Exposure-based therapy, in which recent trauma survivors are instructed to relive the troubling event, may be effective in preventing the progression from acute stress disorder to post-traumatic stress disorder, according to a report in the June issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

Individuals who develop acute stress disorder during or soon after a traumatic event are likely to subsequently develop post-traumatic stress disorder (PTSD), according to background information in the article. PTSD is associated with other mental and physical illnesses, a reduced quality of life and increased health care costs. Both exposure therapy and cognitive restructuring, which focuses on changing maladaptive thoughts and responses to a traumatic event, have been used as early interventions to prevent PTSD in those with acute stress disorder. However, there is evidence that some clinicians do not use exposure therapy because it causes distress for recent trauma survivors.

Richard A. Bryant, Ph.D., of the University of New South Wales, Sydney, Australia, and colleagues conducted a randomized controlled trial involving 90 patients who developed acute stress disorder following a non-sexual assault or motor vehicle crash between March 2002 and June 2006. Thirty participants each were randomly assigned to five weekly 90-minute sessions of exposure therapy or cognitive restructuring, while the remaining 30 were put on a waitlist for treatment. All the patients were assessed at the beginning of the study, after six weeks and six months following treatment.

Sixty-three participants completed the study. After completing treatment, fewer patients in the exposure therapy group (10, or 33 percent) met criteria for PTSD than patients in the cognitive restructuring group (19, or 63 percent) or the wait-list group (23, or 77 percent). At the six-month follow-up, fewer patients in the exposure therapy group (11, or 37 percent) met criteria for PTSD than patients in the cognitive restructuring group (19, or 63 percent), and 14 patients (47 percent) in the exposure group vs. four patients (13 percent) in the cognitive restructuring group achieved full remission.

“Despite some concerns that patients may not be able to manage the distress elicited by prolonged exposure, there was no difference in drop-out rates for the prolonged exposure and cognitive restructuring groups (17 percent vs. 23 percent),” the authors write. In addition, distress ratings were more significantly reduced in the exposure therapy group than the cognitive restructuring group after three sessions.

Exposure therapy may be more effective than cognitive restructuring because it eases the anxiety associated with the traumatic memory and corrects the belief that the memory must be avoided, in addition to encouraging self-control by managing the exposure exercise, the authors note. “The current findings suggest that direct activation of trauma memories is particularly useful for prevention of PTSD symptoms in patients with acute stress disorder,” they conclude. “Exposure should be used in early intervention for people who are at high risk for developing PTSD.”

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(Arch Gen Psychiatry. 2008;65[6]:659-667. Available pre-embargo to the media at http://www.jamamedia.org.)

Editor’s Note: This research was supported by a grant from the National Health and Medical Research Council Program, Canberra, Australia. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Richard A. Bryant, Ph.D.
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