Treating Trauma in Psychosis RCT resultaten

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1 Treating Trauma in Psychosis RCT resultaten Mark van der Gaag PhD Hoogleraar Klinische Psychologie Vrije Universiteit, Amsterdam Hoofd Psychose Onderzoek Parnassia, Den Haag

2 Goedaardige incest (Incest is thought to occur) in approximately 1 in 1.1 million women. There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology. The father-daughter liaison satisfies instinctual drives in a setting were mutual alliance with an omnipotent adult condones the transgression... The act offers an opportunity to test in reality an infantile fantasy whose consequences are found to be gratifying and pleasurable... The ego's capacity for sublimation is favored by the pleasure afforded by incest... such incestuous activity diminishes the subject's chance of psychosis and allows for a better adjustment to the external world. There is often found little deleterious influence on the subsequent personality of the incestuous daughter.. one study found that the vast majority of them were none the worse for the experience. Freedman and Kaplan, Comprehensive Textbook of Psychiatry, 1972.

3 Goedaardige incest (Incest is thought to occur) in approximately 1 in 1.1 million women. There is little agreement about the role of father-daughter incest as a source of serious subsequent psychopathology. The father-daughter liaison satisfies instinctual drives in a setting were mutual alliance with an omnipotent adult condones the transgression... The act offers an opportunity to test in reality an infantile fantasy whose consequences are found to be gratifying and pleasurable... The ego's capacity for sublimation is favored by the pleasure afforded by incest... such incestuous activity diminishes the subject's chance of psychosis and allows for a better adjustment to the external world. There is often found little deleterious influence on the subsequent personality of the incestuous daughter.. one study found that the vast majority of them were none the worse for the experience. Freedman and Kaplan, Comprehensive Textbook of Psychiatry, 1972.

4 Vroegkinderlijk (seksueel) misbruik is een pluripotente Paniek St.n. Sociale fobie GAS 1.9 PTSS Psychotische St.n. Varese et al, 2012 predictor 2.4 Seksueel misbruik in de kindertijd Teicher & Samson, 2013 Depressie Verslaving

5 Meta-analye Childhood Maltreatment (Varese et al. Schiz Bull 2012, 38(4): ) 18 case-control studies (n = 2048 psychotic patients and nonpsychiatric controls), 10 pro-spective and quasi-prospective studies (n = ) and 8 population-based cross-sectional studies (n = ) OR for psychosis = 2.78 (Corrected for other factors (e.g. family history of psychosis, SES, etc) 9 out of the 10 studies that tested for it found a dose response relationship Population attributable risk = 33%

6 Specifieke trauma s specifieke symptomen? N=7353 OR stemmen OR paranoia Verkrachting Fysieke mishandeling Opgroeien in een tehuis Bentall, Wickham, Shevlin, & Varese (2012) NB Van Nierop et al., (2014) vindt dit in ander sample met andere statistische methode niet.

7 The Treating Trauma in Psychosis Trial Agnes van Minnen Daniëlle Tilburgs Mark van der Gaag David van den Berg Paul de Bont Berber van der Vleugel Ad de Jongh

8 Trauma Screening Questionnaire N = 2608 TYPE TRAUMA (eenmalig of vaker) % Ooit een traumatische ervaring gehad 78.2 Seksueel misbruik 32.8 Lichamelijke mishandeling 41.6 Traumatische psychotische episode 78.8 Emotionele mishandeling in de kindertijd 57.9 Overige trauma s (ongeval, ramp, oorlog) 37.6 Ernstige verwaarlozing 30.7

9 Screening with Trauma Screening Questionnaire 2608 patiënten gescreend 455 geïnterviewd met Clinician Administered PTSD Scales (KIP) 16% voldoet aan alle criteria voor PTSS

10 een of meer trauma s(78%) twee of meer trauma s (70%) drie of meer trauma s (60%)

11 Achim, Maziade, Raymond, Olivier, Mérette, & Roy Schizophr Bull 2011, Jul;37(4): De Bont, Van den Berg, Van der Vleugel, De Roos, De Jongh, Van der Gaag, & Van Minnen (Br J Psychiatry 2015,

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13 trauma bij psychose

14 Van den Berg & Van Minnen (VGCt 2011) enquête onder 491 gz-psychologen 1/32

15 Onderzoekers excluderen psychose Ronconi JM, Shiner B, Watts BV. Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD. J Psychiatr Pract 2014, Jan;20(1):25-37.

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17 iedereen mocht meedoen

18 treatment as usual psychose wachtlijst PTSS

19 EXPOSURE + taupsychose

20 EMDR + taupsychose

21 sterk geprotocolleerd

22 gefocust

23 Begin met het aller ergste trauma

24 Alle sessies zijn opgenomen

25 Flow-chart

26 Gemiddelde duur van psychotische symptomen: 21 jaar Gemiddeld aantal suïcide pogingen: 3.0

27 32 Posttraumatische Stress Symptomen: Zelf-Rapportage WL EMDR PE 12 B S1 S2 S3 S4 S5 S6 S7 S8 Post FU

28 100% 11.3% 20.0% 17.0% KIP diagnose post-treatment 90% 80% 70% 32.1% 20.0% 55.3% Post-treatment OR NNT PE vs WL: EMDR vs WL: % 50% 56.6% 60.0% 6-mont FU OR NNT PE vs WL: EMDR vs WL: % 30% 20% 10% 27.7% % Lost to follow-up % Still PTSD % Loss of diagnosis 0% PE EMDR WL

29 80 KIP schaal Post-treatment PE vs WL: EMDR vs WL: 6-mont FU PE vs WL: EMDR vs WL: d=.78 d=.65 d=.63 d= baseline post-treatment* 6-month followup* n=155 n=130 n= month followup* N=86 PE EMDR WL T0-T T2-T *Estimated means (LMM)

30 160 Post-traumatic Cognitons Inventory baseline post-treatment* 6-month followup* n=155 n=130 n=128 PE EMDR WL T0-T T0-T *Estimated means (LMM)

31 Paranoïde gedachten (GPTS-total score) Green et al. Psychological Medicine. 2008;38(1): Baseline Posttreatment 6-mo Follow-up PE + EMDR significant beter dan WL. Effect sizes: >> PE vs WL= 0.62 (p=.005; posttr) and 0.54 (p=.035, 6 mo FU) >> EMDR vs WL =.59 (p=.008, posttr). >> Over time: PE > WL and EMDR > WL

32 Remissie (SCI-PANSS) Andreasen, et al. American Journal of Psychiatry.2005;162(3): Significantl meer subjecten in remissie in PE en EMDR in vergelijking met de WL Odds Ratios >> PE vs WL: 3.39 (p=.008, posttr), 2.36 (p=.020, over time). >> EMDR vs WL: 3.17 (p=.013, posttr)

33 Ernst van depressie (BDI-II) Beck et al. San Antonio, TX: Psychological Corporation; Baseline Posttreatment 6-mo Follow-up PE significant beter dan zowel EMDR als WL. Effect sizes: >> PE vs WL : 0.78 (p<.001, posttr), 0.64 (p=.004, 6moFU), plus significantly better over time (p=.001)

34 Is behandeling veilig?

35 drop-out PE n=13 =24.5% EMDR n=11 =20.0% P=.571 Hembree, et al. J Trauma Stress. 2003;16:

36 veiligheid aantal ernstige negatieve gebeurtenissen Prolonged Exposure EMDR Wacht List

37 Symptom exacerbatie tijdens behandeling (reliable change index) ELKE TOENAME VAN SYMPTOMEN Trauma-Focused Treatment P=.050 Waiting List

38 9 Gemiddeld aantal adverse events TF Treatment Waiting List 0 Baseline to post-treatment Post-treatment to no statistics due to excess of zeros

39 Samengevat Mensen met psychose & PTSS hebben ernstige trauma s meegemaakt PTSS behandeling bij psychose is effectief in het verminderen van klachten Behandeling is veilig en vermindert de kans op negatieve incidenten en revictimisatie Maar., Voor veel mensen waren 8 sessies te weinig Behandeling had op korte termijn weinig effect op het sociaal-maatschappelijk functioneren

40 Met dank voor uw aandacht! DR. MARK VAN DER GAAG HOOGLERAAR KLINISCHE PSYCHOLOGIE, VRIJE UNIVERSITEIT, AMSTERDAM & HOOFD PSYCHOSE ONDERZOEK, PARNASSIA,DEN HAAG