Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression

https://doi.org/10.1016/j.jbtep.2021.101666Get rights and content

Highlights

  • Prolonged Exposure Therapy and sertraline are equally effective for PTSD.

  • Trauma-related guilt decreases equally after psychotherapy and psychopharmacology.

  • Guilt reduction predicts subsequent PTSD and depression reduction.

Abstract

Background and objectives

Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear.

Methods

Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed.

Results

The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24–52) reduction in PTSD and depression, but not impairments in function.

Limitations

Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt.

Conclusions

PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.

Introduction

Rates of posttraumatic stress disorder (PTSD) among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans have ranged from 4% to almost 25% (Fulton et al., 2015; Richardson, Frueh, & Acierno, 2010). Veterans with PTSD are more likely to experience greater clinical and functional impairments, including more psychiatric comorbidities, greater suicide risk, lower reported physical health, and reduced quality of life than those without PTSD (Barrett et al., 2002; Jakupcak et al., 2008, 2009; Pompili et al., 2013; Sayer et al., 2010; Smith et al., 2017). As a result, PTSD is associated with considerable healthcare costs, with the Veterans Affairs (VA) spending 1.4 billion dollars on Veterans with PTSD between 2004 and 2009 (Congressional Budget Office, 2012).

Fortunately, there are trauma-focused treatments that effectively target PTSD, such as Prolonged Exposure (PE), which is considered a frontline treatment (VA/Department of Defense [DoD], 2017). Pharmacotherapy is also used to treat PTSD, including sertraline (SERT), a selective serotonin reuptake inhibitor approved for PTSD by the U.S. Food and Drug Administration (FDA; VA/DoD, 2017). Although not all recipients of PE and SERT respond or fully remit, these two treatments are included in every major clinical practice guideline for PTSD at the highest level of psychotherapy and medication recommendations, respectively (Hamblen et al., 2019). A recent multisite randomized controlled trial in OEF/OIF Veterans compared PE plus SERT (PE + SERT), PE plus placebo (PE + PLB), and SERT plus enhanced medication management (SERT + EMM). EMM was manualized based on present centered therapy (PCT; McDonagh et al., 2005) and included 30 min of psychoeducation, provider support through active listening, and routine medical management. In this trial, which is the parent study of the current investigation, PTSD symptom severity was significantly reduced, but did not differ among the three groups (Rauch, Kim, Powell, Peter, Simon, Acierno et al., 2019). Whether their mechanisms of change are similar or unique, however, requires further study.

Negatively valanced affect and cognitions, such as guilt, are thought to play a critical role in PTSD (Ehring, Ehlers, & Glucksman, 2008; Huang & Kashubeck-West, 2015; Pugh, Taylor, & Berry, 2015; Øktedalen, 2015), so much so that they were officially added as symptoms of PTSD in the latest version of the Diagnostic and Statistical Manual of mental disorders (DSM-5, American Psychological Association [APA, 2013]). Trauma related guilt occurs when individuals experience distress because they believe that they should have thought, felt, or acted differently in response to the traumatic event (Kubany & Watson, 2003). Trauma related guilt is common among Veterans with PTSD and has been associated with PTSD symptom severity, depression, and functional impairment in clinical and experimental studies (Bockers et al., 2016; Browne, Trim, Myers, & Norman, 2015; Cunningham et al., 2018; Held, Owens, Schumm, Chard, & Hansel, 2011; Bub & Lommen, 2017; Norman et al., 2018). For instance, amongst Veterans seeking treatment for PTSD, 40% of the variance in PTSD symptom severity was accounted for by trauma related guilt and shame (Bannister et al., 2018). Furthermore, path analytic findings suggest that trauma related guilt is associated with PTSD symptom severity directly and indirectly through avoidant coping strategies (Held, Owens, Schumm, & Chard, 2011; Street, Gibson, & Holohan, 2005). Taken together, these findings indicate that trauma related guilt is an important contributor to the clinical course of PTSD.

There is growing evidence that trauma-focused therapies may effectively treat trauma related guilt by targeting guilt cognitions (Allard, Norman, Thorp, Browne, & Stein, 2018; Capone et al., accepted; Clifton, Feeny, & Zoellner, 2017; Diehle, Schmitt, Daams, Boer, & Lindauer, 2014; Trachik et al., 2018). Indeed, meta-analytic findings indicate that trauma-focused therapies result in greater reductions in negative posttraumatic cognitions, including trauma related guilt, compared to non-trauma focused therapies (Diehle et al., 2014). A number of studies also indicate that PE reduces trauma related guilt (Capone et al., accepted; Øktedalen, 2015; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Stapleton, Taylor, & Asmundson, 2006; Trachik et al., 2018). For example, a recent study found that exposure therapy resulted in significant reductions in trauma related guilt over time (Trachik et al., 2018). The reduction of trauma related cognitions, such as guilt, is thought to be a mechanism of change within PE and studies have demonstrated that shifts in beliefs predict PTSD symptom change within trauma-focused therapies (Allard et al., 2018; Cooper, Clifton, & Feeny, 2017; Kumpula et al., 2017; Kleim et al., 2013; Zalta, 2015; Zalta et al., 2014). Together, these findings suggest that PE can directly address trauma related guilt by targeting guilt cognitions and in doing so, reduce PTSD symptoms. However, the effect of pharmacotherapies for PTSD on trauma related guilt remains unclear at this time.

This study aimed to address these gaps by examining the effects of a trauma-focused psychotherapy, PE, and a medication approved for the treatment of PTSD, SERT, on trauma related guilt. Data were analyzed from a randomized controlled trial comparing each of the two treatments and their combination in OEF/OIF Veterans (Rauch et al., 2019). We hypothesized that: 1) there would be a decrease in level of trauma related guilt cognitions from baseline to post-treatment (week 24) and follow-up through week 52 regardless of condition; 2) PE + PLB and PE + SERT would be associated with greater reductions in trauma related guilt cognitions than the SERT + EMM condition from baseline to follow up (week 52); 3) reduction in trauma related guilt cognitions through week 12 would predict subsequent (weeks 24–52) reduction in (i) PTSD and (ii) depression, and post-treatment (week 24) reduction in (iii) functioning (which is the last time point this outcome was assessed).

Section snippets

Methods

This study comprises secondary analyses of a four-site (VA Ann Arbor Healthcare System, VA San Diego Healthcare System, Ralph H. Johnson VA Medical Center, and Massachusetts General Hospital Home Base Veterans Program), double-blind, randomized controlled trial study whose full methodology (Rauch, Simon, Kim, Acierno, King, Norman et al., 2018) and primary symptom and retention outcomes (Rauch et al., 2019) are published elsewhere. Participants were Veterans and active duty service members of

Results

Table 1 displays the unadjusted means of each measure at each time point along with the overall effect sizes, assessed as changes from baseline to week 24. Guilt Cognitions scores over time are displayed by treatment arm in Fig. 1, which indicates that the rate of change in Guilt Cognitions was greatest from week 0–12 than for any other study period. The unadjusted means and mixed-effects model showed that the mean Guilt Cognitions scores decreased significantly over the study period (from

Discussion

This study examined changes in trauma related guilt over the course of evidence-based psychotherapy (PE) and medication (SERT) and their combination for the treatment of PTSD. Trauma related guilt improved over the course of all treatments, but reductions in guilt cognitions did not vary by treatment condition. Pre- to mid-treatment reductions in guilt were associated with subsequent reductions in symptoms of PTSD and depression but not improvement in functioning.

While previous research

CRediT authorship contribution statement

Carolyn B. Allard: Conceptualization, Methodology, Validation, Data curation, and, Formal analysis, Investigation, Resources, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration. Sonya B. Norman: Conceptualization, Methodology, Resources, Writing – original draft, Writing – review & editing, Supervision, Project administration. Elizabeth Straus: Data curation, Writing – original draft, Writing – review & editing, Visualization. H. Myra Kim:

Declaration of competing interest

Drs. Allard and Norman receive royalties from Elsevier Press. Dr. Norman receives support from Department of Veterans Affairs (VA), National Institute of Health (NIH), and Department of Defense (DOD). Drs. Strauss and Kim have nothing to disclose. Dr. Stein has in the past three years been a consultant for Actelion, Alkermes, Aptinyx, Bionomics, EpiVario, GW Pharma, Janssen, and Oxeia Biopharmaceuticals. Dr. Stein has stock options in Oxeia Biopharmaceuticals and EpiVario. Dr. Simon in the past

Acknowledgements

This work was supported by the U.S. Department of Defense (DOD) through the U.S. Army Medical Research and Materiel Command (MRMC; Randomized Controlled Trial of Sertraline, Prolonged Exposure Therapy, and Their Combination in OEF/OIF Combat Veterans with PTSD; (Award #W81XWH-11-1-0073; PI: Rauch); the National Center for Advancing Translational Sciences of the National Institutes of Health (Award #UL1TR000433). The DOD had a role in design in that they wanted the study to include only

References (58)

  • R.H. Pietrzak et al.

    An examination of the relation between combat experiences and combat-related posttraumatic stress disorder in a sample of Connecticut OEF–OIF Veterans

    Journal of Psychiatric Research

    (2011)
  • L.R. Pugh et al.

    The role of guilt in the development of post-traumatic stress disorder: A systematic review

    Journal of Affective Disorders

    (2015)
  • Sheila A.M. Rauch et al.

    Integrating biological treatment mechanisms into randomized clinical trials: Design of PROGrESS (PROlonGed ExpoSure and Sertraline Trial)

    Contemporary Clinical Trials

    (2018)
  • B. Trachik et al.

    Combat-related guilt and the mechanisms of exposure therapy

    Behaviour Research and Therapy

    (2018)
  • Benjamin Trachik et al.

    Combat-related guilt and the mechanisms of exposure therapy

    Behaviour Research and Therapy

    (2018)
  • W. Alexander

    Pharmacotherapy for post-traumatic stress disorder in combat veterans: Focus on antidepressants and atypical antipsychotic agents

    Pharmacy and Therapeutics

    (2012)
  • C.B. Allard et al.

    Mid-treatment reduction in trauma-related guilt predicts PTSD and functioning following cognitive trauma therapy for survivors of intimate partner violence

    Journal of Interpersonal Violence

    (2018)
  • Diagnostic and statistical manual of mental disorders

    (2000)
  • Diagnostic and statistical manual of mental disorders

    (2013)
  • M.M. Antony et al.

    Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample

    Psychological Assessment

    (1998)
  • J.A. Bannister et al.

    Differential relationships of guilt and shame on posttraumatic stress disorder among Veterans

    Psychological Trauma: Theory, Research, Practice and Policy

    (2019)
  • D.D. Blake et al.

    The development of a clinician-administered PTSD scale

    Journal of Traumatic Stress

    (1995)
  • L. Boschloo et al.

    The symptom‐specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: Results from an individual patient data meta‐analysis

    World Psychiatry

    (2019)
  • M.J. Bovin et al.

    Development and validation of a measure of PTSD-related psychosocial functional impairment: The Inventory of Psychosocial Functioning

    Psychological Services

    (2018)
  • K.C. Browne et al.

    Trauma-related guilt: Conceptual development and relationship with posttraumatic stress and depressive symptoms

    Journal of Traumatic Stress

    (2015)
  • K. Bub et al.

    The role of guilt in posttraumatic stress disorder

    European Journal of Psychotraumatology

    (2017)
  • Capone, C., Tripp, J.C., Trim, R.S., Davis, B.C., Haller, M., & Norman, S.B. (accepted). Comparing the effects of...
  • J.D. Clapp et al.

    Patterns of change in response to prolonged exposure: Implications for treatment outcome

    Depression and Anxiety

    (2016)
  • L.L. Davis et al.

    Pharmacotherapy for post-traumatic stress disorder: A comprehensive review

    Expert Opinion on Pharmacotherapy

    (2001)
  • Cited by (0)

    View full text