Trauma-Focused Psychotheraphy after a Trial of Medication for Chronic PTSD: Pilot Observations*
Marshall, Randall D., Carcamo, Jaime H., Blanco, Carlos, Liebowitz, Michael, American Journal of Psychotherapy
Background: To date, all clinical trials using a single therapeutic modality (psychotherapy or pharmacotherapy) have found that even the best validated treatments for adults with chronic Posttraumatic Stress Disorder (PTSD) leave a substantial proportion of patients with disabling residual symptoms. Method: We reviewed the treatment course of three research patients with PTSD who received trauma-focused psychotherapy after experiencing a partial response to medication. Structured diagnostic interviews, validated symptom measures, and standardized treatment approaches were used to assess treatment response. Results: all patients partially benefited from medication treatment, and the degree of benefit varied substantially. Also, all patients experienced an additional reduction in PTSD symptoms after a time-limited course of prolonged exposure therapy (PE). This finding differs from anecdotal observations among U.S. War veterans and has never been documented systematically among civilian adults with chronic PTSD. Conclusion: Maximizing treatment outcome in adults with chronic PTSD may require additional psychotherapy after a partial medication response, and further study is warranted.
Recent large multi-center trials have confirmed earlier reports that the SSRIs are effective for the core symptoms of chronic PTSD in noncombat-related trauma populations (1-4). However, these and other pharmacotherapy trials also suggest that full resolution of PTSD symptoms is rare after SSRI treatment alone (5). For example, Connor et al. (2) examined this question directly in a 12-week trial of fluoxetine (N = 27) vs. placebo (N = 26) by identifying individuals with high end-state functioning at treatment completion. High end-state function was defined by very low scores on the Davidson Trauma Scale, TOP-8 (6) and the Sheehan Disability Scale (7). Eleven (41%) fluoxetine-treated patients met these criteria, compared to 1 (4%) placebo-treated patients, demonstrating that 60% of the sample remained symptomatic after fluoxetine treatment.
In a multi-center randomized clinical trial of sertraline vs. placebo in adults with chronic PTSD (N = 187), the mean score at study completion was 43 (standard deviation 28.1) on the Clinician Administered PTSD Scale (CAPS) (8) after 10 weeks of treatment, demonstrating persistence on average of a moderate degree of residual symptomatology (1).
Finally, in the largest medication trial to date, using paroxetine (N = 551), only approximately one third of adults with chronic PTSD achieved high end-state remission (defined as a CAPS score <20) on either 20 mg daily or 40 mg daily (3).
Trauma-focused psychotherapy trials have yielded similar results. Full resolution of PTSD symptoms after an effective and well-validated psychotherapy, such as prolonged exposure (PE), also occurs only in a minority of patients (5). A recent randomized clinical trial examined the relative efficacy in 96 female assault victims with PTSD of nine sessions of prolonged exposure (PE), stress inoculation training (SIT), their combination, versus a wait-list group (9). At completion of the trial there were no significant differences between active treatments, and all were superior to wait-list. In the intent-to-treat sample, high end-state functioning, defined by the authors as scores on the Posttraumatic Stress Symptoms-Interview (PSS-I<20) (10), State-Trait Anxiety Inventory (STAI-S <40) (11), and the Beck Depression Inventory (BDI < 10) (12), was only achieved by 52% of individuals receiving Prolonged Exposure (PE), 31% receiving Stress Inoculation Training (SIT), 27% receiving both treatments, and 0% of those in the wait-list. Although the authors had hypothesized that a combination of two psychotherapies might enhance outcome, in fact the combination of PE and SIT resulted in reduced outcome, perhaps because not as much time could be devoted to the exposure-based techniques. …