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Behavior Therapy 46 (2015) 328 – 341
www.elsevier.com/locate/bt

Are 60-Minute Prolonged Exposure Sessions With 20-Minute

Imaginal Exposure to Traumatic Memories Sufficient to
Successfully Treat PTSD? A Randomized Noninferiority
Clinical Trial
Nitsa Nacasch
Tel-Aviv Brull Community Mental Health Center
Jonathan D. Huppert
The Hebrew University of Jerusalem
Yi-Jen Su
National Taiwan University
Yogev Kivity
The Hebrew University of Jerusalem
Yula Dinshtein
Tel-Aviv Brull Community Mental Health Center
Rebecca Yeh
Edna B. Foa
University of Pennsylvania

90-minute sessions that include 40 minutes of IE in treating

The study aims to determine whether 60-minute sessions of
prolonged exposure (PE) that include 20 minutes of
imaginal exposure (IE) are noninferior to the standard
We want to thank Professor Joseph Zohar for his contribution to
the design and implementation of the study, to Dr. Miki Polliack,
Yonina Zilbermintz, Rachel Gold, and Miri Shalit for their help in
the implementation of the study and to the therapists for their
rigorous implementation of the treatment procedures. Our thanks
are extended to the research assistants at Chaim Sheba Medical
Center, Dana Tzur and Dr. Lea Fostick, and to the research
assistants for their day-to-day help in the study-related activities.
Last but not least we want to express our gratitude to Josephine
Curry, Joseph Carpenter, and Rebecca Yeh from the Department of
Psychiatry at the University of Pennsylvania for their diligent work
in preparing the manuscript for submission.
Address correspondence to Edna B. Foa, Ph.D., Department of
Psychiatry, University of Pennsylvania, 3535 Market Street, 6th
Floor, Philadelphia, PA 19104; e-mail: foa@mail.med.upenn.edu.
0005-7894/© 2014 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
posttraumatic stress disorder (PTSD) and to explore the
relationship of treatment outcome to within- and between-
session habituation and change in negative cognitions.
Thirty-nine adult veterans with chronic PTSD were
randomly assigned to 90-minute (n = 19) or 60-minute
(n = 20) sessions of PE. PTSD symptoms were assessed by
an unaware independent evaluator before and after
treatment and at 6-month follow-up. Self-reports of
depression and negative cognitions were assessed before
and after treatment. Participants in both conditions showed
significant reductions in PTSD symptoms. Sixty-minute
sessions were found to be noninferior to 90-minute sessions
in reducing PTSD symptoms, as the upper bound of the
95% confidence interval for the difference between condi-
tions in the PTSD Symptom Scale–Interview (posttreatment:
6.00; follow-up: 6.77) was below the predefined noninferi-
ority margin (7.00). Participants receiving shorter sessions
 sixty vs. ninety minutes of prolonged exposure
showed less within- and between-session habituation than
those receiving longer sessions, but no group differences in
reductions in negative cognitions were found. The current
findings indicate that the outcomes of 60-minute sessions of
PE do not differ from those of 90-minute sessions. In
addition, change in trauma-related cognitions and between-
session habituation are both potential mechanisms of PE.
Keywords: posttraumatic stress disorder; prolonged exposure;
habituation; fear activation; emotional processing
PROLONGED EXPOSURE THERAPY (PE; Foa, Hembree,
& Rothbaum, 2007), a specific exposure therapy
program for posttraumatic stress disorder (PTSD),
is a highly effective treatment for PTSD across a
variety of traumas (Foa et al., 2005; Powers,
Halpern, Ferenschak, Gillihan, & Foa, 2010). The
PE program usually consists of 8 to 15 weekly or
twice-weekly sessions, each lasting about 90 minutes,
with 45 to 60 minutes of imaginal exposure. The
three main components of PE are in vivo exposure,
imaginal exposure, and processing of the imaginal
exposure (McLean & Foa, 2011). The rationale of PE
is based on emotional processing theory (EPT; Foa,
Huppert, & Cahill, 2006; Foa & Kozak, 1986).
Briefly, EPT proposes that PTSD reflects the presence
of a pathological fear (emotional) structure in which
normally safe stimuli representations are associated
with the meaning of danger, and normal responses to
trauma are associated with the meaning of self-
incompetence. Thus, EPT posits that the erroneous
cognitions that “the world is extremely dangerous”
and “I am extremely weak and incompetent” mediate
the development and maintenance of PTSD by
promoting avoidance that prevents the individual
from testing and disconfirming these cognitions.
According to EPT, treatment that aims at ameliorat-
ing PTSD symptoms should correct these erroneous
associations, either by introducing new information
or strengthening nonpathological associations and
memories (Foa et al., 2006, see also Brewin, 2006).
The course by which these changes occur is called
emotional processing. In PE, emotional processing is
achieved through the use of in vivo exposure to
avoided trauma-related situations and imaginal
exposure to the traumatic event (revisiting of the
traumatic memory in imagination and recounting
it aloud) followed by postexposure processing,
(i.e., discussion of the revisiting experience), which
entails asking how their experience was while
retelling the trauma, what they learned from the
retelling or trauma, acknowledging the courage of the
patient for having recounted the story, emphasizing
to the patients that they did not fall apart from
confronting the memory, and exploring how realistic
329
are their emotions such as guilt or shame in an
indirect and empathic manner. Prior studies have
demonstrated the efficacy of imaginal exposure alone
(Bryant, Moulds, Guthrie, Dang, & Nixon, 2003;
Tarrier et al., 1999) and in vivo exposure alone
(Marks, Lovell, Noshirvani, Livanou, & Thrasher,
1998) in treating PTSD. Furthermore, one study
(Bryant et al., 2008) that included in vivo and
imaginal exposure but excluded processing after
imaginal exposure showed inferior outcomes
compared with studies that included both in vivo
exposure and imaginal exposure followed by cogni-
tive restructuring, suggesting the importance of
conducting processing after imaginal exposure.
EPT posits two mechanisms of PE: activation
(emotional engagement) of the trauma memory
through imaginal and in vivo exposure, and presen-
tation of information during exposure that discon-
firms the expected harm that leads to reductions in
negative cognitions. In addition, EPT proposes three
indicators of emotional processing: fear activation,
within-session habituation (i.e., reduction in distress
levels from the beginning to end of exposure to a
feared memory or stimulus in a treatment session),
and between-session habituation (i.e., reduction of
peak distress levels across successive exposure
sessions). These indicators, along with changes in
negative cognitions, are hypothesized to be associated
with successful outcome (cf. Zalta et al., 2013).
Indeed, the rationale for extending imaginal exposure
to 60 minutes was derived from the supposition
that within-session habituation is associated with
reduction in PTSD symptoms. However, although
longer exposures have been shown to promote
greater within-session habituation than shorter
exposures (Chaplin & Levine, 1981; Rabavilas,
Boulougouris, & Stefanis, 1976; van Minnen & Foa,
2006), between-session—but not within-session—
habituation has been associated with treatment
outcome (Jaycox, Foa, & Morral, 1998; van Minnen
& Hagenaars, 2002). Moreover, in a nonrando-
mized study, van Minnen and Foa (2006) found that
60-minute imaginal exposures did not produce
superior outcomes to 30-minute imaginal exposures
despite greater within-session habituation in the
longer exposures. Furthermore, although no differ-
ences were found in between-session habituation
between the longer and shorter exposures, between-
session habituation was related to treatment out-
come. This raises questions about the importance of
within-session habituation as a reliable indicator of
emotional processing proposed by EPT.
In addition to their theoretical implications, van
Minnen and Foa’s (2006) findings are of practical
importance. At present, there has been widespread
dissemination of PE from academic settings into
330 nacasch et al.
community practice (Foa et al., 2005; Karlin et al.,
2010; McLean & Foa, 2011). One barrier for using
PE in community clinics is the limitation often
imposed on session length by reimbursement policies.
Reducing the length of PE sessions from 90 minutes to
the “standard” psychotherapy 60-minute sessions
would eliminate this critical barrier. Indeed, the
impetus to reduce the length of sessions in van Minnen
and Foa’s study was the change in reimbursement
regulations in the Netherlands. Moreover, the efficacy
of PE in the treatment of individuals suffering from
combat- and terror-related PTSD has been demon-
strated in several recent studies (e.g., Nacasch et al.,
2011; Schneier et al., 2012; Tuerk et al., 2011). The
number of PTSD cases related to combat and terror is
increasing due to the significant rise in worldwide
combat and terror violence over the last decade.
Shortened PE is of great value to address the urgent
need for efficacious and time-limited treatment for
this population.
Despite the promising results of van Minnen and
Foa (2006), their study contains a number of
methodological limitations that prevent strong
conclusions from their work. First, patients were
not randomly assigned to the two conditions.
Second, outcome variables were measured using
self-report data. Third, the follow-up period was
only 1 month, which is not long enough to assess
whether participants in the 30-minute exposure
condition would be more likely to relapse than
those in the 60-minute exposure condition. Last,
although the relationships of within- and between-
session habituation to outcome were examined in
that study, a critical mechanism of PE, reduction in
negative trauma-related cognitions, was not assessed.
Thus, the effects of length of treatment on cognitions
could not be examined. Given these limitations, the
efficacy of shortened imaginal exposure still remains
unestablished and, as the authors stated in their
limitation, needs to be replicated using more rigorous
methodology.
The goals of the present study were to replicate the
findings of van Minnen and Foa (2006) and to
further examine the theoretical and practical impli-
cations of reducing the length of imaginal exposure
in PE by comparing the efficacy of 90-minute PE
sessions that included 40-minute imaginal exposures
with 60-minute PE sessions that included 20-minute
imaginal exposure in participants with chronic
PTSD. To address the limitations of van Minnen
and Foa’s study, in the present study (a) participants
were randomly assigned to 90- or 60-minute PE
sessions, (b) shorter length of imaginal exposure
(i.e., 20 minutes) was adopted, (c) outcome was
assessed by evaluators unaware of treatment condi-
tion, (d) follow-up assessment of PTSD symptom
severity was extended to 6 months, and (e) a measure
of trauma-related cognitions was included.
The above design allowed us to examine the
following hypotheses: (a) noninferiority: patients
who received 60-minute sessions with 20-minute
imaginal exposure would not have significantly less
reduction in PTSD symptoms, depression, and
trauma-related cognitions than patients who received
90-minute sessions with 40-minute imaginal expo-
sure. Confirmation of noninferiority in this trial was
established by showing that the difference in mean
improvement of outcome measures is smaller than a
prespecified noninferiority margin, as defined by the
reliable change index developed by Jacobson and
Truax (1991) and determined for PTSD studies by
Devilly and Foa (2001); (b) habituation: patients
receiving 40-minute imaginal exposure would exhibit
greater within-session habituation than those receiv-
ing 20-minute imaginal exposure but would not differ
in the degree of between-session habituation; (c) there
would be a significant relationship of between-session
habituation, but not within-session habituation, and
reduction in PTSD symptom severity; and (d) there
would be a significant relationship between change in
trauma-related cognitions and change in PTSD
symptoms in both conditions.
Method
participants
To be eligible for the study, patients had to meet
a diagnosis of PTSD and to experience moderate
to severe symptoms for at least 3 months (PTSD
Symptoms Scale–Interview [PSS-I; Foa, Riggs,
Dancu, & Rothbaum, 1993] score ≥ 20), compa-
rable to previous randomized clinical trial (RCT)
studies for standard PE (e.g., Foa, Dancu, et al.,
1999; Foa et al., 2005). PTSD had to be at least as
severe as other psychiatric diagnoses. If treated with
medications, patients had to be on a stable regimen
for at least 3 months prior to pretreatment evaluation
and remain on that dosage throughout treatment.
Adherence was monitored by the patient’s report
to the psychiatrist. Exclusion criteria were current
active substance dependence, current psychotic
symptoms, bipolar disorder, or severe dissociative
symptoms. Patients deemed at high risk for suicidal
behavior (i.e., with intent or plan or both) were also
excluded. Severe dissociative symptoms were deter-
mined at intake through administration of the
Dissociative Experiences Scale (van IJzendoorn &
Schuengel, 1996) and an unstructured clinical
interview by the first author, a psychiatrist (e.g., a
patient became agitated and stopped answering
questions for a number of minutes, appearing to be
dissociated, multiple times throughout the intake
interview).
 sixty vs. ninety minutes of prolonged exposure
Fifteen (75%) of the 60-minute group and 14
(74%) of the 90-minute group were on medications
(predominantly selective serotonin reuptake inhib-
itors [SSRIs] or serotonin-norepinephrine reuptake
inhibitors [SNRIs]) during the entire study. The first
authors monitored the medication of all patients in
the study. None of the patients changed their
medication regimen during their participation in
the study.
Between March 2005 and March 2010, 84
veterans were referred to the PE clinic of the
outpatient psychiatric trauma unit at Sheba Medical
Center for participation in the current study. They
were referred either by psychiatrists of the trauma unit
or by therapists from other mental health clinics. After
an initial screening assessment, eligible individuals
completed all assessments described below. Of these
individuals, 39 participated in the study. Nineteen of
them were randomized to 90-minute PE sessions that
FIGURE 1 Consolidated standards of reporting trials diagram of participant flow through the protocol. Note. PE = prolonged exposure;
PTSD = posttraumatic distress disorder; IE = imaginal exposure.* Not in analyses.
331
included 40-minute imaginal exposures, and 20 were
randomized to 60-minute PE sessions that included
20-minute imaginal exposure (for details see the
CONSORT Chart in Figure 1). A simple randomi-
zation procedure (computer-generated random num-
bers) was conducted prior to Session 3 by a senior
psychiatrist with no clinical involvement in the study.
Two patients dropped out of the study before
randomization and one patient was withdrawn due
to severe dissociation. One patient was withdrawn
after randomization but before starting treatment
because of severe, psychotic depression, and one
dropped out during treatment; both were in the
90-minute condition. The latter patient was included
in intention-to-treat (ITT) analyses.
Table 1 presents the descriptive information of
the study sample. Overall, the mean age of the
participants was 36.87 years (SD = 13.40). Most
participants were male (61.5%), single (46.2%;
332 nacasch et al.

Table 1
Clinical Characteristics and Raw Scores of Symptoms and Trauma-Related Cognitions by Group
Variable 60-min PE 90-min PE
(n = 20) (n = 19)
n % n %
Male 14 70.0 10 52.6
Employed 12 60.0 9 47.3
Marital status
Single 10 50.0 8 42.1
Married 6 30.0 10 52.6
Divorced 4 20.0 1 5.3
Index trauma type
Single terror attack 8 40.0 7 36.8
Combat 5 25.0 6 31.6
Car accident 4 20.0 3 15.8
Other 3 15.0 3 15.8
Injury in trauma 13 65.0 12 63.2
Comorbidity
Major depressive disorder 5 25.0 4 21.1
Anxiety disorder a 11 55.0 2 10.5

n M SD n M SD Cohen’s d
Age (years) 20 34.40 12.24 19 39.47 14.39 0.38
Time since trauma (years) 20 9.18 13.31 19 6.57 9.94 0.22
PSS-I
Pre 20 32.20 5.96 19 31.58 6.38 0.10
Post 20 13.30 9.52 17 12.24 8.02 0.12
FU 14 13.57 9.26 15 12.20 7.78 0.16
BDI
Pre 15 23.13 8.71 19 20.11 9.60 0.33
Post 18 10.89 9.16 15 10.93 8.98 0.00
PTCI
Pre 13 134.08 36.88 14 132.21 30.29 0.06
Post 16 87.25 40.27 16 91.94 37.26 − 0.12
Note. PE = prolonged exposure; PSS-I = PTSD Symptoms–Interview version; Pre = pretreatment; Post = posttreatment; FU = follow-up;
BDI = Beck Depressive Inventory; PTCI = Posttraumatic Cognitions Inventory.
a
Other than posttraumatic disorder.

41.0% married, 17.8% divorced), and employed
(60.0%). The most prevalent index trauma (i.e., the
traumatic event that participants endorsed as the
most distressing and that was the focus of
treatment) was terrorist attack (38.5%), followed
by combat (28.2%), car accidents (17.9%), and
sexual (childhood sexual abuse, rape) and nonsexual
assault (15.4%). Psychiatric comorbidity was com-
mon, with 56.4% of the sample having at least one
comorbid Axis I disorder. The most common
comorbid conditions were current major depressive
disorder (23.1%) and obsessive–compulsive disorder
(23.1%).
There were no significant differences between the
two conditions in demographics, index trauma type,
and clinical characteristics. However, participants in
the short-duration group (60-minute PE session)
were more likely to have another comorbid anxiety
disorder than those in the long-duration group:
90-minute PE session; 55.0% vs. 10.5%, χ 2 (1) =
4.50, p = .03. The study protocol was approved by
the Sheba Medical Center Institutional Review
Board.
design
All eligible individuals were provided written
informed consent after receiving a description of
the study procedures. They were told that some
participants will receive ten to fifteen 60-minute
sessions with 20-minute imaginal exposure to their
most upsetting traumatic memory and other
participants will receive ten to fifteen 90-minute
 sixty vs. ninety minutes of prolonged exposure
sessions with 40-minute imaginal exposure to their
trauma memory. All participants first received two
90-minute sessions (for details, see below).
assessment
Assessments of current PTSD symptoms were con-
ducted by a master’s degree psychologist unaware of
treatment assignment. Assessments were conducted
before and after treatment. Outcome assessments
included the interview of PTSD severity and self-
report measures described below. At 6-month
follow-up, outcome via interview was assessed, but
no self-report measures were administered. Psychol-
ogists who conducted assessments were uninvolved
in treatment, and patients were asked not to disclose
their treatment condition to the evaluators. Given
that all patients received PE, discussion of the content
of treatment would not make the evaluators aware of
their treatment condition.
measures
Diagnostic Interview
The Mini International Neuropsychiatric Interview
5.0 (MINI). The MINI (Sheehan et al., 1998) is a
short, structured diagnostic interview that was used
in the study to determine that the primary diagnosis
was PTSD and to detect the presence of other Axis I
disorders. The interview instrument is designed to
cover 17 major Axis I disorders and has good
correlation with the Structured Clinical Interview for
the DSM-IV (First, Spitzer, Gibbon, & Williams,
1994).
Primary Outcome Measure
The Posttraumatic Symptom Scale-Interview
(PSS-I). The PSS-I (Foa et al., 1993) is a semistruc-
tured interview that consists of 17 items correspond-
ing to the DSM-IV PTSD symptoms. Items are rated
on a scale of 0 (not at all) to 3 (five or more times a
week/almost always) for combined frequency and
severity in the past 2 weeks. Total scores range from 0
to 51 with higher scores indicating more severe PTSD
symptoms; 10 to 15 is considered subclinical, 15 to 20
is mild to moderate, 21 to 25 is moderate, 26 to 30 is
severe, and above 30 is very severe. Interrater
reliability for PTSD diagnosis (r = .91) and overall
severity (ICC = .97) have been shown to be excellent
(for psychometric data see also Foa & Tolin, 2000;
Powers, Gillihan, Rosenfield, Jerud, & Foa, 2012).
Secondary Outcome Measures
Beck Depression Inventory (BDI). The BDI (Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961) is a
21-item self-report inventory designed to measure
symptoms of depression, and addresses the intensity
of cognitive, affective somatic and performance-
related symptoms with regard to depression. The
333
BDI is rated on a 4-point scale, with the total score
ranging from 0 (no symptoms) to 63 (very severe); 14
to 19 is considered mild, 20 to 28 is moderate, and
above 28 is considered severe. Internal consistency
has been found to be high (α = 0.81–0.86; Beck,
Steer, & Garbin, 1988). Scores on the BDI have been
shown to correlate highly with clinician ratings of
depression among female physical and sexual assault
survivors (Foa et al., 1993).
Posttraumatic Cognitions Inventory (PTCI). The
PTCI (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) is a
36-item self-report inventory of trauma-related
thoughts and beliefs that includes three subscales:
negative cognitions about the self, negative cogni-
tions about the world, and self-blame. Respondents
rate the extent to which they agree or disagree with
each statement on a scale of 1 (totally disagree) to 7
(totally agree). Total scores are calculated as the sum
of all items, with higher scores indicating greater
endorsement of negative cognitions. The total scale
and self, world, and self-blame subscales have high
internal consistency (.97, .97, .88, and .86, respec-
tively) and good test–retest reliability (between .74
and .79 for 1 week in one sample, and between .80
and .85 for 3 weeks in a second sample; see also Zalta
et al., 2013). The PTCI total score correlates strongly
with measures of PTSD severity (.79) and depression
(.75), and state- (.70) and trait anxiety (.75).
Subjective Units of Distress (SUDs). The SUDs
scale (Wolpe & Lazarus, 1966) is commonly used as
a subjective verbal rating of discomfort. During the
imaginal exposure, anxiety levels were monitored
regularly using the SUDs on a 0–100 scale, with 0
indicating no feelings of discomfort at all and 100 the
maximum level of discomfort. SUDs were obtained
from the patients at the beginning of the imaginal
exposure (SUDs start), every 5 minutes during the
imaginal exposure, and at the end of the imaginal
exposure (SUDs end).
therapists
Therapy was delivered by eight therapists who were
trained and supervised in PE. Therapists were two
psychiatrists, two master’s degree psychologists,
and four master’s degree social workers. Therapists
participated in a 4-day workshop for PE conducted
by the first and last authors and were supervised in
a training case by an expert trainer who has taught
PE and supervised PE cases for over 10 years (first
author) prior to the start of the study. After the
workshop, a supervision group was established.
The group met once weekly throughout the study
and supervision was conducted through viewing
about 15% of all tapes to ensure adherence to the
334 nacasch et al.
treatment. Because all therapists conducted the
same treatment (PE), had been using PE as their
primary modality for treating PTSD for at least
5 years, and received weekly supervision conducted
by an expert trainer, no formal adherence ratings
were deemed necessary.
treatments
PE was implemented according to the treatment
manual (Foa et al., 2007). The same therapists
delivered both types of treatment. Number of
sessions of those who completed treatment ranged
from 10 to 15. Treatment was determined to be
complete when both the supervisor and therapist
agreed that the patient’s self-reported symptoms of
PTSD remained low and stable. This rationale was
chosen on the basis of a prior finding that the
majority of patients who did not reach at least 70%
reduction in PTSD symptoms after Session 9
benefited from additional sessions (Foa et al.,
2005). The overall mean number of sessions was
13.41 (SD = 2.39). The mean number of sessions for
the short-duration group (M = 13.60, SD = 2.23)
and long-duration group (M = 13.21, SD = 2.59)
were similar, F(1, 37) = 0.25, p = .60. In practice,
patients received either 10(24%), 12(8%), or
15(68%) sessions, and there was no difference
between groups in the percentage who received 15
sessions, χ 2(1) = .21, p = .65.
Prerandomization Phase: Sessions 1 and 2
This phase comprised two 90-minute sessions.
Session 1 included presentation of treatment
rationale, information gathering about trauma
history, identification of the most disturbing trauma,
and breathing retraining. Session 2 included educa-
tion about trauma-related symptoms, rationale and
construction of in vivo exposure hierarchy, and in
vivo homework assignments. In vivo exposure
involved confrontation of situations that were
avoided either because they were trauma reminders
or because they were similar to the traumatic event,
and thus evoked fear that the traumatic event will
occur again. Patients began to confront low-distress-
level situations and proceeded gradually to increas-
ingly more distressing ones.
Postrandomization Treatment Phase: Sessions 3–15
The treatment was identical in the two conditions
with two differences: the short-duration group
received 60-minute sessions with 20-minute imaginal
exposure (in which they were asked to revisit the
traumatic memory in their imagination and by
recounting the story of the trauma aloud), whereas
the long-duration group received 90-minute sessions
with 40-minute imaginal exposure. All other aspects
of the sessions were similar. Sessions 3–14 were
conducted in a similar fashion: homework review,
imaginal exposure for 20 or 40 minutes followed by
a discussion of the imaginal exposure (processing),
and assignment of in vivo exposure homework.
Session 3 included rationale and initiation of
imaginal exposure in which patients were asked to
close their eyes and recount the traumatic memory
aloud. The trauma narratives were audiotaped, and
the patients were asked to listen to the tapes daily.
During the first three imaginal exposures (Sessions 3–
5) patients were guided to repeatedly recount the
traumatic memories from the beginning to the end
within the allotted time (i.e., 20 or 40 minutes). In
Sessions 6–14, patients were guided to repeatedly
imagine and recount the most upsetting part of the
trauma (i.e., “hot spots”) within the allotted time.
The final session consisted of imaginal exposure to
the entire trauma memory once, discussing the
changes that occurred during treatment and the
treatment component they found most helpful.
Patients were asked to listen to a recording of the
whole session (60 or 90 minutes) once per week and
to listen to the imaginal exposure recordings (20 or
40 minutes) daily as homework. The treatment
delivered in the trial followed the protocol used in
previous RCTs for PE (e.g., Foa, Dancu, et al., 1999;
Foa et al., 2005).
manipulation check
One hundred and fifty-five sessions (36% of the
total Sessions 3–15) were examined with regard to
length of session and the length of the imaginal
exposure in 21 randomly selected patients (11 in the
long-duration group and 10 in the short-duration
group). In the short-duration group, the mean
length of sessions was 64 minutes and 43 seconds
(SD = 4.70 minutes) and the mean length of
imaginal exposure was 19 minutes and 27 seconds
(SD = 1.64 minutes). In the long-duration group,
the mean length of sessions was 87 minutes and
54 seconds (SD = 6.11 minutes) and the mean
length of imaginal exposure was 38 minutes and
11 seconds (SD = 3.55 minutes). The mean length
of sessions was significantly different between
groups, F(1, 19) = 89.50, p b .001; the mean length
of imaginal exposure was also significantly different
between groups, F(1, 19) = 232.60, p b .01.
statistical analyses
For Hypothesis 1, our primary analysis, we used tests
for noninferiority of the shorter-duration group
relative to the longer-duration group (Blackwelder,
2004). This is done by examining whether the
difference between the groups at posttreatment and
at follow-up is smaller than a predetermined
clinically reliable difference (i.e., the noninferiority
 sixty vs. ninety minutes of prolonged exposure
margin [“delta”]). In contrast to traditional analyses,
a significant effect in noninferiority tests suggests that
outcome in the short-duration group is noninferior to
the outcome of the long-duration group. We took
two approaches to define delta. First, for each
measure, the deltas were determined using the
reliable change index developed by Jacobson and
Truax (1991) and determined for PTSD studies by
Devilly and Foa (2001). This index represents the
difference between two assessments of a given scale,
which is expected by chance, and is calculated using
the data of the standard deviation of the scale and
test–retest reliability. Using this formula and data
from previous studies about our measures (Foa,
Ehlers, et al., 1999; Oliver & Simmons, 1985;
Powers et al., 2012), we determined that the reliable
change would be 7 points for PSS-I, 4.5 points for
BDI, and 22 points for PTCI. Our clinical experience
suggests that these differences are also clinically
significant. Second, to provide an “effect size” scale
for assessing the size of the difference between the
two groups, we calculated the Cohen’s d (Cohen,
1988) effect size between the two groups. While these
“standardized effect sizes” have been criticized
(Hoenig & Heisey, 2001; Lenth, 2001) as over-
simplifying the process of sample size determination,
they provide a useful scale for comparison of
observed differences. For our purposes, we would
regard effect sizes of less than d = 0.2 (i.e., less than a
“small” effect) as supporting the hypothesis of
noninferiority. We used a one-sided 95% confidence
level and assumed a t distribution for analyses
calculating the difference of the means of the two
treatments and adding or subtracting the product of
the pooled standard error by the critical t value
needed for rejecting the null hypothesis. A priori
power analyses for noninferiority studies (Julious,
2004) indicated that in order to achieve a power of
.80, with a d value of 7 and a standard deviation of 8
on the PSS-I, a sample of 34 would be needed. 1
The data were also examined using multilevel
linear models, which use all available responses
for each subject, and so enable full ITT analyses
(i.e., 60-minute PE: n = 20; 90-minute PE: n = 19).
The models allowed an unstructured covariance
matrix for the repeated measures within subjects,
and treated visit as a categorical variable. Models
were fitted for the PSS-I (using the pretreatment,
posttreatment, and follow-up times) and for the
BDI and PTCI (pre- and posttreatment only).
1 2
Note that the power analysis was calculated only for the main
outcome measure, the PSS-I. The formula for power for effect sizes
for noninferiority we used was n = f(α, β) × 2 × σ2/d2 and f(α,
β) = [Φ−1(α) + Φ−1(β)]2.
335
To assess effect sizes of group differences, raw data
were used to calculate standard Cohen’s d (Cohen,
1988) between groups using pooled variance.
Model-based estimates of d were also calculated
from estimates and standard errors in the mixed-
effects repeated measures models.
For Hypothesis 2, between-session and within-
session habituation were examined by recording
subjective units of distress during imaginal exposures
from each chart (cf. Jaycox et al., 1998; Kozak, Foa,
& Steketee, 1988; van Minnen & Hagenaars, 2002).
We used the first (Session 3) and last (the session
before the final session) imaginal exposure sessions.
Between-session habituation was calculated by
subtracting the peak SUDs of the last session from
the peak SUDs of Session 3 (cf. van Minnen & Foa,
2006). 2 In addition, for both of these imaginal
exposure sessions, the degree of within-session
habituation was computed by subtracting the end
SUDs rating from the peak SUDs rating.
For Hypothesis 3, change in PTSD symptoms and
change in cognitions were calculated as residualized
change scores from pre- to posttreatment in the PSS-I
and PTCI, respectively, and Pearson correlation
coefficients were used to measure within-person
association between the two change scores.
Results
noninferiority between shorter- and
longer-duration groups
See Table 1 for means, standard deviations, and
effect sizes of the outcome measures.
posttraumatic symptoms: pss-i
For the PSS-I outcomes, tests of noninferiority
suggested that the short-duration group was non-
inferior to the long-duration group with respect to the
PSS-I score at posttreatment, t(35) = 2.10, p = .02,
95% CI of observed delta [− 3.88, 6.00], and at
follow-up, t(27) = 1.85, p = .04, 95% CI [− 4.02,
6.77]; in each case, the upper endpoint of the
confidence interval for the observed short minus
long delta is less than our reliable change index,
indicating noninferiority (see Figure 2). In addition,
the observed effect sizes for differences between
groups were d = 0.12 for the posttreatment point and
d = 0.16 for follow-up, both in the “small effect”
range of Cohen’s d scale.
According to multilevel analyses on the PSS-I pre-
to posttreatment, there was a main effect of time,
F(1, 67.55) = 25.84, p b .001, suggesting a
When between-session habituation was defined as the change
in peak SUDs from the third to fourth session, there was no
significant difference between groups, t(27) = .52, p = .61, and
correlations with outcomes were not significant, rs b .15, ps N .60.
336 nacasch et al.
FIGURE 2 Noninferiority margins and 95% confidence intervals
(CI) for difference in outcomes between treatment conditions.
Error bars indicate two-sided 95% CIs. The dashed lines at y = Δ
indicate the minimum clinically reliable difference, or the
noninferiority margin (Δ = 7 for PSS-I, Δ = 4.5 for BDI, Δ = 22
for PTCI). The vertical axis represents differences in PSS-I, BDI, and
PTCI scores between conditions, with negative values indicating
that 60-minute PE sessions resulted in greater improvement in
outcome measures than 90-minute PE sessions. Note. PTSD =
posttraumatic stress disorder; PSS-I = PTSD Symptoms–Interview
version; BDI = Beck Depressive Inventory; PTCI = Posttraumatic
Cognitions Inventory.
substantial decrease in PSS-I over time in both
groups, but there was no Group × Time interaction,
F(1, 68.22) = .12, p = .73, suggesting that there was
not a significant differential change between the two
groups. Results from post to follow-up did not show
either a significant effect of time, F(1, 69.51) = 0.17,
p = .68, or a Group × Time interaction effect, F(1,
68.97) = 0.17, p = .68. The acute time effect was due
to significant decrease from pre- to posttreatment for
each group (18.90 unit decrease for shorter-duration
group: t(37) = 10.88, p b .001; 19.78 unit decrease
for longer-duration group: t(37) = 10.53, p b .001),
with no significant change between posttreatment
and follow-up for either group (p = 0.52 for shorter-
duration group, p = 0.80 for longer-duration
group). Model-based versions of Cohen’s d (based
on least squares means and standard errors) were
0.05, 0.08, and 0.17, for the pretreatment, posttreat-
ment, and follow-up points, respectively. The differ-
ences for the posttreatment and follow-up points are
similar to those found above by direct calculation,
suggesting that missing data had little effect on the
comparisons. As noted above, the effect sizes are all
in the “small” range. In summary, results indicate
that both groups had substantial reduction in
PTSD symptoms, but that there were no apparent
differences between groups at posttreatment or at
follow-up.
depressive symptoms: bdi
For the BDI, we found that tests of noninferiority
approached significance when examining post-
treatment outcomes, t(31) = 1.44, p = .08, 95%
CI [− 5.43, 5.34], suggesting noninferiority. The
observed Cohen’s d between groups was 0.00.
Multilevel analysis of the BDI scores showed a main
effect of time, F(1, 32.5) = 17.68, p b .01, and no
significant Group × Time interaction effect, F(1,
32.4) = 1.99, p = .17. In summary, both groups
demonstrated significant reduction in depression,
with no apparent differences between groups.
change in cognitions: ptci
Noninferiority tests suggested that the short-duration
group was noninferior to the long-duration group
with regard to PTSD-related negative cognitions
level at posttreatment, t(30) = 2.17, p = .02, 95%
CI [− 27.97, 18.59], Cohen d = − .12 (see Figure 2).
Multilevel analysis showed no significant Group ×
Time interaction, F(1, 32) = .28, p = .60, a signifi-
cant effect of time, F(1, 32) = 30.16, p b .0001, and
no significant group effect F(1, 32) = 0.00, p = .95.
Model-based Cohen’s d were .05 for pretreatment
and –.06 for posttreatment. In summary, both groups
demonstrated significant reductions in negative
cognitions, with no apparent differences between
groups.
within- and between-session habituation
Table 2 presents data on the within- and between-
session habituation (also see Figure 3). These data
were collected from an outpatient clinic, so some
cases did not include systematic collection of SUDs
data as part of the clinical record and were therefore
missing. As expected, patients in the long-duration
group showed significantly more within-session
 sixty vs. ninety minutes of prolonged exposure 337

Table 2
Within- and Between-Session Habituation Based on the SUDs Rating During First and Last Exposure Sessions
Variable 60-min PE 90-min PE t p Cohen’s
(n = 16) (n = 12) d
M SD M SD
Session 3
Peak SUDs 78.63 20.07 84.58 11.96 0.91 .37 0.36
End SUDs 71.44 20.46 58.33 16.83 1.81 .08 0.70
Within-session habituation 7.19 6.32 26.25 20.68 3.09 .010 1.25
Last session
Peak SUDs 45.00 13.23 30.21 18.72 2.41 .02 0.91
End SUDs 29.67 14.20 24.79 19.08 0.76 .45 0.29
Within-session habituation 15.33 15.06 5.42 8.11 2.05 .05 0.82
Between-session habituation 36.44 24.63 54.38 16.52 2.18 .04 0.86
Note. PE = prolonged exposure; SUDs = subjective units of distress.

habituation in Session 3, t(27) = 3.50, p = .002, and correlated with each other, r(28) = .29, p = .13;
a trend toward less within-session habituation in the r(27) = − .24, p = .22, respectively.
last session, t(27) = 0.76, p = .05, than patients in When both between-session habituation and
the short-duration group. The long-duration group change in PTCI were simultaneously entered into a
had significantly more between-session habituation regression equation to predict reduction in PSS-I
than the short-duration group, t(27) = 2.18, p = .04. symptoms, the overall model approached significance,
F(2, 15) = 2.59, p = .11, and there was no substantial
correlations among process and outcome change in the partial correlations. Both predictors
variables approached significance (PTCI partial r = .28;
As expected, reduction in PSS-I symptoms was between-session habituation partial r = − .45, p =
significantly correlated with reductions in negative .07), suggesting that cognitive change and between-
cognitions as measured by the PTCI, r(25) = .41, session habituation may be separate indicators of
p = .04. In addition, reduction in PSS-I was emotional processing in PE.
significantly related to greater between-session
habituation, r(28) = − .40, p = .04, but not to greater Discussion
early, r(28) = − .17, p = .39, or late, r(27) = .07, The hypothesis that 60-minute PE sessions with
p = .72, within-session habituation. 20-minute imaginal exposures would yield non-
Reduction in PTCI was not correlated with either inferior outcomes to that of 90-minute sessions
between-, r(18) = .01, p = .97, or early or later with 40-minute imaginal exposures was supported;
within-session habituation, r(18) = − .20, p = .44; no group differences were detected on PTSD symp-
r(17) = .12, p = .66, respectively. Furthermore, toms, depression, and trauma-related cognitions, and
within- and between-session habituation were not noninferiority tests were either significant or close to
significant. Our finding, using an RCT design, that
both the long- and short-duration PE result in similar
outcomes is consistent with van Minnen and Foa’s
100.0 (2006) findings from a nonrandomized sample of 92
90.0 patients. Together, these two studies suggest that
duration of the PE sessions and the imaginal exposure
80.0
SUDs 70.0
60.0
60-min PE
90-min PE
can be considerably shortened without sacrificing the
50.0
40.0
benefit patients derive from treatment. In fact, in the
30.0 present study the imaginal exposure was further
20.0 shortened from van Minnen and Foa’s 30- to
20-minute imaginal exposure. By greatly reducing
10.0
0.0
peak first
exposure
end first
exposure
peak last
exposure
end last
exposure
the duration of the imaginal exposure, we were able
Session
to address successfully the PE treatment components
approximately within the 1-hour “standard” treat-
FIGURE 3 Subjective Units of Distress (SUDs) scale scores ment session duration (after a thorough prerandomi-
during first and last imaginal exposures for completers in 60- and zation 2- to 3-hour assessment, which was not
90-minute PE sessions. Note. PE = prolonged exposure. included in time calculations of the treatment). This
338 nacasch et al.
adaptation renders the treatment less burdensome for
both patients and therapists and more applicable to
community clinical settings that are required to
follow the standard session duration regulated by
reimbursement policy. The current findings should be
replicated in larger, more diverse populations to
determine the generalizability of the results. Notably,
one should not interpret the current findings to
suggest that imaginal exposure shorter than 20 mi-
nutes will also yield a successful outcome. The
efficacy of briefer exposure sessions (e.g., less than
20 minutes) is unknown until empirically studied.
As hypothesized, 40-minute imaginal exposures
resulted in greater within-session habituation than
20-minute exposures. In addition, consistent with
van Minnen and Foa’s (2006) findings, we detected
a significant relationship between PTSD symptom
change and between-session habituation. Contrary
to our hypothesis, however, 40-minute imaginal
exposures resulted in greater between-session
habituation than 20-minute exposures. This finding
is somewhat different from that of van Minnen and
Foa’s study, in which within-session but not between-
session habituation was greater in the 60-minute than
in the 30-minute imaginal exposures. This inconsis-
tency may be due to the differences in the duration of
imaginal exposures in the two studies: 60 versus
40 minutes and 30 versus 20 minutes. In the present
study the long-duration group showed substantial
between-session habituation (M = 54.38 SUDs),
which was significantly greater than that of the
short-duration group (M = 36.44 SUDs). In contrast,
in the van Minnen and Foa study, between-session
habituation did not differ between the long- and
short-duration groups (Ms = 20.2 and 21.1, respec-
tively). This may suggest that a minimal amount of
between-session habituation is required for symptom
reduction, and that any gains beyond this minimum
are only partially contributing to emotional process-
ing and outcomes. In further support of this
interpretation we found that while both the 20- and
40-minute imaginal exposure groups had maximum
between-session habituation levels of over 80 SUDs,
the 20-minute group included a significant propor-
tion of patients (7/16) whose level of between-session
habituation was lower than any of the patients in the
40-minute group. Despite this difference, the overall
relationship of symptom reduction and between-
session habituation was similar in both groups. This
further supports the suggestion that between-session
habituation is related to outcome, but is not a very
strong indicator (Foa et al., 2006). Notably, the
variance in outcome accounted for by between-
session habituation and outcome was 16%, which
allows for many other factors to contribute to
symptom improvement.
The present study showed that PE resulted in a
clinically significant reduction in explicit trauma-
related negative cognitions that the world is extremely
dangerous and that one is extremely incompetent,
with similar reductions in both groups. We also found
a significant correlation between change in negative
cognitions and change in PTSD symptom severity.
Our results are consistent with prior research and
replicate Foa and Rauch’s (2004) study that found
significant correlations between reduction in negative
cognitions and reduction in PTSD symptoms. In a
further study examining the role of cognitions in
ameliorating PTSD via PE, McLean, Su, and Foa
(2015) found that reduction in negative cognitions
mediated symptom reduction in PE. Similarly, Zalta
et al. (2013) found that reduction in trauma-related
negative cognitions preceded reduction of PTSD
symptom severity. Taken together, these findings,
along with those of other studies, support EPT
hypotheses that erroneous cognitions about the self
and the world underlie PTSD and that modification of
these cognitions is a potential mechanism of PE (Foa
& Cahill, 2001). Future studies should consider use of
measures of cognitions that are less biased by demand
characteristics such as implicit measures or reaction
time paradigms.
It is important to note that 20 minutes of
imaginal exposure was sufficient for most patients
to recount the traumatic memory at least once, and
that during the 40-minute imaginal exposure patients
recounted their trauma two to three times. The
findings that patients who recounted their traumatic
memory for 20 minutes experience the same reduc-
tion in trauma-related negative cognitions as those
who recounted it for 40 minutes suggest that
recounting the traumatic memory once in each
session (and then listening to the audiotapes of their
recounting as homework) is sufficient for many
patients to disconfirm their erroneous beliefs that
engaging with the traumatic memory (rather than
avoiding it) would result in them “falling apart”
during such engagement. This experience allows the
changing of patients’ negative cognitions about
themselves.
Interestingly, although the 90-minute PE group
received twice as much imaginal exposure time
compared with the 60-minute PE group, the
number of sessions to reach criteria for treatment
completion was the same in both conditions. This
suggests that more imaginal exposure time does not
expedite symptom reduction. Otherwise, participants
in the 90-minute PE group would have completed
treatment earlier than the 60-minute group. Future
studies should examine this issue further by collecting
a measure of session-by-session PTSD symptom
severity.
 sixty vs. ninety minutes of prolonged exposure
limitations
Some caveats of our study should be recognized
while interpreting the current findings. First, the
sample size was small and the study should be
replicated with a larger sample. Second, partici-
pants were randomized prior to Session 3 rather
than before the beginning of treatment. Although
the differences in duration of treatment sessions and
imaginal exposures started after the randomization,
the possible influence of the fact that the first two
sessions were equivalent in both groups on the
current findings remains unknown. It is possible
that if therapists wish to remain within 60 minutes
for the introductory sessions, it may require three,
rather than two, sessions prior to starting imaginal
exposures. Indeed, three introductory sessions were
used in an uncontrolled study of PE in the Veterans
Administration in the United States (Eftekhari et al.,
2013). In general, therapists may have to be
more efficient with time during 60-minute sessions
than 90-minute sessions. Third, the psychometric
properties of the study measures (e.g., interrater
reliability and percentage agreement of the diagnosis)
and therapist adherence to protocol were not
evaluated in the current study. Fourth, homework
compliance was not measured, and could have
differed between groups. Fifth, the sample was
relatively homogeneous in terms of gender, ethnicity,
and traumas. Taken together with van Minnen and
Foa (2006), however, these results may hold across
populations and cultures, but more data should be
collected on this. Sixth, no data on trauma severity
was collected. Perhaps shorter sessions are insuffi-
cient to address the treatment needs of those exposed
to more severe trauma events. However, the group
did not differ in the number of participants who
were injured during the trauma, a common indicator
of trauma severity. In addition, data were not
available to examine the session-by-session change
in between- or within-session habituation and their
relationships with symptom change, and the data
on within- and between-session habituation were
partial due to therapists not recording these data
systematically. This left these analyses with moderate
power (approximately .65, below the desired
Cohen’s d of .80). The lack of systematic collection
of SUDs could have made the data less reliable and
influenced the results. Finally, it should be noted that
in this study, as well as in previous studies, a self-
report inventory was used to measure negative
cognitions.
Conclusions
In sum, 20-minute imaginal exposure within
60-minute sessions yielded noninferior outcomes
in PTSD symptoms and posttraumatic negative
339
cognitions at posttreatment and follow-up to the
40-minute imaginal exposures and 90-minute
sessions. The current study also showed that longer
imaginal exposures resulted in greater within- and
between-session habituation than shorter expo-
sures. However, because both conditions exhibited
similar efficacy, it can be reasoned that maximal
within- and between-session habituation may not
be necessary conditions for successful PE, although
some level of between-session habituation is related
to outcomes (cf. Foa et al., 2006). In contrast,
negative cognitions and PTSD symptom severity
decreased similarly in the long- and short-treat-
ment-duration groups and were correlated with
reduction of PTSD symptoms severity. These
findings support EPT’s supposition that within-
and between-session habituation are indicators of
emotional processing, whereas reduction of nega-
tive, erroneous cognitions is, as noted above, a
potential mechanism underlying emotional process-
ing and the resultant symptom reduction. Indeed,
change in negative cognitions and between-session
habituation—but not within-session habituation—
was correlated with treatment outcome and none of
the three were correlated with one another.
Disclosure Statement for Authors
All authors report no financial relationships with
commercial interests.
Conflict of Interest Statement
The authors declare that there are no conflicts of interest.
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R E C E I V E D : April 16, 2014
A C C E P T E D : December 6, 2014
Available online 13 December 2014