The Phenomenology, Theory and Treatment of PTSD Edna B. Foa University of Pennsylvania Foa@ mail.med.upenn.edu

Outline of Lecture • What are common reactions to a traumatic event? Historical perspective and current view • Cognitive behavioral theories of PTSD. • Why do some people recover from trauma and others develop chronic PTSD ? • Exposure therapy for chronic PTSD: How effective is it? • What are the mechanisms underlying exposure therapy? • Is exposure therapy safe? • Dissemination of exposure therapy to CBT non-experts: Successes and challenges

Historical Perspective and Current View of Reactions to Traumatic Events

PTSD Across Recent History 1850-60’s

Crimean War

Neurasthenia

1860-1880’s

Railway accidents

Railway spine, spinal concussion

1860’s

US civil war

Soldier’s heart, irritable heart

1871

Da Costa’s syndrome

1910’s

WWI

Disordered action of the heart, effort syndrome, debility, neurocirculatory asthenia, shell shock, hysteria, combat exhaustion

1930’s-40’s

WWII

Combat fatigue, battle fatigue, war neurosis

1980

DSM-III

PTSD

1994

DSM-IV

Acute stress disorder

DSM IV Definition of a Traumatic Experience • A trauma is experiencing or witnessing an event that involves actual or perceived threat of death or injury to oneself or to another person and also • Feeling horrified, terrified or helpless during the event

Examples of Traumatic Experiences • Interpersonal violence • Physical assault, captivity, sexual (rape, incest), combat trauma, terrorism

• Accidents • Car accident, near drowning, work-place injury, serious burn

• Natural Disasters • Earthquake, tsunami, hurricane, typhoon, flooding, tornado

• Other events • Unexpected death of family member or close friend • Seeing another person seriously injured or dying

The Collapse of World Trade Center

The Destruction in New Orleans

Common Reactions During Trauma • Feeling horrified and terrified • Grief and deep sadness • Disbelief, shock, and helplessness

Expression of Horror Watching the WTC Collapsing

Expression of Grief Watching the WTC Collapsing

Expression of Hopelessness After Katrina

Reaction During and After the Great Fire of London, 1666 “A horrid malicious blood fire … so great was our fear, it was enough to put us out of our wits. Afterwards, new [sight] of a chimney fire some distance away put me into much fear and trouble.” Samuel Pepys

After the trauma, trauma reminders evoke reactions, such as fear, to situations which are similar to those experienced during the trauma

Common Reactions After War: Physioneurosis • Persistence of startle response • Proclivity to explosive outbursts • Fixation on the trauma • Constriction of personality • Atypical dream life Kardiner, 1941

DSM-IV Post Traumatic Stress Disorder Symptoms • A. Reexperiencing: Distressing thoughts and feelings about the trauma, nightmares, and flashbacks • B. Avoidance and numbing: avoiding traumarelated situations, thoughts and activities, diminished interest in activities, detachment from others, and restricted range of affect • C. Increased arousal: Sleep disturbances, outburst of anger, difficulty concentrating, hypervigilance

Prevalence of PTSD and Its Cost

PTSD as a Worldwide Problem Germany USA

1.3% 7.8%

Ethiopia

15.8%

Cambodia

28.4%

Algeria

37.4%

de Jong et al., 2001; Kessler et al, 1995; Perkonnig et al., 2000

Prevalence of Trauma and PTSD in Men and Women in the US 100

91.9

90

79.6

Percent (%)

80 70

60.7

60

Trauma PTSD No PTSD

51.2

50 40 30

20.4

20 10

8.1

0 Men

Women

Kessler 1995

Rate of PTSD is Influenced by the Nature of the Trauma Trauma

PTSD

60

Percent

50 40 30 20 10 0 Disaster

Accident

Assault

Molestation

Combat*

Rape

Kessler et al., 1995.

Rate of Recovery After Rape

94%

47% 42%

% with PTSD Symptoms

30 %

25%-15%

?

W

3m

9m 12m

Years

Data form Rothbaum et al., 1992

Impaired Quality of Life With PTSD PTSD

MDD

OCD

US Population

100

Mean SF-36 Score

75

50

25

0 Vitality

Social Function

SF-36 = 36-item short form health survey; lower score = more impairment.

Malik et al.,1999

Summary of Reactions to Trauma • The majority of trauma victims recover with time • PTSD represents a failure of natural recovery • If PTSD does not remit within a year, it will last a lifetime unless treated • PTSD is a highly distressing and debilitating disorder

Cognitive Behavioral Theories of Anxiety Disorders Including PTSD

Cognitive Behavioral Theories of Anxiety Disorders • Theories of classical and operant conditioning that emphasize learning of associations between stimuli and responses (conditioning theory) • Cognitive theories that emphasize the meaning ascribed to events • An assumption that anxiety disorders reflect deficits in coping with anxiety

Cognitive behavioral theories of PTSD are extensions of the above theories of anxiety disorders

Conditioning Theory of Anxiety Disorders • Stage 1 (Acquisition of Fear): Neutral stimuli (e.g., sound) become associated with fear eliciting stimuli (e.g., shock) and thus acquire the ability to elicit fear (classical conditioning) • Stage 2 (Acquisition of Avoidance): Fear is an aversive state, and organisms are motivated to escape or avoid such states. The behavior that is associated with fear reduction (e.g., avoidance, escape) is reinforced and tends to be repeated (instrumental conditioning). Mowrer (1939)

Conditioning Theory of PTSD: Acquisition of Fear (Stage 1) “…a phobia acquired under conditions of combat… provide[s] one of the simplest and most convincing illustrations of the learning of symptoms… [an] officer had not shown any abnormal fear of airplanes before being sent on a difficult mission…Many times during this mission the pilot was exposed to intensely fear-provoking stimuli, such the sight of planes going down and comrades being killed. It is known that intense fear-provoking stimuli of this kind act to reinforce fear response to other cues presented at the same time…” Dollar & Miller (1950)

Conditioning Theory of PTSD: Acquisition of Avoidance (Stage 2) "...Under traumatic conditions of combat the intense drive of fear was learned as a response to the airplane...this intense fear motivated responses of avoiding airplanes, and whenever any one of these responses was successful, it was reinforced by a reduction in the strength of the fear." Dollar & Miller (1950)

Cognitive Theory of Anxiety Disorders • Cognitive theory of emotional disorders assumes emotional reactions are produced by the interpretations of events rather than by the events themselves • Accordingly, different interpretations of the same event evoke different emotions. • Each emotion is associated with a particular type of interpretation • The characteristic interpretation associated with anxiety is perceived danger • Anxiety disorders occur when safe situations are interpreted as dangerous (dysfunctional interpretations)

Cognitive Theory of PTSD • Chronic PTSD symptoms are a consequence of the the victim's dysfunctional interpretations regarding: • Themselves (e.g., negative self esteem) • The traumatic event (e.g., “the trauma was my fault”) • Their PTSD symptoms (e.g., PTSD symptoms are sign of weakness) • People and the world (e.g., loss of trust, lack of safety) • Their future (e.g, “I will never be the same person again”)

Emotional Processing Theory of Anxiety Disorders • Emotional processing theory integrates concepts from conditioning theory and cognitive theory to provide a more comprehensive account of anxiety disorders. It proposes that: • Anxiety occurs when a cognitive fear structure is evoked • Each anxiety disorder is characterized by a specific pathological fear structure • Recovery occurs through modification of the pathological fear structure

Fear Structure • A fear structure is a program for escaping danger that includes representations of: • Feared stimuli, fear responses, and the associations among them (conditioning theory) • The meaning of stimuli and responses (cognitive theory)

Emotional Processing Theory of PTSD Invokes emotional processing theory of anxiety disorders to explain: • Early PTSD symptoms • Natural Recovery • Development, maintenance and treatment of PTSD

Emotional Processing Theory of PTSD: The Trauma Memory A trauma memory is a specific fear structure that includes representations of: • Stimuli present during the trauma • Physiological and behavioral responses that occurred during the trauma • Meanings associated with these stimuli and responses Associations among stimulus, response, and meaning representations may be realistic (functional) or unrealistic (dysfunctional)

Schematic Model of a Memory Shortly After the Rape Afraid

Uncontrollable

I - Me Say “I love you”

Rape Alone

Shoot

Suburbs Home

Scream Freeze

Confused

Man Tall Gun Bald

PTSD Symptoms

Incompetent

Dangerous

Summary: Characteristics of a Trauma Structure • Large number of stimuli • Excessive responses (PTSD symptoms) • Erroneous associations between stimuli and “danger” • Erroneous associations between responses and “incompetent” • Fragmented and poorly organized relationships among representations

Early PTSD Symptoms • Trauma reminders in daily life activate the trauma memory and the associated perception of “danger” and “ self incompetence”. • Activation of the trauma memory is reflected in reexperiencing symptoms and arousal • Re-experiencing and arousal motivate avoidance behavior.

Recovery Processes • Repeated activation of the trauma memory (emotional engagement) • Incorporation of corrective information about “world” and “self” • Activation and disconfirmation occur via confronting trauma reminders (e.g., thinking about, and contact with trauma reminders) • Corrective information consists of the absence of the anticipated harm

Schematic Model of a Recovered Rape Memory Afraid

Uncontrollable

I - Me Say “I love you”

Rape Alone

Man Shoot

Suburbs Home

Scream

Tall Gun Bald

Freeze

Confused

Incompetent

Dangerous

Psychological Mechanisms that Maintain PTSD Persistent cognitive and behavioral avoidance prevents change in the trauma memory by: • Limiting activation of the trauma memory • Limiting exposure to corrective information • Preventing organization of the memory

Schematic Model of a Rape Memory of Chronic PTSD Afraid

Uncontrollable

I - Me Say “I love you”

Rape Alone

Shoot

Suburbs Home

Scream Freeze

Confused

Man Tall Gun Bald

PTSD Symptoms

Incompetent

Dangerous

Dysfunctional, Negative Cognitions Underlying PTSD • The world is extremely dangerous • People are untrustworthy • No place is safe • I (the victim) am extremely incompetent • PTSD symptoms are a sign of weakness • Other people would have prevented the trauma

Negative Cognitions Severity

Severity of Negative Cognitions and PTSD 6

Negative Thoughts About Self Negative Thoughts About World Self-Blame

5 4 3 2 1 0 No Trauma

Trauma/ No PTSD

PTSD

Empirical Evidence for the Efficacy of Cognitive Behavioral Therapy

Cognitive-Behavioral Treatment • Exposure therapy • Cognitive therapy • Anxiety management or stress inoculation training

Exposure Therapy • Derived from conditioning and extinction theory • A set of techniques that are designed to reduce pathological anxiety through extinction by encouraging patients to confront their feared objects, situations, memories, and images in the absence of aversive consequence • Extinction includes severing the association between safe situations and the meaning of “danger”, so that these situations acquire the meaning of “safety” and are no longer feared

Cognitive Therapy • Derived from cognitive theory of emotional disorders • A set of techniques that help patients change their dysfunctional interpretations of safe situations (i.e., dysfunctional cognitions) by: • Identifying the dysfunctional cognitions • Challenging these cognitions • Replacing these cognitions with functional, realistic cognitions

Anxiety Management • Derived from the assumption that anxiety disorders reflect deficits in coping with anxiety • A set of techniques that helps patients manage their anxiety • Relaxation Training • Controlled Breathing • Positive Self-talk and Imagery • Social Skills Training • Distraction Techniques (e.g., thought stopping)

Similarities Among CBT Treatments for Chronic PTSD • All CBT treatments: • Promote safe confrontations with trauma memories and with situations that are trauma reminders • Modify the dysfunctional cognitions underlying PTSD

Published Randomized Studies on Exposure Therapy (EX) Only and EX Plus SIT or CR Chronic PTSD: • EX therapy only

15 studies

• Ex therapy + SIT and/or CR

16 studies

Acute PTSD or ASD • EX only

1 study

•

5 studies

Ex therapy + SIT and/or CR

The Advantages of Exposure Therapy • Exposure therapy, cognitive therapy, and anxiety management are all effective in treating chronic PTSD and associated psychopathology. What are the advantages of exposure therapy? • It has received the most empirical evidence with a wide range of traumas • It has been compared to several other CBT programs for PTSD • It has been successfully disseminated in community clinical settings with no special expertise with CBT

Exposure Therapy Programs • Two exposure therapy programs have been utilized in randomized controlled studies • Foa et al.’s “Prolonged Exposure” program (PE) • Marks et al.’s “Exposure Therapy” program (EX)

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

Prolonged Exposure (PE) Therapy for PTSD (cont’d) • Imaginal exposure: Patients recount the traumatic memories during sessions and listen to the taperecorded recounting between sessions • In vivo exposure: Patients confront safe traumarelated situations and objects between sessions, beginning with less fearful situations and moving on to more fearful ones

Exposure Therapy (EX) for PTSD • 8 or 10 weekly 90-minute sessions • 4 or 5 session of imaginal reliving of trauma during sessions and as homework • 4 or 5 sessions of in vivo exposure to anxiety provoking/avoided situations with homework

Both the PE and EX programs include intensive imaginal and in vivo exposure and therefore they are treated as equivalent programs

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

Comparison of PE, SIT, PE/SIT, and Waitlist With Female Assault Survivors P S S -I T o ta l

40

Pre Post FU

30 20 10 0 PE

SIT

PE+SIT

WL Foa et al., 1999

Effect Size of PTSD Symptoms

Post-Rx Effect Sizes* of PE vs SIT vs PE/SIT: PTSD PE SIT SIT/PE

2 1.5 1 0.5 0 TOTAL

Reexp.

Arousal

*Effect size compared to wait-list group at post-treatment

Avoidance Foa et al., 1999

Cognitive Processing Therapy (CPT) • Cognitive restructuring (Beck, Ellis) focusing on: Safety Trust Power

Esteem Intimacy

• Repeated writing of the traumatic experience • Treatment consists of 12 weekly sessions

Comparison of PE, CPT, and Waitlist With Female Assault Survivors

C A P S T o tal

90

Pre Post FU

60 30 0 PE PE = CPT

CPT

WL Resick et al., 2002

Comparison of CPT and Waitlist With Male and Female Veterans (ITT)

CAPS Total

Pre 80

Post

60

1-Mo FU

40 20 0 CPT

CPT < WL on re-experiencing and numbing

WL

Monson et al., 2005

PE Among 16 U.S. Veterans (PG, VN, OIF, WWII) Plus One EMT

PSS-SR Total

40 30

Pre Post

20 10 0

VN = Vietnam, n = 10; PG = Persian Gulf, n = 4; OIF = Operation Iraqi Freedom, n = 1; WWII = World War 2, n = 1; EMT = Emergency Medical Technician, n = 1.

Albrecht, unpublished

Comparison of CT, Self-help Booklet and Waitlist With MVA Pre Post

PDS Total

30

6-Mo FU 20 10 0 CT CT< Booklet = WL

Self-help Booklet

WL Ehlers et al., 2003

PDS

Comparison of CT and Waitlist With Adult Survivors of Terrorist attack 40

Pre

30

Post

20 10 0 CT Gillespie et al., 2002

Eye Movement Desensitization and Reprocessing (EMDR) • 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

Comparison of EX, EMDR, and Relaxation With Mixed Trauma Survivors C A P S T o tal

90 Pre Post FU

60 30 0 EX EX EMDR

6 Mo FU

Rothbaum et al., 2005

Comparison of Ex/CR, EMDR, and Waitlist With Mixed Gender/Trauma Sample SIP (SR) Total

60

Pre Post

40 20 0 EX+CR

EMDR

WL Power et al., 2002

EX/CR = EMDR

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., 2005

Comparison of PE, PE/CR, and Waitlist With Female Assault Survivors

P S S -I T o tal

40

Pre Post FU

30 20 10 0 PE

PE = PE/CR < WL

PE/CR

WL Foa et al., 2005

Effect Size of PTSD Symptoms

Within Group Effect Sizes PE PE/CR WL

3.5 3 2.5 2 1.5 1 0.5 0

PSS-I

BDI Foa et al., 2005

Comparison of PE and PE/CR for Female Survivors of Rape, Physical Assault, and Childhood Sexual Abuse P S S -I T o tal

40

Pre Post FU

30 20 10 0 Rape

Rape = PA + CSA

Physical Assault

CSA Foa et al., 2005

Comparison of PE and PE/CR With Survivors of Torture C A P S T o tal

100 Pre Post FU

80 60 40 20 0 PE PE = PE/CR

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* Perecent Responders

60 50 40 30 20 10 0

PE

SIT

PE/SIT

Foa et al., 1999

WL

PE

CR

PE/CR

R

Marks et al., 1998

* > 50% improved on PTSD; Standard Error of the Difference (based on SD and test-retest reliability; 7.5 points in the PSSI, 11.4 points on the CAPS)

Dropout Rate in Different Treatments Treatment (25 studies)

Total n

% Dropout

EX Alone SIT or CT Alone

330 222

20.6% 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: χ2 (3, N= 1030) = 1.73, p = 0.631 Hembree et al. 2003

Dissemination of Exposure Therapy to CBT Non-experts: Successes and Challenges

Dissemination Model I: Training Community Clinicians • 4- 5-day intensive training of community therapists by Penn experts • Ongoing weekly supervision which includes review of session videotape by Penn experts and feedback either in person or by email and telephone

PE Effectiveness for PE Experts and Community Therapists in Female Assault Survivors in Philadelphia 40 Pre

35

Post

PSS-I Total

30 25 20 15 10 5 0

Expert

Community Foa et al., 2005

Comparison of PE, PCT, and Waitlist With Female Veterans Pre Post 3-Mo FU 6-Mo FU

CAPS Total

80 60 40 20 0 PE PE