Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling

Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment

Posttraumatic stress disorder (PTSD) is a chronic psychological disorder that can develop after exposure to a traumatic event. This review summarizes the literature on the epidemiology, assessment, and treatment of PTSD. We provide a review of the characteristics of PTSD along with associated risk factors, and describe brief, evidence-based measures that can be used to screen for PTSD and monitor symptom changes over time. In regard to treatment, we highlight commonly used, evidence-based psychotherapies and pharmacotherapies for PTSD. Among psychotherapeutic approaches, evidence-based approaches include cognitive-behavioral therapies (e.g., Prolonged Exposure and Cognitive Processing Therapy) and Eye Movement Desensitization and Reprocessing. A wide variety of pharmacotherapies have received some level of research support for PTSD symptom alleviation, although selective serotonin reuptake inhibitors have the largest evidence base to date. However, relapse may occur after the discontinuation of pharmacotherapy, whereas PTSD symptoms typically remain stable or continue to improve after completion of evidence-based psychotherapy. After reviewing treatment recommendations, we conclude by describing critical areas for future research.

Does Early Psychological Intervention Promote Recovery From Posttraumatic Stress?

In the wake of the terrorist attacks at the World Trade Center, more than 9,000 counselors went to New York City to offer aid to rescue workers, families, and direct victims of the violence of September 11, 2001. These mental health professionals assumed that many New Yorkers were at high risk for developing posttraumatic stress disorder (PTSD), and they hoped that their interventions would mitigate psychological distress and prevent the emergence of this syndrome. Typically developing in response to horrific, life-threatening events, such as combat, rape, and earthquakes, PTSD is characterized by reexperiencing symptoms (e.g., intrusive recollections of the trauma, nightmares), emotional numbing and avoidance of reminders of the trauma, and hyperarousal (e.g., exaggerated startle, difficulty sleeping). People vary widely in their vulnerability for developing PTSD in the wake of trauma. For example, higher cognitive ability and strong social support buffer people against PTSD, whereas a family or personal history of emotional disorder heightens risk, as does negative appraisal of one's stress reactions (e.g., as a sign of personal weakness) and dissociation during the trauma (e.g., feeling unreal or experiencing time slowing down). However, the vast majority of trauma survivors recover from initial posttrauma reactions without professional help. Accordingly, the efficacy of interventions designed to mitigate acute distress and prevent long-term psychopathology, such as PTSD, needs to be evaluated against the effects of natural recovery. The need for controlled evaluations of early interventions has only recently been widely acknowledged.

Psychological debriefing—the most widely used method—has undergone increasing empirical scrutiny, and the results have been disappointing. Although the majority of debriefed survivors describe the experience as helpful, there is no convincing evidence that debriefing reduces the incidence of PTSD, and some controlled studies suggest that it may impede natural recovery from trauma. Most studies show that individuals who receive debriefing fare no better than those who do not receive debriefing. Methodological limitations have complicated interpretation of the data, and an intense controversy has developed regarding how best to help people in the immediate wake of trauma.

Recent published recommendations suggest that individuals providing crisis intervention in the immediate aftermath of the event should carefully assess trauma survivors' needs and offer support as necessary, without forcing survivors to disclose their personal thoughts and feelings about the event. Providing information about the trauma and its consequences is also important. However, research evaluating the efficacy of such “psychological first aid” is needed.

Some researchers have developed early interventions to treat individuals who are already showing marked stress symptoms, and have tested methods of identifying those at risk for chronic PTSD. The single most important indicator of subsequent risk for chronic PTSD appears to be the severity or number of posttrauma symptoms from about 1 to 2 weeks after the event onward (provided that the event is over and that there is no ongoing threat).

Cognitive-behavioral treatments differ from crisis intervention (e.g., debriefing) in that they are delivered weeks or months after the trauma, and therefore constitute a form of psychotherapy, not immediate emotional first aid. Several controlled trials suggest that certain cognitive-behavioral therapy methods may reduce the incidence of PTSD among people exposed to traumatic events. These methods are more effective than either supportive counseling or no intervention.

In this monograph, we review risk factors for PTSD, research on psychological debriefing, recent recommendations for crisis intervention and the identification of individuals at risk of chronic PTSD, and research on early interventions based on cognitive-behavioral therapy. We close by placing the controversy regarding early aid for trauma survivors in its social, political, and economic context.

Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions

Post-traumatic stress disorder (PTSD) is a frequent, tenacious, and disabling consequence of traumatic events. The disorder's identifiable onset and early symptoms provide opportunities for early detection and prevention. Empirical findings and theoretical models have outlined specific risk factors and pathogenic processes leading to PTSD. Controlled studies have shown that theory-driven preventive interventions, such as cognitive behavioral therapy (CBT), or stress hormone-targeted pharmacological interventions, are efficacious in selected samples of survivors. However, the effectiveness of early clinical interventions remains unknown, and results obtained in aggregates (large groups) overlook individual heterogeneity in PTSD pathogenesis. We review current evidence of PTSD prevention and outline the need to improve the disorder's early detection and intervention in individual-specific paths to chronic PTSD.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress: Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

Primary prevention of anxiety disorders in primary care: A systematic review

OBJECTIVE

Anxiety disorders are the most prevalent psychiatric disorders in primary care and have significant social, economic, and interpersonal costs. Primary care is an ideal setting to prevent the appearance of anxiety disorders. The aim of this study was to evaluate the efficacy and cost-effectiveness of primary prevention interventions in anxiety disorders in the adult population receiving primary health care.

METHODS

A literature search was carried out in four databases-PubMed, PsycInfo, Cochrane, and Web of Science-from January 1980 to November 2013. Clinical trials and systematic reviews published in English and non-English languages and that evaluated the efficacy and/or cost-effectiveness of interventions of primary prevention for anxiety in primary care in the general adult population were included. Risk of bias was assessed by the Cochrane Risk Bias Tool and Overview Quality Assessment Questionnaire.

RESULTS

No high-quality research was identified that studied primary prevention of anxiety disorders in the adult population in the primary care setting. The few studies that exist focus on the child-adolescent population or on other types of interventions, usually as secondary prevention.

CONCLUSION

This study emphasizes the need for the development of high-quality clinical trials on the prevention of anxiety disorders in primary care.

Disaster Management: Mental Health Perspective

Disaster mental health is based on the principles of 'preventive medicine' This principle has necessitated a paradigm shift from relief centered post-disaster management to a holistic, multi-dimensional integrated community approach of health promotion, disaster prevention, preparedness and mitigation. This has ignited the paradigm shift from curative to preventive aspects of disaster management. This can be understood on the basis of six 'R's such as Readiness (Preparedness), Response (Immediate action), Relief (Sustained rescue work), Rehabilitation (Long term remedial measures using community resources), Recovery (Returning to normalcy) and Resilience (Fostering). Prevalence of mental health problems in disaster affected population is found to be higher by two to three times than that of the general population. Along with the diagnosable mental disorders, affected community also harbours large number of sub-syndromal symptoms. Majority of the acute phase reactions and disorders are self-limiting, whereas long-term phase disorders require assistance from mental health professionals. Role of psychotropic medication is very limited in preventing mental health morbidity. The role of cognitive behaviour therapy (CBT) in mitigating the mental health morbidity appears to be promising. Role of Psychological First Aid (PFA) and debriefing is not well-established. Disaster management is a continuous and integrated cyclical process of planning, organising, coordinating and implementing measures to prevent and to manage disaster effectively. Thus, now it is time to integrate public health principles into disaster mental health.

Relationship Between Low Back Pain With Quality of Life, Depression, Anxiety and Stress Among Emergency Medical Technicians

Background:

Musculoskeletal disorders have become increasingly common among healthcare providers. They have become the most common cause of work-related disabilities among nurses.

Objectives:

The current cross-sectional study aimed to measure the prevalence of back pains among emergency medical technicians (EMTs), and association of back pain with quality of life, depression, anxiety and stress.

Materials and Methods:

One hundred and eighty registered nurses working as EMTs at the Hamadan Emergency Medical Center were selected by consensus. Data collection tools were Demographic, Perceived Quality-of-Life, Short Form Health Survey (SF-36), and Depression Anxiety Stress Scales (DAS21) and pain scale measurements.

Results:

Data showed that while 50.7% of the participants had an average awareness of the basic principles of back care, the majority (71.8%) had at least one type of back pain. There were associations between the prevalence of pain and depression (P = 0.049), pain and awareness (P = 0.035), and stress and job satisfaction (P = 0.024).

Conclusions:

A large number (about two-thirds) of EMTs had some sort of back pain; it is highly recommended to promote the attitude and motivation of the individuals to take care to prevent back injury and inform them of the principles of back care. Implications for primary prevention and care practice include encouraging EMTs to apply accurate principles of back care.

Psychiatry department response to the Boston Marathon bombings within a level-1 trauma center

In this article we present how the consultation-liaison and psychology divisions of an academic medical center's Department of Psychiatry responded in the first week after the Boston Marathon bombings, specifically in the context of disaster response guidelines and evidence-based approaches to acute trauma. Since the department had to address several complicated matters at multiple levels within the hospital system, we highlight unexpected issues unique to this particular event as they arose within the primary domains of our involvement. This article aims to (1) provide a descriptive analysis of how we enacted disaster and trauma guidelines and evidence-based care within a hospital setting, (2) shed light on the unique and unexpected administrative and systemic issues encountered in our response, and (3) discuss lessons learned, including opportunities to improve trauma-related care.

Psychophysiological response to virtual reality and subthreshold posttraumatic stress disorder symptoms in recently deployed military

OBJECTIVE

Subthreshold posttraumatic stress disorder (PTSD) has garnered recent attention because of the significant distress and functional impairment associated with the symptoms as well as the increased risk of progression to full PTSD. However, the clinical presentation of subthreshold PTSD can vary widely and therefore is not clearly defined, nor is there an evidence-based treatment approach. Thus, we aim to further the understanding of subthreshold PTSD symptoms by reporting the use of a virtual combat environment in eliciting distinctive psychophysiological responses associated with PTSD symptoms in a sample of subthreshold recently deployed US service members.

METHODS

Heart rate, skin conductance, electromyography (startle), respiratory rate, and blood pressure were monitored during three unique combat-related virtual reality scenarios as a novel procedure to assess subthreshold symptoms in a sample of 78 service members. The Clinician-Administered PTSD Scale was administered, and linear regression analyses were used to investigate the relationship between symptom clusters and physiological variables.

RESULTS

Among the range of psychophysiological measures that were studied, regression analysis revealed heart rate as most strongly associated with Clinician-Administered PTSD Scale-based measures hyperarousal (R = 0.11, p = .035,) reexperiencing (R = 0.24, p = .001), and global PTSD symptoms (R = 0.17, p = .003).

CONCLUSIONS

Our findings support the use of a virtual reality environment in eliciting physiological responses associated with subthreshold PTSD symptoms.

Implementing cognitive behavioral therapy in specialty medical settings

This article is an introduction to the second issue of a two-part Special Series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.

Adapting narrative exposure therapy for Chinese earthquake survivors: a pilot randomised controlled feasibility study

BACKGROUND

Narrative exposure therapy (NET) is a brief, manualised treatment for Posttraumatic Stress Disorder (PTSD). It has been shown to have therapeutic benefits for a wide range of individuals and settings. This study, following our previous work applying the original NET in earthquake survivors, aimed to revise NET to be adaptable for treating PTSD after a natural disaster.

METHODS

A randomised waiting-list controlled study was conducted with 30 adult participants with PTSD who were randomly allocated to NET (n = 10), revised NET (NET-R; n = 10) or a waiting list condition (WL; n = 10). Participants in NET and NET-R received treatment immediately; those in the WL condition received NET-R treatment after a waiting period. All groups were assessed on PTSD, general distress, anxiety, depression, social support, coping and posttraumatic change before and after treatment and three-month follow-up.

RESULTS

Compared with WL, both NET and NET-R groups showed significant reductions in PTSD and related symptoms. Significant increases were found in posttraumatic growth, active coping and perceived social support. The WL group showed similar improvements after treatment. Further reductions on PTSD symptoms were found at three months, showing that NET-R is as effective as the original NET in treating post-earthquake traumatic symptoms in adult Chinese earthquake survivors.

CONCLUSIONS

NET-R is a feasible and cost-effective intervention for Chinese earthquake survivors. Further studies are needed to replicate these findings in other survivor populations, and with larger samples and over longer periods. This study highlighted the value of oral narrative approach, which is well-accepted and useful in the context of single natural disaster and lower- income area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-12002931.

The effectiveness of cognitive remediation therapy in patients with a severe or enduring eating disorder: a randomized controlled trial

BACKGROUND

Individuals with eating disorders show deficits in neuropsychological functioning which might preexist and underlie the etiology of the eating disorders and influence relapse. Deficits in cognitive flexibility, i.e., set-shifting and central coherence, might perpetuate the symptoms. Cognitive remediation therapy (CRT) was developed to improve cognitive flexibility, thereby increasing the likelihood of improved outcome. The focus of CRT is on how patients think, rather than on what patients think. The present study investigated the effectiveness of CRT for patients with a severe or enduring eating disorder by means of a randomized controlled trial comparing intensive treatment as usual (TAU) to CRT plus TAU.

METHODS

Eighty-two patients were randomly assigned to CRT plus TAU (n = 41) or TAU alone (n = 41). Outcome measures were set-shifting, central coherence, eating disorder and general psychopathology, motivation, quality of life and self-esteem. Assessments were performed at baseline (n = 82) and after 6 weeks (T1; n = 75) and 6 months (T2; n = 67). Data were analyzed by means of linear mixed model analyses.

RESULTS

Patients who received CRT in addition to TAU improved significantly more with regard to eating disorder-related quality of life at the end of treatment (T1) and eating disorder psychopathology at follow-up (T2), compared to those who received TAU only. Moreover, moderator analyses revealed that patients with poor baseline set-shifting abilities benefited more from CRT than patients with no deficits in set-shifting abilities at baseline; the quality of life of the former group was higher than that of the latter at follow-up.

CONCLUSIONS

CRT seems to be promising in enhancing the effectiveness of concurrent treatment.

Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling

Post-traumatic stress disorder (PTSD) is of great interest to public health, due to the high burden it places on both the individual and society. We meta-analyzed randomized-controlled trials to examine the effectiveness of early trauma-focused cognitive-behavioral treatment (TFCBT) for preventing chronic PTSD. Systematic bibliographic research was undertaken to find relevant literature from on-line databases (Pubmed, PsycINFO, Psyndex, Medline). Using a mixed-effect approach, we calculated effect sizes (ES) for the PTSD diagnoses (main outcome) as well as PTSD and depressive symptoms (secondary outcomes), respectively. Calculations of ES from pre-intervention to first follow-up assessment were based on 10 studies. A moderate effect (ES = 0.54) was found for the main outcome, whereas ES for secondary outcomes were predominantly small (ES = 0.27-0.45). The ES for the main outcome decreased to small (ES = 0.34) from first follow-up to long-term follow-up assessment. The mean dropout rate was 16.7% pre- to post-treatment. There was evidence for the impact of moderators on different outcomes (e.g., the number of sessions on PTSD symptoms). Future studies should include survivors of other trauma types (e.g., burn injuries) rather than predominantly survivors of accidents and physical assault, and should compare early TFCBT with other interventions that previously demonstrated effectiveness.

The development of a population-based automated screening procedure for PTSD in acutely injured hospitalized trauma survivors

OBJECTIVE

This investigation aimed to advance posttraumatic stress disorder (PTSD) risk prediction among hospitalized injury survivors by developing a population-based automated screening tool derived from data elements available in the electronic medical record (EMR).

METHOD

Potential EMR-derived PTSD risk factors with the greatest predictive utilities were identified for 878 randomly selected injured trauma survivors. Risk factors were assessed using logistic regression, sensitivity, specificity, predictive values and receiver operator characteristic (ROC) curve analyses.

RESULTS

Ten EMR data elements contributed to the optimal PTSD risk prediction model including International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) PTSD diagnosis, other ICD-9-CM psychiatric diagnosis, other ICD-9-CM substance use diagnosis or positive blood alcohol on admission, tobacco use, female gender, non-White ethnicity, uninsured, public or veteran insurance status, E-code identified intentional injury, intensive care unit admission and EMR documentation of any prior trauma center visits. The 10-item automated screen demonstrated good area under the ROC curve (0.72), sensitivity (0.71) and specificity (0.66).

CONCLUSIONS

Automated EMR screening can be used to efficiently and accurately triage injury survivors at risk for the development of PTSD. Automated EMR procedures could be combined with stepped care protocols to optimize the sustainable implementation of PTSD screening and intervention at trauma centers nationwide.

The christchurch earthquake: crush injury, neuropathic pain, and posttraumatic stress disorder

On February 22, 2011, an earthquake of magnitude 6.3 struck Christchurch, New Zealand. The peak ground acceleration, a measure of the shaking or intensity of an earthquake, was one of the highest ever recorded worldwide. One hundred and eighty-five people lost their lives; many others were injured. Two cases both involving young women are presented; they sustained crush injuries to limbs after being trapped by falling debris and went on to develop severe neuropathic pain. This report examines the mechanisms of neuropathic pain in the setting of crush injury, the treatment modalities, and the association between chronic pain and posttraumatic stress disorder. These case reports highlight the fact that crush injury is relatively common during major earthquakes and that neuropathic pain is an important sequel of this. Post-traumatic stress disorder is common in earthquake survivors with a recognised association with chronic pain. Pain-related disability may increase as well. Issues such as chronic pain and physical disability should not be overlooked as attention focuses on disaster management and the treatment of life-threatening injuries.

Mild Transient Hypercapnia as a Novel Fear Conditioning Stimulus Allowing Re-Exposure during Sleep

Introduction

Studies suggest that sleep plays a role in traumatic memories and that treatment of sleep disorders may help alleviate symptoms of posttraumatic stress disorder. Fear-conditioning paradigms in rodents are used to investigate causal mechanisms of fear acquisition and the relationship between sleep and posttraumatic behaviors. We developed a novel conditioning stimulus (CS) that evoked fear and was subsequently used to study re-exposure to the CS during sleep.

Methods

Experiment 1 assessed physiological responses to a conditioned stimulus (mild transient hypercapnia, mtHC; 3.0% CO₂; n = 17)+footshock for the purpose of establishing a novel CS in male FVB/J mice. Responses to the novel CS were compared to tone+footshock (n = 18) and control groups of tone alone (n = 17) and mild transient hypercapnia alone (n = 10). A second proof of principle experiment re-exposed animals during sleep to mild transient hypercapnia or air (control) to study sleep processes related to the CS.

Results

Footshock elicited a response of acute tachycardia (30–40 bpm) and increased plasma epinephrine. When tone predicted footshock it elicited mild hypertension (1–2 mmHg) and a three-fold increase in plasma epinephrine. When mtHC predicted footshock it also induced mild hypertension, but additionally elicited a conditioned bradycardia and a smaller increase in plasma epinephrine. The overall mean 24 hour sleep–wake profile was unaffected immediately after fear conditioning.

Discussion

Our study demonstrates the efficacy of mtHC as a conditioning stimulus that is perceptible but innocuous (relative to tone) and applicable during sleep. This novel model will allow future studies to explore sleep-dependent mechanisms underlying maladaptive fear responses, as well as elucidate the moderators of the relationship between fear responses and sleep.

Benefits of immediate EMDR vs. eclectic therapy intervention for victims of physical violence and accidents at the workplace: a pilot study

This study focuses on 34 victims of aggression at the workplace, less than 48 hours following the incident of aggression. We compared victims who received an EMDR emergency protocol (URG-EMDR; n = 19) that we developed with those who received a method of intervention called eclectic therapy (n = 15). The results show that URG-EMDR therapy, provided within 48 hours, resulted in a greater decrease in perceived stress and a lower PCL-S score than eclectic therapy did. The scores were lower in both groups after 24 hours, and after 3 months, the drop was significantly greater among the victims treated with the URG-EMDR protocol; none of the EMDR-treated patients exhibited symptoms of posttraumatic stress.

Interventions to prevent post-traumatic stress disorder: a systematic review

CONTEXT

Traumatic events are prevalent worldwide; trauma victims seek help in numerous clinical and emergency settings. Using effective interventions to prevent post-traumatic stress disorder (PTSD) is increasingly important. This review assessed the efficacy, comparative effectiveness, and harms of psychological, pharmacologic, and emerging interventions to prevent PTSD.

EVIDENCE ACQUISITION

The following sources were searched for research on interventions to be included in the review: MEDLINE; Cochrane Library; CINAHL; EMBASE; PILOTS (Published International Literature on Traumatic Stress); International Pharmaceutical Abstracts; PsycINFO; Web of Science; reference lists of published literature; and unpublished literature (January 1, 1980 to July 30, 2012). Two reviewers independently selected studies, extracted data or checked accuracy, assessed study risk of bias, and graded strength of evidence. All data synthesis occurred between January and September 2012.

EVIDENCE SYNTHESIS

Nineteen studies covered various populations, traumas, and interventions. In meta-analyses of three trials (from the same team) for people with acute stress disorder, brief trauma-focused cognitive behavioral therapy was more effective than supportive counseling in reducing the severity of PTSD symptoms (moderate-strength); these two interventions had similar results for incidence of PTSD (low-strength); depression severity (low-strength); and anxiety severity (moderate-strength). PTSD symptom severity after injury decreased more with collaborative care than usual care (single study; low-strength). Debriefing did not reduce incidence or severity of PTSD or psychological symptoms in civilian traumas (low-strength). Evidence about relevant outcomes was unavailable for many interventions or was insufficient owing to methodologic shortcomings.

CONCLUSIONS

Evidence is very limited regarding best practices to treat trauma-exposed individuals. Brief cognitive behavioral therapy may reduce PTSD symptom severity in people with acute stress disorder; collaborative care may help decrease symptom severity post-injury.

Post-traumatic stress disorder: review of the Comprehensive Soldier Fitness program

Since the start of the wars in Afghanistan and Iraq, the U.S. military has implemented several population-based initiatives to enhance psychological resilience and prevent psychological morbidity in troops. The largest of these initiatives is the Army's Comprehensive Soldier Fitness (CSF) program, which has been disseminated to more than 1 million soldiers. However, to date, CSF has not been independently and objectively reviewed, and the degree to which it successfully promotes adaptive outcomes and prevents the development of deployment-related mental health disorders such as post-traumatic stress disorder (PTSD) is uncertain. This paper critically evaluates the theoretic foundation for and evidence supporting the use of CSF.

A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors

OBJECTIVE

To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury.

BACKGROUND

Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings.

METHODS

The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission.

RESULTS

Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01].

CONCLUSIONS

Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. (

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00270959).

EMDR Individual Protocol for Paraprofessional Use: A Randomized Controlled Trial With First Responders

The eye movement desensitization and reprocessing (EMDR) individual protocol for paraprofessional use in acute trauma situations (EMDR-PROPARA) is part of a project developed at the initiative of Dr. Francine Shapiro. This randomized clinical trial examined the effectiveness of the protocol administered by experienced EMDR therapists. There were 39 traumatized first responders on active duty randomly assigned to receive two 90-min sessions of either EMDR-PROPARA or of supportive counseling. Participants in the EMDR-PROPARA group showed benefits immediately after treatment, with their scores on the Short PTSD Rating Interview (SPRINT) showing further decreases at 3-month follow-up. In comparison, supportive counseling participants experienced a nonsignificant decrease after treatment and an increase in the SPRINT scores at the second follow-up. The significant difference between the two treatments provides preliminary support for EMDR-PROPARA’s effectiveness in reducing severity of posttraumatic symptoms and subjective global improvement. More controlled research is recommended to evaluate further the efficacy of this intervention.

Changes in facets of mindfulness and posttraumatic stress disorder treatment outcome

Though there has been a recent surge of interest in the relations between facets of mindfulness and Posttraumatic Stress Disorder (PTSD), there has been a dearth of empirical studies investigating the impact of changes in facets of mindfulness on PTSD treatment outcomes. The present study tested the prospective associations between pre- to post-treatment changes in facets of mindfulness and PTSD and depression severity at treatment discharge, among 48 military Veterans in residential PTSD treatment adhering to a cognitive-behavioral framework. Together, changes in facets of mindfulness significantly explained post-treatment PTSD and depression severity (19-24% of variance). Changes in acting with awareness explained unique variance in post-treatment PTSD severity and changes in nonjudgmental acceptance explained unique variance in post-treatment depression severity. These results remained significant after adjusting for shared variance with length of treatment stay.

Cognitive processing therapy versus supportive counseling for acute stress disorder following assault: a randomized pilot trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N=30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.

Early intervention may prevent the development of posttraumatic stress disorder: a randomized pilot civilian study with modified prolonged exposure

BACKGROUND

Posttraumatic stress disorder (PTSD) is a major public health concern with long-term sequelae. There are no accepted interventions delivered in the immediate aftermath of trauma. This study tested an early intervention aimed at modifying the memory to prevent the development of PTSD before memory consolidation.

METHODS

Patients (n = 137) were randomly assigned to receive three sessions of an early intervention beginning in the emergency department compared with an assessment only control group. Posttraumatic stress reactions (PTSR) were assessed at 4 and 12 weeks postinjury and depression at baseline and week 4. The intervention consisted of modified prolonged exposure including imaginal exposure to the trauma memory, processing of traumatic material, and in vivo and imaginal exposure homework.

RESULTS

Patients were assessed an average of 11.79 hours posttrauma. Intervention participants reported significantly lower PTSR than the assessment group at 4 weeks postinjury, p < .01, and at 12 weeks postinjury, p < .05, and significantly lower depressive symptoms at week 4 than the assessment group, p < .05. In a subgroup analysis, the intervention was the most effective at reducing PTSD in rape victims at week 4 (p = .004) and week 12 (p = .05).

CONCLUSIONS

These findings suggest that the modified prolonged exposure intervention initiated within hours of the trauma in the emergency department is successful at reducing PTSR and depression symptoms 1 and 3 months after trauma exposure and is safe and feasible. This is the first behavioral intervention delivered immediately posttrauma that has been shown to be effective at reducing PTSR.

A pilot randomized controlled trial of a brief early intervention for reducing posttraumatic stress disorder, anxiety and depressive symptoms in newly diagnosed head and neck cancer patients

OBJECTIVE

Head and neck cancer (HNC) patients have a high incidence of cancer-related posttraumatic stress disorder (PTSD) and other anxiety and depressive disorders. We report the results from the first pilot randomized controlled trial in which the efficacy of an early cognitive-behavioral therapy (CBT) program was compared with a non-directive supportive counseling (SC) intervention in reducing PTSD, general anxiety and depressive symptoms, and improving perceived quality of life in newly diagnosed, distressed HNC patients undergoing radiotherapy.

PATIENTS AND METHODS

Thirty-five HNC patients (mean age=54.8 years; 80% males) with elevated levels of PTSD, depression or anxiety were randomized to seven individual sessions of a multi-modal CBT or non-directive SC, concurrent with patients' radiotherapy. The SC intervention provided non-directive counseling support. PTSD, anxiety and depressive symptoms (primary outcomes), and cancer-related appraisals and quality of life (secondary outcomes) were assessed pre-intervention (baseline), 1 month, 6 months and 12 months post-intervention by diagnostic clinical interviews and validated self-report questionnaires.

RESULTS

The CBT and SC interventions were found to be equal in their effects in reducing PTSD and anxiety symptoms both in the short and longer term. However, up to 67% of patients in the CBT program no longer met clinical or sub-clinical PTSD, anxiety and/or depression by 12 months post-treatment compared with 25% of patients who received SC.

CONCLUSION

Findings indicate that the early provision of psychotherapy has utility in reducing PTSD, anxiety and depressive symptoms, and preventing chronic psychopathology in distressed HNC patients.

Early interventions for PTSD: a review

The high prevalence of trauma exposure and subsequent negative consequences for both survivors and society as a whole emphasize the need for secondary prevention of posttraumatic stress disorder. However, clinicians and relief workers remain limited in their ability to intervene effectively in the aftermath of trauma and alleviate traumatic stress reactions that can lead to chronic PTSD. The scientific literature on early intervention for PTSD is reviewed, including early studies on psychological debriefing, pharmacological, and psychosocial interventions aimed at preventing chronic PTSD. Studies on fear extinction and memory consolidation are discussed in relation to PTSD prevention and the potential importance of immediate versus delayed intervention approaches and genetic predictors are briefly reviewed. Preliminary results from a modified prolonged exposure intervention applied within hours of trauma exposure in an emergency room setting are discussed, along with considerations related to intervention reach and overall population impact. Suggestions for future research are included. Prevention of PTSD, although currently not yet a reality, remains an exciting and hopeful possibility with current research approaches translating work from the laboratory to the clinic.

Acute Psychological Impact of Disaster and Large-Scale Trauma: Limitations of Traditional Interventions and Future Practice Recommendations

Nearly everyone will experience emotional and psychological distress in the immediate aftermath of a disaster or other large-scale traumatic event. Although extremely upsetting and disruptive, the reaction is understood best as a human response to inordinate adversity, which in the majority of cases remits over time without formal intervention. Nevertheless, some people experience sustained difficulties. To prevent chronic post-traumatic difficulties, mental health professionals provide early interventions soon after traumatic exposure. These interventions typically take the form of single-session debriefings, which have been applied routinely following disasters. The research bearing on these traditional forms of early crisis interventions has shown that, although well-received by victims, there is no empirical support for their continued use. However, promising evidence-based, early interventions have been developed, which are highlighted. Finally, traumatic bereavement and complicated grief in survivors of disasters, an area largely neglected in the field, is discussed.

Preventing After-Effects of Disaster Trauma: The Information and Support Centre

This paper describes the establishment and activities of the Information and Support Centres developed in Norway in the aftermath of large-scale accidents and disasters between 1980 and 1990. The function of these Centres is to provide rapid, authoritative information and psychosocial support services for the next-of-kin of disaster victims, including the families of those missing. By gathering together those affected by a particular event, the Centres provide a setting in which individuals and families can support each other. The activities of the psychosocial team include triage for mental-health emergencies, orienting survivors to immediately available local services, communication with family, friends, and community, and other forms of psychological first aid. The psychosocial team also provides linkages to local health, clergy, and other local resources that are near to the family's home and could provide continued care if necessary.

Disaster and Terrorism: Cognitive-Behavioral Interventions

The mental health effects of disaster and terrorism have moved to the forefront in the recent past following the events of 11 September 2001 in the United States. Although there has been a protracted history by mental health researchers and practitioners to study, understand, prevent, and treat mental health problems arising as a result of disasters and terrorism, there still is much to learn about the effects and treatment of trauma. Continued communication among disaster workers, first-response medical personnel, and mental health professionals is part of this process. This paper outlines current knowledge regarding the psychological effects of trauma and best cognitive-behavioral practices used to treat trauma reactions. More specifically, the information presented is a summary of Cognitive-Behavioral Therapy (CBT) interventions that are relevant for responding to and dealing with the aftermath of disasters.

Treating posttraumatic stress disorder in first responders: a systematic review

First responders are generally considered to be at greater risk for full or partial posttraumatic stress disorder (PTSD) than most other occupations because their duties routinely entail confrontation with traumatic stressors. These critical incidents typically involve exposure to life threat, either directly or as a witness. There is a substantial literature that has examined the risk factors, symptom presentation, course, and comorbidities of PTSD in this population. However, to our knowledge, there are no systematic reviews of treatment studies for first responders. We conducted a systematic review of the PTSD treatment literature (English and non-English) in order to evaluate such treatment proposals based on what is known about treating PTSD in first responders. We especially sought to identify randomized controlled trials (RCTs) whose primary outcome was PTSD. Our search identified 845 peer-reviewed articles of which 0.002% (n=2) were bona fide RCTs of PTSD treatment in first responders. Both studies tested a psychosocial treatment. We did not locate a single psychopharmacologic RCT for PTSD in first responders. An additional 2 psychosocial studies and 13 case or observational studies comprised the remaining extant literature. Though both RCTs showed significant large treatment effects (d=1.37; h=0.92), the literature is startlingly sparse and is not sufficient for evidence-based recommendations for first responders.

Stepped early psychological intervention for posttraumatic stress disorder, other anxiety disorders, and depression following serious injury

The best approach for implementing early psychological intervention for anxiety and depressive disorders after a traumatic event has not been established. This study aimed to test the effectiveness of a stepped model of early psychological intervention following traumatic injury. A sample of 683 consecutively admitted injury patients were screened during hospitalization. High-risk patients were followed up at 4-weeks postinjury and assessed for anxiety and depression symptom levels. Patients with elevated symptoms were randomly assigned to receive 4-10 sessions of cognitive-behavioral therapy (n = 24) or usual care (n = 22). Screening in the hospital identified 89% of those who went on to develop any anxiety or affective disorder at 12 months. Relative to usual care, patients receiving early intervention had significantly improved mental health at 12 months. A stepped model can effectively identify and treat injury patients with high psychiatric symptoms within 3 months of the initial trauma.

Vulnerability and Resilience in a Group Intervention with Hospital Personnel during Exposure to Extreme and Prolonged War Stress

The current study presents a pilot demonstration of a new therapeutic procedure to mitigate symptoms of post-traumatic stress disorder (PTSD). The pilot took place during the Second Lebanon War. Vulnerability and resilience statements, as well as post-traumatic symptoms, were measured among special army administrative staff (SAAS) who worked in a hospital setting during extreme and prolonged war stress. All 13 soldiers in the unit studied participated in seven group therapy intervention sessions. It was hypothesized that shifting the focus of therapeutic intervention from the scenes of the events to the personal and professional narratives of preparing for the event would change the content of the soldiers’ narratives. It was believed that subtracting the number of positive statements from the number of negative statements would yield increasingly higher “resilience scores” during and after the war. It also was believed that such a change would be reflected in reduction of post-traumatic symptoms. As expected, the participants showed a decrease in vulnerability and an increase in resilience contents, as well as a decrease in traumatic symptoms during and after the war. These findings may reflect the effects of the ceasefire, the mutually supportive attitude of the participants, and the therapeutic interventions.

Randomized controlled trial of an internet-based intervention using random-digit-dial recruitment: the Disaster Recovery Web project

Disasters occur with high frequency throughout the world and increase risk for development of mental health problems in affected populations. Research focused on the development and evaluation of secondary prevention interventions addressing post-disaster mental health has high potential public-health impact. Toward this end, internet-based interventions (IBIs) are particularly attractive in that they: (1) offer a low-cost means of delivering standardized, targeted, personalized intervention content to a broad audience; and (2) are easily integrated within a stepped care approach to screening and service delivery. We describe a unique study design intended to evaluate an IBI with a disaster-affected population-based sample. Description and rationale are provided for sampling selection and procedures, selection of assessment measures and methods, design of the intervention, and statistical evaluation of critical outcomes. Unique features of this intervention include the use of a population-based sample, telephone and internet-based assessments, and development of a highly individualized web-based intervention. Challenges related to the development and large-scale evaluation of IBIs targeting post-disaster mental health problems, as well as implications for future research and practice are discussed.

Characteristics and efficacy of early psychological interventions in children and adolescents after single trauma: a meta-analysis

BACKGROUND

Single traumatising events are associated with an elevated rate of psychological disorders in children and adolescents. To date, it remains unclear whether early psychological interventions can reduce longer term psychological maladjustment.

OBJECTIVE

To systematically review the literature to determine the characteristics and efficacy of early psychological interventions in children and adolescents after a single, potentially-traumatising event.

DESIGN

Systematic searches were conducted of all relevant bibliographic databases. Studies on early psychological interventions were included if the first session was conducted within 1 month of the event. Two independent observers assessed each study for eligibility, using pre-determined inclusion and exclusion criteria, and rated the study's methodological quality. A meta-analysis was conducted on the group effects between individuals allocated to intervention versus control groups. Hence, effect sizes (ES) and confidence intervals were computed as well as heterogeneity and analogue-to-the ANOVA analyses.

RESULTS

Seven studies (including four randomised controlled trials) met the inclusion criteria. Depending on the specific outcome variable (e.g., dissociation, anxiety and arousal), small to large beneficial ES were noted. Although the meta-analysis revealed unexplained heterogeneity between the ES of the included studies, and although studies varied greatly with regards to their methodological quality and the interventions tested, findings suggest that early interventions should involve psycho-education, provide individual coping-skills and probably involve some kind of trauma exposure. Also, a stepped procedure that includes an initial risk screen and the provision of multiple sessions to those children at risk may be a promising strategy.

CONCLUSIONS

To date, research on the effectiveness of early interventions in children after a potentially traumatising event remains scarce. However, our review suggests that early interventions may be helpful.

A review of acute stress disorder in DSM-5

Acute stress disorder (ASD) was introduced into DSM-IV to describe acute stress reactions (ASRs) that occur in the initial month after exposure to a traumatic event and before the possibility of diagnosing posttraumatic stress disorder (PTSD), and to identify trauma survivors in the acute phase who are high risk for PTSD. This review considers ASD in relation to other diagnostic approaches to acute stress responses, critiques the evidence of the predictive power of ASD, and discusses ASD in relation to Adjustment Disorder. The evidence suggests that ASD does not adequately identify most people who develop PTSD. This review presents a number of options and preliminary considerations to be considered for DSM-5. It is proposed that ASD be limited to describing severe ASRs (that are not necessarily precursors of PTSD). The evidence suggests that the current emphasis on dissociation may be overly restrictive and does not recognize the heterogeneity of early posttraumatic stress responses. It is proposed that ASD may be better conceptualized as the severity of acute stress responses that does not require specific clusters to be present.

Changes in negative beliefs following three brief programs for facilitating recovery after assault

BACKGROUND

This study examines whether changes in negative beliefs about oneself, others, and the world occur as a result of early intervention aimed at preventing the development of chronic PTSD and further explores whether changes in negative beliefs during early intervention mediate long-term changes in psychopathology and functioning.

METHODS

Ninety recent female assault survivors were randomized to 4-week early intervention programs: brief cognitive behavioral intervention, weekly assessment, or supportive counseling (SC). Changes in negative beliefs were examined from preintervention to postintervention.

RESULTS

Negative beliefs improved across interventions, with somewhat less benefit reported by participants receiving SC. As expected, before intervention more severe negative beliefs were associated with higher initial trauma reactions and these negative beliefs generally improved from preintervention to postintervention. Moreover, for the brief cognitive-behavioral intervention, changes in perceptions of self and one's safety mediated longer-term changes in trauma-related symptoms.

CONCLUSIONS

The present results highlight the potential importance of changes in negative beliefs in long-term adjustment of recent assault survivors.

Social, psychological, and behavioral responses to a nuclear detonation in a US city: implications for health care planning and delivery

A nuclear detonation in a US city would have profound psychological, social, and behavioral effects. This article reviews the scientific literature on human responses to radiation incidents and disasters in general, and examines potential behavioral health care provider (BHCP) contributions in the hours and days after a nuclear detonation. In the area directly affected by the blast, the immediate overarching goal of BHCP interventions is the support of lifesaving activities and the prevention of additional casualties from fallout. These interventions include 6 broad categories: promoting appropriate protective actions, discouraging dangerous behaviors, managing patient/survivor flow to facilitate the best use of scarce resources, supporting first responders, assisting with triage, and delivering palliative care when appropriate. At more distant sites, BHCP should work with medical providers to support hospitalized survivors of the detonation. Recommendations are also made on BHCP interventions later in the response phase and during recovery.

Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma

OBJECTIVE

The objective of the study was to develop and implement a stepped collaborative care intervention targeting posttraumatic stress disorder (PTSD) and related comorbidities to enhance the population impact of early trauma-focused interventions.

METHOD

We describe the design and implementation of the Trauma Survivors Outcomes and Support study. An interdisciplinary treatment development team was composed of trauma surgical, clinical psychiatric and mental health services "change agents" who spanned the boundaries between frontline trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures.

RESULTS

Two hundred seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by frontline acute care masters in social work and nurse practioner providers.

CONCLUSIONS

Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other nonspecialty posttraumatic contexts.