1. 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

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 Death Death Serious injury Sexual violation Repeated or extreme exposure to aversive details of the event(s) Repeated or extreme exposure to aversive details of the event(s)  Criterion A2 intense fear, helplessness, horror ExperiencedWitnessed Learned about*

5. 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 Four Symptom Clusters

6. Diagnostic Criteria for PTSD (con’t) Specify if: Acute: duration of symptoms < 3 months Acute: duration of symptoms < 3 months Chronic: duration of symptoms > 3 months Chronic: duration of symptoms > 3 months Delayed Onset: onset of symptoms > 6 months after the stressor Delayed Onset: onset of symptoms > 6 months after the stressor

7. PTSD 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%

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

9. The Scope of the Problem 60-70% 60-70% 7% 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 SF-36 = 36-item short form health survey; lower score = more impairment. Mean SF-36 Score Malik et al.,1999

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

16. Effects of PTSD on Medical Problems Adjusted Odds of Disease in PTSD vs. no PTSD Neurological2.48* Vascular1.88* Respiratory1.43* Gastrointestinal1.96* Metabolic/autoimmune3.32* Musculoskeletal2.52* Sareen et al., 2005

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

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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 High psychiatric and medical comorbidity Low quality of life Low quality of life High suicidalilty High suicidalilty

20. Emotional Processing Theory

21. Emotional Processing Theory of PTSD  Invokes psychological constructs to explain: Early PTSD symptoms Early PTSD symptoms Natural recovery Natural recovery Development, maintenance, and treatment of PTSD 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 feared stimuli The fear responses The fear responses The meaning of stimuli and 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 Stimuli present during and after the trauma Physiological and behavioral responses that occurred during the trauma (fear, guilt, shame) Physiological and behavioral responses that occurred during 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 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 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 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 Repeated activation (i.e., emotional engagement) via confronting trauma reminders+ Corrective information (absence of the anticipated harm) Corrective information (absence of the anticipated harm)= Incorporation of corrective information about the world, self, and others 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 activation of the trauma memory Limiting articulation and organization of the trauma memory Limiting articulation and organization of the trauma memory Limiting exposure to corrective information Limiting exposure to corrective information

28. Erroneous Cognitions Underlying PTSD  The world is extremely dangerous People are untrustworthy People are untrustworthy No place is safe No place is safe  I am extremely incompetent PTSD symptoms are a sign of weakness PTSD symptoms are a sign of weakness Other people would have prevented the trauma 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) Prolonged exposure (PE) Stress inoculation training (SIT) Stress inoculation training (SIT) Cognitive therapy (CPT) 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 1. Breathing retraining 2. Education about common reactions to trauma 3. In vivo exposure 4. Imaginal exposure and processing

39. Main components of PE 1. Breathing retraining 2. Education about common reactions to trauma 3. In vivo exposure 4. 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) (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. 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) Prolonged Exposure (PE) Stress Inoculation Training (SIT) Stress Inoculation Training (SIT) SIT + PE SIT + PE Wait List Controls 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 Exposure (PE) alone PE + Cognitive Restructuring (PE/CR) PE + Cognitive Restructuring (PE/CR) Wait List (WL) 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) Exposure (PE) Cognitive Restructuring (CR) Cognitive Restructuring (CR) PE + CR PE + CR Relaxation Training Relaxation Training Treatment consisted of 10 sessions conducted over 16 weeks Marks et al., 1998

51. Good End State Functioning Post Treatment* * > 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

52. Efficacy of Exposure, EMDR, and Relaxation Efficacy of Exposure, EMDR, and Relaxation Taylor et al., 2003

53. 5-year Follow-up in PE and CPT Resick et al. 2013

54. Percent Relapse of PE and CPT Completers at 5-10 year Follow-up There was a trend for PE to have less relapse than CPT at LTFU, X 2 (1, N =75) 3.8, p =.057. Relapse

55. PE with Veterans

56. PE vs Present Centered Therapy 284 Female Veterans and Active-Duty Personnel with PTSD Random Assignment 141 Total Prolonged Exposure (PE) Prolonged Exposure (PE)Therapy 143 Total Present Centered Therapy (PCT) Schnurr et al., 2007

57. Study Methods  12 sites  Therapy 10 weekly 90-minute sessions 10 weekly 90-minute sessions Comparable format, e.g., # of sessions, individual delivery Comparable format, e.g., # of sessions, individual delivery 52 therapists (PhD, MD, MSW, etc) 52 therapists (PhD, MD, MSW, etc)  Outcomes PTSD (“CAPS” interview), other sxs, functioning, quality of life PTSD (“CAPS” interview), other sxs, functioning, quality of life Assessed before & after treatment, 3 & 6 months later Assessed before & after treatment, 3 & 6 months later Schnurr et al., 2007

58. Efficacy of PE vs. PCT Among Women Veterans With PTSD Overall d =.46 PTSD Severity CAPS

59. 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)

60. Effect of PE on mental health care service utilization Mean number of appointments Tuerk et al. 2012

61. PE with Active Military Members

62. Massed vs Spaced Prolonged Exposure  Recruitment Site: Ft Hood - Texas  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 weeks PE-S: 10 sessions delivered in 8 weeks Present Centered Therapy: 10 sessions delivered in 8 weeks Present 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 Recruited

63. Preliminary Findings  Military 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)

64. Efficacy of Massed PE on Reduction of PTSD Symptoms d=.96, p=.0001

65. Efficacy of Massed PE on Reduction of Depression

66. Efficacy of Massed PE on Anger Reduction

67. Safety and Acceptability of Prolonged Exposure

68. Exacerbation 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 outcome Foa et al., (2002)

69. PTSD Severity and Exacerbation PTSD Severity

70. Improvement and Worsening after Cognitive Behavioral Treatments PE PE+SIT/CR SIT WL PE PE+SIT/CR SIT WL n = 135 n = 66 n =19 n = 99 n = 135 n = 66 n =19 n = 99 Improve on PTSD 93% 86% 84% 36% Worsen on PTSD 0 0 0 8% Worsen on Depression 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).

71. Dropout 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 33526.0% 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

72. Effect of Personality Disorder (PD) on Reduction in PTSD (PSS-I) Hembree et al., 2004 F(1, 73) < 1, ns – (no effect)

73. The Efficacy of PE with Current, Past, or no Depression Hagenaars, van Minnen, & Hoogduin, 2010 PTSD Severity

74. Effect of Personality Disorder (PD) on Reduction in Depression (BDI) Hembree et al., 2004 F(1, 71) < 1, ns – (no effect)

75. PTSD Severity for Low and High State-Anger Patients Treated with PE, SIT, and PE/SIT

76. Effect of PTSD Treatment on State-Anger for Low and High State-Anger Patients Assessment

77. PTSD and Alcohol Dependence Will integrating treatment for alcohol and PTSD produce superior outcomes for AUD and PTSD? PE + CounselingCounseling Naltrexone PE + Counseling Naltrexone Counseling Placebo PE + Counseling Placebo Counseling

78. Percent Days Drinking Study Week %DD Foa et al., 2013

79. The Efficacy of PE with High and Low Dissociations Hagenaars, van Minnen, & Hoogduin, 2010 PTSD Severity

80. The Effects of PE Among Patients with PTSD and TBI Time, F (1.1, 6.8) = 16.6, p =.004; Time*Condition, F (1.1, 6.8) = 5.4, p =.05 Rauch, unpublished data PTSD severity

81. The Effects of PE Among Patients with PTSD and 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 PCL Score 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.

82. The Effects of PE Among Patients with PTSD and TBI Time, F (1.1, 6.8) = 16.6, p =.004; Time*Condition, F (1.1, 6.8) = 5.4, p =.05 Rauch, unpublished data PTSD severity

83. Comorbid BDD 26 Randomized 17 Allocated to DBT+PE 10 Completed treatment 9 Allocated to DBT only 5 Completed treatment 3 Lost to Follow-up 5 Lost to Follow-up 17 Analyzed 9 Analyzed Harned, Korslund, & Linehan, 2014

84. 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. Percentage (%) Suicidal and Non-Suicidal Self-Injury Harned, Korslund, & Linehan, 2014

85. PTSD Severity Harned, Korslund, & Linehan, 2014

86. PTSD Remission % Remitted from PTSD ITT = Intent to Treat TC = 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.

87. PE+DBT in Veterans “JOURNEY”  12 Week Intensive Outpatient Program provided at the Minneapolis VA Healthcare System  Housing provided on site  8 patients at any one time, 4 start every 6 weeks Meis, Meyers, Velasquez, Voller, Thuras, & Kehle-Forbes

88. PTSD Severity (n =29) t (21) = 6.97, p <.001, Cohen’s d = 1.49

89. Weekly Structure  DBT skills groups: 6 hours  Individual DBT: 1-2 hours  Individual PE sessions: 3 hours Imaginal exposure begins week 4 Imaginal exposure begins week 4  Community outings for skills practice/generalization: 6 hours  2 community meetings

90. Borderline Symptom Severity t (14) = 5.44, p <.001, Cohen’s d = 1.40 (1.67)

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

92. Negative Cognitions t (21) = 5.08, p <.001 Cohen’s d = 1.08 (1.39) t (21) = 6.63, p <.001 Cohen’s d = 1.41 (1.64) t (21) = 6.24, p <.001 Cohen’s d = 1.33 (1.70)

93. Treatment of PTSD and Psychosis with Prolonged Exposure Treatment of PTSD and Psychosis with Prolonged Exposure de Bont, van Minnen 2013 (

94. Exclusion criteria  High suicidality  Changes in medication (mood regulators, antipsychotics) within two months prior to the study;  Participant is in seclusion or admitted to a closed ward. Note:  Severity of psychosis was not an exclusion criterion

95. Treatment  Maximum of 8 sessions (90 minutes)  Standard PE, no adjustments for psychosis at all (e.g., stabilization, emotion regulation, skill training)

96. PTSD Severity

97. PTSD Diagnosis

98. % Dropout (ns)

99. Safety  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:4 WL:5

100. Conclusions  PE is effective in reducing PTSD symptoms among patients with medicated psychotic patients who had positive psychotic symptoms (e.g., hallucinations )  Standard treatment protocols can be used, no adaptation necessary  PE is a safe treatment for PTSD in psychotic patients who are stabilized on medication

101. PE is Effective With Complex PTSD Sufferers Comorbid Disorders: Depression Depression Alcohol and Drug Dependent Alcohol and Drug Dependent Borderline Personality Disordered Borderline Personality Disordered High dissociation High dissociation Traumatic Brain Injury patients Traumatic Brain Injury patients Associated symptoms: Guilt Guilt Anger/Aggression Anger/Aggression Suicide gestures Suicide gestures Poor health Poor health

102. Dissemination of PE in the VAs

103. A Top Down Approach??  The Veterans Health Administration initiated a system-wide roll-out of CPT and PE, reflecting strong commitment to implement evidence-based treatments in the VA  Phase I consisted of a two-year training PE to 300 therapists by the developers of PE  The goal: permanent capacity to train and supervise their mental health practitioners in conducting PE

104. PE Training Model Certified PE Clinicians Completed a 4-day workshop followed by weekly individual supervision via viewing session recordings on two cases Completed a 4-day workshop followed by weekly individual supervision via viewing session recordings on two cases Certified PE Supervisors Selected from among the certified clinicians. Selected from among the certified clinicians. Participated in 5-day supervisor workshop at the CTSA Participated in 5-day supervisor workshop at the CTSA 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 workshop Participated in a 3-day trainer workshop

105. Numbers of Therapists Trained in the VA  Total # Clinicians Trained: Over 2000  Consultants: 70  Trainers: 16

106. Effectiveness of PE in the VA  1931 veterans were treated by 804 clinicians who participated in a 4-day workshop on PE  After the workshop, clinicians were supervised on 2 cases  The outcomes of these first were analyzed Eftekhari et al., 2013

107. Effectiveness of PE in the VA Eftekhari et al., 2013

108. Effectiveness of PE in the VA  62.4% of patients exhibited a clinically significant improvement from baseline and post-treatment  49% of patients had PCL scores of less than 50 at the end of treatment, indicating loss of PTSD diagnosis Eftekhari et al., 2013

109. Is Consultation Important?  Workshops are relatively low investment in a training program.  Follow-up consultations, on the other hand, carry are very costly But… But…  In the absence of follow-up consultation (supervision), clinicians are less likely to use the treatment they had learned

110. Consultation Increase Self-Efficacy in Conducting PE (Karlin et al., 2010

111. Implementation of PE in the Military  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 costly Intensive consultations on two cases are quite costly Therapists are more likely to adopt a novel treatment if they receive consultation Therapists are more likely to adopt a novel treatment if they receive consultation  We will test the added value of supervision by comparing training with and without supervision in 3 military bases with 120 Army therapists  Outcomes include: % patients with PTSD who receive PE; therapists attitudes towards PE; patient outcomes

112. Conclusion  Several CBT programs are quite effective for PTSD  PE has received the most empirical evidence with a wide range of traumas  PE is more effective than treatment as usual for combat veterans  PE outcome is not increased by adding CR or SIT  PE is effective with a number of commonly occurring disorders  PE can be successfully disseminated to community clinics with non- CBT experts as therapists  PE can be disseminated effectively over long distances and across cultures

113. Thank you Edna Foa David Yusko Elna Yadin Alan Peterson Strong Star Consortium