Exposure Therapy for the Treatment of Post Traumatic Stress Disorder
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Exposure Therapy for the Treatment of Post Traumatic Stress Disorder Peter W. Tuerk, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences MUSC; Post Traumatic Stress Clinical Team Charleston VAMC. Goals of the Talk.

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Exposure Therapy for the Treatment of Post Traumatic Stress Disorder

Peter W. Tuerk, Ph.D.

Assistant Professor of Psychiatry and

Behavioral Sciences

MUSC;

Post Traumatic Stress Clinical Team

Charleston VAMC


Goals of the talk
Goals of the Talk Disorder

  • To become familiar with the symptoms andpsychological mechanisms of Posttraumatic Stress Disorder (PTSD).

  • To learn about the effective treatment of PTSD via Exposure therapy.

  • To learn about treatment via telehealth


Normal not pathological post trauma reactions 1 3 weeks
NORMAL (not pathological) Post-Trauma Reactions (1-3 weeks) Disorder

  • Emotional:Shock, terror, irritability, blame, anger,

    guilt, grief, sadness, numbing, anhedonia.

  • Cognitive:Concentration impairments, confusion,

    nightmares, intrusive thoughts

  • Interpersonal:Marital / work conflicts, reduced

    intimacy, distrust, social withdrawal

  • Physical:Hyper arousal, fatigue, insomnia, GI distress


Normal post trauma reactions
Normal Post-Trauma Reactions Disorder

Take home point: Most people will experience some of these serious symptoms after a trauma or series of traumas. But most people will get better with simple support, obtained from family, friends, and community.

Treatment is appropriate for those who still have problems 3-12 weeks later.


Rates of diagnosable psychopathology following trauma
Rates of Diagnosable Psychopathology Following Trauma Disorder

  • Lifetime prevalence of PTSD among adult Americans at 6.8%

  • Rape: ~33%

  • Serious Physical assault: 20-33%

  • Oklahoma City Bombing: 33% (directly exposed)

  • Veterans from Iraq &Afghanistan : ~20%

    (45% have symptoms)


PTSD = Disorder

Cluster of Symptoms:


Ptsd symptom clusters
PTSD Symptom Clusters Disorder

  • Re-Experiencing

  • Arousal

  • Avoidance


PTSD Symptoms Disorder

  • Re-Experiencing

  • •recurring intrusive thoughts or images of the

  • event.

    • recurring dreams about the event.

    • experience of severe anxiety when exposed to reminders of event, such as similar locations, noises, or smells.

    • acting or feeling as if the event were recurring (flashbacks).


PTSD Symptoms Disorder

  • Arousal

    • physiological reactivity when exposed to trauma cues.

    • problems falling/staying asleep.

    • increased irritability/ angry outbursts.

    • problems concentrating.

    • overly alert--always scanning environment.

    • elevated startle response.

    • FIGHT OR FLIGHT RESPONSE


PTSD Symptoms Disorder

  • Avoidance

    • avoidance of thoughts, feelings, or conversations related to trauma.

    • avoidance of people, places, or things that are reminders of the trauma.

    • reduction of interest/participation in previously enjoyable/important activities.

    • feelings of detachment/isolation

    • fear of, or inability to feel strong positive or negative emotions--numbing


PTSD Symptoms Disorder

  • Arousal

    • physiological reactivity when exposed to trauma cues.

    • problems falling/staying asleep.

    • increased irritability/ angry outbursts.

    • problems concentrating.

    • overly alert--always scanning environment.

    • elevated startle response.


PTSD Symptoms Disorder

  • Arousal (red also common in bereavement)

    • physiological reactivity when exposed to trauma cues.

    • problems falling/staying asleep.

    • increased irritability/ angry outbursts.

    • problems concentrating.

    • overly alert--always scanning environment.

    • elevated startle response.


PTSD Symptoms Disorder

  • Avoidance

    • avoidance of thoughts, feelings, or conversations related to trauma (or deceased).

    • avoidance of people, places, or things that are reminders of the trauma (or deceased).

    • inability to recall important aspects of event.

    • reduction of interest/participation in previously enjoyable/important activities.

    • feelings of detachment/isolation

    • fear of, or inability to feel strong positive or negative emotions--numbing


PTSD Symptoms Disorder

  • Avoidance (red also common in bereavement)

    • avoidance of thoughts, feelings, or conversations related to trauma (or deceased).

    • avoidance of people, places, or things that are reminders of the trauma (or deceased).

    • inability to recall important aspects of event.

    • reduction of interest/participation in previously enjoyable/important activities.

    • feelings of detachment/isolation

    • fear of, or inability to feel strong positive or negative emotions--numbing


Maintenance of symptoms
Maintenance of Symptoms Disorder

  • Negative Reinforcement

  • The White Bear Phenomenon

  • Maladaptive or incomplete (unprocessed)

    thinking.


Maintenance of symptoms1
Maintenance of Symptoms Disorder

  • Negative Reinforcement


Maintenance of symptoms2
Maintenance of Symptoms Disorder

  • Negative Reinforcement

  • The White Bear Phenomenon


Maintenance of symptoms3
Maintenance of Symptoms Disorder

  • Negative Reinforcement

  • The White Bear Phenomenon

  • Maladaptive or incomplete (unprocessed)

    thinking.


Maintenance of symptoms4
Maintenance of Symptoms Disorder

  • Negative Reinforcement

  • The White Bear Phenomenon

  • Maladaptive or incomplete (unprocessed)

    thinking. Could vs. Should

    Proximity = Responsibility

    Secondary Psychological Gain

    Emotional reasoning test/toe

    Inflated danger estimates


Evidence-Based Treatments Disorder

  • These are treatments that have been

    subjected to between groups study

  • Not merely well-marketed studies

  • All effective treatments for anxiety

    disorders such as PTSD involve some

    form of EXPOSURE Therapy, aimed at

    terminating avoidance.


Exposure therapy for ptsd
Exposure Therapy for PTSD Disorder

  • Some efficacy exists for several types of psychological interventions for PTSD.

  • Strongest evidence exists for exposure-oriented

  • interventions

    • Number of rigorous studies 11-14

    • Quality Reviews 15-16

    • Quality of data

    • Strong effect sizes

      11 Foa, Davidson & Frances, 1999 14 Schnurr et al., 2007

      12 Foa & Rauch, 2004 15 Institute of Medicine, 2007

      13 Foa et al., 2005 16 Bradley et al., 2005


Benefits of Exposure Therapy Disorderfor PTSD

Dissemination Efforts for Prolonged Exposure (PE) in the VA

  • Nationwide dissemination initiatives in PE

  • Multi-year rollouts

  • Four-day workshops, ongoing consultation and supervision

  • with regional trainers, emphasis on fidelity and high quality training.

    Preliminary results of PE with OEF/OIF veterans are promising17-19

    17 Tuerk, Brady, Grubaugh, 2009

    18 Rauch et al., 2009;

    19 Tuerk, Grubaugh, Hamner, Foa, 2009


Maintenance of symptoms5
Maintenance of Symptoms Disorder

  • Negative Reinforcement

  • The White Bear Phenomenon

  • Maladaptive or incomplete (unprocessed)

    thinking. Could vs. Should

    Proximity = Responsibility

    Secondary Psychological Gain

    Emotional reasoning test/toe

    Inflated danger estimates


Exposure Therapy Disorder

  • Exactly what victim DOES NOT want to do

  • Patient must be active participant /

    collaborator. Must feel some control over

    progress of tx.

  • Often combined with some coping

    therapies, such as PMR or Breathing

    Retraining, but is not necessary .


Exposure Therapy Disorder

How does it work?

A large part of the process is due to Habituation.

habituationis an example of learning in which there is a progressive diminution of behavioral response probability with repetition of a stimulus.


Exposure Therapy Disorder

How does it work?

A large part of the process is due to Habituation

Processing and tolerating trauma specific

stimuli promotes habituation to

internal and external trauma cues.


Exposure Therapy Disorder

Chronological Nuts & Bolts:


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation

Symptom hierarchy

Trauma hierarchy


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation

Symptom hierarchy

Trauma hierarchy

Development & practice of

Subjective Units of Distress (SUD’s)


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation

Symptom hierarchy

Trauma hierarchy

Development & practice of

Subjective Units of Distress (SUD’s)

Imaginal Exposure to traumatic memory


Using data to guide treatment and assessment within session and between session suds ratings
Using data to guide treatment and assessment DisorderWithin session and between session SUDs ratings


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation

Symptom hierarchy

Trauma hierarchy

Development & practice of

Subjective Units of Distress (SUD’s)

Imaginal Exposure to traumatic memory

In vivo Exposure to safe situations that are being avoided in everyday life


Exposure Therapy Disorder

Chronological Nuts & Bolts:

Rapport building

Information gathering

Psychoeducation

Symptom hierarchy

Trauma hierarchy

Development & practice of

Subjective Units of Distress (SUD’s)

Imaginal Exposure to traumatic memory

In vivo Exposure to safe situations that are being avoided

Processing or Discussion of the

exposures and traumatic events.


OEF/OIF PE treatment Disorderoutcomes on the

PTSD Checklist (PCL)

OEF/OIF PE treatment outcomes on the

Beck Depression Inventory (BDI)


Exposure Therapy for the treatment of PTSD Disorder

and Alcohol Dependence

Clinical Course


Benefits of telemental health
Benefits of Telemental Health Disorder

  • Lower cost without sacrificing quality of care 11

  • Patient benefits with regard to lost employment time, as well as transportation costs and time 12-14

  • Technology is rapidly increasing system coverage area, thereby increasing reach to rural veterans 15

  • Telemedicine can be applied in cost-efficient manner 16-17

  • Satisfaction with service delivery is high among patients and providers 18-19

  • Efficacy data in telemental health: limited but supportive 20

11 Morland et al., 2003 16 Fortney, Maciejewski, et al., 2005

12 Bose et al., 2001 17 Fortney, Steffick, et al., 2005

13 Elford et al., 2000 18 Frueh et al., 2000

14 Trott & Blignault, 1998 19 Monnier et al., 2003

15 Dunn et al., 2000 20 Ruskin et al., 2004


Results
Results Disorder

PTSD Checklist (PCL-M) outcomes by Prolonged Exposure

(PE) treatment condition, with 95% confidence intervals.


Results1
Results Disorder

Beck Depression Inventory (BDI-II) outcomes by

Prolonged Exposure (PE) treatment condition,

with 95% confidence intervals.


Goals of the talk1
Goals of the Talk Disorder

  • To become familiar with the symptoms andpsychological mechanisms of Posttraumatic Stress Disorder (PTSD).

  • To learn about the effective treatment of PTSD via Exposure therapy.

  • To learn about treatment via telehealth


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