Treatments for PTSD: Understanding the Evidence

S Psychotherapy Bryant, R.A., Moulds, M.L., Guthrie, R.M., Dang, S.T., & Nixon, R.D.V. (2003). Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 71, 706-712. 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 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. Cloitre, M., Koenen, K.C., Cohen, L.R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70, 1067-1074. Fifty-eight women with PTSD related to childhood abuse were randomly assigned to a 2-phase cognitivebehavioral 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 3and 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. Ehlers, A., Clark, D.M., Hackmann, A., McManus, F., & Fennell, M.J.V. (2005). Cognitive therapy for post-traumatic stress disorder: Development and evaluation. Behaviour Research and Therapy, 43, 413-431. The paper describes the development of a cognitive therapy (CT) program for PTSD that is based on a recent cognitive model. In a consecutive case series, 20 PTSD patients treated with CT showed highly significant improvement in symptoms of PTSD, depression and anxiety. A subsequent randomized controlled trial compared CT (N = 14) and a 3-month waitlist condition (WL, N = 14). CT led to large reductions in PTSD symptoms, disability, depression and anxiety, whereas the waitlist group did not improve. In both studies, treatment gains were well maintained at 6-month follow-up. CT was highly acceptable, with an overall dropout rate of only 3%. The intent-to-treat effect sizes for the degree of change in PTSD symptoms from pre-to post­ treatment were 2.70–2.82 (self-report), and 2.07 (assessor-rated). The controlled effect sizes for CT versus WL post-treatment scores were 2.25 (self-report) and 2.18 (assessor-rated). As predicted by the cognitive model, good treatment outcome was related to greater changes in dysfunctional post-traumatic cognitions. Patient characteristics such as comorbidity, type of trauma, history of previous trauma, or time since the traumatic event did not predict treatment response; however, low educational attainment and low socioeconomic status were related to better outcome. Foa, E.B., Hembree, E.A., Cahill, S.P., Rauch, S.A.M., Riggs, D.S., Feeny, N.C., & Yadin, E. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinics. Journal of Consulting and Clinical Psychology, 73, 953-964. Female assault survivors (N = 171) with chronic 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. Litz, B.T., Engel, C.C., Bryant, R.A., & Papa, A. (2007). A randomized, controlled proof-of-concept trial of an internetbased, therapist-assisted self-management treatment for posttraumatic stress disorder. American Journal of Psychiatry, 164, 1676-1683. Objective: The authors report an 8-week randomized, controlled proof-of-concept trial of a new therapistassisted, Internet-based, self-management cognitive behavior therapy versus Internet-based supportive counseling for PTSD. Method: Service members with PTSD from the attack on the Pentagon on September 11th or the Iraq War were randomly