Biomedical Engineering Reference
In-Depth Information
developed to address the effects of war trauma
(e.g., shell shock, combat fatigue) on military
personnel, and later to assist emergency medical
service workers in the wake of deployment [e.g.,
“Critical Incident Stress Management”(CISM)].
A review of the outcomes of randomized controlled
trials of single-session interventions in the after-
math of traumatic exposures concluded that
single-session psychological interventions had no
discernable benefit for individuals who had expe-
rienced motor vehicle accidents, assault, burns,
or other potentially traumatic injuries or medical
conditions (e.g., miscarriage, childbirth), with
two possible exceptions among 11 studies [23].
Studies involving acute life-threatening accidents
or violent assaults and longer follow-up periods
(i.e., 3 months to 3 years) showed no benefit, and
in two cases adverse outcomes, following a single
session of psychosocial intervention. Although
CISM most often is provided in a group format,
no randomized studies have been conducted with
group debriefing.
The best documented approach to brief multi-
session psychosocial intervention in the acute
period following exposure to psychological
trauma is cognitive behavioral therapy (CBT).
CBT involves several component interventions,
including: (a) education about traumatic stress and
PTSD, (b) “imaginal exposure” (i.e., a detailed
repeated oral review of the traumatic event(s)),
(c) “in vivo exposure” (i.e., activities placing the
individual in proximity to reminders of the trau-
matic event(s)), (d) cognitive restructuring (i.e.,
identification and reformulation of thoughts or
beliefs that sustain a sense of fear, helplessness,
or horror), and (e) stress management skills (e.g.,
relaxation or breathing techniques). Three studies
by Bryant [9] provided 5-6 weekly counseling
sessions beginning about two weeks after a motor
vehicle accident or assault to adults with ASD.
CBT was superior to supportive counseling in
reducing the severity of PTSD, depression, and
anxiety symptoms at post-treatment and follow-
up assessments between 4 months and 4 years
later.
Despite these encouraging findings, many
(25-40%) of CBT-treated patients still develop or
fail to remit from PTSD. Ehlers and Clark [23]
describe an alternative approach to the delivery
and testing of CBT designed for acute trauma
survivors who were at highest risk for developing
PTSD. Motor vehicle accident survivors “had to
meet PTSD criteria and report at least moderately
severe symptom severity” after a “3-week self-
monitoring phase” (p. 821). At that point, 3 months
had elapsed since the accident, and participants
were randomized to up to 12 weekly sessions of
CBT, a single session with a clinician and self-
help materials, or “repeated infrequent, assess-
ments of PTSD symptoms” (p. 821). The CBT
model was 2-3 times longer than that provided
previously, delivered at a later time after the trau-
matic incident (i.e., 3-6 months vs. 1-3 months),
and also relied more upon cognitive restructuring
than on imaginal or in vivo exposure. Ehlers and
Clark [23] suggest these changes may account
for the substantially lower rate of drop-outs from
their CBT intervention—in fact, there were no
dropouts. At a 6-month post-treatment follow-up
assessment, approximately 1 year after the acci-
dent, participants receiving CBT were substantially
more likely to be free of PTSD (86-89%) than
the single session or self-assessment participants
(approximately 40%) or than a cohort in a natural-
istic longitudinal sample from the same population
(approximately 30%).
Pharmacological interventions are not as well
developed for persons acutely recovering from
exposure to traumatic stressors, but recent evidence
from a case study and a small randomized clin-
ical trial suggests that prescribing the noradren-
ergic beta-blocker propanolol within the first few
hours of a traumatic accident or assault may
prevent the development of PTSD's persistent
arousal symptoms or the re-emergence of PTSD
in persons who had PTSD in the past [25].
Studies are underway testing other pharmaco-
logical agents, such as neuropeptide Y, corti-
cotrophin releasing factor antagonists, opioids,
benzodiazepines, and selective serotonin reuptake
inhibitors, but no firm evidence as yet firmly
supports any early pharmacotherapy strategy for
acute trauma survivors. Morgan et al. [25] also
warn that pharmacological
treatment should be
