Care for persons exposed to sexual violence: psychological treatment of complex PTSD – A Systematic Review including Ethical Aspects

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SBU Policy support

identifies and presents available scientific evidence to support policy and decision making, including the development of national guidelines, at other government agencies. In consultation with professional experts, SBU staff generates supporting documentation to address the various questions that have been posed.

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Published: Report no: 381 Registration no: SBU 2024/475 ISBN: 978-91-987554-9-7 https://www.sbu.se/381e

Conclusions

  • There are too few well-conducted studies to be able to draw any conclusions about the effects of psychological treatments for persons with complex post-traumatic stress disorder (PTSD).
  • People with complex PTSD may feel fear or shame when talking about their experiences of sexual violence. They may also be afraid of relatives who are their perpetrators or worry about dissemination of private information. Being exposed to sexual violence is an extremely serious assault involving violations of the person's integrity, self-determination, and dignity. It can bring a significant negative impact on health, and harm the person's opportunities to live a safe, rich, and independent life. This means that values such as health and well-being, autonomy, and integrity as well as professional and research ethical aspects are important to consider when caring for people with complex PTSD.

Background

The diagnose complex post-traumatic stress disorder (PTSD) has recently been coined to describe problems related to psychological trauma that is overlapping and yet different to PTSD. The diagnosis describes a traumatization that involves problems included in the PTSD diagnosis, in addition to problems with self-image, social relationships and emotion regulation. The diagnose is particularly common after traumas such as sexual violence. PTSD is a form of psychological trauma. PTSD is a psychiatric diagnosis that describes a condition where a person suffers problems that arose or worsened in connection with a traumatic event. The symptoms include re-experiences of a traumatic event during flashbacks and nightmares, and feeling of tension, vigilance, and avoidance of things reminiscent of the event. Violence in a close relationship is estimated to be related to nearly half of the total burden of PTSD.

To meet the diagnostic criteria for complex PTSD, the person must meet the criteria of ICD-11 for both PTSD and "disturbances in self-organization" (DSO). DSO includes three areas: disturbances in emotion regulation, consistently negative self-image and great difficulty maintaining relationships. These symptoms should be persistent and pervasive, which means that they affect the individual's life in almost all situations in everyday living, over a long period of time.

An excessive focus on what kind of event that caused the symptoms risks forming an image that treatments must be adapted to a specific trauma. Therefore, this report does not consider the reason behind complex PTSD.

As there are uncertainties in how people with complex PTSD should be handled in care, this report investigates the body of evidence for psychological treatment methods for patients with complex PTSD.

Aim

The aim of this report is to evaluate the body of evidence for psychological treatment methods for patients with complex PTSD.

Method

This systematic review has been conducted in accordance with the PRISMA statement. The protocol is registered in Prospero https://www.crd.york.ac.uk/prospero/CRD 42024519015.

For a study to be included in this systematic review, the following inclusion criteria needs to be fulfilled.

Inclusion criteria:

Population
Persons 18 years of age or older diagnosed with complex PTSD according to ICD-11, or adults with diagnosed PTSD and symptoms indicative of complex PTSD (disturbances in self-organization including affect dysregulation, negative self-concept, and disturbances in relationships).

Intervention
Psychological treatments including talking therapies based on a psychological theory provided by health care in Sweden. Descriptions of various assessments before treatment are not included.

Control
A different treatment than that given to the intervention group. The treatment must be relevant to a Swedish context and can be treatment as usual, medication, waiting list or active control treatment.

Outcome
Symptoms of complex PTSD, degree of remission and level of functioning. Symptoms of complex PTSD refers to both symptoms of PTSD and DSO, based on how the diagnosis is defined in ICD-11.

Study design
Randomized controlled trials (RCTs) and systematic reviews based on RCTs.

Language: English, Swedish, Danish, and Norwegian.

Search date: The final literature search was conducted in April 2023.

Databases searched:

  • CINAHL (EBSCO)
  • Cochrane Library (Wiley)
  • Criminal Justice Abstracts (EBSCO)
  • EMBASE (Embase.com)
  • Ovid MEDLINE(R) ALL
  • APA Psycinfo (EBSCO)
  • PTSDpubs (ProQuest)
  • Scopus (Elsevier)
  • Social Services Abstracts (ProQuest)
  • Sociological Abstracts (ProQuest)
  • SocINDEX (EBSCO)

Supplementary searches for ongoing and published systematics reviews and HTA reports were made in the following databases:

  • The Campbell Collaboration
  • Epistemonikos
  • International HTA Database
  • PROSPERO

In addition, searches for ongoing clinical trials were conducted in ClinicalTrials.gov and the International Clinical Trials Registry Platform.

Client/patient involvement: No

Results

This systematic review identified three randomized controlled studies that have investigated psychological treatment methods for persons with complex PTSD or with PTSD and symptoms of complex PTSD. However, none of the studies holds low or moderate risk of bias. The risk of bias was assessed to be high in all three studies due to high attrition rate, deficiencies in outcome measurements, as well as reporting bias.

The three studies, conducted in the Netherlands or in Lithuania, were published between 2006 and 2021. The evaluated interventions were:

  • mindfulness-based intervention compares to waiting list
  • phase-based treatment compared to immediate trauma-focused treatment
  • stabilizing group treatment based on psychoeducation and cognitive behavioural therapy compared to treatment as usual.

The studies that were found to be irrelevant, was excluded because they did not study people with complex PTSD and did not report outcomes that cover the three DSO symptom groups.

Ethics

Not caring for or treating a person exposed to sexual violence can cause a high risk of negative consequences for the patient. Risk assessment, diagnosis, care, and support is therefore very important for the person's future health and quality of life. Although there is a lack of scientific support for interventions in complex PTSD, there are risks in not caring and treating when there is scientific support for the treatment of PTSD, depression and other psychiatric conditions that are common in people who have been sexually abused.

Relevant justice and equality aspects primarily concern accessibility. There are various barriers that can stand in the way for people with complex PTSD, hindering them to seek care. They may sense fear or anxiety to talk about experiences of sexual violence that may be associated with stigma. There may also be fear of blame from relatives who are possibly perpetrators or fear of private information being spread. In addition, it can be difficult for healthcare professionals to identify people in the target group whom they might get in touch with when they seek help for other problems.

It is important that the consent process for participation in research is adapted to needs that may exist in this group. A further aspect of informed consent concerns voluntariness in relation to healthcare professionals. There may be a risk that you want to be accommodating and find it difficult to say no if the question is raised by healthcare staff.

Discussion

SBU found no RCTs with low or moderate risk of bias that examined whether psychological treatments are effective in alleviating symptoms of complex PTSD in people diagnosed with complex PTSD or undiagnosed, but with clear symptoms of complex PTSD. Three relevant RCTs with adult participants were identified, but all of them were judged to have a high risk of bias. Regarding research on complex PTSD, there are several important ethical aspects to consider.

The diagnosis of complex PTSD was formally accepted six years ago with the completion of the International Classification of Diseases ICD-11 by the WHO in 2019. However, the disorder has been discussed for much longer than that. Symptoms of PTSD can be successfully treated across a wide range of PTSD patient populations, with several different psychological treatments, including a variety of cognitive and behavioural therapy treatment protocols. But the state of knowledge is still unclear regarding DSO symptoms.

Conflicts of Interest

In accordance with SBU’s requirements, the experts and scientific reviewers participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

Project group

Experts

  • Filip Arnberg, Uppsala University, Uppsala, Sweden
  • Ulrik Kihlbom, Karolinska institutet, Stockholm, Sweden

SBU

  • Gunilla Fahlström, project manager

External reviewers

Sean Perrin, Lund University, Lund

Flow chart

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