PTSD: Epidemiology, Course, Co-Morbidity and Treatments

Transcription

1 PTSD: Epidemiology, Course, Co-Morbidity and Treatments R. John Sutherland, PhD, LP HealthEast Care System Director for Psychology Training and Certified Nat l PE Trainer for PTSD University of Minnesota IBH Adjunct Professor Emiley Lamberger, MA, Psychology Intern and Tami Nelson, MA, Psychology Intern These slides were mostly created by Edna Foa, PhD Center for Treatment and Study of Anxiety University of Pennsylvania Outline of Lecture Why do some people recover from trauma while others develop chronic PTSD? Emotional processing theory of PTSD Evidence Based psychotherapy for PTSD Prolonged exposure (PE) therapy: Its practice and efficacy Effectiveness of PE in the hands of non-experts Widespread dissemination of PE in the US and around the world Prevalence of Trauma and PTSD Page 1

2 PTSD as a Worldwide Problem de Jong et al., 21; Kessler et al, 1995; Perkonnig et al., 2 Prevalence of PTSD in the USA General population Men: 2% current; 4% lifetime Women: 5% current; 1% lifetime Veteran populations Vietnam: 9% current; 19% lifetime Gulf War: 3-12% lifetime Afghanistan and Iraq: 15-17% current Lifetime Prevalence Of Trauma Men Women Any One Two or more Kessler et al., 2 Page 2

3 Percent (%) Prevalence of Trauma and PTSD in Men and Women in the US Men Women 79.6 Trauma PTSD No PTSD Kessler, 1995 Rate of PTSD is Influenced by the Nature of the Trauma Kessler et al., 1995 Responses to Mass Trauma Specific psychological problems 74% PTSD 64% Depression 37% Anxiety disorders 19% Non-specific distress 39% Health problems and concerns 25% Norris et al, 22 Page 3

4 The Cost and Burden of PTSD Psychiatric Comorbidity of PTSD PTSD has highest psychiatric comorbidity rates of any disorder but depression Among people with current PTSD as primary diagnosis: Any current anxiety or mood disorder (92%) Current Major Depression Disorder (69%) Lifetime alcohol abuse or dependence (31%) Current panic disorder (23%) Current obsessive compulsive disorder (23%) Brown et al., 21 Suicidality in the Past Year (n = 49) Percent (%) (n = 147) Amaya-Jackson et al., 1998 Page 4

5 Effects of PTSD on Medical Problems Adjusted Odds of Disease in PTSD vs. no PTSD Neurological 2.48* Vascular 1.88* Respiratory 1.43* Gastrointestinal 1.96* Metabolic/autoimmune 3.32* Musculoskeletal 2.52* Sareen et al., 25 Outpatient Health Service Utilization* Percent (%) PTSD symptoms (n = 49) Control (n = 147) 2 General Medical Mental Health * Past 6 months Amaya-Jackson et al, 1998 Economic Burden of PTSD Average work loss = 3.6 days/month Annual productivity loss = $ 3 billion Mean number of general medical visits in past year PTSD 5.3 Any anxiety disorder 4.4 Major depression 3.4 Kessler, 1999 Page 5

6 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: High psychiatric and medical comorbidity High unemployment High suicidalilty Processes of Natural Recovery: When Do People Succeed and When Do They Develop PTSD? Rate of Recovery After Rape 94% % with PTSD Symptoms 47% 42% 3 %? 25%-15% W 3m 9m 12m Years Rothbaum et al., 1992 Page 6

7 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 Fear (Emotional) Structure A fear (emotional) structure is a program for escaping danger It includes information about: The feared (emotional) stimuli The fear (emotional) responses The meaning of stimuli and responses The Trauma Memory A trauma memory is a specific fear structure that includes representations of: Stimuli present during and after the trauma Physiological and behavioral responses that occurred during and after the trauma Meanings associated with these stimuli and responses Associations among stimulus, response, and meaning representations may be realistic (functional) or unrealistic (dysfunctional) Page 7

8 Schematic Model of a Memory Shortly After the Rape Say I love you Afraid I - Me Freeze Rape Alone Suburbs Home Scream PTSD Symptoms Uncontrollable Shoot Gun Man Bald Tall Confused Incompetent Dangerous 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 Say I love you Afraid I - Me Freeze Alone Scream Uncontrollable Rape Man Suburbs Shoot Home Gun Bald Tall Confused Incompetent Dangerous Page 8

9 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 Severity of Negative Cognitions and PTSD Negative Cognitions Severity No Trauma Trauma/ No PTSD PTSD Negative Thoughts About Self Negative Thoughts About World Self-Blame Effective Psychotherapy For PTSD Page 9

10 Healing Interventions Individual counseling Support groups Psychodynamic psychotherapy (e.g., psychoanalysis) Hypnotherapy Short-term cognitive behavioral therapy (CBT) The only type of psychotherapy that was systematically studied and therefore is evidence-based Very effective in 8 to 15 sessions CBT Treatments for Chronic PTSD Promote safe confrontations (via exposure, discussions) with trauma reminders (memories, situations) Aim at modifying the dysfunctional cognitions underlying PTSD Cognitive-Behavioral Treatment Can Be Divided Into: Exposure Procedures Anxiety Management Procedures Cognitive therapy Page 1

11 Exposure Therapy A set of techniques that are designed to reduce pathological, dysfunctional anxiety and dysfunctional cognitions by encouraging patients to repeatedly confront safe, trauma-related feared objects, situations, memories, and images Exposure helps patients realized that their feared consequences do not occur and therefore are unrealistic 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 Page 11

12 What is an Evidence-Based Treatment A treatment that was found to be efficacious and effective in several well controlled studies The rules of well controlled studies contain at least the following conditions: The treatment was compared to a no-treatment control group or to other treatments Patients were randomly assigned to treatment groups The results of the treatment were assessed by a valid and reliable measure an independent evaluator The integrity of the treatment is checked Evidence-Based Treatments for PTSD Cognitive Behavior Therapy Prolonged exposure (PE) Stress inoculation training (SIT) Cognitive therapy (CPT) EMDR The Advantage of Prolonged Exposure PE has the largest number of studies supporting its efficacy and effectiveness PE has been found effective with the widest range of trauma populations PE has been studied in many independent centers in the US and around to world PE has been widely disseminated in the US and abroad; Its effectiveness in the hands of non-experts has been documented in several studies Page 12

13 Empirical Evidence for the Efficacy of Prolonged Exposure Prolonged Exposure for PTSD: Treatment Procedures Prolonged, imaginal exposure to the trauma memory (revisiting, recounting, and processing) Repeated in vivo exposure to safe situations that are avoided because of trauma-related fear Psychoeducation: Education about common reactions to trauma Treatment consists of an average of minute sessions Prolonged Exposure The two primary procedures are: Imaginal exposure: repeated revising, recounting, and processing of the traumatic event. The imaginal encounter enhances the processing of the trauma memories and helps attain a realistic perspective on the trauma In-vivo exposure: repeated confrontation with situations, activities, places that are avoided because they are trauma reminders. These encounters reduce trauma-related distress and enables the patient to realize that the avoided situations are not dangerous and that he/she is able to cope with distress Page 13

14 Published RCTs on Exposure Therapy (EX) Only and EX Plus SIT or CR Chronic PTSD: EX therapy only Ex therapy + SIT and/or CR 25 studies 29 studies Acute PTSD or ASD EX only Ex therapy + SIT and/or CR 4 study 6 studies 28 Institute of Medicine Report The committee finds that the evidence is sufficient to conclude the efficacy of exposure therapies in the treatment of PTSD (chapter 4, p. 97) Reference: Institute of Medicine (IOM): 28. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press. PE with Civilian Populations Page 14

15 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 PSS-I Total Pre Post FU PE SIT PE+SIT WL Foa et al., 1999 Post-Rx Effect Sizes* of PE vs SIT vs PE/SIT: PTSD Effect Size of PTSD Symptoms PE SIT SIT/PE TOTAL Reexp. Arousal Avoidance *Effect size compared to wait-list group at post-treatment Foa et al., 1999 Page 15

16 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 sessions for partial responders (< 7% improvement) Foa et al., 25 Comparison of PE, PE/CR, and Waitlist With Female Assault Survivors PSS-I Total Pre Post FU PE PE/CR WL Foa et al., 25 Within Group Effect Sizes 3.5 Effect Size of PTSD Symptoms PSS-I BDI PE PE/CR WL Foa et al., 25 Page 16

17 Comparison of PE and PE/CR for Female Survivors of Rape, Physical Assault, and Childhood Sexual Abuse PSS-I Total Pre Post FU Foa et al., 25 Rape Physical Assault CSA Rape = PA = CSA Rate of Improvement in Completers of 9 vs. 12 Sessions PDS Score Pre Post Sessions Foa et al., Sessions 9 Sessions Study with Men and Women Victims of Mixed Traumas Treatments: Exposure (PE) Cognitive Restructuring (CR) PE + CR Relaxation Training Treatment consisted of 1 sessions conducted over 16 weeks Marks et al., 1998 Page 17

18 Good End State Functioning Post Treatment* Perecent Responders PE SIT PE/SIT WL PE CR PE/CR R Foa et al., 1999 Marks et al., 1998 * > 5% improved on PTSD; <7 BDI; <35 STAI-S 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 Efficacy of 9 PE Sessions Versus 12 CPT Sessions Over 5 Years PTSD Severity (CAPS) CPT PE PreTx PostTx 3 MO 9 MO 5+ Yrs (Resick et al. 213) Page 18

19 Rate of Diagnosis of PTSD and MDD Pre-Treatment and at 5-year Follow-up in PE and CPT Percent Diagnosed Pretx PTSD LTFU Pretx MDD LTFU CPT PE Percent Relapse of PE and CPT Completers at 5-1 year Follow-up Relapse There was a trend for PE to have less relapse than CPT at LTFU, X 2 (1, N =75) 3.8, p =.57. PE is Effective With Complex PTSD Sufferers Page 19

20 PE is Effective With Complex PTSD Sufferers Comorbid Disorders: Depression Alcohol and Drug Dependent Borderline Personality Disordered High dissociation Traumatic Brain Injury patients Associated symptoms: Guilt Anger/Aggression Suicide gestures Poor health Effect of Personality Disorder (PD) on Reduction in PTSD (PSS-I) PTSD Severity Pre Post No PD PD F(1, 73) < 1, ns -- (no effect) Hembree et al., 24 Effect of Personality Disorder (PD) on Reduction in Depression (BDI) Depression Severity No PD PD Pre Post F(1, 71) < 1, ns -- (no effect) Hembree et al., 24 Page 2

21 The Efficacy of PE with Current, Past, or no Depression PTSD Severity Hagenaars, van Minnen, & Hoogduin, 21 PTSD Severity for Low and High State-Anger Patients Treated with PE, SIT, and PE/SIT 4 PSS-I Scores Pretreatment Posttreatment Assessment Low State-Anger High State-Anger Effect of PTSD Treatment on State-Anger for Low and High State-Anger Patients STAXI-State Anger Scores Pretreatment Posttreatment Assessment Low State-Anger High State-Anger Page 21

22 PE and Naltrexone for Patients Comorbid with PTSD and Alcohol Dependence Prolonged Exposure (PE) No Exposure (No-PE) Naltrexone (NAL) PE + NAL (N = 4) Completers = 23 No-PE + NAL (N = 42) Completers = 33 Placebo (PBO) PE + PBO (N = 42) Completers = 26 No-PE + PBO (N = 43) Completers = 29 PTSD Severity PTSD Severity Foa et al., 213 Study Week Percent Days Drinking %DD Naltx + PE Placebo + PE Naltx no PE Placebo No PE Foa et al., 213 Study Week Page 22

23 Alcohol Craving Percent of Patients with Minimal PTSD Symptoms (1 or less on the PSSI) at 6-Motnhs Follow-Up PE + NAL 7 PE + PLA 55 Counseling + NAL 44 Counseling + PLA 37 P =.2 The Efficacy of PE with High and Low Dissociators PTSD Severity Hagenaars, van Minnen, & Hoogduin, 21 Page 23

24 The Effects of PE Among Patients with PTSD and TBI 1 9 PCT PE PTSD severity Pre (n = 8) *Mid (n = 8) *Post (n = 8) Time, F (1.1, 6.8) = 16.6, p =.4; Time*Condition, F (1.1, 6.8) = 5.4, p =.5 Rauch, unpublished data The Effects of PE Among Patients with PTSD and mild TBI PCL Score NOTE: TBI status did not predict post-tx PCL, t(49) =.94, p =.35, or the slope of change over time, t(49)=.3, p =.7. Total ITT sample: t(49)=6.59, p <.1, d = 1.. mtbi: t(1) = 3.65, p <.5, d = Sripada et al., 213 Subject Flow 26 Randomized 17 Allocated to DBT+PE 1 Completed treatment 9 Allocated to DBT only 5 Completed treatment 5 Lost to Follow-up 3 Lost to Follow-up 17 Analyzed 9 Analyzed Harned, Korslund, & Linehan, under review Page 24

25 Suicidal and Non-Suicidal Self-Injury Clients in DBT+ PE were 1.4 to 2.4 times less likely to attempt suicide and 1.3 to 1.5 times less likely to self-injure than those in DBT only. Percentage (%) ITT = Intent to Treat TC = Treatment Completers Harned, Korslund, & Linehan, under review Dissemination of Exposure Therapy to CBT Non-experts: PE Effectiveness for PE Experts and Community Therapists in Female Assault Survivors in Philadelphia 4 PSS-I Total Expert Pre Post Community Foa et al., 25 Page 25

26 Comparison of PE and Treatment as Usual (TAU) in Israel PSS-I Total Pre Post FU PE TAU Nacasch et al., unpublished data Effects of Treatment as Usual (TAU) Versus PE on PTSD Severity in Japan CAPS Severity PE + TAU TAU Pre Txt Post Tx 1 Post Tx 2 Asukai et al., 28 PE Effectiveness Youth Survivors of the Earth Quack in China Pre Post PSS-I Total Adolescents Children Guo, unpublished data Page 26

27 Dissemination of PE in the VAs A Top Down Approach The PE dissemination throughout the VA was initiated by the central office of the Veterans Health Administration, reflecting strong institutional commitment to implement EBTs The goal was to create permanent capacity in the VA system to train and supervise their mental health practitioners in conducting PE PE Training Model Certified PE Clinicians Completed a 4-day interactive, experiential workshops followed by weekly individual supervision via session tapes on two cases Certified PE Consultants (supervisors) Were selected from among the certified clinicians. Participated in 5-day interactive, experiential workshops at the CTSA Certified PE Trainers ( Train-the-Trainer ) Were selected from among the certified consultants Participated in a 3-day interactive, experiential workshop Page 27

28 Numbers Trained in VAMC Total # Clinicians Trained: 154 Consultants: 7 Trainers: 16 88% of therapists completed 2 cases under supervision Is Consultation Important? Workshops are relatively low investment in a training program. Follow-up consultations, on the other hand, are very costly But In the absence of follow-up consultation (supervision), clinicians are less likely to use the treatment they had learned Consultation Increase Self-Efficacy in Conducting PE (Karlin et al., 211) Page 28

29 Conclusion Several CBT programs are effective for PTSD PE has received the most empirical evidence with the widest range of traumas Programs that include both in vivo and imaginal exposure produce excellent outcome and do not benefit from the addition of CR or SIT; the PE treatment is relatively simple and easy to teach PE ameliorates not only PTSD symptoms but also related symptoms e.g., depression, guilt, anger, and health problems PE is effective for PTSD comorbid with other disorders, e.g., depression, alcohol dependence, borderline personality, and Traumatic Brain Injury (TBI) PE can be successfully disseminated to community mental health systems in the US and around the world Page 29