Publication: Eficacia de un programa de tratamiento cognitivo-conductal para trastornos por estrés traumático, depresivos y de ansiedad a largo plazo en víctimas de atentados terroristas
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2016-05-12
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García Vera, María Paz
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Universidad Complutense de Madrid
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Abstract
OBJETIVO Se analiza la eficacia de la terapia cognitivo-conductual centrada en el trauma en víctimas de atentados terroristas con trastorno por estrés postraumático (TEPT) o trastornos de ansiedad o depresivos a muy largo plazo (> 5 años después del atentado). Se pretende, así, engrosar el limitado conocimiento científico sobre la eficacia de los tratamientos en esta población concreta. MÉTODO Un grupo de 120 víctimas directas e indirectas de atentados terroristas cometidos en España una media de 18,43 años atrás, que presentaban aislada o concurrentemente trastorno por estrés postraumático (TEPT; 49,2%), trastorno depresivo mayor (TDM; 40,8%) y otros trastornos de ansiedad (75,8%), fueron aleatorizados en 16 sesiones de Terapia Cognitivo-Conductual (TCC) centrada en el trauma (grupo experimental) o 16 semanas de espera (grupo control). La TCC centrada en el trauma estaba basada en el protocolo de exposición prolongada de Foa y Rothbaum (1998) pero se le añadieron técnicas específicas para el manejo de los trastornos del estado de ánimo y trastornos de ansiedad, se hizo un mayor énfasis en la psicoeducación sobre las reacciones post traumáticas y en la reestructuración cognitiva y se añadieron estrategias de motivación, regulación emocional y terapia narrativa. De las 60 personas que fueron asignadas al grupo experimental, 25 (41,6%) rechazaron la terapia y 10 (28,6%) la abandonaron una vez iniciada. RESULTADOS Las personas del grupo experimental que completaron el tratamiento (n = 25) tenían puntuaciones medias en sintomatología postraumática (PCL), depresiva (BDIL-II) y de ansiedad (BAI) significativamente inferiores a las obtenidas en el pretratamiento. Ninguna de ellas presentó en el postratamiento TEPT ni TDM y se redujo significativamente el porcentaje de otros trastornos de ansiedad. Estos resultados fueron significativamente mejores que los del grupo de control. Se obtuvieron tamaños del efecto pre/post grandes (d PCL = 1,39; d BDI-II = 1,19; d BAI = 1,20) y grandes y medios entre grupos (d PCL = 0,84; d BDI-II = 0,69; d BAI = 0,88). Un 78,3%, 91,7% y 91,7% obtuvieron una puntuación media inferior a la puntuación C para la PCL, el BDI-II y el BAI, y un 56,5%, 45,8% y 54,2% mejoraron según el índice de cambio fiable. Los beneficios se mantuvieron a los 6 meses de seguimiento y el análisis de intención de tratar (n = 35) y el análisis de todas las personas que habían completado el tratamiento (incluyendo al grupo control; n = 40) confirmaron la significación de los datos. La terapia tenía efectos mejores sobre la comorbilidad triple (TEPT, trastornos depresivos y ansiosos), pero no se encontró un efecto positivo de la adición de psicofármacos, en todo caso, peores resultados (por ejemplo, en la puntuación del BAI y la muestra de intención de tratar). CONCLUSIONES Los resultados de este estudio, comparables a los de otros estudios específicos previos, sugieren que la TCC centrada en el trauma y adaptada a víctimas del terrorismo que sufren TEPT o trastornos de ansiedad o depresivos muchos años después de los atentados terroristas, es eficaz. Aunque se recomienda mejorar las técnicas de motivación, hacer nuevos estudios con tamaños muestrales más amplios, donde se realicen análisis de componentes, análisis de la fiabilidad y adherencia al protocolo y atendiendo a diferentes grupos de víctimas y factores de riesgo, los resultados de esta tesis doctoral sustentan firmemente la idea de que la terapia cognitivo-conductual centrada en el trauma debe ser el tratamiento de elección para víctimas del terrorismo con TEPT, TDM u otros trastornos de ansiedad, incluso cuando éstos se presentan de manera comórbida y crónica.
OBJECTIVE This paper examines the efficacy of trauma-focused cognitive-behavioral therapy (TF-CBT) with an exposure component in victims of terrorist attacks with a longstanding history (> 5 years after terrorist attacks) of posttraumatic stress disorder (PTSD), anxiety, or depressive disorders. Thus, it aims to augment the limited scientific knowledge on the efficacy of treatments in this particular population. METHODS 120 direct and indirect victims of terrorist attacks committed in Spain, an average of 18.43 years ago, that presented separately or concurrently post-traumatic stress disorder (PTSD, 49.2%), major depressive disorder (MDD, 40.8%), and other anxiety disorders (75.8%) were randomized into either a 16 session CBT (cognitive behavioral therapy) focused in trauma (treatment group), or a 16 weeks waiting list (control group). The trauma-focused CBT was based in the prolonged exposure protocol of Foa and Rothbaum (1998) with specific techniques for mood disorders, and anxiety disorders, highlighting psychoeducation about posttraumatic reactions, cognitive restructuring and adding some other motivational strategies, emotional regulation and narrative therapy. Of the 60 people who were assigned to the experimental group, 25 (41.6 %) rejected the therapy and 10 (28.6 %) dropped out once it started. RESULTS People in the treatment group who finished the treatment (n = 25) had significantly lower average scores in post-traumatic (PCL), depressive (BDIL-II) and anxiety (BAI) symptomatology than those obtained in pre-treatment, and none of them presented PTSD nor MDD post-treatment, with significant reductions in percentages of other anxiety disorders. These results were significantly better than those of the control group. The pre/post effect size was large (d PCL = 1.39; d BDI-II = 1.19; d BAI = 1.20), and the effect sizes across groups were large and medium (d PCL = 0.84, d BDI-II = 0.69, d BAI = 0.88). A 78.3%, 91.7% and 91.79% obtained an average score below C-score for PCL, BDI-II and BAI, respectively. 56.5%, 45.8% and 54.2% improved according to the RCI (Reliable Change Index). The benefits persisted after 6 months of monitoring, and intention-to-treat analysis (n = 35) and the analysis of all the people who finished the treatment (including the control group, n = 40) confirmed the significance of the data. The therapy had best effects on triple comorbidity (PTSD and depressive and anxiety disorders), and addition of psychoactive drugs did not show positive effects, on the contrary, it was linked to worst outcomes (for example, worst BAI scores in intention-to-treat sample). CONCLUSIONS The results of this study, similar to those of other previous efficacy studies, suggest that this trauma-focused CBT, adapted for victims of terrorism who suffer from PTSD or anxiety or depression disorders many years after the terrorist attacks, is effective. Although it is recommended to improve motivation techniques, and to investigate with larger sample sizes, with specific analysis of the components of treatment, with reliability and adherence to protocol analysis and according to different groups of victims and risk factors, the results of this thesis strongly support the idea that cognitive-behavioral therapy focused on trauma should be the preferred treatment for victims of terrorism with PTSD, MDD or other anxiety disorders, even when they are comorbid and chronic.
OBJECTIVE This paper examines the efficacy of trauma-focused cognitive-behavioral therapy (TF-CBT) with an exposure component in victims of terrorist attacks with a longstanding history (> 5 years after terrorist attacks) of posttraumatic stress disorder (PTSD), anxiety, or depressive disorders. Thus, it aims to augment the limited scientific knowledge on the efficacy of treatments in this particular population. METHODS 120 direct and indirect victims of terrorist attacks committed in Spain, an average of 18.43 years ago, that presented separately or concurrently post-traumatic stress disorder (PTSD, 49.2%), major depressive disorder (MDD, 40.8%), and other anxiety disorders (75.8%) were randomized into either a 16 session CBT (cognitive behavioral therapy) focused in trauma (treatment group), or a 16 weeks waiting list (control group). The trauma-focused CBT was based in the prolonged exposure protocol of Foa and Rothbaum (1998) with specific techniques for mood disorders, and anxiety disorders, highlighting psychoeducation about posttraumatic reactions, cognitive restructuring and adding some other motivational strategies, emotional regulation and narrative therapy. Of the 60 people who were assigned to the experimental group, 25 (41.6 %) rejected the therapy and 10 (28.6 %) dropped out once it started. RESULTS People in the treatment group who finished the treatment (n = 25) had significantly lower average scores in post-traumatic (PCL), depressive (BDIL-II) and anxiety (BAI) symptomatology than those obtained in pre-treatment, and none of them presented PTSD nor MDD post-treatment, with significant reductions in percentages of other anxiety disorders. These results were significantly better than those of the control group. The pre/post effect size was large (d PCL = 1.39; d BDI-II = 1.19; d BAI = 1.20), and the effect sizes across groups were large and medium (d PCL = 0.84, d BDI-II = 0.69, d BAI = 0.88). A 78.3%, 91.7% and 91.79% obtained an average score below C-score for PCL, BDI-II and BAI, respectively. 56.5%, 45.8% and 54.2% improved according to the RCI (Reliable Change Index). The benefits persisted after 6 months of monitoring, and intention-to-treat analysis (n = 35) and the analysis of all the people who finished the treatment (including the control group, n = 40) confirmed the significance of the data. The therapy had best effects on triple comorbidity (PTSD and depressive and anxiety disorders), and addition of psychoactive drugs did not show positive effects, on the contrary, it was linked to worst outcomes (for example, worst BAI scores in intention-to-treat sample). CONCLUSIONS The results of this study, similar to those of other previous efficacy studies, suggest that this trauma-focused CBT, adapted for victims of terrorism who suffer from PTSD or anxiety or depression disorders many years after the terrorist attacks, is effective. Although it is recommended to improve motivation techniques, and to investigate with larger sample sizes, with specific analysis of the components of treatment, with reliability and adherence to protocol analysis and according to different groups of victims and risk factors, the results of this thesis strongly support the idea that cognitive-behavioral therapy focused on trauma should be the preferred treatment for victims of terrorism with PTSD, MDD or other anxiety disorders, even when they are comorbid and chronic.
Description
Tesis inédita de la Universidad Complutense de Madrid, Facultad de Psicología, leída el 14-01-2016