Effects of live exposure on symptoms of posttraumatic stress disorder: The role of reduced behavioral avoidance in improvement
Introduction
Extensive research in the last two decades has demonstrated the effectiveness of cognitive–behavioral interventions in posttraumatic stress disorder (PTSD). The treatments tested in clinical trials often involved a combination of interventions, such as imaginal and live exposure (Brom, Kleber, & Defares,1989; Foa et al., 2005; Ironson, Freund, Strauss, & Williams, 2002; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Paunovic & Öst, 2001; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Taylor et al., 2003), cognitive restructuring (Ehlers et al., 2003; Fecteau & Nicki, 1999; Glynn et al., 1999), and anxiety management techniques (Foa et al., 1999; Foa, Rothbaum, Riggs, & Murdock, 1991; Lee, Gavriel, Drummond, Richards, & Greenwald, 2002) such as relaxation training, coping skills training, breathing training, thought stopping, and guided self-dialog. Relatively little research has been conducted to examine the contribution of these techniques to improvement. Available evidence suggests that cognitive interventions (Foa et al., 2005; Marks et al., 1998; Paunovic & Öst, 2001) or various anxiety management techniques (Foa et al. (1999), Foa, Rothbaum, Riggs, & Murdock (1991)) do not confer additional benefits when used in combination with exposure.
Evidence from anxiety disorder literature points to the importance of focusing on behavioral avoidance in therapy. Most importantly, fear reduction through exposure is known to lead to improvement in most patients with anxiety disorders (Marks & Dar, 2000), including PTSD (Bradley, Greene, Russ, Dutra, & Westen, 2005). In a study (Başogˇlu, Marks, Kılıç, Noshirvani, & O’Sullivan, 1994) of exposure and alprazolam treatment of panic disorder and agoraphobia, patients who showed improvement in avoidance but not in panics were more likely to rate themselves as improved than those who showed improvement in panics but not in avoidance. Furthermore, avoidance was found to be associated with overall illness severity in anxiety disorders (Başogˇlu, Lax, Kasvikis, & Marks, 1988; Başogˇlu, Marks, Kılıç, Noshirvani, & O’Sullivan (1994), Başogˇlu et al. (1994)). Avoidance was also the most important predictor and prominent feature of PTSD in studies of earthquake survivors (Başogˇlu, Şalcıogˇlu, & Livanou, 2002; Başogˇlu et al., 2001). These findings suggest that a treatment focus on behavioral avoidance alone could be sufficient in achieving clinical improvement. Nevertheless, most studies of exposure treatment in PTSD have used either imaginal exposure (Bryant, Moulds, Guthrie, Dang, & Nixon, 2003; Keane, Fairbank, Cadell, & Zimering, 1989; Tarrier et al., 1999) or a combination of imaginal and live exposure (Brom et al., 1989; Foa et al. (1999), Foa et al. (2005), Foa, Rothbaum, Riggs, & Murdock (1991); Ironson et al., 2002; Marks et al., 1998; Paunovic & Öst, 2001; Resick et al., 2002; Taylor et al., 2003). No controlled study has yet examined the effectiveness of live exposure alone in PTSD.
In a series of two uncontrolled and two randomized controlled trials (altogether involving 331 earthquake survivors) we examined the effectiveness of a modified version of behavioral treatment (BT), which involved mainly instructions for live exposure to feared situations. The treatment was designed to enhance sense of control over fear associated with traumatic stressors and distress related to trauma memories and involved no cognitive restructuring, imaginal exposure, or anxiety management technique. This intervention was highly effective, leading to marked improvement in about 80% of the cases, whether delivered in an average of four sessions (Başogˇlu, Livanou, Şalcıogˇlu, & Kalender, 2003) or in a single session (Başogˇlu, Şalcıogˇlu, Livanou, Kalender, & Acar, 2005). In two other studies (Başogˇlu, Livanou, & Şalcıogˇlu, 2003; Başogˇlu, Şalcıogˇlu, & Livanou, 2007) treatment effects were even stronger when the intervention involved a single session of exposure to simulated tremors in an earthquake simulator. The effect sizes on PTSD in all four studies were larger than the mean effect sizes reported for exposure treatment and CBT in a meta-analysis of treatment studies of PTSD (Bradley et al., 2005).
The remarkable potency of a single treatment session raised two important questions. Given that the treatment focused solely on one PTSD symptom (i.e. behavioral avoidance), did improvement generalize to all PTSD symptoms and, if so, what are the mechanisms that might have accounted for this effect? These issues have received little attention in clinical trials, which often reported treatment outcome based on total scores of PTSD measures. Although some studies reported reductions in all three clusters of PTSD symptoms (Foa et al., 1991; van Minnen & Foa, 2006), few examined treatment effects on individual symptoms. In a study (Keane et al., 1989) imaginal exposure was not effective in reducing avoidance, emotional numbing, and guilt, but we do not know if these findings apply to live exposure. In the present report we attempted to address these questions by conducting in-depth analyses of the data from our randomized controlled study (Başogˇlu, Şalcıogˇlu et al., 2005) of single-session behavioral treatment (SSBT) to examine which symptoms improved with treatment. We also examined the data for any evidence of sequential change in symptoms that might provide a clue about possible mechanisms of improvement. In the light of the evidence pointing to the role of fear reduction in improvement, we expected behavioral avoidance to be the first symptom to improve at the first follow-up assessment 6 weeks post-treatment (Hypothesis 1). Because pervasive fear induced by repeated exposures to unpredictable and uncontrollable after-shocks and associated helplessness responses were the most important predictors of earthquake-related PTSD in a previous study (Şalcıogˇlu, 2004), we hypothesized that (a) reduction in avoidance would lead to significant improvement in all PTSD symptoms and (b) less reduction in avoidance would be associated with less improvement in other PTSD symptoms (Hypothesis 2). Our study provided a good opportunity to examine these issues because the treatment did not include any other intervention that might have confounded processes of change during treatment. Furthermore, the intervention was delivered in a single session so that the confounding effects of therapist contact were minimized.
Section snippets
Method
On August 17, 1999, an earthquake of magnitude 7.4 on the Richter scale occurred in the densely populated northwestern part of Turkey, which caused 17,123 deaths and 43,953 injuries (US Geological Survey, 1999). An estimated 214,000 residential units were reduced to rubble or suffered structural damage, leaving tens of thousands of people homeless. This region was hit by a second earthquake on the 12th of November 1999, causing an additional death toll of 832 and about 4950 injuries. The
Sample characteristics
The mean age of the participants was 36.3 (SD=11.5); 50 (85%) were women and 48 (81%) married. Twenty-four (41%) of the participants had primary school education, 14 (24%) secondary, 18 (30%) high school, and 3 (5%) had university education. The level of damage to home was reported as moderate to severe in 33 (56%) and reduced to rubble in 12 (20%). Twelve (20%) survivors were trapped under rubble, 23 (39%) suffered physical injury, and 11 (19%) participated in rescue work. Three (5%) survivors
Discussion
The present study was the third in a series of four studies that demonstrated the effectiveness of control-focused BT. Methodological issues pertaining to main outcome results were discussed in the main report (Başogˇlu, Şalcıogˇlu et al., 2005). Although treatment compliance was not systematically measured, it was clear from follow-up assessments that 90% of the participants conducted self-exposure. Such high rate of compliance with self-exposure instructions was also confirmed by a subsequent
Acknowledgment
The study was supported by the Spunk Fund, Inc. and the preparation of the paper by the Bromley Trust.
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2011, Journal of Psychosomatic ResearchCitation Excerpt :Type of trauma, PTSD chronicity, and the use of empirically supported therapies are factors that could moderate the impact of treatment on sleep. However, inconsistencies regarding the impact on sleep still emerged within studies that recruited victims of rape [13,14], or those who recruited victims of earthquake [4,5], or those who recruited people with combat-related PTSD [7,9,12,15]. Likewise, no pattern could be drawn regarding PTSD chronicity; however, in all the reviewed studies, traumatic events leading to PTSD had occurred at least 3 years before participation to the study on average.
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2010, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :What is more, a decrease in symptoms of avoidance after exposure therapy preceded a decrease in other PTSD symptoms, such as hyper-arousal, numbing and re-experiencing. Vice versa, a lack of improvement in avoidance behaviour was related to a lack of improvement in other PTSD symptoms (Şalcioğlu, Başoğlu, & Livanou, 2007), stressing the central role of avoidance in PTSD maintenance. In addition, exposure treatment is mainly based on extinction learning, and fear extinction has been found to be context dependent (e.g. Effting & Kindt, 2007), stressing the importance of addressing several contexts within exposure therapy.
Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors
2009, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :These studies also showed that reducing therapist involvement did not affect treatment compliance. Over 90% of the survivors complied with self-exposure instructions given in a single session and reduced behavioural avoidance early in treatment was associated with subsequent improvement in all PTSD symptoms (Şalcıoğlu, Başoğlu, & Livanou, 2007a). This implied that reducing therapist involvement even further by delivering self-exposure instructions through other media, such as a self-help manual, might be possible without undermining treatment effectiveness.
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2011, The LancetCitation Excerpt :We did two meta-analyses of studies focusing on young people—one of PTSD symptoms and the other of internalising symptoms (anxiety or depression). The seven studies in adults consisted of a control-focused behavioural treatment of earthquake survivors in Turkey (self-exposure to earthquake-related fears and cessation of avoidance to increase their sense of control),50–52 the aforementioned parenting intervention (weekly group meetings to discuss parent–child interactions and coping strategies),56 testimony therapy for war-affected people in Mozambique (one session on average, detailing the trauma story via narrative),74 trauma healing and reconciliation workshops in civil war-affected Burundi,75 and narrative exposure therapy for refugees in Uganda and orphans and widows in Rwanda (which also included adolescents older than 14 years) (Frank Neuner, Bielefield University, personal communication).54 The meta-analysis of RCTs with adults (nine comparisons, 486 individuals assigned to interventions, and 285 assigned to waiting list or usual care) showed a beneficial effect on PTSD symptoms (standardised mean difference [SMD] −0·38, 95% CI −0·55 to −0·20; figure 3).