A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder

Previous studies have reported that adding cognitive restructuring (CR) to exposure therapy does not enhance treatment gains in posttraumatic stress disorder (PTSD). This study investigated the extent to which CR would augment treatment response when provided with exposure therapy. The authors randomly allocated 118 civilian trauma survivors with PTSD to receive 8 individually administered sessions of either (a) imaginal exposure (IE), (b) in vivo exposure (IVE), (c) IE combined with IVE (IE/IVE), or (d) IE/IVE combined with CR (IE/IVE/CR). There were fewer patients with PTSD in the IE/IVE/CR (31%) condition than the IE (75%), IVE (69%), and IE/IVE (63%) conditions at a 6-month follow-up assessment. The IE/IVE/CR condition resulted in larger effect sizes than each of the other conditions in terms of PTSD and depressive symptoms. These findings suggest that optimal treatment outcome may be achieved by combining CR with exposure therapy in treating PTSD patients.     

Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder

This study investigated the extent to which providing cognitive restructuring (CR) with prolonged imaginal exposure (IE) would lead to greater symptom reduction than providing IE alone for participants with posttraumatic stress disorder (PTSD). Fifty-eight civilian survivors of trauma with PTSD were randomly allocated to IE/CR, IE, or supportive counseling (SC). Treatment involved 8 individual weekly sessions with considerable homework. Independent assessments were conducted pretreatment, posttreatment, and at 6-month follow-up. IE/CR and IE resulted in reduced PTSD and depression compared with SC at posttreatment and follow-up. Further, IE/CR participants had greater reductions in PTSD and maladaptive cognitive styles than IE participants at follow-up. These findings suggest that providing CR in combination with IE may enhance treatment gains.     

Beliefs, sense of control and treatment outcome in post-traumatic stress disorder

BACKGROUND. Few studies have shown that maladaptive beliefs relate to treatment outcome. METHOD: In a randomized controlled study, 87 patients with post-traumatic stress disorder (PTSD) had exposure therapy alone or cognitive restructuring alone, or both combined, or relaxation. Independent blind assessors assessed patients at pre-, mid- and post-treatment and at follow-up; at those times patients rated cognitive, behavioural and emotional aspects of their disorder. RESULTS: Baseline beliefs about mistrust, helplessness, meaninglessness and unjustness of the world related to baseline PTSD symptoms but did not predict treatment outcome, though improvement in certain beliefs correlated with more symptom improvement. Several 'key' beliefs changed after, and none before, symptoms improved. At post-treatment, sense of control and attribution of gains to personal efforts predicted maintenance of gains at follow-up. CONCLUSIONS: Baseline beliefs and improvement in beliefs did not predict outcome. Post-treatment sense of control/internal attribution predicted maintenance of gains at follow-up. How much sense of control is produced by or causes improvement deserves testing.     

Amygdala and ventral anterior cingulate activation predicts treatment response to cognitive behaviour therapy for post-traumatic stress disorder

BACKGROUND: Although cognitive behaviour therapy (CBT) is the treatment of choice for post-traumatic stress disorder (PTSD), approximately half of patients do not respond to CBT. No studies have investigated the capacity for neural responses during fear processing to predict treatment response in PTSD.METHOD: Functional magnetic resonance imaging (fMRI) responses of the brain were examined in individuals with PTSD (n=14). fMRI was examined in response to fearful and neutral facial expressions presented rapidly in a backwards masking paradigm adapted for a 1.5 T scanner. Patients then received eight sessions of CBT that comprised education, imaginal and in vivo exposure, and cognitive therapy. Treatment response was assessed 6 months after therapy completion. RESULTS: Seven patients were treatment responders (defined as a reduction of 50% of pretreatment scores) and seven were non-responders. Poor improvement after treatment was associated with greater bilateral amygdala and ventral anterior cingulate activation in response to masked fearful faces. CONCLUSIONS: Excessive fear responses in response to fear-eliciting stimuli may be a key factor in limiting responses to CBT for PTSD. This excessive amygdala response to fear may reflect difficulty in managing anxiety reactions elicited during CBT, and this factor may limit optimal response to therapy.     

Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial

A new cognitive therapy (CT) program was compared with an established behavioral treatment. Sixty-two patients meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for social phobia were randomly assigned to CT, exposure plus applied relaxation (EXP = AR), or wait-list (WAIT). CT and EXP = AR were superior to WAIT on all measures. On measures of social phobia, CT led to greater improvement than did EXP = AR. Percentages of patients who no longer met diagnostic criteria for social phobia at posttreatment-wait were as follows: 84% in CT, 42% in EXP = AR, and 0% in WAIT. At the 1-year follow-up, differences in outcome persisted. In addition, patients in EXP = AR were more likely to have sought additional treatment. Therapist effects were small and nonsignificant. CT appears to be superior to EXP = AR in the treatment of social phobia.     

Cognitive processing therapy for sexual assault victims.

Cognitive processing therapy (CPT) was developed to treat the symptoms of posttraumatic stress disorder (PTSD) in rape victims. CPT is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Nineteen sexual assault survivors received CPT, which consists of 12 weekly sessions in a group format. They were assessed at pretreatment, posttreatment, and 3- and 6-month follow-up. CPT subjects were compared with a 20-subject comparison sample, drawn from the same pool who waited for group therapy for at least 12 weeks. CPT subjects improved significantly from pre- to posttreatment on both PTSD and depression measures and maintained their improvement for 6 months. The comparison sample did not change from the pre- to the posttreatment assessment sessions.     

A controlled comparison of eye movement desensitization and reprocessing versus exposure plus cognitive restructuring versus waiting list in the treatment of post‐traumatic stress disorder

A total of 105 patients with post‐traumatic stress disorder (PTSD) were randomly allocated to eye‐movement desensitization and reprocessing (EMDR) (n = 39) versus exposure plus cognitive restructuring (E + CR) (n = 37) versus waiting list (WL) (n = 29) in a primary care setting. EMDR and E + CR patients received a maximum of 10 treatment sessions over a 10‐week period. All patients were assessed by blind raters prior to randomization and at end of the 10‐week treatment or waiting list period. EMDR and E + CR patients were also assessed by therapists at the mid‐point of the 10‐week treatment period and on average at 15 months follow‐up. Patients were assessed on a variety of assessor‐rated and self‐report measures of PTSD symptomatology including the Clinician Administered PTSD Scale (CAPS), the Impact of Events Scale (IOE) and a self‐report version of the SI‐PTSD Checklist. Measures of anxiety and depression included the Montgomery Asberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAM‐A) and the Hospital Anxiety and Depression Scale (HADS). A measure of social function, the Sheehan Disability Scale was also used. Drop‐out rates between the three groups were 12 EMDR, 16 E + CR and five WL. Treatment end‐point analyses were conducted on the remaining 72 patients. Repeated measures analysis of variance of treatment outcome at 10 weeks revealed significant time, interaction and group effects for all the above measures. In general there were significant and substantial pre–post reductions for EMDR and E + CR groups but no change for the WL patients. Both treatments were effective over WL. The only indication of superiority of either active treatment, in relation to measures of clinically significant change, was a greater reduction in patient self‐reported depression ratings and improved social functioning for EMDR in comparison to E + CR at the end of the treatment period and for fewer number of treatment sessions for EMDR (mean 4.2) than E + CR (mean 6.4) patients. At 15 months follow‐up treatment gains were generally well‐maintained with the only difference, in favour of EMDR over E + CR, occurring in relation to assessor‐rated levels of clinically significant change in depression. However, exclusion of patients who had subsequent treatment during the follow‐up period diminished the proportion of patients achieving long‐term clinically significant change. In summary, at end of treatment and at follow‐up, both EMDR and E + CR are effective in the treatment of PTSD with only a slight advantage in favour of EMDR. Copyright © 2002 John Wiley & Sons, Ltd.     

A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator

BACKGROUND: Brief interventions are needed in dealing with traumatic stress problems in large survivor populations after devastating earthquakes. The present study examined the effectiveness of a single session of exposure to simulated tremors in an earthquake simulator and self-exposure instructions in reducing post-traumatic stress disorder (PTSD). METHOD: Participants were consecutively recruited from among survivors screened during field surveys in the disaster region in Turkey. Thirty-one earthquake survivors with PTSD were assigned either to a single session of behavioural treatment (n=16) or to repeated assessments (RA; n=15). Assessments in the treatment group were at 4, 8, 12, 24 weeks and 1-2 years post-treatment. The RA cases were assessed at baseline and 4 and 8 weeks after trial entry, after which they received the same treatment and were followed up at 4, 12, 24 weeks and 1-2 years. RESULTS: Between-group treatment effects at week 8 were significant on measures of fear, PTSD and self- and assessor-rated global improvement. Improvement rates were 40% at week 4, 72% at week 12, 80% at week 24, and 80% at 1-2-years' follow-up, with large effect sizes on fear and PTSD measures. Post-session reduction in fear of earthquakes and increased sense of control over fear at follow-up related to improvement in PTSD. CONCLUSION: The study provided further evidence of the effectiveness of a single session of behavioural treatment in reducing fear and PTSD in earthquake survivors. Future research needs to examine the usefulness of earthquake simulators in increasing psychological preparedness for earthquakes.     

Therapist and patient perceptions of alliance and progress in psychological therapy for women diagnosed with gynecological cancers

Objective: The goal was to understand both therapist and patient perspectives on alliance and session progress for women in treatment for gynecological cancer. We used a longitudinal version of the one-with-many design to partition variation in alliance and progress ratings into therapist, patient/dyad, and time-specific components. We also evaluated therapist and patient characteristics that predict alliance and session progress. Method: Two hundred and three women and their therapists completed measures of alliance and session progress across a 6-session course of treatment. Participants also completed preintervention measures of self-esteem, depression, cancer-specific distress, emotional expressivity, and use of protective buffering. Results: Patients reported higher alliance and greater progress than did therapists. When therapists reported particularly strong alliance with particular patients, those patients concurred. More experienced therapists reported higher alliances and more progress but their patients did not agree. Patients who began treatment in more difficult psychosocial circumstances tended to have less positive session outcomes on average but evidenced more improvement across therapy sessions. Conclusions: Patients rated their alliance and progress more positively than did their therapists, although there was substantial relative agreement between therapists and patients. Alliance and progress improved over time, particularly among patients who evidenced higher levels of distress and poorer physical functioning. More experienced therapists were more confident in their abilities but their patients did not share this perception. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A meta-analytic review of prolonged exposure for posttraumatic stress disorder

Two decades of research demonstrate the efficacy of exposure therapy for posttraumatic stress disorder (PTSD). The efficacy of prolonged exposure (PE), a specific exposure therapy program for PTSD that has been disseminated throughout the world, has been established in many controlled studies using different trauma populations. However, a meta-analysis of the effectiveness of PE for PTSD has not been conducted to date. The purpose of the current paper is to estimate the overall efficacy of PE for PTSD relative to adequate controls. We included all published randomized controlled trials of PE vs. control (wait-list or psychological placebo) for the treatment of PTSD in adolescents or adults. Treatments were classified as PE if they included multiple sessions of imaginal and in vivo exposure and were based on the manualized treatment developed by Foa, Rothbaum, Riggs, and Murdock (1991). Thirteen studies with a total sample size of 675 participants met the final inclusion criteria. The primary analyses showed a large effect for PE versus control on both primary (Hedges's g = 1.08) and secondary (Hedges's g = 0.77) outcome measures. Analyses also revealed medium to large effect sizes for PE at follow-up, both for primary (Hedges's g = 0.68) and secondary (Hedges's g = 0.41) outcome measures. There was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT). Effect sizes were not moderated by time since trauma, publication year, dose, study quality, or type of trauma. The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures. PE is a highly effective treatment for PTSD, resulting in substantial treatment gains that are maintained over time.     

A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an african refugee settlement

Little is known about the usefulness of psychotherapeutic approaches for traumatized refugees who continue to live in dangerous conditions. Narrative exposure therapy (NET) is a short-term approach based on cognitive-behavioral therapy and testimony therapy. The efficacy of narrative exposure therapy was evaluated in a randomized controlled trial. Sudanese refugees living in a Ugandan refugee settlement (N = 43) who were diagnosed as suffering from posttraumatic stress disorder (PTSD) either received 4 sessions of NET, 4 sessions of supportive counseling (SC), or psychoeducation (PE) completed in 1 session. One year after treatment, only 29% of the NET participants but 79% of the SC group and 80% of the PE group still fulfilled PTSD criteria. These results indicate that NET is a promising approach for the treatment of PTSD for refugees living in unsafe conditions.     

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.     

Short-term structured treatment for avoidant personality disorder

Forty-two men and 34 women (mean age 27.5 years) who met DSM-III criteria for avoidant personality disorder were randomly assigned to 1 of 3 treatment conditions or to a waiting-list control group. Treatment Ss who participated in a 10-week group treatment program displayed significantly greater improvement on a variety of self-report and behavioral measures than did untreated control subjects. The inclusion of skills-training procedures did not contribute to the effects of graduated exposure procedures alone. The gains made during treatment were maintained over the follow-up period, but few further improvements were made. Clinical significance was evaluated by both the subjective evaluation method and the social comparison method. These procedures indicated that although significant improvements had been made, these avoidant Ss were not functioning at the level of normative comparison samples at treatment termination.     

Brief group therapy in myocardial infarction rehabilitation: three- to four-year follow-up of a controlled trial.

A trial of brief group therapy as part of a rehabilitation program for postmyocardial infarction (MI) patients was carried out. Forty-four patients surviving their first MI were randomly allocated to either group therapy or control group status and were followed over 4 years. An additional group of 17 patients were referred for post-MI group therapy sessions after the termination of the controlled experiment and were followed for 3 years. Patients who received group therapy had significantly less follow-up coronary morbidity and mortality, and returned to work at significant higher percentages than control patients. Although neither group therapy nor control group patients meaningfully altered conventional coronary risk factors, group therapy patients (in the controlled trial) successfully altered selected coronary-prone behaviors. Educational information regarding the physiological and psychological aspects of coronary heart disease, presented in the group therapy sessions, was forgotten over follow-up. It is concluded that the supportive aspects of the group therapy experience played the most important role in determining the rehabilitation advantages seen for treatment patients.     

Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling

Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.     

Two-year follow-up of cognitive--behavioral therapy and supportive counseling in the treatment of persistent symptoms in chronic schizophrenia

The article reports the 2-year follow-up of patients suffering persistent symptoms of schizophrenia who entered a single blind randomized controlled trial. Patients were randomly allocated to cognitive-behavioral therapy (CBT) plus routine care (RC), supportive counseling (SC) plus RC, or RC alone. Treatment took place over 3 months, and follow-up was made 12 and 24 months after treatment finished. Sixty-one patients were available to the 2-year follow-up and assessed for positive and negative symptoms and clinical improvement; all of the 87 patients who entered the trial were assessed for relapse over the follow-up period. On all measures, patients who received RC alone did significantly worse at 2 years. There were no significant differences at 2 years between the CBT and SC groups.     

Treatment of PTSD: stress inoculation training with prolonged exposure compared to EMDR

The effectiveness of Stress Inoculation Training with Prolonged Exposure (SITPE) was compared to Eye Movement Desensitization and Reprocessing (EMDR). Twenty-four participants who had a diagnosis of Post Traumatic Stress Disorder (PTSD) were randomly assigned to one of the treatment conditions. Participants were also their own wait-list control. Outcome measures included self-report and observer-rated measures of PTSD, and self-report measures of depression. On global PTSD measures, there were no significant differences between the treatments at the end of therapy. However on the subscale measures of the degree of intrusion symptoms, EMDR did significantly better than SITPE. At follow-up EMDR was found to lead to greater gains on all measures.     

The emerging evidence for Narrative Exposure Therapy: A review

Individuals who have experienced multiple traumatic events over long periods as a result of war, conflict and organised violence, may represent a unique group amongst PTSD patients in terms of psychological and neurobiological sequelae. Narrative Exposure Therapy (NET) is a short-term therapy for individuals who have PTSD symptoms as a result of these types of traumatic experiences. Originally developed for use in low-income countries, it has since been used to treat asylum seekers and refugees in high-income settings. The treatment involves emotional exposure to the memories of traumatic events and the reorganisation of these memories into a coherent chronological narrative. This review of all the currently available literature investigates the effectiveness of NET in treatment trials of adults and also of KIDNET, an adapted version for children. Results from treatment trials in adults have demonstrated the superiority of NET in reducing PTSD symptoms compared with other therapeutic approaches. Most trials demonstrated that further improvements had been made at follow-up suggesting sustained change. Treatment trials of KIDNET have shown its effectiveness in reducing PTSD amongst children. Emerging evidence suggests that NET is an effective treatment for PTSD in individuals who have been traumatised by conflict and organised violence, even in settings that remain volatile and insecure.     

A naturalistic study of a brief treatment program for survivors of complex trauma

The impact of chronic trauma can be longstanding, affecting survivor affect regulation, consciousness, interpersonal functioning, perceptions of self and others, self-regulation, and somatic experience. There is a growing consensus that multimodal and staged approaches to treatment are necessary to promote healing. However, empirical investigations of such treatments are still needed. The current study used a naturalistic design to examine the impact of a brief, yet intensive, outpatient program on complex PTSD symptoms and attachment classification among women with histories of chronic trauma. Fifty-four women were assessed and followed over an 8-week intervention and six-month follow-up. Significant improvement over time was found for PTSD symptoms, dissociation, emotion regulation, interpersonal problems, sexual problems, alexithymia, and posttraumatic growth. Nearly, all women met criteria for PTSD at baseline, a third of the women who completed the measures no longer had PTSD post-treatment, and 60% showed a clinically significant reduction in PTSD symptoms. Finally, thirty-six women were classified as unresolved on the Adult Attachment Projective. Post-treatment, nine of 26 women who provided follow-up data were no longer classified as unresolved. Notably, those women whose attachment category changed also showed the greatest improvement in all other outcomes. Altogether, these findings suggest that an intensive, stage 1, and multimodal treatment program can benefit women with histories of chronic traumatization.     

Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse

Fifty-eight women with posttraumatic stress disorder (PTSD) related to childhood abuse were randomly assigned to a 2-phase cognitive-behavioral treatment or a minimal attention wait list. Phase 1 of treatment included 8 weekly sessions of skills training in affect and interpersonal regulation; Phase 2 included 8 sessions of modified prolonged exposure. Compared with those on wait list, participants in active treatment showed significant improvement in affect regulation problems, interpersonal skills deficits, and PTSD symptoms. Gains were maintained at 3- and 9-month follow-up. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the value of establishing a strong therapeutic relationship and emotion regulation skills before exposure work among chronic PTSD populations.