Psychological Report Name: Maria Age: 18 Date of Birth: April 2,1994 Date of Evaluation: February 8, 2013 Referral Question: The client was referred because by her family because of continuous disturbance after 3 months of the rape incident. Evaluation Procedures: Maria was interviewed for two hours and administered the Impact of Event Scale – Revised (IES-R) Administered Beck Depression Inventory (BDI) Behavioral Observation The client was wearing pants, T-shirt and jacket, she is 5’2’’ tall and has a brown eyes and fair complexion. During the interview Maria was very aloof and distant.

She is always looking down, maybe because she is shy or ashamed to what had happen to her. Although she was remained seated on her chair you would notice that there is something wrong to her. During the IES and BDI test, she was thinking carefully on what she will answer at some point she really stops to think or skip onto the next item. After the testing you would notice the sadness in her facial expression. Presenting Problem Maria stated that she was raped by a tricycle driver three months ago she said that she was screaming and no one can hear her she was hit for several times due to screaming and she was very helpless.

After the incident, she was very quiet and distant to men also to her father and brother they said that most of the time she was only staying inside her room, doesn’t eat much and sometimes doesn’t eat at all. Her family reported that she hardly sleeps she stays awake until dawn and when she falls asleep they hear her talking while sleeping saying “tulong, tulungan ninyo ako” while crying and they’ll wake her up and after she will just scream thinking that her family embers is the one that raped her. From the day after the incident happened she never acted normal or the way she was before, jolly and very happy person. Background Information Maria was born and raised in Angeles city and her biological parents remained married. Her father is approximately 45 years old, working on their own water refilling station. She described her father as a “very loving and caring father”. She said that she was very close to her father before the incident happened.

Her mother is approximately 44 years old and living as a plain housewife since they were married. She is the third of four siblings, older brother 23, older sister 21 and younger brother 10. She was very close to her family until the incident happened she started being distant to her parents especially to her father and brothers she always want to be alone and she just cries she is also very agitated whenever she rides tricycle even with her family she explains that everything is coming back to me whenever I ride tricycle she noted.

She also doesn’t want to talk about what had happened to her also in school where she is studying as a second year tourism student her parents said that her professor’s are very concerned about what’s happening to Maria because she cannot be able to participate well in her classes and it has already affecting her grades. Interpretations and Impressions On Beck Depression Inventory, she scored 32 which if it scaled from 31-40 you have a severe depression. And on Impact of Event Scale-Revised she scored 10 this scores has an impact on her daily living, attitude, performance and thinking.

DIAGNOSTIC IMPRESSIONS DSM-IV AXIS I: Post Traumatic Stress Disorder, Chronic AXIS II: V71. 09 No Developmental or Personality Disorder Diagnosed AXIS III: No Physical Condition or Disorder Diagnosed Axis IV: recurrent distressing of the event Axis V: GAF 52 Summary and Recommendations Maria is suffering from Post Traumatic Stress Disorder, chronic due to continuous disturbance in dreams, perception, being distant to family especially to men because of the traumatic event that had happened.

The client is recommended to seek further assistance for the treatment of her disorder, including her family to overcome the tragic incident and for them to know how they can help Maria more to get over. And to avoid in developing a personality disorder if her daily living will not change or improve. Treatment Plan * Cognitive Behavioral Therapy (Exposure Therapy) In this therapy Learning skills for coping with anxiety (such as breathing retraining or biofeedback) and dealing with negative thoughts ("cognitive restructuring"), also Managing anger, Preparing for stress reactions ("stress inoculation"), and Handling future trauma. Medication Antidepressants to help her lessen the anxiety, depression, and insomnia that she experience with the condition. . * Brief psychodynamic psychotherapy Achieves a greater sense of self-esteem, Develops effective ways of thinking,s and coping Learns to deal more successfully with intense emotions. http://bjp. rcpsych. org/content/180/3/205. full http://ajp. psychiatryonline. org/data/Journals/AJP/3685/278. pdf http://web. ebscohost. com/ehost/pdfviewer/pdfviewer? sid=b7ef4de4-8c49-401a-8557-6d28a2cf3976%40sessionmgr114&vid=2&hid=124 http://ajp. psychiatryonline. rg/data/Journals/AJP/3715/1229. pdf Resolution of trauma-related guilt following treatment of PTSD in female rape victims: A result of cognitive processing therapy targeting comorbid depression? Pallavi Nishith,a Reginald D. V. Nixon,b,* and Patricia A. Resicka,1 Author information > Copyright and License information > The publisher's final edited version of this article is available at J Affect Disord See other articles in PMC that cite the published article. Go to: ------------------------------------------------- Abstract Background and methods Although Resick et al. 2002) [Resick, P. A. , Nishith, P. , Weaver, T. L. , Astin, M. C. , Feuer, C. A. , 2002. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J. Consult. Clin. Psychol. 70, 867–879. ] reported comparable results for treating rape-related posttraumatic stress disorder (PTSD) using either cognitive-processing therapy (CPT) or prolonged exposure (PE), there was some suggestion that CPT resulted in better outcomes than PE for certain aspects of trauma-related guilt.

The present study revisited these findings to examine whether this effect was a function of improvement in a subset of participants with both PTSD and major depressive disorder (MDD). Results Results indicated that CPT was just as effective in treating ‘pure’ PTSD and PTSD with comorbid MDD in terms of guilt. Clinical significance testing underscored that CPT was more effective in reducing certain trauma-related guilt cognitions than PE. Limitations Findings cannot be generalized to men, and only one measure of guilt was used. Conclusions

The observed superiority of CPT over PE for treating certain guilt cognitions was not due to participant comorbidity. Further research is recommended to untangle the relationship between guilt, depression and differential response to treatment in PTSD following sexual assault trauma. Keywords: PTSD, Depression, Sexual assault, Guilt, Comorbidity, Treatment outcome Go to: ------------------------------------------------- 1. Introduction The high rate of comorbid affective disorders in PTSD has been established in a number of studies including survivors of interpersonal assault.

On average, rates of depression (usually reported as MDD) are approximately 50% (e. g. , Blanchard et al. , 1998; Boudreaux et al. , 1998; Kessler et al. , 1995; North et al. , 1999). Survivors of sexual assault with comorbid depression appear to have poorer outcome following treatment than individuals with PTSD alone (Resick, 2001). In addition, trauma-related guilt has been observed to be more strongly associated with depression than PTSD in treatment seeking rape victims (Bennice et al. , 2001).

Studies of Vietnam veterans and victims of intimate partner violence have shown that trauma-related guilt is strongly correlated with depressive symptomatology (Casardi and O’Leary, 1992; Kubany et al. , 1995), and excessive guilt is a symptom of depression (American Psychiatric Association, 1994). It has also been argued that trauma-related guilt cognitions can result in depressive mood states (Kubany et al. , 2004; Pitman et al. , 1991). The close relationship between trauma-related guilt and depression highlights the importance of investigating these phenomena in the context of treatment outcome research.

Although Resick et al. (2002) recently found that both CPT and PE were comparable in treating rape-related PTSD, individuals who received CPT showed greater reductions on two of the four subscales used to assess trauma-related guilt. These effects were observed on the ‘hindsight bias’ and ‘lack of justification’ scales of the Trauma-Related Guilt Inventory (TRGI; Kubany et al. , 1996). Relative to PE, CPT therapy completers demonstrated effect sizes ranging between 0. 47 and 1. 03 on these guilt measures at posttreatment and at a 9-month follow-up.

Large effect sizes were observed when CPT and PE completers were compared with a minimal attention control group, with effect sizes ranging between 0. 73 and 2. 02 at posttreatment. When compared with the normative data (Kubany et al. , 1996), it can be seen that participants who completed therapy reported pretreatment guilt at levels equal to or higher than treatment-seeking Vietnam veterans and victims of intimate partner violence. Furthermore, levels of guilt at posttreatment and follow-up fell below the mean levels reported for college students exposed to trauma.

In the discussion of their results, Resick et al. (2002) proposed that certain guilt beliefs might require the more substantial cognitive element afforded by CPT. The role of comorbid depression, however, was not examined in relation to these findings. The purpose of the present study was to re-examine the findings of Resick et al. (2002) to test the proposition that the larger effect of CPT on treating trauma-related guilt compared with PE was due to the cognitive therapy component of CPT having an effect upon a subset of participants with comorbid depression.

If trauma-related guilt is more strongly associated with depressive features of a client’s presentation, we would expect that whereas both CPT and PE would be comparable in effectively treating PTSD in individuals with ‘pure’ PTSD, CPT would be more effective in targeting guilt than PE in individuals with comorbid depression. Go to: ------------------------------------------------- 2. Method 2. 1. Participants See Resick et al. (2002) for a detailed description of the original report. Data are presented on treatment completers for whom trauma-related guilt measures were available (N=98).

Participants were randomly allocated to receive either CPT or PE (n=49 for each group), and included the delayed treatment condition in order to increase sample size. On average, the completer sample was aged 33 (S. D. =10. 27) at the time of treatment, and time since the rape was 9. 17 years (S. D. =8. 56). Thirty-eight percent had been sexually abused in childhood, and the majority had experienced major trauma in addition to the index rape: 50% had experienced at least one additional rape, 10% had suffered a serious physical assault, and on average, the group had experienced 5. 69 (S. D. =4. 64) incidents of criminal victimization.

In the CPT group, 27 (55%) participants met criteria for ‘pure’ PTSD (PTSD only) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994), and 22 (45%) met criteria for both PTSD and Major Depressive Disorder (MDD). In the PE group, 28 (57%) and 21 (43%) participants met criteria for PTSD and PTSD+MDD, respectively. 2. 2. Procedures Structured clinical interviews were used to diagnose PTSD and MDD. The Clinician-Administered PTSD Scale (CAPS; Blake et al. , 1990) was used to determine PTSD status, and the mood module of the Structured Interview for DSM-IV-Patient Version (SCID; First et al. 1996) was used to assess MDD. Interviewers were trained by senior faculty, and audiotapes of interviews were randomly checked for reliability. The kappa coefficient for PTSD diagnosis was . 74 (92% interrater agreement) based on 66 tapes, and kappa values for depression and substance use ranged between . 80 and 1. 00, based on 45 tapes. Participants completed following self-report instruments: the PTSD Symptom Scale (PSS; Foa et al. , 1993), the Beck Depression Inventory (BDI; Beck et al. , 1961), and the Trauma-Related Guilt Inventory (TRGI; Kubany et al. , 1996).

The TRGI is a 32-item inventory with a 5-point Likert-type rating scale ranging from extremely true to not at all true. The mean of each scale is used. The following scales were used (alpha coefficients for the overall sample in parentheses): global guilt (. 92); hindsight bias (. 92); lack of justification (. 76); and wrongdoing (. 73). Item examples of these scales are (respectively): I experience intense guilt that relates to what happened; I could have prevented what happened; What I did was completely justified (reverse scored); I did something that went against my values.

In terms of intercorrelations between TRGI scales, values range between . 29 and . 68, suggesting that although related, separate constructs are measured by the subscales. Go to: ------------------------------------------------- 3. Results A preliminary multivariate analysis of variance (MANOVA) for PSS and BDI pretreatment scores indicated a significant effect of diagnosis, F(2,91)=12. 78, p=. 000, ? 2=0. 22. Follow-up analyses demonstrated that the comorbid group had significantly higher scores than the pure PTSD group on the PSS, F(1, 92)=19. 13, p=. 000, ? 2=0. 17, and on the BDI, F(1, 92)=20. 18, p=. 000, ? 2=0. 18.

Chi-square analyses indicated the treatment groups were comparable in terms of comorbidity, and that drop-out was proportional in terms of treatment group and comorbidity (in the CPT group, 10 PTSD and 7 PTSD+MDD participants dropped out of therapy, and 9 and 5 in the PE group, respectively). Reported degrees of freedom vary due to missing data. A 2 (group: CPT, PE) ? 2 (diagnosis: PTSD only, PTSD+MDD) multivariate analysis of covariance (MANCOVA) was conducted for posttreatment guilt scores and controlled the effects of pretreatment guilt levels. Descriptive statistics are reported in Table 1. There was a main effect of group, F(4, 75)=5. 3,p=. 001, ? 2=0. 22, but not for diagnosis, F(4, 75)=0. 58, p=. 68, ? 2=0. 03, nor group by diagnosis interaction, F(4, 75)=0. 37, p=. 83, ? 2=0. 02. Table 1 Means, standard deviations and effect sizes at pre-, post- and 9-month follow-up assessments for cognitive-processing therapy (CPT) and prolonged exposure (PE) Planned comparisons were conducted by dividing the sample into four groups based upon their diagnostic status at pretreatment, those with pure PTSD who had received CPT (CPT: PTSD only), those who had comorbid MDD and received CPT (CPT: PTSD+MDD), and repeated this stratification for the PE condition (i. . , PE: PTSD only, PE: PTSD+MDD). Pretreatment guilt levels were controlled. For the pure PTSD group, CPT participants reported significantly lower hindsight bias scores, F(1, 49)=8. 68, p=. 005, ? 2=0. 15, and lack of justification scores, F(1, 48)=6. 46, p=. 014, ? 2=0. 12, than PE participants. The two groups were comparable in terms of global guilt and wrongdoing scores, F(1, 52)=0. 91, p=. 35, ? 2=0. 02, and F(1, 50)=2. 53, p=. 12, ? 2=0. 05, respectively. A similar pattern of results was evident for the comorbid group: hindsight bias, F(1, 39)=4. 22, p=. 047, ? 2=0. 0; lack of justification scores, F(1, 38)=9. 14, p=. 004, ? 2=0. 19; global guilt, F(1, 40)=2. 01, p=. 17, ? 2=0. 05; wrongdoing scores, F(1, 37)=1. 01, p=. 32, ? 2=0. 03. These results were therefore contrary to the hypothesis that the larger effects of CPT over PE in treating trauma-related guilt were driven by a subset of depressed participants. Controlling for pretreatment PSS and BDI scores did not alter these findings. A 2 (group: CPT, PE) ? 2 (diagnosis: PTSD only, PTSD+MDD) MANCOVA was conducted to examine follow-up guilt scores (with pretreatment guilt levels being controlled).

Main effects of group and diagnosis were nonsignificant, F(4, 52)=1. 61, p=. 19, ? 2=0. 11, and F(4, 52)=0. 84, p=. 51, ? 2=0. 06, as was the group by diagnosis interaction, F(4, 52)=0. 25, p=. 91, ? 2=0. 02. Planned comparisons did not reveal any significant findings. Accordingly, participants with pure PTSD in both groups had comparable levels of guilt: global guilt, F(1, 40)=2. 34, p=. 13, ? 2=0. 06; hindsight bias, F(1, 37)=1. 37, p=. 07, ? 2=0. 08; lack of justification scores, F(1, 35)=0. 34, p=. 57, ? 2=0. 01; wrongdoing scores, F(1, 38)=0. 38, p=. 4, ? 2=0. 01. Findings for the comorbid group were essentially the same: global guilt, F(1, 25)=0. 51, p=. 48, ? 2=0. 02; hindsight bias, F(1, 25)=1. 87, p=. 18, ? 2=0. 07; lack of justification scores, F(1, 26)=3. 92, p=. 058, ? 2=0. 13; wrongdoing scores, F(1, 25)=0. 10, p=. 75, ? 2=0. 00. 3. 1. Clinical significance We then examined the proportion of participants who made reliable and clinically significant changes in trauma-related guilt following treatment as outlined by Jacobson and Truax (1991), which had not been done in the original report.

Jacobson and Truax (1991) define a reliable change by a change of more than 1. 96 S. E. M. s between pretreatment and posttreatment (or follow-up). Individuals were considered to be in the clinical range at pretreatment if they had a mean guilt score of 1. 75 or more (and were therefore included in the analysis), and a mean score of 1. 0 or less was considered to reflect minimal levels of guilt at posttreatment (and follow-up) (E. S. Kubany, personal communication, June 28, 2004). Due to small cell sizes, Fisher’s Exact Test was used. Effect sizes are reported as phi coefficients (? , where . 10 is considered small, . 30 medium, and . 50 large (Cohen, 1988). As indicated in Table 2, greater proportions of CPT than PE participants made clinically significant changes on guilt measures, independent of comorbidity status. Examination of effect sizes suggested that more significant findings favouring CPT would have been observed with increased sample size. Table 2 Proportion of clients who made clinically significant changes at posttreatment and 9-month follow-up Go to: ------------------------------------------------- 4. Discussion

The major finding of the present study was that CPT was an effective means of treating aspects of trauma-related guilt and was generally consistent with the reporting of the original data (Resick et al. , 2002). Contrary to our hypothesis, however, the previously observed difference between CPT and PE on some guilt measures did not appear to be due to CPT having an increased effect on a subset of comorbidly depressed PTSD participants. Rather, CPT resulted in significant reductions of certain guilt cognitions irrespective of comorbidity status.

There was not a statistical difference between the treatments on guilt at follow-up. Although this appears to be contrary to the findings of the original report, this is likely to be due to the fact that (a) pretreatment guilt was controlled in the current analyses, and (b) immediate and delayed treatment recipients were collapsed in analyses to increase power. Examination of the effect sizes and proportion of individuals who made clinically significant change at follow-up still suggests some benefit of CPT over PE.

The question thus remains as to what factor(s) are responsible for the reduction of guilt given that comorbidity did not appear to play a role. Cognitive change has been observed following PTSD treatment even when formal cognitive restructuring has not been used (e. g. , Foa and Rauch, 2004), however this does not explain the differential pattern of findings in the present study. It is possible that certain types of guilt cognition are more likely to require formal cognitive intervention as suggested by Resick et al. (2002).

However when one considers the different types of guilt purported to be measured by the TRGI, one could just as easily make a case that global guilt would be a more pervasive, generalized cognitive style, necessitating cognitive therapy techniques for change to be accomplished. Further research is necessary to elucidate whether certain types of beliefs are more maladaptive than others in the context of PTSD and treatment outcome. Although the major hypothesis was not supported, we feel that the present study adds to the original report of this treatment trial.

In addition to testing a potential mechanism of change (guilt) in the parent study, the present report details the clinical significance of the guilt findings reported in Resick et al. (2002). Thus it was observed that a significant number of participants made clinically significant changes in regard to trauma-related guilt beliefs. These findings provide tentative support for the proposition that a cognitive component may be a useful adjunct for trauma-focused therapies when a client’s presentation is complicated by trauma-related guilt.

This is not surprising given the established efficacy of cognitive therapy for treating dysfunctional or distorted thinking in depression as described by Beck et al. (1979). The fact that cognitive factors have been demonstrated to play a role in both the etiology and maintenance of PTSD (Dunmore et al. , 1999) suggests that further study of the role of trauma-related guilt is warranted. The finding that shame mediates abusive experiences and later depression (Andrews, 1995), and that guilt but not PTSD predicted depression in rape victims (Bennice et al. , 2001) further highlights the importance of examining trauma-related guilt.

Given the increased interest in cognitive models of PTSD (e. g. , Ehlers and Clark, 2000), and the complicating factors of comorbid conditions in PTSD treatment, future studies would benefit from investigating potential mechanisms underlying complicated trauma presentations and developing adjunctive treatments. We recognize several limitations to the present study. First, the findings cannot necessarily be generalized to males. Second, there was some attrition of data at follow-up. Third, only one measure of trauma-related guilt was used. We are currently collecting 5-year follow-up data on the present sample.

By continuing to assess cognitions, we will be able to test the possibility that cognitive factors might also be related to relapse, and plan to examine the role that guilt might play in long-term outcome following interpersonal trauma. Go to: ------------------------------------------------- Acknowledgments This work was supported by Grant NIH-1 R01-MH51509 from the National Institute of Mental Health, awarded to Patricia A. Resick. Go to: ------------------------------------------------- References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.

Washington, DC: Author; 1994. 2. Andrews B. Bodily shame as a mediator between abusive experiences and depression. J. Abnorm. Psychology. 1995;104:277–285. 3. Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring depression. Arch. Gen. Psychiatry. 1961;4:561–571. [PubMed] 4. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy for Depression. New York, NY: Guilford Press; 1979. 5. Bennice JA, Grubaugh AL, Resick PA. Guilt, depression and PTSD among female rape victims. Poster presented at the 17th Annual Meeting of the International Society for Traumatic Stress Studies; New Orleans, USA. 001. 6. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Klauminzer G, Charney DS, et al. A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. Behav. Ther. 1990;18:187–188. 7. Blanchard EB, Buckley TC, Hickling EJ, Taylor AE. Posttraumatic stress disorder and comorbid major depression: is the correlation an illusion? J. Anxiety Disord. 1998;12:21–37. [PubMed] 8. Boudreaux E, Kilpatrick DG, Resnick HS, Best CL, Saunders BE. Criminal victimization, posttraumatic stress disorder and comorbid psychopathology among a community sample of women. J. Trauma. Stress. 998;11:665–678. [PubMed] 9. Casardi M, O’Leary KD. Depression symptomatology, self-esteem, and self-blame in battered women. J. Fam. Violence. 1992;7:249–259. 10. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. 11. Dunmore E, Clark DM, Ehlers A. Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault. Behav. Res. Ther. 1999;37:809–829. [PubMed] 12. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav. Res. Ther. 000;38:319–345. [PubMed] 13. First M, Gibbon M, Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-IV (SCID)New York, NY: Biometric Research Department, New York State Psychiatric Institute; 1996. 14. Foa EB, Rauch SAM. Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. J. Consult. Clin. Psychol. 2004;72:879–884. [PubMed] 15. Foa EB, Riggs DS, Dancu CV, Rothbaum BO. Reliability and validity of a brief instrument for measuring posttraumatic stress disorder.

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Psychopathol. Behav. Assess. 1995;17:353–376. 19. Kubany ES, Haynes SN, Abueg FR, Manke FP, Brennan JM, Stahura C. Development and validation of the trauma-related guilt inventory (TRGI) Psychol. Assess. 1996;8:428–444. 20. Kubany ES, Hill EE, Owens JA, Iannce-Spencer C, McCaig MA, Tremayne KJ. Cognitive trauma therapy for battered women with PTSD (CTT-BW) J. Consult. Clin. Psychol. 2004;72:3–18. [PubMed] 21. North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282:755–762. [PubMed] 22.

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J. Consult. Clin. Psychol. 2002;70:867–879. [PMC free article] [PubMed] Long-Term Outcomes of Cognitive–Behavioral Treatments for Posttraumatic Stress Disorder Among Female Rape Survivors Patricia A. Resick, Lauren F. Williams, Michael K. Suvak, Candice M. Monson, and Jaimie L. Gradus Author information > Copyright and License information > The publisher's final edited version of this article is available at J Consult Clin Psychol See other articles in PMC that cite the published article. Go to: ------------------------------------------------- Abstract

Objective We conducted a long-term follow-up (LTFU) assessment of participants from a randomized controlled trial comparing cognitive processing therapy (CPT) with prolonged exposure (PE) for posttraumatic stress disorder (PTSD). Competing hypotheses for positive outcomes (i. e. , additional therapy, medication) were examined. Method Intention-to-treat (ITT) participants were assessed 5–10 years after participating in the study (M = 6. 15,SD = 1. 22). We attempted to locate the 171 original participants, women with PTSD who had experienced at least one rape.

Of 144 participants located, 87. 5% were reassessed (N = 126), which constituted 73. 7% of the original ITT sample. Self-reported PTSD symptoms were the primary outcome. Clinician-rated PTSD symptoms, comorbid diagnoses, and self-reported depression were secondary outcomes. Results Substantial decreases in symptoms due to treatment (as reported in Resick, Nishith, Weaver, Astin, & Feuer, 2002) were maintained throughout the LTFU period, as evidenced by little change over time from posttreatment through follow-up (effect sizes ranging from pr = . 03 to . 14).

No significant differences emerged during the LTFU between the treatment conditions (Cohen’s d = 0. 06–0. 29). The ITT examination of diagnostics indicated that 22. 2% of CPT and 17. 5% of PE participants met the diagnosis for PTSD according to the Clinician-Administered PTSD Scale (Blake et al. , 1995) at the LTFU. Maintenance of improvements could not be attributed to further therapy or medications. Conclusions CPT and PE resulted in lasting changes in PTSD and related symptoms over an extended period of time for female rape victims with extensive histories of trauma.

Keywords: cognitive processing therapy, prolonged exposure, posttraumatic stress disorder, long-term outcomes, randomized controlled trial Several treatment guidelines for posttraumatic stress disorder (PTSD) have concluded that cognitive-behavioral treatments (CBTs) are efficacious and are recommended as first-line treatments (Cahill, Rothbaum, Resick, & Follette, 2009; Institute of Medicine, 2007; VA/DoD Guideline Working Group, 2010). The specific CBT protocols of cognitive processing therapy (CPT; Chard, 2005; Monson et al. 2006; Resick et al. , 2008; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Resick & Schnicke, 1992) and prolonged exposure (PE; Foa et al. , 1999, 2005; Foa, Rothbaum, Riggs, & Murdock, 1991; Schnurr et al. , 2007) have both been demonstrated to be efficacious in ameliorating PTSD and comorbid depression, anxiety, guilt, and anger. Both protocols are currently being disseminated throughout U. S. Veterans Affairs (VA) facilities and various branches of the military (Karlin et al. , 2010). One important remaining question is whether

PTSD symptom reductions resulting from CBT are long lasting. Follow-up assessments in CBT trials have typically been short (3–6 months). Although some studies have followed participants 1 or more years (Echeburua, de Corral, Sarasua, & Zubizarreta, 1996;Echeburua, de Corral, Zubizarreta, & Sarasua, 1997; Foa et al. , 1999, 2005; Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004), most of these studies had small samples or followed only those who completed treatment and not the intention-to-treat (ITT) sample. There are two notable exceptions. Hien et al. 2009) conducted a multisite trial comparing seeking safety with an educational control condition for substance dependence and comorbid PTSD symptoms (either full or partial PTSD diagnosis). The ITT sample was followed for 1 year (N = 215 at 1-year follow-up). Unfortunately, treatment dropout was high, with only 12% of the sample completing the 12-session protocol, and there were no significant improvements in substance dependence. However, there were overall improvements in PTSD symptoms, which were maintained over the follow-up period; the two conditions did not differ significantly.

Schnurr et al. (2003) followed participants in a large VA multisite trial for up to 24 months after completion of a 30-week trauma-focused group treatment. Although ITT analyses revealed that CBT demonstrated only modest efficacy and did not improve symptoms more than in the control condition, there was no apparent decrement in improvements over the follow-up period. Tarrier and Sommerfield (2004)conducted one of only two studies that followed participants for 5 years after treatment. Their randomized controlled trial found both cognitive therapy and imaginal exposure to be highly efficacious.

Although the follow-up sample was small (n = 32 of 54 in the ITT sample) and excluded treatment dropouts (but included those who did not start), they found that both treatments produced good and lasting outcomes. Cognitive therapy was significantly more efficacious at follow-up than was imaginal exposure, with none of the cognitive therapy participants meeting criteria for PTSD 5 years later. Four of 17 imaginal exposure participants met PTSD criteria, a percentage similar to that for those who had retained their diagnosis at posttreatment and 6-month follow-up (Tarrier et al. 1999). The only other PTSD treatment study that examined participants 5 or more years after treatment was a study of eye movement desensitization and reprocessing therapy by Macklin et al. (2000). Thirteen of 17 veterans who had been treated, and 14 who had not been treated, were assessed 5 years following treatment. They found that the modest gains observed at posttreatment had not only disappeared at follow-up, but participants had significantly worsened from their pretreatment scores.

As this review reveals, there is a dearth of literature on long-term outcomes of PTSD treatment with large samples, particularly for treatments such as CPT and PE, and there are methodological limitations of these studies. The purpose of this study is to report the findings from a long-term follow-up (LTFU) assessment of a randomized controlled trial comparing CPT with PE as the control condition because it was the most established treatment at the time, as well as a waiting list control (Resick et al. , 2002).

In the original trial, participants improved markedly with both CPT and PE compared with the waiting list condition; CPT and PE did not statistically differ on PTSD or depression outcomes but did differ on guilt cognitions and physical symptoms (Galovski, Monson, Bruce, & Resick, 2009; Resick et al. , 2002), with CPT resulting in fewer guilt cognitions and physical symptoms compared with PE. There were small to medium effect sizes favoring CPT over PE on every measure in the ITT sample through the 9-month follow-up.

For the current study, follow-up assessments were conducted 5–10 years after treatment with the goal of examining long-term outcomes among all participants who were randomized in the original trial, except those who were removed from the study due to meeting the exclusion criteria during treatment. Although the original study did not include assessment of participants if they dropped out of treatment, the current study includes all of the originally randomized participants, irrespective of treatment completion.

Self-reported PTSD symptoms were the primary outcome; self-reported depression severity and several common comorbid diagnoses were also examined as outcomes. In addition to examining self-report measures, we examined diagnoses of PTSD, major depressive disorder, panic disorder, and substance dependence/abuse according to clinician interview. Further, we examined whether receiving medication or psychotherapy after participation in the trial accounted for any positive findings during the LTFU. Finally, we examined clinically significant improvement in PTSD symptoms. Go to: ------------------------------------------------ Method The Institutional Review Board (IRB) of the University of Missouri–St. Louis approved the protocol, and participants gave written informed consent prior to enrollment that included follow-up contact information. In the original trial, the 9-month follow-up was not originally proposed. When the IRB approved recontacting participants for the 9-month follow-up (Resick et al. , 2002), we requested approval from the participants for possible other follow-ups, and participants supplied us again with updated follow-up contact information.

The IRB later approved the LTFU data collection specifically. During the data collection, the first author moved to the Department of Veterans Affairs, and under its requirements, the IRB of the VA Boston Healthcare System provided oversight of data analyses. Participants The parent study (Resick et al. , 2002) included 171 adult women randomized into the study who had experienced at least one rape a minimum of 3 months prior to seeking treatment (no upper limit). Most participants (86%) had experienced other traumatic victimizations in addition to the index rape.

Forty-one percent of the sample had been sexually abused (genital contact) as children. The participants reported an average of 6. 4 adult crime incidents (SD = 4. 9) in addition to the index rape. Participants on medications were stabilized per psychiatric consult based on type of medication. Participants had to agree to refrain from other trauma-focused psychotherapy but were permitted to continue with stabilized medications or ongoing supportive therapy. Exclusion criteria included current psychosis, suicidal intent, active self-harm behavior, current dependence on drugs or alcohol, and illiteracy.

Neither personality disorders nor dissociation or dissociative disorders or any other Axis I disorder was excluded. Participants reporting current stalking or involvement in an abusive relationship were excluded. In the case of marital rape, participants must have been out of the relationship for at least 6 months. Typical for studies of the time (Foa et al. , 2005), anyone who met the exclusion criteria during treatment (e. g. , change of medication) was allowed to complete treatment, but no further data were collected (n = 10; see Figure 1). Figure 1 CONSORT flow chart for the entire study, including the long-term follow-up.

Figure 1, the CONSORT chart, shows the flow of participants through the parent study and LTFU (see Table 1 for demographic information at the pretreatment and LTFU assessment occasions). A paired-sample t test indicated that the number of years of education reported at the LTFU was significantly more than the number of years reported at the pretreatment assessment, t(118) = 5. 31, p < . 001. A related-samples Friedman’s two-way analysis of variance (ANOVA) indicated that on average participants endorsed a higher income category at the LTFU (mean rank = 1. 73) compared with the pretreatment assessment (mean rank = 1. 7), ? 2(1, N = 73) = 24. 01, p < . 001. A repeated-measures logistic regression indicated that a higher proportion of participants indicated being in a committed relationship at the LTFU (39%) compared with the pretreatment assessment (24%), Wald ? 2(1, N = 170) = 7. 40, p < . 01. Table 1 Demographic Characteristics for Participants in the Two Treatment Conditions At the LTFU, participants reported a number of negative or traumatic events. Overall, 9% reported experiencing sexual assault, 17% domestic violence, 6% the death of someone in their household, 60% the death of a significant other, 12. % the homicide of a significant other, 39% other crimes, 18% a serious accident, and 35% a serious illness. None of these percentages significantly varied as a function of treatment condition (all ? 2s < 3. 36, all ps > . 19). Measures The PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, & Rothbaum, 1993) is a 17-item scale that assesses all of the criteria for PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. ; DSM–IV; American Psychiatric Association, 1994). For these analyses we used the total frequency score.

The PSS was completed at all major assessment periods and once a week during treatment, yielding 11 data points. The Cronbach’s alpha coefficient at the LTFU was . 93. The other self-report and diagnostic interview measures were given on five occasions: pretreatment, posttreatment, and at 3-month, 9-month, and LTFU. The Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) is a 21-item self-report questionnaire widely used in research on depression (Beck, Steer, & Garbin, 1988). Cronbach’s alpha at LTFU was . 95. The Clinician-Administered PTSD Scale (CAPS; Blake et al. 1995) is a semistructured interview used to assess PTSD severity and determine diagnostic status. For each symptom, an independent clinician rated two separate dimensions—frequency and intensity of symptoms—on a scale ranging from 0–4. For a symptom to be considered clinically significant, it had to meet threshold criteria on both dimensions (i. e. , at least a 1 on frequency and a 2 on intensity). The Structured Clinical Interview for DSM–IV (SCID; First, Spitzer, Gibbon, & Williams, 1996) is a diagnostic interview based on criteria from the DSM–IV.

Three modules were used to assess mood disorders (MDD), panic disorder (PD), and substance use disorders. Each CAPS and SCID-CV interview was audio-recorded. Current diagnosis was based on the current time frame for the respective module, while diagnosis since treatment completion used the “lifetime” modules of the interview measures with the instruction “Since you completed treatment with us on …. ” Assessments were conducted by a team of assessors working on two studies simultaneously: a dismantling study of CPT (Resick et al. , 2008) and this LTFU project.

The procedure for training and preventing interviewer drift is described in more detail in Resick et al. (2008). Independent assessors were unaware of treatment assignment regardless of study. To determine reliability, interviews were drawn randomly from both studies at any of the intake or follow-up sessions. Unfortunately, of the 550 possible interviews in the two studies, only five were drawn from the LTFU for reliability assessment. Overall, there was 100% agreement on CAPS and PTSD diagnosis, 90% agreement on MDD, and 92% agreement on PD.

Cronbach’s alpha for the CAPS severity score at LTFU was . 94. Therapies CPT is predominantly a cognitive therapy; PE is predominantly an exposure therapy. Manuals for the therapies were Resick and Schnicke (1993) and Foa, Hearst, Dancu, Hembree, and Jaycox (1994), respectively. Both active treatments consisted of 13 hr of therapy administered twice per week but were configured slightly differently to maintain protocol integrity as to how the treatments were practiced at the time. PE started with two 1-hr sessions and then changed to seven 90-min sessions to accommodate imaginal xposures. PE also required approximately 90 min of homework per day: 45 min of listening to the recorded exposure sessions and 45 min of in-vivo exposure. CPT was administered with 10 1-hr sessions and two 90-min sessions (to equate with session time for PE). CPT requires less homework time than does PE. Procedures Potential participants were recruited widely throughout the region and treated at a trauma center located on a university campus. Following initial assessment and invitation into the trial, participants were randomized by the data manager to CPT, PE, or waiting list.

The waiting list participants were also randomized into CPT or PE in case they did not improve by the end of the waiting period and wanted treatment. Because improvements were similar to those for the delayed treatment participants (Resick et al. , 2002), they were combined with the original CPT or PE groups for follow-up analyses. For the LTFU, all participants who were randomized into the trial (and not removed from the trial at any point) were invited to participate, regardless of whether and how much therapy they received (n = 171). A number of steps were taken to locate participants for the LTFU assessments.

We began with contact information collected during earlier assessments. Next, we attempted to locate people through various websites available to the general public or specifically geared toward journalists. When those options were exhausted, we enlisted the location assistance of a survey research firm. Once located with identity confirmed, former participants were invited to participate. If they still lived locally, they were invited to return to the university to complete the assessments. If they had moved out of the area, they were interviewed by telephone by clinicians and were mailed the packet of self-report measures to complete.

Prior research with both the CAPS and the SCID-CV has established that in-person and telephone assessments are comparable (Aziz & Kenford, 2004; Crippa et al. , 2008; Rohde, Lewinsohn, & Seeley, 1997). Assessors were again unaware of assigned treatment condition and treatment status of participants at the LTFU. There were no adverse events associated with the follow-up assessments. Of course, over such a long time period the participants had experienced many adverse events, but none were attributed to the therapy they had received years before or to the LTFU assessment itself.

Participants were paid $75 for their participation. Data Analyses Linear mixed-effects modeling was used to examine change over time in the outcomes using HLM 6: Hierarchical Linear and Nonlinear Modeling (Raudenbush, Bryk, & Congdon, 2005). This approach is uniquely suited to the current data and offers several advantages over more traditional approaches (e. g. , repeated-measures ANOVA). In this study there was considerable variability in the timing of assessments, which was readily handled using the mixed-effects approach, with time analyzed as number of months1 since baseline assessment.

Because mixed-effects models are also robust to unbalanced designs (i. e. , variability in total number of assessments), we were able to examine our ITT sample without using any missing data algorithms. Piecewise modeling of the outcomes over time was undertaken to estimate different slopes from pre- to posttreatment (Epoch 1) and posttreatment to LTFU (Epoch 2) using procedures described by Singer and Willett (2003). Because PSS data were collected multiple times during treatment and at the major assessment points, we were able to model both slope and level changes across the epochs.

To accomplish this, the following three time variables were included: (a) number of months since baseline (i. e. , time), (b) a dummy-coded variable indicating whether each assessment was during (coded as 1) or after (coded as 0) treatment (i. e. , epoch), and (c) the product of these two variables, which represents the change in slope across the two epochs. With Epoch 2 (i. e. , the follow-up period) coded as 0, the regression coefficients for the time variable provided an estimate of change over time during the follow-up period, which was the only estimate of interest for the current study. Although the approach just described better captures the processes occurring during and after treatment, having only two assessment points for the first epoch for the outcomes collected on five occasions (i. e. , BDI and CAPS) precluded a test of level change across the epochs. Therefore, these piecewise models were conducted in a different manner. First, the time variable was rescored so that it was zero for every participant at the posttreatment assessment. Thus, the time variable for the follow-up time periods was number of months since the posttreatment assessment, while this time variable for the baseline assessment was set at ? multiplied by the number of months between the baseline and posttreatment assessment. For example, if the original time variable for a participant consisted of 0, 2. 4, 5. 5, 11. 7, and 73. 7 months for the baseline, posttreatment, 3-month follow-up, 9-month follow-up, and LTFU assessments, respectively, then the recoded time variable for this participant would be coded as ? 2. 4, 0, 3. 1, 9. 3, and 71. 3 months. A second time variable that represented the number of months prior to the baseline assessment (e. g. , coded as ? 2. 4, 0, 0, 0, and 0 for the previous example) was created.

When these two time variables were entered into the Level 1 equation predicting the outcome variable, the regression coefficient for first time variable provided an estimate of change during Epoch 2, while the regression coefficient for the second time variable represented the difference in the rate of change over time between the two epochs (Singer & Willett, 2003). Because the current article is exclusively concerned with Epoch 2, we report the estimates for the first time variable (i. e. , change over time during the follow-up period). We examined several alternative ways to model change over time.

As indicated by the deviance statistic (a log-likelihood-based goodness-of-fit statistic) and the amount of within-subject variance accounted for, a linear–linear change model (linear change in both epochs as modeled by the number of months since baseline assessment) fit the data best for the PSS data collected across 11 assessment occasions and the CAPS and BDI collected across five assessment occasions. All of the time coefficients described earlier were modeled as random effects that specify variation in the time coefficients across participants.

To examine treatment effects, a dummy-coded treatment condition variable was included as a Level 2 predictor for each of the time coefficients described earlier (Cohen, Cohen, West, & Aiken, 2003). This enabled us to examine whether change over time during either epoch significantly varied as a function of treatment condition. 3 For estimates of within-subject effect sizes, we report the partial correlation coefficients (pr) for each coefficient. Kirk (1996) suggested . 10, . 24, and . 37 for small, medium, and large effect sizes, respectively.

For estimates of between-groups effect sizes, we report Cohen’s d and use descriptors of effect size offered by Cohen (1988): d = 0. 25 for small, . 50 for medium, and . 80 for large. Power to detect group differences in change over time during Epoch 2 was determined by using the Monte Carlo method (Muthen & Muthen, 2002) with the Mplus statistical software (Muthen & Muthen, 1998–2009). A Monte Carlo simulation study can be used to determine sample size for a specific, hypothesized model (Muthen & Muthen, 2002).

This method involves specifying parameter estimates for a given model and generating 10,000 data sets to determine the percentage of time the parameter estimates were statistically significant (at the p < . 05 level). Therefore, we could determine power for the exact model that we were evaluating with the exact number of observations available (i. e. , 588 observations with participants having either 1, 2, 3, 4, or 5 data points available; M = 3. 44), using actual parameter estimates from the data analyses as starting values. This provided us with a precise estimate of power for the pertinent parameters (i. e. , the Group ?

Time During Epoch 2 interaction). For the piecewise regression analysis with CAPS as the outcome variable (assessed at five time points), the power analysis indicated that we had a power of . 88 to detect a medium effect size difference (pr = . 24) between the two groups in change over time during Epoch 2 and a power of . 60 to detect a small–medium difference (pr = . 17). The power analysis for the PSS analysis (which included 11 assessment points) indicated that we had a power of . 96 to detect a medium effect size difference (pr = . 24) between the two groups in change over time during Epoch 2 and a power of . 2 to detect a small–medium difference (pr = . 17). Thus, the current study was adequately powered to detect meaningful differences between the two groups in change over time during the follow-up period. To rule out the possibility that the results were accounted for by further psychotherapy after completing the program or medication use at the LTFU assessment, secondary analyses were conducted to evaluate whether these variables predicted outcomes at the LTFU. These analyses were conducted on a restricted sample of participants who provided these data (n = 124).

However, these participants were not significantly different on demographic or clinical characteristics from participants who did not provide this information. Go to: ------------------------------------------------- Results Results of Tracking We attempted to find and assess 171 women from the ITT sample. Of those, contact was never established with 24, and three had died. Of the remaining 144 with whom we established contact and verified previous participation, 16 (11%) declined to participate in the LTFU, and two were judged to be inappropriate due to incoherence.

The final sample for the LTFU included 126 women who were assessed 4. 5–10 years4 posttreatment; 87. 5% (126/144) of these located participants (73. 7% of the original sample) completed at least the diagnostic interviews, while 119 completed the entire assessment battery (see Figure 1). However, the use of mixed-effects regression allowed us to include the entire ITT sample in the analyses. The mean number of years from baseline to LTFU was 6. 15 (SD = 1. 22). Symptoms Severity Outcomes PSS (11 assessments) Table 2 presents the coefficients depicting change over time during the follow-up period (i. . , Epoch 2). During Epoch 2, the CPT group did not exhibit significant change in PTSD symptoms, while the PE group exhibited a slight decrease in symptoms that approached significance (p = . 06). The difference in the rate of change during the follow-up period between the groups also approached statistical significance (p = . 06). Table 2 Results From Epoch 2 (LTFU) of the Piecewise Mixed Effects Regression Analyses Examining Long-Term Effects of CPT and PE CAPS and BDI (five assessments) Participants did not exhibit significant change in the CAPS during the follow-up period (b = ? 0. 001, t = ? . 03, ns, pr = . 001). There was also no significant difference between the groups in the rate of change in the CAPS during the follow-up period. Similarly, participants did not exhibit significant change on the BDI during the follow up period (b = . 02, t = 1. 07, ns, pr = . 08), and there was no difference between the groups in change over time during the follow-up period (see Table 2). Potential Moderators Of the 126 participants who provided LTFU data, the mean percentage of treatment sessions completed was 77% (SD = 38%), with no difference between the two treatment conditions (CPT = 78% vs.

PE = 78%). At the LTFU, 73 (60%) of 121 participants indicated that they had received additional treatment since completing the trial, which did not significantly vary as a function of treatment condition (CPT = 59% vs. PE = 62%), ? 2(1, N = 121) = 0. 01, ns. However, only 15 (12%) of the LTFU sample indicated that the additional therapy they received was for trauma or PTSD, with no difference between treatment condition (CPT = 12% vs. PE = 13%), ? 2(1, N = 121) = 0. 10, ns. The number of treatment sessions ranged from 0 to 380, with a mean of 34. 45 (SD = 68. 03) and a median of 6.

The distribution was right-skewed, with a modal number of sessions of 0 (n = 46) and a small number of participants (n = 13) reporting 100 or more additional treatment sessions. The number of treatment sessions attended did not significantly vary as a function of group (M = 28. 79, SD = 55. 90, and 40. 20, SD = 40. 20, for the CPT and PE conditions, respectively). 5 Forty-seven (39%) participants indicated that they had started to take medication since completing the treatment protocol, with no difference between treatment condition (CPT = 41% vs. PE = 37%), ? 2(1, N = 121) = 0. 7, ns, and 41 (34%) indicated that they were currently taking medication, again with no difference between treatment condition (CPT = 34% vs. PE = 33%), ? 2(1, N = 121) = 0. 02. Follow-up regression analyses revealed that the dichotomous variables indicating additional treatment and additional trauma/PTSD treatment did not predict LTFU outcomes on any variables. Number of sessions of therapy received during the LTFU was positively associated with each of the outcome variables. In other words, additional treatment following the trial was associated with worse outcomes at the LTFU assessment.

Therefore, additional treatment could not account for the sustained treatment effects reported earlier. Starting medication during the LTFU was associated with higher CAPS and BDI at the LTFU. Participants who reported being prescribed medication at the LTFU assessment scored significantly higher on both of the outcomes. Again, the important aspect of these findings is that medication was associated with more symptoms at the LTFU and, therefore, could not account for the sustained treatment gains reported earlier. Diagnosis, Relapse, Clinically Significant Improvement

As shown in Table 3, at pretreatment, 100% of participants met full criteria for PTSD on the CAPS in order to be enrolled in the trial, and many had comorbid diagnoses. The percentages and totals of ITT participants who met criteria for these disorders at the LTFU assessment are also presented in Table 3. Repeated-measures logistic regression was conducted to compare the proportions of PTSD, MDD, and PD diagnoses at the pretreatment assessments with the proportions of these diagnoses at the LTFU assessment. The small number of endorsements of alcohol dependence precluded us from completing this analysis for that outcome.

The percentage of participants meeting diagnostic criteria for PTSD (OR = 0. 003, p < . 001) and MDD (OR = 0. 15, p < . 001) decreased over time, while the decrease in PD diagnosis was not significant (OR = 0. 57, p = . 12). No significant Time ? Treatment Condition interactions emerged. Table 3 Means (and Standard Deviations) and Diagnostic Status of Participants Over Time Across the Two Treatment Conditions Of the 98 treatment completers who were assessed at LTFU, there were no differences between CPT and PE in PTSD diagnostic status. For CPT, 18. 4% met criteria for PTSD (9/49); for PE, 14. % met criteria (7/49). Calculating relapse presupposes that someone had recovered in order to relapse. To determine how many participants relapsed at LTFU, we examined participants for whom we had both posttreatment and long-term data. This necessitated only examining successful treatment completers at posttreatment who returned for the follow-up assessment (n = 74). For the CPT group, there were 39 women who had both posttreatment and LTFU assessments who did not have PTSD at posttreatment. At LTFU, of the 39 who had recovered initially, eight were diagnosed with PTSD at the LTFU (20. 5%).

For the PE condition, there were 36 women at posttreatment who did not meet criteria for PTSD. At LTFU, only two had relapsed (5. 6%). There was a marginally significant finding for PE to have less relapse than CPT at LTFU, ? 2(1, N = 75) = 3. 8, p = . 057. The relationship between diagnosis and medication use in the ITT sample was examined at the LTFU assessment. Medication use was marginally significantly associated with LTFU PTSD diagnosis, ? 2(1, N = 121) = 3. 5, p = . 06. Of the participants at LTFU who exhibited PTSD, a higher proportion were on medication (12/41 = 29%) than not on medication (12/80 = 15%).

There was no significant relationship between medication use and current MDD diagnosis, and few women had current depression. There was, however, a significant relationship between current medication use and MDD diagnosis during the LTFU, ? 2(1, N = 78) = 6. 5, p = . 01. Of the 78 women for whom we had both lifetime MDD diagnosis and medication data in this sample, a higher proportion of women on medication at the LTFU assessment endorsed an MDD diagnoses (22/30 = 73%) sometime during the follow-up period compared with those who were not on medication (21/48 = 44%).

Medication use was associated with higher rates of PTSD and MDD. Therefore, medication could not account for the positive outcome at the LTFU assessment. Because diagnosis could change as a result of change in as little as one symptom, many PTSD studies also examine clinically significant change. Using the criteria of a decrease of 10 points on the CAPS as indicative of improvements in quality of life, as established by Lunney and Schnurr (2007), we examined how many ITT participants achieved at least a 10-point change on the CAPS from pretreatment to the LTFU and found that 93. % of the CPT and 91. 9% of the PE participants achieved this level of improvement. Using the Jacobson and Truax (1991) approach, a reliable clinical change on the CAPS is 20 points (Monson et al. , 2008). Given that standard, 88. 5% of CPT and 88. 7% of PE participants improved by at least 20 points on the CAPS. On average, the CPT group improved by 48. 8 points (SD = 26. 4), and the PE group improved by 48. 9 points (SD = 26. 14). If one considers just those who completed treatment, 89. 8% of CPT and 85. 7% of PE participants improved at least 20 points.

None of the percentages varied statistically across the two conditions. Only one person in each condition reported clinically significant worsening at the LTFU for ITT, and only one in PE for treatment completers. Go to: ------------------------------------------------- Discussion This study represents a methodologically rigorous attempt to assess the long-term impact of CBT on PTSD. In the original trial, participants receiving either CPT or PE showed marked improvements in PTSD and depression, from pretreatment to posttreatment. There were few differences between the two treatments in the outcomes.

During the follow-up period, PE participants exhibited small decreases in self-reported PTSD symptoms that approached but did not reach statistical significance. Participants in the PE condition also tended (i. e. , had an effect that approached but did not reach statistical significance) to have fewer people relapse based on PTSD diagnosis. The ITT examination of diagnostics