Bryant, Richard

Guthrie, Rachel M

Moulds, Michelle

Nixon, Reginald David

American Journal of Psychiatry

English

Flinders Academic Commons

Archived at the Flinders Academic Commons:  http://dspace.flinders.edu.au/dspace/  This is the publisher’s copyrighted version of this article.  The original can be found at: http://ajp.psychiatryonline.org/cgi/reprint/160/3/585 © 2003 American Journal of Psychiatry Published version of the paper reproduced here in accordance with the copyright policy of the publisher. Personal use of this material is permitted. However, permission to reprint/republishthis material for advertising or promotional purposes or for creating new collective works forresale or redistribution to servers or lists, or to reuse any copyrighted component of this work in other works must be obtained from American Journal of Psychiatry. Am J Psychiatry 160:3, March 2003 585 http://ajp.psychiatryonline.orgBrief ReportTreating Acute Stress Disorder Following Mild Traumatic Brain InjuryRichard A. Bryant, Ph.D.Michelle Moulds, M.Psych.Rachel Guthrie, M.Psych.Reginald D.V. Nixon, Ph.D.Objective: Acute stress disorder permits early identification oftrauma survivors who are at risk of developing chronic posttrau-matic stress disorder (PTSD). This study aimed to prevent PTSD inpeople who developed acute stress disorder after a mild brain in-jury by early provision of cognitive behavior therapy.Method: Twenty-four civilian trauma survivors with acutestress disorder were given five individually administered ses-sions of either cognitive behavior therapy or supportive coun-seling within 2 weeks of their trauma.Results: Fewer patients receiving cognitive behavior therapythan supportive counseling met criteria for PTSD at a posttreat-ment evaluation (8% versus 58%, respectively). There were alsofewer cases of PTSD at a 6-month follow-up evaluation amongthose receiving cognitive behavior therapy (17%) than amongthose receiving supportive counseling (58%). Patients in the cog-nitive behavior therapy condition displayed less reexperiencingand avoidance symptoms at the follow-up evaluation than pa-tients receiving supportive counseling.Conclusions: These findings suggest that PTSD following mildbrain injury can be effectively prevented with early provision ofcognitive behavior therapy.(Am J Psychiatry 2003; 160:585–587)A cute stress disorder describes posttraumatic stressreactions that occur within 1 month of a trauma (1). Ap-proximately 80% of people with acute stress disorder de-velop posttraumatic stress disorder (PTSD) (2). Two previ-ous treatment studies have demonstrated that only 20% ofpatients with acute stress disorder who received brief cog-nitive behavior therapy have PTSD 6 months later (3, 4).Among patients whose acute stress disorder occurs fol-lowing a mild traumatic brain injury, approximately 80%develop chronic PTSD (5, 6). Mild brain injury includesloss of consciousness at the time of trauma and potentiallysome degree of cognitive impairment (7). Consideringthat cognitive behavior therapy involves exposure totrauma memories and cognitive restructuring, the effectsof mild brain injury may impede the efficacy of cognitivebehavior therapy in these patients. To our knowledge,there have been no controlled treatment studies of acutestress disorder or PTSD following mild brain injury. Thecurrent study tested the efficacy of cognitive behaviortherapy in preventing PTSD in patients who develop acutestress disorder following mild brain injury by providingthese patients with either cognitive behavior therapy orsupportive counseling.MethodPatients were survivors of either motor vehicle accidents ornonsexual assaults who were referred from hospital staff andmental health centers to the PTSD Unit at Westmead Hospital. In-clusion criteria were 1) trauma occurrence within the preceding 2weeks, 2) acute stress disorder criteria met, 3) English proficiency,4) age between 18 and 60 years, and 5) trauma involved mild braininjury, which was defined as posttraumatic amnesia of less than24 hours and Glasgow Coma Scale score of 13–15, which reflectsminimal disruption to consciousness (7). Posttraumatic amnesiawas defined as the period of anterograde amnesia before eventsthat occur after the trauma are recalled in a continuous manner.Twenty-four patients entered the study, and all were retainedfor the 6-month follow-up evaluation. The cognitive behaviortherapy group comprised four men and eight women (mean age=29.42 years, SD=13.93), and the supportive counseling groupcomprised four men and eight women (mean age=33.00 years,SD=14.37). Prior psychiatric diagnoses were noted in two cogni-tive behavior therapy patients (major depression, bulimia ner-vosa) and two supportive counseling patients (major depression,attention deficit disorder).Acute stress disorder was assessed by using the Acute StressDisorder Interview (8). Patients were administered the Impact ofEvent Scale (9), the Beck Depression Inventory (10), and the BeckAnxiety Inventory (11). PTSD was assessed by using the ClinicianAdministered PTSD Scale, Form 2 (12). Before treatment, patientsrated their confidence in treatment (1=“not at all confident,” 10=“extremely confident”).Written informed consent, as approved by the University ofNew South Wales Human Research Ethics Committee, was ob-tained prior to study entry. Patients were assessed at pretreat-ment, posttreatment (within 1 week of treatment completion),and at a 6-month follow-up evaluation by a clinical psychologistwho was blind to treatment condition. All measures were admin-istered at each assessment except that the Acute Stress DisorderInterview was administered at pretreatment and the Clinician Ad-ministered PTSD Scale, Form 2, was administered at posttreat-ment and the follow-up evaluation. Patients were randomly as-signed, through a process of minimization stratified on genderand severity of acute stress disorder, to receive cognitive behaviortherapy or supportive counseling. Each group received five 1½-hour individually administered weekly sessions conducted byclinical psychologists, who followed therapist manuals (availablefrom the first author).The cognitive behavior therapy program comprised 1) educa-tion about trauma reactions, 2) progressive muscle relaxationtraining, 3) imaginal exposure to traumatic memories, 4) cogni-586 Am J Psychiatry 160:3, March 2003BRIEF REPORTShttp://ajp.psychiatryonline.orgtive restructuring, and 5) graded in vivo exposure to avoided situ-ations. Fifty minutes of imaginal exposure to trauma memorieswas performed during each session and also as daily homework.The supportive counseling program comprised education abouttrauma and general problem-solving skills.Analyses of covariance (ANCOVA) that controlled for pretreat-ment symptom severity were conducted for posttreatment and 6-month follow-up scores on the Clinician Administered PTSDScale (intensity and frequency subscales), Impact of Event Scale(intrusions and avoidance subscales), and the Beck DepressionInventory and Beck Anxiety Inventory. We derived Cohen’s d ef-fect size by calculating the mean difference between assessmentsof each treatment condition and dividing this by the pooled stan-dard deviation (13) and then used Hedges G effect sizes to correctfor variations due to small patient group sizes (14).ResultsAll sessions were audiotaped, and 16 therapy sessions(13% of the 120 sessions) were rated by two independentraters for 33 treatment components that were rated aspresent or absent. Sessions were also scored for proficiency(0=“unacceptable,” 6=“superior”). No supportive counsel-ing session included exposure, cognitive restructuring, oranxiety management. The mean rating for exposure, cog-nitive restructuring, and anxiety management in the cog-nitive behavior therapy conditions was 5.1 (SD=1.3).Planned comparisons indicated that before treatment,groups did not differ in terms of age, trauma assessmentinterval, pretreatment severity of acute stress disorder,treatment confidence ratings, or scores on the Impact ofEvent Scale, Beck Depression Inventory, or Beck AnxietyInventory.Chi-square tests indicated that at posttreatment, fewerpatients met criteria for PTSD in the cognitive behaviortherapy group (8%, N=1) than in the supportive counsel-ing group (58%, N=7) (χ 2=6.75, df=1, p< 0.05, with Yates’scorrection [15]). At the 6-month follow-up evaluation,fewer patients met criteria for PTSD in the cognitive be-havior therapy group (17%, N=2) than in the supportivecounseling group (58%, N=7) (χ 2=4.44, df=1, p< 0.05). Theeffect sizes of the different proportion of patients report-ing PTSD was considerable at posttreatment (1.16) andfollow-up (0.87).Table 1 presents the psychopathology scores over thecourse of the study and the effect sizes of the improve-ment from pretreatment to posttreatment and from pre-treatment to the 6-month follow-up evaluation. At post-treatment, ANCOVAs indicated significant effects forscores on the intrusions and avoidance subscales of theImpact of Event Scale, the Beck Anxiety Inventory, and thefrequency and intensity subscales of the Clinician Admin-TABLE 1. Psychopathology at Pretreatment, Posttreatment, and 6-Month Follow-Up in 24 Civilian Trauma Survivors WithAcute Stress Disorder Given Five Sessions of Either Cognitive Behavior Therapy or Supportive CounselingMeasureTreatment GroupCognitive Behavior Therapy (N=12) Supportive Counseling (N=12)ScoreEffect SizebScoreEffect SizebAnalysisaMean SD Mean SD F (df=1, 23) pAcute Stress Disorder Interview, pretreatment 65.42 10.60 62.42 14.58Impact of Event ScaleIntrusion subscalePretreatment 27.83 5.31 24.50 8.20Posttreatment 10.17 10.96 1.83 19.00 8.25 0.82 9.44 0.0066-month follow-up 11.25 9.81 1.93 20.17 9.70 0.46 6.26 0.02Avoidance subscalePretreatment 20.58 5.02 16.25 7.42Posttreatment 4.08 4.60 2.45 16.75 9.97 0.02 47.49 0.0016-month follow-up 7.33 7.22 1.65 15.67 10.49 0.06 9.58 0.005Beck Anxiety InventoryPretreatment 25.58 11.43 26.83 13.90 0.33Posttreatment 13.17 12.65 1.03 21.58 17.49 0.33 3.99 0.056-month follow-up 13.92 10.98 1.04 21.83 18.72 0.31 1.78 0.19Beck Depression InventoryPretreatment 20.42 11.66 24.17 11.96Posttreatment 13.75 12.10 0.56 18.75 12.61 0.44 0.35 0.566-month follow-up 15.42 13.87 0.39 20.33 14.18 0.29 0.16 0.69Clinician Administered PTSD Scale, Form 2cFrequency subscalePosttreatment 13.50 10.24 23.83 15.30 12.88 0.0026-month follow-up 16.83 13.04 25.25 16.21 5.40 0.03Intensity subscalePosttreatment 12.00 9.71 21.33 12.49 11.54 0.0036-month follow-up 14.62 9.12 24.50 13.13 6.75 0.02a Between-group comparisons of the improvement from pretreatment that controlled for pretreatment symptom severity.b Measurement of improvement from pretreatment (Cohen’s d).c No pretreatment scores obtained for this instrument, since pretreatment psychopathology was assessed with the Acute Stress Disorder Inter-view.Am J Psychiatry 160:3, March 2003 587BRIEF REPORTShttp://ajp.psychiatryonline.orgistered PTSD Scale. There was no effect for Beck Depres-sion Inventory scores. At the 6-month follow-up evalua-tion, ANCOVAs indicated main effects for scores on theintrusions and avoidance subscales of the Impact of EventScale and the frequency and intensity subscales of the Cli-nician Administered PTSD Scale. There were no effects forBeck Depression Inventory or Beck Anxiety Inventoryscores.DiscussionThis study demonstrates that brief cognitive behaviortherapy is an effective intervention for patients who sus-tain a mild brain injury. The presence of partial amnesia ofthe trauma as a result of impaired loss of consciousnessdid not reduce the efficacy of strategies involving pro-longed exposure to trauma memories, cognitive restruc-turing, and anxiety management. In contrast to previousresults (4), depression was not markedly improved withcognitive behavior therapy. Depression is common afterbrain injury (8), and the presence of cognitive deficits,postconcussive syndrome, or other sequelae of brain in-jury may have led to persistent depression in our patients.We emphasize that these conclusions are limited by thesmall study group size. Further, we did not index cognitiveimpairment, and this may influence treatment responsefollowing brain injury. The higher rate of PTSD in the cog-nitive behavior therapy group at the 6-month follow-upevaluation (17%) than at posttreatment (8%) suggests sub-sequent follow-up evaluations are needed to index longer-term effects of cognitive behavior therapy. These limita-tions notwithstanding, these results indicate that early in-tervention for patients who develop acute stress disorderafter mild brain injury can lead to significant reductions inPTSD. Considering the prevalence of mild brain injurysustained in traumatic contexts, early application of cog-nitive behavior therapy for those who are at risk of PTSDmay have significant public health benefits.Received Nov. 27, 2001; revision received Aug. 29, 2002; acceptedSept. 19, 2002. From the School of Psychology, University of NewSouth Wales. Address reprint requests to Dr. Bryant, School of Psy-chology, University of New South Wales, Sydney NSW 2052, Australia;r.bryant@unsw.edu.au (e-mail).Supported by a grant from the Motor Accident Authority of NewSouth Wales.References1. Bryant RA, Harvey AG: Acute stress disorder: a critical review ofdiagnostic issues. Clin Psychol Rev 1997; 17:757–7732. Harvey AG, Bryant RA: The relationship between acute stressdisorder and posttraumatic stress disorder following motor ve-hicle accidents. J Consult Clin Psychol 1998; 66:507–5123. Bryant RA, Harvey AG, Sackville T, Dang ST, Basten C: Treatmentof acute stress disorder: a comparison of cognitive-behavioraltherapy and supportive counseling. J Consult Clin Psychol1998; 66:862–8664. Bryant RA, Sackville T, Dang ST, Moulds M, Guthrie R: Treatingacute stress disorder: an evaluation of cognitive behavior ther-apy and supportive counseling techniques. Am J Psychiatry1999; 156:1780–17865. Bryant RA, Harvey AG: Relationship between acute stress disor-der and posttraumatic stress disorder following mild traumaticbrain injury. Am J Psychiatry 1998; 155:625–6296. Bryant RA: Posttraumatic stress disorder and traumatic braininjury: can they co-exist? Clin Psychol Rev 2001; 21:931–9487. American Congress of Rehabilitation Medicine: Definition ofmild traumatic brain injury. J Head Trauma Rehab 1993; 8:86–878. Bryant RA, Harvey AG, Dang ST, Sackville T: Assessing acutestress disorder: psychometric properties of a structured clinicalinterview. Psychol Assess 1998; 10:215–2209. Ho r o w i t z  M J ,  W i l n er  N ,  A l v ar ez  W :  I m pa ct  o f  E v en t  S c al e :  ameasure of subjective stress. Psychosom Med 1979; 41:209–21810. Beck AT, Steer RA, Brown GK: Beck Depression Inventory, 2nded, Manual. San Antonio, Tex, Psychological Corp, 199611. Beck AT, Steer RA: Beck Anxiety Inventory. San Antonio, Tex,Psychological Corp, 199312. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD,Charney DS, Keane TM: The development of a Clinician-Admin-istered PTSD Scale. J Trauma Stress 1995; 8:75–9013. Cohen J: Statistical Power Analysis for the Behavioral Sciences.New York, Academic Press, 198814. Hedges LV: Estimation of effect size from a series of indepen-dent experiments. Psychol Bull 1982; 97:490–49915. Fleiss JL: Statistical Methods for Rates and Proportions, 2nd ed.New York, John Wiley & Sons, 1981

AG: Acute stress disorder: a critical review of diagnostic issues. Clin Psychol Rev

AG: Relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury.

American Congress of Rehabilitation Medicine: Definition of mild traumatic brain injury. J Head Trauma Rehab

Anxiety Inventory.

Depression Inventory, 2nd ed,

Estimation of effect size from a series of independent experiments. Psychol Bull

Ho r o w i t z M J , W i l n er N , A l v ar ez W : I m pa ct o f E v en t S c al e : a measure of subjective stress. Psychosom Med

Posttraumatic stress disorder and traumatic brain injury: can they co-exist? Clin Psychol Rev

Sackville T: Assessing acute stress disorder: psychometric properties of a structured clinical interview. Psychol Assess

Statistical Methods for Rates and Proportions, 2nd ed.

Statistical Power Analysis for the Behavioral Sciences.

The relationship between acute stress disorder and posttraumatic stress disorder following motor vehicle accidents.

TM: The development of a Clinician-Administered PTSD Scale. J Trauma Stress

Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques.

Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling.

Treating Acute Stress Disorder Following Mild
            Traumatic Brain Injury

Richard A. Bryant

Michelle Moulds

Rachel Guthrie

Reginald D.V. Nixon

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Treating Acute Stress Disorder Following Mild Traumatic Brain Injury

http://dspace.flinders.edu.au/xmlui/bitstream/handle/2328/13667/2006004287.pdf?sequence=1

Treating Acute Stress Disorder Following Mild Traumatic Brain Injury

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