Behavioral Activation and Therapeutic Exposure vs. Cognitive Therapy for Grief Among Combat Veterans: A Randomized Clinical Trial of Bereavement Interventions

Approximately two-thirds of Operations Enduring Freedom, Iraqi Freedom, and New Veterans reported knowing someone who was killed or seriously injured, lost someone in their immediate unit, or personally saw dead or seriously injured Americans (Hoge et al., 2004; Thomas et al., 2010; Toblin et al., 2012). Thus, it is not surprising that prevalence of Persistent Complex Bereavement Disorder (PCBD) is high in these groups. Importantly, PCBD impact appears to be independent of both Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (Bonnano, 2007), 2 disorders that are also highly prevalent in these groups, thus tailored treatments for grief are indicated. The Department of Veterans Affairs suggests Cognitive Therapy for Grief as a first line psychotherapy, however treatments relatively more focused on behavior change and exposure to grief cues also may be useful for this population. To address this question, the present study used a randomized controlled trial to compare a 7-session program of Behavioral Activation and Therapeutic Exposure for Grief vs. Cognitive Therapy for Grief among 155 OIF/OEF/OND veterans. Both treatments produced significant treatment gains over baseline, and these improvements were maintained over 6-month followup; however no differences were observed between groups. Given equal efficacy, implications for matching treatment to patient characteristics are discussed.

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DECRYPT trial: study protocol for a phase II randomised controlled trial of cognitive therapy for post-traumatic stress disorder (PTSD) in youth exposed to multiple traumatic stressors

BMJ Open ◽

10.1136/bmjopen-2020-047600 ◽

2021 ◽

Vol 11 (7) ◽

pp. e047600

Author(s):

Leila Allen ◽

Polly-Anna Ashford ◽

Ella Beeson ◽

Sarah Byford ◽

Jessica Chow ◽

...

Keyword(s):

Young People ◽

Cognitive Therapy ◽

Multiple Trauma ◽

Traumatic Stress ◽

Controlled Trial ◽

Post Traumatic Stress ◽

Children And Young People ◽

Post Traumatic ◽

Randomised Controlled ◽

Post Randomisation

BackgroundPost-traumatic stress disorder (PTSD) is a distressing and disabling condition that affects significant numbers of children and adolescents. Youth exposed to multiple traumas (eg, abuse, domestic violence) are at particular risk of developing PTSD. Cognitive therapy for PTSD (CT-PTSD), derived from adult work, is a theoretically informed, disorder-specific form of trauma-focused cognitive–behavioural therapy. While efficacious for child and adolescent single-event trauma samples, its effectiveness in routine settings with more complex, multiple trauma-exposed youth has not been established. The Delivery of Cognitive Therapy for Young People after Trauma randomised controlled trial (RCT) examines the effectiveness of CT-PTSD for treating PTSD following multiple trauma exposure in children and young people in comparison with treatment as usual (TAU).Methods/designThis protocol describes a two-arm, patient-level, single blind, superiority RCT comparing CT-PTSD (n=60) with TAU (n=60) in children and young people aged 8–17 years with a diagnosis of PTSD following multiple trauma exposure. The primary outcome is PTSD severity assessed using the Children’s Revised Impact of Event Scale (8-item version) at post-treatment (ie, approximately 5 months post-randomisation). Secondary outcomes include structured interview assessment for PTSD, complex PTSD symptoms, depression and anxiety, overall functioning and parent-rated mental health. Mid-treatment and 11-month and 29-month post-randomisation assessments will also be completed. Process–outcome evaluation will consider which mechanisms underpin or moderate recovery. Qualitative interviews with the young people, their families and their therapists will be undertaken. Cost-effectiveness of CT-PTSD relative to TAU will be also be assessed.Ethics and disseminationThis trial protocol has been approved by a UK Health Research Authority Research Ethics Committee (East of England–Cambridge South, 16/EE/0233). Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations and clinical workshops.Trial registrationISRCTN12077707. Registered 24 October 2016 (http://www.isrctn.com/ISRCTN12077707). Trial recruitment commenced on 1 February 2017. It is anticipated that recruitment will continue until June 2021, with 11-month assessments being concluded in May 2022.

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Complicated grief: Is there a place in psychiatry?

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.499 ◽

2017 ◽

Vol 41 (S1) ◽

pp. S458-S458

Author(s):

S.L. Azevedo Pinto ◽

J. Soares ◽

A. Silva ◽

R. Curral

Keyword(s):

Depressive Disorders ◽

Complicated Grief ◽

Adjustment Disorder ◽

Classification Systems ◽

Post Traumatic Stress ◽

Adequate Treatment ◽

Psychiatric Syndrome ◽

Persistent Complex Bereavement ◽

Competing Interest ◽

Persistent Complex Bereavement Disorder

IntroductionGrief is as normal reactive to a significant personal loss. It is characterized by affective, cognitive, behavioural and physiological symptoms. The grieving process is usually divided in five different stages, but in most cases presents a benign course, with decreased suffering and better adaptation to the new context. However, when high levels of emotional suffering or disability persist over a long time period, it becomes a case of complicated grief (CG), which should be adequately addressed.ObjectivesTo review the characteristics of CG, the evidence that supports it as an individual pathological entity, and its place in current classification systems.MethodsWe performed a bibliographic search in Pubmed and PsychInfo, of articles written in English, Portuguese and Spanish, containing the key words: grief, bereavement, psychiatry, classification.ResultsThe main issue regarding grief is the degree to which it is reasonable to interfere with a usually benign process. Since DSM-III bereavement has been referred to as an adaptive reaction to an important loss, which should not be diagnosed as major depressive disorder or adjustment disorder. However, DSM-5 has stated persistent complex bereavement disorder as an independent entity. In fact, CG fulfils the general criteria of every psychiatric syndrome, namely regarding specific diagnosis criteria, differential diagnosis from depressive disorders and post-traumatic stress disorder, and improvement with adequate treatment.ConclusionIt is important to correctly approach CG, since it presents with characteristic diagnosis features and much improvement may be achieved once adequate treatment is provided.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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The DECRYPT trial: Study protocol for a phase II randomised controlled trial of cognitive therapy for post-traumatic stress disorder (PTSD) in youth exposed to multiple traumatic stressors.

10.31234/osf.io/wntj5 ◽

2021 ◽

Author(s):

Leila Allen ◽

Polly-Anna Ashford ◽

Ella Beeson ◽

Sarah Byford ◽

Jessica Chow ◽

...

Keyword(s):

Young People ◽

Cognitive Therapy ◽

Multiple Trauma ◽

Traumatic Stress ◽

Controlled Trial ◽

Post Traumatic Stress ◽

Children And Young People ◽

Post Traumatic ◽

Randomised Controlled ◽

Post Randomisation

Background: Post-traumatic stress disorder (PTSD) is a distressing and disabling condition that affects significant numbers of children and adolescents. Youth exposed to multiple traumas (e.g. abuse, domestic violence) are at particular risk of developing PTSD. Cognitive-Therapy for PTSD (CT-PTSD), derived from adult work, is a theoretically-informed, disorder-specific form of trauma-focused cognitive-behavioural therapy (TF-CBT). While efficacious for child and adolescent single-event trauma samples, its effectiveness in routine settings with more complex, multiple-trauma exposed youth has not been established. The Delivery of Cognitive Therapy for Young People after Trauma (DECRYPT) randomised controlled trial (RCT) examines the effectiveness of CT-PTSD for treating PTSD following multiple trauma exposure in children and young people in comparison to treatment as usual (TAU). Methods/Design: This protocol describes a two-arm, patient-level, single blind, superiority RCT comparing CT-PTSD (n=60) to TAU (n=60) in children and young people aged 8-17 years with a diagnosis of PTSD following multiple trauma exposure. The primary outcome is PTSD severity assessed using the Children’s Revised Impact of Event Scale (8-item version) at post-treatment (i.e. approximately five months post-randomisation). Secondary outcomes include structured interview assessment for PTSD, complex PTSD symptoms, depression and anxiety, overall functioning and parent-rated mental health. Mid-treatment and 11- and 29-month post-randomisation assessments will also be completed. Process-outcome evaluation will consider which mechanisms underpin or moderate recovery. Qualitative interviews with the young people, their families and their therapists will be undertaken. Cost-effectiveness of CT-PTSD relative to TAU will be also be assessed.Ethics and dissemination: This trial protocol has been approved by a UK Health Research Authority (HRA) Research Ethics Committee (East of England – Cambridge South, 16/EE/0233). Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations, and clinical workshops.Trial registration: ISRCTN, ISRCTN12077707. Registered 24th October 2016, http://www.isrctn.com/ISRCTN12077707

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Patient characteristics as a moderator of posttraumatic stress disorder treatment outcome: combining symptom burden and strengths

BJPsych Open ◽

10.1192/bjpo.bp.115.000745 ◽

2016 ◽

Vol 2 (2) ◽

pp. 101-106 ◽

Cited By ~ 21

Author(s):

Marylene Cloitre ◽

Eva Petkova ◽

Zhe Su ◽

Brandon J. Weiss

Keyword(s):

Emotion Regulation ◽

Childhood Abuse ◽

Stress Disorder ◽

Controlled Trial ◽

Symptom Burden ◽

Patient Characteristics ◽

Skills Training ◽

Differential Outcome ◽

Post Traumatic Stress

BackgroundPost-traumatic stress disorder (PTSD) psychotherapy research has failed to identify patient characteristics that consistently predict differential outcome.AimsTo identify patient characteristics associated with differential outcome via a statistically generated composite moderator among women with childhood abuse-related PTSD in a randomised controlled trial comparing exposure therapy, skills training and their combination.MethodSix baseline patient characteristics were combined in a composite moderator of treatment effects for PTSD symptoms across the three treatment conditions through a 6-month follow-up.ResultsThe optimal moderator was the combined burden of all symptoms and emotion regulation strength. Those with high moderator scores, reflecting high symptom load relative to emotion regulation, did least well in exposure, moderately well in skills and best in the combination.ConclusionsA clinically meaningful moderator, which combines patient symptom burden and strengths, was identified. Assessment at follow-up may provide a more accurate indicator of variability in outcome than that obtained immediately post-treatment.

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A cognitive approach to persistent complex bereavement disorder (PCBD)

The Cognitive Behaviour Therapist ◽

10.1017/s1754470x17000034 ◽

2017 ◽

Vol 10 ◽

Cited By ~ 2

Author(s):

Michael Duffy ◽

Jennifer Wild

Keyword(s):

Cognitive Model ◽

Diagnostic Category ◽

Post Traumatic Stress ◽

Cognitive Approach ◽

Prolonged Grief ◽

Diagnostic And Statistical Manual ◽

Classification Of Diseases ◽

International Statistical Classification ◽

Persistent Complex Bereavement ◽

Persistent Complex Bereavement Disorder

AbstractPersistent complex bereavement disorder (PCBD) has been included in the appendix of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders as a condition for further study, and a new diagnostic category of prolonged grief disorder (PGD) is likely to be added to the International Statistical Classification of Diseases and Related Health Problems (ICD-11) (Maercker et al., 2013). Whilst there is increasing evidence that prolonged grief has distinct characteristics (Bryant, 2012), there are clinical features that overlap with post-traumatic stress disorder (PTSD), such as intrusive memories, emotional numbing, and avoidance of trauma or loss reminders. Here we describe how the cognitive model for persistent PTSD (Ehlers and Clark, 2000) and trauma-focused cognitive therapy for PTSD (Ehlers et al., 2005) have been helpful in treating persistent complex grief.

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Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: a network analysis

Psychological Medicine ◽

10.1017/s0033291718001769 ◽

2018 ◽

Vol 48 (14) ◽

pp. 2439-2448 ◽

Cited By ~ 18

Author(s):

Matteo Malgaroli ◽

Fiona Maccallum ◽

George A. Bonanno

Keyword(s):

Network Analysis ◽

Graphical Models ◽

Community Sample ◽

Self Report ◽

Post Traumatic Stress ◽

Dsm 5 ◽

Persistent Complex Bereavement ◽

Core Symptoms ◽

Persistent Complex Bereavement Disorder ◽

Conjugally Bereaved

AbstractBackgroundComplicated and persistent grief reactions afflict approximately 10% of bereaved individuals and are associated with severe disruptions of functioning. These maladaptive patterns were defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as persistent complex bereavement disorder (PCBD), but its criteria remain debated. The condition has been studied using network analysis, showing potential for an improved understanding of PCBD. However, previous studies were limited to self-report and primarily originated from a single archival dataset. To overcome these limitations, we collected structured clinical interview data from a community sample of newly conjugally bereaved individuals (N= 305).MethodsGaussian graphical models (GGM) were estimated from PCBD symptoms diagnosed at 3, 14, and 25 months after the loss. A directed acyclic graph (DAG) was generated from initial PCBD symptoms, and comorbidity networks with DSM-5 symptoms of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) were analyzed 1 year post-loss.ResultsIn the GGM, symptoms from the social/identity PCBD symptoms cluster (i.e. role confusion, meaninglessness, and loneliness) tended to be central in the network at all assessments. In the DAG, yearning activated a cascade of PCBD symptoms, suggesting how symptoms lead into psychopathological configurations. In the comorbidity networks, PCBD and depressive symptoms formed separate communities, while PTSD symptoms divided in heterogeneous clusters.ConclusionsThe network approach offered insights regarding the core symptoms of PCBD and the role of persistent yearnings. Findings are discussed regarding both clinical and theoretical implications that will serve as a step toward a more integrated understanding of PCBD.

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Therapeutic Assessment With a Client With Persistent Complex Bereavement Disorder: A Single-Case Time-Series Design

Clinical Case Studies ◽

10.1177/1534650117693942 ◽

2017 ◽

Vol 16 (4) ◽

pp. 295-312 ◽

Cited By ~ 3

Author(s):

Ilaria Durosini ◽

Anna Tarocchi ◽

Filippo Aschieri

Keyword(s):

Time Series ◽

Psychological Treatment ◽

Single Case ◽

Therapeutic Assessment ◽

Post Traumatic Stress ◽

Quasi Experimental ◽

History Of ◽

Post Traumatic ◽

Persistent Complex Bereavement ◽

Persistent Complex Bereavement Disorder

This article presents the results of a study into the effectiveness of therapeutic assessment (TA), a brief form of intervention that incorporates the results of assessment findings into psychological treatment. The history of Anthony, a man who reported symptoms of persistent complex bereavement disorder (PCBD), associated with major depression disorder (MDD) and post-traumatic stress disorder (PTSD), is presented. After his parents’ deaths, Anthony became detached from reality, lost all pleasure in his everyday life, and found it impossible to overcome the devastating feelings related to the loss. Following TA principles, the assessor created a supportive and empathic relationship with Anthony and helped him attain his goals for the assessment. The assessment was monitored using a single-case quasi-experimental design with time-series analysis. Results of this study revealed a specific trajectory of Anthony’s self-reported symptoms and a statistically significant trend toward improvement in severity at the end of the TA. This case study highlights the utility and efficacy of TA in helping clients process traumatic losses and complicated bereavements.

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Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: study protocol for a randomized controlled trial and a controlled trial

European Journal of Psychotraumatology ◽

10.1080/20008198.2021.1987687 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

L. Reitsma ◽

P.A. Boelen ◽

J. de Keijser ◽

L.I.M. Lenferink

Keyword(s):

Posttraumatic Stress Disorder ◽

Randomized Controlled Trial ◽

Posttraumatic Stress ◽

Stress Disorder ◽

Controlled Trial ◽

Depression Symptoms ◽

Randomized Controlled ◽

Online Treatment ◽

Persistent Complex Bereavement ◽

Persistent Complex Bereavement Disorder

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The Link Between Verbal Short-Term Memory and Anomia Treatment Gains

American Journal of Speech-Language Pathology ◽

10.1044/2019_ajslp-18-0176 ◽

2019 ◽

Vol 28 (3) ◽

pp. 1039-1052

Author(s):

Reva M. Zimmerman ◽

JoAnn P. Silkes ◽

Diane L. Kendall ◽

Irene Minkina

Keyword(s):

Short Term Memory ◽

Controlled Trial ◽

Treatment Success ◽

Linear Regression Models ◽

Language Performance ◽

Short Term ◽

Term Memory ◽

Treatment Gains ◽

Post Hoc

Purpose A significant relationship between verbal short-term memory (STM) and language performance in people with aphasia has been found across studies. However, very few studies have examined the predictive value of verbal STM in treatment outcomes. This study aims to determine if verbal STM can be used as a predictor of treatment success. Method Retrospective data from 25 people with aphasia in a larger randomized controlled trial of phonomotor treatment were analyzed. Digit and word spans from immediately pretreatment were run in multiple linear regression models to determine whether they predict magnitude of change from pre- to posttreatment and follow-up naming accuracy. Pretreatment, immediately posttreatment, and 3 months posttreatment digit and word span scores were compared to determine if they changed following a novel treatment approach. Results Verbal STM, as measured by digit and word spans, did not predict magnitude of change in naming accuracy from pre- to posttreatment nor from pretreatment to 3 months posttreatment. Furthermore, digit and word spans did not change from pre- to posttreatment or from pretreatment to 3 months posttreatment in the overall analysis. A post hoc analysis revealed that only the less impaired group showed significant changes in word span scores from pretreatment to 3 months posttreatment. Discussion The results suggest that digit and word spans do not predict treatment gains. In a less severe subsample of participants, digit and word span scores can change following phonomotor treatment; however, the overall results suggest that span scores may not change significantly. The implications of these findings are discussed within the broader purview of theoretical and empirical associations between aphasic language and verbal STM processing.

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