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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 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