Andrea Phelps

Australian guidelines for the treatment of adults with acute stress disorder and post-traumatic stress disorder

Over the past 2–3 years, clinical practice guidelines (CPGs) for post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) have been developed in the USA and UK. There remained a need, however, for the development of Australian CPGs for the treatment of ASD and PTSD tailored to the national health-care context. Therefore, the Australian Centre for Posttraumatic Mental Health in collaboration with national trauma experts, has recently developed Australian CPGs for adults with ASD and PTSD, which have been endorsed by the National Health and Medical Research Council (NHMRC). In consultation with a multidisciplinary reference panel (MDP), research questions were determined and a systematic review of the evidence was then conducted to answer these questions (consistent with NHMRC procedures). On the basis of the evidence reviewed and in consultation with the MDP, a series of practice recommendations were developed. The practice recommendations that have been developed address a broad range of clinical questions. Key recommendations indicate the use of trauma-focused psychological therapy (cognitive behavioural therapy or eye movement desensitization and reprocessing in addition to in vivo exposure) as the most effective treatment for ASD and PTSD. Where medication is required for the treatment of PTSD in adults, selective serotonin re-uptake inhibitor antidepressants should be the first choice. Medication should not be used in preference to trauma-focused psychological therapy. In the immediate aftermath of trauma, practitioners should adopt a position of watchful waiting and provide psychological first aid. Structured interventions such as psychological debriefing, with a focus on recounting the traumatic event and ventilation of feelings, should not be offered on a routine basis.

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life

Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs.

Imagery rehearsal in the treatment of posttraumatic nightmares in Australian veterans with chronic combat-related PTSD: 12-month follow-up data.

Nightmares are often a distressing symptom for veterans with chronic combat-related posttraumatic stress disorder (PTSD). A psychological treatment that has recently shown considerable promise is Imagery Rehearsal Therapy (IRT). In a pilot study by the current authors, IRT was demonstrated to be effective in the treatment of posttraumatic nightmares in a group of combat veterans up to 3-month posttreatment. This study reports the 12-month follow-up data of the pilot study, examining the longer term outcome of the IRT treatment. Twelve Australian Vietnam veterans with chronic combat-related PTSD were treated with 6 once weekly sessions of imagery rehearsal and assessed using standardised measures of nightmare frequency and intensity, PTSD, depression, anxiety and broader symptomatology at intake, posttreatment, and 3-and 12-month follow-up. Significant improvements in targeted nightmare frequency and intensity were evident to 12-month posttreatment. Similarly, improvements in overall PTSD, depression, anxiety, and broader based symptomatology were also maintained to 12 months. This study provides preliminary evidence that the positive treatment effects of IRT on posttraumatic nightmares, PTSD, and broader symptomatology in males with chronic combat-related PTSD are maintained in the longer term.

Treatment of combat-related nightmares using imagery rehearsal: a pilot study.

Posttraumatic nightmares are a hallmark of PTSD and distinct from general nightmares as they are often repetitive and faithful representations of the traumatic event. This paper presents data from a pilot study that examined the use of Imagery Rehearsal in treating combat-related nightmares of 12 Vietnam veterans with PTSD. Three treatment groups, comprising 4 veterans in each, completed standardised treatment across 6 sessions. Treatment effects were investigated using nightmare diaries and established instruments, including the IES-R, BDI, BAI, and SCL-90-R. The data demonstrate significant reductions in nightmares targeted, and improvements in PTSD and comorbid symptomatology. The paper recommends that, on the basis of the promising preliminary data, a randomised control trial be established to assess imagery ability and attidude toward nightmares.

Trauma at the hands of another: longitudinal study of differences in the posttraumatic stress disorder symptom profile following interpersonal compared with noninterpersonal trauma

OBJECTIVE Survivors of traumatic events of an interpersonal nature typically have higher rates of posttraumatic stress disorder (PTSD) than survivors of noninterpersonal traumatic events. Little is known about potential differences in the nature or trajectory of PTSD symptoms in survivors of these different types of traumatic events. The current study aimed to identify the specific symptom profile of survivors of interpersonal and noninterpersonal trauma, and to examine changes in differences in the symptom profile over time. METHOD The study examined PTSD symptom data from 715 traumatic injury survivors admitted to the hospital between April 2004 and February 2006, who were assessed 3, 12, and 24 months after injury using the Clinician-Administered PTSD Scale (primary outcome measure). Multivariate analyses of variance were used to investigate differences in PTSD symptom profile over time between interpersonal and noninterpersonal trauma. RESULTS Multivariate analyses of variance revealed significant differences between the 2 groups in overall severity of PTSD symptoms at each of the 3 time points: 3 months, F(17,696) = 5.86, P < .001; 12 months, F(17,696) = 3.62, P < .001; 24 months, F(17,696) = 3.09, P < .001. Survivors of interpersonal trauma demonstrated significantly (P < .01) higher scores on 14 PTSD symptoms at 3 months after injury but on only 6 symptoms by 24 months. Symptoms on which differences persisted were the PTSD unique symptoms more associated with fear and threat. CONCLUSIONS Interpersonal trauma results in more severe PTSD symptoms in the early aftermath of trauma. Over the course of time, the distinctive persisting symptoms following interpersonal trauma involve fear-based symptoms, which suggest fear conditioning may be instrumental in persistent interpersonal PTSD.

A critical review of the evidence base of imagery rehearsal for posttraumatic nightmares: pointing the way for future research.

In this article, the authors provide information on key characteristics of imagery rehearsal treatment protocols and examine the quality of reporting of randomized controlled and uncontrolled trials of imagery rehearsal for treating posttraumatic nightmares. Using a reliable and valid scale, two independent psychologists rated 16 trials. Most reports provided insufficient information on a range of variables including the definition of treatment delivery (e.g., therapist supervision, treatment fidelity), description of the participant sample, data analysis (e.g., determination of sample size), and treatment assignment (e.g., randomization procedures). Low methodological quality and poor reporting can lead to inflation of estimates of treatment effects and inadequately substantiated conclusions, such as inflated effect sizes in meta-analytic studies. Numerous imagery rehearsal protocols exist, but in some cases are given different names and tested in pilot studies, slowing progression in the field. Randomized controlled trials of imagery rehearsal with credible comparison conditions, examination of predictors of dropout and outcome, as well as dismantling studies of imagery rehearsal treatment components are needed.

Caring for Carers in the Aftermath of Trauma

The potential impact on psychological well-being of working in the caring professions in the aftermath of trauma and disaster has been recognized for many years, with terms such as burnout, compassion fatigue, and vicarious traumatization coined to describe stress-related conditions. Although prevalent, these conditions do not affect all workers in the field. Various studies have investigated potential risk and protective factors. It is argued that the outcomes of this research should be used to guide practical interventions in the workplace designed to minimize stress-related problems. A framework that incorporates interventions at the primary, secondary, and tertiary prevention levels is outlined, and research investigating the efficacy of interventions at each of these levels is recommended.

Psychological first aid following trauma: implementation and evaluation framework for high-risk organizations.

International clinical practice guidelines for the management of psychological trauma recommend Psychological First Aid (PFA) as an early intervention for survivors of potentially traumatic events. These recommendations are consensus-based, and there is little published evidence assessing the effectiveness of PFA. This is not surprising given the nature of the intervention and the complicating factors involved in any evaluation of PFA. There is, nevertheless, an urgent need for stronger evidence evaluating its effectiveness. The current paper posits that the implementation and evaluation of PFA within high risk organizational settings is an ideal place to start. The paper provides a framework for a phasic approach to implementing PFA within such settings and presents a model for evaluating its effectiveness using a logic- or theory-based approach which considers both pre-event and post-event factors. Phases 1 and 2 of the PFA model are pre-event actions, and phases 3 and 4 are post-event actions. It is hoped that by using the Phased PFA model and evaluation method proposed in this paper, future researchers will begin to undertake the important task of building the evidence about the most effective approach to providing PFA in high risk organizational and community disaster settings.

Efficacy of Fifteen Emerging Interventions for the Treatment of Posttraumatic Stress Disorder: A Systematic Review.

Although there is an abundance of novel interventions for the treatment of posttraumatic stress disorder (PTSD), often their efficacy remains unknown. This systematic review assessed the evidence for 15 new or novel interventions for the treatment of PTSD. Studies that investigated changes to PTSD symptoms following the delivery of any 1 of the 15 interventions of interest were identified through systematic literature searches. There were 19 studies that met the inclusion criteria for this study. Eligible studies were assessed against methodological quality criteria and data were extracted. The majority of the 19 studies were of poor quality, hampered by methodological limitations, such as small sample sizes and lack of control group. There were 4 interventions, however, stemming from a mind-body philosophy (acupuncture, emotional freedom technique, mantra-based meditation, and yoga) that had moderate quality evidence from mostly small- to moderate-sized randomized controlled trials. The active components, however, of these promising emerging interventions and how they related to or were distinct from established treatments remain unclear. The majority of emerging interventions for the treatment of PTSD currently have an insufficient level of evidence supporting their efficacy, despite their increasing popularity. Further well-designed controlled trials of emerging interventions for PTSD are required.

Trauma-Related Dreams of Australian Veterans with PTSD: Content, Affect and Phenomenology

Objective: Consensus on the parameters of trauma-related dreams required to meet criteria for post-traumatic stress disorder (PTSD) is critical when: (i) the diagnosis requires a single re-experiencing symptom; and (ii) trauma dreams are prevalent in survivors without PTSD. Method: This study investigated the phenomenology of PTSD dreams in 40 veterans, using structured interview and self-report measures. Results: Dream content varied between replay, non-replay, and mixed, but affect was largely the same as that experienced at the time of trauma across all dream types. ANOVA indicated no difference between dream types on PTSD severity or nightmare distress. Conclusions: The findings provide preliminary support for non-replay dreams to satisfy the DSM B2 diagnostic criterion when the affect associated with those dreams is the same as that experienced at the time of the traumatic event.