Psychotherapy for posttraumatic stress disorder

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Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Psychotherapy for posttraumatic stress disorder Author Barbara O Rothbaum, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Out 4, 2013. INTRODUCTION Posttraumatic stress disorder (PTSD) is a severe, often chronic and disabling disorder, which develops in some persons following exposure to a traumatic event involving actual or threatened injury to themselves or others. PTSD is characterized by intrusive thoughts, nightmares and flashbacks of past traumatic events, avoidance of reminders of trauma, hypervigilance, and sleep disturbance, all of which lead to considerable social, occupational, and interpersonal dysfunction. Treatments for PTSD include medications and psychotherapy [1-5]. Among the psychotherapies, clinical trials most strongly support the use of various types of trauma-focused cognitive behavioral therapy (CBT). CBT typically includes components of cognitive therapy, exposure, and coping skills training. This topic addresses psychotherapy for PTSD. The epidemiology, pathophysiology, clinical manifestations, diagnosis, and pharmacotherapy for PTSD are discussed separately. Dissociative aspects of PTSD are also discussed separately. The epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of acute stress disorder are also discussed separately. (See "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" and "Pharmacotherapy for posttraumatic stress disorder" and "Dissociative aspects of posttraumatic stress disorder: Epidemiology, clinical manifestations, assessment, and diagnosis" and "Acute stress disorder: Epidemiology, clinical manifestations, and diagnosis" and "Treatment of acute stress disorder".) COGNITIVE AND BEHAVIORAL THERAPIES Cognitive and behavioral therapies used to treat PTSD include exposure therapy, cognitive therapy, and various combinations of these modalities, often with other components. These modalities are sometimes described collectively as trauma-focused CBT if they specifically focus on the traumatic material. Cognitive approaches help patients to correct erroneous cognitions, while behavioral approaches aim to decrease symptoms through exposure to reminders of the traumatic event. Theory Prospective studies indicate that PTSD symptoms are almost universal in the immediate aftermath of trauma [6]. The majority of individuals have symptoms of re-experiencing, avoidance, and hyperarousal following a severely traumatic event. For most individuals these symptoms steadily resolve over time, while those who meet diagnostic criteria for PTSD continue to experience the symptoms. PTSD can thus be viewed as a failure of recovery caused in part by a failure of fear extinction following trauma [6,7]. Individuals with PTSD are hypothesized to develop cognitive and behavioral avoidance strategies in an attempt to avoid distressing emotional reactions. The presence of these extensive avoidance responses can interfere with the extinction of fear by limiting the amount of exposure to realistically safe reminders of the traumatic event. Basic science of conditioned fear Following the pairing of an aversive (unconditioned) stimulus (ie, the traumatic event) to a neutral (conditioned) stimulus (ie, stimuli associated with the traumatic event, including recollection of it), a conditioned fear response is established. If the neutral (conditioned) stimulus is then repeatedly presented in the absence of the aversive (unconditioned) stimulus (ie, exposure to stimuli associated with the traumatic event), a procedure known as extinction training, the result is an inhibition of the conditioned fear response to the neutral (conditioned) stimulus. Emotional processing theory holds that PTSD emerges due to the development of a fear network in memory that Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Psychotherapy for posttraumatic stress disorder

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elicits escape and avoidance behavior [8,9]. This theory proposes that effective therapy involves correcting the pathological elements of the fear memory, and that this corrective process is the essence of emotional processing. Two conditions have been proposed as necessary for emotional processing of the traumatic incident to occur. First, the fear memory must be activated. Second, new, corrective information must be provided that includes elements incompatible with the existing pathological components. Exposure procedures consist of helping the patient to confront trauma-related information in a therapeutic manner in order to activate the trauma memory. This activation provides an opportunity for the patient to integrate corrective information and modify pathological components of the trauma memory. Corrective information comes in the form of decreased fear responses while still in the presence of trauma reminders and lack of a recurrence of the trauma even when exposed to trauma reminders. Cognitive therapy The application of cognitive therapy to PTSD is based on the theory that the meanings that we impose on events contribute to emotional states, and therefore changing how we think about them can reduce PTSD symptoms and improve wellbeing. In the cognitive therapies, patients are assisted in thinking about the traumatic event and themselves more realistically. Socratic questioning is used to elicit information and challenge the patients maladaptive beliefs. An example can illustrate the use of cognitive therapy for PTSD. A woman raped by a home intruder wrongly blamed herself. The therapist led the woman through a series of questions about the event, establishing through her answers that her actions were reasonable, that she had not done anything to bring on the event and that she could not have prevented it. She was then asked, if her sister or her daughter behaved in the same way under the same circumstances, would she think they were to blame? Allowing the woman to generate the information in this discussion and then to reevaluate her perceptions was successful in changing her self-blaming beliefs. Efficacy Systematic reviews of cognitive therapy have come to different conclusions regarding effectiveness of cognitive therapy for PTSD, most positive but others finding inadequate evidence to support its efficacy [1,5]. These reviews use different definitions of what constitutes cognitive therapy and different inclusion criteria in selecting randomized trials. Exposure therapy Exposure therapy assists patients in confronting their feared memories and situations in a therapeutic manner. Reexperiencing the trauma through exposure allows it to be emotionally processed so that it can become less painful [8,9]. By repeatedly confronting traumatic memories or safe reminders of a traumatic experience, the individual can experience them safely, repeatedly if needed, until they no longer elicit such strong emotions and can see that they are not dangerous. (See 'Basic science of conditioned fear' above.) Many patients with PTSD mistakenly view remembering or processing the trauma as dangerous probably because it is distressing therefore they devote much effort to avoiding thinking about it. Reexperiencing the trauma through exposure serves to disconfirm this mistaken belief and allows them to experience decreasing levels of distress while still remembering what happened. Exposure therapy programs for PTSD typically incorporate the patients recall of the traumatic event and confrontation with real-life, safe situations that remind the patient of the event, called in vivo exposure. An example of real-life exposure would be the return to the scene of an accident by a person who experienced a motor vehicle accident or driving the same car. Traumatic events can be reexperienced through verbal description, writing, or other means. Following the imaginal or virtual reality exposure portion of a session, it is important for the therapist and the patient to discuss material that emerged during the exposure. The discussion, or processing, often centers on the patients emotional response to the exposure, for example, making explicit that by going through the memory three times, his distress decreased and he was able to remember more. This is also the time for the therapist to use Socratic questioning to challenge maladaptive thoughts the patient may hold, including beliefs related to guilt, blame, and responsibility. Exposure therapy programs often include homework exercises making use of imaginal exposure. In one common approach, a tape recording is made during a session of the patient describing the traumatic event aloud. Between sessions, the patient practices exposure at home, listening to the tape and further processing the traumatic

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Psychotherapy for posttraumatic stress disorder

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material. As an example, prolonged exposure therapy is a specific exposure therapy program developed for PTSD. It consists of breathing retraining, education about common reactions to trauma, imaginal exposure to the trauma memory, processing of the traumatic material, and in vivo exposure to trauma reminders [10]. Prolonged exposure is usually delivered in 9 to 12 weekly or twice weekly, 90 minute sessions, but can be shorter or longer based on the patient's needs and response. A table summarizes a typical course of prolonged exposure (table 1). A more recently developed method for providing exposure therapy is through virtual reality. Virtual reality exposure therapy uses a head-mounted computer display to present the PTSD patient with visual, auditory, tactile, and other sensory material that stimulate traumatic memories and affective response (picture 1) [11]. Virtual reality exposure has been used to treat PTSD among soldiers and veterans exposed to combat, survivors of catastrophic disasters, and in the aftermath of serious motor vehicle accidents [12-15]. Efficacy Exposure therapy is an effective treatment for PTSD. A systematic review identified 23 randomized trials of exposure therapy for PTSD [1]. The trials studied exposure either individually or combined with other interventions, typically in comparison to waiting list status or receiving usual care. Seven of them were judged to be without major methodologic limitations. All seven found that exposure therapy reduced PTSD symptoms. Overall, the degree of improvement was clinically significant. Evidence of efficacy has been demonstrated in populations experiencing multiple types of trauma, though the evidence in military veterans is less consistent than for other groups [1]. As an example, a randomized trial of 277 women with largely chronic PTSD resulting from a mix of traumatic events, including sexual assault and military combat, compared prolonged exposure to present-centered therapy, a supportive intervention [16]. The group receiving prolonged exposure experienced a greater reduction of PTSD symptoms (25 versus 17 points on the Clinician-Administered PTSD Scale) and was more likely to no longer meet diagnostic criteria for PTSD (41 versus 28 percent) compared to the group receiving present-centered therapy. Prolonged exposure continued to show greater benefit three months following treatment. There are no published randomized trials of virtual reality exposure (VRE) for PTSD. Case series and uncontrolled trials suggest that VRE may be an effective treatment [12,13,17-19]. Cognitive behavioral therapy CBT for PTSD includes both cognitive and behavioral components. It can also include additional approaches such as education and coping skills training. Specific programs of trauma-focused CBT vary in their composition. Trials have mostly tested individual CBT in PTSD, but a cognitive-behavioral couple therapy has been tested. (See 'Couples therapy' below.) As an example, cognitive processing therapy (CPT), a widely used therapy for PTSD, is principally a cognitive therapy, though it includes exposure to memories of the trauma. The exposure component consists of writing a detailed account of the trauma and reading it in the presence of the therapist and at home. CPT examines thoughts and feelings that emerge during the exposure exercise and provides training to challenge problematic beliefs about safety, trust, power, control, esteem, and intimacy. Individuals are taught to challenge faulty assumptions and self-statements and to modify maladaptive thoughts and over-generalized beliefs. CPT is used by the United States Veterans Administration to treat military veterans with PTSD. Efficacy In a meta-analysis of 14 randomized trials involving 658 patients with PTSD, trauma-focused CBT led to greater reduction in PTSD symptoms than usual care [20]. Despite the variability among CBT programs, studies comparing components individually or in different combinations have not found them to be consistently associated with differential outcomes [21-24]. As an example, 171 women with PTSD resulting from sexual assault were randomly assigned to either cognitive processing therapy, prolonged exposure, or a waiting-control group [25]. Treatment consisted of 12 sessions conducted twice weekly for 60 to 90 minutes. The therapies were equally effective in reducing PTSD symptoms, and both were substantially more effective than the control intervention. Couples therapy A trial tested a manual-based cognitive-behavioral conjoint therapy for individuals with PTSD and their partners [26]. Forty couples (both heterosexual and same-sex) were randomly assigned to receive the 15-session couples therapy or to a waitlist control. At the end of the trial, participants receiving the couples therapy experienced a greater reduction in PTSD symptom severity and more improvement in intimate relationship

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Psychotherapy for posttraumatic stress disorder

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satisfaction, compared to the control group. Treatment effects were maintained at three-month follow up. (See "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis", section on 'Course'.) Eye movement desensitization and reprocessing Eye movement desensitization and reprocessing (EMDR) is a form of CBT that incorporates saccadic eye movements during exposure [27]. The technique involves the patient's imagining a scene from the trauma, focusing on the accompanying cognition and arousal, while the therapist moves two fingers across the patient's visual field and instructs the patient to track the fingers. The sequence is repeated until anxiety decreases, at which point the patient is instructed to generate a more adaptive thought. An example of a thought initially associated with the traumatic image might include, Im going to die, while the more adaptive thought might end up as, I made it through. Its in the past. Efficacy Most, but not all, systematic reviews and meta-analyses have concluded that EMDR is an efficacious treatment for PTSD [1-4,20,28,29]. A metaanalysis of five randomized trials with a total of 162 patients found EMDR reduced PTSD symptoms more than usual care or waiting list status (SMD=-1.51, 95% CI, -1.87 to -1.15) [20]. Several major practice guidelines but not all have similarly concluded that EMDR is efficacious for PTSD [1,3,4,20]. Some researchers have suggested that exposure is the effective component of EMDR, and eye movements may not be necessary [1], but this hypothesis requires further study. Coping skills training A variety of behavioral techniques are used for PTSD by therapists of all types. In contrast to the therapies above, these interventions do not focus on the patient's trauma. Usually one of several components of a therapy, evidence is lacking to suggest that these techniques are helpful to treat PTSD by themselves. Role playing Assertiveness training Stress management Relaxation exercises Biofeedback, eg, using electromyography, heart rate, or respiration rate Teaching sleep hygiene Recommending exercise PSYCHODYNAMIC PSYCHOTHERAPY Psychodynamic therapy in the treatment of PTSD focuses on improving ego strength and capacity for interpersonal relatedness. Existing evidence is insufficient to evaluate the efficacy of psychodynamic therapy for PTSD [1,11,20]. Only one randomized trial has been conducted, lacking a non-treatment control, which found that patients receiving psychodynamic therapy showed rates of improvement similar to patients receiving hypnosis or systematic desensitization [11]. ECLECTIC PSYCHOTHERAPY In surveys of mental health clinicians in the US and Canada, a majority of clinicians (psychiatrists, psychologists, social workers, and others) identified themselves as practicing an eclectic or integrative form of psychotherapy [30-32]. Eclectic and integrative therapists draw concepts and techniques from a variety of different types of therapy, including dynamic, cognitive, and behavioral approaches [33]. These approaches vary by therapist, and their efficacy for PTSD has not been studied systematically. TREATMENT SELECTION Based on our clinical experience, we suggest first-line treatment of PTSD with an evidence based psychotherapy rather than medication. Evidence-based psychotherapies for PTSD include exposure therapy (eg, prolonged exposure), a combination of exposure and a cognitive therapy (eg, cognitive processing therapy), or with eye movement desensitization and reprocessing (EMDR). Trials have found these therapies to decrease PTSD symptoms compared to control conditions. There is an absence of clinical trials comparing these therapies to medication for PTSD. (See 'Exposure therapy' above and 'Cognitive behavioral therapy' above and 'Eye movement desensitization and reprocessing' above and "Pharmacotherapy for posttraumatic stress disorder", section on 'Comparing pharmacotherapy and psychotherapy'.) Patient presentation can be influential in selecting among types of psychotherapy. If the patient presents with extreme fear and avoidance, an exposure technique will likely be recommended. If the patient presents with extreme guilt and trust issues, cognitive therapy would be recommended. For highly avoidant patients who are difficult to engage, virtual reality exposure could be added where available, as its evocative nature renders it more

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Psychotherapy for posttraumatic stress disorder

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difficult to avoid. If the patient's clinical presentation does not emphasize one of these symptom clusters, then therapy availability and patient preference typically determine type of treatment. Among patients who have not improved after eight or more sessions with a particular approach, the clinician may want to consider another evidence-based treatment (eg, a shift from exposure therapy to cognitive therapy or to pharmacotherapy). A stepped, symptom-driven process of selecting among types of therapies for PTSD has not been tested in clinical trials. (See "Pharmacotherapy for posttraumatic stress disorder".) Cognitive and behavioral therapies require specific training to be applied to PTSD patients. Cognitive processing therapy and prolonged exposure have detailed therapist and patient manuals to guide treatment. The techniques are taught and practiced with experts in two to four day workshops. We recommend that clinicians receive supervision for one to two cases after training. Practitioners from all clinical disciplines (eg, psychologists, psychiatrists, social workers) have been trained in these therapies. COMPARING PSYCHOTHERAPY AND PSYCHOPHARMACOLOGY There are no randomized trials comparing psychotherapy to medication for PTSD. Patients with PTSD were included in an early intervention trial comparing CBT and an SSRI to prevent development of chronic PTSD [34], but results of the study did not distinguish between patients who had experienced PTSD symptoms for more than 30 days and those who did not. (See "Pharmacotherapy for posttraumatic stress disorder", section on 'Prevention'.) COMBINING PSYCHOTHERAPY AND PHARMACOTHERAPY Limited study has found little sustained difference in efficacy between combined CBT/SSRI treatment for PTSD and either intervention as monotherapy [35,36]. D-cycloserine has shown promise in preliminary studies in the augmentation of exposure therapy for several anxiety disorders [37]. Clinical trials of D-cycloserine for PTSD are underway. (See "Pharmacotherapy for posttraumatic stress disorder", section on 'Combining pharmacotherapy and psychotherapy'.) PREVENTION Clinical interventions to prevent the development of PTSD have been tested in individuals who have experienced a traumatic event as well as individuals who have developed an acute stress disorder following a traumatic event. (See "Treatment of acute stress disorder", section on 'Cognitive-behavioral therapy'.) Cognitive behavioral therapy Intervention in people with acute stress disorder with trauma-focused cognitive behavioral therapy (CBT) has been found to reduce the likelihood of PTSD development [38]. A meta-analysis of five randomized trials found that CBT reduced the proportion of patients meeting diagnostic criteria for PTSD at six months (relative risk = 0.56 [95% CI, 0.42 to 0.76]), with continued benefit seen at three years follow up. (See "Treatment of acute stress disorder".) A more recent randomized trial found that CBT administered to individuals meeting PTSD symptom criteria an average of a month following exposure to a traumatic event was more effective than a waitlist control in reducing PTSD at five months following treatment initiation but no more effective at nine months. Two hundred and forty two patients were randomized to receive prolonged exposure (PE), cognitive therapy or a wait list control, or escitalopram or pill placebo [34]. An equipoise-stratified randomization design allowed patients to refuse randomization to up to two treatment arms: 42.6 percent declined the escitalopram/placebo arms, 5 percent declined wait list, 3.3 percent declined cognitive therapy, and 1.2 percent declined prolonged exposure. Compared to patients in the wait list group, patients receiving PE (57.1 versus 21.6 percent) or cognitive therapy (58.7 versus 20.0 percent) were less likely to have PTSD after five months, but no difference between groups was seen at nine months. No difference was seen in the rate of PTSD in patients who received escitalopram compared to pill placebo (61.9 versus 55.6 percent). Psychological debriefing Despite extensive use following disasters and other traumatic events, psychological debriefing has not been found to be effective in preventing PTSD among individuals experiencing a traumatic event [39,40]. Also known as "critical incident stress debriefing", the intervention involves recollecting, articulating, and reworking of the traumatic event, typically in a group format. Meta-analyses of numerous clinical trials found no evidence of effectiveness for either the initial, single-session intervention [39] or for subsequent, multiple-session versions [40].

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INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topic (see "Patient information: Post-traumatic stress disorder (The Basics)") SUMMARY AND RECOMMENDATIONS Cognitive therapy for PTSD aims to help patients correct erroneous cognitions. Behavioral therapy for PTSD seeks to decrease symptoms through exposure. CBT includes both cognitive and behavioral components, often along with other components such as education and coping skills training. (See 'Cognitive behavioral therapy' above.) We recommend treatment of PTSD with exposure therapy (eg, prolonged exposure), with a program that combines exposure therapy and cognitive therapy (eg, cognitive processing therapy), or with eye movement desensitization and reprocessing (EMDR) (Grade 1A). Trials have found these types of psychotherapy to decrease PTSD symptoms compared to control conditions. (See 'Cognitive and behavioral therapies' above.) Based on our clinical experience, we suggest use of one of these psychotherapies over medication for first-line treatment of PTSD (Grade 2C). Comparative trials are lacking between psychotherapy and medication for PTSD. (See 'Cognitive and behavioral therapies' above and 'Eye movement desensitization and reprocessing' above.) For patients who have not improved after eight or more sessions with a particular psychotherapy, a shift to another evidence based psychotherapy or pharmacotherapy should be considered. A selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) can also be used if cognitive and behavioral psychotherapies are not available or if medication treatment is preferred. (See 'Cognitive and behavioral therapies' above and "Pharmacotherapy for posttraumatic stress disorder".) Virtual reality exposure may be useful for the treatment of PTSD, however, randomized trials have not been published. The immersive experience it can provide may be particularly useful for highly avoidant patients who are hard to engage. (See 'Exposure therapy' above.) Trauma-focused CBT for patients with acute stress disorder has been shown to be efficacious in reducing the likelihood of subsequent development of PTSD. (See "Treatment of acute stress disorder", section on 'Efficacy'.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14634 Version 11.0

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Psychotherapy for posttraumatic stress disorder

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GRAPHICS Prolonged exposure therapy session outline

Session
1

Session outline
Present an overview of the program (10-15 minutes) Discuss the treatment procedures that will be used in the program Explain that the focus of the program is on PTSD symptoms Collect information relevant to the trauma using the Trauma Interview (45 minutes) Introduce breathing retraining (10-15 minutes) Assign homework (5 minutes)

Review homework (5-10 minutes) Present agenda for the session (5 minutes) Educate client about PTSD symptoms by discussing common reactions to trauma (25-30 minutes) Discuss the rationale for exposure with emphasis on in vivo (10 minutes) Introduce the Subjective Units of Discomfort Scale (SUDS) (5 minutes) Construct in vivo hierarchy (20 minutes)

Review homework (10-15 minutes) Present agenda for the session (5 minutes) Present rationale for imaginal exposure (10-15 minutes) Conduct imaginal exposure on entire trauma memory (45-60 minutes) Process imaginal exposure (15-20 minutes) Assign homework (5 minutes)

Review homework (10-15 minutes) Present agenda for the session (5 minutes) Conduct imaginal exposure (45-60 minutes) Process imaginal exposure (15-20 minutes) Assign homework (5 minutes)

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Review homework (10 minutes) Present agenda for the session (3 minutes) Conduct imaginal exposure to "hot spots" progressively more as therapy advances (45-60 minutes) Process imaginal exposure (15-20 minutes) Discuss in vivo exposure (10-15 minutes) Assign homework (5 minutes)

10

Review homework (10 minutes) Present agenda for the session (3 minutes) Conduct imaginal exposure to entire trauma memory (20-30 minutes) Review progress and make suggestions for continued practice (30 minutes) Terminate therapy; saying good-bye (5 minutes)

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Psychotherapy for posttraumatic stress disorder

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Reproduced with permission from: Foa EB, Hembree E, Rothbaum BO. In: Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide, Oxford University Press, New York 2007. Copyright 2007 Oxford University Press.

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Virtual Iraq Humvee scenario from two user perspectives

Courtesy of Dr. Skip Rizzo.

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