Sheila A. M. Rauch

Randomized Trial of Prolonged Exposure for Posttraumatic Stress Disorder With and Without Cognitive Restructuring: Outcome at Academic and Community Clinics

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.

Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder.

The authors report on changes in cognitions related to posttraumatic stress disorder (PTSD) among 54 female survivors of sexual and nonsexual assault with chronic PTSD who completed either prolonged exposure alone or in combination with cognitive restructuring. Treatment included 9-12 weekly sessions, and assessment was conducted at pretreatment, posttreatment, and a modal 12-month follow-up. As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttraumatic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported. Reductions in these negative cognitions were significantly related to reductions in PTSD symptoms. The addition of cognitive restructuring did not significantly augment the cognitive changes. Theoretical implications of the results are discussed.

A PILOT STUDY OF GROUP MINDFULNESS-BASED COGNITIVE THERAPY (MBCT) FOR COMBAT VETERANS WITH POSTTRAUMATIC STRESS DISORDER (PTSD)

“Mindfulness‐based” interventions show promise for stress reduction in general medical conditions, and initial evidence suggests that they are accepted in trauma‐exposed individuals. Mindfulness‐based cognitive therapy (MBCT) shows substantial efficacy for prevention of depression relapse, but it has been less studied in anxiety disorders. This study investigated the feasibility, acceptability, and clinical outcomes of an MBCT group intervention adapted for combat posttraumatic stress disorder (PTSD).

Prolonged Exposure for PTSD in a Veterans Health Administration PTSD Clinic

With the move toward dissemination of empirically supported treatments in the Veterans Health Administration (VHA), dissemination of additional data concerning the effectiveness of prolonged exposure (PE) among veterans is important. The authors present clinical treatment data from veterans with chronic posttraumatic stress disorder (PTSD) treated in a VHA PTSD clinic (N = 10). Veterans demonstrated significant reductions in total PTSD symptoms from pre- to posttreatment. Returning veterans from the conflicts in Afghanistan and Iraq and other era veterans (Vietnam Veterans and military sexual trauma veterans) demonstrated significant reductions in PTSD. In addition, veterans demonstrated significant reductions in depression from pre- to posttreatment. In conclusion, PE is effective in reducing the symptoms of PTSD in veterans.

Emotional Processing Theory (EPT) and Exposure Therapy for PTSD

Emotional processing theory developed by E. B. Foa and M. J. Kozak (1986) has informed the conceptualization of anxiety disorders and the development of effective treatments for these disorders, including posttraumatic stress disorder (PTSD). This article presents a summary and update of emotional processing theory as it applies to the treatment of PTSD, data in support of this theory, and clinical examples of how the theory can be used to assist in the treatment of clients with PTSD. Common difficulties confronted during exposure therapy for PTSD, including underengagement and overengagement, are discussed in the context of emotional processing theory and suggestions for how to manage these difficulties are presented.

Review of exposure therapy: a gold standard for PTSD treatment.

Prolonged exposure (PE) is an effective first-line treatment for posttraumatic stress disorder (PTSD), regardless of the type of trauma, for Veterans and military personnel. Extensive research and clinical practice guidelines from various organizations support this conclusion. PE is effective in reducing PTSD symptoms and has also demonstrated efficacy in reducing comorbid issues such as anger, guilt, negative health perceptions, and depression. PE has demonstrated efficacy in diagnostically complex populations and survivors of single- and multiple-incident traumas. The PE protocol includes four main therapeutic components (i.e., psychoeducation, in vivo exposure, imaginal exposure, and emotional processing). In light of PEs efficacy, the Veterans Health Administration designed and supported a PE training program for mental health professionals that has trained over 1,300 providers. Research examining the mechanisms involved in PE and working to improve its acceptability, efficacy, and efficiency is underway with promising results.

Effect of Cognitive-Behavioral Treatments for PTSD on Anger

We investigated three questions related to anger and the treatment of chronic posttraumatic stress disorder (PTSD), utilizing data from a previously published study of cognitive behavioral therapies (CBTs) with female assault victims (Foa, Dancu, Hembree, Jaycox, Meadows, & Street, 1999). The questions were: (1) Do CBTs targeted at PTSD result in a concomitant reduction in anger?, (2) If so, how do these treatments compare with one another?, And (3) Do high levels of pretreatment anger predict poorer outcome on measures of PTSD symptom severity, depression, and general anxiety? Data from the State-Trait Anger Expression Inventory at pretreatment and posttreatment assessments were available for 67 participants randomly assigned to receive prolonged exposure (PE; n = 19), stress inoculation training (SIT; n = 18), combined treatment (PE/SIT; n = 17), or waitlist control (WL; n = 13). Compared to WL, treatments significantly lowered levels of state-anger. Comparisons among active treatments indicated significantly lower state-anger for SIT compared to PE/SIT, but PE did not differ from SIT or PE/SIT. Treatment gains were maintained at follow-up. Pretreatment state-anger was correlated with posttreatment PTSD symptom severity and depression, but multiple regression analyses revealed that pretreatment state-anger did not predict posttreatment PTSD symptom severity or depression beyond the corresponding pretreatment levels of PTSD and depression. A sub-group analysis compared treated participants with clinically significant pretreatment elevations in state-anger (n = 9) to the remainder of the treated participants (n = 45). No significant difference in state-anger was found between groups at posttreatment. The high state-anger group reported greater anger than the low state-anger group at follow-up, but the high state-anger group remained significantly less angry at follow-up than at pretreatment. Thus, CBTs for PTSD reduced anger and pretreatment anger did not reduce the efficacy of these treatments for PTSD and associated psychopathology.

Beyond the manual: The insider's guide to Prolonged Exposure therapy for PTSD

Prolonged Exposure therapy (PE; Foa & Rothbaum, 1998) has strong empirical support for its efficacy in reducing trauma-related psychopathology in individuals with chronic PTSD (Rothbaum, Meadows, Resick, & Foy, 2000) . In the process of providing PE to many clients and in training therapists in a variety of settings in its use, we at the Center for the Treatment and Study of Anxiety have amassed extensive experience with this therapy. This article extends the treatment guidelines provided in the PE treatment manual by sharing the knowledge and wisdom that years of experience have brought us. We emphasize the importance of forging a strong therapeutic alliance and providing a thorough rationale for treatment, discuss ways to implement in-vivo and imaginal exposure so as to promote effective emotional engagement with traumatic memories, and conclude with some recommendations for how therapists who conduct PE for PTSD can take care of themselves while delivering a therapy that is very rewarding and, at times, emotionally challenging.

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder

Background: Postraumatic stress disorder (PTSD) is associated with significant health risk, illness, and functional impairment, e.g., Green and Kimerling [2004: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Phychological Association] Kimerling et al. [2000: Trauma and Health: J Trauma Stress 13:115–128]. Methods: These analyses examined whether negative health perceptions and general social functioning change with treatment of chronic PTSD among women from a randomized controlled study comparing prolonged exposure (PE; n=48) or PE combined with cognitive restructuring (PE/CR; n=40) to waitlist (n=19; Foa et al., 2005: J Consult Clin Psychol 73:953–964]. Results: Self‐ reported physical health difficulties were significantly reduced in the PE and PE/CR conditions compared to the waitlist condition. These reductions did not demonstrate significant change during the 12 month follow‐up period. Self‐reported discomfort associated with physical health difficulties did not demonstrate significant change over treatment. No difference was detected between the active treatment and waitlist conditions. Both the PE and PE/CR groups reported improved social functioning at post treatment compared to the waitlist. Additional improvement in general social functioning was found between 3 and 12 month follow‐up assessments. Changes in PTSD and depressive symptoms over treatment accounted for 29% of the variance in reduction of reported health problems and 30% of the variance in improvement of general social functioning. Importantly, only changes in PTSD symptoms significantly contribute to the model predicting change in physical health problems with depression associated only at a trend level. However, collinearity between PTSD and depression makes interpretation difficult. Conclusions: Negative health perceptions and general social function improve with PE. Changes in depression and PTSD with treatment are related to these changes. Depression and Anxiety, 2009.

Health service utilization before and after evidence-based treatment for PTSD.

Posttraumatic stress disorder (PTSD) is associated with functional impairment, co-occurring diagnoses, and increased health care utilization. Associated high demand for health care services is an important contributor to the large public-health cost of PTSD. Treatments incorporating exposure therapy are efficacious in ameliorating or eliminating PTSD symptoms. Accordingly, the Veterans Health Administration has made significant investments toward nationwide dissemination of a manualized exposure therapy protocol, prolonged exposure (PE). PE is effective with veterans; however, the relationship between PE and mental health service utilization is unknown. The current study investigates PE as it relates to actual tracked mental health service utilization in an urban VA medical center. A sample of 60 veterans with a diagnosis of PTSD was used to examine mental health service utilization in the 12-months prior to and 12-months after being offered PE. Hierarchical Linear Models and traditional repeated-measures ANOVA were used to estimate R²- and d-type effect sizes for service utilization. Associated estimated cost saving are reported. PE was associated with large reductions in symptoms and diagnosis remission. Treatment was also associated with statistically significant, large reductions in mental health service utilization for veterans who completed treatment. Findings suggest that expanding access to PE can increase access to mental health services in general by decreasing ongoing demand for specialty care clinical services.