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Abstract

This study presents secondary analyses of a recently published trial in which post-traumatic stress disorder (PTSD) patients with psychosis (n = 108) underwent 8 sessions of trauma-focused treatment, either prolonged exposure (PE) or eye movement desensitisation and reprocessing (EMDR) therapy. 24.1% fulfilled the criteria for the dissociative subtype, a newly introduced PTSD subtype in DSM-5. Treatment outcome was compared for patients with and without the dissociative subtype of PTSD. Patients with the dissociative subtype of PTSD showed large reductions in clinician-administered PTSD scale (CAPS) score, comparable with patients without the dissociative subtype of PTSD. It is concluded that even in a population with severe mental illness, patients with the dissociative subtype of PTSD do benefit from trauma-focused treatments without a pre-phase of emotion regulation skill training and should not be excluded from these treatments.
In the latest version of the DSM, the DSM-5,
1
a dissociative subtype
of post-traumatic stress disorder (PTSD) is included. Patients with
this dissociative subtype meet the full criteria for PTSD and, in
addition, show persistent or recurrent symptoms of dissociation.
These symptoms may take the form of depersonalisation, i.e.
experiences of feeling detached from one’s body (e.g. like watching
yourself from the outside); and/or derealisation, i.e. experiences
of unreality of surroundings (e.g. the world around you is
experienced as unreal or dreamlike). The addition of this
dissociative subtype was partly based on the neurobiological
finding that patients with the dissociative subtype of PTSD show
midline prefrontal inhibition of limbic regions that are involved in
emotion regulation, leading to emotional overmodulation.
2
With respect to the clinical implications of the addition of the
dissociative subtype to the DSM, it was assumed that patients with
the dissociative subtype of PTSD, on the basis of these impaired
emotion regulation capacities, are not indicated for trauma-
focused treatments (TFTs) such as prolonged exposure (PE) or
eye movement desensitisation and reprocessing (EMDR) therapy.
3
These TFTs typically activate the fear network and are aimed at
emotional processing of trauma- related information within that
network. For patients with the dissociative subtype of PTSD, it
was assumed that the ability to adequately activate the fear
network would be limited owing to emotional overmodulation,
and that, as a result, TFT could not be effective.
2
Instead,
clinicians were advised to provide these patients with a phase-
based treatment approach, in which they learn to better regulate
their emotions before they enter TFT.
2
Correspondingly, many
clinicians hesitate to provide TFT to individuals with PTSD who
have dissociative symptoms.
4
Presumably, this contraindication
would apply even more to patients with severe mental illness,
for instance, PTSD patients with psychotic disorder such as
schizophrenia and schizoaffective disorder. These disorders are
characterised by delusions, hallucinations, disorganised speech,
disorganised behaviour and negative symptoms. Although
dissociation and psychosis are related and are interactive symptom
domains,
5
the typical characteristic of severe impairment in reality
testing in psychosis is not a feature of dissociation. Having
clinically relevant dissociative symptoms in addition to psychotic
symptoms may lead to even more reservations among clinicians
regarding the use of TFT in these patients. Thus far, however, there
is a lack of clinical studies into the effects of TFT on patients with
the dissociative subtype of PTSD in patient populations with
severe mental illness.
Method
In this brief report, we want to address this topic by comparing
patients with psychosis with and without the dissociative
subtype of PTSD, who underwent TFT without any pre-phase of
emotion regulation skill training. We performed a secondary
analysis of a large randomised clinical trial among PTSD patients
with psychosis (for details, see de Bont et al
6
), comparing 8
sessions of TFT – either PE (n= 53) or EMDR (n= 55) therapy
– with waiting list (n= 47) for PTSD patients with psychosis. In
earlier papers, we have reported that TFT was more effective than
waiting list in primary (PTSD symptoms)
7
and secondary (psychosis
and depression)
8
outcomes, and that TFT did not lead to adverse
events or symptom exacerbations in this patient population.
9
To test the assumptions above, we compared effects of TFT for
patients (PE and EMDR combined; n= 108) with and without the
dissociative subtype of PTSD, as established with items 29
(derealisation) and/or 30 (depersonalisation) (frequency 51 and
intensity 52) on the clinician-administered PTSD scale (CAPS).
10
The trial design was approved by the medical ethics committee
of the VU University Medical Center and was registered at
isrctn.com (ISRCTN79584912).
1
Effectiveness of trauma-focused treatment
for patients with psychosis with and without
the dissociative subtype of post-traumatic
stress disorder
A. van Minnen, B. van der Vleugel, D. van den Berg, P. de Bont, C. de Roos, M. van der Gaag
and A. de Jongh
Summary
This study presents secondary analyses of a recently
published trial in which post-traumatic stress disorder
(PTSD) patients with psychosis (n= 108) underwent 8 sessions
of trauma-focused treatment, either prolonged exposure
(PE) or eye movement desensitisation and reprocessing
(EMDR) therapy. 24.1% fulfilled the criteria for the
dissociative subtype, a newly introduced PTSD subtype
in DSM-5. Treatment outcome was compared for patients
with and without the dissociative subtype of PTSD.
Patients with the dissociative subtype of PTSD showed
large reductions in clinician-administered PTSD scale
(CAPS) score, comparable with patients without the
dissociative subtype of PTSD. It is concluded that even
in a population with severe mental illness, patients
with the dissociative subtype of PTSD do benefit from
trauma-focused treatments without a pre-phase of emotion
regulation skill training and should not be excluded from
these treatments.
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.
Copyright and usage
BThe Royal College of Psychiatrists 2016.
The British Journal of Psychiatry
1–2. doi: 10.1192/bjp.bp.116.185579
Short report
Results
We found that 24.1% of our population fulfilled the criteria of the
dissociative subtype, a proportion comparable with other studies.
3
All patients fulfilled diagnostic criteria for a psychotic disorder
(60.2% had schizophrenia and 29.6% schizoaffective disorder)
and full diagnostic criteria for PTSD. Most patients had
experienced severe childhood trauma. In the PTSD, dissociative
subtype group, 7 patients dropped out (26.9%) v. 17 patients
(20.7%) in the PTSD no-dissociative subtype group (w
2
(1,
n= 108) = 5.08, P= 0.59). The following analyses were performed
in the subgroup of completers (n= 82; post-treatment data were
missing for 2 treatment completers). Patients with the dissociative
subtype of PTSD showed a similar decrease in PTSD symptoms on
the CAPS (within-group Cohen’s d= 1.63) to that of the patients
without the dissociative subtype of PTSD (within-group Cohen’s
d= 1.68), w ith large reductions observed in both groups (see
Fig. 1). Patients with the dissociative subtype of PTSD showed
significantly more severe PTSD symptoms at pre-treatment
(t(80) = 70.29, P= 0.005), whereas at post-treatment, CAPS
scores did not significantly differ (t(80) = 71.34, P= 1.85).
Discussion
Our data showed that even in one of the most vulnerable patient
populations – patients with a psychotic disorder and PTSD –
individuals with the dissociative subtype of PTSD showed large
improvements in PTSD symptoms and responded in a similar
way to those without the dissociative subtype of PTSD. Our data
are in line with several other studies in other patient populations
(e.g., Wolf et al
11
) and thereby add to the consistent findings that
patients with dissociative subtype benefit from TFTs comparably to
patients without this subtype. Also, patients with the dissociative
subtype of PTSD did not drop out more often than patients
without the dissociative subtype of PTSD, suggesting that TFT is
not intolerable for PTSD patients with dissociative subtype.
Our study needs replication in this specific patient population,
especially because symptoms of psychosis and dissociation are
highly related
5
, and more sophisticated measures of dissociative
subtype could be used in future studies. Despite these limitations,
however, our data strongly indicate that there is no need to
withhold patients with the dissociative subtype of PTSD from
TFT, or to add a pre-phase of emotion regulation skills for
patients with this subtype. Together with the many recent and
consistent findings that patients with the dissociative subtype of
PTSD respond equally well to regular TFT as do patients
without the dissociative subtype of PTSD (e.g. Wolf et al
11
), this
study showed that patients with the dissociative subtype of PTSD
do not need a different treatment (see also De Jongh et al
12
for a
similar discussion). For clinicians, it may be valuable to know that,
in contrast to their clinical view,
4
patients with the dissociative sub-
type of PTSD can be effectively and safely treated with prolonged
exposure therapy or EMDR therapy, using standard treatment
protocols without preparatory emotion regulation skill training.
Agnes van Minnen, PhD, Radboud University Nijmegen, Behavioural Science
Institute, NijCare, The Netherlands, and MHO Pro Persona, Centre for Anxiety Disorders
Overwaal, Nijmegen, The Netherlands; Berber M. van der Vleugel, MSc, Community
Mental Health Service GGZ Noord-Holland Noord; David P. G. van den Berg,MSc,
Parnassia Psychiatric Institute, Den Haag, The Netherlands; Paul A. J. M. de Bont,
MSc, Mental Health Organization (MHO) GGZ Oost Brabant, The Netherlands; Carlijn
de Roos, MSc, MHO Rivierduinen, The Netherlands; Mark van der Gaag, PhD, VU
University Amsterdam and EMGO Institute for Health and Care Research, Department
of Clinical Psychology, and Parnassia Psychiatric Institute, Den Haag, The Netherlands;
Ad de Jongh, PhD, 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
Correspondence: Agnes van Minnen, Radboud University Nijmegen,
Behavioural Science Institute, NijCare, PO Box 9104, 6500 HE Nijmegen, The
Netherlands. Email: a.van.minnen@propersona.nl
First received 25 Mar 2015; final revision 16 May 2016; accepted 24 May 2016
Funding
This study was funded by the Dutch Support Foundation ‘Stichting tot Steun VCVGZ’, P.O.
Box 9219, 6800 HZ Arnhem, +31(26) 38 98900, E-mail: info@stichtingtotsteunVCVGZ.nl
(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.
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2
van Minnen et al
Dissociative subtype
No dissociative subtype
90 –
80 –
70 –
60 –
50 –
40 –
30 –
20 –
10 –
0–
Pre-treatment Post-treatment
Fig. 1 CAPS (clinician-administered post-traumatic stress
disorder scale) scores for patients with (
n
= 18, 22%) and
without (
n
= 64, 78.0%) dissociative subtype in completers.
10.1192/bjp.bp.116.185579 published online August 4, 2016 Access the most recent version at DOI: BJP
Jongh
A. van Minnen, B. van der Vleugel, D. van den Berg, P. de Bont, C. de Roos, M. van der Gaag and A. de
post-traumatic stress disorder
psychosis with and without the dissociative subtype of
Effectiveness of trauma-focused treatment for patients with
References http://bjp.rcpsych.org/content/early/2016/07/21/bjp.bp.116.185579#BIBL
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Background: Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them. Objectives: To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults. Search methods: We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial). DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias. Main results: We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1). The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17 studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect. Authors' conclusions: The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.
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Objectives: Most clinicians refrain from trauma treatment for patients with psychosis because they fear symptom exacerbation and relapse. This study examined the negative side effects of trauma-focused (TF) treatment in patients with psychosis and posttraumatic stress disorder (PTSD). Methods: Analyses were conducted on data from a single-blind randomized controlled trial comparing TF treatment (N = 108; 8 sessions prolonged exposure or eye movement desensitization) and waiting list (WL; N = 47) among patients with a lifetime psychotic disorder and current chronic PTSD. Symptom exacerbation, adverse events, and revictimization were assessed posttreatment and at 6-month follow-up. Also investigated were symptom exacerbation after initiation of TF treatment and the relationship between symptom exacerbation and dropout. Results: Any symptom exacerbation (PTSD, paranoia, or depression) tended to occur more frequently in the WL condition. After the first TF treatment session, PTSD symptom exacerbation was uncommon. There was no increase of hallucinations, dissociation, or suicidality during the first 2 sessions. Paranoia decreased significantly during this period. Dropout was not associated with symptom exacerbation. Compared with the WL condition, fewer persons in the TF treatment condition reported an adverse event (OR = 0.48, P = .032). Surprisingly, participants receiving TF treatment were significantly less likely to be revictimized (OR = 0.40, P = .035). Conclusions: In these participants, TF treatment did not result in symptom exacerbation or adverse events. Moreover, TF treatment was associated with significantly less exacerbation, less adverse events, and reduced revictimization compared with the WL condition. This suggests that conventional TF treatment protocols can be safely used in patients with psychosis without negative side effects.
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A dissociative subtype of posttraumatic stress disorder (PTSD) was recently added to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) and is thought to be associated with poor PTSD treatment response. We used latent growth curve modeling to examine data from a randomized controlled trial of prolonged exposure and present-centered therapy for PTSD in a sample of 284 female veterans and active duty service members with PTSD to test the association between the dissociative subtype and treatment response. Individuals with the dissociative subtype (defined using latent profile analysis) had a flatter slope (p = .008) compared with those with high PTSD symptoms and no dissociation, such that the former group showed, on average, a 9.75 (95% confidence interval [-16.94, -2.57]) lesser decrease in PTSD severity scores on the Clinician Administered PTSD Scale (Blake et al., 1995) over the course of the trial. However, this effect was small in magnitude. Dissociative symptoms decreased markedly among those with the subtype, though neither treatment explicitly addressed such symptoms. There were no differences as a function of treatment type. Results raise doubt about the common clinical perception that exposure therapy is not effective or appropriate for individuals who have PTSD and dissociation, and provide empirical support for the use of exposure treatment for individuals with the dissociative subtype of PTSD. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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The efficacy of posttraumatic stress disorder (PTSD) treatments in psychosis has not been examined in a randomized clinical trial to our knowledge. Psychosis is an exclusion criterion in most PTSD trials. To examine the efficacy and safety of prolonged exposure (PE) therapy and eye movement desensitization and reprocessing (EMDR) therapy in patients with psychotic disorders and comorbid PTSD. A single-blind randomized clinical trial with 3 arms (N = 155), including PE therapy, EMDR therapy, and waiting list (WL) of 13 outpatient mental health services among patients with a lifetime psychotic disorder and current chronic PTSD. Baseline, posttreatment, and 6-month follow-up assessments were made. Participants were randomized to receive 8 weekly 90-minute sessions of PE (n = 53), EMDR (n = 55), or WL (n = 47). Standard protocols were used, and treatment was not preceded by stabilizing psychotherapeutic interventions. Clinician-rated severity of PTSD symptoms, PTSD diagnosis, and full remission (on the Clinician-Administered PTSD Scale) were primary outcomes. Self-reported PTSD symptoms and posttraumatic cognitions were secondary outcomes. Data were analyzed as intent to treat with linear mixed models and generalized estimating equations. Participants in the PE and EMDR conditions showed a greater reduction of PTSD symptoms than those in the WL condition. Between-group effect sizes were 0.78 (P < .001) in PE and 0.65 (P = .001) in EMDR. Participants in the PE condition (56.6%; odds ratio [OR], 3.41; P = .006) or the EMDR condition (60.0%; OR, 3.92; P < .001) were significantly more likely to achieve loss of diagnosis during treatment than those in the WL condition (27.7%). Participants in the PE condition (28.3%; OR, 5.79; P = .01), but not those in the EMDR condition (16.4%; OR, 2.87; P = .10), were more likely to gain full remission than those in the WL condition (6.4%). Treatment effects were maintained at the 6-month follow-up in PE and EMDR. Similar results were obtained regarding secondary outcomes. There were no differences in severe adverse events between conditions (2 in PE, 1 in EMDR, and 4 in WL). The PE therapy and EMDR therapy showed no difference in any of the outcomes and no difference in participant dropout (24.5% in PE and 20.0% in EMDR, P = .57). Standard PE and EMDR protocols are effective, safe, and feasible in patients with PTSD and severe psychotic disorders, including current symptoms. A priori exclusion of individuals with psychosis from evidence-based PTSD treatments may not be justifiable. isrctn.com Identifier: ISRCTN79584912.
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Aims Many individuals with schizophrenia are reported to have maladaptive expression and processing of emotion. This may take the form of conscious and implicit processes. Potential regulatory processes underlying schizophrenia are reviewed. We aimed to estimate effect sizes, potential heterogeneity and publication bias across three areas of measurement: a range of cognitive emotion regulation strategies1 (CERS), alexithymia and dissociation. Method Data were pooled from 47 case-control studies involving measures of experiential avoidance, attentional deployment, cognitive reappraisal, emotion management, dissociation and alexithymia. All studies were rated for quality, risk of bias and publication bias. Results The following effect sizes (g) were observed: emotion management: 0.96 [0.77, 1.14] and cognitive reappraisal: 0.49 [0.32, 0.66] were negatively associated with schizophrenia. Experiential avoidance: -0.44 [-0.59, -0.29], attentional deployment -0.96 [-1.18, -0.75], dissociation: -0.86 [-1.13, -0.60] and alexithymia: -1.05 [-1.45, -0.65] were positively associated with schizophrenia. Subgroups of dissociation and attentional deployment were also analysed. Meta-analyses revealed potential publication bias and heterogeneity in the study of CERS in schizophrenia. Conclusions A marked difference in the implementation of CERS is associated with schizophrenia compared to controls. Dissociation variables and alexithymia are also implicated and may be implicated in adaptive cognitive emotional regulation. Theoretical and research implications are discussed.
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Background: Trauma contributes to psychosis and in psychotic disorders post-traumatic stress disorder (PTSD) is often a comorbid disorder. A problem is that PTSD is underdiagnosed and undertreated in people with psychotic disorders. This study's primary goal is to examine the efficacy and safety of prolonged exposure and eye movement desensitization and reprocessing (EMDR) for PTSD in patients with both psychotic disorders and PTSD, as compared to a waiting list. Secondly, the effects of both treatments are determined on (a) symptoms of psychosis, in particular verbal hallucinations, (b) depression and social performance, and (c) economic costs. Thirdly, goals concern links between trauma exposure and psychotic symptomatology and the prevalence of exposure to traumatic events, and of PTSD. Fourthly predictors, moderators, and mediators for treatment success will be explored. These include cognitions and experiences concerning treatment harm, credibility and burden in both participants and therapists. Methods/design: A short PTSD-screener assesses the possible presence of PTSD in adult patients (21- to 65- years old) with psychotic disorders, while the Clinician Administered PTSD Scale interview will be used for the diagnosis of current PTSD. The M.I.N.I. Plus interview will be used for diagnosing lifetime psychotic disorders and mood disorders with psychotic features. The purpose is to include consenting participants (N = 240) in a multi-site single blind randomized clinical trial. Patients will be allocated to one of three treatment conditions (N = 80 each): prolonged exposure or EMDR (both consisting of eight weekly sessions of 90 minutes each) or a six-month waiting list. All participants are subjected to blind assessments at pre-treatment, two months post treatment, and six months post treatment. In addition, participants in the experimental conditions will have assessments at mid treatment and at 12 months follow-up. Discussion: The results from the post treatment measurement can be considered strong empirical indicators of the safety and effectiveness of prolonged exposure and EMDR. The six-month and twelve-month follow-up data have the potential of reliably providing documentation of the long-term effects of both treatments on the various outcome variables. Data from pre-treatment and midtreatment can be used to reveal possible pathways of change. Trial registration: Trial registration: ISRCTN79584912.
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Clinical and neurobiological evidence for a dissociative subtype of posttraumatic stress disorder (PTSD) has recently been documented. A dissociative subtype of PTSD is being considered for inclusion in the forthcoming Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) to address the symptoms of depersonalization and derealization found among a subset of patients with PTSD. This article reviews research related to the dissociative subtype including antecedent, concurrent, and predictive validators as well as the rationale for recommending the dissociative subtype. The relevant literature pertaining to the dissociative subtype of PTSD was reviewed. Latent class analyses point toward a specific subtype of PTSD consisting of symptoms of depersonalization and derealization in both veteran and civilian samples of PTSD. Compared to individuals with PTSD, those with the dissociative subtype of PTSD also exhibit a different pattern of neurobiological response to symptom provocation as well as a differential response to current cognitive behavioral treatment designed for PTSD. We recommend that consideration be given to adding a dissociative subtype of PTSD in the revision of the DSM. This facilitates more accurate analysis of different phenotypes of PTSD, assist in treatment planning that is informed by considering the degree of patients’ dissociativity, will improve treatment outcome, and will lead to much-needed research about the prevalence, symptomatology, neurobiology, and treatment of individuals with the dissociative subtype of PTSD.