Treating Acute Stress Disorder:

An Evaluation of Cognitive Behavior Therapy

and Supportive Counseling Techniques
Richard A. Bryant, Ph.D., Tanya Sackville, M.Psych., Suzanne T. Dang, M.Psych.,
Michelle Moulds, M.Psych., and Rachel Guthrie, M.Psych.

Objective: Acute stress disorder permits an early identification of trauma survivors who
are at risk of developing chronic posttraumatic stress disorder (PTSD). This study aimed to
prevent PTSD by an early provision of cognitive behavior therapy. Specifically, this study indexed the relative efficacy of prolonged exposure and anxiety management in the treatment of acute stress disorder. Method: Forty-five civilian trauma survivors with acute
stress disorder were given five sessions of 1) prolonged exposure (N=14), 2) a combination
of prolonged exposure and anxiety management (N=15), or 3) supportive counseling (N=
16) within 2 weeks of their trauma. Forty-one trauma survivors were assessed at the 6month follow-up. Results: Fewer patients with prolonged exposure (14%, N=2 of 14) and
prolonged exposure plus anxiety management (20%, N=3 of 15) than supportive counseling (56%, N=9 of 16) met the criteria for PTSD after treatment. There were also fewer
cases of PTSD in the prolonged exposure group (15%, N=2 of 13) and the prolonged exposure plus anxiety management group (23%, N=3 of 13) than in the supportive counseling group (67%, N=10 of 15) 6 months after the trauma. Chronic PTSD in the supportive
counseling condition was characterized by greater avoidance behaviors than in the prolonged exposure condition or the prolonged exposure plus anxiety management condition
Conclusions: These findings suggest that PTSD can be effectively prevented with an
early provision of cognitive behavior therapy and that prolonged exposure may be the most
critical component in the treatment of acute stress disorder.
(Am J Psychiatry 1999; 156:17801786)

cute stress disorder describes posttraumatic stress

reactions that occur between 2 days and 4 weeks following a trauma (1). A major use of this diagnosis is
that it can identify many individuals in the acute phase
who will subsequently develop chronic posttraumatic
stress disorder (PTSD). For example, between 78%
and 82% of motor vehicle accident survivors who satisfy the criteria for acute stress disorder suffer PTSD 6
months posttrauma (2, 3). These patterns contrast
with evidence that whereas 94% of rape victims meet
the symptomatic criteria shortly after their assaults,
only 47% still meet these criteria 3 months after the
trauma (4). It appears that the particular diagnostic
Received Dec. 3, 1998; revision received April 15, 1999;
accepted April 30, 1999. From the School of Psychology, University of New South Wales. Address reprint requests to Dr. Bryant,
School of Psychology, University of New South Wales, Sydney
NSW 2052, Australia; r.bryant@unsw.edu.au (e-mail).
Supported by a grant from the National Health and Medical
Research Council.

1780

criteria in acute stress disorder permit a more accurate

identification of those individuals who will not naturally recover from the adverse effects of their traumatic
experience.
The capacity to identify in the acute trauma phase
those individuals who are at risk of developing chronic
PTSD provides an opportunity to prevent the development of chronic PTSD through early intervention. Numerous studies have evaluated early treatment programs for posttraumatic stress. One early study (5)
reported that recent rape victims demonstrated comparable symptom reduction following either behavioral
intervention, repeated assessment, or delayed assessment. Another study (6) provided recent assault victims with either four sessions of cognitive behavior
therapy or repeated assessments. Whereas 10% of the
cognitive behavior therapy group and 70% of the repeated assessment group met the criteria for PTSD 2
months after the trauma, 6 months after the assault,
the rates of PTSD were comparable (cognitive behavAm J Psychiatry 156:11, November 1999

BRYANT, SACKVILLE, DANG, ET AL.

ior therapy group=11%, assessment comparison

group=22%). These studies did not treat people with
acute stress disorder, however, and accordingly, it is
possible that these earlier studies employed samples
that may have experienced transient posttraumatic
stress reactions that did not develop into persistent
PTSD. In the only treatment study to date of acute
stress disorder (7), five sessions of either cognitive behavior therapy or supportive counseling were provided
to civilian trauma survivors who met the criteria for
acute stress disorder. Cognitive behavior therapy involved prolonged imaginal exposure, cognitive therapy, and anxiety management, and supportive counseling included nondirective counseling and general
problem solving. This study found that 17% and 67%
of the cognitive behavior therapy and supportive counseling groups, respectively, met the criteria for PTSD 6
months after the trauma. This finding indicated that
cognitive behavior therapy was an effective technique
for resolving acute trauma responses that would otherwise lead to chronic PTSD.
The current study aimed to replicate and extend
these previous findings by identifying the critical ingredients of cognitive behavior therapy that can prevent
PTSD in people with acute stress disorder. Specifically,
previous studies have argued that the therapeutic gains
achieved by cognitive behavior therapy are primarily
mediated by the activation of fear networks as a result
of prolonged exposure (6, 7). It is proposed that resolution of a traumatic experience requires prolonged activation of trauma-related mental representations in
order to allow habituation of anxiety and modification
of maladaptive trauma-related beliefs (8). This interpretation is consistent with finding that chronic PTSD
is mediated by deficits in accessing trauma memories
during the acute trauma phase (9). It is also supported
by evidence that prolonged exposure leads to longstanding gains in the treatment of chronic PTSD (8).
The other active component of cognitive behavior
therapy is anxiety management, which is included to
reduce the arousal symptoms associated with acute
stress disorder. There is increasing evidence that acute
stress reactions are mediated by elevated arousal. Biological models of PTSD propose that excessive arousal
at the time of the traumatic experience results in strong
fear conditioning that results in PTSD (10). This notion is supported by recent findings that people who
subsequently develop PTSD show higher levels of heart
rates in the acute phase after a traumatic event than
those who do not develop PTSD (11, 12). This evidence suggests that the reduction of arousal in the
acute phase may prevent the development of PTSD.
There is evidence that anxiety management techniques
can lead to significant reductions in PTSD symptoms
(8, 13). Accordingly, this study indexed the extent to
which the benefits of prolonged exposure can be enhanced by also providing anxiety management to recent trauma survivors who suffer acute stress disorder.
Additionally, we compared these treatments to supportive counseling to provide an index of the benefits
Am J Psychiatry 156:11, November 1999

TABLE 1. Characteristics of Civilian Trauma Survivors With

Acute Stress Disorder Given Cognitive and Behavior Therapy
2 Weeks After Experiencing Trauma
Prolonged
Exposure
Plus Anxiety
Management
(N=15)

Prolonged
Exposure
(N=14)

Supportive
Counseling
(N=16)

Mean SD Mean SD Mean SD

Characteristic
Age (years)
32.53 10.92 32.50 13.39 36.69 12.01
Interval between
trauma and
assessment (days) 10.34 3.34 9.98 4.10 10.56 3.39
Posttreatment
follow-up interval
(months)
7.00 1.55 7.31 1.18 7.41 1.96
Expectancy of
treatment successa 8.18 2.93 8.01 3.01 7.10 2.23
Acute stress disorder
14.73 2.02 13.29 3.15 13.01 2.08
severityb
a 1=not at all confident, 10=extremely confident.
b Range=119; higher score indicates greater severity

of active treatments relative to nonspecific therapy. On

the premise that the combined treatment program
would have an additive benefit in treating acute stress
disorder, we predicted that prolonged exposure plus
anxiety management would result in fewer PTSD
symptoms than prolonged exposure and that both
treatments would be more effective than supportive
counseling.

METHOD
Patients
Patients were survivors of either motor vehicle accidents or nonsexual assault who were referred to the PTSD Unit at Westmead
Hospital, Sydney, New South Wales, Australia. The referral sources
included hospital staff, local community mental health centers, and
police. Inclusion criteria included 1) having been involved in either a
motor vehicle accident or a nonsexual assault within the past 2
weeks, 2) satisfying the criteria for acute stress disorder, 3) proficiency in English, and 4) aged 1860 years. Exclusion criteria
included 1) current suicidal ideation (N=4), 2) a diagnosis of
psychosis, organic mental disorder, or substance abuse (N=8), and
3) evidence of brain injury sustained in the trauma (N=3).
There were initially 66 patients in the study but 11 (four in prolonged exposure plus anxiety management, four in prolonged exposure, and three in supportive counseling) dropped out of treatment
before completion of all treatment sessions. In terms of completed
treatment, there were 15 (seven women and eight men) patients in
the prolonged exposure plus anxiety management condition, 14
(seven women and seven men) in the prolonged exposure condition,
and 16 (nine women and seven men) in the supportive counseling
condition. There were seven motor vehicle accident survivors in each
group, and eight, seven, and nine nonsexual assault victims in the
prolonged exposure plus anxiety management, prolonged exposure,
and supportive counseling groups, respectively. Each group included
several patients who did not fully satisfy the criteria for acute stress
disorder because they reported only two, rather than three, dissociative symptoms (two in prolonged exposure plus anxiety management, two in prolonged exposure, and three in supportive counseling). Table 1 presents the mean participant characteristics. One-way
analyses of variance (ANOVAs) indicated no significant differences
between groups in terms of age, intervals between trauma and as-

1781

TREATING ACUTE STRESS DISORDER

sessment, intervals before posttreatment follow-up, or pretreatment

acute stress disorder severity.

Diagnostic Measures
The Acute Stress Disorder Interview (14) is a structured clinical
interview that is based on the DSM-IV criteria for acute stress disorder, contains 19 dichotomously scored items that relate to the symptoms of acute stress disorder, and provides a total score of acute
stress severity (range=119). The Acute Stress Disorder Interview
possesses sound test-retest reliability (r=0.95), sensitivity (91%), and
specificity (93%).
The Clinician Administered PTSD Scale, Form 2 (15), was employed for posttreatment and follow-up diagnostic assessments because the time frame of these assessments required PTSD, rather
than acute stress disorder, diagnostic decisions. The Clinician Administered PTSD Scale, Form 2, assesses the frequency and severity
of each PTSD symptom in the context of the last week and possesses
sound test-retest reliability and strong convergent validity with standard measures of PTSD (15).

Self-Report Measures
The Impact of Event Scale (16) is a 15-item, self-report inventory
that indexes intrusive and avoidance symptoms of posttraumatic
stress.
The Beck Depression Inventory (17) is a 21-item inventory that
indexes depression and correlates soundly (0.620.66) with clinician
ratings of depression.
The State-Trait Anxiety Inventory (18) state anxiety scale contains 20 items that index state anxiety and possesses sound test-retest reliability (0.730.86) and strong internal consistency (0.83
0.92).
After explanation of the treatment rationale, patients were asked
to rate their confidence in the expected efficacy of their treatment by
completing a 10-point Likert scale (1=not at all confident, 10=extremely confident).

Procedure
After complete description of the study to the patients, written informed consent was obtained. Patients were assessed before treatment (time 1), after treatment (time 2), and at 6-month follow-up
(time 3). All posttreatment and follow-up assessments were conducted by a clinical psychologist (T.S., S.T.D., M.M., or R.G.) who
was blind to treatment group status. All measures were administered
at each assessment, except that the Acute Stress Disorder Interview
was administered at time 1 and the Clinician Administered PTSD
Scale, Form 2, was administered at times 2 and 3. Patients who met
the criteria for acute stress disorder were randomly allocated to one
treatment program. Each group received five 1.5-hour individually
administered sessions conducted by one of the four clinical psychologists. Each therapist was trained in the therapy protocols by the
first author (R.A.B.). Sessions occurred once weekly. Treatment adherence was facilitated by strict compliance with therapy manuals
and was monitored by the first author (R.A.B.), who reviewed case
notes and monitoring records of each participant on a weekly basis.
The first session comprised education about trauma reactions,
breathing retraining, training in progressive muscle relaxation, and
learning self-talk exercises to manage anxiety-producing situations.
Subsequent to the initial session, patients completed each of these
techniques on a daily basis as homework, and patients progress was
monitored at each session. The second session involved the rationale
for exposure and commencement of prolonged imaginal exposure to
traumatic memories. Fifty minutes of each of the final four sessions
were devoted to patients reliving their traumas by focusing attention
on their memories and engaging with their affective responses. These
narratives were not audiotaped, but patients were instructed to complete this exposure in the same manner as in therapy as daily homework. Following each exposure session, cognitive restructuring of
fear-related beliefs that were identified during the exposure was conducted. Cognitive restructuring involved teaching patients to identify irrational, threat-related beliefs and to enhance realistic thinking
by evaluating thoughts against the available evidence. Cognitive re-

1782

structuring was combined with exposure in this study because of the

reported utility of modifying trauma-related cognitions that are elicited by exposure (19). Sessions 4 and 5 also included in vivo exposure and relapse-prevention exercises.
The first session involved education about trauma reactions and
an explanation of prolonged exposure. The second session focused
on prolonged exposure, in the same manner as described in the prolonged exposure plus anxiety management condition. Each prolonged exposure session was followed by cognitive restructuring.
Care was taken to ensure that equivalent time was allocated to imaginal exposure in both the prolonged exposure plus anxiety management and prolonged exposure conditions because previous work has
indicated that the efficacy of combined treatments may be reduced
by restricting the time available to exposure (20). Accordingly, the
prolonged exposure condition was supplemented with supportive
counseling to ensure that the active treatment components were controlled across the prolonged exposure plus anxiety management and
the prolonged exposure conditions. Prolonged exposure and cognitive restructuring were continued in each session. Sessions 4 and 5
included in vivo exposure and relapse-prevention exercises.
The first session involved education about trauma and an explanation of the nature of supportive counseling. The following sessions
included general problem-solving skills and the provision of an unconditionally supportive role for the therapist. Homework involved
diary keeping of current problems and mood states. Supportive
counseling specifically avoided exposure or anxiety management
techniques.

RESULTS

Preliminary Analyses

The seven patients who displayed two acute dissociative symptoms of stress disorder did not differ from
patients who displayed the required three dissociative
symptoms on any pretreatment measures, including
the Impact of Event Scale, the State-Trait Anxiety Inventory, and the Beck Depression Inventory. That is,
these patients displayed comparable levels of acute
psychopathology as those who met the full criteria.
The 11 patients who dropped out of treatment differed
from those who completed treatment in terms of the
severity of their acute stress disorder (F=2.48, df=2,
54, p<0.05) and their State-Trait Anxiety Inventory
scores for state anxiety (F=3.55, df=2, 64, p<0.01).
That is, those who dropped out of treatment reported
more severe acute stress disorder and higher scores for
state anxiety than those who completed therapy. Of
the 45 patients who completed treatment, four (two in
prolonged exposure plus anxiety management, one in
prolonged exposure, and one in supportive counseling)
were not included in the follow-up assessment because
two could not be contacted and two were instructed by
legal counsel not to participate.
Diagnostic Status

McNemars chi-square tests indicated that at posttreatment, fewer patients in the prolonged exposure
plus anxiety management group (20%, N=3 of 15) and
the prolonged exposure group (14%, N=2 of 14) met
the criteria for PTSD than in the supportive counseling
group (56%, N=9 of 16) (2=7.43, N=45, df=2, p<
0.05, with Yatess correction [21]). Paired chi-square
Am J Psychiatry 156:11, November 1999

BRYANT, SACKVILLE, DANG, ET AL.

comparisons indicated that more patients in the supportive counseling group met the criteria for PTSD
than in the prolonged exposure plus anxiety management group ( 2 =4.27, N=31, df=1, p<0.05, with
Yatess correction) and in the prolonged exposure
group (2=5.54, N=30, df=1, p<0.02, with Yatess correction). Similarly, at the 6-month follow-up, fewer patients in the prolonged exposure plus anxiety management (23%, N=3 of 13) and prolonged exposure
(15%, N=2 of 13) groups met the criteria for PTSD
than in the supportive counseling group (67%, N=10
of 15) (2=9.39, N=41, df=2, p<0.01, with Yatess correction). Paired chi-square comparisons indicated that
more patients in the supportive counseling group met
the criteria for PTSD than in the prolonged exposure
plus anxiety management group (2=5.36, N=28, df=
1, p<0.05, with Yatess correction) and in the prolonged exposure group (2=7.59, N=28, df=1, p<0.01,
with Yatess correction).
Posttraumatic Stress Severity

A series of three-(group) by-three (assessment), repeated-measures ANOVAs were conducted on Impact

of Event Scale, State-Trait Anxiety Inventory, and Beck
Depression Inventory scores (table 2). Post hoc Tukey
comparisons were conducted with an adjusted alpha
rate of 0.01 to provide an overall significance level of
0.05. A three-by-three, repeated-measures ANOVA on
Impact of Event Scale scores for instruction indicated a
significant main effect for time (F=56.05, df=2, 37, p<
0.001) and a significant group-by-time interaction effect (F=5.03, df=4, 76, p<0.001). Post hoc Tukey comparisons indicated that patients reported higher Impact
of Event Scale scores for intrusion at time 1 than at
times 2 and 3. When we used post hoc t tests, patients
in supportive counseling reported higher Impact of
Event Scale scores for intrusion at posttreatment than
did patients with prolonged exposure (t=4.08, df=28,
p<0.001).
A three-by-three, repeated-measures ANOVA on Impact of Event Scale avoidance scores indicated a significant main effect for time (F=26.78, df=2, 37, p<0.001)
and a significant group-by-time interaction effect (F=
2.98, df=4, 76, p<0.05). Post hoc comparisons indicated that patients reported higher Impact of Event
Scale avoidance scores at time 1 than at times 2 and 3.
Further, supportive counseling patients displayed
higher Impact of Event Scale scores for avoidance at
the 6-month follow-up than both the patients with
prolonged exposure plus anxiety management (t=3.91,
df=26, p<0.01) and the patients with prolonged exposure (t=11.75, df=26, p<0.001).
A three-by-three, repeated-measures ANOVA on
State-Trait Anxiety Inventory scores for state anxiety
indicated a significant main effect for time (F=29.45,
df=2, 37, p<0.001) and a significant group-by-time interaction effect (F=2.58, df=4, 76, p<0.05). Post hoc
comparisons indicated that patients reported higher
State-Trait Anxiety Inventory scores for state anxiety
Am J Psychiatry 156:11, November 1999

TABLE 2. Psychopathology Scores for Civilian Trauma Survivors With Acute Stress Disorder Given Cognitive and Behavior Therapy 2 Weeks After Experiencing Trauma
Prolonged
Exposure
Plus Anxiety
Management
(N=15)
Measure and Time
Impact of Event
Scale score
Intrusion
Pretreatment
Posttreatment
Follow-upa
Avoidance
Pretreatment
Posttreatment
Follow-upa
State-Trait Anxiety
Inventory score
for state anxiety
Pretreatment
Posttreatment
Follow-upa
Beck Depression
Inventory score
Pretreatment
Posttreatment
Follow-upa
Clinician Administered
PTSD Scale, Form 2
Symptom
Frequency
Posttreatment
Follow-upa
Symptom
Intensity
Posttreatment
Follow-upa
a N=41.

Mean

SD

Prolonged
Exposure
(N=14)
Mean

28.46 5.59 27.62

13.15 15.81 8.54
10.31 10.00 11.08

SD

Supportive
Counseling
(N=16)
Mean

SD

6.08 26.47
8.64 22.80
8.86 15.67

4.69
9.17
6.34

26.46 6.54 26.46 9.02 22.73

10.31 10.54 7.92 8.20 21.33
8.54 10.20 8.38 10.32 20.13

5.57
6.23
4.66

54.77 10.28 51.69 12.41 50.47 7.39

34.31 16.95 35.92 10.12 41.47 12.91
35.00 12.91 36.62 12.69 44.73 7.34
20.08 12.52 19.69 11.38 20.47
8.92 8.98 7.77 7.70 13.73
8.92 8.98 7.97 7.76 13.73

7.19
7.21
7.21

13.69 10.93 11.31 10.73 22.60 11.26

14.62 13.72 12.62 13.63 26.47 8.40
12.00 10.31 9.92 9.00 20.53 10.72
15.00 13.68 12.23 11.77 29.00 9.91

at time 1 than at times 2 and 3. The supportive counseling patients displayed only marginally higher StateTrait Anxiety Inventory scores for state anxiety at the
6-month follow-up than both the patients with prolonged exposure plus anxiety management (t=2.50,
df=26, p<0.02) and the patients with prolonged exposure (t=2.08, df=26, p<0.05).
A three-by-three, repeated-measures ANOVA on
Beck Depression Inventory scores indicated a significant main effect for time (F=19.95, df=2, 37, p<0.001).
Post hoc comparisons indicated that patients reported
higher Beck Depression Inventory scores at time 1 than
at times 2 and 3.
Separate three-by-two, repeated-measures ANOVAs
were also conducted on Clinician Administered PTSD
Scale, Form 2, scores for intensity and frequency; the
Clinician Administered PTSD Scale, Form 2, scores
were obtained only after treatment and at follow-up. A
three-by-two, repeated-measures ANOVA of Clinician
Administered PTSD Scale, Form 2, scores for intensity
indicated significant main effects for time (F=8.26, df=
1, 38, p<0.01) and group (F=8.07, df=2, 38, p<0.001).
Patients reported lower scores for intensity after treat1783

TREATING ACUTE STRESS DISORDER

TABLE 3. Rate of Improvement for Civilian Trauma Survivors With Acute Stress Disorder After Cognitive and Behavior Therapy
Given 2 Weeks After Experiencing Trauma

Time and Measure

Posttreatment
Impact of Event Scale score
Intrusion
Avoidance
State-Trait Anxiety Inventory score for state anxiety
Beck Depression Inventory score
Follow-up (N=41)
Impact of Event Scale score
Intrusion
Avoidance
State-Trait Anxiety Inventory score for state anxiety
Beck Depression Inventory score

Patients Showing Improvement

(scoring 2 SDs below pretreatment mean)
Prolonged
Exposure
Plus Anxiety
Prolonged
Supportive
Management
Exposure
Counseling
(N=15)
(N=14)
(N=16)
N
%
N
%
N
%

12
10
8
3

80
67
53
20

10
10
6
3

71
71
43
21

6
4
2
3

38
25
13
19

6.69
8.39
6.32
0.03

0.05
0.02
0.05
n.s.

10
8
5
2

77
62
38
15

8
9
6
3

62
69
46
23

9
3
2
2

60
20
13
13

1.04
8.16
3.98
0.54

n.s.
0.02
n.s.
n.s.

ment than at follow-up. The supportive counseling patients reported higher scores for intensity than did the
patients with prolonged exposure (t=4.09, df=26, p<
0.001) and the patients with prolonged exposure plus
anxiety management (t=3.13, df=26, p<0.01). A threeby-two, repeated-measures ANOVA of Clinician Administered PTSD Scale, Form 2, scores for frequency
indicated a significant main effect for group (F=4.18,
df=2, 38, p<0.05). Post hoc comparisons indicated that
supportive counseling patients reported higher scores
for frequency than did the patients with prolonged exposure (t=3.48, df=26, p<0.01) and the patients with
prolonged exposure plus anxiety management (t=3.13,
df=26, p<0.01).
Treatment Effects

To index the clinical significance of therapy gains,

we followed Jacobson and Truaxs (22) suggested technique for when population norms are unavailable.
That is, because of the lack of normative data on acute
stress disorder populations, we defined clinical improvement as a reduction of at least 2 standard deviations below the pretreatment mean of our study group.
Table 3 presents the summary data of treatment effects. At posttreatment, more patients with prolonged
exposure plus anxiety management and more patients
with prolonged exposure than patients with supportive
counseling improved in terms of the Impact of Event
Scale scores for intrusion and avoidance and StateTrait Anxiety Inventory scores for state anxiety. The
groups did not differ on Beck Depression Inventory
scores. At the follow-up assessment, more patients
with prolonged exposure plus anxiety management
and more patients with prolonged exposure than patients with supportive counseling improved in terms of
Impact of Event Scale scores for avoidance.
1784

Analysis
2 (df=2)

DISCUSSION

These findings replicate a previous report that acute

stress disorder can be effectively treated, and PTSD
prevented, with a brief intervention of cognitive behavior therapy in the acute posttrauma phase (7). In contrast to previous reports that approximately 80% of
individuals who initially meet the criteria for acute
stress disorder will suffer chronic PTSD 6 months after
the trauma (2, 3), this study found that relatively few
individuals met the criteria for PTSD after either prolonged exposure plus anxiety management (23%, N=3
of 13) or prolonged exposure (15%, N=2 of 13).
Contrary to our expectations, there were no differences in outcomes between the prolonged exposure
and prolonged exposure plus anxiety management
groups. This pattern suggests that anxiety management did not add to the treatment gains obtained by
prolonged exposure. It may be argued that habituation
of anxiety through prolonged exposure and modification of maladaptive beliefs through cognitive therapy
were the critical therapeutic processes that mediated
adaptation. This interpretation is consistent with evidence that whereas anxiety management can result in
immediate symptom reduction in chronic PTSD, prolonged exposure leads to a more effective long-term reduction of PTSD symptoms (8). This finding may be
interpreted in terms of information-processing theory,
which holds that recovery from trauma requires 1) activation of traumatic memories and 2) modification of
threat-based beliefs to correct the fear networks that
perpetuate PTSD symptoms (23).
An unexpected finding in this study was that
whereas prolonged exposure plus anxiety management
and prolonged exposure produced greater reductions
in avoidance behavior at follow-up, there were comparable reductions in intrusive and arousal symptoms
across all groups. This finding may be understood, in
part, in the context of evidence that whereas intrusions
Am J Psychiatry 156:11, November 1999

BRYANT, SACKVILLE, DANG, ET AL.

can decline with time, avoidance behaviors can develop as time passes (24). It appears that a significant
benefit for patients who received prolonged exposure
plus anxiety management and prolonged exposure was
that they did not develop avoidance behaviors that
were evident in those who received supportive counseling. The active treatments may have resulted in reductions in acute symptoms that would otherwise have
elicited avoidance behavior.
The rate of PTSD in those who received supportive
counseling (67%, N=10 of 15) was comparable to previous reports of treating acute stress disorder with supportive counseling (7). Although the rate of PTSD following supportive counseling was significantly higher
than the rates following the active treatments, the rate
of PTSD 6 months after supportive counseling was less
than the incidence of 80% that has been reported in
prospective studies of acute stress disorder (2, 3). This
finding suggests that therapeutic support may play
some helpful role in ameliorating the symptoms of
acute stress disorder. These benefits appear to be marginal, however, in comparison to the positive effects of
cognitive behavior therapy.
Conclusions from this study need to be interpreted in
the context of several methodological issues. First,
these results are applicable only to motor vehicle accident and nonsexual assault victims and should not be
generalized to other trauma populations. Second, we
did not index comorbidity issues. The influence of
early intervention on long-term depression, substance
abuse, and other comorbid conditions commonly associated with PTSD would strengthen our conclusions
concerning the use of treating acute stress disorder.
Third, the diagnosis of acute stress disorder is a recent
development, and its validity has yet to be firmly established. Although the Acute Stress Disorder Interview
has strong psychometric properties, our initial assessments could have been stronger by including interrater
reliability checks. Fourth, we did not include the Clinician Administered PTSD Scale at the initial assessment
because of patients acute stress disorder status. Completion of the Clinician Administered PTSD Scale at
each assessment would have permitted a stronger measurement of the effects of treatment on PTSD symptoms. Fifth, this studys use of combined prolonged
exposure and cognitive therapy did not permit delineation of the relative effects of imaginal exposure and
cognitive therapy. Although information-processing
theories posit that prolonged exposure can facilitate
cognitive restructuring (25), recent commentaries have
questioned this assumption (26). Future treatment
studies of acute stress disorder could usefully compare
the efficacy of prolonged exposure and prolonged exposure combined with cognitive therapy. Finally, we
recognize that our group size was modest, and it is possible that increased power may have resulted in a more
stringent comparison of prolonged exposure and prolonged exposure plus anxiety management. Relatedly,
we recognize that we included seven patients who displayed two, rather than the required three, dissociative
Am J Psychiatry 156:11, November 1999

symptoms. We concluded that these patients should be

included in the study because 1) they reported comparable psychopathology levels to those who reported
three dissociative symptoms, 2) there is no empirical
justification for the stipulation of three dissociative
symptoms in the acute stress disorder criteria (1), and
3) there is evidence that these patients are as likely to
suffer chronic PTSD as those who meet the full criteria
for acute stress disorder (3, 27).
We recognize that patients who dropped out of treatment were characterized by more severe acute stress
disorder and higher levels of anxiety. This pattern suggests that whereas early intervention has a strong potential to prevent PTSD, those individuals who are
most distressed may not be amenable to early intervention. Alternatively, different strategies may need to be
developed to meet the particular needs of more severely distressed individuals in the acute phase. Considering the prominence of acute dissociative symptoms in patients with acute stress disorder, future
treatment studies should investigate strategies that
may facilitate exposure in patients with dissociative
disorder. Techniques such as hypnotherapy may be
useful for acute dissociative symptoms and should be
evaluated through controlled outcome studies (28).
Empirically determining the optimal components of
acute stress disorder treatments will facilitate our ability to prevent PTSD in acutely traumatized patients
who are most at risk of long-term disorder.
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2. Bryant RA, Harvey AG: Relationship of acute stress disorder
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brain injury. Am J Psychiatry 1998; 155:625629
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