Primum Non Nocere (First Do No Harm): Symptom Worsening and Improvement in Female Assault Victims After Prolonged Exposure for PTSD

Jayawickreme, Nuwan; Cahill, Shawn P.; Riggs, David S.; Rauch, Sheila A. M.; Resick, Patricia A.; Rothbaum, Barbara O.; Foa, Edna B.

doi:10.1002/da.22225

Cited by 56 publications

(38 citation statements)

References 24 publications

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“…This means that when a clinician is faced with increases in symptoms (either PTSD or comorbid symptoms) after initiation of imaginal exposure, it can be expected that if PE is continued, the symptoms will eventually decrease significantly and the patient will profit as much from the treatment as patients without initial exacerbations. This is further reified by a recent large study ( N = 361) of pooled data across RCTs [140] showing that, at post-treatment, reliable worsening of PTSD symptoms after PE was non-existent and reliable worsening of depression was low (1.5 %), with no differences from other trauma-focused treatments (CPT, EMDR).…”

Section: Discussionmentioning

confidence: 91%

Changes in Comorbid Conditions After Prolonged Exposure for PTSD: a Literature Review

Minnen

Zoellner

Harned

et al. 2015

Curr Psychiatry Rep

105

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Prolonged exposure (PE) is an effective psychological treatment for patients who suffer from PTSD. The majority of PTSD patients have comorbid psychiatric disorders, and some clinicians are hesitant to use PE with comorbid patients because they believe that comorbid conditions may worsen during PE. In this article, we reviewed the evidence for this question: what are the effects of PE on comorbid symptoms and associated symptomatic features? We reviewed findings from 18 randomized controlled trials of PE that assessed the most common comorbid conditions (major depression, anxiety disorders, substance use disorders, personality disorders, and psychotic disorders) and additional symptomatic features (suicidality, dissociation, negative cognitions, negative emotions, and general health and work/social functioning). Although systematic research is not available for all comorbid populations, the existing research indicates that comorbid disorders and additional symptomatic features either decline along with the PTSD symptoms or do not change as a result of PE. Therefore, among the populations that have been studied to date, there is no empirical basis for excluding PTSD patients from PE due to fear of increases in comorbid conditions or additional symptomatic features. Limitations of the existing research and recommendations for future research are also discussed.

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Section: Discussionmentioning

confidence: 91%

Changes in Comorbid Conditions After Prolonged Exposure for PTSD: a Literature Review

Minnen

Zoellner

Harned

et al. 2015

Curr Psychiatry Rep

105

View full text Add to dashboard Cite

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“…First, comorbid major depressive disorder strongly predicted dropout in Prolonged Exposure but not Interpersonal Psychotherapy or Relaxation Therapy. Prolonged Exposure was developed to target anxiety; although it often reduces depressive symptoms (14,46), it may treat major depressive disorder less effectively. Alternatively, comorbid major depression may have rendered tolerating Prolonged Exposure more difficult.…”

Section: Discussionmentioning

confidence: 99%

Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD

Markowitz¹,

Petkova²,

Neria³

et al. 2015

AJP

293

214

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Background Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). No treatment benefits all patients, however. We tested Interpersonal Psychotherapy, which has demonstrated antidepressant efficacy and showed promise in pilot PTSD research, as a non-exposure-based, non-cognitive behavioral PTSD treatment. Methods A randomized, fourteen-week trial compared Interpersonal Psychotherapy; Prolonged Exposure, an exposure-based exemplar; and Relaxation Therapy, an active control psychotherapy. Subjects were 110 unmedicated patients having DSM-IV chronic PTSD and Clinician-Administered PTSD Scale (CAPS) score >50. Randomization stratified for comorbid major depression. We hypothesized Interpersonal Psychotherapy would be no more than minimally inferior (CAPS difference <12.5 points) to Prolonged Exposure. Results All therapies had large within-group pre/post effect sizes (d=1.32–1.88). Response rates (>30% CAPS improvement) were: Interpersonal Psychotherapy 63%, Prolonged Exposure 47%, Relaxation Therapy 38% (n.s.). Interpersonal psychotherapy and Prolonged Exposure CAPS outcome differed by 5.5 points (n.s.); the null hypothesis of more than minimal Interpersonal Psychotherapy inferiority was rejected (p=0.035). Patients with comorbid major depression dropped out from Prolonged Exposure nine times more than non-depressed Prolonged Exposure patients. Interpersonal Psychotherapy and Prolonged Exposure improved quality of life and social functioning more than Relaxation Therapy. Conclusions This first controlled study of individual Interpersonal Psychotherapy for PTSD demonstrated non-inferiority to the “gold standard” PTSD treatment. Interpersonal Psychotherapy had (non-significantly) lower attrition and higher response rates than Prolonged Exposure. Contradicting a widespread clinical belief, PTSD treatment may not require cognitive behavioral exposure to trauma reminders. Moreover, as differential therapeutics, patients with comorbid major depression may fare better in Interpersonal Psychotherapy than Prolonged Exposure.

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“…Yet, no previous studies have supported the accuracy of this belief (Griffin, Resick., Waldrop, & Mechanic, 2003; Harned et al, 2013; Pedersen, Kaysen, Lindgren, Blayney, & Simpson, 2014; Larson, Stirman, Smith, & Resick, in press). Recent studies have found that significant symptom exacerbation is extremely rare in EBTs, and that even when clients do experience transient symptom increases, they still ultimately experience significant symptom reduction (Jayawickreme et al, 2013; Larsen et al, in press). Another study concluded that individuals on a wait list and in supportive therapy experienced greater symptom worsening than those in a trauma-focused treatment (Ehlers et al, 2014).…”

Section: Discussionmentioning

confidence: 99%

Providers’ perspectives of factors influencing implementation of evidence-based treatments in a community mental health setting: A qualitative investigation of the training–practice gap.

Marques¹,

Dixon²,

Valentine³

et al. 2016

Psychological Services

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The present study aimed to elucidate relations between provider perceptions of aspects of the Consolidated Framework for Implementation Research (CFIR; Damshroder et al., 2009) and provider attitudes towards the implementation of evidence-based treatments (EBTs) in an ethnically diverse community health setting. Guided by directed content analysis, we analyzed 28 semi-structured interviews that were conducted with providers during the pre-implementation phase of a larger implementation study for Cognitive Processing Therapy for Posttraumatic Stress Disorder (CPT-C for PTSD, Resick et al., 2008). Our findings extend the existing literature by also presenting provider-identified client-level factors that contribute to providers' positive and negative attitudes towards EBTs. Provider-identified client-level factors include: client motivation to engage in treatment, client openness to EBTs, support networks of family and friends, client use of community and government resources, the connection and relationship with their therapist, client treatment adherence, client immediate needs or crises, low literacy or illiteracy, low levels of education, client cognitive limitations, and misconceptions about therapy. These results highlight the relations between provider perceptions of their clients, provider engagement in EBT training, and subsequent adoption of EBTs. We present suggestions for future implementation research in this area.

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Primum Non Nocere (First Do No Harm): Symptom Worsening and Improvement in Female Assault Victims After Prolonged Exposure for PTSD

Abstract: PE and a number of other empirically supported therapies are efficacious and safe treatments for PTSD, reducing the frequency of which symptom worsening occurs in the absence of treatment.

Cited by 56 publications

References 24 publications

Changes in Comorbid Conditions After Prolonged Exposure for PTSD: a Literature Review

Changes in Comorbid Conditions After Prolonged Exposure for PTSD: a Literature Review

Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD

Providers’ perspectives of factors influencing implementation of evidence-based treatments in a community mental health setting: A qualitative investigation of the training–practice gap.

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