A randomized controlled trial of Deep Brain Reorienting: a neuroscientifically guided treatment for post-traumatic stress disorder.

BACKGROUND: Advanced neuroscientific insights surrounding post-traumatic stress disorder (PTSD) and its associated symptomatology should beget psychotherapeutic treatments that integrate these insights into practice. Deep Brain Reorienting (DBR) is a neuroscientifically-guided psychotherapeutic intervention that targets the brainstem-level neurophysiological sequence that transpired during a traumatic event. Given that contemporary treatments have non-response rates of up to 50% and high drop-out rates of >18%, DBR is investigated as a putative candidate for effective treatment of some individuals with PTSD. OBJECTIVE: To conduct an interim evaluation of the effectiveness of an eight-session clinical trial of videoconference-based DBR versus waitlist (WL) control for individuals with PTSD. METHOD: Fifty-four individuals with PTSD were randomly assigned to DBR (N = 29) or WL (N = 25). At baseline, post-treatment, and three-month follow-up, participants' PTSD symptom severity was assessed using the Clinician Administered PTSD Scale (CAPS-5). This is an interim analysis of a clinical trial registered with the U. S. National Institute of Health (NCT04317820). RESULTS: Significant between-group differences in CAPS-total and all subscale scores (re-experiencing, avoidance, negative alterations in cognitions/mood, alterations in arousal/reactivity) were found at post-treatment (CAPS-total: Cohen's d = 1.17) and 3-month-follow-up (3MFU) (CAPS-total: Cohen's d = 1.18). Significant decreases in CAPS-total and all subscale scores were observed within the DBR group pre - to post-treatment (36.6% CAPS-total reduction) and pre-treatment to 3MFU (48.6% CAPS-total reduction), whereas no significant decreases occurred in the WL group. After DBR, 48.3% at post-treatment and 52.0% at 3MFU no longer met PTSD criteria. Attrition was minimal with one participant not completing treatment; eight participants were lost to 3MFU. CONCLUSIONS: These findings provide emerging evidence for the effectiveness of DBR as a well-tolerated treatment that is based on theoretical advances highlighting alterations to subcortical mechanisms in PTSD and associated symptomatology. Additional research utilizing larger sample sizes, neuroimaging data, and comparisons or adjacencies with other psychotherapeutic approaches is warranted.Trial registration: ClinicalTrials.gov identifier: NCT04317820..

First study to evaluate the effects of Deep Brain Reorienting (DBR) therapy on PTSD symptoms.Eight internet-based DBR sessions resulted in significant decreases in PTSD symptoms post-treatment and at 3-month follow-up in comparison to a waitlist group.Large effect sizes and a low drop-out rate suggest that DBR may be an effective, well-tolerated neuroscientifically guided treatment for PTSD.

Shame as an evolved basic affect - Approaches to it within the Comprehensive Resource Model (CRM).

Shame is an evolved emotional response which requires relational evaluation at a prefrontal cortical level but which has the visceral sensation and defence response impulse of a basic affect. We argue that the severe forms of shame, those residual from traumatic interpersonal experiences, have midbrain and diencephalic components mediating experiences of painful withdrawal while anhedonia is derived from a negatively valenced state of the mesolimbic dopamine system. This specific form of separation distress, with a characteristic sense of exclusion and unworthiness, benefits in treatment from the presence of attachment resources which allow secure access to the core distress. We discuss the use of the Comprehensive Resource Model (CRM) in the psychotherapy of post-traumatic states in which shame is prominent.

Identifying patients with complex PTSD.

While the common perception of post-traumatic stress disorder (PTSD) is of an individual suffering from a single traumatic event, clinicians need to be aware of those people who have been exposed to multiple potentially traumatic events. Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role; thus the trauma incorporates a betrayal of trust. Disclosure can be a problem particularly with complex trauma such as sexual abuse or domestic violence, and is often incremental as trust with the clinician is formed. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Recognition of the neurobiological insults imposed by complex trauma and the implications for psychotherapeutic interventions.

Considerable research has been conducted on particular approaches to the psychotherapy of post-traumatic stress disorder (PTSD). However, the evidence indicates that modalities tested in randomised controlled trials (RCTs) are far from 100% applicable and effective and the RCT model itself is inadequate for evaluating treatments of conditions with complex presentations and frequently multiple comorbidities. Evidence at levels 2 and 3 cannot be ignored. Expert-led interventions consistent with the emerging understanding of affective neuroscience are needed and not the unthinking application of a dominant therapeutic paradigm with evidence for PTSD but not complex PTSD. The over-optimistic claims for the effectiveness of cognitive-behavioural therapy (CBT) and misrepresentation of other approaches do not best serve a group of patients greatly in need of help; excluding individuals with such disorders as untreatable or treatment-resistant when viable alternatives exist is not acceptable.

Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective.

Evidence of efficacy in studies of post-traumatic conditions is largely derived from studies in which variables are kept to a minimum. Extrapolation of treatments from uncomplicated disorders to complex conditions may therefore be called evidence-based without being evidenced. Complex conditions with polysymptomatic presentations and extensive comorbidity are being denied proper evaluation, and patients most severely traumatised from the early stages of their development are not provided with rigorously evaluated psychotherapies because they are more difficult to study in the manner approved by research protocols. Such evidence as there is suggests that the simple extension of treatments for uncomplicated disorders is seriously inadequate. This has significant implications for health services responsible for the provision of the most efficacious treatments to those whose disorders arise from severe trauma, often very early in their life.