Variations on a Theme Studies of Other Exposure Protocols

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Civilian Samples

Several recent studies compared exposure therapy protocols other than PE with alternative CBT interventions. Marks et al. (1998) compared exposure, CR, and their combination with a relaxation control group. Like PE, the exposure therapy used in this study included imaginal and in vivo exercises. However, whereas the two modalities are administered simultaneously in PE, the program examined by Marks et al. (1998) presented the modalities sequentially; the first five sessions were limited to imaginal exposure and corresponding homework, and the remaining five sessions focused on in-ses-sion, therapist-assisted in vivo exposure and corresponding homework. Immediately after treatment, the exposure, cognitive, and combined interventions were superior to relaxation, and they retained their superiority at follow-up. Comparisons among the three interventions failed to reveal any consistent pattern of superior performance for one treatment over the others. Notably, like the Foa et al. (2002a) study, the combined exposure plus CR group was not better than the groups that received either treatment alone.

Taylor et al. (2003) utilized an eight-session variation of the Marks et al. (1998) exposure therapy protocol (four sessions of imaginal exposure fol lowed by four sessions of in vivo exposure) compared to EMDR and relaxation. All three groups showed significant improvement in PTSD symptoms at the end of treatment. The exposure therapy group was significantly more improved than the group that received relaxation training. In contrast, the EMDR group did not differ from either the relaxation group or the exposure therapy group.

Power and colleagues (2002) utilized Marks et al.'s (1998) combined treatment protocol (imaginal and in vivo exposure plus CR), offering patients up to 10 sessions over 10 weeks of exposure therapy or EMDR or wait list. Both active treatments resulted in significant reductions in PTSD severity, anxiety, depression, and functional impairment, and both treatments were superior to the waiting-list condition, which showed very little change. Few differences were observed between the two active treatments, except that EMDR required, on average, fewer sessions (4.2 vs. 6.4) and achieved greater reduction in depression scores.

Devilly and Spence (1999) compared a CBT intervention, called trauma treatment protocol (combines imaginal and in vivo exposure with elements of SIT), and additional CT techniques to EMDR. Both treatments produced significant improvements from pre- to posttreatment. However, the trauma treatment protocol was found to be superior to EMDR both immediately after treatment and at the 3-month follow-up assessment. Whereas individuals treated with the trauma treatment protocol maintained their treatment gains at the follow-up assessment, individuals treated with EMDR displayed evidence of relapse on several measures.

Lee, Gavriel, Drummond, Richards, and Greenwald (2002) compared the combination of imaginal and in vivo exposure plus SIT with EMDR. All participants completed a 6-week waiting-list phase before beginning active treatment. very little change in PTSD symptoms was observed during the waiting-list period, followed by significant reductions after completion of either active treatment. There were no differences between groups at posttreatment. However, at follow-up results slightly favored EMDR due to further gains obtained during follow-up in the EMDR condition, compared to no additional improvement in the exposure therapy plus SIT condition.

Echeburua et al. (1997) compared a group of survivors treated with six sessions of combined gradual exposure and CR to a group of survivors treated with Bernstein and Borkovec's (1973) protocol for progressive relaxation training. Although both groups displayed significant improvement on measures of PTSD, fear, and depression, improvement was significantly greater in the exposure condition than the relaxation condition. This group difference was maintained at each of the 3-, 6-, and 12-month follow-up assessments.

Tarrier et al. (1999) compared an exposure therapy that included only imaginal exposure to CT. Both groups improved significantly from pre- to posttreatment on measures of PTSD, depression, and anxiety, and these improvements persisted through follow-up. There were no differences observed between the two treatment groups at either posttreatment or follow-up.

Bryant, Moulds, Guthrie, Dang, and Nixon (2003a) compared eight sessions of imaginal exposure, either alone or combined with CR, with supportive counseling. Both immediately after treatment and at follow-up, each of the exposure therapy groups was superior to supportive counseling on measures of PTSD symptoms, anxiety, depression, and trauma-related cognitions. Slightly superior results were obtained in the imaginal exposure plus CR condition, compared to imaginal exposure alone, on one measure of trauma-related reexperiencing symptoms (posttreatment and at follow-up) and on trauma-related cognitions (follow-up only).

Cloitre and her colleagues (2002) examined the efficacy of a treatment that sequentially combined skills training in affect and interpersonal regulation (STAIR) followed by imaginal exposure for treating PTSD. Their sample consisted of a group of women who had been sexually abused as children. Compared to a waiting-list condition, the combined treatment was highly effective in reducing PTSD symptoms, depression, and anxiety as well as improving affect regulation and interpersonal functioning. Cloitre et al. (2002) hypothesized that preliminary treatment with STAIR would facilitate their patients' ability to participate in, and benefit from, the imaginal exposure component of the treatment. However, as we have noted elsewhere (Cahill, Zoelner, Feen, & Riggs, 2004), the design of this study precludes any strong conclusions about whether the addition of STAIR enhanced treatment compliance or outcome (for a rejoinder, see Cloitre, Storall-McClough, & Levitt, 2004).

Fecteau and Nicki (1999) provided four sessions of CBT that combined education, breathing retraining, imaginal and in vivo exposure, and CR for PTSD following a recent motor vehicle accident. Compared to a waiting-list group, this brief CBT program resulted in significant reductions in PTSD symptoms, anxiety, depression, and heart-rate reactivity in response to script-driven imagery of the participants' accidents.

Blanchard et al. (2003) examined a CBT program that combined exposure therapy (i.e., exposure to the memory of the trauma by writing a trauma narrative and reading it repeatedly), in vivo exposure, relaxation training, and behavioral activation for the treatment of PTSD associated with automobile accidents. At posttreatment, the CBT program was superior to supportive psychotherapy and a waiting-list group on measures of PTSD, depression, and anxiety. At a 3-month follow-up assessment, the CBT group continued to show less severe symptoms than did the supportive counseling group.

Kubany and his colleagues (Kubany et al., 2003, 2004) used a CT focused on guilt-related issues in combination with limited exposure to treat women with PTSD and guilt related to domestic violence. Additional aspects of the intervention included psychoeducation about PTSD and related issues, managing unwanted contact with the abuser, self-advocacy, decision making, and anger management. Compared to a waiting-list condition, this cognitive-behavioral treatment program was very effective in reducing symptoms of PTSD, depression, and guilt and in improving self-esteem (Kubany et al., 2004).

In summary, several CBT interventions that incorporate exposure techniques have been found to be effective in the amelioration of PTSD in civilian samples.

Veteran Samples

There are no studies of PE per se in treating combat veterans with PTSD; however, several studies have examined other forms of exposure therapy in this population. The initial trials of exposure therapy for PTSD were conducted using samples of veterans with combat-related PTSD. In the first of these studies, Keane, Fairbank, Caddell, and Zimering (1989) compared Vietnam veterans treated with 14-16 90-minute sessions of imaginal exposure (which they called implosive or flooding therapy; see Lyons & Keane, 1989) to a waiting-list control group. Veterans in both groups were maintained on whatever psychiatric mediations that had been prescribed prior to participation in the study. Results indicated that, compared to those on the waiting-list, participants treated with exposure displayed significantly more improvement on PTSD reexperiencing symptoms, state-anxiety (but not trait-anxiety), and depression. Treatment did not appear to have an effect on the emotional numbing and social avoidance associated with PTSD.

Two additional studies of veteran samples soon followed. Cooper and Clum (1989) compared veterans receiving standard VA outpatient treatment supplemented with imaginal exposure to a group receiving standard treatment alone. Veterans in the imaginal exposure group received up to 14 90-minute individual sessions with the exposure therapist, though the maximum number of sessions devoted to conducting exposure was 9. Results indicated that augmenting standard care with imaginal exposure improved outcome on state-anxiety (but not trait-anxiety), subjective anxiety in response to a slide show of trauma-related images and sounds, and sleep disturbance. Unlike Keane et al. (1989), Cooper and Clum (1989) did not find a significant effect of treatment on depression. Boudewyns and Hyer (1990; see also Boudewyns, Hyer, Woods, Harrison, & McCranie, 1990) compared veterans treated with specialized VA inpatient care supplemented with 1012 50-minute sessions of imaginal exposure to a group whose inpatient treatment was supplemented with "more conventional individual psychotherapy" (Boudewyns et al., 1990, p. 361). No group differences were found immediately after treatment. However, veterans whose treatment was supplemented with imaginal exposure showed greater gains on the Veterans Adjustment Scale at a 3-month follow-up assessment.

More recently, Glynn, et al. (1999) compared veterans treated with 13-14 90-minute sessions of imaginal exposure plus CR with a standard care control group and a third group that received the imaginal exposure plus CR intervention supplemented by 16-18 additional sessions of behavioral family therapy. All of the veterans were allowed to remain on previously prescribed psychiatric medications. The various dependent variables in this study were factor analyzed and yielded a positive symptoms factor (i.e., reexperiencing, hyperarousal) and negative symptoms factor (i.e., avoidance, emotional numbing). Results revealed that, compared to the waiting-list condition, treatment with imaginal exposure plus CR resulted in significant improvement on the positive symptoms but not the negative symptoms. Contrary to expectations, adding behavioral family therapy did not enhance outcome.

In sum, although PE has not been tested directly in samples of combat veterans, studies using variations of exposure therapy with veterans have consistently revealed significant benefits for this treatment approach. However, the magnitude of the improvement has been somewhat limited. Furthermore, the benefits of exposure treatment appear to be greater for symptoms of intrusion and arousal than for avoidance and numbing. These studies represent very strict tests of exposure therapy. In all of the trials, exposure was compared to other treatments focused on PTSD symptoms: either a continuation of treatment that the veterans were already receiving or focused PTSD interventions. An important consideration in evaluating the results of these studies is the well-recognized reality that there are incentives for veterans to emphasize their symptoms and to minimize treatment gains (e.g., gaining or losing service-connected disability compensation; for additional discussion, see Frueh, Hamner, Cahill, Gold, & Hamlin, 2000). It should also be noted that the exposure interventions in these studies emphasized imaginal exposure, to the relative neglect of in vivo exposure. It is possible that the results of exposure therapy with this population, particularly on measures of avoidance and withdrawal, could be improved with in vivo exposure to social situations. Finally, no studies with veteran populations have compared PE alone with PE combined with another treatment approach. The only study (Glynn et al., 1999) that attempted to augment exposure therapy with other behavioral interventions found that adding behavioral family therapy did not produce any further gains.

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