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. 2014 Mar;45(1):97-104.
doi: 10.1016/j.jbtep.2013.09.003. Epub 2013 Sep 13.

Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD

Ellen J Bluett  1 , Lori A Zoellner, Norah C Feeny
Affiliations

Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD

Ellen J Bluett et al. J Behav Ther Exp Psychiatry. 2014 Mar.

Abstract

Background and objectives: Clinically, many individuals persist in prolonged exposure therapy (PE) for chronic PTSD despite continuing distress during recounting of the trauma memory (imaginal exposure). Theorists suggest that distress reduction is necessary for successful treatment outcome (e.g., Foa & Kozak, 1986), while others suggest otherwise (e.g., Craske et al., 2008). This study examined clinically reliable changes in distress, relations to broad clinical outcomes, and whether homework adherence affected this relationship.

Method: In 116 patients with PTSD, first to last imaginal exposure sessions' peak and average distress was examined, calculating reliable change in distress. Homework adherence and helpfulness were examined. At post-treatment, PTSD symptoms (re-experiencing, avoidance, hyperarousal), depression, and functioning were examined.

Results: Patients exhibited a lack of reliable change in distress (64.7%) more than a reliable change in distress (35.3%). Although no difference in post-treatment PTSD diagnostic status, individuals experiencing a reliable change in distress reported lower PTSD severity (re-experiencing, hyperarousal), depression, and better functioning. Further, perceived helpfulness of imaginal homework had an indirect effect on this relationship.

Limitations: This study did not utilize a distress tolerance self-report measure; however, examined self-reported distress during imaginal exposure.

Conclusions: Results are encouraging for clinicians treating PTSD with PE, arguing that lack of reliable change in distress to the trauma memory does not result in treatment failure. Patient "buy in" to homework, rather than amount completed, was related to the process of distress reduction. Results suggest that distress reduction in imaginal exposure is not a key mechanism underlying therapeutic change in PE.

Keywords: Distress; Homework; PTSD; Prolonged exposure; Reliable change; Treatment outcome.

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