Sudden gains in routine clinical care: application of a permutation test for trauma-focused cognitive behavioural therapy.

Background: Sudden gains, defined as large and stable improvements of psychopathological symptoms, are a ubiquitous phenomenon in psychotherapy. They have been shown to occur across several clinical contexts and to be associated with better short-term and long-term treatment outcome. However, the approach of sudden gains has been criticized for its tautological character: sudden gains are included in the computation of treatment outcomes, ultimately resulting in a circular conclusion. Furthermore, some authors criticize sudden gains as merely being random fluctuations.Objective: Use of efficient methods to evaluate whether the amount of sudden gains in a given sample lies above chance level.Method: We used permutation tests in a sample of 85 patients with posttraumatic stress disorder (PTSD) treated with trauma-focused cognitive behaviour therapy in routine clinical care. Scores of self-reported PTSD symptom severity were permuted 10.000 times within sessions and between participants to receive a random distribution.Results: Altogether, 18 participants showed a total of 24 sudden gains within the first 20 sessions. The permutation test yielded that the frequency of sudden gains was not beyond chance level. No significant predictors of sudden gains were identified and sudden gains in general were not predictive of treatment outcome. However, subjects with early sudden gains had a significantly lower symptom severity after treatment.Conclusions: Our data suggest that a significant proportion of sudden gains are due to chance. Further research is needed on the differential effects of early and late sudden gains.

Treatment-related sudden gains exhibit clinical significance when their manifestation is above chance level.We used permutation tests to examine their occurrence in trauma-focused cognitive behaviour therapy as applied in a naturalistic treatment setting.The occurrence of sudden gains in general was not significantly higher than chance, yet early sudden gains were associated with improved treatment outcome.

Do changes in dysfunctional posttraumatic cognitions differentially predict PTSD symptom clusters?

OBJECTIVE: In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity-despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters. METHOD: As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models. RESULTS: Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for. CONCLUSION: The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparing PTSD symptom networks in type I vs. type II trauma survivors.

Background: Network analysis has gained increasing attention as a new framework to study complex associations between symptoms of post-traumatic stress disorder (PTSD). A number of studies have been published to investigate symptom networks on different sets of symptoms in different populations, and the findings have been inconsistent. Objective: We aimed to extend previous research by testing whether differences in PTSD symptom networks can be found in survivors of type I (single event; sudden and unexpected, high levels of acute threat) vs. type II (repeated and/or protracted; anticipated) trauma (with regard to their index trauma). Method: Participants were trauma-exposed individuals with elevated levels of PTSD symptomatology, most of whom (94%) were undergoing assessment in preparation for PTSD treatment in several treatment centres in Germany and Switzerland (n = 286 with type I and n = 187 with type II trauma). We estimated Bayesian Gaussian graphical models for each trauma group and explored group differences in the symptom network. Results: First, for both trauma types, our analyses identified the edges that were repeatedly reported in previous network studies. Second, there was decisive evidence that the two networks were generated from different multivariate normal distributions, i.e. the networks differed on a global level. Third, explorative edge-wise comparisons showed moderate or strong evidence for specific 12 edges. Edges which emerged as especially important in distinguishing the networks were between intrusions and flashbacks, highlighting the stronger positive association in the group of type II trauma survivors compared to type I survivors. Flashbacks showed a similar pattern of results in the associations with detachment and sleep problems (type II > type I). Conclusion: Our findings suggest that trauma type contributes to the heterogeneity in the symptom network. Future research on PTSD symptom networks should include this variable in the analyses to reduce heterogeneity.

Antecedentes: El análisis de redes ha ganado cada vez más atención como un nuevo marco para estudiar asociaciones complejas entre síntomas del Trastorno de Estrés Postraumático (TEPT). Se han publicado una cantidad de estudios para investigar las redes de síntomas en diferentes conjuntos de síntomas en distintas poblaciones, y los hallazgos han sido inconsistentes.Objetivos: Nuestro objetivo fue ampliar la investigación previa probando si se pueden encontrar diferencias entre las redes de síntomas del TEPT en sobrevivientes de trauma de tipo 1 (evento único; súbito e inesperado, niveles elevados de amenaza aguda) versus los de tipo 2 (eventos repetidos y/o prolongados; anticipados) (con respecto a su trauma índice).Métodos: Los participantes eran individuos expuestos al trauma con niveles elevados de sintomatología de TEPT, la mayoría de los cuales (94%) se sometían a una evaluación en preparación para el tratamiento del TEPT en varios centros de Alemania y Suiza (n = 286 con tipo 1 y n = 187 con tipo 2 de trauma). Estimamos modelos gráficos Bayesianos Gaussianos para cada tipo de grupo de trauma y exploramos las diferencias entre los grupos en la red de síntomas.Resultados: En primer lugar, para ambos tipos de trauma, nuestros análisis identificaron los bordes que se reportaron repetidamente en estudios de redes anteriores. En segundo lugar, hubo evidencia decisiva que las dos redes fueron generadas de diferentes distribuciones normales multivariadas, es decir, las redes diferían a nivel global. En tercer lugar, las comparaciones exploratorias de los bordes mostraron una evidencia de moderada a fuerte para 12 bordes específicos. Los bordes que surgieron como especialmente importantes para distinguir las redes fueron las intrusiones y flashbacks, destacando la asociación fuertemente positiva entre los grupos de tipo 2 en comparación con los sobrevivientes de trauma del grupo de tipo 1. Los flashbacks mostraron un patrón similar de resultados en las asociaciones con desapego y problemas de sueño (tipo 2 > tipo 1).Conclusiones: Nuestros resultados sugieren que el tipo de trauma contribuye a la heterogeneidad en los síntomas de red. La investigación futura sobre las redes de los síntomas de TEPT debería incluir esta variable en los análisis para reducir la heterogeneidad.

The dissociative subtype of PTSD in trauma-exposed individuals: a latent class analysis and examination of clinical covariates.

Background: A dissociative subtype of posttraumatic stress disorder (D-PTSD) was introduced into the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) but latent profiles and clinical correlates of D-PTSD remain controversial. Objective: The aims of our study were to identify subgroups of individuals with distinct patterns of PTSD symptoms, including dissociative symptoms, by means of latent class analyses (LCA), to compare these results with the categorization of D-PTSD vs. PTSD without dissociative features according to the CAPS-5 interview, and to explore whether D-PTSD is associated with higher PTSD severity, difficulties in emotion regulation, and depressive symptoms. Method: A German sample of treatment-seeking individuals was investigated (N = 352). We conducted an LCA on the basis of symptoms of PTSD and dissociation as assessed by the CAPS-5. Moreover, severity of PTSD (PCL-5), difficulties in emotion regulation (DERS), and depressive symptoms (BDI-II) were compared between patients with D-PTSD according to the CAPS-5 interview and patients without dissociative symptoms. Results: LCA results suggested a 5-class model with one subgroup showing the highest probability to fulfill criteria for the dissociative subtype and high scores on both BDI and DERS. Significantly higher scores on the DERS, BDI and PCL-5 were found in the D-PTSD group diagnosed with the CAPS-5 (n = 75; 35.7%). Sexual trauma was also reported more often by this subgroup. When comparing the dissociative subtype to the LCA results, only a partial overlap could be found. Conclusions: Our findings suggest that patients with D-PTSD have significantly more problems with emotion regulation, more depressive symptoms, and more severe PTSD-symptoms. Given the results of our LCA, we conclude that the dissociative subtype seems to be more complex than D-PTSD as diagnosed by means of the CAPS-5.

Antecedentes: Un subtipo disociativo del trastorno de estrés postraumático (TEPT-D) fue introducido en la 5ª edición del Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM-5), pero los perfiles latentes y los correlatos clínicos del TEPT-D siguen siendo controversiales. Objetivo Los objetivos de nuestro estudio fueron identificar subgrupos de individuos con distintos patrones de síntomas de TEPT, incluyendo síntomas disociativos, mediante análisis de clases latentes (LCA, por sus siglas en inglés), comparar estos resultados con la categorización de TEPT-D vs. TEPT sin rasgos disociativos según la entrevista CAPS-5, y explorar si el TEPT-D se asocia con una mayor gravedad del TEPT, dificultades en la regulación de las emociones y síntomas depresivos.Método: Se investigó una muestra alemana de individuos que buscaban tratamiento (N = 352). Se realizó un LCA sobre la base de los síntomas de TEPT y disociación evaluados por el CAPS-5. Además, se comparó la gravedad del TEPT (PCL-5), las dificultades en la regulación de las emociones (DERS) y los síntomas depresivos (BDI-II) entre los pacientes con TEPT según la entrevista CAPS-5 y los pacientes sin síntomas disociativos.Resultados: Los resultados del LCA sugirieron un modelo de 5 clases con un subgrupo que mostraba la mayor probabilidad de cumplir los criterios del subtipo disociativo y altas puntuaciones tanto en el BDI como en el DERS. Se encontraron puntuaciones significativamente más altas en el DERS, el BDI y el PCL-5 en el grupo de TEPT-D diagnosticado con el CAPS-5 (n = 75; 35,7%). Este subgrupo también informó con más frecuencia de traumas sexuales. Al comparar el subtipo disociativo con los resultados del LCA, sólo se pudo encontrar una superposición parcial. Conclusiones Nuestros resultados sugieren que los pacientes con TEPT-D tienen significativamente más problemas con la regulación emocional, más síntomas depresivos y síntomas de TEPT más graves. Dados los resultados de nuestro LCA, concluimos que el subtipo disociativo parece ser más complejo que el TEPT-D diagnosticado mediante el CAPS-5.

Confirmatory factor analysis of the Clinician-Administered PTSD Scale (CAPS-5) based on DSM-5 vs. ICD-11 criteria.

Introduction: Many studies have investigated the latent structure of the DSM-5 criteria for posttraumatic stress disorder (PTSD). However, most research on this topic was based on self-report data. We aimed to investigate the latent structure of PTSD based on a clinical interview, the Clinician-Administered PTSD Scale (CAPS-5). Method: A clinical sample of 345 participants took part in this multi-centre study. Participants were assessed with the CAPS-5 and the Posttraumatic Stress Disorder Checklist (PCL-5). We evaluated eight competing models of DSM-5 PTSD symptoms and three competing models of ICD-11 PTSD symptoms. Results: The internal consistency of the CAPS-5 was replicated. In CFAs, the Anhedonia model emerged as the best fitting model within all tested DSM-5 models. However, when compared with the Anhedonia model, the non-nested ICD-11 model as a less complex three-factor solution showed better model fit indices. Discussion: We discuss the findings in the context of earlier empirical findings as well as theoretical models of PTSD.

Introducción: Muchos estudios han investigado la estructura latente de los criterios DSM-5 para el trastorno de estrés postraumático (TEPT). Sin embargo, la mayoría de la investigación en este tema estuvo basada en datos de auto-reporte. Nuestro objetivo fue investigar la estructura latente del TEPT basado en una entrevista clínica, la Escala de TEPT administrada por el Clínico (CAPS-5 por su sigla en inglés).Método: En este estudio multicéntrico participó una muestra clínica de 345 personas. Los participantes fueron evaluados con la CAPS-5 y la Lista de Chequeo de Trastorno de Estrés Postraumático (PCL-5, por su sigla en inglés). Evaluamos ocho modelos competitivos de síntomas de TEPT del DSM-5 y tres modelos competitivos de síntomas de TEPT de la CIE-11.Resultados: La consistencia interna de la CAPS-5 fue replicada. En los AFC el modelo de anhedonia emergió como el de mejor ajuste entre todos los modelos del DSM-5 evaluados. Sin embargo, cuando se comparó con el modelo de anhedonia, el modelo no anidado de CIE-11 como una solución menos compleja de tres factores mostró mejores índices de ajuste de modelo.Discusión: Discutimos los hallazgos en el contexto de los resultados empíricos previos y de los modelos teóricos del TEPT.

Mechanisms of Change in Trauma-Focused Treatment for PTSD: The Role of Rumination.

OBJECTIVE: Cognitive behavioral therapy (CBT) has been well established in the treatment of posttraumatic stress disorder (PTSD). In recent years, researchers have begun to investigate its underlying mechanisms of change. Dysfunctional cognitive content, i.e. excessively negative appraisals of the trauma or its consequences, has been shown to predict changes in PTSD symptoms over the course of treatment. However, the role of change in cognitive processes, such as trauma-related rumination, needs to be addressed. The present study investigates whether changes in rumination intensity precede and predict changes in symptom severity. We also explored the extent to which symptom severity predicts rumination. METHOD: As part of a naturalistic effectiveness study evaluating CBT for PTSD in routine clinical care, eighty-eight patients with PTSD completed weekly measures of rumination and symptom severity. Lagged associations between rumination and symptoms in the following week were examined using linear mixed models. RESULTS: Over the course of therapy, both ruminative thinking and PTSD symptoms decreased. Rumination was a significant predictor of PTSD symptoms in the following week, although this effect was at least partly explained by the time factor (e.g., natural recovery or inseparable treatment effects). Symptom severity predicted ruminative thinking in the following week even with time as an additional predictor. CONCLUSIONS: The present study provides preliminary evidence that rumination in PTSD is reduced by CBT for PTSD but does not give conclusive evidence that rumination is a mechanism of change in trauma-focused treatment for PTSD.

Brief imagery rescripting vs. usual care and treatment advice in refugees with posttraumatic stress disorder: study protocol for a multi-center randomized-controlled trial.

Background: Many refugees have experienced multiple traumatic events in their country of origin and/or during flight. Trauma-related disorders such as posttraumatic stress disorder (PTSD) or complex PTSD (CPTSD) are prevalent in this population, which highlights the need for accessible and effective treatment. Imagery Rescripting (ImRs), an imagery-based treatment that does not use formal exposure and that has received growing interest as an innovative treatment for PTSD, appears to be a promising approach. Objective: This randomized-controlled trial aims to investigate the efficacy of ImRs for refugees compared to Usual Care and Treatment Advice (UC+TA) on (C)PTSD remission and reduction in other related symptoms. Method: Subjects are 90 refugees to Germany with a diagnosis of PTSD according to DSM-5. They will be randomly allocated to receive either UC+TA (n = 45) or 10 sessions of ImRs (n = 45). Assessments will be conducted at baseline, post-intervention, three-month follow-up, and 12-month follow-up. Primary outcome is the (C)PTSD remission rate. Secondary outcomes are severity of PTSD and CPTSD symptoms, psychiatric symptoms, dissociative symptoms, quality of sleep, and treatment satisfaction. Economic analyses will investigate health-related quality of life and costs. Additional measures will assess migration and stress-related factors, predictors of dropout, therapeutic alliance and session-by-session changes in trauma-related symptoms. Results and Conclusions: Emerging evidence suggests the suitability of ImRs in the treatment of refugees with PTSD. After positive evaluation, this short and culturally adaptable treatment can contribute to close the treatment gap for refugees in high-income countries such as Germany. Trial registration: German Clinical Trials Register under trial number DRKS00019876, registered prospectively on 28 April 2020.

Antecedentes: Muchos refugiados han experimentado múltiples eventos traumáticos en su país de origen y/o durante la huida. Los trastornos relacionados con el trauma, como el trastorno de estrés postraumático (TEPT) o el trastorno de estrés postraumático complejo (TEPTC), son frecuentes en esta población, lo que pone de relieve la necesidad de un tratamiento accesible y eficaz. La reescritura de imágenes (ImRs, en sus siglas en inglés), un tratamiento basado en imágenes que no utiliza la exposición formal y que ha recibido un creciente interés como tratamiento innovador para el TEPT, parece ser un enfoque prometedor.Objetivo: Este ensayo controlado aleatorizado tiene como objetivo investigar la eficacia de la ImRs para los refugiados en comparación con cuidado habitual y consejería de tratamiento (UC+TA) en la remisión del TEPT(C) y la reducción de otros síntomas relacionados.Método: Los sujetos son 90 refugiados en Alemania con un diagnóstico de TEPT según el DSM-5. Serán asignados aleatoriamente para recibir UC+TA (n = 45) o diez sesiones de ImRs (n = 45). Las evaluaciones se llevarán a cabo al inicio, post-intervención, con un seguimiento de tres meses y un seguimiento de 12 meses. El resultado primario es la tasa de remisión del TEPT(C). Los resultados secundarios son la gravedad de los síntomas del TEPT y del TEPTC, los síntomas psiquiátricos, los síntomas disociativos, la calidad del sueño y la satisfacción del tratamiento. Los análisis económicos investigarán la calidad de vida y los costos relacionados con la salud. Medidas adicionales evaluarán los factores relacionados con la migración y el estrés, los predictores de la deserción, la alianza terapéutica y los cambios sesión por sesión en los síntomas relacionados con el trauma.Resultados y conclusiones: Las evidencias emergentes sugieren la idoneidad de la ImRs en el tratamiento de los refugiados con TEPT. Después de una evaluación positiva, este tratamiento corto y culturalmente adaptable puede contribuir a reducir la brecha de tratamiento para los refugiados en países de altos ingresos como Alemania.

[Diagnostics of posttraumatic stress disorder according to DSM-5 and ICD-11]. / Diagnostik der PTBS im Spannungsfeld von DSM-5 und ICD-11.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems (ICD-11, Version 2018) differ with respect to the diagnostic criteria of posttraumatic stress disorder (PTSD). The present study investigated the implications of these differences for the classification of PTSD within a sample of German survivors of various traumatic events. PATIENTS AND METHODS: A total of 341 trauma survivors who participated in a multicenter study were classified according to DSM-5 and ICD-11 and the results were compared. The PTSD checklist for DSM-5 (PCL-5) was used to diagnose PTSD. The ICD-11 PTSD cases were identified using a "restrictive" and a "wide" operationalization of re-experiencing symptoms (i. e. with and without intrusive memories). Depression and the level of trauma-related impairment were also assessed. RESULTS: The diagnosis rate using ICD-11 was significantly lower than under DSM-5 (DSM-5 64.5%, ICD-11 54.0%, p < 0.001) using a restrictive operationalization of re-experiencing symptoms but differences disappeared when using a wide operationalization. Rates of comorbidity with depression were reduced under ICD-11. Individuals with high and low levels of trauma-related impairment were equally likely to receive a PTSD diagnosis under ICD-11. DISCUSSION: Differences in the diagnosis rates between ICD-11 and DSM-5 depend on the operationalization of the specific ICD-11 re-experiencing requirements. Precise diagnostic guidelines are necessary to avoid inconsistent diagnoses.

Testing the ICD-11 proposal for complex PTSD in trauma-exposed adults: factor structure and symptom profiles.

Background: The proposed ICD-11 criteria for trauma-related disorders define posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (cPTSD) as separate disorders. Results of previous studies support the validity of this concept. However, due to limitations of existing studies (e.g. homogeneity of the samples), the present study aimed to test the construct validity and factor structure of cPTSD and its distinction from PTSD using a heterogeneous trauma-exposed sample. Method: Confirmatory factor analyses (CFAs) were conducted to explore the factor structure of the proposed ICD-11 cPTSD diagnosis in a sample of 341 trauma-exposed adults (n = 191 female, M = 37.42 years, SD = 12.04). In a next step, latent profile analyses (LPAs) were employed to evaluate predominant symptom profiles of cPTSD symptoms. Results: The results of the CFA showed that a six-factor structure (i.e. symptoms of intrusion, avoidance, hyperarousal and symptoms of affective dysregulation, negative self-concept, and interpersonal problems) fits the data best. According to LPA, a four-class solution optimally characterizes the data. Class 1 represents moderate PTSD and low symptoms in the specific cPTSD clusters (PTSD group, 30.4%). Class 2 showed low symptom severity in all six clusters (low symptoms group, 24.1%). Classes 3 and 4 both exhibited cPTSD symptoms but differed with respect to the symptom severity (Class 3: cPTSD, 34.9% and Class 4: severe cPTSD, 10.6%). Conclusions: The findings replicate previous studies supporting the proposed factor structure of cPTSD in ICD-11. Additionally, the results support the validity and usefulness of conceptualizing PTSD and cPTSD as discrete mental disorders.

Antecedentes: Los criterios propuestos por la CIE-11 para los trastornos relacionados con trauma, define el trastorno de estrés postraumático (TEPT) y el trastorno de estrés postraumático complejo (TEPTc) como dos trastornos separados. Los resultados de estudios previos apoyan la validez de este concepto. Sin embargo, debido a las limitaciones de los estudios existentes (ej. Homogeneidad de las muestras), el presente estudio tuvo como objetivo probar la validez de constructo y la estructura factorial del TEPTc y su distinción del TEPT utilizando una muestra heterogénea expuesta a trauma. Metodo: Se realizaron análisis de factores confirmatorios (AFCs) para explorar la estructura de los factores del diagnóstico propuesto de TEPTc por la CIE-11 en una muestra de 341 adultos expuestos al trauma (n = 191 mujeres, M = 37.42 años, SD = 12.04). En un siguiente paso, se emplearon análisis de perfil latente (APL) para evaluar los perfiles de síntomas predominantes de los síntomas de TEPTc. Resultados: Los resultados de la AFC mostraron que una estructura de seis factores (es decir, síntomas de intrusión, evitación, hiperalerta y síntomas de desregulación afectiva, autoconcepto negativo y problemas interpersonales) se ajusta mejor a los datos. Según los APL, una solución de cuatro clases caracteriza de manera óptima los datos. La clase 1 representa un trastorno de estrés postraumático moderado y síntomas bajos en los grupos de específicos de TEPTc (grupo de trastorno de estrés postraumático, 30.4%). La clase 2 mostró una baja gravedad de los síntomas en los seis conglomerados (grupo de síntomas bajos, 24.1%). Las clases 3 y 4 mostraron síntomas de TEPTc, pero difirieron con respecto a la gravedad de los síntomas (clase 3: TEPTc, 34.9% y clase 4: TEPTc grave, 10.6%). Conclusiones: Los hallazgos replican estudios previos que respaldan la estructura de factores propuesta del TEPTc en la CIE-11. Además, los resultados respaldan la validez y la utilidad de conceptualizar el TEPT y el TEPTc como trastornos mentales distintos.

Defining the index trauma in post-traumatic stress disorder patients with multiple trauma exposure: impact on severity scores and treatment effects of using worst single incident versus multiple traumatic events.

Background: A diagnosis of post-traumatic stress disorder (PTSD) requires the identification of one or more traumatic events, designated the index trauma, which serves as the basis for assessment of severity of PTSD. In patients who have experienced more than one traumatic event, severity may depend on the exact definition of the index trauma. Defining the index trauma as the worst single incident may result in PTSD severity scores that differ from what would be seen if the index trauma included multiple events. Objective: This study aimed to investigate the impact of the definition of the index trauma on PTSD baseline severity scores and treatment outcome. Method: A planned secondary analysis was performed on data from a subset (N = 58) of patients enrolled in a trial evaluating the efficacy of a 12 week residential dialectical behavioural therapy programme for PTSD related to childhood abuse (DBT-PTSD). Assessments of the severity of PTSD were conducted at admission, at the end of the 12 week treatment period, and at 6 and 12 weeks post-treatment, using the Clinician-Administered PTSD Scale. The index trauma was defined with respect to both the worst single incident and up to three qualitatively distinct traumatic events. Results: When the index trauma included multiple traumas, PTSD severity scores were significantly higher and improvements from pre- to post-treatment were significantly lower than when the index trauma was defined as the worst single incident. Conclusions: In patients with PTSD who have experienced multiple traumas, defining the index trauma as the worst single incident may miss some aspects of clinically relevant symptomatology, thereby leading to a possibly biased interpretation of treatment effects. In DBT-PTSD, treatment effects were lower when the index trauma included multiple traumatic events. More research is needed to determine the impact of the various index trauma definitions on the evaluation of other trauma-focused treatments.

Antecedentes: Para diagnosticar un trastorno de estrés postraumático (TEPT) se requiere la identificación de uno o más eventos traumáticos. La designación del trauma índice sirve para evaluar la severidad del TEPT. En pacientes que han experimentado más de un evento traumático, la severidad podría depender de la definición exacta que se le otorgue al trauma índice. Definir el trauma índice como el peor incidente podría resultar en puntajes de severidad diferentes a los obtenidos si el trauma índice incluyera o comprendiera eventos múltiples.Objetivo: Este estudio investiga el impacto de la definición del trauma índice sobre los puntajes de severidad basal de TEPT y los resultados del tratamiento.Método: Se realizó un análisis secundario planificado sobre los datos de una muestra (N = 58) de pacientes reclutados para un ensayo que evaluaba la eficacia de un programa residencial DBT-TEPT de 12 semanas para TEPT relacionado a abuso infantil. Se evaluó la severidad del TEPT usando la escala de TEPT Administrada por el clínico al inicio, al final del periodo de 12 semanas de tratamiento, y a las 6 y 12 semanas posteriores al tratamiento. El trauma índice se definió tanto para el peor incidente como para hasta tres eventos cualitativamente distintos.Resultados: Cuando el trauma índice incluye múltiples traumas, los puntajes de severidad de TEPT fueron significativamente más altos y la mejoría posterior al tratamiento fue significativamente más baja comparado a cuando el trauma índice era definido solamente con el peor incidente.Conclusiones: En pacientes con TEPT que han experimentado múltiples traumas, definir el trauma índice con el peor incidente puede pasar por alto algunos aspectos de la sintomatología clínicamente relevantes, conduciendo a posibles interpretaciones sesgadas de los efectos del tratamiento. En DBT-TEPT, los efectos del tratamiento fueron menores cuando el trauma índice incluyó eventos traumáticos múltiples. Se requiere mayor investigación para determinar el impacto de las diversas definiciones de trauma índice sobre la evaluación de resultados de otros tratamientos focalizados en trauma.

The German version of the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): psychometric properties and diagnostic utility.

BACKGROUND: The Posttraumatic Stress Disorder (PTSD) Checklist (PCL, now PCL-5) has recently been revised to reflect the new diagnostic criteria of the disorder. METHODS: A clinical sample of trauma-exposed individuals (N = 352) was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the PCL-5. Internal consistencies and test-retest reliability were computed. To investigate diagnostic accuracy, we calculated receiver operating curves. Confirmatory factor analyses (CFA) were performed to analyze the structural validity. RESULTS: Results showed high internal consistency (α = .95), high test-retest reliability (r = .91) and a high correlation with the total severity score of the CAPS-5, r = .77. In addition, the recommended cutoff of 33 on the PCL-5 showed high diagnostic accuracy when compared to the diagnosis established by the CAPS-5. CFAs comparing the DSM-5 model with alternative models (the three-factor solution, the dysphoria, anhedonia, externalizing behavior and hybrid model) to account for the structural validity of the PCL-5 remained inconclusive. CONCLUSIONS: Overall, the findings show that the German PCL-5 is a reliable instrument with good diagnostic accuracy. However, more research evaluating the underlying factor structure is needed.

Comparison of DSM-5 and proposed ICD-11 criteria for PTSD with DSM-IV and ICD-10: changes in PTSD prevalence in military personnel.

Background: Recently, changes have been introduced to the diagnostic criteria for posttraumatic stress disorder (PTSD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Objectives:This study investigated the effect of the diagnostic changes made from DSM-IV to DSM-5 and from ICD-10 to the proposed ICD-11. The concordance of provisional PTSD prevalence between the diagnostic criteria was examined in a convenience sample of 100 members of the German Armed Forces. Method: Based on questionnaire measurements, provisional PTSD prevalence was assessed according to DSM-IV, DSM-5, ICD-10, and proposed ICD-11 criteria. Consistency of the diagnostic status across the diagnostic systems was statistically evaluated. Results: Provisional PTSD prevalence was the same for DSM-IV and DSM-5 (both 56%) and comparable under DSM-5 versus ICD-11 proposal (48%). Agreement between DSM-IV and DSM-5, and between DSM-5 and the proposed ICD-11, was high (both p < .001). Provisional PTSD prevalence was significantly increased under ICD-11 proposal compared to ICD-10 (30%) which was mainly due to the deletion of the time criterion. Agreement between ICD-10 and the proposed ICD-11 was low (p = .014). Conclusion: This study provides preliminary evidence for a satisfactory concordance between provisional PTSD prevalence based on the diagnostic criteria for PTSD that are defined using DSM-IV, DSM-5, and proposed ICD-11. This supports the assumption of a set of PTSD core symptoms as suggested in the ICD-11 proposal, when at the same time a satisfactory concordance between ICD-11 proposal and DSM was given. The finding of increased provisional PTSD prevalence under ICD-11 proposal in contrast to ICD-10 can be of guidance for future epidemiological research on PTSD prevalence, especially concerning further investigations on the impact, appropriateness, and usefulness of the time criterion included in ICD-10 versus the consequences of its deletion as proposed for ICD-11.

Planteamiento. Recientemente, se han introducido cambios en los criterios diagnósticos para el trastorno por estrés postraumático (TEPT) según el Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM) y la Clasificación Internacional de Enfermedades (CIE).Objetivos. Este estudio investigó el efecto de los cambios diagnósticos realizados del DSM-IV al DSM-5 y de la CIE-10 a la propuesta de la CIE-11. La concordancia de la prevalencia provisional del TEPT entre los criterios diagnósticos se examinó en una muestra de conveniencia de 100 miembros de las Fuerzas Armadas alemanas. Método. Basándose en mediciones de cuestionarios, la prevalencia provisional del TEPT se evaluó de acuerdo con el DSM-IV, el DSM-5, la CIE-10 y los criterios propuestos por la CIE-11. Se evaluó estadísticamente la consistencia del estado diagnóstico en todos los sistemas de diagnóstico. Resultados. La prevalencia provisional del TEPT fue la misma para el DSM-IV y el  DSM-5 (56%), y comparable en DSM-5 frente a la propuesta de la CIE-11 (48%), y el grado de acuerdo entre el DSM-IV y el DSM-5 y entre el DSM-5 y la propuesta de la CIE-11 fue alto (ambos p <0,001). La prevalencia provisional del TEPT aumentó significativamente en la propuesta de la CIE-11 en comparación con la CIE-10 (30%), debido principalmente a la supresión del criterio de tiempo. El grado de acuerdo entre la CIE-10 y la propuesta de la CIE-11 fue bajo (p = 0,014). Conclusión. Este estudio proporciona evidencia preliminar de una concordancia satisfactoria entre la prevalencia provisional del TEPT basada en los criterios diagnósticos para el TEPT que se definen usando el DSM-IV, el DSM-5 y la propuesta de la CIE-11. Esto apoya que se asuman un conjunto de síntomas centrales del TEPT como se sugiere en la propuesta de la CIE-11, cuando al mismo tiempo se daba una concordancia satisfactoria entre la propuesta de la CIE-11 y el DSM. El hallazgo de un aumento de la prevalencia provisional de TEPT en la propuesta de la CIE-11 en contraste con la CIE-10 puede ser una guía para futuras investigaciones epidemiológicas sobre la prevalencia del TEPT, especialmente en relación con investigaciones adicionales sobre el impacto, la idoneidad y la utilidad del criterio de tiempo incluido en la CIE-10 frente a las consecuencias de su supresión, como se propone para la CIE-11.