Evidence-Based Treatment for Posttraumatic Stress Disorder: Preparing for the Aftermath of Disaster Shawn P. Cahill, Ph.D. Center for the Treatment and Study of Anxiety University of Pennsylvania
The Problem of PTSD
PTSD A. Exposure to a traumatic event as defined by both A1 and A2 A1. Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others A2. Person s response involves intense fear, helplessness, or horror
PTSD (cont d) B. Traumatic event is persistently reexeperienced (need at least one) (1) Recurrent, intrusive, distressing recollections; (2) recurrent distressing dreams; (3) flashbacks; (4) psychological distress in response to reminders; (5) cued physiological reactivity
PTSD (cont d) C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (need at least three) (1) Avoiding thoughts, feelings, conversations about trauma; (2) avoiding activities, people, places, or people that arouse recollections of the trauma; (3) Inability to recall important aspects of the trauma; (4) marked diminished interest or participation in significant activities; (5) feelings of detachment or estrangement from others; (6) restricted range of affect; (7) sense of foreshortened future
PTSD (cont d) D. Persistent symptoms of increased arousal (need at least two) (1) Difficulty falling or staying asleep; (2) irritability or outbursts of anger; (3) difficulty concentrating; (4) hypervigilance; (5) exaggerated startle response E. Duration of disturbance is more than one month Acute PTSD: Duration is 1-3 months Chronic PTSD: Duration is > 3 months Specify if delayed onset: Symptom onset > 6 months after trauma
Lifetime Prevalence Of Trauma 100 80 Percent (%) 60 40 20 0 Any One Multiple Men Women Kessler et al., 1995
Lifetime Prevalence Of PTSD In The Community 20 Percent (%) 15 10 5 0 Davidson et al., 1991 Breslau et al., 1991 Kessler et al., 1995
Prevalence of PTSD by Gender 20 Percent (%) 15 10 5 0 Breslau et al., 1991 Kessler et al., 1995 Resnick et al., 1993 Males Females
Rate of PTSD is Influenced by the Nature of the Trauma Percent (%) 60 50 40 30 20 10 0 Disaster Accident Assault Molestation Combat* Rape Trauma PTSD Kessler et al., 1995
Natural Recovery: Percentage of Victims with PTSD as a Function of Time 100 Percent (%) 80 60 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 Weekly Assessment Rape Victims Non-Sexual Assault
Percentage of Victims with PTSD 100 Percent (%) 80 60 40 20 0 1 Wk 1 Mo 2 Mos 3 Mos 6 Mos 12 Mos Assessment Rape Victims Non-Sexual Assault
Comorbidity with PTSD 100 80 60 40 20 0 MD Dys Phobia Soc Anx Agora GAD PD Alc Drug Any Kessler et al., 1995 Women Men
PTSD Impairs Quality of Life 60 Percent (%) 40 20 0 Not Working Fair or Poor Health Reduced Well Being Physical Limitations Violent Behavior Past Year PTSD Non-PTSD
Predictors of PTSD from Meta-analyses analyses Brewin et al. (2000) Trauma severity Lack of social support Additional life stress Gender Age at trauma Race Education Prior trauma Psychiatric history Ozer et al. (2003) Prior trauma Prior psychological adjustment Family history of psychopathology Perceived life threat Posttrauma social support Peritraumatic emotional response Peritraumatic dissociation
Epidemiology of 9/11
Immediate Reactions Random Digit Dialing, nationally representative sample of 560 US adults between 9/14/01 9/16/01 44% of adults had a substantial stress reaction Predictors: Gender (female), race/ethnicity (non-white), prior mental health problems (yes), distance from WTC (closer), hours of TV viewing (more) Schuster et al., 2001
Acute Reactions Random Digit Dialing, representative sample of 1008 adults living south of 110 th St. in Manhattan between 10/16/01 11/15/01 Overall incidence of PTSD was 7.5%, but 20% for those living south of Canal St. Predictors: Gender (female), race/ethnicity (non-white; trend), stressors in past year (more), social support (less), distance of residence from WTC (closer), directly witnessed events (yes), loss of possessions (yes), involved in rescue (yes), lost of job (yes), symptoms of panic attack during or soon after event (yes) Galea et al., 2002
Natural Recovery National probability sample of 3496 US adults received Web-based survey 9-23 days after 9/11; a random subsample of 1069 participants living outside of New York City received a second survey two months following 9/11, and third wave (n = 787) was completed six months after 9/11 17% of participants had PTSD two months after 9/11, compared to 5.8% at six months Predictors: Gender (female), prior physician diagnosis of depression or anxiety disorder (yes), marital status (separated), physical illness (yes), severity of exposure to attacks (greater severity), early disengagement of coping efforts (yes) Silver et al., 2002
Acute Stress Disorder and the Prediction of PTSD
Acute Stress Disorder (ASD) A. Exposure to a traumatic event B. Dissociation either while experiencing or after experiencing the trauma (at least 3): Numbing, detachment, absence of emotional responsiveness Reduction in awareness of one s surroundings Derealization Depersonalization Dissociative amnesia
ASD (cont d) C. Reexperiencing the trauma through recurrent images, thoughts, dreams, illusions, flashbacks, distress upon exposure to reminders of the trauma (at least 1) D. Marked avoidance of stimuli that arouse recollections of the trauma E. Marked symptoms of anxiety or increased arousal F. Disturbance causes functional impairment G. Lasts a minimum of 2 days, a maximum of 4 weeks, and occurs within 4 weeks of the trauma
Why ASD? Recognize posttraumatic stress can occur in the acute trauma phase Permit the prediction of chronic PTSD ASD emphasizes the role of dissociative symptoms in preventing long-term recovery
Criticisms of ASD Insufficient evidence to support the necessity of dissociation in the acute trauma response Questionable practice to introduce a new diagnosis in order to predict another diagnosis Concern about pathologizing transient stress reactions Questionable practice to distinguish between two diagnoses with similar symptom clusters on the basis of duration Harvey & Bryant, 2002
ASD and Chronic (6 mos) PTSD Following MVA 100 80 Percent 60 40 ASD Chronic PTSD 20 0 Harvey & Bryant, 1998 Full Partial None *Partial ASD and PTSD: Meets criteria for all but one symptom cluster
Relationship Between ASD and Chronic PTSD 100 75 Percent 50 25 Full PTSD Partial PTSD* None 0 Full ASD Partial ASD* None Harvey & Bryant, 1998 (Table 1) *Partial ASD and PTSD: Meets criteria for all but one symptom cluster
Relationship Between ASD and Acute PTSD in College Students Following 9/11 Percent Acute PTSD 45 40 35 30 25 20 15 10 5 0 ASD No ASD Blanchard et al., 2004
ASD, PTSD, and Depression in College Students Following 30 25 9/11 Percent 20 15 10 5 ASD PTSD Depression 0 Albany, NY Augusta, GA Fargo, ND Blanchard et al., 2004
Predictive Model of PTSD and Depression in College Students Following 9/11 Gender PTSD TV Hours Past Dep ASDS Knew Died Depression Traumas Blanchard et al., 2004 Rep Acts
Breakdown of Model: Step 1 PTSD ASDS Depression Rep Acts
Breakdown of Model: Step 2 Gender PTSD Past Dep ASDS Depression Traumas Rep Acts
Breakdown of Model: Step 3 Gender PTSD TV Hours Past Dep ASDS Knew Died Depression Traumas Rep Acts
Breakdown of Model: Step 4 Gender PTSD TV Hours Past Dep ASDS Knew Died Depression Traumas Rep Acts
Full Model Gender PTSD TV Hours Past Dep ASDS Knew Died Depression Traumas Rep Acts
Conclusion Reaction to mass trauma (e.g., 9/11) similar to reactions to other types of traumas (e.g., rape, physical assault, motor vehicle accidents, etc.) Effect of media exposure and reparative acts
Treatment of PTSD
Empirically Supported Treatments for PTSD Medications with FDA indication for PTSD Sertraline (Zoloft) Paroxetine (Paxil) Cognitive Behavior Therapy Exposure therapy Stress inoculation training (SIT) Cognitive therapy (CT, CR, CPT) Combinations of exposure therapy with SIT and/or CR EMDR
Efficacy of Sertraline Brady et al., 2000 Davidson et al., 2001 80 80 70 70 CAPS 60 50 CAPS 60 50 40 40 30 Wk 0 Wk 12 30 Wk 0 Wk 12 SERT PBO SERT PBO
Efficacy of Medication: Paroxetine: 80 70 Marshall et al., 2001 80 70 Tucker et al., 2001 CAPS 60 50 CAPS 60 50 40 40 30 Wk 0 Wk 12 30 Wk 0 Wk 12 PAROX (20 mg) PAROX (40 mg) PBO PAR PBO
Summary of Medication Substantial placebo effect Significant medication effect Residual symptoms Many non-responders Many responders still experience significant symptoms
Cognitive-Behavioral Treatment Anxiety management or stress inoculation training (SIT) Cognitive therapy (CT) Exposure therapy As primary intervention Combined with SIT or CT EMDR
Anxiety Management A set of techniques that helps patients manage their anxiety Relaxation training Controlled breathing Positive self-talk and guided imagery Social skills training Distraction techniques (e.g., thought stopping)
Cognitive Therapy A set of techniques that help patients change their negative, unrealistic cognitions by: Identifying dysfunctional, unrealistic, or unhelpful cognitions (thoughts and beliefs) Challenging these cognitions Replacing these cognitions with more functional, realistic, or helpful cognitions
Exposure Therapy A set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, prolonged exposure [PE], flooding).
EMDR Components 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
Efficacy of CBT for PTSD Marks et al., 1998 Foa et al., 1999 Percent Good End-State Functioning* 100 80 60 40 20 0 Post-Tx Percent Good End-State Functioning* 100 80 60 40 20 0 Post-Tx FU PE CR PE/CR RLX * > 50% decrease on PSS, BDI < 7, STAI-S < 35. PE SIT PE/SIT WL * PSS-I < 20, BDI < 10, STAI-S < 40.
Efficacy of CBT for PTSD (cont d) Resick et al., 2002 Rothbaum et al., 2005 Percent Good End- State Functioning* 100 80 60 40 20 0 Post- Tx 6-Mo FU 9-Mo FU Percent Good End- State Functioning* 100 80 60 40 20 0 Post-Tx 6- Mo FU PE CPT WL PE EMDR WAIT * PSS < 20, BDI < 10. * > 50% decrease on CAPS, BDI < 10, STAI-S < 40.
Efficacy of Treatment for PTSD: Change in PTSD Status Condition N Conditions Mean Completers 95% CI All active Tx 29 67.4% 61.3 73.2 CBT 4 56.2% 33.8 78.7 EMDR 7 64.9% 46.9 82.8 EX 8 68.0% 57.3 78.7 EX+CBT 7 70.0% 59.0 81.0 SC 7 39.3% 21.2 57.3 WL 8 16.4% -0.39 33.1 Bradley et al., 2005
Paroxetine vs. PE/SIT 80 70 CAPS 60 50 40 30 Wk 0 Wk 12 Frommberger et al., 2004 PAR PE/SIT
Efficacy of CBT: Summary Several forms of CBT are efficacious Treatment gains generally maintained at follow-up (up to 1 year) Some patients show only a partial or no response (residual symptoms) Combined treatments (PE/SIT, PE/CR) not significantly more efficacious than individual treatments (PE, SIT, CR) CBT and SSRI of comparable efficacy
Improving Treatment Outcome
Strategies for Improving Treatment Outcome Combining treatments within the same treatment modality (i.e., psychotherapy or medication) Adding SIT or CR to PE (hasn t worked very well) What about combining medications? Extending duration of treatment Combining treatments across treatment modalities SSRI+CBT (e.g., adding CBT to medication)
Sertraline Continuation CAPS 80 70 60 50 40 30 20 10 0 Open label continuation treatment Double blind acute treatment Wk 0 Wk 12 36 Londborg et al., 2001
Response Status after 36 Weeks of Sertraline 60 50 Percent 40 30 20 10 0 Wk 36 Continuous Responder Relapser Eventual Responder Non-Responder
Time to Discontinuation Due to Relapse or Clinical Deterioration Kaplan-Meier Survival Probability 1.0 0.8 0.6 0.4 0.2 0.0 0 4 8 12 16 20 24 28 Weeks Sertraline Placebo Davidson, Pearlstein et al., 2001.
Flexible Dosing of Psychotherapy Patients were randomly assigned to PE, PE/CR, or WL Patients who achieved a minimum 70% reduction on self-reported PTSD severity by session 8 terminated at session 9 Others were offered additional sessions, to a total of 12 Foa, Hembree, Cahill et al., 2005
Effects of PE and PE/CR in Female Assault Victims 40 PTSD Severity (PSS-I) 30 20 10 0 PE PE/CR WL Pre Post FU
Continuation Treatment for Partial Responders 40 PTSD Severity 30 20 10 0 Pre S-8 S-10 S-12 Post 9 Sessions 10-12 Sessions
Augmenting SSRI with CBT: Study Design Sertraline Only (10 weeks, open label treatment) Continue Sertraline Only (5 weeks) Sertraline + PE (5 week, 2x weekly therapy) Rothbaum, Cahill, Foa, Davidson et al. (2006)
Overall Effects of SSRI Augmentation by CBT 40 PTSD Severity 30 20 10 * * ns * ns 0 Wk 0 Wk 10 Wk 15 Assessment SERT SERT/PE
CBT Augmentation for Medication Partial-Responders 40 Phase I Remitters Phase I Partial-Responders PTSD Severity 30 20 10 * * ns * * * ns * * ns ns * 0 ns ns Wk 0 Wk 10 Wk 15 Wk 40 Wk 0 Wk 10 Wk 15 Wk 40 Assessment SERT SERT/PE
Improving Outcome: Summary Strategies that haven t worked: Combining separately effective CBT programs Strategies that have worked: Extending treatment (SSRI and CBT) Augmenting SSRI with CBT for SSRI partial responders Strategies to be investigated: Augmenting CBT with medication Augmenting SSRI with other medications
Treatment of ASD/ Prevention of Chronic PTSD
Treatment of ASD/Prevention of Chronic PTSD Little research on treatment of ASD, compared to amount of research on PTSD Extant research on CBT for ASD yields similar results/conclusions as research on CBT for PTSD
CBT for Treatment of ASD/ Prevention of PTSD (Bryant et al., 1998, 1999, 2003a, 2005) Percent PTSD 90 80 70 60 50 40 30 20 10 0 1 2 3 4 2 4 1 2 3 4 1 2 3 4 2 4 1 2 3 4 Post 6-Mo FU CBT PE CBT+Hyp 1 MVA, IA 3 MBI: MVA, NSA MVA: Natural recovery (6 mos post-trauma) 2 MVA, NSA 4 Civilian trauma SC
Use of Evidence-Based Treatments
Survey of Psychologists Attitudes and Utilization of Exposure Therapy for PTSD Survey of 852 psychologists from New Hampshire, Vermont, and Texas (San Antonio & Austin) 58 surveys were undeliverable 217 of 794 surveys were returned (27.3%), of which 10 provided no relevant data Final n = 207 Becker, Zayfert, & Anderson (2004)
Do Therapists Treat PTSD? # of PTSD Patients Treated < 11 11-25 26-50 51+ Missing data
Are Therapists Trained in the Use of Exposure Therapy? 100 Percent Trained 80 60 40 20 0 Im Exp for PTSD IV Exp for PTSD Exp for Anx DO
Do Therapists Use Exposure Therapy? The Effect of Training Main Sample (n = 207) No Training (n = 148) Trained (n = 59) Patients Treated with Imaginal Exposure None < 50% 50% - 80% > 80%
Reasons for not Using Imaginal Exposure to Treat PTSD Percent Endorsing 75 50 25 0 Limited Training Prefers "Individualized" Treatment Fear of Patient Decompensation All participants (n = 207) Trained in IE but not Using (n = 27)
Psychotropic Treatment of PTSD: Use Patterns PTSD Depr PTSD/Depr 60 50 % Usage 40 30 20 10 0 SSRI TRAZ ATYP NEUR BZ Mellman et al, 2003
Stepped Care Model of Intervention for Trauma Survivors CBT Experts Psychiatrists MA therapists Primary care Drs. Drs., nurses, teachers, social workers, clerics PRE-TRAUMA EDUCATION OF THE PUBLIC