Overview

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

Nature of Trauma and PTSDNature of Trauma and PTSD

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

(%

)

The Scope of the ProblemThe Scope of the Problem

60-70% 60-70%

7%7%

Experience trauma

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

Rate of PTSD by Trauma TypeRate of PTSD by Trauma Type


The Cost and Burden of PTSD The Cost and Burden of PTSD

ComorbidityComorbidity


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

Per

cen

t (%

)Suicidality in the Past Year Suicidality in the Past Year

Amaya-Jackson et al., 1998

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

Video clipVideo clip

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 TheoryEmotional Processing Theory

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

PTCI Scale Scores by Participant GroupPTCI Scale Scores by Participant Group

Foa et al., 1999

Effective Psychotherapy Effective Psychotherapy

For PTSDFor PTSD

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.

Video clipVideo clip

Empirical Evidence for Empirical Evidence for

Prolonged ExposureProlonged Exposure

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.

PE with Civilian PopulationsPE with Civilian Populations

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 with VeteransPE with Veterans

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

PE with Active Military MembersPE with Active Military Members

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

Efficacy of Massed PE on Reduction Efficacy of Massed PE on Reduction of Depressionof Depression

Efficacy of Massed PE on Anger Efficacy of Massed PE on Anger Reduction Reduction

Safety and Acceptability of Prolonged Safety and Acceptability of Prolonged ExposureExposure

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


PTSD SeverityPTSD Severity


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

PTSD Severity (n =29)PTSD Severity (n =29)

t (21) = 6.97, p < .001, Cohen’s d = 1.49

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)

Suicidal IdeationSuicidal Ideation

t (21) = 3.45, p = .002, Cohen’s d = 0.74 (0.69)

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)

PTSD Severity PTSD Severity

PTSD DiagnosisPTSD Diagnosis

% Dropout (ns)% Dropout (ns)

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

Dissemination of PE Dissemination of PE in the VAsin the VAs

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




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


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

Thank youThank you

Edna FoaEdna Foa

David YuskoDavid Yusko

Elna YadinElna Yadin

Alan PetersonAlan Peterson

Strong Star ConsortiumStrong Star Consortium

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