Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims

Emergency evaluation and intervention with female victims of rape and other violence

Given the high prevalence of crime within the general population and the increased rates of victimization among those seeking medical care, professionals who work in emergency departments, primary care medical facilities, or mental health settings need to be prepared to address physical and psychological problems related to sexual and physical assault. In this paper, interpersonal violence prevalence studies are reviewed in terms of study design and findings for sexual assault and physical assault. Common injuries following both forms of assault are documented, followed by a review of long-term medical outcomes. In addition to a review of physical health outcomes, primary psychological effects of violence are also reviewed. Strategies with which to screen for interpersonal violence in the medical setting are offered, and issues related to mandatory reporting are summarized. Interventions for assault victims that can be implemented in the medical setting are outlined, and a new hospital-based treatment for victims of rape is described.

Intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor

Previous research has consistently demonstrated a positive association between intrusive thoughts about stressful experiences and psychological distress. The strength of this relation, however, has varied considerably across studies. To examine the possibility that an individual's sense of global meaning (i.e., the existential belief that one's life has purpose and order) may moderate the relation between intrusive thoughts and psychological distress, the authors conducted telephone assessments of 61 women who had survived breast cancer. Results confirmed that the frequency of intrusive thoughts was positively related to psychological distress. Global meaning, moreover, moderated the relation between intrusive thoughts and psychological distress consistent with the authors' hypotheses. Among women with lower global meaning, more frequent intrusive thoughts were associated with higher psychological distress. No association was found between intrusive thoughts and psychological distress among those participants with higher global meaning.

Fear, helplessness, and horror in posttraumatic stress disorder: investigating DSM-IV criterion A2 in victims of violent crime

A DSM-IV diagnosis of posttraumatic stress disorder (PTSD) required for the first time that individuals must report experiencing intense fear, helplessness, or horror at the time of the trauma. In a longitudinal study of 138 victims of violent crime, we investigated whether reports of intense trauma-related emotions characterized individuals who, after 6 months, met criteria for PTSD according to the DSM-III-R. We found that intense levels of all 3 emotions strongly predicted later PTSD. However, a small number of those who later met DSM-III-R or ICD criteria for PTSD did not report intense emotions at the time of the trauma. They did, however, report high levels of either anger with others or shame.

Dysfunctional meaning of posttraumatic intrusions in chronic PTSD

The paper suggests that the negative idiosyncratic meaning of posttraumatic intrusions (e.g., 'I am going crazy') and cognitive strategies intended to control the intrusions play a major role in maintaining posttraumatic stress disorder. Two studies of 159 and 138 motor vehicle accidents survivors showed that the dysfunctional meaning of intrusions explained a proportion of the variance of the intrusion-related distress, strategies used to end the intrusions, and PTSD severity that was not explained by intrusion frequency, accident severity, or by general catastrophic thoughts when anxious. Rumination, thought suppression, and distraction when having intrusions showed substantial correlations with PTSD severity, as did avoidance of reminders of the accident. The results have implications for the treatment of chronic PTSD.

Prevalence and impact of posttraumatic stress disorder-like symptoms on patients with fibromyalgia syndrome

OBJECTIVE

Traumatic events can result in a set of symptoms including nightmares, recurrent and intrusive recollections, avoidance of thoughts or activities associated with the traumatic event, and symptoms of increased arousal such as insomnia and hypervigilance. These posttraumatic stress disorder (PTSD)-like symptoms are frequently observed in persons with chronic pain syndromes. Little is known about how these two phenomena interact with one another. The present study evaluated PTSD-like symptoms in patients with fibromyalgia syndrome (FMS) and examined the relation between PTSD-like symptoms and problems associated with FMS.

DESIGN

Ninety-three consecutive patients underwent a comprehensive FMS evaluation and completed self-report questionnaires measuring PTSD-like symptoms, disability, and psychosocial responses to their pain condition. Subjects were divided in two groups based on level of self-reported PTSD-like symptoms.

RESULTS

Approximately 56% of the sample reported clinically significant levels of PTSD-like symptoms (PTSD+). The PTSD+ patients reported significantly greater levels of pain (p < 0.01), emotional distress (p < 0.01), life interference (p < 0.01), and disability (p < 0.01) than did the patients without clinically significant levels of PTSD-like symptoms (PTSD-). Over 85% of the PTSD+ patients compared with 50% of the PTSD- patients demonstrated significant disability. Based on response to the Multidimensional Pain Inventory, a significantly smaller percentage of PTSD+ patients were classified as adaptive copers (15%) compared with the PTSD- group (48.2%).

CONCLUSIONS

Results suggest that PTSD-like symptoms are prevalent in FMS patients and may influence adaptation to this chronic illness. Clinicians should assess the presence of these symptoms, as the failure to attend to them in treatment may impede successful outcomes.

Randomized clinical trial of brief eclectic psychotherapy for police officers with posttraumatic stress disorder

The authors report on a randomized, controlled clinical trial on the treatment of posttraumatic stress disorder (PTSD), comparing manualized psychotherapy to wait-list control. This is the first study to evaluate Brief Eclectic Psychotherapy (BEP), which combines cognitive-behavioral and psychodynamic approaches within one treatment method. Forty-two police officers with the diagnosis of PTSD participated in the study; 22 were randomly assigned to the treatment group and 20 to the wait-list control group. Assessments of PTSD and comorbid conditions were made 1 week before treatment, after treatment session 4, upon termination of treatment (16 sessions), and at follow-up 3 months later. As expected, no significant differences between groups were observed at pretest or at session 4. At posttest and at follow-up, BEP had produced significant improvement in PTSD, in work resumption, and in some comorbid conditions.

Brief psychological interventions ("debriefing") for trauma-related symptoms and the prevention of post traumatic stress disorder

OBJECTIVES

To assess the effectiveness of brief psychological debriefing for the management of psychological distress after trauma, and the prevention of post traumatic stress disorder.

SEARCH STRATEGY

Electronic searching of MEDLINE, EMBASE, PsychLit, PILOTS, Biosis, Pascal, Occ.Safety and Health, CDSR and the Trials Register of the Depression, Anxiety and Neurosis group. Hand search of Journal of Traumatic Stress. Contact with leading researchers.

SELECTION CRITERIA

The inclusion criteria for all randomized studies was that they should focus on persons recently (one month or less) exposed to a traumatic event, should consist of a single session only, and that the intervention involve some form of emotional processing/ventilation by encouraging recollection/reworking of the traumatic event accompanied by normalisation of emotional reaction to the event.

DATA COLLECTION AND ANALYSIS

8 trials fulfilled the inclusion criteria. Quality was generally poor. Data from two trials could not be synthesised.

MAIN RESULTS

Single session individual debriefing did not reduce psychological distress nor prevent the onset of post traumatic stress disorder (PTSD). Those who received the intervention showed no significant short term (3-5 months) in the risk of PTSD (pooled odds ratio 1.0, 95% ci 0.6-1.8). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2.9, 95% ci 1.1-7.5). The pooled odds ratio for the two trials with follow ups just included unity (odds ratio 2.0, 95% ci 0.9-4.5). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety.

REVIEWER'S CONCLUSIONS

There is no current evidence that psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease.

Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques

OBJECTIVE

Acute stress disorder permits an early identification of trauma survivors who are at risk of developing chronic posttraumatic stress disorder (PTSD). This study aimed to prevent PTSD by an early provision of cognitive behavior therapy. Specifically, this study indexed the relative efficacy of prolonged exposure and anxiety management in the treatment of acute stress disorder.

METHOD

Forty-five civilian trauma survivors with acute stress disorder were given five sessions of 1) prolonged exposure (N = 14), 2) a combination of prolonged exposure and anxiety management (N = 15), or 3) supportive counseling (N = 16) within 2 weeks of their trauma. Forty-one trauma survivors were assessed at the 6-month follow-up.

RESULTS

Fewer patients with prolonged exposure (14%, N = 2 of 14) and prolonged exposure plus anxiety management (20%, N = 3 of 15) than supportive counseling (56%, N = 9 of 16) met the criteria for PTSD after treatment. There were also fewer cases of PTSD in the prolonged exposure group (15%, N = 2 of 13) and the prolonged exposure plus anxiety management group (23%, N = 3 of 13) than in the supportive counseling group (67%, N = 10 of 15) 6 months after the trauma. Chronic PTSD in the supportive counseling condition was characterized by greater avoidance behaviors than in the prolonged exposure condition or the prolonged exposure plus anxiety management condition.

CONCLUSIONS

These findings suggest that PTSD can be effectively prevented with an early provision of cognitive behavior therapy and that prolonged exposure may be the most critical component in the treatment of acute stress disorder.

Prevention of post-rape psychopathology: preliminary findings of a controlled acute rape treatment study

Violent sexual assault such as rape typically results in extremely high levels of acute distress. The intensity of these acute psychological reactions may play a role in later recovery, with higher levels of immediate distress associated with poorer outcome. Unfortunately, post-rape forensic evidence collection procedures may serve to increase, rather than reduce initial distress, potentially exacerbating future psychopathology. To address these concerns, an acute time-frame hospital-based video intervention was developed to: (a) minimize anxiety during forensic rape exams, and (b) prevent post-rape posttraumatic stress disorder (PTSD), panic, and anxiety. Preliminary data indicated that (1) psychological distress at the time of the exam was strongly related to PTSD symptomatology 6 weeks post-rape, and (2) the video intervention successfully reduced distress during forensic exams.

Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a "heart attack" within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

[How to prevent post-traumatic stress disorder before traumatization occurs?]

OBJECTIVE

To provide an update on methods of preventing the onset of posttraumatic stress disorder (PTSD) before trauma occurs.

METHOD

Survey and analysis of the literature (mainly articles) found in the Medline, Psychinfo, and Pilot databases.

RESULTS

Most research focuses on identifying risk factors and reinforcing individual resistance as the prime means of preventing PTSD. The severity of the trauma is by far the most serious risk factor. To reinforce resistance and prevent the onset of PTSD, the army has favoured psychoeducational approaches. However, the literature survey has found no pretrauma prevention program for other high-risk occupations.

CONCLUSION

The usefulness of identified risk factors for the primary prevention of PTSD is limited, since with the exception of the trauma itself, they play a minor role on the onset of severe-trauma PTSD. Psychoeducational approaches aimed at reinforcing the resistance of individuals at risk are promising, but their potential has to be further explored in individuals in high-risk trades. Finally, it has been suggested that other avenues of research in the primary prevention (pretrauma) of PTSD be explored. These include the identification of possible protection factors, the influence of genetic make-up and of biological variables, the cumulative effects of exposure to stressors, and the presence of chronic stressors.

Acute stress disorder and posttraumatic stress disorder in victims of violent crime

OBJECTIVE

In a group of crime victims recruited from the community, the authors investigated the ability of both a diagnosis of acute stress disorder and its component symptoms to predict posttraumatic stress disorder (PTSD) at 6 months.

METHOD

A mixed-sex group of 157 victims of violent assaults were interviewed within 1 month of the crime. At 6-month follow-up 88% were reinterviewed by telephone and completed further assessments generating estimates of the prevalence of PTSD.

RESULTS

The rate of acute stress disorder was 19%, and the rate of subsequent PTSD was 20%. Symptom clusters based on the DSM-IV criteria for acute stress disorder were moderately strongly interrelated. All symptom clusters predicted subsequent PTSD, but not as well as an overall diagnosis of acute stress disorder, which correctly classified 83% of the group. Similar predictive power could be achieved by classifying the group according to the presence or absence of at least three reexperiencing or arousal symptoms. Logistic regression indicated that both a diagnosis of acute stress disorder and high levels of reexperiencing or arousal symptoms made independent contributions to predicting PTSD.

CONCLUSIONS

This exploratory study provides evidence for the internal coherence of the new acute stress disorder diagnosis and for the symptom thresholds proposed in DSM-IV. As predicted, acute stress disorder was a strong predictor of later PTSD, but similar predictive power may be possible by using simpler criteria.

Brief early psychological interventions following trauma: a systematic review of the literature

A systematic literature search/review was undertaken of brief early psychological interventions following trauma. Only six randomized controlled trials were found, and none of these included group interventions. Of the six trials, two studies associated the intervention with a positive outcome, two demonstrated no difference on outcome between intervention and non-intervention groups, and two showed some negative outcomes in the intervention group. This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that there is an urgent need for randomized controlled trials of group debriefing and other early interventions.

Follow-up of sexual assault victims

OBJECTIVES

Our goal was to describe medical findings and health-related concerns of sexual assault victims who returned for follow-up and to assess demographic and assault characteristics of victims who used follow-up services compared to those who did not.

STUDY DESIGN

This study is a retrospective cohort analysis involving records from two sources: the acute sexual assault evidentiary examination and the SAFE (Sexual Assault Follow-up Evaluation) Clinic visit. Data were extracted from the records of 389 adolescent and adult victims who reported an acute sexual assault and underwent a complete evidentiary examination between January 1, 1995, and June 30, 1997. Descriptive statistics were generated on demographic and historical information, assault characteristics, and medical and laboratory findings. For the subgroup that presented for follow-up, additional descriptive statistics were generated to describe their interim history, concerns, medical outcomes, treatments, and psychosocial functioning. Chi2 analyses were used to identify differences in the group that returned for follow-up compared with the group that did not. Statistical significance was defined as P < .05.

RESULTS

There were no differences in age, race, or perpetrator factors between patients who used follow-up services and patients who did not return to the SAFE Clinic. Similarly, there were no other assault characteristics, relationships, or physical examination findings that were associated with follow-up patterns. A total of 31% (n = 122) of all sexual assault victims returned for a follow-up visit. Physical complaints were reported by 42.6%, but 98.0% had normal findings at a general examination, and 94.8% had a normal result of gynecologic examination. Pregnancy and sexually transmitted diseases, including human immunodeficiency virus, were identified through the follow-up clinic. Since the assault, 49.2% had been sexually active, 10% with multiple partners and 73.3% without consistent condom use. Disturbances in sleep, sexual function, and appetite were commonly reported among victims at follow-up. Numerous assault-related fears were reported.

CONCLUSIONS

Among recent rape victims, follow-up rates are low, and there are no factors that correlate with the use of follow-up services. Those who do come in for follow-up have physical complaints and health-related concerns that are related to their recent assault, but most have normal physical findings. Efforts to reach sexual assault victims will require aggressive and innovative strategies to remain in contact with women and girls after rape.

Pilot evaluation of hypnotic medication during acute traumatic stress response

Early intervention aimed at secondary prevention is a high priority for posttraumatic stress disorder (PTSD) research. Disrupted sleep may have a role in the initiation and maintenance of PTSD. Three of the participants were recruited from a surgical trauma service, and one had sought treatment in a psychiatric setting. All were within 1-3 weeks of trauma exposure and had acute PTSD symptoms that included disturbed sleep. Temazepam, a benzodiazepine hypnotic, was administered for 5 nights, tapered for 2 nights, and then discontinued. Evaluations 1-week after the medication had been discontinued revealed improved sleep and reduced PTSD severity. These observations suggest an approach that may be clinically useful and a need for more systematic trials.

Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials

This meta-analysis synthesized the results from controlled, clinical trials of psychotherapeutic treatments for posttraumatic stress disorder (PTSD). Psychotherapeutic modalities included behavioral, cognitive, and psychodynamic treatments, in group and individual settings. Participants in the studies included combat veterans from the Vietnam and Lebanon Wars, crime-related victims, and severe bereavement sufferers. The impact of psychotherapy on PTSD and psychiatric symptomatology was significant, d = .52, r = .25, when measured immediately after treatments were administered. Similarly, there was no decay in the effect of treatment at follow-up, d = .64, r = .31. Moreover, for target symptomes of PTSD and general psychological symptomes (intrusion, avoidance, hyperarousal, anxiety, and depression), effect sizes were significant, ranging from r's of .2-.49. Results suggest substantial promise for improving psychological health and decreasing related symptoms for those suffering from PTSD.

Special feature: theory and treatment development and evaluation: reflections on Benjamin's "models for treatment"

To make the final point of this commentary clear at the outset, I could not agree with Dr. L. S. Benjamin's comments more, on the one hand, and could not disagree more, on the other hand. I will first review the points that I not only agree with but also think are extremely important. I will then beg to differ with some of her conclusions (at least as I interpret then), and with her analysis of the outcomes of the one cognitive-behavioral treatment of a personality disorder she reviewed in some detail.

Brief psychological intervention with traumatized young women: the efficacy of eye movement desensitization and reprocessing

To study the efficacy of eye movement desensitization and reprocessing (EMDR) with traumatized young women, 60 women between the ages of 16 and 25 were randomly assigned to two sessions of either EMDR or an active listening (AL) control. Factorial ANOVA interaction effects and simple main effects for outcome measure (Beck Depression Inventory, State-Trait Anxiety Inventory, Penn Inventory for Posttraumatic Stress Disorder, Impact of Event Scale, Tennessee Self-Concept Scale) indicated significant improvement for both groups and significantly greater pre-post change for EMDR-treated participants. Pre-post effect sizes for the EMDR group averaged 1.56 compared to 0.65 for the AL group. Despite treatment brevity, the posttreatment outcome variable means of EMDR-treated participants compared favorably with nonpatient or successfully treated norm groups on all measures.

Acute stress disorder: a critical review of diagnostic issues

Acute stress disorder (ASD) is a recently developed diagnosis that describes posttraumatic stress reactions that occur in the first month following a trauma. Diagnostic criteria include dissociative, intrusive, avoidance, and arousal symptoms. ASD was driven by the proposal that trauma leads to dissociative reactions, and these are predictive of longer-term psychopathology. This paper reviews a series of anomalies in the diagnostic criteria, highlights discrepancies between criteria for ASD and posttraumatic stress disorder (PTSD), and illustrates the lack of empirical evidence for some assumptions inherent in the conceptualization of ASD. It is argued that future revisions of ASD criteria need to be based on empirical evidence of acutely traumatized individuals.

Psychosocial treatments for posttraumatic stress disorder: a critical review

Posttraumatic stress disorder (PTSD) has been the subject of growing recognition since its inception in 1980. Owing in part to the relatively recent inclusion of PTSD in the psychiatric nomenclature, research is only beginning to address its treatment in methodologically rigorous studies. In this review, we discuss issues such as prevalence of trauma and of PTSD, and gold standards for treatment outcome research. We then critically review the extant literature on the treatment of PTSD. Finally, we include a discussion of issues specific to various trauma populations and factors that may influence treatment efficacy across types of trauma.