Furthermore, we still do not know which treatment components are most effective and acceptable for people with PTSD following complex-trauma histories. Because of the narrow analytical focus and ...limitations of the current evidence base, we conducted a systematic review to identify and integrate all direct and indirect comparisons of psychological and pharmacological treatments versus usual care and active controls in treating mental health problems in people with a history of complex traumatic events. Secondary outcomes were reductions in symptoms of disturbances of self-organisation (affect dysregulation; negative self-concept; disturbances in relationships); reduction in symptoms of depression and anxiety, dissociation, functional somatic syndromes; acceptability (attrition); adverse events and harms from trial data (e.g., worsening of traumatic stress symptoms); suicidal ideation, attempts, and completion; and quality of life measured by validated clinician-rated scales. Search strategy and selection criteria Literature searches were initially conducted in April 2017 in these databases: CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress (PILOTS), PsycINFO, and Science Citation Index. ...update searches using the MEDLINE and PsycINFO databases were carried out in October 2019.
Background: Psychological therapies are the recommended first-line treatment for post-traumatic stress disorder (PTSD). Previous systematic reviews have grouped theoretically similar interventions to ...determine differences between broadly distinct approaches. Consequently, we know little regarding the relative efficacy of the specific manualized therapies commonly applied to the treatment of PTSD.
Objective: To determine the effect sizes of manualized therapies for PTSD.
Methods: We undertook a systematic review following Cochrane Collaboration guidelines. A pre-determined definition of clinical importance was applied to the results and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
Results: 114 randomized-controlled trials (RCTs) of 8171 participants were included. There was robust evidence that the therapies broadly defined as CBT with a trauma focus (CBT-T), as well as Eye Movement Desensitization and Reprocessing (EMDR), had a clinically important effect. The manualized CBT-Ts with the strongest evidence of effect were Cognitive Processing Therapy (CPT); Cognitive Therapy (CT); and Prolonged Exposure (PE). There was also some evidence supporting CBT without a trauma focus; group CBT with a trauma focus; guided internet-based CBT; and Present Centred Therapy (PCT). There was emerging evidence for a number of other therapies.
Conclusions: A recent increase in RCTs of psychological therapies for PTSD, results in a more confident recommendation of CBT-T and EMDR as the first-line treatments. Among the CBT-Ts considered by the review CPT, CT and PE should be the treatments of choice. The findings should guide evidence informed shared decision-making between patient and clinician.
The primary aim of this study was to provide an assessment of the current prevalence rates of International Classification of Diseases (11th rev.) posttraumatic stress disorder (PTSD) and complex ...PTSD (CPTSD) among the adult population of the United States and to identify characteristics and correlates associated with each disorder. A total of 7.2% of the sample met criteria for either PTSD or CPTSD, and the prevalence rates were 3.4% for PTSD and 3.8% for CPTSD. Women were more likely than men to meet criteria for both PTSD and CPTSD. Cumulative adulthood trauma was associated with both PTSD and CPTSD; however, cumulative childhood trauma was more strongly associated with CPTSD than PTSD. Among traumatic stressors occurring in childhood, sexual and physical abuse by caregivers were identified as events associated with risk for CPTSD, whereas sexual assault by noncaregivers and abduction were risk factors for PTSD. Adverse childhood events were associated with both PTSD and CPTSD, and equally so. Individuals with CPTSD reported substantially higher psychiatric burden and lower levels of psychological well‐being compared to those with PTSD and those with neither diagnosis.
Resumen
Spanish s by Asociación Chilena de Estrés Traumático (ACET)
El Trastorno de Estrés Postraumático y el Trastorno de Estrés Postraumático Complejo de la CIE‐11 en los Estados Unidos: Un Estudio Basado en la Población
TEPT Y TEPT COMPLEJO EN LOS ESTADOS UNIDOS
El objetivo principal de este estudio fue proporcionar una evaluación de las tasas de prevalencia actuales del trastorno de estrés postraumático (TEPT) y el TEPT complejo (TEPT‐C) según la Clasificación Internacional de Enfermedades (11ª rev.) en la población adulta de los Estados Unidos y para identificar las características y los correlatos asociados con cada trastorno. Un total de 7.2% de la muestra cumplió con los criterios ya sea para TEPT o TEPT‐C, y las tasas de prevalencia fueron 3.4% para TEPT y 3.8% para TEPT‐C. Las mujeres fueron más propensas que los hombres a cumplir los criterios tanto para el TEPT como para el TEPT‐C. El trauma acumulativo en la edad adulta se asoció tanto con el TEPT como con el TEPT‐C; sin embargo, el trauma infantil acumulativo se asoció más fuertemente con el TEPT‐C que con el TEPT. Entre los estresores traumáticos que ocurren en la infancia, el abuso sexual y físico por parte de los cuidadores se identificaron como los eventos asociados con riesgo de TEPT‐C, mientras que la agresión sexual por parte de los no cuidadores y el secuestro fueron factores de riesgo para el TEPT. Los eventos adversos en la infancia se asociaron tanto con el TEPT como con el TEPT‐C, de forma equivalente. Las personas con TEPT‐C informaron sustancialmente mayor carga psiquiátrica y menores niveles de bienestar psicológico en comparación con aquellos con TEPT y aquellos sin diagnóstico.
抽象
Traditional and Simplified Chinese s by the Asian Society for Traumatic Stress Studies (AsianSTSS)
簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯
ICD‐11 PTSD and Complex PTSD in the United States: A population‐based study
Traditional Chinese
標題: 美國根據ICD‐11的準則確診的PTSD與CPTSD個案:人口研究
撮要: 本研究的主要目的為評估目前的美國成年人當中, 根據<國際疾病與相關健康問題統計分類第十一版>(ICD‐11)的準則而確診患創傷後壓力症(PTSD)和複雜型創傷後壓力症(CPTSD)的患病率, 並辨識兩種病症的特徵和關連因素。共有7.2%的樣本符合患PTSD或CPTSD的準則, 而PTSD的患病率為3.4%, CPTSD的患病率為3.8%。女性比男性有較大機會同時符合患PTSD及CPTSD的準則。累積的成年創傷跟PTSD及CPTSD都有關, 可是累積的童年創傷跟CPTSD的關連比跟PTSD的關連更強。在童年的創傷壓力源當中, 照料者施加的性虐和體虐跟有風險患CPTSD相關, 而非照料者作出性侵犯及綁架乃患PTSD的風險因素。童年的負面事件跟PTSD及CPTSD都有關, 兩者的關連同等。CPTSD患者相比起PTSD患者或無患兩者的人士, 有顯著較大的精神負擔及較低水平的心理健康。
Simplified Chinese
标题: 美国根据ICD‐11的准则确诊的PTSD与CPTSD个案:人口研究
撮要: 本研究的主要目的为评估目前的美国成年人当中, 根据<国际疾病与相关健康问题统计分类第十一版>(ICD‐11)的准则而确诊患创伤后压力症(PTSD)和复杂型创伤后压力症(CPTSD)的患病率, 并辨识两种病症的特征和关连因素。共有7.2%的样本符合患PTSD或CPTSD的准则, 而PTSD的患病率为3.4%, CPTSD的患病率为3.8%。女性比男性有较大机会同时符合患PTSD及CPTSD的准则。累积的成年创伤跟PTSD及CPTSD都有关, 可是累积的童年创伤跟CPTSD的关连比跟PTSD的关连更强。在童年的创伤压力源当中, 照料者施加的性虐和体虐跟有风险患CPTSD相关, 而非照料者作出性侵犯及绑架乃患PTSD的风险因素。童年的负面事件跟PTSD及CPTSD都有关, 两者的关连同等。CPTSD患者相比起PTSD患者或无患两者的人士, 有显著较大的精神负担及较低水平的心理健康。
Co-morbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) are common, difficult to treat, and associated with poor prognosis. This review aimed to determine the efficacy of ...individual and group psychological interventions aimed at treating comorbid PTSD and SUD, based on evidence from randomised controlled trials. Our pre-specified primary outcomes were PTSD severity, drug/alcohol use, and treatment completion. We undertook a comprehensive search strategy. Included studies were rated for methodological quality. Available evidence was judged through GRADE. Fourteen studies were included. We found that individual trauma-focused cognitive–behavioural intervention, delivered alongside SUD intervention, was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment, and at subsequent follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment but there was an effect at 5–7months. Fewer participants completed trauma-focused intervention than TAU. We found little evidence to support the use of individual or group-based non-trauma-focused interventions. All findings were judged as being of low/very low quality. We concluded that there is evidence that individual trauma-focused psychological intervention delivered alongside SUD intervention can reduce PTSD severity, and drug/alcohol use. There is very little evidence to support use of non-trauma-focused individual or group-based interventions.
•Comorbid PTSD and SUD are difficult to treat.•Drop-out from treatment is high.•There is evidence of benefit from approaches that include trauma-focused intervention.•There is little evidence for non-trauma-focused approaches at present.•The quality of current evidence is low.
Background: Despite the established efficacy of psychological therapies for post-traumatic stress disorder (PTSD) there has been little systematic exploration of dropout rates.
Objective: To ...ascertain rates of dropout across different modalities of psychological therapy for PTSD and to explore potential sources of heterogeneity.
Method: A systematic review of dropout rates from randomized controlled trials (RCTs) of psychological therapies was conducted. The pooled rate of dropout from psychological therapies was estimated and reasons for heterogeneity explored using meta-regression.
Results:: The pooled rate of dropout from RCTs of psychological therapies for PTSD was 16% (95% CI 14-18%). There was evidence of substantial heterogeneity across studies. We found evidence that psychological therapies with a trauma-focus were significantly associated with greater dropout. There was no evidence of greater dropout from therapies delivered in a group format; from studies that recruited participants from clinical services rather than via advertisements; that included only military personnel/veterans; that were limited to participants traumatized by sexual traumas; that included a higher proportion of female participants; or from studies with a lower proportion of participants who were university educated.
Conclusions: Dropout rates from recommended psychological therapies for PTSD are high and this appears to be particularly true of interventions with a trauma focus. There is a need to further explore the reasons for dropout and to look at ways of increasing treatment retention.
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.
...a glass half full sort of person, I slid into a state of great anxiety, frightened to be alone, scared to be in a group, reluctant to go out, and terrified of staying at home.
Abstract Background The WHO International Classification of Diseases, 11th version (ICD-11), has proposed two related diagnoses following exposure to traumatic events; Posttraumatic Stress Disorder ...(PTSD) and Complex PTSD (CPTSD). We set out to explore whether the newly developed ICD-11 Trauma Questionnaire (ICD-TQ) can distinguish between classes of individuals according to the PTSD and CPTSD symptom profiles as per ICD-11 proposals based on latent class analysis. We also hypothesized that the CPTSD class would report more frequent and a greater number of different types of childhood trauma as well as higher levels of functional impairment. Methods Participants in this study were a sample of individuals who were referred for psychological therapy to a National Health Service (NHS) trauma centre in Scotland (N=193). Participants completed the ICD-TQ as well as measures of life events and functioning. Results Overall, results indicate that using the newly developed ICD-TQ, two subgroups of treatment-seeking individuals could be empirically distinguished based on different patterns of symptom endorsement; a small group high in PTSD symptoms only and a larger group high in CPTSD symptoms. In addition, CPTSD was more strongly associated with more frequent and a greater accumulation of different types of childhood traumatic experiences and poorer functional impairment. Limitations Sample predominantly consisted of people who had experienced childhood psychological trauma or been multiply traumatised in childhood and adulthood. Conclusions CPTSD is highly prevalent in treatment seeking populations who have been multiply traumatised in childhood and adulthood and appropriate interventions should now be developed to aid recovery from this debilitating condition.
Post-traumatic stress disorder (PTSD) is a debilitating mental health disorder that may develop after exposure to traumatic events. Substance use disorder (SUD) is a behavioural disorder in which the ...use of one or more substances is associated with heightened levels of distress, clinically significant impairment of functioning, or both. PTSD and SUD frequently occur together. The comorbidity is widely recognised as being difficult to treat and is associated with poorer treatment completion and poorer outcomes than for either condition alone. Several psychological therapies have been developed to treat the comorbidity, however there is no consensus about which therapies are most effective.
To determine the efficacy of psychological therapies aimed at treating traumatic stress symptoms, substance misuse symptoms, or both in people with comorbid PTSD and SUD in comparison with control conditions (usual care, waiting-list conditions, and no treatment) and other psychological therapies.
We searched the Cochrane Depression, Anxiety and Neurosis Group's Specialised Register (CCDANCTR) all years to 11 March 2015. 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). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov, contacted experts, searched bibliographies of included studies, and performed citation searches of identified articles.
Randomised controlled trials of individual or group psychological therapies delivered to individuals with PTSD and comorbid substance use, compared with waiting-list conditions, usual care, or minimal intervention or to other psychological therapies.
We used standard methodological procedures expected by Cochrane.
We included 14 studies with 1506 participants, of which 13 studies were included in the quantitative synthesis. Most studies involved adult populations. Studies were conducted in a variety of settings. We performed four comparisons investigating the effects of psychological therapies with a trauma-focused component and non-trauma-focused interventions against treatment as usual/minimal intervention and other active psychological therapies. Comparisons were stratified for individual- or group-based therapies. All active interventions were based on cognitive behavioural therapy. Our main findings were as follows.Individual-based psychological therapies with a trauma-focused component plus adjunctive SUD intervention was more effective than treatment as usual (TAU)/minimal intervention for PTSD severity post-treatment (standardised mean difference (SMD) -0.41; 95% confidence interval (CI) -0.72 to -0.10; 4 studies; n = 405; very low-quality evidence) and at 3 to 4 and 5 to 7 months' follow-up. There was no evidence of an effect for level of drug/alcohol use post-treatment (SMD -0.13; 95% CI -0.41 to 0.15; 3 studies; n = 388; very low-quality evidence), but there was a small effect in favour of individual psychological therapy at 5 to 7 months (SMD -0.28; 95% CI -0.48 to -0.07; 3 studies; n = 388) when compared against TAU. Fewer participants completed trauma-focused therapy than TAU (risk ratio (RR) 0.78; 95% CI 0.64 to 0.96; 3 studies; n = 316; low-quality evidence).Individual-based psychological therapy with a trauma-focused component did not perform better than psychological therapy for SUD only for PTSD severity (mean difference (MD) -3.91; 95% CI -19.16 to 11.34; 1 study; n = 46; low-quality evidence) or drug/alcohol use (MD -1.27; 95% CI -5.76 to 3.22; 1 study; n = 46; low-quality evidence). Findings were based on one small study. No effects were observed for rates of therapy completion (RR 1.00; 95% CI 0.74 to 1.36; 1 study; n = 62; low-quality evidence).Non-trauma-focused psychological therapies did not perform better than TAU/minimal intervention for PTSD severity when delivered on an individual (SMD -0.22; 95% CI -0.83 to 0.39; 1 study; n = 44; low-quality evidence) or group basis (SMD -0.02; 95% CI -0.19 to 0.16; 4 studies; n = 513; low-quality evidence). There were no data on the effects on drug/alcohol use for individual therapy. There was no evidence of an effect on the level of drug/alcohol use for group-based therapy (SMD -0.03; 95% CI -0.37 to 0.31; 4 studies; n = 414; very low-quality evidence). A post-hoc analysis for full dose of a widely established group therapy called Seeking Safety showed reduced drug/alcohol use post-treatment (SMD -0.67; 95% CI -1.14 to -0.19; 2 studies; n = 111), but not at subsequent follow-ups. Data on the number of participants completing therapy were not for individual-based therapy. No effects were observed for rates of therapy completion for group-based therapy (RR 1.13; 95% CI 0.88 to 1.45; 2 studies; n = 217; low-quality evidence).Non-trauma-focused psychological therapy did not perform better than psychological therapy for SUD only for PTSD severity (SMD -0.26; 95% CI -1.29 to 0.77; 2 studies; n = 128; very low-quality evidence) or drug/alcohol use (SMD 0.22; 95% CI -0.13 to 0.57; 2 studies; n = 128; low-quality evidence). No effects were observed for rates of therapy completion (RR 0.91; 95% CI 0.68 to 1.20; 2 studies; n = 128; very low-quality evidence).Several studies reported on adverse events. There were no differences between rates of such events in any comparison. We rated several studies as being at 'high' or 'unclear' risk of bias in multiple domains, including for detection bias and attrition bias.
We assessed the evidence in this review as mostly low to very low quality. Evidence showed that individual trauma-focused psychological therapy delivered alongside SUD therapy did better than TAU/minimal intervention in reducing PTSD severity post-treatment and at long-term follow-up, but only reduced SUD at long-term follow-up. All effects were small, and follow-up periods were generally quite short. There was evidence that fewer participants receiving trauma-focused therapy completed treatment. There was very little evidence to support use of non-trauma-focused individual- or group-based integrated therapies. Individuals with more severe and complex presentations (e.g. serious mental illness, individuals with cognitive impairment, and suicidal individuals) were excluded from most studies in this review, and so the findings from this review are not generalisable to such individuals. Some studies suffered from significant methodological problems and some were underpowered, limiting the conclusions that can be drawn. Further research is needed in this area.
Summary
We review the applications and results of voxel‐based morphometry (VBM) studies that have reported brain changes associated with temporal lobe epilepsy (TLE). A PubMed search yielded 18 ...applications of VBM to study brain abnormalities in patients with TLE up to May 2007. Across studies, 26 brain regions were found to be significantly reduced in volume relative to healthy controls. There was a strong asymmetrical distribution of temporal lobe abnormalities preferentially observed ipsilateral to the seizure focus, particularly of the hippocampus (82.35% of all studies), parahippocampal gyrus (47.06%), and entorhinal (23.52%) cortex. The contralateral hippocampus was reported as abnormal in 17.65% of studies. There was a much more bilateral distribution of extratemporal lobe atrophy, preferentially affecting the thalamus (ipsilateral = 61.11%, contralateral = 50%) and parietal lobe (ipsilateral = 47.06%, contralateral = 52.94%). VBM generally reveals a distribution of brain abnormalities in patients with TLE consistent with the region‐of‐interest neuroimaging and postmortem literature. It is unlikely that VBM has any clinical utility given the lack of robustness for individual comparisons. However, VBM may help elucidate some unresolved important research questions such as how recurrent temporal lobe seizures affect hippocampal and extrahippocampal morphology using serial imaging acquisitions.
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