Terapie Cognitiva Comportamentala

pentru Stresul Post-Traumatic

Diagnosticarea Stresului Post-
Traumatic
Definitia unei Traume :
Persoana a fost expusa la un eveniment
traumatic in timpul caruia :


1) Persoana a experimentat, a fost martora, sau
s-a confruntat cu un eveniment care implica
moarte fizica , amenintarea cu moartea sau
vatamare, sau o amenintare la adresa
integritatii fizice a persoanei respective sau a
altora.



2) Reactia persoanei respective a implicat o
teama profunda , neajutorare, sau groaza.

502a
Amintiri tulburatoare despre trauma
Vise tulburatoare legate de eveniment
Retrairea experientei (flashuri)
Tulburari psihologice in timpul expunerii la
factori traumatici (interni sau externi)
Reactivitate psihologica la factori care
declanseaza evenimentul traumatic .
A. Retrairi

Eforturi pentru a evita gandurile si
sentimentele legate de trauma
Eforturi pentru a evita activitati sau situatii
legate de trauma
Amnezie psihogenica
Interes scazut pentru orice fel de activitati
Detasare fata de cei din jur
O gama restransa de trairi afective
Scurtarea duratei de viata
B. Indepartare persistenta de
eveniment
Fobii specifice
Teama evidenta si persistenta fata de
obiecte sau situatii clar delimitate ca
fiind fobice
Contactul cu stimulul fobic provoaca
o reactie anxioasa imediata
Situatia care declanseaza fobia este
evitata
Tulburari ale somnului
Iritabilitate sau izbucniri furioase
Dificultate in concentrare
Hipervigilenta
Reactie exagerata de spaima
C. Surescitare crescuta
Anxietate si ingrijorare excesiva
Agitatie, dificultate in concentrare,
iritabilitate, tensiune musculara sau
tulburari ale somnului
Generalizarea tulburarilor anxioase
Unele simptome ale Stresului Post-
Traumatic se suprapun cu simptome fobice
(ex. tulburari cauzate de evenimente
traumatice si evitarea unor asemenea
evenimente )
Alte simptome ale Stresului Post-Traumatic
se suprapun cu tulburari anxioase
generalizate (ex., hipervigilenta, surescitare
crescuta)
Intrepatrunderea simptomelor
Stresului Post-Traumatic cu alte
tulburari anxioase

Un conflict intre tendina de a trai permanent cu
un sentiment de ameninare si tendina de a
evita propagarea acelui sentiment (ex.,
sustragere comportamentala i cognitiva )
Ceea ce distinge Stresul Post-Traumatic este:
Un proces bifazic de retraire si de negare cu
reactii penduland intre indrazneala excesiva si
amorteala (Horowitz, van der Kolk).

Un aspect comun tuturor tulburarilor anxioase
este :
Cand eforturile de a reduce tulburarea printr-o
evitare activa dau gre, se instaleaza o
atitudine de izolare .
Criteriile de diagnosticare ale Stresului Post-
Traumatic
E. Durata tulburarii depaseste o luna
F. Afectiunea cauzeaza tulburari
semnificative sau deteriorari ale
functiilor de baza .
Criterii de diagnostic pentru Stresul
Post-Traumatic
Specificati daca:
Acut: daca durata simptomelor este sub 3
luni
Cronic: daca durata simptomelor este de 3
luni sau mai mare
Izbucnire
Intarziata: daca durata simptomelor este de cel
putin 6 luni dupa declansarea
situatiei de stres
Raspandirea Traumei si Stresului
Post-Traumatic la barbati si femei in
Statele Unite
60.7
51.2
8.1
20.4
91.9
79.6
0
10
20
30
40
50
60
70
80
90
100
Men Women
P
e
r
c
e
n
t

(
%
)
Trauma
PTSD
No PTSD
Kessler 1995
Rata Stresului Post-Traumatic este
influentata de Natura Traumei
Kessler 1995
0
10
20
30
40
50
60
Disaster Accident Assault Molestation Combat* Rape
P
e
r
c
e
n
t

(
%
)
Trauma PTSD

15.2% din 500,000 de veterani vietnamezi ,
adepti ai programului Veterans Truth
Project
17.8% din 9.9 milioane femei victime ale
molestarii fizice
13% din 13.8 milioane femei victime ale
abuzului sexual
3.4% din femei victime ale unor traume
non-criminale
Cifrele curente ale Stresului Post-
Traumatic in randul indivizilor
traumatizati
Morbiditate crescuta la Stresul
Post-Traumatic
% Rates
PTSD Non PTSD
Psihiatrica
Tulburare Anxioasa
Generalizata (GAD) 53
Depresie Majora 30 4
Somatizare 12 0
Abuz / Dependenta de droguri 9 1
Medicala
Astm pulmonar 13 5
Ulcer pepsic 13 4
Hipertensiune 31 18
Davidson 1991
Kessler et al. 1999
0
1
2
3
4
5
6
7
PTSD GAD Panica Anxietate
Sociala
Orice
Anxietate
P
r
o
p
o
r
t
i
a

S
a
n
s
e
l
o
r

Riscul tentativelor de sinucidere in
randul pacientilor cu tulburari
anxioase
19% din pacientii cu PTSD
vor incerca
sa se sinucida
Pacientii cu PTSD sunt
de 6 ori mai predispusi
la sinucidere decat
la autocontrol


0
25
50
P
r
o
c
e
n
t

Nu
muncesc
Limitare
fizica
Bunastare
redusa

Sanatate
satisfacatoare
sau subreda
Zatzick DF et al.
Comportare
violenta
anul trecut

PTSD Non-PTSD
Stresul Post-Traumatic afecteaza
calitatea vietii
33.2
22.6
35.5
39.5
49.2
16.0
26.5
9.9 9.8
4.3
Kessler., 2000; Kessler et al., 1999
Diminuarea activitatii in medie= 3.6 zile/luna
Pierderi anuale ale productivitatii = $ 3 miliarde
Solicitare servicii medicale : cifra medie a
vizitelor medicale generale pe anul trecut
PTSD 5.3
Orice tulburare anxioasa 4.4
Depresie majora 3.4
Implicatiile economice ale Stresului
Post-Traumatic
0
25
50
75
100
Vitality Social Function
PTSD MDD OCD US Population
Calitate necorespunzatoare a vietii
datorita Stresului Post-Traumatic
S
h
o
r
t


S
u
r
v
e
y


S
c
o
r
e

0
25
50
75
100
Vitality Social Function
PTSD
US Population
Depression
Calitate scazuta a vietii datorata
Stresului Post-Traumatic
Malik et al. J Trauma Stress. 1999
Short
Survey
Consecinte economice datorate
Stresului Post-Traumatic

Pierderi ale productivitatii anuale = $3 miliarde
(SUA)

Diminuarea activitatii in medie = 3.6 zile/luna
Nivelul productivitatii scazute datorat Stresului
Post-Traumatic este similar cu cel al depresiei
1. Kessler and Frank, Psychol Med: 1997: 27: 861.
2. Breslau et al, Arch Gen Psychiatry, 1998: 55:626.
3. Solomon and Davidson, J Clin Psychiatry, 1997: 58: suppl 9: 5.
Sumar al reactiilor la trauma
Majoritatea victimelor unei traume se refac in timp

Stresul Post-Traumatic reprezinta o esuare a
procesului de recuperare pe cai naturale

Dupa un an , Stresul Post-Traumatic nu se
diminueaza fara tratament

Stresul Post-Traumatic este o afectiune care
tulbura profund si debiliteaza



Prezentarea in teorie a Stresului
Post-Traumatic
Procentajul victimelor afectate de Stresul
Post-Traumatic
Assessment
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12
Rape Victims
Non-Sexual Assault
P
e
r
c
e
n
t
a
g
e

Procentajul victimelor afectate de Stresul
Post-Traumatic
0
10
20
30
40
50
60
70
80
90
100
Rape Victims
Non-Sexual Assault
P
e
r
c
e
n
t
a
g
e

1 Wk 1 Month 2 Mos. 3 Mos. 6 Mos. 12 Mos.
Assessment
Teoria Procesului Emotional declansat de
Stresul Post-Traumatic
Recurge la termeni psihologici pentru a explica :
Primele simptome ale Stresului Post-
Traumatic
Recuperarea pe cai naturale
Aparitia, dezvoltarea si tratarea Stresului
Post-Traumatic


Structura sentimentului de
teama
Aceasta structura este un program care
ajuta la inlaturarea senzatiei de pericol
Include informatii despre :
Stimulii care induc frica
Reactiile declansate de frica
Conceptele de stimuli si reactii
Memoria Traumei
Este o structura specifica a sentimentului de teama
care include reprezentari ale:
Stimulilor declansati in timpul traumei
Reactiilor psihologice si comportamentale care
au avut loc in timpul traumei
Explicatiilor asociate cu acesti stimuli si aceste
reactii
Asociatiile create si explicatiile acestor
fenomene pot fi realistice sau nerealistice
Model schematic al unei Memorii la
scurt timp dupa Viol
Arma
Barbat Viol
Teama
Tipat
Confuza Neputina
Eu
Necontrolat
Foc de arma
Chel
Inalt
Nu
misca
Spune
Te
iubesc
Singura
Suburbii
Acasa
Simptomele
Stresului Post-Traumatic

Periculos
Chel
Caracteristicile structurii unei
traume recente
Un numar mare de stimuli
Reactii exagerate (simptome ale Stresului
Post-Traumatic)
Asociatii gresite intre stimuli si sentimentul de
pericol
Asociatii gresite intre reactii si sentimentul de
neputinta
Legaturi fragmentare si ineficient organizate
intre reprezentarile diferitelor senzatii
Primele simptome ale Stresului Post-
Traumatic
Factorii traumatici care actioneaza in viata
cotidiana declanseaza memoria traumei si
senzatiile asociate de pericolsi de neputinta
Activarea memoriei traumei este reflectata in
retrairea simptomelor si surescitare
Retrairea simptomelor si surescitarea motiveaza
atitudinea de evitare a amintirilor traumatice
Procesul de recuperare
Activarea constanta a memoriei traumatice (implicare
emotionala )
Inducerea unor informatii corective asupra
conceptelor de lume inconjuratoare si viata
interioara
Activarea si rectificarea unor anumite informatii au loc
prin confruntarea cu respectivii factori traumatici
(ex. Inducerea unor ganduri care sa faca legatura cu
factorii traumatici )
Informatiile corective constau in absenta sentimentului
negativ anticipat de pacient
Modelul schematic al unei memorii
refacute dupa un viol
Inalt
Arma
Chel
Foc de
arma
Barbat
Acasa
Viol
Tipat
Confuza Neputinta
Teama
Eu
Necontrolat
Nu
misca
SpuneTe
iubesc
Singura Suburbii
Periculos
Calculul apogeului reactiilor si al
psihopatologiei persistente
0
2
4
6
8
10
12
Peak during wks 1-2 Peak during wks 2-6
S
e
v
e
r
i
t
y

Depression PTSD
0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6 7 8 9 10 11 12
immediate
delayed
Modele de recuperare:
Exemple de cazuri

P
T
S
D
-
S
e
v
e
r
i
t
y

Time (in weeks)
Caracteristici ale relatarilor despre
Viol povestite de pacienti
Fragmentare (e.g. repetitii , pauze in
vorbire )
Incoerenta in spatiu si timp (ex.Din
senin era langa pat)
Ganduri ce reflecta confuzie (ex. Nu
pot sa cred ca se intampla asta Ce
se va intampla in continuare?)
Gradul de intelegere al relatarilor despre
traume si aspecte psihopatologice
Reading Level
T
r
a
u
m
a


P
a
t
h
o
l
o
g
y

R = -.72
1.5
1.0
2.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0

-2 -1 0 1 2 3
Corelatii intre exprimarea relatarilor si
aspectele psihopatologice
2 Weeks 12 Weeks
Grade Level Grade Level

BDI -0.55 -0.11
STAI-S -0.80* -0.46
PSS -0.35 -0.60*
* p < 0.05
Stres Post-Traumatic Cronic
Excluderea persistenta de tip cognitiv si
comportamental a factorilor traumatici previne
orice modificare a memoriei traumei prin :
Limitarea activarii memoriei traumei
Limitarea expunerii la informatii corective
Limitarea exprimarii memoriei traumei
impiedicand astfel organizarea memoriei

Model schematic al memorarii
patologice a unui Viol ( Stres Post-
Traumatic Cronic )
Inalt
Arma
Foc de
arma
Necontrolat
Viol
Teama
Eu
Tipat
Confuza Neputinta
Barbat
Chel
Nu
Misca
Spune
Te
iubesc
Singura Suburbii
Acasa
Simptomele
Stresului
Post-Traumatic
Periculos
Perceptii eronate privind Stresul Post-
Traumatic
Lumea este extrem de periculoasa
Oamenii nu sunt de incredere
Nici un loc nu este sigur
Sunt foarte neputincios
Simptomele Stresului Post-Traumatic
sunt un semn de slabiciune
Alte persoane ar fi putut preveni
trauma


Post-Traumatic Cognition Inventory
Scale Scores
by Participant Group
0
1
2
3
4
5
6
No Trauma Trauma/
No PTSD
PTSD
Negative Thoughts
About Self
Negative Thoughts
About World
Self-Blame
M
e
d
i
a
n

S
c
a
l
e
d

S
c
o
r
e
s

Suport empiric pentru Teoria Procesarii
Emotionale :
Factori estimativi ai unei recuperari lente
Perceptii negative despre propria persoana si lumea
inconjuratoare
O interpretare negativa a simptomelor Stresului
Post-Traumatic (incompetenta propriei persoane)
O evaluare negativa a reactiilor altor persoane
(lumea este periculoasa)
Excluderea factorilor care declanseaza trauma (
impiedica rectificarea perceptiilor negative despre
propria persoana si lumea inconjuratoare

Suport Empiric pentru Teoria Pocesarii
Emotionale: Factori estimativi ai unei
recuperari lente (continuare)
Suprimarea primelor simptome; inlaturarea
gandurilor (excludere de tip cognitiv)
Reflectie constanta (sustragere de la o
procesare corecta a memoriei si de la
rectificarea perceptiilor negative )
Disociere permanenta (lipsa implicarii
emotionale)
O elaborare si organizare ineficienta a
relatarii despre trauma
Factori care incurajeaza perceptii negative
si evitarea contactului cu evenimentul
traumatic
Evitarea contactului cu evenimentul traumatic este
motivata de o surescitare intensa care in schimb
este influentata de:
Severitatea traumei
Deficit biologic in dozarea senzatiei de
surescitare (ex., cortizon scazut?)
Perceptiile negative sunt influentate de :
Istoricul medical traumatic anterior
Prezenta unor cazuri psihopatologice in cadrul
familiei
Lipsa ajutorului social sau ineficienta acestuia
Factori care determina dezvoltarea
Stresului Post-Traumatic
Factori pre-traumatici
Idei despre propria persoana
Idei despre lumea inconjuratoare
Memorarea evenimentului traumatic
Memorarea unor evenimente post-
traumatice
Recuperarea este impiedicata
Atunci cand trauma distorsioneaza perceptia
asupra propriei persoane ca fiind foarte
capabila si cea despre lume ca fiind sigura
SAU
Cand trauma subliniaza o imagine a propriei
persoane ca fiind neputincioasa si a lumii ca
fiind extrem de periculoasa
Fragmented memory of the trauma is
constructed
This memory record includes representations
of:
intense fear and confusion
body state (e.g., physical
pain, touch of penetrator,
struggle)
thoughts and ideas which reflect
confusion (e.g., I cant believe it is
happening)
strong images of specific details
Trauma Records
Post Trauma Events That
Impede Emotional Processing
Lasting emotional disturbances (e.g.,
nightmares, sleeplessness)
Disruption in daily functioning
Reactions of others (e.g., get on with
your life)
Schematic Model of
Emotional Processing
Recovery Pathology
Schemas

Self
Schema
World
Schema
Traumatic
Event
Trauma
Records
Post-Trauma
Events
Post-Trauma
Records
Pre-Trauma
Records
Schematic Model of
Recovery Following Trauma
Recovery
Schemas

Self
Schema I
am mostly
competent.
World
Schema
The world is
mostly safe.
Traumatic
Event
Trauma
Records
It was not my
fault; I handled
it as well as
could be
expected.
Post-Trauma
Events
Post-Trauma
Records
Some but not all
people can be
trusted; PTSD
symptoms are
normal and
temporary.
Pre-Trauma Records
Balanced, flexible premises
about self and world
Schematic Model of Developing
Pathology Following Trauma
Pathology
Schemas

Self
Schema
I am entirely
incompetent.
World
Schema
The world is
entirely
dangerous.
Traumatic
Event
Trauma
Records
It is my fault.
Post-Trauma
Events
Post-Trauma
Records
People are
untrustworthy;
PTSD symptoms
are dangerous.
Pre-Trauma Records
Rigid premises about self
and world
1038
Treatment of Chronic PTSD
CBT Treatments for Chronic PTSD
Promote safe confrontations (via exposure,
discussions) with trauma reminders (memories,
situations)
Aim at modifying the dysfunctional cognitions
underlying PTSD
Exposure Procedures
Anxiety Management Procedures
Cognitive therapy
Cognitive-Behavioral Treatment Can Be
Divided Into:
A set of techniques designed to help
patients confront their feared objects,
situations, memories, and images (e.g.,
systematic desensitization, flooding).
Exposure Therapy
Anxiety Management Treatment
Relaxation Training
Controlled Breathing
Positive Self-talk and Imagery
Social Skills Training
Distraction Techniques
(e.g., thought stopping)
Cognitive Therapy
Identifying dysfunctional, erroneous
thoughts and beliefs (cognitions)

Challenging these cognitions

Replacing these cognitions with functional,
realistic cognitions
PTSD Treatments: Review
Exposure Therapy
Anxiety Management Therapy
Cognitive Therapy
Combinations
EMDR

PTSD Symptom Checklist Score
In Combat Veterans
0
10
20
30
40
50
60
Implosive Therapy Wait List Control
Pre
Post
FU
Conditions
Prolonged Exposure Therapy (PE) for
PTSD
Breathing retraining: 10 minutes in session 1

Education about common reactions to trauma (25
minutes in session 2)

Imaginal exposure (reliving) to the trauma
memory (30-45 minutes during sessions 3-12)

In vivo exposure to trauma reminders in life
between sessions
9-12 weekly or twice weekly 90-minute sessions
Study I With Women Assault Victims
Treatments:
Prolonged Exposure (PE)
Stress Inoculation Training (SIT)
SIT + PE
Wait List Controls
Treatments included 9 sessions conducted
over 5 weeks
Foa et al.,1999
PE Vs SIT Vs PE/SIT Vs WL

0
10
20
30
40
50
60
70
80
90
100
PE
SIT
PE/SIT
WL
P
e
r
c
e
n
t

P
a
t
i
e
n
t
s

w
i
t
h

P
T
S
D

Post-Tx 6 Mo FU Last Available FU
(M = 10.7 mos.)
Foa et al., 1999
Post-Rx Effect Sizes* of PE vs SIT
vs PE/SIT: PTSD
0
0.5
1
1.5
2
TOTAL Reexp. Arousal Avoidance
E
f
f
e
c
t

S
i
z
e

o
f

P
T
S
D

S
y
m
p
t
o
m
s
PE
SIT
SIT/PE
*Effect size compared to wait-list group at post-treatment
Foa et al., 1999

Study II With Women Assault Victims

Treatments:
Exposure (PE) alone
PE + Cognitive Restructuring (PE/CR)
Wait List (WL)

Treatment includes 9 weekly sessions,
extended to 12 for partial responders (< 70%
improvement)


Foa et al., in preparation
Percent of Patients With PTSD Diagnosis

0
10
20
30
40
50
60
70
80
90
100
PE
PE/CR
WL
P
e
r
c
e
n
t

Post-Tx Last FU

Foa et al., in preparation
0
0.5
1
1.5
2
2.5
3
3.5
E
f
f
e
c
t

S
i
z
e

o
f

P
T
S
D

S
y
m
p
t
o
m
s
PE
PE/CR
WL
PSS-I BDI

Within Group Effect Sizes

Foa et al., in preparation
Rate of Improvement in Completers
of 9 vs. 12 Sessions
0
5
10
15
20
25
30
35
Pre 2 4 6 8 10 12 Post
Sessions
P
D
S

S
c
o
r
e
12 Sessions
9 Sessions
PE VS PE and CR With Torture
Victims

0
5
10
15
20
25
30
35
40
45
Pre Post FU
P
T
S
D

S
e
v
e
r
i
t
y
PE
PE/CR
Paunovic & Ost, 2001
Study with Men and Women Victims of
Mixed Traumas
Treatments:
Exposure (PE)
Cognitive Restructuring (CR)
PE + CR
Relaxation Training

Treatment consisted of 10 sessions conducted over 16
weeks


Marks et al., 1998
Good End State Functioning
Post Treatment*
0
10
20
30
40
50
60
P
e
r
e
c
e
n
t

R
e
s
p
o
n
d
e
r
s
* > 50% improved on PTSD; <7 BDI; <35 STAI-S
Foa et al., 1999 Marks et al., 1998
PE SIT PE/SIT WL PE CR PE/CR R
CT and EX vs. Combined Treatment
0
20
40
60
80
100
Post-tx Last FU
CT
CT + EX
M
e
a
n

P
e
r
c
e
n
t


C
h
a
n
g
e

Post-tx Last FU
EX
EX + CT
Study Design
Sertraline Only
(10 weeks)
Continue Sertraline Only
(5 weeks)
Sertraline + PE
(5 week, 2x weekly therapy)
PTSD: Effect Sizes for SIP
Completer Sample (n=42)
0
0.5
1
1.5
2
2.5
3
Post-Tx (15 Wk)
PE+SRT
SRT
Foa et al. In Progress


S
t
r
u
c
t
u
r
e
d

I
n
t
e
r
v
i
e
w

(
S
I
P
)

PE+SRT > SRT
0
5
10
15
20
25
30
35
40
45
0 10 15 0 10 15
S
I
P

(
0
-
6
8
)
PE+SRT
SRT
Partial Excellent
Excellent response equals > decrease of 2 SD
PTSD: PE Following
Partial or Excellent SRT Response
Completer Sample (n=42)
Weeks
Foa et al. In Progress

1270
Cognitive Processing Therapy
Cognitive restructuring (Beck, Ellis)
focusing on:
Safety Esteem
Trust Intimacy
Power
Repeated writing of the traumatic
experience
Treatment consists of 12 weekly sessions
Effects of PE and CPT
Completer Sample



0
10
20
30
40
50
60
70
80
Pre Post 3 Month 9 Month
PE
CPT
WL
Assessment Point
S
e
l
f
-
r
e
p
o
r
t
e
d

P
T
S
D

S
e
v
e
r
i
t
y

Resick et al., 2001
1034N

Access trauma images and memories
Evaluate their aversive qualities
Generate alternative cognitive appraisal
Focus on the alternative
Sets of lateral eye movements while
focusing on response

K8
EMDR Components
The Effects of PE/SIT and EMDR
on PTSD: PSS-SR
S
e
v
e
r
i
t
y

Pre Post 3 Mo FU
PE/SIT
EMDR
Devilly & Spence, 1999
12
15
18
21
24
27
30
33
36
39
0
1153
Good End State Functioning*
0
20
40
60
80
Post-Tx 6 Mo FU
EMDR
PE
WL
At 6 Mo FU PE > EMDR; p <.02
P
e
r
c
e
n
t

R
e
s
p
o
n
d
e
r
s

*CAPS 50% ; BDI < 10; STAI-S < 40

Rothbaum, Astin, & Marsteller, ISTSS, 2001
Effects of Eye Movement in EMDR: IES
0
5
10
15
20
25
30
Movement Fixed
Pre
Post
Pitman et al., 1996
1155
Effects of Eye Movement in
EMDR: CAPS
0
10
20
30
40
50
60
70
Movement Fixed
Pre
Post
Pitman et al., 1996
1156
Safety and Acceptability of
Prolonged Exposure
Exacerbation of Symptoms
Minority of clients in treatment show a reliable
exacerbation of symptoms
10.5% in PTSD symptoms
21.1% in Anxiety symptoms
9.2% in Depressive symptoms
Exacerbation of symptoms was not associated
with:
treatment drop out
poorer treatment outcome



Foa, Zoellner, Feeny, Hembree, & Alvarez (2002)
PTSD Severity and Exacerbation
(N = 76)
0
5
10
15
20
25
30
35
Pre-
Tx
Week
2
Week
4
Week
6
Week
8
Post-
Tx
No Exacerbation
Exacerbation
P
T
S
D

S
e
v
e
r
i
t
y

Symptom Worsening after Cognitive
Behavioral Treatments
PE PE/SIT PE/CR SIT WL
n = 75 n = 22 n = 46 n = 19 n = 39
Worsening
of PTSD

0

1 (5%)

0

0

3 (8%)
Worsening
of PTSD,
Dep. or Anx.

5 (7%)

6 (27%)

3 (7%)

2 (10%)

20 (51%)
Improve on
PTSD

71 (95%)

16 (73%)

43 (94%)

16 (84%)

14 (36%)
Worsening = Increase in symptoms by => 1 point
Improve = Decrease in symptoms by => 7 points
Dropout Rate by
Treatment Category
Treatment (25 studies) Total n % Dropout

EX Alone 330 20.6%
SIT or CT Alone 222 22.1%
EX plus CT or SIT 335 26.0%
EMDR 143 18.9%
Controls (Active and WL) 543 11.4%

No difference among active treatments:

2
(3, N= 1030) = 1.73, p = 0.631


Treating Patients with PTSD and AD PTSD:
Symptom Changes
Completers

0
5
10
15
20
25
30
35
Total Reexp Avoid Arousal
Pre No PE
Post - No PE
Pre - PE
Post - PE
Treating Patients with PTSD and AD
Percent Days Drinking
Completers

0
20
40
60
80
100
No PE PE
P
e
r
c
e
n
t
Pre No PE Post - No PE Pre - PE Post - PE
Treating Patients with PTSD and AD
Alcohol Cravings
Completers

0
5
10
15
20
25
No PE PE
P
A
C
S
Pre No PE Post - No PE Pre - PE Post - PE
Dissemination of Prolonged
Exposure
Dissemination Model I:
Training Community Clinicians



4- 5-day intensive training of community
therapists by Penn experts
Ongoing weekly supervision by Penn experts

Model I: PE in
Sexual Assault Survivors (n=123)
0
5
10
15
20
25
30
35
40
Pre
Post
Expert Community
P
S
S
-
I

T
o
t
a
l

Foa et al., in progress
Dissemination Model II:
Training the Supervisor



3-4 week training of community supervisor
at Penn
5-day intensive training of community
therapists by Penn expert with assistance
of community supervisor
Community supervisor directly supervises
community therapists and occasionally
consults with Penn expert

Dissemination of PE With Israeli Combat and
Terror Survivors (Tel Hashomer)
0
5
10
15
20
25
30
35
40
PSS-I BDI
Pre
Post
P
S
S
-
I

T
o
t
a
l

Nacasch et al., unpublished data
Dissemination of PE With Israeli
Terror Survivors (Jerusalem)
0
5
10
15
20
25
30
35
40
PDS BDI
Pre
Post
P
S
S
-
I

T
o
t
a
l

Friedman et al., unpublished data
PE for PTSD received the

2001 Exemplary Substance Abuse Prevention Program
Award from the

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services
Administration (SAMHSA)

and was selected as a Model Program for national
dissemination


Indications and Counterindications
for Exposure Treatment
Indications
Pervasive trauma-related anxiety and avoidance
Anxiety about the PTSD symptoms themselves
Fear of loss of control or going crazy
Counterindications
Psychosis, severe dissociative symptoms,
PTSD symptoms related to realistic guilt and
shame (e.g., murdering or raping during war)
1092
Emotional Processing During
Therapy Requires:
Accessing of the fear structure
(fear activation)
Availability of corrective
information
827
PTSD, Fear Expression, Anger and
Emotional Processing
Pre-treatment During Treatment Post-treatment
Percent
Improvement
(PTSD + Phobic +
General Anxiety)
PTSD
Symptoms
Phobic
Reaction
Anger
Facial
Fear
Expression
.67
.65
.44
.77
829
Mechanisms of Therapy
for PTSD
Promotion of emotional
engagement with the traumatic
memories
Modification of the erroneous
cognitions underlying PTSD

1118
Cognitive Modifications
During Exposure Therapy
Repeated reliving of the trauma promotes:
Habituation of anxiety (disconfirming anxiety
stays forever I will go crazy)
Discrimination between remembering and
re-encountering
Differentiation of the trauma from similar but
safe events (disconfirming the world is
extremely dangerous)
Association of PTSD symptoms with mastery
rather than incompetence (disconfirming I am
incompetent)
Organization of the trauma narratives
1037
Effect of Treatment on PTSD Related
Cognitions
1
2
3
4
5
6
7
Pre Post Follow-up
Self
World
Blame
Relationship between Changes in
Cognitions and in PTSD after Exposure
Therapy




PTCI

PSSI

Self

World

Self-
Blame

Total


Reexperiencing


.66


.46


.27


.59


Avoidance


.60


.37


.27


.53

Arousal


.50


.42


.30


.50


Total


.63


.46


.29


.58

All p < .05. Foa & Rauch, in press

Schematic Model of a Pathological
Trauma Memory
Scream
Confused Incompetent
Afraid
I -
Me
Uncontrollable
Rape Man
Shoot
Gun
Bald
Tall
Freeze
Say
I love
you
Alone Suburbs
Home
PTSD
Symptoms
Dangerous
Conclusions
Several CBT programs are highly effective for
PTSD:
Stress inoculation training
Cognitive therapy (more studies are needed)
PE has received the widest empirical evidence
Clinicians who are not experts in cognitive
behavior therapy can successfully learn PE in
short period of time



Early Psychological Interventions
Percentage of Victims with PTSD
0
20
40
60
80
100
1 Week 1 Month 2 Mos. 3 Mos. 6 Mos.
Rape Victims
Non-Sexual Assault
P
e
r
c
e
n
t
a
g
e

Assessment
Early Psychological Intervention
Crisis Interventions:
Critical Incident Stress Debriefing (CISD; e.g.
Mitchel, 1983)
Psychological Debriefing (PD; e.g. Dyzegzov, 1986)
Cognitive Behavioral Prevention Programs:
Prolonged Exposure (PE)
Prolonged Exposure + Stress Inoculation Training
(PE/SIT)

Psychological Debriefing (PD)
A single session intervention
Typically within 72 hours post-trauma
Delivered in a group or individual setting
Encourage a full narrative account of the
trauma (facts, cognitions, feelings)
Normalize emotional reactions
Prepare for later emotional reactions
Different Strategies for Early
Intervention
Very brief intervention for everyone
(e.g., 1-session debriefing, not effective as an
individual treatment)

Course of individual CBT for selected people at
high risk of chronic symptoms
(controlled trials: Foa, Bryant, Ehlers)
Impact of Event Scale (IES) in
Women After Miscarriage

0
5
10
15
20
25
30
One
week
4 months One
week
4 months
PD
Control
Lee et al., 1996
S
e
v
e
r
i
t
y

Intrusion Avoidance
IES and CAPS Scores in
MVA Victims

0
10
20
30
40
Pre 3 months Pre 3 months
PD
Control
Conlon et al., 1999
S
e
v
e
r
i
t
y

IES total CAPS
Bisson et al., 1997 Control < PD

Impact of Event Scale (IES)
in Burn Victims

0
5
10
15
20
25
Baseline 3 Month 13 Month
PD
Control
I
E
S

Percentage of PTSD Diagnosis
Bisson et al., 1997
Psych Debrief Control


PTSD 3 Mo 21% 15%

PTSD 13 Mo 26% 9% *


*Control < PD
1214
Hobbs et al., 1996
Impact of Event Scale (IES)
in MVA Victims

0
5
10
15
20
Baseline 4 Month
PD
Control
I
E
S

Effects of PD on MVA Victims with High
and Low Initial Impact of Event Scale

0
5
10
15
20
25
30
35
40
Baseline 4 Months 3 Years
PD/High Scorers Control/High Scorers
PD/Low Scorers Control/Low Scorers
I
E
S

Mayou et al., 2000
Conclusion
The data on the usefulness of PD are equivocal
with most studies failing to detect long term
benefits
One-session of PD, delivered within 48 hours
post-trauma, may impede natural recovery
Victims with severe initial reactions to the
trauma may be especially vulnerable to the
negative impact of PD


Possibly Misleading Assumptions in
Early Intervention Research

Going over trauma memories is always helpful
The earlier, the better
The earlier, the easier or cheaper

Why are 1-session debriefing and exposure
instructions not effective? Speculations
Wrong message: May make negative interpretation of
symptoms worse in the long-term
Too early: Very early exposure may interfere with
natural recovery processes
- automatic processes leading to fading memories
- natural rhythm of processing the event
intermittently (small doses, alternatingwith
resuming everyday life)
CBT Prevention Program
Four to five weekly sessions
Typically within 2-5 weeks post-trauma
Delivered in individual setting
Intervention Includes:
Discussions of normal reactions to assault
Breathing retraining
Deep muscle relaxation
Recounting the assault
Cognitive restructuring
Exposure in vivo assignments

CBT Vs Assessment Control
PTSD Symptom Severity
0
5
10
15
20
25
30
35
40
Initial
Assessment
2-Month
Assessment
BP AC
Foa et al., 1995
Bryant et al., 1998 PE/SIT < SC

Comparison of PE/SIT and SC
for MVA/Industrial Victims with ASD

0
10
20
30
40
50
60
Pre-Tx Post-Tx 6 Mo. FU
PE/SIT
SC
I
m
p
a
c
t

o
f

E
v
e
n
t


1220
Bryant et al., 1999
Comparison of PE, PE/SIT, and SC for
MVA / Assault Victims with ASD

0
10
20
30
40
50
60
Pre-Tx Post-Tx 6 Mo. FU
PE
PE/SIT
SC
I
m
p
a
c
t

o
f

E
v
e
n
t

PE, PE/SIT < SC
1218
Good End State Functioning
1
0
20
40
60
80
100
Post-treatment
6 Months
P
e
r
c
e
n
t

R
e
s
p
o
n
d
e
r
s


Foa et al., 2001
1
PSS-I < 15; BDI < 10; BAI < 10
BP AC SC

*
*
Conclusion
4-5 CBT sessions delivered at least two
weeks after the trauma accelerate recovery
Similar to treatment of chronic PTSD,
Prolonged Exposure alone is as effective as
more complex programs

1222-N
Assessment
Who should receive PE?
Individuals with chronic PTSD and related
psychopathology following all types of
trauma

This includes individuals with comorbid
problems (e.g., depression, other anxiety
disorders, substance abuse, Axis II
disorders)




Populations with whom PE has not yet
been studied
Individuals with PTSD who also have current:
Psychosis
Dissociative Identity Disorders (e.g., multiple
personality disorder)
Serious self-injurious behavior (e.g., cutting,
self-mutilating)
Imminent threat of suicidal or homicidal
behavior
PTSD related to intentionally harming another
person (e.g., murdering or raping)



Importance of Assessment
Conduct initial evaluation to:
Obtain detailed trauma history, determine
index trauma
Confirm diagnosis of PTSD (or at least
presence of significant symptoms), and that
PTSD is among the current primary
problems
Assess for presence of comorbid disorders




Assessment of Trauma-Related
Psychopathology
Assessment of PTSD symptoms
Interviewer measure
PTSD Symptom Scale (PSS-I)
Self-report measure
Posttraumatic Diagnostic Scale (PDS)



Trauma-Related Psychopathology
Assessment of other disorders and
symptoms
Interviewer measures
SCID-IV, MINI
Self-report measures
Beck Depression Inventory (BDI)
State-Trait Anxiety Inventory (STAI)
Posttraumatic Cognitions Inventory
(PTCI)


Assessment of Trauma-related Symptoms
During and Pre-Post Treatment
Intra-therapy assessment
PDS, BDI, PTCI every other session
Permits assessment of change during
therapy; helpful for tracking progress and
giving feedback to patient
Pre and Post-treatment assessment
Administer PSS-I interview to evaluate
changes in trauma-related symptoms
PTSD Symptom Scale Interview (PSS-I)
Flexible, semi-structured interview to allow
clinicians to make a diagnosis of PTSD
Estimates severity of the symptoms
When administering the PSSI, interviewers link
the symptoms to a single identified target or
index trauma
Typically this is the trauma identified by patient
as causing the most current distress, but the
PSSI may be used to assess symptoms relative
to any identifiable traumatic event




PSS-I
Interviewer should establish the time frame in
which symptoms are to be reported (and may
need to remind patient of this periodically)
PSS-I has been found valid for assessing
symptoms over the course of a month and
over a two-week period
The PSS-I could be used to assess symptoms
over longer and shorter periods of time, but
the validity of the interview under these
conditions has not been examined





PSS-I
In scoring each item on the PSS-I the
interviewer integrates all of the information
obtained during the interview
Final severity rating combines interviewers
impressions of the frequency and the intensity
with which the symptoms are experienced
PSS-I manual offers guidelines for making
such ratings for each symptom






Administration of PSS-I
Instructions:
I want to get a really good picture of how things
have been going for you in the past 2 weeks in
terms of trauma related difficulties. So, today is
(insert date)_, two weeks ago takes us back to
(insert date)_, this is the period of time that I will
focus on. Remember that throughout the
interview I will be asking about difficulties related
to the event that you identified as the most
distressing, the (repeat event). Do you have any
questions?