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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


  • 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



Learned about*


Serious injury

Sexual violation

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

  • Criterion A2 intense fear, helplessness, horror


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



Experience trauma


Rate of PTSD by Trauma Type

Kessler et al., 1995


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)


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.

Empirical evidence for prolonged exposure

Empirical Evidence for Prolonged Exposure

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)


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


Prolonged Exposure (PE)

Stress Inoculation Training (SIT)


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 Assault Survivors


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 Survivorsof Mixed Traumas


Exposure (PE)

Cognitive Restructuring (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* Survivors


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

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


Efficacy of Exposure, EMDR, and Relaxation Survivors

Taylor et al., 2003


5-year Follow-up in PE and CPT Survivors

Resick et al. 2013

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.


Pe with veterans

PE with Veterans Follow-up

Pe vs present centered therapy
PE Follow-upvs Present Centered Therapy

284 Female Veterans and Active-Duty Personnel

with PTSD


141 Total

Prolonged Exposure (PE)


143 Total

Present Centered

Therapy (PCT)

Schnurr et al., 2007

Schnurr et al., 2007

Study methods
Study Methods Follow-up

  • 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


Efficacy of PE vs. PCT Among Women Veterans With PTSD Follow-up

Overall d = .46

PTSD Severity CAPS

Schnurr et al., 2007

Comparing pe vs pe via telehealth
Comparing PE vs. PE Via Follow-upTelehealth.

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 Follow-up

Mean number of appointments

Tuerk et al. 2012

Massed vs spaced prolonged exposure
Massed Follow-upvs 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 Follow-up

Military personnel were randomized to

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

MCC (2 weeks of minimal contact control)


Exacerbation of Symptoms Follow-up

  • 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)


    PTSD Severity and Exacerbation Follow-up

    PTSD Severity

    Improvement and worsening after cognitive behavioral treatments
    Improvement and Worsening after Cognitive Behavioral Treatments


    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).


    Dropout Rate by Treatment Category Treatments

    • 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 (PSS-I)

    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 severity for low and high state anger patients treated with pe sit and pe sit
    PTSD Severity for Low and High State-Anger Depression (BDI) Patients Treated with PE, SIT, and PE/SIT

    Effect of ptsd treatment on state anger for low and high state anger patients
    Effect of PTSD Treatment on State-Anger Depression (BDI) for Low and High State-Anger Patients


    Ptsd and alcohol dependence
    PTSD and Alcohol Dependence Depression (BDI)

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

    Percent days drinking
    Percent Days Drinking Depression (BDI)


    Study Week

    Foa et al., 2013

    The efficacy of pe with high and low dissociations
    The Efficacy of PE with High and Low Dissociations Depression (BDI)

    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 Depression (BDI)

    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 Depression (BDI)

    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 Depression (BDI)

    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 Depression (BDI)

    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 Depression (BDI)

    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 Depression (BDI)

    Harned, Korslund, & Linehan, 2014

    Ptsd remission
    PTSD Remission Depression (BDI)

    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 Depression (BDI)


    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


    PTSD Severity (n =29) Depression (BDI)

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

    Weekly structure
    Weekly Structure Depression (BDI)

    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 Depression (BDI)

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

    Suicidal ideation
    Suicidal Ideation Depression (BDI)

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

    Negative cognitions
    Negative Cognitions Depression (BDI)

    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)

    Treatment of ptsd and psychosis with prolonged exposure

    Treatment of PTSD and Psychosis with Prolonged Exposure Depression (BDI)

    de Bont, van Minnen 2013


    Exclusion criteria
    Exclusion criteria Depression (BDI)

    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.


    Severity of psychosis was not an exclusion criterion

    Treatment Depression (BDI)

    Maximum of 8 sessions (90 minutes)

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

    Ptsd severity1
    PTSD Severity Depression (BDI)

    Ptsd diagnosis
    PTSD Diagnosis Depression (BDI)

    Dropout ns
    % Dropout (ns) Depression (BDI)

    Safety Depression (BDI)

    • 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.


        WL: 5

    Conclusions Depression (BDI)

    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 Depression (BDI)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

    Dissemination of pe in the vas
    Dissemination of PE Depression (BDI)in the VAs

    A top down approach
    A Top Down Approach?? Depression (BDI)

    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 Depression (BDI)

    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


    Numbers of Therapists Trained in the VA Depression (BDI)

    • Total # Clinicians Trained: Over 2000

    • Consultants: 70

    • Trainers: 16

    Effectiveness of pe in the va
    Effectiveness of PE in the VA Depression (BDI)

    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 Depression (BDI)

    Eftekhari et al., 2013

    Effectiveness of pe in the va2
    Effectiveness of PE in the VA Depression (BDI)

    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? Depression (BDI)

    Workshops are relatively low investment in a training program.

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


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

    Consultation increase self efficacy in conducting pe
    Consultation Increase Self-Efficacy in Depression (BDI)Conducting PE

    (Karlin et al., 2010

    Implementation of pe in the military
    Implementation of PE in the Military Depression (BDI)

    • 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 Depression (BDI)

    • 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 Depression (BDI)

    Edna Foa

    David Yusko

    Elna Yadin

    Alan Peterson

    Strong Star Consortium