research article open access trauma-focused ......research article open access trauma-focused...

van Dam et al BMC Psychiatry 2013 13172httpwwwbiomedcentralcom1471-244X13172

RESEARCH ARTICLE Open Access

Trauma-focused treatment for posttraumaticstress disorder combined with CBT for severesubstance use disorder a randomized controlledtrialDebora van Dam12 Thomas Ehring13 Ellen Vedel2 and Paul MG Emmelkamp14

Abstract

Background This randomized controlled trial (RCT) investigated the effectiveness of a combined treatment for co-morbid Posttraumatic Stress Disorder (PTSD) and severe Substance Use Disorder (SUD)

Methods Structured Writing Therapy for PTSD (SWT) an evidence-based traumafocused intervention was addedon to Treatment As Usual (TAU) consisting of an intensive cognitive behavioral inpatient or day group treatmentfor SUD The outcomes of the combined treatment (TAU + SWT) were compared to TAU alone in a sample of 34patients

Results Results showed a general reduction of SUD symptoms for both TAU + SWT and TAU Treatmentsuperiority of TAU + SWT was neither confirmed by interaction effects (time x condition) for SUD or PTSDsymptoms nor by a group difference for SUD diagnostic status at post-treatment However planned contrastsrevealed that improvements for PTSD severity over time were only significant within the TAU + SWT group Inaddition within the TAU + SWT group the remission of PTSD diagnoses after treatment was significant which wasnot the case for TAU Finally at post-treatment a trend was noticed for between group differences for the numberof PTSD diagnoses favoring TAU + SWT above TAU

Conclusions In sum the current study provides preliminary evidence that adding a trauma-focused treatment onto standard SUD treatment may be beneficial

Keywords Posttraumatic stress disorder Substance use disorder Comorbidity Randomized controlled trialTrauma-focused treatment Integrated treatment

BackgroundOver the past decade the detection and treatment ofposttraumatic stress disorder (PTSD) among substanceuse disorder (SUD) patients have increasingly been stud-ied [1-3] This trend mirrors a need in clinical practiceas the number of SUD patients meeting diagnostic cri-teria for PTSD is relatively large (20-30) [23] Import-antly there is evidence that this patient group suffersfrom more severe complaints and more relapses in

Correspondence deboravandamjellineknl1Department of Clinical Psychology University of Amsterdam Weesperplein4 1018 XA Amsterdam The Netherlands2Jellinek Substance Abuse Treatment Center Arkin Postbus 3907 1001 ASAmsterdam The NetherlandsFull list of author information is available at the end of the article

copy 2013 van Dam et al licensee BioMed CentrCommons Attribution License (httpcreativecreproduction in any medium provided the or

substance use than SUD patients without comorbidPTSD [45] This suggests that the common treatmentapproach whereby SUD and PTSD are treated sequen-tially and within different treatment centers may not beoptimal [6-8]Several theories have been developed to explain the

high comorbidity between PTSD and SUD Most evi-dence is available for the self-medication theory [9]which suggests that substances are used to alleviate orsuppress PTSD symptoms In line with this theory re-search investigating the chronology of PTSD and SUDhas shown that SUD is preceded by PTSD more oftenthan vice versa [1011] that the exacerbation of PTSDsymptoms is the most important factor in predicting

al Ltd This is an Open Access article distributed under the terms of the Creativeommonsorglicensesby20) which permits unrestricted use distribution andiginal work is properly cited

van Dam et al BMC Psychiatry 2013 13172 Page 2 of 13httpwwwbiomedcentralcom1471-244X13172

relapse following SUD treatment [12] and that improve-ments in PTSD symptoms are associated with subse-quent improvements in substance dependence [1314]In addition experimental research suggests that trauma-related cues can trigger a craving response [15]On the other hand there are also theoretical and em-

pirical grounds to assume an inverse relationship Thehigh risk hypothesis poses that SUD augments the riskfor traumatic experiences and thereby the chance fordeveloping PTSD [16] In addition SUD may interferewith habituation to the trauma memory [11] and thewithdrawal of substances may evoke traumatic memoriesand trigger PTSD symptoms as it resembles physicalexperiences during trauma [11] In line with thesehypotheses there is some evidence to suggest that insome cases SUD precedes PTSD in the development ofthis comorbidity in addition the treatment of SUDalone has been shown to lead to a reduction of PTSDsymptoms [17-20]Taken the two perspectives together a reciprocal rela-

tionship between both disorders appears to be the mostlikely explanation for the high co-morbidity betweenPTSD and SUD [111] This hypothesis is also supportedby recent data indicating that the vast majority of pa-tients first reported trauma then substance use whichagain was followed by additional traumatic experiencesand further substance use [21] This chronology suggeststhat patientsrsquo substance use indeed increases after havingexperienced trauma and that high levels of substanceuse may in turn increase the risk for other traumaticevents A mutual relationship between PTSD and SUDimplies that PTSD symptoms may exacerbate in the firstperiod of abstinence and that PTSD complaints mayimprove when abstinence is maintained Consequentlyit appears likely that a sequential treatment approach in-creases the risk that patients drop out of SUD treatmentprematurely and therefore do not receive PTSD treat-ment either It is therefore plausible to assume thatpatients will benefit more from combined treatmentinterventions for PTSD and SUDExisting treatments for concurrent PTSD and SUD are

based on two different approaches Some authors sug-gest that PTSD among SUD patients should be treatedaccording to the guidelines for PTSD in general whichrecommend trauma focused-cognitive behavioral treat-ment (TF-CBT) and EMDR [22] An important elementof TF-CBT is imaginal exposure Patients are asked torevisit their traumatic event in their imagination anddescribe it in great detail [23] In EMDR the client isinstructed to focus on the traumatic memory and simul-taneously perform rhythmic eye movements [24]A contrasting point of view is that trauma-focused

interventions may be too invasive for patients withconcurrent PTSD and SUD and that these interventions

put patients at risk for relapse treatment dropout andother adverse events [2526] Based on this idea non-trauma-focused interventions have been developed thatfocus on the present or past aspects of the patientrsquos lifeother than the trauma and that do not require patientsto revisit or reprocess the trauma [eg 25] The aim ofthese treatments is to provide patients with coping skillsto manage their trauma symptoms and to improve func-tioning The majority of treatments developed for con-current PTSD and SUD to date are non-trauma-focused[727-29] Although some programs include in vivo ex-posure [29] or sharing traumatic experiences within thegroup [28] they are best characterized as non-trauma-focused treatments as they do not comprise exposure tothe trauma memory as a main ingredient Existingintegrated treatments using a non-trauma-focused ap-proach appear to be successful in reducing PTSD andSUD symptoms but their results are generally notsuperior to active control conditions such as regularSUD treatment [13031] However integrated cognitivebehavioral therapy a non-trauma-focused therapy basedon a cognitive restructuring approach appears to be apositive exception to this rule [21]Recent evidence suggests that patients with concurrent

PTSD and SUD may benefit from trauma-focused inter-ventions and that these interventions are more effectivein reducing symptoms of PTSD than treatment-as-usual[13233] Importantly it appears that exposure-based in-terventions are not necessarily associated with an in-crease in attrition or relapse to drugs or alcohol [35]Until now trauma-focused interventions have not beenstudied within severe SUD patients allocated to intensiveSUD treatment Attention for PTSD symptoms appearsespecially important for this patient group as untreatedPTSD symptoms can be expected to be related to anumber of clinical complications Earlier research hasshown that PTSD symptoms in SUD patients are associ-ated with increased relapse in substance use [133536]and with more problems in mental health physicalhealth and social relationships [37] To our knowledgethis randomized controlled trial (RCT) is the first studybridging this gapAn evidence-based trauma-focused intervention for

PTSD was added on to a regular intensive cognitivebehavioral SUD program for severe SUD patients whichwas the treatment-as-usual (TAU) for this sample [38]The study aimed to investigate the effectiveness ofadding PTSD treatment to the intensive SUD treatmentprogram compared to TAU ie the intensive SUD treat-ment program only The trauma-focused interventionwas Structured Writing Therapy (SWT) for PTSD [39]SWT uses specific writing assignments to reprocesspainful trauma memories and it encourages cognitivereappraisal of trauma-related thoughts and social sharing


of the traumatic event Results from several studies sup-port the effectiveness of SWT in the treatment of PTSD[39-41] In addition SWT has been shown to reducelevels of intrusions and avoidance depression anxietyand somatization [41]The current study originated from an RCT investigat-

ing the effectiveness of an integrated outpatient treat-ment for concurrent PTSD and SUD (Van Dam VedelEhring Emmelkamp Integrated trauma-focused treat-ment for concurrent posttraumatic stress disorder andsubstance use disorder a randomized controlled trialsubmitted) In comparison to the earlier study thecurrent investigation focused on patients with more se-vere SUD symptoms who were attending inpatient orday treatment Furthermore in contrast to the earlierstudy among outpatients SWT was not integrated intothe SUD intervention but added on to TAU The pa-tients randomized to the experimental condition (TAU +SWT) received 10 individual sessions of SWT inaddition to the regular SUD program An add-on ap-proach seemed more appropriate for this study as SWTis provided as an individual therapy By adding SWT onto the regular SUD program all patients received thesame group intervention for SUD Therefore they allbenefited equally from group dynamics and they all re-ceived the same dose of SUD treatment whether theywere allocated to TAU or TAU + SWTThe aim of this RCT was to investigate the effective-

ness of a combined treatment for comorbid PTSD andsevere SUD Three hypotheses were tested The first hy-pothesis was based on the theory that PTSD and SUDare reciprocally related In line with this assumption weexpected that both TAU and TAU + SWT would be ef-fective in decreasing symptoms of SUD and PTSD Sec-ondly we expected that patients receiving TAU + SWTwould achieve significantly higher improvements onPTSD symptoms than patients in the TAU conditionThirdly following from the self-medication hypothesiswe hypothesized that TAU + SWT would be more effect-ive in reducing symptoms of SUD than TAU alone

MethodParticipantsFigure 1 summarizes the flow of participants throughthe study A consecutive sample of 34 patients wasrecruited from the Jellinek Substance Abuse TreatmentCenter in Amsterdam The Netherlands All patientswere allocated to intensive inpatient or day group treat-ment for SUD Allocation for treatment followed the prin-ciples of stepped care Therefore all patients included inthe current study suffered from severe substance abuseand had already been allocated to two or more SUDtherapies in the past five years Three patients droppingout the earlier study investigating integrated outpatient

treatment for concurrent PTSD and SUD (Van DamVedel Ehring Emmelkamp Integrated trauma-focusedtreatment for concurrent posttraumatic stress disorderand substance use disorder a randomized controlled trialsubmitted) were also included into the current studyRecruitment and eligibility criteria were parallel to thisearlier study Patients were recruited between July 2008and July 2011 Inclusion criteria were (1) a diagnosis ofsubstance abuse or substance dependence according toDSM-IV (2) a diagnosis of full-blown or partial PTSD[42] according to DSM-IV (partial PTSD was defined asmeeting symptom criteria for the reexperiencing clusterand for either the avoidancenumbing cluster or thehyperarousal cluster) (3) being allocated to intensivegroup treatment either as day treatment or as in-patient(4) being 18 years or older and (5) sufficient under-standing of the Dutch or English language Exclusioncriteria were (1) a diagnosis of Borderline PersonalityDisorder (2) other severe (psychiatric) problems thatrequired immediate clinical care (eg psychotic symp-toms manic episode current suicidal ideation severedomestic violence) (3) severe cognitive disorders or(4) receiving concurrent psychotherapy for any kind ofpsychological disorder Patients receiving medication forpsychological complaints (eg antidepressant medication)were included in the study if they remained on a stabledose during the course of the study This was the case forsix patients (18) At 3 month follow-up patients wereasked whether they had been any change in medicationprescription during the follow-up interval One patient(3) reported a change in medication treatment betweenpost-treatment and follow-up and two patients (6)reported to have started new medication treatment withina month after treatment No group differences were foundbetween the CBTSUD + SWT and CBTSUD conditionfor the number of patients using medication during treat-ment or medication changes after treatment (Fisherrsquosexact test prsquos gt 245)Patients in both conditions were considered dropouts

if they ended TAU for SUD prematurely Patients in theTAU + SWT group were additionally labeled as dropoutif they attended less than 75 of the SWT treatmentsessions (le 7) Dropout patterns for TAU + SWT (N = 19)revealed that ten patients completed treatment (53) Theother nine patients ended treatment before the fifth SWTsession (47) Three of them dropped out of treatmenteven before SWT started (33) In this study non-response was not equal to treatment dropout as all pa-tients could participate in study measurements whetherthey completed treatment or notTables 1 and 2 summarize sample characteristics and

between group analyses The overall sample consistedof 23 males and 11 females with a mean age of 423(SD = 90) No significant differences between treatment

508 positive PTSD screens

19 SWT +9 dropout

15 TAU4 dropout

42 eligible

36 t1 (pre-treatment)

6 declined (did not want to participate)

36 randomly allocated

16 completed t2 (mid-treatment)14 completed t3 (post-treatment)14 completed t4 (3 mo follow up)

19 in ITT analyses


15 in ITT analyses

34 received ge 1 session

2 patients referred to TAU withdrew from study after randomization

466 ineligible205 no (subthreshold) PTSD 141 allocated to outpatient treatment 44 severe (psychiatric) problems 23 concurrent psychotherapy23 Borderline Personality Disorder

4 severe cognitive problems 5 language

17 other4 unknown

Figure 1 CONSORT flowchart of the recruitment and retention of participants t1 = baseline ITT = Intent-to-treat


conditions were found for sample characteristics or drop-out rates χ2rsquos (1 N = 34)le 303 prsquos ge 22 In addition nogroup differences were revealed for baseline symptomseverities trsquos (32) le 0617 prsquos ge 54 or for diagnostic statusFisherrsquos exact prsquos ge 08

TreatmentsTreatment as usual (TAU) consisted of a regular intensivetreatment program for SUD based on the principles ofcognitive behavioral therapy (CBT) [38] The treatmentwas delivered in a group format and included coping skilltraining for alcohol andor drug abuse an evidence-basedtreatment for SUD [38] Coping skill training for SUDteaches patients to recognize high risk situations preced-ing substance use and offers strategies to deal with crav-ing and relapse Training tools are modeling behavioralpractice and homework assignments [43] Coping skillstraining for SUD was offered twice a week for the firstsix weeks (2 h group sessions) After that weeklysessions were provided for a period of 8 weeks

Furthermore TAU incorporated social skills training relax-ation training psycho-education motivational interviewingsessions basic CBT-training relapse prevention sessionsand emotion-regulation training In addition to attendingthe group training program patients had weekly sessionswith an individual therapist No interventions related toPTSD symptoms were carried out during these individualtreatment sessions The duration of the intensive part ofthe treatment program varied from 6 to 12 weeks Onaverage patients attended the program four days a weekDependent on the individual needs of each patient TAUcould be followed on an inpatient or an outpatient (daytreatment) basis All patients followed a detoxificationprogram before starting the treatment programTAU + SWT existed of the same treatment program as

described above except for ten individual sessions ofSWT that were added on to the program SWT startedafter patients had been abstinent for 4 to 6 weeks Thetreatment was drawn from a former protocol [44] Ther-apy sessions were offered weekly and lasted 45ndash60 min

Table 1 Sample characteristics demographic variables

Demographics Total (n = 34) TAU + SWT (n = 19) TAU (n = 15) Between group analyses

Mean age (SD) 423 (90) 426 (84) 419 (100) t (33) = 021 p = 84

Gender n () χ2 (1 N = 34) = 0012 p = 92

Male 23 (676) 13 (684) 10 (667)

Female 11 (324) 6 (316) 5 (333)

Ethnicity n () χ2 (4 N = 34) = 2962 p = 56

Dutch 23 (676) 13 (684) 10 (667)

European (other) 2 (59) 1 (53) 1 (67)

Arabic Moroccan Turkish 4 (118) 1 (53) 3 (200)

Black Surinamese Caribbean 4 (118) 3 (158) 1 (67)

Other 1 (29) 1 (53) 0 (0)

Education (certificate) n () χ2 (3 N = 34) = 0404 p = 94

No education primary school 11 (324) 6 (316) 5 (333)

Secondary school lower level 8 (235) 4 (211) 4 (267)

Secondary school higher level 9 (265) 5 (263) 4 (267)

Postsecondary 6 (176) 4 (211) 2 (133)

Relationship status n () χ2 (2 N = 34) = 2859 p = 24

Single 31 (912) 17 (895) 14 (933)

Partner 2 (59) 2 (105) 0 (0)

Missing 1 (29) 0 (0) 1 (67)

Source of income n () χ2 (2 N = 34) = 3026 p = 22

No work 22 (647) 10 (526) 12 (800)

Work 11 (324) 8 (421) 3 (200)

Missing 1 (29) 1 (53) 0 (0)

Dropouts n ()

SUD treatment amp SWT 13 (382) 9 (474) 4 (267) χ2 (1 N = 34) = 1521 p = 30

SUD treatment 12 (353) 8 (421) 4 (267) χ2 (1 N = 34) = 0875 p = 48

Baseline Measures

Mean PDS (SD) 295 (100) 304 (97) 283 (107) t (33) = 062 p = 54

Mean TLFB (SD) 200 (272) 199 (293) 201 (254) t (33) = 019 p = 99

Note TAU Treatment As Usual SWT Structured Writing Treatment


SWT consists of the following three phases self-confrontation cognitive reappraisal and sharingfarewellThe self-confrontation phase comprised trauma-focusedexposure and guided patients to write in detail aboutthe most traumatic event(s) they had experienced Thewriting had to be in the first person and in the presenttense addressing sensory experiences painful factsthoughts and emotions experienced during the traumaThe phase of cognitive reappraisal focused on changingdysfunctional appraisals related to the traumatic eventand its consequences For this purpose patients wereasked to write a letter of advice to an (imaginary) friendor loved one imagining that they had experienced thesame event Patients were asked to give advice to thisperson on how to handle thoughts emotions and conse-quences related to the trauma In a second step the

patient was instructed to write a similar letter to him- orherself The final phase consisted of a lsquosharing andfarewell ritualrsquo that was aimed at finding closure of thetraumatic event(s) In this final letter the patientreflected on the trauma its impact on hisher life andhisher resolutions for dealing with the trauma in the fu-ture During the whole treatment writing assignmentswere introduced and discussed during the treatmentsessions TAU + SWT also incorporated two flexiblesessions Patients and therapists could decide what ofthe former SWT assignments they wanted to give extraattention If necessary it was possible to use the flexiblesessions in advance to prolong the self-confrontation orthe cognitive reappraisal phaseIn order to prepare patients with concurrent PTSD

and SUD for possible difficulties during detoxification

Table 2 Sample characteristics diagnostic status (current)

Diagnostic status Total (n = 34) TAU + SWT (n = 19) TAU (n = 15) Between group analyses (Fisherrsquos exact)

PTSD diagnosis (full-blown) n () 21 (618) 9 (474) 12 (800) p = 08

Primary SUD diagnosis n ()

Alcohol not in remission 16 (441) 11 (579) 5 (333) p = 19

Drugs not in remission 15 (441) 8 (421) 7 (467)

Cannabis 4 (118) 1 (53) 3 (200) p = 30

Cocaine 10 (294) 6 (316) 4 (267) p = 10

Other 1 (29) 1 (53) 0 (0) p = 10

Substance Dependence 30 (882) 18 (947) 12 (800) p = 30

Substance Abuse 1 (29) 1 (53) 0 (0) p = 10

Other axis-I diagnoses n ()

Depressive disorder 11 (324) 4 (211) 7 (467) p = 15

Panic disorder 3 (88) 1 (53) 2 (133) p = 57

Panic disorder with agoraphobia 2 (58) 0 (0) 2 (133) p = 19

Social Phobia 4 (118) 2 (105) 2 (133) p = 10

Specific phobia 2 (58) 1 (53) 1 (67) p = 10

Obsessive compulsive disorder 0 (0) 0 (0) 0 (0) -

General anxiety disorder 1 (29) 0 (0) 1 (67) p = 44

Eating disorder 0 (0) 0 (0) 0 (0) -


and SUD treatment psycho-education about the viciouscircle of PTSD and SUD was provided in the first treat-ment session [6] For ethical reasons psycho-educationwas not only provided in the TAU + SWT condition butalso in the TAU condition Patients in the TAU + SWTgroup received psycho-education from their SWTtherapist In the TAU condition psycho-education wasprovided by the individual TAU therapist

TherapistsAll SWT therapists were regular therapist of the Jellinekwith a masterrsquos degree in clinical psychology and add-itional formal training in cognitive behavioral therapyTherapist treatment adherence was monitored in weeklysupervision sessions by the last author

MeasuresThe outcome measures for PTSD and SUD were changein the severity of PTSD symptoms and change in sub-stance use respectively Further outcome measures werePTSD and SUD diagnostic status The PosttraumaticDiagnostic Scale (PDS) [45] was used to assess PTSDsymptom severity The PDS consists of 17 items corre-sponding to the DSM-IV PTSD that are rated on a 4-point Likert-scale (0 = not at all or only one time 3 = fiveor more times a weekalmost always) and 9 itemsassessing impairment in different life areas PTSD symp-tom severity scores are obtained by summing the 17symptom items with higher scores indicating greatersymptomatology [45] The PDS has shown to perform

well within an SUD population revealing excellent in-ternal consistency good test ndashre-test reliability andgood convergent validity with PTSD diagnosis [46] Alsohigh sensitivities and moderate specificities were foundfor the PDS within this population [346] By means ofthe Timeline Follow Back (TLFB) [47] retrospective esti-mates of daily use of alcohol and drugs were obtained fora time frame of 90 days Its psychometric characteristicsfor alcohol use have been extensively evaluated [4849] Inour study alcohol consumption was converted to standarddrinks and drug use was converted to gramsDSM-IV axis I disorders including SUD and PTSD

were assessed with the Structured Clinical Interview forDSM-IV Axis I Disorders (SCID-I) [5051] The SCID-Ihas shown a fair interrater agreement for the SUD mod-ule (kappa = 065) and an excellent interrater agreementfor the PTSD module (kappa = 077) [52] To screen for(partial) PTSD the Jellinek-PTSD (J-PTSD) screeningquestionnaire was used [53] The J-PTSD was specific-ally developed to screen for PTSD in SUD patients Thesensitivity (87) specificity (75) and overall efficiency(77) are high using a cutoff score of 2 [53] The McLeanScreening Instrument for Borderline Personality Disorder(MSI-BPD) [54] was used to screen for BorderlinePersonality Disorder (BPD) The MSI-BPD has shown agood sensitivity (81) and specificity (85) for a cutoffscore of 7 [54] Patients with a score of ge 7 were invitedfor further assessment Borderline Personality Disorderwas assessed with the Structured Clinical Interview forDSM-IV Axis II Disorders (SCID-II) [55] The SCID-II


has shown very high interrater agreement for the BPDmodule (kappa = 091) [52]

ProceduresAll patients attending a regular intake at the Jellinekwere screened with the Jellinek-PTSD screening ques-tionnaire for PTSD If the screener was positive patientswere invited for further assessment in order to deter-mine diagnostic status If a formal diagnosis for (partial)PTSD was obtained eligible patients received writteninformation about the study and gave written informedconsent Patients willing to participate were invited againfor the pre-treatment assessment (t1) After pre-treatmentassessment patients were randomly assigned to eitherTAU + SWT or TAU by asking them to draw one out oftwo closed envelopes Each patient was approached for anadditional three assessments during the study mid-treatment (t2) (after the fifth session) post-treatment (t3)and 3 months post-treatment (t4) Patients were invited tothe Jellinek treatment center for all assessments exceptfor the shorter 3-month follow-up which was adminis-tered via telephone If a patient was unable to come to theJellinek for a face-to-face assessment the mid-treatmentor post-treatment assessments were also administered bytelephone (n = 7 at post-treatment) There was no financialcompensation for research and treatment participationThe study was approved by the ethics committee of

the University of Amsterdam (Faculty of Social and Be-havioral Sciences reference number 2008-KP-342) andsubmitted to the Clinical Trials Register ClinicalTrialsgov (Trial NCT00763542)

Statistical methodsAll analyses were performed using the IBM StatisticalPackage for Social Science (SPSS) version 190 forWindows T tests and χ2 tests were used to compareboth treatment conditions on sample characteristics anddropout rates Treatment effects were investigated withintent to treat (ITT) analyses Patients were categorizedas ITT if they attended at least one therapy sessionOverall missing data patterns showed very low percentagesof item non-response (lt 2) except for one secondary out-come measure concerning craving (5 item non-response)This justified the use of response function imputation [56]Figure 1 shows that unit non-response was lower than 21over all measurementsMissing data by unit non-response was handled by

Multiple Imputation (MI) (m = 5) Whole scales wereimputed using the complete datafile (k = 91) [57] Allanalyses were performed on average values derived fromthe imputed dataset For the dependent variables PDStotal score and TLFB (days of abstinence) a GeneralLinear Model (GLM) repeated measures was performedPlanned repeated contrasts for time were performed

for each condition separately (at mid-treatment post-treatment and at 3 month follow up) Rank-transformationwas performed additionally if variables were not normallydistributed [58]Non-parametric tests were used to examine differences

for diagnostic status (Fisherrsquos exact test and McNemars χ2)from pre- to post-treatment and follow-up Effect sizeswere calculated for all primary outcome measures

ResultsTreatment effectsDescriptive data for the primary outcome measures aredisplayed in Tables 3 and 4 All values are estimatedvalues based on pooled outcomes on the imputeddataset The outcome measures for PTSD were PTSDsymptom severity (PDS) and PTSD diagnostic status(SCID diagnosis) The outcome measures for SUD werethe number of abstinent days (TLFB) and SUD diagnos-tic status (SCID diagnosis)

PTSD symptom severityGLM repeated measures analyses on the imputeddataset revealed a main effect for time F(3 34) = 637p = 001 partial η2 = 0166 and no main effect for condi-tion F(1 34) = 001 p = 921 partial η2 = 0 No significantinteraction effect was found between condition andtime F(3 34) = 192 p = 132 partial η2 = 0059Planned contrast analyses were performed for both

treatment groups to assess the decrease in symptoms frompre- to mid-treatment from mid- to post-treatment andfrom post-treatment to follow-up For the TAU + SWTgroup a significant decrease in PTSD severity was foundfrom mid-treatment to post-treatment F(1 19) = 931p = 007 partial η2 = 0341 but not from pre-treatment tomid-treatment F(1 19) = 067 p = 424 partial η2 = 0036or from post-treatment to follow up F(1 19) = 301p = 100 partial η2 = 0143 For the TAU group no signifi-cant decreases in PTSD symptom severity were foundbetween the measurement points Frsquos (1 15) le 0924prsquos ge 353 partial η2rsquos le 062

PTSD diagnostic statusFor both conditions differences for PTSD diagnosticstatus were investigated with McNemar χ2 Overall asignificant increase was found for the number of remit-ted cases (partial and full-blown) in the TAU + SWTcondition McNemars χ2 (1 N = 19) = 82 p = 004 Morespecifically there was a significant decrease for partialPTSD McNemars χ2 (1 N = 19) =507 p = 024 but notfor full-blown PTSD McNemars χ2 (1 N = 19) = 017p = 680 For TAU no differences were found for PTSDdiagnoses McNemars χ2 (1 N = 26) le 100 prsquos gt 317To investigate differences for PTSD diagnoses betweenTAU + SWT and TAU at post-treatment a Fisherrsquos

Table 3 Descriptive analyses for PTSD for intent to treat sample (N = 34) (estimated values)

Variable(primaryoutcomemeasures)

TAU + SWT (A) (N = 19) TAU (B) (N = 15) GLM Partial η2 Contrast Partial η2 GLM Partial η2 GLM partialbη2

pre mid post fu pre mid post fu Time Time 1 pre-mid 1 pre-mid condition condition Time condition

Time condition

2 mid-post 2 mid-post

3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062

McN χ2 OR 3 Fisher t 4 φ5

SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -

B 0Partial ampFull-blown

Partial PTSD 10 (526) - 28 (147) - 3 (200) - 24 (160) - A 01 - minus0028 - -

B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08

Note PTSD Posttraumatic Stress Disorder TAU Treatment as usual SWT Structured Writing Therapy PDS Posttraumatic Diagnostic Scale SCID Structured Clinical Interview of DSM IV PTSD Posttraumatic stress disorderA = TAU + SWT B = TAU pre pre-treatment mid mid-treatment post post-treatment Fu follow up McN χ2 = McNemars χ2 OR odds ratio Pl Con planned contrastsp lt005 p lt 0001 t trend ns not significant3OR = increase of cases decrease of cases4Overall Fisherrsquos excact test was calculated for PTSD diagnosis (p = 006)φ5 Phi (measure of effectsize)

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Table 4 Descriptive analyses for SUD for intent to treat sample (N = 34) (estimated values)

Variable (primaryoutcome measures)

TAU + SWT (A) (N = 19) TAU (B) (N = 15) GLM Partial η2 Contrast Partial η2 GLM Partial η2 GLM partial η2

pre post fu pre post fu Time Time 1 pre-post 1 pre-post condition condition Time condition

Time condition

2 post-fu 2 post-fu

TLFB M (SD) Number ofabstinent days

199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052

McN χ2 OR 5 Fisher φ

SCID n () Primary SUDdiagnosis

- -

In remission 6 1 (53) 166 (874) - 3 (200) 102 (680) - A 1560 ns minus0244 - -

B 7

SCID n () 7 Total NSUD diagnoses

- -

In remission 1 (53) 164 (863) - 3 (200) 92 (613) - A 1540 ns minus0293 - -

B t 8 49

(Single SUD diagnosisnot in remission)

9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -

(2 SUD diagnoses not inremission)

6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -

(ge 3 SUD diagnosesnotin remission)

3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -

Note PTSD Posttraumatic Stress Disorder TAU Treatment as usual SWT Structured Writing Therapy PDS Posttraumatic Diagnostic Scale SCID Structured Clinical Interview of DSM IV PTSD Posttraumatic stress disorderA = TAU + SWT B = TAU pre pre-treatment mid mid-treatment post post-treatment Fu follow up McN χ2 = McNemars χ2 OR odds ratio Pl Con = planned contrasts p lt005 p lt 0001 t trend ns not significantφ Phi (measure of effectsize)5OR = increase of cases decrease of cases (Breslow amp Day 1980) OR was not calculated when the denominator equals zero6SUD has been diagnosed however the diagnosis is partially or completely in remission during the last month7No analyses were performed for variables in parentheses taking into account small sample sizes and inflation of chance8p = 006

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van Dam et al BMC Psychiatry 2013 13172 0 of 13httpwwwbiomedcentralcom1471-244X13172

exact test [a] was carried out Post-treatment resultsindicated a trend for between-group differences inPTSD diagnostic status (p = 06) After TAU + SWTless patients were diagnosed with PTSD than afterTAU

AbstinenceOverall abstinence from alcohol and drugs was calculatedfrom participantsrsquo TLFB reports for a 90 day time windowThe GLM analysis showed a significant main effect fortime F(2 34) = 4238 p lt 001 partial η2 = 0570 indicatingan increase for the number of drug and alcohol free daysfrom pre-treatment to follow up Neither a main effect forcondition F(2 34) = 035 p = 557 partial η2 = 0011nor an Time x Condition interaction effect were foundF(2 34) = 048 p = 620 partial η2 = 015 Outcomeswere similar after rank-transformation [59]For each treatment condition planned contrast ana-

lyses were performed to assess changes in abstinencefrom pre- to post-treatment and from post-treatmentto follow-up For TAU + SWT significant increases inabstinence were found from pre-treatment to post-treatment F(1 19) = 6521 p lt 001 partial η2 = 0784and significant decreases in abstinence from post-treatment to follow-up F(1 19) = 7422 p = 014 partialη2 = 0292 The TAU group only revealed an increase forabstinence from pre-treatment to post-treatment F(1 15) =28139 p lt 001 partial η2 = 0668 No significant changesfor abstinence were found for TAU from post-treatmentto follow-up F(1 15) = 0767 p = 396 partial η2 = 0052

SUD diagnostic statusTo compare SUD diagnostic status from pre- to post-treatment McNemar χ2 analyses were performed foreach treatment group Outcomes for TAU + SWT allshowed significant decreases for SUD diagnostic statusMcNemars χ2rsquos (1 N = 19) ge 144 prsquos lt 001) For TAUthe number of Primary SUD diagnoses decreased sig-nificantly from pre- to post-treatment McNemars χ2 (1N = 15) = 47 p = 03 and a trend was noticed for thedecrease of total number of SUD diagnoses McNemarsχ2 (1 N = 15) = 34 p = 06Post-treatment differences for SUD diagnostic status

between TAU + SWT and TAU were investigated bymeans of Fisherrsquos exact tests [b] which revealed nodifferences between both groups (prsquos gt 23)

Discussion and conclusionsThe aim of this RCT was to investigate the effectivenessof adding treatment for concurrent PTSD on to an in-tensive SUD treatment program It was expected thatthe combination of these two evidence-based treatmentswould lead to improved prognoses

According to the first hypothesis a reduction of SUDand PTSD symptoms was expected in both conditionsThis expectation was generally confirmed by findings forSUD Overall there was a significant decrease of SUDsymptoms from pre-treatment to follow-up Plannedcontrasts showed an increase in abstinence for bothTAU and TAU + SWT during treatment but also somedecrease of improvements from post-treatment tofollow-up for TAU + SWT In addition both groupsshowed a significant remission for the primary SUDdiagnosis Furthermore a significant reduction for thetotal number of SUD diagnoses was found in the TAU +SWT group and a trend was found for TAU In sumboth conditions were effective in reducing SUD whichwas to be expected as SUD was targeted in the sameway in both groups Importantly the current results alsoshow that it appears safe to provide trauma-focusedtreatment for PTSD in combination with SUD treat-ment which is in contrast to frequent clinical beliefBased on the idea that SUD and PTSD are mutually

maintained by a vicious cycle it was expected that suc-cessful SUD treatment should also reduce symptomlevels of PTSD Hypothesis 1 therefore also predictedthat PTSD should significantly be reduced in both treat-ment conditions At the same time Hypothesis 2 pre-dicted that PTSD should improve more after combinationtreatment compared to TAU Analyses testing these twohypotheses provided somewhat mixed results Symptomlevels of PTSD significantly decreased over time in theoverall sample which can be interpreted as support forHypothesis 1 In contrast to Hypothesis 2 no significantinteraction between time and condition emerged ie wedid not find clear-cut evidence for a superiority of SWT+TAU over TAU However there was indirect evidencesuggesting that the addition of SWT to TAU may be bene-ficial First planned contrasts showed only a significantreduction of PTSD symptoms during SWT for the TAU +SWT group but no significant reductions for PTSD dur-ing or after TAU This indicates that the overall decreaseof PTSD in both groups could mainly be attributed to theresults of the SWT+TAU condition Furthermore PTSDdiagnoses decreased in both conditions but this reductionwas only significant in the TAU + SWT condition Finallyat post-treatment a trend was found for between-groupdifferences for PTSD diagnostic status indicating thatfewer patients were diagnosed with PTSD (partial or full-blown) after TAU+ SWT than after TAUThirdly we expected that TAU + SWT would be more

effective in reducing symptoms of SUD than TAU aloneThis prediction was based on the self-medication hy-pothesis which suggests that successful PTSD treatmentmay lead to more sustainable abstinence as the need toself-medicate is reduced This hypothesis was notsupported by any type of analysis


In sum both treatments were found to be equally ef-fective in treating SUD We found preliminary evidencesuggesting that SWT + TAU may be more effective intreating PTSD symptoms than TAU although this wasnot supported by the crucial Time x Condition inter-action on PTSD symptom severities but only by a num-ber of indirect findings The fact that the interactioneffect was not significant may be due to different factorsFirst differences between both groups were difficult todetect due to the small sample size and therefore re-duced power Another possibility is that the dose ofSWT treatment was too low to realize significant im-provements for PTSD symptoms Interestingly the re-duction of diagnostic status in the combinationcondition was only significant for the partial PTSDgroup but not for patients with full-blown PTSD Thiscould also be interpreted as support for the idea thattrauma survivors with SUD and high symptom levels ofPTSD may need a higher dose of treatment In any casea replication of the findings in a larger sample is neces-sary before any firm conclusions can be drawnIn an earlier study we evaluated integrated trauma-

focused SWT for PTSD and CBT for SUD within a largersample of outpatients (N= 96) (Van Dam Vedel EhringEmmelkamp Integrated trauma-focused treatment forconcurrent posttraumatic stress disorder and substanceuse disorder a randomized controlled trial submitted)These outcomes showed that PTSD and SUD symptomswere treated effectively in both conditions In additioncompleter analyses favored trauma-focused integratedtreatment above CBT for SUD in reducing PTSD symp-tom severity Apart from sample size there were otherimportant differences in sample characteristics betweenthe present and the previous study Most importantly thecurrent patient sample was more severe This was mir-rored by the need for a more intensive treatment programfor SUD complaints but also in less mean abstinent daysat baseline (20 versus 34) and slightly higher mean base-line scores for PTSD (30 versus 27) Sample characteristicsfor both studies showed that the current sample com-prised relatively more men more patients with a lowereducation more patients without a relationship and morepatients without work Although the present patient groupwas more severe overall dropout percentages were lower(overall 38 TAU + SWT 47 TAU 27) compared tothe previous study (overall 46 TAU + SWT 51 TAU40) but also compared to other findings in this area ofresearch [1] Importantly dropout percentages did not dif-fer significantly between conditions although a studycomprising a larger sample size and therefore higher stat-istical power is necessary to provide conclusive evidenceon this issue Although the dropout rates observed in thecurrent study are comparable to earlier research in thisfield they are nevertheless far from satisfactory Future

research should aim at improving the acceptability of inte-grated treatments for PTSD and SUD Notably in thecurrent study most patients dropped out before SWTstarted (33) or during the first phase of self-confrontationof the SWT treatment (56) Only one patient ended treat-ment just after the self-confrontation phase (11) Thissuggests that patients were inclined to shudder from or ter-minate during the assignments comprising trauma-focusedexposure Future studies should explore whether a longerphase of preparation for trauma-focused treatment mayincrease the acceptability of this type of interventionThe lack of significant between-group differences for

SUD in the current study is consistent with previousfindings in less severe patients [12133] (Van DamVedel Ehring Emmelkamp Integrated trauma-focusedtreatment for concurrent posttraumatic stress disorderand substance use disorder a randomized controlled trialsubmitted) There may be several explanations for thisphenomenon (Van Dam Vedel Ehring EmmelkampIntegrated trauma-focused treatment for concurrentposttraumatic stress disorder and substance use dis-order a randomized controlled trial submitted) FirstSUD treatment was equal in both conditions whichmay have been so effective that group differences wereleveled out In addition long-term follow-up may beneeded to prove differences between the two conditionson SUD outcomes PTSD improvements have a betterchance to positively influence SUD symptoms after alonger period of time [21] (Van Dam Vedel EhringEmmelkamp Integrated trauma-focused treatment forconcurrent posttraumatic stress disorder and substanceuse disorder a randomized controlled trial submitted)A 1-year follow-up assessment is currently underwayBesides the small sample size a number of additional

limitations are noteworthy First the current samplecomprised a mixed group of inpatients and day-care pa-tients However the setting for inpatients and day-carepatients was very similar For example both groupsattended their treatment at the same location the con-tent of both programs was alike and most importantthe group intervention for SUD was the same in bothconditions Second patients suffering from borderlinepersonality disorder were excluded from the study dueto ethical reasons It is therefore not clear whether thecurrent results also apply to this subgroup of patientsThird whereas diagnoses of PTSD and SUD wereestablished using structured clinical interviews at pre-and post-treatment the 3 month follow-up assessmentexclusively comprised self-report measures which canbe regarded as a limitation of the current study A 1 yearfollow-up assessment including structured clinical inter-views to assess diagnostic criteria is currently underwayand will provide more conclusive evidence on the long-term effects of the two treatment conditions


An important strength of this RCT is its specific focuson external validity The intervention was studied in aroutine clinical setting under everyday circumstancesThis means that results can easily be generalized toregular clinical practice Another strength was that allpatients were offered the same type of SUD treatmentfacilitating interpretations about the added value ofTAU + SWT compared to TAUAlthough the small sample size and the indirect nature

of findings supporting a superiority of SWT + TAU pre-vent us from drawing firm conclusions the outcomes ofthis study are encouraging enough to continue investigat-ing trauma-focused treatment for patients with concurrentPTSD and SUD Trauma-focused PTSD treatmentpreliminary appears more effective in decreasing PTSDand SUD symptoms than SUD treatment alone withoutjeopardizing patientrsquos safety or treatment retention[3334] also if it concerns a more severe SUD patientgroup

EndnotesaFisherrsquos excact test was calculated with integersbFisherrsquos excact test was calculated with integers

Competing interestsThe authors declare that they have no competing interests

Authorsrsquo contributionsPE contributed to the writing of the research proposal participated in thedesign of the study supervised the research therapists supervised data-collection processes and read and reviewed the manuscript EV contributedto the writing of the research proposal participated in the design of thestudy supervised data-collection processes and read and reviewed themanuscript TE carried out the submission of the research to the ethicscommittee participated in the design of the study supervised andparticipated in data-collection supervised data analyses and read andreviewed the manuscript DD contributed to the study design carried outand supervised participant recruitment inclusion and measurements carriedout data analyses and contributed to the writing of the research manuscriptAll authors read and approved the final manuscript

AcknowledgementsThis study was supported by the Royal Netherlands Academy of Arts andSciences (Academy professorship awarded to Paul Emmelkamp) We aregrateful to the staff of the Jellinek for their contributions especially therapistsMiriam Wilcke Mirte Heringa Ilja Schurink Sylvia Oude Egberink Carlijn deVries Kim de Bruijn Sandra Mocking and Romy Koch We would also like tothank Niels Smits (VU University) for his valuable contribution todata-analyses

Author details1Department of Clinical Psychology University of Amsterdam Weesperplein4 1018 XA Amsterdam The Netherlands 2Jellinek Substance AbuseTreatment Center Arkin Postbus 3907 1001 AS Amsterdam TheNetherlands 3Institute of Psychology University of Muumlnster Fliednerstr 2148149 Muumlnster Germany 4King Abdulaziz University PO Box 80203Jeddah Saudi Arabia

Received 11 February 2013 Accepted 12 June 2013Published 19 June 2013

References1 Van Dam D Vedel E Ehring T Emmelkamp PMG Psychological treatments

for concurrent posttraumatic stress disorder and substance use disorderA systematic review Clin Psychol Rev 2012 32(3)202ndash214

2 Kimerling R Trafton JA Nguyen B Validation of a brief screen forPost-Traumatic Stress Disorder with substance use disorder patientsAddict Behav 2006 31(11)2074ndash2079

3 Van Dam D Ehring T Vedel E Emmelkamp PMG Validation of the PrimaryCare Posttraumatic Stress Disorder screening questionnaire (PC-PTSD) incivilian substance use disorder patients J Subst Abuse Treat 201039(2)105ndash113

4 Back S Dansky BS Coffey SF Saladin ME Sonne S Brady KT Cocainedependence with and without post-traumatic stress disorder acomparison of substance use trauma history and psychiatriccomorbidity Am J Addict 2000 9(1)51ndash62

5 Najavits LM Weiss RD Shaw SR A clinical profile of women withposttraumatic stress disorder and substance dependence Psychol AddictBehav 1999 13(2)98ndash104

6 Ford JD Russo EM Mallon SD Integrating treatment of posttraumatic stressdisorder and substance use disorder J Couns Dev 2007 85(4)475ndash490

7 McGovern MP Lambert-Harris C Acquilano S Xie HY Alterman AI Weiss RDA cognitive behavioral therapy for co-occurring substance use andposttraumatic stress disorders Addict Behav 2009 34(10)892ndash897

8 Najavits LM Harned MS Gallop RJ Butler SF Barber JP Thase ME Crits-Christoph P Six-month treatment outcomes of cocaine-dependentpatients with and without PTSD in a multisite national trialJ Stud Alcohol Drugs 2007 68(3)353ndash361

9 Khantzian E The self-medication hypothesis of addictive disorders focuson heroin and cocaine dependence Am J Psychiatry 1985142(11)1259ndash1264

10 Watt MH Ranby KW Meade CS Sikkema KJ MacFarlane JC Skinner DPieterse D Kalichman SC Posttraumatic stress disorder symptomsmediate the relationship between traumatic experiences anddrinking behavior among women attending alcohol-serving venuesin a South African township J Stud Alcohol Drugs 201273(4)549ndash558

11 Stewart SH Conrod PJ Psychosocial models of functional associationsbetween posttraumatic stress disorder and substance use disorder InTrauma and substance abuse Causes consequences and treatment ofcomorbid disorders Edited by Ouimette P Brown PJ Washington DCAmerican Psychological Association 200329ndash55

12 Clark HW Masson CL Delucchi KL Hall SM Sees KL Violent traumaticevents and drug abuse severity J Subst Abuse Treat 2001 20(2)121ndash127

13 Back SE Brady KT Sonne SC Verduin ML Symptom improvement in co-occurring PTSD and alcohol dependence [Erratum appears in J NervMent Dis 2006 Nov194(11)825] J Nerv Ment Dis 2006 194(9)690ndash696

14 Hien DA Jiang HP Campbell ANC Hu MC Miele GM Cohen LR BrighamGS Capstick C Kulaga A Robinson J et al Do Treatment Improvements inPTSD Severity Affect Substance Use Outcomes A Secondary AnalysisFrom a Randomized Clinical Trial in NIDArsquos Clinical Trials NetworkAm J Psychiatry 2010 167(1)95ndash101

15 Coffey SF Saladin ME Drobes DJ Brady KT Dansky BS Kilpatrick DGTrauma and substance cue reactivity in individuals with comorbidposttraumatic stress disorder and cocaine or alcohol dependenceDrug Alcohol Depend 2002 65(2)115ndash127

16 Hien DA Cohen LR Campbell A Is traumatic stress a vulnerabilityfactor for women with substance use disorders Clin Psychol Rev 200525813ndash823

17 Hien DA Cohen LR Miele GM Litt LC Capstick C Promising treatments forwomen with comorbid PTSD and substance use disordersAm J Psychiatry 2004 161(8)1426ndash1432

18 Hien DA Wells EA Jiang HP Suarez-Morales L Campbell ANC Cohen LRMiele GM Killeen T Brigham GS Zhang YL et al Multisite RandomizedTrial of Behavioral Interventions for Women With Co-Occurring PTSDand Substance Use Disorders J Consult Clin Psychol 2009 77(4)607ndash619

19 Zlotnick C Johnson J Najavits LM Randomized controlled pilot study ofcognitive-behavioral therapy in a sample of incarcerated women withsubstance use disorder and PTSD Behav Ther 2009 40(4)325ndash336

20 Cohen LR Hien DA Treatment outcomes for women with substanceabuse and PTSD who have experienced complex trauma Psychiatr Serv2006 57(1)100ndash106


21 McGovern MP Lambert-Harris C Alterman AI Xie H Meier A A RandomizedControlled Trial Comparing Integrated Cognitive Behavioral Therapy VersusIndividual Addiction Counseling for Co-occurring Substance Use andPosttraumatic Stress Disorders J Dual Diagn 2011 7(4)207ndash227

22 NICE Clinical Guideline 26 Post-traumatic Stress Disorder The Managementof PTSD in Adults and Children in Primary and Secondary Care 2005httpguidanceniceorgukCG26[NICE guidelines

23 Foa E Hembree EA Rothbaum B Prolonged Exposure Therapy for PTSDEmotional Processing of Traumatic Experiences Therapist Guide New YorkOxford University Press 2007

24 Shapiro F Eye Movement Desensitization and Reprocessing Basic PrinciplesProtocols and Procedures 2nd edition New York The Guilford Press 2001

25 Najavits LM Treatment of posttraumatic stress disorder and substanceabuse Clinical guidelines for implementing Seeking Safety therapyAlcohol Treat Q 2004 22(1)43ndash62

26 Pitman RK Altman B Greenwald E Longpre RE Macklin ML Poireacute RESteketee GS Psychiatric complications during flooding therapy forposttraumatic stress disorder J Clin Psychiatry 1991 52(1)17ndash20

27 Najavits LM Runkel R Neuner C Frank AF Thase ME Crits-Christoph PBlaine J Rates and symptoms of PTSD among cocaine-dependentpatients J Stud Alcohol 2003 64(5)601ndash606

28 Donovan B Padin-Rivera E Kowaliw S ldquoTranscendrdquo initial outcomes froma posttraumatic stress disordersubstance abuse treatment programJ Trauma Stress 2001 14(4)757ndash772

29 Triffleman E Carroll K Kellogg S Substance dependence posttraumaticstress disorder therapy - An integrated cognitive-behavioral approachJ Subst Abuse Treat 1999 17(1ndash2)3ndash14

30 Boden MT Kimerling R Jacobs-Lentz J Bowman D Weaver C Carney DWalser R Trafton JA Seeking Safety treatment for male veterans with asubstance use disorder and post-traumatic stress disordersymptomatology Addiction 2012 107(3)578ndash586

31 McHugo GJ Fallot RD Multisite Randomized Trial of BehavioralInterventions for Women With Co-occurring PTSD and Substance UseDisorders J Dual Diagn 2011 7(4)280ndash284

32 Coffey SF Stasiewicz PR Hughes PM Brimo ML Trauma-focused imaginalexposure for individuals with comorbid posttraumatic stress disorderand alcohol dependence Revealing mechanisms of alcohol craving in acue reactivity paradigm Psychol Addict Behav 2006 20(4)425ndash435

33 Mills K Teesson M Back SE Brady KT Baker AL Hopwood S Sannibale CBarrett EL Merz S Rosenfeld J et al Integrated exposure-based therapyfor co-occurring posttraumatic stress disorder and substancedependence A randomized controlled trial J Am Med Assoc 2012308(7)690ndash699

34 Brady KT Dansky BS Back SE Foa EB Carroll KM Exposure therapy in thetreatment of PTSD among cocaine-dependent individuals preliminaryfindings J Subst Abuse Treat 2001 21(1)47ndash54

35 Norman SB Tate SR Anderson KG Brown SA Do trauma history and PTSDsymptoms influence addiction relapse context Drug Alcohol Depend2007 90(1)89ndash96

36 Read JP Brown PJ Kahler CW Substance use and posttraumatic stressdisorders symptom interplay and effects on outcome Addict Behav 200429(8)1665ndash1672

37 Najavits LM Gastfriend DR Barber JP Reif S Muenz LR Blaine J Frank ACrits-Christoph P Thase M Weiss RD Cocaine dependence with andwithout PTSD among subjects in the National Institute on Drug AbuseCollaborative Cocaine Treatment Study Am J Psychiatry 1998155(2)214ndash219

38 Emmelkamp PMG Vedel E Evidence-Based Treatment for Alcohol and DrugAbuse A Practitionerrsquos Guide to Theory Methods and Practice New YorkRouteledge Taylor amp Francis Group 2006

39 Van Emmerik AAP Kamphuis JH Emmelkamp PMG Treating Acute StressDisorder and Posttraumatic Stress Disorder with Cognitive BehavioralTherapy or Structured Writing Therapy A Randomized Controlled TrialPsychother Psychosom 2008 77(2)93ndash100

40 Lange A Van de Ven JP Schrieken B Emmelkamp PMG InterapyTreatment of posttraumatic stress through the Internet a controlledtrial J Behav Ther Exp Psychiatry 2001 3273ndash90

41 Lange A Rietdijk D Hudcovicova M Van de Ven JP Schrieken BEmmelkamp PMG Interapy A controlled randomized trial of thestandardized treatment of posttraumatic stress through the InternetJ Consulting Clin Psychol Addict Behav 2003 71901ndash909

42 Blanchard EB Hickling EJ Taylor AE Loos WR Gerardi RJ Psychologicalmorbidity associated with motor vehicle accidents Behav Res Ther 199432(3)283ndash290

43 Monti PM Kadden RM Rohsenow DJ Cooney NL Abrams DB Treatingalcohol dependence a coping skills training guide New York The GuilfordPress 2002

44 Van Emmerik AAP Prevention and treatment of chronic posttraumatic stressdisorder University of Amsterdam 2004

45 Foa EB Cashman L Jaycox L Perry K The Validation of a Self-ReportMeasure of Posttraumatic Stress Disorder The Posttraumatic DiagnosticScale Psychol Assess 1997 9(4)445ndash451

46 Powers MB Gillihan SJ Rosenfield D Jerud AB Foa EB Reliability andvalidity of the PDS and PSS-I among participants with PTSD and alcoholdependence J Anxiety Disord 2012 26(5)617ndash623

47 Sobell LC Sobell MB The reliability of the alcohol timeline followbackwhen administered by telephone and by computer Drug Alcohol Depend1996 42(1)49ndash54

48 Vakili S Sobell LC Sobell MB Simco ER Agrawal S Using the TimelineFollowback to determine time windows representative of annual alcoholconsumption with problem drinkers Addict Behav 2008 33(9)1123ndash1130

49 Fals-Stewart W OrsquoFarrell TJ Freitas TT McFarlin SK Rutigliano P Thetimeline followback reports of psychoactive substance use by drug-abusing patients Psychometric properties J Consult Clin Psychol 200068(1)134ndash144

50 First MB Spitzer RL Gibbon M Williams JBW Structured clinical interview foraxis I DSM-IV disordersmdashPatient edition (SCID-IP version 20) New York USABiometrics Research Department 1996

51 Van Groenestijn MAC Akkerhuis GW Kupka RW Schneider N Nolen WAGestructureerd klinisch interview voor de vaststelling van DSM-IV as-Istoornissen (SCID-I) [Structured Clinical Interview for DSM-IV Axis I disorders(SCID-I)] Lisse The Netherlands Swets amp Zeitlinger 1999

52 Lobbestael J Leurgans M Arntz A Inter-rater reliability of the StructuredClinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis IIDisorders (SCID II) Clin Psychol Psychother 2010 18(1)75ndash79

53 Van Dam D Ehring T Vedel E Emmelkamp PMG Screening forposttraumatic stress disorder in civilian substance use disorder patientsCross-validation of the Jellinek-PTSD screening questionnaire J SubstAbuse Treat 2013 44(1)126ndash131

54 Zanarini MC Vujanovic AA Parachini EA Boulanger JL Frankenburg FRHennen J A Screening Measure for BPD The McLean ScreeningInstrument for Borderline Personality Disorder (MSI-BPD) J Pers Disord2003 17(6)568ndash573

55 Weertman A Arntz A Kerkhofs MLM Gestructureerd diagnostisch interviewvoor DSM-IV persoonlijkheidsstoornissen (SCID II) [Structural and ClinicalInterview for DSM-IV personality disorders (SCID II)] Lisse The NetherlandsSwets Test Publisher 2000

56 Van Ginkel JR Van der Ark LA Sijtsma K Multiple imputation of test andquestionnaire data and influence on psychometric results Multivar BehavRes 2007 42(2)387ndash414

57 Graham JW Missing Data Analysis Making It Work in the Real WorldAnnu Rev Psychol 2009 60(1)549ndash576

58 Conover WJ The rank transformationmdashan easy and intuitive way toconnect many nonparametric methods to their parametric counterpartsfor seamless teaching introductory statistics courses Wiley InterdisciplinaryRev Comput Stat 2012 4(5)432ndash438

doi1011861471-244X-13-172Cite this article as van Dam et al Trauma-focused treatment forposttraumatic stress disorder combined with CBT for severe substanceuse disorder a randomized controlled trial BMC Psychiatry 2013 13172

Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects

PTSD symptom severity

PTSD diagnostic status

Abstinence

SUD diagnostic status

Discussion and conclusions

Endnotes

Competing interests

Authorsrsquo contributions

Acknowledgements

Author details

References

van Dam et al BMC Psychiatry 2013 13172 of 13httpwwwbiomedcentralcom1471-244X13172

relapse following SUD treatment [12] and that improve-ments in PTSD symptoms are associated with subse-quent improvements in substance dependence [1314]In addition experimental research suggests that trauma-related cues can trigger a craving response [15]On the other hand there are also theoretical and em-

pirical grounds to assume an inverse relationship Thehigh risk hypothesis poses that SUD augments the riskfor traumatic experiences and thereby the chance fordeveloping PTSD [16] In addition SUD may interferewith habituation to the trauma memory [11] and thewithdrawal of substances may evoke traumatic memoriesand trigger PTSD symptoms as it resembles physicalexperiences during trauma [11] In line with thesehypotheses there is some evidence to suggest that insome cases SUD precedes PTSD in the development ofthis comorbidity in addition the treatment of SUDalone has been shown to lead to a reduction of PTSDsymptoms [17-20]Taken the two perspectives together a reciprocal rela-

tionship between both disorders appears to be the mostlikely explanation for the high co-morbidity betweenPTSD and SUD [111] This hypothesis is also supportedby recent data indicating that the vast majority of pa-tients first reported trauma then substance use whichagain was followed by additional traumatic experiencesand further substance use [21] This chronology suggeststhat patientsrsquo substance use indeed increases after havingexperienced trauma and that high levels of substanceuse may in turn increase the risk for other traumaticevents A mutual relationship between PTSD and SUDimplies that PTSD symptoms may exacerbate in the firstperiod of abstinence and that PTSD complaints mayimprove when abstinence is maintained Consequentlyit appears likely that a sequential treatment approach in-creases the risk that patients drop out of SUD treatmentprematurely and therefore do not receive PTSD treat-ment either It is therefore plausible to assume thatpatients will benefit more from combined treatmentinterventions for PTSD and SUDExisting treatments for concurrent PTSD and SUD are

based on two different approaches Some authors sug-gest that PTSD among SUD patients should be treatedaccording to the guidelines for PTSD in general whichrecommend trauma focused-cognitive behavioral treat-ment (TF-CBT) and EMDR [22] An important elementof TF-CBT is imaginal exposure Patients are asked torevisit their traumatic event in their imagination anddescribe it in great detail [23] In EMDR the client isinstructed to focus on the traumatic memory and simul-taneously perform rhythmic eye movements [24]A contrasting point of view is that trauma-focused

interventions may be too invasive for patients withconcurrent PTSD and SUD and that these interventions

put patients at risk for relapse treatment dropout andother adverse events [2526] Based on this idea non-trauma-focused interventions have been developed thatfocus on the present or past aspects of the patientrsquos lifeother than the trauma and that do not require patientsto revisit or reprocess the trauma [eg 25] The aim ofthese treatments is to provide patients with coping skillsto manage their trauma symptoms and to improve func-tioning The majority of treatments developed for con-current PTSD and SUD to date are non-trauma-focused[727-29] Although some programs include in vivo ex-posure [29] or sharing traumatic experiences within thegroup [28] they are best characterized as non-trauma-focused treatments as they do not comprise exposure tothe trauma memory as a main ingredient Existingintegrated treatments using a non-trauma-focused ap-proach appear to be successful in reducing PTSD andSUD symptoms but their results are generally notsuperior to active control conditions such as regularSUD treatment [13031] However integrated cognitivebehavioral therapy a non-trauma-focused therapy basedon a cognitive restructuring approach appears to be apositive exception to this rule [21]Recent evidence suggests that patients with concurrent

PTSD and SUD may benefit from trauma-focused inter-ventions and that these interventions are more effectivein reducing symptoms of PTSD than treatment-as-usual[13233] Importantly it appears that exposure-based in-terventions are not necessarily associated with an in-crease in attrition or relapse to drugs or alcohol [35]Until now trauma-focused interventions have not beenstudied within severe SUD patients allocated to intensiveSUD treatment Attention for PTSD symptoms appearsespecially important for this patient group as untreatedPTSD symptoms can be expected to be related to anumber of clinical complications Earlier research hasshown that PTSD symptoms in SUD patients are associ-ated with increased relapse in substance use [133536]and with more problems in mental health physicalhealth and social relationships [37] To our knowledgethis randomized controlled trial (RCT) is the first studybridging this gapAn evidence-based trauma-focused intervention for

PTSD was added on to a regular intensive cognitivebehavioral SUD program for severe SUD patients whichwas the treatment-as-usual (TAU) for this sample [38]The study aimed to investigate the effectiveness ofadding PTSD treatment to the intensive SUD treatmentprogram compared to TAU ie the intensive SUD treat-ment program only The trauma-focused interventionwas Structured Writing Therapy (SWT) for PTSD [39]SWT uses specific writing assignments to reprocesspainful trauma memories and it encourages cognitivereappraisal of trauma-related thoughts and social sharing










19 SWT +9 dropout

15 TAU4 dropout

42 eligible





19 in ITT analyses


15 in ITT analyses





17 other4 unknown









Mean age (SD) 423 (90) 426 (84) 419 (100) t (33) = 021 p = 84

Gender n () χ2 (1 N = 34) = 0012 p = 92

Male 23 (676) 13 (684) 10 (667)

Female 11 (324) 6 (316) 5 (333)

Ethnicity n () χ2 (4 N = 34) = 2962 p = 56

Dutch 23 (676) 13 (684) 10 (667)

European (other) 2 (59) 1 (53) 1 (67)



Other 1 (29) 1 (53) 0 (0)





Postsecondary 6 (176) 4 (211) 2 (133)


Single 31 (912) 17 (895) 14 (933)

Partner 2 (59) 2 (105) 0 (0)

Missing 1 (29) 0 (0) 1 (67)


No work 22 (647) 10 (526) 12 (800)

Work 11 (324) 8 (421) 3 (200)

Missing 1 (29) 1 (53) 0 (0)

Dropouts n ()



Baseline Measures

Mean PDS (SD) 295 (100) 304 (97) 283 (107) t (33) = 062 p = 54

Mean TLFB (SD) 200 (272) 199 (293) 201 (254) t (33) = 019 p = 99












Cannabis 4 (118) 1 (53) 3 (200) p = 30

Cocaine 10 (294) 6 (316) 4 (267) p = 10

Other 1 (29) 1 (53) 0 (0) p = 10





Panic disorder 3 (88) 1 (53) 2 (133) p = 57


Social Phobia 4 (118) 2 (105) 2 (133) p = 10



























Time condition


3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062


SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -



B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08


vanDam

etalBM

CPsychiatry

201313172Page

8of

13httpw

wwbiom






Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


vanDam

etalBM

CPsychiatry

201313172Page

9of

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wwbiom
























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References










19 SWT +9 dropout

15 TAU4 dropout

42 eligible





19 in ITT analyses


15 in ITT analyses





17 other4 unknown









Mean age (SD) 423 (90) 426 (84) 419 (100) t (33) = 021 p = 84

Gender n () χ2 (1 N = 34) = 0012 p = 92

Male 23 (676) 13 (684) 10 (667)

Female 11 (324) 6 (316) 5 (333)

Ethnicity n () χ2 (4 N = 34) = 2962 p = 56

Dutch 23 (676) 13 (684) 10 (667)

European (other) 2 (59) 1 (53) 1 (67)



Other 1 (29) 1 (53) 0 (0)





Postsecondary 6 (176) 4 (211) 2 (133)


Single 31 (912) 17 (895) 14 (933)

Partner 2 (59) 2 (105) 0 (0)

Missing 1 (29) 0 (0) 1 (67)


No work 22 (647) 10 (526) 12 (800)

Work 11 (324) 8 (421) 3 (200)

Missing 1 (29) 1 (53) 0 (0)

Dropouts n ()



Baseline Measures

Mean PDS (SD) 295 (100) 304 (97) 283 (107) t (33) = 062 p = 54

Mean TLFB (SD) 200 (272) 199 (293) 201 (254) t (33) = 019 p = 99












Cannabis 4 (118) 1 (53) 3 (200) p = 30

Cocaine 10 (294) 6 (316) 4 (267) p = 10

Other 1 (29) 1 (53) 0 (0) p = 10





Panic disorder 3 (88) 1 (53) 2 (133) p = 57


Social Phobia 4 (118) 2 (105) 2 (133) p = 10



























Time condition


3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062


SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -



B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08


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Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


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Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References



Mean age (SD) 423 (90) 426 (84) 419 (100) t (33) = 021 p = 84

Gender n () χ2 (1 N = 34) = 0012 p = 92

Male 23 (676) 13 (684) 10 (667)

Female 11 (324) 6 (316) 5 (333)

Ethnicity n () χ2 (4 N = 34) = 2962 p = 56

Dutch 23 (676) 13 (684) 10 (667)

European (other) 2 (59) 1 (53) 1 (67)



Other 1 (29) 1 (53) 0 (0)





Postsecondary 6 (176) 4 (211) 2 (133)


Single 31 (912) 17 (895) 14 (933)

Partner 2 (59) 2 (105) 0 (0)

Missing 1 (29) 0 (0) 1 (67)


No work 22 (647) 10 (526) 12 (800)

Work 11 (324) 8 (421) 3 (200)

Missing 1 (29) 1 (53) 0 (0)

Dropouts n ()



Baseline Measures

Mean PDS (SD) 295 (100) 304 (97) 283 (107) t (33) = 062 p = 54

Mean TLFB (SD) 200 (272) 199 (293) 201 (254) t (33) = 019 p = 99












Cannabis 4 (118) 1 (53) 3 (200) p = 30

Cocaine 10 (294) 6 (316) 4 (267) p = 10

Other 1 (29) 1 (53) 0 (0) p = 10





Panic disorder 3 (88) 1 (53) 2 (133) p = 57


Social Phobia 4 (118) 2 (105) 2 (133) p = 10



























Time condition


3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062


SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -



B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08


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Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


vanDam

etalBM

CPsychiatry

201313172Page

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wwbiom
























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References







Cannabis 4 (118) 1 (53) 3 (200) p = 30

Cocaine 10 (294) 6 (316) 4 (267) p = 10

Other 1 (29) 1 (53) 0 (0) p = 10





Panic disorder 3 (88) 1 (53) 2 (133) p = 57


Social Phobia 4 (118) 2 (105) 2 (133) p = 10



























Time condition


3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062


SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -



B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08


vanDam

etalBM

CPsychiatry

201313172Page

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13httpw

wwbiom






Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


vanDam

etalBM

CPsychiatry

201313172Page

9of

13httpw

wwbiom
























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References

















Time condition


3 post-fu 3 post-fu

PDS totalM (SD)

304 (97) 282 (90) 176 (120) 235 (148) 283 (107) 265 (98) 243 (91) 217 (94) A + B

0166 1 A ns B ns A 0036B 0037

ns 0000 ns 0059

2 A B ns A 0341B 0040

3 A ns B ns A 0143B 0062


SCID (PTSD)n ()

PTSD 19 (100) - 98 (518) - 15 (100) - 132(880)

- A 0 - minus0390 - -



B 08

Full-blownPTSD

9 (474) - 7 (368) - 12 (800) - 108(720)

- A 07 - minus0353 - -

B 08


vanDam

etalBM

CPsychiatry

201313172Page

8of

13httpw

wwbiom






Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


vanDam

etalBM

CPsychiatry

201313172Page

9of

13httpw

wwbiom
























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References





Time condition

2 post-fu 2 post-fu


199 (293) 768 (155) 610 (308) 201 (254) 660 (303) 586 (384) A + B 0570 1 A B A 0784B 0668

ns 0011 ns 015

2 A B ns A 0292B 0052



- -


B 7


- -


B t 8 49


9 (474) 26 (137) - 6 (400) 58 (687) - - - - - - -


6 (316) 0 (0) - 3 (200) 0 (0) - - - - - - -


3 (158) 0 (0) - 3 (200) 0 (0) - - - - - - -


vanDam

etalBM

CPsychiatry

201313172Page

9of

13httpw

wwbiom
























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References























































































Abstract

Background

Methods

Results

Conclusions

Background

Method

Participants

Treatments

Therapists

Measures

Procedures

Statistical methods

Results

Treatment effects



Abstinence



Endnotes

Competing interests


Acknowledgements

Author details

References

research article open access trauma-focused ......research article open access trauma-focused...

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