Exposure Therapy Beats Counseling for PTSD in Teen Girls

Deborah Brauser

December 30, 2013

Prolonged exposure therapy (PET) is more effective than counseling in young girls with posttraumatic stress disorder (PTSD) related to sexual abuse.

A randomized trial of 61 girls with this type of PTSD showed that those who received 14 weekly sessions of PET had significantly greater improvement in symptom severity, depression, and overall functioning compared with their counterparts who received 14 sessions of supportive counseling.

Patients in the PET group were also significantly more likely to no longer have a PTSD diagnosis after treatment and to maintain benefit at 12-month follow-up.

"An important clinical implication of these results is the feasibility of disseminating and implementing prolonged exposure [therapy] in community mental health clinics for adolescents who are motivated to participate in treatment," the investigators, led by Edna B. Foa, PhD, University of Pennsylvania in Philadelphia, write.

The investigators note that PET was successful despite the fact that it was implemented by counselors who had no previous training in this type of therapy and who had very little supervision from experts.

"This is important because the need for evidence-based treatment of PTSD far exceeds the availability of these services," they write.

The study was published in the December 25 issue of JAMA.

Rare Treatment for Teens

With PET, patients re-experience a traumatic event by remembering and engaging with reminders of the trauma.

According to the investigators, it is "the most studied evidence-based, theory-driven treatment for adults with PTSD, but it is rarely provided to adolescents because of concern that it may exacerbate PTSD symptoms or the belief that patients must master coping skills before exposure can safely be provided."

However, they hypothesized that this form of therapy could be modified for adolescents and administered in community mental health clinics.

The researchers enrolled 61 girls between the ages of 13 and 18 years (mean age, 15.3 years; 56% black, 18% white, 17% Hispanic, 9% other). All were seeking treatment at a rape crisis center in Philadelphia and had a clinical diagnosis of PTSD, as determined using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

Participants were randomly assigned to receive either 14 weeks of 60- to 90-minute sessions of PET (n = 31) or the same amount of supportive, client-centered therapy for traumatized children (supportive counseling, n = 30).

Treatment was delivered by 4 master's level counselors who attended a 4-day PET training workshop and 2 2-day supportive counseling training sessions prior to the study's start. Group supervision of the counselors was given only every other week from 2 of the study authors.

The Child PTSD Symptom Scale–Interview was used to assess the study's primary outcome measure of PTSD symptom severity. Secondary outcomes included the presence or absence of PTSD, as measured with the DSM-IV Schedule for Affective Disorders and Schizophrenia for School-Age Children; the Children's Global Assessment Scale was used to measure functioning.

These measures were assessed prior to the start of treatment, at the treatment midpoint, at treatment's end, and at follow-ups conducted up to 12 months later.

The Child PTSD Symptom Scale–Self Report and the Children's Depression Inventory were also administered throughout the treatment period.

Although both treatments were beneficial, girls who underwent PET experienced significantly greater improvement in symptom severity on both the Interview and Self-Report versions of the Child PTSD Symptom Scale (P < .001 and P = .02, respectively) than those who received supportive counseling.

They also had significantly greater improvement on the Children's Global Assessment Scale and the Children's Depression Inventory (both, P = .008), and they had a greater loss of PTSD diagnosis (difference of 29.3%, P = .01).

At 12-month follow-up, all treatment differences for PET from baseline remained significant, including results on both versions of the symptom severity scale (both, P = .02) and on the global functioning (P = .01), depression (P = .02), and loss of PTSD diagnosis (P = .01) assessments.

The investigators note that PET is recommended as a first-line treatment for PTSD in adults by both the Veteran Affairs system and the Department of Defense.

In addition, "community mental health clinics, and especially rape crisis clinics, which routinely treat traumatized patients, are a logical target for disseminating prolonged exposure," they write.

Concerns of Harm Allayed

"Findings from the current report by Foa et al should allay therapist concerns about any potential harmful effects of exposure and the need for extensive preparation of the patient for exposure," Sean Perrin, PhD, from the Department of Psychology at Lund University in Sweden, writes in an accompanying editorial.

Dr. Perrin notes that "the heightened arousal" that often accompanies the start of this type of treatment usually goes away within a few sessions. In addition, symptoms often decrease rapidly between sessions.

"Thus, the heightened arousal that many therapists fear causing…is an expected and integral part of the recovery process."

Dr. Perrin adds that more studies are now needed, as well as an increased awareness about the safety and effectiveness of PET and other similar treatments.

"Research is also needed to determine the minimum amount of training and supervision for therapists to effectively deliver prolonged exposure…to patients with PTSD and other anxiety disorders," he concludes.

The study was funded by a grant from the National Institute of Mental Health. Dr. Foa reports having received research funding from the Department of Defense, the Department of Veterans Affairs, and the National Institutes of Health and having published books on PTSD treatment. Another study author reports having received research funding from the Department of Defense. The other 2 study authors and Dr. Perrin have reported no relevant financial disclosures.

JAMA. 2013:310;2650-2657, 2619-2620. Abstract, Editorial

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