Exposure Therapy in PTSD

1. Exposure Therapy in PTSD Wounds of War Conference Diane T. Castillo, Ph.D. Coordinator, WSDTT February 7, 8, 2008

2. Overview of Effective Treatments for PTSD Two most effective treatments Exposure Therapy Cognitive Restructuring Other effective treatments SIT Assertiveness Training Relaxation Training EMDR From: Rothbaum, et.al., 2000In Effective Treatments for PTSD by Foa, Keane, & Friedman

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

4. Empirical Support for Exposure Therapy • For Chronic PTSD: • 22 Published randomized studies on exposure therapy alone • 25 Published randomized studies on exposure therapy with other interventions (SIT and/or CR)

5. What Is Exposure Therapy? • Exposure therapy is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure, flooding).

6. Theoretical Rationale for Exposure Therapy Combination of: Classical conditioning (traumatic event), e.g., little Hans Instrumental conditioning Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, restaurants, movies Engagement of avoidance activities to reduce anxiety Result is world starts to shrink

7. Theoretical Rationale for Exposure Therapy (cont.) • Imaginal reexposure to memory of trauma in safe setting results in desensitization/habituation of conditioned associations between traumatic memory and negative emotions

8. Presentation to Patients 7-11 example

9. How Does Exposure Therapy Work? Two Essential Ingredients in Emotional Processing of Trauma: • Accessing the fear structure (fear activation) • Availability of corrective information

10. Two Exposure Models Flooding (Keane) Prolonged Exposure or PE (Foa) Both Keane and Foa models use systematic repeated imaginal exposure to memory of the trauma 1 time telling of trauma--NOT systematic exposure therapy—some desensitization can occur Examples: Trauma processing (ind/group) EMDR

11. Keane’s Flooding Model Once through in 60 min. session Therapist-guided Therapist asks questions on senses (seeing, hearing, smelling, thinking, feeling) for each step in the trauma Therapist slows story down at worst points Repeated imaginal exposure in subsequent sessions Rating of SUDs (Subjective Units of Distress) on 100 point scale

12. Foa’s Prolonged Exposure Highly developed protocol Imaginal exposure In-vivo exposure Prolonged (imaginal) exposure: 10-15 90 minute sessions, more as needed 60 min of repetitions in 1st session, 45-30 in subsequent Patient instructed to describe event as many times within allotted time Little or no therapist intervention Later sessions address “hot spots” Assess SUDS level (scale of 1 to 100) every 5 min.

13. Foa’s Protocols Prolonged (imaginal) exposure (cont.): Audio tape full session, with separate tape for exposure piece Pt listens to exposure tape daily Pt listens to session 1x Homework, homework, homework In vivo exposure: Hierarchy of avoided situations listed Rate each on 100 point scale Select 2-3 at 40-60 level Face min of 3x, if not daily in week Practice breathing exercise daily

14. Dateline Videotape

15. How to address with patients Education, education, education Introduce as option in 1st assessment Raise at option at end/beginning each group Use mantra “the more you face it the easier it gets; the more you avoid it, the worse it gets” Teach theoretical rationale Always emphasize choice

16. Setting the Stage—safety nets At home: Inform family next 2 months will be rough Ask for support from family/friends ahead of time Find safe place in home to write By therapist: Tell pt AND be available for same day calls Give pt option of coming in for 2nd session in a week Give pt option of phone therapy session, even if brief

17. Examples • Male combat vet • Female rape survivor

18. Indications: Single trauma Recent trauma (<1 year) Multiple traumas Select worst—decide this with the patient One that causes most current distress If all else equal, the 1st one in series Years of trauma (e.g., childhood sexual abuse)

19. Contraindications No alcohol/substance use during treatment Recommend no anxiolytics or changes (stable min. 1 mo.) Not during period of instability—as best as can—not during recent loss, no current abuse (e.g., pt. living back at home) Must be patient’s choice

20. Variations Traditional—individual sessions Group—WSDTT—max. of 3 pts for 6 weeks Long distance—monthly visits

21. Therapist considerations Countertransference If you decide to do it, get supervision Consider the message, if you back off Debriefing after exposure work May experience nightmares Use same strategies as pt Others?

22. Discussion Role play—non-traumatic event Questions Wrap-up