Evidence-based treatment for post-disaster traumatic stress

1. Evidence-based treatment for post-disaster traumatic stress Nebraska Disaster Behavioral Health Conference July 14, 2006 Laura.Gibson@uvm.edu The University of Vermont National Center for PTSD

2. Overview of talk Best practice approaches for post-disaster traumatic stress across time periods Core elements of CBT National Center for PTSD�s manualized intervention for Post-disaster Distress

3. Foa and Meadows� �Gold Standards� for Clinical Research 1.���� clearly defined target symptoms 2.���� reliable and valid measures 3.���� blind evaluators 4.���� assessor training 5.���� manualized, replicable specific treatment programs 6.���� random assignment to treatment 7.���� objective treatment adherence measure In our review, we also attended to methodological strengths and limitations, with reference to Foa and Meadows� (1997) gold standards for clinical research. The reason for attention to gold standards is that there are sometimes RCT�s that are not internally valid due to the above factors. All studies in the current review met at least 3 of these gold standards � most of the studies meet several of these factors. Studies that met all 7 gold standards are noted with a *. Patricia � you may want to note that the vast majority of studies reviewed did not provide detailed information about the level of assessor training. The benefit of the doubt was given in this area, when it could not be determined from information in the article itself. The other standards were usually easy to ascertain from the manuscripts. In our review, we also attended to methodological strengths and limitations, with reference to Foa and Meadows� (1997) gold standards for clinical research. The reason for attention to gold standards is that there are sometimes RCT�s that are not internally valid due to the above factors. All studies in the current review met at least 3 of these gold standards � most of the studies meet several of these factors. Studies that met all 7 gold standards are noted with a *. Patricia � you may want to note that the vast majority of studies reviewed did not provide detailed information about the level of assessor training. The benefit of the doubt was given in this area, when it could not be determined from information in the article itself. The other standards were usually easy to ascertain from the manuscripts.

4. Immediate Phase Interventions: 1st 2 weeks High evidence: none Low evidence base, (although widely applied): Outreach � primarily Psychological First Aid Critical Incident Stress Debriefing

5. Psychological First Aid: 1st 2 weeks Not a therapeutic technique, per se Refers to the provision of warmth and basic human comfort and support. Does not promote emotional processing or disclosure of traumatic experiences. Flexible, supportive, problem-solving. No formal research support exists. Considered to be �non-toxic� and �evidence- consistent� by NIMH expert panel

6. Debriefing: 1st 2 weeks Also widely applied at present. HOWEVER, At least 12 well designed randomized controlled trails (RCTs) of debriefing as early intervention have been published. Most find no effect or slight worsening of symptoms Multiple reviews have concluded that debriefing is ineffective at best or harmful at worst Caveats: Lack of uniformity/standardization of interventions, more severe injuries (despite randomization) in debriefed grp in 3 debriefing studies that found worse outcomes in debriefed group.

7. NIMH Expert Panel Recommendations: 1st 2 weeks Recommended: PFA appears evidence-consistent, non-toxic. Not recommended: CISD (given the negative findings and the findings re: worsening of sx) CBT and EMDR may be contra-indicated, given that they both encourage disclosure and emotional processing and may interrupt a necessary down-time. Systematic research lacking for 1st 2 weeks

8. Early interventions (2 wks-3 mos): High Evidence: None Medium Evidence: Cognitive behavioral therapy (CBT) Low Evidence: Debriefing, EMDR, Alternative Interventions

9. Early interventions (2 wks- 3 mos) Critical Incident Stress Debriefing (CISD) psychoeducation, normalization of stress reactions, promotion of emotional processing through discussion of the experience Cognitive behavioral therapy (CBT) Psychoeducation, exposure, breathing retraining, cognitive restructuring

10. CISD as early intervention At least 12 RCTs of CISD as early intervention Multiple reviews have concluded that debriefing is ineffective at best or harmful at worst Caveats: Lack of uniformity of interventions, more severe injuries (despite randomization) in debriefed grp in 3 debriefing studies that found worse outcomes in debriefed group

11. CBT as early intervention 5 of 6 studies showed CBT outperformed supportive interventions in the first month post-trauma MVA/industrial accident/assault survivors (Bryant et al., 1998; 1999; 2005) Sexual assault survivors (Echeburua et al., 1996; Foa et al., 1995) One study found CBT equivalent to supportive intervention in MVA survivors, but had unique methodological limitations (Brom et al. 1993) Practical issues: availability of trained therapists, client willingness to engage in CBT The studies with the strongest research support in the first month after a trauma are cognitive behavioral in nature. * Bryant�s RCT�s met all 7 gold standards. These interventions were all individual tx, introduced within approximately one month of a trauma. They average 5 sessions (typically 1.5 hours each) in length. More specific slide summary�Three of four Level A RCTs related to early cognitive-behavioral interventions (Bryant et al., 1998; Bryant et al., 1999; Echeburua, 1996) found clear superiority of the CBT group in reducing PTSD symptomatology compared to a control group, while one (Brom et al., 1993) did not. In addition, a controlled (but not randomized) comparison of a CBT versus an assessment-only condition in the acute phase post-trauma found fewer PTSD symptoms in the CBT group at a 5.5 month follow-up (Foa et al., 1995). Methodological limitations in Brom study: While this study was a randomized and controlled trial, it contained some significant limitations, such as a lack of blind evaluators and a lack of objectively measured treatment fidelity. The study is also limited by the fact that despite randomization, the intervention group had higher trauma-related symptoms prior to the intervention. The studies with the strongest research support in the first month after a trauma are cognitive behavioral in nature. * Bryant�s RCT�s met all 7 gold standards. These interventions were all individual tx, introduced within approximately one month of a trauma. They average 5 sessions (typically 1.5 hours each) in length. More specific slide summary�Three of four Level A RCTs related to early cognitive-behavioral interventions (Bryant et al., 1998; Bryant et al., 1999; Echeburua, 1996) found clear superiority of the CBT group in reducing PTSD symptomatology compared to a control group, while one (Brom et al., 1993) did not. In addition, a controlled (but not randomized) comparison of a CBT versus an assessment-only condition in the acute phase post-trauma found fewer PTSD symptoms in the CBT group at a 5.5 month follow-up (Foa et al., 1995). Methodological limitations in Brom study: While this study was a randomized and controlled trial, it contained some significant limitations, such as a lack of blind evaluators and a lack of objectively measured treatment fidelity. The study is also limited by the fact that despite randomization, the intervention group had higher trauma-related symptoms prior to the intervention.

12. CBT: Primary Components Psychoeducation Active problem-solving, coping skills Cognitive Restructuring Exposure exercises (primarily for anxiety disorders)

14. Example thinking �targets� �I can�t survive another hurricane season� �Flying is extremely dangerous� �I don� t deserve to have survived Katrina, since my husband did not�

15. Exposure Components Used for many anxiety disorders Confronting �fear of fear� Confront avoided places, thoughts, feelings, or situations in a safe manner Often done with assistance of friend or family member Often work on exposure assignments for homework

16. Bryant et al. 1998 ASD trial 10 days post trauma Random assignment of 24 accident survivors with ASD to five 1.5 hr individual sessions of CBT vs. supportive counseling CBT group showed decreased incidence of PTSD at post-tx & 6 month follow-up CBT group showed greater reductions in depressive sx Bryant et al. 1998 Some of the most well controlled and relevant studies of early interventions in the face of potentially traumatizing events have been conducted by Richard Bryant and colleagues (Bryant, Harvey, Dang, Sackville, & Basten, 1998, Level A+; Bryant, Sackville, Dang, Moulds, & Guthrie, 1999, Level A+). Bryant and colleagues� research to date has met all of the gold standard criteria delineated by Foa and Meadows (1997) and has utilized randomized, controlled trials. In addition, unlike most studies to date, the work by Bryant and colleagues has utilized a diagnosis of Acute Stress Disorder (ASD) as one of the inclusion criteria for participation in the studies. Bryant et al.�s 1998 study: At a mean of 10 days post-trauma, Bryant and colleagues randomly assigned adult MVA or industrial accident survivors to five individual, 1.5 hour sessions of either a cognitive behavioral treatment or a supportive counseling control condition. Fewer individuals in the CBT group met criteria for PTSD at post-treatment and at 6 months post-treatment. They also showed greater reductions in intrusive, avoidance, and depressive symptoms than those in the supportive counseling condition. Some of the most well controlled and relevant studies of early interventions in the face of potentially traumatizing events have been conducted by Richard Bryant and colleagues (Bryant, Harvey, Dang, Sackville, & Basten, 1998, Level A+; Bryant, Sackville, Dang, Moulds, & Guthrie, 1999, Level A+). Bryant and colleagues� research to date has met all of the gold standard criteria delineated by Foa and Meadows (1997) and has utilized randomized, controlled trials. In addition, unlike most studies to date, the work by Bryant and colleagues has utilized a diagnosis of Acute Stress Disorder (ASD) as one of the inclusion criteria for participation in the studies. Bryant et al.�s 1998 study: At a mean of 10 days post-trauma, Bryant and colleagues randomly assigned adult MVA or industrial accident survivors to five individual, 1.5 hour sessions of either a cognitive behavioral treatment or a supportive counseling control condition. Fewer individuals in the CBT group met criteria for PTSD at post-treatment and at 6 months post-treatment. They also showed greater reductions in intrusive, avoidance, and depressive symptoms than those in the supportive counseling condition.

17. CBT condition Education about trauma reactions Progressive muscle relaxation training Imaginal exposure to traumatic memories Cognitive restructuring of fear-related beliefs Graded in vivo exposure to avoided situations HW: practice imaginal exposure

18. Supportive counseling condition Education about trauma General problem-solving Unconditional support HW: diary keeping of current problems and mood states

19. ASD and PTSD Caseness

20. BDI scores

21. 4-year follow-up, N=41 Tracked down 41 eligible participants of 80 from 2 tx studies (64%) 25 of original 41 CBTers (62%) 16 of 24 SC pts (67%) 2 (8%) of CBT pts and 4 (25%) SC pts met PTSD criteria CBT pts had less intense PTSD sx and fewer avoidant sx Bryant et al. 2003

22. Later-stage treatment: 3 Months & Onward High level of evidence: Cognitive behavioral therapy (CBT) Medium level of evidence: -- Eye Movement Desensitization and Reprocessing (EMDR) Low evidence: Interpersonal, Psychodynamic/analytic, alternative treatments

23. A word on the EMDR vs. CBT Debate Proliferation of randomized controlled trials on EMDR over last few years, several that include CBT comparison Quality of studies favoring EMDR generally not of caliber of those favoring CBT Several studies have now found that eye movements do not contribute to outcome, raising question of whether the effective component of EMDR is actually exposure (a CBT component) EMDR remains controversial � studies have shown that the eye movements don�t contribute, suggesting that mechanism of action may actually be exposure Note that in 2 of the 3 studies that found slight superiority of EMDR, the interviewers were not blind to conditions and were not always independent of the therapist Of those that examined speed of response, 1 favored CBT and 2 favored EMDR In 4 of 5 RCTs comparing CBT vs. EMDR, drop-out rates were equivalent Ironson et al 2002 was the exception, finding lower drop out rate in EMDR group EMDR remains controversial � studies have shown that the eye movements don�t contribute, suggesting that mechanism of action may actually be exposure Note that in 2 of the 3 studies that found slight superiority of EMDR, the interviewers were not blind to conditions and were not always independent of the therapist Of those that examined speed of response, 1 favored CBT and 2 favored EMDR In 4 of 5 RCTs comparing CBT vs. EMDR, drop-out rates were equivalent Ironson et al 2002 was the exception, finding lower drop out rate in EMDR group

24. CBT for PTSD Multiple RCTs indicate CBT outperforms no-treatment and SC Debate about relative contributions of CR vs. Exposure Further research would help clarify which components of CBT are best tolerated, work most quickly, and are most efficacious At least 5 RCTs have compared variations of CR with variants of exposure, but lack of uniformity across studies makes it hard to draw conclusions. For example, 2 of the studies (Bryant et al 2003 and Tarrier et al 1999) used imaginal exposure alone which may have decreased the strength of the exposure condition. At least 5 RCTs have compared variations of CR with variants of exposure, but lack of uniformity across studies makes it hard to draw conclusions. For example, 2 of the studies (Bryant et al 2003 and Tarrier et al 1999) used imaginal exposure alone which may have decreased the strength of the exposure condition.

25. EMDR for PTSD 5 of 5 RCTs (CBT vs. EMDR) showed that both CBT and EMDR were efficacious in reducing PTSD sx 3 of 5 found slight superiority of EMDR; 2 found slight superiority of CBT in terms of sx reduction EMDR remains controversial � studies have shown that the eye movements don�t contribute, suggesting that mechanism of action may actually be exposure Note that in 2 of the 3 studies that found slight superiority of EMDR, the interviewers were not blind to conditions and were not always independent of the therapist Of those that examined speed of response, 1 favored CBT and 2 favored EMDR In 4 of 5 RCTs comparing CBT vs. EMDR, drop-out rates were equivalent Ironson et al 2002 was the exception, finding lower drop out rate in EMDR group EMDR remains controversial � studies have shown that the eye movements don�t contribute, suggesting that mechanism of action may actually be exposure Note that in 2 of the 3 studies that found slight superiority of EMDR, the interviewers were not blind to conditions and were not always independent of the therapist Of those that examined speed of response, 1 favored CBT and 2 favored EMDR In 4 of 5 RCTs comparing CBT vs. EMDR, drop-out rates were equivalent Ironson et al 2002 was the exception, finding lower drop out rate in EMDR group

26. Summary: Evidence base for early intervention High level of evidence: none Medium level of evidence: CBT Low levels of evidence: CISD, EMDR, Psychodynamic therapy, �Alternative� therapies Low level of evidence reflects either negative findings or lack of quality studies � point out that psychodynamic is difficult to study b/c of difficulty in manualizingLow level of evidence reflects either negative findings or lack of quality studies � point out that psychodynamic is difficult to study b/c of difficulty in manualizing

27. Summary: evidence base for later-stage interventions High level of evidence: CBT Medium level of evidence: EMDR Low level of evidence: Interpersonal, Psychodynamic/analytic therapy, �Alternative� therapies None of these studies were conducted with populations exposed to mass violence or disaster Put EMDR in medium category b/c the RCTs had some major probls � e.g. lack of blind raters�not as methodologically sound a research base as the CBT studies or SSRI studiesNone of these studies were conducted with populations exposed to mass violence or disaster Put EMDR in medium category b/c the RCTs had some major probls � e.g. lack of blind raters�not as methodologically sound a research base as the CBT studies or SSRI studies

28. National Center for PTSD Intervention for Postdisaster Distress

29. Evidence Informed Intervention Identified effective interventions for the range of problems most common after disasters PTSD Depression Other anxiety disorders Selected core elements from these empirically supported treatments that were found across disorders

30. Overview An 8-12 session manualized intervention to treat a range of postdisaster symptoms Designed to be one part of larger disaster mental health system response To be implemented no sooner than 60 days postdisaster For individuals showing more than transient stress response Intermediate step between crisis counseling and longer term mental health treatment

31. Three Main Components Psychoeducation Taught in Session 1 Anxiety management/Coping Skills Taught in Session 2 Cognitive Restructuring (CR) Taught in Sessions 3 and 4 Practiced in Sessions 5-8/12

32. Education Topics PTSD Common Reactions (anxiety, sadness, guilt/shame, anger) Depression Anxiety Substance abuse Grief/bereavement Sleep problems/nightmares Problems with functioning (work, relationships, physical)

33. Cognitive Restructuring Introduced in sessions 3 and 4; practiced through remainder of the treatment �Backbone� of treatment Clients taught connection between problematic thinking and feeling patterns Ultimate goal is to change problematic feelings/behaviors by putting thoughts into more realistic/balanced perspective. Can be used for wide variety of problematic cognitive, emotional, and behavioral patterns

34. Rationale for CR Feelings are connected to thoughts. Our thoughts greatly affect our mood Examples: lying in bed and hear a loud noise Life experiences shape people�s �automatic thoughts� and belief systems. Traumatic experiences are a type of life experience that greatly shape our thinking. These thoughts are often automatic and we may not be aware of them. First step is to become aware of our thoughts

35. Problematic Thinking Styles Goal: To teach clients to identify Problematic Thinking Styles that they may be using. Problematic Thinking Styles are a group of thinking patterns that people often have in their reactions to everyday events, but which are often unhelpful and unnecessary, and contribute to negative feelings. Includes: All or None Thinking; Overgeneralizing; Must, Should, Never; Catastrophizing; Emotional Reasoning, Overestimation of Risk, and Self-blame.

36. 5 Steps of Cognitive Restructuring Describe the upsetting situation Identify strongest emotion Identify strongest thought Challenge your thoughts Make a decision: Either change the thought, develop an action plan, or both.

37. CR: Katrina/Superdome Situation: Seeing a teenage girl sexually assaulted at the superdome Feeling: Guilt/Shame Thought: It�s my fault the girl was raped.

38. CR: Example continued 4. Challenge the thought: �Evidence� for the thought: 1) I saw it happen, 2) I was the only one there, 3) I didn�t do anything. (*note � does not have to be �solid� evidence at this point) Evidence against the thought: 1) I yelled out �stop�, 2) there were 3 men, 3) they had a knife, 4) I asked a police officer for help

39. CR: Example continued 5. Make a Decision: Evidence does NOT support the thought. More balanced thought: �I did everything I could do in a horrible situation.� Help the client work on bringing this alternative thought to mind to challenge the more automatic, guilt-inducing thought