Comparing phase-based treatment, prolonged exposure, and skills-training for Complex Posttraumatic Stress Disorder: A randomized controlled trial.

OBJECTIVE: This study examines treatment effects in STAIR Narrative Therapy (SNT), a phase-based treatment where Skills Training in Affective and Interpersonal Regulation (STAIR) precedes Narrative Therapy (NT), compared to Prolonged Exposure (PE) and to STAIR. METHOD: Ninety-two adult patients diagnosed with DSM-5 PTSD and ICD-11 CPTSD following childhood abuse were randomly assigned to enhanced versions of SNT (12 group STAIR sessions + 8 individual NT sessions), PE (8-16 individual sessions), or STAIR (12 group STAIR sessions) provided in residential care. Outcome was assessed by mixed models. RESULTS: PE produced greater improvements in DSM-5 PTSD symptoms compared to SNT from pre-treatment to post-treatment, but not compared to STAIR. Reductions in ICD-11 CPTSD symptoms were not significantly different among conditions. From pre-treatment to 1 year follow-up, PE produced greater PTSD symptom improvements than SNT and STAIR, and PE and STAIR produced greater CPTSD symptom improvements than SNT. CONCLUSIONS: The predicted stronger effect of SNT compared to PE and STAIR on DSM-5 PTSD and ICD-11 CPTSD symptoms was not supported by the findings. The benefits of immediate trauma-focused treatments (TFT) as compared to phase-based treatments, and the potential non-inferiority of skills-training as compared to TFT in CPTSD needs to be further investigated.

Parenting interventions for families with refugee backgrounds: a randomized factorial, mixed-methods design study protocol.

BACKGROUND: Raising children in new social and cultural contexts can be challenging for parents. In order to help parents address these challenges, the Norwegian government has instituted a policy of mandatory parent training for families who settle in Norway as refugees. The Incredible Years (IY) and The International Child Development Programme (ICDP) have been widely adopted throughout Norway. They have similar aims: to improve parenting through positive parenting practices and development of attachment behaviors. We will evaluate the use of these programs and a measurement feedback system (MFS) to give regular feedback to interventionists about parents' progress during the course of the parenting intervention. METHODS: The study is a mixed method, randomized factorial design aimed at evaluating the effect of parenting interventions and the use of feedback to address parental stress, child behavior, resilience, and parents' mental health. Factor 1 is based on random assignment to one of the parenting interventions IY or ICDP. The parenting interventions are delivered over 15 weeks (IY) or 12 weeks (ICDP) in group-based settings. Factor 2 is based on random assignment of the parenting groups to the (a) with MFS or (b) without MFS condition. The MFS is answered weekly via a phone app, MittEcho, and results are sent to group leaders in the MFS condition. Additionally, the study explores the experiences of families settling in a new cultural context and participating with parenting programs via qualitative interviews. Participants will be recruited from a population of parents with children between the age of 6 and 12 years who settled in Norway as refugees within the previous 9 years. The target sample size is N = 360; n (IY) = 180, n (ICDP) = 180 families. This study is a collaboration between first-line, municipal services; their national governing agencies; family representatives; and a national network of research organizations. DISCUSSION: This study endeavors to provide information about what helps families with refugee background integrate successfully into new cultural contexts with different laws, norms, and expectations. Whether or not these interventions can help to normalize this experience, reduce stress, and provide parents with new tools to improve their parenting and the lives of their children are important questions which we address. These findings can lead to the further establishment of evidence-based practices in Norway. TRIAL REGISTRATION: ISRCTN35008070 . Registered on February 24, 2020.

Psychometric properties of the International Trauma Questionnaire (ITQ) examined in a Norwegian trauma-exposed clinical sample.

BACKGROUND: The International Trauma Questionnaire (ITQ) is a self-report measure for post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD), corresponding to the diagnostic criteria in the International Classification of Diseases, 11th Revision (ICD-11). A 12-item version of the ITQ based on samples from English-speaking countries has been presented, and the wider generalizability to other languages needs to be examined. OBJECTIVE: The current study examines the psychometric properties of scores from a longer, preliminary 22-item version of the ITQ and the current reduced 12-item version by means of generalizability theory (G-theory) and confirmatory factor analysis (CFA). METHOD: The 22-item version of the ITQ was translated into Norwegian and administered to patients in two trauma treatment trials (total N = 202). A generalizability study was used to investigate the psychometric properties of scores reflecting CPTSD. G-theory was also used to investigate alternative measurement designs to optimize the sufficient number of items that provide acceptable generalizability and dependability of scores. Model fit to the theoretical factor structure was then examined by CFA, both for the 22-item version and for the 12-item version of the ITQ. RESULTS: The two subscales negative self-concept and relational disturbances had acceptable generalizability coefficients. We found substantial measurement error related to affective dysregulation, mainly attributable to affective hyperactivation. A latent factor structure model with two separate affective dysregulation factors: hyperactivation and deactivation, represented the data well in the 22-item version. The proposed confirmatory structure model for the 12-item short form did not converge in the CFA. CONCLUSION: This study supports the applicability of the ITQ in a non-English-speaking country and provides support for the validity of the Norwegian translation. Further research is needed to improve the psychometric properties of the affective dysregulation subscale.

Antecedentes: El Cuestionario Internacional de Trauma (ITQ en su sigla en inglés) es una medida de autoreporte para el trastorno de estrés postraumático (TEPT) y el trastorno de estrés postraumático complejo (TEPT-C), que corresponde a los criterios de diagnóstico de la CIE-11. Recientemente, se presentó una versión de ITQ de 12 ítems basada en muestras de países de habla inglesa, y es necesario examinar la posibilidad de generalización a otros idiomas.Objetivo: El presente estudio examina las propiedades psicométricas de los puntajes de una versión preliminar más larga de 22 ítems del ITQ y la versión reducida actual de 12 ítems por medio de la Teoría de la Generalización (TG) y el Análisis Factorial Confirmatorio (AFC).Método: La versión de 22 ítems de ITQ fue traducida al noruego y fue administrada a los pacientes en dos ensayos de tratamiento de trauma (total N = 202). Se usó un estudio de Generalización para investigar las propiedades psicométricas de las puntuaciones que reflejan el TEPT-C. La TG también se usó para investigar los diseños de medición alternativos para optimizar el número de ítems suficientes para proporcionar una generalización y confiabilidad aceptables de los puntajes. El ajuste del modelo a la estructura factorial teórica se examinó mediante un análisis factorial confirmatorio, tanto para la versión de 22 ítems como para la versión de 12 ítems del ITQ.Resultados: Las dos subescalas de autoconcepto negativo y la de perturbación en las relaciones tenían coeficientes de generalización aceptables. Encontramos un error de medición sustancial relacionado con la desregulación afectiva, principalmente atribuible a la hiperactivación afectiva. Un modelo de estructura factorial latente con dos factores de desregulación afectiva separados, hiperactivación y desactivación, representó bien los datos en la versión de 22 ítems. El modelo de estructura confirmatoria propuesto para el formato corto de 12 ítems no convergió en el análisis AFC.Conclusión: El presente estudio respalda la aplicabilidad de ITQ en un país de habla no inglesa, y brinda soporte para la validez de la traducción al noruego. Se necesita más investigación para mejorar las propiedades psicométricas de la subescala de desregulación afectiva.

Psychometric Properties of the General Anxiety Disorder 7-Item (GAD-7) Scale in a Heterogeneous Psychiatric Sample.

The GAD-7 is commonly used as a measure of general anxiety symptoms across various settings and populations. However, there has been disagreement regarding the factor structure of the GAD-7, and there is a need for larger studies investigating the psychometric properties of the measure. Patients undergoing treatment (N = 1201), both inpatient and outpatient patients, completed the GAD-7 at pre- and post-treatment. Measures of depression, well-being, and other anxiety measures were also completed, making it possible to investigate convergent and divergent validity. Internal consistency and convergent validity were excellent for the total sample, and there was acceptable variation related to treatment groups. We conducted an exploratory factor analysis (EFA) on a random sample (50%) of the patients at intake and then conducted a confirmatory factor analysis (CFA) to confirm the factor structure in the other part of the sample at intake. The EFA indicated a clear one-factor solution, but the one-factor solution with CFA provided a poor fit to the data. Correlating the residuals among items assessing somatic symptoms led to a good fit in a respecified CFA solution. The GAD-7 has excellent internal consistency, and the one-factor structure in a heterogeneous clinical population was supported.

The temporal dynamics of symptoms during exposure therapies of PTSD: a network approach.

Background: Analysis of dynamic (temporal) networks allows an identification of important targets of treatment. Objective: This study examined the dynamic network of symptoms in patients diagnosed with post-traumatic stress disorder (PTSD) during exposure therapy. Method: Patients (n = 65) were randomized to either standard prolonged exposure, which includes imaginal exposure to the traumatic memory, or modified prolonged exposure, where imagery re-scripting of the memory replaced imaginal exposure, in a 10-week residential program. They completed a measure of DSM-IV PTSD symptoms weekly. The multilevel vector autoregressive (mlVAR) model was used to analyse the data, producing a temporal (dynamic), contemporaneous, and between-person network. Results: Physiological reactivity to reminders in a given week was positively related to distress reactivity and to flashbacks the subsequent week. Hypervigilance one week was positively related to startle response and external avoidance the subsequent week. In addition, sleep problems were positively predicted by previous week internal avoidance and negatively predicted by previous week flashbacks. Hypervigilance and physiological reactivation had the highest out-strength, indicating that they were the most predictive of other symptoms. Conclusions: The present within-person results make a preliminaryrect basis for the recommendation to monitor and facilitate change in physiological reactivation and hypervigilance in the treatment of PTSD. Future studies should examine the replicability of our temporal PTSD network and also include causal variables beyond symptoms.

Objetivo: Este estudio examinó la red dinámica de síntomas en pacientes diagnosticados con trastorno de estrés postraumático (TEPT) durante la terapia de exposición.Método: Los pacientes (n = 65) se asignaron al azar a una exposición prolongada estándar, que incluye la exposición imaginaria al recuerdo traumático, o la exposición prolongada modificada, donde la re-escritura imaginaria del recuerdo reemplazó a la exposición imaginaria, en un programa residencial de 10 semanas. Ellos completaron una medición de los síntomas del TEPT según DSM-IV semanalmente. El modelo de vectores autorregresivos multinivel (mlVAR) se usó para analizar los datos, produciendo una red temporal (dinámica), contemporánea y entre personas.Resultados: La reactividad fisiológica a los recordatorios en una semana determinada se relacionó positivamente con la reactividad de angustia y con los flashbacks de la semana siguiente. La hipervigilancia de una semana se relacionó positivamente con la respuesta de sobresalto y la evitación externa la semana siguiente. Además, los problemas de sueño fueron predichos positivamente por la evitación interna de la semana anterior y predichos negativamente por los flashbacks de la semana anterior. La hipervigilancia y la reactivación fisiológica tuvieron la mayor resistencia, lo que indica que fueron los más predictivos de otros síntomas.Conclusiones: Los resultados actuales intra-sujeto constituyen una base preliminar para la recomendación de monitorear y facilitar el cambio en la reactivación fisiológica y la hipervigilancia en el tratamiento del trastorno de estrés postraumático. Los estudios futuros deberían examinar la replicabilidad de nuestra red temporal de TEPT y también incluir variables causales más allá de los síntomas.

The Mobility Inventory for Agoraphobia Avoidance Alone Scale: Factor Structure and Psychometric Properties of Subscales.

In this study, we investigated the factor structure of situational fears in agoraphobia by examining four models of the Avoidance Alone items in the Mobility Inventory for Agoraphobia. A main sample of 327 agoraphobic patients and an independent control sample of 64 agoraphobic patients were studied. A confirmatory factor analysis supported a four-factor model including a public places, an enclosed spaces, a public transportation, and an open spaces factor both for pre- and posttreatment data. The convergent and divergent validity of subscales derived from the four factors were supported by an expected pattern of correlations with interview-based measures. These subscales also proved to have satisfactory internal consistencies in the independent sample.

Exposure and non-fear emotions: A randomized controlled study of exposure-based and rescripting-based imagery in PTSD treatment.

Interventions involving rescripting-based imagery have been proposed as a better approach than exposure-based imagery when posttraumatic stress disorder (PTSD) is associated with emotions other than fear. Prior research led to the study's hypotheses that (a) higher pretreatment non-fear emotions would predict relatively better response to rescripting as compared to exposure, (b) rescripting would be associated with greater reduction in non-fear emotions, and (c) pretreatment non-fear emotions would predict poor response to exposure. A clinically representative sample of 65 patients presenting a wide range of traumas was recruited from patients seeking and being offered PTSD treatment in an inpatient setting. Subjects were randomly assigned to 10 weeks of treatment involving either rescripting-based imagery (Imagery Rescripting; IR) or exposure-based imagery (Prolonged Exposure; PE). Patients were assessed on outcome and emotion measures at pretreatment, posttreatment and 12 months follow-up. Comparison to control benchmarks indicated that both treatments were effective, but no outcome differences between them appeared. None of the initial hypotheses were supported. The results from this study challenge previous observations and hypotheses about exposure mainly being effective for fear-based PTSD and strengthen the notion that exposure-based treatment is a generally effective treatment for all types of PTSD.

Self-compassion influences PTSD symptoms in the process of change in trauma-focused cognitive-behavioral therapies: a study of within-person processes.

UNLABELLED: Although self-compassion is considered a promising change agent in the treatment of posttraumatic stress disorder (PTSD), no studies of this hypothesis exist. This study examined the within-person relationship of self-compassion components (self-kindness, common humanity, mindfulness, self-judgment, isolation, over-identification) and subsequent PTSD symptoms over the course of therapy. METHOD: PTSD patients (n = 65) were randomized to either standard prolonged exposure, which includes imaginal exposure (IE) to the traumatic memory, or modified prolonged exposure, where imagery re-scripting (IR) of the memory replaced IE as the imagery component of prolonged exposure in a 10 weeks residential program. They were assessed weekly on self-compassion and PTSD symptom measures. The centering method of detrending was used to separate the variance related to the within-person process of change over the course of treatment from between-person variance. RESULTS: The self-compassion components self-kindness, self-judgment, isolation, and over-identification had a within-person effect on subsequent PTSD symptoms. These relationships were independent of therapy form. The within-person relationship between self-judgment and subsequent PTSD symptoms was stronger in patients with higher initial self-judgment. By contrast, there were few indications that within-person variations in PTSD symptoms predict subsequent self-compassion components. CONCLUSION: The results support the role of self-compassion components in maintaining PTSD and imply the recommendation to facilitate decrease of self-judgment, isolation, and over-identification and increase of self-kindness in the treatment of PTSD patients. The reduction of self-judgment appears to be most important, especially for patients with a high initial level of self-judgment.

Predictors of short- and long-term avoidance in completers of inpatient group interventions for agoraphobia.

BACKGROUND: Little is currently known about predictors of follow-up outcome of psychological treatment of agoraphobia. In this study, we wished to examine predictors of short- and long-term avoidance after inpatient group interventions for agoraphobia. METHODS: Ninety-six (68%) of 141 agoraphobic patients (74% women) who had completed treatment in two open and one randomized controlled trial (RCT) were followed up 13 to 21 years after start of treatment. RESULTS: Major depression at pre-treatment predicted less short-term (up to one year after end of treatment) improvement in agoraphobic avoidance. Working and being married/cohabiting at pre-treatment predicted greater long-term (across one-year, two-year, and 13-21 years follow-up) improvement. In contrast, the duration of agoraphobia, amount of Axis I and II co-morbidity, being diagnosed with avoidant, dependent, and obsessive-compulsive personality disorder, and the use of antidepressants and benzodiazepines the month before intake to treatment, were unrelated to short-term as well as long-term outcome. LIMITATIONS: As many as 31.9% of the included patients did not attend long-term follow-up and the power of the study was limited. The long time period between the two and 13-21 year follow-ups is a limitation, in which it is difficult to assess what actually happened. Although all the patients received some form of CBT, there was variability among the treatments. CONCLUSIONS: The only short-term predictor identified represented a clinical feature, whereas the long-term predictors represented features of the patients' life situation. The limited power of the study precludes the inference that non-significant predictors are unrelated to follow-up outcome.

Trauma-related shame and guilt as time-varying predictors of posttraumatic stress disorder symptoms during imagery exposure and imagery rescripting--A randomized controlled trial.

OBJECTIVE: The specific aims of this study are to examine trauma-related shame and guilt as time-varying predictors of symptoms of posttraumatic stress disorder (PTSD). METHOD: Sixty-five patients were included in the statistical analyses and the multilevel modeling analyses supported three major findings. RESULTS: (i) Patients with a higher level of shame and guilt at the start of treatment displayed a higher level of PTSD symptoms over the course of treatment compared to other patients. (ii) Time-specific change in shame and guilt predicted the level of PTSD symptoms 3 days later from session to session during treatment. (iii) No significant differences were evident between prolonged exposure (PE) and modified PE to include imagery rescripting in the within-person process of change in PTSD symptoms from session to session during therapy. CONCLUSIONS: This trial reports the first evidence that within-person change in shame and guilt predicts change in PTSD symptoms from session to session during treatment.

Experience of affects predicting sense of self and others in short-term dynamic and cognitive therapy.

The present study examined whether levels of activating affects (AA) and inhibitory affects (IA) were related to change toward more compassionate and realistic levels of sense of self (SoS) and sense of others (SoO). The sample included 47 patients diagnosed with cluster C personality disorders, who received 40 sessions of either cognitive therapy or short-term dynamic therapy (see the randomized controlled trial study, Svartberg, Stiles, & Seltzer, 2004). A total of 927 videotaped sessions were rated with the use of the observational instrument, Achievement of Therapeutic Objectives Scale. Longitudinal multilevel modeling enabled the examination of both between-person effects and within-person changes in level of AA and IA. Patients with better ability to experience AA at the start of therapy displayed significantly higher SoS and SoO across sessions compared with other patients. Patients who experienced higher levels of IA at the start of therapy displayed lower levels of SoS across sessions. A patient experiencing more AA than usual for him/her self within a session predicted an increased level of SoS and SoO at the next measuring point. There were no different change patterns in the 2 treatment groups. Results suggest that focus within therapy sessions on increasing patients' AA can help facilitate change in SoS and SoO toward more compassionate and realistic quality.

Psychometric properties of the outcome questionnaire-45.2: the Norwegian version in an international context.

OBJECTIVE: Monitoring of ongoing psychotherapy is of crucial importance in improving the quality of mental health care by detecting therapies being off track, which requires that the instrument used is psychometrically sound. This study investigates the psychometric properties of the Norwegian version of the Outcome Questionnaire 45.2 (OQ-45) and situates the results in an international context. METHOD: Data from one non-clinical sample (N = 338) and one clinical sample (N = 560) were compared to international samples investigating reliability, cut-offs, and factor structure. RESULTS: The results show adequate reliability and concurrent validity. CONCLUSIONS: The means, clinical cut-offs, and the reliable change index vary across countries. However, the means of the OQ-45 for nonclinical samples correlate highly with external values of national well-being, indicating that the OQ-45 is a valid instrument internationally. The factor analyses in the present study do not confirm the hypothesized factor structure of the OQ-45, but are similar to the results internationally.

Alliance and outcome in varying imagery procedures for PTSD: a study of within-person processes.

The present study examined both the intraindividual relationship between alliance components (task, goal, and bond) and subsequent posttraumatic stress disorder (PTSD) symptoms over the course of therapy and the interindividual relationships between the initial level of the alliance components and overall PTSD outcome. PTSD patients (n = 65) were randomized to either standard prolonged exposure, which includes imaginal exposure (IE) to the traumatic memory, or modified prolonged exposure, where imagery rescripting (IR) of the memory replaced IE as the imagery component of prolonged exposure in a 10-week residential program. They were assessed repeatedly (weekly) on alliance and PTSD symptom measures. The centering method of detrending (Curran & Bauer, 2011) was used to separate the variance related to the intraindividual process of change during treatment (within-person component) from the variance related to initial individual differences (between-person component). The hypothesis of a negative within-person effect of the alliance components agreement about the tasks of therapy and bond on subsequent PTSD symptoms was supported for the component task agreement. As expected, this effect was stronger in IE than in IR. Moreover, there was a negative relationship between interindividual differences in initial Task and Bond scale scores and slope of PTSD symptoms over the course of therapy. By contrast, within-person variations in PTSD symptoms did not predict subsequent alliance components. The present results suggest the importance of agreement about therapy tasks during the process of IE or IR within prolonged exposure for PTSD patients, particularly in IE.