1. Behavioral Activation Strategies for the Treatment of PTSD

2. Acknowledgments Amy Wagner, PhD Portland VAMC Sona Dimidjian, PhD,
MIRECC fellow, Seattle VAMC
Lisa Roberts, PhD
Former MIRECC fellow, Viterion, inc.
Christopher Martell, PhD
University of Washington
Private Practice

3. Origins of Behavioral Activation
BA as an application of reinforcement theory to the treatment of depression (e.g., Lewinsohn, 1974)
The behavioral component of cognitive therapy treatment for depression (Beck, 1976)
BA is an independently effective intervention for depression (e.g., Dimidjian et al., 2006; Jacobson et al., 1996)
BA has evolved into a stand-alone behavioral treatment for Major Depressive Disorder (see Martell, Addis and Jacobson, 2001)

4. What is Behavioral Activation?
Structured, brief psychosocial approach
Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments
Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems
Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking

5. Key Elements of BA Behavioral case conceptualization
Functional analysis
Activity monitoring and scheduling
Emphasis on avoidance patterns
Emphasis on routine regulation
Behavioral strategies for targeting worry or rumination
Goals are specific to the individual (not necessarily pleasant events)

6. Course of BA Orient to treatment Develop treatment goals
Treatment rationale, including conceptualization of psychological distress and primary treatment strategies
Role of therapist/patient
Develop treatment goals
Behavioral analyses
Repeated application of activation and engagement strategies
Troubleshooting
Treatment review and relapse prevention

7. Structure of Sessions Set collaborative agenda Review homework
Review weekly activities
Troubleshoot problem behaviors
Assign new homework
Ask for feedback

8. Presentation of Treatment Rationale
Emphasize relationships between environment, mood (or anxiety) and activity
Highlight vicious cycle that can develop between depressed mood, withdrawal/avoidance, and worsened mood (or anxiety)
Suggest activation as a tool to break this cycle and support problem solving
Emphasize an “outside  in” approach: act according to a plan or goal rather than a feeling or internal state

9. BA Activity Chart Central tool of BA Uses
Monitor baseline assessment of activity
Monitor mood and intensity ratings
Monitor mastery and pleasure ratings
Monitor breadth or restriction of activity
Monitor range of feelings
Schedule activation assignments
Evaluate progress

10. Rationale for Applying BA to PTSD
Veteran’s preferences for treatment approaches-(e.g, Johnson & Lubin 1997)
PTSD and Depression
High rates of co-morbidity-(Orsillo et al., 1996)
Common features:
Poor quality of life
Decreased physical activity and poor health behaviors
Passive/avoidant style coping
Restricted social/interpersonal functioning
Decreased participation in pleasurable activities
Absence of positive mood states and lack of future-oriented thinking

11. Cognitive Behavioral Models of PTSD
Exposure to a negative (traumatic) event represents classical conditioning and can produce a change in the individual’s view of him/herself and the world
Anxiety responses generalize over time, such that any number of situations or triggers induce a trauma-related response
Avoidance behaviors perpetuate the learned stress-response and may inform an individual’s sense of self-efficacy

12. Traditional CBT Approaches to PTSD Treatment
Exposure based therapies often directly target re-experiencing, avoidance of reminders/discussions/thoughts of the trauma, and hyperarousal symptoms of PTSD
Cognitive strategies address self-schemas and personal scripts, viewing these beliefs to be an obstacle to change

13. CBT Conceptualization of PTSD
Prior Life Functioning
Traumatic Events (s)
Symptoms
*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological
Restricted Range of Behavior
Less Rewarding Life

14. Traditional CBT Treatment for PTSD
Prior Life Functioning
Traumatic Events (s)
Symptoms
*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological
Traditional CBT Therapy
Focus: Learn coping skills to decrease arousal symptoms; revisit the traumatic event until it no longer produces arousal; address trauma-related schemas
Restricted Range of Behavior
Less Rewarding Life
Goals
Decrease symptom severity in order to increase functioning

15. Behavioral Activation for PTSD Conceptualization
Prior Life Functioning
Traumatic Events (s)
Symptoms
*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological
Behavioral Activation
Focus: Present centered therapy Working from the outside-in
Restricted Range of Behavior
Less Rewarding Life
Goals
*Broadening behavior
*Defining values & achieving goals
*More fulfilling life

16. Support for BA as a PTSD Treatment
Clinical case studies: BA improves PTSD and co-morbid Major Depression-Mulick et al., 2004
BA is superior to treatment as usual for recently traumatized population-Wagner et al., 2006

17. Open Trial of BA for Chronic PTSD Jakupcak et al., 2006
Participants Enrolled N=11
10 men; 1 woman; All Participants were White
Age M(SD) 51.2 (12.65)
Education M(SD) 15 (2)
Vietnam era 9
Post Vietnam 2

18. Trauma Exposure and Symptom Profiles
Trauma type
8 VN Vets-Combat
1 VN Vet-Training Accident
1 Female-Military Sexual Assault
1 Post VN era Vet-Peace Keeping (sniper fire; mass graves)
Depression, Pain Symptoms, and Compensation
4 Major Depression/3 dystymia/1 etoh dependence, remission
7 Chronic pain
7 Actively seeking service connection for PTSD

19. Outcome Measures
Clinician Administered PTSD Scale (CAPS) Blake et al., 1990
The PTSD Checklist (PCL)
Weathers et al., 1993
Beck Depression Inventory (BDI)
Beck & Steer, 1987
Quality of Life Inventory (QOLI)
Frisch, 1994

20. Attrition Dropped out (n = 1; travel)
Completed 15 of 16 sessions; lost to follow up (n = 1)

21. Symptom Severity One-tailed Paired t-test
Pre Post t (df) Hedge’s g
M SD M SD _____
CAPS (22) 60 (24) (8)* .58
PCL (13) 48 (20) (9)
BDI (15) 22 (17) (9)
QOLI (1.6) .11 (1.4) (8)
*p < .05

22. Individual Change Scores
CAPS; reliable change at |9| points
Five of nine of participants showed improvement
PCL; reliable change at |5| points
Six of ten showed improvement; 1 deteriorated
BDI; reliable change at |5| points
four of ten showed improvement; four deteriorated
QOLI; reliable change at |.7| points
Four of nine showed improvement

23. Case Example (“non-responder”)
VN veteran, heavy combat exposure
Chronic, vivid re-experiencing symptoms
Was previously functioning in occupational roles despite PTSD symptoms
No history of PTSD treatment
Current stressors: Death of parents, lay-offs, financial, health concerns and chronic pain (related to service)
Severe Depression

24. Veteran’s values and goals
Reparation*
Providing for families (children*)
Self-Reliance
Goals:
Resume work
Provide for family members
Improve health (related to first two goals)

25. Vicious Circle Lack of employment Lack of financial resources
Inability to $ support families
Decreased visits with grandchildren
Increased depression
Decreased motivation for health/wellness
Increased physical pain
Difficulties seeking employment opportunities (health related)

26. Example Assignments Diet Walking (failures and successes)
Employment seeking
Talk to friends and associates
Submit job applications (not only in desired field)
Begin work (not necessarily only in desired field)
Spend time with grandchildren (telephone, visits with or without bringing ‘gifts’)

27. Outcomes No change in PTSD symptom severity
No reliable change in depression scores
Increase in quality of life scores
Lost over 20 lbs
Lowered high blood pressure
Returned to work (incrementally moving toward desired positions)
Improved ability to provide financial support
Increased time spent with family members

28. Increasing non-symptom experiences
PTSD
Depression
Chronic Pain

29. Increasing non-symptom experiences
PTSD
Depression
Chronic Pain

30. Address common myths about activation and change
Will-power or “Nike” model of change
Too similar to “just get over it”

31. Address common myths about activation and change
Emphasize
Role of the therapist
Focused activation based on careful behavioral analyses
Graded task assignment
Difficulty of change

32. Discussion, Questions, and Future Directions
BA may have potential as a treatment for PTSD and Chronic Pain symptoms, especially to address quality of life
BA may be an appropriate, first line intervention as part of a stepped care approach to treating recently returning combat veterans
Initiated open trial of BA for recently returning combat veterans with PTSD delivered in a Primary Care Clinic
Planned randomized, multi-site study for returning combat veterans

33. Workshop overview Basic epidemiology and patient characteristics
A model of integrated care for OIF/OEF veterans
Federal and State collaboration in Washington State
An integrated model of primary stepped care at VA Puget Sound, Seattle
Adapting evidence-based PTSD treatments in secondary prevention efforts for OIF/OEF veterans

34. Specific Clinical Challenges
Fitness for Duty Recommendations
Confidentiality
Documentation

35. VA/DoD Clinical Practice Guideline for Acute Stress Disorder and PTSD

36. Soldier/Veteran Self-Assessment http://www.pdhealth.mil/mhsa.asp
Voluntary, anonymous, self-directed
PTSD
Depression
ETOH
Bipolar disorder
GAD
Results and resources at end of assessment

37. The Iraq War Clinician’s Guide http://www. ncptsd. va
Assessment guidelines
Treating medical casualty evacuees
Treating the traumatized Amputee
Primary care based treatment of Iraq veterans
Military sexual trauma
Assessment and treatment of anger
Treatment of traumatic grief
Substance abuse
Impact of deployment on family members

38. Information for Veterans/Family
The Iraq War Clinician’s Guide
Information for Veterans/Family
War zone-related stress reactions: what veterans and family members need to know
Depression
Stress, trauma, and alcohol/drug use
Coping with sleep problems
Coping with traumatic stress reactions
Homecoming: dealing with changes and expectations
Homecoming: Tips for reunion

39. Resilience Training in OIF/OEF Returnees National Center for PTSD
Coping with transition stress
Improving sleep
Managing stress
Dealing with anger
Reintegrating

40. Psychological First Aid http://www.ncptsd.va.gov/pfa/PFA.html
Contact and engagement
Safety and comfort
Stabilization
Information gathering: identify needs and concerns
Practical assistance
Connection with social supports
Information on coping
Linkage with collaborative services

41. Battlemind Training http://www. armyg1. army
Buddies (cohesion) vs. withdrawal
Aggressive driving (combat) vs. defensive driving
Accountability vs. control
Discipline and ordering vs. conflict
Targeted vs. inappropriate aggression
Lethally armed vs. “locked and loaded” at home
Emotional control vs. anger/detatchment
Tactical awareness vs. hypervigilance
The alcohol transition
Myths vs. facts of mental health