CLASIFICACIÓN DE LOS TRASTORNOS DEL LENGUAJE 6

Across two studies we showed that sexual trauma survivors with a diagnosis of chronic PTSD endorsed a greater diversity of negative emotion descriptors when describing either their current self-structure or their autobiographical past, relative to healthy control participants who had no such trauma history. The current results mirror those in another chronic mental health condition – recurrent Major Depressive Disorder (Werner-Seidler et al., 2018) but are somewhat divergent from earlier studies using community samples

(Quoidbach et al., 2014) which suggested that greater emodiversity (including in the negative valence domain) is associated with fewer symptoms of mental ill health. In light of the results from our studies, we propose that in a wider community context, greater negative

emodiversity may be associated with protection against mental health difficulties, but that this protective factor is not evident for chronically unwell individuals.

Throughout this thesis, we have discussed how the affective domain problems identified in CPTSD have been characterised by emotion dysregulation. Multiple early traumatic experiences commonly result in impairment in developmental processes including the ability to recognise, identify and regulate emotion. In light of the results from study 4, we suggest that chronic emotional disorders such as recurrent depression and PTSD could be associated with an enhanced underlying capacity for emotion regulation but that emotions in

dysfunctionality that individuals with these disorders are trying to regulate. This theory is consistent with individuals with PTSD reporting that they spend large amounts of their time trying to regulate aversive negative cognitions and affect, and supported by our findings from studies 1 and 2 - that individuals with PTSD commonly use strategies to compartmentalise or

“ring-fence” the distressing or toxic information related to their past traumatic experiences.

Individuals with PTSD are therefore highly practiced with the techniques even if they are often experienced as ineffectual.

CHAPTER 6

Research paper: Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal trauma¹⁰

Authors: Clifford, G., Meiser-Stedman, R., Johnson, R. D., Hitchcock, C., & Dalgleish, T.

Accepted for publication in European Journal of Psychotraumatology on 17/06/2018 Preprint: https://psyarxiv.com/85bm9/

Citation: Clifford, G., Meiser-Stedman, R., Johnson, R. D., Hitchcock, C., & Dalgleish, T.

(2018). Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal

trauma. European journal of psychotraumatology, 9(1), 1495980.

doi:10.1080/20008198.2018.1495980

For this paper, the candidate planned the study, collected all of the data, analysed the results and wrote the paper. The co-authors supervised the research process and made comments on iterative drafts of the manuscript.

6.1 Background

As discussed in Chapter 1, some researchers have argued that interventions for PTSD should be adapted to address the additional symptoms identified in individuals presenting with more complex presentations of the disorder. An expert consensus survey (Cloitre et al., 2012) indicated that 84% of 50 expert clinicians endorsed a phase-based or sequenced approach as a first line treatment for CPTSD, involving three phases, each with a distinct function. STAIR is a phase-based, sequential treatment that has been specifically developed to treat women (in individual therapy) who had experienced childhood sexual abuse. The efficacy of the phase-based treatment approach for treating CPTSD has only been addressed in two studies to date,

but at present, there is no clear evidence-base to demonstrate consistently superior treatment effects for the use of a standard or phase-based approach to treating complex features (e.g.,Wagenmans, Van Minnen, Sleijpen, & De Jongh, 2018; Bongaerts, Van Minnen, & De Jongh, 2017; Van Minnen et al., 2012).

Group therapy for PTSD is not currently included in any treatment guidelines (e.g. Forbes et al., 2010). However, the group–based format is commonly used in health care settings (e.g., Foy et al., 2000), and a recent meta-analysis demonstrated its efficacy, relative to waitlist control, in reducing PTSD symptoms (d=0.56; Sloan et al., 2013). Some evidence has emerged in recent years to demonstrate that group treatments have promising effects on both core PTSD

symptoms (e.g., Sikkema et al., 2007) and the negative affect cluster of symptoms for

samples with complex trauma histories (e.g., group therapy for incarcerated women; Bradley

& Follingstad, 2003; trauma-focused group therapy; Classen et al., 2011). However, in reviewing the literature, it becomes clear that the majority of group-based interventions have not explicitly addressed the complex features of CPTSD.

In study 5, we describe the development, facilitation and evaluation of a group intervention for individuals who had experienced repeated interpersonal trauma: an Emotion-and Memory-Processing Group Programme. We implemented the recommended phased-based approach for more complex presentations of PTSD and phased-based our group programme on the STAIR (Cloitre, Cohen, & Koenen, 2006) protocol.

As discussed in Chapter 1, the cardinal symptoms of PTSD centre on intrusive memories of the traumatic experience that are prototypically high in frequency, sensorily-laden,

involuntary, distressing, fragmented and relatively immune to attempts at prevention. To facilitate group-based delivery, we replaced the NST phase of the STAIR programme with a number of different mnemonic control techniques, such as identifying triggers to traumatic memories and describing the associated meanings, emotions and physiological sensations,

cognitive/narrative restructuring and imagery rescripting. Analysis of memory processes in PTSD and their link with problematic appraisals and behaviors that maintain PTSD has led to the

development of specific theory-guided treatment procedures for this condition (e.g. Ehlers &

Clark, 2000; Ehlers, Clark, Hackmann, McManus, & Fennell, 2005). We incorporated a number of these specific theory-guided treatment procedures into our intervention to facilitate processing of trauma memories in a group format.

As explored throughout this thesis, the affective domain problems in CPTSD have been characterised by emotion dysregulation, including alterations in attention and consciousness (e.g. dissociation, depersonalization, and derealization). We therefore also incorporated

sessions into the group programme on emotional awareness, psychoeducation and regulation. The final protocol therefore consisted of a skills training in affective and interpersonal regulation (STAIR) phase, a memory processing phase, and a consolidation phase which was delivered over twelve group-based sessions.

We completed a three-group case series of the Emotion- and Memory-Processing Group Programme for complex features of PTSD with female survivors of rape or sexual assault.

Guidance on the development of complex interventions (e.g., Medical Research Council [MRC], 2000) recommends that novel clinical techniques are first piloted in small studies, such as case series that serve to establish the promise of a new approach, and are important in refining an intervention (through use of clinician and participant feedback) prior to commencement of trials.

The key focus of study 5 was to develop the novel treatment manual to the point that it may be evaluated in a future feasibility trial, and to provide a preliminary, uncontrolled estimate of any effects of the intervention.

Study 5 details the delivery of the programme, and provides a preliminary examination of acceptability, feasibility and the potential efficacy of the intervention in reducing symptoms of PTSD, along with measures of complex features, namely emotion dysregulation, dissociation,

and interpersonal difficulties.

The full treatment manual for the group is included in Appendix 5.0 at the end of the thesis.

6.2 Research paper: Developing an Emotion- and Memory-Processing Group