ARTICLE IN BRIEF
✓ Twice as many women veterans achieved remission from posttraumatic stress disorder after ten weeks of “prolonged exposure” cognitive behavioral therapy than did counterparts who had more traditional “present-centered” therapy.
Women veterans suffering from posttraumatic stress disorder (PTSD) may recover more quickly if they participate in cognitive behavioral therapy (CBT) in which they are asked to repeatedly and vividly “re-experience” traumatic events rather than simply discussing current difficulties with a therapist, according to the first study to compare the two therapies.
Twice as many women achieved remission after ten weeks of “prolonged exposure” cognitive behavioral therapy than did counterparts who had more traditional “present-centered” therapy, researchers at the Department of Veterans Affairs (VA) National Center for Post-Traumatic Stress Disorder in White River Junction, VT, reported in the Feb. 28 issue of the Journal of the American Medical Association (297:820–830).
The differences were consistent over time but improvement in the prolonged-exposure group occurred much sooner. There was no difference between the groups after three and six months.
The trial involved 277 women veterans and seven women on active duty. On average, the defining event or events occurred 23 years earlier, lead author Paula P. Schnurr, PhD, deputy executive director of the center and a research professor of psychiatry at Dartmouth Medical School, said in a telephone interview.
The women were randomly assigned to prolonged exposure therapy delivered in ten weekly 90-minute sessions. Symptom severity was assessed before and after treatment, and after three and six months.
Total PTSD remission was achieved in 15.2 percent for CBT versus 6.9 percent for PCT. In the CBT group, 41 percent no longer met diagnostic criteria for PTSD after 10 weeks, compared to 27.8 percent in the PCT group, a significant difference.
“Other studies in smaller groups of carefully selected [PTSD] patients, with therapists experienced in this type of treatment, have shown prolonged-exposure cognitive therapy can be effective,” said Dr. Schnurr. “But our intention was to evaluate it in a more clinically realistic setting with therapists ranging from novices to experts.”
Because women have traditionally been excluded from combat, most PTSD research of women in the military has dealt with sexual assault. The same was true in the current study, where 90 percent of the women reported sexual trauma, including 70 percent where sexual trauma was related to their military service and 20 percent with combat-related trauma, Dr. Schnurr noted.
While most of the women were not involved in current military operations in Iraq or Afghanistan, the benefits of CBT should be equally applicable in these women veterans, Dr. Schnurr said.
Figure. Dr. Paula P....Image Tools
“With the high prevalence of PTSD among personnel returning from service in Iraq and Afghanistan, the challenge for large health-care systems, like those of the VA and the Department of Defense, is to find efficient ways to train personnel to promote application of these effective treatments,” Dr. Schnurr added.
In light of the findings, the VA is seeking ways to increase delivery of cognitive therapy services, she told Neurology Today.
HIGH DROPOUT RATE
Neuropsychologist Jack Ginsberg, PhD, a PTSD researcher at the Dorn VA Medical Center in Columbia, SC, commented that while the benefits of CBT for PTSD are well-known, the therapy is often traumatic and is associated with a high attrition rate.
“This is an informative study, but the findings are not that surprising,” he told Neurology Today in a telephone interview. “Its biggest strength is that it was a large and well-controlled study. We hope it will start a discussion of ‘business-as-usual' in PTSD treatment for these patients.”
However, the high dropout rate with prolonged-exposure CBT remains a problem, noted Dr. Ginsberg, an adjunct research assistant professor of pharmacology, physiology, and neuroscience at the University of South Carolina School of Medicine in Columbia.
“The problem will be keeping these patients coming back for treatment,” he said. “The study creates the impression that there is a deficiency in the VA's handling of the problem, and I don't feel that is the case, but one way the results could be interpreted is that prolonged exposure to CBT can supplement, or be integrated with, the less intense present-centered therapy.”
“The cost of the higher earlier response rate with prolonged exposure therapy is likely to be a higher attrition rate,” Dr. Ginsberg said. “The VA can't be sure which patients will be able to handle it, and the question is: Would you rather help more people recover or help fewer people recover more quickly?”
Dr. Schnurr agreed that exposure therapy can be traumatic and that attrition is a very difficult problem, especially in women. “Our dropout rate was about 30 percent, but it's typically around 20 to 30 percent. We'd like to develop and work on strategies to retain more patients by helping them develop better coping skills for managing treatment.”
LATENT PHYSICAL CONCERNS
PTSD is also associated with a considerable physical toll on women veterans over time, noted Rolland S. Parker, PhD, adjunct professor of clinical neurology at New York University School of Medicine in New York City.
“Often symptoms like chronic fatigue and sleep disorders are attributed to PTSD when they are actually physical changes on major body systems caused by ongoing and long-term stress, or previous brain damage of which the person is unaware since the injury was not studied at the time,” he told Neurology Today in a telephone interview. “It is important for these veterans to have comprehensive physical exams, and that each case is assigned to one physician who will be responsible for monitoring their treatment and recovery throughout the care cycle. There really must be better coordination.”
Dr. Parker noted that as veterans move back to their communities, they are often shuttled between different physicians and other health problems can be overlooked by a particular practitioner who has focused upon a different condition. If the etiology is not determined because the original injury to the brain or other tissue is not considered, there can be “emotional overlay” masking more subtle physical trauma, he explained.
Another problem is that injury victims are often prescribed medications by different physicians who do not coordinate with each other, he noted. “This increases the risk of a cognitive disorder caused by drug interactions. One may also consider unanticipated effects if the medications are neuroactive and stimulate receptor sites in non-target tissues or the brain. One consequence of disease or trauma is reduced effectiveness of the blood-brain and other barriers.”
He also said there is ample evidence that long-term stress causes physical exhaustion that goes far beyond simply being tired. “Long-term emotional stress increases the body's allostatic load, causing dysregulation of the immune, endocrine, hormonal, circadian, and cardiovascular systems,” he said.
Dr. Parker suspects that that the condition, known as “allostatic load,” is the cause of “burnout” in many PTSD patients and the fatigue characteristic of persons with such conditions as the postconcussive syndrome.
“Cognitive therapy likely would reduce stress, and contribute towards the resumption of the normal condition of successful physiological control in difficult situations,” Dr. Parker noted.
It is very important that we study combat veterans returning from Iraq, he said. “Combat troops have a high likelihood of experiencing either overt or occult TBI after blast injury, and also PTSD, according to current statistics, and we need to provide them with the best treatment available.”
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• Frayne S, Seaver M, Loveland S, et al. Burden of medical illness in women with depression and post-traumatic stress disorder. Arch Int Med 2004:164;1306–1312.
• Yaeger D, Himmelfarb N, Cammack BS, Mintz J. DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military Sexual Trauma. J Gen Intern Med