Top PDF A comparison of PTSD and subthreshold PTSD symptom network structures

A comparison of PTSD and subthreshold PTSD symptom network structures

A comparison of PTSD and subthreshold PTSD symptom network structures

investigating if a structural model of DSM-IV PTSD fit data of a Mexican sample as well as it fit data of a U.S. sample. The authors found that the structure of DSM-IV PTSD applied equally to the two samples. However, when the authors controlled for the severity of trauma, the Mexican sample reported more intrusion and avoidance symptoms, and the U.S. sample reported more arousal symptoms. Nonetheless, the results support extending the DSM-IV conceptualization of PTSD to Mexican samples. Furthermore, a qualitative study that coded free-response answers given by Mexicans from Guadalajara, Jalisco; Homestead, Florida; and Puerto Angel, Oaxaca provides converging evidence that DSM- IV PTSD criteria accurately reflect the post-traumatic symptoms experienced by these participants (Norris et al., 2001b), replicating the findings of the first study. Taken together, the results provide a solid rationale for using measures of DSM-IV PTSD in Mexican samples to study the effects of PTSD and subPTSD in people from Latin American communities. To date, there have been no published studies investigating the PTSD symptom network structure in Latinos. However, doing so would generate hypotheses about potential causal associations between symptoms, as well as symptoms that are the most central in this population. The proposed advantage to uncovering central symptoms is that it elucidates symptoms that might be the most important on which to intervene.
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A cross-cultural comparison of ICD-11 Complex PTSD symptom networks in Austria, Lithuania, and UK

A cross-cultural comparison of ICD-11 Complex PTSD symptom networks in Austria, Lithuania, and UK

To our knowledge, no study thus far has used a network analytical approach to investigate the ICD-11 formulation of CPTSD. Knefel, Tran, and Lueger-Schuster (2016) used a network approach to investigate the comorbidity of ICD-11 CPTSD and borderline personality disorder in a sample of adult survivors of child maltreatment and found that “feelings of worthlessness” was the most central CPTSD symptom in the resulting network. Two studies that evaluated the network properties of PTSD as defined in the fifth edition of the Di- agnostic and Statistical Manual of Mental Disorders (DSM-5) found that “negative trauma related emotions” and “reactivity to cues” were among the most central symptoms in both net- works (Armour, Fried, Deserno, Tsai, & Pietrzak, 2017; Spiller et al., 2017). The network approach is still relatively new in the study of psychopathology, and it is not yet clear how robust the results from single data sets are and whether they will replicate and generalize to other samples (Epskamp, Borsboom, & Fried, 2017; Fried et al., 2018). For example, although “detachment” was among the most central symptoms in one of the aforemen- tioned studies (Armour et al., 2017), this was not the case in the other study, wherein “self-destructive or reckless behavior” was instead central (Spiller et al., 2017). Fried et al. (2018) addressed this issue and compared the network structures of PTSD as defined in the fourth edition of the DSM (DSM-IV) across four samples. The authors found good support for the replicability of network models. Therefore, we followed this approach and analyzed the network models of ICD-11 CPTSD in four different samples from four different countries: Austria, Lithuania, and the United Kingdom (Scotland and Wales). Our aims were to (a) investigate the network structure in four differ- ent samples using an estimation procedure that took similarities between the samples into account, (b) find central symptoms within the networks, (c) test the accuracy of these estimations, and (d) compare the networks across the four samples.
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A comparison of cognitive functioning, resilience, and childhood trauma among individuals with SAD and PTSD

A comparison of cognitive functioning, resilience, and childhood trauma among individuals with SAD and PTSD

As previously mentioned, the frontal lobes are responsible for the regulation of attention (Lezak, 2004). Attention entails the careful attendance to target stimuli while inhibition is associated with the recruitment of the executive attention network localized in the anterior cingulate cortex (ACC) (Lezak, 2004). Together with the cingulate cortex (CC), the PFC mediates the capacity to make and control shifts in attention (Lezak, 2004). The ACC maintains social mores and regulates fear related behaviour and selective attentional processing (Bush, Luu, & Posner, 2000). The PFC and the ACC have been shown to be co-active when new problems arise that need solving (Lezak, 2004). This co-activation lasts till the task is learned and is no longer present when the task becomes automatic (Lezak, 2004). The CC consists of numerous specialized subdivisions that subserve cognitive, motor, nociceptive and visuospatial functions (Bush et al., 2000). The ACC is regarded as ‘executive’ in function and can be differentiated from the posterior cingulate cortex (PCC) based upon its specific projection patterns and functions which are divided into specific areas that control emotional and cognitive information (Bush et al., 2000). The cognitive division of the ACC comes into action when cognitively demanding tasks that involve stimulus-response selection in the face of competing streams of information (Bush et al., 2000) are undertaken. This has been shown to be most effectively measured with the Stroop Task (Miyake et al., 2000) (the Stroop task is discussed in detail in the measurement section of Chapter 4).
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Victimization and PTSD in Ugandan Youth

Victimization and PTSD in Ugandan Youth

In order to facilitate a cross cultural comparison this study is a replica of studies carried out in European pop- ulations. Only 38.6% of males and 33.3% of females are enrolled in secondary education thus leaving out the vast majority of young Ugandans not enrolled in the school system. Because of language difficulties the data was gathered in three major cities, thus leaving out smaller cities and the large rural population. Despite the grade level, a compensatory, supportive data collection approach was applied. It would also be expected that cultural differences would make the list of 20 potentially traumatic events incomprehensive. There are wide- spread beliefs in witchcraft and possession by demonic powers in Uganda and exposure to these sorts of events could have been included in the list of potentially traumatic events. Indeed one of the subjects noted, in the comment section on the final page of the questionnaire that she believed to have been bewitched by her step- mother and as a consequence suffered from hallucinations at night.
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PTSD and Sleep

PTSD and Sleep

Neylan, T. C., Marmar, C. R., Metzler, T. J., Weiss, D. S., Zatzick, D. F., Delucchi, K. L., . . . Schoenfeld, F. B. (1998). Sleep disturbances in the Vietnam generation: Findings from a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry, 155, 929-933. doi:10.1176/ajp.155.7.929 Objective: This study analyzed questionnaire items that address complaints about sleep from the National Vietnam Veterans Readjustment Study, a nationally representative sample of the 3.1 million men and women who served in Vietnam. This study compared the frequency of nightmares and difficulties with sleep onset and sleep maintenance in male Vietnam theater veterans with male Vietnam era veteran and male civilian comparison subjects. It focused on the role of combat exposure, nonsleep posttraumatic stress disorder (PTSD) symptoms, comorbid psychiatric and medical disorder, and substance abuse in accounting for different domains of sleep disturbance. Method: The authors undertook an archival analysis of the National Vietnam Veterans Readjustment Study database using correlations and linear statistical models. Results: Frequent nightmares were found exclusively in subjects diagnosed with current PTSD at the time of the survey (15.0%). In the sample of veterans who served in Vietnam (N=1,167), combat exposure was strongly correlated with frequency of nightmares, moderately correlated with sleep onset insomnia, and weakly correlated with disrupted sleep maintenance. A hierarchical multiple regression analysis showed that in Vietnam theater veterans, 57% of the variance in the frequency of nightmares was accounted for by war zone exposure and non-sleep-related PTSD symptoms. Alcohol abuse, chronic medical illnesses, panic disorder, major depression, and mania did not predict the frequency of nightmares after control for nonsleep PTSD symptoms. Conclusions: Frequent nightmares appear to be virtually specific for PTSD. The nightmare is the domain of sleep disturbance most related to exposure to war zone traumatic stress. Pollack, M. H., Hoge, E. A., Worthington, J. J., Moshier, S. J., Wechsler, R. S., Brandes, M., & Simon, N. M. (2011). Eszopiclone for the treatment of posttraumatic stress disorder and associated insomnia: A randomized, double-blind, placebo-controlled trial. Journal of Clinical Psychiatry, 72, 892-897. doi:10.4088/JCP.09m05607gry Objective: The development of novel strategies for the treatment of posttraumatic stress disorder (PTSD) represents a critical public health need. We present the first prospective, randomized, double-blind, placebo-controlled trial of a non-benzodiazepine hypnotic agent for the treatment of PTSD and associated insomnia.
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Memory performance of war veterans with PTSD

Memory performance of war veterans with PTSD

12- Misra, R., Crist, M., & Burant, C. J. Relationships among life stress, social support, academic stressors, and reactions to stressors of international students in the United States. Intern J Stre manag, 2003, 10 (2): 137-157. 13- Misra, R., McKean, M., West, S., & Tony, R. Academic Stress of College Students: Comparison of Student and Faculty Perceptions. Colle Stud J, 2000, 34(2): 236-246.

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Vietnam Veterans and PTSD

Vietnam Veterans and PTSD

Air Force Health Study (AFHS). 2005. An epidemiologic investigation of health effects in Air Force personnel following exposure to herbicides: Comprehensive report. Science Application International Corporation: McLean, VA. Contract No. F41624–01-C-1012. SAIC Project No. 01-0813-04-2273. This report summarizes results from the AFHS 2002 follow-up physical examination. The AFHS was undertaken to determine whether adverse health effects attributable to exposure to herbicides existed in Veterans of Operation Ranch Hand. The men assigned to Operation Ranch Hand flew aerial herbicide spray missions in Vietnam from 1962 to 1971. A comparison cohort comprised Air Force Veterans who served in Southeast Asia during the same time period and who were not involved with spraying herbicides. A total of 1,951 Veterans participated in the 2002 physical examination 777 Ranch Hands & 1,174 Comparisons. Statistical analyses assessed differences between Ranch Hands & Comparisons & associations between health- related endpoints & extrapolated initial dioxin, dioxin category, and dioxin measured in 1987. The study has insufficient statistical power to assess increases in the risk of rare diseases. Consistent with past AFHS reports, current results indicate a significant & clinically meaningful adverse relation between type-2 diabetes & exposure to dioxin. Brooks, M.S., Laditka, S.B., & Laditka, J.N. (2008a). Long-term effects of military service on mental health among Veterans of the Vietnam war era. Military Medicine, 173, 570-575. doi:10.7205/ MILMED.173.6.570 Comparing outcomes of Veterans who served in Vietnam and those who served elsewhere, we examined treatment of PTSD, treatment of other mental health conditions, psychiatric treatment location, and six mental health well-being measures. The analytic sample consisted of nationally representative data from the 2001 NSV. Analyses included multivariate logistic regression that controlled for sociodemographic characteristics. Of Vietnam War-era Veterans in the NSV (N = 7,914), 3,937 served in Vietnam and 3,977 served elsewhere. These Veterans were stratified into < 60 years of age (n = 6,141) and > or = 60 years of age (n = 1,766). Veterans who served in Vietnam had notably poorer mental health than did those who served elsewhere. There were striking mental health differences between younger and older Veterans; younger Veterans had substantially worse measures of mental health. These results suggest greater resource needs among younger Vietnam War Veterans. Clinicians and the VA should focus on mental health services for younger Veterans. Goldberg, J., Magruder, K.M., Forsberg, C.W., Friedman, M.J., Litz, B.T., Vaccarino, V., . . . Smith, N.L. (in press). Prevalence of
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Reactivity and Recovery Among OIF/OEF/OND Combat Veterans: Do Those with Subthreshold PTSD Differ From Veterans with and without PTSD?

Reactivity and Recovery Among OIF/OEF/OND Combat Veterans: Do Those with Subthreshold PTSD Differ From Veterans with and without PTSD?

In the current study, Veterans with PTSD exhibited less recovery than Veterans without PTSD and – after parsing out the subthreshold PTSD group from the No PTSD group -those with subthreshold PTSD. There were no significant differences noted in recovery observed for the comparison of PTSD-S and PTSD-. Our findings are expected and congruent with current research reporting delayed recovery among those with PTSD (Norte et al 2013; Sack, 2004; Yehuda 2007; Pole, 2007). While adaptive in the short-term, chronic over-activation of either axes results in the inability to recovery to a homeostatic state, resulting in long-term activation of the stress response even after acute threats have passed or subsided (Carlson & Chamberlain; 2005; Goertzel, et al., 2006; Korte, Koolhaas, Wingfield, & McEwen, 2005; Lupien et al., 2006). Thus, the physiological mechanisms underlying the two processes of reactivity and recovery should be assessed so as to provide greater insight into the cardiovascular mechanisms underlying the stress response than either measure alone.
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PTSD symptomics: network analyses in the field of psychotraumatology

PTSD symptomics: network analyses in the field of psychotraumatology

connections among items in the network, or the central- ity estimates), precluding reliable generalizations. Studies with larger samples, on the other hand, often feature general population samples that may not be too infor- mative about the processes in patients. A potential way forward is the analysis of large clinical datasets (e.g. Fried, Eidhof et al., 2017). Second, it is crucial that researchers start focusing on the assessment and analysis of dynamic, temporal data (Bringmann et al., 2016 ; Epskamp et al., 2017; Hamaker & Wichers, 2017). This allows the field to move from modelling cross-sectional group-level data to modelling the temporal dynamics of causal systems across time, and might bring us closer to developing novel recommendations for intervention or prevention strategies (Bos et al., 2017). Third, more attention to modelling the dynamics of causal systems also allows a renewed focus on personalized medicine, seeing that time-series network models are not limited to modelling the symptom dynamics of groups of patients, but can also be used to obtain idiographic network structures for individual patients (Epskamp, van Borkulo et al., 2017; Fisher & Boswell, 2016; Kroeze et al., 2017). Fourth, there is evidence that biological markers are differentially related to specific psychopathology symptoms (e.g. inflammatory markers and depression symptoms; Jokela, Virtanen, & Batty, 2016). Including (neuro-) bio- logical measures associated with PTSD and its comorbid disorders in network analyses might move the field beyond ‘symptomics’ and help us better understand the complex relationships between neurobiological altera- tions (over time) and the development of trauma related psychopathology (Olff & van Zuiden, 2017). This is con- sistent with recent calls to include variables beyond symptoms in psychopathology network models (Fried & Cramer, 2017; Jones, Heeran, & McNally, 2017).
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Evaluating the stability of DSM-5 PTSD symptom network structure in a national sample of U.S. military veterans

Evaluating the stability of DSM-5 PTSD symptom network structure in a national sample of U.S. military veterans

stability of PTSD symptoms in the broader population of trauma-af- fected veterans. Given the dimensional nature of PTSD (Armour et al., 2016), this can be considered a particular strength. At the same time, future studies are required to investigate network stability in clinical PTSD samples. Second, our sample was comprised predominantly of older white male veterans. Further research is needed to evaluate whether networks replicate across more diverse populations (Fried and Cramer, 2017). Third, we relied on self-report data of the 20 DSM-5 criterion symptoms for PTSD and not structured clinical interviews. It should be noted that the DSM-IV version of the PCL demonstrated moderate-to-high concordance rates with structured diagnostic inter- views for PTSD in previous analyses (Hopwood et al., 2008; Harrington and Newman, 2007); further work is needed to assess the extent to which this is the case for DSM-5-based instruments. Fourth, the nature of index traumas used in the current study was heterogeneous. This may be an advantage because fi ndings can be considered representative of the broader population of trauma-affected individuals and the traumas to which they have been exposed. At the same time, future work may complement this approach. Given that trauma exposure may be linked to differential expression of PTSD symptoms (Armour and Shevlin, 2013; Kelley et al., 2009), it may prove useful to compare PTSD symptom networks in populations that di ff er in index trauma. In rela- tion to that, it should be noted that previous research has shown that PTSD symptom levels around 2–4 weeks after exposure predict symptom development better than levels directly after exposure (Ehlers and Clark, 2003). Stability of PTSD symptom network structures may thus be investigated with the first symptom assessment taking place during this acute time window. Fifth, given that we analyzed data from the entire sample of trauma-exposed veterans, results do not provide information about individual variability in response to trauma, which may be characterized by chronic, recovering, resilient, and delayed symptom courses (e.g., Bonanno and Mancini, 2008); further long- itudinal research using larger samples is needed to assess how PTSD symptom network structures may change as a function of common PTSD symptom trajectories.
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A research programme to evaluate DBT-PTSD, a modular treatment approach for Complex PTSD after childhood abuse

A research programme to evaluate DBT-PTSD, a modular treatment approach for Complex PTSD after childhood abuse

meta-cognitive and meta-emotional awareness, which en- ables them to process these automatic thoughts and emo- tional patterns from a more distanced perspective, learn to control the emotion driven action tendencies and re- place them by functional behaviour. Acceptance and com- mitment therapy [62] provides valuable interventions here. Furthermore, this treatment consists of many helpful interventions for the recognition and implementation of values and therewith the improvement of the quality of life. Precisely because the self-concept is often character- ized by trauma-related emotions such as shame or guilt, disgust and self-hate, many patients have significant diffi- culties dealing with themselves in a sympathetic and self-valuing manner – which is also frequently reflected in problems relating to interpersonal issues. In addition to the DBT-concept of teaching self-validation, in compassion-focused therapy [63], these difficulties are ad- dressed through the training of a compassionate perspec- tive towards oneself and other people. Here, compassion is defined as sensitivity towards one’s own suffering and that of other persons with a deep commitment to mitigate the suffering, and this thereby encompasses both an em- pathic, attentive and a purposeful, powerful component. All of these sources of DBT-PTSD are, in turn, anchored in the principles of mindfulness. Because many trauma- tized patients experience longer mindfulness meditations as unpleasant and encumbering at least at the beginning of the treatment, skills-based mindfulness is facilitated in DBT-PTSD. In this, the psychological active principles of mindfulness are portioned into individual skills suitable to a daily routine and shorter mindfulness exercises without relying on formal meditation as a necessary experience.
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Evaluating patterns and predictors of symptom change during a three week intensive outpatient treatment for veterans with PTSD

Evaluating patterns and predictors of symptom change during a three week intensive outpatient treatment for veterans with PTSD

In addition to these primary intervention components, several secondary intervention components were offered during the three-week IOP program. IOP participants attended experiential and didactic sessions on healthy living that focused on nutrition and physical activity. They also participated in art therapy and groups with a chaplain that focused on making meaning from military service. Psychoeducation sessions focused on common challenges in service members with PTSD such as sleep, pain, relationships, and cognitive health. IOP partici- pants had the option to do up to 6 sessions of acupunc- ture, meet with a psychiatrist or nurse practitioner for medication management, and meet with a VA Liaison for case management services to assist with continuity of care upon discharge. They were also offered referrals for neuropsychological assessment in cases of suspected traumatic brain injury. Case management services were provided to address legal, financial, or other psychosocial needs. IOP participants attended planned weekend social outings in the city both for enjoyment and as opportun- ities to practice newly acquired skills (e.g., sports events, city tours). Psychoeducation sessions were offered to family members during the third week of the program in-person or via telehealth. Finally, outreach coordina- tors worked with participants routinely to ensure that veterans were connected to appropriate aftercare re- sources (e.g., psychotherapy, pharmacotherapy, voca- tional services, meditation groups, yoga classes).
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TREATMENT OF PTSD AND SUBSTANCE ABUSE COMORBIDITY

TREATMENT OF PTSD AND SUBSTANCE ABUSE COMORBIDITY

Estimates indicate that the prevalence rates of PTSD and cocaine dependence are high. Studies suggest that approximately 45% of cocaine-dependent individuals will meet criteria of PTSD (8% PTSD individuals (Calhoun et al., 2000)) at some point during their lifetime. Furthermore, 24% of cocaine- dependent individuals will meet criteria for current PTSD (Back, Dansky, Carroll, Foa, & Brady, 2001). In general, cocaine and opiate users report higher rates of exposure to traumatic events when compared to abusers of other groups of substances. Additionally, cocaine users appear more vulnerable to developing PTSD after exposure to a trauma, as well as experience more severe symptoms of PTSD and increased levels of social impairment (Back et al., 2001). PTSD and cocaine dependence appear to be related through the second pathway (Stewart et al., 1999). The effects of cocaine serve to intensify PTSD symptoms, especially while one is withdrawing from cocaine. As a result, any attempts to reduce cocaine use serve to induce both symptoms of cocaine withdrawal and a concurrent increase in distress associated with trauma symptoms (Back et al., 2001).
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Disclosure: A brief history of PTSD:

Disclosure: A brief history of PTSD:

Disclosure: I present the following opinions in the context of my experience as a psychiatrist who provides both treating assessments and care for my patients and non-treating assessments and reports for examinees at the request of third-parties. I have cared for patients since I became a psychiatrist in 2003; I have performed at least 500 non-treating assessments since I started keeping track of my non-treating statistics in 2011. As of 2015, I have accepted medicolegal referrals at a rate of approximately 60% defence and 40% plaintiff files. With respect to Post Traumatic Stress Disorder (PTSD), I have assessed both patients and examinees who have developed PTSD from a range of traumas, including sexual assault, catastrophic collisions, catastrophic non-collision accidents, workplace accidents in the oil patch and animal assault. I have assessed examinees who believed they sustained PTSD, but actually did not. I have treated patients with PTSD. I have collaborated with psychologists in the treatment of PTSD. My experience as a psychiatrist has caused me to conclude that PTSD is a serious but usually treatable mental disorder. Due to the controversies associated with the diagnosis and treatment of PTSD, I try to align my clinical opinions as closely as possible to the peer reviewed scientific data published by the academic researchers whose job it is to study PTSD.
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Personal wellbeing in posttraumatic stress disorder (PTSD): association with PTSD symptoms during and following treatment

Personal wellbeing in posttraumatic stress disorder (PTSD): association with PTSD symptoms during and following treatment

Third, our results also suggest that improved perceived personal wellbeing is associated with older age, and im- provements in PTSD and depressive symptoms. This is consistent with findings regarding the similar construct of quality of life [26]. Given that both depression and PTSD are thought to be characterised in part by dis- torted cognitions about the self, the world and the future [27, 28], it is not surprising that improvement in depres- sion and PTSD symptoms might be associated with changes in perceived personal wellbeing. For instance, depressed individuals have been demonstrated to hold a pervasive and general negative outlook with a tendency to attribute negative events to stable, internal and global factors [29] which could conceivably influence their rat- ings of personal wellbeing.
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Neuroimaging in PTSD-related psychotherapies

Neuroimaging in PTSD-related psychotherapies

Symptom provocation paradigms are an extremely useful and powerful way of delineating the functional anatomy of the traumatic memory that characterizes PTSD. Changes in local activations in response to specific tasks point to neural processing dysfunctions. In this respect, autobiographical trauma-script exposure (Pavic et al. 2003 ; Lindauer et al. 2004 ; Pagani et al. 2005 ) or audio and visual trauma-related stimuli (Liberzon et al. 1999 ; Zubieta et al. 1999 ) proved to be a valid approach to elicit cerebral blood flow (CBF) changes in PTSD, and improved technical and methodological features have made neuroimaging studies particu- larly suitable in in vivo investigations into the neurobiology of emotions. It is worth noting that since the neutral script administered to the patient is experienced as a new procedure, stress levels can rise and/or attention levels can be below nor- mal levels and, finally, that the resting state may differ from one investigation to the next. To some extent, the above factors are responsible for inconsistency across PTSD research results.
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HOWARD s PTSD TECHNIQUE

HOWARD s PTSD TECHNIQUE

Post-Traumatic Stress Disorder (PTSD) can be one of the toughest conditions to treat successfully. The United States Military is now using Acupuncture including Auricular Therapy to address pain and PTSD. As an acupuncturist and a disabled vet, this has opened my eyes to some of the possible causes and triggers of PTSD. My clinical knowledge along with my 6 years of active duty have shown me the possibly of successfully using Auricular Therapy to treat Wounded Warriors with PTSD.

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Treating Sleep Problems in PTSD and TBI

Treating Sleep Problems in PTSD and TBI

prazosin for nightmares with PTSD that I started using it for vets with mTBI/PTSD complex with great success. I have also been lobbying for more extensive use in VA…. I am writing to let you know that prazosin will be included in the VA/DoD treatment guidelines for mTBI

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Psychosis, Catatonia and Post-psychosis PTSD

Psychosis, Catatonia and Post-psychosis PTSD

Thus, she presented at least four conditions (recent trauma, psychosis, paranoia, catatonia) that rendered her to be at significant risk for post- psychotic PTSD. The mechanisms underlying her nightmares and post-psychotic PTSD may have been triggered by the catecholamine overdrive associated with psychosis, a phenomenon previously described in critically ill individuals [13,14]. She did not meet full criteria for PTSD (re-experiencing, avoidance, hyperarousal, negative alteration of cognition), but she exhibited characteristics of PTSD. Given
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An exploration of shame in PTSD treatment and psychosis

An exploration of shame in PTSD treatment and psychosis

40 Centred Therapy (CCT). They found that children who received TF-CBT significantly improved more than those who received CCT for PTSD as measured on the re- experiencing, avoidance and hypervigilance scales of the Kiddie-Sads-Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1996) and shame as measured on The Shame Questionnaire (Shame; Feiring, Taska & Lewis, 1999). The effect sizes were small for all of the above measures apart from avoidance (d = 0.70) which was medium (Cohen, 1992). Deblinger, Mannarino, Cohen and Steer (2006) followed up the participants and re-administered the outcome measures at six and twelve months and showed that the treatment gains had been maintained. Additionally Deblinger, Mannarino, Cohen, Runyon and Steer (2011) also showed children with PTSD with a history of sexual abuse, completing either TF-CBT with or without Trauma Narrative significantly improved in relation to their levels of shame and PTSD symptoms. They did not find a significant difference when comparing the treatments and there were comparable large effect sizes. Mannarino, Cohen, Deblinger, Runyon and Steer (2012) continued this study by re-administering outcome measures at six and twelve months and found that the treatment gains had been maintained.
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