Elsevier

Behaviour Research and Therapy

Volume 77, February 2016, Pages 68-77
Behaviour Research and Therapy

Symptom exacerbations in trauma-focused treatments: Associations with treatment outcome and non-completion

https://doi.org/10.1016/j.brat.2015.12.009Get rights and content

Highlights

  • We examined symptom exacerbations in three trauma-focused treatments for PTSD.

  • A minority of participants in all three treatments experienced exacerbations.

  • Exacerbations predicted somewhat higher symptoms but not therapy non-completion.

  • Significant improvements were seen even in those who experienced exacerbations.

  • Diagnostic and trauma-related factors did not predict symptom exacerbations.

Abstract

Trauma-focused treatments are underutilized, partially due to clinician concerns that they will cause symptom exacerbation or dropout. We examined a sample of women undergoing Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and a version of CPT (CPT-C) without a written trauma narrative to investigate the possibility of symptom exacerbation. Participants (n = 192) were drawn from two RCT's. Participants were administered self-report measures of PTSD symptoms (i.e., the PTSD Symptom Scale or Posttraumatic Diagnostic Scale [PSS/PDS]) and the Clinician-Administered PTSD Scale. Exacerbations were defined as increases greater than 6.15 points on the PSS/PDS. A minority of participants experienced PTSD exacerbations during treatment, and there were no significant differences across treatment type (28.6% in CPT, 20.0% in PE, and 14.7% in CPT-C). Neither diagnostic nor trauma-related factors at pre-treatment predicted symptom exacerbations. Those who experienced exacerbations had higher post-treatment PSS/PDS scores and were more likely to retain a PTSD diagnosis (both small but statistically significant effects). However, even those who experienced an exacerbation experienced clinically significant improvement by end of treatment. Further, symptom exacerbations were not related to treatment non-completion. These results indicate that trauma-focused treatments are safe and effective, even for the minority of individuals who experience temporary symptom increases.

Section snippets

Participants

This study combined data from two randomized controlled trials of cognitive-behavioral therapy for PTSD with female victims of interpersonal violence (Resick et al., 2008, Resick et al., 2002). The first study compared CPT, PE, and a wait-list condition; those in the wait-list were randomly assigned to either CPT or PE after 6 weeks. The second study was a dismantling study comparing full CPT to its components: a written account only condition and a cognitive therapy only condition (CPT-C).

Symptom exacerbation frequencies: comparison across conditions

In this sample, a nontrivial minority of patients experienced a symptom exacerbation at some point in the treatment (CPT = 28.6% at any point, 13.4% at session 4; CPT-C = 14.7% at any point, 2.9% at session 4; and PE = 20.0% at any point, 15% at session 4). See Table 1 for the numbers and percentages of participants experiencing an exacerbation at each session.2

Discussion

This study examined whether trauma-focused treatments were associated with symptom exacerbations. Results are similar to those found by Foa et al. (2002), with remarkably similar percentages of participants experiencing session 4 exacerbations in both studies, despite differences in methodology (i.e., weekly sessions in Foa et al. vs. twice weekly sessions in these studies). Further extending the literature on symptom exacerbations, we also examined symptom exacerbations at any point in

Conflicts of interest

None.

Financial support

None.

Acknowledgments

This manuscript was funded by NIMH grants #1-R01-MH51509 and 2-R01-MH51509 awarded to Patricia Resick. It is partially the result of work supported with resources and the use of facilities at the Clement J. Zablocki VAMC, Milwaukee, WI.

References (57)

  • R.K. Pitman et al.

    Emotional processing and outcome of imaginal flooding therapy in Vietnam veterans with chronic posttraumatic stress disorder

    Comprehensive Psychiatry

    (1996)
  • A.B. Rowan et al.

    Posttraumatic stress disorder in a clinical sample of adults sexually abused as children

    Child Abuse & Neglect

    (1994)
  • N.R. Stein et al.

    Trajectories of response to treatment for posttraumatic stress disorder

    Behavior Therapy

    (2012)
  • I.M. Aderka et al.

    Sudden gains in prolonged exposure for children and adolescents with posttraumatic stress disorder

    Journal of Consulting and Clinical Psychology

    (2011)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • D.D. Blake et al.

    A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1

    The Behavior Therapist

    (1990)
  • D.D. Blake et al.

    The development of a clinician- administered PTSD scale

    Journal of Traumatic Stress

    (1995)
  • K.M. Chard et al.

    Dissemination and experience with cognitive processing therapy

    Journal of Rehabilitation Research and Development

    (2012)
  • M. Cloitre et al.

    Skills training in affective and interpersonal regulation followed by exposure: a phase-based treatment for PTSD related to childhood abuse

    Journal of Consulting and Clinical Psychology

    (2002)
  • J.M. Cook et al.

    A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs

    Journal of Traumatic Stress

    (2013)
  • J.M. Cook et al.

    Bridging the gap between posttraumatic stress disorder research and clinical practice: the example of exposure therapy

    Psychotherapy: Theory, Research, Practice, Training

    (2004)
  • G.J. Devilly et al.

    The investigation of exposure and cognitive therapy: comment on Tarrier et al. (1999)

    Journal of Consulting and Clinical Psychology

    (2001)
  • G.J. Devilly et al.

    Perceived distress and endorsement for cognitive or exposure-based treatments following trauma

    Australian Psychologist

    (2008)
  • A. Ehlers et al.

    A randomized controlled trial of 7-day intensive and standard weekly cognitive therapy for PTSD and emotion-focused supportive therapy

    American Journal of Psychiatry

    (2014)
  • E.L. Feindler et al.

    Assessment of family violence: A handbook for researchers and practitioners

    (2003)
  • E.B. Foa

    Posttraumatic stress diagnostic scale

    (1995)
  • E.B. Foa et al.

    The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale

    Psychological Assessment

    (1997)
  • E.B. Foa et al.

    Prolonged exposure (PE) manual

    (1994)
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