Cognitive Behavioral Treatment for PTSD in People with Serious Mental Illness: A Randomized Controlled Trial

1. Cognitive Behavioral Treatment for PTSD in People with Serious Mental Illness:A Randomized Controlled Trial Stephanie Marcello, Ph.D. marcelsc@umdnj.edu University of Medicine and Dentistry of New Jersey University Behavioral HealthCare

2. Research sponsored by the National Institute of Mental Health Collaborating Organizations: Dartmouth Medical School Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey University of Maryland Baltimore NJ Research Team: Steve Silverstein, Ph.D. (site PI) Weili Lu, Ph.D. (Project Coordinator) Stephanie Marcello, Ph.D. (Supervisor) Philip Yanos, Ph.D. (Supervisor) Dartmouth Research Team: Kim T. Mueser, Ph.D. (PI) Stanley D. Rosenberg, Ph.D. (Co-PI) Jennifer Gottlieb, Ph.D. (Project Coordinator)

3. Overview of Presentation • Trauma and SMI • Symptoms of PTSD • Treatments for PTSD • Study Design • Cognitive Restructuring • Results • Review

4. Background: Trauma HistoriesandPosttraumatic Stress Disorder in People with SMI

5. Background • People with Serious Mental Illness (SMI) are more likely to be exposed to trauma in their lifetime than people in the general population. • Estimates of lifetime exposure to traumatic events in people with SMI range from 34% to 98% (Mueser et al., 1998). • Trauma higher in SMI population. • About 50% of people with SMI report childhood sexual or physical abuse.

6. Trauma • Psychological trauma typically refers to exposure to an uncontrollable event which is perceived to threaten a person’s survival or integrity (Herman, 1992). • Common types of trauma • Sexual and physical abuse • Unexpected death of a loved one • Rape • Assault • Witnessing a crime • Combat • Natural disasters • Being threatened with bodily harm • Negative consequences associated with exposure to trauma • Poorer outcomes • More severe psychiatric symptoms • Increased rates of substance abuse

7. Posttraumatic Stress Disorder (PTSD) • Rates of current PTSD in clients with SMI, have been found to range between 29% and 43% compared to lifetime PTSD in the general population that range between 8% and 12% (Mueser, et al., 2001). • Multiple psychiatric and behavioral problems are associated with trauma, but PTSD is the most common and best-defined consequence of trauma. • Rates are higher in people with SMI (2% vs. 35%).

8. Background (continued) • PTSD in clients with SMI is associated with: • poorer outcomes, including; more severe psychiatric symptoms • more frequent hospitalizations • increased rates of substance use and depression • higher rates of suicidality • More severe cognitive impairment • Greater instances of restraints (Read et al., 1998; Resnick et al., 2003)

9. Background (continued) • Despite the high rates of PTSD in people with SMI, it is under diagnosed and rarely treated. • There is an urgent need for effective treatments with this population. • PTSD may be underestimated. • The validity of people’s accounts of traumatic events has been controversial and even greater concern exists for people with a SMI. However, research has shown high internal and inter-rater reliability, demonstrating that people with SMI accounts of trauma experiences have high reliability.

10. Interactive Model of Trauma, PTSD, and SMI (Mueser et al., 2002).

11. Symptoms of PTSD

12. Symptoms of PTSD • 1) Re-experiencing the Trauma • Intrusive memories of the event • Nightmares • Flashbacks • Distress when exposed to trauma cues • Physiological reactivity when exposed to trauma cues

13. Symptoms of PTSD • 2)Overarousal • Hypervigilance • Exaggerated startle response • Difficulty falling or staying asleep • Difficulty concentrating • Irritability, anger outbursts

14. Symptoms of PTSD • 3) Avoidance of Trauma Related Stimuli • Efforts to avoid thoughts, feelings or events associated with the trauma • Inability to recall important aspects of the trauma • Diminished interests • Detachment from others • Restricted affect • Sense of a foreshortened future

15. Associated Symptoms of PTSD • Distressing feelings (fear and anxiety, sadness and depression, guilt and shame, anger) • Suicidality, self-injurious behavior • Substance abuse • Relationship difficulties • Hallucinations and Mild delusions

16. Treatments for PTSD

17. Treatment Options for PTSD • Psychosocial • Exposure therapy • Cognitive therapy • EMDR • Anxiety management • Hypnotherapy • Pharmacological • MAOI’s • SSRI’s • Mood stabilizers • Anti-anxiety agents

18. Cognitive Restructuring • Connection between thoughts and feelings • Examine evidence for and against thoughts • Challenge and modify beliefs through evidence • Develop action plans

19. Mueser, Rosenberg and Colleagues-Modifications for SMI population • Exposure components eliminated • Simplified strategies for clinicians • Emphasize collaboration with treatment team • Increase flexibility

20. Cognitive Restructuring for People with PTSD and SMI:Study Design and Screening

21. Study Design(Mueser, Rosenberg and Collegues) • The study is a 4-year randomized, controlled trial that will compare the 12-16 week CBT for PTSD program with a brief (3 week) PTSD treatment program at 4 sites operated by UBHC in New Jersey (New Brunswick or Newark), including 2 day treatment programs and 2 outpatient clinics. • N= 200 • Weekly sessions

22. CBT TAU Figure 2: CAPS Severity PTSD Diagnosis PTSD Knowledge Posttraumatic Cognitions Beck Depression Inventory Beck Anxiety Inventory BPRS Total SF-12 Physical SF-12 Mental

23. Assessment of Trauma and PTSD • Clients present differently • Prepare clients • Avoided loaded words such as “abuse” or “rape” unless the client uses them • Be very matter-of-fact

24. Stressful Events Screening QuestionnaireUBHC Screening • 16 questions • Sexual abuse/assault, physical abuse/assault, witnessing violence, accidents, combat and unexpected death of a loved one.

25. PCL-S • PTSD Checklist is 17-times, self-report • DSM-IV-TR • Total scores over 45 indicate probable PTSD. • Good reliability.

28. Overview of Treatment

29. Therapy Modules • Overview (Session 1) • Crisis Planning (Session 1) • Breathing Retraining (Session 1) • Psychoeduction I (Session 2) • Psychoeducation II (Session 3) • Cognitive restructuring I (Sessions 4-6) • Cognitive restructuring II (Sessions 5-14) • Termination (Sessions 12-16)

30. Session Structure • Review previous session (have client take active role in session) • Review homework • Set an agenda • Material for session • Assign homework

31. Strategies for Improving Homework • Develop assignments collaborative. • Create a plan to complete homework in session. • Consider the term “homework”. • Review importance of homework. • Practice homework in session. • Troubleshoot or problem solve.

32. Monitor symptoms of PTSD and Depression • Utilize PCL and BDI-II to monitor symptoms every third session. • Incorporate into treatment • Handouts utilized throughout

33. PCL and BDI tracking sheet

34. Module 1: Overview of treatmentSession 1 • Review the program (handout) • Discussion of three components • 1) Breathing Retraining • 2) Psychoeducation • 3) Cognitive Restructuring

35. Module 2: Crisis PlanningSession 1 • Identify crisis • Warning signs • Social supports • Develop a crisis plan

36. Module 3: Breathing Retraining/Relaxation StrategiesSession 1 • Education • Instructions • Practice in session • Tailoring relaxation to individual clients • Homework- Troubleshooting

37. Breathing Retraining Worksheet • STEPS: • 1) Choose a word that you associate with relaxation, such as CALM or RELAX or PEACEFUL. • 2) Inhale through your nose and exhale slowly though your mouth. Take normal breathes. • 3) While you exhale, say the relaxing word you have chosen. Say it very slowly like this, “caaaaaaalm.” • 4) Pause after exhaling before taking your next breathe. Count to four before inhaling each new breathe. • 5) Repeat this sequence 10 to 15 times. **Not everyone will respond to this breathing retraining exercise. They may have a hard time relaxing or have trauma-associations to words such as calm or relax. Alternatives are: Muscualr relaxation, imagining a peaceful scene

38. Module 4: PsychoeducationSession 2 • Goals of Psychoeducation • Common reactions to trauma I:PTSD • Reexperiencing • Avoidance • Overarousal

39. Psychoeducation Teaching Principles • Be interactive, not didactic • Provide factual information • Explore relevance of facts to client’s experiences • Check comprehension and retention • Show empathy

40. Teaching methods • 1) The therapist first describes the symptoms of problem area. • 2) The therapist elicits the clients understanding and experiences with the symptoms or problem area. • 3) The client records their experiences in the pertinent worksheet.

41. Recurrent memories or images of event Distressing dreams/nightmares Acting or feeling like event is happening again (flashback) Intense distress when reminded of event Intense bodily reactions when reminded of event Describe some of the re-experiencing symptoms you had: 1) Images 2)Intrusive thoughts 3) Nightmares 4) Flashbacks 5) Upsetting reminders Which of these is most upsetting? Which is most frequent? Re-experiencing the Event Worksheet # ___

42. Module 5: Psychoeducation IISession 3 • Associated Difficulties/Common Reactions to Trauma • Negative feelings: fear/anxiety, sadness/depression, guilt/shame, anger • Relationship difficulties • Drugs and Alcohol abuse

43. Putting it All TogetherPsychoeducation • Discuss how symptoms/problems related to PTSD have impacted the person’s life (i.e., how would their life be different if they never experienced a trauma?) • Develop specific, concrete goals. • Provide encouragement.

44. Module 6: Cognitive Restructuring ISessions 4-6 • Association between thoughts and feelings • Life experiences and trauma shape thinking • Beliefs • Common Styles of Thinking

45. Common Styles of Thinking • All or nothing thinking • Overgeneralization • “Must”, “should” or “never” statements • Catastrophizing • Emotional reasoning • Overestimation of risk • Inaccurate or excessive self-blame • Mental Filter

46. Common Styles of Thinking (continued) • Several sessions to teach • Homework to identify and correct common styles of thinking • Have the client give an example of each, discuss why it is inaccurate to think this way, how they felt, examining a more accurate thought.

47. Common Styles of Thinking Practice Worksheet

48. Module 7: Cognitive Restructuring IISessions 5-14 • 5 Steps of CR • 1) Situation- Ask yourself “What happened that made me upset?” • 2) Feeling- Identify your strongest feeling (fear/anxiety, sadness/depression, guilt/shame, anger). • 3) Thought- “What am I thinking that led me to feel this way?” • 4) Evaluate your thought- List evidence for and against your thought. • 5) Outcome- “Does the evidence support my thought or not?” • A) If no, what is a more realistic thought? • B) If yes, develop an action plan

49. Guide to Thoughts and Feelings

50. Strategies for developing more realistic thoughts • Ask questions: • Is there an alternative way of looking at the situation? • How would someone else think about this situation? • What would be the worst thing that could happen? • If this were true what does it mean? • How would someone else think about this situation?