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.