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7 Treatment
Pages 231-292

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From page 231...
... and even those who have symptoms within 2 weeks after a traumatic event. The chapter begins with a description of the many psychosocial therapies whose efficacy is supported by an established evidence base -- randomized controlled trials (RCTs)
From page 232...
... Some studies use at least a 50% reduction in PTSD symptoms to indicate a satisfactory response; another indicator of a satisfactory response is a score of 15 on the Posttraumatic Stress Diagnostic Inventory to indicate subclinical PTSD severity and a score of 10 to indicate remission (Foa et al., 1993)
From page 233...
... Many treatment programs combine components of each of those general treatment groups, and CBT has become an overarching concept that includes variants of exposure therapy, stress inculcation training, cognitive therapies, and their combinations. Exposure Therapies Exposure therapies are designed to reduce PTSD symptoms and related problems (such as depression, anger, and guilt)
From page 234...
... and acute stress disorder (Bryant et al., 1999; Foa et al., 1995, 2006)
From page 235...
... is another exposure therapy protocol that has been examined in RCTs both as an addendum to PE and as a stand-alone therapy for victims of childhood sexual abuse. The patient first engages in an imaginal exposure, immediately followed by a rescripting, in which the patient is encouraged to revisit the trauma while developing mastery imagery by imagining himself or herself as an adult entering
From page 236...
... . Other meta-analyses have shown that exposure therapy is more effective than "non–trauma-focused" treatments or WL in reducing PTSD symptoms, but the differences in outcomes among the different exposure therapies was not significant (Bisson and Andrew, 2007; Seidler and Wagner, 2006)
From page 237...
... In PTSD treatment, the target is thoughts and beliefs related to a traumatic experience (for example, survival guilt, self-blame for causing the trauma, feelings of personal inadequacy, or worries about the future) with the goal of modifying them to reduce PTSD symptoms and improve mood and functioning.
From page 238...
... Two RCTs that compared cognitive trauma therapy for battered women to WL found that patients who received the treatment experienced large reductions in PTSD symptoms, depression, and guilt, and increases in self-esteem (Kubany et al., 2003, 2004)
From page 239...
... Significant reductions in PTSD symptoms and anxiety symptoms were detected compared with the result of WL in an RCT of 42 police officers after the 16 sessions and at 3-month follow-up. It is unclear which of the several treatment compo
From page 240...
... . The results of the studies suggest that relaxation has at best a moderate effect on PTSD symptoms, but it is not as effective as exposure or cognitive therapy.
From page 241...
... Imaginal exposure but not STAIR reduced PTSD symptoms; moreover, imaginal exposure increased emotional regulation as much as did STAIR despite being delivered at the second stage of treatment. In a follow-up study, Cloitre et al.
From page 242...
... No differences were found between groups in PTSD symptoms after treatment, and both groups showed significant improvements.
From page 243...
... Finally, multiple channel exposure therapy -- which incorporates PE, CPT, and interoceptive exposure for panic disorder -- was found to be superior to a control group in women who have PTSD and comorbid panic attacks (Falsetti et al., 2005)
From page 244...
... Until the results from the four ongoing RCTs are available, there is insufficient evidence for the efficacy of the virtual Iraq/Afghanistan VRE in reducing PTSD symptoms. Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT)
From page 245...
... is a mixed individual and group therapy for veterans who have combat-related PTSD that focuses on such PTSD symptoms as social withdrawal, numbing, expression of anger, and interpersonal difficulties. The therapy combines intensive individual exposure therapy, programmed practice, and structured social and emotional skills training groups.
From page 246...
... The VA/DoD, International Society for Traumatic Stress Studies (ISTSS) , American Psychiatric Association (APA)
From page 247...
... . A meta-analysis of the effectiveness of pharmacotherapy compared with psychotherapy for the treatment of combat-related PTSD found that pharmacotherapy resulted in a significantly greater decrease in PTSD symptoms from baseline than did psychotherapy within a 6-month timeframe, based on standardized scores (Stewart and Wrobel, 2009)
From page 248...
... , analysis of response by trauma type found that combat-related PTSD responded better to the drug than to placebo; however, the number of cases of combat-related PTSD in these studies was small, less than 10% of the total number of patients in each RCT. There have been no placebo-controlled trials of the SSRIs fluvoxamine or escitalopram.
From page 249...
... Anticonvulsants Four placebo-controlled trials have failed to show the benefit of lamotrigine, tiagabine, topiramate, or divalproex (Davidson et al., 2007; Davis et al., 2008a; Hertzberg et al., 1999; Tucker et al., 2007)
From page 250...
... or single dose use in close proximity to psychotherapy that this is difficult to translate into everyday clinical situations. Antiadrenergic Drugs The alpha-1 adrenergic blocker prazosin has been shown to be more effective than placebo for reducing PTSD-associated sleep disturbances in three trials, two in veterans with combat-related chronic PTSD (Raskind et al., 2003, 2007)
From page 251...
... . Special Considerations in Pharmacotherapy for PTSD There are two issues that merit consideration when prescribing pharmacotherapy for PTSD: polypharmacy, the use of multiple drugs for PTSD symptoms; and maintenance of drug therapy and its implications for relapse.
From page 252...
... There have been five trials of long-term maintenance or relapse prevention in people who responded to short-term treatment with antidepressants or anticonvulsants in PTSD. Two placebo-controlled relapseprevention studies found that fluoxetine maintenance led to a lower chance of relapse than placebo over 1 year (Davidson et al., 2005b; Martenyi et al., 2002a)
From page 253...
... ; however, combination strategies that involve acute administration of DCS during exposure therapy are being studied (for example, Ressler et al., 2004)
From page 254...
... . INTEGRATIVE COLLABORATIVE CARE Three large-scale randomized effectiveness trials have successfully used collaborative care models to target and reduce PTSD symptoms in civilian patients presenting at primary care and acute care medical settings (Craske et al., 2011; Zatzick et al., 2004, 2012)
From page 255...
... . Among the six couples who completed the treatment, five of the patients no longer met the criteria for PTSD, and there were across-treatment effect-size improvements in patients' total PTSD symptoms according to independent clinician assessment and reports from the patients and partners.
From page 256...
... Although there are findings related to moderation of PTSD symptoms, improvements in relationship satisfaction proved to be uneven. Limitations of this study include the small sample size and the absence of a control sample (Monson et al., 2011)
From page 257...
... PTSD symptoms were significantly associated with the degree of relationship concerns. Finally, soldiers revealed a surprising preference for family-based interventions over individual treatment and attached higher importance to family-based interventions tailored to address mental health problems and co-occurring family problems.
From page 258...
... (2010) obtained beneficial results with SKY in a nonrandomized controlled trial with 183 survivors of the 2004 Asian tsunami; SKY alone and SKY followed by 3–8 hours of exposure therapy were both more effective than a 6-week WL.
From page 259...
... Both treatments produced improvement, but the combined CBT–acupuncture group performed significantly better. Emotional Freedom Technique and Thought Field Therapy The emotional freedom technique (EFT)
From page 260...
... brainwave neurofeedback therapy. One study conducted in 20 Vietnam combat veterans who had PTSD and comorbid alcohol abuse found significant improvement after treatment that was maintained at 30 months (Peniston, 1998; Peniston and Kulkosky, 1991)
From page 261...
... . Three brief case reports of patients who had PTSD symptoms after sexual trauma and responded to homeopathy were identified (Coll, 2002; Katz, 1996; Morrison and National Center for Homeopathy, 1993)
From page 262...
... . A retrospective chart review found that 12 patients who had PTSD and depression responded partially, that is, depressive but not PTSD symptoms improved after electroconvulsive therapy (Watts, 2007)
From page 263...
... . Results indicated that 40 therapy sessions in 1 month were safe and that there were significant improvements in both postconcussive syndrome and PTSD symptoms (Harch et al., 2012)
From page 264...
... At the very least, the committee believes mental health care providers in the DoD and the VA should adhere to their own guideline for the management of PTSD in service members and veterans, respectively. VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress This guideline, issued in 2010, constitutes an update of the 2004 guideline (VA and DoD, 2004, 2010)
From page 265...
... The working group noted that therapy provided in clinical trial settings differs from therapy practiced in day-to-day care, and the recommendations in the guideline represent the techniques and protocols as reported in the RCTs. Although benzodiazepines have historically been used as effective treatments for anxiety and insomnia, the guideline recommends against their use as preventive measures "due to lack of evidence for effectiveness and risks that may outweigh potential benefits." Studies with propranolol have had mixed results, and overall the VA/DoD guideline concluded that despite some positive results, "the size and weak study designs of the investigations do not allow for definitive conclusions regarding the value of these medications in preventing the development of PTSD symptoms after traumatic events." The VA/DoD 2010 guideline states that "there is insufficient evidence to draw concrete conclusions or make specific recommendations regarding the use of pharmacological agents for prevention of PTSD." The guideline further concludes that there is insufficient evidence to recommend the use of CAM approaches as a first-line treatment for PTSD; however, it states that CAM approaches may be considered as adjunctive treatments for specific symptoms of PTSD such as relaxation techniques (for example, yoga and massage)
From page 266...
... The guidance also states that clinicians should use the 2010 VA/ DoD guideline when treating patients with symptoms of traumatic stress. American Psychiatric Association Guideline The APA published Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder in October 2004 and followed it with a Guideline Watch in March 2009, which updated the research review of PTSD treatments.
From page 267...
... Using the questions as guidance, a group separate from the guideline development group reviewed RCTs and conducted formal meta-analyses. Effect sizes for clinical effectiveness were determined, as were relative risk ratios to represent clinically significant differences.
From page 268...
... Australian National Health and Medical Research Council Guidelines The Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder were published by the Australian Centre for Posttraumatic Mental Health (NHMRC, 2007)
From page 269...
... International Society for Traumatic Stress Studies Guidelines A group of PTSD treatment experts developed a set of PTSD treatment guidelines, Effective Treatments for PTSD: Second Edition, for ISTSS, a group of practitioners in different disciplines, which were issued in 2009. The focus of the guidelines was on identifying any evidence available to support the use of numerous psychotherapeutic and psychopharmacologic treatments for PTSD that were currently in use.
From page 270...
... Patient education C Relaxation C Dialectic behavioral I Therapy Acceptance and I commitment therapy Family therapy I
From page 271...
... MAOI = monoamine oxidase inhibitor; SNRI = serotonin norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.
From page 272...
... The committee further found there was sufficient evidence on the basis of RCTs of the efficacy of exposure therapy to treat PTSD, but that there was inadequate evidence for the efficacy of EMDR, cognitive restructuring, and coping skills training. The committee also concluded there was inadequate evidence on the efficacy of therapy delivered in a group format.
From page 273...
... The drugs are fluoxetine, paroxetine, sertraline, and venlafaxine-extended release. SUMMARY There are numerous psychosocial treatments for PTSD, many of which are variants of evidence-based treatments, such as exposure therapy and cognitive therapy.
From page 274...
... 2010. Efficacy of exposure therapy for Japanese patients with posttraumatic stress disorder due to mixed traumatic events: A randomized controlled study.
From page 275...
... 2009. Group cognitive behavior therapy for chronic posttraumatic stress disorder: An initial randomized pilot study.
From page 276...
... 2008. A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder.
From page 277...
... 2004. Repetitive transcranial magnetic stimulation of the right dorsolateral prefrontal cortex in post traumatic stress disorder: A double-blind, placebo-controlled study.
From page 278...
... 2006a. Treatment of posttraumatic stress disorder with venlafaxine ex tended release -- a 6-month randomized controlled trial.
From page 279...
... 2002. Virtual reality exposure therapy for World Trade Center post-traumatic stress disorder: A case report.
From page 280...
... 1999a. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims.
From page 281...
... 2007. Acupuncture for posttraumatic stress disorder: A randomized controlled pilot trial.
From page 282...
... 2011. Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: A review.
From page 283...
... 2001. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial.
From page 284...
... 2011. Prolonged exposure therapy for post-traumatic stress disorder: A review of evidence and dissemination.
From page 285...
... 2010. Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: A randomized control comparison with treatment as usual.
From page 286...
... 2002. A controlled comparison of eye movement desensitization and reprocessing ver sus exposure plus cognitive restructuring versus waiting list in the treatment of post traumatic stress disorder.
From page 287...
... 2001. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder.
From page 288...
... 2007. Cognitive be havioral therapy for posttraumatic stress disorder in women -- a randomized controlled trial.
From page 289...
... 2008. Paroxetine-CR augmenta tion for posttraumatic stress disorder refractory to prolonged exposure therapy.
From page 290...
... 2008. Treating acute stress disorder and posttraumatic stress disorder with cognitive behavioral therapy or structured writing therapy: A randomized controlled trial.
From page 291...
... 1994. A trial of eye movement desensitization compared to image habituation training and ap plied muscle relaxation in post-traumatic stress disorder.
From page 292...
... 1997. An affect-management group for women with posttraumatic stress disorder and histories of childhood sexual abuse.


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