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Cited by 71Posttraumatic Stress Disorder ResearchPsychotherapy Techniques and ApplicationsPsychoanalysis and Psychopathology Research

Does change in distress matter? Mechanisms of change in prolonged exposure for PTSD

Open access
Bluett, Ellen J., Zoellner, Lori A., Feeny, Norah C.·2014·Journal of Behavior Therapy and Experimental Psychiatry
DOI 10.1016/j.jbtep.2013.09.003PMC PMC3883671
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Abstract

Background and objectives Clinically, many individuals persist in prolonged exposure therapy (PE) for chronic PTSD despite continuing distress during recounting of the trauma memory (imaginal exposure). Theorists suggest that distress reduction is necessary for successful treatment outcome (e.g., Foa & Kozak, 1986), while others suggest otherwise (e.g., Craske et al., 2008). This study examined clinically reliable changes in distress, relations to broad clinical outcomes, and whether homework adherence affected this relationship. Method In 116 patients with PTSD, first to last imaginal exposure sessions' peak and average distress was examined, calculating reliable change in distress. Homework adherence and helpfulness were examined. At post-treatment, PTSD symptoms (re-experiencing, avoidance, hyperarousal), depression, and functioning were examined. Results Patients exhibited a lack of reliable change in distress (64.7%) more than a reliable change in distress (35.3%). Although no difference in post-treatment PTSD diagnostic status, individuals experiencing a reliable change in distress reported lower PTSD severity (re-experiencing, hyperarousal), depression, and better functioning. Further, perceived helpfulness of imaginal homework had an indirect effect on this relationship. Limitations This study did not utilize a distress tolerance self-report measure; however, examined self-reported distress during imaginal exposure. Conclusions Results are encouraging for clinicians treating PTSD with PE, arguing that lack of reliable change in distress to the trauma memory does not result in treatment failure. Patient "buy in" to homework, rather than amount completed, was related to the process of distress reduction. Results suggest that distress reduction in imaginal exposure is not a key mechanism underlying therapeutic change in PE. © 2013 Elsevier Ltd. All rights reserved.

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Crossref · 10.1016/j.jbtep.2013.09.003

Cites

75 of 75 references verified0 citation errors · 0 not checkable

Statistics

10 tests recomputed · 0 with the reported and recomputed p on opposite sides of .05

Claims the paper makes

9 of 50 cited sources checked · 9 supported · 0 flagged

  • Premisecitation

    Lower distress tolerance is associated with higher PTSD symptom severity.

    “recent studies have shown that lower distress tolerance is associated with higher PTSD symptom severity (Marshall-Berenz, Vujanovic & Zvolensky, 2011; Vujanovic, Bonn-Miller, Potter, Marshall, & Zvolensky, 2011; Vujanovic, Hart, Potter, Berenz, Niles, & Bernstein, 2013).”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites Marshall-Berenz, Vujanovic & Zvolensky, 2011 source
    • cites Vujanovic, Bonn-Miller, Potter, Marshall, & Zvolensky, 2011 source
    • cites Vujanovic, Hart, Potter, Berenz, Niles, & Bernstein, 2013 source
  • Premisecitation

    Consistent with modern learning models of extinction, the expectation of an aversive event followed by its absence leads to new inhibitory learning.

    “Consistent with modern learning models of extinction (e.g., Bouton, 2004), the expectation of an aversive event followed by the absence of its occurrence leads to new inhibitory learning.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Bouton, 2004 source
  • Findingown data

    Perceived helpfulness of imaginal homework had an indirect effect on the relationship between reliable change in distress and treatment outcome.

    “Further, perceived helpfulness of imaginal homework had an indirect effect on this relationship.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patients who experienced a reliable change in distress reported lower PTSD severity in re-experiencing and hyperarousal symptoms than those who did not.

    “Although no difference in post-treatment PTSD diagnostic status, individuals experiencing a reliable change in distress reported lower PTSD severity (re-experiencing, hyperarousal), depression, and better functioning.”
    Quote in the paperSubstantial claim
  • Findingown data

    Patients who experienced a reliable change in distress reported better functioning than those who did not.

    “Although no difference in post-treatment PTSD diagnostic status, individuals experiencing a reliable change in distress reported lower PTSD severity (re-experiencing, hyperarousal), depression, and better functioning.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 37
  • May combine two claims. 24

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The ASI has good test-retest reliability and high internal consistency.

    “This measure has good test-retest reliability (Rodriguez, Bruce, Pagano, Spencer, & Keller, 2004) and high internal consistency (Reiss et al, 1986).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Rodriguez, Bruce, Pagano, Spencer, & Keller, 2004 source
    • cites Reiss et al, 1986 source

  • Classified as probably not a substantial claim.

    Premisecitation

    There is considerable debate over whether between-session habituation is necessary in exposure therapy.

    “Recently, there has been considerable debate over the necessity of between-session habituation in individuals undergoing exposure therapy (Baker et al., 2010; Craske et al., 2008).”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Baker et al., 2010 source
    • cites Craske et al., 2008 source

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisecitation

    Distress tolerance may be exhibited as the ability to pursue goal-directed activity while experiencing emotional distress and to withstand experiential discomfort.

    “The toleration of distress may be exhibited as the ability to move in a goal-directed activity while experiencing emotional distress and the ability to withstand experiential discomfort (e.g., Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005; Daughters et al., 2009).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Brown, Lejuez, Kahler, Strong, & Zvolensky, 2005 source
    • cites Daughters et al., 2009 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Anxiety sensitivity is associated with higher PTSD symptoms.

    “Although anxiety sensitivity is often not studied in the PTSD literature, anxiety sensitivity is associated with higher PTSD symptoms (e.g., Berenz, Vujanovic, Coffey & Zvolensky, 2012).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Berenz, Vujanovic, Coffey & Zvolensky, 2012 source

  • May combine two claims.

    Premisecitation

    In a study of in vivo exposure for panic disorder and agoraphobia, neither within-session nor between-session habituation indicated better outcomes.

    “A recent study by Meuret et al. (2012) examined both within- and between-session habituation during in vivo exposures for individuals with panic disorder and agoraphobia. Results showed that neither within-session or between-session habituation indicated better outcomes (Meuret, Seidel, Rosenfield, Hofmann, & Rosenfield, 2012).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Meuret et al. (2012) source

  • May combine two claims.

    Findingown data

    Controlling for pre-treatment depression severity, post-treatment depression (BDI) was lower for those who showed a reliable change in distress than for those who did not, for both peak SUDs (M=5.14 vs 9.86, F(2,79)=7.62, p=.007, g=0.55) and mean SUDs (M=4.89 vs 9.47, F(2,79)=6.31, p=.01, g=0.53).

    “Specifically, at post-treatment, controlling for pre-treatment severity, depression (BDI) for those who showed a reliable change in distress was lower (peak: M = 5.14, SE = 1.36; mean: M = 4.89, SE = 1.53) than those who did not (peak: M = 9.86, SE = 1.03, F (2,79) = 7.62, p = .007, Hedges’ g = 0.55; mean: M = 9.47, SE = 0.98, F (2,79) = 6.31, p = .01, Hedges’ g = 0.53).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

  • May combine two claims.

    Findingown data

    Among 88 participants, 28.4% (n=25) showed a reliable reduction in mean SUDs from first to last imaginal exposure, while 71.2% (n=63) did not; the difference was significant, χ2(1)=16.41, p<.001.

    “Of the 88 participants, only 35.3% (n = 31) displayed a reliable change in distress for peak SUDs and 28.4% (n = 25) for mean SUDs. Lack of reliable change in SUDs was found in 64.7% (n = 57) for peak SUDs and 71.2% (n = 63) for mean SUDs. Thus, inconsistent with our hypothesis, a lack of reliable change in SUDs was more prevalent than reliable change, peak SUDs: χ2(N = 88, 1) = 7.68, p = .006;”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

  • May combine two claims.

    Findingown data

    Controlling for pre-treatment functioning, post-treatment functioning (SDS) was better for those who showed a reliable change in distress than for those who did not, for both peak SUDs (M=6.97 vs 11.49, F(2,76)=9.80, p=.002, g=0.63) and mean SUDs (M=7.03 vs 10.98, F(2,76)=6.41, p=.01, g=0.54).

    “Further, functioning (SDS), controlling for pre-treatment functioning, was better in those displaying a reliable change in distress (peak: M = 6.97, SE = 1.15; mean: M = 7.03, SE = 1.32) than those who did not (peak: M = 11.49, SE = 0.87, F (2,76) = 9.80, p = .002, Hedges’ g = 0.63; mean: M = 10.98, SE = 0.84, F (2,76) = 6.41, p =.01, Hedges’ g = 0.54).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

  • May combine two claims.

    Findingown data

    Perceived helpfulness of imaginal homework had a significant indirect effect on the relationship between reliable change in peak SUDs and post-treatment PTSD severity, but this indirect effect was not significant for in vivo homework.

    “As seen in Table 2, perceived helpfulness of imaginal homework was positively associated with a reliable reduction of distress for peak SUDs and post-treatment PTSD severity. The indirect effect of perceived helpfulness was only found to be significant when examining imaginal homework but not for in vivo homework.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Controlling for pre-treatment re-experiencing severity, post-treatment re-experiencing (PSS-I) was lower for those who showed a reliable change in distress than for those who did not, for both peak SUDs (M=1.39 vs 2.84, F(2,80)=5.71, p=.02, g=0.47) and mean SUDs (M=1.34 vs 2.71, F(2,80)=4.63, p=.04, g=0.45).

    “Consistent with our hypothesis, again controlling for respective pre-treatment severity, post-treatment re-experiencing (PSS-I) was lower for those who showed a reliable change in distress (peak: M = 1.39, SE = 0.48; mean: M = 1.34, SE = 0.53) versus those who did not (peak: M = 2.84, SE = 0.37; mean: M = 2.71, SE = 0.35) in the re-experiencing cluster, peak: F (2, 80) = 5.71, p = .02, Hedges’ g =”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

  • May combine two claims.

    Findingown data

    Among 88 participants, 35.3% (n=31) showed a reliable reduction in peak SUDs from first to last imaginal exposure, while 64.7% (n=57) did not; the difference was significant, χ2(1)=7.68, p=.006.

    “Of the 88 participants, only 35.3% (n = 31) displayed a reliable change in distress for peak SUDs and 28.4% (n = 25) for mean SUDs. Lack of reliable change in SUDs was found in 64.7% (n = 57) for peak SUDs and 71.2% (n = 63) for mean SUDs. Thus, inconsistent with our hypothesis, a lack of reliable change in SUDs was more prevalent than reliable change, peak SUDs: χ2(N = 88, 1) = 7.68, p = .006;”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Individuals who had a reliable change in distress had lower post-treatment PTSD symptoms, depression, and better general functioning than those who did not.

    “Individuals who had a reliable change in distress had lower post-treatment PTSD symptoms, depression, and better general functioning than those who did not.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Controlling for pre-treatment hyperarousal severity, post-treatment hyperarousal (PSS-I) was lower for those who showed a reliable change in distress than for those who did not, for both peak SUDs (M=2.97 vs 4.46, F(2,80)=5.32, p=.02, g=0.45) and mean SUDs (M=2.71 vs 4.42, F(2,80)=6.43, p=.01, g=0.53).

    “There was a similar pattern for post-treatment hyperarousal (PSS-I), with lower hyperarousal for those showed a reliable reduction in distress (peak: M = 2.97, SE = 0.51; mean: M = 2.71, SE = .56) than those who did not (peak: M = 4.46, SE = 0.39; mean: M = 4.42, SE = 0.37), F (2, 80) = 5.32, p = .02, Hedges’ g = 0.45; mean: F (2, 80) = 6.43, p = .01, Hedges’ g = 0.53).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The PSS-I was assessed at pre- and post-treatment with at least two weeks between the last treatment session and post-treatment interview to avoid confounding by treatment.

    “The PSS-I was assessed at both pre- and post-treatment, with a minimum two-week separation between the last treatment session and post-treatment interview so that assessment was not confounded by treatment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In another study, a limited measure of homework compliance was not associated with clinical improvement.

    “In the other (van Minnen et al., 2002), a limited measure of homework compliance was not associated with clinical improvement.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites van Minnen et al., 2002 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Emotional processing theory identifies three indicators that emotional processing has occurred: fear structure activation, within-session habituation, and between-session habituation.

    “In this theory, there are three indicators identifying that emotional processing has occurred: the fear structure must be activated, (as evidenced by physiological reactivity, behavioral avoidance, or by self-report distress); there is a decrease in fear during exposure sessions, that is, within-session habituation; and finally, there is a decrease in initial reactions to the feared stimuli across”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    An individual with strong homework adherence has had more exposure to the fear memory, possibly affecting how much habituation occurs between sessions and ultimately treatment outcome.

    “An individual with strong homework adherence has had more exposure to the fear memory, possibly affecting how much habituation occurs between sessions and ultimately affecting treatment outcome (Huppert, Roth, Ledley, & Foa, 2006).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Huppert, Roth, Ledley, & Foa, 2006 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Jaycox et al. (1998) reported that individuals with higher fear activation and gradual habituation had better post-treatment end-state functioning, particularly lower re-experiencing symptoms, than those with lack of between-session habituation.

    “Using cluster analysis, Jaycox et al. (1998) reported that those with a pattern of higher fear activation and gradual habituation had better post-treatment end-state functioning, particularly on lower re-experiencing symptoms, than those who had a pattern of lack of between-session habituation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Jaycox et al. (1998) source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The SCID-IV has high inter-rater reliability.

    “This measure has high inter-rater reliability (Skre, Onstad, Torgersen, & Kringlen, 1991).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Skre, Onstad, Torgersen, & Kringlen, 1991 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Emotional processing theory holds that emotional processing occurs when new information is introduced into an existing fear structure to change emotional responding.

    “As defined by Foa and Kozak (1986), emotional processing is the course by which new information is introduced into an existing fear structure in order to change emotional responding.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Foa & Kozak, 1986 source

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Most prior studies failed to examine clusters of PTSD symptoms.

    “most have failed to examine clusters of PTSD symptoms”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Within-session habituation has been related to better treatment outcome in some studies.

    “as well as within-session habituation (e.g., Borkovec & Sides, 1979; Foa & Kozak, 1986, 1997; Grayson et al., 1982; Kozak, Foa, & Steketee, 1998; Lang, Melamed, & Hart, 1970; Watson & Marks, 1971)”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Borkovec & Sides, 1979 source
    • cites Foa & Kozak, 1986 source
    • cites Grayson et al., 1982 source

  • May combine two claims.

    Premisecitation

    In exposure therapy, studies often show that activation of fear, within-session habituation, and between-session habituation result in better treatment outcome.

    “In exposure therapy, studies often show that these indicators result in better treatment outcome.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    Homework adherence may affect the relationship between between-session habituation and better treatment outcome.

    “potentially affecting the relationship between between-session habituation and better treatment outcome.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    No prior studies have examined broader social, work, and family functioning.

    “and none have examined broader social, work, and family functioning.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Between-session habituation has been related to better treatment outcome in some studies.

    “and between-session habituation (e.g., Foa, Grayson, & Stektee, 1982; Jaycox et al., 1998; Kamphius & Telch, 2000; Kozak et al., 1998; van Minnen & Hagenaars, 2002; Rauch et al., 2004; Telch et al., 2004).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Foa, Grayson, & Stektee, 1982

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Jaycox et al., 1998 source
    • cites Kamphius & Telch, 2000

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    No studies have examined whether change in distress across sessions was reliable or clinically meaningful.

    “Furthermore, no studies have examined whether or not the change in distress across sessions was reliable or a clinically meaningful change”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The BDI demonstrates good reliability and validity.

    “The BDI demonstrates good reliability and validity (Beck, Steer, & Garbin, 1988).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Beck, Steer, & Garbin, 1988

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In this study, 10% were rated for diagnostic reliability, with acceptable reliability for major depression, anxiety disorders, substance abuse disorders, and other diagnoses.

    “In this study, 10% were rated for diagnostic reliability. Reliability was acceptable for major depression (κ = .68, ppos = .88, pneg = .80), anxiety disorders (κ = 1.00, ppos = 1.00, pneg = 1.00), substance abuse disorders (ppos = .00, pneg = 1.00), and other diagnoses (ppos = 0.00, pneg = 1.00).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In one study, more self-directed exposure (imaginal exposure homework) was related to greater reduction of anxiety both after and between exposure sessions, but the study did not directly examine the effect of homework on treatment outcome.

    “In one, more self-directed exposure (i.e., imaginal exposure homework) was related to greater reduction of anxiety both after and between exposure sessions; however, they did not directly examine the effect of homework on treatment outcome.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    van Minnen and Hagenaars (2002) found that greater habituation between early therapy sessions (session 1 to session 2) was associated with better treatment outcome.

    “Similarly, van Minnen and Hagenaars (2002) found that greater habituation between early therapy sessions, session 1 to session 2, was associated with better treatment outcome.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites van Minnen and Hagenaars (2002) source

  • Classified as probably not a substantial claim.

    Premisecitation

    Homework adherence reflects the extent to which the client completes exposure tasks outside of treatment sessions.

    “Homework adherence reflects the extent to which the client completes exposure tasks outside of treatment sessions (Kazantzis, Deane, & Ronan, 2000)”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Kazantzis, Deane, & Ronan, 2000 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In this study, about 10% of cases were re-rated for diagnostic reliability, and overall PTSD severity scores had high reliability (ICC = .985).

    “In this study, approximately 10% of the cases were re-rated for diagnostic reliability. Overall, reliability was high with good reliability for overall PTSD severity scores (ICC = .985).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    A strong historical literature indicates that between-session habituation is an indicator of successful treatment outcome.

    “Although there is a strong historical literature suggesting that between-session habituation is an indicator of successful treatment outcome (e.g., Grayson, Foa, & Stektee, 1982; Jaycox, Foa, & Moral, 1998; Kamphius & Telch, 2000; Kozak, Foa, & Steketee, 1988; Rauch, Foa, Furr, & Filip, 2004; Telch et al., 2004; van Minnen & Hagenaars, 2002)”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Grayson, Foa, & Stektee, 1982 source
    • cites Jaycox, Foa, & Moral, 1998

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Kamphius & Telch, 2000

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PSS-I has good convergent validity, test-retest reliability, and inter-rater reliability.

    “The PSS-I has good convergent validity, test-retest reliability, and inter-rater reliability (Foa, Cashman, Jaycox, & Perry, 1997; Foa & Tolin, 2000).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Foa, Cashman, Jaycox, & Perry, 1997 source
    • cites Foa & Tolin, 2000 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Evaluators blind to treatment condition conducted initial eligibility interviews.

    “After informed consent procedures, evaluators blind to eventual treatment condition conducted initial eligibility interviews (PSS-I, SCID-IV).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The cut-off for reliable change may have been too stringent, resulting in a small number of individuals displaying between-session distress reduction.

    “First, our cut-off for reliable change may have been too stringent, resulting in the small number of individuals displaying between-session distress reduction.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Trained raters reviewed 10% of videotapes to assess essential treatment components and protocol violations.

    “Trained raters reviewed 10% of videotapes, assessing essential treatment components and protocol violations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study did not examine between-session distress reduction of imaginal exposure homework.

    “We also did not examine between-session distress reduction of imaginal exposure homework.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Patterns of distress reduction across in vivo exposure may differ from imaginal exposure because patients may generalize what is learned in session to other real world stimuli.

    “Patterns of distress reduction across in vivo exposure may differ from imaginal exposure, because patients may generalize what is learned in session to other real world stimuli.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    The results highlight the need for a theoretical integration that allows for a higher order mechanism, such as expectancy, that accounts for both habituation and lack of habituation during exposure therapy.

    “The results from this study highlight the need for a theoretical integration that allows for higher order mechanism, such as expectancy, that accounts for both habituation and lack of habituation during exposure therapy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Overall PE therapist competence was very good (M = 2.73, SD = .32).

    “Overall PE therapist competence was very good (M = 2.73, SD = .32).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Therapists participated in an initial multi-day workshop and received weekly supervision.

    “These therapists participated in initial multi-day workshop and received weekly supervision.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    Given the small number of individuals showing reliable change in fear, the present study raises further questions regarding the critical role of between-session habituation during imaginal exposure for the treatment of chronic PTSD.

    “Nevertheless, given the small number of individuals showing reliable change in fear, the present study raises further questions regarding the critical role of between-session habituation during imaginal exposure for the treatment of chronic PTSD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    In this protocol, the first and last imaginal exposure sessions utilize the same, full trauma memory, mitigating the issue of shifting focus.

    “However, in this protocol, the first and the last imaginal exposure sessions utilize the same, full trauma memory, mitigating this issue.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    PE providers completed 90% of essential components, and no protocol violations were observed.

    “For essential components, PE providers completed 90%. No protocol violations were observed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The study did not examine SUDs ratings for in vivo exposure.

    “Although we examined a direct behavioral indicator of distress in session, we did not examine SUDs ratings for in vivo exposure.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Independent evaluators were trained to an 80% criterion on interview measures and participated in routine reliability checks.

    “These independent evaluators were trained to an 80% criterion on interview measures prior to conducting interviews and participated in routine reliability checks.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Of those who completed pre-treatment measures, 21 dropped out before imaginal exposure and 7 did not complete at least two imaginal exposure sessions, leaving 28 excluded; these 28 did not differ from the 88 who completed at least two sessions on key demographic or baseline variables including PTSD severity.

    “Of men and women who completed pre-treatment measures, 21 dropped out of treatment prior to the onset of imaginal exposure and an additional 7 did not complete at least two imaginal exposure sessions, which was necessary for calculating reliable change in distress (SUDs), and therefore were not used for analysis. These individuals (n = 28) did not differ from those who completed at least two”
    Quote in the paperSubstantial claim
49 of 49

  • The paper relies on this without support.

    Perceived helpfulness of imaginal homework is a valid indicator of patient buy-in to homework.

    “Patient “buy in” to homework, rather than amount completed, was related to the process of distress reduction.”

  • The paper relies on this without support.

    The study sample is representative of adults receiving prolonged exposure for chronic PTSD.

    “In the present study, participants (N = 116) were part of a larger two site, randomized clinical trial who received prolonged exposure (PE).”

  • The paper relies on this without support.

    Mean SUDs during imaginal exposure is a valid indicator of between-session habituation.

    “mean SUDs was utilized to capture general distress over the approximately 30-45 minutes of imaginal exposure”
3 of 3

Statistics that don’t add up

Each reported p-value recomputed from its test statistic and degrees of freedom.

  • Inconsistent p-value: F (2,79) = 7.62, p = .007

    Minor

    The paper reports p = .007 here; recomputing from the test statistic and its degrees of freedom gives p < .001. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .007 · recomputed p < .001

  • Inconsistent p-value: F (2, 80) = 5.71, p = .02

    Minor

    The paper reports p = .02 here; recomputing from the test statistic and its degrees of freedom gives p = .005. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .02 · recomputed p = .005

  • Inconsistent p-value: F (2,76) = 9.80, p = .002

    Minor

    The paper reports p = .002 here; recomputing from the test statistic and its degrees of freedom gives p < .001. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .002 · recomputed p < .001

  • Inconsistent p-value: F (2, 80) = 4.63, p = .04

    Minor

    The paper reports p = .04 here; recomputing from the test statistic and its degrees of freedom gives p = .013. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .04 · recomputed p = .013

  • Inconsistent p-value: F (2, 80) = 5.32, p = .02

    Minor

    The paper reports p = .02 here; recomputing from the test statistic and its degrees of freedom gives p = .007. The check cannot tell whether the statistic or the p-value is the misprint.

    Reported p = .02 · recomputed p = .007

5 of 5

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Doesn’t add upF(2, 80) = 5.71reported p = .02 · recomputed p = .005

    “F (2, 80) = 5.71, p = .02”

  • Doesn’t add upF(2, 80) = 4.63reported p = .04 · recomputed p = .013

    “F (2, 80) = 4.63, p = .04”

  • Doesn’t add upF(2, 80) = 5.32reported p = .02 · recomputed p = .007

    “F (2, 80) = 5.32, p = .02”

  • Doesn’t add upF(2, 79) = 7.62reported p = .007 · recomputed p < .001

    “F (2,79) = 7.62, p = .007”

  • Doesn’t add upF(2, 76) = 9.8reported p = .002 · recomputed p < .001

    “F (2,76) = 9.80, p = .002”

  • Not confirmedF(1, 80) = 6.2reported p = .02 · recomputed p = .015

    “F (1, 80) = 6.20, p = .02”

  • ConsistentF(1, 80) = 5.7reported p = .02 · recomputed p = .019

    “F (1, 80) = 5.70, p = .02”

  • ConsistentF(2, 80) = 6.43reported p = .01 · recomputed p = .003

    “F (2, 80) = 6.43, p = .01”

    The paper prints p at a floor (such as p < .001)

  • ConsistentF(2, 79) = 6.31reported p = .01 · recomputed p = .003

    “F (2,79) = 6.31, p = .01”

    The paper prints p at a floor (such as p < .001)

  • ConsistentF(2, 76) = 6.41reported p = .01 · recomputed p = .003

    “F (2,76) = 6.41, p = .01”

    The paper prints p at a floor (such as p < .001)

10 of 10

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Self-check results appear here once an independent check has confirmed them.

Cites

Flagged first, then by citations

5 of the 80 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Bluett, E. J., Zoellner, L. A., & Feeny, N. C.
Affiliations
  • University of Washington (US)
  • Case Western Reserve University (US)
Corresponding author
Bluett, Ellen J.
ORCID
Venue
Journal of Behavior Therapy and Experimental Psychiatry
Publisher
Elsevier BV
Published
2014-03
Volume
45
Issue
1
Pages
97-104
ISSN
0005-7916 (ISSN-L)
DOI
10.1016/j.jbtep.2013.09.003
PMC
PMC3883671
OpenAlex
W2022399122
Semantic Scholar
072784d6a44f7f34de034b2bc4d246c120a0fbb5
Cited by
71
References
80
Citations by year
2026: 6 · 2025: 1 · 2024: 2 · 2023: 6 · 2022: 6 · 2021: 3 · 2020: 5 · 2019: 6 · 2018: 5 · 2017: 8 · 2016: 13 · 2015: 8 · 2014: 2
FWCI
8.52
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Behavior Therapy and Experimental Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (R01MH066347, R01MH066348)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords
prolonged exposure therapy, post-traumatic stress disorder, distress reduction, imaginal exposure, homework adherence, mechanisms of change, depression, functioning, re-experiencing, hyperarousal, avoidance
MeSH terms
Adult, Anxiety, Depression, Disability Evaluation, Female, Humans, Implosive Therapy, Male, Middle Aged, Psychiatric Status Rating Scales, Stress Disorders, Post-Traumatic, Reproducibility of Results

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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