Prolonged Exposure vs Eye Movement Desensitization and Reprocessing vs Waiting List for Posttraumatic Stress Disorder in Patients With a Psychotic Disorder

Abstract

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. OBJECTIVE 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. DESIGN, SETTING, AND PARTICIPANTS 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. INTERVENTIONS 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. MAIN OUTCOMES AND MEASURES 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. RESULTS 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). CONCLUSIONS AND RELEVANCE 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. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN79584912

Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD

“…These findings are consistent with the results of a secondary analysis of a treatment study of narrative exposure therapy (NET) and treatment as usual among severely traumatized asylum seekers and refugees, which showed that DS did not substantially moderate the treatment outcomes (Halvorsen, Stenmark, Neuner, & Nordahl, 2014). A recent study replicated these findings by generalizing the results to individuals with a severe psychiatric condition and performing a secondary analysis of a randomized clinical trial comparing prolonged exposure with EMDR therapy among PTSD patients with psychosis (van den Berg et al, 2015; van Minnen et al, 2016). Patients with and without DS showed a similar decrease in PTSD symptoms with large effect sizes observed in both groups.…”

Intensive EMDR to Treat Patients With Complex Posttraumatic Stress Disorder: A Case Series

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There is mounting support for the notion that also, individuals with severe, or "complex," forms of PTSD respond positively to TFTs and that neither trauma history, comorbidity, nor severe dissociative symptoms negatively affect clients' response to TFTs Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002;Hagenaars, van Minnen, & Hoogduin, 2010;Jerud, Pruitt, Zoellner, & Feeny, 2016;Olatunji, Cisler, & Tolin, 2010;van den Berg et al, 2015;van Minnen, Arntz, & Keijsers, 2002;van Minnen, Harned, Zoellner, & Mills, 2012; There is mounting evidence suggesting that by increasing the frequency of treatment sessions, posttraumatic stress disorder (PTSD) treatment outcomes significantly improve. As part of an ongoing research project, this study examined the safety and effectiveness of intensive eye movement desensitization and reprocessing (EMDR) therapy in a group of seven (four female) patients suffering from complex PTSD and multiple comorbidities resulting from childhood sexual abuse, physical abuse, and/or work and combatrelated trauma.

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The Trauma and Life Events (TALE) checklist: development of a tool for improving routine screening in people with psychosis

“…It has also been used in trauma-focused therapy trials for PTSD in psychosis (e.g. van den Berg et al, 2015). …”

“…Multifactorial models of the pathways from traumatic events to psychosis have been proposed, and psychological therapies for post-traumatic stress responses in psychosis show promise (Hardy, 2017; van den Berg et al, 2015). This work has led to calls for the routine screening of trauma and post-traumatic stress responses in clinical practice (NICE, 2014).…”