Background: The aim of the present randomized controlled trial was to compare the outcome of 2 active treatments for posttraumatic stress disorder (PTSD) as a consequence of war and torture: narrative exposure therapy (NET) and stress inoculation training (SIT). Methods: Twenty-eight PTSD patients who had experienced war and torture, most of them asylum seekers, received 10 treatment sessions of either NET or SIT at the Outpatient Clinic for Refugees, University of Konstanz, Germany. Posttests were carried out 4 weeks after treatment, and follow-up tests were performed 6 months and 1 year after treatment. The main outcome measure was the PTSD severity score according to the Clinician-Administered PTSD Scale (CAPS) at each time point. Results: A significant reduction in PTSD severity was found for NET, but not for SIT. A symptom reduction in the NET group occurred between pretest and the 6-month follow-up examination, the effect size being d = 1.42 (for SIT: d = 0.12), and between pretest and the 1-year follow-up, the effect size being d = 1.59 (for SIT: d = 0.19). The rates and scores of major depression and other comorbid disorders did not decrease significantly over time in either of the 2 treatment groups. Conclusions: The results indicate that exposure treatments like NET lead to a significant PTSD symptom reduction even in severely traumatized refugees and asylum seekers.

Keywords:
Posttraumatic stress disorder, Organized violence, Refugees, Narrative exposure therapy, Stress inoculation training
1.
de Jong JT, Komproe IH, van Ommeren M: Common mental disorders in postconflict settings. Lancet 2003;361:2128–2130.
2.
Karunakara U, Neuner F, Schauer M, Singh K, Hill K, Elbert T, Burnham G: Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandan nationals in the West Nile. Afr Health Sci 2004;4:83–93.
3.
Bichescu D, Schauer M, Saleptsi E, Neculau A, Elbert T, Neuner F: Long-term consequences of traumatic experiences: an assessment of former political detainees in Romania. Clin Pract Epidemiol Ment Health 2005;1:17.
4.
Vojvoda D, Weine SM, McGlashan T, Becker DF, Southwick SM: Posttraumatic stress disorder symptoms in Bosnian refugees 3 1/2 years after resettlement. J Rehabil Res Dev 2008;45:421–426.
5.
Schaal S, Elbert T: Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan adolescents. J Trauma Stress 2006;19:95–105.
6.
Silove D, Steel Z, McGorry P, Mohan P: Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in Tamil asylum-seekers: comparison with refugees and immigrants. Acta Psychiatr Scand 1998;97:175–181.
7.
Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T: Psychological trauma and evidence for enhanced vulnerability for PTSD through previous trauma in West Nile refugees. BMC Psychiatry 2004;4:34.
8.
Gäbel U, Ruf M, Schauer M, Odenwald M, Neuner F: Prävalenz der posttraumatischen Belastungsstörung (PTSD) und Möglichkeiten der Ermittlung in der Asylverfahrenspraxis. Z Klin Psychol 2006;35:12–20.
9.
Otto MW, Hinton D, Korbly NB, Chea A, Ba P, Gershuny BS, Pollack MH: Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs. sertraline alone. Behav Res Ther 2003;41:1271–1276.
10.
Hinton DE, Pham T, Tran M, Safren SA, Otto MW, Pollack MH: CBT for Vietnamese refugees with treatment-resistant PTSD and panic attacks: a pilot study. J Trauma Stress 2004;17:429–433.
11.
Snodgrass L, Yamamoto J, Frederick C, Ton-That N, Foy D, Chan L, Wu J, Hahn P, Shinh D, Nguyen L, de Jonge J, Fairbanks L: Vietnamese refugees with PTSD symptomatology: intervention via a coping skills model. J Trauma Stress 1993;6:569–575.
12.
Weine SM, Kulenovic AD, Pavkovic I, Gibbons R: Testimony psychotherapy in Bosnian refugees: a pilot study. Am J Psychiatry 1998;155:1720–1726.
13.
Basoglu M, Ekblad S, Bäärnhielm S, Livanou M: Cognitive-behavioral treatment of tortured asylum seekers: a case study. J Anxiety Disord 2004;18:357–369.
14.
Hinton DE, Chhean D, Pich V, Safren SA, Hofmann SG, Pollack MH: A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: a cross-over design. J Trauma Stress 2005;18:617–629.
15.
Paunovic N, Öst LG: Cognitive-behavior therapy vs. exposure therapy in the treatment of PTSD in refugees. Behav Res Ther 2001;39:1183–1197.
16.
Neuner F, Kurreck S, Ruf M, Odenwald M, Elbert T, Schauer M: Can asylum seekers with posttraumatic stress disorder be successfully treated? A randomized controlled pilot study. Cogn Behav Ther 2010;39:81–91.
17.
Foa EB, Rothbaum BO, Riggs DS, Murdock TB: Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol 1991;59:715–723.
18.
Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP: A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol 1999;67:194–200.
19.
Bichescu D, Neuner F, Schauer M, Elbert T: Narrative exposure therapy for political imprisonment-related chronic posttraumatic stress disorder and depression. Behav Res Ther 2007;45:2212–2220.
20.
Neuner F, Onyut PL, Ertl V, Odenwald M, Schauer E, Elbert T: Treatment of posttraumatic stress disorder by trained lay counselors in an African refugee settlement: a randomised controlled trial. J Consult Clin Psychol 2008;76:686–694.
21.
Neuner F, Schauer M, Klaschik C, Karunakara U, Elbert T: A comparison of narrative exposure therapy, supportive counseling, and psychoeducation for treating posttraumatic stress disorder in an African refugee settlement. J Consult Clin Psychol 2004;72:579–587.
22.
Schaal S, Elbert T, Neuner F: Narrative exposure therapy versus group interpersonal psychotherapy – a controlled clinical trial with orphaned survivors of the Rwandan genocide. Psychother Psychosom 2009;78:298–306.
23.
Schauer M, Neuner F, Elbert T: Narrative Exposure Therapy: A Short-Term Intervention for Traumatic Stress Disorders after War, Terror, or Torture. Ashland, Hogrefe & Huber, 2005.
24.
Vivo: Vivo Haft-, Kriegs- und Folterereignisfragebogen (deutsche Fassung). 2006. http://www.vivofoundation.net/modules. php?name=News&file=article&sid=58 (accessed August 7, 2008).
25.
Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, Keane TM: The development of a clinician-administered PTSD scale. J Trauma Stress 1995;8:75–90.
26.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar G: The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59:22–33.
27.
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62.
28.
Hamilton M: Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol 1967;6:278–296.
29.
Weathers FW, Ruscio AM, Keane TM: Psychometric properties of nine scoring rules for the Clinician Administered Posttraumatic Stress Disorder Scale. Psychol Assess 1999;11:124–133.
30.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4, Text Revision. Washington, American Psychiatric Association, 2000.
31.
Cook RJ, Zeng L, Yi GY: Marginal Analysis of Incomplete Longitudinal Binary Data: A Cautionary Note on LOCF Imputation. Biometrics 2004;60:820–828.
32.
Hamer RM, Simpson PM: Last observation carried forward versus mixed models in the analysis of psychiatric clinical trials. Am J Psychiatry 2009;166:639–641.
33.
Fong YT, Rai SN, Lam KS: Use of multiple imputation on linear mixed model and generalized estimating equations for longitudinal data analysis: a simulation study. Abstracts SCRA 2006-FIM XIII-Thirteenth International Conference of the Forum for Interdisciplinary Mathematics on Interdisciplinary Mathematical and Statistical Techniques, Lisbon-Tomar, 2006.
34.
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M: Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behav Res Ther 2005;43:413–431.
35.
Foa EB, Hembree EA, Cahill SP, Rauch SA, Riggs DS, Feeny NC, Yadin E: Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol 2005;73:953–964.
36.
Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA: A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002;70:867–879.
37.
van Minnen A, Arntz A, Keijsers GP: Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout. Behav Res Ther 2002;40:439–457.
© 2011 S. Karger AG, Basel
2011
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.