Evidence-Based Treatment for Posttraumatic Stress Disorder: Preparing for the Aftermath of Disaster...
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Transcript of Evidence-Based Treatment for Posttraumatic Stress Disorder: Preparing for the Aftermath of Disaster...
Evidence-Based Treatment for Evidence-Based Treatment for Posttraumatic Stress Disorder: Posttraumatic Stress Disorder:
Preparing for the Aftermath Preparing for the Aftermath of Disasterof Disaster
Shawn P. Cahill, Ph.D.Center for the Treatment and
Study of Anxiety
University of Pennsylvania
The Problem of PTSDThe Problem of PTSD
PTSDPTSD• 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)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)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)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 Lifetime Prevalence Of TraumaTrauma
0
20
40
60
80
100
Any One Multiple
Per
cen
t (%
)
Men Women
Kessler et al., 1995
Lifetime Prevalence Of PTSD Lifetime Prevalence Of PTSD In The CommunityIn The Community
0
5
10
15
20
Davidson et al.,1991
Breslau et al., 1991 Kessler et al., 1995
Per
cen
t (%
)
Prevalence of PTSD by GenderPrevalence of PTSD by Gender
0
5
10
15
20
Breslau et al., 1991 Kessler et al., 1995 Resnick et al., 1993
Per
cen
t (%
)
Males Females
Rate of PTSD is Influenced by Rate of PTSD is Influenced by the Nature of the Traumathe Nature of the Trauma
0102030405060
Disas
ter
Accid
ent
Assau
lt
Mole
stat
ion
Combat
*
Rape
Per
cen
t (%
)
Trauma PTSD
Kessler et al., 1995
Natural Recovery:Percentage of Victims with PTSD
as a Function of Time
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12
Weekly Assessment
Per
cen
t (%
)
Rape Victims Non-Sexual Assault
Percentage of Victims with PTSD
0
20
40
60
80
100
1 Wk 1 Mo 2 Mos 3 Mos 6 Mos 12 Mos
Assessment
Per
cen
t (%
)
Rape Victims Non-Sexual Assault
Comorbidity with PTSDComorbidity with PTSD
0
20
40
60
80
100
MD
Dys
Phobia
Soc Anx
AgoraG
AD PDAlc
Drug
Any
Women MenKessler et al., 1995
PTSD Impairs Quality of Life
0
20
40
60
NotWorking
Fair or PoorHealth
ReducedWell Being
PhysicalLimitations
ViolentBehaviorPast Year
Per
cen
t (%
)
PTSD Non-PTSD
Predictors of PTSD from Predictors of PTSD from Meta-analysesMeta-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 9/11Epidemiology of 9/11
Immediate ReactionsImmediate 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 ReactionsAcute Reactions• Random Digit Dialing, representative sample of
1008 adults living south of 110th 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 RecoveryNatural 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 Acute Stress Disorder and the Prediction of PTSDPrediction of PTSD
Acute Stress Disorder (ASD)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)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?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 ASDCriticisms 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) ASD and Chronic (6 mos) PTSD Following MVAPTSD Following MVA
0
20
40
60
80
100
Full Partial None
Perc
ent
ASD
Chronic PTSD
Harvey & Bryant, 1998
*Partial ASD and PTSD: Meets criteria for all but one symptom cluster
Relationship Between ASD Relationship Between ASD and Chronic PTSDand Chronic PTSD
0
25
50
75
100
Full ASD Partial ASD* None
Perc
ent Full PTSD
Partial PTSD*
None
Harvey & Bryant, 1998 (Table 1)
*Partial ASD and PTSD: Meets criteria for all but one symptom cluster
Relationship Between ASD Relationship Between ASD and Acute PTSD in College and Acute PTSD in College
Students Following 9/11Students Following 9/11
0
5
10
15
20
25
30
35
40
45
ASD No ASD
Perc
ent A
cute
PTS
D
Blanchard et al., 2004
ASD, PTSD, and Depression ASD, PTSD, and Depression in College Students Following in College Students Following
9/119/11
0
5
10
15
20
25
30
Albany, NY Augusta, GA Fargo, ND
Perc
ent ASD
PTSD
Depression
Blanchard et al., 2004
Predictive Model of PTSD and Predictive Model of PTSD and Depression in College Depression in College
Students Following 9/11Students Following 9/11Gender
TV Hours
Past Dep
Knew Died
Traumas
ASDS
Rep Acts
PTSD
Depression
Blanchard et al., 2004
Breakdown of Model: Step 1Breakdown of Model: Step 1
ASDS
PTSD
Depression
Rep Acts
Breakdown of Model: Step 2Breakdown of Model: Step 2
ASDS
Rep Acts
PTSD
Depression
Gender
Past Dep
Traumas
Breakdown of Model: Step 3Breakdown of Model: Step 3
ASDS
Rep Acts
PTSD
Depression
Gender
Past Dep
Traumas
TV Hours
Knew Died
Breakdown of Model: Step 4Breakdown of Model: Step 4
ASDS
Rep Acts
PTSD
Depression
Gender
Past Dep
Traumas
TV Hours
Knew Died
Full ModelFull Model
Gender
TV Hours
Past Dep
Knew Died
Traumas
ASDS
Rep Acts
PTSD
Depression
ConclusionConclusion
• 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 PTSDTreatment of PTSD
Empirically Supported Empirically Supported Treatments for PTSDTreatments 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 SertralineEfficacy of SertralineBrady et al., 2000
30
40
50
60
70
80
Wk 0 Wk 12
CA
PS
SERT PBO
Davidson et al., 2001
30
40
50
60
70
80
Wk 0 Wk 12
CA
PS
SERT PBO
Efficacy of Medication: Efficacy of Medication: Paroxetine: Paroxetine:
Marshall et al., 2001
30
40
50
60
70
80
Wk 0 Wk 12
CA
PS
PAROX (20 mg)
PAROX (40 mg)
PBO
Tucker et al., 2001
30
40
50
60
70
80
Wk 0 Wk 12
CA
PS
PAR PBO
Summary of MedicationSummary of Medication
• Substantial placebo effect
• Significant medication effect
• Residual symptoms– Many non-responders– Many responders still experience significant
symptoms
• Anxiety management or stress inoculation training (SIT)
• Cognitive therapy (CT)
• Exposure therapy– As primary intervention
– Combined with SIT or CT
• EMDR
Cognitive-Behavioral TreatmentCognitive-Behavioral Treatment
Anxiety Management 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 TherapyCognitive 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
A set of techniques designed to help
patients confront their feared objects,
situations, memories, and images
(e.g., systematic desensitization,
prolonged exposure [PE], flooding).
Exposure TherapyExposure Therapy
• 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
EMDR ComponentsEMDR Components
Efficacy of CBT for PTSDEfficacy of CBT for PTSD
Marks et al., 1998
0
20
40
60
80
100
Post-TxPerc
en
t G
oo
d E
nd
-Sta
te
Fu
ncti
on
ing
*
PE CR PE/CR RLX
Foa et al., 1999
0
20
40
60
80
100
Post-Tx FUPerc
en
t G
oo
d E
nd
-Sta
te
Fu
ncti
on
ing
*
PE SIT PE/SIT WL
* > 50% decrease on PSS, BDI < 7, STAI-S < 35.
* PSS-I < 20, BDI < 10, STAI-S < 40.
Efficacy of CBT for PTSD (cont’d)Efficacy of CBT for PTSD (cont’d)
Resick et al., 2002
0
20
40
60
80
100
Post-Tx
6-MoFU
9-MoFU
Perc
en
t G
oo
d E
nd
-
Sta
te F
un
cti
on
ing
*
PE CPT WL
Rothbaum et al., 2005
0
20
40
60
80
100
Post-Tx 6- Mo FUP
erc
en
t G
oo
d E
nd
-S
tate
Fu
ncti
on
ing
*
PE EMDR WAIT
* PSS < 20, BDI < 10. * > 50% decrease on CAPS, BDI < 10, STAI-S < 40.
Efficacy of Treatment for PTSD: Efficacy of Treatment for PTSD: Change in PTSD StatusChange in PTSD Status
Condition NConditions MeanCompleters 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
30
40
50
60
70
80
Wk 0 Wk 12
CA
PS
PAR PE/SITFrommberger et al., 2004
Efficacy of CBT: SummaryEfficacy 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 OutcomeImproving Treatment Outcome
Strategies for Improving Strategies for Improving Treatment OutcomeTreatment 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 ContinuationSertraline Continuation
0
10
20
30
40
50
60
70
80
Wk 0 Wk 12 36
CA
PS
Double blind
acute
treatment
Open label
continuation
treatment
Londborg et al., 2001
Response Status after 36 Response Status after 36 Weeks of SertralineWeeks of Sertraline
0
10
20
30
40
50
60
Wk 36
Per
cen
t
Continuous Responder Eventual Responder
Relapser Non-Responder
Time to Discontinuation Due to Time to Discontinuation Due to Relapse or Clinical DeteriorationRelapse or Clinical Deterioration
Kap
lan
-Mei
er S
urv
ival
P
rob
abil
ity
Weeks
Davidson, Pearlstein et al., 2001.
0.0
0.2
0.4
0.6
0.8
1.0
0 4 8 12 16 20 24 28
Placebo
Sertraline
Flexible Dosing of Flexible Dosing of PsychotherapyPsychotherapy
• 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 Effects of PE and PE/CR in Female Assault VictimsFemale Assault Victims
0
10
20
30
40
PE PE/CR WL
PT
SD
Sev
erit
y (P
SS
-I)
Pre Post FU
Continuation Treatment for Continuation Treatment for Partial RespondersPartial Responders
0
10
20
30
40
Pre S-8 S-10 S-12 Post
PT
SD
Sev
erit
y
9 Sessions 10-12 Sessions
Augmenting SSRI with CBT: Augmenting SSRI with CBT: Study DesignStudy 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 Overall Effects of SSRI Augmentation by CBTAugmentation by CBT
0
10
20
30
40
Wk 0 Wk 10 Wk 15
Assessment
PT
SD
Sev
erit
y
SERT SERT/PE
*
*
ns
ns
*
CBT Augmentation for Medication CBT Augmentation for Medication Partial-RespondersPartial-Responders
0
10
20
30
40
Wk 0 Wk10
Wk15
Wk40
Wk 0 Wk10
Wk15
Wk40
Assessment
PT
SD
Sev
erit
y
SERT SERT/PE
*
*
* ns*
*
ns
ns
Phase I Remitters Phase I Partial-Responders
**
ns
ns
*ns
Improving Outcome: SummaryImproving 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/Treatment of ASD/Prevention of Chronic PTSDPrevention of Chronic PTSD
Treatment of ASD/Prevention Treatment of ASD/Prevention of Chronic PTSDof 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/CBT for Treatment of ASD/Prevention of PTSD Prevention of PTSD
(Bryant et al., 1998, 1999, 2003a, 2005)(Bryant et al., 1998, 1999, 2003a, 2005)
0
10
20
30
40
50
60
70
80
90
Post 6-Mo FU
Per
cen
t P
TS
D
CBT
PE
CBT+Hyp
SC
1 11 12 2 2 23 3 3 34 4 4 42 24 4
1 – MVA, IA 3 – MBI: MVA, NSA MVA: Natural recovery (6 mos post-trauma)2 – MVA, NSA 4 – Civilian trauma
Use of Evidence-Based Use of Evidence-Based Treatments Treatments
Survey of Psychologists’ Attitudes and Survey of Psychologists’ Attitudes and Utilization of Exposure Therapy for PTSD 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?Do Therapists Treat PTSD?
< 11
11 - 25
26 - 50
51+
Missing data
# of PTSD Patients Treated
Are Therapists Trained in the Are Therapists Trained in the Use of Exposure Therapy?Use of Exposure Therapy?
0
20
40
60
80
100
Im Exp for PTSD IV Exp for PTSD Exp for Anx DO
Per
cen
t T
rain
ed
Do Therapists Use Exposure Do Therapists Use Exposure Therapy? The Effect of TrainingTherapy? The Effect of Training
None
< 50%
50% -80%
> 80%
No Training (n = 148) Trained (n = 59)Patients Treated with Imaginal
Exposure
Main Sample (n = 207)
Reasons for not Using Imaginal Reasons for not Using Imaginal Exposure to Treat PTSDExposure to Treat PTSD
0
25
50
75
Limited Training Prefers"Individualized"
Treatment
Fear of PatientDecompensation
Per
cen
t E
nd
ors
ing
All participants (n = 207) Trained in IE but not Using (n = 27)
Psychotropic Treatment of Psychotropic Treatment of PTSD: Use PatternsPTSD: Use Patterns
0
10
20
30
40
50
60
SSRI TRAZ ATYP NEUR BZ
PTSD Depr PTSD/Depr
% U
sag
e
Mellman et al, 2003
Stepped Care Model of InterventionStepped Care Model of Intervention for Trauma Survivors for Trauma Survivors
PRE-TRAUMA EDUCATION OF THE PUBLIC
Drs., nurses, teachers,social workers, clerics
MA therapistsPrimary
care Drs.
CBT Experts
Psy-chiatrists