Epidemiology of Post-Traumatic Stress Disorder

Epidemiology and Treatment of Post-Traumatic Stress Disorder (PTSD)

Description of PTSD symptoms.

Epidemiology of PTSD.

Common contextual features.

Theoretical Conceptualization

In their study, “Cognitive Processing Therapy for Veterans With Military-Related Posttraumatic Stress Disorder,” Monson, Schnurr, Resick, Friedman, Young-Xu and Stevens (2006) report that their trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments for this veteran population.

The researchers established a three-phase screening process using some straightforward criteria for participation in this study. Subjects were required to have been diagnosed with some type of military-related PTSD in order to be eligible; furthermore, those subjects that were actively receiving psychopharmacological treatment were allowed to continue their treatment but were deemed eligible only if they had been on a stable regimen for at minimum of 2 months prior to entry into the study entry. In addition, psychotherapeutic interventions that were not specifically focused on PTSD treatment were allowed to continue as well. Any of the following criteria would prevent a subject from participating in the study: (a) current uncontrolled psychotic or bipolar disorder; (b) substance dependence, but subjects with substance abuse diagnoses were included in the study; – prominent current suicidal or homicidal ideation; and (d) significant cognitive impairment.

Subjects. Of the 93 patients referred by a VAMC for participation, 64 (or 68.8%) were deemed to meet the study criteria. Of these, 60 subjects (54 men, 6 women) were randomized into the trial with an overall dropout rate of 16.6% (20% from the CPT treatment and 13% from the wait-list condition). The authors report, “There were no statistically significant differences between the two conditions in baseline characteristics. These sample characteristics are consistent with those found in veterans seeking PTSD treatment within the VA” (Monson et al., p. 898).

Research Design. This study used a wait-list controlled trial of cognitive processing therapy (CPT). Both clinician-administered instruments for structured interviews and a self-report instrument were used to assess the study subjects. Subjects found to be eligible for participation were randomized to receive the treatment immediately or to wait for 10 weeks to receive the treatment (10 weeks was equivalent to the ideal 6 weeks of the two-times-a-week sessions and the 1-month follow-up period for those in the CPT condition); the videotaped sessions were evaluated by an independent expert and adherence to the research design was determined to be good at 93% adherence.

Statistics. Estimates of sample size were calculated by the study’s biostatistician to confirm or refute the primary hypothesis that CPT would result in significantly lower clinician-rated overall PTSD symptoms in comparison with the wait-list condition.

Results. These researchers found that random regression analyses of the intention-to-treat sample identified significant improvements in PTSD and the comorbid symptoms in the CPT condition when compared with the wait-list condition. Just under half (40%) of the intention-to-treat sample who received CPT failed to meet criteria for a PTSD diagnosis, and exactly half (50%) were determined to have experienced a reliable change in their PTSD symptoms at posttreatment assessment (the authors also note that there was no relationship between PTSD disability status and outcomes).

Study Two — Introduction. The second study, entitled, “A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness,” by Mueser, Rosenberg, Xie, Jankowski, Bolton, Lu, Rosenberg, McHugo and Wolfe (2008), developed a cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) in order to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers.

CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program.

Methods. Because of the extensive literature on borderline personality disorder and PTSD, we evaluated Axis II diagnosis of borderline personality disorder with the SCID-II. SCID assessments and trauma history were administered only at baseline, with the remaining assessments repeated at posttreatment and 3- and 6-month follow-ups. The primary outcome measures were PTSD severity and diagnosis, and the secondary outcomes were measures of knowledge about PTSD, trauma-related cognitions, depression, anxiety, perceived health and mental health functioning, and working alliance with the case manager. The researchers also report that all of the subjects participating in this study were in receipt of comprehensive treatment for their psychiatric illness at their local community mental health center and continued to receive these services throughout the study period, regardless of which treatment group they were assigned to. Comprehensive mental health treatment at these centers included pharmacological treatment and monitoring, case management, supportive counseling, and access to psychiatric rehabilitation programs such as vocational rehabilitation. No efforts were made to control or modify any of these services provided to study participants.

Subjects. Inclusion criteria for participation in the study were (a) minimum age 18 years; (b) designation by the states of New Hampshire or Vermont as having a severe mental illness, defined as a DSM-IV Axis I disorder and persistent impairment in the areas of work, school, or ability to care for oneself; – DSM-IV diagnosis of major depression, bipolar disorder, schizoaffective disorder, or schizophrenia; (d) current DSM-IV diagnosis of PTSD; and (e) legal ability and willingness to provide informed consent to participate in the study. We initially planned to enroll and treat only clients who met criteria for “severe” PTSD based on the Clinician Administered PTSD Scale as a CAPS-Total score greater than or equal to 65. However, due to lower-than-expected recruitment rates we modified this criterion to include all clients with PTSD based on CAPS. Exclusion criteria for participation in the study were (a) psychiatric hospitalization or suicide attempt within the past 3 months; and (b) current DSM-IV substance dependence.

Research design. A randomized controlled trial was conducted to compare the CBT for PTSD program with comprehensive mental health treatment as usual (TAU) in clients with severe mental illness who were receiving services at four publicly funded community mental health centers in the northeastern United States. Assessments were conducted by blinded interviewers at baseline, following the 4- to 6-month treatment period for the CBT program, and 3 and 6 months later. Recruitment for the study began in May 2002, and the last interview was conducted in February 2006. Axis I psychiatric disorders other than PTSD were assessed with the Structured Clinical Interview for DSM-IV.

Statistics. Two-tailed t tests and X2 analyses were used to compare the CBT and TAU groups on demographic characteristics, psychiatric history, and outcome measures at baseline. Prior to statistical modeling we conducted descriptive statistical analyses and examined the distributions of each variable for skewness and possible outliers. Intent-to-treat analyses were conducted to determine treatment effects on the primary outcome measures. Because there were no significant differences between CBT and TAU on these variables at baseline, and because there were only three follow-up assessment points, rather than fitting parametric curves with random effects we elected to include the baseline as a covariate and fit baseline adjusted mean response profile models.

Results. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations.

Study Three — Introduction. The purpose of the final study reviewed, “A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence,” by Resick, Galovski, Uhlmansiek, Scher, Clum and Young-Xu (2008), was to conduct a dismantling study of cognitive processing therapy in which the full protocol was compared with its constituent components — cognitive therapy only (CPT-C) and written accounts (WA) — for the treatment of posttraumatic stress disorder (PTSD) and comorbid symptoms. The intent-to-treat (ITT) sample included 150 adult women with PTSD who were randomized into 1 of the 3 conditions. Each condition consisted of 2 hours of therapy per week for 6 weeks; blind assessments were conducted before treatment, 2 weeks following the last session, and 6 months following treatment. Measures of PTSD and depression were collected weekly to examine the course of recovery during treatment as well as before and after treatment. Secondary measures assessed anxiety, anger, shame, guilt, and dysfunctional cognitions. Independent ratings of adherence and competence were also conducted.

Methods. Participants were recruited broadly throughout the St. Louis metropolitan area through referrals from victim assistance agencies, community therapists, flyers, newspaper advertisements, and word of mouth. Exclusion criteria from the trial included illiteracy, current psychosis, suicidal intent, or dependence upon drugs or alcohol. In addition, participants could not be in a currently abusive relationship or being stalked. Participants were included if they had experienced sexual or physical assault in childhood or adulthood and met criteria for PTSD at the time of the initial assessment, were at least 3 months posttrauma (no upper limit), and if on medication, were stabilized. Women with current substance dependence were included if/when they had been abstinent for 6 months. Those with substance abuse were permitted to participate if they agreed to desist in usage during the period of treatment. Following telephone screening, potential participants were invited to be assessed for possible participation, at which time they discussed and signed informed consent for participation.

Subjects. A total of 256 women were assessed for possible participation by assessors who were blind to group assignment. The most common reasons for exclusion from the study (n = 94) were not meeting the criteria for PTSD (n = 28), current substance dependence (n = 12), medication instability (n = 11), and current abuse or stalking Sixteen women failed to complete the initial assessment. Of 162 women randomized into the trial, 12 were terminated from the study, by design, for meeting exclusion criteria subsequent to new violence (women had to be at least 3 months posttrauma), changes in medication, or psychosis. Among them, one WA participant was terminated from the trial when the therapist stopped the protocol because of increased suicidal ideation. These terminations were evenly distributed across groups. Therefore, the intent-to-treat (ITT) sample included 150 women. There was one other unrelated adverse event during the trial.

Research design. Interviews using the Clinician-Administered PTSD Scale (CAPS) were used to assess DSM-IV PTSD diagnosis and PTSD symptom severity; in addition, Structured Clinical Interview for DSM-IV Axis I Disorders — Patient Edition (SCID) were used. In this study, we assessed panic disorder, major depressive disorder (MDD), and substance abuse/dependence. The psychotic screen of the SCID was used for exclusion purposes. The Beck Depression Inventory — II (BDI-II), the Experience of Shame Scale (ESS) and the Personal Beliefs and Reactions Scale (PBRS), the State-Trait Anger Expression Inventory (STAXI), State-Trait Anxiety Inventory (STAI), the Therapeutic Outcome Questionnaire, and the Trauma-Related Guilt Inventory (TRGI) were used for the study’s self-report scales. The study subjects were randomly assigned to CPT, CPT-C, or WA.

Statistics. Multiple paired t tests.

Results. Analyses with the ITT sample and with study completers indicate that patients in all three treatments improved substantially on PTSD and depression, the primary measures, and improved on other indices of adjustment; however, there were significant group differences in symptom reduction during the course of treatment whereby the CPT-C condition reported greater improvement in PTSD than the WA condition. Both components of CPT as well as the full protocol were successful in treating PTSD and other secondary symptoms in this highly traumatized and chronic sample, as evidenced by the large decreases in PTSD and depression symptoms. The results of the trial were quite similar to other trials of cognitive behavioral treatments for PTSD, with large improvements realized over the 6 weeks of treatment and maintained throughout the follow-up period. Participants improved, across conditions, not only on PTSD symptoms but also on depression, anxiety, anger, guilt, shame, and cognitive distortions.

Discussion

All three of the studies reviewed complied with internal review board requirements and followed established protocols for administering the instruments used. Further, all three studies evinced some degree of effectiveness of the CPT approach in treating their respective populations.

Conclusion

References

Barlow, DH (ed.). Clinical handbook of psychological disorders (3rd ed.).

Monson, C.M., Schnurr, P.P., Resick, P.A.., Friedman, M.J., Young-Xu, Y. & Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898-907.

Mueser, K.T., Rosenberg, S.D., Xie, H., Jankowski, M.K., Bolton, E.E., Lu, W. Rosenberg, H.J., McHugo, G.J. & Wolfe, R. (2008). A randomized controlled trial of cognitive- behavioral treatment for posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 76(2), 259-271.

Resick, P.A., Galovski, T.E., Uhlmansiek, M.O., Scher, C.D., Clum, G.A. & Young-Xu, Y.

2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76(2), 243-258.

Draft: The Epidemiology and Treatment of Posttraumatic Stress Disorder

Introduction

Description of PTSD symptoms.

Epidemiology of PTSD.

Common contextual features.

Theoretical Conceptualization

Study One — Introduction. In their study, “Cognitive Processing Therapy for Veterans With Military-Related Posttraumatic Stress Disorder,” Monson, Schnurr, Resick, Friedman, Young-Xu and Stevens (2006) report that their trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments for this veteran population.

Methods. The researchers established a three-phase screening process using some straightforward criteria for participation in this study. Subjects were required to have been diagnosed with some type of military-related PTSD in order to be eligible; furthermore, those subjects that were actively receiving psychopharmacological treatment were allowed to continue their treatment but were deemed eligible only if they had been on a stable regimen for at minimum of 2 months prior to entry into the study entry. In addition, psychotherapeutic interventions that were not specifically focused on PTSD treatment were allowed to continue as well. Any of the following criteria would prevent a subject from participating in the study: (a) current uncontrolled psychotic or bipolar disorder; (b) substance dependence, but subjects with substance abuse diagnoses were included in the study; – prominent current suicidal or homicidal ideation; and (d) significant cognitive impairment.

Study Two — Introduction.

Methods.

Subjects.

Research design.

Statistics.

Results.

Discussion.

Study Three — Introduction.

Methods.

Subjects.

Research design.

Statistics.

Results.

Discussion

Conclusion

References

Barlow, DH (ed.). Clinical handbook of psychological disorders (3rd ed.).

Resick, P.A., Galovski, T.E., Uhlmansiek, M.O., Scher, C.D., Clum, G.A. & Young-Xu, Y.

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