of clinically meaningful improvement in PTSD symptoms using electronic health record data from the U.S. Department of Veterans Affairs. Our cohort included patients with a diagnosis of PTSD who had repeated symptom measurements using the PTSD Checklist over a 20-year period (N = 168,941). We calculated observed numbers based on patients taking each drug or mechanistically related class of drugs and the expected numbers based on the tree as a whole. ResultsMedications typically used to treat PTSD, such as the Food and Drug Administration–approved agent sertraline, were associated with improvement in PTSD symptoms, but the effects were small. Several, but not all, direct-acting antivirals used in the treatment of hepatitis C virus demonstrated a strong association with PTSD improvement. The finding was robust to a sensitivity analysis excluding patients who received established PTSD treatments, including trauma-focused psychotherapy, concurrent with hepatitis treatment. ConclusionsOur exploratory approach both demonstrated findings that are consistent with what is known about pharmacotherapy for PTSD and uncovered a novel class of medications that may improve PTSD symptoms.

Integrated Trauma-Focused Psychotherapy for Traumatic Stress and Substance Use: Two Adolescent Case Studies

Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed.

Trauma-focused psychotherapies for post-traumatic stress disorder: A systematic review and network meta-analysis.

IntroductionMeta‐analytic reviews suggest similar outcomes across trauma‐focused psychotherapies for adults with post‐traumatic stress disorder (PTSD). However, this conclusion may be premature due to suboptimal statistical‐review methodologies. Network meta‐analysis (NMA) allows a detailed rank‐ordering of the efficacy of established psychotherapy interventions derived from indirect evidence as well as results from direct head‐to‐head comparisons.ObjectiveWe sought to determine the efficacy and attrition rates of psychotherapy interventions for PTSD by applying NMA.MethodsWe searched EMBASE, PsychINFO, PTSDPubs and PubMed for randomised controlled trials that compared psychotherapies either head‐to‐head or against controls for adults with PTSD. A frequentist NMA was used to compare direct and indirect effects to determine the efficacy and attrition rates of psychotherapy interventions.ResultsOf the 5649 papers identified, 82 trials comprising of 5838 patients were included. The network comprised 17 psychotherapies and four control conditions. Network estimates indicated superior efficacy of meta‐cognitive therapy and cognitive processing therapy over other psychotherapies (ESs between = 0.26 and 2.32). Written exposure therapy and narrative exposure therapy were associated with lower risk of drop out when considered alongside other psychotherapies. Confidence in the network meta‐analytic estimates was considered moderate for both outcomes.ConclusionsIn broad terms, therapeutic commensurability was evident. Nevertheless, with additional studies and larger sample sizes, meta‐cognitive and written exposure therapies could indeed differentiate themselves from other approaches as having favourable efficacy and acceptability respectively. These findings may inform clinical decision‐making, as well as guide future research for PTSD.

Inefficient Attentional Control Explains Verbal-Memory Deficits Among Military Veterans With Posttraumatic Reexperiencing Symptoms.

Among individuals with posttraumatic stress disorder (PTSD), verbal learning and memory are areas of weakness compared with other cognitive domains (e.g., visuospatial memory). In this study, previously deployed military veterans completed clinical assessments of word memory and vocabulary (n = 243) and a laboratory task measuring encoding, free recall, repetition priming, and recognition of words (n = 147). Impaired verbal memory was selectively related to reexperiencing symptoms of PTSD but was not associated with other symptom groupings or blast-induced traumatic brain injury. Implicit priming of response times following word repetition was also unrelated to clinical symptoms. Instead, slowed response times during encoding explained associations between reexperiencing and memory performance. These findings are consistent with alterations in attentional control explaining PTSD-related verbal-memory deficits. Such findings have implications for understanding trauma-focused psychotherapy and recovery, which may depend on efficient attentional processing of words to alter posttraumatic reexperiencing symptoms.

STRESS IN CHILDREN PATHOLOGY: FROM PSYCHOSOMATICS TO MOLECULAR BIOLOGY

During childhood, 3 levels of stress were proposed: positive, tolerable and toxic. The toxic stress produced by the strong, frequent and prolonged activation of the body’s response systems is a generator of behavioral and somatic sequelae. Child abuse is present in all social media in different countries. The absence of basic care has devastating effects on social and cognitive development, as found in institutionalized children. Attachment behavior and fear memory are considered stress-related biological systems. The response to stress is driven by the dynamics of cortisol secretion and its interaction with its cellular receptor. It plays a central role in the response to aggression through the process of methylation, decreased gene expression in the hippocampus and increased response to stress. Stress treatment is variable in efficiency and involves preventive measures (family and community), at school, bullying, psychological counseling, trauma-focused psychotherapy, cognitive therapy, through music.

Reaching the Unreached: Bridging Islam and Science to Treat the Mental Wounds of War.

Radical new paradigms are needed to equip non-professionals and leverage community faith-based infrastructure to address the individual and communal wounds of war- and conflict-related trauma. Muslims in war-torn regions like Somalia experience high rates of trauma and posttraumatic stress; yet, lack of providers, potential stigma, and lack of integration with one's faith are substantial barriers to care. In this pre-post feasibility clinical trial (NCT03761732), mosque leaders implemented a brief, group- and mosque-based intervention, Islamic Trauma Healing, targeting trauma-related psychopathology and community reconciliation for trauma survivors (N = 26) in Somaliland, Somalia. Leaders were trained in a brief 2-day training, with supervision provided remotely via WhatsApp. This six-session intervention combines empirically-supported trauma-focused psychotherapy and Islamic principles, focusing on wisdom from the lives of the Prophets and turning to Allah in dua about trauma. There were large, clinically meaningful effects for PTSD (g = 1.91), depression (g = 2.00), somatic symptoms (g = 2.73), and well-being (g = 1.77). Qualitative data from group members highlighted how well the program was aligned with their Islamic faith, built community, and need to expand the program. These results highlight the feasibility of this non-expert, easily up-scalable mental health approach in war-torn Muslim regions and refugee communities. This program has the potential to provide a low-cost, self-sustaining, Islam-based intervention addressing the psychological wounds of war consistent with the IOM's call to develop novel approaches to address unmet clinical needs.ClinicalTrials.gov Identifier: NCT03761732.

Veterans with poor PTSD treatment adherence: Exploring their loved ones' experience of PTSD and understanding of PTSD treatment.

Trauma-focused psychotherapies such as cognitive processing therapy (CPT) and prolonged exposure (PE) are some of the most effective treatments available for posttraumatic stress disorder (PTSD). These treatments have been widely disseminated and promoted throughout the VA Health care System. However, adherence to and completion of these protocols among veterans is often poor, resulting in diminished impact. "Support persons" (SPs) such as relatives and close friends may provide a source of emotional or practical support in treatment, but little is known about how SPs are involved in or exposed to treatment principles and activities. The primary goal of the current research was to examine the experience of SPs of veterans who had poor adherence to treatment. We were interested in SPs' knowledge about the treatment, their level of involvement in treatment activities or sessions, and their potential interest in more participation or education. Qualitative analyses were used to examine data collected from interviews with 19 SPs of veterans who had an unsuccessful course of CPT or PE. Results indicated generally very low levels of knowledge and treatment participation. However, among most SPs there was substantial interest in the possibility of more treatment involvement, particularly in order to receive guidance from the clinician about how to respond to the veteran's symptoms. We suggest that it is possible and desirable to incorporate loved ones more formally into such protocols. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Accelerated resolution therapy and a thematic approach to military experiences in US Special Operations Veterans

Accelerated Resolution Therapy (ART) is an emerging therapeutic intervention that has demonstrated effectiveness in treating post-traumatic stress, anxiety and depression. The ART protocol aligns with first-line trauma-focused psychotherapies and clinical...

What Really Changes in Therapy: A Symptom Network Study of PTSD Across Two Populations

Trauma-focused psychotherapy is considered frontline intervention for PTSD. Therapy success is defined by symptom severity reduction, measured by total scores from a clinical interview or self-report questionnaire. However, this method does not specify which symptoms change, and whether this change is consistent across populations, or tools. In the current study we examined PTSD change using symptom networks in two populations undergoing psychotherapy.

Neural activity during response inhibition associated with improvement of dysphoric symptoms of PTSD after trauma-focused psychotherapy\u2014an EEG-fMRI study

Although trauma-focused cognitive behavioural therapy (TF-CBT) is the frontline treatment for posttraumatic stress disorder (PTSD), up to one half of patients do not respond optimally to this treatment. Inhibitory functions are important for successful management of PTSD, yet there is a dearth of knowledge regarding the extent to which neural mechanisms unpinning response inhibition are associated with TF-CBT response. Treatment-seeking PTSD patients (n = 40) were assessed during a response inhibition task (the Go/No-Go task) while undergoing functional magnetic imaging (fMRI) and event-related potentials (ERP) in separate sessions. PTSD symptom severity was assessed with the Clinician-Administered PTSD Scale, before undergoing nine sessions of TF-CBT. They were then reassessed post-treatment to estimate reduction in fear and dysphoric symptoms of PTSD. Although neural responses during the inhibitory task did not predict overall symptom change, reduced activation in the left precuneus and the right superior parietal cortex predicted greater improvement in dysphoric symptoms. ERP responses during response inhibition indicated that lower P3 peak latency predicted greater reduction of dysphoric symptoms. There were no significant predictors of changes of fear symptoms. These findings indicate that neural activity associated with response inhibition can act as a predictive biomarker of TF-CBT response for PTSD symptoms. This pattern of findings underscores the importance of delineating the role of biomarkers to predict remission of subtypes of PTSD.

The effect of childhood trauma and trauma-focused psychotherapy on blood expression in patients with major depressive disorder

The only available genome-wide study (Minelli et al., 2018) indicated an association between the neglect CT and MED22, a transcriptional factor gene. To verify how the dysregulation of MED22 could be affected by environmental and genetic factors, we carried out an analysis on these components and a longitudinal study concerning the effect of trauma-focused psychotherapy in MDD patients that experienced CT. On a large mRNA sequencing dataset including 368 MDD patients we computed the genetic (GReX) and the environmental (EReX) components affecting gene expression in relation to CT. Furthermore, we measured the expression of MED22 in 22 MDD patients treated with trauma-focused psychotherapy. The dissection of MED22 expression profiles revealed an association of neglect with environmental and genetic components (p=6x10-3 p=2.6x10-4). Furthermore, in an independent cohort of 177 controls, we also observed a significant association between cis-eSNPs of MED22 and higher neuroticism scores (best p-value: 0.00848) that are usually associated with a decreased amount of resilience to stress events. Finally, the results of psychotherapy revealed a reduction of depressive symptomatology (p<0.001) and 73% of patients resulted responders at the follow-up visit. MED22 expression during psychotherapy showed a change trend (p=0.057) with an interaction effect with response (p=0.035). Responder and non-responder patients showed MED22 expression differences at different trauma-focused psychotherapy timepoints (p=0.15; p=0.012) and at the follow-up (p=0.021). Our results provide insights suggesting that some biological and clinical consequences of CT depend on genetic background and environmental factors that could induce vulnerability or resilience to stressful life events.DisclosureNo significant relationships.

Behavioral health clinicians endorse stellate ganglion block as a valuable intervention in the treatment of trauma-related disorders

The stellate ganglion block (SGB) procedure has been used successfully for over 10 years to treat post-traumatic stress symptoms in thousands of US military service members, civilians, and veterans in...

Post-traumatic stress disorder: update on diagnosis and treatment

SUMMARYPost-traumatic stress disorder (PTSD) is a common trauma and stressor-related disorder. Trauma-focused psychotherapies and selective serotonin reuptake inhibitors represent current state of the art treatment for PTSD, with current evidence favouring psychotherapy as first-line treatment. Much room remains for development of more effective therapeutics. This article give a brief update on diagnosis and treatment of PTSD.

Augmentation of EMDR with multifocal transcranial current stimulation (MtCS) in the treatment of fibromyalgia: study protocol of a double-blind randomized controlled exploratory and pragmatic trial

BackgroundFibromyalgia (FM) is a generalized, widespread chronic pain disorder affecting 2.7% of the general population. In recent years, different studies have observed a strong association between FM and psychological trauma. Therefore, a trauma-focused psychotherapy, such as eye movement desensitization and reprocessing (EMDR), combined with a non-invasive brain stimulation technique, such as multifocal transcranial current stimulation (MtCS), could be an innovative adjunctive treatment option. This double-blind randomized controlled trial (RCT) analyzes if EMDR therapy is effective in the reduction of pain symptoms in FM patients and if its potential is boosted with the addition of MtCS.MethodsForty-five patients with FM and a history of traumatic events will be randomly allocated to Waiting List, EMDR + active-MtCS, or EMDR + sham-MtCS. Therapists and patients will be kept blind to MtCS conditions, and raters will be kept blind to both EMDR and MtCS. All patients will be evaluated at baseline, post-treatment, and follow-up at 6 months after post-treatment. Evaluations will assess the following variables: sociodemographic data, pain, psychological trauma, sleep disturbance, anxiety and affective symptoms, and wellbeing.DiscussionThis study will provide evidence of whether EMDR therapy is effective in reducing pain symptoms in FM patients, and whether the effect of EMDR can be enhanced by MtCS.Trial registrationClinicalTrials.gov NCT04084795. Registered on 2 August 2019.

Trauma and Police Violence: Issues and Implications for Mental Health Professionals.

In this piece, the authors present the case of a young Black American man who experienced symptoms of post-traumatic stress disorder after an episode of police violence. Through engagement with this case, the authors consider whether trauma-focused psychotherapies, particularly trauma-focused cognitive behavioral therapies (TF-CBT), are equipped to attend to contextual factors relevant to traumatic experiences of police violence. The authors suggest further research to determine for whom and in what contexts standard forms of psychotherapy as well as alternatives to TF-CBT are effective, and augmenting provider education to include advocacy strategies aimed at reducing police violence-advocacy that is relevant in the context of nationwide protests occurring after the officer-perpetrated killings of George Floyd, Breonna Taylor, and others.

Inflammation-related microRNAs are involved in stressful life events exposure and in trauma-focused psychotherapy in treatment-resistant depressed patients

ABSTRACT Background: About 30% of major depressive disorder (MDD) patients are classified as resistant to treatment (treatment-resistant depression, TRD). Among the factors associated with unfavourable treatment outcomes, stressful life events play a relevant role, and trauma-focused psychotherapy has been successfully proposed for the treatment of patients with a history of such events. Stressful experiences are related to enhanced inflammation and, recently, microRNAs (miRNAs) have emerged as potential mediators of the association between these experiences and psychiatric disorders. To date, no study has explored the effects of stressful life events on miRNAs in MDD patients. Objective: The objective of the present study was to assess possible miRNA blood expression alterations in TRD patients induced by the exposure to stressful life events and to investigate the effects of trauma-focused psychotherapy on the expression profiles of the same miRNAs, as well as their possible predictivity in relation to therapy outcome. Method: The basal levels (T0) of seven candidate miRNAs (miR-15a/miR-29a/miR-125b/miR-126/miR-146a/miR-195/let-7f) were measured in the whole blood of 41 TRD patients. A subgroup of patients (n = 21) underwent trauma-focused psychotherapy; for all of them, miRNA levels were also longitudinally assessed (T4: after 4 weeks of treatment; T8: end of treatment; T12: follow-up visit), contextually to clinical evaluations. Results: miR-146a levels negatively correlated with recent stressful life event scores (p = .001), whereas the levels of miR-15a, miR-29a, miR-126, miR-195, and let-7f changed during the psychotherapy (best p = 1.98*10−9). miR-29a was also identified as a response predictor, with lower baseline levels predicting non-response (p = .019) or worse improvement in mood symptoms (p = .032). Conclusions: The study results could contribute to clarify the underlying molecular mechanisms and to identify novel biomarkers of stressful experiences and response to targeted treatments.

Individual prediction of trauma-focused psychotherapy response in youth with posttraumatic stress disorder using resting-state functional connectivity

Randomized controlled trials have shown efficacy of trauma-focused psychotherapies in youth with posttraumatic stress disorder (PTSD). However, response varies considerably among individuals. Currently, no biomarkers are available to assist clinicians in identifying youth who are most likely to benefit from treatment. In this study, we investigated whether resting-state functional magnetic resonance imaging (rs-fMRI) could distinguish between responders and non-responders on the group- and individual patient level. Pre-treatment rs-fMRI was recorded in 40 youth (ages 8–17 years) with (partial) PTSD before trauma-focused psychotherapy. Change in symptom severity from pre- to post-treatment was assessed using the Clinician-Administered PTSD scale for Children and Adolescents to divide participants into responders (≥30% symptom reduction) and non-responders. Functional networks were identified using meta-independent component analysis. Group-differences within- and between-network connectivity between responders and non-responders were tested using permutation testing. Individual predictions were made using multivariate, cross-validated support vector machine classification. A network centered on the bilateral superior temporal gyrus predicted treatment response for individual patients with 76% accuracy (pFWE = 0.02, 87% sensitivity, 65% specificity, area-under-receiver-operator-curve of 0.82). Functional connectivity between the frontoparietal and sensorimotor network was significantly stronger in non-responders (t = 5.35, pFWE = 0.01) on the group-level. Within-network connectivity was not significantly different between groups. This study provides proof-of-concept evidence for the feasibility to predict trauma-focused psychotherapy response in youth with PTSD at an individual-level. Future studies are required to test if larger cohorts could increase accuracy and to test further generalizability of the prediction models.

“It didn't fit for me:” A qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans.

Trauma-focused psychotherapies, such as prolonged exposure and cognitive processing therapy, are the most effective forms of treatment for posttraumatic stress disorder. These treatments are commonly delivered in the Veterans Health Administration; however, dropout means that some veterans fail to benefit. Ending treatment prematurely is a common problem across psychotherapies, with on average, 20% to 25% of patients dropping out. The purpose of this study was to examine veterans' self-reported reasons for dropping out of prolonged exposure or cognitive processing therapy. Veterans who dropped out from prolonged exposure or cognitive processing therapy (N = 28) completed qualitative interviews about their experiences. Interviews were coded by 2 coders using grounded theory. Therapy-related barriers were the largest category reported, and included lack of buy-in to the rationale or specific therapy tasks, believing that treatment was not working, alliance issues, or switching to a different treatment. Practical barriers and finding treatment "too stressful" were also common reasons for dropout. This research provides information that can shape how PTSD treatments are delivered in health care settings. Therapy-related barriers were the largest group, suggesting that providers may need to find more effective ways to communicate the rationale for these therapies or to tailor them to individual patients' needs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Randomised controlled trial of integrated trauma-focused psychotherapy for traumatic stress and substance use among adolescents: trial protocol

IntroductionPost-traumatic stress disorder (PTSD) and substance use disorder frequently co-occur and tend to have their onset during adolescence. Although research has highlighted the importance of treating these disorders in an...

Trauma-focused psychotherapy response in youth with posttraumatic stress disorder is associated with changes in insula volume

Randomized controlled trials have shown efficacy of trauma-focused psychotherapies in youth with posttraumatic stress disorder (PTSD), but little is known about the relationship between treatment response and alternations in brain structures associated with PTSD. In this study, we longitudinally examined the association between treatment response and pre-to posttreatment changes in structural magnetic resonance imaging (MRI) scans using a voxel-based morphometry approach. We analyzed MRI scans of 35 patients (ages 8–18 years, 21 female) with PTSD (80%) or partial PTSD (20%) before and after eight weekly sessions of trauma-focused psychotherapy. PTSD severity was assessed longitudinally using the Clinician-Administered PTSD scale for Children and Adolescents to divide participants into responders and non-responders. Group by time interaction analysis showed significant differences in grey-matter volume in the bilateral insula due to volume reductions over time in non-responders compared to responders. Despite the significant group by time interaction, there were no significant group differences at baseline or follow-up. As typical development is associated with insula volume increase, these longitudinal MRI findings suggest that treatment non-response is associated with atypical neurodevelopment of the insula, which may underlie persistence of PTSD in youth. The absence of structural MRI changes in treatment responders, while in need of replication, suggest that successful trauma-focused psychotherapy may not directly normalize brain abnormalities associated with PTSD.