Stress inoculation training
SIT is a collection of several techniques designed to manage stressful situations and problematic emotional reactions.7 Applied to PTSD,8-10 SIT consists of training in controlled breathing, progressive muscle relaxation, guided positive imagery, thought stopping, and cognitive restructuring (discussed below). The rationale for SIT assumes that individuals will differ in how they experience and express anxiety, and one goal of treatment is to match interventions with specific symptoms. For example, controlled breathing and progressive muscle relaxation may be used to target the symptoms of physiological arousal, whereas thought stopping is designed to disrupt intrusive recollections about the trauma or other anxiety-provoking thoughts and images (eg, worry, rumination about current life stressors).
Cognitive therapy, developed initially as a treatment for depression11 and later extended to the treatment of anxiety,12 is based on the idea that it is not actual events that cause problematic emotional reactions but a person's interpretation of those events. Accordingly, cognitive therapy techniques, of which cognitive restructuring is one of the most basic, are designed to help patients identify and challenge their inaccurate or unhelpful cognitions and replace them with more realistic or helpful ones. Cognitive restructuring is designed to accomplish this through systematic review of evidence for and against a target belief or evaluation of the pros and cons of maintaining the belief. It incorporates careful consideration of the likelihood or actual cost of anticipated consequences, investigating possible alternative explanations for difficult or challenging situations, or attempting to view the situation from the perspective of another.
Eye movement desensitization and reprocessing
EMDR has 2 major components: repeated brief (approximately 30 seconds each) imaginal exposure to trauma- related thoughts, images, and memories (desensitization); and a form of cognitive restructuring called reprocessing. The unique feature of EMDR is that the therapist induces a series of rapid left-to-right eye movements by instructing the patient to follow the therapist's hand as it is moved back-and-forth across the patient's visual field during desensitization and reprocessing. In some cases, therapists may replace eye movements with one of several other possible forms of lateral alternation, such as the patient alternately tapping the left and right hands or the therapist presenting tones alternately to the left and right of the patient. Shapiro,4 the originator of EMDR, has hypothesized that trauma can disrupt the normal functioning of the information processing system, which prevents recovery from PTSD symptoms. She has further speculated that "the information-processing mechanism may be activated when attention is elicited by or focused on the external cues [eg, tracking the therapist's fingers] . . . [and that] the simultaneous focus on the traumatic memory may cause the activated system to process the dysfunctionally stored material."
Although much of the initial research on EMDR suffered from significant methodological limitations,13-17 more recent research has established the basic efficacy of EMDR for PTSD.18,19 However, dismantling studies have repeatedly failed to find superior outcome for EMDR treatment that includes the use of rapid eye movements compared with a range of control conditions, including conducting EMDR while having patients close their eyes or focus on a set point.20 Accordingly, it would seem likely that the benefit of EMDR is best attributed to the elements it has in common with other forms of CBT (ie, brief imaginal exposure and cognitive restructuring conducted within a supportive relationship).
Efficacy of CBT
The efficacy of CBT in the treatment of PTSD has been studied in a number of randomized controlled studies. A recent meta-analysis of treatments for PTSD identified 26 studies that yielded 44 active treatment conditions, 37 (84%) of which involved CBT, 8 active control conditions (eg, supportive counseling, relaxation), and 15 waitlist control conditions.21BT) that produced a mean between-group effect size of 1.11 (CI, 0.76 to 1.47).
Focusing on the CBT conditions, the effect sizes ranged between a mean of 1.43 for EMDR and 1.66 for exposure therapy plus cognitive restructuring, with no significant differences emerging across different CBT categories. Several studies also reported the percentage of patients that no longer met diagnostic criteria for PTSD after completing treatment. Among 29 active treatment conditions, 26 of which were some form of CBT, 67% of patients did not meet criteria for PTSD following treatment, with average rates ranging between 65% for EMDR and 70% for exposure therapy plus cognitive restructuring. Again, there were no significant differences among types of CBT. By comparison, 39% of patients completing an active control treatment and 16% of patients completing waitlist lost the PTSD diagnosis.
In their meta-analysis, Bradley and colleagues21 found that the various studies comprised a broad range of trauma populations, including female victims of sexual and physical assault both in adulthood and in childhood, male combat veterans, male and female victims of motor vehicle accidents, male and female refugees, and mixed sex/mixed trauma samples made up mostly of victims of violent crime and motor vehicle accidents. Although their meta-analysis focused exclusively on measures of PTSD, the effects of CBT in the studies analyzed were not limited to PTSD. Concomitant improvements were also found on measures such as depression,9,10 anxiety,9,10 anger,22 and guilt.23 Moreover, follow-up assessments at 3 to 12 months showed that the treatment gains were well maintained.9,10