Psychiatry - July 2008 - (Page 46)

Stage 2).13 Issues related to sleep hygiene, circadian rhythm disturbance, or insufficient sleep may also increase nightmares.13 TREATING PTSD THAT INCLUDES ENTIRE CLUSTER OF PTSD SYMPTOMS A recent meta-analysis and systematic review of the literature done by Bisson and colleagues18 included 38 studies of various forms of psychotherapeutic treatment for PTSD in different patient populations (e.g., including Vietnam veterans only, women only), and concluded that the evidence base is strongest for traumafocused CBT (including prolonged exposure therapy [PE] and then eye movement desensitization and reprocessing [EMDR]), with no difference in positive response between the two forms of therapy. They did not find as much evidence in support of psychodynamic approaches; however, they note that there were few studies done and that does not necessarily imply lack of efficacy. By their nature, psychodynamic approaches are difficult to administer in a uniform way and this makes systematic study difficult. Cognitive behavioral therapy (CBT). Perhaps the best known of the manualized therapies, CBT was developed by A. Beck and explicated by J. Beck,19 and seeks to help the patient understand and change the way he or she thinks about the world and thus change his or her mood. Therapy has a specific, narrow focus and takes place over 12 to 16 sessions with the idea that if one problem can be mastered, the skills learned can be generalized to other problems. Studies have shown that traumafocused CBT (e.g., CPT, prolonged exposure [PE], and variants) is superior to a generalized form of CBT (e.g., relaxation training) when treating patients with PTSD,20, 21 and therefore discussion will focus on the major forms of trauma-focused CBT. A thorough discussion of the evidence for various forms of trauma-focused CBT is provided in the review by Bisson and Andrew.21 46 Psychiatry 2008 [ J U L Y ] Cognitive processing therapy (CPT). Developed by Resick and colleagues,22 CPT is a manualized therapy that focuses on getting a patient past “stuck points” and processing the impact of the traumatic event on the patient. Patients who are very uncomfortable discussing the traumatic material may find this of benefit as the focus is on the impact to the patient (i.e., their beliefs as to why it happened and how it has changed the way they see themselves and the world around them). Several studies have shown the efficacy of this approach, including a wait-list controlled trial done with 54 men and six women with combat-related trauma in an intention-to-treat analysis. At the conclusion of the study, 40 percent of patients no longer met criteria for PTSD, and 50 percent had “a reliable change in symptoms from their pretreatment assessment.”23 In a study of 71 women with at least one episode of childhood sexual abuse, only seven percent of women who underwent CPT met criteria for PTSD at the end of the study, versus 74 percent of a minimal-attention control, and improvements in function were sustained at one-year follow-up.24 None of the women in this study had a worsening of symptoms. Case 4. Miss E was a 26-year-old transfer student from Nigeria at a local university who presented to the local college mental health service with severe nightmares, ruminations, and hyperarousal symptoms, which were interrupting her college education, following an ethnically motivated gang rape several years ago. She underwent a course of 12 sessions of CPT with improvement of all symptoms, with therapy focused on “stuck points” revolving around self-blame for the rape. Prolonged exposure (PE) therapy. Developed by Foa,25 PE is a manualized therapy designed to lessen the threat of the trauma to the patient. This is done in a series of 12 to 16 sessions where the patient re-examines the traumatic event multiple times until the fear response is lessened to a manageable level, or ideally, extinguished. A randomized controlled trial of 277 female veterans and seven female active duty service members found that exposure therapy was superior to present-centered therapy and that those in the exposure condition were more likely to no longer meet criteria for PTSD and to achieve complete remission.26 One hundred and seventy-one women with chronic PTSD were randomly assigned to a course of PE with cognitive restructuring or a wait-list control. Investigators found no difference between treatment conditions (i.e., no benefit to the additional cognitive restructuring component), but also found that patients of therapists with minimal experience administering CBT did just as well as those of CBT experts.27 In a separate study of 171 women with chronic PTSD, patients were assigned to cognitive processing therapy, PE therapy, or a minimal attention control.28 No significant difference was found between the two treatment groups, although each had an over 25-percent dropout rate, compared with 15 precent of the control group. CPT seemed to be slightly more effective than PE for improving some measures of guilt.28 Case 5. Staff sergeant (SSgt) B was a 45-year-old active duty service member who had served three tours of duty in Iraq. Prior to deployment, he had no significant mental health history. Since his return from the first tour, he had trouble sleeping, and his wife reported that he frequently kicked and punched in his sleep, and she was sleeping in a separate bed because of this. SSgt B reported extensive flashbacks to, ruminations of, and nightmares of his time in Iraq and a particular mission in which he was confronted with the gruesome remains of an individual who had accidentally detonated a bomb he was making. SSgt B engaged in a course of PE therapy in which he initially related

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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