Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up

The long-term benefits of cognitive behaviour therapy (CBT) for trauma survivors with acute stress disorder were investigated by assessing patients 3 years after treatment. Civilian trauma survivors (n=87) were randomly allocated to six sessions of CBT, CBT combined with hypnosis, or supportive counselling (SC), 69 completed treatment, and 53 were assessed 2 years post-treatment for post-traumatic stress disorder (PTSD) with the Clinician-Administered PTSD Scale. In terms of treatment completers, 2 CBT patients (10%), 4 CBT/hypnosis patients (22%), and 10 SC patients (63%) met PTSD criteria at 2-years follow-up. Intent-to-treat analyses indicated that 12 CBT patients (36%), 14 CBT/hypnosis patients (46%), and 16 SC patients (67%) met PTSD criteria at 2-year follow-up. Patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received SC. These findings point to the long-term benefits of early provision of CBT in the initial month after trauma.     

A Randomized Trial of Cognitive Behaviour Therapy and Cognitive Therapy for Children with Posttraumatic Stress Disorder Following Single-Incident Trauma

The present study compared the efficacy of trauma-focused cognitive behavior therapy (CBT) with trauma-focused cognitive therapy (without exposure; CT) for children and youth with posttraumatic stress disorder (PTSD). Children and youth who had experienced single-incident trauma (N = 33; 7–17 years old) were randomly assigned to receive 9 weeks of either CBT or CT which was administered individually to children and their parents. Intent-to-treat analyses demonstrated that both interventions significantly reduced severity of PTSD, depression, and general anxiety. At posttreatment 65% of CBT and 56% of the CT group no longer met criteria for PTSD. Treatment completers showed a better response (CBT: 91%; CT: 90%), and gains were maintained at 6-month follow-up. Maternal depressive symptoms and unhelpful trauma beliefs moderated children’s outcome. It is concluded that PTSD secondary to single-incident trauma can be successfully treated with trauma-focused cognitive behavioural methods and the use of exposure is not a prerequisite for good outcome.     

A randomized clinical trial comparing affect regulation and social problem-solving psychotherapies for mothers with victimization-related PTSD

Addressing affect dysregulation may provide a complementary alternative or adjunctive approach to the empirically supported trauma memory processing models of cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). A CBT designed to enhance affect regulation without trauma memory processing—trauma affect regulation: guide for education and therapy (TARGET)—was compared to present centered therapy (PCT) and wait-list (WL) conditions in a randomized clinical trial with 146 primarily low-income and ethnoracial minority mothers with PTSD. TARGET achieved statistically and clinically significant improvement on PTSD and affect regulation measures compared to WL, with more consistent and sustained (over a 6-month follow-up period) evidence of improvement than PCT. Drop-out rates (~ 25%) were comparable in TARGET and PCT, similar to those previously reported for trauma memory processing CBTs. Symptom worsening was rare (2–8%) and transient. Affect regulation-based CBT without trauma memory processing warrants further research as a potentially efficacious therapy for victimization-related PTSD.     

Linguistic Predictors of Post‐Traumatic Stress Disorder Symptoms Following 11 September 2001

Prior research has linked content analysis drawn from text narratives to psychopathology in trauma survivors. This study used a longitudinal design to determine whether linguistic elements of narrative memories of first hearing about the events of 11 September 2001 predict later post‐traumatic stress disorder (PTSD). Narratives and self‐report PTSD symptoms were collected within 1 week and again 5 months after 9/11 in 40 undergraduates. People who used more “we” words at Time 1 had fewer acute PTSD symptoms. Use of more cognitive mechanism words, more religion words, more first‐person singular pronouns, and fewer anxiety words at Time 1 were related to more chronic PTSD symptoms. Linguistic characteristics accounted for variance in chronic PTSD symptoms above and beyond acute PTSD symptoms. This study provides evidence that lasting PTSD symptoms can be predicted through language in the immediate aftermath of the trauma. Copyright © 2011 John Wiley & Sons, Ltd.     

Cognitive behavioral therapy of violence-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) represents the most common psychiatric condition following exposure to violence. Although an increasing number of cognitive behavioral therapy (CBT) studies point to efficacy of this approach in ameliorating PTSD following violence, the methodological rigor of many studies has not been optimal. Further, a significant proportion of traumatized individuals does not benefit from CBT. This article reviews CBT outcome studies, discusses the methodological limitations of CBT studies for PTSD, and offers suggestions for future research. This review highlights the need for more systematic studies of components of CBT with a range of trauma populations to delineate the parameters of effective CBT for individuals with PTSD.     

A prospective study of psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder

This study investigated the role of acute arousal in the development of posttraumatic stress disorder (PTSD). Hospitalized motor-vehicle-accident survivors (n = 146) were assessed for acute stress disorder (ASD) within 1 month of the trauma and were reassessed (n = 113) for PTSD 6 months posttrauma. Heart rate (HR) and blood pressure (BP) were assessed on the day of hospital discharge. Participants with subclinical ASD had higher HR than those with ASD and no ASD. Participants who developed PTSD had higher HR in the acute posttrauma phase than those without PTSD. Diagnosis of ASD and resting HR accounted for 36% of the variance of the number of PTSD symptoms. A formula composed of a diagnosis of ASD or a resting HR of > 90 beats per minute possessed strong sensitivity (88%) and specificity (85%) in predicting PTSD. These findings are discussed in terms of acute arousal and longer term adaptation to trauma.     

Acceptance and Commitment Therapy for Treatment-Resistant Posttraumatic Stress Disorder: A Case Study

An adult woman with chronic posttraumatic stress disorder (PTSD) and major depressive disorder who was nonresponsive to 20 sessions of cognitive behavior therapy (CBT) is presented in this case study. Two months after her CBT trial, she was treated with 21 sessions of Acceptance and Commitment Therapy (ACT) for PTSD. Measurements of PTSD severity, depression, anxiety, psychological flexibility and trauma-related thoughts and beliefs were taken at pretreatment, after Sessions 8 and 16, and at posttreatment. Results showed significant reduction on all measures throughout treatment, except for trauma-related thoughts and beliefs, which did not decrease until near the end of treatment. Strengths, limitations, and future directions are discussed.     

The Unique Relationship of Emotion Regulation and Alexithymia in Predicting Somatization Versus PTSD Symptoms

Posttraumatic stress disorder (PTSD) has received considerable attention in the field of trauma studies. Yet trauma survivors suffer from other psychological and physical symptoms including somatic complaints, or somatization. The extent to which the same emotional processes that predict PTSD are implicated in somatization has remained relatively unexamined. We contend that emotion regulation difficulties and alexithymia are also implicated in somatization, and the way in which these factors interact differentially place one at risk for somatization or PTSD. Regression analyses revealed that emotion regulation difficulties were more highly correlated with somatization for individuals who also reported greater alexithymia. This interaction was not observed for PTSD symptoms where both alexithymia and emotion regulation difficulties uniquely predicted PTSD symptoms.     

Group Cognitive Behavioral Treatment for PTSD: Treatment of Motor Vehicle Accident Survivors

Individual cognitive behavioral therapies (CBT) are now considered the first-line treatment for posttraumatic stress disorder (PTSD; Foa, Keane, & Friedman, 2000). As mental health reimbursement becomes more restricted, it is imperative that we adapt individual-format therapies for use in a small group format. Group therapies have a number of advantages, including provision of a natural support group, the ability to reach more patients, and greater cost efficiency. In this article, we describe the development of a group CBT for PTSD in the aftermath of a serious motor vehicle accident (MVA). Issues unique to the group treatment format are discussed, along with special considerations such as strategies to reduce the potential for triggering reexperiencing symptoms during group sessions. A case example is presented, along with discussion of group process issues. Although still in the early stages, this group CBT may offer promise as an effective treatment of MVA-related PTSD.     

An Integrative Approach to Conceptualizing and Treating Complex Trauma

Complex trauma (CT) often presents with polymorphous symptoms (i.e., emotional dysregulation, dissociation, somatic distress) resulting from repeated and chronic exposure to traumatic stressors. While the public is increasingly aware of posttraumatic stress disorder (PTSD) and its accompanying symptoms, the phenomena of complex trauma is less recognized and understood. Since the trauma reactions with CT typically occur during childhood, and the symptoms go well beyond PTSD, the authors of this article assert that an integrative approach is needed that synthesizes the most effective elements of cognitive-behavioral therapy (CBT) while blending a self-psychological approach. A review of the literature addresses the definition of complex trauma, cognitive-behavioral conceptualizations and treatment approaches, self-psychological models, current theories of attachment, and advances in neuropsychoanalysis. An integrative model is then proposed, supported by clinicians in the trauma field, identifying three intertwined phases of treatment.     

Peritraumatic and persistent panic attacks in acute stress disorder

This study examined the prevalence of peritraumatic and persistent panic symptoms following trauma. Survivors of civilian trauma (n=30) with either acute stress disorder (ASD) or no acute stress disorder (non-ASD) were administered the Panic Module of the Structured Clinical Interview for DSM-IV (SCID). Participants also completed the Impact of Event Scale, Acute Stress Disorder Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Anxiety Sensitivity Index. Panic attacks were experienced by 77% of participants during their trauma, and 47% reported recurrent panic attacks post-trauma. ASD participants demonstrated more panic symptoms during and after their trauma than non-ASD participants. Posttraumatic panic was most strongly associated with anxiety sensitivity. These findings are discussed in terms of cognitive factors that may mediate posttrauma panic and treatment implications for managing posttraumatic anxiety.There is increasing evidence that panic attacks play a role in psychopathological response to trauma. A significant proportion of people with panic disorder report a history of trauma (). Moreover, two-thirds of trauma survivors report panic attacks within the previous 2 weeks (). There is also evidence that people with posttraumatic stress disorder (PTSD) display elevated levels of anxiety sensitivity (). Recent attention has focused on acute panic reactions because of proposals that panic during trauma may condition trauma-related cues to subsequent panic (). There is evidence that panic attacks occur in 53-90% of trauma survivors during the traumatic experience (). Further, people with acute stress disorder (ASD) are more likely to report peritraumatic panic attacks than non-ASD individuals. ASD is a useful framework in which to investigate the role of panic in posttraumatic stress because ASD describes acute responses to trauma that are strongly predictive of chronic PTSD ().This study investigated the relationship between peritraumatic panic and ongoing panic attacks following trauma. Specifically, we indexed panic attacks during trauma and subsequent to trauma in trauma survivors with and without ASD. We also indexed the extent to which distorted interpretations about somatic sensations may be associated with panic attacks following trauma. We considered that the strong evidence that maladaptive appraisals of somatic sensations mediate panic () is directly relevant to posttraumatic panic. We hypothesized that ASD participants would report more peritraumatic and persistent panic than non-ASD participants, and that this panic would be associated with dysfunctional interpretations about somatic stimuli.     

Cognitive Behavioral Therapy for PTSD: The Role of Complex PTSD on Treatment Outcome

Posttraumatic stress disorder (PTSD) represents an often chronic and debilitating mental illness resulting from exposure to trauma. Although the most compelling evidence for the treatment of PTSD is cognitive behavioral therapy (CBT), many patients experience residual functional impairment, or relapse, suggesting that this approach does not work for all cases of PTSD. Repeated severe trauma, particularly during development, might increase the risk for a more intricate clinical profile, called complex PTSD (CPTSD), which might contribute to poorer treatment response. The following provides a comprehensive summary of the evidence examining whether CPTSD symptomatology is related to poorer treatment outcome of CBT, reviews the literature on the treatment of CPTSD, and offers insights into current issues and future directions of the construct.     

The organisation and content of trauma memories in survivors of road traffic accidents

We investigated the trauma narratives of 131 road traffic accident survivors prospectively, at 1 week, 6 weeks, and 3 months post-trauma. At 1 and 6 weeks, narratives of survivors with acute stress disorder (ASD) or post-traumatic stress disorder (PTSD) were less coherent and included more dissociation content. By 3 months, their narratives also contained more repetition, more non-consecutive chunks, and more sensory words. Traumatic brain injury was associated with a separate characteristic, confusion, at all three time points. Three aspects of narrative organisation at 1 week--repetition, non-consecutive chunks, and coherence--predicted PTSD severity at 3 months after controlling for initial symptoms. The results suggest both a strong concurrent and predictive relationship between narrative disorganisation and ASD/PTSD but that as people recover from ASD, their narratives do not necessarily become less disorganised.     

First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

Background

Despite evidence supporting cognitive behavioural therapy (CBT)‐based interventions as the most effective approach for treating post‐traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)‐based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

Aims

Existing research exploring effective therapeutic interventions for PTSD includes trauma‐focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT‐based techniques over CBT‐based techniques for the treatment of PTSD.

Results

The evidence reviewed provided examples supporting PDT‐based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

Conclusion/Implications

The need to routinely observe evidence‐based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT‐based interventions for the treatment of PTSD are identified.     

Psychological Treatments for Symptoms of Posttraumatic Stress Disorder in Children,Adolescents, and Young Adults: A Meta-Analysis

Meta-analyses of the treatment of posttraumatic stress disorder (PTSD) in childhood and adolescence are restricted to specific trauma, selected interventions, and methodologically rigorous studies. This large meta-analysis quantifies the effects of psychological treatments for PTSD symptoms in children and adolescents. An extensive literature search yielded a total of 13,040 articles; 135 studies with 150 treatment conditions (N = 9562 participants) met the inclusion criteria (psychological interventions with children and/or adolescents with PTSD symptoms that report quantitative measures of symptom change). The mean effect sizes (ESs) for PTSD symptoms ranged from large to small, depending on the control condition. Cognitive behavioral therapy (CBT) yielded the highest ESs. Age and caretaker involvement were identified as moderators. CBT, especially when conducted in individual treatment with the inclusion of parents, is a highly effective treatment for trauma symptoms. Psychological treatments need to be modified to address younger patients’ specific needs.     

A prospective study of appraisals in childhood posttraumatic stress disorder

This study investigated the predictors of posttraumatic stress disorder (PTSD) in children following a diagnosis of traumatic injury. Children (N=76) aged between 7 and 13 who were admitted to hospital following injury were assessed within a month of trauma for acute stress disorder (ASD), negative appraisals, as well as parental stress reactions. Children (N=62) were re-assessed 6-months later for PTSD and negative appraisals. The majority of the variance of chronic posttraumatic stress was accounted for by negative appraisals about future harm. This study supports cognitive models of PTSD, and suggests that younger children who exaggerate their vulnerability after trauma exposure are high risk for PTSD after trauma.     

Traumatic memories and pseudomemories in posttraumatic stress disorder

Intrusive imagery was investigated in survivors of motor vehicle accidents with (a) posttraumatic stress disorder (PTSD) and accurate recall of the trauma, (b) PTSD and amnesia of the trauma, (c) no PTSD, or (d) control participants who simulated PTSD. Imagery was precipitated by presentation of an audiotape of a motor vehicle accident. Whereas the traumatic imagery of participants who had accurate recall of their trauma was consistent with third party accounts of the trauma, the imagery of amnesic participants was inconsistent with these accounts. Participants were then interviewed about cognitive and emotional aspects of their responses. All participants with PTSD and simulators reported similar levels of imagery detail, involuntariness, re-experiencing, and emotional response, and reported higher levels than participants with no PTSD. Findings are discussed in terms of cognitive and contextual factors that can mediate accurate and inaccurate traumatic imagery. © 1998 John Wiley & Sons, Ltd.     

Holocaust survivors in a primary care setting: fifty years later

Past studies have not assessed the prevalence of emotional disturbances in Holocaust survivors seeking medical treatment in a family practice environment. The present study examined the prevalence of lifetime (the presence of symptomatology at any time) and current posttraumatic stress disorder (PTSD) symptoms, general anxiety, and depression in Holocaust survivors seeking medical treatment in a primary care setting. 20 of the 27 Holocaust survivors in our sample received a current diagnosis of PTSD and reported significant symptoms of depression and general anxiety. Although 74% of the survivors were currently diagnosed with PTSD, participants in this study had reported an overall decline in reexperiencing, hyperarousal, and overall PTSD symptoms but exhibited increased avoidance and numbing symptoms throughout the lifespan. These preliminary results suggest that removing avoidance as a defense mechanism during the course of psychotherapy may leave these survivors without an adequate way for coping with their trauma, subsequently increasing their vulnerability to psychopathology. Implications for psychological interventions are provided.     

Trauma‐focused CBT with maltreated children: A clinic‐based evaluation of a new treatment manual

The effectiveness of a locally developed trauma‐focused cognitive behavioural therapy (TF‐CBT) program for maltreated children with post‐traumatic stress disorder (PTSD) was examined across different therapists in a child protection clinic setting. An earlier phase of the research piloting the program had provided promising results. This second phase involved two studies evaluating the completed TF‐CBT manual delivered by (a) the developer and (b) other therapists. A single‐case multiple‐baseline design was used to demonstrate the controlling effects of the treatment on PTSD symptoms and child coping. Eight 9–13‐year‐old abused children with PTSD were treated. Positive outcomes support the effectiveness of the TF‐CBT program delivered by both the developer and other therapists. The study design and methodology were robust enough to confirm empirically the clinically beneficial effects and potential for this new program. It was also apparent, however, from study limitations, including missing data for some patients, that there are a number of challenges in carrying out such research in a busy child protection service setting with multiply‐abused patients. This paper considers implications and ways forward for engaging in empirically supported practice as well as future development and research.     

Neurocognitive function in monozygotic twins discordant for combat exposure: relationship to posttraumatic stress disorder

Neuropsychological deficits have been reported among trauma survivors with posttraumatic stress disorder (PTSD). It is often assumed that these cognitive difficulties are toxic consequences of trauma exposure. Alternatively, they may reflect preexisting characteristics that contribute to the likelihood of developing PTSD. To address this possibility, the authors evaluated cognitive performance in monozygotic twin pairs who were discordant for combat exposure. Pairs were grouped according to whether the combat-exposed brother developed PTSD. The combat-unexposed cotwins of combat veterans with PTSD largely displayed the same performance as their brothers, which was significantly lower than that of non-PTSD combat veterans and their brothers. The results support the notion that specific domains of cognitive function may serve as premorbid risk or protective factors in PTSD.