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PTSD and Evidence-Based Practices

Exposure Therapy

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EXPOSURE THERAPY

 

1.)                Description of Exposure Therapy

 

        Exposure Therapy is a well-established treatment for PTSD that requires the patient to focus on and describe the details of a traumatic experience.  It is a systematic process that takes place in a safe environment.

        Exposure interventions usually involve the confrontation of feared stimuli either through imagination or in person.   

       In the treatment of chronic PTSD, exposure typically includes imaginal exposure (IE) to memories of the trauma and in vivo exposure (IV) to safe situations that are avoided because they elicit fear or memories of the trauma.

        IE and IV are usually combined in treatment and are referred to as Prolonged Exposure (PE).

        Often, Prolonged Exposure Therapy is accompanied by other types of Cognitive-Behavioral Interventions because:

-         Exposure Therapy has been shown to reduce symptoms of PTSD associated with anxiety and fear, such as: flashbacks, nightmares, and avoidance of persons, places, and objects associated with the trauma (closely and/or more remotely associated).  However, it needs to be supplemented by other kinds of CBT strategies because it does not in itself alleviate other symptoms of PTSD such as: social isolation, difficulties with anger and anger control, guilt, unemployment, and family discord.

        Prolonged Exposure (PE) is a behavioral treatment based upon theories of Classical Conditioning that relies on exposure, habituation, desensitization, and extinction to facilitate emotional processing of fear. 

        The following is an example of a Prolonged Exposure Treatment Model that was developed at the Center for the Treatment and Study of Anxiety in Philadelphia (Foa and Rothbaum, 1997).

-         The PE treatment program contains four main components: education about PTSD symptoms, breathing retraining, in vivo exposure, and imaginal exposure.  Patients are seen for 9-12 weeks, for approximately an hour and a half each session.  After 9 weeks, treatment progress is reviewed; if the patient has not improved markedly (at least 70% reduction of PTSD symptom severity), an additional three sessions are offered.  At the end of each session, homework is assigned to be completed during the subsequent week.

        Most manualized treatments for PTSD range from 6-36 sessions, administered over a period of 4-24 weeks. 

        In order for any type of Exposure Therapy to work, three psychological factors that are involved in the successful processing of a traumatic event must be present:

-         Emotional engagement with the trauma memory

-         Organization and articulation of the trauma narrative

-         Modification of basic core beliefs about the world and about oneself (because often following a traumatic event, some of the person’s cognitions become dysfunctional)

 

 

EXPOSURE THERAPY and SMI

 

        Clinical lore suggests that exposure therapy is not suitable for persons with psychotic illness; however, there are few or no empirical data to support this.  In fact, recent evidence suggests that individuals with SMI may be quite capable of completing various cognitive-behavioral strategies under the proper conditions.

        Based on the clinical experience of Frueh, Buckley, Cusack, Kimble, Grubaugh, Turner, & Keane, Exposure Therapy can be successfully used with persons with psychotic symptoms, as long as those symptoms are relatively stable and extra support and care are provided during the course of treatment.

        A multicomponent, cognitive-behavioral treatment model is appropriate for chronic and severe PTSD among people with SMI who are treated in public-sector mental health clinics.

        This model includes a comprehensive treatment designed specifically to target various aspects of the clinical syndrome associated with PTSD in persons with SMI, particularly emotional and physical reactivity to traumatic cues, intrusive symptoms and avoidance behavior, impaired interpersonal skills and emotion modulation (e.g. anger control), and reduced range of enjoyable social activities. 

        The program incorporates the PTSD psychosocial treatment approach with the most empirical support (exposure therapy), with a social skills and anxiety management training component that has been shown to work for other clinical populations.

 

Proposed Cognitive-Behavioral Treatment Model for PTSD in persons with severe mental illness: Multicomponent program overview (Frueh et. al, 2004).

Phase

Component

Number of Sessions

Phase 1

Education

Anxiety management and skills training

Social Skills training

Homework

1-3

1-3, and then incorporated throughout

6-14

Incorporated throughout

Phase 2

Exposure Therapy

Homework

6-12

Incorporated throughout

Upon Completion

Long-term follow-up care

Ongoing

 

        The above outlined model is likely to require 15-30 sessions and could be paced differently depending on the nature of the treatment setting.

 

 

2.)                Goals/Targets/Desired Outcomes of Exposure Therapy

 

        The goal of Exposure Therapy is to help the patient resume preassault functioning and be able to remember the trauma without undue anxiety and distress.

        Exposure Therapy emphasizes the reduction of avoidance, flashbacks, and nightmares.  It aims to decrease anxiety and fear of the traumatic experience.

 

 

3.)                Nature of Evidence (plus table)

 

        There are many Randomized Control Trials that test the efficacy of PE with various populations, including: Vietnam Veterans, Adult Survivors of Childhood Sexual Abuse, Rape Victims, and Victims of Physical Assault.

 

Study

Results of Prolonged Exposure

Results of Comparison Group(s)

Foa, Hembree, Cahill, Rauch, Riggs, Feeny, & Yadin, 2005

PE – decreased PTSD symptoms, reduced levels of Depression, significant improvement in work and social functioning.

PE/CR – same as PE but addition of CR did not enhance treatment outcome.

WL – did not reduce PTSD symptoms or levels of Depression significantly.

 

Rauch, Foa, Furr, & Filip, 2004

 

PE – decreased PTSD symptoms (Anxiety and Fear)

 

PE/CR – no significant differences found with addition of CR

 

Cloitre, Chase Stovall-McClough, Miranda, & Chemtob, 2004

 

No PE alone

 

STAIR/MPE – (STAIR = skills training in affect and interpersonal regulation, MPE = Modified Prolonged Exposure)

A positive therapeutic relationship in the initial phase of treatment predicted PTSD symptom reduction at the end of treatment.  Furthermore, this success was mediated through an improvement in the capacity to regulate negative mood state during the emotionally intense intervention of exposure therapy.

 

Taylor, Thordarson, Fedoroff, Maxfield, Lovell, & Ogronniczuck, 2003

PE – superior to relaxation at each of the posttreatment, follow-up, and sustained variables, superior to EMDR but not statistically significant.

88% no longer meeting criteria for PTSD posttreatment and follow-up.

80% no longer meeting criteria for PTSD sustained.

EMDR – 60% no longer meeting criteria for PTSD posttreatment, 68% no longer meeting criteria for PTSD follow-up, 52% no longer meeting criteria for PTSD sustained.

 

Relaxation – 40% no longer meeting criteria for PTST posttreatment, 48% no longer meeting criteria for PTSD follow-up, 30% no longer meeting criteria for PTSD sustained.

 

4.)                Future Research/Limitations

 

        Although Randomized Control Trials have shown the efficacy of Prolonged Exposure, clinicians are not using this technique in clinical settings.

        Training is required to break down biases toward utilizing this technique.

        Training is also required so that the clinician feels comfortable utilizing this technique with various populations and with additional CBT interventions.

        When Prolonged Exposure Therapy is first introduced in treatment, the client’s level of both fear and anxiety should increase.  However, after “a few” sessions, the client should begin to habituate, and both fear and anxiety levels should decrease.  Additional research is needed to figure out how many sessions are “a few”, so that if the client is not responding, an alternate intervention could be implemented. 

        Further research is currently aimed at eliciting the mechanisms of change in Exposure Therapy.

        Research literature is mixed – are additional CBT interventions required to augment PE for certain populations but not for others?  Additional research is required here.

-         Authors in the field of trauma, particularly those working with victims of child abuse, have shown through their research that PE should be supplemented with other CBT strategies to produce more positive outcomes in the reduction of PTSD symptomology (i.e. STAIR/MPE, STAIR/IE).  Authors include: Briere, Cloitre, Herman, van der Kolk, McFarlane, & van der Hart.

-         Other authors have shown through their research that additional CBT strategies to PE are unnecessary, as PE has shown positive outcomes in the reduction of PTSD symptomology by itself.  Authors include: Foa, Feeny, Riggs, Cahill, Zoellner, & Rauch.  

 

 

 

 

 

 

 

 

 

 

 

 

Amber Hursh, Justin Reimenschneider, Justine Tedesco
RSSW 705 Evidence-Based Practice in Mental Health
Dr. Zvi Gellis, SUNY Albany, Rockefeller College of Social Work