Phase-based treatment versus direct trauma-focused treatment in patients with complex PTSD.


Complex Post Traumatic Stress Disorder (Complex PTSD) is a term used to denote a severe form of PTSD following repeated interpersonal traumatization in childhood. This construct comprises symptom clusters reflecting difficulties in regulating emotions, disturbances in relational capacities, alterations in attention and consciousness, adversely affected belief systems, and somatization. The lifetime prevalence of PTSD in the Netherlands has been estimated 7.4 % (De Vries & Olff, 2009), and approximately 25% of patients with PTSD would suffer from Complex PTSD (Wolf et al., 2014). According to clinical guidelines, treatment should be ‘phase-based’, indicating that patients with Complex PTSD symptoms will profit more from trauma-focused treatment if this phase in treatment is preceded by a stabilization phase aimed at achieving patient safety and improving emotion regulation, patients’ positive self-concept, and interpersonal skills. The expectation is that the patient that suffers from complex PTSD will notbe able to tolerate the negative emotions resulting from a trauma focused treatment. Patients suffering from Complex PTSD are by many healthcare providers still viewed as a vulnerable patient group, to be handled with caution.However, empirically, the superiority of a phase-based approach (i.e., starting with a stabilization phase) is yet to be established. Properly designed studies in which a phase-based treatment is compared to a condition in which the treatment directly focusses on processing the content of the traumatic memories are lacking. Offering a phased based treatment might also prove to be unnecessary or even, given that stabilization may prevent patients from receiving effective treatment. As an example of this from another field, recent findings showed that trauma focused treatment is feasible and effective in patients suffering from psychosis, another patient group commonly thought to be too vulnerable to tolerate high levels of negative emotions resulting fromdirect exposure to traumatic memories (De Bont et al., 2013).

The purpose of the present study is to determine superiority in efficacy of a phase-based treatment (i.e., EMDR therapy preceded by Skills Training in Affective and Interpersonal Regulation, STAIR) versus trauma-focused treatment alone (i.e., EMDR therapy) to treat individuals suffering from (Complex) PTSD due to a history of repeated sexual and/or physical abuse in childhood (by a caretaker or person in authority, and before the age of 18). Our first aim is to test the hypothesis that a phase-based treatment (EMDR preceded by STAIR) is significantly more effective compared to direct trauma-focused treatment (EMDR alone). Outcome is determined in terms of proportion of lost PTSD diagnoses and decrease of PTSD symptoms, comorbid symptom decrease, lower drop-out rate, and increased quality of life. Our second aim is to identify possible predictors of worse outcome and drop-out (e.g. pre-treatment anxiety, depression, and personality disorders).

Is trauma-focused therapy preceded by a stabilization treatment indeed more effective than direct trauma-focused treatment alone?
What are predictors of worse-outcome or deterioration?

Design: A randomized controlled trial, with two conditions (STAIR-EMDR therapy versus EMDR therapy alone).

Studie populatie: Patients between 18- and 65-years of age, meeting the criteria for the diagnoses PTSD (according to DSM-5) and reporting symptoms of Complex PTSD due to a history of repeated sexual and/or physical abuse in childhood by a caretaker or person in authority (before the age of 18).

The treatment of patients with Complex PTSD is subject to international debate. International guidelines formulated by the ISTSS (Cloitre et al., 2011) prescribe phase-based treatment for patients with Complex PTSD. As a result, in clinical practice, phase-based treatment is widely practiced. However, evidence for the superiority of phase-based treatment above direct trauma-focused treatment is lacking, while it is also unclear which patient characteristics, if any, determine whether a phase-based treatment is necessary or useful instead of direct trauma-focused treatment (in this case EMDR therapy).

Promotie begeleiding:
Professor A. de Jongh, Universiteit van Amsterdam (promotor)
Dr. R. Huntjens, Rijksuniversiteit Groningen (copromotor)
Dr. Maarten van Dijk, Dimence (copromotor)

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Interne afdeling(en): regio Almelo, Zwolle, Zutphen, Deventer en Twello.
Externe partij(en): , UvA (Amsterdam), RuG (Groningen), Arq expert centrum voor psychotrauma.

In kader van:
Duur van het onderzoek:
september 2016 tot december 2019
In uitvoering
Noortje van Vliet