Exposure Therapy for the Treatment of Post Traumatic Stress Disorder Peter W. Tuerk, Ph.D.

1. Exposure Therapy for the Treatment of Post Traumatic Stress Disorder Peter W. Tuerk, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences MUSC; Post Traumatic Stress Clinical Team Charleston VAMC

2. Goals of the Talk • To become familiar with the symptoms andpsychological mechanisms of Posttraumatic Stress Disorder (PTSD). • To learn about the effective treatment of PTSD via Exposure therapy. • To learn about treatment via telehealth

3. NORMAL (not pathological) Post-Trauma Reactions (1-3 weeks) • Emotional:Shock, terror, irritability, blame, anger, guilt, grief, sadness, numbing, anhedonia. • Cognitive:Concentration impairments, confusion, nightmares, intrusive thoughts • Interpersonal:Marital / work conflicts, reduced intimacy, distrust, social withdrawal • Physical:Hyper arousal, fatigue, insomnia, GI distress

4. Normal Post-Trauma Reactions Take home point: Most people will experience some of these serious symptoms after a trauma or series of traumas. But most people will get better with simple support, obtained from family, friends, and community. Treatment is appropriate for those who still have problems 3-12 weeks later.

5. Rates of Diagnosable Psychopathology Following Trauma • Lifetime prevalence of PTSD among adult Americans at 6.8% • Rape: ~33% • Serious Physical assault: 20-33% • Oklahoma City Bombing: 33% (directly exposed) • Veterans from Iraq &Afghanistan : ~20% (45% have symptoms)

6. PTSD = Cluster of Symptoms:

7. PTSD Symptom Clusters • Re-Experiencing • Arousal • Avoidance

8. PTSD Symptoms • Re-Experiencing • •recurring intrusive thoughts or images of the • event. • recurring dreams about the event. • experience of severe anxiety when exposed to reminders of event, such as similar locations, noises, or smells. • acting or feeling as if the event were recurring (flashbacks).

9. PTSD Symptoms • Arousal • physiological reactivity when exposed to trauma cues. • problems falling/staying asleep. • increased irritability/ angry outbursts. • problems concentrating. • overly alert--always scanning environment. • elevated startle response. • FIGHT OR FLIGHT RESPONSE

10. PTSD Symptoms • Avoidance • avoidance of thoughts, feelings, or conversations related to trauma. • avoidance of people, places, or things that are reminders of the trauma. • reduction of interest/participation in previously enjoyable/important activities. • feelings of detachment/isolation • fear of, or inability to feel strong positive or negative emotions--numbing

11. PTSD Symptoms • Arousal • physiological reactivity when exposed to trauma cues. • problems falling/staying asleep. • increased irritability/ angry outbursts. • problems concentrating. • overly alert--always scanning environment. • elevated startle response.

12. PTSD Symptoms • Arousal (red also common in bereavement) • physiological reactivity when exposed to trauma cues. • problems falling/staying asleep. • increased irritability/ angry outbursts. • problems concentrating. • overly alert--always scanning environment. • elevated startle response.

13. PTSD Symptoms • Avoidance • avoidance of thoughts, feelings, or conversations related to trauma (or deceased). • avoidance of people, places, or things that are reminders of the trauma (or deceased). • inability to recall important aspects of event. • reduction of interest/participation in previously enjoyable/important activities. • feelings of detachment/isolation • fear of, or inability to feel strong positive or negative emotions--numbing

14. PTSD Symptoms • Avoidance (red also common in bereavement) • avoidance of thoughts, feelings, or conversations related to trauma (or deceased). • avoidance of people, places, or things that are reminders of the trauma (or deceased). • inability to recall important aspects of event. • reduction of interest/participation in previously enjoyable/important activities. • feelings of detachment/isolation • fear of, or inability to feel strong positive or negative emotions--numbing

16. Maintenance of Symptoms • Negative Reinforcement • The White Bear Phenomenon • Maladaptive or incomplete (unprocessed) thinking.

17. Maintenance of Symptoms • Negative Reinforcement

18. Maintenance of Symptoms • Negative Reinforcement • The White Bear Phenomenon

19. Maintenance of Symptoms • Negative Reinforcement • The White Bear Phenomenon • Maladaptive or incomplete (unprocessed) thinking.

20. Maintenance of Symptoms • Negative Reinforcement • The White Bear Phenomenon • Maladaptive or incomplete (unprocessed) thinking. Could vs. Should Proximity = Responsibility Secondary Psychological Gain Emotional reasoning test/toe Inflated danger estimates

21. Evidence-Based Treatments • These are treatments that have been subjected to between groups study • Not merely well-marketed studies • All effective treatments for anxiety disorders such as PTSD involve some form of EXPOSURE Therapy, aimed at terminating avoidance.

22. Exposure Therapy for PTSD • Some efficacy exists for several types of psychological interventions for PTSD. • Strongest evidence exists for exposure-oriented • interventions • Number of rigorous studies 11-14 • Quality Reviews 15-16 • Quality of data • Strong effect sizes 11 Foa, Davidson & Frances, 1999 14 Schnurr et al., 2007 12 Foa & Rauch, 2004 15 Institute of Medicine, 2007 13 Foa et al., 2005 16 Bradley et al., 2005

23. Benefits of Exposure Therapy for PTSD Dissemination Efforts for Prolonged Exposure (PE) in the VA • Nationwide dissemination initiatives in PE • Multi-year rollouts • Four-day workshops, ongoing consultation and supervision • with regional trainers, emphasis on fidelity and high quality training. Preliminary results of PE with OEF/OIF veterans are promising17-19 17 Tuerk, Brady, Grubaugh, 2009 18 Rauch et al., 2009; 19 Tuerk, Grubaugh, Hamner, Foa, 2009

24. Maintenance of Symptoms • Negative Reinforcement • The White Bear Phenomenon • Maladaptive or incomplete (unprocessed) thinking. Could vs. Should Proximity = Responsibility Secondary Psychological Gain Emotional reasoning test/toe Inflated danger estimates

26. Exposure Therapy • Exactly what victim DOES NOT want to do • Patient must be active participant / collaborator. Must feel some control over progress of tx. • Often combined with some coping therapies, such as PMR or Breathing Retraining, but is not necessary .

27. Exposure Therapy How does it work? A large part of the process is due to Habituation. habituationis an example of learning in which there is a progressive diminution of behavioral response probability with repetition of a stimulus.

28. Exposure Therapy How does it work? A large part of the process is due to Habituation Processing and tolerating trauma specific stimuli promotes habituation to internal and external trauma cues.

29. Exposure Therapy Chronological Nuts & Bolts:

30. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering

31. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation

32. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation Symptom hierarchy Trauma hierarchy

33. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation Symptom hierarchy Trauma hierarchy Development & practice of Subjective Units of Distress (SUD’s)

34. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation Symptom hierarchy Trauma hierarchy Development & practice of Subjective Units of Distress (SUD’s) Imaginal Exposure to traumatic memory

37. Using data to guide treatment and assessment Within session and between session SUDs ratings

38. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation Symptom hierarchy Trauma hierarchy Development & practice of Subjective Units of Distress (SUD’s) Imaginal Exposure to traumatic memory In vivo Exposure to safe situations that are being avoided in everyday life

39. Exposure Therapy Chronological Nuts & Bolts: Rapport building Information gathering Psychoeducation Symptom hierarchy Trauma hierarchy Development & practice of Subjective Units of Distress (SUD’s) Imaginal Exposure to traumatic memory In vivo Exposure to safe situations that are being avoided Processing or Discussion of the exposures and traumatic events.

41. OEF/OIF PE treatmentoutcomes on the PTSD Checklist (PCL) OEF/OIF PE treatment outcomes on the Beck Depression Inventory (BDI)

42. Exposure Therapy for the treatment of PTSD and Alcohol Dependence Clinical Course

43. Benefits of Telemental Health • Lower cost without sacrificing quality of care 11 • Patient benefits with regard to lost employment time, as well as transportation costs and time 12-14 • Technology is rapidly increasing system coverage area, thereby increasing reach to rural veterans 15 • Telemedicine can be applied in cost-efficient manner 16-17 • Satisfaction with service delivery is high among patients and providers 18-19 • Efficacy data in telemental health: limited but supportive 20 11 Morland et al., 2003 16 Fortney, Maciejewski, et al., 2005 12 Bose et al., 2001 17 Fortney, Steffick, et al., 2005 13 Elford et al., 2000 18 Frueh et al., 2000 14 Trott & Blignault, 1998 19 Monnier et al., 2003 15 Dunn et al., 2000 20 Ruskin et al., 2004

44. Results PTSD Checklist (PCL-M) outcomes by Prolonged Exposure (PE) treatment condition, with 95% confidence intervals.

45. Results Beck Depression Inventory (BDI-II) outcomes by Prolonged Exposure (PE) treatment condition, with 95% confidence intervals.

46. Goals of the Talk • To become familiar with the symptoms andpsychological mechanisms of Posttraumatic Stress Disorder (PTSD). • To learn about the effective treatment of PTSD via Exposure therapy. • To learn about treatment via telehealth