Empirically Supported Psychological Treatments: Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) has been recognized by the Institute of Medicine (2007) as one of the most effective treatments for PTSD. This chapter provides a brief overview of the CPT session content, the underlying mechanisms of the therapy, a review of the empirically based literature outlining the treatment effectiveness, limitations of the therapy, and areas of future research. In addition, the authors discuss the utility of the various versions of CPT, including cognitive only (CPT-C), group, individual, and combination. Further the research supporting the effectiveness of CPT for treating PTSD related to a variety of traumas, (e.g., combat, child abuse, and rape) and the significant impact CPT can have in areas of mental health related to PTSD (e.g., anger, guilt, social functioning) are described.

Epidemiology of Posttraumatic Stress Disorder in Adults

Posttraumatic stress disorder (PTSD) was established in 1980, when it was incorporated in the DSM-III. The PTSD definition brackets a distinct set of stressors—traumatic events—from other stressful experiences and links it causally with a specific response, the PTSD syndrome. Explicit diagnostic criteria in DSM-III made it feasible to conduct large-scale epidemiological surveys on PTSD and other psychiatric disorders, using structured diagnostic interviews administered by nonclinicians. Epidemiologic research has been expanded from Vietnam veterans, who were the center of DSM-III PTSD study, to civilian populations and postwar regions worldwide. This chapter summarizes information on the prevalence estimates of PTSD in U.S. veterans of the Vietnam War, soldiers returning from deployment in Iraq and Afghanistan, and civilian populations. It outlines research findings on the course of PTSD, risk factors, comorbidity with other psychiatric disorders, and the risk for other posttrauma disoders. It concludes with recommendations for future research.

Empirically Supported Psychological Treatments: EMDR

In this chapter we review the empirical foundation for Eye Movement Desensitization and Reproessing Therapy (EMDR) for posttraumatic stress disorder. We present a brief description of the therapy, critically review recent primary and meta-analytic investigations concerning its efficacy and effectiveness, offer a summary of recent primary investigations that addressed the mechanism of action for EMDR, and based on this overall review, we suggest limitations with recommendations for future research. Recent empirical investigations of the efficacy of EMDR have improved along a number of important dimensions, and these along with the few completed effectiveness trials, position this therapy among evidence-based frontline interventions for PTSD. What is less thoroughly researched, and thus less well understood, are putative models of its theoretical mechanism of action. In addition to continuing specific improvements in research concerning efficacy and effectiveness, we recommend more and higher quality empirical studies of its mechanism of action.

Individual Approaches to Prevention and Early Intervention

This chapter provides an overview of individual and small group-based approaches for prevention and early intervention of posttraumatic stress disorder (PTSD). Using the Institute of Medicine's (IOM) classification system for preventive interventions of mental disorders (universal, selective, and indicated), we describe individual and small group early interventions and review the effectiveness of these strategies. Specifically, psychological debriefing, psychological first aid, and psychoeducation have been used as selective interventions targeting individuals exposed to trauma with varying degrees of success. However, there is strong empirical support for using cognitive behavioral therapy as an indicated preventive intervention to help symptomatic individuals in the weeks or months following traumatic exposure. A review of the literature also suggests that future research should explore different modes of delivery and devote more attention to determining the best time to intervene after traumatic exposure.

PTSD at Late Life: Context and Treatment

Our knowledge about the role of aging as a moderating or mediating influence on the expression of posttraumatic symptoms, and their remission and resolution, is nascent. This is reflected in the current state of empirically supported psychotherapies for older adults with PTSD. At this time, there are no empirically validated psychotherapeutic or psychopharmacologic treatments for this age group. This chapter highlights general issues and other factors unique to aging, such as changes in cognition, that must be taken into consideration when embarking on PTSD treatment with older adults. We review extant psychotherapy research that has applicability to this cohort: treatment studies on anxiety and depression for older adults, as well as treatment studies for younger adults with PTSD. Next, we describe promising PTSD interventions for older adults that have yet to be tested on large samples or in randomized controlled trials. The chapter culminates in the presentation of a multi-modal psychotherapy intervention designed to address factors unique to aging, and which involves a gentler version of trauma-related therapy that allows exposure to be optional.

Traumatic Stress in Older Adults

This chapter focuses on older adult trauma survivors. Information is presented on prevalence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD); course, functional impairment, suicide risk, and health care utilization in older adults with PTSD; and the impact of demographic factors such as gender, ethnicity, and race on PTSD in older individuals. In general, rates of ASD and PTSD are lower in older adults compared to other age groups. PTSD in older adults has been linked to suicidal ideation and attempts, functional impairment, physical health, and increased healthcare utilization. Although delayed onset of PTSD has been empirically verified in some military samples with World War II veterans and younger adult civilians, it is rare in the absence of any prior symptoms and might more accurately be labeled “delayed recognition.” More information on trauma and PTSD in diverse populations of older adults is needed, such as racial and ethnic minorities, those with severe physical or mental impairment, noncommunity-residing groups, and those from nonindustrialized countries.

Future of Classification in Posttraumatic Stress Disorder

This chapter reviews the status of modifications to the definition of PTSD and proposed changes for DSM-5. We include a brief history of the diagnosis and trace its evolution in the Diagnostic and Statistical Manual of Mental Disorders (DSM). We discuss some of the current controversies related to the definition of PTSD including its location among the anxiety disorders, the utility of Criterion A and its subcomponents, and the factor structure of the symptoms. We review the rationale for the addition of new symptoms and modifications to existing criteria now and conclude with comments on future directions for research on PTSD.

Traumatic Stress Disorders in Children and Adolescents

Many children and adolescents who experience potentially traumatic events, such as natural disasters, acts of violence, physical injuries, child abuse, and life-threatening medical illnesses, display significant stress symptoms. In fact, these potentially traumatic events can lead to the development of acute stress disorder (ASD) and/or posttraumatic stress disorder (PTSD) and cause significant psychological impairment. In this chapter, we discuss the types of potentially traumatic events that lead to ASD or PTSD in youth, as well as various aspects of trauma exposure. We next review available evidence on the definition, prevalence, and course of ASD and PTSD in youth, and the risk factors associated with their development. To date, relatively few studies have examined ASD and existing evidence calls into question the validity of dissociative symptoms as part of the existing ASD diagnostic criteria for youth. In contrast, many studies have evaluated PTSD and its symptoms in youth exposed to trauma, although PTSD prevalence rates vary substantially depending on a host of factors, including the type of traumatic event experienced, the degree of exposure to the event, and the informant for PTSD symptoms, among other factors. We also discuss developmental considerations for the ASD and PTSD diagnoses and directions for future research. The chapter closes with a brief summary of proposed changes to the diagnostic criteria for ASD and PTSD in youth that are being considered for the DSM-5.

Community-based Early Intervention with Trauma Survivors

The numbers of individuals affected by frequently occurring traumatic events such as accidents and assaults, as well as large-scale traumas such as war and disaster, call for systematic, comprehensive community-based responses to manage mental health consequences of such exposure. Comprehensive early response by the community to its trauma-exposed members requires integration of several key response components. Communities should develop immediate response services, educate the affected community, reach out to survivors, engage in efficient early identification of those at risk, implement community-wide early intervention counseling services, monitor those at risk, train and support providers, monitor the well-being and needs of the affected population, and provide additional large-community interventions and programs. These services should encompass both trauma survivors and their family members and should target a range of potential negative outcomes, including posttraumatic stress disorder, depression, substance abuse, and impairments in functioning. Increased attention should be given to training and supporting providers, integration of online interventions into community-based service delivery, and program monitoring and evaluation. Those who serve sexual assault survivors, crime victims, deployed military personnel, physically injured assault and motor vehicle accident survivors, and disaster-affected groups can potentially learn much from one another, and efforts should be under taken to ensure that “cross-fertilization” of perspectives can occur in the service of creating integrated and comprehensive community-based responses to trauma.

The Epidemiology of Acute Stress Disorder and Other Early Responses to Trauma in Adults

Acute stress disorder (ASD) is an anxiety disorder characterized by exposure to a traumatic event followed by symptoms of re-experiencing, avoidance, hyper-arousal, peritraumatic dissociation, and impairment in functioning. ASD's time-limited duration (two days to one month) makes it distinct from but related to posttraumatic stress disorder (PTSD), which is diagnosed after one month. ASD's brief duration has contributed to a dearth of large-scale, population-based studies. Smaller studies have sought to determine rates of ASD after specific events in select populations; others have focused on ASD's role in predicting PTSD. Much can be learned from existing epidemiological studies. ASD's prevalence varies from 3% in a population of accident victims to 59% in female sexual assault victims. Female gender is a key risk factor; marital status, ethnicity, and socioeconomic status have also been associated with ASD in some studies. Comorbidities include depressive and anxiety disorders and substance use disorders.