Behavioral Activation Strategies for the Treatment of PTSD

1. Behavioral Activation Strategies for the Treatment of PTSD

2. Acknowledgments Amy Wagner, PhD Portland VAMC Sona Dimidjian, PhD, MIRECC fellow, Seattle VAMC Lisa Roberts, PhD Former MIRECC fellow, Viterion, inc. Christopher Martell, PhD University of Washington Private Practice

3. Origins of Behavioral Activation • BA as an application of reinforcement theory to the treatment of depression (e.g., Lewinsohn, 1974) • The behavioral component of cognitive therapy treatment for depression (Beck, 1976) • BA is an independently effective intervention for depression (e.g., Dimidjian et al., 2006; Jacobson et al., 1996) • BA has evolved into a stand-alone behavioral treatment for Major Depressive Disorder (see Martell, Addis and Jacobson, 2001)

4. What is Behavioral Activation? • Structured, brief psychosocial approach • Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments • Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems • Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking

5. Key Elements of BA • Behavioral case conceptualization • Functional analysis • Activity monitoring and scheduling • Emphasis on avoidance patterns • Emphasis on routine regulation • Behavioral strategies for targeting worry or rumination • Goals are specific to the individual (not necessarily pleasant events)

6. Course of BA • Orient to treatment • Treatment rationale, including conceptualization of psychological distress and primary treatment strategies • Role of therapist/patient • Develop treatment goals • Behavioral analyses • Repeated application of activation and engagement strategies • Troubleshooting • Treatment review and relapse prevention

7. Structure of Sessions • Set collaborative agenda • Review homework • Review weekly activities • Troubleshoot problem behaviors • Assign new homework • Ask for feedback

8. Presentation of Treatment Rationale • Emphasize relationships between environment, mood (or anxiety) and activity • Highlight vicious cycle that can develop between depressed mood, withdrawal/avoidance, and worsened mood (or anxiety) • Suggest activation as a tool to break this cycle and support problem solving • Emphasize an “outside  in” approach: act according to a plan or goal rather than a feeling or internal state

9. BA Activity Chart • Central tool of BA • Uses • Monitor baseline assessment of activity • Monitor mood and intensity ratings • Monitor mastery and pleasure ratings • Monitor breadth or restriction of activity • Monitor range of feelings • Schedule activation assignments • Evaluate progress

10. Rationale for Applying BA to PTSD • Veteran’s preferences for treatment approaches-(e.g, Johnson & Lubin 1997) • PTSD and Depression • High rates of co-morbidity-(Orsillo et al., 1996) • Common features: • Poor quality of life • Decreased physical activity and poor health behaviors • Passive/avoidant style coping • Restricted social/interpersonal functioning • Decreased participation in pleasurable activities • Absence of positive mood states and lack of future-oriented thinking

11. Cognitive BehavioralModels of PTSD • Exposure to a negative (traumatic) event represents classical conditioning and can produce a change in the individual’s view of him/herself and the world • Anxiety responses generalize over time, such that any number of situations or triggers induce a trauma-related response • Avoidance behaviors perpetuate the learned stress-response and may inform an individual’s sense of self-efficacy

12. Traditional CBT Approaches to PTSD Treatment • Exposure based therapies often directly target re-experiencing, avoidance of reminders/discussions/thoughts of the trauma, and hyperarousal symptoms of PTSD • Cognitive strategies address self-schemas and personal scripts, viewing these beliefs to be an obstacle to change

13. CBT Conceptualization of PTSD Prior Life Functioning Traumatic Events (s) Symptoms *Affective (Mood) *Avoidance Behaviors *Cognitive *Physiological Restricted Range of Behavior Less Rewarding Life

14. Traditional CBT Treatment for PTSD Prior Life Functioning Traumatic Events (s) Symptoms *Affective (Mood) *Avoidance Behaviors *Cognitive *Physiological Traditional CBT Therapy Focus: Learn coping skills to decrease arousal symptoms; revisit the traumatic event until it no longer produces arousal; address trauma-related schemas Restricted Range of Behavior Less Rewarding Life Goals Decrease symptom severity in order to increase functioning

15. Behavioral Activation for PTSDConceptualization Prior Life Functioning Traumatic Events (s) Symptoms *Affective (Mood) *Avoidance Behaviors *Cognitive *Physiological Behavioral Activation Focus: Present centered therapy Working from the outside-in Restricted Range of Behavior Less Rewarding Life Goals *Broadening behavior *Defining values & achieving goals *More fulfilling life

16. Support for BA as a PTSD Treatment • Clinical case studies: BA improves PTSD and co-morbid Major Depression-Mulick et al., 2004 • BA is superior to treatment as usual for recently traumatized population-Wagner et al., 2006

17. Open Trial of BA for Chronic PTSDJakupcak et al., 2006 Participants Enrolled N=11 10 men; 1 woman; All Participants were White Age M(SD) 51.2 (12.65) Education M(SD) 15 (2) Vietnam era 9 Post Vietnam 2

18. Trauma Exposure and Symptom Profiles • Trauma type • 8 VN Vets-Combat • 1 VN Vet-Training Accident • 1 Female-Military Sexual Assault • 1 Post VN era Vet-Peace Keeping (sniper fire; mass graves) • Depression, Pain Symptoms, and Compensation • 4 Major Depression/3 dystymia/1 etoh dependence, remission • 7 Chronic pain • 7 Actively seeking service connection for PTSD

19. Outcome Measures • Clinician Administered PTSD Scale (CAPS) Blake et al., 1990 • The PTSD Checklist (PCL) Weathers et al., 1993 • Beck Depression Inventory (BDI) Beck & Steer, 1987 • Quality of Life Inventory (QOLI) Frisch, 1994

20. Attrition • Dropped out (n = 1; travel) • Completed 15 of 16 sessions; lost to follow up (n = 1)

21. Symptom Severity One-tailed Paired t-test Pre Post t (df)Hedge’s g M SD M SD _____ CAPS 75 (22) 60 (24) 2.47 (8)* .58 PCL 52 (13) 48 (20) 1.00 (9) .38 BDI 26 (15) 22 (17) 0.86 (9) .30 QOLI -.88 (1.6) .11 (1.4) -2.10 (8) -.61 *p < .05

22. Individual Change Scores • CAPS; reliable change at |9| points • Five of nine of participants showed improvement • PCL; reliable change at |5| points • Six of ten showed improvement; 1 deteriorated • BDI; reliable change at |5| points • four of ten showed improvement; four deteriorated • QOLI; reliable change at |.7| points • Four of nine showed improvement

23. Case Example (“non-responder”) • VN veteran, heavy combat exposure • Chronic, vivid re-experiencing symptoms • Was previously functioning in occupational roles despite PTSD symptoms • No history of PTSD treatment • Current stressors: Death of parents, lay-offs, financial, health concerns and chronic pain (related to service) • Severe Depression

24. Veteran’s values and goals • Values: • Reparation* • Providing for families (children*) • Self-Reliance • Goals: • Resume work • Provide for family members • Improve health (related to first two goals)

25. Vicious Circle • Lack of employment • Lack of financial resources • Inability to $ support families • Decreased visits with grandchildren • Increased depression • Decreased motivation for health/wellness • Increased physical pain • Difficulties seeking employment opportunities (health related)

26. Example Assignments • Diet • Walking (failures and successes) • Employment seeking • Talk to friends and associates • Submit job applications (not only in desired field) • Begin work (not necessarily only in desired field) • Spend time with grandchildren (telephone, visits with or without bringing ‘gifts’)

27. Outcomes • No change in PTSD symptom severity • No reliable change in depression scores • Increase in quality of life scores • Lost over 20 lbs • Lowered high blood pressure • Returned to work (incrementally moving toward desired positions) • Improved ability to provide financial support • Increased time spent with family members

28. Increasing non-symptom experiences PTSD Depression Chronic Pain

29. Increasing non-symptom experiences PTSD Depression Chronic Pain

30. Address common myths about activation and change • Will-power or “Nike” model of change • Too similar to “just get over it”

31. Address common myths about activation and change Emphasize • Role of the therapist • Focused activation based on careful behavioral analyses • Graded task assignment • Difficulty of change

32. Discussion, Questions, and Future Directions • BA may have potential as a treatment for PTSD and Chronic Pain symptoms, especially to address quality of life • BA may be an appropriate, first line intervention as part of a stepped care approach to treating recently returning combat veterans • Initiated open trial of BA for recently returning combat veterans with PTSD delivered in a Primary Care Clinic • Planned randomized, multi-site study for returning combat veterans

33. Workshop overview • Basic epidemiology and patient characteristics • A model of integrated care for OIF/OEF veterans • Federal and State collaboration in Washington State • An integrated model of primary stepped care at VA Puget Sound, Seattle • Adapting evidence-based PTSD treatments in secondary prevention efforts for OIF/OEF veterans

34. Specific Clinical Challenges • Fitness for Duty Recommendations • Confidentiality • Documentation

35. VA/DoD Clinical Practice Guideline for Acute Stress Disorder and PTSD http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm

36. Soldier/Veteran Self-Assessmenthttp://www.pdhealth.mil/mhsa.asp • Voluntary, anonymous, self-directed • PTSD • Depression • ETOH • Bipolar disorder • GAD • Results and resources at end of assessment

37. The Iraq War Clinician’s Guidehttp://www.ncptsd.va.gov/war/guide/index.html • Assessment guidelines • Treating medical casualty evacuees • Treating the traumatized Amputee • Primary care based treatment of Iraq veterans • Military sexual trauma • Assessment and treatment of anger • Treatment of traumatic grief • Substance abuse • Impact of deployment on family members

38. The Iraq War Clinician’s Guidehttp://www.ncptsd.va.gov/war/guide/index.html Information for Veterans/Family • War zone-related stress reactions: what veterans and family members need to know • Depression • Stress, trauma, and alcohol/drug use • Coping with sleep problems • Coping with traumatic stress reactions • Homecoming: dealing with changes and expectations • Homecoming: Tips for reunion

39. Resilience Training in OIF/OEF ReturneesNational Center for PTSD • Coping with transition stress • Improving sleep • Managing stress • Dealing with anger • Reintegrating

40. Psychological First Aid http://www.ncptsd.va.gov/pfa/PFA.html • Contact and engagement • Safety and comfort • Stabilization • Information gathering: identify needs and concerns • Practical assistance • Connection with social supports • Information on coping • Linkage with collaborative services

41. Battlemind Traininghttp://www.armyg1.army.mil/hr/dcs/Annex/Battlemind%20Training%20II%20Briefing%20Speaker%20Notes.ppt • Buddies (cohesion) vs. withdrawal • Aggressive driving (combat) vs. defensive driving • Accountability vs. control • Discipline and ordering vs. conflict • Targeted vs. inappropriate aggression • Lethally armed vs. “locked and loaded” at home • Emotional control vs. anger/detatchment • Tactical awareness vs. hypervigilance • The alcohol transition • Myths vs. facts of mental health