Download No Slide Title

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
 Empirical
evidence for PE
 Safety
and tolerability of PE
 Efficacy
of PE with comorbid problems
Nature of Trauma and PTSD
A. Definition of a Trauma
Death
Experienced
Serious injury
Witnessed
Sexual violation
Learned about*
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)
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
Germany
Denmark
USA
1.3%
9%
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 of Trauma in the US
100
90
80
70
60
50
40
30
20
10
0
Men
Women
61
51
34
27
Any
26
One
25
Two or more
Kessler et al., 2000
The Scope of the Problem
60-70%
7%
Experience
trauma
Prevalence of Trauma and PTSD in
Men and Women in the US
70
60
Trauma
60.7
PTSD
Percent (%)
51.2
50
40
30
20.4
20
10
8.1
0
Men
Women
Kessler, 1995
Rate of PTSD by Trauma Type
Kessler et al., 1995
The Cost and Burden of PTSD
Comorbidity
Kessler et al., 1995
Mean SF-36 Score
Impaired Quality of Life with PTSD
SF-36 = 36-item short form health survey; lower score = more impairment.
Malik et al.,1999
Percent (%)
Suicidality in the Past Year
Amaya-Jackson et al., 1998
Effects of PTSD on Medical Problems
Adjusted Odds of Disease in PTSD
vs. no PTSD
Neurological
2.48*
Vascular
1.88*
Respiratory
1.43*
Gastrointestinal
1.96*
Metabolic/autoimmune
3.32*
Musculoskeletal
2.52*
Sareen et al., 2005
Outpatient Health Service Utilization*
* Past 6 months
Amaya-Jackson et al, 1998
Video clip
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
Emotional Processing Theory of PTSD
 Invokes psychological constructs



to explain:
Early PTSD symptoms
Natural recovery
Development, maintenance, and treatment of PTSD
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


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





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
•
Trauma reminders  activate trauma memory and
associated perception of danger and incompetence
•
Activation of the trauma memory is reflected in reexperiencing and arousal symptoms, which motivate
avoidance
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
 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
 The


I
world is extremely dangerous
People are untrustworthy
No place is safe
am extremely incompetent


PTSD symptoms are a sign of weakness
Other people would have prevented the trauma
PTCI Scale Scores by Participant Group
Foa et al., 1999
Effective Psychotherapy
For PTSD
Cognitive-Behavioral Treatment
Can Be Divided Into:

Exposure Procedures
 Anxiety Management Procedures
 Cognitive 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

Relaxation Training

Controlled Breathing

Positive Self-talk and Imagery

Social Skills Training

Distraction Techniques (e.g., thought stopping)
Cognitive Therapy

Identifying dysfunctional, erroneous thoughts and beliefs
(cognitions)

Challenging these cognitions

Replacing these cognitions with functional, realistic
cognitions
Evidence-Based Treatments for PTSD


Cognitive Behavior Therapy

Prolonged exposure (PE)

Stress inoculation training (SIT)

Cognitive therapy (CPT)
EMDR
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

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
1. Breathing retraining
2. Education about common reactions to trauma
3. In vivo exposure
4. Imaginal exposure and processing
Main components of PE
1. Breathing retraining
2. Education about common reactions to trauma
3. In vivo exposure
4. Imaginal exposure and processing
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.
Video clip
Empirical Evidence for
Prolonged Exposure
Published RCTs on Exposure Therapy (EX)
Chronic PTSD:
 EX therapy only
 Ex therapy + SIT and/or CR
25 studies
29 studies
Acute PTSD or ASD
 EX only
 Ex therapy + SIT and/or CR
4 studies
6 studies
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.
PE with Civilian Populations
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
Comparison of PE, SIT, PE/SIT, and Waitlist
With Female Assault Survivors
40
Pre
Post
FU
PSS-I Total
30
20
10
0
PE
SIT
PE+SIT
WL
Foa et al., 1999
Study II With Women Assault Victims
Treatments:
 Exposure (PE) alone
 PE + Cognitive Restructuring (PE/CR)
 Wait List (WL)
Foa et al., 2005
Comparison of PE, PE/CR, and Waitlist
With Female Assault Survivors
PSS-I Total
40
Pre
Post
FU
30
20
10
0
PE
PE/CR
WL
Foa et al., 2005
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*
Perecent Responders
60
50
40
30
20
10
0
PE
SIT
PE/SIT
WL
Foa et al., 1999
* > 50% improved on PTSD; <7 BDI; <35 STAI-S
PE
CR
PE/CR
R
Marks et al., 1998
PTSD Severity CAPS
Efficacy of Exposure, EMDR, and
Relaxation
90
80
70
60
50
40
30
20
10
0
Pre
Post
FU
EX
EMDR
RLX
Taylor et al., 2003
Percent Diagnosed
5-year Follow-up in PE and CPT
100
90
80
70
60
50
40
30
20
10
0
CPT
PE
Pretx
LTFU
PTSD
Resick et al. 2013
Percent Relapse of PE and CPT Completers
at 5-10 year Follow-up
Relapse
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 vs Present Centered Therapy
284 Female Veterans and Active-Duty Personnel
with PTSD
Random Assignment
141 Total
Prolonged Exposure (PE)
Therapy
143 Total
Present Centered
Therapy (PCT)
Schnurr et al., 2007
Schnurr et al., 2007
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
Efficacy of PE vs. PCT Among Women Veterans
With PTSD
PTSD Severity CAPS
90
Overall d = .46
80
70
60
50
40
30
20
PE
PCT
Schnurr et al., 2007
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)
Mean number of appointments
Effect of PE on mental health care
service utilization
1-yr before PE
14
1-yr after PE
12
10
8
6
4
2
0
PE completers
PE non-completers
Tuerk et al. 2012
PE with Active Military Members
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

Military personnel were randomized to
PE-M (10 PE sessions derived in 2 weeks)
MCC (2 weeks of minimal contact control)
Efficacy of Massed PE on Reduction of
PTSD Symptoms
d=.96, p=.0001
Efficacy of Massed PE on Reduction
of Depression
Efficacy of Massed PE on Anger
Reduction
Safety and Acceptability of Prolonged
Exposure
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)
PTSD Severity and Exacerbation
35
No Exacerbation
30
Exacerbation
PTSD Severity
25
20
15
10
5
0
Pre-Tx
Week 2 Week 4 Week 6 Week 8 Post-Tx
Improvement and Worsening after
Cognitive Behavioral Treatments
Improve on PTSD
Worsen on PTSD
Worsen on Depression
PE
PE+SIT/CR
SIT
WL
n = 135
n = 66
n =19
n = 99
93%
0
86%
0
84%
0
36%
8%
2%
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
Treatment (25 studies)
Total n
% Dropout
EX Alone
SIT or CT Alone
330
222
20.6%
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)
F(1, 73) < 1, ns – (no effect)
Hembree et al., 2004
PTSD Severity
The Efficacy of PE with Current, Past, or no
Depression
Hagenaars, van Minnen, & Hoogduin, 2010
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
Effect of PTSD Treatment on State-Anger
for Low and High State-Anger Patients
Assessment
PTSD and Alcohol Dependence
Will integrating treatment for alcohol and PTSD produce
superior outcomes for AUD and PTSD?
PE + Counseling
Counseling
Naltrexone
Naltrexone
PE + Counseling
Naltrexone
Counseling
Placebo
Placebo
PE + Counseling
Placebo
Counseling
%DD
Percent Days Drinking
80
Naltx + PE
70
Placebo + PE
60
Naltx no PE
50
Placebo No PE
40
30
20
10
0
0
4
8
12
16
Study Week
20
24
38
52
Foa et al., 2013
The Efficacy of PE with High and Low
Dissociations
PTSD Severity
30
High dissociation (n=15)
25
Low dissociation (n-21)
20
15
10
5
0
Pre
Post
Follow-up
Hagenaars, van Minnen, & Hoogduin, 2010
PTSD severity
The Effects of PE Among Patients with
PTSD and TBI
100
90
80
70
60
50
40
30
20
10
0
PCT
Pre (n = 8)
Time, F (1.1, 6.8) = 16.6, p = .004;
Time*Condition, F (1.1, 6.8) = 5.4, p = .05
*Mid (n = 8)
PE
*Post (n = 8)
Rauch, unpublished data
The Effects of PE Among Patients with PTSD
and mild TBI
PCL Score
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.
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 TBI
100
PCT
PTSD severity
90
PE
80
70
60
50
40
30
20
10
0
Pre (n = 8)
*Mid (n = 8)
Time, F (1.1, 6.8) = 16.6, p = .004;
Time*Condition, F (1.1, 6.8) = 5.4, p = .05
*Post (n = 8)
Rauch, unpublished data
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
Percentage (%)
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.
ITT = Intent to Treat
TC = Treatment Completers
Harned, Korslund, & Linehan, 2014
PTSD Severity
Harned, Korslund, & Linehan, 2014
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.
100
% Remitted from PTSD
90
80
80
70
60
58
50
60
50
40
DBT + DBT PE (TC)
33
40
DBT + DBT PE (ITT)
30
DBT (TC)
20
DBT (ITT)
0
10
0
0
Post-treatment
ITT = Intent to Treat
TC = Treatment Completers
3-month Follow Up
Harned, Korslund, & Linehan, 2014
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
PTSD Severity (n =29)
t (21) = 6.97, p < .001,
Cohen’s d = 1.49
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
t (14) = 5.44, p < .001,
Cohen’s d = 1.40 (1.67)
Suicidal Ideation
t (21) = 3.45, p = .002,
Cohen’s d = 0.74 (0.69)
Negative Cognitions
t (21) = 5.08, p < .001
Cohen’s d = 1.08
(1.39)
t (21) = 6.63, p < .001
Cohen’s d = 1.41 (1.64)
t (21) = 6.24, p < .001
Cohen’s d = 1.33 (1.70)
(
Treatment of PTSD and Psychosis with
Prolonged Exposure
de Bont, van Minnen 2013
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

Maximum of 8 sessions (90 minutes)

Standard PE, no adjustments for psychosis at all (e.g.,
stabilization, emotion regulation, skill training)
PTSD Severity
PTSD Diagnosis
% Dropout (ns)
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

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
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
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
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
 Total # Clinicians Trained:
Over 2000
 Consultants:
70
 Trainers:
16
Effectiveness of PE in the VA

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 first were analyzed
Eftekhari et al., 2013
Effectiveness of PE in the VA
Eftekhari et al., 2013
Effectiveness of PE in the VA

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
Eftekhari et al., 2013
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
Consultation Increase Self-Efficacy in
Conducting PE
Clinician self-efficacy to deliver PE
6.6
Self-efficacy (0-7)
6.4
6.2
6
5.8
5.6
5.4
5.2
5
Pre-training
(Karlin et al., 2010
Post-workshop
Post-consultation
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

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 nonCBT experts as therapists

PE can be disseminated effectively over long distances and across
cultures
Thank you
Edna Foa
David Yusko
Elna Yadin
Alan Peterson
Strong Star Consortium