Treatment of Acute Stress Disorder
Treatment of Acute Stress Disorder
Treatment of Acute Stress Disorder
Age, mean (SD), y 37.9 (15.6) 33.7 (15.1) 34.7 (11.4) F89 = 0.68 .51 Days since trauma, mean (SD)
19.4 (8.9) 20.8 (7.4) 22.4 (7.4) F89 = 1.07 .35 NART Score, mean (SD) 25.3 (8.4) 28.2 (5.7) 28.1 (7.0) F89 = 0.43 .41
Ethnicity, No. (%)
2
White 27 (90) 26 (87) 25 (83) = .059 .75
Asian 3 (10) 4 (13) 5 (17)
Sex, No. (%)
2
Men 11 (37) 12 (40) 15 (50) = 1.18 .55 Women 19 (63) 18 (60) 15 (50)
2 2
Single, No. (%) 18 (60) 16 (53) 11 (37) = 1.10 .67 Employed, No. (%) 23 (77) 24 (80) 24 (82) = 0.64
.79
Trauma type, No. (%)
2
MVC 8 (27) 10 (33) 15 (50) = 1.20 .57 Assault 22 (73) 20 (67) 15 (50)
2
Comorbid MDD, No. (%) 15 (50) 13 (43) 14 (47) = 0.78 .42 Comorbid anxiety disorder, No. (%) 2 (6) 1 (3)
2 2
1 (3) = 0.78 .52 Comorbid substance use disorder, No. (%) 0 1 (3) 1 (3) = 0.88 .82
Logic of treatment rating, mean (SD)a 7.5 (1.4) 7.8 (1.4) NA F59 = 0.56 .46
Expectancy (confidence) rating, mean (SD)b 7.2 (1.7) 7.1 (1.8) NA F59 = 0.07 .86
Abbreviations: MDD, major depressive disorder; MVC, motor vehicle crash; NA, not applicable; NART, National
Adult Reading Test.
aLogic of treatment was rated on a 10-point scale: 1, not at all logical; 10, extremely logical.
bFrom credibility/expectancy questionnaire.
PTSD.21 Moreover, CR can be effective in treating
chronic PTSD.22 Accordingly, it is logical to expect that
CR could be beneficial in treating ASD.
included PE and CR. Some commentators have suggested The goal of this randomized controlled trial was to
that PE may not be the optimal strategy because of the conduct the first evaluation of PE vs CR in the treatment
distress that it elicits.17 Furthermore, there is evidence that of ASD. These 2 treatment conditions were compared
many mental health care providers do not use exposure with a wait-list control group, in which patients were
therapy for trauma survivors because it causes distress.18 assessed at baseline and again 6 weeks later, to determine
These factors point to the need for study of the relative the efficacy of PE and CR relative to no treatment.
efficacy of exposure-based and non-exposure– based Patients in the wait-list group were then offered active
therapy for patients with ASD. The major alternative to treatment, and patients in the PE and CR groups were
PE is CR, which involves identification and modification subsequently assessed 6 months after treatment. We
of maladaptive appraisals of the traumatic event, one’s focused on patients with ASD because, although this
response to the experience, and the future. There is much diagnosis fails to identify many people who will develop
evidence that maladaptive appraisals are characteristic of chronic PTSD,23 most studies indicate that people who do
ASD19,20 and are strongly predictive of subsequent
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23 Followed up 19 Followed up
02 Had no contact 04 Had no contact DATA ANALYSIS
To determine the relative effects of the 3 treatment conditions,
Figure 1. Patient enrollment, randomization, and treatment. ASD
weperformedmultivariateanalysesofcovariance(MANCOVAs)
indicates acute stress disorder. for each of the 2 sets of continuous assessments (PTSD
symptoms and associated symptoms) using the pretreatment
scores as covariates. If multivariate effects of condition were
utes, and patients were instructed to verbalize reliving the
significant, we conducted univariate ANCOVAs and tested
trauma experience in a vivid manner that involved all perceptual
differences between groups using Tukey comparisons. We
and emotional details. Imaginal exposure was not audiotaped,
report completer analyses and intent-to-treat analyses, in which
but participants were given explicit instructions on how to
we used the last observation carried forward procedure.
complete the exercise. Participants engaged in imaginal
Treatment effect sizes were between treatment conditions at
exposure on a daily basis for homework. Session 2 included
posttreatment and followup. We derived Cohen d effect size by
review of homework, introduction of in vivo exposure, and a
calculating the mean difference between assessments of each
50-minute session of imaginal exposure. Session 3 included
treatment condition and dividing this by the pooled standard
review of homework and completion of hierarchy for in vivo
deviation.39 We used Hedges g effect sizes to correct for
exposure. Following this session, participants completed
variations caused by small sample sizes.40 Finally, we calculated
imaginal exposure and in vivo exposure for daily homework.
high end-state adjustment as being below specific cutoff scores
Session 4 included review of homework, imaginal exposure,
for PTSD, depression, and anxiety scales at the follow-up
and review of in vivo exposure. Session 5 was identical to
assessment. We adopted a conservative estimate of good end-
Session 4, with the addition of relapse prevention strategies that
state adjustment for PTSD by following an established cutoff
instructed participants to rehearse the strategies learned during
score of 19 on the CAPS-2 (combining frequency and intensity
therapy whenever they perceived increases in PTSD symptoms.
scores) to indicate the absence of PTSD,41 a cutoff of 10 on the
BDI-2,42 and a cutoff of 12 on the BAI.43 To estimate the number
Cognitive Restructuring of patients required in the PE group for 1 patient to achieve a
response outcome that would not have been achieved with CR,
Session 1 focused on psychoeducation and the introduction of we calculated the number of patients needed to treat as 1 divided
CR. Session 2 comprised identification of maladaptive thoughts by the proportion responding to PE. Efficacious treatments
about the traumatic event and the person’s responses to the typically have a number needed to treat between 2 and 4. 44
event and to issues occurring in the posttrauma environment; at
this point, patients began monitoring automatic thoughts as
daily homework. Session 3 included review of homework and RESULTS
CR. Cognitive restructuring involved daily monitoring of
thoughts and affective states, modifying thoughts by Socratic
questioning, probabilistic reasoning, and evidence-based
PRELIMINARY ANALYSES
thinking.38 The common themes of CR involved addressing
catastrophic appraisals of future harm, guilt about one’s Planned comparisons of treatment completers and
behavior during the trauma, and excessive appraisals about treatment dropouts indicated no differences between
one’s capacity to cope with the stress reactions. Following this those who did and did not drop out of treatment on any
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60
50
40
30
20
1 2 3 4 5
Session, No.
80
Prolonged exposure (n = 30)
Cognitive restructuring (n = 30)
70 Wait-list control group (n
= 30)
60
50
40
30
20
Baseline Posttreatment 6-Month Follow-up
Table 3. Effect Sizes on Outcome Measures for Intent-to-Treat and Completer Analyses
EffectSize(95%ConfidenceInterval)
Posttreatment Follow-up
Characteristic PE vs WL CR vs WL PE vs CR PE vs CR
Intent-to-treat
CAPS-2 0.95 (0.42-1.49) 0.50 (−0.01 to 1.10) 0.42 (−0.09 to 0.92) 0.60 (0.08-1.11) IES-Intrusions 0.85 (0.32-1.38) 0.41
(−0.10 to 0.92) 0.44 (−0.07 to 0.95) 0.63 (0.11-1.15)
IES-Avoidance 0.93 (0.39-1.46) 0.47 (−0.04 to 0.98) 0.43 (−0.08 to 0.94) 0.44 (−0.02 to 1.01)
BAI 0.42 (0.09-0.93) 0.27 (−0.24 to 0.78) 0.67 (0.15-1.19) 0.63 (0.11-1.15)
BDI-2 0.75 (0.23-1.27) 0.22 (−0.29 to 0.73) 0.54 (0.01-1.05) 0.60 (0.09-1.12)
Completer
CAPS-2 1.10 (0.48-1.72) 0.59 (−0.01 to 1.93) 0.47 (−0.10 to 1.04) 0.86 (0.27-1.45)
IES-Intrusions 1.12 (0.50-1.74) 0.50 (−0.10 to 1.11) 0.59 (0.02-1.76) 0.87 (0.28-1.47) IES-Avoidance 1.10 (0.46-1.71)
0.54 (−0.09 to 1.10) 0.53 (−0.05 to 1.10) 0.92 (0.52-1.51) BAI 0.52 (−0.07 to 1.11) 0.27 (−0.23 to 0.97) 0.89 (0.29-1.50)
0.62 (0.04-1.20)
BDI-2 0.63 (0.04-1.23) 0.11 (−0.48 to 0.70) 0.51 (−0.07 to 1.08) 0.37 (0.18-0.97)
Abbreviations: BAI, Beck Anxiety Inventory; BDI-2, Beck Depression Inventory 2; CAPS-2, Clinician-Administered PTSD Scale 2; CR,
cognitive restructuring; IES, Impact of Event Scale; PE, prolonged exposure; PTSD, posttraumatic stress disorder; WL, wait-list.
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