Faculty Bibliography

This randomized controlled trial assessed the efficacy of a five-session version of Skills Training in Affective and Interpersonal Regulation (STAIR) among veterans obtaining treatment in primary care. Veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression (N = 26) were enrolled and randomized into either five-session STAIR or treatment as usual (TAU). Assessments of PTSD symptoms (PTSD Checklist for DSM-5; PCL-5), depression (Beck Depression Inventory-II; BDI-II), emotion regulation (Difficulties in Emotion Regulation Scale; DERS), and social engagement difficulties (World Health Organization Disability Assessment 2.0; WHODAS-2) were assessed at pretreatment, posttreatment, and 3-month follow-up assessments. Participants assigned to the five-session STAIR condition reported significant improvements on all measures, whereas those assigned to TAU showed no change. Group × Treatment interactions were significant for all outcomes, and effect sizes for the interactions ranged from moderate to large, Hedge's gs = 0.81 for the PCL-5, 1.15 for the BDI-II, 0.75 for the DERS, and 0.81 for the WHODAS-2. The results indicate that five-session STAIR, a brief, skills-focused treatment, may be effective in reducing a range of symptoms and in improving social functioning among veterans treated in primary care settings.

BACKGROUND:Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse, and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at risk of not only posttraumatic stress disorder (PTSD) but also other mental health comorbidities. Whereas evidence-based psychological and pharmacological treatments are effective for single-event PTSD, it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events. METHODS AND FINDINGS/RESULTS:We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised controlled trials (RCTs) and non-RCTs of psychological and pharmacological treatments for PTSD symptoms in people exposed to complex traumatic events, published up to 25 October 2019. We adopted a nondiagnostic approach and included studies of adults who have experienced complex trauma. Complex-trauma subgroups included veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web-based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs, for a total of 6,158 participants, were included in meta-analyses across the primary and secondary outcomes; 18 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ± 9.3 years, and 42% were male. Nine non-RCTs were included. The mean age of participants in the non-RCTs was 40.6 ± 9.4 years, and 47% were male. The average length of follow-up across all included studies at posttreatment for the primary outcome was 11.5 weeks. The pairwise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k = 46; n = 3,389; standardised mean difference [SMD] = -0.82, 95% confidence interval [CI] -1.02 to -0.63) and active control (k-9; n = 662; SMD = -0.35, 95% CI -0.56 to -0.14) at posttreatment and also compared with inactive control at 6-month follow-up (k = 10; n = 738; SMD = -0.45, 95% CI -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k = 31; n = 2,075; SMD = -0.87, 95% CI -1.11 to -0.63; I2 = 82.7%, p = 0.000) and anxiety (k = 15; n = 1,395; SMD = -1.03, 95% CI -1.44 to -0.61; p = 0.000) at posttreatment compared with inactive control. Sleep quality was significantly improved at posttreatment by psychological interventions compared with inactive control (k = 3; n = 111; SMD = -1.00, 95% CI -1.49 to -0.51; p = 0.245). There were no significant differences between psychological interventions and inactive control group at posttreatment for quality of life (k = 6; n = 401; SMD = 0.33, 95% CI -0.01 to 0.66; p = 0.021). Antipsychotic medicine (k = 5; n = 364; SMD = -0.45; -0.85 to -0.05; p = 0.085) and prazosin (k = 3; n = 110; SMD = -0.52; -1.03 to -0.02; p = 0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills-based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions, we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower dropout, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma-focused interventions across trauma subgroups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multicomponent interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k = 17; n = 1,077; mean difference = -37.95, 95% CI -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have overlooked certain complex-trauma populations with severe and enduring mental health comorbidities. Additionally, the relative contribution of skills-based intervention components was not feasibly evaluated in the network meta-analysis. CONCLUSIONS:In this systematic review and meta-analysis, we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multicomponent interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority.

OBJECTIVE:The ICD-11 Trauma Questionnaire (ITQ) was developed as a joint effort by researchers from several countries to evaluate post-traumatic stress (PTSD) and complex-PTSD (C-PTSD) symptoms. This study is part of a multi-center international collaborative research project that aims to provide psychometric support for this initial instrument in different languages, considering the specific contexts related to complex traumatization. This study verified the psychometric characteristics of the Portuguese version of the ITQ, evaluating symptoms beyond those described the existing literature. METHODS:We examined the results of a convenience sample totaling 268 Portuguese and Angolan participants. Two instruments were applied: the ITQ, which evaluates symptoms resulting from a traumatic life event, and the Life Events Checklist (LEC), which evaluates stressful life events. The general characteristics of the scales are described, and reliability analysis and validity studies were performed. RESULTS:Cronbach's alpha varied between 0.84 and 0.88, and the exploratory factorial analysis results were consistent with the concept of C-PTSD, with five components explaining 61.58% of scale variance. CONCLUSION/CONCLUSIONS:The results suggest good psychometric characteristics for the Portuguese version of the ITQ, and thus it can be included in protocols intended evaluating complex traumatic symptoms.

BACKGROUND:The recently released 11th edition of International Classification of Diseases (ICD-11) included new definitions of disorders specifically associated with stress. Complex post-traumatic stress disorder (CPTSD) was included in ICD-11 as a new trauma-related disorder which could develop following prolonged or reoccurring traumatic experiences. Research on ICD-11 PTSD and CPTSD validity and epidemiology has, so far, mostly been conducted in adult population. This is the first study to explore the construct validity of the Child and Adolescent version of International Trauma Questionnaire (ITQ-CA) as a measure of ICD-11 CPTSD symptoms. METHODS:The study was based on a sample of 932 adolescents from the general population aged 12-16 (M = 14.25, SD = 1.27) years exposed to various traumatic experiences. We used confirmatory factor analysis (CFA) and latent class analysis (LCA) to test validity of the ITQ-CA scores from adolescents. RESULTS:The best fitting measurement model included six correlated factors representing the three PTSD and three DSO symptom clusters. LCA analysis revealed four classes whose symptom profiles were reflective of 'CPTSD', 'PTSD', 'DSO only', and 'Baseline'. CONCLUSIONS:Findings of the study provide support for the construct validity of the ICD-11 PTSD and CPTSD among adolescents.

ICD-11 complex post-traumatic stress disorder (PTSD) is a new disorder that describes the more complex reactions that are typical of individuals exposed to chronic trauma. The addition of this disorder as distinct from PTSD is expected to provide greater precision in the diagnosis of trauma populations and more personalised and effective treatment.

BACKGROUND:Adjustment disorder (AjD) is one of the most frequently used diagnoses in psychiatry but a diagnostic definition for AjD was only introduced in release of the ICD-11. This study sought to develop and validate a new measure operationalizing the ICD-11's narrative description of AjD, and to determine the current rate of people meeting the symptoms indicative of AjD in the general population of the Republic of Ireland. METHODS:The International Adjustment Disorder Questionnaire (IADQ) was constructed to measure the core diagnostic criteria of ICD-11 AjD: stressor exposure, preoccupations with, and failure to adapt to, the stressor, timing of symptom onset, and functional impairment. A nationally representative sample (N = 1,020) of adults from Ireland completed the IADQ. RESULTS:Confirmatory factor analysis supported construct validity and the reliability estimates were excellent. The IADQ correlated strongly with depression, anxiety, and posttraumatic stress. The criteria were met by 7.0% of the sample, adjusted for other exclusionary disorders. DISCUSSION/CONCLUSIONS:The IADQ is a measure based on the ICD-11's description and produces reliable scores, however it should not be used for clinical assessment until validated with clinical interviews.

The ICD-11 includes two trauma disorders: Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). CPTSD is a disorder comprised of PTSD and Disturbance in Self-Organization (DSO) symptoms. Evidence supports the construct validity of PTSD and CPTSD, however, the temporal stability of these constructs has rarely been tested. This study examined the diagnostic stability of PTSD and CPTSD, and the temporal associations between PTSD and DSO symptoms over a period of one-year. Data were collected from a nationally representative sample of Israeli adults (n = 1,003) and one year later a random half of this sample were reassessed (n = 543). There were no statistically significant changes in rates of PTSD (6.7%, 5.3%) and CPTSD (4.9%, 3.7%) over time. Latent variable cross-lagged analysis indicated that PTSD and DSO symptoms were stable over time and that DSO symptoms predicted subsequent PTSD symptoms. Results suggest that ICD-11 PTSD and CPTSD are stable constructs in the general population over a period of one year. We discuss the possibility that these findings are influenced by the specific cultural context of Israel. Additionally, given the stability and influence of DSO symptoms we discuss the potential value of psychological therapies that directly address these symptoms.

Debate exists in the trauma literature regarding the role of dissociation in traumatic stress disorders. With the release of the new ICD-11 diagnostic guideline for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD), this issue warrants further attention. In the current study, we provide a preliminary assessment of the associations between ICD-11 CPTSD and dissociative experiences. This study is based on a sample (N = 106) of highly traumatized clinical patients from the United Kingdom who completed measures of traumatic stress and dissociative experiences. The majority of participants met the diagnostic criteria for CPTSD (69.1%, n = 67), with few patients qualifying for a diagnosis of PTSD (9.3%, n = 9). Those with CPTSD had significantly higher levels of dissociative experiences compared to those with PTSD (Cohen's d = 1.04) and those with no diagnosis (Cohen's d = 1.44). Three CPTSD symptom clusters were multivariately associated with dissociation: Affective Dysregulation (β = .33), Re-experiencing in the here and now (β = .24), and Disturbed Relationships (β = .22). These findings indicate that dissociative experiences are particularly relevant for clinical patients with CPTSD. Future longitudinal work will be needed to determine if dissociation is a risk factor for, or outcome of, CPTSD.

Background: Adverse childhood experiences (ACEs) have been identified as an important public health problem with serious implications. Less well understood is how distinct configurations of childhood adversities carry differential risks for mental health, emotional, and social outcomes later in life. Objective: To determine if distinct profiles of childhood adversities exist for males and females and to examine if unique associations exist between the resultant latent profiles of childhood adversities and multiple indicators of mental health and social and emotional wellbeing in adulthood. Method: Participants (N = 1,839) were a nationally representative household sample of adults currently residing in the USA and the data were collected via online self-report questionnaires. Latent class analysis was used to identify the optimal number of classes to explain ACE co-occurrence among males and females, separately. ANOVAs, chi-square tests, and t-tests were used to compare male and female classes across multiple mental health, emotional, and social wellbeing variables in adulthood. Results: Females were significantly more likely than males to report a range of ACEs and mental health, social, and emotional difficulties in adulthood. Two- and four-class models were identified as the best fit for males and females, respectively, indicating more complexity and variation in ACE exposures among females. For males and female, ACEs were strongly associated with poorer mental health, emotional, and social outcomes in adulthood. Among females, growing up in a dysfunctional home environment was a significant risk factor for adverse social outcomes in adulthood. Conclusions: Males and females have distinct patterns of childhood adversities, with females experiencing more complex and varied patterns of childhood adversity. These patterns of ACEs were associated with numerous negative mental, emotional, and social outcomes among both sexes.

This letter to the editor responds to a recent EJPT editorial and following commentary which express concerns about the validity of the ICD-11 complex PTSD (CPTSD) diagnosis. Achterhof and colleagues caution that latent profile analyses and latent class analyses, which have been frequently used to demonstrate the discriminative validity of the ICD-11 PTSD and CPTSD constructs, have limitations and cannot be relied on to definitively determine the validity of the diagnosis. Ford takes a broader perspective and introduces the concept of 'cPTSD' which describes a wide ranging set of symptoms identified from studies related to DSM-IV, DSM-V and ICD-11 and proposes that the validity of the ICD-11 CPTSD is in question as it does not address the multiple symptoms identified from previous trauma-related disorders. We argue that ICD-11 CPTSD is a theory-driven, empirically supported construct that has internal consistency and conceptual coherence and that it need not explain nor resolve the inconsistencies of past formulations to demonstrate its validity. We do agree with Ford and with Achterhof and colleagues that no one single statistical process can definitively answer the question of whether CPTSD is a valid construct. We reference several studies utilizing many different statistical approaches implemented across several countries, the overwhelming majority of which have supported the validity of ICD-11 as a unique construct. We conclude with our own cautions about ICD-11 CPTSD research to date and identify important next steps.