Trauma-related emotions and radical acceptance in dialectical behavior therapy for posttraumatic stress disorder after childhood sexual abuse

Nora Görg, Kathlen Priebe, Jan R Böhnke, Regina Steil, Anne S Dyer, Nikolaus Kleindienst, Nora Görg, Kathlen Priebe, Jan R Böhnke, Regina Steil, Anne S Dyer, Nikolaus Kleindienst

Abstract

Background: Posttraumatic Stress Disorder (PTSD) related to childhood sexual abuse (CSA) is often associated with a wide range of trauma-related aversive emotions such as fear, disgust, sadness, shame, guilt, and anger. Intense experience of aversive emotions in particular has been linked to higher psychopathology in trauma survivors. Most established psychosocial treatments aim to reduce avoidance of trauma-related memories and associated emotions. Interventions based on Dialectical Behavior Therapy (DBT) also foster radical acceptance of the traumatic event.

Methods: This study compares individual ratings of trauma-related emotions and radical acceptance between the start and the end of DBT for PTSD (DBT-PTSD) related to CSA. We expected a decrease in trauma-related emotions and an increase in acceptance. In addition, we tested whether therapy response according to the Clinician Administered PTSD-Scale (CAPS) for the DSM-IV was associated with changes in trauma-related emotions and acceptance. The data was collected within a randomized controlled trial testing the efficacy of DBT-PTSD, and a subsample of 23 women was included in this secondary data analysis.

Results: In a multilevel model, shame, guilt, disgust, distress, and fear decreased significantly from the start to the end of the therapy whereas radical acceptance increased. Therapy response measured with the CAPS was associated with change in trauma-related emotions.

Conclusions: Trauma-related emotions and radical acceptance showed significant changes from the start to the end of DBT-PTSD. Future studies with larger sample sizes and control group designs are needed to test whether these changes are due to the treatment.

Trial registration: ClinicalTrials.gov, number NCT00481000.

Keywords: Dialectical behavior therapy; Exposure therapy; Posttraumatic stress disorder.

Figures

Fig. 1
Fig. 1
Illustration of data inclusion: Change of distress ratings of a participant. Sessions within weeks 2–4 were used to calculate emotion scores at the start of the treatment. The end of the treatment comprised the final 2 weeks before admission (weeks 13 and 14). Only sessions marked in grey were used to estimate the models
Fig. 2
Fig. 2
Change in trauma-related emotions and acceptance; Mean ± 1 SE of trauma-related emotions at the start and end of the treatment. In brackets: Standardized mean of the differences (SMD)
Fig. 3
Fig. 3
Model coefficients; Estimated coefficients ±1 SE for the effect of therapy response on trauma-related emotions

References

    1. Badour CL, Resnick HS, Kilpatrick DG. Associations between specific negative emotions and DSM-5 PTSD among a National Sample of interpersonal trauma survivors. J Interpers Violence. 2015; doi:10.1177/0886260515589930.
    1. Coyle E, Karatzias T, Summers A, Power M: Emotions and emotion regulation in survivors of childhood sexual abuse: the importance of “disgust” in traumatic stress and psychopathology. Eur J Psychotraumatol. 2014;5. doi: 10.3402/ejpt.v3405.23306.
    1. Santangelo P, Reinhard I, Mussgay L, Steil R, Sawitzki G, Klein C, et al. Specificity of affective instability in patients with borderline personality disorder compared to posttraumatic stress disorder, bulimia nervosa, and healthy controls. J Abnorm Psychol. 2014;123:258–272. doi: 10.1037/a0035619.
    1. Andrews B, Brewin CR, Rose S, Kirk M. Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse. J Abnorm Psychol. 2000;109:69–73. doi: 10.1037/0021-843X.109.1.69.
    1. Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B. Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depress Anxiety. 2013;30:55–60. doi: 10.1002/da.22002.
    1. deRoon-Cassini TA, Mancini AD, Rusch MD, Bonanno GA. Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis. Rehabil Psychol. 2010;55:1–11. doi: 10.1037/a0018601.
    1. Foa EB, Riggs DS, Massie ED, Yarczower M. The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behav Ther. 1995;26:487–499. doi: 10.1016/S0005-7894(05)80096-6.
    1. Holl J, Wolff S, Schumacher M, Höcker A, Arens EA, Spindler G, et al. Substance use to regulate intense posttraumatic shame in individuals with childhood abuse and neglect. Dev Psychopathol. 2016; doi:10.1017/S0954579416000432:1-13.
    1. Leskela J, Dieperink M, Thuras P. Shame and posttraumatic stress disorder. J Trauma Stress. 2002;15:223–226. doi: 10.1023/A:1015255311837.
    1. Saraiya T, Lopez-Castro T. Ashamed and afraid: a scoping review of the role of shame in post-traumatic stress disorder (PTSD) J Clin Med. 2016;5:94. doi: 10.3390/jcm5110094.
    1. Stotz SJ, Elbert T, Müller V, Schauer M. The relationship between trauma, shame, and guilt: findings from a community-based study of refugee minors in Germany. Eur J Psychotraumatol. 2015;6:25863. doi: 10.3402/ejpt.v6.25863.
    1. Talbot JA, Talbot NL, Tu X. Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse. J Trauma Stress. 2004;17:445–448. doi: 10.1023/B:.
    1. Orth U, Wieland E. Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: a meta-analysis. J Consult Clin Psychol. 2006;74:698–706. doi: 10.1037/0022-006X.74.4.698.
    1. You S, Talbot NL, He H, Conner KR. Emotions and suicidal ideation among depressed women with childhood sexual abuse histories. Suicide Life Threat Behav. 2012;42:244–254. doi: 10.1111/j.1943-278X.2012.00086.x.
    1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5. Washington, DC: American Psychiatric Association; 2013.
    1. American Psychiatric Association . Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR) Washington, DC: American Psychiatric Association; 2000.
    1. Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ. Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013;74:541–550. doi: 10.4088/JCP.12r08225.
    1. Foa EB, Cahill SP. Psychological therapies: emotional processing. In: Smelser NJ, Baltes B, editors. International encyclopedia of the social and behavioral sciences. 2001. pp. 12363–12369.
    1. Lang PJ. Imagery in therapy: an information processing analysis of fear. Behav Ther. 1977;8:862–886. doi: 10.1016/S0005-7894(77)80157-3.
    1. Power MJ, Fyvie C. The role of emotion in PTSD: two preliminary studies. Behav Cogn Psychother. 2013;41:162–172. doi: 10.1017/S1352465812000148.
    1. Herman JL. Trauma and recovery: the aftermath of violence - from domestic abuse to political terror. New York: Guilford Press; 1992.
    1. McLean CP, Foa EB. Emotions and emotion regulation in posttraumatic stress disorder. Curr Opin Psychol. 2017;14:72–77. doi: 10.1016/j.copsyc.2016.10.006.
    1. Resick PA, Miller MW. Posttraumatic stress disorder: anxiety or traumatic stress disorder? J Trauma Stress. 2009;22:384–390. doi: 10.1002/jts.20437.
    1. Allard CB, Norman SB, Thorp SR, Browne KC, Stein MB. Mid-treatment reduction in trauma-related guilt predicts PTSD and functioning following cognitive trauma therapy for survivors of intimate partner violence. J Interpers Violence. 2016; doi:10.1177/0886260516636068:0886260516636068.
    1. Ginzburg K, Butler LD, Giese-Davis J, Cavanaugh CE, Neri E, Koopman C, et al. Shame, guilt, and posttraumatic stress disorder in adult survivors of childhood sexual abuse at risk for human immunodeficiency virus: outcomes of a randomized clinical trial of group psychotherapy treatment. J Nerv Ment Dis. 2009;197:536–542. doi: 10.1097/NMD.0b013e3181ab2ebd.
    1. Harned MS, Ruork AK, Liu J, Tkachuck MA. Emotional activation and habituation during Imaginal exposure for PTSD among women with borderline personality disorder. J Trauma Stress. 2015;28:253–257. doi: 10.1002/jts.22013.
    1. Nishith P, Nixon RDV, Resick PA. Resolution of trauma-related guilt following treatment of PTSD in female rape victims: a result of cognitive processing therapy targeting comorbid depression? J Affect Disord. 2005;86:259–265. doi: 10.1016/j.jad.2005.02.013.
    1. Pitman RK, Orr SP, Altman B, Longpre RE. Emotional processing and outcome of imaginal flooding therapy in Vietnam veterans with chronic post-traumatic stress disorder. Compr Psychiatry. 1996;37:409–418. doi: 10.1016/S0010-440X(96)90024-3.
    1. Bluett EJ, Zoellner LA, Feeny NC. Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD. J Behav Ther Exp Psychiatry. 2014;45:97–104. doi: 10.1016/j.jbtep.2013.09.003.
    1. Gallagher MW, Resick PA. Mechanisms of change in cognitive processing therapy and prolonged exposure therapy for PTSD: preliminary evidence for the differential effects of hopelessness and habituation. Cogn Ther Res. 2012;36
    1. Jaycox LH, Foa EB, Morral AR. Influence of emotional engagement and habituation on exposure therapy for PTSD. J Consult Clin Psychol. 1998;66:185–192. doi: 10.1037/0022-006X.66.1.185.
    1. Rauch SA, Foa EB, Furr JM, Filip JC. Imagery vividness and perceived anxious arousal in prolonged exposure treatment for PTSD. J Trauma Stress. 2004;17:461–465. doi: 10.1007/s10960-004-5794-8.
    1. Sripada RK, Rauch SA. Between-session and within-session habituation in prolonged exposure therapy for posttraumatic stress disorder: a hierarchical linear modeling approach. J Anxiety Disord. 2015;30:81–87. doi: 10.1016/j.janxdis.2015.01.002.
    1. van Minnen A, Foa EB. The effect of imaginal exposure length on outcome of treatment for PTSD. J Trauma Stress. 2006;19:427–438. doi: 10.1002/jts.20146.
    1. van Minnen A, Hagenaars M. Fear activation and habituation patterns as early process predictors of response to prolonged exposure treatment in PTSD. J Trauma Stress. 2002;15:359–367. doi: 10.1023/A:1020177023209.
    1. Wisco BE, Baker AS, Sloan DM. Mechanisms of change in written exposure treatment of posttraumatic stress disorder. Behav Ther. 2016;47:66–74. doi: 10.1016/j.beth.2015.09.005.
    1. Rupp C, Doebler P, Ehring T, Vossbeck-Elsebusch AN. Emotional processing Theory put to test: a meta-analysis on the association between process and outcome measures in exposure therapy. Clin Psychol Psychother. 2016; doi:10.1002/cpp.2039:n/a-n/a.
    1. Foa EB, Riggs DS, Dancu CV, Rothbaum BO. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress. 1993;6:459–473. doi: 10.1002/jts.2490060405.
    1. Badour CL, Feldner MT. Disgust and Imaginal exposure to memories of sexual trauma: implications for the treatment of posttraumatic stress. Psychol Trauma. 2016;8:267–275. doi: 10.1037/tra0000079.
    1. Øktedalen T, Hoffart A, Langkaas TF. Trauma-related shame and guilt as time-varying predictors of posttraumatic stress disorder symptoms during imagery exposure and imagery rescripting-a randomized controlled trial. Psychother Res. 2015;25:518–532. doi: 10.1080/10503307.2014.917217.
    1. Blake DD, Weathers FW, Nagy LM, Kaloupek D, Klauminzer G, Charney DS, et al. Clinician-administered PTSD scale (CAPS) instruction manual. Boston: National Center for Posttraumatic Stress Disorder; 2000.
    1. Weathers FW, Ford J. Psychometric properties of the PTSD Checklist (PCL-C, PCL-S, PCL-M, PCL-PR) In: Stamm H, editor. Measurement of stress, trauma, and adaptation. Lutherville: Sidran Press; 1996.
    1. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64:1152–1168. doi: 10.1037/0022-006X.64.6.1152.
    1. Seligowski AV, Lee DJ, Bardeen JR, Orcutt HK. Emotion regulation and posttraumatic stress symptoms: a meta-analysis. Cogn Behav Ther. 2015;44:87–102. doi: 10.1080/16506073.2014.980753.
    1. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy. The process and practice of mindful change. 2. New York City: Guilford Press; 2011.
    1. Linehan MM. DBT skills training manual. 2. New York: Guilford Publications; 2015.
    1. Steil R, Dyer A, Priebe K, Kleindienst N, Bohus M. Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program. J Trauma Stress. 2011;24:102–106. doi: 10.1002/jts.20617.
    1. Bohus M, Dyer AS, Priebe K, Krüger A, Kleindienst N, Schmahl C, et al. Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychother Psychosom. 2013;82:221–233. doi: 10.1159/000348451.
    1. Kleindienst N, Priebe K, Görg N, Dyer A, Steil R, Lyssenko L, et al. State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder. Eur J Psychotraumatol. 2016;7:30375. doi: 10.3402/ejpt.v7.30375.
    1. Krüger A, Ehring T, Priebe K, Dyer AS, Steil R, Bohus M. Sudden losses and sudden gains during a DBT-PTSD treatment for posttraumatic stress disorder following childhood sexual abuse. Eur J Psychotraumatol. 2014:5.
    1. Krüger A, Kleindienst N, Priebe K, Dyer AS, Steil R, Schmahl C, et al. Non-suicidal self-injury during an exposure-based treatment in patients with posttraumatic stress disorder and borderline features. Behav Res Ther. 2014;61:136–141. doi: 10.1016/j.brat.2014.08.003.
    1. Cederberg JT, Cernvall M, Dahl J, von Essen L, Ljungman G. Acceptance as a mediator for change in acceptance and commitment therapy for persons with chronic pain? Int J Behav Med. 2016;23:21–29. doi: 10.1007/s12529-015-9494-y.
    1. Cutajar MC, Mullen PE, Ogloff JR, Thomas SD, Wells DL, Spataro J. Psychopathology in a large cohort of sexually abused children followed up to 43 years. Child Abuse Negl. 2010;34:813–822. doi: 10.1016/j.chiabu.2010.04.004.
    1. Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatr. 2005;162:214–227. doi: 10.1176/appi.ajp.162.2.214.
    1. Zlotnick C, Shea TM, Rosen K, Simpson E, Mulrenin K, Begin A, et al. An affect-management group for women with posttraumatic stress disorder and histories of childhood sexual abuse. J Trauma Stress. 1997;10:425–436.
    1. McDonagh A, Friedman M, McHugo G, Ford J, Sengupta A, Mueser K, et al. Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. J Consult Clin Psychol. 2005;73:515–524. doi: 10.1037/0022-006X.73.3.515.
    1. Cloitre M, Stovall-McClough KC, Nooner K, Zorbas P, Cherry S, Jackson CL, et al. Treatment for PTSD related to childhood abuse: a randomized controlled trial. Am J Psychiatr. 2010;167:915–924. doi: 10.1176/appi.ajp.2010.09081247.
    1. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38:319–145. doi: 10.1016/S0005-7967(99)00123-0.
    1. First MB, Spitzer RL, Gibbon M, Williams JBW, Benjamin LS. User’s guide for the structured clinical Interview for DSM-IV Axis I disorders (SCID-I) – clinical version. Washington: American Psychiatric Press; 1997.
    1. Loranger AW, Janca A, Sartorius N. ICD-10 International Personality Disorder Examination Cambridge. Cambridge: Cambridge University Press; 1997.
    1. Derogatis L. SCL-90-R. Administration, scoring and procedures manual-II for the revised version and other instruments of the psychopathology rating scale series. Towson: Clinical Psychometric Research; 1992.
    1. Hien DA, Wells EA, Jiang H, Suarez-Morales L, Campbell AN, Cohen LR, et al. Multisite randomized trial of behavioral interventions for women with co-occurring PTSD and substance use disorders. J Consult Clin Psychol. 2009;77:607–619. doi: 10.1037/a0016227.
    1. Long JD. Longitudinal data analysis for the behavioral sciences using R. Thousand Oaks: Sage; 2012.
    1. Azari R, Li L, Tsai C-L. Longitudinal data model selection. Comput Stat Data Anal. 2006;50:3053–3066. doi: 10.1016/j.csda.2005.05.009.
    1. R Core Team . R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing; 2016.
    1. Bates D, Maechler M, Bolker B, Walker S. Fitting linear mixed-effects models using lme4. J Stat Softw. 2015;67:1–48. doi: 10.18637/jss.v067.i01.
    1. Castonguay LG, Barkham M, Lutz W, McAleavey A. Practice-oriented research: approaches and applications. In: Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. 6. Hoboken: Wiley; 2013. pp. 85–133.
    1. Lambert MJ. The efficacy and effectiveness of psychotherapy. In: Lambert MJ, editor. Bergin and Garfield’s handbook of psychotherapy and behavior change. 6. Hoboken: Wiley; 2013. pp. 169–218.
    1. Shimokawa K, Lambert MJ, Smart DW. Enhancing treatment outcome of patients at risk of treatment failure: meta-analytic and mega-analytic review of a psychotherapy quality assurance system. J Consult Clin Psychol. 2010;78:298–311. doi: 10.1037/a0019247.
    1. Görg N, Priebe K, Deuschel T, Schüller M, Schriner F, Kleindienst N, et al. Computer-assisted in Sensu exposure for posttraumatic stress disorder: development and evaluation. JMIR Ment Health. 2016;3:e27. doi: 10.2196/mental.5697.
    1. Browne KC, Trim RS, Myers US, Norman SB. Trauma-related guilt: conceptual development and relationship with posttraumatic stress and depressive symptoms. J Trauma Stress. 2015;28:134–141. doi: 10.1002/jts.21999.
    1. Lee DA, Scragg P, Turner S. The role of shame and guilt in traumatic events: a clinical model of shame-based and guilt-based PTSD. Brit J Med Psychol. 2001;74:451–466. doi: 10.1348/000711201161109.
    1. Brewin CR, Andrews B, Rose S. Fear, helplessness, and horror in posttraumatic stress disorder: investigating DSM-IV criterion A2 in victims of violent crime. J Trauma Stress. 2000;13:499–509. doi: 10.1023/A:1007741526169.
    1. Lutz W, Stulz N, Martinovich Z, Leon SC, Saunders SM. Methodological background of decision rules and feedback tools for outcomes management in psychotherapy. Psychother Res. 2009;19:502–510. doi: 10.1080/10503300802688486.
    1. Siddique J, Brown CH, Hedeker D, Duan N, Gibbons RD, Miranda J, et al. Missing data in longitudinal trials - part B, analytic issues. Psychiatr Ann. 2008;38:793–801. doi: 10.3928/00485713-20081201-09.
    1. Lutz W, Böhnke JR, Köck K. Lending an ear to feedback systems: evaluation of recovery and non-response in psychotherapy in a German outpatient setting. Community Ment Health J. 2011;47:311–317. doi: 10.1007/s10597-010-9307-3.
    1. Trull TJ, Ebner-Priemer UW. Using experience sampling methods/ecological momentary assessment (ESM/EMA) in clinical assessment and clinical research: introduction to the special section. Psychol Assess. 2009;21:457–462. doi: 10.1037/a0017653.

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