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Long-term outcomes of trauma-focused treatment in psychosis

Published online by Cambridge University Press:  07 February 2018

David van den Berg ,
Paul A. J. M. de Bont ,
Berber M. van der Vleugel ,
Carlijn de Roos ,
Ad de Jongh ,
Agnes van Minnen  and
Mark van der Gaag
David van den Berg*
Affiliation:
Parnassia Psychiatric Institute, Den Haag, The Netherlands
Paul A. J. M. de Bont
Affiliation:
Mental Health Organization (MHO) GGZ Oost Brabant, The Netherlands
Berber M. van der Vleugel
Affiliation:
Community Mental Health Service GGZ, Noord-Holland Noord
Carlijn de Roos
Affiliation:
MHO Rivierduinen, The Netherlands
Ad de Jongh
Affiliation:
Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, and School of Health Sciences, Salford University, Manchester, UK
Agnes van Minnen
Affiliation:
Radboud University Nijmegen, Behavioural Science Institute, NijCare, The Netherlands, and PSYTREC Psychotrauma Expertise Center, Bilthoven, The Netherlands
Mark van der Gaag
Affiliation:
VU University Amsterdam and EMGO Institute for Health and Care Research, Department of Clinical Psychology, and Parnassia Psychiatric Institute, Den Haag, The Netherlands
*
Correspondence: David van den Berg, Parnassia Psychiatric Institute, Research and Innovation department, Zoutkeetsingel 40, 2512HN The Hague, The Netherlands. Email: d.vandenberg@parnassia.nl
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Summary

We present 12-month follow-up results for a randomised controlled trial of prolonged exposure and eye movement desensitisation and reprocessing (EMDR) therapy in 85 (78.8%) participants with psychotic disorder and comorbid post-traumatic stress disorder (PTSD). Positive effects on clinician-rated PTSD, self-rated PTSD, depression, paranoid-referential thinking and remission from schizophrenia were maintained up to 12-month follow-up. Negative post-traumatic cognitions declined in prolonged exposure and were stable in EMDR. A significant decline in social functioning was found, whereas reductions in interference of PTSD symptoms with social functioning were maintained. These results support that current PTSD guidelines apply to individuals with psychosis.

Declaration of interest

M.v.d.G. and D.v.d.B. receive income for published books on psychotic disorders and for the training of postdoctoral professionals in the treatment of psychotic disorders. A.d.J. receives income for published books on EMDR therapy and for the training of postdoctoral professionals in this method. A.v.M. receives income for published book chapters on PTSD and for the training of postdoctoral professionals in prolonged exposure. C.d.R. receives income for the training of postdoctoral professionals in EMDR therapy.

Type
Short report
Information
The British Journal of Psychiatry , Volume 212 , Issue 3 , March 2018 , pp. 180 - 182
Copyright
Copyright © The Royal College of Psychiatrists 2018 

The importance of both trauma and post-traumatic stress disorder (PTSD) in psychosis are increasingly acknowledged. The available data suggest that trauma-focused treatments (TFTs) with direct trauma memory processing are particularly effective in reducing PTSD symptoms in patients with psychosis.Reference Sin and Spain 1 – Reference Brand, McEnery, Rossell, Bendall and Thomas 3 A large randomised controlled trial (RCT) found TFT to be effective and safe in patients with both psychosis and PTSD.Reference van den Berg, de Bont, van der Vleugel, de Roos, de Jongh and Van Minnen 4 , Reference van den Berg, de Bont, van der Vleugel, de Roos, de Jongh and van Minnen 5 Furthermore, TFT had neutral to positive effects on symptoms of psychosis, depression and social functioning.Reference de Bont, van den Berg, van der Vleugel, de Roos, de Jongh and van der Gaag 6 In this RCT, two different TFTs, prolonged exposure therapy and eye movement desensitisation and reprocessing therapy (EMDR), were compared with waiting list for TFT at baseline, post-treatment, and at 6-month follow-up. Compared with the waiting list for TFT, both prolonged exposure and EMDR significantly decreased clinician-rated PTSD symptoms, self-rated PTSD symptoms, negative post-traumatic cognitions and paranoid-referential thinking. In both TFT conditions, significantly more participants achieved remission from schizophrenia. Only prolonged exposure was found to significantly reduce the severity of depression symptoms. In comparison to the waiting list for TFT, there were no significant effects for prolonged exposure and EMDR on social functioning and voice hearing. Effects observed at post-treatment were generally maintained until 6-month follow-up. In this short report, we present the 12-month follow-up outcomes for prolonged exposure and EMDR on PTSD, depression, social functioning and psychosis.

Method

In this single-blind RCT with three arms, participants (n = 155) that met both criteria for a lifetime psychotic disorder (61.3% schizophrenia and 29.0% schizoaffective disorder) and full criteria for PTSD received eight sessions of TFT (i.e. prolonged exposure or EMDR), or remained on the waiting list for TFT. All participants received treatment-as-usual for psychosis. Participants in the waiting list condition received their TFT of choice after the 6-month follow-up assessment, since we considered it unethical to withhold treatment for longer than 6 months. The prolonged exposure and EMDR groups were also assessed at 12-month follow-up. This trial was set up in accordance with the Consolidated Standards of Reporting Trials guidelines and received ethical approval from the medical ethics committee of the VU University Medical Center in Amsterdam and was registered at isrctn.com (ISRCTN79584912). See van den Berg et al Reference van den Berg, de Bont, van der Vleugel, de Roos, de Jongh and Van Minnen 4 and de Bont et al Reference de Bont, van den Berg, van der Vleugel, de Roos, Mulder and Becker 7 for full details of the trial. At 12-month follow-up, 43 (81.1%) participants in the prolonged exposure condition and 42 (76.4%) participants in the EMDR condition completed all assessments and were included in the analyses.

For this report, we compared the 12-month follow-up outcomes for prolonged exposure and EMDR with 6-month outcomes to test whether the effects endured in the long term. We also tested whether there were significant differences between prolonged exposure and EMDR at 12-month follow-up. Continuous outcomes (severity of clinician-rated PTSD,Reference Blake, Weathers, Nagy, Kaloupek, Gusman and Charney 8 self-rated PTSD,Reference Foa, Riggs, Dancu and Rothbaum 9 negative post-traumatic cognitions,Reference Foa, Ehlers, Clark, Tolin and Orsillo 10 depression,Reference Beck, Steer and Brown 11 social functioningReference Morosini, Magliano, Brambilla, Ugolini and Pioli 12 and paranoid thinkingReference Green, Freeman, Kuipers, Bebbington, Fowler and Dunn 13 ) were analysed with paired sample t-tests (changes between the 6-month and 12-month follow-up) and independent sample t-tests (differences between prolonged exposure and EMDR at 12-month follow-up). Total scores for voice hearing (Auditory Hallucinations Rating Scale) and delusions (Delusions Rating Scale; DRS) on the Psychotic Symptom Rating Scales (PSYRATS)Reference Haddock, McCarron, Tarrier and Faragher 14 were not normally distributed because of an excess of zero scores (i.e. participants without active voices or delusions at a certain time point) and were analysed with the Wilcoxon signed-rank test and the Mann-Whitney U-test. Remission from schizophrenia status (dichotomous) on the Structured Clinical Interview for Symptoms of Remission,Reference Andreasen, Carpenter, Kane, Lasser, Marder and Weinberger 15 was analysed with McNemar's test and χ2 test for independence. All analyses were repeated with last-observation-carried-forward (LOCF) as sensitivity analysis. Scientists have to balance the decision of whether to adjust for multiple testing (to reduce the chance of type 1 errors, but at the expense of increasing the chance of type 2 errors) on the specific context and research question (e.g. see work by RothmannReference Rothman 16 ). In this study, we primarily wanted to test whether treatment effects endured in the long term, an effect that is generally observed in RCTs testing prolonged exposure or EMDR. In this context, we believe type 2 errors are more undesirable than type 1 errors, and therefore did not adjust for multiple testing.

Results

Supplementary Fig. 1 (available at https://doi.org/10.1192/bjp.2017.30) presents the mean observed scores. There were no significant changes in severity of clinician-rated PTSD symptoms in prolonged exposure (t[42] = 0.59, P = 0.559) or EMDR (t[38] = 0.38, P = 0.707) between the 6-month and 12-month follow-up, or in self-rated PTSD symptoms (prolonged exposure: t[43] = −0.66, P = 0.514; EMDR: t[38] = −0.15, P = 0.879). There were significant further reductions in severity of post-traumatic cognitions in prolonged exposure between the 6-month and 12-month follow-up (t[41] = 2.14, P = 0.038), but not in EMDR (t[38] = 0.36, P = 0.722). No changes in depression symptoms were observed in prolonged exposure (t[41] = 0.40, P = 0.689) or EMDR (t[38] = 1.26, P = 0.217). There was a significant decrease in level of social functioning in both PE (t[41] = 4.31, p < 0.001) and EMDR (t[38] = 2.08, P = 0.044) between the 6-month and 12-month follow-up. There were no significant changes in severity of paranoid thinking in prolonged exposure (t[41] = −1.22, P = 0.231) or EMDR (t[38] = 1.35, P = 0.184). For all participants, there were no changes in the Auditory Hallucinations Rating Scale total score in prolonged exposure (z = −1.81, P = 0.071) or EMDR (z = −0.54, P = 0.586), or in delusions on the DRS between the 6-month and 12-month follow-up (prolonged exposure: z = −1.06, P = 0.287; EMDR: z = −0.26, P = 0.794). Also, no changes were found in the number of participants in remission from schizophrenia in prolonged exposure (P = 0.388) or EMDR (P = 0.999).

Analyses for differences between prolonged exposure and EMDR at 12-month follow-up yielded no significant results for any of the outcome variables. The outcomes of the LOCF sensitivity analyses were similar to the original results; the only difference was that, in the LOCF analyses, there was a significant decrease in the DRS total score in both prolonged exposure (z = −3.36, P = 0.001) and EMDR (z = −2.43, P = 0.015).

Discussion

Prolonged exposure and EMDR were previously found to be effective, safe and feasible in patients with psychosis and comorbid PTSD without the use of stabilising psychotherapeutic interventions.Reference van den Berg, de Bont, van der Vleugel, de Roos, de Jongh and Van Minnen 4 – Reference de Bont, van den Berg, van der Vleugel, de Roos, de Jongh and van der Gaag 6 The present study shows that these effects remained at 12-month follow-up. More specifically, there were no differences between the 6-month and 12-month follow-up in clinician-rated PTSD, self-rated PTSD, depression, paranoid-referential thinking, voice hearing, delusions or the number of participants in remission from schizophrenia. Negative post-traumatic cognitions declined further in prolonged exposure, but not in EMDR. At 12-month follow-up, there were no differences between prolonged exposure and EMDR on any of the outcomes. Although replication of our findings is necessary, these results appear to suggest that TFT with direct trauma memory processing has long-term neutral to positive effects on symptoms of PTSD, depression and psychosis.

It is difficult to interpret the observed decline in social functioning in the context of clear improvements in symptoms. This is in contrast to the fact that the presence of PTSD symptoms in psychosis has been found to be associated with lower levels of social functioning.Reference Seow, Ong, Mahesh, Sagayadevan, Shafie and Chong 17 Interestingly, there were significant reductions in interference of PTSD symptoms with social functioning from baseline to 6-month follow-up on the Clinician-Administered PTSD Scale (items 20–22) compared with the waiting list for TFT in both prolonged exposure (t[136] = −2.73, P = 0.007) and EMDR (t[136] = −3.50, P = 0.001); moreover, these effects endured throughout the 12-month follow-up (prolonged exposure: t[42] = 1.39, P = 0.170; EMDR: t[38] = −1.08, P = 0.285). This suggests that, in this severely traumatised sample with severe and complex (and often neglected) symptom profiles (and problems in many domains of life), many factors other than PTSD may influence social functioning. Therefore, interventions on other maintaining factors are probably necessary to support further recovery. It should also be noted that we used a very short and global assessment of social functioning, which might limit the reliability and validity. Similarly, the PSYRATS (the measure used for voice hearing and delusions) is problematic, since it starts with a dichotomous question about the presence of voices or delusions.Reference de Bont, van den Berg, van der Vleugel, de Roos, de Jongh and van der Gaag 6 Therefore, future studies should test the effects of TFT on social functioning and symptoms of psychosis in everyday life using finer-tuned measures, e.g. the experience sampling method.Reference Van Os, Delespaul, Wigman, Myin-Germeys and Wichers 18 Longer follow-up periods are also desirable, but pose ethical problems.

We conclude that TFT has long-term positive effects on symptoms of PTSD, depression and psychosis in people with severe psychotic disorders, and that there seems to be no reason to exclude individuals with psychosis from TFT. Although replication of these findings and more research on the long-term effects on social functioning is required, these findings provide further support for the notion that the current guidelines for PTSD also apply to individuals with psychosis.

Funding

This study was funded by the Dutch Support Foundation ‘Stichting tot Steun VCVGZ’ (awarded to M.v.d.G.). Stichting tot Steun VCVGZ had no part in the design and conduct of the study or decisions about this report.

Supplementary material

Supplementary material is available online at https://doi.org/10.1192/bjp.2017.30.

References

1 Sin, J, Spain, D. Psychological interventions for trauma in individuals who have psychosis: a systematic review and meta-analysis. Psychosis 2017; 9: 67–81.CrossRefGoogle Scholar
2 Hardy, A, van den Berg, D. Healing traumatic memories in psychosis: a response to Sin and Spain (2016). Psychosis 2016; 9: 95–6.Google Scholar
3 Brand, RM, McEnery, C, Rossell, S, Bendall, S, Thomas, N. Do trauma-focussed psychological interventions have an effect on psychotic symptoms? A systematic review and meta-analysis. Schizophr Res 2017, in press.Google ScholarPubMed
4 van den Berg, DP, de Bont, PA, van der Vleugel, BM, de Roos, C, de Jongh, A, Van Minnen, A, et al. Prolonged exposure vs eye movement desensitization and reprocessing vs waiting list for posttraumatic stress disorder in patients with a psychotic disorder: a randomized clinical trial. JAMA Psychiatry 2015; 72: 259–67.Google Scholar
5 van den Berg, DP, de Bont, PA, van der Vleugel, BM, de Roos, C, de Jongh, A, van Minnen, A, et al. Trauma-Focused treatment in PTSD patients with psychosis: symptom exacerbation, adverse events, and revictimization. Schizophr Bull 2016; 42: 693–702.CrossRefGoogle ScholarPubMed
6 de Bont, PA, van den Berg, DP, van der Vleugel, BM, de Roos, C, de Jongh, A, van der Gaag, M, et al. Prolonged exposure and EMDR for PTSD v. A PTSD waiting-list condition: effects on symptoms of psychosis, depression and social functioning in patients with chronic psychotic disorders. Psychol Med 2016; 46: 2411–21.CrossRefGoogle Scholar
7 de Bont, PA, van den Berg, DP, van der Vleugel, BM, de Roos, C, Mulder, CL, Becker, ES, et al. A multi-site single blind clinical study to compare the effects of prolonged exposure, eye movement desensitization and reprocessing and waiting list on patients with a current diagnosis of psychosis and co morbid post traumatic stress disorder: study protocol for the randomized controlled trial treating trauma in psychosis. Trials 2013; 14: 151.Google Scholar
8 Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Gusman, FD, Charney, DS, et al. The development of a clinician-administered PTSD scale. J Trauma Stress 1995; 8: 75–90.Google Scholar
9 Foa, EB, Riggs, DS, Dancu, CV, Rothbaum, BO. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress 1993; 6: 459–73.Google Scholar
10 Foa, EB, Ehlers, A, Clark, DM, Tolin, DF, Orsillo, SM. The posttraumatic cognitions inventory (PTCI): development and validation. Psychol Assess 1999; 11: 303–14.CrossRefGoogle Scholar
11 Beck, AT, Steer, RA, Brown, GK. Manual for the Beck Depression Inventory-II. Psychological Corporation, 1996.Google Scholar
12 Morosini, PL, Magliano, L, Brambilla, L, Ugolini, S, Pioli, R. Development, reliability and acceptability of a new version of the DSM-IV social and occupational functioning assessment scale (SOFAS) to assess routine social functioning. Acta Psychiatr Scand 2000; 101: 323–9.Google ScholarPubMed
13 Green, CE, Freeman, D, Kuipers, E, Bebbington, P, Fowler, D, Dunn, G, et al. Measuring ideas of persecution and social reference: the green et al. Paranoid thought scales (GPTS). Psychol Med 2008; 38: 101–11.Google Scholar
14 Haddock, G, McCarron, J, Tarrier, N, Faragher, EB. Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychol Med 1999; 29: 879–89.CrossRefGoogle ScholarPubMed
15 Andreasen, NC, Carpenter, WT, Kane, JM, Lasser, RA, Marder, SR, Weinberger, DR. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatry 2005; 162: 441–9.Google Scholar
16 Rothman, KJ. Six persistent research misconceptions. J Gen Intern Med 2014; 29: 1060–4.CrossRefGoogle ScholarPubMed
17 Seow, LS, Ong, C, Mahesh, MV, Sagayadevan, V, Shafie, S, Chong, SA, et al. A systematic review on comorbid post-traumatic stress disorder in schizophrenia. Schizophr Res 2016; 176: 441–51.Google Scholar
18 Van Os, J, Delespaul, P, Wigman, J, Myin-Germeys, I, Wichers, M. Psychiatry beyond labels: introducing contextual precision diagnosis across stages of psychopathology. Psychol Med 2013; 43: 1563–7.CrossRefGoogle ScholarPubMed
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