Treatment of Posttraumatic Stress Disorder An Assessment of the Evidence (2008) / Chapter Skim
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4 Evidence and Conclusions: Psychotherapy
4 Evidence and Conclusions: Psychotherapy
Pages 93-136
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From page 93... ...
: exposure, cognitive restructuring, coping skills 93
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From page 94... ...
Exposure refers to several closely related techniques such as prolonged exposure, direct exposure therapy, and multiple channel exposure therapy, and they are evaluated here as one category, both alone and in combination with other approaches. The category of coping skills training includes stress inoculation therapy, relaxation, biofeedback, and so on.
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From page 95... ...
to wait-list or usual care controls. The category of exposure comprised exposure therapies alone and several different combinations of exposure with cognitive restructuring or coping skills training.
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From page 96... ...
One of these studies with no major limitations in male veterans with chronic PTSD showed both reductions in a primary PTSD scale and the loss of PTSD diagnosis with cognitive processing therapy (a combination of exposure and cognitive restructuring) (Monson et al., 2006)
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From page 97... ...
. The committee found it difficult to judge the validity of the results comparing exposure therapy to a coping skills training program or present-centered therapy overall because four of the eight studies had major limitations, but the remaining studies support the overall conclusion that exposure therapy is efficacious.
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From page 98... ...
-- had no major limitations and it showed that the two therapies were equivalent. The study was small, however, so the committee could not judge whether it had adequate power to detect a clinically significant difference, and thus did not reach a conclusion regarding the equivalency of the two treatments.
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From page 99... ...
EYE MOVEMENT DESENSITIZATION AND REPROCESSING The committee identified a diverse literature of 10 randomized trials of EMDR compared with various other therapies and wait list or alone compared with wait-list control. The mean age in these studies was in the 30s to the 40s (with a wider range for civilian studies, typically including participants from age 18 to the 70s, and a narrower range for studies in veterans, generally of the Vietnam War)
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From page 100... ...
ITT (LOCF) CAPS sexual abuse E+CR (36)
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From page 101... ...
Principal Limitations Yes No major limitations –32.9 Yes –13.2 Yes 76.73, 79.10 Yes No major limitations –24.59 –3.07 40% 3% Yes Yes NR No major limitations –23.4 –5.8 Yes 65.46, 68.30 Yes 93% No major limitations –56.5 26% –5.3 Yes 35.1, 30, 35.5 NR High dropout handled –16.1 with BOCF, high –13.7 Yes differential dropout –6.5 Yes Yes 74.85, 75.91 Yes 60% No major limitations –35.60 (compared to 0%, then –2.86, then delayed WL 50% –28.00 group, no after WL treated ) Yes 69.9, 67.7, 72.0 High attrition handled –16.8 Yes 27.6% with LOCF, high –20.5 Yes 31.8% differential dropout –6.5 17.4% Yes M(SD)
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From page 102... ...
ITT (LOCF) CAPS sexual abuse, E+CR (41)
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From page 103... ...
Principal Limitations Yes 68.2, 65.0, High dropout handled 65.8 with LOCF and high Yes 76.2% differential dropout –44.5 Yes 44.4% –24.9 –11.8 Yes 72.9, 71.9h High dropout handled –57.1 Yes 91% with LOCF and high –5.6, then No, then yes 80% differential dropout –49.8 Yes 25.2, 2.0, 19.5 (at 1-year No major limitations follow-up) –6.1 Yesi –2.2 No 71% +1.7 21% 20% Yes 80.9, 79.1 High dropout handled –70.8 Yes 94% with LOCF and high –3.0, then Yes 93% differential dropout –67.5 Yes 69 NR High dropout handled –38 Yes with LOCF and high –7 differential dropout Yes Yes NR High dropout, no –23.3 treatment of missing data, –13.5 high differential dropout –3 Yes Relatively high dropout –35.68 Yes 53% handled with LOCF –31.71 Yes 53% –0.59 2% continued
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From page 104... ...
k NR TSC-40l 2001 sexual abuse E+CR (14) Unclear CS (7)
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From page 105... ...
Principal Limitations NR NR NR High dropout handled –8.1 (both Tx No with LOCF and high groups) differential dropout, non –3.8 standard PTSD measure; assessor blinding or independence not reported Yes M(SD)
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From page 106... ...
If only one trauma type is listed, at least 80% of the study population reported that type of trauma. bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data)
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From page 107... ...
Diagnosis (%) Principal Limitations Yes 38% dropout handled –24.7 Yes 41.0% appropriately; 17% –17.8 27.8% differential dropout (odds ratio 1.8)
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From page 108... ...
If only one trauma type is listed, at least 80% of the study population reported that type of trauma. bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data)
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From page 109... ...
Principal Limitations Yes 80.41, 82.01 No ≥10 pts CAPS No major limitations –6.41 ↓ (34% dropout well –5.98 38.8% handled) 37.5% Yes 2 standard 32% dropout handled NR Yes deviations with LOCF No decrease in score but reported by symptom category Yes NR NR Dropout from 33% –30 Yes 25% to 46% handled with –36 Yes 35% LOCF –38 Yes 37% –14 45% Yes 32.5 No major limitation –19.8 Yes 90% –11.3 10% Yes –8.0 (E and All subjects EMDR groups)
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From page 110... ...
bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data) from baseline data (before treatment began)
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From page 111... ...
No 98.4, 95.1 Dropout data aggregated –52.4 Yes 25% for both arms; assessor –56.1 Yes blinding or independence not reported NR 36.25, 35.09 35% dropout without –21.83 Yes (superior) 58.33% adequate treatment; 15% –10.45 27.27% dropout differential; assessor blinding or independence NR Yes 77.76, 71.14 No No major limitations –26.94 42% –22.9 59% scores for all arms are nearly the same; otherwise, baseline scores listed individually in order of arm.
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From page 112... ...
The committee noted that some experts have questioned whether the eye movement component adds benefit to the reprocessing component, but the committee identified no adequately designed studies testing the hypothesis and so was unable to reach a conclusion. Synthesis: The committee found the overall body of evidence for EMDR to be low quality to inform a conclusion regarding treatment efficacy.
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From page 113... ...
COGNITIVE RESTRUCTURING The committee identified three RCTs of cognitive restructuring compared with coping skills training or an educational booklet. One study suffered high dropout rates (up to 46 percent)
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From page 114... ...
ITT (NR) CAPS 2005 sexual abuse E (23)
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From page 115... ...
Principal Limitations Yes ~64c Yes No major limitations –14.5 67% –1.9 11% Yes NR No No major limitations –33.23 73% –39.15 76% –30.95 59% Yes M(SD) NR No major limitations Yes 95% (but outcome data not Yes 75% reported)
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From page 116... ...
If only one trauma type is listed, at least 80% of the study population reported that type of trauma. bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data)
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From page 117... ...
Diagnosis (%) Principal Limitations Yes 2 standard 32% dropout handled NR Yes deviations with LOCF No decrease in score but reported by symptoms category Yes NR All subjects Outcome data aggregated, –8.0 (E and No 78% baseline uninterpretable EMDR groups)
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From page 118... ...
COPING SKILLS THERAPIES The committee found 10 RCTs of coping skills training compared to minimum care, or compared to another treatment modality and minimum care. Most of the trials had major limitations including high rates of dropout, inadequate handling of missing values, high differential dropout among arms, and lack of assessor blinding or independence.
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From page 119... ...
Principal Limitations Yes F I per PDSg No major limitations ~32f ~26 20.5 16.5 Yes 85.7% 9.7 7.1 21.4% 7.2 3.5 27.6% Yes 77.76, 71.14 No major limitations –26.94 No 42% –22.9 59% Yes NR NR Dropout from 33% to –30 Yes 75% 46% handled with LOCF –36 Yes 65% –38 Yes 63% –14 55% cSelf-help booklet. dRepeated assessments.
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From page 120... ...
ITT (LOCF) CAPS sexual abuse E+CR (29)
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From page 121... ...
Principal Limitations Yes 69.9, 67.7, 41% dropout handled 72.0 Yes 27.6% with LOCF; 28% –16.8 Yes 31.8% differential dropout –20.5 17.4% –6.5 Yes 68.2, 65.0, 65.8, DO 69.2 27.1% dropout rate; 21% Yes 76.2% differential dropout –44.5 Yes 44.4% –24.9 –11.8 No ~72 NR –15.02 39% dropout handled –19.17 Yes with LOCF and mean –5.88 Yes replacement; 39% differential dropout; no assessor blinding or independence Yes 25.2, 2.0, 19.5 (at 1-year follow-up) No major limitations –6.1 Yesf –2.2 No 71% +1.7 21% 20% NR NR No NR Dropout or completer –8.1 (both Tx numbers not reported; groups)
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From page 122... ...
If only one trauma type is listed, at least 80% of the study population reported that type of trauma. bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data)
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From page 123... ...
Principal Limitations Yes ~52 (at 3-month No major limitations follow-up)
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From page 124... ...
25Patients had mild to severe posttraumatic stress (not PTSD diagnosis)
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From page 125... ...
In general, studies of exposure (including studies of exposure plus cognitive restructuring and exposure plus coping skills training) administered the treatment in individual, rather than group sessions.
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From page 126... ...
If only one trauma type is listed, at least 80% of the study population reported that type of trauma. bPTSD outcome measure change data were obtained either directly from the study, when provided, or by subtracting data reported at treatment completion (not follow-up data)
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From page 127... ...
Principal Limitations Yes 100.0% Same as 42% dropout –83.3% Yes baseline and –25.0% change Yes 11.5e No major limitations (but –8 Yes 91% broken –3 50% in 4 Ss) No No relapse No assessor blinding or Yes at 30 months independence 31, 36 –21 80% –0 0% NR NR Assessor blinding or 19.4 Yes independence not reported 17.1 Yes 13.6 Yes 4.6 dOutcome measure was "recovery proportions," including no PTSD and fewer than six symptoms (SI-PTSD used to determine both)
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From page 128... ...
2005. Single-session be havioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial.
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From page 129... ...
Principal Limitations Yes 65.46, 68.30 Yes 93% No major limitations –56.5 26% –5.3 Yes M(SD) NR Dropout or completer Yes 91.7% numbers not reported 33.3% Yes 80.41, 82.01 No ≥10 pts drop No major limitations –6.41 on CAPS (34% dropout well –5.98 38.8% handled)
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From page 130... ...
2003. A randomized controlled trial of cognitive therapy, a self-help booklet, and re peated assessments as early interventions for posttraumatic stress disorder.
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From page 131... ...
1999. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims.
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From page 132... ...
2001. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial.
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From page 133... ...
2005. Randomized trial of cognitive-be havioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse.
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From page 134... ...
1997. A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims.
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From page 135... ...
1999. A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder.
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