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EXPOSURE THERAPY FOR PTSD
Barbara Olasov Rothbaum, PhD1
Emory University School of Medicine
Department of Psychiatry
Edna B. Foa, PhD2
Department of Psychiatry
Allegheny University
A variety of terms have been used to label therapy that consists of prolonged
exposure to anxiety-provoking stimuli. These include flooding, imagi-nal exposure,
in vivo exposure, prolonged expo-sure, and directed exposure. In this paper
we will refer to all these therapy programs collectively as exposure. Exposure
methods share the common feature of helping anxious patients confront their
fear-evoking stimuli with the aim of reducing the irrational fear or anxiety.
Most exposure therapy programs do not consist solely of exposure but include
other components such as psychoeducation or relaxation training. The exposure
components, however, are typically more central and occupy much more time than
these other components; the latter are often presented as preliminary ways of
building up to the exposure. Details on the imple-mentation of exposure for
PTSD have been pro-vided in Foa and Rothbaum (1998).
Exposure has been a treatment of choice for many anxiety disorders for several
decades. In treatment programs for PTSD, imaginal exposure typically involves
repeated reliving of the traumatic event. In vivo exposure involves planned
confrontations with situations or objects associated with the trauma and that
are therefore anxiety-evoking. The first reference in the modern literature
to imaginal ex-posure applied to PTSD was a case study by Keane and Kaloupek
published in 1982. Only three con-trolled studies have examined the utility
of pro-longed imaginal exposure (PE) for reducing PTSD and related pathology
in male Vietnam veterans. Treatment was conducted over 6 to 16 sessions. In
one study (Cooper & Clum, 1989), all clients re-ceived the ³standard² PTSD treatment
(weekly individual and group therapies) in addition to ex-posure. In the second
study (Keane et al., 1989), patients receiving PE were compared to a waiting-list
control group (WAIT). During each session, patients were initially instructed
to relax. The pa-tients subsequently received 45 minutes of imagi-nal flooding,
followed by relaxation. In the third study, all patients received a group treatment
mi-lieu program; one-half received additional PE, and the remaining patients
received weekly individual traditional psychotherapy (Boudewyns & Hyer, 1990;
Boudewyns et al., 1990).
All three studies found some benefit to the PE patients compared to the control
group, but the effects were small. In the Cooper and Clum (1989) study, PE reduced
the PTSD symptoms, but had little effect on depression or trait anxiety. A mixed
picture emerged from the Keane et al. (1989) study: therapists rated exposure
clients as more improved on PTSD symptoms than control clients, but on self-report
measures of these symptoms, no differences were detected. However, exposure
patients did rate themselves as more improved on general psy-chopathology measures
than did those in the WAIT control. Boudewyns and Hyer (1990) found no group
differences on psychophysiological measures, but at the three-month follow-up,
the exposure group improved more on the Veterans Adjustment Scale (VAS). Regardless
of treatment, a positive relation-ship was found between psychophysiological
re-duction to combat-related stimuli following treat-ment and improvement on
the VAS. In further analysis of the data with additional patients, a higher
percentage of the exposure-treated clients were classified as successes when
compared with those receiving traditional therapy (Boudewyns et al., 1990).
An uncontrolled report found that flood-ing benefited Vietnam veterans with
PTSD only on avoidance symptoms as measured by the IES and self-recorded number
of daily intrusions (Pitman et al., 1996). Cautions regarding using exposure
with guilt memories rather than anxious memories have been put forward by Pitman
et al. (1991).
Recently, a new medium for conducting expo-sure therapy has been introduced:
Virtual Reality Exposure (VRE; Rothbaum et al., in press). VRE presents the
user with a computer-generated view of a virtual world that changes in a natural
way with head motion. During VRE sessions, clients wear the head-mounted display
with stereo ear-phones that provide visual and audio cues consis-tent with being
in a ³Virtual Vietnam.² Clients in one investigation are exposed to two virtual
envi-ronments, a Huey helicopter flying over a virtual Vietnam and a clearing
surrounded by jungle. In this way, patients are repeatedly exposed to their
most traumatic memories but immersed in Viet-nam stimuli. The results of the
first patient to com-plete the Virtual Vietnam treatment are encourag-ing: scores
on all measures decreased from pre- to post-treatment.
The first report on the application of exposure therapy to PTSD rape victims
appeared in 1991
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with a controlled study by Foa et al. (see also a case report
by Rothbaum and Foa, 1991). Rape victims with PTSD were
randomly assigned to one of four conditions: stress inocu-
lation training (SIT), prolonged exposure (PE), supportive
counseling (SC), or wait-list control (WL). SIT is a treatment
package of anxiety management techniques developed for
victims who remained highly fearful three months after
being raped (Kilpatrick et al., 1982). SC utilized a problem-
solving approach for daily problems. Treatments were
delivered in nine biweekly 90-minute individual sessions.
All conditions produced improvement on all measures
immediately post-treatment and at follow-up. SIT pro-
duced significantly more improvement on PTSD symp-
toms than WL immediately following treatment. At follow-
up, PE produced superior outcome on PTSD symptoms.
Clients who received PE continued to improve after treat-
ment termination, whereas clients in the SIT and SC condi-
tions evidenced no change between post-treatment and
follow-up. This study demonstrated that rape victims tol-
erated exposure therapy well as no differential dropout
emerged. The case study indicated that other traumatic
conditions and complications, such as conversion mutism,
could also be alleviated by exposure.
A second controlled study compared PE, SIT, the combi-
nation of SIT and PE, and a wait-list control group in clients
with PTSD post sexual and non-sexual assault (Foa et al., in
press). All three active treatments showed significant im-
provement in PTSD symptoms and depressive symptoms
at post-test, and the wait-list did not improve. These treat-
ment effects were maintained at six-month follow-up. On
most outcome measures PE was more effective than the
other two treatments, although this difference did not
always reach significance. An examination of patients who
achieved good end-state functioning showed that 21% of
patients in SIT, 46% of patients in PE, and 32% of patients
in SIT/PE achieved this goal at post-treatment. At six-
month follow-up, 75% of patients in PE, 68% of patients in
SIT, and 50% of patients in SIT/PE lost the PTSD diagnosis,
whereas all wait-list patients retained the diagnosis. The
hypothesis that the combined treatment would be superior
was not supported. The authors suggested that these re-
sults may be due to the fact the clients in that condition
actually received less prolonged imaginal exposure and SIT
training than participants in the individual treatments, as
treatment sessions were all equal in length. In a third study,
9-12 weekly sessions of PE alone were compared to PE
combined with cognitive restructuring. Preliminary re-
sults indicated that both treatments were highly effective,
but PE alone was more efficient. More than half the clients
in that group achieved over 70% improvement on PTSD
symptoms after 9 sessions; only 15% of the combined group
achieved that status after 9 sessions, and those remaining
required 3 additional sessions to arrive at the same out-
come (Foa, personal communication). Versions of the PE
program have been helpful in preventing the development
of chronic PTSD following rape (Foa et al., 1995a) and in
treating PTSD in abused children (Deblinger et al., 1990).
Cognitive Processing Therapy (CPT) is a combination
therapy for rape victims with PTSD that includes educa-
tion, exposure, and cognitive restructuring components.
Results were very encouraging for the efficacy of CPT in
this population (Resick & Schnicke, 1992). In a preliminary
report of a controlled trial comparing CPT, PE, and Wait-
ing List Control groups, Nishith and Resick (in press)
reported that female sexual assault survivors who re-
ceived CPT (n = 29) or PE (n = 26) were significantly more
improved than the Wait List Control (n = 29) group from
pre- to post-treatment on PTSD and depressive symp-
tomatology. CPT and PE were equally effective in reduc-
ing PTSD.
Additional studies also provide support for the efficacy
of exposure treatment for PTSD in samples heterogeneous
with regard to their traumas. Richards et al. (1994) treated
participants with PTSD with either four sessions of imagi-
nal exposure followed by four sessions of in vivo expo-
sure, or in vivo followed by imaginal exposure. Patients in
both treatment conditions improved considerably. At post-
treatment and at one-year follow-up, no patients met
criteria for PTSD. The only notable difference between the
two exposure types was in the area of phobic avoidance,
for which in vivo exposure appeared to be more effective
regardless of the order in which it was presented. In
another study of outpatients with PTSD resulting from a
variety of traumas (Marks et al., 1998), exposure, cognitive
therapy, and exposure plus cognitive therapy combina-
tion were equally successful in reducing PTSD at post-
treatment and 6-month follow-up. All three treatments
were more effective than relaxation.
Exposure therapy was compared to cognitive therapy in
a mixed sample of trauma survivors (Tarrier et al., 1999).
There was a significant improvement on all measures at
post-treatment which was maintained at follow-up for
both treatments, with no significant differences between
the two treatments. An open trial of eight weekly sessions
of imaginal and in vivo exposure treatment with mixed
trauma survivors with PTSD also suggested that exposure
was efficacious (Thompson et al., 1995). Exposure therapy
combined with stress inoculation training was helpful for
survivors of motor vehicle accidents (Hickling & Blanchard,
1997).
How does exposure therapy work? It has been sug-
gested that PTSD, like other anxiety disorders, reflects the
presence of a pathological fear structure in memory (Foa
& Kozak, 1986; Foa et al., 1989). Memory fear structures
are thought to include representations of stimuli, responses,
and their meaning. The memory structure is activated by
trauma-related information. Because the number of stimuli
and response representations is thought to be particularly
large in the trauma-fear structure of individuals with
PTSD, it is easily accessed, resulting in PTSD symptoms.
Emotional processing theory proposes that successful
therapy involves correcting the pathological elements of
the fear structure (Foa & Kozak, 1986). Exposure proce-
dures consist of confronting the patient with trauma-re-
lated information, thus activating the trauma memory.
This activation constitutes an opportunity for corrective
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information to be integrated in the trauma memory, and
thus modify the pathological elements of that memory. Of
particular relevance to PTSD is a study demonstrating that
fear activation during reliving of the traumatic memory
(imaginal exposure) promotes successful outcome (Foa et
al., 1995b). Several mechanisms are thought to be involved
in the specific changes that successful therapy promotes in
patients with PTSD. First, repeated imaginal reliving of the
trauma is thought to promote habituation and thus reduce
anxiety previously associated with the trauma memory,
and correct the erroneous idea that anxiety stays forever
unless avoidance or escape is realized. Second, the process
of deliberately confronting the feared memory blocks nega-
tive reinforcement connected with the fear reduction fol-
lowing cognitive avoidance of trauma-related thoughts
and feelings. Third, repeated reliving of the trauma in a
therapeutic, supportive setting incorporates safety infor-
mation into the trauma memory, thereby helping the pa-
tient to realize that remembering the trauma is not danger-
ous. Fourth, focusing on the trauma memory for a pro-
longed period helps the patient to differentiate the trauma
event from other non-traumatic events, thereby rendering
the trauma as a specific occurrence rather than as a repre-
sentation of a dangerous world and of an incompetent self.
Fifth, the process of imaginal reliving helps change the
meaning of PTSD symptoms from a sign of personal in-
competence to a sign of mastery and courage. Sixth, pro-
longed, repeated reliving of the traumatic event affords the
opportunity for focusing on details central to negative
evaluations of themselves and modify those evaluations.
The mechanisms most salient during in vivo exposure are
the correction of erroneous probability estimates of danger
and habituation of fearful responses to trauma relevant
stimuli. Other theorists have emphasized other cognitive
aspects (Brewin et al., 1996).
The results from the studies discussed above consis-
tently support the efficacy of imaginal and in vivo expo-
sure for the treatment of PTSD resulting from a variety of
traumas. In general, these studies are well-controlled,
leading to strong conclusions. Exposure therapy tends to
be relatively short-term and well-tolerated, even by very
impaired individuals, and thus should be considered a
treatment option in many cases of PTSD.
SELECTED ABSTRACTS
BOUDEWYNS, P.A., & HYER, L. (1990). Physiological re-
sponse to combat memories and preliminary treatment out-
come in Vietnam veteran PTSD patients treated with direct
therapeutic exposure. Behavior Therapy, 21, 63-87. Two individual
treatment conditions for PTSD in Vietnam veterans were com-
pared: Direct therapeutic exposure (DTE) was compared to con-
ventional one-on-one counseling (controls). All patients received
an intensive group treatment milieu program in a VA inpatient
treatment program specifically designed for PTSD. Physiological
responses to imaginal exposure scenes of stressful memories of
combat were recorded. These physiological measures were taken
prior to treatment, and immediately following treatment. Three
physiological responses were evaluated: Heart rate, frontalis
electromyography, and skin conductance. All three measures
indicated strong responding to the exposure scenes at both pre-
and post-treatment. While there were no significant differences
between the treatment conditions in physiological responding
after therapy, there were trends that indicated that the DTE group
had decreased physiological responding to the exposure scenes
when compared to controls that could prove significant at planned
follow-up. Subjects were also given a preliminary psychological
and behavioral evaluation to determine treatment outcome at
three months following treatment. This evaluation indicated that
the DTE-treated group improved when compared to controls.
Results supported the notion that those subjects who did evi-
dence decreased physiological responding to the imaginal scenes
immediately following treatment also improved psychologically
at three months follow-up when compared to subjects who did
not have reduced physiological responding, regardless of treat-
ment received.
COOPER, N.A., & CLUM, G.A. (1989). Imaginal flooding as a
supplementary treatment for PTSD in combat veterans: A con-
trolled study. Behavior Therapy, 3, 381-391. The present study
examined the incremental effectiveness of imaginal flooding (IF)
over standard psychotherapeutic and pharmacologic approaches
in the treatment of combat-related PTSD. Evidence was found
supportive of IF's effectiveness with regard to self-report symp-
toms directly related to the traumatic event(s), state anxiety,
subjective anxiety in response to traumatic stimuli, and sleep
disturbance. Flooding had no effect on level of depression or trait
anxiety, indicating that it is a useful adjunctive treatment for
PTSD but cannot likely be used as the sole vehicle of change.
FOA, E.B., HEARST-IKEDA, D., & PERRY, K.J. (1995a). Evalu-
ation of a brief cognitive-behavioral program for the preven-
tion of chronic PTSD in recent assault victims. Journal of Consult-
ing and Clinical Psychology, 63, 948-955. The efficacy of a brief
prevention program (BP) aimed at arresting the development of
chronic PTSD was examined with 10 recent female victims of
sexual and nonsexual assault who received 4 sessions of a cogni-
tive-behavioral program shortly after the assault. Their PTSD and
depression severity was compared with that of 10 matched recent
female assault victims who received repeated assessments of
their trauma-related psychopathology (assessment control; AC).
The BP program consisted of education about common reactions
to assault and cognitive-behavioral procedures. Two months
postassault, victims who received the BP program had signifi-
cantly less severe PTSD symptoms than victims in the control
condition; 10 percent of the former group met criteria for PTSD
versus 70 percent of the latter group. Five and a half months
postassault, victims in the BP group were significantly less de-
pressed than victims in the AC group and had significantly less
severe reexperiencing symptoms.
FOA, E.B., & KOZAK, M.J. (1986). Emotional processing of
fear: Exposure to corrective information. Psychological Bulletin,
99, 20-35. In this article we propose mechanisms that govern the
processing of emotional information, particularly those involved
in fear reduction. Emotions are viewed as represented by infor-
mation structures in memory, and anxiety is thought to occur
when an information structure that serves as a program to escape
or avoid danger is activated. Emotional processing is defined as
the modification of memory structures that underlie emotions. It
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is argued that some form of exposure to feared situations is
common to many psychotherapies for anxiety, and that confron-
tation with feared objects or situations is an effective treatment.
Physiological activation and habituation within and across expo-
sure sessions are cited as indicators of emotional processing, and
variables that influence activation and habituation of fear re-
sponses are examined. These variables and the indicators are
analyzed to yield an account of what information must be inte-
grated for emotional processing of a fear structure. The elements
of such a structure are viewed as cognitive representations of the
stimulus characteristic of the fear situation, the individual's
responses in it, and aspects of its meaning for the individual.
Treatment failures are interpreted with respect to the interference
of cognitive defenses, autonomic arousal, mood state, and erro-
neous ideation with reformation of targeted fear structures. Ap-
plications of the concepts advanced here to therapeutic practice
and to the broader study of psychopathology are discussed.
FOA, E.B., RIGGS, D.S., MASSIE, E.D., & YARCZOWER, M.
(1995b). The impact of fear activation and anger on the efficacy
of exposure treatment for posttraumatic stress disorder. Behav-
ior Therapy, 26, 487-499. This paper explores the hypothesis that
fear activation during exposure treatment promotes improve-
ment. Twelve female assault victims diagnosed with PTSD re-
ceived treatment that included prolonged repeated reliving of
the assault in imagination. Two measures of fear activation were
used: Facial fear expression coded from videotapes of the first
reliving session and the client's highest reported distress score
during the same session. The results indicated that clients who
evidenced more severe PTSD prior to treatment displayed more
intense facial fear expressions during the first reliving of the
assault and benefited more from treatment than did clients who
had less severe PTSD and displayed less fear. In contrast, clients
who reported more anger prior to treatment tended to display
less fear expression during reliving of the trauma and benefited
less from treatment than less angry clients. The relationship of
pretreatment PTSD and anger severity to improvement seems to
be mediated by fear facial expression and was not simply a
product of regression toward the mean of extreme pretreatment
scores. The results are discussed within an emotional processing
theory of fear.
FOA, E.B., & ROTHBAUM, B.O. (1998). Treating the trauma of
rape: A cognitive-behavioral therapy for PTSD. New York: Guilford.
The aims of this book are to present a picture of PTSD and related
problems that is grounded in the research literature and to
provide a detailed guide to conducting effective treatment pro-
grams for clients who suffer from trauma-related psychological
problems. The authors review the literature on posttrauma dis-
turbances and on the relative efficacy of various treatments in
overcoming these disturbances. They outline a theoretical ac-
count for why some victims develop PTSD and others do not, and
they suggest that victims who develop certain beliefs are more
likely to develop PTSD than victims who do not develop such
beliefs. Different cognitive-behavioral techniques are presented
rather than a step-by-step guide, because clients differ in the
specifics of their problems and dysfunctional beliefs. Throughout
they focus on women who have been sexually assaulted and as a
result have developed chronic symptoms of PTSD, giving ex-
amples from their clinical practice. [Adapted from Text]
FOA, E.B., ROTHBAUM, B.O., RIGGS, D., & MURDOCK, T.
(1991). Treatment of posttraumatic stress disorder in rape vic-
tims: A comparison between cognitive-behavioral procedures
and counseling. Journal of Consulting and Clinical Psychology, 59,
715-723. Rape victims with PTSD (N = 45) were randomly as-
signed to one of four conditions: Stress inoculation training (SIT),
prolonged exposure (PE), supportive counseling (SC), or wait-list
control (WL). Treatments consisted of nine biweekly 90-min
individual sessions conducted by a female therapist. Measures of
PTSD symptoms, rape-related distress, general anxiety, and de-
pression were administered at pretreatment, posttreatment, and
follow-up (M = 3.5 months posttreatment). All conditions pro-
duced improvement on all measures immediately posttreatment
and at follow-up. However, SIT produced significantly more
improvement on PTSD symptoms than did SC and WL immedi-
ately following treatment. At follow-up, PE produced superior
outcome on PTSD symptoms. The implications of these findings
and direction for treatment and future research are discussed.
FOA, E.B., STEKETEE, G., & ROTHBAUM, B.O. (1989). Behav-
ioral/cognitive conceptualizations of post-traumatic stress dis-
order. Behavior Therapy, 20, 155-176. In this chapter, we summa-
rize only cognitive-behavioral interventions examined in well-
controlled studies or in case reports that included at least
semistructured assessments for evaluating treatment outcome.
We begin with a brief review of the theory underlying the
cognitive-behavioral treatment of PTSD. [Text, p. 492]
KEANE, T.M., FAIRBANK, J.A., CADDELL, J.M., &
ZIMERING, R.T. (1989). Implosive (flooding) therapy reduces
symptoms of PTSD in Vietnam combat veterans. Behavior
Therapy, 20, 245-260. In a randomized clinical trial, 24 Vietnam
veterans with a diagnosis of PTSD were randomly assigned either
to a group receiving 14 to 16 sessions of implosive (flooding)
therapy or to a waiting-list control. Standard psychometrics were
administered before, following, and six months after treatment,
and therapist ratings of symptomotology were concurrently ob-
tained in personal interviews. When compared to the waiting-list
control, those subjects receiving implosive therapy showed sig-
nificant improvement across many of the psychometric measures
and the therapist ratings of psychopathology. Specific changes in
the re-experiencing dimension of PTSD, anxiety, and depression
were notable, while treatment did not seem to influence the
numbing and social avoidance aspects of PTSD. The results are
discussed with respect to the importance of systematic exposure
to traumatic, as one component of comprehensive treatment of
combat-related PTSD, and the need for skills training interven-
tions directed at improving social competence in interpersonal
interactions.
KEANE, T.M., & KALOUPEK, D.G. (1982). Imaginal flooding
in the treatment of posttraumatic stress disorder. Journal of
Consulting and Clinical Psychology, 50, 138-140. A 36-year-old
Vietnam veteran was treated for the anxiety-related symptoms of
a PTSD. Therapy consisted of 19 sessions over a 22-day inpatient
hospitalization. Primary treatment was the exposure technique
of imaginal flooding using the intrusive thoughts (nightmares,
flashbacks) associated with the traumatic events. Self-monitored
data, psychological test instruments, and physiological respond-
ing (heart rate) during scene presentation provided empirical,
objective evidence for treatment efficacy. A 12-month follow-up
assessment indicated improved adjustment as supported by
employment status, residential stability, emotional involvement,
and self-report of anxiety, nightmares, and flashbacks.
NISHITH, P., & RESICK, P.A. (in press). Cognitive-behavioral
intervention. In D.J. Miller (Ed.), Handbook of PTSD. New York:
Plenum. Through the 1970s and 1980s cognitive-behavioral theo-
ries have emerged as viable alternatives to crisis theory and
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dynamic theory in the development of structured, research-
based treatment protocols for PTSD. This chapter focuses on the
theoretical underpinnings of the different cognitive-behavioral
approaches and the therapies that have evolved from these
approaches. The authors review the literature on systematic
desensitization, stress inoculation training, flooding, prolonged
exposure, eye movement desensitization and reprocessing, cog-
nitive processing therapy, and cognitive-behavioral therapy with
children. They find that cognitive-behavioral interventions with
single or multiple treatment components, in general, result in
decrease or remission of posttrauma sequelae when compared to
wait-list controls. Current directions of research, such as adapt-
ing existing protocols to differing populations, mechanisms
through which treatments work, markers of recovery, and
comorbidity, are also discussed. [Adapted from Text]
PITMAN, R.K., ALTMAN, B., GREENWALD, E., LONGPRE,
R.E., MACKLIN, M.L., POIRE, R.E., & STEKETEE, G.S. (1991).
Psychiatric complications during flooding therapy for post-
traumatic stress disorder. Journal of Clinical Psychiatry, 52, 17-20.
The authors use six case vignettes to illustrate underrecognized
complications occurring during flooding therapy for PTSD,
including exacerbation of depression, relapse of alcoholism, and
precipitation of panic disorder. A common denominator to the
majority of these cases appears to be the mobilization of negative
posttrauma appraisal, accompanied by shame, guilt, and anger.
The authors suggest that flooding may not be helpful for these
negative emotions in the manner that it is for anxiety. Sugges-
tions for preventing and treating complications of flooding
therapy for PTSD include employing more cognitive forms of
therapy in cases at risk; supporting abstinence from alcohol and
other substances; providing adjunctive pharmacologic treat-
ment as indicated, e.g., tricyclics for depression or panic; and
providing long-term follow-up.
RICHARDS, D.A., LOVELL, K., & MARKS, I.M. (1994). Post-
traumatic stress disorder: Evaluation of a behavioral treatment
program. Journal of Traumatic Stress, 7, 669-680. The relative
values of imaginal and real-life exposure exercises were tested in
this study by randomizing 14 patients who met DSM-III-R crite-
ria for PTSD at least 6 months after the initiating trauma to one of
two groups. Group 1 (n = 7) had four weekly, hour-long sessions
of imaginal exposure followed by four weekly, hour-long ses-
sions of live exposure. Group 2 (n = 7) had the reverse order of
four live exposure sessions followed by four imaginal exposure
sessions. Both groups improved significantly on both PTSD-
specific measures and measures of general health post-treatment,
and significantly further on 7 out of 12 measures at follow-up 12
months post-treatment. Clinical improvement was in the order of
65-80 percent reduction in target symptoms. On one measure
only (problem 2 - phobic avoidance), live exposure yielded more
improvement than imaginal exposure whether given first or
second. The importance of both live and imaginal exposure to all
relevant cues, behavioral and cognitive, is discussed, together
with the value of self-exposure homework for patients with
PTSD.
ROTHBAUM, B.O., & FOA, E.B. (1991). Exposure treatment of
PTSD concomitant with conversion mutism: A case study.
Behavior Therapy, 22, 449-456. A case report of the successful
treatment by exposure of a woman diagnosed with PTSD con-
comitant with conversion mutism is described. PTSD and conver-
sion disorder are both thought to be caused by emotionally
traumatic experiences, but the symptomatology is quite differ-
ent. Etiological theories of the two disorders are discussed, and
mechanisms underlying the successful outcome of exposure
treatment are considered.
ROTHBAUM, B.O., HODGES, L., ALARCON, R., READY, D.,
SHAHAR, F., GRAAP, K., PAIR, J., HEBERT, P., GOTZ, D.,
WILLS, B., & BALTZELL, D. (in press). Virtual reality exposure
therapy for PTSD Vietnam veterans: A case study. Journal of
Traumatic Stress. Virtual reality (VR) integrates real-time com-
puter graphics, body tracking devices, visual displays, and other
sensory input devices to immerse a participant in a computer-
generated virtual environment that changes in a natural way
with head and body motion. VR exposure (VRE) is proposed as
an alternative to typical imaginal exposure treatment for Vietnam
combat veterans with posttraumatic stress disorder (PTSD). This
report presents the results of the first Vietnam combat veteran
with PTSD to have been treated with VRE. The patient was
exposed to two virtual environments, a virtual Huey helicopter
flying over a virtual Vietnam and a clearing surrounded by
jungle. The patient experienced a 34% decrease on clinician-rated
PTSD and a 45% decrease on self-rated PTSD.
TARRIER, N., PILGRIM, H., SOMMERFIELD, C., FARAGHER,
B., REYNOLDS, M., GRAHAM, E., & BARROWCLOUGH, C.
(1999). A randomized trial of cognitive therapy and imaginal
exposure in the treatment of chronic posttraumatic stress disor-
der. Journal of Consulting and Clinical Psychology, 67, 13-18. A
randomized trial was performed in which imaginal exposure (IE)
and cognitive therapy (CT) were compared in the treatment of
chronic PTSD. Patients who continued to meet PTSD caseness at
the end of a 4-week symptom-monitoring baseline period (n = 72)
were randomly allocated to either IE or CT. There was a signifi-
cant improvement in all measures over treatment and at follow-
up, although there were no significant differences between the
two treatments at any assessment. A significantly greater number
of patients who showed worsening over treatment received IE,
although this effect was not found at follow-up. Patients who
worsened showed a greater tendency to miss treatment sessions,
rated therapy as less credible, and were rated as less motivated by
the therapist. It was concluded that either exposure or a challenge
to cognition can result in symptom reduction, although neither
resulted in complete improvement.
ADDITIONAL CITATIONS
Annotated by the Editorial Staff
BOUDEWYNS, P.A., HYER, L., WOODS, M.G., HARRISON,
W.R., & MCCRANIE, E. (1990). PTSD among Vietnam veter-
ans: An early look at treatment outcome using direct thera-
peutic exposure. Journal of Traumatic Stress, 3, 359-368.
Assigned 58 Vietnam veterans with PTSD to receive exposure or
conventional therapy as part of an inpatient treatment. Positive
outcomes in anxiety, depression, and social skills were more
likely in the exposure group.
BOWEN, G.R., & LAMBERT, J.A. (1985). Systematic desensi-
tization therapy with post-traumatic stress disorder cases. In
C.R. Figley (Ed.), Trauma and its wake (Vol. 2, pp. 280-291). New
York: Brunner/Mazel.
Measured responses to viewing combat stress and non-combat
stress scenes in 10 veterans with PTSD. Initially subjects were
more distressed when viewing combat scenes. After therapy,
their reactions to the two types of scenes did not differ signifi-
cantly.
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BREWIN, C.R., DALGLEISH, T., & JOSEPH, S. (1996). A dual
representation theory of posttraumatic stress disorder. Psy-
chological Review, 103, 670-686.
Presents a cognitive model of two types of memories for trau-
matic events: Consciously processed, verbally accessible memo-
ries, and nonconscious, situationally accessible memories. Differ-
ent PTSD symptoms can be linked to the two processes and
require different treatment.
BROM, D., KLEBER, R.J., & DEFARES, P.B. (1989). Brief psy-
chotherapy for posttraumatic stress disorders. Journal of Con-
sulting & Clinical Psychology, 57, 607-612.
Randomly assigned 112 people meeting DSM-III criteria for
PTSD to psychodynamic treatment, hypnotherapy, trauma de-
sensitization, or waiting list. The therapies were equally effective
in reducing symptoms.
DEBLINGER, E., MCLEER, S.V., & HENRY, D. (1990). Cogni-
tive behavioral treatment for sexually abused children suf-
fering post-traumatic stress: Preliminary findings. Journal of
the American Academy of Child & Adolescent Psychiatry, 29, 747-
752.
Treated 19 sexually abused girls and their non-offending caretak-
ers with 12 sessions of cognitive-behavioral therapy. Pre- and
post-assessments revealed significant improvement in PTSD.
ECHEBURUA, E., DE CORRAL, P., ZUBIZARRETA, I., &
SARASUA, B. (1997). Psychological treatment of chronic post-
traumatic stress disorder in victims of sexual aggression.
Behavior Modification, 21, 433-456.
Randomly assigned 20 female rape victims with severe PTSD to
gradual self-exposure and cognitive restructuring therapy or
progressive relaxation training. The former was clearly superior
to the latter in reducing PTSD.
FOA, E.B., DANCU, C.V., HEMBREE, E.A., JAYCOX, L.H.,
MEADOWS, E.A., & STREET, G.P. (1999). A comparison of
exposure therapy, stress inoculation training, and their com-
bination for reducing posttraumatic stress disorder in female
assault victims. Journal of Consulting and Clinical Psychology, 67,
194-200.
Randomly assigned 96 women with PTSD due to assault to
prolonged exposure therapy, stress inoculation training, com-
bined exposure and inoculation, or wait-list control. All treat-
ments yielded superior outcomes relative to the wait list.
FOA, E.B., & MEADOWS, E.A. (1997). Psychosocial treat-
ments for posttraumatic stress disorder: A critical review.
Annual Review of Psychology, 48, 449-480.
Reviews the literature on timing and efficacy of crisis interven-
tion, hypnotherapy, psychodynamic, and cognitive-behavioral
treatments. The authors include "gold standards" for therapy-
outcome study design and find cognitive-behavioral therapies to
have the best-documented successes.
FRANK, E., ANDERSON, B., STEWART, B.D., DANCU, C.,
HUGHES, C., & WEST, D. (1988). Efficacy of cognitive behav-
ior therapy and systematic desensitization in the treatment of
rape trauma. Behavior Therapy, 19, 403-420.
Randomly assigned 84 treatment-seeking rape victims to cogni-
tive-behavioral therapy or systematic desensitization. Both re-
sulted in clinically significant improvement in symptoms.
FRUEH, B.C., TURNER, S.M., BEIDEL, D.C., MIRABELLA,
R.F., & JONES, W.J. (1996). Trauma Management Therapy: A
preliminary evaluation of a multicomponent behavioral treat-
ment for chronic combat-related PTSD. Behavior Research &
Therapy, 34, 533-543.
Treated Vietnam veterans with PTSD with a combination of imagi-
nal flooding and group therapy. Eleven subjects completed treat-
ment and were improved on clinician-rated, self-rated, and physi-
ological measures.
HICKLING, E.J. & BLANCHARD, E.B. (1997). The private
practice psychologist and manual-based treatments: Post-trau-
matic stress disorder secondary to motor vehicle accidents.
Behavior Research and Therapy, 35, 191-203.
Implemented a pilot study of cognitive-behavioral treatment of
PTSD in MVA. Ten patients were treated using a manualized
protocol. There was significant improvement in PTSD symptoms
immediately and 3 months post-treatment.
KILPATRICK, D.G., VERONEN, L.J., & RESICK, P.A. (1982).
Psychological sequelae to rape: Assessment and treatment
strategies. In D. Dolays & R. Meredith (Eds.), Behavioral medicine:
Assessment and treatment strategies (pp. 473-497). NY: Plenum.
Reviews the literature on the effects of rape and discusses treat-
ment, emphasizing behavioral approaches.
MARKS, I.M., LOVELL, K., NOSHIRVANI, H., LIVANOU, M.,
& THRASHER, S. (1998). Treatment of posttraumatic stress
disorder by exposure and/or cognitive restructuring: A con-
trolled study. Archives of General Psychiatry, 55, 317-325.
Randomly assigned 77 PTSD patients to receive either prolonged
exposure, cognitive restructuring, combined exposure and re-
structuring, or relaxation training. All treatments were equiva-
lently effective in reducing PTSD symptoms.
PITMAN, R.K., ORR, S.P., ALTMAN, B., LONGPRE, R.E., POIRE,
R.E., MACKLIN, M.L., MICHAELS, M.J., & STEKETEE, G.S.
(1996). Emotional processing and outcome of imaginal flood-
ing therapy in Vietnam veterans with chronic posttraumatic
stress disorder. Comprehensive Psychiatry, 37, 409-418.
Examined effectiveness of EMDR with and without eye move-
ments in treating seventeen Vietnam veterans with chronic PTSD.
Both were equally effective in reducing symptoms.
RESICK, P.A. & SCHNICKE, M.K. (1992). Cognitive processing
therapy for sexual assault victims. Journal of Consulting and
Clinical Psychology, 60, 748-756.
Treated nineteen rape victims with cognitive-processing therapy
and compared them to a waiting-list sample of 20 rape victims.
Treated patients achieved and maintained significant improve-
ment in both PTSD and depression.
ROTHBAUM, B.O. & FOA, E.B. (1992). Exposure therapy for
rape victims with post-traumatic stress disorder. The Behavior
Therapist, 15, 219-222.
Discusses theory of and describes procedures of exposure therapy
for rape victims. Evidence of success and examples of treatment
sessions are included.
THOMPSON, J.A., CHARLTON, P.F.C., KERRY, R., LEE, D., &
TURNER, S.W. (1995). An open trial of exposure therapy based
on deconditioning for post-traumatic stress disorder. British
Journal of Clinical Psychology, 34, 407-416.
Treated 23 patients with PTSD or subsyndromal symptoms with a
debriefing session followed by eight weekly sessions of imaginal
and in vivo exposure, resulting in significant reductions in symp-
toms from pre- to post-treatment on CAPS scores.
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RECENT RESEARCH AT THE NATIONAL CENTER FOR PTSD
During FY 1998, research at the National Center for
PTSD focused on a range of topics designed to advance the
clinical care and welfare of America's veterans.
Assessment. The Center has worked on developing and
refining measures to improve diagnostic accuracy and to
assess traumatic exposure. Most of this research is con-
ducted by the Center's Behavioral Science Division, which
has developed the Clinician Administered PTSD Scale and
other widely used measures. In FY 1998, the CAPS was
translated from English into eight other languages. An-
other area of assessment research was the development
and testing of brief, cost-effective PTSD screening mea-
sures to be used in primary-care settings.
Causes and consequences. Psychobiology is an important
part of the Center's research program. Most of this work is
conducted at the Clinical Neurosciences Division, where
one line of investigation has focused on the hippocampus.
This research has revealed less hippocampal volume and
greater memory deficits in male Vietnam veterans with
PTSD. During FY 1998, the Division found that these
results also apply to women. The Behavioral Science and
Education Divisions are collaborating on a related study
that combines neuroimaging, electrophysiological, and
behavioral methods to study the hippocampus in indi-
viduals with PTSD. In addition, the Sleep Laboratory at the
Education Division is conducting ongoing laboratory and
ambulatory sleep research protocols aimed at understand-
ing the sleep complaints of PTSD patients.
The Behavioral Science Division, in collaboration with
the Women's Health Sciences Division, reported on the
impact of premilitary, war-zone, and postmilitary factors
on PTSD symptom severity in Vietnam veterans. This
work points to the importance of examining exposure to
multiple stressful events over time rather than concentrat-
ing on the impact of a single traumatic event. The Execu-
tive, Behavioral Science, and Women's Health Sciences
Divisions also investigated the physical health conse-
quences associated with trauma and PTSD.
Treatment. The development and evaluation of new treat-
ments for PTSD has always been a significant focus of the
Center's research activity. The Executive Division led the
primary study on treatment in FY 1998, CS#420, a 10-site
randomized clinical trial of trauma focus group therapy for
combat-related PTSD in male Vietnam veterans. The study,
the largest PTSD treatment study ever funded by the VA,
is expected to be completed in June, 2000.
A variety of projects focused on other forms of psycho-
therapy. One study evaluated a structured, brief group
treatment that targets ambivalence about changing PTSD
symptoms and comorbid problem behaviors in male Viet-
nam veterans. Another project examined effective treat-
ments for anger in veterans with PTSD. Additional studies
addressed PTSD problems from nonmilitary stressors af-
fecting veterans. One such project is a randomized clinical
trial of exposure and cognitive restructuring for treating
PTSD in adult female survivors of childhood sexual abuse.
Another, conducted in conjunction with the DoD, is a
randomized clinical trial to evaluate a cognitive approach
to treating female victims of spousal battering.
The Clinical Neurosciences Division began an innova-
tive study to test whether the beta-blocker propranolol
administered within the first 24 hours after a rape will help
to lessen the severity of traumatic memories in rape vic-
tims. The Division also expanded a double-blind, placebo-
controlled trial of clonidine, which is not a beta-blocker
but, like propranolol, reduces acute stress-induced neu-
rotransmitter changes.
Evaluation research. Since 1988, the Northeast Program
Evaluation Center has served as the Evaluation Division of
the Center. In 1998, the Division issued the third report of
the National Mental Health Program Performance Moni-
toring System. The Evaluation Division also issued the
third report on the treatment outcomes of specialized
PTSD inpatient programs. These data are used widely in
making programmatic changes as part of VA's commit-
ment to continuous improvement in the cost-effectiveness
of service delivery. Close attention to maintaining clinical
focus and maximizing efficiency has resulted in a doubling
in the number of veterans receiving specialized PTSD
treatment at VAMCs, from 33,015 in 1995 to 66,625 in 1998.
Special populations. Some research efforts were aimed at
understanding and dealing with the unique circumstances
of special populations. During the past year, the 4th wave
of data was collected in a longitudinal study of approxi-
mately 3,000 male and female veterans who served in the
Gulf War shortly after these veterans returned home in
1991. The Clinical Neurosciences Division continued its
work on another longitudinal study of Gulf War veterans.
Center research integrates women into projects when-
ever possible, while selected projects focus exclusively on
women. For example, the Women's Health Sciences Divi-
sion continued to disseminate findings from a survey of
women veterans' perceptions and experiences in accessing
VA health care services. A follow-up study of women
veterans who use VA care is currently proposed to exam-
ine the factors associated with a history of sexual assault.
The Center also has been active in research on the needs
of veterans from ethnocultural minority groups. In FY
1998, data analysis continued on the Matsunaga Vietnam
Veterans Project, a large epidemiological study modeled
on the NVVRS, which targeted Vietnam veterans of Ameri-
can Indian and Asian/Pacific Islander ethnic backgrounds.
In addition, the Pacific Islands Division continued its effort
to develop a questionnaire for assessing race-related events
with Asian American Vietnam veterans.
The Center expanded its investigations into the effects of
active duty-related stressors. The Women's Health Sci-
ences Division entered its second year of the DoD-funded
research on women in the Marine Corps. The Clinical
Neurosciences Division, in collaboration with DoD, is
investigating the biological and psychological effects of
high-intensity military training. Prospective longitudinal
Prev Page 8 Next
studies of PTSD are underway to determine if it is possible
to identify resilient and vulnerable subgroups.
The Behavioral Sciences Division has been at the fore-
front of investigating the psychological consequences of
peacekeeping missions for U.S. military personnel. A study
of military personnel in Bosnia, conducted in collaboration
with Walter Reed Army Institute of Research, is a land-
mark effort: for the first time, mental health status prior to
deployment was assessed, so that it will be possible to
determine the impact of military deployment.
For more information about Center activities in FY
1998, see the Center's Web site: www.dartmouth.edu/
dms/ptsd/AR98.html
PILOTS UPDATE
When a controlled vocabulary is used to index a biblio-
graphical database, users should begin their search of the
literature by consulting the thesaurus in which that vo-
cabulary is set out and the relationships among terms
indicated. Even when an index term seems (and is) obvi-
ous, using the thesaurus will often suggest ways of im-
proving a search. "Hurricanes" is a term included in the
PILOTS Thesaurus. But the thesaurus will also suggest the
broader term "Natural Disasters," which some searchers
will find useful in ensuring that they retrieve the maximum
possible number of papers relevant to their topic.
Often the appropriate term to choose in searching is not
so obvious. The feature article in this issue of the PTSD
Research Quarterly deals with "Exposure Therapy for PTSD."
A search of the PILOTS database using the command FIND
TOPIC EXPOSURE ADJ THERAPY (performed before the
Spring update) yields 31 results. But if we use the descrip-
tor "Implosive Therapy," as the PILOTS Thesaurus tells us
to do, we retrieve 102 citations. These include 26 of the 31
terms we found in our first search; the other five are
indexed under "systematic desensitization therapy" or
other terms that appear more exactly to describe their
content.
There are two lessons to be learned from this. One is that
using the PILOTS Thesaurus will lead to more effective
searching of the PILOTS database. (This applies to other
databases as well: MEDLINE and PSYCINFO searches will
also produce better results if the appropriate thesauri are
used in planning them.) The other is that a controlled
vocabulary does not always use what would seem to be the
obvious terminology. Why is this?
When the PILOTS database was started nearly 10 years
ago, a preliminary set of terms was chosen by examining
the existing traumatic stress literature. Over ten years there
have been additions to the language of PTSD research, and
changes in the way that terms are used. (For example, many
writers now use "critical incident stress debriefing" in a
broader sense than CISD's inventor intended.) When we
chose "Implosive Therapy" as the descriptor to cover flood-
ing, imaginal exposure, and image habituation training,
we were guided not only by our sense of the contemporary
literature but also by the example of the Thesaurus of Psycho-
logical Index Terms, which used that term in indexing Psy-
chological Abstracts and PSYCINFO.
Terms change over time. Has the traumatic stress field
adopted "Exposure Therapy" so widely that we should
substitute it for "Implosive Therapy" in the PILOTS The-
saurus? The fact that the leading experts who have sur-
veyed the topic for this Research Quarterly chose to title their
article "Exposure Therapy for PTSD" would suggest that
we should at least consider it. And consider it we shall, as
part of the ongoing process of keeping the PILOTS Thesau-
rus up-to-date as a useful key to the traumatic stress
literature.
But we shall also remember the value of consistency in
indexing, and the disadvantages of requiring experienced
users of the PILOTS database to adapt to frequent changes
in indexing terminology. In deciding what to do about the
exposure therapy literature we shall, as always, try to strike
the best balance between innovation and consistency. The
choice we make will be reflected in the PILOTS Thesau-
rus-which will continue to be the best place to begin a
search of the traumatic stress literature.
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