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Prolonged Exposure Therapy for Posttraumatic Stress Disorder Carmen P. McLean, Ph.D. Center for the Treatment & Study of Anxiety Department of Psychiatry University of Pennsylvania. Overview. Nature of trauma and PTSD Emotional Processing Theory Overview of Prolonged Exposure therapy

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Prolonged Exposure Therapy for Posttraumatic Stress DisorderCarmen P. McLean, Ph.D.Center for the Treatment & Study of AnxietyDepartment of PsychiatryUniversity of Pennsylvania

overview
Overview
  • Nature of trauma and PTSD
  • Emotional Processing Theory
  • Overview of Prolonged Exposure therapy
  • Empirical evidence for PE
  • Safety and tolerability of PE
  • Efficacy of PE with comorbid problems
a definition of a trauma
A. Definition of a Trauma

Experienced

Witnessed

Learned about*

Death

Serious injury

Sexual violation

Repeated or extreme exposure to aversive details of the event(s)

  • Criterion A2 intense fear, helplessness, horror
slide5

Four Symptom Clusters

B. Re-experiencing (1)

E.g., dreams, flashbacks

C. Avoidance/Numbing (3)

E.g., Psychogenic amnesia, detachment

D. Changes in Cognition and Mood (3)

E.g., Self-blame, negative view of others

E. Hyperarousal (3)

E.g., sleep disturbance, jumpiness

diagnostic criteria for ptsd con t
Diagnostic Criteria for PTSD (con’t)

Specify if:

  • Acute: duration of symptoms < 3 months
  • Chronic: duration of symptoms > 3 months
  • Delayed Onset: onset of symptoms > 6 months after the stressor
ptsd as a worldwide problem
PTSD as a Worldwide Problem

Germany 1.3%

Denmark 9%

USA 7.8%

Ethiopia 15.8%

Cambodia 28.4%

Algeria 37.4%

de Jong et al., 2001; Kessler et al, 1995; Perkonnig et al.,2000

prevalence o f trauma in t he us
Prevalence of Trauma in the US

Prevalence (%)

Kessler et al., 2000

the scope of the problem
The Scope of the Problem

60-70%

7%

Experience trauma

slide11

Rate of PTSD by Trauma Type

Kessler et al., 1995

comorbidity
Comorbidity

Kessler et al., 1995

impaired quality of life with ptsd
Impaired Quality of Life with PTSD

Mean SF-36 Score

SF-36 = 36-item short form health survey; lower score = more impairment.

Malik et al.,1999

suicidality in the past year
Suicidalityin the Past Year

Percent (%)

Amaya-Jackson et al., 1998

outpatient health service utilization
Outpatient Health Service Utilization*

Amaya-Jackson et al, 1998

* Past 6 months

summary of reactions to trauma
Summary of Reactions to Trauma

Majority of trauma survivors recover without intervention

PTSD can be viewed as a failure of natural recovery

PTSD is a highly distressing and debilitating disorder:

High psychiatric and medical comorbidity

Low quality of life

High suicidalilty

emotional processing theory of ptsd
Emotional Processing Theory of PTSD
  • Invokes psychological constructs to explain:
    • Early PTSD symptoms
    • Natural recovery
    • Development, maintenance, and treatment of PTSD
fear emotional structure

Fear (Emotional) Structure

A fear (emotional) structure is a program for escaping danger

It includes information about:

The feared stimuli

The fear responses

The meaning of stimuli and responses

trauma memory
Trauma Memory
  • Is a specific emotional structure that includes representations of:
    • Stimuli present during and after the trauma
    • Physiological and behavioral responses that occurred during the trauma (fear, guilt, shame)
    • Meanings associated with these stimuli and responses
  • Associations among stimulus, response, and meaning representations may be realistic or unrealistic
pathological early trauma structure
Pathological/Early Trauma Structure
  • Large number of stimuli
  • Excessive responses (PTSD symptoms)
  • Erroneous associations between stimuli and “danger”
  • Erroneous associations between responses and “incompetent”
  • Fragmented and poorly organized relationships among representations
early ptsd symptoms
Early PTSD Symptoms
  • Trauma reminders  activate trauma memory and associated perception of danger and incompetence
  • Activation of the trauma memory is reflected in re-experiencing and arousal symptoms, which motivate avoidance
recovery processes
Recovery Processes
  • Repeated activation (i.e., emotional engagement) via confronting trauma reminders

+

  • Corrective information (absence of the anticipated harm)

=

  • Incorporation of corrective information about the world, self, and others
chronic ptsd
Chronic PTSD
  • Persistent cognitive and behavioral avoidance prevents recovery by:
    • Limiting activation of the trauma memory
    • Limiting articulation and organization of the trauma memory
    • Limiting exposure to corrective information
erroneous cognitions underlying ptsd
Erroneous Cognitions Underlying PTSD
  • The world is extremely dangerous
    • People are untrustworthy
    • No place is safe
  • I am extremely incompetent
    • PTSD symptoms are a sign of weakness
    • Other people would have prevented the trauma
exposure procedures anxiety management procedures cognitive therapy
Exposure Procedures

Anxiety Management Procedures

Cognitive therapy

Cognitive-Behavioral Treatment

Can Be Divided Into:

exposure therapy
Exposure Therapy

Designed to reduce pathological, dysfunctional anxiety and dysfunctional cognitions by encouraging patients to confront safe, trauma-related feared objects, situations, memories, and images

Exposure helps patients realize that their feared consequences do not occur and therefore are unrealistic

anxiety management treatment
Anxiety Management Treatment

Relaxation Training

Controlled Breathing

Positive Self-talk and Imagery

Social Skills Training

Distraction Techniques (e.g., thought stopping)

cognitive therapy
Cognitive Therapy

Identifying dysfunctional, erroneous thoughts and beliefs (cognitions)

Challenging these cognitions

Replacing these cognitions with functional, realistic cognitions

evidence based treatments for ptsd
Evidence-Based Treatments for PTSD

Cognitive Behavior Therapy

Prolonged exposure (PE)

Stress inoculation training (SIT)

Cognitive therapy (CPT)

EMDR

ebts for chronic ptsd
EBTs for Chronic PTSD

Promote safe confrontations (via exposure, discussions) with trauma reminders (memories, situations)

Aim at modifying the dysfunctional cognitions underlying PTSD

the advantage of prolonged exposure
The Advantage of Prolonged Exposure
  • Has the largest number of studies supporting its efficacy and effectiveness
  • Effective with the widest range of trauma populations
  • Studied in many independent centers in the US and around to world
  • Widely disseminated in the US and abroad;
  • Effectiveness in the hands of non-experts has been documented in several studies
main components of pe
Main components of PE
  • Breathing retraining
  • Education about common reactions to trauma
  • In vivo exposure
  • Imaginal exposure and processing
main components of pe1
Main components of PE
  • Breathing retraining
  • Education about common reactions to trauma
  • In vivo exposure
  • Imaginal exposure and processing
prolonged exposure
Prolonged Exposure

The two primary procedures are:

In-vivo exposure: repeated confrontation with situations, activities, places that are avoided because they are trauma reminders.

Imaginal exposure and processing:repeated revising, recounting, and processing of the traumatic event.

published rcts on exposure therapy ex
Published RCTs on Exposure Therapy (EX)

Chronic PTSD:

EX therapy only 25 studies

Ex therapy + SIT and/or CR 29 studies

Acute PTSD or ASD

EX only 4 studies

Ex therapy + SIT and/or CR 6 studies

2008 institute of medicine report
2008 Institute of Medicine Report

“The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD”

(chapter 4, p. 97)

Reference:

Institute of Medicine (IOM): 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

study i with women assault victims
Study I With Women Assault Victims

Treatments:

Prolonged Exposure (PE)

Stress Inoculation Training (SIT)

SIT + PE

Wait List Controls

Treatments included 9 sessions conducted over 5 weeks

Foa et al.,1999

study ii with women assault victims
Study II With Women Assault Victims

Treatments:

Exposure (PE) alone

PE + Cognitive Restructuring (PE/CR)

Wait List (WL)

Foa et al., 2005

study with men and women victims of mixed traumas
Study with Men and Women Victims of Mixed Traumas

Treatments:

Exposure (PE)

Cognitive Restructuring (CR)

PE + CR

Relaxation Training

Treatment consisted of 10 sessions conducted over 16 weeks

Marks et al., 1998

good end state functioning post treatment
Good End State Functioning Post Treatment*

PE SIT PE/SIT WL PE CR PE/CR R

Foa et al., 1999 Marks et al., 1998

* > 50% improved on PTSD; <7 BDI; <35 STAI-S

percent relapse of pe and cpt completers at 5 10 year follow up
Percent Relapse of PE and CPT Completers at 5-10 year Follow-up

There was a trend for PE to have less relapse than CPT at LTFU, X2(1, N =75) 3.8, p =.057.

Relapse

pe vs present centered therapy
PE vs Present Centered Therapy

284 Female Veterans and Active-Duty Personnel

with PTSD

RandomAssignment

141 Total

Prolonged Exposure (PE)

Therapy

143 Total

Present Centered

Therapy (PCT)

Schnurr et al., 2007

Schnurr et al., 2007

study methods
Study Methods
  • 12 sites
  • Therapy
    • 10 weekly 90-minute sessions
    • Comparable format, e.g., # of sessions, individual delivery
    • 52 therapists (PhD, MD, MSW, etc)
  • Outcomes
    • PTSD (“CAPS” interview), other sxs, functioning, quality of life
    • Assessed before & after treatment, 3 & 6 months later

Schnurr et al., 2007

slide58

Efficacy of PE vs. PCT Among Women Veterans With PTSD

Overall d = .46

PTSD Severity CAPS

Schnurr et al., 2007

comparing pe vs pe via telehealth
Comparing PE vs. PE Via Telehealth.

PTSD Checklist (PCL) and Beck Depression Inventory (BDI) outcomes by Prolonged Exposure (PE) treatment condition, with 95% confidence intervals (N=37).

Tuerk et al. (2010)

effect of pe on mental health care service utilization
Effect of PE on mental health care service utilization

Mean number of appointments

Tuerk et al. 2012

massed vs spaced prolonged exposure
Massed vs Spaced Prolonged Exposure

Recruitment Site: Ft Hood - Texas

Military OIF/OEF personnel are randomized to one of four conditions:

PE- M: 10 session delivered in 2 weeks

PE-S: 10 sessions delivered in 8 weeks

Present Centered Therapy: 10 sessions delivered in 8 weeks

Minimal Contact control delivered in 2 weeks

277 of 360 Participants Recruited

preliminary findings
Preliminary Findings

Military personnel were randomized to

PE-M (10 PE sessions derived in 2 weeks)

MCC (2 weeks of minimal contact control)

slide68

Exacerbation of Symptoms

  • Minority of clients in treatment show a reliable exacerbation of symptoms
      • 10.5% in PTSD symptoms
      • 21.1% in Anxiety symptoms
      • 9.2% in Depressive symptoms
  • Exacerbation of symptoms was not associated with:
      • treatment drop out
      • poorer treatment outcome
  • Foa et al., (2002)
improvement and worsening after cognitive behavioral treatments
Improvement and Worsening after Cognitive Behavioral Treatments

PE PE+SIT/CR SIT WL

n = 135 n = 66 n =19 n = 99

Improve on PTSD93% 86% 84% 36%

Worsen on PTSD0 0 0 8%

Worsen on Depression2% 2% 0 12%

Worsening and improvement = Increase or decrease in symptoms by => Standard Error of the Difference (based on SD and test-retest reliability (7.5 points in the PSSI, 11.4 points on the CAPS; 4.5 points on the BDI).

slide71

Dropout Rate by Treatment Category

  • Treatment (25 studies) Total n % Dropout
    • EX Alone 330 20.6%
    • SIT or CT Alone 222 22.1%
    • EX plus CT or SIT 335 26.0%
    • EMDR 143 18.9%
    • Controls (Active and WL) 543 11.4%
    • No difference among active treatments:
    • 2 (3, N= 1030) = 1.73, p = 0.631

Hembree et al., 2003

effect of personality disorder pd on reduction in ptsd pss i
Effect of Personality Disorder (PD) on Reduction in PTSD (PSS-I)

Hembree et al., 2004

F(1, 73) < 1, ns – (no effect)

the efficacy of pe with current past or no depression
The Efficacy of PE with Current, Past, or no Depression

PTSD Severity

Hagenaars, van Minnen, & Hoogduin, 2010

effect of personality disorder pd on reduction in depression bdi
Effect of Personality Disorder (PD) on Reduction in Depression (BDI)

F(1, 71) < 1, ns – (no effect)

Hembree et al., 2004

ptsd and alcohol dependence
PTSD and Alcohol Dependence

Will integrating treatment for alcohol and PTSD produce superior outcomes for AUD and PTSD?

percent days drinking
Percent Days Drinking

%DD

Study Week

Foa et al., 2013

the efficacy of pe with high and low dissociations
The Efficacy of PE with High and Low Dissociations

PTSD Severity

Hagenaars, van Minnen, & Hoogduin, 2010

the effects of pe among patients with ptsd and tbi
The Effects of PE Among Patients with PTSD and TBI

PTSD severity

Time, F (1.1, 6.8) = 16.6, p = .004;

Time*Condition, F (1.1, 6.8) = 5.4, p = .05

Rauch, unpublished data

the effects of pe among patients with ptsd and mild tbi
The Effects of PE Among Patients with PTSD and mild TBI

NOTE: TBI status did not predict post-tx PCL, t(49) = −0.94, p = .35, or the slope of change over time, t(49)=−0.3, p = .70.

PCL Score

Total ITT sample: t(49)=6.59, p < .001, d = 1.00.

mTBI: t(10) = 3.65, p < .005, d = 1.81.

Sripada et al ., 2013

the effects of pe among patients with ptsd and tbi1
The Effects of PE Among Patients with PTSD and TBI

PTSD severity

Time, F (1.1, 6.8) = 16.6, p = .004;

Time*Condition, F (1.1, 6.8) = 5.4, p = .05

Rauch, unpublished data

comorbid bdd
Comorbid BDD

26 Randomized

17 Allocated to DBT+PE

10 Completed treatment

9 Allocated to DBT only

5 Completed treatment

5 Lost to Follow-up

3 Lost to Follow-up

17 Analyzed

9 Analyzed

Harned, Korslund, & Linehan, 2014

suicidal and non suicidal self injury
Suicidal and Non-Suicidal Self-Injury

Clients in DBT+ PE were 1.4 to 2.4 times less likely to attempt suicide and 1.3 to 1.5 times less likely to self-injure than those in DBT only.

Percentage (%)

ITT = Intent to Treat

TC = Treatment Completers

Harned, Korslund, & Linehan, 2014

ptsd severity
PTSD Severity

Harned, Korslund, & Linehan, 2014

ptsd remission
PTSD Remission

At post-treatment, clients in DBT+ PE were 1.8 to 2.0 times more likely to have remitted from PTSD than those in DBT. At follow-up, no DBT clients remained in remission.

% Remitted from PTSD

ITT = Intent to Treat

TC = Treatment Completers

Harned, Korslund, & Linehan, 2014

pe dbt in veterans
PE+DBT in Veterans

“JOURNEY”

12 Week Intensive Outpatient Program provided at the Minneapolis VA Healthcare System

Housing provided on site

8 patients at any one time, 4 start every 6 weeks

Meis, Meyers, Velasquez, Voller,

Thuras, & Kehle-Forbes

slide88

PTSD Severity (n =29)

t (21) = 6.97, p < .001, Cohen’s d = 1.49

weekly structure
Weekly Structure

DBT skills groups: 6 hours

Individual DBT: 1-2 hours

Individual PE sessions: 3 hours

Imaginal exposure begins week 4

Community outings for skills practice/generalization: 6 hours

2 community meetings

borderline symptom severity
Borderline Symptom Severity

t (14) = 5.44, p < .001, Cohen’s d = 1.40 (1.67)

suicidal ideation
Suicidal Ideation

t (21) = 3.45, p = .002, Cohen’s d = 0.74 (0.69)

negative cognitions
Negative Cognitions

t (21) = 5.08, p < .001

Cohen’s d = 1.08 (1.39)

  • t (21) = 6.24, p < .001
  • Cohen’s d = 1.33 (1.70)

t (21) = 6.63, p < .001

Cohen’s d = 1.41 (1.64)

exclusion criteria
Exclusion criteria

High suicidality

Changes in medication (mood regulators, antipsychotics) within two months prior to the study;

Participant is in seclusion or admitted to a closed ward.

Note:

Severity of psychosis was not an exclusion criterion

treatment
Treatment

Maximum of 8 sessions (90 minutes)

Standard PE, no adjustments for psychosis at all (e.g., stabilization, emotion regulation, skill training)

safety
Safety
  • A serious adverse event is:
    • Suicide or suicide attempt;
    • Self mutilation in need of intervention;
    • Psychological crisis in need of intervention;
    • A crisis admission to hospital;
    • Violent behavior that requires restraint.

PE:4

WL: 5

conclusions
Conclusions

PE is effective in reducing PTSD symptoms among patients with medicated psychotic patients who had positive psychotic symptoms (e.g., hallucinations )

Standard treatment protocols can be used, no adaptation necessary

PE is a safe treatment for PTSD in psychotic patients who are stabilized on medication

pe is effective with complex ptsd sufferers
PE is Effective With Complex PTSD Sufferers

Comorbid Disorders:

  • Depression
  • Alcohol and Drug Dependent
  • Borderline Personality Disordered
  • High dissociation
  • Traumatic Brain Injury patients

Associated symptoms:

  • Guilt
  • Anger/Aggression
  • Suicide gestures
  • Poor health
a top down approach
A Top Down Approach??

The Veterans Health Administration initiated a system-wide roll-out of CPT and PE, reflecting strong commitment to implement evidence-based treatments in the VA

Phase I consisted of a two-year training PE to 300 therapists by the developers of PE

The goal: permanent capacity to train and supervise their mental health practitioners in conducting PE

pe training model
PE Training Model

Certified PE Clinicians

  • Completed a 4-day workshop followed by weekly individual supervision via viewing session recordings on two cases

Certified PE Supervisors

  • Selected from among the certified clinicians.
  • Participated in 5-day supervisor workshop at the CTSA

Certified PE Trainers (“Train-the-Trainer”)

  • Were selected from among the certified supervisors
  • Participated in a 3-day trainer workshop
slide105

Numbers of Therapists Trained in the VA

  • Total # Clinicians Trained: Over 2000
  • Consultants: 70
  • Trainers: 16
effectiveness of pe in the va
Effectiveness of PE in the VA

Eftekhari et al., 2013

1931 veterans were treated by 804 clinicians who participated in a 4-day workshop on PE

After the workshop, clinicians were supervised on 2 cases

The outcomes of these firstwereanalyzed

effectiveness of pe in the va1
Effectiveness of PE in the VA

Eftekhari et al., 2013

effectiveness of pe in the va2
Effectiveness of PE in the VA

Eftekhari et al., 2013

62.4% of patients exhibited a clinically significant improvement from baseline and post-treatment

49% of patients had PCL scores of less than 50 at the end of treatment, indicating loss of PTSD diagnosis

is consultation important
Is Consultation Important?

Workshops are relatively low investment in a training program.

Follow-up consultations, on the other hand, carry are very costly

But…

In the absence of follow-up consultation (supervision), clinicians are less likely to use the treatment they had learned

implementation of pe in the military
Implementation of PE in the Military
  • This study with the Army is motivated by the following:
    • Workshops are relatively inexpensive
    • Intensive consultations on two cases are quite costly
    • Therapists are more likely to adopt a novel treatment if they receive consultation
  • We will test the added value of supervision by comparing training with and without supervision in 3 military bases with 120 Army therapists
  • Outcomes include: % patients with PTSD who receive PE; therapists attitudes towards PE; patient outcomes
conclusion
Conclusion
  • Several CBT programs are quite effective for PTSD
  • PE has received the most empirical evidence with a wide range of traumas
  • PE is more effective than treatment as usual for combat veterans
  • PE outcome is not increased by adding CR or SIT
  • PE is effective with a number of commonly occurring disorders
  • PE can be successfully disseminated to community clinics with non-CBT experts as therapists
  • PE can be disseminated effectively over long distances and across cultures
thank you

Thank you

Edna Foa

David Yusko

Elna Yadin

Alan Peterson

Strong Star Consortium

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