1. The European Network for Traumatic Stress Training & Practice www.tentsproject.eu

2. Cognitive Therapy and the treatment of PTSD and ASD Chris Freeman MD

3. Contents  What is CBT  General principles of psychological treatment  A typical course of treatment  Evidence base for CBT in PTSD  Evidence base for CBT in Acute stress disorder  CBT compared with other psychological treatments and drugs

4. What is CBT Several different models of CBT but all share some common characteristics Even EMDR has some CBT principles but it will be covered in a separate set of slides Brief Eclectic Therapy (BEP) has some CBT techniques but is a separate psychotherapy despite being grouped with CBT by NICE. (National Institute of Clinical Excellence UK)

5. General principles of psychological treatment Assessment and formulation is crucial This should be carried out before ASD and PTSD treatment.

6. CBT for PTSD. The Evidence

7. Ways of changing trauma memories : How CBT models differ. Prolonged exposure to trauma memory (Foa: imaginal reliving; Resick: trauma narrative) Updating worst moments in memory (Ehlers & Clark) Brief exposure to image with rapid eye movements or other bilateral stimulation (Shapiro) In vivo exposure Discrimination of triggers (Ehlers & Clark)

8. Evidence Base reviewed by NICE EMDR: 11 studies compared with W/L or other psychological interventions CBT: 16 studies compared with W/L or other psychological interventions ECBT: 16 studies compared with W/L or other psychological interventions SM: 7 studies compared with W/L or other psychological interventions GCBT: 4 studies compared with W/L or other psychological interventions Other: 6 studies compared with W/L or other psychological interventions

9. NICE Guidelines 2005: Systematic Review of Psychological Treatments for PTSD – Effect sizes compared to wait list A priori threshold d =.08 13 RCTs 4 RCTs 3 RCTs 2 RCTs

10. Psychological Interventions Exposure based CBT demonstrated more clinically important effects on self report PTSD symptoms and PTSD diagnosis than W/L. Limited evidence of superiority on clinician rated PTSD symptoms, depression and anxiety Not superior to stress management or other treatments and outcomes varied substantially

11. Psychological Interventions EMDR found support but not as strong as TFCBT Clinically important benefits on clinician rated but not self report PTSD symptoms compared to W/L Limited evidence for clinically important effects on anxiety and depression EMDR was superior to supportive/non-directive therapy but not stress management.

12. Evidence base since NICE Several new studies but no change in conclusions above 4 additional studies comparing trauma focussed CBT with waiting list I additional study comparing trauma focussed CBT with other treatment

13. Recommendations from evidence base: 1 All PTSD sufferers should be offered a course of trauma focused psychological therapy on an individual, out-patient basis (A) Trauma focused psychological interventions should be offered regardless of the time elapsed since the trauma (B)

14. Recommendations from evidence base: 2 CBT should be offered even if key trauma was a long time ago Individual face to face therapy is first choice Course of treatment for a single trauma is 8-12 60 min. sessions Treatment must be flexible with longer sessions if trauma story being related.

15. Recommendations from evidence base: 3 Trauma focused psychological interventions should be 8-12 sessions long when the PTSD has arisen from a single incident. (B) If the traumatic event is being discussed sessions should be longer (90 mins), offered on a regular and continuous basis (weekly) with the same person. (B)

16. Recommendations from evidence base: 4 In cases of multiple trauma, traumatic bereavement, chronic disability arising from the trauma, significant co-morbidity or social problems longer treatment duration should be considered (> 12 sessions). (C) Treatment should be delivered by competent individuals with appropriate training and supervision. (C)

17. Acute Stress Disorder (ASD) Evidence recently reviewed by Roberts 2009 Evidence supports effectiveness of trauma focussed CBT over control Self help booklets are not superior to control condition (Ehlers 2003) Studies that offer brief treatment (5 sessions) treat ASD and PTSD symptoms but not depression or anxiety. Need longer treatment 12 hours + to treat wider symptoms

18. Acute Stress Disorder Studies have tended to treat patients in first 3 months so subjects are a combination of ASD and acute PTSD Evidence base is very similar to PTSD but fewer studies

19. ASD Sessions should be 90 minutes long if using imaginal exposure Combination treatments should not be used Treatment should be individual not group Treatment should not begin within 2 weeks of the trauma

20. Training for therapy Used to assumed that therapists needed to be competent in general CBT and then trained in Trauma Focussed CBT Northern Ireland studies show this may not be necessary

21. Drug treatment compared with psychotherapy No head to head trials so we have to assess drug trial evidence separately and compare at a clinical level

22. What are essential ingredients Trauma focussed Target trauma memories Target trauma beliefs and meanings Provide exposure Provide a safe secure setting

23. Drop out rates: different CBT models compared Different psychological treatments may not differ much in symptom reduction They do differ significantly in acceptability

24. General points on effectiveness of CBT (effectiveness v.s. efficacy) 67% of those who complete treatment no longer meet PTSD criteria But: pre post symptom scores negatively correlated with drop out rates indicating that those who don’t improve may drop out Trials exclude approx. 30% of referrals which is lower than for other diagnoses e.g.. Depression Combat related PTSD consistently shows poorer outcome