View
21
Download
0
Category
Tags:
Preview:
DESCRIPTION
Prolonged Exposure Therapy for Posttraumatic Stress Disorder Carmen P. McLean, Ph.D. Center for the Treatment & Study of Anxiety Department of Psychiatry University of Pennsylvania. Overview. Nature of trauma and PTSD Emotional Processing Theory Overview of Prolonged Exposure therapy - PowerPoint PPT Presentation
Citation preview
Prolonged Exposure Therapy for Prolonged Exposure Therapy for Posttraumatic Stress DisorderPosttraumatic Stress Disorder
Carmen P. McLean, Ph.D.Carmen P. McLean, Ph.D.
Center for the Treatment & Study of AnxietyCenter for the Treatment & Study of AnxietyDepartment of PsychiatryDepartment of Psychiatry
University of PennsylvaniaUniversity of Pennsylvania
OverviewOverview
Nature of trauma and PTSDNature of trauma and PTSD
Emotional Processing Theory Emotional Processing Theory
Overview of Prolonged Exposure therapyOverview of Prolonged Exposure therapy
Empirical evidence for PEEmpirical evidence for PE
Safety and tolerability of PESafety and tolerability of PE
Efficacy of PE with comorbid problemsEfficacy of PE with comorbid problems
A. Definition of a TraumaA. Definition of a Trauma DeathDeath
Serious injurySerious injury
Sexual violation Sexual violation
Repeated or extreme exposure Repeated or extreme exposure to aversive details of the event(s) to aversive details of the event(s)
Criterion A2 Criterion A2 intense fear, helplessness, horrorintense fear, helplessness, horror
ExperiencedExperienced
WitnessedWitnessed
Learned about* Learned about*
B. Re-experiencing (1)B. Re-experiencing (1)– E.g., dreams, flashbacksE.g., dreams, flashbacks
C. Avoidance/Numbing (3)C. Avoidance/Numbing (3)– E.g., Psychogenic amnesia, detachmentE.g., Psychogenic amnesia, detachment
D. Changes in Cognition and Mood (3)D. Changes in Cognition and Mood (3)– E.g., Self-blame, negative view of othersE.g., Self-blame, negative view of others
E. Hyperarousal (3)E. Hyperarousal (3)– E.g., sleep disturbance, jumpinessE.g., sleep disturbance, jumpiness
Four Symptom ClustersFour Symptom Clusters
Diagnostic Criteria for PTSD (con’t)Diagnostic Criteria for PTSD (con’t)
Specify if:Specify if:
• Acute:Acute: duration of symptoms < 3 months duration of symptoms < 3 months
• Chronic: Chronic: duration of symptoms > 3 monthsduration of symptoms > 3 months
• Delayed Onset: Delayed Onset: onset of symptoms > 6 months after onset of symptoms > 6 months after the stressorthe stressor
PTSD as a Worldwide ProblemPTSD as a Worldwide Problem
de Jong et al., 2001; Kessler et al, 1995; Perkonnig et al., 2000
Germany 1.3%
Denmark 9%
USA 7.8%
Ethiopia 15.8%
Cambodia 28.4%
Algeria 37.4%
Prevalence of Trauma in the USPrevalence of Trauma in the US
61
2734
51
26 25
0102030405060708090
100
Any One Two or more
Men Women
Kessler et al., 2000
Pr e
v ale
nce
(%
)
Prevalence of Trauma and PTSD in Prevalence of Trauma and PTSD in Men and Women in the USMen and Women in the US
60.7
51.2
8.1
20.4
0
10
20
30
40
50
60
70
Men Women
Per
cen
t (%
)
Trauma PTSD
Kessler, 1995
Impaired Quality of Life with PTSDImpaired Quality of Life with PTSD
SF-36 = 36-item short form health survey; lower score = more impairment.
Mea
n S
F-3
6 S
core
Malik et al.,1999
Effects of PTSD on Medical ProblemsEffects of PTSD on Medical Problems
Adjusted Odds of Disease in PTSD vs. no PTSD
Neurological 2.48*
Vascular 1.88*
Respiratory 1.43*
Gastrointestinal 1.96*
Metabolic/autoimmune 3.32*
Musculoskeletal 2.52*
Sareen et al., 2005
* Past 6 months
Outpatient Health Service Utilization*Outpatient Health Service Utilization*
Amaya-Jackson et al, 1998
Summary of Reactions to TraumaSummary of Reactions to Trauma
Majority of trauma survivors recover without Majority of trauma survivors recover without interventionintervention
PTSD can be viewed as a failure of natural recovery PTSD can be viewed as a failure of natural recovery
PTSD is a highly distressing and debilitating disorder:PTSD is a highly distressing and debilitating disorder: High psychiatric and medical comorbidity High psychiatric and medical comorbidity
Low quality of lifeLow quality of life
High suicidalilty High suicidalilty
Emotional Processing Theory of PTSDEmotional Processing Theory of PTSD
Invokes psychological constructs to explain:Invokes psychological constructs to explain: Early PTSD symptoms Early PTSD symptoms Natural recovery Natural recovery Development, maintenance, and treatment of PTSDDevelopment, maintenance, and treatment of PTSD
Fear (Emotional) StructureFear (Emotional) Structure
A fear (emotional) structure is a program for escaping A fear (emotional) structure is a program for escaping dangerdanger
It includes information about:It includes information about:
• The feared stimuliThe feared stimuli
• The fear responsesThe fear responses
• The meaning of stimuli and responsesThe meaning of stimuli and responses
Trauma MemoryTrauma Memory
Is a specific emotional structure that includes representations of:Is a specific emotional structure that includes representations of:
Stimuli present during and after the traumaStimuli present during and after the trauma
Physiological and behavioral responses that occurred during Physiological and behavioral responses that occurred during the trauma (fear, guilt, shame)the trauma (fear, guilt, shame)
Meanings associated with these stimuli and responses Meanings associated with these stimuli and responses
Associations among stimulus, response, and meaning Associations among stimulus, response, and meaning representations may be realistic or unrealisticrepresentations may be realistic or unrealistic
Pathological/Early Trauma StructurePathological/Early Trauma Structure
Large number of stimuli Large number of stimuli Excessive responses (PTSD symptoms)Excessive responses (PTSD symptoms) Erroneous associations between stimuli and “danger”Erroneous associations between stimuli and “danger” Erroneous associations between responses and “incompetent”Erroneous associations between responses and “incompetent” Fragmented and poorly organized relationships among Fragmented and poorly organized relationships among
representationsrepresentations
Early PTSD SymptomsEarly PTSD Symptoms
• Trauma reminders Trauma reminders activate trauma memory and activate trauma memory and associated perception of danger and incompetenceassociated perception of danger and incompetence
• Activation of the trauma memory is reflected in re-Activation of the trauma memory is reflected in re-experiencing and arousal symptoms, which motivate experiencing and arousal symptoms, which motivate avoidanceavoidance
Recovery ProcessesRecovery Processes
• Repeated activation (i.e., emotional Repeated activation (i.e., emotional engagement) via confronting trauma reminders engagement) via confronting trauma reminders ++
• Corrective information (absence of the Corrective information (absence of the anticipated harm)anticipated harm)==
• Incorporation of corrective information about Incorporation of corrective information about the world, self, and othersthe world, self, and others
Chronic PTSDChronic PTSD
Persistent cognitive and behavioral avoidance Persistent cognitive and behavioral avoidance prevents recovery by:prevents recovery by: Limiting activation of the trauma memoryLimiting activation of the trauma memory Limiting articulation and organization of the Limiting articulation and organization of the
trauma memorytrauma memory Limiting exposure to corrective informationLimiting exposure to corrective information
Erroneous Cognitions Erroneous Cognitions Underlying PTSDUnderlying PTSD
The world is extremely dangerousThe world is extremely dangerous People are untrustworthyPeople are untrustworthy No place is safeNo place is safe
I am extremely incompetentI am extremely incompetent PTSD symptoms are a sign of weaknessPTSD symptoms are a sign of weakness Other people would have prevented the traumaOther people would have prevented the trauma
Exposure ProceduresExposure Procedures Anxiety Management ProceduresAnxiety Management Procedures Cognitive therapyCognitive therapy
Cognitive-Behavioral TreatmentCognitive-Behavioral TreatmentCan Be Divided Into:Can Be Divided Into:
Exposure TherapyExposure Therapy Designed to reduce pathological, dysfunctional anxiety and Designed to reduce pathological, dysfunctional anxiety and
dysfunctional cognitions by encouraging patients to confront dysfunctional cognitions by encouraging patients to confront safe, trauma-related feared objects, situations, memories, and safe, trauma-related feared objects, situations, memories, and images images
Exposure helps patients realize that their feared consequences do Exposure helps patients realize that their feared consequences do not occur and therefore are unrealisticnot occur and therefore are unrealistic
Anxiety Management TreatmentAnxiety Management Treatment
Relaxation TrainingRelaxation Training
Controlled BreathingControlled Breathing
Positive Self-talk and ImageryPositive Self-talk and Imagery
Social Skills TrainingSocial Skills Training
Distraction Techniques (e.g., thought stopping)Distraction Techniques (e.g., thought stopping)
Cognitive TherapyCognitive Therapy
Identifying dysfunctional, erroneous thoughts and beliefs Identifying dysfunctional, erroneous thoughts and beliefs (cognitions)(cognitions)
Challenging these cognitions Challenging these cognitions
Replacing these cognitions with functional, realistic Replacing these cognitions with functional, realistic cognitionscognitions
Evidence-Based Treatments for PTSDEvidence-Based Treatments for PTSD
Cognitive Behavior TherapyCognitive Behavior Therapy Prolonged exposure (PE)Prolonged exposure (PE) Stress inoculation training (SIT)Stress inoculation training (SIT) Cognitive therapy (CPT)Cognitive therapy (CPT)
EMDREMDR
EBTs for Chronic PTSDEBTs for Chronic PTSD
Promote safe confrontations (via exposure, discussions) with Promote safe confrontations (via exposure, discussions) with trauma reminders (memories, situations) trauma reminders (memories, situations)
Aim at modifying the dysfunctional cognitions underlying PTSDAim at modifying the dysfunctional cognitions underlying PTSD
The Advantage of Prolonged ExposureThe Advantage of Prolonged Exposure Has the largest number of studies supporting its efficacy and Has the largest number of studies supporting its efficacy and
effectivenesseffectiveness
Effective with the widest range of trauma populationsEffective with the widest range of trauma populations
Studied in many independent centers in the US and around to Studied in many independent centers in the US and around to world world
Widely disseminated in the US and abroad; Widely disseminated in the US and abroad;
Effectiveness in the hands of non-experts has been Effectiveness in the hands of non-experts has been documented in several studies documented in several studies
Main components of PEMain components of PE1.1. Breathing retrainingBreathing retraining
2.2. Education about common reactions to traumaEducation about common reactions to trauma
3.3. In vivo exposure In vivo exposure
4.4. Imaginal exposure and processingImaginal exposure and processing
Main components of PEMain components of PE1.1. Breathing retrainingBreathing retraining
2.2. Education about common reactions to traumaEducation about common reactions to trauma
3.3. In vivo exposure In vivo exposure
4.4. Imaginal exposure and processingImaginal exposure and processing
Prolonged ExposureProlonged Exposure
The two primary procedures are:The two primary procedures are:
In-vivo exposureIn-vivo exposure:: repeated confrontation with situations, activities, repeated confrontation with situations, activities, places that are avoided because they are trauma reminders. places that are avoided because they are trauma reminders.
Imaginal exposure and processingImaginal exposure and processing:: repeated revising, recounting, repeated revising, recounting, and processing of the traumatic event. and processing of the traumatic event.
Published RCTs on Exposure Therapy (EX)Published RCTs on Exposure Therapy (EX)
Chronic PTSD:Chronic PTSD: EX therapy only EX therapy only 25 studies25 studies Ex therapy + SIT and/or CR Ex therapy + SIT and/or CR 29 studies29 studies
Acute PTSD or ASDAcute PTSD or ASD
EX onlyEX only 4 studies 4 studies Ex therapy + SIT and/or CR Ex therapy + SIT and/or CR 6 studies 6 studies
2008 Institute of Medicine Report2008 Institute of Medicine Report
““The committee finds that the evidence is sufficient to conclude the The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD” efficacy of exposure therapies in the treatment of PTSD”
(chapter 4, p. 97) (chapter 4, p. 97)
Reference:Reference:
Institute of Medicine (IOM): 2008. Institute of Medicine (IOM): 2008. Treatment of posttraumatic Treatment of posttraumatic stress disorder: An assessment of the evidence.stress disorder: An assessment of the evidence. Washington, DC: Washington, DC: The National Academies Press.The National Academies Press.
Study I With Women Assault VictimsStudy I With Women Assault Victims
Treatments:Treatments:
Prolonged Exposure (PE)Prolonged Exposure (PE)
Stress Inoculation Training (SIT)Stress Inoculation Training (SIT)
SIT + PESIT + PE
Wait List ControlsWait List Controls
Treatments included 9 sessions conducted over 5 weeksTreatments included 9 sessions conducted over 5 weeks
Foa et al.,1999
Comparison of PE, SIT, PE/SIT, and Waitlist Comparison of PE, SIT, PE/SIT, and Waitlist With Female Assault SurvivorsWith Female Assault Survivors
0
10
20
30
40
PE SIT PE+SIT WL
PS
S-I
Tot
al
PrePostFU
Foa et al., 1999
Study II With Women Assault VictimsStudy II With Women Assault Victims
Treatments:Treatments: Exposure (PE) alone Exposure (PE) alone PE + Cognitive Restructuring (PE/CR) PE + Cognitive Restructuring (PE/CR) Wait List (WL)Wait List (WL)
Foa et al., 2005
Comparison of PE, PE/CR, and Waitlist Comparison of PE, PE/CR, and Waitlist With Female Assault SurvivorsWith Female Assault Survivors
0
10
20
30
40
PE PE/CR WL
PS
S-I
Tot
al
PrePostFU
Foa et al., 2005
Study with Men and Women Victims Study with Men and Women Victims of Mixed Traumasof Mixed Traumas
Treatments:Treatments: Exposure (PE)Exposure (PE) Cognitive Restructuring (CR)Cognitive Restructuring (CR) PE + CRPE + CR Relaxation TrainingRelaxation Training
Treatment consisted of 10 sessions conducted over 16 weeksTreatment consisted of 10 sessions conducted over 16 weeks
Marks et al., 1998
Good End State Functioning Post Treatment*Good End State Functioning Post Treatment*
0
10
20
30
40
50
60
Pere
cent
Res
pond
ers
* > 50% improved on PTSD; <7 BDI; <35 STAI-S
Foa et al., 1999 Marks et al., 1998
PE SIT PE/SIT WL PE CR PE/CR R
Efficacy of Exposure, EMDR, and Efficacy of Exposure, EMDR, and RelaxationRelaxation
Taylor et al., 2003
0
10
20
30
40
50
60
70
80
90
EX EMDR RLX
PT
SD
Sev
erit
y C
AP
S
Pre
Post
FU
5-year Follow-up in PE and CPT5-year Follow-up in PE and CPT
0
1020
30
4050
60
70
8090
100
Pretx LTFU
PTSD
Perc
ent D
iagn
osed
CPTPE
Resick et al. 2013
Percent Relapse of PE and CPT Completers Percent Relapse of PE and CPT Completers at 5-10 year Follow-upat 5-10 year Follow-up
There was a trend for PE to have less relapse than CPT at LTFU, X2(1, N =75) 3.8, p =.057.
Relapse
PE vs Present Centered TherapyPE vs Present Centered Therapy
284 Female Veterans and Active-Duty Personnel 284 Female Veterans and Active-Duty Personnel with PTSDwith PTSD
RandomRandom AssignmentAssignment
141 Total141 Total Prolonged Exposure (PE)Prolonged Exposure (PE)
TherapyTherapy
143 Total143 TotalPresent CenteredPresent CenteredTherapy (PCT)Therapy (PCT)
Schnurr et al., 2007Schnurr et al., 2007
Study MethodsStudy Methods 12 sites12 sites
TherapyTherapy
10 weekly 90-minute sessions10 weekly 90-minute sessions
Comparable format, e.g., # of sessions, individual deliveryComparable format, e.g., # of sessions, individual delivery
52 therapists (PhD, MD, MSW, etc)52 therapists (PhD, MD, MSW, etc)
OutcomesOutcomes
PTSD (“CAPS” interview), other sxs, functioning, quality of PTSD (“CAPS” interview), other sxs, functioning, quality of lifelife
Assessed before & after treatment, 3 & 6 months laterAssessed before & after treatment, 3 & 6 months later
Schnurr et al., 2007
Schnurr et al., 2007
Efficacy of PE vs. PCT Among Women Efficacy of PE vs. PCT Among Women Veterans With PTSDVeterans With PTSD
20
30
40
50
60
70
80
90
PE PCT
Overall d = .46
PT
SD
Sev
erit
y C
AP
S
Comparing PE vs. PE Via Telehealth.Comparing PE vs. PE Via Telehealth.
PTSD Checklist (PCL) and Beck Depression Inventory (BDI) outcomes by Prolonged Exposure (PE) treatment condition, with 95% confidence intervals (N=37).
Tuerk et al. (2010)
Effect of PE on mental health care Effect of PE on mental health care service utilizationservice utilization
0
2
4
6
8
10
12
14
PE completers PE non-completers
1-yr before PE
1-yr after PE
Mea
n n
um
ber
of
app
oin
tmen
ts
Tuerk et al. 2012
Massed vs Spaced Prolonged ExposureMassed vs Spaced Prolonged Exposure
Recruitment Site: Ft Hood - TexasRecruitment Site: Ft Hood - Texas
Military OIF/OEF personnel are randomized to one of four conditions: Military OIF/OEF personnel are randomized to one of four conditions:
PE- M: 10 session delivered in 2 weeks PE- M: 10 session delivered in 2 weeks
PE-S: 10 sessions delivered in 8 weeksPE-S: 10 sessions delivered in 8 weeks
Present Centered Therapy: 10 sessions delivered in 8 weeksPresent Centered Therapy: 10 sessions delivered in 8 weeks
Minimal Contact control delivered in 2 weeks Minimal Contact control delivered in 2 weeks
277 of 360 Participants Recruited277 of 360 Participants Recruited
Preliminary FindingsPreliminary Findings
Military personnel were randomized toMilitary personnel were randomized to
PE-M (10 PE sessions derived in 2 weeks)PE-M (10 PE sessions derived in 2 weeks) MCC (2 weeks of minimal contact control) MCC (2 weeks of minimal contact control)
Efficacy of Massed PE on Reduction of Efficacy of Massed PE on Reduction of PTSD SymptomsPTSD Symptoms
d=.96, p=.0001
Exacerbation of SymptomsExacerbation of Symptoms
Minority of clients in treatment show a reliable exacerbation of symptoms
• 10.5% in PTSD symptoms
• 21.1% in Anxiety symptoms
• 9.2% in Depressive symptoms
Exacerbation of symptoms was not associated with:
• treatment drop out
• poorer treatment outcomeFoa et al., (2002)
PTSD Severity and Exacerbation PTSD Severity and Exacerbation
0
5
10
15
20
25
30
35
Pre-Tx Week 2 Week 4 Week 6 Week 8 Post-Tx
No Exacerbation
Exacerbation
PT
SD
Sev
erit
y
Improvement and Worsening after Improvement and Worsening after Cognitive Behavioral TreatmentsCognitive Behavioral Treatments
PE PE+SIT/CR SIT WLPE PE+SIT/CR SIT WL n = 135 n = 66 n =19 n = 99n = 135 n = 66 n =19 n = 99
Improve on PTSDImprove on PTSD 93% 86% 84% 36%93% 86% 84% 36%
Worsen on PTSDWorsen on PTSD 0 0 0 8%0 0 0 8%
Worsen on DepressionWorsen on Depression 2% 2% 0 12%2% 2% 0 12%
Worsening and improvement = Increase or decrease in symptoms by => Standard Error of the Difference (based on SD and test-retest reliability (7.5 points in the PSSI, 11.4 points on the CAPS; 4.5 points on the BDI).
Dropout Rate by Treatment CategoryDropout Rate by Treatment Category
Treatment (25 studies) Total n % Dropout
EX Alone 330 20.6%
SIT or CT Alone 222 22.1%
EX plus CT or SIT 335 26.0%
EMDR 143 18.9%
Controls (Active and WL) 543 11.4%
No difference among active treatments:
2 (3, N= 1030) = 1.73, p = 0.631
Hembree et al., 2003
Effect of Personality Disorder (PD) on Effect of Personality Disorder (PD) on Reduction in PTSD (PSS-I)Reduction in PTSD (PSS-I)
Hembree et al., 2004F(1, 73) < 1, ns – (no effect)
The Efficacy of PE with Current, Past, or no The Efficacy of PE with Current, Past, or no DepressionDepression
Hagenaars, van Minnen, & Hoogduin, 2010
PT
SD
Sev
erit
y
Effect of Personality Disorder (PD) on Effect of Personality Disorder (PD) on Reduction in Depression (BDI)Reduction in Depression (BDI)
Hembree et al., 2004F(1, 71) < 1, ns – (no effect)
PTSD Severity for Low and High State-Anger PTSD Severity for Low and High State-Anger Patients Treated with PE, SIT, and PE/SIT Patients Treated with PE, SIT, and PE/SIT
Effect of PTSD Treatment on State-AngerEffect of PTSD Treatment on State-Anger for Low and High State-Anger Patients for Low and High State-Anger Patients
Assessment
PTSD and Alcohol DependencePTSD and Alcohol Dependence
Will integrating treatment for alcohol and PTSD Will integrating treatment for alcohol and PTSD produce superior outcomes for AUD and PTSD?produce superior outcomes for AUD and PTSD?
PE + Counseling Counseling
Naltrexone NaltrexonePE + Counseling
NaltrexoneCounseling
Placebo PlaceboPE + Counseling
PlaceboCounseling
Percent Days DrinkingPercent Days Drinking
0
10
20
30
40
50
60
70
80
0 4 8 12 16 20 24 38 52
Naltx + PE
Placebo + PE
Naltx no PE
Placebo No PE
Study Week
%D
D
Foa et al., 2013
The Efficacy of PE with High and Low The Efficacy of PE with High and Low DissociationsDissociations
0
5
10
15
20
25
30
Pre Post Follow-up
High dissociation (n=15)
Low dissociation (n-21)
Hagenaars, van Minnen, & Hoogduin, 2010
PT
SD
Sev
erit
y
The Effects of PE Among Patients with The Effects of PE Among Patients with PTSD and TBIPTSD and TBI
0
10
20
30
40
50
60
70
80
90
100
Pre (n = 8) *Mid (n = 8) *Post (n = 8)
PCT PE
Time, F (1.1, 6.8) = 16.6, p = .004; Time*Condition, F (1.1, 6.8) = 5.4, p = .05 Rauch, unpublished data
PT
SD
sev
erit
y
The Effects of PE Among Patients with PTSD The Effects of PE Among Patients with PTSD and mild TBIand mild TBI
Total ITT sample: t(49)=6.59, p < .001, d = 1.00.mTBI: t(10) = 3.65, p < .005, d = 1.81. Sripada et al ., 2013
PC
L S
core
NOTE: TBI status did not predict post-tx PCL, t(49) = −0.94, p = .35, or the slope of change over time, t(49)=−0.3, p = .70.
The Effects of PE Among Patients with PTSD The Effects of PE Among Patients with PTSD and TBIand TBI
0
10
20
30
40
50
60
70
80
90
100
Pre (n = 8) *Mid (n = 8) *Post (n = 8)
PCT PE
Time, F (1.1, 6.8) = 16.6, p = .004; Time*Condition, F (1.1, 6.8) = 5.4, p = .05 Rauch, unpublished data
PT
SD
sev
erit
y
Comorbid BDDComorbid BDD
26 Randomized
17 Allocated to DBT+PE
10 Completed treatment
9 Allocated to DBT only
5 Completed treatment
3 Lost to Follow-up5 Lost to Follow-up
17 Analyzed 9 Analyzed
Harned, Korslund, & Linehan, 2014
ITT = Intent to Treat
TC = Treatment Completers
Clients in DBT+ PE were 1.4 to 2.4 times less likely to attempt suicide and 1.3 to 1.5 times less
likely to self-injure than those in DBT only.
Perc
en
tag
e
(%)
Suicidal and Non-Suicidal Self-InjurySuicidal and Non-Suicidal Self-Injury
Harned, Korslund, & Linehan, 2014
PTSD RemissionPTSD Remission
0
10
20
30
40
50
60
70
80
90
100
Post-treatment 3-month Follow Up
80
605850
40
0
33
0
DBT + DBT PE (TC)
DBT + DBT PE (ITT)
DBT (TC)
DBT (ITT)
% R
emit
ted
fro
m P
TS
D
ITT = Intent to TreatTC = Treatment Completers Harned, Korslund, & Linehan, 2014
At post-treatment, clients in DBT+ PE were 1.8 to 2.0 times more
likely to have remitted from PTSD than those in DBT. At follow-up,
no DBT clients remained in remission.
PE+DBT in VeteransPE+DBT in Veterans
““JOURNEY”JOURNEY”12 Week Intensive Outpatient Program provided at 12 Week Intensive Outpatient Program provided at the Minneapolis VA Healthcare Systemthe Minneapolis VA Healthcare SystemHousing provided on siteHousing provided on site8 patients at any one time, 4 start every 6 weeks8 patients at any one time, 4 start every 6 weeks
Meis, Meyers, Velasquez, Voller, Thuras, & Kehle-Forbes
Weekly StructureWeekly Structure
DBT skills groups: 6 hoursDBT skills groups: 6 hours
Individual DBT: 1-2 hoursIndividual DBT: 1-2 hours
Individual PE sessions: 3 hoursIndividual PE sessions: 3 hours Imaginal exposure begins week 4Imaginal exposure begins week 4
Community outings for skills practice/generalization: Community outings for skills practice/generalization: 6 hours6 hours
2 community meetings2 community meetings
Borderline Symptom SeverityBorderline Symptom Severity
t (14) = 5.44, p < .001, Cohen’s d = 1.40 (1.67)
Negative CognitionsNegative Cognitions
t (21) = 5.08, p < .001Cohen’s d = 1.08 (1.39)
t (21) = 6.63, p < .001Cohen’s d = 1.41 (1.64)
t (21) = 6.24, p < .001Cohen’s d = 1.33 (1.70)
Treatment of PTSD and Psychosis with Treatment of PTSD and Psychosis with Prolonged Exposure Prolonged Exposure
de Bont, van Minnen 2013
(
Exclusion criteriaExclusion criteria High suicidalityHigh suicidality
Changes in medication (mood regulators, antipsychotics) within Changes in medication (mood regulators, antipsychotics) within two months prior to the study; two months prior to the study;
Participant is in seclusion or admitted to a closed ward.Participant is in seclusion or admitted to a closed ward.
Note:Note:
Severity of psychosis was not an exclusion criterionSeverity of psychosis was not an exclusion criterion
TreatmentTreatment
Maximum of 8 sessions (90 minutes)Maximum of 8 sessions (90 minutes)
Standard PE, no adjustments for psychosis at all (e.g., Standard PE, no adjustments for psychosis at all (e.g., stabilization, emotion regulation, skill training) stabilization, emotion regulation, skill training)
SafetySafety
A serious adverse event is: A serious adverse event is: Suicide or suicide attempt;Suicide or suicide attempt; Self mutilation in need of intervention;Self mutilation in need of intervention; Psychological crisis in need of intervention;Psychological crisis in need of intervention; A crisis admission to hospital;A crisis admission to hospital; Violent behavior that requires restraint.Violent behavior that requires restraint.
PE:PE: 44
WL:WL: 55
ConclusionsConclusions PE is effective in reducing PTSD symptoms among patients PE is effective in reducing PTSD symptoms among patients
with medicated psychotic patients who had positive psychotic with medicated psychotic patients who had positive psychotic symptoms (e.g., hallucinations ) symptoms (e.g., hallucinations )
Standard treatment protocols can be used, no adaptation Standard treatment protocols can be used, no adaptation necessarynecessary
PE is a safe treatment for PTSD in psychotic patients who are PE is a safe treatment for PTSD in psychotic patients who are stabilized on medication stabilized on medication
PE is Effective With Complex PE is Effective With Complex PTSD SufferersPTSD Sufferers
Comorbid Disorders:Comorbid Disorders: DepressionDepression Alcohol and Drug DependentAlcohol and Drug Dependent Borderline Personality DisorderedBorderline Personality Disordered High dissociationHigh dissociation Traumatic Brain Injury patientsTraumatic Brain Injury patients
Associated symptomsAssociated symptoms:: GuiltGuilt Anger/AggressionAnger/Aggression Suicide gesturesSuicide gestures Poor healthPoor health
A Top Down Approach??A Top Down Approach??
The Veterans Health Administration initiated a system-wide roll-out The Veterans Health Administration initiated a system-wide roll-out of CPT and PE, reflecting strong commitment to implement of CPT and PE, reflecting strong commitment to implement evidence-based treatments in the VA evidence-based treatments in the VA
Phase I consisted of a two-year training PE to 300 therapists by the Phase I consisted of a two-year training PE to 300 therapists by the developers of PE developers of PE
The goal: permanent capacity to train and supervise their mental The goal: permanent capacity to train and supervise their mental health practitioners in conducting PEhealth practitioners in conducting PE
PE Training ModelPE Training Model
Certified PE CliniciansCertified PE Clinicians
• Completed a 4-day workshop followed by weekly individual Completed a 4-day workshop followed by weekly individual supervision via viewing session recordings on two casessupervision via viewing session recordings on two cases
Certified PE SupervisorsCertified PE Supervisors
• Selected from among the certified clinicians. Selected from among the certified clinicians.
• Participated in 5-day supervisor workshop at the CTSAParticipated in 5-day supervisor workshop at the CTSA
Certified PE Trainers (“Train-the-Trainer”)Certified PE Trainers (“Train-the-Trainer”)
• Were selected from among the certified supervisors Were selected from among the certified supervisors
• Participated in a 3-day trainer workshopParticipated in a 3-day trainer workshop
Numbers of Therapists Trained in the VA Numbers of Therapists Trained in the VA
Total # Clinicians Trained: Over 2000
Consultants: 70
Trainers: 16
Effectiveness of PE in the VAEffectiveness of PE in the VA
1931 veterans were treated by 804 clinicians who participated in a 1931 veterans were treated by 804 clinicians who participated in a 4-day workshop on PE4-day workshop on PE
After the workshop, clinicians were supervised on 2 casesAfter the workshop, clinicians were supervised on 2 cases
The outcomes of these The outcomes of these firstfirst werewere analyzedanalyzed
Eftekhari et al., 2013
Effectiveness of PE in the VAEffectiveness of PE in the VA
62.4% of patients exhibited a clinically significant 62.4% of patients exhibited a clinically significant improvement from baseline and post-treatmentimprovement from baseline and post-treatment
49% of patients had PCL scores of less than 50 at the end of 49% of patients had PCL scores of less than 50 at the end of treatment, indicating loss of PTSD diagnosistreatment, indicating loss of PTSD diagnosis
Eftekhari et al., 2013
Is Consultation Important?Is Consultation Important?
Workshops are relatively low investment in a training Workshops are relatively low investment in a training program. program.
Follow-up consultations, on the other hand, carry are very Follow-up consultations, on the other hand, carry are very costlycostly
But… But…
In the absence of follow-up consultation (supervision), In the absence of follow-up consultation (supervision), clinicians are less likely to use the treatment they had learnedclinicians are less likely to use the treatment they had learned
Consultation Increase Self-Efficacy in Consultation Increase Self-Efficacy in Conducting PEConducting PE
5
5.2
5.4
5.6
5.8
6
6.2
6.4
6.6
Pre-training Post-workshop Post-consultation
Self-
effic
acy
(0-7
)
Clinician self-efficacy to deliver PE
(Karlin et al., 2010
Implementation of PE in the MilitaryImplementation of PE in the Military
This study with the Army is motivated by the following: This study with the Army is motivated by the following: Workshops are relatively inexpensive Workshops are relatively inexpensive Intensive consultations on two cases are quite costlyIntensive consultations on two cases are quite costly Therapists are more likely to adopt a novel treatment if they receive Therapists are more likely to adopt a novel treatment if they receive
consultationconsultation
We will test the added value of supervision by comparing training with We will test the added value of supervision by comparing training with and without supervision in 3 military bases with 120 Army therapistsand without supervision in 3 military bases with 120 Army therapists
Outcomes include: % patients with PTSD who receive PE; therapists Outcomes include: % patients with PTSD who receive PE; therapists attitudes towards PE; patient outcomesattitudes towards PE; patient outcomes
ConclusionConclusion Several CBT programs are quite effective for PTSD Several CBT programs are quite effective for PTSD
PE has received the most empirical evidence with a wide range of PE has received the most empirical evidence with a wide range of traumas traumas
PE is more effective than treatment as usual for combat veteransPE is more effective than treatment as usual for combat veterans
PE outcome is not increased by adding CR or SITPE outcome is not increased by adding CR or SIT
PE is effective with a number of commonly occurring disordersPE is effective with a number of commonly occurring disorders
PE can be successfully disseminated to community clinics with non-PE can be successfully disseminated to community clinics with non-CBT experts as therapistsCBT experts as therapists
PE can be disseminated effectively over long distances and across PE can be disseminated effectively over long distances and across culturescultures
Recommended