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Study Protocol                                                                                  

Effects of the guided disclosure protocol on 
post-traumatic growth: A randomized control 
trial designed to observe psychophysiological 
alterations in traumatic stress subjects 
Shamoon Noushad1,2,3 & Sadaf Ahmed1,3 
1Advance Educational Institute & Research Center 
2Dadabhoy Institute of Higher Education 
3Psychophysiology Research Lab, Biological Research Center, University of Karachi 

 

Abstract 
Background: The two constructs traumatic stress and Post-Traumatic Growth 
(PTG) are distinct and the psychophysiological relationship is yet to be explained. 
It’s a long debate that the victims who survive through the traumatic event only 
perceive that their suffering has helped them in improving their lives after the 
event or the experience actually improved functioning. The purpose of designing 
this randomized control trial is to observe psychophysiological alterations 
associated with post traumatic growth in traumatic stress subjects. 
Methodology: This Multicenter study is planned to investigate the effectiveness of 
the guided disclosure protocol for the promotion of post-traumatic growth (PTG), 
in the traumatic stress subjects and to determine whether PTG is associated with 
psychophysiological alterations i.e. (C-Reactive Protein, Brain Derived 
Neurotropic Factor, Interlukin-6, Cortisol, Heart Rate Variability and brain 
waves). Study subjects meeting eligibility criteria will be randomized into two 
groups. Guided disclosure protocol (GDP) will be used as intervention vs the 
control. Blinded treatment will be provided and the subjects will be made to 
complete study questionnaires (Screening, Traumatic Stress Scale SSS, Trauma 
Symptom Checklist, Post-traumatic growth Inventory) at baseline and at post-
intervention (3-months later). 
Discussion: This study might give us insight about application and efficacy of 
Guided disclosure protocol in a population that is seeking help and 
underrepresented to be clinical. Moreover, one of the more hopeful findings of this 
research will be significant information about trauma-related psychophysiological 
effects. 
 

Keywords 
Guided disclosure protocol, Post-traumatic growth, psychophysiological 

alterations, Trauma Symptom Checklist. 

Citation: Noushad S, Ahmed S. Effects 
of the guided disclosure protocol on 
post-traumatic growth: A randomized 
control trial designed to observe 
psychophysiological alterations in 
traumatic stress subjects. APP. 2019; 
6(1):41-51 
 
Corresponding Author Email: 
shamoon@aeirc-edu.com 
 
DOI: 10.29052/2412-3188.v6.i1.2019.41-51 

 
Received 11/03/2019 
 
Accepted 03/06/2019 
 
Published 12/10/2019 
 
Copyright © The Author(s). 2019 This  
is an open access article distributed 
under the terms of the Creative 
Commons Attribution 4.0 International 
License, which permits unrestricted 
use, distribution, and reproduction in 
any medium, provided the original 
author and source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

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

https://doi.org/10.29052/2412-3188.v6.i1.2019.
http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)


 

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Introduction  
Traumatic stress is an outcome of single or a 
cumulative series of trauma exposure that 
enduring symptoms conditioned with 
previous frightening experiences that 
threatens persons existence and sense of 
safety in conditions like physical shock, 
harassment, abusive relationships, sexual 
abuse, police brutality, judicial corruption, 
domestic violence, natural disasters, motor 
vehicle accident, community violence etc. 
Traumatic stress involves both biological and 
psychological aspects and as research 
progress in the field there had been 
exploration of numerous etiological factors 
with the main mechanisms remain 
imprecise1. According to the neurobiological 
findings, the stress and resilience model 
needs to put together to understand these 
factors2 as the underlying biology is the major 
contributing factor for triggering 
psychological risk and the resilience factors3. 
It is evident that the symptoms of traumatic 
stress and Post Traumatic Growth (PTG) co-
occur in accordance with trauma type4. 
Where PTG is considered as positive 
psychosomatic transformation experienced 
as a result of adversity and other miseries to 
rise at an improved and quality 
psychophysiological state. 
 
In response to any traumatic event the 
neurophysiological factors get triggered like 
HPA axis5, that initiate a cascade to 
influences neuronal pathways via 
dopaminergic6,7, glutamatergic8, and 
serotonergic systems9, to cause changes in the 
perception and performance. Numerous 
biomarkers associated with different 
biological domains such as monoaminergic 
systems, neuroendocrinological pointers, 
inflammatory molecules, genomics, 
psychophysiological markers and 
neuroanatomical changes had been identified 
for assessment of post-traumatic stress risk 
and consequences10. The inherent 
symptomatic diversity among the post-
traumatic stress subjects, and other similar 
psychiatric and medical conditions makes the 
identification of appropriate biomarker for 

post-traumatic stress diagnosis much 
complex11-13. 
 
Inflammatory markers, brain-derived 
neurotrophic factor (BDNF), and alterations 
from the HPA axis are few of the Resilience-
specific biological factors that had been 
discovered and studied in the past14,15. While 
cortisol remain the key hormone that release 
in response to stress stimuli from the adrenal 
gland and controlled by the HPA axis16. The 
Trauma subjects show increased stress 
sensitivity as the cortisol level is naturally 
reduced among these subjects after getting 
exhaust initially17. There is a strong 
relationship between trauma and 
inflammatory markers as indicated by a 
number of comorbidities like physical18, 
inflammation19 and metabolic illness20. The 
level of pro-inflammatory cytokines such as 
interleukin (IL)-6, IL-1 and IL-2 are high in 
traumatic subjects21,22. While C reactive 
protein (CRP) is considered as 
psychophysiological biomarker of post-
traumatic stress with increased level of CRP 
is observed among traumatic stress 
subjects23. The most recurrent biological 
finding in traumatic stress is higher 
autonomic activity and changes in brain 
functionality that can be detected by 
numerous recordings such as, HRV 
measurement, skin conductance, brain waves 
and facial electromyography responding 
during internal, mental imagery of the 
traumatic event and upon exposure to 
external, trauma-related cues.  
 
According to the Posttraumatic growth 
(PTG) model, traumatic events function as 
catalyst and aid in individual growth to 
develop various coping strategies and it must 
be considered as a challenge24,25. Although 
the memories and feelings associated with a 
traumatic event are stressful26, but the 
dealing strategy and experience can be 
altered by the individual’s perspective 
regarding the event and through this the 
aftermath could be transformed25. 
 
Depending upon psychological symptoms, 
self-report and patient’s observation, 



 

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particularly within military personnel, is 
inadequate as impairment may occur due to 
various factors, including other combat-
related injuries like mild traumatic brain 
injury27,28. Similarly, without the assessment 
of psychological factors associated with 
perceived stress, resilience, and struggling 
experiences and only concentrating on the 
biological foundation would limit one’s 
knowledge regarding the etiological factors 
associated with the trauma. The primary 
mechanisms cannot be studied properly 
unless the stress related problems are studied 
along with the coping strategies29,30. For 
assessment, diagnosis, inhibition and 
treatment, the markers (psychological, 
biological, and genetic) could assist mainly in 
the high-risk groups31,32. 
 
Several researchers reported immunological 
differences between studies including 
participants who disclosed traumatic or 
upsetting events compared with those in a 
nondisclosure condition33. Results of these 
type of studies have been interpreted as 
evidence for the link between inhibition of 
strong emotions and the development of 
physical disease34. The benefits of disclosure-
based interventions may depend on the 
extent to which individuals become 
emotionally and cognitively involved in the 
disclosure process, reorganize the meaning of 
the traumatic event, and reduce avoidance of 
the stressful topic35.  
 
A number of studies had been conducted 
including subjects from public healthcare 
settings, experienced stress due to ill health 
or trauma36-39. It is evident that the expressive 
writing benefits also extend to the normal 
population other than students40,41. It is noted 
that the lung function improvises in asthma 
patients42 and symptomatic relief is observed 
in patients with rheumatoid arthritis43. 
Additionally, decreased physical symptoms 
were observed among the patients of Stage I 
or II breast cancer having received the 
medical treatment, after 3 months of the 
handling with expressive writing showed 
better outcomes as compared to control 
group44. While there are few outcomes that 

indicate reduced health related behaviours 
due to expressive writing i.e. declining 
clinical attendance and work absenteeism45. 
 
Written disclosure protocols, in which 
individuals express their thoughts and 
emotions about traumatic or stressful life 
events, have been associated with 
improvements in both psychological and 
physical health46. The effectiveness of GDP in 
comparison to the standard disclosure 
protocols is under discussion and various 
studies have investigated the efficacy of the 
two. The purpose of designing this 
randomized control trial is to observe 
psychophysiological alterations associated 
with post traumatic growth in traumatic 
stress subjects.  

 

Methodology 
Study design 
The study will be conducted as multicenter 
randomized controlled trial. On the basis of 
eligibility criteria subjects providing consent 
to participate in the study will be randomized 
into two groups, experimental group 
including those who receive the intervention 
and a control group receiving control 
intervention. The study outcomes will be 
monitored in subjects of both groups at 
different intervals i.e. at baseline and at 3-
month follow-up (post-interventional). 
 
Ethical Concerns 
The study protocol was approved by the 
Ethics Committee of Pakistan Medical 
Association Committee on Ethics (Reference 
Code no. 2019/ERC/6-94). And registered by 
the Clinicaltrial.gov (Registration number 
NCT04217863)47. 
  
Participants 
Subjects for the present study will be 
recruited from 5 centers (based in Karachi, 
Pakistan). The targeted population includes 
subjects from diverse ethnicity and 
considered eligible for participation in the 
study if they indicated in a pre-screening 
form that they had experienced traumatic 
event. These subjects will be invited to 



 

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participate in the study through 
advertisement on notice board of each center. 
A written informed consent will be obtained 
from each study subject after providing 
detailed information regarding objectives of 
the study and its duration.  
 
Eligibility criteria 
Inclusion criteria 
All subjects fulfilling the below given criteria 
will be included:  
1. Subjects aged 18 years or over  
2. Must be disease free, there must be no 

evidences of any metastatic disease 
3. Property of written and spoken English 

language. 
4. Experienced any traumatic event in last 12 

Months. 
 

Exclusion criteria 
1. Subjects who received a structured 

psychological intervention for at least 6 
months during the last 3 years performed 
by a psychologist or psychiatrist will be 
excluded.  

2. Those with codified psychiatric disorder 
(according to the Diagnostic and Statistical 
Manual of Mental Disorders, Fifth Edition 
(DSM-V) who received 
Psychopharmacological treatment during 
the last 3 years will also be excluded from 
the study sample. 

 
Interventions  
The experimental intervention (GDP):  
It includes three writing sessions of 20 
minutes where the participants will be made 
to recall the facts regarding the traumatic 
event first and then the emotions triggered 
related to the revealed facts will be 
channelized. The information related to the 
immediate priority changes due to the revival 
of the traumatic history and its reflection on 
current feelings will be collected. Moreover, 
the learned coping mechanisms will also be 
inquired and how the traumatic event altered 
their vision and their personalities and how it 
helps in coping with future difficulties.  
 
The original instructions will be translated 
into local language and altered according to 

the specific traumatic experience. In the 
following, a fusion of the tasks concerning 
each of the three writing sessions is shown.  

1. Participants will be required to describe 
memories associated with traumatic 
event in a sequential order, with an 
objective and detached attitude.  

2. They will be asked to describe:  
a. Their opinion regarding the traumatic 

event and emotions perceived during the 
experience.  

b. Its impact on their daily lives, and how it 
has altered their attitudes toward life. 

3. The actual situation will be focused, 
while reviving the whole traumatic event 
experience which aids in exploring the 
following aspects:   

a. Present thoughts and feelings regarding 
the traumatic experience, and also clarify 
the differences between the ones felt at 
the time of traumatic event in 
comparison to the current feelings. 

b. How much they understand and 
appreciate themselves for successfully 
dealing with the traumatic event 

c. To what extent the traumatic event has 
modified their vision, attitude, 
knowledge, and skills, and how it can 
help in their future; 

d. What will be their future reactions to 
other similar events. 
 

For the writing session it is mandatory to 
maintain standard experimental 
environment with maximum silence so that 
the subject can write peacefully without 
getting disturbed. Two weeks after the initial 
assessment, the first writing session will be 
performed followed by two sessions once 
every 2 weeks. 
 
The control intervention: 
In control intervention the subjects will be 
required to take three 20-minute writing 
sessions, in which they will be asked to write 
about their daily events of the past week, the 
writing must focus on the facts and highlight 
an objective and detached attitude. It has 
shown potential improvements after the 
guided disclosure protocol (GDP). Works 
through the placebo effect. Same protocol 



 

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will be followed for these subjects as the one 
used for GDP.  
 
A day prior to each writing session, in both 
conditions either experimental or control the 
researcher will communicate with each study 
subject via telephone in order to give them a 
reminder to perform the writing task and to 
check their understanding regarding the 
instructions given in the booklet. Details 
regarding the inability to contact the subject 
will also be recorded in the patient form. 
 
Recruitment & Assessment Procedures  
Recruitment and baseline assessment: 
One or more researchers will be involved in 
the process of recruitment and evaluation. 
Prior training sessions will be conducted by 
principal investigator regarding study aims 
and procedures for all the researchers 
involved in the study. The participants will 
be directed towards the researchers who are 
responsible for explaining the study aims and 
conduction as well. An information sheet 
including subject’s socio-demographic 
characteristics will be provided to each 
individual. A written informed consent will 
be taken from each subject before initiation of 
the study. Confidentiality will be maintained 
during and after the study for both written 
process and assessment records. A baseline 
questionnaire (Screening, TSS, PTGI, TSC) 
and booklet with detailed instructions will be 
provided to the study subjects according to 
the groups allocated. The subjects will be 
kept blinded regarding the study treatment 
and hypotheses during the study conduction. 
All the variables (CRP, BDNF, IL-6, Cortisol, 
HRV, Glutamate and brain waves) will also 
be measured at baseline. 
 
Post-intervention and follow-up 
assessments:  
After 3 months post-interventional 
assessment will be performed i.e. Follow-up 
evaluation, with the same time tolerance as 
that for baseline. During this the booklets 
with written scripts will be returned to each 
of them individually.   
 

 

Procedure 
The Screening questionnaire will be utilized 
for assessment. Subjects reporting of 
experiencing at least one traumatic 
experience are kept inclusive.  
 
Study Hypothesis  
1. It is hypothesized that higher scores on the 

Post-traumatic Growth Inventory (PTGI) 
will be observed among the subjects 
enrolled in the GDP group as compared to 
the control group.  

2. We expect the variation in 
psychophysiological markers i.e. CRP, 
BDNF, IL-6, Cortisol, HRV and brain 
waves among the subjects of GDP group 
as compared to those in the control group. 

3. It is expected that lower scores on the 
Traumatic Stress Scale and Trauma 
Symptom Checklist 40 (TSC-40) with 
subscale composition of dissociation, 
anxiety, depression, SATI, sleep 
disturbance and sexual problems will be 
observed among the subjects enrolled in 
the GDP group as compared to the control 
group. 

 
Measures 
Post-Traumatic Growth (PTG)48 
PTG will be assessed using the Italian version 
of the PTGI. This inventory is comprising of 
21 questions based on 5 factors. The 1st factor 
shares spiritual modifications (2 items), 2nd 
factor relates to self-conception and 
alterations in viewpoints (Changes in 
Philosophy) (7 items), 3rd factor describes 
relationship changes (5 items), 4th factor 
relates to finding new motivations and 
interests in life (3 items) and the 5th factor 
explores the discovery of individual 
resources attainable by themselves and 
others (3 items). Respondents will be tracked 
for the changes that have been produced due 
to their illness. Likert scale will be used for 
rating where 0 means no change experienced, 
to increasing consequently as 5 means change 
experienced to a greater degree.  
 
Traumatic Stress Scale (Sadaf Stress Scale)49 
The Traumatic Stress Scale sub section of 
sadaf stress scale (version 2) measures 



 

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exposure to any trauma such as criminal 
victimization, natural disaster, witnessing or 
confronting such situations or itself 
experiencing them as actual or threatened 
death (or serious injury) to self or others 
which can dwell a person into traumatic 
stress. This scale comprises of 8 questions 
which measures traumatic stress in 
categories of normal, mild, moderate & 
severe. 
 
Trauma Symptom Checklist50 
The TSC-40 is a research measure that 
evaluates symptomatology in adults 
associated with childhood or adult traumatic 
experiences. It measures aspects of 
posttraumatic stress and other symptom 
clusters found in traumatized individuals. 
This measure assesses trauma-related 
problems in categories like Dissociation, 
Anxiety, Depression, SATI (Sexual Abuse 
Trauma Index), Sleep Disturbance & Sexual 
Problems. 
 
Brain waves 
The voltage fluctuations within the neurons 
or the electrical activity of neurons due to 
ionic flow is recorded as brain waves through 
electroencephalogram while the record itself 
is the EEG that shows waves or oscillations 
indicating electrical activity. The (Muse, 
RRID:SCR_014418) Brain-Sensing 
Headband51 will be utilized to record the 
brain waves i.e. Alpha waves, Beta waves, 
Theta waves & Gamma waves.   
 
Cortisol 
A negative association exists between cortisol 
and left hippocampal volume among patients 
with other psychiatric disorders like 
depression and PTSD due to trauma. 
Memory and learning skills are affected by 
elevated cortisol levels. It increases the risk 
for depression, mental illness, and also 
decreases the life expectancy. 
Chemiluminescent micro particle 
immunoassay (CMIA) will be used for 
assessment of cortisol levels.   

 
 
 

  Brain-derived neurotrophic factor (BDNF) 
The changes in the BDNF Levels are 
associated with traumatic stress or the 
changes in the physiological systems in 
relation to a stress response. Cognitive 
functioning is mainly altered in cases with 
alterations in BDNF levels. Human BDNF 
ELISA (Enzyme-Linked Immunosorbent 
Assay) kit will be utilized for BDNF assay.  
 
C - Reactive Protein (CRP) 
For measuring systemic inflammation, CRP 
is an ideal measure. In vitro immune 
turbidimetric method will be utilized for the 
quantifiable determination of CRP in human 
serum and plasma.  
 
Heart Rate Variability 
Temperature, heart rate variability, pulse 
rate, blood pressure will be recorded through 
Electro Power Lab52 and analysis through 
MATLAB. 
 
Interleukin-6 (IL-6) 
Physical and psychological stress alter 
plasma cytokines levels particularly 
interleukin-6 (IL-6). Serum concentrations of 
IL-6, will be assayed by means of enzyme-
linked immunosorbent assay techniques, 
based on appropriate and validated sets of 
monoclonal antibodies. 
 
Glutamate 
Elevated levels of an excitatory 
neurotransmitter known as “Glutamate” 
which is an amino acid, is greatly reported in 
cases of neurotoxicity which causes neuronal 
death. Glutamate Assay Kit will be utilized 
for the estimation. 
 
Sample size 
A sample size of 246 was calculated with at 
least 123 subjects will be placed in both 
groups for statistically significant variation of 
PTG to be observed among GDP versus 
control groups. It was calculated according to 
meta-analysis on PTG53, where an estimated 
effect size of 0.36 (equally with both Hedges’ 
g and Cohen’s d) with a two-sided test using    
G power 3.1.354, alpha 0.05 and a power of 
0.80. 



 

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   Randomization 

Subjects on the basis of eligibility criteria will 
be randomly allocated to the GDP or control 
group in the 1:1 ratio. Computer generated 
random numbers are used for 
randomization. After taking subjects basic 
information, a unique code will be provided 
to each included subject by the study center. 
The code will be mentioned on each form of 
each individual subject.   
 
Statistical Analysis 
The data will be analysed using 2 × 2 mixed 
factorial design analysis of variance 
(ANOVA) in order to calculate whether there 
exists a significant change in PTG among the 
subjects of intervention and control group. 
After intervention if a higher ratio of PTG will 
be observed in GDP group, the interventional 

impact of the five factors of PTG will be 
examined with further analysis. Sequentially 
for each secondary outcome further 
ANOVAs will used to examine differences 
between groups at 3 months and after 
baseline. Adjusted ANOVA will be 
performed keeping socio-demographic and 
other variables as co-variants, to determine 
whether the socio-demographic and other 
characters could result in alterations in the 
effect between the two groups.  For the effect 
of GDP on constructed meaning regression-
based approach will be utilized. According to 
previous literature in order to estimate a 
simple mediation model ordinary least-
square regression models is becoming a 
common practice which is considered as 
appropriate as structural equation 
modelling55-57. 

 

 

Figure 1: Flowchart of study procedure. 
 

 

 

 



 

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Discussion   
Psychophysiological studies have 
demonstrated that what individuals think 
and feel has a measurable effect on the 
nervous, immune and behavioural 
responses, demonstrating that the line 
between physical and mental health is not as 
solid as we once believed. This might give us 
insight about application and efficacy of 
Directed Written Disclosure in a population 
that is seeking help and underrepresented to 
be clinical. Moreover, one of the more 
hopeful findings of this research will be 
significant information about trauma-related 
effects that can be managed and possibly 
reversed and will help trauma survivors for 
number of specific actions to downregulate 
their stress response and halt their decline 
into serious health problems.  
 
Conceptualizing traumatic stress as a 
disorder of the brain’s fear system, with 
emotional processing dysregulation within 
its circuitry, has generated a significant body 
of research over the past decade that has 
illuminated the neuroimmunological and 
psychophysiological mechanisms that 
underlie this problem.  
 

Acknowledgement  
Authors highly appreciate and acknowledge 
the efforts of Yusra Saleem.  
 

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