Marit Sijbrandij M.A.Miranda Olff Ph.D.Johannes B. Reitsma M.D., Ph.D.Ingrid V.E. Carlier Ph.D.Mirjam H. de Vries M.A.Berthold P.R. Gersons M.D., Ph.D.

The American Journal of Psychiatry. Published Online: 1 Jan 2007 https://ajp.psychiatryonline.org/doi/10.1176/ajp.2007.164.1.82

Introduction

The conditional risk of developing post-traumatic stress disorder (PTSD) after a traumatic event is 9.2% (Breslau N, Kessler RC etc., 1998). Prior to the present study, there had been a number of experiments (e.g., Foa et al., 1995) in which CCST had proven effective in treating acute stress disorder in victims of physical trauma of varying severity. However, they lacked a control comparison group that did not receive treatment, had a small sample size that included victims of a particular type of trauma, and lacked monitoring of therapists' compliance with the protocol and analysis of patients' intention to treat. The goal of this study was to evaluate the effectiveness of short-term cognitive behavioral therapy (CBT) for patients with acute posttraumatic stress disorder (PTSD) resulting from various types of psychological trauma, taking these methodological nuances into account.

Methods

143 patients with acute PTSD were randomly assigned to two groups: the ACPT group (N = 79) and the comparison group (N = 64). Inclusion criteria were 1) meeting diagnostic criteria for acute PTSD according to DSM-IV, ignoring the time criterion of symptom duration of at least 1 month, 2) the traumatic event occurred between 2 weeks and 3 months before the experiment, 3) the traumatic event had ended at the time of inclusion, 4) age 18 years or older, 5) Dutch language proficiency. Exclusion criteria were 1) suicidal ideation and 2) fulfilling diagnostic criteria for psychotic, organic disorder, substance abuse, or chronic PTSD according to DSM-IV. The mean age was 37.5 years for the CCPT group and 37.8 years for the comparison group. The primary outcome measure was the PTSD assessment using a 17-item structured interview for PTSD, which records the presence and severity of DSM-IV diagnostic criteria for PTSD. The SCID-I clinical interview was used to assess the comorbidity of DSM-IV axis 1 disorders. Secondary criteria were anxiety and depression as measured by the Hospital Anxiety and Depression Scale HADS. Assessment was performed before intervention as well as 1 week and 4 months after therapy. Finally, at the end of therapy, patients in the CBT group were interviewed on a scale of 1 to 4 (1 = "very satisfied" to 4 = "very dissatisfied") if they were satisfied with the intervention. The baseline criteria for a successful intervention were a 60% reduction in PTSD symptoms scores in the CBT group compared to a spontaneous 30% reduction in the comparison group.

Main part

The cognitive-behavioral therapy program was based on the model developed by Foa et al. (1997) for female rape victims (4), adapted for victims of all kinds of trauma. It consisted of four weekly CBT sessions of approximately 120 minutes per session. The first session focused on information gathering, psychoeducation, identification of cognitive distortions, and avoidant situations after the traumatic event. In the second session, the list of avoidable situations was supplemented and ordered according to the degree of anxiety each situation caused the patient. Patients did deep muscle relaxation exercises, which were audio-recorded for self-performance between sessions. Next, the patient recounted the traumatic experience in the present tense (imaginary exposure), which was also audio-recorded. Cognitive restructuring was performed. In between sessions, patients were asked to listen to the audio recording several times to practice going through avoided situations in a safe environment (in vivo exposure). The third session consisted of repetition of this homework, visual exposure (45 minutes) and cognitive restructuring. The fourth session consisted of a homework review, imaginal exposure (30 minutes), and cognitive restructuring. At the conclusion of the intervention, the therapist discussed with patients their patient progress. Patients in the comparison group did not receive the intervention, but were evaluated at the same follow-up time as patients in the cognitive-behavioral therapy group.

Results

One week after the intervention, the CBT group had significantly fewer PTSD symptoms than the comparison group, but this difference decreased to nonsignificant 4 months after the study. Similar results were obtained when assessing anxiety and depression. An assessment 4 months after completion of treatment showed that the use of CBT resulted in a significant reduction in PTSD scores in patients with baseline comorbid major depression. Patients who were included in the study within the first month after the traumatic event showed sustained significant reductions in PTSD symptoms, as indicated by evaluations 1 week and 4 months after completion of therapy.

Conclusions

Brief early cognitive-behavioral therapy accelerated recovery from symptoms of acute PTSD, but did not affect long-term outcomes. It showed increased efficacy in patients with baseline comorbid depression and patients who were included in the study within 1 month of the traumatic experience. The findings suggest the likelihood of successful use of CCPT in hospital settings limited by length of stay.