June 1, 2007
Psychiatric Times.
No. 7
Rape-Related PTSD: Issues and Interventions
Dean G. Kilpatrick, PhD, Ananda B. Amstadter, MS, Heidi S. Resnick, PhD, and Kenneth J. Ruggiero, PhD
Dr Kilpatrick is a distinguished university professor, Ananda Amstadter is a predoctoral fellow, Dr Resnick is professor, and Dr Ruggiero is assistant professor in the department of psychiatry and behavioral sciences, National Crime Victims Research and Treatment Center, Medical University of South Carolina in Charleston. They report no conflicts of interest concerning the subject matter of this article.
Pharmacological early interventions
The release of stress hormones, such as epinephrine, following a traumatic event assists in memory consolidation and learning,31 and therefore ß-adrenergic antagonists, such as propranolol, may attenuate these effects. A randomized placebo-controlled 10-day trial of propranolol beginning 6 hours after a traumatic event (trauma types were not detailed in this report) was conducted.32 One month rates of PTSD were 30% in the placebo group and 18% in the propranolol group. Furthermore, the propranolol group was less physiologically responsive to an idiographic trauma script than the placebo group.
A subsequent nonrandomized controlled trial of propranolol with survivors of motor vehicle accidents or victims of physical assault yielded similar results,33 suggesting that propranolol may successfully prevent PTSD. Propranolol has also been found to be efficacious in an open trial with pediatric burn patients.34 These results are promising; however, the findings need replication with larger RCTs.
Treatment modalities for PTSD Psychosocial interventions
Guideline recommendations for the treatment of PTSD are provided by Foa and colleagues,35,36 as well as by the International Society of Traumatic Stress Studies.37 Generally 4 psychosocial intervention techniques are endorsed for adults: exposure therapy, cognitive therapy, anxiety management training, and psychoeducation. These techniques are rarely used alone and are more frequently part of a multicomponent treatment program whose efficacy in RCTs is shown in the Table and detailed below.
Prolonged exposure (PE)38 has received substantial empirical support in the treatment of assault-related PTSD. PE typically consists of 8 to 12 sessions in which both imaginal and in vivo exposure is used. During imaginal exposure, the patient visualizes the traumatic event and describes the event in detail while being encouraged by the therapist to focus on the most emotional aspects of the event. Eleven RCTs supporting the efficacy of PE have been conducted,39-49 and 9 of these included rape victims. Cognitive processing therapy (CPT), a treatment program supplementing exposure-based techniques with psychoeducation and cognitive restructuring, was first studied in a group format and compared with a waitlist control in a sample of rape victims, with results indicating its efficacy in reducing PTSD symptoms.50
More recently, CPT and PE were found to be equally effective over a minimal attention control for rape- related PTSD.44 General CBT programs have also been supported in numerous RCTs for PTSD.51-54 Existing data also provide support for the ability of stress inoculation therapy (SIT)55 to reduce symptoms of PTSD. SIT has been found to be as effective as PE, and 2 trials have found SIT to reduce symptoms compared with controls.40,41 Although the aforementioned studies support the efficacy of these interventions, it should be noted that a substantial percentage of those treated do not improve, underscoring the need for continued treatment development and evaluation.
In comparison to the adult literature, the treatment outcome literature for child sexual abuse is scarce. Although other RCTs of treatment for PTSD of child sexual abuse have been conducted56 the treatment program that received the most support is trauma-focused CBT (TF-CBT).57 Five RCTs of TR-CBT have been undertaken,57-61 all of which included child sexual abuse. These trials support the superiority of TF-CBT over play therapy and SC. A review by Cohen62 provides detailed information for treating children with PTSD, and the reader is referred to that article for more information. (Clinicians seeking additional information on TF-CBT can visit the Web site, http://tfcbt.musc.edu, which provides an innovative training program that follows the organization of the TF-CBT model.)
Pharmacological treatment
SSRIs have received the most empirical attention in the treatment of PTSD, and in fact sertraline and paroxetine, both SSRIs, are the only medications that have received FDA approval for treatment of PTSD.63 The expert consensus guidelines for PTSD36 endorse SSRIs as the most desirable pharmacological treatment for PTSD. In a recent article, Davidson64 reports on alternative pharmacological treatments and the reader is referred to that source for an in-depth review of alternative treatments.
As shown in the Table, 10 RCTs have examined SSRIs for adults with PTSD; generally, findings showed efficacy over placebo (9 positive trials, 1 negative trial). On average, trials of SSRIs resulted in a minimum of a 30% reduction in PTSD symptoms, which is less of a reduction than was seen in CBT treatment trials. Results of fluoxetine trials of 5 and 12 weeks' duration with civilian and combat traumas indicated that the medication group had greater decreases in PTSD symptoms than the placebo group.64-67 In large-scale 12-week RCTs, efficacy for paroxetine treatment was found over placebo.68,69 Notably, both of these trials included victims of rape. Two trials of sertraline also reported positive results for paroxetine compared with placebo.70,71 A recent trial of patients with PTSD found both sertraline and venlafaxine more effective than placebo in treating PTSD.72
Although SSRIs are the first-line pharmacological treatment of PTSD, other classes of drugs have been investigated in mixed trauma samples that included rape victims. Mirtazapine, a noradrenergic and specific serotonergic antidepressant, was effective over placebo.73 Lamotrigine, an anticonvulsant, has also shown preliminary efficacy in a small double-blind controlled study.74 In a small open-label trial of prazosin, an α1-adrenergic antagonist, sleep disturbances and nightmares were found to improve.75 Many other agents, such as antipsychotics and mood stabilizers, have been used in the treatment of combat-related PTSD; however, these medications have not been studied in the treatment of rape-related PTSD.64
Of note is a recent trial that first treated all patients, including rape victims, with sertraline for 10 weeks, showing significant improvement.76 Following this 10-week trial, 5 additional weeks of sertraline treatment were administered, with half of the patients also receiving 10 sessions of PE. Results indicate that 5 additional weeks of treatment with sertraline alone did not reduce symptoms past their level at week 10 of the trial, while the addition of PE did reduce symptoms significantly. This novel study combining psychosocial and pharmacological treatments highlights the potential importance of adjunctive therapy.
Pharmacological interventions are often used to treat children with PTSD, yet very few studies have evaluated the efficacy of these agents.36 To date, there are no double-blind RCTs for children with PTSD; however, a few small open-label trials exist. For example, clonidine, an adrenergic blocking agent, has been evaluated in an open trial for preschool children exposed to sexual or physical abuse or neglect. Results from this trial indicate that clonidine may be effective in symptom reduction.77
Rape and sexual assault are prevalent forms of victimization and often precipitate PTSD. Although promising early interventions and treatment for chronic psychopathology exist, the treatment response rate is not 100%, thereby demonstrating the need for further research on treatment development and efficacy.
- Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry. 2001;58:485-492.
- Foa EB, Hembree EA, Cahill SP, et al. Randomized trial of
prolonged exposure for posttraumatic stress disorder
with and without cognitive restructuring: outcome at academic
and community clinics. J Consult Clin Psychol.
2005;73:953-968.
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