Exposure Therapy Tops Cognitive Restructuring in Preventing PTSD

By John Gever
SYDNEY, 04 jun 2008-- Accident and assault victims suffering acute stress should receive prolonged-exposure therapy to prevent posttraumatic stress disorder, researchers here said.
In a randomized trial, only 37% of patients who began prolonged-exposure therapy shortly after a traumatic event had developed PTSD six months later, compared with 63% of those treated with cognitive restructuring (P=0.05), reported Richard A. Bryant, Ph.D., of the University of New South Wales, and colleagues in the June issue of Archives of General Psychiatry.
It's the first head-to-head comparison of the two major treatment approaches for patients with acute stress disorder, the researchers said.
Some 47% of those receiving prolonged-exposure therapy had full remission of acute stress disorder symptoms, compared with only 13% of patients treated with cognitive restructuring (P=0.005).
"Despite some concerns that patients may not be able to manage the distress elicited by [prolonged-exposure therapy], there was no difference in dropout rates," Dr. Bryant and colleagues said. In fact, mean distress ratings for each session were significantly lower among those receiving prolonged-exposure therapy.
"Exposure should be used in early intervention for people who are at high risk for developing PTSD," the researchers concluded.
In prolonged-exposure therapy, patients are encouraged to relive the traumatic event over and over. They may describe it verbally in detail in sessions with a therapist and do daily homework assignments that force patients to go over the event in their minds.
Dr. Bryant and colleagues said many clinicians have resisted using exposure therapy because they worry the distress it creates may drive patients away from therapy altogether.
Cognitive restructuring involves identifying unhealthy thoughts and emotional responses to the trauma and tries to modify them by having patients apply rational analysis. The unhealthy thoughts typically revolve around guilt about behavior during the trauma and excessive worry about future harm and their reactions to the stress.
The researchers recruited 90 patients who had been involved in motor vehicle accidents or non-sexual assaults and who met criteria for acute stress disorder -- 30 patients were assigned to prolonged-exposure therapy, 30 to cognitive restructuring, and 30 were assigned to a wait list. Patients on the wait list were reassessed six weeks later and then offered unspecified active treatment.
For both treatment types, patients received five 90-minute sessions at weekly intervals. They were assessed primarily with the Clinician-Administered PTSD Scale-2, as well as with other standard psychological checklists and questionnaires.
Five patients in the prolonged-exposure group and seven in the cognitive restructuring group did not complete the treatment, including two in each group who had adverse reactions to the therapies.
At the six-week evaluation, 71% of the wait-listed patients met standard criteria for PTSD, compared with 52% of those assigned to cognitive restructuring and 12% of those receiving prolonged-exposure therapy (P<0.001).
Dr. Bryant and colleagues pointed out that cognitive restructuring "achieved a modest effect size for most assessments relative to the wait-list group" after treatment. That's an indication that cognitive restructuring also is effective, if somewhat less so than prolonged-exposure therapy.
"We recognize that it does provide an alternate early intervention for patients who are unsuitable for prolonged-exposure [therapy] or unwilling to participate," they said.
The researchers said that most of the earlier research on exposure therapy had combined it with cognitive restructuring. "Prolonged-exposure [therapy] probably accounted for many of the therapy gains in previous studies," they said, but acknowledged that their head-to-head study did not allow for a comparison with the additive effects of the two approaches.
In fact, they suggested, adding cognitive restructuring later in treatment, following initial therapy with prolonged exposure, may provide the best results.
Dr. Bryant and colleagues noted several limitations to their study. Because it focused on accident and non-sexual assault victims, their results may not be generalizable to other populations such as war veterans or victims of sexual assault, they said.
The researchers also noted that they did not assess for all psychiatric disorders known to affect trauma survivors, nor did they assess functioning.
Exposure therapy supported by virtual reality technology was recently reported to be effective against PTSD in soldiers returning from Iraq (See: Virtual Reality PTSD Therapy Shows Promise in Iraq Veterans).
The study was funded by the National Health and Medical Research Council Program. No potential conflicts of interest were reported.
Primary source: Archives of General PsychiatrySource reference:Bryant R, et al "Treatment of acute stress disorder: a randomized controlled trial" Arch Gen Psychiatry 2008; 65: 659-67.

More evidence sought on PTSD treatments

By LAURAN NEERGAARD, AP Medical WriterThu Oct 18, 6:09 PM ET
There isn't enough evidence to tell if most treatments for post-traumatic stress disorder work, says a scientific review that highlights the urgency of finding answers as thousands of suffering veterans return from Iraq.
The one proven treatment is exposure therapy in which PTSD patients are gradually exposed to sights and sounds that essentially simulate their trauma, to help them learn to cope, advisers to the government reported Thursday.
The lack of evidence for other therapies doesn't mean patients should give them up — they still should get whatever care their personal doctors deem most promising, stressed Thursday's report from the Institute of Medicine.
"The take-home message for patients should be that they seek care," said Dr. David Matchar of Duke University, who co-authored the report, which was requested by the Department of Veterans Affairs as it struggles with an influx of patients.
"That is the way medicine is practiced — we do the best we can with what we've got," Matchar added. But, "we need better."
While PTSD was first recognized in Vietnam veterans, war is far from its only trigger. Crime, accidents and other trauma can cause it in civilians, too. Sufferers experience nightmares, flashbacks and physical symptoms that make them feel as if they are reliving the trauma, even many years later.
"Not only veterans, but millions who have been exposed to trauma suffer from PTSD," noted Dr. Alfred Berg of the University of Washington, who chaired the Institute of Medicine panel. "Research on this disorder should be a high priority, and VA should take the lead to ensure that the specific needs of veterans are addressed adequately."
Today, PTSD is the most commonly diagnosed mental disorder among veterans returning from Iraq and Afghanistan, affecting an estimated 13 percent and 6 percent of them, respectively, the report found.
Delays in care for both mental and physical health problems plague many injured veterans, as the Pentagon and VA struggle with backlogs in processing disability benefits and in coordinating services. Ensuring prompt PTSD care was a key recommendation of a presidential panel appointed last summer to investigate those problems.
Thursday's report addresses a somewhat different issue: Once a patient arrives for treatment, what to offer? The VA asked the prestigious Institute of Medicine to review the scientific evidence for medications and psychological treatments — before the department updates its own treatment guidelines.
Exposure therapies already are offered in the VA system, and "we will redouble our efforts to ensure our mental health staff are trained to provide these effective psychotherapies," said Antonette Zeiss, a clinical psychologist who is deputy chief of VA's mental health services.
Other existing treatments will remain, too, she said, but VA officials planned to meet Thursday to begin planning new research to better prove their value.
"The other treatments have not definitely been shown to be effective. That's different from being shown to be ineffective," Zeiss cautioned. "They are some of the best clinical tools we have. But we should continue to try to understand them better, understand for whom they work."
Aside from exposure therapies, most of the research so far done on other treatments has been of poor quality, Berg said. Some studies had huge numbers of participants drop out, for example, meaning there's no way to know if they left in frustration or because they felt better. Many lumped together patients with varying degrees of PTSD, spurred by very different traumas, making it hard to tease out effects.
Few studies even have tracked patients for longer than six or 12 months to see if any treatment effects last, even though PTSD in many people lasts far longer.
"It's the poster child for difficult research," Matchar said.
Aside from which treatments truly work, the report raised a list of additional concerns:
_It's not clear if veterans and civilians need different types of therapy.
_Depression and other co-existing problems may complicate treatment.
_It's not clear if treatment works best soon after symptoms begin, or is equally effective later.

Study finds drug helps PTSD nightmares

SEATTLE -- A generic drug already used by millions of Americans for high blood pressure and prostate problems has been found to improve sleep and lessen trauma nightmares in veterans with posttraumatic stress disorder (PTSD).
"This is the first drug that has been demonstrated effective for PTSD nightmares and sleep disruption," said Murray A. Raskind, MD, executive director of the mental health service at the Veterans Affairs Puget Sound Health Care System and lead author of a study appearing April 15 in Biological Psychiatry.
The randomized trial of 40 veterans compared a nightly dose of prazosin (PRAISE-oh-sin) with placebo over eight weeks. Participants continued to take other prescribed medications over the course of the trial.
At the end of the study, veterans randomized to prazosin reported significantly improved sleep quality, reduced trauma nightmares, a better overall sense of well being, and an improved ability to function.
"These nighttime symptoms are heavily troublesome to veterans," said Raskind, who also is director of VA’s VISN 20 (Veterans Integrated Service Network #20) Mental Illness Research, Education and Clinical Centers program (MIRECC). "If you get the nighttime symptoms under control, veterans feel better all around."
http://www.eurekalert.org/pub_releases/2007-04/var-sfd041107.php