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Original Research

A Randomized Controlled Trial of the Safety and Promise of Cognitive-Behavioral Therapy Using Imaginal Exposure in Patients With Posttraumatic Stress Disorder Resulting From Cardiovascular Illness

Eyal Shemesh, MD; Rachel A. Annunziato, PhD; Beth D. Weatherley, PhD; Gad Cotter, MD; John R. Feaganes, PhD; Mugdha Santra, MD; Rachel Yehuda, PhD; and David Rubinstein, MD

Published: April 13, 2010

Article Abstract

Objective: We investigated the physical safety of cognitive-behavioral therapy (CBT) utilizing imaginal exposure in patients who suffered from posttraumatic stress disorder (PTSD) following a life-threatening cardiovascular event.

Method: In this phase I, prospective, single-blind trial conducted from April 2006 through April 2008, we randomly assigned 60 patients to receive either 3 to 5 sessions of imaginal exposure therapy (experimental group) or 1 to 3 educational sessions only (control group). Criteria for PTSD and other mental health disorders were evaluated according to DSM-IV using the full Structured Clinical Interview for DSM-IV (SCID). Safety assessments included patients’ blood pressure and pulse before and after each study session and the occurrence of deaths, hospitalizations, repeat myocardial infarctions, or invasive procedures. We also investigated the effects of the treatment on PTSD symptoms (Impact of Event Scale and Posttraumatic Stress Disorder Scale), depression (Beck Depression Inventory-II), and the Clinical Global Impressions-Severity of Illness (CGI-S) scale.

Results: There were no significant differences between the experimental and control groups and between exposure and nonexposure sessions in any of the safety measures. In addition, confidence intervals were such that the nonsignificant effects of exposure therapy were not of clinical concern. For example, the mean difference in systolic pressure between control and exposure sessions was 0.5 mm Hg (95% CI, −6.1 to 7.1 mm Hg). Nonsignificant improvements were found on all psychiatric measures in the experimental group, with a significant improvement in CGI-S in the entire cohort (mean score difference, −0.6; 95% CI, −1.1 to −0.1; P‘ ‰=‘ ‰.02) and a significant improvement in PTSD symptoms in a subgroup of patients with acute unscheduled cardiovascular events and high baseline PTSD symptoms (mean score difference, −1.2; 95% CI, −2.0 to −0.3; P‘ ‰=‘ ‰.01).

Conclusions: Cognitive-behavioral therapy that includes imaginal exposure is safe and promising for the treatment of posttraumatic stress in patients with cardiovascular illnesses who are traumatized by their illness.

Trial Registration: Identifier: NCT00364910

J Clin Psychiatry

Submitted: January 21, 2009; accepted August 14, 2009.

Online ahead of print: April 6, 2010 (doi:10.4088/JCP.09m05116blu).

Corresponding author: Eyal Shemesh, MD, Division of Developmental and Behavioral Health, Department of Pediatrics, Box 1198, Mount Sinai Medical Center, OneGustave L. Levy Place, New York, NY 10029 (

Volume: 71

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