Imaginal exposure exacerbation revisited: Deconstructing patient characteristics associated with worse reactions to the initiation of imaginal exposure in PTSD.

OBJECTIVE: This study examines whether imaginal exposure leads to symptom exacerbation, systematically comparing individuals who received prolonged exposure (PE) to those who received pharmacotherapy. The study also examined whether common clinical features increase the likelihood of symptom exacerbation. METHOD: In 151 men and women with PTSD, we examined rates of reliable exacerbation of PTSD and depression symptoms after initiation of imaginal exposure and compared it to those receiving sertraline. We also examined relationships between exacerbation, treatment outcome, dropout, imaginal distress, and specific clinical features, including co-occurring MDD, multiple co-occurring disorders, childhood sexual abuse as target trauma, and a history of childhood physical or sexual abuse. RESULTS: Symptom exacerbation was not more common in PE compared to sertraline, not associated with higher dropout, or predictive of worse outcome. Those with co-occurring depression or multiple disorders, a target trauma of child sexual abuse, or a history of child abuse reported functionally equivalent peak distress at onset of imaginal as those without these characteristics. These factors did not lead to more exacerbation or worse adherence. CONCLUSION: Exacerbation was not specific to PE and patients with and without symptom worsening showed comparable treatment gains, suggesting symptom exacerbation may reflect a common clinical process.

An Investigation of Depression, Trauma History, and Symptom Severity in Individuals Enrolled in a Treatment Trial for Chronic PTSD.

OBJECTIVE: To explore how factors such as major depressive disorder (MDD) and trauma history, including the presence of childhood abuse, influence diverse clinical outcomes such as severity and functioning in a sample with posttraumatic stress disorder (PTSD). METHOD: In this study, 200 men and women seeking treatment for chronic PTSD in a clinical trial were assessed for trauma history and MDD and compared on symptom severity, psychosocial functioning, dissociation, treatment history, and extent of diagnostic co-occurrence. RESULTS: Overall, childhood abuse did not consistently predict clinical severity. However, co-occurring MDD, and to a lesser extent a high level of trauma exposure, did predict greater severity, worse functioning, greater dissociation, more extensive treatment history, and additional co-occurring disorders. CONCLUSION: These findings suggest that presence of co-occurring depression may be a more critical marker of severity and impairment than history of childhood abuse or repeated trauma exposure. Furthermore, they emphasize the importance of assessing MDD and its effect on treatment seeking and treatment response for those with PTSD.

Trauma Narratives: It's What You Say, Not How You Say It.

Structural and content- related features of trauma narratives of traumatic events may help explain the development of PTSD. In a sample of 35 female assault survivors, we examined the association between the structure and content of trauma narratives and PTSD and other trauma-related reactions (i.e., depression, anxiety, anger, dissociation, and guilt). When controlling for recounting style and recounting distress, narrative structure was not strongly associated with PTSD or other trauma-related reactions. In contrast, the content of the trauma narratives (more positive and negative emotion words, higher cognitive process, and less self-focus being) was associated with lower symptomatology. Taken together, trauma narrative content rather than grammatical structure of the narrative may be more reflective of underlying emotional processing of the traumatic memory or lack thereof.

Individual differences in trauma disclosure.

BACKGROUND AND OBJECTIVES: Findings on disclosure and adjustment following traumatic events have been mixed. Better understanding of individual differences in disclosure may help us better understand reactions following trauma exposure. In particular, studying disclosure patterns for those with and without psychopathology and for different types of emotional experiences may help clarify the relationship between disclosure, event emotionality, trauma exposure, and PTSD. METHODS: In this study, 143 men and women with (n=67) and without (n=43) chronic PTSD and without trauma exposure (n=33) provided information on disclosure for a traumatic/severe life event, a negative event, and a positive event. RESULTS: Individuals with PTSD reported greater difficulty disclosing their traumatic event compared to those with trauma exposure no PTSD and those with no-trauma exposure. However, individuals with PTSD reported disclosing the traumatic event a similar number of times and with similar levels of detail to those with trauma exposure but no PTSD. Both sexual and childhood trauma were associated with greater disclosure difficulty. LIMITATIONS: Although control event types (positive, negative) were selected to control for the passage of time and for general disclosure style, they do not control for salience of the event and results may be limited by control events that were not highly salient. CONCLUSIONS: The present findings point to a dynamic conceptualization of disclosure, suggesting that the differential difficulty of disclosing traumatic events seen in individuals with PTSD is not simply a function of the amount of disclosure or the amount of details provided.

"Dwelling in the Past": The Role of Rumination in the Treatment of Posttraumatic Stress Disorder.

Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an "optimal dose" of exposure during treatment.

Factors Associated with Choice of Exposure Therapy for PTSD.

Exposure therapy, despite its demonstrated efficacy for chronic PTSD, remains underutilized across clinical settings. One suggested cause is that traumatized clients may not prefer exposure treatment. This paper reviews the current literature on factors associated with treatment preference for exposure therapy. Contrary to expectations, exposure-based therapy is not only perceived as a viable therapy but is well regarded among current therapy choices by potential clients. In particular, we highlight the central role of client beliefs about the need to talk about problems, the efficacy of treatment, and perceived need for help as crucial factors potentially impacting preference for exposure therapy. Importantly, fear of exposure treatment does not appear to play a significant role. To increase utilization, clinicians should provide clients information to address factors believed to increase preference for effective treatment.