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Nearly all of the randomized controlled trials of psychotherapy published since 2004 have examined interventions that many experts consider to be components of cognitive-behavioral therapy (CBT). As described in the 2007 report of the Institute of Medicine (2), therapeutic approaches and techniques overlap across psychotherapies, and there is no consensus on how these psychotherapies should be categorized. This review follows the approach of the Institute of Medicine report, grouping approaches and techniques as follows: CBTs that include elements of exposure, eye-movement desensitization and reprocessing (EMDR), other psychotherapies, and group psychotherapy. Research published since 2004 supports, in particular, exposure-based CBTs such as cognitive processing therapy and prolonged exposure therapy as effective treatments for PTSD when delivered in individual formats.

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Exposure-Based CBTs

Trials of exposure-based CBTs conducted in the last several years generally included components of psychoeducation, breathing, and relaxation training. By definition, these exposure therapies also incorporated into the therapy sessions some form of reexposure to past traumatic experience (e.g., imaginal, in vivo, directed therapeutic, written, verbal, or taped narrative recountings). In addition, homework was often included. The generalizability of the results of many of these studies to typical clinical populations is limited by high dropout rates, lack of intention-to-treat analysis, and lack of clarity regarding blinding of assessors. Nevertheless, several well-designed studies augment prior knowledge.

In 2006, Monson et al. (38) reported the results of a waitlist-controlled study of cognitive processing therapy in 60 combat veterans. The overall dropout rate was 16.6% (20% from cognitive processing therapy, 13% from waitlist), but random regression analyses of the intention-to-treat sample revealed significant improvements in both PTSD and co-occurring depressive symptoms in the treatment group compared with the waitlist group. At completion of the study, 40% of those in the intention-to-treat group receiving cognitive processing therapy no longer met criteria for a PTSD diagnosis, and 50% had a reliable decrease in their PTSD symptoms.

The effectiveness of cognitive processing therapy was also examined in a controlled study reported in 2005 by Chard (39) of 71 adult sexual abuse survivors with PTSD. The control was a minimal-attention waitlist group. Participants were assessed pretreatment, immediately after treatment, 3 months after treatment, and 1 year after treatment using the CAPS and a variety of other clinician-administered rating scales. Analysis demonstrated that cognitive processing therapy was superior to waitlist in reducing PTSD symptoms and that reductions were maintained for at least 1 year.

A recent study by Resick et al. (40) attempted to dismantle the components of cognitive processing therapy and determine their relative contributions to treatment efficacy. In this study, 150 adult women with PTSD were randomized into one of three conditions: 1) full cognitive processing therapy, which included both exposure (i.e., writing and reading a detailed account of the trauma) and cognitive therapy (i.e., challenging patient assertions about the meaning of the trauma and the implications for the patient's life); 2) cognitive therapy without the writing and reading component; and 3) the writing and reading component without cognitive therapy. All conditions included 2 hours of therapy per week for 6 weeks. Patients were assessed for PTSD (using CAPS) and depression in a blinded manner weekly, 2 weeks after the last session of therapy, and at 6 months. At the conclusion of the study, all treatment completers still met criteria for PTSD. However, substantial improvement was observed in all three treatment groups on primary PTSD and depression outcomes as well as on secondary measures of anxiety, guilt, and shame. Cognitive therapy without exposure was associated with greater improvement than the exposure-only condition, suggesting that the cognitive component of this therapy (i.e., altering the meaning of the traumatic event) may be an active treatment mechanism that may occur without repeated and explicitly evoked fear memories. It also suggests that cognitive processing therapy might be characterized as a more cognitive than exposure-based therapy. Similar dismantling studies are under way and will be important to further clarify the active components of various psychotherapies for PTSD. Research questions include how cognitive components as compared with exposure components may be variably effective depending on factors such as the stage of the disorder (e.g., early compared with late), the presence of particular symptoms (e.g., dissociation, high levels of arousal, avoidance), and, of course, therapist variables.

Prolonged exposure therapy was studied in a randomized controlled trial reported in 2007 by Schnurr et al. (41) of female veterans (N = 277) and active duty personnel (N = 7) across 12 sites specializing in medical treatment for military veterans, including nine Veterans Affairs hospitals, two Veterans Affairs counseling centers, and one military hospital. Patients were randomly assigned to receive prolonged exposure therapy (N = 141) or present-centered therapy (N = 143) delivered in 10 weekly 90-minute sessions. Blinded assessors collected data before and immediately after treatment and 3 and 6 months after treatment. Immediately after treatment, the prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD criteria (41% compared with 27.8%, odds ratio [OR] = 1.80, confidence interval [CI] = 95%) and more likely to achieve full remission (15.2% compared with 6.9%, OR = 2.43, CI = 95%). These results were maintained at 3- and 6-month follow-up. It should be noted that although this was a study of military personnel and veterans, 70% of participants indicated sexual trauma as their index (worst) traumatic experience, and there was a 17% differential dropout rate between prolonged exposure and present-centered therapy, with more participants dropping out of the prolonged exposure arm.

A controlled study reported in 2005 by Rothbaum et al. (42) evaluated the relative efficacy of prolonged exposure therapy and EMDR. In this study, 74 adult female rape victims (index rape occurring either in adulthood or childhood) were randomized into 9-session prolonged exposure, EMDR, and waitlist control groups. Dropout rates across the groups were not significantly different (13% prolonged exposure, 20% EMDR, 16.7% waitlist). Immediately following treatment, the groups receiving prolonged exposure and EMDR both demonstrated statistically significant improvement across three outcome measures, including a 50% or more decrease from baseline in CAPS score (p = 0.001). Posttreatment, 95% of participants who received prolonged exposure therapy and 75% of participants who received EMDR no longer met criteria for PTSD, and individuals who received both treatments showed significantly reduced depressive symptoms and dissociative symptoms immediately and at 6 months. Results were maintained at 6-month follow-up for the prolonged-exposure group across PTSD, depressive, and dissociative symptoms but maintained to a significantly lesser extent for the EMDR group with regard to PTSD.

The effectiveness of brief exposure therapy has been demonstrated in two recent studies reported in 2005 and 2007 by Basoglu et al. (43, 44). In the first study, 59 earthquake survivors with PTSD assessed by CAPS were randomized to a single-session exposure-based behavioral therapy intervention (in which the intensity of simulated trauma was adjusted in accordance with the patient's personal feelings of comfort) or to a waitlist (43). At 6, 12, and 24 weeks posttreatment, as well as at 1–2 years posttreatment, the treatment group was observed to have significant decreases in CAPS score, Beck Depression Inventory (BDI) score, and other patient self-measures of fear, anxiety, or overall impression. With regard to CAPS, effect sizes were considerable (Cohen's d = 0.7–1.4), and improvement rate rose from 49% at week 6 to over 80% at other assessment points.

In the second study (44), 31 earthquake survivors with PTSD were randomized to a single-session exposure-based behavioral therapy (N = 16) or to repeated assessments (N = 15). Participants were assessed at 4, 8, 12, and 24 weeks posttreatment and again after 1–2 years. Again, significant between-group treatment effects were observed in PTSD (assessed by CAPS) and assessor-rated global improvement (Global Improvement Scale–Assessor [GIS–A]), with significant between-group treatment effects observed in both outcome measures at week 8. Improvement rates of 40% at week 4 rose to 80% by week 24 and at 1–2 year follow-up, with large effect sizes (Cohen's d = 0.9–1.7) noted across primary measures at week 8.

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EMDR

EMDR continues to be examined as a treatment for victims of trauma; however, many of the studies published since 2004 include participants without a formal PTSD diagnosis. An exception is a study reported in 2007 by van der Kolk et al. (9), in which 88 patients with PTSD were randomly assigned to 8 weeks of EMDR, fluoxetine, or placebo. Symptoms were assessed using the CAPS and BDI-II immediately posttreatment and at 6 months. At 6-month follow-up, 75% of the adult-onset (compared with 33% of the childhood-onset) patients receiving EMDR achieved remission as compared to none of the patients receiving fluoxetine. Neither treatment produced complete symptom remission in the majority of the patients with childhood-onset PTSD. It should be noted that fluoxetine was discontinued at termination of the 8-week treatment phase, so the poor SSRI outcomes at 6 months should not be surprising.

Another exception is a study reported in 2007 by Högberg et al. (45) of 24 transportation workers who had either been assaulted or who had witnessed a person-under-train accident and who met DSM-IV criteria for PTSD. Participants were randomized to either five sessions of EMDR or to a waitlist. After treatment, eight of 13 patients receiving EMDR (67%) no longer met criteria for PTSD compared with one of 11 (11%) patients on the waitlist (p = 0.02). Significant differences were also observed in Global Assessment of Functioning and HAM-D scores.

Neither of these studies dismantled the effects of exposure compared with eye-movement components of the treatment. Previous studies (summarized in the 2004 guideline) have shown the eye movements not to be critical to the treatment effect. These small studies suggest efficacy of brief EMDR in sexual assault victims and witnesses to vehicular accidents but cannot be generalized to combat veterans.

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Other Psychotherapies

Since publication of the 2004 guideline, studies of other types of psychotherapy, including coping skills therapy, eclectic psychotherapy, psychodynamic psychotherapy, cognitive restructuring, and brainwave neurofeedback, have also been published, but the utility and generalizability of conclusions from these studies are limited by methodological issues such as lack of formalized diagnostic procedures, inclusion of non-PTSD patients, very high dropout rates, unspecified handling of dropouts or missing data, and lack of blinding of assessors. A study reported in 2004 by Neuner et al. (46) of coping skills therapy in 43 war refugees was methodologically sound but failed to demonstrate a differential effect of treatment. As noted in the 2004 guideline, although controlled studies of psychodynamic psychotherapy are lacking, clinical consensus reflects the idea that a psychodynamic approach is useful in helping the patient integrate past traumatic experience(s) into a more adaptive or constructive schema of risk, safety, prevention, and protection, thereby reducing core symptoms of PTSD.

Case reports (47, 48) have recently suggested that exposure-based therapy may be facilitated through the use of computerized audio-visual simulations of a traumatic combat environment. The effectiveness of this facilitated CBT—termed "virtual reality therapy"—in disaster workers with PTSD has also been demonstrated in a small controlled trial. In 2007, Difede et al. (49) assigned 21 September 11 terrorist attack workers to either virtual reality treatment (N = 13) or waitlist control (N = 8). The treatment group showed a significant decline in CAPS scores compared with the waitlist group. While these reports are encouraging, larger randomized controlled trials must replicate such findings before virtual reality therapy can be recommended with the highest levels of confidence.

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Group Psychotherapy

The majority of psychotherapies may be delivered in either individual or group formats. Of the studies reviewed above, the 2005 study by Chard (39) comparing cognitive processing therapy to minimal attention waitlist used both individual and group therapy formats (participants in the treatment group received both individual and group therapy in the first 9 weeks, followed by 7 weeks of group therapy, then one session of individual therapy). Effects of group therapy compared with individual therapy were not clearly demonstrated in this study. While there is a substantial descriptive literature for group therapy for PTSD, well-designed studies of cognitive processing therapy and other psychotherapies delivered in group formats are needed in the future in order to validate the efficacy of this method of delivery.

References

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