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PTSD Therapies Safe, Effective for Comorbid Psychosis

Wednesday, January 21, 2015  
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Deborah Brauser

February 02, 2015

Therapies commonly used to treat posttraumatic stress disorder (PTSD) are effective and safe for patients with comorbid PTSD and psychosis, new research suggests.

David van den Berg


A randomized, controlled trial with three arms that included 155 adult patients with a lifetime psychotic disorder and current, chronic PTSD showed that those who received prolonged exposure (PE) or eye movement desensitization and reprocessing therapy (EMDR) for 8 weeks had a greater reduction in trauma symptoms and were more likely to achieve "loss of diagnosis" compared with wait- listed participants.


In addition, the PE group was more likely than the wait-listed group to gain full remission from PTSD. There were no differences between any of the groups with regard to treatment-related serious adverse events (SAEs).


"It was not a surprise...that guideline trauma treatments were effective in people with psychosis," lead author David P. G. van den Berg, clinical psychologist and PhD student from Parnassia Psychiatric Institute, Den Haag, the Netherlands, told Medscape Medical News.


"We were surprised, however, how effective these treatments were ― especially considering that most people in our study experienced severe childhood traumatization and were only given eight sessions of therapy," said van den Berg.


The investigators note that most past PTSD studies have excluded patients with comorbid psychotic disorders, such as schizophrenia.


"The present results are at odds with these prejudices," they write.


The study was published online January 21 in JAMA Psychiatry.


Lack of Evidence


The researchers note that PE and EMDR are commonly recommended as first-line treatment for PTSD throughout the world.


Although 1 in 8 patients with a psychotic disorder also has PTSD, "clinicians seem reluctant" to treat these individuals, write the investigators. In addition, "robust evidence for the efficacy and safety of PE and EMDR in patients with psychosis is lacking."


For the current study, 155 patients between the ages of 18 and 65 years (mean age, 41.2 years; 54% women) with both PTSD and severe psychosis were recruited from 13 outpatient mental health services in the Netherlands between September 2011 and April 2013.


All were randomly assigned to receive either PE (n = 53) or EMDR (n = 55) in 90-minute sessions for 8 weeks, or were wait-listed (n = 47).


Assessments for all patients were conducted at baseline, at the end of treatment, and at a 6-month posttreatment follow-up.


The primary outcome measures included PTSD diagnosis and severity of symptoms, as shown by scores on the Clinician-Administered PTSD Scale (CAPS), and full remission ― which was defined as a CAPS score of less than 20.


Secondary measures included symptom frequency on the Posttraumatic Stress Symptom Scale Self-Report (PSS-SR) and "trauma-related cognitive distortions" on the Posttraumatic Cognitions Inventory (PTCI).




Results showed that compared with the wait-listed group, the PE and EMDR groups both had significantly better CAPS total scores, signifying reduced symptoms, at end of treatment (P < .001 and P = .001, respectively) and at the 6-month follow-up (P = .002 and P = .009, respectively).

None of these measures differed significantly between the two treatment groups.


Loss of PTSD diagnosis was also more likely to be achieved and maintained at posttreatment and at 6 months by the PE (P = .006 and P = .003, respectively) and EMDR (P < .001 and P < .002, respectively) groups in comparison with the wait-listed group.


The self-reported PSS-SR and PTCI scores were also significantly lower for the PE and EMDR groups compared with the wait-listed group at the posttreatment and 6-month follow-up. And again, there were no significant differences between the treatment groups.


Although those receiving PE were more likely than those wait-listed to achieve full PTSD remission (P = .01 at both timepoints), whereas those receiving EMDR were not, there were no significant differences in remission achievement when the two treatment groups went head to head.


No between-group differences were found for SAEs. Although four SAEs were reported in the wait-listed group, two in the PE group, and one in the EMDR group, "none...were judged to have been induced by the study," report the investigators.


"We believe that this study demonstrates the efficacy and safety of trauma treatment in psychosis," they write.


The researchers pointed out that the findings are generalizable to clinical practice because of "the use of standard protocols with patients in routine long-term care" and the limited loss of patients to follow-up.


Van den Berg noted that the investigators are now pursuing several new initiatives, including treating trauma in young people who are having psychoticlike experiences.


"This is linked to a second research line in which we are targeting traumas that appear to be directly or indirectly related to psychotic symptoms, such as auditory verbal hallucinations or paranoia. For instance, targeting experiences of sexual abuse that are clearly linked to voice hearing or targeting physical abuse experiences that trigger paranoia," he reported.


"These are promising fields of research."


A full list of potential conflicts can be found in the original article.


JAMA Psychiatry. Published online January 21, 2015. Abstract

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