#23: Body therapy for the rehabilitation of veterans with PTSD: Study design and preliminary results
Nanna Gram Ahlmark1*, Anders Dahl2*, Henrik Steen Andersen3, Tine Tjørnhøj-Thomsen4, Susan Andersen5
*Denotes equal first authors
1,2,4,5: National institute of Public Health, University of Southern Denmark 3: Danish Military Psychiatric Center, Capital Region of Denmark
Corresponding author: Nanna Gram Ahlmark, National Institute of Public Health, University of Southern Denmark
Background: PTSD implies complex physical and psychosocial problems for the affected veterans and their families. Treatment options today are primarily medically and psychologically founded but show limited effects. Body therapy regarding PTSD is subject of increased attention. In 2015, a Danish pilot study was conducted exploring body therapy for PTSD. The study showed positive results and formed basis for this trial.
Methods: The intervention will be evaluated in a two-arm randomised controlled trial (1:1). The study population is 42 in total. The control group receives treatment as usual. The intervention group receives treatment as usual and body therapy as add-on. The intervention includes physical treatment of the body along with meditation. Participants will complete four web-based
questionnaires assessing PTSD, depression, quality of life, function level and body awareness: at baseline, 3 months post-baseline, 6 months post baseline and at 12-months follow-up. Linear regression and mixed effects models will be used to assess intervention effects. Furthermore, an ethnographic study based on in-depth interviews, focus group and participant observations will examine participants’ experiences of the body treatment and changes in their everyday life.
Data collection: The data collection is finished for baseline and midways assessments with very promising response rates; 100% and 98%, respectively. The data collection for post-intervention is on-going with a preliminary response rate of 90%. The qualitative data generation is almost
complete with 15 interviews and 7 participant observation and 1 focus group.
Conclusion: This study will examine the efficacy of body therapy for PTSD and how the treatment is affecting daily life. Once our data collection is completed, we will examine intervention effects and how durability of intervention sessions may impact outcomes.
#24: ICD-11 PTSD and Complex PTSD in Treatment-seeking Danish Veterans: A Latent Profile Analysis
Sofie Folke, PhD1, 2, Anni B. S. Nielsen, PhD1, 3, Søren Bo Andersen, PhD1, Thanos Karatzias, PhD4, 5, Karen-Inge Karstoft, PhD1, 6
1 Research and Knowledge Centre, the Danish Veterans Centre, Ringsted, Denmark.
2 Department of Military Psychology, the Danish Veterans Centre, Copenhagen, Denmark.
3 The Research Unit and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
4 School of Health and Social Care, Edinburgh, Napier University, Edinburgh, UK.
5 Rivers Centre for Traumatic Stress, NHS, Lothian, Edinburgh, UK.
6 Department of Psychology, University of Copenhagen, Copenhagen, Denmark.
Email-addresses:
SF: vetc-mpa43@mil.dk ABSN: vetc-vic004@mil.dk SBA: vetc-chvic@mil.dk TK: t.karatzias@napier.ac.uk KIK: vetc-vic01@mil.dk
Abstract
Introduction: The WHO International Classification of Diseases, 11th version (ICD-11), includes a trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD) distinct from
posttraumatic stress disorder (PTSD). Results from previous studies support the validity of this distinction. However, no studies to date have evaluated the ICD-11 model of PTSD and CPTSD in treatment-seeking military veterans. The aim of the present study was to determine if the
distribution of symptoms in treatment-seeking Danish veterans were consistent with the ICD-11 PTSD and CPTSD symptom profiles. Based on previous studies, we hypothesized that separate classes representing PTSD and CPTSD would be found, that membership of a potential CPTSD-class would be predicted by a larger number of childhood traumas, and that a potential distinction between PTSD and CPTSD would be supported by differences in sociodemographic and functional outcomes.
Method: Participants (N =1,541) were formerly deployed Danish soldiers who completed proxy
32 report measures of traumatic life events, prior to starting treatment at the Military Psychology Department of the Danish Defence.
Results: All hypotheses were supported. Latent profile analysis (LPA) revealed separate classes representing PTSD and CPTSD. In comparison to the PTSD-class, membership of the CPTSD-class was predicted by more childhood traumatic experiences, and members of this class were more likely being single/divorced/widowed and more likely to use psychotropic medication. Besides a PTSD-class and a CPTSD-class, LPA revealed a Low Symptoms-class, a Moderate DSO-class, a Hyperarousal-class, and a High DSO-class, with clear differences in functional outcomes between classes.
Discussion and conclusion: Findings replicate previous studies supporting the distinction between ICD-11 PTSD and CPTSD. In addition, there seems to be groups of treatment-seeking military veterans that do not fulfill full criteria for a trauma-related disorder. Further research should explore subsyndromal PTSD and CPTSD profiles in veterans and other populations.
#25: Profilbaseret behandling af veteraner – kliniske interventionsstudier Sofie Folke1, 2, Nikolai C. Roitmann1 og Kasper Eskelund Folke1, 2
1 Militærpsykologisk Afdeling, Veterancentret, København, Danmark
2 Veterancentrets Videnscenter, Ringsted, Danmark Sofie Folke: vetc-mpa43@mil.dk
Nikolai C. Roitmann: vetc-mpa202@mil.dk Kasper Eskelund: vetc-mpa41@mil.dk Abstracts:
Generel indledning
Militærpsykologisk Afdeling (MPA) under Veterancentret tilbyder psykologisk behandling til danske krigsveteraner og deres pårørende. Som udgangspunkt tilbydes evidensbaserede
psykologiske behandlingsmetoder såsom prolonged exposure (PE) og cognitive processing therapy (CPT), mens nye og mere eksperimentelle behandlingsformer tilbydes i forskningsprojekter, hvor effekten af behandlingen monitoreres, og hvor klienterne giver informeret samtykke til at deltage.
Vi vil i dette oplæg præsentere tre aktuelle kliniske interventionsstudier ved MPA. Det første projekt er et udviklingsprojekt hvor et modulopbygget behandlingsprogram til veteraner med kompleks-PTSD udvikles og evalueres. Det andet projekt er et pilotprojekt, hvor 10 danske
krigsveteraner, udsendt til enten Afghanistan eller Irak, modtager virtual reality eksponeringsterapi (VRET). Pilotprojektet undersøger, hvorvidt VRET er relevant og gennemførbart for danske soldater med PTSD. Det tredje projekt er et feasibility-studie hvor 20 veteraner, der ikke havde responderet på gentagne behandlingsforsøg modtog neurofeedback-behandling med fokus på regulering af hyperarousal.
34
#26: ”Modular CBT for Complex-PTSD” (MCC projektet)
Introduktion: Den nye ICD-11 diagnose Kompleks-PTSD (KPTSD) kalder på længerevarende behandlingstilbud ift. eksisterende behandlingstilbud til PTSD, samt mulighed for at kunne personalisere behandlingen til den enkelte klients præferencer og mest fremtrædende symptomer.
Formålet med MCC projektet er at udvikle og evaluere et modulopbygget behandlingsprogram til veteraner med KPTSD. Formålet med det modulopbyggede program er at behandlingsmodulerne skal kunne kombineres på forskellig vis, således at de matcher klientens præferencer og mest fremtrædende symptomer.
Metode: I 2019 er fem CBT behandlingsmoduler, der fokuserer på 1) PTSD-symptomer, 2)
vanskeligheder med emotionsregulering, 3) negativt selvbillede, 4) interpersonelle problemer og 5) søvnproblemer og traumerelaterede mareridt, blevet udviklet ved MPA i samarbejde med forskere ved Edinburgh Napier Universitet i Skotland. Primo 2020 vil det modulopbyggede program blive afprøvet i en række velkontrollerede kliniske casestudier ved MPA. Ultimo 2020 vil MCC
programmet blive evalueret i et randomiseret kontrolleret forsøg, hvor veteraner med KPTSD (N=60) randomiseres til MCC versus ”treatment as usual” ved MPA.
Resultater, Diskussion og Konklusion: Med den nye ICD-11 diagnose KPTSD, som er
kendetegnet ved flere symptomer og større funktionsnedsættelse end PTSD, ses der et behov for at udvikle og afprøve nye, mere længerevarende, behandlingsformer til klienter med KPTSD
(Karatzias et al., 2019). I sin opbygning søger MCC projektet at muliggøre individualisering af behandlingen samt at medinddrage klienter i behandlingsbeslutninger (ved at klienten er med til at vælge rækkefølgen og antal behandlingsmoduler), hvilket forventes at øge den terapeutiske alliance og reducere dropout.
#27: Brug af virtual reality i eksponeringsterapi til PTSD
Introduktion: Virtual reality eksponerings terapi (VRET) har vist sig at være ligeså effektivt til at behandle PTSD symptomer, som traditionel eksponeringsterapi (Gonçalves, Pedrozo, Coutinho, Figueira, & Ventura, 2012; Greg M. Reger et al., 2016). I Danmark er teknologien endnu ikke afprøvet i forbindelse med behandling af PTSD, hvilket understreger behovet for at undersøge, hvorvidt VRET er relevant og gennemførbart for danske soldater med PTSD, som har været udsendt til enten Afghanistan eller Irak.
Metode: Et ikke-kontrolleret, mixed-method studie, der følger 10 danske krigsveteraner med PTSD før, under og efter deres VRET behandlingsforløb. Behandlingens effekt måles på PTSD
symptomer ved CAPS-5 (primært outcomemål), samt på depression, angst, livskvalitet og psykosocial funktion (sekundære outcomemål). Endvidere afsøges kvalitativt, hvordan VR teknologien opleves, accepteres og tages i mod af deltagerne. Herunder deltagernes eventuelle forslag til forbedringer og eventuelle behov for danske tilpasninger af den amerikanske software.
Resultater: Univariat deskriptiv statistik anvendes til at beskrive demografiske og kliniske
variabler for samplet ved baseline. Effektanalyse i form af ”paired t-test” og Wilcoxon signed ranks test” (præ-post, præ-3 mdr, post-3 mdr) for primære og sekundære outcomemål.
Diskussion: En prædiktor for dropout af PTSD behandling for danske krigsveteraner er lavere alder (Folke et al. 2019) I en klinisk setting vurderes VRET at være en mere attraktiv mulighed for især den yngre del af målgruppen end traditionel eksponeringsterapi og kan medvirke til at motivere og fastholde veteraner i PTSD behandlingen.
36
#28: Neurofeedback as a treatment for hyperarousal in treatment-resistant PTSD
Introduction: Hyperarousal is a common symptom following exposure to trauma and a core PTSD symptom. Unfortunately, the presence of pronounced hyperarousal is associated with lower
treatment outcomes for other trauma-related symptoms. This underlines the need for treatments addressing this specific symptom. EEG-neurofeedback may provide a route to specifically regulating hyperarousal.
Method: Participants (N=20) were recruited among Danish treatment-seeking veterans, selected for presenting a symptom combination with pronounced and primary hyperarousal and having been participating in multiple unsuccessful treatment attempts. Neurofeedback was given as a treatment in 36 sessions with three sessions per week, each consisting of 20-35 minutes of active training. The neurofeedback protocol was designed in NeuroGuide (Applied Neuroscience, Inc.), targeting power and connectivity in source-localized EEG between fronto-limbic regions and within prefrontal cortex in areas associated with hyperarousal and in the frequency range 1-30 hz. Training targets were set in relation to a normative database of EEG in healthy adults. Trauma-related
symptomatology was assessed with PCL-C and DASS-42.
Results: 50% of participants reported a substantial reduction in PTSD symptoms. Affective and anxiety symptoms as registered by DASS-42 were largely unchanged. However, stress symptoms recorded with DASS-42 showed a substantial decrease.
Discussion: In 50% of a sample that had not responded to previous treatments, neurofeedback was effective in reducing trauma-related symptomatology. The change was mainly seen in stress symptoms. This is expected as the intervention was specifically targeting hyperarousal. Potential and limitations of neurofeedback as a therapy for trauma reactions as well as lessons learned are presented.
#29: Pretreatment Predictors of Dropout from Cognitive Behavioral Therapy for PTSD in a Military Psychology Clinic
Sofie Folke1, 2, Nikolai C. Roitmann1, Dorte Hjortkjær1, Søren Bo Andersen2, Anni B. S. Nielsen2,3
1 Department of Military Psychology, the Danish Veterans Centre, Copenhagen, Denmark.
2 Research and Knowledge Centre, the Danish Veterans Centre, Ringsted, Denmark.
3 The Research Unit and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark.
Sofie Folke: vetc-mpa43@mil.dk
Nikolai C. Roitmann: vetc-mpa202@mil.dk Dorte Hjortkjær: vetc-ldkl@mil.dk
Søren Bo Andersen: vetc-chvic@mil.dk Anni B.S. Nielsen: vetc-vic004@mil.dk
Introduction: Cognitive-behavioral therapies (CBTs) for posttraumatic stress disorder (PTSD) have been shown to be effective, though they can be limited by relatively high treatment dropout rates. Dropout rates have generally been reported to be higher in “real world” military PTSD clinics (32-72%; Jefrey et al., 2014; Zayfert et al., 2005) as compared to research studies (12-39%;
Steenkamp et al., 2015). The current study examined pre-treatment predictors of dropout from CBT for PTSD in a “real world” military psychology clinic within the Danish Defence.
Methods: Study participants were 89 Danish military veterans with probable PTSD (DSM-IV) who received individual CBT for PTSD (primarily prolonged exposure and cognitive processing
therapy) at the Military Psychology Department within the Danish Defense. Participants were included if they started treatment in 2014 to 2018. Multivariate logistic regression analysis with inclusion of possible risk factors was used to predict treatment dropouts versus treatment completion. Results are presented as Odds ratios with 95% confidence interval (CI).
Results: Twenty-four veterans (27%) dropped out of treatment prematurely. Multivariate logistic regression analysis found higher odds for lower age (OR: 0.89; 95% CI: 0.82-0.97) and alcohol consumption exceeding weekly recommendations (OR: 7.47; 95% CI: 1.46-38.29) among treatment dropouts (n=24) versus treatment completers (n=65).
38 Discussion: The finding that lower age and higher alcohol consumption predict dropout from individual CBT for PTSD is in line with findings from studies in military PTSD clinics in the US (e.g. Garcia et al., 2011; Harpaz-Rotem & Rosenheck, 2011; Niles et al., 2017; Kehle-Forbes et al., 2015).
Conclusion: As a next step, we aim to include more clients in the study, apply machine learning methods to identify predictors, and investigate clients’ reasons for dropping out of treatment based on clients’ treatment records.
#30: Virker kropsterapi i PTSD-behandlingen? Evaluering af “Basic Body Awareness Therapy” til veteraner som del af tværfaglig traumebehandling
Julie Wedel Gjelstrup1, Henrik T. Machon1, Ditte Larsen1, Janne F. Hertz1, Nikolai C. Roitmann1, Louise Lau Justesen1, Anni B.S. Nielsen2
1 Militærpsykologisk Afdeling, Veterancentret, København, Danmark; 2 Videncentret, Veterancentret, Ringsted, Danmark; Julie Wedel Gjelstrup: vetc-mpa09@mil.dk; Henrik T.
Machon: mpa502@mil.dk; Ditte Larsen: mpa501@mil.dk; Janne F. Hertz: mpa241@mil.dk; Nikolai C. Roitmann: mpa202@mil.dk; Louise Lau Justesen: vetc-mpa08@mil.dk; Anni B.S. Nielsen: vetc-vic004@mil.dk
Introduktion: Kropsorienteret terapi ved PTSD er udbredt i traumeklinikker både internationalt og nationalt, og særligt Basic Body Awareness Therapy (BBAT) anvendes i nordisk regi. Blandt personer med PTSD er der kun få undersøgelser, der undersøger, hvilken ændring BBAT har på bevægelseskvaliteten, kropsoplevelsen og smerter – og undersøgelserne har blandede resultater.
Dette projekt undersøger, om BBAT øger bevægelseskvaliteten, reducerer PTSD-symptomer, samt bedrer kropsoplevelsen blandt veteraner med PTSD, der behandles i Militærpsykologisk Afdeling (MPA).
Metode: Ikke-kontrolleret kohortedesign. Deltagerne undersøges før og efter de har modtaget 12 BBAT behandlinger af fysioterapeuter tilknyttet MPA. Deltagernes bevægelseskvalitet,
selvrapporterede subjektive-, kropslige-, PTSD-, depressions-, angst- og stress-symptomer, samt kropsbevidsthed og regulering registreres via behandlende fysioterapeuter samt selvudfyldte spørgeskemaer. Projektet følges også af fysioterapistuderende på Københavns Professionshøjskole.
Projektets løbetid er fra 2019 til 2020.
Foreløbige resultater: Siden 2019 er over 20 klienter startet på BBAT. Foreløbige resultater indsamlet via fysioterapistuderende tyder på, at klienterne sætter pris på BBAT og bedrer deres kropsoplevelse.
Diskussion og konklusion: De foreløbige resultater tyder på, at der er en bedring af klienternes kropsoplevelse. Grundet få afsluttede klienter er det på tidspunktet for abstractets udformning endnu ikke muligt at vurdere, hvorvidt der er en bedring af klienternes bevægelseskvalitet og de øvrige faktorer, der skal evalueres på.
40
#31: Trajectories of depression symptoms from pre- to post- deployment: does previous trauma predict symptom increase?
Karen-Inge Karstofta, b, Anni B.S. Nielsena, c, Cherie Armourd, Mia S. Vedtoftea, Søren B.
Andersena
a Research and Knowledge Centre, the Danish Veteran Centre, Ringsted, Denmark.
b Department of Psychology, University of Copenhagen, Denmark.
c The Research Unit and Section of General Practice, Institute of Public Health, University of Copenhagen, Denmark.
d School of Psychology, Queens University Belfast, Belfast, Northern Ireland.
Karen-Inge Karstoft: vetc-vic01@mil.dk Anni B. S. Nielsen: vetc-vic004@mil.dk Cherie Armour: c.armour@qub.ac.uk Mia S. Vedtofte: vetc-vic02@mil.dk Søren B. Andersen: vetc-chvic@mil.dk Introduction
A significant minority of individuals experience depression following military deployment. The course of depression symptoms varies over time and across individuals; several factors including combat exposure influence depressions incidence and course. Importantly, previous trauma, especially in childhood, have been found increase the risk of post-deployment depression. The aim of the current study is twofold: To estimate trajectories of depression symptoms from before through years after deployment, and to evaluate the relative importance of trauma in childhood and adult life as well neuroticism in predicting these trajectories, alone and in combination with combat exposure.
Methods
In a prospective sample of 530 soldiers deployed to Afghanistan in 2009, we estimated trajectories of depression symptoms from before through 6.5 years after deployment applying Latent Growth
Mixture Modeling. In a multinomial logistic regression model, we tested if childhood and adult life trauma predicted trajectory membership in combination with combat exposure and personality.
Results
We identified a large trajectory of few depression symptoms from before through 6.5 years after deployment (Low-stable, 86.5%), a trajectory with somewhat elevated symptoms
(Medium-fluctuating, 4.0%), and a trajectory with few symptoms before deployment and a steep increase to a severe symptom level 6.5 years after deployment (Low-increasing, 9.4%). The Low-increasing trajectory was predicted by rank and childhood trauma, while the Medium-fluctuating trajectory was predicted by neuroticism, adult life trauma, and post-deployment PTSD-symptoms.
Discussion and conclusion
Depression symptoms follow a heterogeneous course from before through 6.5 years after
deployment in a cohort of 530 soldiers deployed to Afghanistan, with 9.4% experiencing symptom increase, resulting in severe symptoms 6.5 years after deployment. Trajectories are differentially predicted by rank, childhood and adult life trauma as well as neuroticism and PTSD-symptoms, illustrating the clinical importance of taking individual differences of symptom course into account.
42
#32: Brug af nyere (datadrevne) metoder til identifikation af sårbarhed og personalisering af behandling
Karen-Inge Karstoft1, Lars Nissen1, Kasper Eskelund1,2 og Sofie Folke1,2
1Veterancentrets Videncenter, Ringsted, Danmark; 2Militærpsykologisk Afdeling, Veterancentret, København, Danmark
Introduktion
PTSD og andre psykiske lidelser ses hos en betragtelig del af militært ansatte efter udsendelse til krigsområder. Tidligere forskning har identificeret en række risikofaktorer for udsendelsesrelateret PTSD, men indtil nu har forsøg på at udvikle præcise screeningsmodeller ikke været succesfulde. I de senere år har prædiktionsmodeller baseret på machine learning (ML) vundet indpas i litteraturen og har vist sig med relativt høj præcision at kunne identificere dem, der udvikler PTSD som følger af en traumatisk hændelse. Ligeledes har ML og andre datadrevne metoder vist sig at kunne skelne mellem forskellige subtyper af traumereaktioner.
Metode
Vi tester forskellige ML-algoritmer (Support Vector Machines, Random Forests, Penalized Regression, Gradient Boosting Machines) i kohortestudier af tre hold udsendt til Afghanistan (N=871) samt i registerdata for den samlede veteranpopulation (N≈28.000) med det formål at forudsige individuel risiko for PTSD og andre psykiske lidelser efter udsendelse, samt at identificere risikofaktorer for denne udvikling.
Blandt behandlingssøgende veteraner (N=1541) undersøger vi, om vi med latent klasseanalyse kan identificere subtyper af PTSD og kompleks PTSD, der eventuelt vil drage nytte af forskellige behandlingstilbud.
Resultater
Vi finder, at psykiatriske diagnoser i årene efter udsendelse i de bedste modeller kan forudsiges med moderat nøjagtighed (AUC≈0.69) baseret på registerdata tilgængelige før udsendelse, og at PTSD 2.5 og 6.5 år efter udsendelse kan forudsiges med høj nøjagtighed (AUC=0.78) baseret på
spørgeskemadata indsamlet 6 måneder efter udsendelse.
Blandt behandlingssøgende veteraner identificerer vi seks forskellige subtyper tydeligt adskilt af symptomer på PTSD og kompleks PTSD. Subtyperne afspejles i funktionsniveau og blandt dem med komplekse PTSD-symptomer er der sammenhæng med flere traumer i barndommen.
Diskussion og konklusion
Datadrevne metoder har potentiale til både at øge præcisionen i screeningsredskaber, og kan ligeledes bruges til personalisering af behandling alt efter det dominerede symptomudtryk. For at sikre generaliserbarheden og replikerbarheden er det centralt, at prædiktionsalgoritmerne valideres prospektivt. For den datadrevne afdækning af subtyper og symptomprofiler er det centralt ligeledes at inddrage biologiske og kognitive data.
44
#33: Active Self-Tracking of Subjectively Experienced PTSD Symptoms: Case Studies in Military PTSD
Larsen, JE, Eskelund, K, Thormann, T., Christiansen, TB Introduction
Psychotherapeutic treatment of PTSD entirely depends on patient's ability to recall from memory and articulate occurrences of symptoms and triggers experienced in everyday life situations. Present methods such as questionnaires, diaries, and recall rely on the patient’s memory. However, the patient’s ability to recollect past events is often hampered by cognitive dysfunction or psychological factors such as guilt, shame or distrust. We present a novel method for making patients’
subjectively experienced symptoms accessible.
Method
Our approach consists of a one-button, wearable instrument that enables patients to actively self-track PTSD symptoms in everyday life. The instrument’s single button can be activated in a sub-second interaction the moment a symptom occurs. Accurate time-stamps are stored for all observations and enable patient and therapist to jointly analyze and explore both individual occurrences and patterns of symptoms.
We report on feasibility tests in five cases with veterans diagnosed with PTSD. The most prominent symptom was preceded with a distinct somatic marker that was individually identified during a bespoke extension of CBT-based psychotherapy. A specific, individual observation protocol specifying button presses for making observations of the symptom of interest was defined in collaboration with each participant.
Results
Four out of five participating veterans were capable of using the instrumentation and register symptom events throughout everyday life in up to a 3.5 month duration. The acquired data revealed symptoms dynamics that were not perceptible by patients from recall and that had not previously been articulated during therapy. Self-tracking directed patient’s attention towards symptom-spawning situations and directed treatment efforts, also through falsification of hypotheses about symptom dynamics and triggers on the part of the therapists.
Discussion
Self-tracking of symptom markers can circumvent present limitations on information available for therapist and patient, given that the patient is capable of identifying markers that can be registered.