Sheila A.M. Rauch, Ph.D., ABPP Atlanta VAMC Emory University School of Medicine Disclaimer: The views expressed in this presentation are solely those of the authors and do not reflect an endorsement by or the official policy of the U.S. Army, the U.S. Air Force, the Department of Defense, the Department of Veterans Affairs, the academic affiliations of the authors, or the U.S. Government.
Disclosures Dr. Rauch has received/s DOD and VA funding Dr. Rauch has received fees for consulting from the American Association for Suicidology and Massachusetts General Hospital
Preface Lecture is focused solely on neuroscience research and applications to PE True cutting edge with much of this still in development and not yet tested PE is robust and the best course is to follow the manual and stick to the theory behind PE DO the thing you are afraid of over and over and it gets easier If the patient is not fully responding Are you targeting the core fear? Are there avoidances that are interfering with the Doing?
Outline BRIEF review of PE and components Emotional Processing Theory and Inhibitory Learning What does this mean for PE? Recent advances from neuroscience of PTSD Safety Learning versus habituation of SUDS Application Future Directions
Efficacy of PE Prolonged Exposure (PE) has proven effectiveness (VA/DOD PTSD Treatment Guideline, 2010; Foa, Keane, Friedman, & Cohen, 2008) Reduces PTSD, general anxiety, depression. Reduces guilt and anger (Cahill, Rauch, Hembree, & Foa, 2003; Foa, et al., 2005). Effective in highly comorbid and complex patient populations with PTSD (i.e., van den Berg, et al., 2015; Yuen, et al, 2015) Flexible and used with complex patient presentations Components include imaginal exposure, in vivo exposure, and emotional processing
Proposed PE Mechanisms of Action Emotional Processing Theory Emotional Engagement Extinction/habituation Changes in negative thoughts about the self and world Inhibitory Learning/Safety Learning (Craske, et al., 2014) Expectancy violation Deepened extinction Occasional reinforced extinction Removal of safety signals Variability Retrieval cues Multiple contexts Affect labeling
Utilizing Imaginal Exposure Increase engagement with sensory probes Assist in organizing the memory and providing context by probing for thoughts and feelings Probing What are you thinking? What are you feeling? during the exposure Once engaged focus on contextual factors influencing behavior What is happening? What are you doing?
In Vivo Exposure Exposure to the people, places, and things that remind the patient of the target trauma Hierarchical Patient directed as homework Good tool to drive home self-assessment in the moment Focus on areas most important for this specific patient s function Critical to generalization of benefits
Emotional Processing Review of imaginal and in vivo exposures proceeds through: How it went New or changed elements either included or excluded What does that mean about you then? Now? Focus on success and progress Focus on previously discounted context Non-directive reflection of the patients own thoughts
Facilitating Processing Open ended questions Focus on reflection allows review of beliefs and opportunity to draw new conclusions Opening processing "How was the exposure for you today?" or "What was different about the exposure experience for you today?" Draws focus in on those previously unattended or discounted elements that are most salient for them following the imaginal exposure Bring focus to neglected elements that may be important Gently point out in processing "I noticed that you did not include.." This will assist the patient in not discounting information or content that needs to be included
Creating New Meaning- CONTEXT Reevaluation of actions in context Organizing chaos can allow new understanding Understand why and what this means about him/her then and now. Decide what if anything remains and what he/she wants to do to address it (i.e., making amends, etc.)
Emotional Engagement in PE EPT (Rauch & Foa, 2006) Better activation produces better outcome Inhibitory learning (Craske, et al., 2014) Memory activation is necessary Level of activation does not influence outcome Amygdala must be activated in order to effectively learn to inhibit fear (extinction; Milad et al, 2009; Nader et al, 2000). Strength of emotional memories is dependent on catecholamines and glucocorticoids in the brain (de Quervian et al, 2014). Memories can return to a malleable state where new information can become part of the memory (Schwabe et al, 2014) through the process of reconsolidation.
Cortisol in Response to Personal Trauma Script Greater cortisol response to a one minute personal trauma script prior to therapy predicted larger symptom reduction in PE but not PCT (Rauch et al, 2015). In PE, both pre-cortisol response and change in cognitions predict change in PTSD. In PCT, only change in cognitions predicted change in PTSD.
Enhancing Emotional Engagement Standard PE protocol suggests probes for emotion at points in the imaginal exposure (IE) where emotion is missing Prepatory cues prior to IE olfactory trauma cues auditory trauma cues Physical exercise before IE (Powers et al., 2015) Agents to activate sympathetic nervous system (i.e., yohimbine, etc; Wangelin, et al., 2013)
Extinction in PE Extinction refers to learning of a competing safe or inhibitory association for a previously learned fear association Reduction of fear expression when confronted with trauma-related stimuli (either the memory or things associated with the memory) Extinction learning includes contextualization specifically selecting appropriate responses to safety cues and threat cues based on context (Maren, et al., 2013)
Evidence: Extinction in PE (cont) Between session habituation more consistently related response than within-session habituation (Sripada & Rauch; Rauch, et al., 2004; dekleine et al, 2015). Improvement can occur without SUDs reduction (Bluett et al, 2014). Possible reasons for inconsistency Waxing and waning of distress based on specific session content. Processing always results in reduced distress
Evidence: Extinction in PE (cont) Trauma-potentiated startle increased and then decreased in PE responders, whereas low responders showed a relatively flat response profile (Robison- Andrew, et al, 2014) Medications that enhance extinction learning have had mixed results (Rothbaum et al, 2014; Difede, et al, 2014; dekliene et al, 2014)
Enhancing Extinction in PE Increase repetition or duration DCS- for people identified as slower extinguishers prior to treatment Cortisol administration or increase cortisol through other means such as exposure to novel environment or other specific stressor Increasing safety learning that is critical to extinction by making implicit learning explicit
Changes in Negative Thoughts in PE Reduction in negative thoughts about the self and world cognitions drives PTSD symptom change (Kumpula, et al., under review; Zalta, et al, 2014).
Thoughts and Biology HPA reactivity to traumatic cues prior to treatment predicts response to PTSD treatment (Rauch et al., 2015). Both changes in negative thoughts about the self and the level of HPA reactivity to trauma script uniquely predicted treatment reductions in PTSD (Rauch et al., 2015). Treatment related increased competence to handle negative affect: May reflect changes in the dedicated neurocircuitry, or more general modulation of the hypothalamic pituitary adrenal (HPA) axis, which in turn modulates brain circuitry
Enhancing Self Competence for Negative Affect in PE Increase focus on mastery in the trauma and now Change in meaning of trauma to focus on increased function Decrease focus on I wish or what if Enhanced learning of specific safety cues Focused generalization of exposure learning
Safety Learning/Inhibitory Learning Focus on tolerance of negative affect NOT reduction of SUDS Large part of exposure and emotional processing making the implicit learning explicit reflection on key meaning elements with the patient Processing is non-directive and focused on reflection Moving the patient from a memory context of personal incompetence to a more flexible or competent context Discriminate safety from threat Modulate attention accordingly Reduce overgeneralization Involves both top-down and bottom-up neurocircuitry.
Summary PE is a highly effective and well studied protocol Even beyond RCTs, thousands of clinicians with varied experience currently use the protocol with highly complex and comorbid patients with success. Advances in neuroscience provide direction for how to improve treatment through: Increasing speed of response Augmentation Novel treatments Additional research and neuroscience informed clinical practice can help us continue to improve efficacy and effectiveness of PE