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Behavioral Activation Strategies for the Treatment of PTSD.

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Presentation on theme: "Behavioral Activation Strategies for the Treatment of PTSD."— Presentation transcript:

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

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

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

8 Presentation of Treatment Rationale Emphasize relationships between environment, mood (or anxiety) and activity 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) 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 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 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 Central tool of BA Uses Uses Monitor baseline assessment of activity Monitor baseline assessment of activity Monitor mood and intensity ratings Monitor mood and intensity ratings Monitor mastery and pleasure ratings Monitor mastery and pleasure ratings Monitor breadth or restriction of activity Monitor breadth or restriction of activity Monitor range of feelings Monitor range of feelings Schedule activation assignments Schedule activation assignments Evaluate progress Evaluate progress

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

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

14 Traditional CBT Treatment for PTSD Prior Life FunctioningTraumatic Events (s) Symptoms *Affective (Mood) *Avoidance Behaviors *Cognitive *Physiological Restricted Range of Behavior Less Rewarding Life Goals Decrease symptom severity in order to increase functioning 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

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

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

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

20 Attrition Dropped out (n = 1; travel) Dropped out (n = 1; travel) Completed 15 of 16 sessions; lost to follow up (n = 1) 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 75 (22) 60 (24) 2.47 (8)*.58 PCL 52 (13) 48 (20) 1.00 (9).38 BDI 26 (15) 22 (17) 0.86 (9).30 QOLI -.88 (1.6).11 (1.4)-2.10 (8) -.61 *p <.05

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

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

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

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

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

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

28 Increasing non-symptom experiences PTSDDepression Chronic Pain

29 Increasing non-symptom experiences PTSDDepression Chronic Pain

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

31 Address common myths about activation and change Emphasize Role of the therapist Role of the therapist Focused activation based on careful behavioral analyses Focused activation based on careful behavioral analyses Graded task assignment Graded task assignment Difficulty of change 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 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 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 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 Planned randomized, multi-site study for returning combat veterans

33 Workshop overview Basic epidemiology and patient characteristics Basic epidemiology and patient characteristics A model of integrated care for OIF/OEF veterans A model of integrated care for OIF/OEF veterans Federal and State collaboration in Washington State Federal and State collaboration in Washington State An integrated model of primary stepped care at VA Puget Sound, Seattle 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 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 PTSD_Base.htm PTSD_Base.htm

36 Soldier/Veteran Self-Assessment Voluntary, anonymous, self-directed Voluntary, anonymous, self-directed PTSD PTSD Depression Depression ETOH ETOH Bipolar disorder Bipolar disorder GAD GAD Results and resources at end of assessment Results and resources at end of assessment

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

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

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

40 Psychological First Aid Contact and engagement Contact and engagement Safety and comfort Safety and comfort Stabilization Stabilization Information gathering: identify needs and concerns Information gathering: identify needs and concerns Practical assistance Practical assistance Connection with social supports Connection with social supports Information on coping Information on coping Linkage with collaborative services Linkage with collaborative services

41 Battlemind Training efing%20Speaker%20Notes.ppt efing%20Speaker%20Notes.ppt efing%20Speaker%20Notes.ppt Buddies (cohesion) vs. withdrawal Buddies (cohesion) vs. withdrawal Aggressive driving (combat) vs. defensive driving Aggressive driving (combat) vs. defensive driving Accountability vs. control Accountability vs. control Discipline and ordering vs. conflict Discipline and ordering vs. conflict Targeted vs. inappropriate aggression Targeted vs. inappropriate aggression Lethally armed vs. “locked and loaded” at home Lethally armed vs. “locked and loaded” at home Emotional control vs. anger/detatchment Emotional control vs. anger/detatchment Tactical awareness vs. hypervigilance Tactical awareness vs. hypervigilance The alcohol transition The alcohol transition Myths vs. facts of mental health Myths vs. facts of mental health


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