Exposure-Based Therapy for Post-Traumatic Stress Disorder in Children and Adults
Rachamim, Lilach, Nacasch, Nitsa, Shafran, Naama, Tzur, Dana, Gilboa-Schechtman, Eva, The Israel Journal of Psychiatry and Related Sciences
Abstract: We review the main components of Cognitive Behavioral Therapy (CBT) in the treatment of Post-traumatic Stress Disorder (PTSD) and the various treatment protocols that were found to be effective in treating this disorder in adult and pediatric populations. We highlight Prolonged Exposure (PE) therapy, which received strong empirical support, and was widely disseminated in Israel. We provide a detailed description of the PE treatment protocol for adults and children, and review studies conducted in Israel. We discuss clinical issues commonly raised by professionals starting to utilize PE and other trauma-focused treatment protocols. Finally, we discuss the open questions in the treatment of PTSD, and suggest some ideas for future research.
PTSD Symptoms and Prevalence
PTSD is an anxiety disorder characterized by symptoms of reexperiencing (e.g., nightmares, intrusive thoughts), avoidance of trauma-related stimuli and thoughts (e.g., situations, places), and hyperarousal (e.g., sleep problems, hypervigilence) (1). Epidemiological studies have estimated the lifetime prevalence of PTSD among adults as ranging from 7 to 24% (2, 3). Among children and adolescents, the prevalence of PTSD is estimated to be between 0.5% and 14.5% (4, 4).
Main Components of CBT for PTSD
The accumulation of empirical evidence for the benefits of CBT in PTSD has been recognized by tile Practice Guidelines of the International Society for Traumatic Stress Studies (6). Moreover, the U.S. Department of Health recommended the use of psychological treatment for PTSD, while concluding that there is "most evidence for cognitive behavioral methods"(7).
CBT for the treatment of PTSD encompasses numerous diverse techniques such as exposure therapy, cognitive restructuring, and anxiety management. Exposure techniques (ET) include flooding, systematic desensitization, graded invivo exposures, and prolonged recall of a painful memory. All ET methods share the common feature of confrontation with anxiety-provoking, yet realistically quite safe situations, memories and images. In cognitive restructuring (CR) techniques, patients are encouraged to challenge unhelpful cognitions. Typically, in PTSD, CR patients re-examine their attributions of self-blame with respect to the traumatic event, as well as their views that the world is mostly dangerous, and that people cannot be trusted (8, 9). Anxiety management (AM) techniques are designed to teach patients ways of relaxation and self-soothing which include breathing retraining and muscle relaxation.
Most effective CBT packages for PTSD encompass several components. Most include psychoeducation, that is, information about post-traumatic reactions and explanation of the rationale of the treatment. Most packages include several components in addition to psychoeducation, such as ET and AM (e.g., 10). Treatment packages differ in the relative emphasis of each of these components. Comparative studies have generally found equivalence in outcome among exposure, cognitive therapy and combinations of these interventions (11). However, among the various CBT interventions, ET has gained the greatest support across the widest range of populations (12-17; see also 18 for extensive review).
All the studies listed above focus on the treatment of adult PTSD sufferers. Compared to adults, there has been a paucity of methodologically rigorous studies for the treatment of PTSD in children and adolescents. PTSD treatment studies that have been conducted with a pediatric population consistently support the efficacy of CBT interventions in treating PTSD among sexually abused children (19-22) and young victims of other types of trauma (23-26). Indeed, the majority (57% to 92%) of children (ages 7-18) who received CBT in these studies exhibited significant improvement in posttraumatic distress.
Empirical Evidence for the Efficacy of Various Treatment Packages for PTSD
a) Cognitive Processing Therapy (CPT)
In CPT, a trauma-focused intervention, patients undergo cognitive training for challenging dysfunctional cognitions, particularly self blame, and process the traumatic event via detailed writing. …