Exposure therapy trumped supportive counseling for adolescent PTSD

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Exposure therapy doesn’t worsen childhood PTSD

Although more trials of prolonged exposure for sexually abused children and adolescents are needed, there is no theoretical or practical reason to assume that prolonged exposure will not be equally effective for PTSD arising from other types of traumas or in children.

The findings from this study should allay therapist concerns about any potential harmful effects of exposure and the need for extensive preparation of the patient for exposure. The heightened arousal that many therapists fear they will cause by leading the patients through exposure exercises is an expected and integral part of the recovery process; it usually dissipates within a few sessions and leads to rapid reductions in symptoms between sessions.

Research is also needed to determine the minimum amount of training and supervision for therapists to effectively deliver prolonged exposure and similar exposure-focused treatments to patients with PTSD and other anxiety disorders.

Dr. Sean Perrin is a lecturer at Lund (Sweden) University and King’s College London. He said he had no relevant financial disclosures. He made these remarks in an editorial accompanying Dr. Foa’s study (JAMA 2013;310:2619-20 [doi:10.1001/jama.2013.283944]).



Prolonged-exposure therapy – a standard treatment for posttraumatic stress disorder in adults – worked better than supportive counseling did to help adolescent girls to recover from sexual abuse, based on the results of a randomized trial comparing 3 months of weekly exposure therapy in 31 girls to supportive counseling in 30 others.

Further, the technique succeeded with master’s level mental health counselors who provided the exposure therapy after a 4-day training session, plus two follow-up sessions.

Dr. Edna Foa

Those in the prolonged-exposure group improved from a baseline mean of 27.3 points to 6.7 points, an overall shift from moderately severe to below-threshold PTSD, on the clinician-assessed 51-point Child PTSD Symptom Scale–Interview. The supportive counseling group improved from a mean of 29.4 points to 16.1 points, going from an overall score of moderately severe to mild PTSD. The difference in outcomes was significant.

Prolonged-exposure therapy is rarely provided to adolescents because of concern that it may exacerbate PTSD symptoms or because of the belief that patients must master coping skills before exposure can safely be provided, noted study researcher Edna Foa, Ph.D., of the department of psychiatry at the University of Pennsylvania, Philadelphia, and her colleagues.

The findings imply that prolonged exposure therapy can be successfully administered by newly trained counselors at community mental health and rape crisis clinics. "This is important because the need for evidence-based treatment of PTSD far exceeds the availability of these services," the researchers wrote in a study published online Dec. 24 in JAMA.

The study subjects were recruited from Women Organized Against Rape, a rape crisis center in Philadelphia. They were 13-18 years old, with a mean age of about 15 years. More than half had at least one comorbid psychiatric diagnosis. Actively suicidal girls and those with uncontrolled bipolar disorder, schizophrenia, conduct disorder, or pervasive developmental disorder were excluded from the study, along with those who had started psychiatric drugs within 3 months.

Treatment included discussing the rationale for exposure, recounting the event, breathing exercises, and homework, plus a final project, such as making a booklet about the trauma and gains made in treatment. Counselors listened actively and with empathy during sessions, encouraged the girls to talk about their feelings, and told them they believed in their ability to cope. Not one of the girls in supportive counseling described their trauma during the sessions.

The exposure group completed a mean of 12 sessions; the supportive group, 11 sessions. Up to 14 sessions were available for both groups. More than 90% (28) of exposure subjects completed their sessions; 83.3% (25) of supportive counseling patients completed theirs.

Participants who received prolonged-exposure therapy had greater improvement in PTSD symptoms and were more likely to lose their PTSD diagnosis than were those who received supportive counseling. By the end of their sessions, about three-quarters (24) of the prolonged-exposure girls – but less than half (13) of the supportive counseling subjects – no longer met DSM-IV criteria for PTSD, also a significant difference.

The results of prolonged exposure also were superior to those of supportive counseling at 12-month follow-up, said Dr. Foa (JAMA 2013;310:2650-57 [doi:10.1001/jama.2013.282829]).

Those given exposure therapy also did significantly better on clinician- or subject-assessed measures of symptoms, depression, and function; the differences persisted through 12-months of follow-up.

The National Institutes of Health funded the work. The authors said they had no relevant commercial disclosures.

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