– Literature

 

A brief indication of relevant literature on treatment  

Psychological treatments from different theoretical perspectives have been found to be effective for chronic PTSD in several reviews (e.g. Van Etten & Taylor, 1988; Bradley et al al, 2005; Bisson et al. 2007). Psycholgical treatments that have proved to be most effective in the treatment of PTSD are the ones that focuse on the trauma memory, especially episodic memory of the traumatic event. Most evidence is available for trauma-focused psychotherapies such as Cognitive Behavioural Therapy (TF-CBT) and EMDR. Literature on these treatments for PTSD regard mostly chronic PTSD.  Trauma treatment may include different stages, from preparation and stabilization to trauma processing and enhancement of adaptive emotional, behavioural and social functioning. A complete structure can be found in the handbook: Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (2009)-Christine Courtois Christine A. Courtois (Editor), New York: The Guilford Press. The latest publication in the field is Robin Shapiro’s book:  The trauma treatment handbook: Protocols across the Spectrum (Norton Prof. Books), Oct. 2010. Another coming publication is M. Basoglu and E. Salcioglu’s “A Mental Healthcare Model for Mass Trauma Survivors: Control focused behavioural treatment of earthquake, war and torture trauma”  (March 2011), Cambridge University Press

Below you can find the abstracts of important articles identified in the field of treatment of PTSD.

Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis

J.I.Bisson, A. Ehlers, R. Matthews, S. Pilling, D. Richards and S. Turner (2007) British Journal of Psychiatry, 198, 97-104

Thirty-eight randomized controlled trials were included in the included in the meta-analysis. Trauma-focused cognitive  behavioural therapy (TFCBT), eye movement desensitization and reprocessing (EMDR), stress management and group cognitive behavioural therapy improved PTSD symptoms more than Symptoms more waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR but therewas some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress smanagement was superior to other therapies. Conclusions: The first-line psychological treatment for PTSD should be trauma-focused (TFCBT or EMDR).

Effective Psychotherapies for Posttraumatic Stress Disorder: A Review and Critique

Marylene Cloitre (2009) CNS Spect.; 14:1 (suppl 1): 32-43

This report reviews and critiques the psychotherapy literature for the treatment of post-traumatic stress disorder (PTSD) and systematically presents data on sample size, rates of completion and effect sizes. Substantial progress has been made in the use of cognitive behavioral therapies and eye movement desensitization and reprocessing for the resolution of PTSD. Innovations in  PTSD treatments are identified. Further advances are needed in the treatment of populations with complex and chronic forms of PTSD such as those found in childhood abuse populations, refugee populations, and those experiencing chronic mental illness. The need to address comorbid emotional, social, and physical health consequences of trauma, to implement treatments in community-based settings, and to incorporate larger systems of care into study designs is noted.

Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: a meta-analytic study

G. H. Seidler and F. E. Wagner (2006)  Psychological Medicine, 36, 1515-1522

 Eye movement desensitization and reprocessing (EMDR) and trauma-focused cognitive-behavioral therapy (CBT) are both widely used in the treatment of post-traumatic stress disorder (PTSD). There has, however, been debate regarding the advantages of one approach over the other. This study sought to determine whether there was any evidence that one treatment was superior to the other. A systematic review was perfomed of the literature dating from 1989 to 2005 and identified eight publications describing treatment outcomes of EMDR and CBT in active–active comparisons. Seven of these studies were investigated meta-analytically. The superiority of one treatment over the other could not be demonstrated. Trauma-focused CBT and EMDR tend to be equally efficacious. Differences between the two forms of treatment are probably not of clinical significance. While the data indicate that moderator variables influence treatment efficacy, we argue that because of the small number of original studies, little benefit is to be gained from a closer examination of these variables. Further research is needed within the framework of randomized controlled trials. Conclusions. Results suggest that in the treatment of PTSD, both therapy methods tend to be equally efficacious. We suggest that future research should not restrict its focus to the efficacy, effectiveness and efficiency of these therapy methods but should also attempt to establish which trauma patients are more likely to benefit from one method or the other. What remains unclear is the contribution of the eye movement component in EMDR to treatment out come.

The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons

Steven G. Benish, Zac E. Imel, Bruce E. Wampold  (2008)   Clinical Psychology Review 28, 746-758

Psychotherapy has been found to be an effective treatment of post-traumatic stress disorder (PTSD), but meta-analyses have yielded inconsistent results on relative efficacy of psychotherapies in the treatment of PTSD. The present meta-analysis controlled for potential confounds in previous PTSD meta-analyses by including only bona fide psychotherapies, avoiding categorization of psychotherapy treatments, and using direct comparison studies only. The primary analysis revealed that effect sizes were homogenously distributed around zero for measures of PTSD symptomatology, and for all measures of psychological functioning, indicating that there were no differences between psychotherapies. Additionally, the upper bound of the true effect size between PTSD psychotherapies was quite small. These results suggest that despite strong evidence of psychotherapy efficaciousness vis-à-vis no treatment or common factor controls, bona fide psychotherapies produce equivalent benefits for patients with PTSD.

Do all psychological treatments really work the same in post traumatic stress disorder?

Anke Ehlers, Jonathan Bisson, David M. Clark, Mark Creamer, Steven Pillinge, David Richards, Paula P. Schnurr, Stuart Turner, William Yule (2010) Clinical Psychological Review, Mar; 30 (2) 269-76

A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746–758) concluded that all bona fide treatments are equally effective in post traumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benishetal.'s (2008) meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account th need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

A meta-analytic investigation of therapy modality outcomes for sexually abused children and adolescents: An exploratory study

Melanie D. Hetzel-Riggina,  Amy M. Brauschb, Brad S. Montgomery  (2007) Child Abuse & Neglect 31, 125-141

The purpose of the study was to investigate the independent effects of different treatment elements on a number of secondary problems related to childhood and adolescent sexual abuse, as well as investigate a number of different moderators of treatment effectiveness. Twenty-eight studies that provided treatment outcome results for children and adolescents who had been sexually abused were included in the meta-analysis. Different aspects of psychological treatment, such as specific treatment modalities (individual, cognitive-behavioral, etc.) or secondary problems (behavior problems, psychological distress, etc.) were investigated. The overall mean weighted effect size for the meta-analysis was d=.72 (SE=.02). The results indicate that psychological treatment after childhood or adolescent sexual abuse tended to result in better outcomes than no treatment. There was significant heterogeneity in the effectiveness of the various psychological treatment elements. Play therapy seemed to be the most effective treatment for social functioning, whereas cognitive-behavioral, abuse-specific, and supportive therapy in either group or individual formats was most effective for behavior problems. Cognitive-behavioral, family, and individual therapy seemed to be the most effective for psychological distress, and abuse-specific, cognitive-behavioral, and group therapy appeared to be the most effective for low self-concept. Conclusions: The choice of therapy modality should depend on the child’s main presenting secondary problem. Further research should be conducted investigating other possible moderators and secondary problem outcomes.

– Literature