Participants and procedure
This 12-month follow-up study consisted of data collected from patients participating in a pilot study [
12] and an open trial [
14] of an 8-day intensive treatment programme for PTSD. All patients referred had to be 18 years or older, previously diagnosed with PTSD, and had to have at least one previous treatment attempt for their PTSD. Exclusion criteria included acute suicidality, psychosis, severe drug addiction, and insufficient fluency in Norwegian. Prior to inclusion, patients underwent a diagnostic assessment, including medical and mental health history, and completed relevant self-report questionnaires. Diagnosis was determined by using diagnostic interviews, either the MINI Plus 5.0 interview [
15] or the ADIS-IV [
16], in addition to the PTSD Symptom Scale Interview (PSS-I) [
17]. Of the patients referred to the clinic between August 2018 and March 2021, 31.8% chose intensive treatment over traditional outpatient treatment. Five of these were not eligible to partake in the study due to either not consenting to research, not showing up at treatment start, or treatment deviating from the protocol (i.e. group size less than three). This left 35 eligible participants for analysis.
In the interim between assessment and the 8-day intensive programme, the patients had 3.2 (
SD = 0.9) preparatory sessions. The preparation included defining targets for imaginal exposure, constructing in vivo exposure tasks, and receiving further information about the programme. The eight days had a similar structure. Each day consisted of 90 min individual PE, 45 min group physical activity (PA), 90 min individual EMDR, and 45 min group psychoeducation, in that order. The PE sessions followed the PE protocol including imaginal exposure, processing, and homework assignments [
18]. The participants listened to audio recordings of the imaginal exposure and completed in vivo exercises at home daily. In the EMDR sessions, the focus was on desensitization, installation, body scan, and closure; targeting trauma memories, triggers and future templates, following the EMDR protocol [
19].
To prevent therapist drift and under-utilization of exposure interventions, therapists rotated between patients from session to session. Patients met between four to seven different therapists during the programme, depending on the size of the patient group. The psychoeducation took place in a group setting (three to six patients) and focused on themes from the PE manual; posttraumatic symptoms as normal reactions to trauma, the rationale for exposure treatment, avoidance, negative thoughts, feelings, self-esteem, and relapse prevention. The PA, led by a physiotherapist, was also group based. The goal of the PA was to give the patients exercises of moderate intensity, that demanded attention and activation of the whole body, and to give them experiences of mastery and strength. All participants were offered an individual follow-up session at two weeks, three months, and 12 months after the intensive programme.
The sample had a mean age of 38.5 years, and most participants were female (91.4%). Twenty-nine patients had Norwegian as their first language and all participants spoke Norwegian adequately. The sample had 3.1 (
SD = 1.6, range 1–6) prior psychotherapies, defined as evenly sessions attended for at least three months. Traumas reported included domestic violence, childhood sexual and physical abuse, rape, terrorist attack, witnessing murder, and war. Most of the patients had experienced multiple traumas (
n = 31, 88.6%) and 25 (71.4%) reported sexual traumas. The mean number of years since symptoms of PTSD first occurred was 15.8 years (
SD = 10.8). 51% (
n = 18) used current psychotropic medication including benzodiazepines (
n = 9), antidepressants (
n = 7), antipsychotic (
n = 4), and stimulants (
n = 1). The nine patients on prescription benzodiazepines were encouraged to abstain from use during treatment, which they adhered to. Other medications were stable during treatment and there were no reports on changes in medications during follow-up. Twelve patients had one comorbid disorder, one patient had two comorbid disorders, two had three comorbid disorders, while 19 were not diagnosed with a comorbid disorder. Comorbid disorders included: Attention deficit/hyperactivity disorder (
n = 2), social anxiety disorder (
n = 2), depression (
n = 11), personality disorder (
n = 3), obsessive-compulsive disorder (
n = 1), alcohol abuse (
n = 1), and unspecified eating disorder (
n = 1). A summary of the group´s background information is displayed in Table
1.
Table 1
Sample characteristics at pre-treatment
Age | 38.46 | 12.58 | | |
Female gender | | | 32 | 91.4 |
Duration of disorder in years | 15.81 | 10.96 | | |
Previous psychotherapies | 3.11 | 1.60 | | |
Previous psychopharm. tx | | | 26 | 74.3 |
Current psychopharm. tx | | | 18 | 51.4 |
Comorbid disorder | | | 16 | 45.7 |
Previous drug abuse | | | 10 | 28.6 |
Current drug abuse | | | 1 | 2.9 |
Employment | | | | |
Full-time work | | | 4 | 11.4 |
Part-time work | | | 2 | 5.7 |
Student | | | 2 | 5.7 |
Sick leave | | | 8 | 22.9 |
Work assessment allowance | | | 10 | 28.6 |
Disability pension | | | 8 | 22.9 |
No employment | | | 1 | 2.9 |
Civil status | | | | |
Single | | | 15 | 42.9 |
In a relationship | | | 4 | 11.4 |
Cohabitant | | | 8 | 22.9 |
Married | | | 7 | 20.0 |
Divorced | | | 1 | 2.9 |
Ethnic minority | | | 6 | 17.1 |
Measures
A collection of self-report questionnaires and a structured diagnostic interview for PTSD were used to measure symptoms pre-treatment, two weeks post-treatment, and at 3- and 12-month follow-up. Independent assessors administered the diagnostic interviews conducted after treatment.
Diagnostic status was assessed using the PSS-I [
17] at pre-treatment, post-treatment, and at 3- and 12-month follow-up. The PSS-I is a diagnostic interview corresponding with the PTSD criteria in DSM-IV. It consists of 17 items, scaled from 0 to 3 with a total score from 0 to 51. To meet diagnostic criteria, according to the PSS-I, the patient needs at least one endorsed symptom (score 1 or more) on “re-experiencing” (items 1–5), at least three from “avoidance” (items 6–12), and at least two from “arousal” (items 13–17). This study defined a cut-off score at 20 and a reliable change index (RCI) at 8 points. Cronbach’s alpha was 0.75. The updated PSS-I-5 was not available in Norwegian at the start of the study.
Self-reported PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5) [
20]. The PCL-5 consists of 20 items on a scale from 0 to 4 (not at all to extremely), with a total score ranging from 0 to 80. To meet diagnostic criteria when using PCL-5 it is required with at least one endorsed symptom (score 2 or more) on “intrusion” (items 1–5) and “avoidance” (items 6–7), and two on “cognitions and mood” (items 8–14) and “arousal” (items 15–20). As in the Improving Access to Psychological Therapies Programme [
21], this study used a cut-off at 32 and the RCI was set at 10 points. Cronbach’s alpha was 0.84.
To assess severity of depression and anxiety, this study used the Beck Depression inventory (BDI-II) [
22] and the Beck Anxiety Inventory (BAI) [
23]. Both scales consist of 21 items, rated from 0 to 3. Higher scores represent higher levels of symptoms. Grade of severity are typically divided in mild (14–19), moderate (20–28), and severe (29–63) for the BDI-II, and minimal (0–7), mild (8–15), moderate (16–25), and severe (26–63) for the BAI. Cut-off was in this study set to 11 with the RCI at 12 points for the BAI, and at 15 points on the BDI-II with a RCI of 9 points. Cronbach’s alpha for BDI was 0.86, and for BAI 0.91.
To assess the impact of the patients’ mental health on their functional capacity at home, in social activities, personal relationships, and at work, this study used the Work and Social Adjustment Scale (WSAS) [
24]. WSAS has five items rated on a scale from 0 to 8 (not at all to very severely). Higher scores indicate lower functioning (< 15 mild, 15–30 moderate, and > 30 severe). The present study set the cut-off to 17 and the RCI to 8 points. Cronbach’s alpha was 0.77.
The patients’ subjective psychological well-being was assessed using the five-item World Health Organization Well-Being Index (WHO-5) [
25]. Five positively phrased items are rated from 0 to 5 (none of the time to all of the time). Scores are multiplied, resulting in a total range from 0 to 100. In the present study, cut-off was set to 29 as previously done in a study on depression [
26] and the RCI at 10 points. Cronbach’s alpha was 0.83.
Interpersonal distress was assessed with the Inventory of interpersonal problems (IIP-64) [
27] consisting on 64 items, rated on a 0–4 scale. These results are presented as mean item scores. Higher levels on interpersonal problems result in higher scores. As commonly used in studies with Norwegian samples, a cut-off value of 1.03 and a RCI of at least 0.38 was used. Cronbach’s alpha was 0.89.
Statistical analyses
Missing data was imputed using the expectation-maximization method [
28]. Little’s missing completely at random test indicated that data was missing completely at random (
x2 = 191.79,
p = .85). Repeated measures ANOVA was used to test for changes in symptoms, functioning, interpersonal problems, and well-being. The analyses used data from four assessments (pre-treatment, post-treatment, and 3- and 12-month follow-up). Effect sizes were reported using partial eta squared (
η2) and Cohen’s
d (using pooled
SD). Typical standards for
η2 are small (0.01), medium (0.06), and large (0.14), while for Cohen’s
d the most common cut-offs are small (0.2), medium (0.5) and large (0.8). Treatment response rates were also calculated using percentages scoring below clinical cut-off, achieving reliable change, and clinically significant change (recovery) which combines the first two criteria [
29].