A Randomized Controlled Trial of the Safety and Promise of Cognitive-Behavioral Therapy Using Imaginal Exposure in Patients With Posttraumatic Stress Disorder Resulting From Cardiovascular Illness

Division of Developmental and Behavioral Health, Department of Pediatrics, Box 1198, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
The Journal of Clinical Psychiatry (Impact Factor: 5.5). 04/2010; 72(2):168-74. DOI: 10.4088/JCP.09m05116blu
Source: PubMed


We investigated the physical safety of cognitive-behavioral therapy (CBT) utilizing imaginal exposure in patients who suffered from posttraumatic stress disorder (PTSD) following a life-threatening cardiovascular event.
In this phase I, prospective, single-blind trial conducted from April 2006 through April 2008, we randomly assigned 60 patients to receive either 3 to 5 sessions of imaginal exposure therapy (experimental group) or 1 to 3 educational sessions only (control group). Criteria for PTSD and other mental health disorders were evaluated according to DSM-IV using the full Structured Clinical Interview for DSM-IV (SCID). Safety assessments included patients' blood pressure and pulse before and after each study session and the occurrence of deaths, hospitalizations, repeat myocardial infarctions, or invasive procedures. We also investigated the effects of the treatment on PTSD symptoms (Impact of Event Scale and Posttraumatic Stress Disorder Scale), depression (Beck Depression Inventory-II), and the Clinical Global Impressions-Severity of Illness (CGI-S) scale.
There were no significant differences between the experimental and control groups and between exposure and nonexposure sessions in any of the safety measures. In addition, confidence intervals were such that the nonsignificant effects of exposure therapy were not of clinical concern. For example, the mean difference in systolic pressure between control and exposure sessions was 0.5 mm Hg (95% CI, -6.1 to 7.1 mm Hg). Nonsignificant improvements were found on all psychiatric measures in the experimental group, with a significant improvement in CGI-S in the entire cohort (mean score difference, -0.6; 95% CI, -1.1 to -0.1; P = .02) and a significant improvement in PTSD symptoms in a subgroup of patients with acute unscheduled cardiovascular events and high baseline PTSD symptoms (mean score difference, -1.2; 95% CI, -2.0 to -0.3; P = .01).
Cognitive-behavioral therapy that includes imaginal exposure is safe and promising for the treatment of posttraumatic stress in patients with cardiovascular illnesses who are traumatized by their illness. Identifier: NCT00364910.

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    • "In contrast, while well-supported evidencebased interventions exist for PTSD (for example, exposurebased interventions and cognitive processing therapy), such interventions are typically delivered within specialty mental health settings. Although safe (e.g., Shemesh et al., 2011), no interventions have demonstrated consistent effect in the primary care setting (Possemato, 2011; Schnurr et al., 2012). Early pilot work by Cigrang et al. (2011) that blended elements of prolonged exposure and cognitive processing showed promise in reducing PTSD symptoms in a small sample (n = 15) of active duty service members. "
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    ABSTRACT: Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.
    Full-text · Article · Nov 2012 · Journal of Clinical Psychology in Medical Settings
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    • "This finding is in line with the established knowledge that the most effective psychotherapies for PTSD are those focusing on the psychological trauma [19]. Importantly , trauma-focused CBT seems safe in patients with PTSD resulting from cardiovascular illness (including MI) since hemodynamic activity does not evidently increase during imaginal exposure therapy [20]. In addition, selective serotonin reuptake inhibitors (SSRIs) in sufficiently high doses are first-line drugs to treat PTSD [21] and SSRIs (but not tricyclic antidepressants, TCAs) are also safely administered to patients with CHD [22]. "
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    ABSTRACT: Posttraumatic stress disorder (PTSD) prospectively increases the risk of incident cardiovascular disease (CVD) independent of other risk factors in otherwise healthy individuals. Between 10% and 20% of patients develop PTSD related to the traumatic experience of myocardial infarction (MI). We investigated the hypothesis that PTSD symptoms caused by MI predict adverse cardiovascular outcome. We studied 297 patients (61 ± 10 years, 83% men) who self-rated PTSD symptoms attributable to a previous index MI. Non-fatal CVD-related hospital readmissions (i.e. recurrent MI, elective and non-elective intracoronary stenting, bypass surgery, pacemaker implantation, cardiac arrhythmia, cerebrovascular event) were assessed at follow-up. Cox proportional hazard models controlled for demographic factors, coronary heart disease severity, major CVD risk factors, cardiac medication, and mental health treatment. Forty-three patients (14.5%) experienced an adverse event during a mean follow-up of 2.8 years (range 1.3-3.8). A 10 point higher level in the PTSD symptom score (mean 8.8 ± 9.0, range 0-47) revealed a hazard ratio (HR) of 1.42 (95% CI 1.07-1.88) for a CVD-related hospital readmission in the fully adjusted model. A similarly increased risk (HR 1.45, 95% CI 1.07-1.97) emerged for patients with a major or unscheduled CVD-related readmission (i.e. when excluding patients with elective stenting). Elevated levels of PTSD symptoms caused by MI may adversely impact non-fatal cardiovascular outcome in post-MI patients independent of other important prognostic factors. The possible importance of PTSD symptoms as a novel prognostic psychosocial risk factor in post-MI patients warrants further study.
    Full-text · Article · Apr 2011 · Journal of Cardiology
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    • "Many studies have tried to evaluate the effectiveness of CBT in these conditions, ranging from malignancy, cardiovascular disorders, physical trauma, brain injuries, and postnatal PTSD.16,17 The physical safety of CBT utilizing imaginal exposure in patients who suffer PTSD following a life-threatening cardiovascular event has been established.16 In a study of myocardial infarction survivors with PTSD, it was found that PTSD symptoms and cardiovascular risk improved in patients who received CBT. "
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    ABSTRACT: Post-traumatic stress disorder (PTSD) is a psychiatric sequel to a stressful event or situation of an exceptionally threatening or catastrophic nature. Cognitive behavioral therapy (CBT) has been used in the management of PTSD for many years. This paper reviews the effectiveness of CBT for the treatment of PTSD following various types of trauma, its potential to prevent PTSD, methods used in CBT, and reflects on the mechanisms of action of CBT in PTSD. Electronic databases, including PubMed, were searched for articles on CBT and PTSD. Manual searches were conducted for cross-references in the relevant journal sites. The current literature reveals robust evidence that CBT is a safe and effective intervention for both acute and chronic PTSD following a range of traumatic experiences in adults, children, and adolescents. However, nonresponse to CBT by PTSD can be as high as 50%, contributed to by various factors, including comorbidity and the nature of the study population. CBT has been validated and used across many cultures, and has been used successfully by community therapists following brief training in individual and group settings. There has been effective use of Internet-based CBT in PTSD. CBT has been found to have a preventive role in some studies, but evidence for definitive recommendations is inadequate. The effect of CBT has been mediated mostly by the change in maladaptive cognitive distortions associated with PTSD. Many studies also report physiological, functional neuroimaging, and electroencephalographic changes correlating with response to CBT. There is scope for further research on implementation of CBT following major disasters, its preventive potential following various traumas, and the neuropsychological mechanisms of action.
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