1. Exposure Therapy in PTSD Wounds of War Conference Diane T. Castillo, Ph.D. Coordinator, WSDTT February 7, 8, 2008

2. Overview of Effective Treatments for PTSD Two most effective treatments Two most effective treatments Exposure Therapy Exposure Therapy Cognitive Restructuring Cognitive Restructuring Other effective treatments Other effective treatments SIT SIT Assertiveness Training Assertiveness Training Relaxation Training Relaxation Training EMDR EMDR From: Rothbaum, et.al., 2000 In Effective Treatments for PTSD by Foa, Keane, & Friedman From: Rothbaum, et.al., 2000 In Effective Treatments for PTSD by Foa, Keane, & Friedman

3. 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). The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD (chapter 4, p. 97). From: Institute of Medicine (OIM): 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.

4. Empirical Support for Exposure Therapy For Chronic PTSD: For Chronic PTSD: 22 Published randomized studies on exposure therapy alone 22 Published randomized studies on exposure therapy alone 25 Published randomized studies on exposure therapy with other interventions (SIT and/or CR) 25 Published randomized studies on exposure therapy with other interventions (SIT and/or CR)

5. What Is Exposure Therapy? Exposure therapy is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure, flooding). Exposure therapy is a set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure, flooding).

6. Theoretical Rationale for Exposure Therapy Combination of: Classical conditioning (traumatic event), e.g., little Hans Classical conditioning (traumatic event), e.g., little Hans Instrumental conditioning Instrumental conditioning Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, restaurants, movies Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, restaurants, movies Engagement of avoidance activities to reduce anxiety Engagement of avoidance activities to reduce anxiety Result is world starts to shrink Result is world starts to shrink

7. Theoretical Rationale for Exposure Therapy (cont.) Imaginal reexposure to memory of trauma in safe setting results in desensitization/habituation of conditioned associations between traumatic memory and negative emotions Imaginal reexposure to memory of trauma in safe setting results in desensitization/habituation of conditioned associations between traumatic memory and negative emotions

8. Presentation to Patients 7-11 example 7-11 example

9. How Does Exposure Therapy Work? Two Essential Ingredients in Emotional Processing of Trauma: Accessing the fear structure (fear activation) Accessing the fear structure (fear activation) Availability of corrective information Availability of corrective information

10. Two Exposure Models Flooding (Keane) Flooding (Keane) Prolonged Exposure or PE (Foa) Prolonged Exposure or PE (Foa) Both Keane and Foa models use systematic repeated imaginal exposure to memory of the trauma Both Keane and Foa models use systematic repeated imaginal exposure to memory of the trauma 1 time telling of trauma--NOT systematic exposure therapysome desensitization can occur 1 time telling of trauma--NOT systematic exposure therapysome desensitization can occur Examples: Examples: Trauma processing (ind/group) Trauma processing (ind/group) EMDR EMDR

11. Keanes Flooding Model Once through in 60 min. session Once through in 60 min. session Therapist-guided Therapist-guided Therapist asks questions on senses (seeing, hearing, smelling, thinking, feeling) for each step in the trauma Therapist asks questions on senses (seeing, hearing, smelling, thinking, feeling) for each step in the trauma Therapist slows story down at worst points Therapist slows story down at worst points Repeated imaginal exposure in subsequent sessions Repeated imaginal exposure in subsequent sessions Rating of SUDs (Subjective Units of Distress) on 100 point scale Rating of SUDs (Subjective Units of Distress) on 100 point scale

12. Foas Prolonged Exposure Highly developed protocol Highly developed protocol Imaginal exposure Imaginal exposure In-vivo exposure In-vivo exposure Prolonged (imaginal) exposure: Prolonged (imaginal) exposure: 10-15 90 minute sessions, more as needed 10-15 90 minute sessions, more as needed 60 min of repetitions in 1 st session, 45-30 in subsequent 60 min of repetitions in 1 st session, 45-30 in subsequent Patient instructed to describe event as many times within allotted time Patient instructed to describe event as many times within allotted time Little or no therapist intervention Little or no therapist intervention Later sessions address hot spots Later sessions address hot spots Assess SUDS level (scale of 1 to 100) every 5 min. Assess SUDS level (scale of 1 to 100) every 5 min.

13. Foas Protocols Prolonged (imaginal) exposure (cont.): Prolonged (imaginal) exposure (cont.): Audio tape full session, with separate tape for exposure piece Audio tape full session, with separate tape for exposure piece Pt listens to exposure tape daily Pt listens to exposure tape daily Pt listens to session 1x Pt listens to session 1x Homework, homework, homework Homework, homework, homework In vivo exposure: In vivo exposure: Hierarchy of avoided situations listed Hierarchy of avoided situations listed Rate each on 100 point scale Rate each on 100 point scale Select 2-3 at 40-60 level Select 2-3 at 40-60 level Face min of 3x, if not daily in week Face min of 3x, if not daily in week Practice breathing exercise daily Practice breathing exercise daily

14. Dateline Videotape

15. How to address with patients Education, education, education Education, education, education Introduce as option in 1 st assessment Introduce as option in 1 st assessment Raise at option at end/beginning each group Raise at option at end/beginning each group Use mantra the more you face it the easier it gets; the more you avoid it, the worse it gets Use mantra the more you face it the easier it gets; the more you avoid it, the worse it gets Teach theoretical rationale Teach theoretical rationale Always emphasize choice Always emphasize choice

16. Setting the Stagesafety nets At home: At home: Inform family next 2 months will be rough Inform family next 2 months will be rough Ask for support from family/friends ahead of time Ask for support from family/friends ahead of time Find safe place in home to write Find safe place in home to write By therapist: By therapist: Tell pt AND be available for same day calls Tell pt AND be available for same day calls Give pt option of coming in for 2 nd session in a week Give pt option of coming in for 2 nd session in a week Give pt option of phone therapy session, even if brief Give pt option of phone therapy session, even if brief

17. Examples Male combat vet Male combat vet Female rape survivor Female rape survivor

18. Indications: Single trauma Single trauma Recent trauma (<1 year) Recent trauma (<1 year) Multiple traumas Multiple traumas Select worstdecide this with the patient Select worstdecide this with the patient One that causes most current distress One that causes most current distress If all else equal, the 1 st one in series If all else equal, the 1 st one in series Years of trauma (e.g., childhood sexual abuse) Years of trauma (e.g., childhood sexual abuse)

19. Contraindications No alcohol/substance use during treatment No alcohol/substance use during treatment Recommend no anxiolytics or changes (stable min. 1 mo.) Recommend no anxiolytics or changes (stable min. 1 mo.) Not during period of instabilityas best as cannot during recent loss, no current abuse (e.g., pt. living back at home) Not during period of instabilityas best as cannot during recent loss, no current abuse (e.g., pt. living back at home) Must be patients choice Must be patients choice

20. Variations Traditionalindividual sessions Traditionalindividual sessions GroupWSDTTmax. of 3 pts for 6 weeks GroupWSDTTmax. of 3 pts for 6 weeks Long distancemonthly visits Long distancemonthly visits

21. Therapist considerations Countertransference Countertransference If you decide to do it, get supervision If you decide to do it, get supervision Consider the message, if you back off Consider the message, if you back off Debriefing after exposure work Debriefing after exposure work May experience nightmares May experience nightmares Use same strategies as pt Use same strategies as pt Others? Others?

22. Discussion Role playnon-traumatic event Role playnon-traumatic event Questions Questions Wrap-up Wrap-up