Mediators of Change in a Condensed Online Exposure-based Intervention Provided Soon After Trauma: Insights from a Randomised Controlled Trial

Overview

Journal Eur J Psychotraumatol

Date 2024 Dec 2

PMID 39621100

Authors

Maria Bragesjo

Filip K Arnberg

Erik Andersson

Affiliations

Soon will be listed here.

Abstract

The active mechanisms of change are unclear in early-provided exposure-based interventions for psychological trauma. This study aimed to address this gap by analysing weekly data from a randomised trial involving a 3-week therapist-guided online intervention based on prolonged exposure compared to a waiting-list control group. The objective was to investigate whether changes in each of the four subscales of the Posttraumatic Stress Disorder Checklist, fifth version (PCL-5; i.e. intrusions, avoidance behaviours, negative alternations in cognitions and hyperarousal) during the three-week intervention period mediated subsequent improvements in other post-traumatic stress symptoms at the controlled 1-month follow-up. We included baseline levels of both the mediator and the outcome as well as changes in the outcome from baseline to week 3 as covariates in a mediation model. The results showed that reductions in avoidance during the intervention period mediated reduced symptom levels of intrusions, negative alternations in cognitions, and hyperarousal at week 7 (z-scores of indirect effect estimates = -0.12 to -0.07). No other PCL-5 subscales were found to be mediators of change. The results from this study highlight the importance of addressing avoidance behaviours in online exposure-based interventions provided in the early aftermath of trauma. Sensitivity analysis showed that the mediation effects were sensitive to assumptions related to mediator-outcome confounders, which could be considered a study limitation. ClinicalTrials.gov identifier: NCT03850639.

References

Harvey A, Bryant R . Predictors of acute stress following mild traumatic brain injury. Brain Inj. 1998; 12(2):147-54. DOI: 10.1080/026990598122773. View

Watts B, Schnurr P, Mayo L, Young-Xu Y, Weeks W, Friedman M . Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. J Clin Psychiatry. 2013; 74(6):e541-50. DOI: 10.4088/JCP.12r08225. View

Hermosilla S, Forthal S, Sadowska K, Magill E, Watson P, Pike K . We need to build the evidence: A systematic review of psychological first aid on mental health and well-being. J Trauma Stress. 2022; 36(1):5-16. PMC: 10624106. DOI: 10.1002/jts.22888. View

Rothbaum B, Kearns M, Price M, Malcoun E, Davis M, Ressler K . Early intervention may prevent the development of posttraumatic stress disorder: a randomized pilot civilian study with modified prolonged exposure. Biol Psychiatry. 2012; 72(11):957-63. PMC: 3467345. DOI: 10.1016/j.biopsych.2012.06.002. View

Maples-Keller J, Post L, Price M, Goodnight J, Burton M, Yasinski C . Investigation of optimal dose of early intervention to prevent posttraumatic stress disorder: A multiarm randomized trial of one and three sessions of modified prolonged exposure. Depress Anxiety. 2020; 37(5):429-437. PMC: 7347250. DOI: 10.1002/da.23015. View

Hamblen J, Norman S, Sonis J, Phelps A, Bisson J, Nunes V . A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy (Chic). 2019; 56(3):359-373. DOI: 10.1037/pst0000231. View

Song H, Fang F, Tomasson G, Arnberg F, Mataix-Cols D, Fernandez de la Cruz L . Association of Stress-Related Disorders With Subsequent Autoimmune Disease. JAMA. 2018; 319(23):2388-2400. PMC: 6583688. DOI: 10.1001/jama.2018.7028. View

Bragesjo M, Arnberg F, Olofsdotter Lauri K, Aspvall K, Sarnholm J, Andersson E . Condensed Internet-delivered prolonged exposure provided soon after trauma: a randomised trial. Psychol Med. 2023; 53(5):1989-1998. PMC: 10106292. DOI: 10.1017/S0033291721003706. View

North C, Nixon S, Shariat S, Mallonee S, McMillen J, Spitznagel E . Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999; 282(8):755-62. DOI: 10.1001/jama.282.8.755. View

10.

Bragesjo M, Arnberg F, Sarnholm J, Olofsdotter Lauri K, Andersson E . Condensed internet-delivered prolonged exposure provided soon after trauma: A randomised pilot trial. Internet Interv. 2021; 23:100358. PMC: 7771112. DOI: 10.1016/j.invent.2020.100358. View

11.

Kumpula M, Pentel K, Foa E, LeBlanc N, Bui E, McSweeney L . Temporal Sequencing of Change in Posttraumatic Cognitions and PTSD Symptom Reduction During Prolonged Exposure Therapy. Behav Ther. 2017; 48(2):156-165. DOI: 10.1016/j.beth.2016.02.008. View

12.

Zalta A, Gillihan S, Fisher A, Mintz J, McLean C, Yehuda R . Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. J Consult Clin Psychol. 2013; 82(1):171-5. PMC: 3951922. DOI: 10.1037/a0034735. View

13.

Lee D, Schnitzlein C, Wolf J, Vythilingam M, Rasmusson A, Hoge C . PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS. Depress Anxiety. 2016; 33(9):792-806. DOI: 10.1002/da.22511. View

14.

Kumpula M, Orcutt H, Bardeen J, Varkovitzky R . Peritraumatic dissociation and experiential avoidance as prospective predictors of posttraumatic stress symptoms. J Abnorm Psychol. 2011; 120(3):617-27. PMC: 3170875. DOI: 10.1037/a0023927. View

15.

McFarlane A, Atchison M, Rafalowicz E, Papay P . Physical symptoms in post-traumatic stress disorder. J Psychosom Res. 1994; 38(7):715-26. DOI: 10.1016/0022-3999(94)90024-8. View

16.

Gueorguieva R, Krystal J . Move over ANOVA: progress in analyzing repeated-measures data and its reflection in papers published in the Archives of General Psychiatry. Arch Gen Psychiatry. 2004; 61(3):310-7. DOI: 10.1001/archpsyc.61.3.310. View

17.

Kessler R, Sonnega A, Bromet E, Hughes M, Nelson C . Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52(12):1048-60. DOI: 10.1001/archpsyc.1995.03950240066012. View

18.

Kazdin A . Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007; 3:1-27. DOI: 10.1146/annurev.clinpsy.3.022806.091432. View

19.

Cooper A, Clifton E, Feeny N . An empirical review of potential mediators and mechanisms of prolonged exposure therapy. Clin Psychol Rev. 2017; 56:106-121. PMC: 5578395. DOI: 10.1016/j.cpr.2017.07.003. View

20.

Imai K, Keele L, Tingley D . A general approach to causal mediation analysis. Psychol Methods. 2010; 15(4):309-34. DOI: 10.1037/a0020761. View