Chronic PTSD Treated With Metacognitive Therapy: An Open Trial

This paper reports on an open trial of metacognitive therapy (MCT) for chronic PTSD. MCT does not require imaginal reliving, prolonged exposure, or challenging of thoughts about trauma. It is based on an information-processing model of factors that impede normal and in-built recovery processes. It is targeted at modifying maladaptive styles of worry/rumination and attention so that emotional processing can proceed spontaneously. Eleven out of 13 patients with a mean duration of PTSD of 19.5 months completed treatment. Therapists followed the treatment manual by Wells and Sembi (2004b). Self-report measures of PTSD symptoms, anxiety and depression, and assessor ratings of PTSD were administered at pre- and posttreatment, and at 3- and 6-month follow-up. Treatment appeared to result in large and significant improvements on all measures of PTSD and general measures of anxiety and depression. Statistically significant treatment gains were maintained at 3- and 6-month follow-up. Jacobson's criteria for recovery showed that 90% of patients were recovered at posttreatment. At 6-month follow-up approximately 89% were recovered or reliably improved. Results suggest that MCT could be highly effective and extend evidence of its applicability to more treatment-resistant chronic PTSD cases. Comparisons against other active interventions are now clearly indicated.     

Metacognitive therapy in recurrent depression: A case replication series in Denmark

Metacognitive therapy (MCT) for depression is derived from the Wells and Matthews (1994) self‐regulatory model, in which a Cognitive‐Attentional Syndrome (CAS) is the cause of psychological disorders. MCT for depression focuses on identifying patients' CAS and helps them to stop it. The CAS consists of worry, rumination and dysfunctional coping strategies. The focus in MCT is on removing the CAS by challenging positive and negative metacognitive beliefs and eliminating dysfunctional behaviors. In this case series, MCT was delivered to four depressed Danes and treatment was evaluated in 5–11 sessions of up to one hour each. An A‐B design with follow‐up at 3 and 6 months was conducted and the primary outcome was Beck's Depression Inventory II (BDI‐II). We measured CAS processes with the Major depressive Disorder Scale (MDD‐S). The results of the case series showed clinically significant improvements in depressive symptoms, rumination and metacognitive beliefs and the effects were still present at follow‐up for all patients. The small number of patients and decreasing baselines observed in some cases limits the conclusions. However, the results suggest that this treatment is feasible and was associated with large improvements in symptoms when delivered away from its point of origin and in a Danish help‐seeking sample.     

Cognitive-behavior therapy vs exposure therapy in the treatment of PTSD in refugees

The present study investigated the efficacy of cognitive-behavior therapy (CBT) and exposure therapy (E) in the treatment of post-traumatic stress disorder (PTSD) in refugees. Sixteen outpatients fulfilling the DSM-IV criteria for PTSD were randomized to one of the two treatments. Assessor and self-report measures of PTSD-symptoms, generalized anxiety, depression, quality of life and cognitive schemas were administered before and after treatment, and at a 6-month follow-up. The patients were treated individually for 16-20 weekly sessions. The results showed that both treatments resulted in large improvements on all the measures, which were maintained at the follow-up. There was no difference between E and CBT on any measure. E and CBT led to a 48 and 53% reduction on PTSD-symptoms, respectively, a 49 and 50% reduction on generalized anxiety, and a 54 and 57% reduction on depression. The results were maintained at the 6-month follow-up. The conclusion that can be drawn is that both E and CBT can be effective treatments for PTSD in refugees.     

Cognitive processing therapy for chronic PTSD from childhood sexual abuse: A case study

This paper describes a case of chronic Post-traumatic Stress Disorder (PTSD), as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 4th edn; American Psychiatric Association, 1994). The client has a long history of childhood sexual abuse (CSA), as well as repeated sexual victimization as an adult and addiction issues. She presented with significant avoidance symptoms, including a highly restricted range of affect and distinct feelings of detachment from others. These symptoms had been greatly reduced by the end of the 17-week therapy including both individual and group modalities. The paper elaborates on theoretical issues, the Cognitive Processing Therapy model (Resick & Schnicke, 1993) as it was adapted for use with survivors of childhood sexual abuse, the various phases of the therapeutic process, and specific examples of therapeutic change with this particularly complicated case.     

A preliminary investigation of sudden gains in exposure therapy for PTSD

The purpose of the current study was to examine sudden gains in those receiving treatment for PTSD and whether these rapid changes were related to overall symptom reduction in a small sample of female assault survivors with PTSD undergoing prolonged exposure (PE) therapy. Sudden gains were found to occur in 52% of the sample. Among those who experienced a sudden gain, the average magnitude (12.4 points) accounted for 61% of overall symptom reduction. Importantly, treatment outcome was better for those who experienced sudden gains than those who did not. The experience of a sudden gain may result in patients becoming more fully engaged with treatment, and recognition of them may result in identifying potential process-related predictors of treatment response.     

Metacognitive therapy in treatment-resistant depression: a platform trial

Patients with treatment-resistant depression received up to 8 sessions of metacognitive therapy (MCT) targeting attentional control, rumination, worry, and metacognitive beliefs. A baseline period was followed by weekly sessions with follow-up assessments at 6 and 12 months post treatment. Large and statistically significant improvements occurred in all symptom measures at post treatment and were maintained over follow-up. Two out of 3 process measures significantly improved at post treatment and all of these measures were improved at follow-up. Treatment was associated with similar response rates on the BDI and Hamilton rating scale. Using liberal criteria 80% of completers were classified as recovered at post treatment and 70% at follow-up on the BDI. In the intention to treat sample 66.6% were recovered at post treatment and 58.3% at follow-up. More stringent criteria showed 60% recovery rates at post treatment and at 12 m. The results suggest that MCT could be a brief and effective treatment and they provide a precedent for more definitive randomized controlled trials.     

Augmenting treatment efficiency in exposure therapy for PTSD: a randomized double-blind placebo-controlled trial of yohimbine HCl

The alpha-2 adrenergic receptor antagonist, yohimbine, can facilitate fear extinction in animals and humans. One potential mechanism is increased noradrenergic activity and associated arousal in the presence of conditioned stimuli. Accordingly, yohimbine might augment prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD), where heightened exposure-oriented arousal is a theorized driver and empirical predictor of treatment success. A double-blind placebo-controlled randomized trial (NCT 01031979) piloted yohimbine augmentation in 26 males with combat-related PTSD. Participants were given one-time dose of yohimbine or placebo prior to the first imaginal exposure. Subsequently, both arms completed standard PE. The primary outcome was trauma-cued heart-rate reactivity a week after the drug/exposure visit, a highly specified, objective measure sensitive to incremental change. Secondary outcomes included arousal during the drug/exposure visit and slope of distress, PTSD, and depression over the course of PE. Consistent with hypothesis, yohimbine led to higher objective and subjective arousal during the drug/exposure visit and to lower trauma-cued heart-rate reactivity one-week later. One dose of yohimbine also led to greater between-session habituation and more rapid improvement on depression, but not PTSD, over the course of care. Results of this controlled pilot indicate support for continued investigation of yohimbine-augmented exposure therapy for PTSD.     

Gestalt therapy in the treatment of Vietnam veterans experiencing PTSD symptomatology

In the author's clinical work with Vietnam veterans experiencing symptoms of PTSD, Gestalt theory and concepts have proven to be very helpful in (a) conceptualizing what sustains Vietnam as a deleterious problem in the lives of these veterans and (b) providing techniques which are effective in helping them overcome their Vietnam-related troubles. Although of great potential, the author feels that the effective application of Gestalt therapy techniques necessitates the kind of prudent clinical discretion which ordinarily requires a solid background in general psychotherapy and specialized training in Gestalt theory, concepts, and techniques.     

Heart rate during group flooding therapy for PTSD

The objective of this study was to assess, via heart rate, the arousal levels of participants in group trauma reexposure therapy for posttraumatic stress disorder, and so to better understand this common mode of treatment, particularly in regards to its presumed curative factor, extinction. Six Vietnam combat-related PTSD inpatients participated twice weekly in group trauma reexposure therapy during which their electrocardiograms were recorded. Heart rate was quantified continuously off-line. Heart rates of participantsnot directly engaged in imaginal reexposure to their personal combat traumas consistently exhibited mild linear declines from the beginnings to the ends of the approximately 2.5 hour sessions. Participants actively engaged in personal combat trauma reexposure exhibited higher whole-session heart rates. Most also exhibited more specific elevation extending over the later portions of therapy sessions during which intensive reexposure usually occurred. Surprisingly, no patients exhibitedfocal increases in heart rate concurrent with periods of most intensive traumatic incident review as judged from videotape. Administering imaginal reexposure in a group context does not preclude substantial physiological (sympathetic) arousal, as is preconditional for extinction. Under conditions in which the actively engaged reexposure patient is reliably identified, group trauma reexposure therapy may not provide an opportunity for “vicarious” flooding in nonengaged participants.     

Intuition in family therapy: A short manual on post-modern witchcraft

Intuition is an important part of a mature clinician's work. Yet, it is a component of clinical work which is looked upon with suspicion, due in part to the Middle-Age's association between intuition and the work of witches. This paper describes a tenuous link between intuition, witches, and Carl Whitaker. Patterns for including intuition in family therapy are discussed.     

A survey of psychologists' attitudes towards and utilization of exposure therapy for PTSD

Although research supports the efficacy of exposure therapy for PTSD, some evidence suggests that exposure is under-utilized in general clinical practice. The purpose of this study was to assess licensed psychologists' use of imaginal exposure for PTSD and to investigate perceived barriers to its implementation. A total of 852 psychologists from three states were randomly selected and surveyed. An additional 50 members of a trauma special interest group of a national behavior therapy organization were also surveyed. The main survey results indicate that a large majority of licensed doctoral level psychologists do not report use of exposure therapy to treat patients with PTSD. Although approximately half of the main study sample reported that they were at least somewhat familiar with exposure for PTSD, only a small minority used it to treat PTSD in their clinical practice. Even among psychologists with strong interest and training in behavioral treatment for PTSD, exposure therapy is not completely accepted or widely used. Clinicians also appear to perceive a significant number of barriers to implementing exposure.     

Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome and comparison to treatment delivered in person

Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n = 62) or in person (n = 27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.     

Prolonged exposure therapy for chronic combat-related PTSD: a case report of five veterans

Prolonged exposure (PE) therapy has been found efficient in reducing posttraumatic stress disorder (PTSD) symptoms mostly among rape victims, but has not been explored in combat-related PTSD. Five patients with severe chronic PTSD, unresponsive to previous treatment (medication and supportive therapy) are described. Patients were evaluated with the PTSD Symptom Scale-Interview, and Beck Depression Inventory, before and after 10-15 sessions of PE therapy. All five patients showed marked improvement with PE, with a mean decrease of 48% in PTSD Symptom Scale-Interview score and 69% in Beck Depression Inventory score. Moreover, four patients maintained treatment gains or kept improving 6-18 months after the treatment. The results suggest that PE was effective in reducing combat-related chronic PTSD symptoms.