Exposure Therapy in Exposure Therapy in PTSDPTSD

Wounds of War ConferenceWounds of War ConferenceDiane T. Castillo, Ph.D.Diane T. Castillo, Ph.D.Coordinator, WSDTTCoordinator, WSDTTFebruary 7, 8, 2008February 7, 8, 2008

Overview of Effective Overview of Effective Treatments for PTSDTreatments for PTSD

► Two most effective treatmentsTwo most effective treatments Exposure TherapyExposure Therapy Cognitive RestructuringCognitive Restructuring

►Other effective treatmentsOther effective treatments SITSIT Assertiveness TrainingAssertiveness Training Relaxation TrainingRelaxation Training EMDREMDR

► From: Rothbaum, et.al., 2000From: Rothbaum, et.al., 2000 In In Effective Treatments for Effective Treatments for PTSDPTSD by Foa, Keane, & Friedman by Foa, Keane, & Friedman

2008 Institute of Medicine 2008 Institute of Medicine ReportReport

►““The committee finds that the The committee finds that the evidence is sufficient to conclude the evidence is sufficient to conclude the efficacy of exposure therapies in the efficacy of exposure therapies in the treatment of PTSD” (chapter 4, p. 97).treatment of PTSD” (chapter 4, p. 97).

From: Institute of Medicine (OIM): 2008. From: Institute of Medicine (OIM): 2008. Treatment of posttraumatic stress disorder: Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, An assessment of the evidence. Washington, DC: The National Academies Press.DC: The National Academies Press.

Empirical Support for Exposure Empirical Support for Exposure TherapyTherapy

►For Chronic PTSD:For Chronic PTSD:►22 Published randomized studies on 22 Published randomized studies on

exposure therapy aloneexposure therapy alone►25 Published randomized studies on 25 Published randomized studies on

exposure therapy with other exposure therapy with other interventions (SIT and/or CR)interventions (SIT and/or CR)

What Is Exposure Therapy?What Is Exposure Therapy?

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

Theoretical Rationale for Theoretical Rationale for Exposure TherapyExposure Therapy

Combination of:Combination of: Classical conditioning (traumatic event), Classical conditioning (traumatic event),

e.g., little Hanse.g., little Hans Instrumental conditioningInstrumental conditioning

►Memory of trauma is paired/conditioned to Memory of trauma is paired/conditioned to current, unrelated events, e.g., crowds, current, unrelated events, e.g., crowds, restaurants, movies restaurants, movies

►Engagement of avoidance activities to reduce Engagement of avoidance activities to reduce anxietyanxiety

►Result is world starts to shrinkResult is world starts to shrink

Theoretical Rationale for Theoretical Rationale for Exposure Therapy (cont.)Exposure Therapy (cont.)

► Imaginal reexposure to memory of Imaginal reexposure to memory of trauma in safe setting results in trauma in safe setting results in desensitization/habituation of desensitization/habituation of conditioned associations between conditioned associations between traumatic memory and negative traumatic memory and negative emotionsemotions

Presentation to PatientsPresentation to Patients

►7-11 example7-11 example

How Does Exposure Therapy How Does Exposure Therapy Work?Work?

Two Essential Ingredients in Emotional Two Essential Ingredients in Emotional Processing of Trauma:Processing of Trauma:

►Accessing the fear structure (fear Accessing the fear structure (fear activation)activation)

►Availability of corrective informationAvailability of corrective information

Two Exposure ModelsTwo Exposure Models

► Flooding (Keane)Flooding (Keane)► Prolonged Exposure or PE (Foa)Prolonged Exposure or PE (Foa)► Both Keane and Foa models use systematic Both Keane and Foa models use systematic

repeated imaginal exposure to memory of the repeated imaginal exposure to memory of the traumatrauma

► 1 time telling of trauma--NOT systematic 1 time telling of trauma--NOT systematic exposure therapy—some desensitization can exposure therapy—some desensitization can occuroccur

► Examples:Examples: Trauma processing (ind/group)Trauma processing (ind/group) EMDREMDR

Keane’s Flooding ModelKeane’s Flooding Model

►Once through in 60 min. sessionOnce through in 60 min. session► Therapist-guidedTherapist-guided► Therapist asks questions on senses (seeing, Therapist asks questions on senses (seeing,

hearing, smelling, thinking, feeling) for each hearing, smelling, thinking, feeling) for each step in the traumastep in the trauma

► Therapist slows story down at worst pointsTherapist slows story down at worst points► Repeated imaginal exposure in subsequent Repeated imaginal exposure in subsequent

sessionssessions► Rating of SUDs (Subjective Units of Distress) Rating of SUDs (Subjective Units of Distress)

on 100 point scaleon 100 point scale

Foa’s Prolonged ExposureFoa’s Prolonged Exposure►Highly developed protocolHighly developed protocol

Imaginal exposureImaginal exposure In-vivo exposureIn-vivo exposure

► Prolonged (imaginal) exposure:Prolonged (imaginal) exposure: 10-15 90 minute sessions, more as needed10-15 90 minute sessions, more as needed 60 min of repetitions in 160 min of repetitions in 1stst session, 45-30 in session, 45-30 in

subsequentsubsequent Patient instructed to describe event as many Patient instructed to describe event as many

times within allotted timetimes within allotted time Little or no therapist interventionLittle 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.

Foa’s ProtocolsFoa’s Protocols

► Prolonged (imaginal) exposure (cont.):Prolonged (imaginal) exposure (cont.): Audio tape full session, with separate tape for Audio tape full session, with separate tape for

exposure pieceexposure piece Pt listens to exposure tape dailyPt listens to exposure tape daily Pt listens to session 1xPt listens to session 1x Homework, homework, homeworkHomework, homework, homework

► In vivo exposure:In vivo exposure: Hierarchy of avoided situations listedHierarchy of avoided situations listed Rate each on 100 point scaleRate each on 100 point scale Select 2-3 at 40-60 levelSelect 2-3 at 40-60 level Face min of 3x, if not daily in weekFace min of 3x, if not daily in week

► Practice breathing exercise dailyPractice breathing exercise daily

Dateline VideotapeDateline Videotape

How to address with patientsHow to address with patients

► Education, education, educationEducation, education, education Introduce as option in 1Introduce as option in 1stst assessment assessment Raise at option at end/beginning each groupRaise at option at end/beginning each group Use mantra “the more you face it the easier it Use mantra “the more you face it the easier it

gets; the more you avoid it, the worse it gets”gets; the more you avoid it, the worse it gets”

► Teach theoretical rationaleTeach theoretical rationale► Always emphasize choiceAlways emphasize choice

Setting the Stage—safety Setting the Stage—safety netsnets

► At home:At home: Inform family next 2 months will be roughInform family next 2 months will be rough Ask for support from family/friends ahead of timeAsk for support from family/friends ahead of time Find safe place in home to writeFind safe place in home to write

► By therapist:By therapist: Tell pt AND be available for same day callsTell pt AND be available for same day calls Give pt option of coming in for 2Give pt option of coming in for 2ndnd session in a session in a

weekweek Give pt option of phone therapy session, even if Give pt option of phone therapy session, even if

briefbrief

ExamplesExamples

►Male combat vetMale combat vet►Female rape survivorFemale rape survivor

Indications:Indications:

►Single traumaSingle trauma►Recent trauma (<1 year)Recent trauma (<1 year)►Multiple traumasMultiple traumas

Select worst—decide this with the patientSelect worst—decide this with the patient One that causes most current distressOne that causes most current distress If all else equal, the 1If all else equal, the 1stst one in series one in series Years of trauma (e.g., childhood sexual Years of trauma (e.g., childhood sexual

abuse)abuse)

ContraindicationsContraindications

►No alcohol/substance use during No alcohol/substance use during treatmenttreatment

►Recommend no anxiolytics or changes Recommend no anxiolytics or changes (stable min. 1 mo.)(stable min. 1 mo.)

►Not during period of instability—as best Not during period of instability—as best as can—not during recent loss, no as can—not during recent loss, no current abuse (e.g., pt. living back at current abuse (e.g., pt. living back at home)home)

►Must be patient’s choiceMust be patient’s choice

VariationsVariations

►Traditional—individual sessionsTraditional—individual sessions

►Group—WSDTT—max. of 3 pts for 6 Group—WSDTT—max. of 3 pts for 6 weeksweeks

►Long distance—monthly visitsLong distance—monthly visits

Therapist considerationsTherapist considerations

►CountertransferenceCountertransference If you decide to do it, get supervisionIf you decide to do it, get supervision Consider the message, if you back offConsider the message, if you back off

►Debriefing after exposure workDebriefing after exposure work►May experience nightmaresMay experience nightmares►Use same strategies as ptUse same strategies as pt►Others?Others?

DiscussionDiscussion

►Role play—non-traumatic eventRole play—non-traumatic event►QuestionsQuestions►Wrap-upWrap-up