Article summary with Effect of Prolonged Exposure, intensified Prolonged Exposure and STAIR+Prolonged Exposure in patients with PTSD related to childhood abuse: a randomized controlled trial by Oprel a.o. - 2021

What is the relationship between childhood abuse and PTSD?

Childhood physical and sexual abuse are important risk factors for the development of post-traumatic stress disorder (PTSD). Both childhood abuse and childhood abuse-related PTSD (CA-PTSD) are associated with sever psychiatric symptoms and negative long-term outcomes, emphasizing the need for effective treatment. There’s a limited number of studies assessing trauma-focused treatment among those with CA-PTSD, and it is therefore uncertain how effective trauma-focused treatment is in this group of patients.

Patients with CA-PTSD more often experience emotional regulation difficulties and interpersonal problems than patients with non-CA-PTSD. Additionally, co-morbid diagnoses are more common in these patients – particularly depression, substance abuse, and personality disorders.

A recent meta-analysis indicated that patents with PTSD related to childhood trauma don’t benefit optimally from treatment. Compared with patients with PTSD related to trauma in adulthood, they improve less on PTSD symptoms, emotion regulation and interpersonal functioning.

What is the aim of this study?

The aim of this study was to investigate whether the effectiveness and the dropout rates of trauma-focused treatment for TPSD can be improved in patients with CA-PTSD. Prolonged Exposure (PE), an established treatment of PTSD was compared with two adaptations of PE:

• The first was an intensified version of PE (iPE). It was expected that offering several sessions per week would lead to faster improvement and lower drop-out rates.
• The second adaptation was a phase-based treatment in which PE is preceded by Skills Training in Affective and Interpersonal Regulation (STAIR). This treatment is based on the notion that emotion regulation and interpersonal problems interfere not only with daily life functioning but also the processing of trauma memories and that improvement in these capacities during the STAIR phase facilitates the effectiveness of PE.

The following hypotheses were tested:

1. iPE and STAIR+PE lead to more clinician-rated and self-reported PTSD symptom reduction than PE from baseline to follow-up.
2. iPE leads to faster improvement, that is, it leads to more clinician-rated and self-reported PTSD symptom reduction than PE and STAIR-PE from baseline to the first assessment.
3. STAIR+PE leads to more improvement in emotion regulation, interpersonal problems, and self-esteem than PE and iPE from baseline to follow-up.
4. iPE and STAIR+PE result in lower drop-out rates from treatment than PE.

What method was used?

In this randomized-controlled trial, the authors compared the effectiveness of PE, iPE and STAIR+PE. Participants were recruited in two outpatient mental health services specializing in the treatment of trauma-related disorders located in the Hague and Rotterdam, the Netherlands. Inclusion criteria were:

1. ages 18-65
2. a PTSD diagnosis according to DSM-5 classification
3. traumata related to childhood sexual and/or physical abuse that occurred before 18 years of age, committed by a primary caretaker or an authority figure as index event
4. sufficient fluency in Dutch to complete the treatment and research protocols

Exclusion criteria were:

1. involvement in a compensation case or legal procedures concerning admission or stay in the Netherlands
2. pregnancy given the limited available information about safety
3. severe non-suicidal self-injury (NSSI) which required hospitalization during the past 3 months
4. severe suicidal behaviour: a suicide attempt during the past 3 months or acute suicidal ideations with serious intent to die with a specific plan for suicide and preparatory acts
5. severe disorder in the use of alcohol or drugs in the last 3 months
6. cognitive impairment
7. changes in psychotropic medication in the 2 months prior to inclusion
8. engagement in any current psychological treatment

PE was delivered in 16 weekly face-to-face sessions of 90 minutes. PE is a form of cognitive behavioural therapy involving psychoeducation about PTSD, imaginal exposure (repeatedly recounting the most disturbing traumatic memories) and exposure in vivo (repeatedly approaching trauma-related stimuli.

iPE was delivered in 14 face-to-face sessions of 90 minutes which started with 3 sessions per week for 3 weeks followed by 2 sessions after one and 2 months.

STAIR+PE was delivered in 8 weekly face-to-face sessions of 60 minutes for STAIR and 8 weekly face-to-face sessions of 90 minutes for PE. STAIR+PE comprised skill training and prolonged exposure.

What were the results?

149 patients were randomly assigned to PE (48), iPE (51) or STAIR+PE (50). All treatments resulted in large improvements in clinician assessed and self-reported PTSD symptoms from baseline to 1-year follow-up, with no significant differences among treatments. iPE led to faster initial symptom reduction than PE for self-report PTSD symptoms but not clinician-assessed symptoms and faster initial symptom reduction than STAIR+PE for self-reported and clinician-assessed symptoms. STAIR+PE did not result in significantly more improvement from baseline to 1-year follow-up on the secondary outcome emotion regulation, interpersonal problems and self-esteem compared to PE and iPE. Dropout rates did not differ significantly between conditions.

What conclusions were made?

The three variants of Pe were each effective treatments of PTSD in patients with CA-PTSD.

• The hypothesis that iPE and STAIR+PE result in larger PTSD symptom reductions compared to PE from baseline to 1-year follow-up was not supported. There were no significant differences between PE and iPE/STAIR+PE at post-treatment or at 1-year follow-up. It was found that STAIR+PE led to more improvement than PE in the post-treatment to follow-up phase on interviewer-assessed but not self-reported PTSD symptoms.
• The hypothesis that iPE would lead to faster symptom improvement than PE and STAIR+PE was partly supported. Compared with PE, iPE led to faster improvement on self-reported but not interviewer-assessed PTSD symptom severity. iPE led to faster improvement than STAIR+PE on both self-reported and interview-based assessments.
• The hypothesis that STAIR+PE leads to more improvement in emotion regulation, interpersonal problems and self-concept compared to PE and iPE was not supported. There were no significant differences between STAIR+PE and PE/iPE post-treatment or at 1-year follow-up. STAIR+PE showed more improvement in emotion regulation and interpersonal problems post-treatment to 1-year follow-up compared to PE, but not compared to iPE.
• The final hypothesis that iPE (27% dropout) and STAIR+PE (18% dropout) would lead to lower dropout rates than PE (29%) was not supported. PE led to significantly more early completers (23% early completers) compared to iPE (2% early completers) and STAIR+PE (4% early completers), but this may be related to the relatively large amount of exposure sessions in PE (16 sessions) compared to iPE (14 sessions) and STAIR+PE (8 sessions).

The results of this study demonstrate that PE, iPE, and STAIR+PE are effective treatments for CA-PTSD. intensifying treatment may speed up recovery but does not lead to an overall better outcome. Moreover, all treatments led to improvements in emotion regulation, interpersonal problems, and self-esteem from baseline to follow-up.

To conclude, iPE and STAIR+PE did not improve the overall outcome of PE. All treatments were effective for patients with CA-PTSD.