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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence 4 Evidence and Conclusions: Psychotherapy Psychotherapeutic interventions for posttraumatic stress disorder (PTSD) vary in their emphasis on reexposure to trauma-related memories and stimuli, cognitive restructuring of the trauma experience, expression and management of emotion, training in stress management (including relaxation training), and general social and vocational support. Although a number of these treatments emphasize one of these components, many combine more than one either implicitly or by design, and relatively few studies dismantled effective components of the psychotherapy. A more complete description of psychotherapy is provided in Appendix A. The committee noted that virtually all of the recent literature on psychotherapies for PTSD examines interventions that some experts consider components of cognitive-behavioral therapy (CBT). For example, Harvey et al. (2003) describe four basic components of CBT: psychoeducation, exposure, cognitive restructuring, and anxiety management training. The theoretical literature also acknowledges the overlap among these approaches as well as incomplete understanding of the mechanisms at work when these interventions are used (Foa and Meadows, 1997; Foa et al., 2000; Harvey et al., 2003). Nonetheless, the committee found that the psychotherapeutic approaches studied in the literature are segmented into CBT components alone and in various combinations. In presenting the summaries below, the committee has grouped therapies based on its understanding of the psychotherapeutic literature and for convenience of exposition, but is aware that others have and may organize the literature differently. The committee identified the following categories of psychotherapies (as used in a treatment condition or “arm”): exposure, cognitive restructuring, coping skills
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence training, exposure plus cognitive restructuring, exposure plus coping skills, eye movement desensitization and reprocessing (EMDR), other psychotherapies, and group format psychotherapy. 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. The category of cognitive restructuring refers to psychotherapies designed to help individuals with PTSD alter their understanding of the meaning of their traumatic experiences, for example, by considering their adaptive responses to the trauma as well as the helplessness inflicted by it. The treatment modalities assessed in this chapter were individually administered with a few exceptions where psychotherapy was administered in a group format. The majority of psychotherapy studies compared one or more active treatments to a wait-list control. Less frequently, the control was usual care (such as non-PTSD specific care) or minimum care (such as phone counseling). A smaller proportion of the psychotherapy studies compared active treatment to an active control such as a coping skills training program (e.g., relaxation) or present-centered therapy. The committee included 52 studies of psychotherapies (reasons for exclusion are listed in the individual sections below). Of the included studies, 18 had no major limitations and thus were most informative to the committee’s conclusions regarding efficacy of a treatment modality (see evidence tables following each treatment for a summary of these studies), but such studies were considered in the context of the body of evidence for each treatment modality. Trauma types in these studies included combat (within the United States and internationally), sexual abuse, physical assault, accidental injury, motor vehicle accidents (MVAs), natural disaster, witnessing (death or genocide), being a victim of crime, and being a refugee. When analyzing the studies by sex, population, or trauma type, the committee labeled the study as being “predominantly” one type of sex, population, or trauma if 80 percent of the study population or more was of one type of sex, population, or trauma. The committee labeled the study as “mixed” if 79 percent or less of the study population was of one type of sex, population, or trauma. Eleven studies had a predominantly male population, 25 had a female population, and 15 had a mixed (male and female) population. Ten studies were in veteran populations, 17 included victims of sexual or physical abuse, and 23 had a mixed or other trauma type.1 The committee found that in the psychotherapy literature, as in the pharmacotherapy literature, with few exceptions, when a veteran 1 Some studies did not include sex or trauma type.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence population predominated, the participants were mostly male, and when the majority of cases had been sexually abused or assaulted, participants were mostly female although there are instances when that is not the case. With mixed trauma type, the sex ratios were more equally divided. EXPOSURE THERAPIES The committee found a substantial number of randomized controlled trials (RCTs) comparing exposure therapies (alone or with some other component) 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. The large number of studies of exposure therapy comprises the range of features found in the rest of the psychotherapy studies, with regard to length of treatment, variety of trauma, age of participants, training of clinicians, and so on. Participants in the exposure therapy studies had suffered a variety of traumas, including combat-related, sexual abuse and/or assault, civil war, and motor vehicle accident. The mean age of study participants ranged from early-20s to the 50s, with most studies reporting a mean age between the mid-30s and mid-40s. Few studies reported duration of illness, but many provided information about the time since trauma, which ranged from several months in studies with rape survivors to more than two decades in studies with veterans. Some studies, such as those in survivors of sexual assault, included only female participants, while many others had a mix of men and women, and studies in people traumatized by combat had all male participants. Some, but not all, studies provided information about the race/ethnicity of participants. In most studies, participants were white, with a smaller number of studies reporting percentages of non-white participants at approximately 20 percent, 30 percent, and in a few cases, nearly 50 percent. Exposure therapy included psychoeducation, breathing retraining, and relaxation, in addition to exposure (specifically imaginal and in vivo exposure, flooding, directed therapeutic exposure, etc.). Some exposure therapy programs also required completing homework, generally repeated exposure to a trauma tape or other record of the trauma narrative. Exposure studies, like other psychotherapy studies, are lengthy and require considerable investment of time, emotion, and effort. Most studies administered exposure and usually also the comparison treatments for at least several weeks (e.g., 4.5, 9–12, 30 weeks). Only a small number of studies provided treatment in one session or for a short time: one 60-minute session in Basoglu et al. (2005), one session in Basoglu et al. (2007), two 90-minute sessions in Boudewyns et al. (1993).
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Most studies reported that study therapists had at least master’s level training and frequently held doctorates in psychology, clinical psychology, or clinical social work. Only one study used therapists with less then graduate training but considerable counseling experience, and a few studies used graduate students. Most studies used psychologists, but several studies also used marriage and family counselors (MFCCs), licensed clinical social workers, and one study also used nurses. The majority of studies reported that study therapists were trained and supervised. The majority of exposure therapy studies did not report on or measure adverse events associated with their treatment condition. Only Monson et al. (2006), Foa et al. (2005), Schnurr et al. (2007), and Chard (2005) measured adverse events. Many studies conducted follow-up after the completion of treatment. The earliest timing of follow-up assessments was 1 month, and the latest was between 1 and 2 years after treatment. Some studies took follow-up measures at 3, 6, and 9 months post-treatment. Of the 23 studies in this category, 16 had major limitations including high dropout rates,2 absent or weak treatment of missing values, lack of assessor independence, not conducting an intention to treat analysis, or failure to report a critical characteristic (Blanchard and Hickling, 2004; Boudewyns et al., 1993; Classen et al., 2001; Cloitre et al., 2002; Falsetti et al., 2001; Foa et al., 1991, 1999, 2005; Glynn et al., 1999; Keane et al., 1998; Kubany et al., 2003, 2004; McDonagh et al., 2005; Power et al., 2002; Resick et al., 2002; Rothbaum et al., 2005). Eight studies met most or all of the quality criteria outlined in Chapter 2 (the main shortcoming in two of these studies was in the handling of substantial dropout rates with less robust statistical methods and or assessor blinding or independence) (Basoglu et al., 2005, 2007; Chard, 2005; Fecteau and Nicki, 1999; Hinton et al., 2005; Keane et al., 1989; Monson et al., 2006; Rothbaum et al., 2005). All eight of these studies demonstrated a statistically significant improvement with treatment to a primary PTSD scale or to the loss of PTSD diagnosis. 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). The committee identified eight additional RCTs comparing exposure therapies to an active control (coping skills training program or present-centered therapy). Four of the studies had major limitations, such as high dropout rates and either presenting only a completer analysis or using last observation carried forward (LOCF) despite dropout rates of up to 2 The APA (2004) review of the literature identifies high rate of dropout as a challenge of exposure therapies.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence 40 percent (Boudewyns et al., 1990; Marks et al., 1998, 2007; Taylor et al., 2003; Vaughan et al., 1994). Four studies had few or no limitations. One small study conducted among mostly female victims of abuse or MVA found substantial decrease in Clinician Administered PTSD Scale (CAPS) scores and loss of diagnosis (Bryant et al., 2003). One was conducted in male veterans with chronic PTSD showing no benefit of trauma-focused therapy administered in groups compared with present-centered therapy (Schnurr et al., 2003). Another study among female veterans with PTSD, 70 percent of whom nominated sexual assault as their index (worst) trauma, showed a benefit of individually administered exposure therapy (Schnurr et al., 2007). A single small study of female victims of sexual assault showed significant improvements in both a global PTSD scale and in loss of diagnosis (Echeburua et al., 1997). 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. Synthesis: The committee judged that the quality of the overall body of evidence supporting exposure therapies is moderate to high, with the best studies all pointing in the same direction with an important clinical benefit. The committee is confident in both the presence of a positive effect and in its clinical significance. Further research is likely to refine estimates of the effect in different settings and populations, but is unlikely to change confidence in the overall estimate of effect. Conclusion: The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD. Comment The evidence for efficacy of exposure therapy in veterans—especially in males with chronic PTSD—is less consistent than the general body of evidence. Also, it should be noted that, as described above and in Appendix A, exposure therapies (e.g., prolonged exposure), as delivered often contain components of other CBT approaches, such as cognitive restructuring and coping skills training. Thus the conclusion that the evidence supports the efficacy of exposure therapy should not be interpreted too narrowly. Head-to-Head Comparisons Because the committee judged the evidence sufficient to establish efficacy of exposure therapies, it also reviewed the literature where an
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence exposure therapy was compared with some other intervention.3 If evidence strongly supported equivalency of the other therapy compared with exposure therapy, it would add support for the other therapy. We identified seven such studies, but only one—a comparison of exposure therapy with cognitive restructuring in a mixed trauma population (Tarrier et al., 1999)—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. Exclusion Notes Several exposure trials were excluded because they were not randomized (or only partially randomized) (Brady et al., 2001;4 Cloitre and Koenen, 2001;5 Cooper and Clum, 1989;6 Humphreys et al., 1999;7 Monson et al., 20058). Trials that did not include a comparison or control group were also excluded (Basoglu et al., 2003;9 Forbes et al., 2002;10 Frommberger et al., 2004;11 Najavits et al., 1998). Three trials included participants not formally diagnosed with PTSD, or only part of the sample was diagnosed so were excluded (Foa et al., 1995;12 Lubin et al., 1998;13 Valentine and Smith, 2001). There were also two studies where PTSD was not the main 3 After this report was released an additional head-to-head study was brought to the committee’s attention (Ironson et al., 2002). Because of lack of clarity regarding inclusion criteria, the randomization protocol, and the treatment actually delivered, the study was uninformative regarding the principal comparison of PE to EMDR. 4 This study also looked at dual diagnosis (PTSD and cocaine addiction) and had a high dropout rate greater than 50 percent. 5 This was a naturalistic study where treatment was interpersonal process group therapy in patients with and without bipolar disorder. 6 Randomization was not 100 percent. Patients were assigned to standard treatment or standard treatment plus imaginal flooding. 7 Program evaluation. 8 This was a preliminary program effectiveness study that compared two variations of CBT in a veteran population. 9 Modified behavioral treatment given to N = 231 earthquake survivors; duration of treatment and improvement of symptoms were outcomes. 10 Longitudinal trial examining predictors of response versus treatment efficacy. 11 This trial compared paroxetine treatment (10–50 mg dosages given) versus CBT treatment (exposure and cognitive restructuring). PTSD and depression symptomatology were outcome variables. 12 Subjects diagnosed with PTSD per Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III), but mean duration of illness was 15 days (9.40 for control), corresponding to the current definition for acute stress disorder. 13 Patients only had PTSD symptoms, not PTSD diagnosis.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence study outcome, and neither study included overall PTSD outcome measures (Boudewyns and Hyer, 1990; Chemtob et al., 199714). Falsetti et al. (2003) was excluded because it is an additional analysis of Falsetti et al. (2001) that does not include PTSD outcome data (although it includes other data for the complete sample, unlike the 2001 publication, which was preliminary). See Tables 4-1, 4-2, and 4-3 for a summary of included studies. 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). The sex of participants varied in a pattern similar to that described in Chapter 3—in four studies where the trauma was combat, most or all participants were male; participants in the two studies with sexual assault/abuse victims were all female, and participants with a variety of trauma types included a mix of men and women. Approximately half of the studies provided race/ethnicity data, with the range of white participants from 54 to 68 percent. Most studies reported duration of PTSD diagnosis or exposure to index trauma with a range from approximately 1 year in a study of occupational witnessing man-under-train accidents to two decades in the case of veterans. Treatment length ranged from 2 sessions to 10 weekly sessions, and duration of sessions was generally 90 minutes. Most studies provided information about therapists administering the treatment, and they typically were reported as being licensed, trained at master’s level or above, and having received EMDR training (some had level II training). Most therapists also were supervised. Some studies did not conduct follow-up after the completion of treatment, while others conducted follow-up at 3, 6, 12, or 15 months. Six trials had major limitations such as lack of assessor blinding or independence, high dropout rates, or weak (or no) treatment of missing values (Boudewyns et al., 1993; Jensen, 1994; Marcus et al., 1997; Power et al., 2002; Rothbaum, 1997; Silver et al., 1995). Four studies had few or no major limitations, and of those, two showed statistically significant improvement in CAPS score or a significant difference in loss of diagnosis in the treated group (Carlson et al., 1998; Hogberg et al., 2007; Rothbaum et al., 2005; van der Kolk et al., 2007). The study by Carlson and colleagues was a small trial in male veterans, and it showed no effect post-treatment. The study by van der Kolk and colleagues was an RCT comparing EMDR, 14 Anger is main outcome. This trial was done with Vietnam War veterans.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence TABLE 4-1 Exposure Study Populationa Arm (N) Handling of Dropouts and % Completed Tx by Arm PTSD Outcome Measure Basoglu et al., 2007 Female, nat. disaster Total (31) 100% CAPS E (16) WL (15) Monson et al., 2006 Male, combat Total (60) ITT (random regression) CAPS E+CR (30) 80% WL (30) 87% Basoglu et al., 2005c Female, nat. disaster Total (59) 100% CAPS E+CR (31) WL (28) Chard, 2005 Female, sexual abuse Total (71) ITT (LOCF) CAPS E+CR (36) 83.3% MC (35) 80.0% Foa et al., 2005 Female, S&NS abuse Total (179) ITT (BOCF)d PSS-I E (79) 59% E+CR (74) 66% WL (26) 96% Hinton et al., 2005 Mixed sex, witness genocide Total (40) None CAPS E+CR No dropouts WL, then E+CRe McDonagh et al., 2005 Female, sexual abuse Total (74) ITT (LOCF) CAPS E+CR (29) 59% CS (22) 91% WL (23) 87% Rothbaum et al., 2005 Female, sexual abuse, assault Total (72) ITT (but only completer reported) CAPS 83.3% total E (23) 87.0% EMDR (25) 80.0% WL (24) 83.3%
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Assessor Blinded? Baselineb and Change in PTSD Measure Statistically Significant? (versus control) Loss of Diagnosis (%) 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 with BOCF, high differential dropout −16.1 −13.7 Yes −6.5 Yes Yes 74.85, 75.91 Yes 60% No major limitations −35.60 (compared to delayed WL group, no after WL treated ) 0%, then −2.86, then 50% −28.00 Yes 69.9, 67.7, 72.0 High attrition handled with LOCF, high differential dropout −16.8 Yes 27.6% −20.5 Yes 31.8% −6.5 17.4% Yes M(SD) NR Treatment of missing data not reported Yes 95% Yes 75% 10%
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Study Populationa Arm (N) Handling of Dropouts and % Completed Tx by Arm PTSD Outcome Measure Blanchard et al., 2004 Mixed sex, MVA Total (98) ITT (reanalysis incl. dropouts) CAPS E+CR (36) 75.0% CS (37) 72.9% WL (25) 96.0% Kubany et al., 2004 Female, abuse Total (125) ITTg CAPS E+CR-If (63) 73.1% E+CR-Df (62) 56.5% Neuner, 2004 Female, mixed Total (43) Restricted maximum likelihood procedure PTSD diagnosis per PDS E (17) 94% CS (14) 86% MC (12) 100% Kubany et al., 2003 Female, assault Total (37) ITT (LOCF) CAPS E+CR-If (19) 94.7% E+CR-Df (18) 77.7% Cloitre et al., 2002 Female, S&NS abuse Total (58) ITT (LOCF) CAPS E+CS (31) 71% WL (27) 89% Power et al., 2002 Mixed sex, MVA, other Total (105) None IOEj EMDR (39) 70% E+CR (37) 59% WL (29) 83% Resick et al., 2002 Female, sexual abuse, assault Total (121) ITT (LOCF) CAPS E+CR (41) 73.2% E (40) 72.7% MC (40) 85.1%
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Assessor Blinded? Baselineb and Change in PTSD Measure Statistically Significant? (versus control) Loss of Diagnosis (%) Principal Limitations Yes 68.2, 65.0, High dropout handled with LOCF and high differential dropout 65.8 Yes 76.2% −44.5 Yes 44.4% −24.9 −11.8 Yes 72.9, 71.9h High dropout handled with LOCF and high differential dropout −57.1 Yes 91% −5.6, then No, then yes 80% −49.8 Yes 25.2, 2.0, 19.5 (at 1-year follow-up) No major limitations −6.1 Yesi −2.2 No 71% +1.7 21% 20% Yes 80.9, 79.1 High dropout handled with LOCF and high differential dropout −70.8 Yes 94% −3.0, then Yes 93% −67.5 Yes 69 NR High dropout handled with LOCF and high differential dropout −38 Yes −7 Yes Yes NR High dropout, no treatment of missing data, high differential dropout −23.3 −13.5 −3 Yes Relatively high dropout handled with LOCF −35.68 Yes 53% −31.71 Yes 53% −0.59 2%
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence TABLE 4-8 Other Psychotherapies Study Populationa Arm (N) Handling of Dropouts and % Completed Tx by Arm PTSD Outcome Measure Lindauer et al., 2005 Mixed sex, mixed trauma Total (24) ITT PTSD diagnosis per SI-PTSD OT (BEP)c (12) 58% WL (12) 92% Gersons et al., 2000 Mixed sex, police work Total (42) NR PTSD symptomsd(SI-PTSD data NR) OT (BEP) (22) 100% WL (20) 95% Peniston and Kulkosky, 1991 Total (29) MMPI-PTSD Male, trauma type NR OT (BN)f (15) UCg (14) 100% Brom et al., 1989 Mixed sex, mixed trauma Total (112) NR IES Total E (31) 90.3% OT (H)h (29) 89.7% OT (P)i (29) 89.7% WL (23) 86.9%+ aIn the population column, male alone or female alone denotes that at least 80% of the study population was male or female. 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) from baseline data (before treatment began). Average baseline score when reported or when baseline scores for all arms are nearly the same; otherwise, baseline scores listed individually in order of arm. cBrief eclectic psychotherapy, a combination of CBT and psychodynamic approaches including relationship and work issues. what was considered an adequate dose of 80 percent of treatment sessions). See Table 4-9 for a summary of included studies. Synthesis: The committee judged the overall body of evidence regarding group therapy formats to be low quality to inform a conclusion regarding efficacy because of the lack of well-designed studies comparing group and individual formats and including appropriate controls. The committee is uncertain about the presence of an effect, and believes that future well-designed studies will have an important impact on confidence in the effect and the size of the effect.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Assessor Blinded? Baselineb and Change in PTSD Measure Statistically Significant? (versus control) Loss of Diagnosis (%) Principal Limitations Yes 100.0% Same as baseline and change 42% dropout −83.3% Yes −25.0% Yes (but broken in 4 Ss) 11.5e No major limitations −8 Yes 91% −3 50% No No relapse at 30 months No assessor blinding or independence Yes 31, 36 −21 80% −0 0% NR NR Assessor blinding or independence not reported 19.4 Yes 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). eData not provided; figures estimated based on visual inspection of a bar graph, with the help of a ruler. fBrainwave neurofeedback. gUsual care. hHypnosis. iPsychodynamic therapy. Conclusion: The committee concludes that the evidence is inadequate to determine the efficacy of group therapy formats in the treatment of PTSD. SUMMATION Based on its assessment of the psychotherapy approaches for which randomized controlled trials were available—exposure, EMDR, cognitive
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence TABLE 4-9 Group Therapy Study Populationa Arm (N) Handling of Dropouts and % Completed Tx by Arm PTSD Outcome Measure Chard et al., 2005 Female, sexual abuse Total (71) ITT (LOCF) CAPS E+CR (36) 83.3% MC (35) 80.0% Falsetti, et al. 2001 Female, mixed trauma Total (22) NR CAPS E (7) Unclear WL (15)m Schnurr et al., 2003 Male, combat Total (360) Mixed model CAPS E+CR (180) 66% CS (PCT) (180) 75% Zlotnick, 1997 Female, childhood sexual abuse Total (48)c Completers DTS CS (17) 71% WL (16) 75% aIn the population column, male alone or female alone denotes that at least 80% of the study population was male or female. 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 restructuring, coping skills training, other therapies, and psychotherapies administered in a group format—the committee found the evidence for all but one psychotherapeutic approach inadequate to reach a conclusion regarding efficacy. The evidence was sufficient to conclude the efficacy of exposure therapies in treating patients with PTSD. REFERENCES APA (American Psychiatric Association). 2004. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Washington, DC: APA. Basoglu, M., M. Livanou, E. Salcioglu, and D. Kalender. 2003. A brief behavioural treatment of chronic post-traumatic stress disorder in earthquake survivors: Results from an open clinical trial. Psychological Medicine 33(4):647-654. Basoglu, M., E. Salcioglu, M. Livanou, D. Kalender, and G. Acar. 2005. Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress 18(1):1-11. Basoglu, M., E. Salcioglu, and M. Livanou. 2007. A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator. Psychological Medicine 37(2):203-213.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence Assessor Blinded? Baselineb and Change in PTSD Measure Statistically Significant? (versus control) Loss of Diagnosis (%) Principal Limitations Yes 65.46, 68.30 Yes 93% No major limitations −56.5 26% −5.3 Yes M(SD) NR Dropout or completer numbers not reported Yes 91.7% 33.3% Yes 80.41, 82.01 No ≥10 pts drop on CAPS No major limitations (34% dropout well handled) −6.41 −5.98 38.8% 37.5% No (self-response) 66.88, 74.69 29% dropout rate with completers analysis −21.12 Yes 87% − 1.63 41% provided, or by subtracting data reported at treatment completion (not follow-up data) from baseline data (before treatment began). Average baseline score when reported or when baseline scores for all arms are nearly the same; otherwise, baseline scores listed individually in order of arm. cFifteen dropped out. Blanchard, E. B., and E. J. Hickling. 2004. The Albany treatment study: A randomized, controlled comparison of cognitive-behavioral therapy and support in the treatment of chronic PTSD secondary to MVAs. In After the crash: Psychological assessment and treatment of survivors of motor vehicle accidents, 2nd ed. Washington, DC: American Psychological Association. Pp. 315-347. Boudewyns, P. A., and L. Hyer. 1990. Physiological response to combat memories and preliminary treatment outcome in Vietnam veteran PTSD patients treated with direct therapeutic exposure. Behavior Therapy 21(1):63-87. Boudewyns, P. A., and L. A. Hyer. 1996. Eye movement desensitization and reprocessing (EMDR) as treatment for post-traumatic stress disorder. Clinical Psychology and Psychotherapy 3(3):185-195. Boudewyns, P. A., L. Hyer, M. G. Woods, W. R. Harrison, and E. McCranie. 1990. PTSD among Vietnam veterans: An early look at treatment outcome using direct therapeutic exposure. Journal of Traumatic Stress 3(3):359-368. Boudewyns, P. A., S. Stwertka, L. Hyer, J. Albrecht, and E. Sperr. 1993. Eye movement desensitization for PTSD of combat: A treatment outcome pilot study. Behavior Therapist 16(2):29-33. Brady, K. T., B. S. Dansky, S. E. Back, E. B. Foa, and K. M. Carroll. 2001. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. Journal of Substance Abuse Treatment 21(1):47-54.
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