Overview

1. Prolonged Exposure Therapy for Posttraumatic Stress DisorderCarmen P. McLean, Ph.D.Center for the Treatment & Study of AnxietyDepartment of PsychiatryUniversity of Pennsylvania

2. 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

3. Nature of Trauma and PTSD

4. A. Definition of a Trauma Experienced Witnessed Learned about* Death Serious injury Sexual violation Repeated or extreme exposure to aversive details of the event(s) • Criterion A2 intense fear, helplessness, horror

5. 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

6. 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

7. PTSD as a Worldwide Problem Germany 1.3% Denmark 9% USA 7.8% Ethiopia 15.8% Cambodia 28.4% Algeria 37.4% de Jong et al., 2001; Kessler et al, 1995; Perkonnig et al.,2000

8. Prevalence of Trauma in the US Prevalence (%) Kessler et al., 2000

9. The Scope of the Problem 60-70% 7% Experience trauma

10. Prevalence of Trauma and PTSD in Men and Women in the US Kessler, 1995

11. Rate of PTSD by Trauma Type Kessler et al., 1995

12. The Cost and Burden of PTSD

13. Comorbidity Kessler et al., 1995

14. Impaired Quality of Life with PTSD Mean SF-36 Score SF-36 = 36-item short form health survey; lower score = more impairment. Malik et al.,1999

15. Suicidalityin the Past Year Percent (%) Amaya-Jackson et al., 1998

16. Effects of PTSD on Medical Problems Sareen et al., 2005

17. Outpatient Health Service Utilization* Amaya-Jackson et al, 1998 * Past 6 months

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19. 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

20. Emotional Processing Theory

21. Emotional Processing Theory of PTSD • Invokes psychological constructs to explain: • Early PTSD symptoms • Natural recovery • Development, maintenance, and treatment of PTSD

22. 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

23. 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

24. 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

25. Early PTSD Symptoms • Trauma reminders  activate trauma memory and associated perception of danger and incompetence • Activation of the trauma memory is reflected in re-experiencing and arousal symptoms, which motivate avoidance

26. 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

27. 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

28. Erroneous Cognitions Underlying PTSD • The world is extremely dangerous • People are untrustworthy • No place is safe • I am extremely incompetent • PTSD symptoms are a sign of weakness • Other people would have prevented the trauma

29. PTCI Scale Scores by Participant Group Foa et al., 1999

30. Effective Psychotherapy For PTSD

31. Exposure Procedures Anxiety Management Procedures Cognitive therapy Cognitive-Behavioral Treatment Can Be Divided Into:

32. 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

33. Anxiety Management Treatment Relaxation Training Controlled Breathing Positive Self-talk and Imagery Social Skills Training Distraction Techniques (e.g., thought stopping)

34. Cognitive Therapy Identifying dysfunctional, erroneous thoughts and beliefs (cognitions) Challenging these cognitions Replacing these cognitions with functional, realistic cognitions

35. Evidence-Based Treatments for PTSD Cognitive Behavior Therapy Prolonged exposure (PE) Stress inoculation training (SIT) Cognitive therapy (CPT) EMDR

36. EBTs for Chronic PTSD Promote safe confrontations (via exposure, discussions) with trauma reminders (memories, situations) Aim at modifying the dysfunctional cognitions underlying PTSD

37. 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

38. Main components of PE • Breathing retraining • Education about common reactions to trauma • In vivo exposure • Imaginal exposure and processing

39. Main components of PE • Breathing retraining • Education about common reactions to trauma • In vivo exposure • Imaginal exposure and processing

40. 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.

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42. Empirical Evidence for Prolonged Exposure

43. Published RCTs on Exposure Therapy (EX) Chronic PTSD: EX therapy only 25 studies Ex therapy + SIT and/or CR 29 studies Acute PTSD or ASD EX only 4 studies Ex therapy + SIT and/or CR 6 studies

44. 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.

45. PE with Civilian Populations

46. 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

47. Comparison of PE, SIT, PE/SIT, and Waitlist With Female Assault Survivors Foa et al., 1999

48. Study II With Women Assault Victims Treatments: Exposure (PE) alone PE + Cognitive Restructuring (PE/CR) Wait List (WL) Foa et al., 2005

49. Comparison of PE, PE/CR, and Waitlist With Female Assault Survivors Foa et al., 2005

50. 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