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Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis

Published online by Cambridge University Press:  12 March 2019

Thanos Karatzias Open the ORCID record for Thanos Karatzias [Opens in a new window] ,
Philip Murphy ,
Marylene Cloitre ,
Jonathan Bisson ,
Neil Roberts ,
Mark Shevlin ,
Philip Hyland ,
Andreas Maercker ,
Menachem Ben-Ezra  and
Peter Coventry
...Show all authors
Thanos Karatzias*
Affiliation:
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK NHS Lothian, Rivers Centre for Traumatic Stress, Edinburgh, UK
Philip Murphy
Affiliation:
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Marylene Cloitre
Affiliation:
Department of Psychiatry and Behavioral Sciences, Stanford University, California, USA National Center for PTSD, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
Jonathan Bisson
Affiliation:
Cardiff University, School of Medicine, Cardiff, UK
Neil Roberts
Affiliation:
Cardiff University, School of Medicine, Cardiff, UK Psychology and Counselling Directorate, Cardiff and Vale University Health Board, Cardiff, UK
Mark Shevlin
Affiliation:
Ulster University, School of Psychology, Derry, UK
Philip Hyland
Affiliation:
National College of Ireland, School of Business, Dublin, Ireland
Andreas Maercker
Affiliation:
Department of Psychology, Psychopathology and Clinical Interventions, University of Zurich, Zurich, Switzerland
Menachem Ben-Ezra
Affiliation:
School of Social Work, Ariel University, Ariel, Israel
Peter Coventry
Affiliation:
Department of Health Sciences and Centre for Reviews and Dissemination, University of York, York, UK
Susan Mason-Roberts
Affiliation:
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Aoife Bradley
Affiliation:
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
Paul Hutton
Affiliation:
Edinburgh Napier University, School of Health & Social Care, Edinburgh, UK
*
Author for correspondence: Thanos Karatzias, E-mail: t.karatzias@napier.ac.uk
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Abstract

Background

The 11th revision to the WHO International Classification of Diseases (ICD-11) identified complex post-traumatic stress disorder (CPTSD) as a new condition. There is a pressing need to identify effective CPTSD interventions.

Methods

We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for post-traumatic stress disorder (PTSD), where participants were likely to have clinically significant baseline levels of one or more CPTSD symptom clusters (affect dysregulation, negative self-concept and/or disturbed relationships). We searched MEDLINE, PsycINFO, EMBASE and PILOTS databases (January 2018), and examined study and outcome quality.

Results

Fifty-one RCTs met inclusion criteria. Cognitive behavioural therapy (CBT), exposure alone (EA) and eye movement desensitisation and reprocessing (EMDR) were superior to usual care for PTSD symptoms, with effects ranging from g = −0.90 (CBT; k = 27, 95% CI −1.11 to −0.68; moderate quality) to g = −1.26 (EMDR; k = 4, 95% CI −2.01 to −0.51; low quality). CBT and EA each had moderate–large or large effects on negative self-concept, but only one trial of EMDR provided useable data. CBT, EA and EMDR each had moderate or moderate–large effects on disturbed relationships. Few RCTs reported affect dysregulation data. The benefits of all interventions were smaller when compared with non-specific interventions (e.g. befriending). Multivariate meta-regression suggested childhood-onset trauma was associated with a poorer outcome.

Conclusions

The development of effective interventions for CPTSD can build upon the success of PTSD interventions. Further research should assess the benefits of flexibility in intervention selection, sequencing and delivery, based on clinical need and patient preferences.

Keywords

Childhood traumaCPTSDmeta-analysispsychological therapiesrandomised controlled trialssystematic review

Information

Type
Review Article
Information
Psychological Medicine , Volume 49 , Issue 11 , August 2019 , pp. 1761 - 1775
Copyright
Copyright © Cambridge University Press 2019 

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References

Azad Marzabadi, E and Hashemi Zadeh, SM (2014) The effectiveness of mindfulness training in improving the quality of life of the war victims with post traumatic stress disorder (PTSD). Iranian Journal of Psychiatry 9, 228–236.Google Scholar
Barrera, TL, Mott, JM, Hofstein, RF and Teng, EJ (2013) A meta-analytic review of exposure in group cognitive behavioral therapy for posttraumatic stress disorder. Clinical Psychology Review 33, 24–32.Google Scholar
Benish, SG, Imel, ZE and Wampold, BE (2008) The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: a meta-analysis of direct comparisons. Clinical Psychology Review 28, 746–758.Google Scholar
Bisson, J and Andrew, M (2007) Psychological treatment of post-traumatic stress disorder (PTSD) Cochrane Database of Systematic Reviews 18, CD003388.Google Scholar
Bisson, JI, Ehlers, A, Matthews, R, Pilling, S, Richards, D and Turner, S (2007) Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis. British Journal of Psychiatry 190, 97–104.Google Scholar
Bisson, JI, Roberts, NP, Andrew, M, Cooper, R and Lewis, C (2013) Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systemic Reviews 13, CD003388.Google Scholar
Bradley, R, Greene, J, Russ, E, Dutra, L and Westen, D (2005) A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 162, 214–227.Google Scholar
Brewin, CR, Cloitre, M, Hyland, P, Shevlin, M, Maercker, A, Bryant, RA, Humayun, A, Jones, LM, Kagee, A, Rousseau, C, Somasundaram, D, Suzuki, Y, Wessely, S, van Ommeren, M and Reed, GM (2017) A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review 58, 1–15.Google Scholar
Callahan, KL, Price, JL and Hilsenroth, MJ (2004) A review of interpersonal psychodynamic group psychotherapy outcomes for adult survivors of childhood sexual abuse. International Journal of Group Psychotherapy 54, 491–519.Google Scholar
Cloitre, M (2015) The ‘one size fits all’ approach to trauma treatment: should we be satisfied? European Journal of Psychotraumatology 6, 27344.Google Scholar
Cloitre, M, Stovall-McClough, KC, Nooner, K, Zorbas, P, Cherry, S, Jackson, CL, Gan, W and Petkova, E (2010) Treatment for PTSD related to childhood abuse: a randomized controlled trial. American Journal of Psychiatry 167, 915–924.Google Scholar
Cloitre, M, Courtois, CA, Ford, JD, Green, BL, Alexander, P, Briere, J, Herman, JL, Lanius, R, Stolbach, BC, Spinazzola, J, Van der Kolk, BA and Van der Hart, O (2012 a) The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Retrieved from http://www.istss.org/ISTSS_Main/media/Documents/ISTSS-Expert-Concesnsus-Guidelines-for-Complex-PTSD-Updated-060315.pdfGoogle Scholar
Cloitre, M, Petkova, E, Wang, J and Lu Lassell, F (2012 b) An examination of the influence of a sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse. Depression and Anxiety 29, 709–717.Google Scholar
Cloitre, M, Garvert, DW, Brewin, CR, Bryant, RA and Maercker, A (2013) Evidence for proposed ICD-11 PTSD and complex PTSD: a latent profile analysis. European Journal of Psychotraumatology 4, doi: 10.3402/ejpt.v4i0.20706.Google Scholar
Cohen, J (1988) Statistical Power Analysis in the Behavioral Sciences. Hillsdale, NJ: Erlbaum.Google Scholar
Cusack, K, Jonas, DE, Forneris, CA, Wines, C, Sonis, J, Middleton, JC, Feltner, C, Brownley, KA, Olmsted, KR, Greenblatt, A, Weil, A and Gaynes, BN (2016) Psychological treatments for adults with PTSD: a systematic review and meta-analysis. Clinical Psychology Review 43, 128–141.Google Scholar
Deeks, JJ, Altman, DG and Bradburn, MJ (2001) Statistical methods for examining heterogeneity and combining results from several studies in meta-analysis. Systematic Reviews in Health Care: Meta-Analysis in Context, Chapter 15, 285–312. https://doi.org/10.1002/9780470693926.ch15.Google Scholar
De Jongh, A, Resick, PA, Zoellner, LA, van Minnen, A, Lee, CW, Monson, CM, Foa, EB, Wheeler, K, Broeke, ET, Feeny, N, Rauch, SA, Chard, KM, Mueser, KT, Sloan, DM, van der Gaag, M, Rothbaum, BO, Neuner, F, de Roos, C, Hehenkamp, LM, Rosner, R and Bicanic, IA (2016) Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety 33, 359–369.Google Scholar
DerSimonian, R and Laird, N (1986) Meta-analysis in clinical trials. Control Clinical Trials 7, 177–188.Google Scholar
Duval, S and Tweedie, R (2000) Trim and fill: a simple funnel plot based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56, 455–463.Google Scholar
Egger, M, Smith, GD, Schneider, M and Minder, C (1997) Bias in meta-analysis detected by a simple, graphical test. British Medical Journal (Clinical Research Ed.) 315, 629–634.Google Scholar
Ehring, T, Welboren, R, Morina, N, Wicherts, JM, Freitag, J and Emmelkamp, PMG (2014) Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review 34, 645–657.Google Scholar
Elklit, A, Hyland, P and Shevlin, M (2014) Evidence of symptom profiles consistent with posttraumatic stress disorder and complex posttraumatic stress disorder in different trauma samples. European Journal of Psychotraumatology 5, 24221.Google Scholar
Foa, EB, Keane, TM, Friedman, MJ and Cohen, JA (2009) Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York: Guilford Press.Google Scholar
Furukawa, TA (1999) From effect size into number needed to treat. Lancet 353, 1680.Google Scholar
Furukawa, TA and Leucht, S (2011) How to obtain NNT from Cohen's d: comparison of two methods. PLoS ONE 6, e19070. doi: 10.1371/journal.pone.0019070.Google Scholar
Guyatt, GH, Oxman, AD, Vist, GE, Kunz, R, Falck-Ytter, Y, Alonso-Coello, P and Schünemann, HJ and GRADE Working Group (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal 336, 924–926.Google Scholar
Harned, MS, Korslund, KE and Linehan, MM (2014) A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy 55, 7–17.Google Scholar
Herman, J (1992) Complex PTSD: a syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress 5, 377–391.Google Scholar
Higgins, JPT and Green, S (2011) Cochrane Handbook for Systematic Reviews of Interventions. England: The Cochrane Collaboration and John Wiley & Sons Ltd.Google Scholar
Higgins, JP, Altman, DG, Gøtzsche, PC, Jüni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L and Sterne, JA, Cochrane Bias Methods Group and Cochrane Statistical Methods Group (2011) The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343, d5928.Google Scholar
Hyland, P, Murphy, J, Shevlin, M, Vallières, F, McElroy, E, Elklit, A, Christoffersen, M and Cloitre, M (2017 a) Variation in post-traumatic response: the role of trauma type in predicting ICD-11 PTSD and CPTSD symptoms. Social Psychiatry and Psychiatric Epidemiology 52, 727–736.Google Scholar
Hyland, P, Shevlin, M, Brewin, CR, Cloitre, M, Downes, A, Jumbe, S, Karatzias, T, Bisson, JI and Roberts, NP (2017 b) Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire. Acta Psychiatrica Scandinavica 136, 313–322.Google Scholar
Hyland, P, Ceannt, R, Daccache, F, Abou Daher, R, Sleiman, J, Gilmore, B, Byrne, S, Shevlin, M, Murphy, J and Vallières, F (2018) Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon? Global Mental Health 5, e14.Google Scholar
Imel, ZE, Laska, K, Jakupcak, M and Simpson, TL (2013) Meta-analysis of dropout in treatments for PTSD. Journal of Consulting and Clinical Psychology 81, 394–404.Google Scholar
Karatzias, T, Shevlin, M, Fyvie, C, Hyland, P, Efthymiadou, E, Wilson, D, Roberts, N, Bisson, JI, Brewin, CR and Cloitre, M (2016) Evidence of distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). Journal of Affective Disorders 207, 181–187.Google Scholar
Karatzias, T, Shevlin, M, Fyvie, C, Hyland, P, Efthymiadou, E, Wilson, D, Roberts, N, Bisson, JI, Brewin, CR and Cloitre, M (2017) Evidence of distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) based on the new ICD-11 Trauma Questionnaire (ICD-TQ). Journal of Anxiety Disorders 207, 181–187.Google Scholar
Kline, AC, Cooper, AA, Rytwinksi, NK and Feeny, NC (2018) Long-term efficacy of psychotherapy for PTSD: a meta-analysis of randomized controlled trials. Clinical Psychology Review 59, 30–40.Google Scholar
Knefel, M, Garvert, DW, Cloitre, M and Lueger-Schuster, B (2015) Update to an evaluation of ICD-11 PTSD and complex PTSD criteria in a sample of adult survivors of childhood institutional abuse by Knefel & Lueger-Schuster (2013): a latent profile analysis. European Journal of Psychotraumatology 6, 25290.Google Scholar
Krupnick, JL, Green, BL, Stockton, P, Miranda, J, Krause, E and Mete, M (2008) Group interpersonal psychotherapy for low-income women with posttraumatic stress disorder. Psychotherapy Research: Journal of the Society for Psychotherapy Research 18, 497–507.Google Scholar
Maercker, A, Brewin, CR, Bryant, RA, Cloitre, M, Reed, GM, van Ommeren, M, Humayun, A, Jones, LM, Kagee, A, Llosa, AE, Rousseau, C, Somasundaram, DJ, Souza, R, Suzuki, Y, Weissbecker, I, Wessely, SC, First, MB and Saxena, S (2013) Proposals for mental disorders specifically associated with stress in the ICD-11. Lancet 381, 1683–1685.Google Scholar
Mills, KL, Teesson, M, Back, SE, Brady, KT, Baker, AL, Hopwood, S, Sannibale, C, Barrett, EL, Merz, S, Rosenfeld, J and Ewer, PL (2012) Integrated exposure-based therapy for co-occurring posttraumatic stress disorder and substance dependence: a randomized controlled trial. Journal of the American Medical Association 308, 690–699.Google Scholar
Morina, N, Wicherts, JM, Lobbrecht, J and Priebe, S (2014) Remission from post-traumatic stress disorder in adults: a systematic review and meta-analysis of long term outcome studies. Clinical Psychology Review 34, 249–255.Google Scholar
National Collaborating Centre for Mental Health (2014) Psychosis and Schizophrenia in adults: treatment and management: Updated edition 2014. National Institute for Health and Care Excellence (UK) 14–36.Google Scholar
Peleikis, DE and Dahl, AA (2005) A systematic review of empirical studies of psychotherapy with women who were sexually abused as children. Psychotherapy Research 15, 304–315.Google Scholar
Perkonigg, A, Höfler, M, Cloitre, M, Wittchen, HU, Trautmann, S and Maercker, A (2016) Evidence for two different ICD-11 posttraumatic stress disorder in a community sample of adolescents and young adults. European Archives of Psychiatry and Clinical Neuroscience 266, 317–328.Google Scholar
Roberts, NP, Roberts, PA, Jones, N and Bisson, JI (2015) Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clinical Psychology Review 38, 25–38.Google Scholar
Sachser, C, Keller, F and Goldbeck, L (2016) Complex PTSD as proposed for ICD-11: validation of a new disorder in children and adolescents and their response to trauma-focused cognitive behavioral therapy. Journal of Child Psychology and Psychiatry 58, 160–168.Google Scholar
Shapiro, F (1995) Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and Procedures. New York: Guilford Press.Google Scholar
Shevlin, M, Hyland, P, Karatzias, T, Roberts, N and Bisson, J (2017) Examining the disconnect between psychometric models and clinical reality. Journal of Anxiety Disorders 24, 54–59.Google Scholar
Sloan, DM, Feinstein, BA, Gallagher, MW, Beck, JG and Keane, TM (2013) Efficacy of group treatment for posttraumatic stress disorder symptoms: a meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy 5, 176–183.Google Scholar
Taylor, JE and Harvey, ST (2009) Effects of psychotherapy with people who have been sexually assaulted: a meta-analysis. Aggression and Violent Behaviour 14, 273–285.Google Scholar
Taylor, JE and Harvey, ST (2010) A meta-analysis of the effects of psychotherapy with adults sexually abused in childhood. Clinical Psychology Review 30, 749–767.Google Scholar
Watts, BV, Schnurr, PP, Mayo, L, Young-Xu, Y, Weeks, WB and Friedman, MJ (2013) Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry 74, 541–550.Google Scholar
World Health Organization (2018) The ICD-11 for mortality and morbidity statistics. Retrieved from https://icd.who.int/browse11/l-m/e.Google Scholar
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