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

Early psychosocial interventions after disasters, terrorism, and other shocking events: guideline development

Although most victims of disasters, terrorism, or other shocking events recover on their own, a sizable amount of these victims develops long-term disaster-related problems. These victims should receive timely and appropriate psychosocial help. This article describes the development of guidelines on psychosocial interventions during the first 6 weeks after a major incident. Scientific literature, expert opinions, and consensus among relevant parties in the clinical field were used to formulate the recommendations. Early screening, a supportive context, early preventive and curative psychosocial interventions, and the organization of interventions are covered. The implications for the clinical field and future research are discussed. It is concluded that the international knowledge base provides valuable input for the development of national guidelines. However, the successful implementation of such guidelines can take place only if they are legitimated and accepted by local key actors and operational target groups. Their involvement during the development process is vital.

Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review

BACKGROUND

Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD.

METHODS

Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites.

RESULTS

The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT.

CONCLUSION

There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.

Internet-based prevention of posttraumatic stress symptoms in injured trauma patients: design of a randomized controlled trial

BACKGROUND

Injured trauma victims are at risk of developing Posttraumatic Stress Disorder (PTSD) and other post-trauma psychopathology. So far, interventions using cognitive behavioral techniques (CBT) have proven most efficacious in treating early PTSD in highly symptomatic individuals. No early intervention for the prevention of PTSD for all victims has yet proven effective. In the acute psychosocial care for trauma victims, there is a clear need for easily applicable, accessible, cost-efficient early interventions.

OBJECTIVE

To describe the design of a randomized controlled trial (RCT) evaluating the effectiveness of a brief Internet-based early intervention that incorporates CBT techniques with the aim of reducing acute psychological distress and preventing long-term PTSD symptoms in injured trauma victims.

METHOD

In a two armed RCT, 300 injured trauma victims from two Level-1 trauma centers in Amsterdam, the Netherlands, will be assigned to an intervention or a control group. Inclusion criteria are: being 18 years of age or older, having experienced a traumatic event according to the diagnostic criteria of the DSM-IV and understanding the Dutch language. The intervention group will be given access to the intervention's website (www.traumatips.nl), and are specifically requested to login within the first month postinjury. The primary clinical study outcome is PTSD symptom severity. Secondary outcomes include symptoms of depression and anxiety, quality of life, and social support. In addition, a cost-effectiveness analysis of the intervention will be performed. Data are collected at one week post-injury, prior to first login (baseline), and at 1, 3, 6 and 12 months. Analyses will be on an intention-to-treat basis.

DISCUSSION

The results will provide more insight into the effects of preventive interventions in general, and Internet-based early interventions specifically, on acute stress reactions and PTSD, in an injured population, during the acute phase after trauma. We will discuss possible strengths and limitations.

Effects of additional prolonged exposure to psychoeducation and relaxation in acute stress disorder

We investigated the effect of prolonged exposure (PE) on the heart rate (HR) and skin conductance response to trauma-related stimuli in acute stress disorder (ASD). Forty recent trauma victims with ASD were randomly assigned to three sessions of either PE or supportive counseling (SC) with both groups also receiving psychoeducation and progressive relaxation. Assessments were carried out before and after treatment and again after 3 months. Four years later, patients were asked by telephone whether they had received further treatment. There were no significant group differences with regard to symptomatic improvement at the end of treatment. Both groups showed initial cardiac acceleration to trauma-related pictures. After treatment the PE group showed attenuation of the HR response and a reduction in spontaneous fluctuations (SF) whereas the SC group showed a decelerative (orienting) response and a marginal increase in SF. Following SC, 43% received further treatment compared to 9% after PE.

Post-traumatic stress disorder: present and future

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event - an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity. It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed. Indeed, a 'threat' as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

The relationship between sleep disturbance and the course of anxiety disorders in primary care patients

This study examined the relationship between sleep disturbance and the course of anxiety disorders in primary care patients. Participants were part of the Primary Care Anxiety Project (PCAP), a naturalistic, longitudinal study of anxiety disorders in primary care. Participants completed an intake evaluation and follow-up assessments at 6 months, 12 months, and annually thereafter. Only participants with sleep data at intake were included in the current study (n=533). The majority (74%) reported experiencing sleep disturbance at intake. Those with a diagnosis of generalized anxiety disorder (GAD) or post-traumatic stress disorder (PTSD) were over 2 times more likely to have sleep problems. Sleep disturbance at intake did not relate to the longitudinal course of GAD, social phobia, panic disorder, or obsessive-compulsive disorder. However, it did predict the course of PTSD, controlling for comorbid major depressive disorder (MDD) and having more than one anxiety disorder diagnosis intake, those with sleep disturbance at intake being less likely to remit from PTSD in the 5 years of follow-up. By year 5, only 34% of those with sleep problems at intake remitted from PTSD whereas 56% of those without sleep disturbance remitted from the disorder. The findings suggest that sleep disturbance in PTSD may have prognostic significance and may be important to address in clinical interventions.

[Targeted prevention of posttraumatic stress disorder]

Posttraumatic stress disorder (PTSD) is a severe, frequently chronic condition with a high rate of co-morbidity with other psychiatric syndromes. In contrast to the majority of psychiatric disorders, the traumatic event in PTSD constitutes a clearly defined etiological factor. A growing understanding of the mechanisms contributing to the development of PTSD has highlighted the possibilities for early preventive psychological and pharmacological treatment during the so-called golden hours after a traumatic experience. Whereas preliminary evidence suggests that a pharmacological recalibration of the HPA system and cognitive behavioral therapy may be helpful, other frequently used strategies, such as psychological debriefing or benzodiazepine treatment, seem to be largely ineffective, possibly even worsening PTSD symptoms.

The long-term psychological sequelae of orofacial injury

Significant subsets of patients who experience orofacial injury are at risk for developing adverse psychological sequelae such as posttraumatic stress disorder and depression. If undetected and untreated, the psychopathology can become recalcitrant and burden the social and vocational functioning of the patients and greatly diminish their quality of life. The hospital encounter and follow-up care visits provide the oral and maxillofacial surgeon with opportunities to screen for emerging psychological problems. Several screening instruments are available to assist the surgeon in identifying individuals who are at risk for subsequent mental health problems. Facilitated referrals to mental health services can be a practical approach for improving comprehensive medical care for vulnerable individuals and for reducing the potential morbidity of these covert, but disabling, sequelae.

Early psychological interventions to treat acute traumatic stress symptoms

BACKGROUND

The amelioration of psychological distress following traumatic events is a major concern. Systematic reviews suggest that interventions targeted at all of those exposed to such events are not effective at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of treating acute traumatic stress problems.

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments and interventions commenced within three months of a traumatic event aimed at treating acute traumatic stress reactions. The review followed the guidelines of the Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches were performed of of CCDAN Registers up to August 2008. Editions of key journals were searched by hand over a period of two years; personal communication was undertaken with key experts in the field; online discussion fora were searched.

SELECTION CRITERIA

Randomised controlled trials of any psychological intervention or treatment designed to reduce acute traumatic stress symptoms, with the exception of single session interventions.

DATA COLLECTION AND ANALYSIS

Data were entered and analysed for summary effects using Review Manager 5.0 software. Standardised mean differences were calculated for continuous variable outcome data. Relative risks were calculated for dichotomous outcome data. When statistical heterogeneity was present a random effects model was applied.

MAIN RESULTS

Fifteen studies (two with long term follow-up studies) were identified examining a range of interventions.In terms of main findings, twelve studies evaluated brief trauma focused cognitive behavioural interventions (TF-CBT). TF-CBT was more effective than a waiting list intervention (6 studies, 471 participants; SMD -0.64, 95% CI -1.06, -0.23) and supportive counselling (4 studies, 198 participants; SMD -0.67, 95% CI -1.12, -0.23). Effects against supportive counselling were still present at 6 month follow-up (4 studies, 170 participants; SMD -0.64, 95% CI -1.02, -0.25). There was no evidence of the effectiveness of a structured writing intervention when compared against minimal intervention (2 studies, 149 participants; SMD -0.15, 95% CI -0.48, 0.17).

AUTHORS' CONCLUSIONS

There was evidence that individual TF-CBT was effective for individuals with acute traumatic stress symptoms compared to both waiting list and supportive counselling interventions. The quality of trials included was variable and sample sizes were often small. There was considerable clinical heterogeneity in the included studies and unexplained statistical heterogeneity observed in some comparisons. This suggests the need for caution in interpreting the results of this review. Additional high quality trials with longer follow up periods are required to further test TF-CBT and other forms of psychological intervention.

Temporal relations between sleep problems and both traumatic event exposure and PTSD: a critical review of the empirical literature

There has been growing interest in the interrelations among traumatic event exposure, posttraumatic stress disorder (PTSD), and sleep problems. A wealth of research has examined the associations among these factors and there is an emerging literature focused on how sleep problems relate to both traumatic event exposure and PTSD across time. The current review provides a detailed analysis of studies pertaining to the temporal patterning of sleep problems and traumatic event-related factors (e.g., traumatic event exposure, PTSD) and draws conclusions regarding the current state of this literature. Research coalesces to suggest (1) exposure to a traumatic event can interfere with sleep, (2) PTSD is related to the development of self-reported sleep problems, but evidence is less clear regarding objective indices of sleep, and (3) limited evidence suggests sleep problems may interfere with recovery from elevated posttraumatic stress levels. Future research now needs to focus on understanding mechanisms involved in these patterns to inform the prevention and treatment of comorbid sleep problems and PTSD.

How do the young suicide survivors wish to be met by psychologists? A user study

Little user-knowledge has been documented on the experiences of young suicide bereaved with psychosocial assistance and therapy. Thirty-two adolescents who had lost a close family member or friend by suicide participated in a research project by filling in questionnaires and participating in focus group interviews. The article explores the young people's experiences with and wishes for help from psychologists, and shows that the young bereaved do not receive the psychological assistance they wish for and need. The shortcomings are discussed in relation to the organization, form, and contents of the help. In order to reach youth with adequate assistance in an extreme life situation, it is worth listening to their opinions about how they want to be approached in the wake of a suicide.

Psychosocial interventions for the prevention of disability following traumatic physical injury

BACKGROUND

Traumatic physical injury can result in many disabling sequelae including physical and mental health problems and impaired social functioning.

OBJECTIVES

To assess the effectiveness of psychosocial interventions in the prevention of physical, mental and social disability following traumatic physical injury.

SEARCH STRATEGY

The search was not restricted by date, language or publication status. We searched the following electronic databases; Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Controlled Trials metaRegister (www.controlled-trials.com), AMED (Allied & Complementary Medicine), ISI Web of Science: Social Sciences Citation Index (SSCI), PubMed. We also screened the reference lists of all selected papers and contacted authors of relevant studies. The latest search for trials was in February 2008.

SELECTION CRITERIA

Randomised controlled trials that consider one or more defined psychosocial interventions for the prevention of physical disability, mental health problems or reduced social functioning as a result of traumatic physical injury. We excluded studies that included patients with traumatic brain injury (TBI).

DATA COLLECTION AND ANALYSIS

Two authors independently screened the titles and abstracts of search results, reviewed the full text of potentially relevant studies, independently assessed the risk of bias and extracted data.

MAIN RESULTS

We included five studies, involving 756 participants. Three studies assessed the effect of brief psychological therapies, one assessed the impact of a self-help booklet, and one the effect of collaborative care. The disparate nature of the trials covering different patient populations, interventions and outcomes meant that it was not possible to pool data meaningfully across studies. There was no evidence of a protective effect of brief psychological therapy or educational booklets on preventing disability. There was evidence from one trial of a reduction in both post-traumatic stress disorder (PTSD) and depressive symptoms one month after injury in those who received a collaborative care intervention combined with a brief psycho-educational intervention, however this was not retained at follow up. Overall mental health status was the only disability outcome affected by any intervention. In three trials the psychosocial intervention had a detrimental effect on the mental health status of patients.

AUTHORS' CONCLUSIONS

This review provides no convincing evidence of the effectiveness of psychosocial interventions for the prevention of disability following traumatic physical injury. Taken together, our findings cannot be considered as supporting the provision of psychosocial interventions to prevent aspects of disability arising from physical injury. However, these conclusions are based on a small number of disparate trials with small to moderate sample sizes and are therefore necessarily cautious. More research, using larger sample sizes, and similar interventions and patient populations to enable pooling of results, is needed before these findings can be confirmed.

Posttraumatic stress disorder and stress-related disorders

Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder. Symptoms present shortly after an exposure to a traumatic event, abate with time in the majority of those who initially express them, and leave a significant minority with chronic PTSD. PTSD may be treated with pharmacotherapy or psychotherapy. Treatment of the early expressions of the disorder constitutes a separate domain of theory and research. Treatment of chronic PTSD often stabilizes the condition but rarely produces stable remission. This article reviews the empirical evidence on the treatment of acute and chronic PTSD, outlines similarities and differences between PTSD and other Axis I disorders, evaluates new therapeutic approaches, and discusses the implications of current knowledge for the forthcoming DSM-V.

Multiple session early psychological interventions for the prevention of post-traumatic stress disorder

BACKGROUND

The prevention of long-term psychological distress following traumatic events is a major concern. Systematic reviews have suggested that individual Psychological Debriefing is not an effective intervention at preventing post traumatic stress disorder (PTSD). Recently other forms of intervention have been developed with the aim of preventing PTSD.

OBJECTIVES

To examine the efficacy of multiple session early psychological interventions commenced within three months of a traumatic event aimed at preventing PTSD. Single session individual/group psychological interventions were excluded.

SEARCH STRATEGY

Computerised databases were searched systematically, the most recent search was conducted in August 2008. The Journal of Traumatic Stress and the Journal of Consulting and Clinical Psychology were handsearched for the last two years. Personal communication was undertaken with key experts in the field.

SELECTION CRITERIA

Randomised controlled trials of any multiple session early psychological intervention or treatment (two or more sessions) designed to prevent symptoms of PTSD.

DATA COLLECTION AND ANALYSIS

Data were entered using Review Manager software. The methodological quality of included studies was assessed individually by two review authors. Data were analysed for summary effects using Review Manager 4.2. Mean difference was used for meta-analysis of continuous outcomes and relative risk for dichotomous outcomes.

MAIN RESULTS

Eleven studies with a total of 941 participants were found to have evaluated brief psychological interventions aimed at preventing PTSD in individuals exposed to a specific traumatic event, examining a heterogeneous range of interventions. Eight studies were entered into meta-analysis. There was no observable difference between treatment and control conditions on primary outcome measures for these interventions at initial outcome (k=5, n=479; RR 0.84; 95% CI 0.60 to 1.17). There was a trend for increased self-report of PTSD symptoms at 3 to 6 month follow-up in those who received an intervention (k=4, n=292; SMD 0.23; 95% CI 0.00 to 0.46). Two studies compared a memory structuring intervention against supportive listening. There was no evidence supporting the efficacy of this intervention.

AUTHORS' CONCLUSIONS

The results suggest that no psychological intervention can be recommended for routine use following traumatic events and that multiple session interventions, like single session interventions, may have an adverse effect on some individuals. The clear practice implication of this is that, at present, multiple session interventions aimed at all individuals exposed to traumatic events should not be used. Further, better designed studies that explore new approaches to early intervention are now required.

Early prognostic screening for posttraumatic stress disorder with the Davidson Trauma Scale and the SPAN

BACKGROUND

This study examined the accuracy of the 17-item Dutch version of the Davidson Trauma Scale (DTS) and the four-item SPAN (Startle, Physiological Arousal, Anger and Numbness) to detect survivors at risk for posttraumatic stress disorder (PTSD) within the first 2 weeks after the trauma.

METHODS

203 civilian survivors of recent trauma with relatively mild symptoms completed the DTS a mean of 8.7 days after experiencing trauma. SPAN scores were computed from the DTS. At a mean of 64.6 days posttrauma, 160 respondents were assessed for diagnosis of PTSD with the Structured Interview for PTSD.

RESULTS

Receiver operating characteristic curves showed that the DTS showed good overall screening accuracy (84%). At a cut-off value of 64, the DTS demonstrated a sensitivity of 0.86, a specificity of 0.70, a positive predictive value (PPV) of 0.12, and a negative predictive value (NPV) of 0.98. Overall accuracy of the SPAN was good (89%). At a cut-off of 10 the SPAN showed a sensitivity of 0.86, a specificity of 0.86, a PPV of 0.22, and a NPV of 0.98. The low PPVs were possibly due to the low of prevalence of PTSD in our sample (4.4%).

CONCLUSIONS

This study shows that both the DTS and the SPAN are comparably accurate in screening early trauma survivors at risk for developing PTSD. The very brief four-item SPAN may be preferred over the longer 17-item DTS especially in settings in which time and resources are limited. Future studies should aim to cross-validate these results in random samples.

Cognitive-behavioral psychology: implications for disaster and terrorism response

Given the personal and societal costs associated with acute impairment and enduring post-traumatic stress disorder (PTSD), the mental health response to disasters is an integral component of disaster response planning. The purpose of this paper is to explore the compatibility between cognitive-behavioral psychology and the disaster mental health model, and explicate how cognitive-behavioral perspectives and intervention methods can enhance the effectiveness of disaster mental health services. It is argued that cognitive-behavioral methods, if matched to the contexts of the disaster and the needs of individuals, will improve efforts to prevent the development of PTSD and other trauma-related problems in survivors of disaster or terrorist events. First, the similarities between models of care underlying both disaster mental health services and cognitive-behavioral therapies are described. Second, examples of prior cognitive-behavioral therapy-informed work with persons exposed to disaster and terrorism are provided, potential cognitive-behavioral therapy applications to disaster and terrorism are explored, and implications of cognitive-behavioral therapy for common challenges in disaster mental health is discussed. Finally, steps that can be taken to integrate cognitive-behavioral therapy into disaster mental health are outlined. The aim is to prompt disaster mental health agencies and workers to consider using cognitive-behavioral therapy to improve services and training, and to motivate cognitive-behavioral researchers and practitioners to develop and support disaster mental health response.

A meta-analytic review of the effects of psychotherapy control conditions for anxiety disorders

BACKGROUND

Little is known about the magnitude of improvement associated with psychotherapy control conditions for adult anxiety disorders. This information is important for the design of psychosocial treatment efficacy studies.

METHOD

We performed a computerized search of treatment outcome studies of anxiety disorders conducted between the first available year and 1 March 2007. In addition, we examined the reference lists from identified articles and asked international experts to identify eligible studies. We included studies that randomly assigned adult patients suffering from anxiety disorders to either cognitive-behavioral treatment or psychotherapy control condition. For each study, the two authors independently selected psychometrically sound measures of anxiety disorder severity. In addition, we collected data on attrition and treatment response.

RESULTS

Of the 1165 studies that were initially identified, 19 studies (454 patients) met inclusion criteria and were included in the analyses. The random effects analysis yielded a pre- to post-treatment Hedges' g effect size of 0.45 (95% confidence interval 0.35-0.46, z=8.50, p<0.001). The mean weighted response and attrition rates were 25.0% and 14.2%, respectively. There was no evidence for publication bias, nor was there a significant relationship between the effect size and diagnostic group, study year or number of treatment sessions.

CONCLUSIONS

Psychotherapy control conditions are associated with significant improvements when administered to adults suffering from anxiety disorders. In addition, they are associated with a relatively low attrition rate. These findings can inform the design of future psychotherapy outcome studies.

HOPE for battered women with PTSD in domestic violence shelters

Do you feel overwhelmed when attempting to treat battered women with ongoing safety concerns? Could battered women in shelters benefit from psychotherapy in addition to the case management they traditionally receive? What type of treatment would be most beneficial for battered women in shelters? Posttraumatic Stress Disorder (PTSD) is the most prevalent disorder associated with intimate partner violence (IPV). PTSD is associated with severe impairment and loss of resources which can severely impact a sheltered battered woman's ability to establish long-term safety for herself and her children. Conequently, we have developed a new treatment for sheltered battered women with Posttraumatic Stress Disorder (PTSD), Helping to Overcome PTSD through Empowerment (HOPE). HOPE is a short-term cognitive-behavioral treatment in a preliminary stage of development for battered women with PTSD in domestic violence shelters. It focuses on stabilization, safety, and empowerment and teaches women skills to manage their PTSD symptoms which may interfere with their ability to access important community resources and establish safety for themselves and their children. A case example utilizing HOPE is offered. Future directions and clinical applications are discussed.

Using evidence to inform clinical practice shortly after traumatic events

Despite ongoing gaps in our knowledge, there is now considerable research evidence available to inform clinical decisions and treatment plans shortly after traumatic events. The author uses two fictional cases to illustrate an evidence-based approach to clinical management following traumatic events. The importance of fully assessing individuals and tailoring management plans to address their specific needs optimally is highlighted by considering two distinct, but familiar types of presentation.

Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: a systematic review and meta-analysis

BACKGROUND

Early trauma-focused cognitive-behavioural therapy (TFCBT) holds promise as a preventive intervention for people at risk of developing chronic post-traumatic stress disorder (PTSD). The aim of this review was to provide an updated evaluation of the effectiveness of early TFCBT on the prevention of PTSD in high risk populations.

METHODS

We performed a systematic literature search in international electronic databases (MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL, ISI and PILOTS) and included randomised controlled trials comparing TFCBT delivered within 3 months of trauma, to alternative interventions. All included studies were critically appraised using a standardised checklist. Two independent reviewers selected studies for inclusion and assessed study quality. Data extraction was performed by one reviewer and controlled by another. Where appropriate, we entered study results into meta-analyses.

RESULTS

Seven articles reporting the results of five RCTs were included. All compared TFCBT to supportive counselling (SC). The study population was patients with acute stress disorder (ASD) in four trials, and with a PTSD diagnosis disregarding the duration criterion in the fifth trial. The overall relative risk (RR) for a PTSD diagnosis was 0.56 (95% CI 0.42 to 0.76), 1.09 (95% CI 0.46 to 2.61) and 0.73 (95% CI 0.51 to 1.04) at 3-6 months, 9 months and 3-4 years post treatment, respectively. A subgroup analysis of the four ASD studies only resulted in RR = 0.36 (95% CI 0.17 to 0.78) for PTSD at 3-6 months. Anxiety and depression scores were generally lower in the TFCBT groups than in the SC groups.

CONCLUSION

There is evidence for the effectiveness of TFCBT compared to SC in preventing chronic PTSD in patients with an initial ASD diagnosis. As this evidence originates from one research team replications are necessary to assess generalisability. The evidence about the effectiveness of TFCBT in traumatised populations without an ASD diagnosis is insufficient.

Information-provision intervention for children and their parents following pediatric accidental injury

OBJECTIVE

This study evaluated an early intervention for children and their parents following pediatric accidental injury.

METHOD

Information booklets provided to participants within 72 h of the initial trauma detailed common responses to trauma, the common time course of symptoms, and suggestions for minimizing any post-trauma distress. Following admission for traumatic injuries sustained in motor vehicle accidents, falls and sporting injuries a total of 103 children (aged 7-15) and their parents were evaluated at pre-intervention, 1 month, and 6 months post-trauma. The intervention (N = 33) was delivered to one of two hospitals, the second hospital was the control (N = 70).

RESULTS

Analyses indicated that the intervention reduced child anxiety symptoms at 1-month follow-up and parental posttraumatic intrusion symptoms and overall posttraumatic symptoms at the 6-month follow-up. No other differences between the intervention and control groups were found.

CONCLUSION

Overall, the information-based early intervention is simple, cost-effective method of reducing child and parent distress post-trauma.

Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: a randomized controlled trial

BACKGROUND

Writing assignments have shown promising results in treating traumatic symptomatology. Yet no studies have compared their efficacy to the current treatment of choice, cognitive behavior therapy (CBT). The present study evaluated the efficacy of structured writing therapy (SWT) and CBT as compared to a waitlist control condition in treating acute stress disorder (ASD) and posttraumatic stress disorder (PTSD).

METHODS

A randomized controlled trial was conducted at an outpatient clinic. Participants (n = 125) (a) satisfied DSM-IV criteria for ASD or PTSD, (b) were 16 years or older, (c) were sufficiently fluent in Dutch or English, (d) had no psychiatric problems except ASD or PTSD that would hinder participation or required alternative clinical care, and (e) received no concurrent psychotherapy. Treatment consisted of five 1.5-hour sessions of CBT or SWT for participants with ASD or acute PTSD and ten 1.5-hour sessions for participants with chronic PTSD. Outcome measures included the Structured Clinical Interview for DSM-IV, Impact of Event Scale, Beck Depression Inventory, State-Trait Anxiety Inventory and the Dissociative Experiences Scale.

RESULTS

At posttest and follow-up, treatment was associated with improved diagnostic status and lower levels of intrusive symptoms, depression and state anxiety, while a trend was noted for the reduction of avoidance symptoms. Treatment did not result in lower levels of trait anxiety or dissociation. No differences in efficacy were detected between CBT and SWT.

CONCLUSIONS

The present study confirmed the efficacy of CBT for ASD and PTSD and identified SWT as a promising alternative treatment.

Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials

OBJECTIVE

Cognitive-behavioral therapy (CBT) is frequently used for various adult anxiety disorders, but there has been no systematic review of the efficacy of CBT in randomized placebo-controlled trials. The present study meta-analytically reviewed the efficacy of CBT versus placebo for adult anxiety disorders.

DATA SOURCES

We conducted a computerized search for treatment outcome studies of anxiety disorders from the first available date to March 1, 2007. We searched MEDLINE, PsycINFO, PubMed, Scopus, the Institute of Scientific Information, and Dissertation Abstracts International for the following terms: random*, cognitive behavior*therap*, cognitive therap*, behavior*therap*, GAD, generalized anxiety disorder, OCD, obsessive compulsive disorder, social phobia, social anxiety disorder, specific phobia, simple phobia, PTSD, post-traumatic stress disorder, and acute stress disorder. Furthermore, we examined reference lists from identified articles and asked international experts to identify eligible studies.

STUDY SELECTION

We included studies that randomly assigned adult patients between ages 18 and 65 years meeting DSM-III-R or DSM-IV criteria for an anxiety disorder to either CBT or placebo. Of 1165 studies that were initially identified, 27 met all inclusion criteria.

DATA EXTRACTION

The 2 authors independently identified the eligible studies and selected for each study the continuous measures of anxiety severity. Dichotomous measures reflecting treatment response and continuous measures of depression severity were also collected. Data were extracted separately for completer (25 studies for continuous measures and 21 studies for response rates) and intent-to-treat (ITT) analyses (6 studies for continuous measures and 8 studies for response rates).

DATA SYNTHESIS

There were no significant differences in attrition rates between CBT and placebo. Random-effects models of completer samples yielded a pooled effect size (Hedges' g) of 0.73 (95% CI = 0.88 to 1.65) for continuous anxiety severity measures and 0.45 (95% CI = 0.25 to 0.65) for depressive symptom severity measures. The pooled odds ratio for completer treatment response rates was 4.06 (95% CI = 2.78 to 5.92). The strongest effect sizes were observed in obsessive-compulsive disorder and acute stress disorder, and the weakest effect size was found in panic disorder. The advantage of CBT over placebo did not depend on placebo modality, number of sessions, or study year.

CONCLUSIONS

Our review of randomized placebo-controlled trials indicates that CBT is efficacious for adult anxiety disorders. There is, however, considerable room for improvement. Also, more studies need to include ITT analyses in the future.

Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.

An acute post-sexual assault intervention to prevent drug abuse: updated findings

Sexual assault and rape routinely produce extreme distress and negative psychological reactions in victims. Further, past research suggests that victims are at increased risk of developing substance use or abuse post-rape. The post-rape forensic medical exam may itself exacerbate peritraumatic distress because it includes cues that may serve as reminders of the assault, thereby potentiating post-assault negative sequelae. To address these problems, a two-part video intervention was developed to take advantage of the existing sexual assault forensic exam infrastructure, and to specifically (a) minimize anxiety/discomfort during forensic examinations, thereby reducing risk of future emotional problems, and (b) prevent increased substance use and abuse following sexual assault. Updated findings with a sample of 268 sexual assault victims participating in the forensic medical exam and completing one or more follow-up assessments at: (1)<3 months post-assault; (2) 3 to 6 months post-assault; or (3) 6 months or longer post-assault indicated that the video was associated with significantly lower frequency of marijuana use at each time point, among women who reported use prior to the assault.

A randomized controlled clinical treatment trial for World Trade Center attack-related PTSD in disaster workers

This article describes a controlled clinical trial of cognitive-behavioral treatment (CBT) for disaster workers. Despite high rates of PTSD in disaster workers worldwide, there have been no randomized trials of PTSD treatment. Participants were randomly assigned to a 12-week cognitive-behavioral exposure treatment (CBT, N = 15) or a treatment-as-usual (N = 16) condition. Eight CBT and 14 treatment-as-usual participants completed treatment. An ANOVA examining changes in Clinician-Administered PTSD Scale scores found significant main effects of Time, Group, and a Time x Group interaction (p's < 0.010) with a significantly greater decline in symptom scores in the CBT group. Between-group effect sizes were large. Dropout was associated with lower income, less education, and higher alcohol consumption. This project demonstrates the feasibility of recruitment in the aftermath of a catastrophic event, the relevance of a brief focused intervention comprised of CBT and exposure, and the need to eliminate barriers to treatment retention associated with income and education.

Posttraumatic stress disorder: etiology, epidemiology, and treatment outcome

Posttraumatic stress disorder (PTSD) results from exposure to a traumatic event that poses actual or threatened death or injury and produces intense fear, helplessness, or horror. U.S. population surveys reveal lifetime PTSD prevalence rates of 7% to 8%. Potential reasons for varying prevalence rates across gender, cultures, and samples exposed to different traumas are discussed. Drawing upon a conditioning model of PTSD, we review risk factors for PTSD, including pre-existing individual-based factors, features of the traumatic event, and posttrauma social support. Characteristics of the trauma, particularly peritraumatic response and related cognitions, and posttrauma social support appear to confer the greatest risk for PTSD. Further work is needed to disentangle the interrelationships among these factors and elucidate the underlying mechanisms. Based upon existing treatment outcome studies, we recommend use of exposure therapies and anxiety management training as first-line treatment for PTSD. Among psychopharmacological treatments, selective serotonin reuptake inhibitors evidence the strongest treatment effects, yet these effects are modest compared with psychological treatments.

Correlates of acute stress disorder in cancer patients

This study investigated the correlates of acute stress disorder (ASD) following a diagnosis of cancer. Adults diagnosed with first onset head, neck, or lung malignancy (N = 82) were assessed within one month of diagnosis using the ASD Interview, and the Structured Clinical Interview for DSM-IV to index the incidence of ASD and other affective disorders following their cancer diagnosis. Participants were also administered questionnaires that assessed dissociative symptoms, coping strategies, and quality of life. Acute stress disorder was diagnosed in 28% of participants. Acute stress disorder severity was associated with gender, elevated dissociative responses, trait anxiety, and preoccupation with one's diagnosis, and a decline in cognitive functioning. This study provides evidence for identifying recently diagnosed cancer patients who may benefit from psychological assistance.

Randomized controlled evaluation of an early intervention to prevent post-rape psychopathology

A randomized between-group design was used to evaluate the efficacy of a video intervention to reduce post-traumatic stress disorder (PTSD) and other mental health problems, implemented prior to the forensic medical examination conducted within 72 h post-sexual assault. Participants were 140 female victims of sexual assault (68 video/72 nonvideo) aged 15 years or older. Assessments were targeted for 6 weeks (Time 1) and 6 months (Time 2) post-assault. At Time 1, the intervention was associated with lower scores on measures of PTSD and depression among women with a prior rape history relative to scores among women with a prior rape history in the standard care condition. At Time 2, depression scores were also lower among those with a prior rape history who were in the video relative to the standard care condition. Small effects indicating higher PTSD and Beck Anxiety Inventory (BAI) scores among women without a prior rape history in the video condition were observed at Time 1. Accelerated longitudinal growth curve analysis indicated a videoxprior rape history interaction for PTSD, yielding four patterns of symptom trajectory over time. Women with a prior rape history in the video condition generally maintained the lowest level of symptoms.

Preventing violence — caring for victims

Part of the great tradition of surgery, exemplified by the Royal College precept, 'From Here Health', is that surgeons are committed to prevention as well as cure. King James IV and his able contemporary in China, where this lecture was delivered, Emperor Hongzhi, would have approved of it. This tradition has, perhaps, been neglected since the emergence of public health as a medical specialty. However, opportunities and reasons for surgeons to contribute to prevention have never been greater. Community violence prevention--increasing public safety in the towns and cities in which surgeons work--is an example. Primary prevention of injury achieved by collecting and sharing unique information about weapons and the locations of assault, secondary prevention achieved by combining wound care with motivational interviewing to reduce alcohol misuse, and tertiary prevention achieved by early referral to mental health professionals for treatment of post-traumatic stress, have been integrated into a new care pathway which combines prevention with surgical care. Individuals and communities would benefit substantially if every surgical specialty incorporated prevention--a professionally highly-rewarding activity--into its training curriculum.

Quality of life after multiple trauma: the effect of early onset psychotherapy on quality of life in trauma patients

BACKGROUND AND AIMS

The aim of this study was to improve health-related quality of life (HRQOL) related to depression, anxiety, pain, physical functioning and social aspects for severely injured trauma survivors by early onset cognitive behavioural therapy applied on the surgical ward.

MATERIALS AND METHODS

The study was a randomised, controlled study. Of 298 primary screened patients 171 were eligible and randomised. Ninety-two patients adhered to follow-up investigations at 6 and 12 months. Main outcome measure was a sum score according to O'Brien calculated of five different questionnaires (BDI, SF-36, STAI, SCL 90R, F-SOZU-22).

RESULTS

The sum score for overall HRQOL did not show significant group differences at follow-up. Effects on HRQOL sub-dimensions within groups have been found. In the dimension of depression therapy group showed significant improvement from the first measurement to discharge from hospital (p < 0.001), 6 MFU (p = 0.004) and to 12 MFU (p = 0.013). Measures of anxiety showed significant improvement for the therapy group at discharge from hospital (p = 0.001). In the control group there was only a significant reduction in depression and anxiety from surgical ward to discharge (p = 0.013/p = 0.031).

CONCLUSIONS

Early onset cognitive therapy is not effective in improving overall HRQOL of severely injured patients but shows promising effects on depression and anxiety up to 12 months after trauma.

A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions

Although efforts to prevent posttraumatic stress disorder (PTSD) have met with relatively limited success, theoretically driven preventive approaches with promising efficacy are emerging. The current article critically reviews investigations of PTSD prevention programs that target persons at risk for being exposed to a traumatic event or who have been exposed to a traumatic event. This review uniquely extends prior reviews in this area by using theories of PTSD to suggest future directions in the area of PTSD prevention. The authors first discuss the primary mechanisms of action believed to account for the failure for PTSD symptoms to remit among a substantial minority of traumatic event-exposed individuals. Second, empirical progress in PTSD prevention efforts is reviewed. Third, the authors consider how existing prevention programs target these mechanisms of action. Finally, the authors consider directions for future research in the area of targeted PTSD prevention.

Preventing alcohol-related violence: a public health approach

BACKGROUND

Studies of the relationship between alcohol and violent injury confirm that while there is some evidence of a direct pharmacological association, many other factors are relevant to the frequency and severity of both violent perpetration and being a victim of violence. It is now widely recognized that official police statistics are a poor indicator of the nature and extent of public violence.

AIMS

Accident and emergency departments and trauma surgeons are not only in a position to provide more accurate information on the nature and extent of clinically significant injury, but they can contribute substantially to violence prevention. This can be achieved through individually targeted interventions in conjunction with other clinicians on the one hand, and on the other through public health and community initiatives, in conjunction with other community agencies, including the police and local authorities. This article describes some of those initiatives and the evidence underpinning them.

Ready! Fire! Aim! The Status of Psychological Debriefing and Therapeutic Interventions: In the Work Place and after Disasters

Psychological debriefing (PD) is a brief, short-term intervention aimed at mitigating long-term distress and preventing the emergence of posttraumatic stress. In recent years, it has become a ubiquitous intervention, one which has evolved as almost prescriptive following harrowing events and grew through a practical need to offer assistance to those who are exposed to severe trauma. Despite disturbing data from the recent refereed literature of psychology, it is still referred to as the “standard of care” for disaster and crisis response and its use in many quarters continues. This article critically reviews the evidence for and against its use and outlines the weaknesses in the research. The emphasis of this review is on the appropriateness of debriefing in organizations. This article also proposes a set of hypothesized constructs that may, in part, be responsible for the paradoxical effects found in some outcome studies on debriefing. Guidelines are also proposed to help organizations and professionals react appropriately using evidence-based interventions.

Do all children need intervention after exposure to tsunami?

Children are uniquely vulnerable in the context of a major natural disaster like tsunami. Post disaster intervention studies in children are few, especially from developing countries like India. An intervention programme for children was developed and conducted at Srinivasapuram, a coastal hamlet in Chennai, a year after tsunami. Sixty-five children who participated in all the six intervention modules were compared to 70 children who did not participate in the intervention. All the children were assessed before and after intervention using the Youth Self Report (YSR) form of Child Behaviour Check List (CBCL) in addition to PTSD symptoms. Children in the two groups were comparable in socio-demographic factors and exposure to tsunami. Prevalence of family psychopathology was more in the intervention group. Only hyperactivity problems were significantly reduced after intervention (z = 2.41 p = 0.016). Children in the intervention group appreciated expression of positive emotions (F = 8.044 p = 0.005) and were also more likely to desist from smoking (F = 6.102 p = 0.003) compared to the control group. The majority of the children are likely to be resilient and only children with pre-existing vulnerability require specific and specialized interventions.

In vivo flooding for anxiety disorders: proposing its utility in the treatment posttraumatic stress disorder

Exposure techniques have now been used in the treatment of anxiety disorders for several decades. Although such techniques are a dominant feature of current therapies for disorders such as posttraumatic stress disorder and acute stress disorder, examination of their relative merits has been less studied. The purpose of this review is to suggest the usefulness of in vivo flooding in the treatment of posttraumatic stress. We discuss the relevant exposure literature by briefly examining the efficacy of these techniques in the treatment of anxiety. The theoretical and methodological limitations of investigations to date of exposure methods that have been used in posttraumatic stress treatment studies are then reviewed. We highlight the fact that in vivo flooding, an exposure technique that has been used to treat some anxiety-based disorders, has received scant clinical and research attention as a treatment for posttraumatic stress. A case is made for further study of in vivo flooding in the treatment of posttraumatic stress.

Disseminating early interventions following trauma

Dissemination of effective early interventions following trauma is necessary to ensure the provision of the best possible care in a timely manner. To achieve this, agreement from all key stakeholders is required regarding the messages to be disseminated and the means of dissemination. This article is based on a National Institute of Mental Health sponsored symposium on the dissemination of early interventions at the 21st annual meeting of the International Society for Traumatic Stress Studies in Toronto in 2005. The current knowledge base regarding the effectiveness and dissemination of early interventions (defined here as those that are begun within the first 3 months after exposure) following trauma for children, adolescents, and adults is considered.

[Incidence- and reaction-related predictors of the acute and posttraumatic stress disorder in disaster workers]

OBJECTIVES

This recent study assesses the correlation of incidence- and reaction-related variables to predict acute and posttraumatic stress disorder in rescue workers after the catastrophe of Kaprun (2000) in Austria, Europe.

METHODS

In a prospective longitudinal study, 250 emergency medical personnel, crisis intervention teams and police officers were assessed using the Acute Stress Disorder Scale (ASD), the Posttraumatic Stress Diagnostic Scale (PDS) and an incidence- and reaction-related questionnaire 6 weeks and 6 months after their mission.

RESULTS

After 6 weeks, 7.3 % of the emergency medical personnel, 22.2 % of the crisis intervention team workers and 25.7 of police officers suffered from ADS. At 6 months after the disaster, 6.3 % of all rescue workers showed PTSD. The incidence-related predictors of PTSD assessed in the study were duration of the mission and early arrival at the site. Uncertainty about the help given was found to be a reaction-related predictor.

CONCLUSIONS

This study provides further support for the usefulness of incidence- and reaction-related factors to predict acute and posttraumatic stress disorder in rescue workers. These results will aid in the development of special prevention strategies for rescue workers.

A cognitive-behavioral treatment for battered women with PTSD in shelters: findings from a pilot study

Despite the high rates of posttraumatic stress disorder (PTSD) among battered women in shelters, virtually no treatments for these women have been developed or tested. This study evaluated the initial feasibility and efficacy of an individual, cognitive-behavioral treatment for battered women with PTSD or subthreshold PTSD in shelters. Eighteen women participated in an open-trial where they received a new treatment, Helping to Overcome PTSD with Empowerment (HOPE). Intent-to-treat analyses indicate that participants experienced significant decreases in PTSD symptoms, depressive symptoms, in their loss of resources and degree of social impairment; and significant increases in their effective use of community resources. These gains were maintained over time. Results should be interpreted with caution due to the small sample size and lack of a control group.

Emotional or educational debriefing after psychological trauma. Randomised controlled trial

BACKGROUND

Recent studies show that individual single-session psychological debriefing does not prevent and can even aggravate symptoms of post-traumatic stress disorder (PTSD).

AIMS

We studied the effect of emotional ventilation debriefing and educational debriefing v. no debriefing on symptoms of PTSD, anxiety and depression.

METHOD

We randomised 236 adult survivors of a recent traumatic event to either emotional ventilation debriefing, educational debriefing or no debriefing (control) and followed up at 2 weeks, 6 weeks and 6 months.

RESULTS

Psychiatric symptoms decreased in all three groups over time, without significant differences between the groups in symptoms of PTSD (P=0.33). Participants in the emotional debriefing group with high baseline hyperarousal score had significantly more PTSD symptoms at 6 weeks than control participants (P=0.005).

CONCLUSIONS

Our study did not provide evidence for the usefulness of individual psychological debriefing in reducing symptoms of PTSD, anxiety and depression after psychological trauma.

Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study

Early interventions that reduce the societal burden of mental health problems in the aftermath of disasters and mass violence have the potential to be enormously valuable. Internet-based interventions can be delivered widely, efficiently, and at low cost and as such are of particular interest. We describe the development and feasibility analysis of an Internet-delivered intervention designed to address mental health and substance-related reactions in disaster-affected populations. Participants (n = 285) were recruited from a cohort of New York City-area residents that had been followed longitudinally in epidemiological research initiated 6 months after the terrorist attacks of September 11, 2001. The intervention consisted of 7 modules: posttraumatic stress/panic, depression, generalized anxiety, alcohol use, marijuana use, drug use, and cigarette use. Feasibility data were promising and suggest the need for further evaluation.