Interventions for Posttraumatic Stress Disorder Arousal and Reactivity Symptoms in Adults with a History of Childhood Adversity: Scoping Review

Abstract

Purpose: Adverse Childhood Experiences (ACE) predispose individuals to adult-onset posttraumatic stress disorder (PTSD) with amplified arousal and reactivity symptoms (A&R). This review aimed to identify interventions for reducing A&R symptoms in adults diagnosed with PTSD and a history of ACEs. Method: Systematic scoping review of RCT and quasi-experimental studies in peer-reviewed journals using Arksey and O’Malley’s 5-Stage Framework. Extracted data were analyzed descriptively and thematically. Results: Five articles met inclusion criteria. Skills training in affect and interpersonal regulation (STAIR) with exposure, Cognitive Behavioral Therapy (CBT-PE), Interpersonal Processing Group Therapy (IPG), and Trauma-informed yoga interventions were identified. STAIR (d = −1.45, 95% CI [−2.10, −0.80), CBT-PE (d = −1.21, 95% CI [−1.92, −0.51]), and IPG (d = −1.33, 95% CI [−2.07, −0.58]) had large effects on A&R symptoms. Discussion: CBT exposure-based treatments were supported interventions for reducing A&R symptoms in adults diagnosed with PTSD and a history of ACEs.

Keywords

Scoping review ACEs PTSD Arousal and Reactivity intervention adult childhood adversity

Posttraumatic Stress Disorder (PTSD) is a chronic health and psychological condition that affects approximately six to eight percent of the United States population (American Psychiatric Association [APA], 2013; Schein et al., 2021). PTSD is one of the most serious outcomes of exposure to a traumatic event and has been linked to numerous psychological, social, medical, and physical health problems (Pacella, Hruska, & Delahanty, 2013; Wafa et al., 2019). It is estimated that approximately 30%–40% of individuals will develop PTSD after a discrete traumatic event and those with histories of Adverse Childhood Experiences (ACEs) are especially at risk (Gould et al., 2021; Kessler et al., 2005). Over the last 20 years, PTSD research has included a growing focus on specific clinical and behavioral presentations in order to best inform clinical interventions (Pietrzak et al., 2014; Yufik & Simms, 2010). The Diagnostic and Statistical Manual for Mental Disorders (DSM-5) diagnostic criteria for PTSD is categorized into four symptom clusters: hyperarousal and reactivity, avoidance, negative cognitions and mood, and intrusive thoughts (APA, 2013). Arousal and Reactivity (A&R) symptoms, known as Criterion E, has the most identifiable and potentially problematic psychosocial behaviors for individuals with PTSD. This symptom cluster includes: (a) irritable behavior and anger, (b) reckless or self-destructive behavior, (c) hypervigilance, (d) exaggerated startle response, (e) problems with concentration, and (f) sleep disturbance (APA, 2013). The A&R cluster is reportable by the service user, observable by those close to the service user, and even detectable by psychophysiological biological marker tests (Pole, 2007). A&R behaviors are associated with increased emotional regulation difficulties, interpersonal problems, and suicidality (Brown, Contractor, & Benhamou, 2018; Ehring et al., 2014). Individuals that report the most severe A&R symptoms are often the victims of Adverse Childhood Experiences (ACEs) which are associated with increased incidences of PTSD.

Adverse Childhood Experiences and PTSD

ACEs are defined as exposure to one or more of 10 categories of childhood abuse, neglect, and household dysfunction. These categories include emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, household substance abuse, mental illness in the household, parental separation or divorce, and/or a criminal household member (Anda et al., 2006; Dong et al., 2004; Korotana, Dobson, Pusch, & Josephson, 2016). The scope of recognized ACEs has recently expanded to include racial/ethnic discrimination, bullying, economic hardship, and community violence (Finkelhor, Shattuck, Turner, & Hamby, 2013; Mersky, Janczewski, & Topitzes, 2017). ACEs are associated with increased risk for suboptimal mental health outcomes, including PTSD (Brewin, Andrews, & Valentine, 2000; Cloitre et al., 2019; Frewen, Zhu, & Lanius, 2019; Green et al., 2010; Lippard & Nemeroff, 2020). In a 20-year prospective study of adults, individuals with a history of physical abuse, sexual abuse, or neglect had 1.75 times higher odds of developing PTSD than individuals without these childhood adversities. Furthermore, 30.9% of the ACE sample had either a history of, or current PTSD, versus 20.4% of the matched controls (Widom, 1999)

Dysregulation of the stress response system may contribute to PTSD symptomology in ACE populations. Chronic exposure to ACEs may lead to more A&R symptoms because of the physiological changes in the stress response system, which may be a mechanism underlying vulnerability to PTSD. In a sample of adults admitted to the emergency department immediately following a traumatic event, Gould et al. (2021) found that prior ACEs predicted the immediate stress reaction to the current trauma and the course of PTSD symptoms over a 6-month period. ACE populations diagnosed with PTSD have uniquely complex A&R symptomatology that includes increased emotional regulation issues, self-destructive behaviors, impulsivity, and interpersonal difficulties (Briere, Kaltman, & Green, 2008; Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Karatzias et al., 2019). This more severe clinical presentation of PTSD is associated with poorer treatment responses to both pharmacotherapy and psychotherapy (Lippard & Nemeroff, 2020; Nemeroff, 2016). For this reason, knowledge regarding effective treatments targeting the A&R symptoms for populations with a history of ACEs is of particular importance.

Interventions for PTSD in ACEs Population

A discourse has emerged that examines whether empirically supported, trauma-focused interventions such as Cognitive Behavioral Therapy (CBT) for adult-onset trauma in non-ACEs populations can be equally effective for the ACEs population (Cloitre et al., 2011; Dorrepaal et al., 2012; van Minnen, Harned, Zoellner, & Mills, 2012). This question has been difficult to answer due to the ACEs population’s underrepresentation in research directly focused on PTSD interventions (Ehring et al., 2014). Support for adult-onset trauma treatment with ACEs populations is based on the complex clinical features and symptomology that extends beyond PTSD symptoms alone (Ehring et al., 2014). Ehring and colleagues (2014) conducted a meta-analysis of studies evaluating the efficacy of psychological interventions for adults with PTSD and a history of childhood physical and sexual abuse. The analysis included 16 randomized control trials and found individual trauma focused treatments (TF-CBT and EMDR) were more effective at reducing PTSD symptoms compared to group-format or non-trauma-focused treatments (Ehring et al., 2014). However, the study did not evaluate or report changes in PTSD symptom clusters, which could have been different for those with a history of ACEs.

Taylor and Harvey’s (2010) meta-analysis examined 44 studies of adults with a history of childhood sexual abuse within 59 treatment conditions for an in-depth evaluation of treatment characteristics and outcomes. Individual-format interventions had more significant effect sizes compared to couple-based or group treatments on PTSD/trauma symptom outcomes (Taylor & Harvey, 2010). Psychotherapies that included homework as opposed to clinical sessions alone were more effective reducing PTSD/trauma and internalization symptom outcomes, compared to externalizing, interpersonal functioning, self-esteem, or global functioning outcomes (Taylor & Harvey, 2010). Coventry et al. (2020) performed a systematic review and network analysis to assess effective psychological interventions to manage symptomology of complex traumas, including 17 studies of childhood sexual abuse survivors with PTSD. CBT (CBT-PE) and phased-based approaches that included imagery exposure or cognitive restructuring were the most effective treatments for reducing trauma symptoms in the ACEs population. However, again, the study did not report specific symptom cluster measures to delineate treatment effects on separate PTSD symptom clusters, to include A&R symptoms.

Interventions for Arousal and Reactivity (A&R) Symptoms

Research on PTSD interventions that focus on the amelioration of A&R symptomology in ACEs populations is limited. Trauma-focused interventions have emerged as potentially effective treatment modalities for reducing PTSD symptoms for adults with a history of ACEs and PTSD diagnosis. However, current literature has traditionally focused on global PTSD symptoms and excluded evaluation of individual symptom clusters (Wooldridge, Bosch, Crawford, Morland, & Afari, 2020). Since individuals with PTSD and a history of ACEs have complex clinical presentations, it would be advantageous to evaluate the effects of interventions on separate symptom clusters. Meta-analyses conducted on PTSD interventions have not directly focused on A&R symptom changes and only include psychotherapy or psychopharmaceutic interventions (Bradley et al., 2005; Ehring et al., 2014; Watts et al., 2013). Evidence does exist for the effectiveness of somatic or Complementary and Alternative Medicine (CAM) interventions targeting the A&R aspects of PTSD such as acupuncture, meditation, bio and neurofeedback, mindfulness, and physical exercise (Grant et al., 2018; Hegberg, Hayes, & Hayes, 2019; Hilton et al., 2017; Oded, 2018). An improved understanding of intervention studies that evaluate PTSD A&R clusters within a population of adults who have a history of adverse childhood experiences will better inform clinical case conceptualization and treatment.

Purpose of Scoping Review

To our knowledge, no previous reviews have summarized the extant literature on interventions for the A&R symptoms of PTSD in adults with a history of ACEs. The aim of this scoping review is to summarize what is known about the interventions and their effects on PTSD and A&R symptoms for service users with a history of ACEs. This information is relevant for social work clinical practice, policy development, and community prevention-focused initiatives. The specific research questions guiding this scoping review are: (1) What are the interventions for A&R symptoms in adults diagnosed with PTSD and a history of adverse childhood experiences? (2) What are the treatment effects of identified interventions on PTSD symptom severity and A&R symptomology? and (3) What are the characteristics of the included samples?

Method

Scoping reviews are appropriate when a relevant body of literature has not yet been comprehensively reviewed (Peters et al., 2015), consequently, the present study was designed as a scoping review. It is informed by the methodological frameworks established by Arksey and O’Malley (2005) and Colquhoun et al. (2014) that consist of (a) identifying a research question, (b) identifying relevant literature, (c) study selection, (d) charting the data and (e) collating, summarizing, and reporting the results. In the interest of providing an overview of the existing evidence base while maintaining consistency with scoping review methodology, appraisal of study quality including risk of bias assessment was not conducted (Peters et al., 2015). As presented in the Appendix, this study followed the steps set out by the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR) checklist (Tricco et al., 2018).

Study Eligibility Criteria

In order to answer the research questions of interest, studies were eligible for inclusion in this scoping review if they met the following criteria: (a) Publication characteristics: published articles (U.S. or international) in peer-reviewed journals between 1980 and 2022 and written in English in order to capture the most recent knowledge within the scope of reviewer language proficiency; (b) Population: Adult only sample (age 18 years or older) with a PTSD diagnosis, with or without comorbid conditions, and a history of ACEs; (c) Intervention: non-pharmacological PTSD-focused intervention in any treatment setting; (d) Comparison: intervention is compared with an alternative intervention, a control group, or no-intervention placebo group; (e) Outcome: Reported post-intervention change or no change outcome data of A&R symptoms of PTSD diagnoses; (f) Study Design: either a Randomized Control Trial (RCT) or quasi-experimental design.

PTSD and Arousal and Reactivity symptoms (A&R)

Studies must include a PTSD diagnosis and A&R symptom outcome measures assessed with a valid instrument and report pre-to-post treatment changes. DSM-5 PTSD diagnostic criteria were used to define A&R symptom outcomes of interest. Measurement instruments can include either a global PTSD measure subscale or a dedicated symptom measure. The PTSD Checklist (PCL), Clinician-Administered PTSD Scale (CAPS), Modified PTSD Symptom Scale (MPSS), PTSD Symptom Scale (PSS) are examples of global PTSD severity measures that include A&R outcome subscales. Examples of measures by A&R symptoms are (a) irritability and anger: State-Trait Anger Expression Inventory (STAXI) Inventory of Altered Self Capacities (IASC), Negative Mood Regulation Scale (NMR), State-Trait Anxiety Inventory state anxiety subscale (STAIs), and the Cook-Medley Hostility Scale (Cook); (b) reckless or self-destructive outcomes: the International Personality Disorder Examination (PDE) (items related to reckless drinking, substance use, and self-harm); (c) hypervigilance: Impact of Event Scale-Revisited (IES-R); (d) exaggerated startle response: heartrate and other bio-measures; (e) sleep disturbance: Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI).

Types of interventions

Study interventions must focus on A&R symptoms and may include (one or more) psychotherapy or behavioral intervention. Examples may include but are not limited to trauma-focused therapies, psychoeducation, and alternatives/holistic approaches, such as meditation, mindfulness, stellate ganglion block, biomarker amelioration, biofeedback, neurofeedback, or sleep treatment.

Exclusion criteria

In addition, five exclusion criteria were applied: (1) sample size of fewer than 30 participants to increase external validity, (2) not written in English, (3) participants 17 years old or younger, (4) intervention outcome data not reported or not in a quantitative format, (5) A&R symptoms not measured and reported with a valid measurement instrument.

Search Strategy

The coauthors systematically searched 12 electronic databases through EBSCOHost and PubMed platforms to identify and retrieve all relevant published studies. Searched databases included (1) Academic Search Complete, (2) CINAHL Plus, (3) Health Source: Nursing/Academic Edition, (4) MEDLINE, (5) Military & Government Collection, (6) Psychology and Behavioral Sciences Collection, (7) APA PsycInfo, (8) Science and Technology Collection, (9) SocINDEX, (10) ERIC, (11) Education Source, and (12) PubMed.

The search strategy and process were refined iteratively. First, coauthors identified key concepts and the following search terms: “adverse childhood experiences,” “post traumatic stress disorder,” “arousal and reactivity,” “adults,” and “intervention.” Search terms were refined through librarian consultation and database thesaurus, index, and subject heading functions. Initial search tests produced limited results. Coauthors decided to remove “intervention” from search strategy. The final search terms were grouped into four categories with Boolean operators (AND OR) and wildcard symbols: (1) “adverse child*” OR (child* n3 abuse*) OR “child* neglect” OR (child* n3 trauma*) OR “child* maltreatment” OR “child* adversity”; AND (2) post-traumatic OR posttraumatic OR PTSD; AND (3) agitat* OR arousal OR hypervigilan* OR “startle response*” OR reckless OR self-destructive OR reactivity OR anger OR concentrat* OR “sleep problem*” OR “sleep issue*” OR “sleep difficult*” OR “emotion* regulat*” OR “emotion* dysregulat*” OR amygdala OR “startle reflex” OR (sleep* n3 disorder*) OR Parasomnia; AND (4) adult* OR longterm OR long-term OR longitudinal OR lifespan.

Hand searching was conducted to identify relevant articles inadvertently missed during systematic database search. Hand searching consistent of a keyword search in Google Scholar, review of full text article reference lists, and studies identified in prior reviews. The most recent search was conducted on February 9^th, 2022.

Data Coding, Extraction, and Analysis

A codebook was developed to organize and extract data from included studies. Two study authors reviewed and coded all final full-text articles separately. Cohen’s weighted kappa was used to assess inter-rater agreement as a measure of reliability. Coded variables were: (a) type of ACEs, (b) intervention, (c) treatment format, (d) therapy mode, (e) study design, (f) type of A&R symptom, (g) PTSD and A&R measurement instrument, (h) outcome data for PTSD and A&R at posttreatment timepoint for treatment and control/comparison groups (sample size, mean, and standard deviation), (i) gender, (j) age, (k) race and ethnicity, (l) education level, (m) employment, (n) income, (o) presence and type of fidelity monitoring during study, (p) source and type of funding. Coding differences were reviewed and discussed to reach a consensus.

Data Analysis

The Levac, Colquhoun, and O’Brien (2010) scoping review data analysis framework guided this study. Extracted data were analyzed using descriptive numerical summary and thematic analysis to answer study research questions. The analysis sought to provide relevant information for social work practitioners. Descriptive statistics were synthesized for sample demographics, symptomology, interventions, study designs, and measures. Treatment outcomes were assessed by intervention effects (Cohen’s d) on PTSD and A&R symptoms. Effect sizes estimated the mean difference between experimental and control groups at post-treatment timepoint on self-report measures reported by included studies. Analyses were conducted with STATA 17 statistical software by inputting mean, standard deviation, and sample size data extracted from selected studies (Stata Corp, 2021).

Results

The initial search of electronic databases identified 2112 articles. An additional 37 articles were identified by hand searching. As shown in Figure 1, the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Chart depicts the search and screening process leading to results. Electronic articles were downloaded to EndNote reference management software; 904 duplicates were removed. The remaining 1245 articles were then downloaded into Rayyan, a systematic review website, for title and abstract screening (Ouzzani, Hammady, Fedorowicz, & Elmagarmid, 2016). Two authors reviewed and independently screened article titles and abstracts for inclusion and exclusion criteria; 1212 articles were excluded for failure to meet inclusion criteria. The remaining 33 articles were full text reviewed. An additional 28 articles were excluded based on: failure to measure or report PTSD and A&R symptoms (n =11), failure to include a control group (n = 9), or failure to include an adult population with diagnosed with PTSD and ACEs (n = 8). Five studies met full inclusion criteria and were included in this scoping review.

Figure 1.

Preferred reporting items for systematic reviews and meta-analysis diagram.

Participant Characteristics

Consistent with inclusion criteria, all five included studies were comprised of adult participants with a history of adverse childhood experiences and current diagnosed PTSD. All included studies included populations with co-morbid mental health conditions, ACEs, and PTSD, but did not provide specific within-group condition prevalence rates. Cloitre, Koenen, Cohen, & Han, (2002) reported that 45% of their sample had major depression, 79% had an anxiety disorder, and 25% were taking or had taken psychotropic medications. Borderline Personality Disorder (BPD) was reported in 10.8% (McDonagh et al., 2005), 10.2% (Cloitre & Koenen, 2001), and 24% (Cloitre et al., 2010) of study participants. All five studies included screeners to assess for psychiatric conditions, but no further specificity regarding diagnosis prevalence was reported. All studies excluded participants with active substance use disorders or suicidality, while other common exclusion criteria were psychosis, cognitive impairments, and other medical issues likely to comprise participant engagement. McDonagh et al. (2005) contained the most stringent exclusion criteria that included issues such as mania, hypomania, schizophrenia, dissociative disorders, bipolar disorder, or severe depression. The population (of all studies) had an average age of 38.5 years old; were 100% female; 82% had at least some college or a college degree; 70% were employed either fulltime or parttime; 35% had an average income under $30,000 (of the three studies that reported income); and race/ethnicity demographics were 60% Caucasian, 15% Hispanic, and 14% African American. Participants’ ACEs histories could be classified as either physical abuse (34%) or childhood sexual abuse (85%). The most interesting population characteristics were the inclusion of only female participants and overrepresentation of childhood sexual abuse.

Description of Studies

All five included studies were United States published peer-reviewed articles with outcome measures for the PTSD and A&R symptoms. The average sample size was 70 participants. As reported in Table 1, four studies were RCTs and one was a quasi-experimental design. Three studies had waitlist controls and four had active treatment comparison groups. Cloitre and Koenen (2001) compared treatment groups with member diagnoses with borderline personality disorder (BPD) to groups without a BPD diagnosis. McDonagh et al. (2005) compared CBT-PE to Present Centered Therapy (PCT). Cloitre et al. (2010) compared three phase-based protocols: STAIR followed by modified prolonged exposure, to STAIR followed by supportive counselling and supportive counselling followed by PE (without STAIR). Trauma centered yoga was compared to a supportive women’s health education comparison group (van der Kolk et al., 2014).

Table 1.

Study Characteristics.

Author, Year	Study Design	Sample Gender	Type of ACE	Intervention	Control	PTSD A&R symptoms	Measurements
Cloitre and Koenen (2001)	Quasi-experimental	F	Sexual abuse	Interpersonal process Group format	Waitlist	Anger Current anxiety	Three subscales of state-trait anger expression inventory (STAXI) State trait anxiety inventory (STAIs)
Cloitre et al. (2002)	Randomized clinical trial	F	Physical and/or sexual abuse	Phase based: skills training, modified prolonged exposure	Minimal attention waitlist	Emotion regulation Anger Current anxiety	General expectancy for negative mood regulation scale (NMR) Anger expression subscale (Ax/Ex) of STAXI STAIs
Cloitre et al. (2010)	Randomized controlled trial	F	Physical and/or sexual	Phase-based: STAIR/Exposure>	Phase based Support/Exposure or STAIR/ Support	Emotion regulation Anger Current anxiety	NMR AxEx STAIs
McDonagh et al. (2005)	Randomized clinical trial	F	Sexual abuse	CBT (prolonged exposure)	Present-centered therapy (PCT), or waitlist	Hostility Anger Current anxiety	Cook–Medley hostility scale STAXI STAIs
Van der Kolk et al. (2014)	Randomized controlled trial	F	Unspecified: Interpersonal assault in childhood	Trauma Center trauma-sensitive yoga (TCTSY)	Active control: women’s health education	Affect regulation Emotional control	Inventory of altered self-capacities subscales

Note. TAU = Treatment as usual; A&R = Arousal and Reactivity symptoms; d= Cohen’s d effect size; STAXI = State trait anger expression inventory; NMRS = General expectancy for negative mood regulation scale; AX/EX = Anger subscale (state trait anger expression inventory); Cook = Cook Medley Hostility Scale.

Posttraumatic stress disorder and A&R symptoms were measured by self-report instruments at baseline and post-treatment. PTSD symptom severity was measure by the Clinician Administered PTSD Scale (CAPS) in four studies, while one study (Cloitre & Koenen, 2001) used the PTSD Symptom Scale (PSS-SR). A&R symptoms were measured by the (a) State-Trait Anxiety Inventory state anxiety subscale, STAI (n = 5); (b) State-Trait Anger Expression Inventory, STAXI (n = 4); (c) Negative Mood Regulation Scale, NMR (n = 2); (d) Inventory of Altered Self Capacities, IASC (n = 1); and (e) Cook-Medley Hostility Scale, Cook (n = 1).

Description of Interventions

The study’s primary aim was to identify interventions for A&R symptoms in the population of interest. Four interventions were identified across all included studies: A phased-based protocol consisting of skills training in affect and interpersonal regulation (STAIR) followed by modified prolonged exposure (PE), Trauma-focused CBT, Interpersonal Processing Group Therapy (IPG), and Trauma-informed yoga. Two studies investigated the phase-based treatment consisting of STAIR followed by modified prolonged exposure (PE) (Cloitre et al., 2002, 2010). The phase-based protocol is a cognitive behavioral therapy (CBT) based approach delivered in 16 sessions over a 12-week period (entire program). STAIR phase-one treatment consists of eight weekly one-hour long sessions focused on emotion management and interpersonal skill development through psychoeducation, role plays, emotions and cognition labeling, cognitive restructuring, and homework activities. Phase-two consists of eight 90-minute modified prolonged exposure sessions delivered individually over 4 weeks. Trauma-focused CBT is a manualized 14-session individual psychotherapy for those with a history childhood related sexual abuse. The intervention is comprised of psychoeducation, prolonged exposure, cognitive restructuring, in-vivo exposure, and homework assignments (McDonagh et al., 2005). IPG is a 12-week manualized approach delivered in 90-minute weekly group sessions, led by two co-therapists. IPG group sessions are process oriented and focused on present relationship dynamics, the influence of traumatic experiences, and increasing emotional control and flexibility (Cloitre & Koenen, 2001). Trauma informed yoga is a protocolized yoga program delivered through 60-minute weekly classes over a 10-week period. It includes Hatha-yoga elements and components dedicated to breathing, posture, meditation, body control, and body curiosity (van der Kolk et al., 2014). Across all included studies, CBT based interventions were the most common treatment approach for reducing A&R symptoms of PTSD. Three of the five studies used CBT based approaches with Prolonged Exposure (PE). The remaining two studies examined IPG and Trauma informed yoga. All interventions were delivered by practitioners that belonged to either social work or clinical psychology disciplines. Education and experience levels ranged from graduate student to doctoral level practitioner. Four studies included only female practitioners, while one did not specify gender.

Intervention Effects

Intervention effects were assessed by the mean difference between treatment group and control group on reported PTSD and A&R measures at posttreatment for each included study. Table 2 and Table 3 provides summaries of extracted data, measures, and calculated effect sizes with 95% confidence intervals (Cohen’s d) for each included study. Outcome data (n, M, SD) were only available for treatment completers in two studies (Cloitre et al., 2002; Cloitre & Koenen, 2001). Two other studies only reported intent-to-treat (ITT) outcome data (Cloitre et al., 2010; van der Kolk et al., 2014). McDonagh et al. (2005) provided both completer and ITT data; effect sizes were only calculated for completer data because ITT data included imputed missing data.

Table 2.

Summary of Intervention Effects on PTSD Symptoms.

Author (Year)	Intervention	Treatment Group			Comparison	Control Group			Measure	ES	95% CI
		n	M	SD		n	M	SD
Cloitre and Koenen (2001)	IPG	34	51.18	23.87	WL	15	70.75	25.90	PSS	−0.80	[−1.43, −0.17]
Cloitre and Koenen (2001)	IPG BPD-	18	44.72	27.02	BPD+	16	57.63	20.71	PSS	−0.53	[−1.22, 0.15]
Cloitre et al. (2002)	STAIR/PE	22	31.00	25.20	WL	24	62.00	22.70	CAPS	−1.30	[−1.93, −0.66]
Cloitre et al. (2002)	STAIR/PE	22	29.00	27.60	WL	24	58.00	28.60	MPSS	−1.03	[−1.65, −0.42]
McDonagh et al. (2005)	CBT-PE	17	38.50	27.70	WL	20	62.50	17.00	CAPS	−1.07	[−1.76, −0.37]
McDonagh et al. (2005)	CBT-PE	17	38.50	27.70	PCT	20	44.90	22.10	CAPS	−0.26	[−0.91, 0.39]
Cloitre et al. (2010)	STAIR/PE	33	32.70	19.37	ST/SUP	38	32.32	23.04	CAPS	0.02	[−0.45, 0.48]
Cloitre et al. (2010)	STAIR/PE	33	14.00	11.46	ST/SUP	38	14.50	12.79	MPSS	−0.04	[−0.51, 0.43]
Cloitre et al. (2010)	STAIR/PE	33	32.70	19.37	SUP/PE	33	39.72	18.34	CAPS	−0.37	[−0.86, 0.11]
Cloitre et al. (2010)	STAIR/PE	33	14.00	11.46	SUP/PE	33	19.00	9.83	MPSS	−0.47	[−0.96, 0.02]
van der Kolk et al. (2014)	Yoga	31	49.48	25.16	SUP Ed.	29	63.49	25.48	CAPS	−0.55	[−1.04, −0.04]

Note. ES = Effect size, Cohen’s d; CI = confidence interval; IPG = Interpersonal Processing Group; BPD = borderline personality disorder diagnosis; BPD- = Group without BPD members; BPD+ = Group with BPD members; WL = waitlist control; STAIR/PE = STAIR with exposure; ST/SUP = STAIR with support; SUP/PE = Support followed by Exposure; CBT-PE = Cognitive Behavioral Therapy with modified PE; PCT= Present Centered Therapy; Yoga = Trauma-informed yoga; SUP Ed. = supportive women’s health education class control group; PSS = Post Traumatic Stress Disorder Symptom Scale; CAPS= Clinician Administered PTSD Scale; MPSS= Modified PTSD Symptom Scale.

Table 3.

Summary of Intervention Effects on Arousal and Reactivity Symptoms.

Author (Year)	Intervention	Treatment Group			Comparison-Group				Measure	ES	95% CI
		n	M	SD	Control	n	M	SD
Cloitre and Koenen (2001)	IPG	34	44.99	9.30	WL	15	49.21	10.33	STAIs	−0.44	[−1.05, 0.17]
Cloitre and Koenen (2001)	IPG BPD-	18	38.78	9.48	BPD+	16	51.19	9.18	STAIs	−1.33	[−2.07, −0.58]
Cloitre and Koenen (2001)	IPG BPD-	18	18.00	4.90	BPD+	16	22.00	3.50	AX/In	−0.93	[−1.64, −0.22]
Cloitre and Koenen (2001)	IPG BPD-	18	13.00	2.70	BPD+	16	16.00	2.20	AX/Out	−1.21	[−1.94, −0.48]
Cloitre and Koenen (2001)	IPG BPD-	18	25.00	8.60	BPD+	16	31.00	6.40	AX/EX	−0.79	[−1.48, −0.09]
Cloitre et al. (2002)	STAIR/PE	22	110.00	19.50	WL	24	85.00	18.60	NMR	1.31	[0.68, 1.95]
Cloitre et al. (2002)	STAIR/PE	22	24.00	9.40	WL	24	36.00	7.10	AX/EX	−1.45	[−2.10, −0.80]
Cloitre et al. (2002)	STAIR/PE	22	36.00	8.60	WL	24	55.00	14.90	STAIs	−1.54	[−2.20, −0.89]
McDonagh et al. (2005)	CBT-PE	17	11.20	3.40	WL	20	12.90	4.80	STAXI	−0.40	[−1.06, 0.25]
McDonagh et al. (2005)	CBT-PE	17	39.40	11.90	WL	20	52.70	10.10	STAIs	−1.21	[−1.92, −0.51]
McDonagh et al. (2005)	CBT-PE	17	12.90	7.60	WL	20	20.40	9.00	Cook	−0.89	[−1.57, −0.22]
McDonagh et al. (2005)	CBT-PE	17	11.20	3.40	PCT	20	12.10	4.90	STAXI	−0.21	[−0.86, 0.44]
McDonagh et al. (2005)	CBT-PE	17	39.40	11.90	PCT	20	45.60	11.00	STAIs	−0.54	[−1.20, 0.12]
McDonagh et al. (2005)	CBT-PE	17	12.90	7.60	PCT	20	14.90	7.00	Cook	−0.28	[−0.92, 0.37]
Cloitre et al. (2010)	STAIR/PE	33	110.50	16.17	ST/SUP	38	105.70	16.77	NMR	0.29	[−0.18, 0.76]
Cloitre et al. (2010)	STAIR/PE	33	21.00	8.37	ST/SUP	38	23.60	6.64	AX/EX	−0.35	[−0.82, 0.12]
Cloitre et al. (2010)	STAIR/PE	33	39.20	9.92	ST/SUP	38	42.90	12.34	STAIs	−0.33	[−0.80, 0.14]
Cloitre et al. (2010)	STAIR/PE	33	110.50	16.17	SUP/PE	33	105.80	17.11	NMR	0.28	[−0.20, 0.77]
Cloitre et al. (2010)	STAIR/PE	33	21.00	8.37	SUP/PE	33	26.50	7.70	AX/EX	−0.68	[−1.18, −0.19]
Cloitre et al. (2010)	STAIR/PE	33	39.20	9.92	SUP/PE	33	41.10	12.13	STAIs	−0.17	[−0.65, 0.31]
van der Kolk et al. (2014)	Yoga	31	68.88	13.31	SUP Ed.	29	69.48	14.26	IASC-AD	−0.04	[−0.55, 0.46]
van der Kolk et al. (2014)	Yoga	31	67.17	15.32	SUP Ed.	29	68.51	17.17	IASC-TR	−0.08	[−0.59, 0.42]

Note. STAIs = State Trait Anxiety Inventory; AX/In =Holding Anger In subscale of State Trait Anger Expression Inventory; AX/Out = Expressing Anger Outwardly subscale of State Trait Anger Expression Inventory; AX/EX = Anger Expression subscale of State Trait Anger Expression Inventory; Cook = Cook Medley Hostility Scale; NMR = General Expectancy for Negative Mood Regulation; IASC-AD = Affect Dysregulation subscale of Inventory of Altered Self Capacities; IASC–TR= Tension Reduction subscale of Inventory of Altered Self Capacities.

All four represented interventions had a large effect on PTSD symptom severity compared to their comparison group at posttreatment. Table 2 shows included intervention’s effect (Cohen’s d) on PTSD symptoms compared to comparison group at posttreatment timepoint. Compared to a waitlist control posttreatment, the earlier phased based STAIR/PE study had the largest effect on PTSD symptoms, as measured by the CAPS, (d = −1.30, 95% CI [−1.93, −0.66]). However, the STAIR followed by PE protocol did not have a differential effect on PTSD symptom severity, compared to intervention comparisons (STAIR followed by supportive counselling and supportive counselling followed by PE). Three interventions, IPG, STAIR, and CBT-PE, had effects on A&R symptoms compared to their comparison group posttreatment. Table 3 reports the Cohen’s d effect size for each included intervention (treatment compared to control) on measured A&R symptoms posttreatment. Interpersonal Processing Group therapy with members not diagnosed with borderline personality disorder (IPG BPD-) compared to groups with BPD diagnosed members, had a large effect on anger (d = −1.33, 95% CI [−2.07, −0.58]) and anxiety (d = −0.79, 95% CI [−1.48, −0.09]). The phased-based STAIR/PE treatment had a large effect on anger (d = −1.45, 95% CI [−2.10, −0.80]), emotion regulation (d = 1.31, 95% CI [0.68, 1.95]), and anxiety (d = −1.54, 95% CI [−2.20, −0.89]) symptoms, compared to waitlist control group. The STAIR/PE protocol had differential effects on anger only when compared to supportive therapy followed by PE (SUP/PE) d = −0.68, 95% CI [−1.18, −0.19]. CBT-PE had a large effect on hostility (d = −0.80, 95% CI [−1.43, −0.17]) and anxiety (d = −0.80, 95% CI [−1.43, −0.17]). Yoga had a medium effect on PTSD (d = −0.55, 95% CI [−1.04, −0.04]) compared to supportive women’s education, but not on A&R symptoms.

Fidelity of Treatment

All studies reported that clinicians were trained in the treatment modality; however, only one study (Cloitre et al., 2002) reported ongoing training refreshment during treatment delivery. All studies reported that treatment deliverers received clinical supervision during treatment delivery; four studies reported weekly supervision, and one study (van der Kolk et al., 2014) did not specify the frequency of supervision. Three studies included fidelity rating or adherence monitoring of treatment delivery: Cloitre et al. (2002), Cloitre et al. (2010), and McDonagh et al. (2005). Only one study (Cloitre et al., 2010) had fidelity rating or adherence monitoring by external or independent raters and reported fidelity scores. Cloitre et al. (2010) reported that among the 10% of sessions that were randomly chosen for fidelity rating, 92% of the required elements were delivered with an average competence score of 3.14 (on a 1-4 Likert scale).

Sources of Funding

Three studies received funding from the National Institute of Mental Health (Cloitre et al., 2002, 2010; McDonagh et al., 2005). One of those (McDonagh et al., 2005) received additional funding from the National Center for Post-Traumatic Stress Disorder. Two studies (Cloitre & Koenen, 2001; van der Kolk et al., 2014) did not include a funding statement.

Discussion and Application to Practice

The first goal of this review was to identify interventions that have been tested on PTSD A&R symptoms in adults with a history of ACEs. CBT based approaches were included in three of the five identified studies, which is consistent with current research outcomes on PTSD treatment that is not focused on A&R symptoms or ACE populations. For example, a meta-analysis (Watts et al., 2013) of 81 studies of psychotherapies and somatic treatments for PTSD demonstrated that CBT was included in 72% of the treatments. While the lack of diversity in treatment approach may support the position of CBT as a well-known evidence-based practice for PTSD it is also important to consider that other types of intervention are underrepresented in PTSD research. For example, Leichsenring and Steinert (2017) claim that the preeminence of CBT is due to the lack of high-quality studies in other psychotherapy approaches and may not be solely attributable to the performance of CBT. Furthermore, there was only one study in the sample (trauma informed yoga) that demonstrated an approach to treatment rooted in traditional cultural practices. The ubiquitousness of CBT based approaches that have not been tailored to accommodate diverse cultures and groups also represents a lack of cultural and spiritual inclusivity in this sample of interventions. Given the increasing diversity of the U.S. population and the prevalence of trauma and PTSD globally, there is increasing need for culturally appropriate A&R focused PTSD treatments for non-Westerners and other marginalized groups (Bryant-Davis, 2019; Ennis et al., 2020; Giammusso et al., 2018).

The second goal of the review was to assess the effectiveness of identified interventions. There was supportive evidence for the efficacy of CBT-PE, STAIR, and Interpersonal Group Therapy for reducing PTSD and A&R symptoms. Trauma informed yoga was supported as effective for reducing PTSD symptoms severity, but not the specific A&R symptoms measured.

In the context of this sample, two CBT treatments stood out with the greatest effect sizes on PTSD symptoms when compared to waitlist controls. Those were CBT-PE (d = −1.07, 95% CI [−1.76, −0.37]) and CBT based STAIR followed by prolonged exposure (d = −1.30, 95% CI [−1.93, −0.66]). The highest effect sizes on A&R symptoms were also found in the CBT based STAIR followed by prolonged exposure protocol, on two dimensions of A&R; those were anger (d = −1.45, 95% CI [-2.10, −0.80]) and anxiety (d = −1.54, 95% CI [−2.20, −0.89]). This is consistent with current research outcomes on PTSD treatment that is not focused on A&R symptoms or ACEs populations. The meta-analysis performed by Watts et al. (2013) confirmed not only the popularity of CBT as an intervention of choice, but also the performance of CBT which had the greatest overall effect (Hedges’s g = 1.26). This is an important finding, as it suggests that current CBT practice may suffice for the treatment of adults with PTSD and a history of ACEs; however, it is also important to consider limitations of the individual studies that are related to outcomes on the A&R symptoms. Importantly, this review found that there is a scarcity of research on the specific effects of interventions on A&R symptoms with adults with ACEs history. While the studies included in this review measured some A&R symptoms, none of them were designed to capture and measure all the dimensions of A&R symptomatology. Furthermore, the measurement of A&R symptoms occurred as part of larger research agendas that were broadly focused on PTSD symptom reduction and not specifically focused on treatment outcomes for A&R symptoms in adults with PTSD and a history of ACEs. This is despite the fact that the A&R cluster of symptoms has been shown to be difficult to treat and may complicate the recovery of those with ACEs backgrounds (Lippard & Nemeroff, 2020).

There are limitations in the present studies that need to be considered. Three out of five studies in this sample demonstrated a larger effect on PTSD symptoms compared measured A&R symptoms. The interventions included in those studies were: Trauma informed yoga (PTSD: d = −0.55, 95% CI [−1.04, −0.04] vs. no statistically significant effect on affect dysregulation or tension); CBT-PE (PTSD: d = −1.07, 95% CI [-1.76, −0.37] vs. no statistically significant difference on anger and d = −0.89, 95% CI [-1.57, −0.22] on hostility compared to waitlist controls); and Interpersonal process therapy (PTSD: d = −0.80, 95% CI [-1.43, −0.17] vs. no statistically significant difference on anxiety when compared to waitlist controls). This pattern may suggest that A&R symptoms do not always decline at the same rate as overall PTSD symptom reduction. It would be important to discover whether this outcome holds true for A&R symptom resolution in treatment for PTSD in populations without ACEs. Future research could include a large-scale comparative analysis of global PTSD symptoms versus A&R symptoms in ACEs and non-ACEs groups. This could be accomplished by reporting PTSD measure subscale along with over severity scores. One research study of a CBT based treatment (CPT) for PTSD in a non-ACEs, male, veteran sample found a large effect (d = 0.97) for global PTSD symptom reduction compared to anger (d = 0.36) symptoms (Forbes et al., 2012). This provides preliminary evidence that the differences in effect size in our study might be a more ubiquitous outcome. Ultimately, more research is needed to corroborate or disconfirm the implications of this finding.

Two studies in our sample tested phase-based treatment protocols that incorporated emotional regulation skills training before CBT based exposure treatment (STAIR and phase-based CBT). Cloitre et al. (2002) tested emotion regulation skills before modified exposure and found that participants received a greater improvement for PTSD and emotion regulation than waitlist participants. Cloitre et al. increased rigor in the 2010 phase-based study and compared affect regulation training before exposure therapy to two other phase-based approaches: (1) affect regulation training /supportive counseling, and (2) supportive counseling/exposure. While all three treatment conditions resulted in reduced PTSD symptom severity at post-treatment, three and 6 month follow up assessments showed that individuals in the STAIR/PE group were more likely to maintain those gains than those in the other treatment conditions (X² = 7.22, df = 2, p = .03). The STAIR/PE treatment outcomes also demonstrated a significant effect on anger symptoms at posttreatment assessment (d = 0.68, 95% CI [−1.18, −0.19]). These studies suggest that phased based PTSD interventions that incorporate emotion regulation to address A&R symptom profiles may be helpful for those with PTSD and a history of ACEs. This finding is consistent with current efforts to implement phase-based treatment as a best practice for individuals with complex presentations of PTSD, such as in cPTSD (Cloitre et al., 2011). This effort is supported by evidence; a recent meta-analysis of 13 studies examining the effects of phase-based treatments for PTSD found large effect sizes (d = 1.39, 95% CI [0.99, 1.79]) when comparing treatment and control groups in individuals with complex PTSD (Corrigan, Fitzpatrick, Hanna, & Dyer, 2020). Notably, the majority of these studies contained elements of emotion regulation training in the first phase, which is in alignment with the idea that individuals with highly complex PTSD presentations will benefit from a period of stabilization before entering treatments that focus exclusively on trauma symptoms. Therefore, phase-based treatment that includes emotion regulation show some promise and are worthy of further research.

The last goal of this review was to document the demographic characteristics of the samples in the identified studies. Another important finding impacting social work practice is that all the samples were 100% female and 60% White. The exclusive female sample may be explained by the fact that females are statistically more likely to experience PTSD. Olff (2017) reported the lifetime prevalence of PTSD is 10–12% in women versus five to six percent in men. It has also been noted that the prevalence of cPTSD (which is associated with childhood trauma) in adults in the United States is significantly higher for women than for men (OR = 1.82, 95% CI [1.44, 4.45]) (Cloitre et al., 2019). Another possibility is that males tend to underreport ACEs and adult trauma, delay reporting, and are influenced by gender norms and social implications (Easton et al., 2014). This suggests ease in recruiting female participants for study samples compared to males. Concerning the issues of gender non-binary or transgender populations, scientific research is lagging in these populations, and our study sample reflects that issue (Austin, Herrick, & Proescholdbell, 2016). The predominately White, female sample limits the applications to social work practice because the sample populations of all included studies did not include a significant proportion of racial and ethnic minority individuals, males, gender non-binary, or transgender individuals and others that may be treated in social work practice. The homogeneity of the study samples is also consistent with claims that researchers are less likely to seek out participation of members of marginalized communities during the development and testing of new interventions (Bryant-Davis, 2019). Both recruitment and retainment of individuals within minoritized groups is a problem that has been identified across various social science disciplines (George, Duran, & Norris, 2014). While these populations have been under-researched in intervention work, they may be the groups that are most likely to develop PTSD, and therefore, the most likely to require appropriate services. Past research, for example, shows that ACEs tend to occur more frequently in minoritized populations due to socio-economic factors (Cronholm et al., 2015; Cubbin et al., 2019). We also know that those with ACEs have a high prevalence of PTSD compared to the general population (Gould et al., 2021). Thus, the lack of diversity here is a limitation for social work practice. At the same time, research on A&R in PTSD is critically necessary in order to provide appropriate services for populations that are minoritized and have been historically underserved, due to higher ACEs.

This study was limited by the number of available studies for review that target, measure, and report outcomes of A&R symptoms with adult ACEs populations. The small sample size (n = 5) reveals a meaningful gap but cannot be relied on to provide broadly generalizable results. All the studies included in this review contained various limitations and possible risk of bias, however, these risks are not fully elucidated due to the study methodology which did not include a risk of bias assessment. One study for example, lacked randomization and other studies did not blind samples and may have limitations in the way they report findings. There was considerable variation in how each study measured and evaluated A&R symptoms. In the pool of five studies, there were four different screening measures used which limits comparisons between studies. Reporting of post-treatment A&R symptom changes was also inconsistent across studies. Future studies should emphasize detailed reporting on all A&R measures implemented in data collection. This research endeavor excluded literature that was not written in English. As such, these results are assumed to bias English language publications and may have excluded a significant number of studies conducted in countries and cultures where English is not commonly used in scientific discourse. The sample of interventions in this study also bias cultural perspectives common to Western empirical thought. Therefore, it must be assumed that the results of this study represent a narrow perspective; for example, the conceptualization of trauma itself may lack cultural inclusivity (Bryant-Davis, 2019). The examination of culturally tailored and culturally emergent interventions is a nascent area of inquiry (Bryant-Davis, 2019; Ennis et al., 2020) that may demonstrate value for A&R symptoms for adults with PTSD and a history of ACEs in the future.

Conclusion and Implications for Social Work Practice and Research

The results of this review demonstrate a scarcity of research addressing A&R symptoms in adults with PTSD and a history of ACEs. While the identified studies included some measurements of A&R symptoms, not a single study included all dimensions of A&R symptomatology. Furthermore, each study was focused more broadly on PTSD symptom resolution rather than specifically on A&R symptoms. This gap illustrates a need to establish an evidence base of treatments that target A&R symptoms in adults with PTSD and a history of ACEs to guide the practice of social work. Among the studies reviewed, CBT was found to achieve the strongest effect sizes on both PTSD and A&R symptoms. However, these findings are not generalizable due to the predominance of White females in the study samples, which is especially meaningful for social work practice given the diverse populations that social workers encounter. Additionally, the dominance of CBT oriented interventions reveals a lack of culturally appropriate treatment options that target A&R symptoms in adults with PTSD and a history of ACEs. It is recommended that social work researchers investigate culturally tailored and culturally emergent interventions for PTSD and specifically for A&R symptoms with diverse samples. This is of critical importance given the disproportionate experience of ACEs and PTSD in minoritized groups.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jose E. Velasquez

Laura H. Dosanjh

Appendix

Section	Item	Prisma-SCR Checklist	Reported on Page #
Title
Title	1	Identify the report as a scoping review.	p.1 & 2
Abstract
Structured summary	2	Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.	p.2
Introduction
Rationale	3	Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.	p.7
Objectives	4	Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.	p.7 &8
Methods
Protocol and registration	5	Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.	None exists
Eligibility criteria	6	Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide arationale.	p.8
Information sources*	7	Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.	pp.9–10
Search	8	Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.	pp.9–10
Selection of sources of evidence†	9	State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.	pp.8–9
Data charting process‡	10	Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.	p.11
Data items	11	List and define all variables for which data were sought and any assumptions and simplifications made.	p.11
Critical appraisal of individual sources of evidence§	12	If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).	Not done.
Synthesis of results	13	Describe the methods of handling and summarizing the data that were charted.	p.11
Results
Selection of sources of evidence	14	Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.	p.12 and PRISMA chart.
Characteristics of sources of evidence	15	For each source of evidence, present characteristics for which data were charted and provide the citations.	Table 1, table, 2, table 3, and pp.12–16
Critical appraisal within sources of evidence	16	If done, present data on critical appraisal of included sources of evidence (see item 12).	Not done
Results of individual sources of evidence	17	For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.	Table 1, 2, 3 and pp. 12–16.
Synthesis of results	18	Summarize and/or present the charting results as they relate to the review questions and objectives.	Table 1,2, 3
Discussion
Summary of evidence	19	Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.	pp.17–21
Limitations	20	Discuss the limitations of the scoping review process.	p.21
Conclusions	21	Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.	p. 22
Funding
Funding	22	Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.	p. 17

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