Preventing PTSD Through Early Intervention After a Traumatic Incident
(Quick
Summary: early research on a specific cognitive behavioral protocol
has yielded the following results: following a trauma, symptomatic patients
treated with the protocol had an 8-10% likelihood of developing PTSD versus
patients who received no treatment or supportive counseling, who had 70-84%
likelihood of PTSD)
Promising
Developments in the Treatment Research:
We believe that it is important to pass on information that a treatment protocol for preventing PTSD has been researched and has received very strong initial support. This preventative treatment, applied in the days or weeks following a trauma, is a derivative of a procedure called Prolonged Exposure, which is a cognitive behavioral therapy developed primarily by Edna Foa, Ph.D. There is a solid body of empirical research on prolonged exposure, and it repeatedly has been demonstrated to have among the highest success rates and lowest relapse rates among treatments for people who already have PTSD.
Controlled studies on the derivative treatment for preventing PTSD were conducted with women who were physically or sexually assaulted as well as with people who were involved in motor vehicle or industrial accidents. Treatment was initiated approximately two weeks following the trauma.
q In the study of sexual and non-sexual assault survivors who met criteria for PTSD (except for duration criteria), results were as follows:
o For people who received no treatment:
§ 70% of people who received no treatment met criteria for PTSD at the end of the study.
§ Five and a half months after the assault, 56% of the people who received no treatment also had symptoms of moderate-to-severe depression.
o For people who received the treatment derived from Foa’s protocol for Prolonged Exposure:
§ only 10% met criteria for PTSD at the end of the study
§ Five and a half months after the trauma none of them had symptoms of even mild depression.
q
In the study of motor
vehicle accident and industrial accident survivors with Acute Stress Disorder,
subjects in the study received either supportive counseling or treatment derived
from prolonged exposure.
o
In the Supportive
Counseling group, results indicated that:
§
83% of people ended up
with a diagnosis of PTSD at the end of the study.
§
At the end of a six month
follow up period, with 67% of the supportive counseling people still meeting
criteria for PTSD,
o
In the group that
received the protocol derived from Prolonged Exposure:
§
8% of the people ended up
with a diagnosis of PTSD at the end of the study
§
At the end of a six month
follow up period only 17% of them met criteria for PTSD, indicating that
treatment effects were highly durable for most people
What
About the Various Forms of Trauma Debriefing?
The practice of debriefings
following a traumatic event gained popularity in the 1980s and 1990s.
It was hoped that "Critical Incident Stress
Debriefing" (CISD) would be effective in preventing
posttraumatic stress and some para-professionals still advocate this approach.
However, of the controlled research studies that have been completed, the
evidence indicates that CISD does not prevent PTSD.
More disconcerting is that some studies have found it may put certain
individuals at risk for adverse effects, compared to people who did not
participate in a debriefing. Also,
research indicates that the people who rate debriefing least favorably are those
who have been most affected by the trauma, whereas those who were less affected
rate debriefing more favorably. In
other words, the people most in need give debriefings the lowest ratings.
On a positive note, debriefing may
be important in helping survivors mobilize social and professional supports
following a traumatic incident. The importance of this benefit should not
be underestimated since, during the disorientation that often follows a trauma,
having a clear sense of how to mobilize supports can be essential.
Why is Prevention of
Posttraumatic Stress Disorder Important?
Unfortunately, traumatic events and their sequelae are a fact of life for a disturbingly large percentage of the U.S. population. PTSD affects approximately 9-15% of the population. One study reported a lifetime prevalence of PTSD after rape of 35%, and a current prevalence of 13%. Following aggravated assault, lifetime prevalence was 39% and current prevalence was 12%. The majority of studies find that about 70-95% of people have significant posttraumatic symptoms following a trauma, and that three months after the trauma these symptoms remit spontaneously for only around half of the people who experience them.
In addition to the severe distress endured by people with PTSD, a number of other health-related problems are common. For example, women who were raped report poorer physical health, visit their physicians more frequently, and are more likely to undergo surgery than women who have not been assaulted. About 50% of women with PTSD have a comorbid diagnosis of depression, increasing their risk for suicide. About 50% of men with PTSD have a comorbid substance abuse disorder.
Our Recommendations:
It is likely that not all patients require intervention immediately following a traumatic occurrence. Depending on the intensity and duration of the trauma, there will be people who will make it through unscathed. Often, if a person appears to be coping well and denies symptoms of Acute Stress Disorder or PTSD, they may not need specialized care (although one’s professional judgment must be the final arbiter).
For people who show signs of Acute Stress Disorder or PTSD (including symptoms of intrusive recollections, avoidance, numbing, and physiological hyperarousal when confronted with reminders of the trauma) psychological intervention, either alone or in combination with medication, may be indicated. In our opinion, the available research provides strong preliminary support for the protocol derived from Prolonged Exposure.
We feel that debriefing can be useful following traumatic experiences to help people identify community and interpersonal supports and provide them with information to help them recognize PTSD symptoms. However, it is important to keep in mind that there is no evidence that debriefing prevents PTSD, and that those who may be most affected by the trauma may benefit least from debriefing. We agree with international working groups that recommend that debriefings are not necessarily appropriate or beneficial following trauma, and that decisions to use debriefings should be made based on a balanced review of known risks versus possible benefits.
What
Sonnet Psychological, LLC Can Offer:
We
seek to provide information to community health care professionals and to
provide effective, research-based treatment for patients.
If you would like more information on treatments with empirically
demonstrated efficacy please feel free to contact us at any time.
We are often able to make arrangements for consultations or
presentations.
We
work hard to keep our skills and knowledge current and we welcome patient
referrals. In
addition to providing effective treatments for PTSD, we are able to offer
research-based treatments for other anxiety disorders (as well as a variety of
other psychological issues) in a warm, supportive environment.
Resources:
Avery,
A, King, S, Bretherton, R, & Orner, R. (1999). Deconstructing psychological
debriefing and the emergence of calls for evidence-based practice.
Traumatic StressPoints, 13:2, 6-8.
Bryant,
R.A., Harvery, A.G., Dang, S.T., Sackville, T., Basten, C. (1998). Treatment of
acute stress disorder: A comparison of cognitive-behavioral therapy and
supportive counseling.
Journal of Consulting and Clinical Psychology, 66, 862-866.
Foa,
E.B., Davidson, J.R.T., & Frances, A. (1999) The expert consensus guideline
series: Treatment of posttraumatic stress disorder.
The Journal of Clinical Psychiatry, 60, (supl 16).
Foa,
E.B., Hearst-Ikeda, D., Perry, K.J. (1995). Evaluation of a brief
cognitive-behavioral program for the prevention of chronic PTSD in recent
assault victims.
Journal of Consulting and Clinical Psychology, 63, 948-955.
Foa,
E.B. & Rothbaum, B.O. (1998). Treating the Trauma of Rape. New York:
The Guilford Press.
Orner,
R. (1997). Emergency services may abandon critical incident stress debriefing. Traumatic
StressPoints, 11:1, 5.