Feasibility of Virtual Reality Exposure Therapy in the Treatment of Danish Veterans with Post-Traumatic Stress Disorder: A Mixed Method Pilot Study.

The BraveMind virtual reality exposure therapy (VRET) has been developed and has shown efficacy for U.S. service members and veterans. As the first study to date, the present study examined the feasibility of BraveMind VRET for non-U.S. military veterans. Moreover, the study sought to explore in-depth the participants' experiences with BraveMind VRET. Nine Danish veterans with post-traumatic stress disorder (PTSD) after deployment to Afghanistan participated in the study. PTSD, depression, and quality of life were assessed at pretreatment, post-treatment, and 3-month followup. The treatment consisted of 10 BraveMind VRET sessions. Semistructured interviews with treatment completers were conducted post-treatment to ascertain views about the treatment, in general, and the BraveMind VR system in particular. Thematic qualitative analysis was conducted at the semantic level using an inductive approach. There were significant reductions in pre- to post-treatment self-reported PTSD and significant improvements in quality of life. Treatment gains were maintained at 3-month followup. Pre- to post-treatment Cohen's d effect sizes were large for self-reported PTSD (PTSD Checklist-Civilian Version [PCL-C]: d = 1.55). Qualitative results indicated that the virtual environment of the BraveMind VR system does not entirely map the reality of Danish soldiers in Afghanistan. However, this was not experienced as a hindering factor in therapy. Findings indicate that BraveMind VRET is an acceptable, safe, and effective treatment for Danish veterans with PTSD. The qualitative results emphasize the importance of a strong therapeutic alliance, as VRET is experienced as more emotional straining than regular trauma-focused therapy.

Risk factors, comorbidity and social impairment of ICD-11 PTSD and complex PTSD in Danish treatment-seeking military veterans.

PURPOSE: While a number of studies have investigated risk factors and comorbidities of ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) in various trauma exposed samples, few studies have been conducted in military samples. Existing studies with military samples have included rather small samples. The aim of the present study was to identify risk factors and comorbidities of ICD-11 PTSD and CPTSD in a large sample of previously deployed, treatment-seeking soldiers and veterans. METHODS: Previously deployed, treatment-seeking Danish soldiers and veterans (N = 599), recruited from the Military Psychology Department of the Danish Defense, completed the International Trauma Questionnaire (ITQ), as well as questionnaires of common mental health difficulties, trauma exposure, functioning and demographics. Multivariate multinomial logistic regression analysis explored differences in self-reported exposure to adversity and health outcomes between those meeting ICD-11 criteria for probable PTSD, CPTSD and no trauma disorder. RESULTS: A total of 13.0% met probable ICD-11 criteria for PTSD and 31.4% for CPTSD. Risk factors for CPTSD (compared to those with no trauma disorder) included exposure to warfare or combat, longer duration since the traumatic event and being single. Those with CPTSD were more likely than those with PTSD or no trauma disorder to endorse symptoms of depression, anxiety, stress, use of psychotropic medication, and suicide attempts. CONCLUSION: CPTSD is a more common and debilitating condition compared to PTSD in treatment-seeking soldiers and veterans. Further research should focus on testing existing and novel interventions for CPTSD in the military.

Evaluation of a standardized posttraumatic stress disorder treatment framework in routine mental health care: Effectiveness and predictors of treatment outcome in a consecutive sample.

The primary aim of the present study was to evaluate the effectiveness of standardized care package (CP) treatment for posttraumatic stress disorder (PTSD) in a Danish sample of adult psychiatric outpatients (N = 948). Secondary aims were to identify baseline predictors of treatment outcomes and investigate between-group differences in outcomes with regard to sex and treatment modality (i.e., group vs. individual therapy). The naturalistic, nonrandomized study followed a pre-post design. Patient data from five psychiatric outpatient clinics were collected between March 2011 and November 2017. Data were drawn from self-report questionnaires (i.e., SCL-90-R, WHO-5, BHS) and therapist-reported measures (i.e., GAF-S, GAF-F) administered at baseline and posttreatment. Between-group effects for sex and therapy modality (group vs. individual) were analyzed using analyses of variance, and possible predictors of outcomes were selected through LASSO regression and analyzed via hierarchical regression. Pre-post effects were small to moderate, ds = 0.39-0.69. No differences emerged regarding treatment modality, but women had significantly better outcomes than men. Aside from sex, only baseline symptom severity predicted outcomes. The effectiveness of the CP treatment was generally limited, indicating the need to implement improved therapeutic practices, such as the use of evidence-based treatments, and to provide better training to mental health clinicians. The findings underscore the need for further comparisons of group and individual treatment modalities using evidence-based therapies as well as the need to investigate factors that may affect treatment outcome.

PTSD and complex PTSD in treatment-seeking Danish soldiers: a replication of Folke et al. (2019) using the International Trauma Questionnaire.

Background: While empirical support for the ICD-11 distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing, empirical research into the ICD-11 model of CPTSD in military populations is scarce and inconsistent. Objective: To replicate a study from our own group identifying distinct classes based on CPTSD symptoms using the International Trauma Questionnaire (ITQ) and to identify predictors and functional outcomes associated with a potential distinction between PTSD and CPTSD. Method: Formerly deployed treatment-seeking Danish soldiers (N = 294) completed the ITQ and self-report measures of traumatic life events prior to treatment. Latent profile analysis (LPA) was used to extract classes based on CPTSD symptoms. Results: LPA revealed four classes; (1) high CPTSD symptoms ('CPTSD', 28.7%); (2) high PTSD symptoms and lower DSO symptoms ('PTSD', 23.5%); (3) high DSO symptoms ('DSO', 17.3%); and (4) low symptoms ('Low Symptoms', 30.5%). In comparison to the PTSD-class, CPTSD-class membership was not predicted by traumatic events in adult life and in childhood. The CPTSD class was more often single/divorced/widowed compared to the PTSD class. Moreover, the CPTSD class more often used psychotropic medicine compared to the DSO-class and Low Symptoms-class. Conclusion: Using the ITQ, this study yields empirical support for the ICD-11 model of CPTSD within a clinical sample of veterans. The results replicate findings from our previous study that also identified distinct profiles of ICD-11 PTSD and CPTSD.

Antecedentes: Si bien, el soporte empírico de la clasificación de la CIE-11 para la distinción entre el trastorno de estrés postraumático (TEPT) y TEPT complejo (TEPTC) está creciendo, la investigación empírica sobre el modelo del TEPTC según la CIE-11 en poblaciones militares es escasa e inconsistente.Objetivo: Replicar un estudio de nuestro propio grupo identificando distintas clases basadas en los síntomas del TEPTC utilizando el Cuestionario Internacional de Trauma (ITQ por sus siglas en inglés) e identificar los predictores y las consecuencias funcionales asociadas a una posible distinción entre TEPT y TEPTC.Método: Los soldados daneses que estuvieron en despliegue y en búsqueda de tratamiento (N= 294) completaron el cuestionario de la ITQ y medidas de auto-reporte en relación a eventos traumáticos a lo largo de la vida antes del tratamiento. Se utilizó el análisis de perfil latente (APL) para extraer clases basadas en los síntomas del TEPTC.Resultados: El APL reveló cuatro clases; (1) síntomas elevados de TEPTC ('TEPTC', 28.7%); (2) síntomas elevados de TEPT y síntomas más bajos de Alteraciones en la Auto-Organización (DSO por sus siglas en inglés) ('TEPT', 23.5%); (3) síntomas elevados de DSO ('DSO', 17.3%); y (4) síntomas bajos ('Síntomas bajos', 30.5%). En comparación con la clase de TEPT, la afiliación a la clase del TEPTC no estuvo predicha por eventos traumáticos en la adultez y en la infancia. La clase TEPTC era más frecuentemente soltero/divorciado/viudo, en comparación con la clase TEPT. Además, la clase TEPTC utilizó con mayor frecuencia medicamentos psicotrópicos en comparación con la clase DSO y la clase de Síntomas bajos.Conclusiones: Utilizando el cuestionario ITQ, este estudio proporciona apoyo empírico para el modelo de TEPTC de la CIE-11 dentro de una muestra clínica de veteranos. Los resultados replican los hallazgos de nuestro estudio anterior, que tambien identificó distintos perfiles de TEPT y TEPTC según la clasificación de la CIE-11.

The PTSD help app in a Danish PTSD population: research protocol of a randomized controlled feasibility trial.

BACKGROUND: Due to an increase in PTSD patients seeking help in the Danish mental health sector and the addition of Complex PTSD to the ICD-11, there is a need to increase efficiency of existing treatments for PTSD. mHealth interventions have been shown to reduce PTSD symptoms. Therefore, the implementation of a mHealth intervention designed for psychiatric PTSD patients as a therapy add-on may improve treatment outcome. No study to date has explored the effects of mHealth interventions for PTSD in the Danish mental health sector, the feasibility and effect of this type of intervention needs testing. METHODS: The study is an investigator-initiated randomized controlled feasibility trial investigating the clinical mHealth tool PTSD help combined with care as usual (CAU) compared to CAU for adults with PTSD. Seventy patients will be recruited and receive either the mHealth intervention combined with CAU or CAU alone. The primary feasibility outcome is the proportion of eligible patients that participate in the study until the end assessment. Secondary outcome data consists of the fraction of compliant patients in the experimental group and exploratory data on PTSD help on PTSD symptom severity, level of psychological distress, sleep quality, dissociation symptoms, therapy readiness, quality of life, disability levels, and recovery. DISCUSSION: This study may help increase our knowledge of possible benefits of, as well as potential barriers to, the implementation of mHealth tools in the psychiatric sector. It may also provide a cost-efficient means to increase therapy outcomes and decrease the duration of suffering for PTSD patients in the psychiatric sector. TRIAL REGISTRATION: The trial is registered at ClinicalTrials.gov (ID: NCT03862703) https://clinicaltrials.gov/ct2/show/NCT03862703 on the 27 of February 2019 and has been approved by the Danish Data Protection Agency (journal number: VD-2018-200 ISuite number 6443). Referring to the committee law §2, the National Committee on Health Research Ethics (DNVK) [H-18024180] decided that the study could proceed without approval as the use of PTSD help did not constitute a health science intervention according to Danish health science legislation.

Reflective functioning, psychotherapeutic alliance, and outcome in two psychotherapies for bulimia nervosa.

Mentalization is a developmental achievement defined as the capacity to understand behavior in terms of mental states. This study investigated mentalization in psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) through a secondary data analysis of findings from a randomized controlled trial for bulimia nervosa. It was hypothesized that mentalization would predict alliance and outcome in both treatments, whereas increase in mentalization was only expected after PPT. Furthermore, it was investigated whether change in mentalization predicted symptom change. A total of 70 participants with bulimia nervosa were randomized to PPT or CBT. Participants were assessed at 3 time points with the Eating Disorder Examination and the Adult Attachment Interview (rated for reflective functioning [RF]). Therapy sessions were rated with the Vanderbilt Therapeutic Alliance Scale. Higher intake RF significantly predicted better alliance, whereas no association was observed between RF and outcome. A significant interaction between time, therapy type, and RF found RF improving more in PPT than in CBT. There was a significant association between RF change and symptom change in the PPT group. The study suggests a relation between RF and psychotherapy process, whereas the relation between RF and outcome is more complex. Furthermore, PPT seems to enhance mentalization, which seems related to symptomatic improvement, suggesting that mentalization might serve as a specific mechanism of change in PPT. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

ICD-11 PTSD and complex PTSD in treatment-seeking Danish veterans: a latent profile analysis.

Background: The WHO International Classification of Diseases, 11th version (ICD-11), includes a trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD) distinct from posttraumatic stress disorder (PTSD). Results from previous studies support the validity of this distinction. However, no studies to date have evaluated the ICD-11 model of PTSD and CPTSD in treatment-seeking military veterans. Objective: To determine if the distribution of symptoms in treatment-seeking Danish veterans was consistent with the ICD-11 PTSD and CPTSD symptom profiles. Based on previous studies, we hypothesized that separate classes representing PTSD and CPTSD would be found that membership of a potential CPTSD-class would be predicted by a larger number of childhood traumas, and that a potential distinction between PTSD and CPTSD would be supported by differences in sociodemographic and functional outcomes. Method: Participants (N = 1,541) were formerly deployed Danish soldiers who completed proxy measures of ICD-11 PTSD and disturbances in self-organization (DSO) symptoms, along with self-report measures of traumatic life events, prior to starting treatment at the Military Psychology Department of the Danish Defence. Results: All hypotheses were supported. Latent profile analysis (LPA) revealed separate classes representing PTSD and CPTSD. In comparison to the PTSD-class, membership of the CPTSD-class was predicted by more childhood traumatic experiences, and members of this class were more likely being single/divorced/widowed and more likely to use psychotropic medication. Besides a PTSD-class and a CPTSD-class, LPA revealed a Low Symptoms-class, a Moderate DSO-class, a Hyperarousal-class, and a High DSO-class, with clear differences in functional outcomes between classes. Conclusion: Findings replicate previous studies supporting the distinction between ICD-11 PTSD and CPTSD. In addition, there seem to be groups of treatment-seeking military veterans that do not fulfil full criteria for a trauma-related disorder. Further research should explore subsyndromal PTSD and CPTSD profiles in veterans and other populations.

Antecedentes: La Clasificación Internacional de Enfermedades de la OMS, 11ª versión (CIE-11), incluye un diagnóstico relacionado con el trauma para el trastorno de estrés postraumático complejo (TEPT-C) distinto del trastorno de estrés postraumático (TEPT). Los resultados de los estudios anteriores respaldan la validez de esta distinción. Sin embargo, ningún estudio hasta la fecha ha evaluado el modelo CIE-11 del TEPT y TEPT-C en veteranos militares en busca de tratamiento.Objetivo: Determinar si la distribución de los síntomas en los veteranos daneses en busca tratamiento fue consistente con los perfiles de los síntomas del TEPT y TEPT-C de la CIE-11. Basados en estudios previos, planteamos la hipótesis de que se encontrarían clases separadas que representan el TEPT y TEPT-C, que la pertenencia a la clase potencial del TEPT-C sería predicha por un mayor número de traumas infantiles, y que una posible distinción entre el TEPT y TEPT-C sería apoyada por las diferencias en los resultados sociodemográficos y funcionales.Método: Los participantes (N = 1,541) fueron soldados daneses desplegados anteriormente, que completaron medidas indirectas del TEPT CIE-11 y la alteración en los síntomas de autoorganización (DSO en su sigla en inglés), junto con medidas de autoinforme de los eventos traumáticos de la vida, antes de comenzar el tratamiento en el Departamento de Psicología Militar de la Defensa Danesa.Resultados: Todas las hipótesis fueron sustentadas. El análisis de perfil latente (APL) reveló clases separadas que representan el TEPT y TEPT-C. En comparación con la clase del TEPT, la pertenencia a la clase del TEPT-C fue predicha por más experiencias traumáticas infantiles, y los miembros de esta clase eran más propensos a ser solteros/divorciados/viudos y más propensos a usar medicamentos psicotrópicos. Además de una clase del TEPT y una clase del TEPT-C, el APL reveló una clase de Síntomas Bajos, una clase de DSO Moderado, una clase de Hiperactivación y una clase de DSO Alto, con claras diferencias en los resultados funcionales entre las clases.Conclusión: Los resultados replican los estudios previos que respaldan la distinción entre el TEPT y TEPT-C del CIE-11. Adicionalmente, parece haber grupos de veteranos militares en busca de tratamiento que no cumplen con los criterios completos para un trastorno relacionado con el trauma. Los estudios futuros deben explorar los perfiles del TEPT y TEPT-C sub-sindrómico en veteranos y otras poblaciones.

Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome.

OBJECTIVE: The association between in-session silences and client attachment, therapeutic alliance, and treatment outcome was investigated in two treatments for bulimia nervosa. METHOD: 69 women and one man were randomized to two years of psychoanalytic psychotherapy (PPT) or 20 sessions of cognitive behavioral therapy (CBT). Client attachment was assessed using the Adult Attachment Interview. Early, middle and late sessions (N = 175) were evaluated with the Vanderbilt Therapeutic Alliance Scales, and quality of in-session silences was coded with the Pausing Inventory Categorization System (PICS). Multilevel Poisson and linear regression analyses were performed. RESULTS: Coders identified 6236 pauses, which were more frequent in PPT than in CBT. Higher pausing frequency and higher relative frequency of obstructive pauses were associated with client insecure attachment as well as with poorer treatment alliance, and accounted for part of the relation between client attachment and therapeutic alliance. Good outcome clients had higher relative frequency of productive pauses, especially in mid-treatment, and lower relative frequency of obstructive pauses, especially in late treatment. CONCLUSION: The study further validates the PICS. Findings indicate that therapists may be able to use in-session silences as an indicator of client attachment insecurity and as a prognostic sign of eventual treatment outcome.

Therapist adherence is associated with outcome in cognitive-behavioral therapy for bulimia nervosa.

Studies of therapist adherence in relation to treatment outcome have produced mixed results. The aim of the present study was to investigate change in therapist adherence to cognitive-behavioral therapy (CBT) for bulimia nervosa over time, and to investigate the relationship between adherence and client outcome in early, middle, and late phases of treatment. Thirty-six clients received the focused form of "enhanced" CBT (CBT-E) for bulimia nervosa. Trained observers rated audiotapes of 92 full-length therapy sessions from early (Session 3), middle (Session 11), and late phases (Session 20) of treatment using the Cognitive-Behavioral Therapy Treatment Protocol Adherence Scale. Change in adherence across the 3 treatment phases was examined using multilevel analysis. The relationship between early, middle, and late adherence levels and end-of-treatment binging frequency was examined using multilevel Poisson regression analysis. Adherence decreased significantly over the course of treatment. Higher levels of therapist adherence in early and middle phases of treatment were associated with reduced binging frequency, whereas higher levels of adherence measured late in treatment was not. Results indicate that therapists' adherence to the CBT-E treatment protocol decreases over time and that high levels of protocol adherence in early and middle phases of treatment are more important for positive client outcomes than high levels of adherence in the end of treatment. (PsycINFO Database Record

Personality disorders: patient characteristics and level of outpatient treatment service.

BACKGROUND: In this naturalistic study, patients with personality disorders (N = 388) treated at Stolpegaard Psychotherapy Center, Mental Health Services, Capital Region of Denmark were allocated to two different kinds of treatment: a standardized treatment package with a preset number of treatment hours (basic hospital service) and 2: a specialized treatment program for the most severely affected patients without a predetermined restricted number of treatment hours and significantly more individual psychotherapy (regional specialized hospital services). AIMS: To investigate patient characteristics associated with clinicians' allocation of patients to the two different personality disorder services. METHODS: Patient characteristics across eight domains were collected in order to study whether there were systematic differences between patients allocated to the two different treatments. Patient characteristics included measures of symptom severity, personality pathology, trauma and socio-demographic characteristics. Significance testing and binary regression analysis were applied to identify important predictors. RESULTS: Patient characteristics on fifteen variables differed significantly, all in the expected direction, with patients in regional specialized hospital services showing more pathology and psychosocial problems. In the regression model, only age and two variables capturing psychosocial functioning remained significant predictors of allocation. DISCUSSION: The finding that younger age was the most significant predictor of longer treatment replicates an earlier finding of allocation to treatment for personality disorder. Overall, this study therefore lends further support to the importance of demographic and social contextual factors in clinicians' allocation of patients to different treatment services for personality disorder.

Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa.

OBJECTIVE: This study investigated the relation between clients' attachment patterns and the therapeutic alliance in two psychotherapies for bulimia nervosa. METHOD: Data derive from a randomized clinical trial comparing cognitive-behavioral therapy (CBT) and psychoanalytic psychotherapy (PPT) for bulimia nervosa. Client attachment patterns were assessed with the Adult Attachment Interview. Independent raters scored audiotapes of early, middle, and late therapy sessions for 68 clients (175 sessions) using the Vanderbilt Therapeutic Alliance Scale. RESULTS: Client attachment security was found to be a significant (p = .007) predictor of alliance levels at the three measured time points, with clients higher on attachment security developing stronger alliances with their therapists in both treatments as compared to clients higher on attachment insecurity. No evidence was found to support a hypothesized interaction whereby dismissing clients would develop weaker alliances in PPT and preoccupied clients would develop weaker alliances in CBT. CONCLUSIONS: As the first study to examine client attachment and therapeutic alliance using observer-based instruments, this study supports the theoretical assumption that clients with secure attachment patterns are likely to develop stronger alliances with their therapist across different treatment settings.

A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa.

OBJECTIVE: The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD: A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. RESULTS: Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. CONCLUSIONS: Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.