Journal of Traumatic Stress, Vol. 14, No.

4, 2001

Translating Research Findings to PTSD Prevention: Results of a RandomizedControlled Pilot Study

Yori Gidron,1,7 Reuven Gal,2 Sara Freedman,3 Irit Twiser,4,5 Ari Lauden,4,5 Yoram Snir,5,6 and Jonathan Benjamin4,5

Based on therapeutic studies revealing positive prognostic factors and on research ndings revealing how trauma is processed, we developed the memory structuring intervention (MSI) in attempt to prevent posttraumatic stress disorder (PTSD). The MSI attempts to shift processing of traumatic memory from uncontrollable somatosensory and affective processes to more controlled linguistic and cognitive processes by providing patients organization, labeling, and causality. In a single-blind randomizedcontrolled pilot study, 17 trafc accident victims at risk for PTSD (heart rate >94 BPM) were assigned to two MSI or two supportivelistening control sessions. Three months later, MSI patients reported signicantly less frequent intrusive, arousal, and total PTSD symptoms than controls. A replication study with a larger sample is underway.
KEY WORDS: PTSD; prevention; memory processing; randomized-controlled trial.

Considering both the frequency and impact of motor vehicle accidents (MVA), this stressor is the leading preceding traumatic event of posttraumatic stress disorder (PTSD) in Western countries (Norris, 1992). The mean prevalence of PTSD following MVA is 1020% (range 839%; e.g., Blanchard et al., 1996; Kuch, Cox, & Evans, 1996; Ursano et al., 1999). This variability results from differences in
1 Department of Sociology of Health, Faculty of Health Sciences, Ben-Gurion University, Beer Sheeba,

Israel.
2 Carmel

Institute for Social Studies, Zikron Yaacov, Israel. of Psychiatry, Hadassah University Medical Center, Jerusalem, Israel. 4 Department of Psychiatry, Soroka Medical Center of the Kupat Holim Civic Fund. 5 Faculty of Health Sciences, Ben-Gurion University, Beer Sheeba, Israel. 6 Department of Emergency Medicine, Soroka Medical Center of the Kupat Holim Civic Fund. 7 To whom all correspondence should be addressed at Department of Sociology of Health, Faculty of Health Sciences, Ben-Gurion University, Beer Sheeba, Israel.
3 Department

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0894-9867/01/1000-0773$19.50/1
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2001 International Society for Traumatic Stress Studies

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sampling, timing, and type of assessment of PTSD between studies (Blaszczynski et al., 1998). Risk factors for developing PTSD following MVA include prior psychopathology, peritraumatic dissociation, perceived severity of the MVA, high heart rate (HR) upon admission to the emergency room and initially frequent or severe intrusions (e.g., Blanchard et al., 1996; Shalev, Peri, Canetti, & Schreiber, 1996; Shalev et al., 1998; Ursano et al., 1999). To date, there have been four controlled clinical trials that attempted to prevent PTSD following MVA, all which have failed (Brom, Kleber, & Hofman, 1993; Conlon, Fahy, & Conroy, 1999; Hobbs, Mayou, Harrison, & Worlock, 1996; Mayou, Ehlers, & Hobbs, 2000). These interventions either tried to help patients cope with and assimilate the event several weeks after the MVA (Brom et al., 1993) or provided debrieng sessions (Conlon et al., 1999; Hobbs et al., 1996; Mayou et al., 2000). One trial did not target patients at risk for PTSD (Brom et al., 1993), contributing to oor effects. In two studies, debrieng was found to be associated with worse symptoms (Hobbs et al., 1996; Mayou et al., 2000), and has been suggested not be used (Kenardy, 2000). A fourth trial (Bryant, Harvey, Dang, Sackville, & Basten, 1998) compared a cognitivebehavioral treatment (CBT, n = 12) with a counseling control condition (n = 12) in prevention of PTSD among victims of civil traumatic events (trafc and home accidents) already manifesting acute stress reactions. Six months later, two CBT patients (17%), compared to 8 controls (67%), had PTSD. This study suggests that cognitive modication may be a necessary component for preventing the worsening of PTSD symptoms, but this form of treatment did not prevent or reduce its expected prevalence. These previous interventions did not systematically address what may be one of the major etiological factors in PTSD: the manner in which traumatic events are processed in memory (Siegel, 1995). Important clues from other clinical studies reveal some ways in which prognosis may be improved. Foa, Molnal, and Kashman (1995) showed that among PTSD victims of rape undergoing ooding therapy, an increasingly organized description of their trauma was associated with a better prognosis. In studies using writing as a form of trauma disclosure, Pennebaker and Francis (1996) and Pennebaker (1996) found a positive correlation between number of words reecting insight or causality and health improvements. Another set of studies provides further clues concerning the nature in which trauma is encoded and processed. Specically, van der Kolk and Fisler (1995) found that unlike nontraumatic but mildly stressful memories, traumatic memories were recalled as sensory, affective, and fragmented information. Likewise, research focusing on the cognitive processes following traumatic experiences found that PTSD patients respond differently (i.e., demonstrate a longer delay) in color naming trauma-related words than in neutral words, whereas non-PTSD controls do not show such a differential response (e.g., Cassidy, McNally, & Zeitlin, 1992; Foa, Feske, Mardoc, Kozak, & McCarthy, 1991; Moradi, Taghavi, Neshat Doost, Yule, & Dalgleish, 1999). This delay may reect PTSD patients inability

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to disregard trauma-related cues (content of traumatic words). In contrast, combat veterans who did not develop PTSD showed greater activation of brain regions that may be capable of inhibiting uncontrollable and affective responses, compared to veterans who did develop PTSD (Bremner et al., 1999). Activating such brain regions may provide trauma victims the necessary control over uncontrollable intrusive traumatic memories (van der Kolk, 1994). Finally, a recent (not yet published) study found that the comprehensibility subscale of the sense of coherence (perceived order and predictability of events), explained a great proportion of the variance in PTSD symptoms (Luszczynska-Cieslak, personal communications, August 2000). The congruence in the ndings reviewed above supports theoretical contentions (Siegel, 1995; van der Kolk, 1994; van der Kolk & Fisler, 1995) that traumatic information is encoded mainly in a somatosensory, affective, nonlinguistic, and relatively uncontrolled fragmented memory. Prevention or reduction of PTSD intensity may need to focus on shifting the processing of traumatic information from affective, somatosensory, and uncontrollable fragmented memory processes to linguistic, controllable, and more cognitive memory processes. This processing shift may not be achieved by all interventions that include emotional ventilation or debrieng alone. This processing shift may be achieved by providing chronological organization and causality to patients memory, together with cognitive labeling of their somatic and affective reactions. Such techniques may enhance control over uncontrollable memory processes typical of PTSD. This rationale led us to develop and propose a new structured method, based on the theoretically meaningful and broad empirical ndings reviewed above: the memory-structuring intervention (MSI). Having outlined the rationale, we tested in a pilot study the effects of the MSI versus a supportive-listening control condition on the frequency of PTSD symptoms following an MVA. We used a single-blind randomizedcontrolled design and hypothesized that survivors of MVA who received the MSI would report less frequent symptoms of PTSD at a 3-month followup than controls receiving the same number of supportive-listening sessions. Method Participants Seventeen patients (8 women, 9 men) admitted consecutively to the Soroka Medical Centers Emergency Room (ER) in Beer Sheeba, South of Israel, took part in this study. Patients met the following inclusion criteria: (1) Survived an MVA within the last 24 hr; (2) Did not have brain damage; (3) Were discharged from hospital within 24 hr after admission, indicating minor injury only; and (4) Had heart rate 95 BPM upon admission into the ER (a PTSD predictor; Shalev et al., 1998). The study was approved by the Ethics Committee of the University Hospital.

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Measures Background and psychological assessment. Gender and age were recorded. To assess patients PTSD risk prole briey, each patient was asked single-item questions concerning intrusions (reliving experiences), peritraumatic dissociation (amnesia or losing sense of time), and undergoing psychological treatment prior to the MVA. Each item was answered either Yes or No. To assess PTSD symptoms, the Posttraumatic Diagnostic Scale (PTDS; Foa, Cashman, Jacox, & Kevin, 1997) was used at the 34 month follow-up. This scale includes 17 items based on DSM-IV criteria of PTSD, and has been validated against the Structured Clinical Interview (Spitzer, Williams, Gibbons, & First, 1990). It has good reliability, validity, sensitivity, and specicity. In the current study, the internal consistency of the PTDS was found as = .89, and of its subscales as = .87 for intrusions, = .66 for avoidance, and = .68 for arousal. Interventions Interventions were conducted by telephone because of logistic reasons. The MSI was conducted as following. (a) Time sections: Therapist approaches the trauma survivor with an a priori set of time sections in his/her mind (e.g., in an MVA: the hours before the accident; the rst minutes of driving; the accident; the arrival of medical assistance; arrival at the hospital). (b) Listening to and clarifying patients details. Therapist actively listens to and writes down details of the patients story, while clarifying factual, sensory, and affective details (e.g., Patient: I shouted after falling; Therapist: Did you shout because of pain at that moment?; Patient: I shouted because my back hurt me). Details are noted by the therapist in their corresponding time sections, together with precise labels for thoughts and feelings, to enhance structure and cognitive processing of sensory/affective reactions. (c) Memory structuring: Therapist repeats the trauma narrative in an organized, labeled, and logical manner, adding initial implications for the patients life (insight). (d) Patients structured description: Patient describes the traumatic event in the same structured, labeled, and logical manner as the therapist did. At this point, patients usually add further details, describe the event in a more objective journalistic manner, and appear less aroused. (e) Practice structured description: Until the subsequent session, patient is asked to practice telling friends or family members the structured version of the traumatic event, to enhance the attempted memory shift. (f) Rehearsal with therapist: In the second meeting, patients practiced for the last time disclosing the traumatic memory in its structured manner. Finally, the patient was taught about the importance of and asked about his/her social support (a predictor of delayed PTSD in MVA; Buckley, Blanchard, & Hickling, 1996).

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In the supportive-listening control condition, patients were also phoned twice, and were invited to describe the event to the counselor. The counselor provided supportive listening, and informed controls about the availability of treatment from the PTSD unit in the hospital. This condition attempted to control for therapist contact, attention to the problem, and simple disclosure and ventilation without guidance. Procedure Patients meeting the inclusion criteria were contacted by phone by the counselor 24 hr following their MVA. They were informed about an ongoing study on the psychological aspects of MVA, and were asked to answer a few questions. Those providing verbal consent were then asked the three PTSD risk-factor prole questions (intrusions, dissociation, prior psychological treatment). Nearly all patients who were approached agreed to take part in the study. They were then (and on the following day) addressed by the counselor according to their randomly preassigned group status (supportive listening: n = 9; experimental MSI: n = 8). To reduce subject demoralization and attrition, patients were not informed about the existence of two types of intervention until the end of the follow-up conversation. Three to four months later, patients were contacted over the phone by a researcher blind to patients group status, for evaluation of PTSD. In cases of PTSD (based on Foa et al.s 1997 criteria), patients were advised to seek help from the PTSD unit at the Soroka Medical Center. Results Table 1 depicts the age, gender, PTSD risk-factor prole, and PTSD total and subscale scores of MSI and control subjects. No signicant differences were found in relation to age, gender, or risk-factor prole data between the two groups. At the 34 month follow-up, 5 of the 17 patients (29%) met DSM-IV criteria for PTSD using Foa et al.s cutoff (Foa et al., 1997). Four of them were controls (44%) and one was in the MSI condition (12%). All following, results are reported with one-tailed p values. At follow-up, MSI patients reported signicantly less frequent total PTSD symptoms [t(13) = 2.36, p < .05], less frequent intrusion symptoms [t(10) = 2.50, p < .05] and less frequent arousal symptoms [t(15) = 1.90, p < .05].8 No signicant differences were found in relation to avoidance symptoms. Differences between conditions in total PTSD symptoms remained signicant when controlling separately for prior psychological treatment, peritraumatic dissociation, and early
8 The degrees of freedom vary among tests because of signicant differences in variances among groups;

hence, violating Levenes test for equality of variances.

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Gidron, Gal, Freedman, Twiser, Lauden, Snir, and Benjamin Table 1. Background, PTSD Risk-Prole, and 3 4 Month Follow-Up of PTSD Scores of MVA Victims Undergoing Supportive-Listening (Control) or Memory-Structuring (Experimental) Treatments Variable Background Gender Age average (years) PTSD risk prole (%) Peritraumatic dissociation Early intrusions Pre-MVA psychological treatment PTSD measures (at 34 months) Total PTDS score Arousal Avoidance Intrusions Control group (n = 9) 4 women, 5 men 36.2 62 11 50 18.5 7.7 5.1 5.8 Experimental group (n = 8) 3 women, 5 men 40.1 44 12 78 8.1 4.2 2.2 1.6

Note. PTSD: Post-traumatic stress disorder; PTDS: Posttraumatic Diagnostic Scale; MVA: Motor vehicle accident. p < .05, one-tailed.

intrusions (which, though not signicantly, appeared to differ between groups at baseline). Discussion This paper presents the rationale and preliminary testing of the efcacy of a new brief intervention aimed at preventing PTSD. The MSI was derived from results of studies revealing prognostic factors predictive of improvement in therapeutic settings, and from convergence of recent studies informing us how trauma is processed and encoded in memory. To the best of our knowledge, this is among the rst studies demonstrating the effectiveness of a simple, inexpensive intervention, signicantly reducing and perhaps preventing PTSD symptoms in MVA victims. This is in contrast with previous attempts (Brom et al., 1993; Conlon et al., 1999; Hobbs et al., 1996; Mayou et al., 2000). The results of the current pilot study were obtained using a randomized-controlled single-blind design, seeking MVA victims at risk for PTSD. The simplicity and duration of treatment make the MSI feasible for training nonprofessionals in the prevention of PTSD under acute conditions. Replication of these preliminary results with larger samples and performing content analysis on patients narratives will support the theoretical contention that a shift in memory processes may be a key factor in PTSD prevention. The ndings of this pilot study must be seen as preliminary, and need to be replicated in a larger sample (currently underway). Furthermore, the maintenance of effects over time was not shown, and this requires further study. In addition, no baseline levels of PTSD symptoms were obtained, and thus we cannot state with

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condence that the MSI reduced symptoms. Such an assessment was not used because it was thought to be unsuitable to administer a PTSD scale within the 24 hr following the MVA. Given previous negative ndings concerning various debrieng methods (Kenardy, 2000), it is possible that part of the observed effects stem from controls not improving. However, the magnitude of our effects suggest that the differences between groups found at follow-up also reect the effects of the experimental MSI intervention. Another limitation is that MSI patients received more therapist time than controls. This reduces the ability to state that the MSI was the only causal factor in our results, rather than the amount of time spent speaking to the therapist. However, previous intervention studies reviewed above, which included simple ventilation or repeated debrieng sessions, were not successful. Finally, the MSI may be unsuitable for trauma victims suffering from amnesia concerning the event. Should these preliminary results be replicated, this intervention may have preventive value in relation to a common psychiatric outcome of MVA (and other traumatic events), an outcome with important consequences for patients quality of life (Mayou, Tyndel, & Bryant, 1997; Zatzick et al., 1997). We plan to test the effects of MSI on brain processes associated with PTSD as well as with chronic PTSD patients. Acknowledgments The authors thank Ms. Iirit Azar, Ms. Ksenija Kontak, MA, Mr. Dragan Jusupovic, MA, & Ms. Gordana Kuterovac, MA, for their kind assistance and collaboration. References
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