Evidence-based answers from the Family Physicians Inquiries Network
What is the most effective way to relieve symptoms of acute stress disorder?
James M. Scott III, MD; Neil Nipper, MD Eglin Air Force Base Family Medicine Residency, Eglin AFB, Fla Rita Smith, MS, MEd Lackland Air Force Base Medical Library, Lackland AFB, Tex
cognitive behavioral therapy (CBT) that emphasizes exposure-based treatment is the most effective intervention for adults with acute stress disorder (ASD) (strength of recommendation [SOR]: B, meta-analysis of limited-quality randomized controlled trials [RCTs]). Exposure-based therapy reduces
symptoms in adults with ASD more than ...view middle of the document...
3 Exposure-based therapy reduces subsequent PTSD symptoms in adults with ASD
more than cognitive restructuring.2 Exposurebased CBT attempts to decrease unrealistic anxiety by challenging anxiety-provoking thoughts, situations, activities, and people that are not fundamentally dangerous.4 Both exposure-based therapy and cognitive restructuring are better than no treatment at all.3 A small 2008 RCT evaluated the effect of weekly 90-minute CBT sessions with daily homework activities that were started within 1 month after a motor vehicle accident or nonsexual assault for patients with ASD.2 Only 33% of patients who received exposurebased therapy had PTSD symptoms 6 weeks after starting treatment, whereas 63% of the cognitive restructuring group and 77% of untreated patients had PTSD at the 6-week follow-up.2
Medication shows no clear benefit over CBT A 2007 meta-analysis of mixed-method trials concluded that medication should not be substituted for CBT, which is more effective.5 The evidence showed no clear benefit for pharmacologic treatment; medication was as effective as placebo, but with higher drop-out rates.5
C ON TIN U ED
Exposure-based therapy reduces subsequent symptoms of post-traumatic stress disorder in adults with acute stress disorder more than cognitive restructuring.
VOL 59, NO 8 | AUGUST 2010 | THE JOURNAL OF FAMILY PRACTICE
The Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD)
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:*
1. Have had nightmares about it or thought about it when you did not want to? YES NO 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO 3. Were constantly on guard, watchful, or easily startled? YES NO 4. Felt numb or detached from others, activities, or your surroundings? YES NO
*Score 1 point for each “yes” answer. A score of 3 or higher has a sensitivity of 78% and specificity of 87% for PTSD. Source: Prins A et al. Prim Care Psychiatry. 2003.8
Medication should not be substituted for cognitive behavioral therapy, which is more effective.
The US Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of PTSD and the 2007 Australian Guidelines for the Treatment of Adults with ASD and PTSD recommend 3 early interventions for patients exposed to traumatic events:5,6 • early assessment • watchful waiting if ASD is not present • psychological first aid (includes things like reducing physiologic arousal, ensuring patient’s safety and security, and encouraging active use of social support and self-care strategies). The US and Australian guidelines also recommend educating patients about typical responses to traumatic events...