Treatment Of Acute Stress Disorder Research Articles

Consensus on the pharmacological treatment of acute stress disorder in Chinese pilots: a Delphi study

BackgroundAppropriate medication is very important for pilots with acute stress disorder. Improper medication can not only affect the physical and mental health of the pilots but can also endanger flight safety. Hence, we aimed to quickly and effectively relieve symptoms and restore cognitive function by forming a consensus of Chinese experts on the pharmacological treatment of acute stress disorder in pilots using the Delphi method.MethodsRelevant literature was searched to enumerate the current status of pharmacological treatment of acute stress disorder in pilots, followed by two rounds of expert consultation and discussion according to the listed status of the survey using the Delphi method. A descriptive statistical method was used to analyze the basic information, authority coefficients, concentration of opinions, and survey items of the experts to develop a consensus on the pharmacological treatment of acute stress disorder in pilots.ResultsA total of 16 experts in psychiatry, pharmacology, and aerospace medicine from different provinces and cities across China were invited for consultation. The recovery rate of the two rounds of consultation was 100%, and the expert authority coefficients were 0.897 and 0.906, respectively. Kendall’s coefficient of concordance of indicators at all levels was 0.564–0.594 (p < 0.01). Based on the number of votes received, alprazolam tablets (16), eszopiclone tablets (15), and lorazepam tablets (14) were recommended for the treatment of excitatory psychomotor symptoms of acute stress disorder; paroxetine tablets (15) and sertraline tablets (15) were available for psychomotor depressive symptoms; olanzapine tablets (15), olanzapine orally disintegrating tablets (14), and quetiapine fumarate tablets (14) were selected for psychotic symptoms.ConclusionsThis study formed a consensus on rapid and effective pharmacological treatment for different symptoms of acute stress disorder pilots, which provides a reference for clinical treatment.

Micro-dose, macro-impact: Leveraging psychedelics in frontline healthcare workers during the COVID-19 pandemic

AbstractBackground and aimsThe COVID-19 pandemic exacerbated pre-existing high-levels of physician stress and burnout1. In order to help treat frontline colleagues who were diagnosed with acute stress disorder, we chose a non-psychedelic, ketamine micro-dose treatment strategy for symptom management.MethodsWe provided care virtually, and all patients were prescribed sublingual ketamine once daily. Each patient was evaluated using the NIH-PROMIS CAT assessments for stress, depression, anxiety, and PTSD via a remote, HIPAA compliant patient self-reporting platform. Progress was tracked and assessed against a baseline value obtained prior to the start of treatment. Patient progress was evaluated at a 4–6-week interval. Patients did not report any significant side effects to the treatment regimen.Results100% (25/25) of patients experienced improved anxiety, 92% (23/25) experienced improved stress, 96% (24/25) experienced improved PTSD, and 91% (20/22) experienced improved depression.ConclusionsWhile we cannot draw definitive conclusions from the association demonstrated by this data, we believe these results demonstrate that further research into the efficacy of daily, short-term ketamine micro-doses for treatment of acute stress disorder is warranted.

Australian guidelines for the prevention and treatment of posttraumatic stress disorder: Updates in the third edition.

This paper describes the development of the third edition of the National Health and Medical Research Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, posttraumatic stress disorder and Complex posttraumatic stress disorder, highlighting key changes in scope, methodology, format and treatment recommendations from the previous 2013 edition of the Guidelines. Systematic review of the international research was undertaken, with GRADE methodology used to assess the certainty of the evidence, and evidence to decision frameworks used to generate recommendations. The Guidelines are presented in an online format using MAGICApp. Key changes since the publication of the 2013 Guidelines include a new conditional recommendation for Child and Family Traumatic Stress Intervention for children and adolescents with symptoms within the first 3 months of trauma, and a strong recommendation for trauma-focused cognitive behaviour therapy for the child alone or with a caregiver, for those with diagnosed posttraumatic stress disorder. For adults with posttraumatic stress disorder, strong recommendations are made for specific types of trauma-focused cognitive behaviour therapy and conditional recommendations are made for five additional psychological interventions. Where medication is indicated for adults with posttraumatic stress disorder, venlafaxine is now conditionally recommended alongside sertraline, paroxetine or fluoxetine. These Guidelines, based on systematic review of the international literature, are intended to guide decision making for practitioners, service planners, funders and those seeking treatment for trauma related mental health concerns. For an Australian Guideline, a critical limitation is the absence of research on the treatment of Australian Aboriginal and Torres Strait Islander peoples. The new online format of the Australian posttraumatic stress disorder Guidelines means that they can be updated as sufficient new evidence becomes available.

Quality of Life After Violent Crime: The Impact of Acute Stress Disorder, Posttraumatic Stress Disorder, and Other Consequences.

Victims of violent crime (VVC) are at risk of developing acute stress disorder (ASD) and subsequent posttraumatic stress disorder (PTSD). In addition, VVC are more likely to have low social support due to stigmatization and victim-blaming, and PTSD is frequently associated with depression, anxiety, and impaired quality of life (QoL). The present study aimed to determine the impact of ASD, PTSD, depressive symptoms, anxiety symptoms, and perceived social support in relation to four domains of QoL among VVC. Individuals were recruited as part of a longitudinal study assessing the efficacy of a brief cognitive behavioral treatment for ASD. Participants (N = 127) were interviewed and completed self-report measures within 30 days of experiencing a violent crime (T0 ) and at assessments 2 months (T1 ) and 6 months (T2 ) after the event. Depressive symptoms, ASD, and PTSD were found to be associated with lower QoL ratings in all four domains. Anxiety symptoms were found to be associated with lower ratings in the physical health and psychological QoL domains. Perceived social support was found to be associated with higher QoL ratings in all domains. The proportions of QoL variance explained by the combined fixed and random effects combined ranged from 70% to 79%. Future research considerations include an examination of how early interventions for VVC could prevent QoL deterioration by targeting ASD and PTSD development, depressive and anxiety symptoms, and social support.

The Current Evidence for Acute Stress Disorder.

The aim of this review is to provide a summary of the current evidence pertaining to the course of acute and chronic posttraumatic stress, the diagnosis of acute stress disorder (ASD), and treatment of acute stress disorder and prevention of posttraumatic stress disorder (PTSD). Although acute stress disorder was introduced partly to predict subsequent PTSD, longitudinal studies indicate that ASD is not an accurate predictor of PTSD. Recent analytic approaches adopting latent growth mixture modeling have shown that trauma-exposed people tend to follow one of four trajectories: (a) resilient, (b) worsening, (c) recovery, and (d) chronically distressed. The complexity of the course of posttraumatic stress limits the capacity of the ASD diagnosis to predict subsequent PTSD. Current evidence indicates that the treatment of choice for ASD is trauma-focused cognitive behavior therapy, and this intervention results in reduced chronic PTSD severity. Recent attempts to limit subsequent PTSD by early provision of pharmacological interventions have been promising, especially administration of corticosterone to modulate glucocorticoid levels. Although the ASD diagnosis does not accurately predict chronic PTSD, it describes recently trauma-exposed people with severe distress. Provision of CBT in the acute phase is the best available strategy to limit subsequent PTSD.

Treatment of acute stress disorder for victims of violent crime

BackgroundVictims of violent crime are at elevated risk of developing acute stress disorder (ASD) as well as subsequent post-traumatic stress disorder (PTSD), both of which are linked to severe psychological distress. The aim of this 12-month prospective study was to evaluate the efficacy of cognitive-behavioral therapy (CBT) vs. cognitive-behavioral therapy with a significant other (CBT-SO), relative to usual care (UC), for the improvement of post-traumatic, depression and anxiety symptoms and the prevention of PTSD among victims of violent crime with ASD. MethodsA total of 166 victims of violent crime with ASD were assigned to CBT (n = 54), CBT-SO (n = 52) or UC (n = 60). Self-report assessments and diagnostic interviews were completed at pre-treatment and post-treatment as well as at 6-month and 12-month follow-ups. ResultsCBT and CBT-SO participants had fewer depression symptoms than those in the UC group up to 12 months post-event. Significantly fewer participants in the CBT condition met criteria for PTSD than in the UC group up to 12 months post-event. The CBT group did not differ from the CBT-SO group on any variable at any assessment time. LimitationsFindings must be interpreted in light of the quasi-experimental nature of the study and limitations concerning the management of missing data. ConclusionsFurther research is warranted in order to assess whether more extensive involvement of a significant other in therapy may lead to better outcomes for victims of violent crime with ASD.

The course, prediction, and treatment of acute and posttraumatic stress in trauma patients: A systematic review.

Trauma patients suffer from acute stress disorder (ASD) and posttraumatic stress disorder (PTSD), but it is unknown how these disorders develop over time and when treatment is effective. Our aim was to systematically review (1) the course and predictors of ASD and PTSD after trauma and (2) which and when psychological treatments are effective. Embase, Medline, Web of Science, Scopus, PsycInfo, Cinahl, Cochrane, PubMed, and Google Scholar were searched up to September 14, 2015. Quality was assessed with STROBE and CONSORT checklists. Overall, 45 (68%) observational studies and 21 (32%) intervention studies were included. Forty-seven (85%) were of lower (level of evidence (LoE) 3) or poor quality (LoE 4). ASD was found during hospitalization (range 1-37%) and about 30% experienced PTSD 1 month after trauma (LoE 3). The onset of PTSD was within 3 months but also up to 12 months after trauma (LoE 3). Especially in patients with ASD, patients showed PTSD symptoms after 6 years (LoE 3). ASD and PTSD were associated with sociodemographic factors (e.g., being female, younger age, financial problems, and low income), reduced cognitive functioning, and physical (e.g., pain), social (e.g., low social support), and psychological problems (e.g., hyperarousal) or disorders (e.g., ASD). Early treatment in the first weeks after trauma can be preventive for PTSD, but effective treatment for ASD is still unclear. Compared to other psychological treatments, the most effective and examined treatment for PTSD was cognitive behavioral therapy (CBT). A large number of studies of lower or poor quality present inconsistent findings on the course of ASD and PTSD. Predictors for ASD and PTSD were identified. Early treatment can be preventive for PTSD, as CBT is the most effective treatment. However, good qualitative observational and intervention studies are lacking and needed. Systematic review, level III.

Cognitive Processing Therapy for the Treatment of Acute Stress Disorder Following Sexual Assault: A Randomised Effectiveness Study

The effectiveness of individually administered cognitive processing therapy (CPT) when compared with treatment as usual (TAU) in a community sexual assault centre was tested. Trauma survivors with acute stress disorder (ASD) following sexual assault were randomised to either CPT (n= 25) or TAU (n= 22), and assessed at pretreatment, posttreatment, and 3-, 6- and 12-month follow-up. Both groups demonstrated large reductions in PTSD and depression symptoms following treatment, and these gains were maintained over the course of follow-ups (Cohen'sds for PTSD symptom reductions ranging between 0.76 to 1.45). Although smaller and not always consistent, between-group effect sizes typically favoured CPT. Effect sizes (d) ranged between 0.13–0.50 for posttraumatic stress and 0.13–0.41 for depression over the course of follow-ups. Independent assessment of PTSD severity indicated more CPT participants reached good end-state functioning at 12-month follow-up (50%) than TAU (31%). Although both treatments were effective, there were some indications that CPT led to better outcomes relative to therapists delivering their usual therapy. The present study demonstrates that evidence-based, trauma-focused therapy such as CPT can be effective when delivered as an early intervention in a routine mental health setting.

Utilizing Telehealth to Support Treatment of Acute Stress Disorder in a Theater of War: Prolonged Exposure via Clinical Videoconferencing.

Posttraumatic stress disorder (PTSD) and acute stress disorder are prevalent mental health diagnoses associated with the military operations in Iraq and Afghanistan and are especially significant in service members returning from combat. Prolonged exposure (PE) therapy is a highly effective behavioral treatment for these symptoms, and providing this treatment as soon as possible, even in the midst of a soldier's combat deployment, has strong potential benefits. In the current case study, telehealth technology was used to support the delivery of PE therapy to treat a service member diagnosed with acute stress disorder in a war zone. PE was conducted face-to-face on the relatively secure Forward Operating Base for the first half of therapy and via clinical videoconferencing (CV) to the service member's remote combat outpost during the later stages of therapy. The service member exhibited marked improvements in symptoms over 10 sessions. Results are consistent with previous empirical findings and highlight the potential benefits of using telehealth to deliver evidenced-based treatment for traumatic stress disorders in a war zone. This case study provides a preliminary working model for delivering PE in a combat environment using multiple delivery systems. Benefits and clinical utility of CV-delivered exposure therapy are discussed, particularly for providers pending future operational deployments (e.g., including members of the military, independent government agencies, and first responders) and for those treating patients in remote locations.

Effects of the EMDR Protocol for Recent Traumatic Events on Acute Stress Disorder: A Case Series

The purpose of this study was to evaluate the effectiveness of the eye movement desensitization and reprocessing (EMDR) protocol for recent traumatic events in the treatment of acute stress disorder. Within weeks of being exposed to an isolated traumatic event, 7 adults diagnosed with acute stress disorder were provided with multiple sessions of the EMDR protocol for recent traumatic events, an extended version of the EMDR therapy standard protocol. In each case, an individual’s subjective distress caused by the traumatic events was measured using the Impact of Events Scale-Revised and the goal of alleviating symptoms was accomplished. The positive results suggest the EMDR protocol for recent traumatic events may be an effective means of providing early treatment to victims of trauma, potentially preventing the development of the more severe symptoms of posttraumatic stress disorder.

Reducing the Effects of Trauma

What is offered here is a practical tool within the Australian Social Work context for understanding and reducing the effects of trauma on individuals following a threat to their personal safety as the result of a crime We have identified within our Social Work experiences of working with people affected by a traumatic event that what is of benefit to these people and what helps them work through their individual trauma experience is a tiered approach of intervention which reduces the psychological effect of trauma. Through some professional development focussed on the Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Mental Health and linking theory to practice we have been working towards an adaptive practice model which we can utilize within our Social Work roles (Australian Centre for Posttraumatic Mental Health, 2013). It ties together a stepped care approach by the Australian Centre for Posttraumatic Mental Health (2013) and practical strategies for working with people who have experienced trauma. We have also reflected on how this knowledge and practice model has been effective in working with people affected by trauma from our own practice experience.

Sustaining the Conservationist

Environmental work is emotionally laden because of the struggle on behalf of ethical positions and the daily experience of loss and frustration. Such ongoing stressful experiences may be understood better within a trauma-based framework that acknowledges their implications, similar to clinical diagnosis and treatment of acute stress disorder and posttraumatic stress disorder. This paper reports on two studies of the emotional experience of environmentalists, conservationists, and environmental educators working with profound awareness of how current human behavior is degrading the environment, some would say beyond recovery. It explores the question of whether these environmentally aware workers may suffer from a subtype of acute stress disorder and posttraumatic sequelae. The results suggest that there is reason to believe this subtype exists and is mediated by cortical assessments of salience and urgency. This paper suggests results that are ominous for mental health professionals—that indicators of depression, anxiety, and enervation are significantly elevated in those arguably most needed to help society come to terms with the problems we face in a degrading biosphere. We conclude that mental health professionals are urgently needed to help those who are at risk of becoming debilitated by their knowledge of the consequences of human impact on the planet and recommend that these professionals work to develop a new language, context, and treatment for this subtype condition.

Acute Stress Disorder and Forms of Narrative Disruption

Intervening with persons in the immediate aftermath of potentially traumatic events poses a number challenges for clinicians. Particularly in clinics that serve military personnel or other populations whose livelihoods may depend on regaining functioning efficiently following trauma, there is a need for sensitive and effective psychotherapies for acute stress disorder (ASD), a diagnostic category which attempts to capture maladaptive responses to trauma within the initial four weeks. In this context, Palgi and Ben-Ezra (2010) developed "Back to the Future," a novel treatment for ASD guided by narrative and constructivist understandings of posttraumatic adjustment (e.g., Neimeyer, 2009; White &amp; Epston, 1990). One of the distinctive aspects of Palgi and Ben-Ezra's approach involves a departure from exposure-oriented models of psychotherapy so as not to strengthen the substantive core of the traumatic experience for the survivor -- called the "traumatic nucleus" -- in the early adjustment period. My discussion of Palgi and Ben-Ezra's case of Mr. G and related general issues uses a framework of three common forms of narrative disruption after trauma. Specifically, I first discuss "narrative dominance" as a particular strength of the Back to the Future

Propranolol Does Not Reduce Risk for Acute Stress Disorder in Pediatric Burn Trauma

Acute stress disorder (ASD) can interfere with satisfactory recovery of children with severe burn injuries. Recent studies have found propranolol to be effective in reducing posttraumatic symptoms, but the benefits of this medication with ASD are unknown. Therefore, we hypothesized that individuals who were administered propranolol acutely would be less likely to develop ASD than those who were not. A review of electronic medical records was conducted on the children included in a previous blinded randomized-control trial, in which the participants received propranolol or no propranolol during the acute phase of recovery (first 30 days). These data were merged with electronic information regarding medication treatment for ASD. The psychologists and clinicians who had previously assessed for ASD for purposes of treating the children's distress were blinded to who received propranolol and who did not. There were 363 participants (232 boys, 131 girls) and the mean total body surface area was 56%. Of this sample, 22 participants had been previously diagnosed and treated for ASD, and 341 were in a non-ASD group. Eight percent of those children who received propranolol required treatment for ASD, whereas 5% of children who received no propranolol also required treatment for ASD. No statistically significant difference was noted. Propranolol was not found to influence the risk for subsequent ASD. This finding is in contrast to the observed benefit of propranolol reported in other studies with different at risk populations. Further exploration is warranted to assess the possible long-term benefit on posttraumatic symptoms in pediatric burn survivor patients.

Guideline Watch (March 2009): Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder

APA’s Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder was published in October 2004. Since that time, a number of well-designed randomized controlled trials of pharmacological and psychotherapeutic interventions for posttraumatic stress disorder (PTSD) have been conducted in various populations exposed to trauma. Numerous case reports, small case series, and open trials have also been reported, but they will not be the focus of this guideline watch. While early intervention studies for acute stress disorder (ASD) are currently in progress, no major research on the treatment of ASD has been completed since publication of the 2004 guideline. Factors predicting development of ASD or PTSD have still not been established. A 2008 study by Bryant et al. (1) found that ASD was a poorer predictor of getting PTSD than just having PTSD criteria alone in the acute stage. In response to increased attention on U.S. military veterans returning from combat in Iraq and Afghanistan, the Institute of Medicine has also reviewed and summarized the evidence supporting treatment for PTSD (2). The 2007 report recognizes that there is evidence for the pharmacological treatment of combat-related PTSD but states that this evidence is not as strong as the evidence for treatment of other trauma-related PTSD. In particular, the report states that large randomized controlled trials, consid-

Systematic Review and Meta-Analysis of Multiple-Session Early Interventions Following Traumatic Events

The authors sought to determine the efficacy of multiple-session psychological interventions to prevent and treat traumatic stress symptoms beginning within 3 months of a traumatic event. Nine computerized databases were searched, and manual searches were conducted of reference lists of selected articles as well as two journals. In addition, key researchers in the field were contacted to determine whether they were aware of other relevant studies. The reviewers identified randomized controlled trials of multiple-session psychological treatments aimed at preventing or reducing traumatic stress symptoms in individuals within 3 months of exposure to a traumatic event. Details of the studies were independently extracted by two reviewers, and outcome data were entered into the Review Manager software package. Quality assessment was also conducted by two researchers independently. Twenty-five studies examining a range of interventions were identified. For treatment of individuals exposed to a trauma irrespective of their symptoms, there was no significant difference between any intervention and usual care. For treatment of traumatic stress symptoms irrespective of diagnosis, trauma-focused cognitive-behavioral therapy (CBT) was more effective than waiting list or supportive counseling conditions. The difference was greatest for treatment of acute stress disorder and acute posttraumatic stress disorder. Trauma-focused CBT within 3 months of a traumatic event appears to be effective for individuals with traumatic stress symptoms, especially those who meet the threshold for a clinical diagnosis.

Treatment of Acute Stress Disorder: A Randomized Controlled Trial

Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Intent-to-treat analyses indicated that at post-treatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD (Fig 3).

Prolonged Exposure Therapy Helps Ward off PTSD

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessProlonged Exposure Therapy Helps Ward off PTSDAaron LevinAaron LevinSearch for more papers by this authorPublished Online:4 Jul 2008https://doi.org/10.1176/pn.43.13.0013aPatients with acute stress disorder had fewer posttraumatic stress disorder (PTSD) symptoms at follow-up after a clinical trial of exposure-based therapy than did patients getting cognitive restructuring therapy or placed on a treatment waiting list, according to Australian psychologist Richard Bryant, Ph.D.More attention in recent years to early intervention following traumatic events has increased interest in what the primary therapeutic approach should be, wrote Bryant and colleagues in the June Archives of General Psychiatry.The researchers studied 90 patients who had experienced nonsexual assault or a motor vehicle crash and were diagnosed with acute stress disorder (ASD) from 2002 to 2006. They were randomized to receive five 90-minute sessions of either prolonged exposure therapy or cognitive restructuring therapy. A third group was placed on a wait list and told they would be reassessed after six weeks and then offered active treatment.Prolonged exposure patients were told to “verbalize reliving the trauma experience in a vivid manner that involved all perceptual and emotional details.” They were given homework exercises. Later sessions and homework included visualizing images of trauma exposure and real-life exposure to associations with their trauma. The last session included relapse-prevention strategies to help patients damp down PTSD symptoms if they recurred.Cognitive restructuring (CR) treatment involved identifying and monitoring maladaptive thoughts by “Socratic questioning, probabilistic reasoning, and evidence-based thinking.” Some homework and relapse prevention were included in this treatment too.Prolonged exposure showed large effect sizes, and cognitive restructuring showed moderate effect sizes, compared with the wait-list group. After six weeks, 33 percent of the exposure group met PTSD criteria compared with 63 percent of the cognitive restructuring patients, and 77 percent of those on the wait list.At the six-month follow-up, 37 percent of the exposure group met PTSD criteria while 63 percent of the cognitive restructuring group did. The researchers did not compare a combination of the two therapies with the single treatments.The effect was seen early in the course of exposure treatment, even as cognitive restructuring patients continued experiencing distress.Many therapists hesitate to use exposure therapy because it can cause distress and possibly drive patients away from therapy, according to the researchers. However, only five subjects reported adverse effects, all due to high distress, and dropped out of the study. Two subjects were in the exposure arm, and two were in the CR arm. Overall, patients getting exposure therapy reported less distress at the end of the last three sessions than did patients getting CR therapy.“Dropout rates in the present study were comparable to dropout rates across chronic PTSD studies,” wrote Bryant and colleagues.In a rigorous review of treatments for PTSD, the U.S. Institute of Medicine last fall said that the only treatment for PTSD supported by a strong evidence base was exposure therapy.“The current findings suggest that direct activation of trauma memories is particularly useful for prevention of PTSD symptoms in patients with ASD,” they wrote. “[A]daptation occurs when the individual repeatedly engages with trauma reminders and learns that there is no aversive outcome.”The study showed that not only was using prolonged exposure treatment beneficial, but also it did not result in more therapy dropouts or aversive responses than other approaches.For Bryant and colleagues, the conclusions are clear. “[T]here is a need to better educate mental health care providers about the use of [prolonged exposure] as a frontline intervention for ASD,” they said.“Treatment of Acute Stress Disorder: A Randomized Controlled Trial” is posted at<http://archpsyc.ama-assn.org/cgi/content/short/65/6/659>.▪ ISSUES NewArchived

Treatment of Acute Stress Disorder

Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Intent-to-treat analyses indicated that at posttreatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD.

Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Post-Traumatic Stress Disorder

Over the past 2-3 years, clinical practice guidelines (CPGs) for post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) have been developed in the USA and UK. There remained a need, however, for the development of Australian CPGs for the treatment of ASD and PTSD tailored to the national health-care context. Therefore, the Australian Centre for Posttraumatic Mental Health in collaboration with national trauma experts, has recently developed Australian CPGs for adults with ASD and PTSD, which have been endorsed by the National Health and Medical Research Council (NHMRC). In consultation with a multidisciplinary reference panel (MDP), research questions were determined and a systematic review of the evidence was then conducted to answer these questions (consistent with NHMRC procedures). On the basis of the evidence reviewed and in consultation with the MDP, a series of practice recommendations were developed. The practice recommendations that have been developed address a broad range of clinical questions. Key recommendations indicate the use of trauma-focused psychological therapy (cognitive behavioural therapy or eye movement desensitization and reprocessing in addition to in vivo exposure) as the most effective treatment for ASD and PTSD. Where medication is required for the treatment of PTSD in adults, selective serotonin re-uptake inhibitor antidepressants should be the first choice. Medication should not be used in preference to trauma-focused psychological therapy. In the immediate aftermath of trauma, practitioners should adopt a position of watchful waiting and provide psychological first aid. Structured interventions such as psychological debriefing, with a focus on recounting the traumatic event and ventilation of feelings, should not be offered on a routine basis.