Bob was a 53-year-old father of three who had driven tractor trailers for over 20 years when the accident he’d always feared finally happened. While he was driving along a two-lane highway, another vehicle crossed into his lane, forcing him to put his truck partially onto the shoulder to avoid a collision. The shoulder gave way and his rig went off the road, causing the trailer to jackknife and swing around, nearly destroying the cab where he sat. Though shaken and bruised, he didn’t suffer any serious physical injuries and the pain from the accident diminished within a few weeks. Bob began, however, to show signs of a post-traumatic stress reaction (PTSD) almost immediately. Nightmares of crashes and jackknifing trucks disturbed him every night. He wouldn’t drive and was terrified when he was near any truck as a passenger. Most noticeable to his relatives was that he just didn’t seem to be himself. He had been a warm, funny man who’d loved his large extended family. Now he was withdrawn, avoiding gatherings and showing little interest in the world.

Which therapy is best?

New research gives us better directions on how to approach treating patients like Bob. In a recent study (Archives of General Psychiatry 2008:65:659-67), researchers assessed 90 people who’d either experienced a car crash or a nonsexual assault and who met criteria for acute stress disorder (ASD). People who have ASD are at high risk for developing chronic PTSD. The subjects were randomized to receive prolonged exposure therapy, cognitive restructuring or no treatment at all, and were reassessed at 6 weeks.

Prolonged exposure treatment was comprised of 5 weekly sessions that included education about PTSD and exposure, followed by verbal descriptions to “re-live” the trauma in as much detail as possible. Patients had to repeat this on their own as homework. Session 2 introduced in vivo exposure (i.e. sitting in a truck, for Bob) and continued imaginal exposure. In cognitive restructuring, maladaptive thoughts about the traumatic event were addressed along with the person’s other responses to it. Homework included daily monitoring of thoughts and affective states, and modifying them by Socratic questioning and evidence-based reasoning.

At the 6-month follow-up, those who had exposure therapy were significantly less likely to meet criteria for PTSD than those who’d had cognitive restructuring (37% vs 63%, P = .05) and more likely to be in full remission (47% vs 13%). Some research has suggested that therapists are reluctant to do exposure treatment because it’s very distressing to patients. The trial somewhat artificially separated the 2 treatments (they’re often combined in clinical practice) in order to pinpoint the differences in effectiveness. None of the treated patients had received medication, again to keep effects clear.

Bob’s sleep disturbance was initially addressed with quetiapine and venlafaxine as well as gabapentin. The medications seemed to help him tolerate the subsequent exposure therapy, which reduced his symptoms greatly.