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The Timing of Trauma Treatment

In this year alone, hundreds of terrorist attacks have been attempted or completed. Most were in Iraq, Afghanistan, and Pakistan, but some occurred in China, Russia, Northern Ireland, and Norway, where a right-wing extremist set off bombs and shot teenagers and legislators at a summer camp, killing 77. Attacks, counterattacks, and retaliatory air strikes raged between Israel and the Palestinian territories. In total, terrorist incidents killed more than 2,100 people around the world in 2011. Thousands more were injured or witnessed the maiming or killing of others—an experience that can leave survivors with devastating psychological effects.

Clinical researchers have long debated when and how to give services after disasters. Now researchers at Hadassah University Hospital, the principal urgent-care center treating traumatic injuries in Jerusalem, have provided some answers from their study of patients who received emergency treatment between 2003 and 2007. The results appeared in the October issue of Archives of General Psychiatry.

To assemble the study participants, researchers called more than 5,000 patients who’d experienced a potentially traumatic event about 10 days after the occurrence to inquire whether they needed assistance and wanted to join the study. Most chose not to or didn’t meet study criteria. Eventually, 242 patients were enrolled; among them were 201 who’d been in auto accidents and 26 who’d been hurt in a terrorist attack. All were judged to have symptoms of acute stress disorder, such as difficulty sleeping, heightened anxiety, trouble concentrating, and intrusive flashbacks of the event. The purpose of the study was to determine the best ways to keep short-term, acute stress symptoms from developing into full-blown post-traumatic stress disorder (PTSD), characterized by symptoms that last at least a month and sometimes for years.

The participants were divided into five groups. One group was treated weekly with exposure therapy. They were taught breathing techniques, educated about trauma, and guided to reexperience the event that triggered their distress as a means of overcoming it. The second group received Cognitive-Behavioral Therapy (CBT), which taught them to examine and modify their negative and distorted thoughts related to the event without reliving the experience. The third group was given the antidepressant Lexapro, while the fourth received a placebo. A fifth group was placed on a waiting list and not treated at all for five months.

After the initial five months of therapy, medication, placebo, or waiting, PTSD symptoms were seen in 20 percent of those who received CBT, 22 percent of patients who received exposure therapy, 56 percent of those given placebos, 59 percent of those on the waiting list, and 62 percent of those who took Lexapro. The waiting-list patients with PTSD were then offered exposure therapy.

When the groups were reassessed at nine months, the number of patients treated with medication or placebo who had PTSD had dropped but was still nearly twice as large as in the groups who’d been treated with therapy. For those who’d been on the waiting list for the first five months and started treatment later, therapy still had a substantial benefit, cutting the number with PTSD to 23 percent, about the same percentage as those who’d started therapy five months earlier.

The study results indicate that both forms of therapy—CBT and exposure therapy—were the most successful in helping prevent PTSD. Furthermore, it appears that therapists can help patients without asking them to reengage in an intensive way with the memories of the event itself, says Arieh Shalev, the Hadassah psychiatrist who led the research. Skilled therapists and patients can therefore choose whichever type of therapy they’re most comfortable with and get good results, he adds.

There’s also some leeway in how quickly treatment needs to be provided, as it seems that people who receive therapy later ultimately have the same benefit from therapy as those who start earlier. In the aftermath of the 9/11 attacks in New York, many therapists were criticized for racing to provide assistance while survivors were still coping with more pressing issues. Shalev thinks that such speed was probably unnecessary. “The problem with providing therapy as early as possible is that often there’s no ability to offer comprehensive services,” he notes. Assisting with food, housing, and basic survival should be the priority after a disaster, Shalev says—and, as the study results show, there’s no magic time frame within which therapy must begin.

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