Effects of Antagonistic Actions in Response to Trauma Exposure
Condition: Post Traumatic Stress Disorder
MeSH terms: Stress Disorders, Traumatic; Stress Disorders, Post-Traumatic
Study type: Interventional

Summary: 
      The overarching objective of this study is to investigate the use of antagonistic actions as
      a treatment augmentation strategy for enhancing emotional processing during exposure to
      trauma-relevant stimuli. To accomplish this, participants (N = 84) reporting exposure to a
      combat, sexual assault, physical assault, or motor vehicle accident Criterion A trauma will
      be randomized to one of three experimental conditions: (a) Psychoeducation alone (PSYED); (b)
      Psychoeducation followed by repeated exposure to trauma-videoclips (PSYED + EXP); or (c)
      Psychoeducation followed by repeated exposure to trauma-videoclips while engaging in
      antagonistic actions (PSYED + EXP + AA). Antagonistic action strategies during exposure to
      the trauma-videoclips will include (a) adopting an open posture; (b) eating a palatable
      snack; (c) smiling; and (d) wishing on high levels of emotional distress.

      The investigators expect that (a) those randomized to receive psychoeducation alone will show
      less improvement relative to the two groups that receive psychoeducation plus repeated
      exposure to trauma-videoclips; (b) those receiving psychoeducation in combination with
      repeated exposure to trauma-videoclips while performing antagonistic actions will show
      significantly enhanced treatment outcome at the one-month follow-up relative to the other two
      treatment arms; (c) participants with greater PTSD symptom severity are likely to have a
      poorer treatment outcome to PSYED alone; (d) changes in trauma-related threat appraisals,
      coping self-efficacy, and safety behaviors will each independently mediate the effects of
      treatment; and (e) participants displaying reductions in their emotional reactivity are more
      likely to have a reduction in PTSD symptoms.
    

Detailed description: 
      Over 70% of Americans are exposed to trauma during their lifetime and approximately 5.6% will
      meet diagnostic criteria for posttraumatic stress disorder. Posttraumatic stress disorder
      (PTSD) can significantly interfere with social functioning, work, and increase one's risk for
      other physical and mental health problems. Trauma-focused psychotherapies for PTSD have been
      shown to outperform more traditional supportive psychotherapy or pharmacotherapy and have
      become the first line of treatment for PTSD. However, the impact of trauma-focused therapy
      such as Prolonged Exposure (PE) is reduced, due to high rates of attrition ranging from 38.5%
      to 50%. Thus, there is a clear need to develop treatments for PTSD that are more palatable.

      Preliminary evidence suggests that exposure-based treatment may be enhanced by having
      patients engage in antagonistic actions (e.g., smiling, laughing, adopting an open posture,
      wishing on threatening outcomes) during exposure to the feared target. Prior research found
      that these actions increased the efficacy of exposure therapy among a sample of 88 patients
      with acrophobia. Specifically, participants were instructed to stand at the railing and look
      over the edge while shaking their head to induce dizziness, standing at the edge without
      holding onto the railing, or walking towards the railing with their eyes closed and hands
      behind their back. Participants in the antagonistic action exposure group exhibited a
      significantly greater reduction in peak fear over the course of the study compared to all
      other groups (89% reduction versus 54%). Although promising, augmenting exposure therapy with
      antagonistic actions has yet to be tested for enhancing exposure therapy for PTSD. For the
      present study, antagonistic actions will include (a) adopting an open posture; (b) eating a
      palatable snack; (c) smiling; and (d) wishing on high levels of emotional distress (e.g.,
      "come on distress hit me with your best shot").

      There is a gap in the literature on antagonistic actions related specifically to trauma
      exposure. By better understanding mechanisms underlying reactions to a trauma video clip and
      trauma symptom development, the investigators can begin to reduce the debilitating effects of
      psychopathology following exposure to traumatic events in the future.

      The study is a 3 x 3 mixed model experimental design with treatment Condition as a
      three-level between-subjects factor and assessment period (baseline vs posttreatment vs
      follow-up) as a three-level within subjects factor. Participants (N = 84) reporting exposure
      to a combat, sexual assault, physical assault, or motor vehicle accident Criterion A trauma
      will complete a battery of baseline trauma-related symptom measures followed by a trauma
      memory provocation involving watching a brief trauma-relevant videoclip, during which
      behavioral and subjective indices of emotional reactivity will be collected. Participants
      will be stratified based on their trauma symptom severity (PCL-5) and trauma type (LEC-5) and
      then randomized to one of three conditions: (a) Psychoeducation alone (PSYED); (b)
      Psychoeducation followed by repeated exposure to trauma-videoclips (PSYED + EXP); or (c)
      Psychoeducation followed by repeated exposure to trauma-videoclips while engaging in
      antagonistic actions (PSYED + EXP + AA). Antagonistic action strategies during exposure to
      the trauma-videoclips will include (a) adopting an open posture; (b) eating a palatable
      snack; (c) smiling; and (d) wishing on high levels of emotional distress (e.g., "come on
      distress hit me with your best shot").

      Participants randomized to the two trauma videoclip exposure arms will receive six 3-minute
      video exposure trials with an inter-trial interval of 2 minutes, during which participants
      will complete ratings of (a) peak subjective distress during the trauma-videoclip; (b)
      anticipated subjective distress for the next trial; and (c) level of confidence for coping
      with their own trauma memory.
    

Intervention name(s): Psychoeducation; Exposure
Intervention type(s): Behavioral; Behavioral
Intervention description(s): psychoeducational materials on trauma and safety behaviors; six 3-minute video exposure trials with an inter-trial interval of 2 minutes
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: post traumatic stress disorder; PTSD; psychoeducation; exposure; trauma; combat; sexual assault; physical assault; motor vehicle accident