Steven E. Bruce, Ph.D. PTSD Preven2on and Treatment Center for Trauma Recovery University of Missouri-St. Louis Washington University School of Medicine
Prevalence of Trauma and PTSD 70-90% of all individuals have experienced at least one trauma2c event in their life2mes. 1-2 Life2me prevalence of PTSD has been es2mated to range from 5% to 12%. 2 1 Soloman S., & Davidson, J. (1997). Trauma: Prevalence, Impairment, Service use, and cost. Journal of Clinical Psychiatry, 58 (suppl 9), 5-11. 2 Kessler et al., (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19. 10
So Who Gets PTSD? Exposure alone does not account for the rela2onship between distress and a trauma2c event. Type and Severity of trauma(s) # of traumas (>50% have experienced more than one trauma) Examine Vulnerability Those with high levels of symptoms early on are at risk of subsequent PTSD Failure to Recover gene2c, neural risk factors
Summary of Reactions to Trauma The majority of trauma vic2ms recover with 2me PTSD represents a failure of natural recovery AYer one year, PTSD does not remit without treatment
Three Year Course of PTSD CumulaEve Probability of Recovery Probability of Recovery 1 0.8 0.6 0.4 0.2 0.86 0.3 0 0 13 26 39 52 65 78 91 104* 117 130 143 156 Weeks Since Intake PTSD MDD-CDS
Resilience & Preven2on A preven2ve public health approach: 1. Reduce Trauma Exposure 2. Iden2ty popula2ons at risk via early detec2on and interven2on for those with severe distress or symptoms
PTSD and serotonin transporter gene profile (5-HTT) 80% 70% 60% 50% 40% 30% PTSD (n=100) No PTSD (n=197) 20% 10% 0% s/s s/l l/l Lee et al. Depression and Anxiety, 2005
Resilience & Preven2on A preven2ve public health approach: 1. Reduce Trauma Exposure 2. Iden2ty popula2ons at risk via early detec2on and interven2on for those with severe distress or symptoms 3. Treatment of PTSD
Treatment and Preven2on
Defini2on of Preven2on the act or prac2ce of keeping something from happening the act or prac2ce of stopping something bad from happening Preven2on should be conceptualized across the life span.
Inten2onal vs. Non-Inten2onal Traumas
Inten2onal vs. Non-Inten2onal Traumas 1-Month PTSD rate 35 30 25 20 15 10 5 0 Inten2onal Non-Inten2onal Inten2onal Non-Inten2onal Santiago et al (2013). A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events. Plos One, 11;8(4):e59236. doi: 10.1371/journal.pone.0059236
Treatment
PTSD: Best Prac2ces Psychotherapy Cogni2ve Processing Therapy (CPT) Prolonged Exposure (PE)
Cogni2ve Processing Therapy (CPT) Designed for sexual assault vic2ms Elicits memories of the event by having the pa2ent describe the trauma2c event in wri2ng and then read the account Uses cogni2ve therapy to correct maladap2ve cogni2ons with emphasis on themes of: safety, trust, power, esteem, and in2macy Resick & Schnicke (1992)
CPT RATIONALE PTSD symptoms are aeributed to a "stalling out" in the natural process of recovery What interferes with natural recovery from PTSD? Avoidance Behaviors reinforce Distorted beliefs about the trauma and become Generalized to current life situa2ons Cogni2ve-focused techniques are used to help pa2ents move past stuck points and progress toward recovery.
Stuck points SAFETY I cannot protect myself/others. The world is completely dangerous. TRUST Other people should not trust me. The government cannot be trusted. POWER/CONTROL I must control everything that happens to me. People in authority always abuse their power. ESTEEM I deserve to have bad things happen to me People are by nature evil and only out for themselves. INTIMACY I am unlovable because of the trauma. If I let other people get close to me, I'll get hurt again.
CPT Sessions Session 1: Introduc2on and Educa2on Session 2: The Meaning of the Event Session 3: Iden2fica2on of Thoughts and Feelings Session 4: Remembering the Trauma2c Event Session 5: Iden2fica2on of Stuck Points Session 6: Challenging Ques2ons Session 7: Paeerns of Problema2c Thinking Session 8: Safety Issues Session 9: Trust Issues Session 10: Power/Control Issues Session 11: Esteem Issues Session 12: In2macy Issues and Meaning of the Event
Comparison of 9 PE Sessions, 12 CPT Sessions, and Waitlist With Female Assault Survivors CAPS Total 90 60 30 Pre Post FU 0 PE CPT WL Resick et al., 2002 PE = CPT
CAPS Severity 80 70 60 50 40 30 20 10 0 Pre Post 3 mo 9 mo 5+ yr CPT PE CPT, N= 83 55 50 41 63 PE, N= 88 55 51 39 64
Amygdala ac2vity reduc2on ayer Treatment 0.03 0.02 0.01 0-0.01-0.02-0.03 PTSD Pre- Treatment Post- Treatment -21-0.04-0.05
1. Cognitive control, regulation of negative affect Yang et al (submitted to AJP). Cognitive Behavioral Therapy Improves Prefrontal Cortex Activity Across Major Depression and PTSD: Evidence from Longitudinal Task-based fmri
CPT normalized the baseline deficient amygdala FC within the IFG region among patients. CPT generates meaningful changes in brain activity by increasing the capacity for top-down emotion regulation Shou et al (2017). Cognitive behavioral therapy increases amygdala connectivity with the cognitive control network in both MDD and PTSD. Neuroimage: Clinical
CPT: Individual vs. Group Resick et al (2016). Effect of Group vs Individual Cognitive Processing Therapy in Active-Duty Military Seeking Treatment for Posttraumatic Stress Disorder A Randomized Clinical Trial. JAMA Psychiatry, E1-E9.
Conclusions: Treatment and Preven2on 1. Relapse Preven2on 2. Reduc2on of Trauma Exposure 3. Reduced likelihood of PTSD with new traumas 4. Scarr (1983) people make their own environments
It s never too late to prevent future trauma exposure and PTSD symptoms