Evidence-based treatment for adult women with child abuse-related Complex PTSD: a quantitative review

Figures & data

Fig. 1 RCTs on child abuse (CA) and or PTSD.

Category A: CA-related Complex PTSD (4 RCTs): All study participants diagnosed with Complex PTSD or >50% with personality disorder; PTSD as target symptoms. All CA. All CA as index trauma.

Category B: CA-related PTSD (3 RCTs): All study participants diagnosed with PTSD as target symptoms. Outcome measures also covering some Complex PTSD symptoms All CA. All CA as index trauma.

Category C: All PTSD + mainly CA (9 RCTs): All study participants diagnosed with PTSD as target symptoms. >50% CA or <50% but CA population analyzed separately. Index trauma sometimes CA, mainly rape or domestic violence.

Category D: All CA + mainly PTSD (5 RCTs): Study participants >50% PTSD or substantial PTSD symptomatology (PTSD patients not analyzed separately); PTSD as target symptoms. All CA. All CA as index trauma.

Category E: Mainly PTSD + mainly CA (3 RCTs): Study participants >50% PTSD (as target symptoms) and >50% CA.

Table 1 Study characteristics of randomized controlled trials with CA-related (Complex) PTSD (A+B): N, population, recruitment, inclusion and exclusion criteria, assessment and severity of trauma and symptoms and previous treatments

							Assessment			Severity
Author, year	N	Population	Recruitment	Inclusion criterion	Exclusion criteria	Inclusion ratea	Trauma	Axis I	Axis II	Trauma	Symptom	Comorbidity	Previous treatments
Zlotnick et al., 1997 (A)	48	All women Mean age 39 yrs 99% White 33% College degree 29% Low income	Referred	CSA-related Complex PTSD (DSM-IV)	Psychosis, substance abuse, DID	NR	CTQ	CAPS SIDES	NR	PTSD based on sexual abuse before age 17, above threshold CTQ 77% CSA by relative 35% parent 37% rape Mean age of onset 6.9 yrs; Mean 3.7 abusers	DTS 70 DES 22	100% Complex PTSD	50% previous hospitalization
Classen, Koopman, Nevillmanning, & Spiegel, 2001 (B)	55	All women Mean age ca. 38 yrs 64% White 44% College degree 80% Employed	Advertisement newspapers, flyers, radio, community agencies	CSA-related PTSD (DSM-IV)	Schizophrenia, dementia, delirium, amnesic/cognitive disorders, ritual abuse, current psychotherapy, alcohol/drug dependence, current suicidality (last month)	58%	SES	TSC-40	NR	At least two explicit memories of sexual abuse that involved genital contact; at least two sexual abuse events between 3–15 yrs of age; perpetrator at least 5 yrs older.	Only difference scores reported	NR	NR
Cloitre et al., 2002 (B)	58	All women Mean age 34 yrs 46% White 52% College degree 75% Employed or student	Self-referred advertisements	CA-related PTSD (DSM-IV)	BPD, Organic or psychotic mental disorder, substance dependence, eating disorder, dissociative disorder, bipolar disorder-I, suicide attempt or hospitalization during last 3 months	56%	CMIS SAAIVS	CAPS Blind for condition SCID-I	SCID-II	At least 1 clear memory - CSA: at least 1 time sexual contact before age 18 perpetrator at least 5 yrs older - CPA: parent/other adult in charge purposely hurt leaving e.g., bruises 48% CSA+CPA 39% CSA “only” 13% CPA “only”	CAPS 70 MPSS-SR 70 BDI 24	45% MDD 79% anxiety disorder 25% past substance abuse 16% past eating disorder	29% need of ER past year
Chard, 2005 (B)	71	All women Mean age ca. 33 yrs Mean education 14 yrs 81% White	Advertising, letters, presentations to local health professionals.	CSA-related PTSD (DSM-IV)	Suicidal intent, substance dependence, current trauma, medical disorders, unstable medication during last 3 months, substance abuse during last 3 months	81%	STI SAEQ	CAPS SCID-I	NR	At least 1 sexual incident as defined by state law, at least 1 memory Mean age of onset 6.4 yrs 57% >100 times, 63% >1 abuser, 84% by a relative	CAPS 67 BDI 24 DES 19	40% MDD	NR
McDonagh et al., 2005 (A)	74	All women Mean age ca. 40 yrs	NR	CSA-related Complex	NO personality disorder was an exclusion criteria. Medical disorders, (hypo)	30%	ELS	CAPS SCID-I	SCID-II	Sex contact with anyone at least 5 yrs older when under 16. PTSD	CAPS 70 BDI 18 DES 15	100% personality disorder	NR
		95% White 80% High school or higher 83% Employed	NR	PTSD (DSM-IV)	mania, schizophrenia, schizoaffective disorders, psychosis, DID, organic psychosis, severe, bipolar or psychotic depressive disorder, current alcohol/drug abuse last 3 months, active suicidality, history of 2 suicide attempts, abusive partner	30%	ELS	CAPS SCID-I	SCID-II	intrusion (partly) related. At least 1 clear detailed memory Much CSA+CPA and much adult abuse, majority involved penetration by a relative	DES 15	(10.8% BPD)	NR
Cloitre et al., 2010 (A)	104	All women Mean age ca. 36 yrs 35% white 88% high school 33% unemployed	NR	CA-related Complex PTSD (DSM-IV)	Substance dependence, psychotic symptoms, cognitive impairment, bipolar disorder, active suicidality requiring ER, current PTSD focused psychotherapy	34%	NR	CAPS Blind for condition	SCID-II	Primary diagnosis of CA-related PTSD by care taker/someone in authority before age 18 90% CSA 80% CPA Much additional adult abuse Mean 6.5 traumatic experiences	CAPS 64 BDI 21	90% Axis I diagnosis 50% personality disorder (24% BPD)	Mean 2 previous psychological treatments
Dorrepaal et al., 2012 (A)	71	All women Mean age 40 yrs Mean education 9.9 yrs 17% employed	Referred patients	CA-related PTSD and Complex PTSD (DSM-IV)	Long-lasting psychosis, DID, severe substance abuse interfering with compliance, antisocial personality disorder	79%	STI	CAPS SIDES blind	96% Axis I (55% MDD) 75% Axis II (52% BPD) 70% used psychotropic medication (47% SSRI/SNRI, 25% sedatives, >50% antipsychotics)	CA before age 16 as defined by STI 93% CSA >50% CSA+CPA >50% additional adult abuse	DTS 85 DES 25	96% Axis I (55% MDD) 75% Axis II (52% BPD) 70% used psychotropic medication (47% SSRI/SNRI, 25% sedatives, over 50% antipsychotics)	Mean 2 previous psychological treatments

BDI=Beck Depression Interview; BPD=borderline personality disorder; CAPS=Clinician-Administered PTSD Scale; CBT=cognitive behavioral therapy; CMIS= Childhood Maltreatment Interview Schedule; CA=child abuse; CPA=child physical abuse; CSA=child sexual abuse; CTQ= Childhood Trauma Questionnaire; DES=Dissociative Experiences Scale; DID=dissociative identity disorder; ELS=evaluation of lifetime stressors; ER=emergency room; MDD=major depressive disorder; MPSS-SR=Modified Posttraumatic Stress Disorder Symptom Scale—Self-Report; NR=not reported; SAAIVS= Sexual Assault and Additional Interpersonal Violence Schedule; SAEQ=Sexual Abuse Exposure Questionnaire; SCID-I/SCID-II=Structured Clinical Interview for DSM-IV—for Axis I/Axis II; SES=Sexual Experiences Survey; SIDES=Structured Interview for Disorders of Extreme Stress; SIDP-IV=Structured Interview for DSM-IV Personality Disorders; STI=Structured Trauma Interview; TSC-40=Trauma Symptom Checklist-40.

a Included patients/recruited patients×100%.

Table 2 Treatment characteristics of randomized controlled trials with CA-related (Complex) PTSD (A+B)

1st Author, year	Active treatment	Format	Index trauma	Target symptoms	Psycho-education	CT/CR	Affect management	Exposure techniques	Social skills	Home work
Zlotnick et al., 1997 (A)	AM	15 weekly 90 min group sessions added to TAU	CSA	PTSD and affect dysregulation	+	±2 sessions	+	−	−	+
Classen et al., 2001 (B)	TFT+PFT	24 weekly 90 min group sessions	CSA	TFT: Work through, integrate. PFT: Modify maladaptive patterns	+	PFT+some basic assumptions	PFT: ±?	TFT: +?	Interpersonal learning?	?
Cloitre et al., 2002 (B)	STAIR+PE	8 weekly 60 min & 8 twice-a-week individual 90 min sessions	CA	PTSD and affect regulation	STAIR: +	+	STAIR: +	PE: +	STAIR: +	+
Chard, 2005 (B)	CPT-SA	17 weekly 90 min group sessions combined with 10 weekly 60 min individual sessions	CSA	PTSD, fear and attachment,	+	CPT-SA: +	_	WA: +	−	+
McDonagh et al., 2005 (A)	CBT PCT	7 weekly 120 min sessions followed by 7 individual 90 min sessions	CSA	CBT: Fear extinction and cognitive restructuring PCT: Change in traumagenic dynamics	+	CBT: + PCT: −	CBT: − PCT: Problem solving	CBT:+(PE) PCT: −	CBT: − PCT: Problem solving skills	+
Cloitre et al., 2010 (A)	STAIR/PE STAIR/Sup Sup/PE	16 weekly individual sessions	CSA	PTSD and affect dysregulation and interpersonal difficulties	PE: + STAIR: +	PE: + STAIR: +	PE: − STAIR: +	PE: + STAIR: −	PE: + STAIR: +	PE: + STAIR: +
Dorrepaal et al., 2012 (A)	CBT group	20 weekly 120 min group sessions added to TAU	CA	PTSD and Complex PTSD (Affect dysregulation, Dissociation, Self-esteem, Interpersonal difficulties, Somatization and Future meaning)	+	+	+	−	+	+

AM=affect management; C(S)A=child (sexual) abuse; CBT=cognitive behavioral therapy; CPT-SA=cognitive processing therapy for sexual abuse survivors; CR=cognitive restructuring; CT=cognitive therapy; PE=prolonged exposure; PFT=present focused therapy; STAIR=Skills Training in Affect and Interpersonal Regulation; Sup=supportive treatment; TFT=trauma focused therapy; WA=written accounts.

Table 3 Drop-out rates, pretreatment and posttreatment scores (mean, SD), and effect sizes of pretreatment versus posttreatment and treatment versus waiting list or other treatment, recovery and improvement rates on PTSD symptom severity (completers and intention-to-treat) per included study

						Posttreatment score				Effect size				Post
				MEASURE/Prescore		Completer		ITT		pre vs post (Cohen's d)		treatment vs. control (Cohen's d corrected)		Recovery rate		Improvement rate
	Treatment or WL	N (N completer)	Drop-out	M	SD	M	SD	M	SD	Completer	ITT	Completer	ITT	Completer	ITT	Completer	ITT
Zlotnick et al., 1997 (A)	AM TAU+WL	24 (16) 24 (17)	33% 29%	DTS 66.9 74.7	22.00 25.83	45.76 73.06	34.12 29.86	52.2a 73.5		0.91 0.07	0.63a 0.05	0.84	0.58a	87% 41%	61%a 30%	–	–
Classen et al., 2001 (B)	TFT+PFT WL only	14+7 34	NR	TSC-40 g – –	– –	– –	– –	– –	– –	8.1 3.8	17.0 14.1	– –	– –	– –	– –	– –	– –
Cloitre et al., 2002 (B)	STAIR+PE WL only STAIR+PE WL only	31 (22) 27 (24)	29% 11%	MPSS-SR 69 73 CAPS 69 69	16.6 18.6 16.3 16.6	29 58 31 62	27.6 28.6 25.2 22.7	40.6a 59.7 42.0 62.7		2.31 0.87 2.36 0.43	1.64a 0.77 1.68 0.39	1.45 1.93	0.87a 1.29	77% 25%	55%a 22%	46% 4%	33%a 4%
Chard, 2005 (B)	CPT-SA WL (MA) CPT-SA WL (MA)	36 (30) 35 (28)	17% 20%	CAPS 65.5 68.3 MPSS-SR 57.6 57.5	26.4 23.7 22.9 24.7	9.00 63.0 7.54 57.7	11.0 30.7 9.51 27.5	18.4a 64.0 15.9 57.7		2.29 0.22 2.14 −0.01	1.91a 0.17 1.78 −0.01	2.07 2.15	1.73a 1.79	93% 26%	78%a 21%	79% 4%	66%a 3%
McDonagh et al., 2005 (A)	CBT PCT WL only	29 (17) 22 (20) 23 (20)	41% 9% 13%	CAPS 67.1 67.5 70.0	18.4 15.1 16.9	38.5 44.9 62.5	27.7 22.1 17.0	53.1 47.2 65.5	28.8 22.4 18.6	1.75 1.39 0.44	1.03 1.26 0.40	1.29 0.93 0.37c	0.63 0.86 −0.23c	47% 35% 20%	28% 32% 17%	–	–
Cloitre et al., 2010 (A)	STAIR/PE STAIR/Sup Sup/PE STAIR/PE STAIR/Sup Sup/PE	33 (28) 38 (28) 33 (20)	15% 26% 39%	CAPS 63.1 64.3 64.5 PTSD-SR 36.7 39.9 38.2	18.3 21.2 15.9 12.9 12.7 11.1	27.3b 20.9 23.6 9.95 5.43 6.52		32.7 32.3 39.7 14.0 14.5 19.0	19.4 23.0 18.3 11.5 12.8 9.83	1.94b 2.35 2.22 2.21 2.85 2.84	1.65 1.73 1.34 1.87 2.10 1.59	−0.28d 0.14e −0.41f −0.64d 0.23e −0.41f	0.30d 0.39e −0.09f −0.22d 0.51e 0.29f	72%b 64% 55%	61% 47% 33%	32%b 33% 10%	27% 24% 6%
Dorrepaal et al., 2012 (A)	CBT group TAU+WL	38 (31) 33 (29)	18% 12%	DTS crsf 91.4 80.5	21.8 23.1	66.7 65.5	29.4 30.3	69.6 66.5	27.4 29.8	1.12 0.68	0.99 0.63	0.44	0.35	–	–	55% 24%	45% 21%

AM=affect management; CAPS=Clinician-Administered PTSD Scale; CBT=cognitive behavioral therapy; CPT-SA=cognitive processing therapy for sexual abuse survivors; DTS=Davidson Trauma Scale; ITT=intention-to-treat; M=mean; MA=minimal attention; MPSS-SR=Modified Posttraumatic Stress Disorder Symptom Scale—Self-Report; NR=not reported; PTSD-SR=PTSD Self-Report; PE=prolonged exposure; PFT=present focused therapy; SD=standard deviation; STAIR= Skills Training in Affect and Interpersonal Regulation; TAU=treatment as usual; TSC-40=Trauma Symptom Checklist-40; TFT=trauma focused therapy; WL=waiting list.

a Mean ITT is estimated from mean completers, N ITT and N completers, assuming non-completers did not change;

b mean completers is estimated from mean ITT, N completers and N ITT, assuming non-completers did not change;

c CBT vs. PCT;

d STAIR/PE vs. Sup/PE;

e STAIR/Sup vs. Sup/PE;

f STAIR/PE vs. STAIR/Sup;

g change scores as reported in article, unknown if standardized.

Table 4 Aggregated drop-out, prescores and postscores, and effect sizes for PTSD symptom changes, and recovery and improvement rate across CA-related PTSD studies by type of treatment

						PTSD change score					Post
			PTSD score			Pre versus post		Treatment versus control
			Pre*	Post*		Effect size (d)		Effect size (d) post–post corrected			Recovery rate8			Improvement rate9
Treatment type	N	Drop-out (%)		Completer	ITT	Completer	ITT	N	Completer	ITT	N	Completer (%)	ITT (%)	N	Completer (%)	ITT (%)
All active conditions together (A+B)	9	25a	68	34	42	1.7c	1.3f	6	1.2	0.9	8	68g	50i	6	45j	34l
CBT1,3,4,5,6,7	8	26b	68	33	42	1.7	1.3	5	1.3	0.8	7	72h	52	6	45	34
PE no AM4,5,6	3	32	64	23	36	2.1d	1.4	2	1.7n	1.2o	3	70	48	2	52	38
AM no PE1,6,7	3	24	74	44	51	1.4d,e	1.1	2	0.6n,p	0.4o	2	73	52	2	44	34
AM & PE3,6	2	22	66	29	37	2.1e	1.7	1	1.6p	1.1	2	74	58	2	38	30
PCT5	1	9b	68	45	47	1.4	1.3	1	0.9	0.9	1	35h	32	0
Control conditions1,3,4,5,7	5	16a	72	64	65	0.4c	0.3f	0			4	27g	22i	3	11j	9l
WL only3,4,5	3	15	68	61	62	0.4	0.3	0			3	24	20	2	4k	3m
TAU during WL1,7	2	18	78	69	70	0.4	0.4	0			1	41	30	1	24k	21m

AM=affect management; CA=child abuse; CBT=cognitive behavioral therapy; ITT=intention-to-treat; PCT=present centered treatment; PE=prolonged exposure; TAU=treatment as usual; WL=waiting list.

* Without Cloitre et al., 2010 due to incomparability of score ranges.

1 Zlotnick et al., 1997;

2 Classen et al., 2001;

3 Cloitre et al., 2002;

4 Chard, 2005;

5 McDonagh et al., 2005;

6 Cloitre et al., 2010;

7 Dorrepaal et al., 2012;

8 Percentage decrease of PTSD diagnoses as reported by author;

9 Percentage of patients that improved as defined by author.

Pre–post effect sizes, recovery and improvement rates were tested: active vs. control; CBT vs. PCT; the three subtypes of CBT amongst each other; and the two types of control conditions:

a,b,d,e,k,m,o Differences between groups of studies with the same superscript are significant at p<0.05 as a result of modest overlap of confidence intervals.

c,f,g,h,i,j,l,p,n Differences between groups of studies with the same superscript are significant at p<0.01 as a result of non-overlap of confidence intervals.

Table 5 Aggregated drop-out, prescores and postscores, and effect sizes for PTSD symptom changes, and recovery and improvement rate across CA-related Complex PTSD studies by type of study population

						PTSD change score					Post
			PTSD score			Pre versus post		Treatment versus control
			Pre*	Post*		Effect size (d)		Effect size (d) post–post corrected			Recovery rate8			Improvement rate9
Study population	N	Drop-out (%)		Completer	ITT	Completer	ITT	N	Completer	ITT	N	Completer (%)	ITT (%)	N	Completer (%)	ITT (%)
CA-related Complex PTSD (A)1,5 ^(2x),6 ^(3x),7	7	26	69	38	46	1.6d,e	1.2f,g	4	0.8t	0.6u	6	60h,i	44k,l	4	35o	26q
CA-related PTSD (B)3,4	2	22	65	19	29	2.3d	1.8f	2	1.9t	1.4u	2	87h	67k	2	65o	51q
Within CA-related Complex PTSD (A):
CBT	6	28a	70	37	46	1.6	1.2	3	0.7	0.5	5	65j	46	4	35	26
With PE no AM5,6	2	40b,c	66	31	45	2.0	1.2	1	1.2	0.6	2	51	31m,n	1	10p	6r,s
With AM no PE1,6,7	3	24b	74	44	51	1.4	1.1	2	0.6	0.4	2	73	52m	2	44p	34r
With AM & PE6	1	15c	63	27	33	1.9	1.6	0			1	71	61n	1	32	27s
PCT5	1	9a	68	45	47	1.4	1.3	1	0.9	0.9	1	35j	32	0
Control conditions1,5,7	3	16	75	67	68	0.4e	0.4g				2	30i	24l	1	24	21
WL only5	1	13	70	62	65	0.4	0.4				1	20	17	0
TAU during WL1,7	2	18	78	69	70	0.4	0.4				1	41	30	1	24	21

AM=affect management; CA=child abuse; CBT=cognitive behavioral therapy; ITT=intention-to-treat; PCT=present centered treatment; PE=prolonged exposure; TAU=treatment as usual; WL=waiting list.

* Without Cloitre et al., 2010 due to incomparability of score ranges.

1 Zlotnick et al., 1997;

2 Classen et al., 2001;

3 Cloitre et al., 2002;

4 Chard, 2005;

5 McDonagh et al., 2005;

6 Cloitre et al., 2010;

7 Dorrepaal et al., 2012;

8 Percentage decrease of PTSD diagnoses as reported by author;

9 Percentage of patients that improved as defined by author.

Pre–post effect sizes, recovery and improvement rates were tested: CA-related Complex PTSD (A) vs. CA-related PTSD (B); active vs. control; CBT vs. PCT and the three subtypes of CBT amongst each other, and the two types of control conditions:

a,b,c,d,f,j,l,m,s Differences between groups of studies with the same superscript are significant at p<0.05 as a result of modest overlap of confidence intervals.

e,g,h,i,k,n,o,p,q,r,t,u Difference between groups of studies with the same superscript are significant at p<0.01 as a result of non-overlap of confidence intervals.

Zlotnick C, Shea T. M, Rosen K, Simpson E, Mulrenin K, Begin A, etal. An affect-management group for women with posttraumatic stress disorder and histories of childhood sexual abuse. Journal of Traumatic Stress. 1997; 10: 425–436.

 PubMed Web of Science ®Google Scholar

Classen C, Cavanaugh E. C, Kaupp J. W, Kraemer H. C, Aggarwal R, Palesh O. G, etal. Comparison of trauma-focused and present-focused group therapy for survivors of childhood sexual abuse: A randomized controlled trial. Psychological Trauma: Theory, Research, Practice, and Policy. 2011; 3: 84–93.

 Web of Science ®Google Scholar

Cloitre M, Koenen K. C. The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse. International Journal of Group Psychotherapy. 2001; 51: 379–398.

 PubMed Web of Science ®Google Scholar

Callahan K. L, Price J. L, Hilsenroth M. J. A review of interpersonal-psychodynamic group psychotherapy outcomes for adult survivors of childhood sexual abuse. International Journal of Group Psychotherapy. 2004; 54: 491–519.

 PubMed Web of Science ®Google Scholar

McDonagh A, Friedman M, McHugo G, Ford J, Sengupta A, Mueser K, etal. Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology. 2005; 73: 515–524.

 PubMed Web of Science ®Google Scholar

Cloitre M, Koenen K. C, Cohen L. R, Han H. Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology. 2002; 70: 1067–1074.

 PubMed Web of Science ®Google Scholar

Davidson J. R, Book S. W, Colket J. T, Tupler L. A, Roth S, David D, etal. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychological Medicine. 1997; 27: 153–160.

 PubMed Web of Science ®Google Scholar