Terapie Cognitiva Comportamentala pentru Stresul Post-Traumatic

Prezentata de

Dr. Edna B. Foa

Centrul pentru Tratamentul si Studiul Anxietatii Universitatea din Pennsylvania

Diagnosticarea Stresului PostTraumatic

Definitia unei Traume :

Persoana a fost expusa la un eveniment traumatic in timpul caruia : 1)Persoana a experimentat, a fost martora, sau s-a confruntat cu un eveniment care implica moarte fizica , amenintarea cu moartea sau vatamare, sau o amenintare la adresa integritatii fizice a persoanei respective sau a altora. 2) Reactia persoanei respective a implicat o teama profunda , neajutorare, sau groaza. 502a

A. Retrairi
Amintiri tulburatoare despre trauma Vise tulburatoare legate de eveniment Retrairea experientei (flashuri) Tulburari psihologice in timpul expunerii la factori traumatici (interni sau externi) Reactivitate psihologica la factori care declanseaza evenimentul traumatic .

B. Indepartare persistenta de eveniment

Eforturi pentru a evita gandurile si sentimentele legate de trauma Eforturi pentru a evita activitati sau situatii legate de trauma Amnezie psihogenica Interes scazut pentru orice fel de activitati Detasare fata de cei din jur O gama restransa de trairi afective Scurtarea duratei de viata

Fobii specifice
Teama evidenta si persistenta fata de obiecte sau situatii clar delimitate ca fiind fobice Contactul cu stimulul fobic provoaca o reactie anxioasa imediata Situatia care declanseaza fobia este evitata

C. Surescitare crescuta
Tulburari ale somnului Iritabilitate sau izbucniri furioase Dificultate in concentrare Hipervigilenta Reactie exagerata de spaima

Generalizarea tulburarilor anxioase

Anxietate si ingrijorare excesiva Agitatie, dificultate in concentrare, iritabilitate, tensiune musculara sau tulburari ale somnului

Intrepatrunderea simptomelor Stresului Post-Traumatic cu alte tulburari anxioase

Unele simptome ale Stresului PostTraumatic se suprapun cu simptome fobice (ex. tulburari cauzate de evenimente traumatice si evitarea unor asemenea evenimente ) Alte simptome ale Stresului Post-Traumatic se suprapun cu tulburari anxioase generalizate (ex., hipervigilenta, surescitare crescuta)

Un aspect comun tuturor tulburarilor anxioase este :

Un conflict intre tendina de a trai permanent cu un sentiment de ameninare si tendina de a evita propagarea acelui sentiment (ex., sustragere comportamentala i cognitiva ) Ceea ce distinge Stresul Post-Traumatic este: Un proces bifazic de retraire si de negare cu reactii penduland intre indrazneala excesiva si amorteala (Horowitz, van der Kolk).

Cand eforturile de a reduce tulburarea printr-o evitare activa dau gre, se instaleaza o atitudine de izolare .

Criteriile de diagnosticare ale Stresului PostTraumatic

E. Durata tulburarii depaseste o luna F. Afectiunea cauzeaza tulburari semnificative sau deteriorari ale functiilor de baza .

Criterii de diagnostic pentru Stresul Post-Traumatic

Specificati daca: Acut: daca durata simptomelor este sub 3 luni

Cronic: daca durata simptomelor este de 3 luni sau mai mare Izbucnire Intarziata: daca durata simptomelor este de cel putin 6 luni dupa declansarea situatiei de stres

Raspandirea Traumei si Stresului Post-Traumatic la barbati si femei in Statele Unite

Kessler 1995

Rata Stresului Post-Traumatic este influentata de Natura Traumei

Kessler 1995

Cifrele curente ale Stresului PostTraumatic in randul indivizilor traumatizati

15.2% din 500,000 de veterani vietnamezi , adepti ai programului Veterans Truth Project 17.8% din 9.9 milioane femei victime ale molestarii fizice 13% din 13.8 milioane femei victime ale abuzului sexual 3.4% din femei victime ale unor traume non-criminale

Morbiditate crescuta la Stresul Post-Traumatic

% Rates PTSD Non PTSD Psihiatrica Tulburare Anxioasa Generalizata (GAD) 53 Depresie Majora 30 Somatizare 12 Abuz / Dependenta de droguri 9 Medicala Astm pulmonar 13 Ulcer pepsic 13 Hipertensiune 31

4 0 1 5 4 18
Davidson 1991

Riscul tentativelor de sinucidere in randul pacientilor cu tulburari anxioase

7 6

Proportia Sanselor

5 4 3 2 1 0

Pacientii cu PTSD sunt de 6 ori mai predispusi la sinucidere decat la autocontrol

PTSD

GAD

Panica

19% din pacientii cu PTSD vor incerca sa se sinucida

Anxietate Sociala

Orice Anxietate
Kessler et al. 1999

Stresul Post-Traumatic afecteaza calitatea vietii

PTSD
50

Non-PTSD 49.2 39.5 33.2 26.5 16.0

Procent

35.5
25

22.6 9.8 4.3 9.9

Nu Sanatate Bunastare muncesc satisfacatoare redusa sau subreda

Limitare Comportare fizica violenta anul trecut

Zatzick DF et al.

Implicatiile economice ale Stresului Post-Traumatic

Diminuarea activitatii in medie= 3.6 zile/luna Pierderi anuale ale productivitatii = $ 3 miliarde Solicitare servicii medicale : cifra medie a vizitelor medicale generale pe anul trecut PTSD 5.3

Orice tulburare anxioasa 4.4 Depresie majora

Kessler., 2000; Kessler et al., 1999

3.4

Calitate necorespunzatoare a vietii datorita Stresului Post-Traumatic

Short Survey

Score

Calitate scazuta a vietii datorata Stresului Post-Traumatic

Short Survey

Malik et al. J Trauma Stress. 1999

Consecinte economice datorate Stresului Post-Traumatic

Pierderi ale productivitatii anuale = $3 miliarde (SUA) Diminuarea activitatii in medie = 3.6 zile/luna Nivelul productivitatii scazute datorat Stresului Post-Traumatic este similar cu cel al depresiei
1. Kessler and Frank, Psychol Med: 1997: 27: 861. 2. Breslau et al, Arch Gen Psychiatry, 1998: 55:626. 3. Solomon and Davidson, J Clin Psychiatry, 1997: 58: suppl 9: 5.

Sumar al reactiilor la trauma

Majoritatea victimelor unei traume se refac in timp Stresul Post-Traumatic reprezinta o esuare a procesului de recuperare pe cai naturale Dupa un an , Stresul Post-Traumatic nu se diminueaza fara tratament Stresul Post-Traumatic este o afectiune care tulbura profund si debiliteaza

Prezentarea in teorie a Stresului Post-Traumatic

Procentajul victimelor afectate de Stresul Post-Traumatic

Percentage

Procentajul victimelor afectate de Stresul Post-Traumatic

Percentage 1 Wk

1 Month

2 Mos. 3 Mos. 6 Mos. Assessment

12 Mos.

Teoria Procesului Emotional declansat de Stresul Post-Traumatic

Recurge la termeni psihologici pentru a explica : Primele simptome ale Stresului PostTraumatic Recuperarea pe cai naturale Aparitia, dezvoltarea si tratarea Stresului Post-Traumatic

Structura sentimentului de teama

Aceasta structura este un program care ajuta la inlaturarea senzatiei de pericol Include informatii despre : Stimulii care induc frica Reactiile declansate de frica Conceptele de stimuli si reactii

Memoria Traumei
Este o structura specifica a sentimentului de teama care include reprezentari ale: Stimulilor declansati in timpul traumei Reactiilor psihologice si comportamentale care au avut loc in timpul traumei Explicatiilor asociate cu acesti stimuli si aceste reactii Asociatiile create si explicatiile acestor fenomene pot fi realistice sau nerealistice

Model schematic al unei Memorii la scurt timp dupa Viol

Teama Eu
Spune Te iubesc Nu misca Simptomele Stresului Post-Traumatic Singura Tipat

Necontrolat Viol
Suburbii Acasa

Barbat
Foc de arma Inalt Chel Chel

Arma

Confuza

Neputina

Periculos

Caracteristicile structurii unei traume recente

Un numar mare de stimuli Reactii exagerate (simptome ale Stresului Post-Traumatic) Asociatii gresite intre stimuli si sentimentul de pericol Asociatii gresite intre reactii si sentimentul de neputinta Legaturi fragmentare si ineficient organizate intre reprezentarile diferitelor senzatii

Primele simptome ale Stresului PostTraumatic

Factorii traumatici care actioneaza in viata cotidiana declanseaza memoria traumei si senzatiile asociate de pericolsi de neputinta Activarea memoriei traumei este reflectata in retrairea simptomelor si surescitare Retrairea simptomelor si surescitarea motiveaza atitudinea de evitare a amintirilor traumatice

Procesul de recuperare
Activarea constanta a memoriei traumatice (implicare emotionala ) Inducerea unor informatii corective asupra conceptelor de lume inconjuratoare si viata interioara Activarea si rectificarea unor anumite informatii au loc prin confruntarea cu respectivii factori traumatici (ex. Inducerea unor ganduri care sa faca legatura cu factorii traumatici ) Informatiile corective constau in absenta sentimentului negativ anticipat de pacient

Modelul schematic al unei memorii refacute dupa un viol

Teama Eu
SpuneTe iubesc Nu misca Singura Tipat

Necontrolat Viol
Suburbii

Foc de arma

Barbat Arma Inalt Chel

Acasa

Confuza

Neputinta

Periculos

Calculul apogeului reactiilor si al psihopatologiei persistente

Severity

Depression

PTSD

Modele de recuperare: Exemple de cazuri

45 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12

PTSD-Severity

immediate delayed

Time (in weeks)

Caracteristici ale relatarilor despre Viol povestite de pacienti

Fragmentare (e.g. repetitii , pauze in vorbire ) Incoerenta in spatiu si timp (ex.Din senin era langa pat) Ganduri ce reflecta confuzie (ex. Nu pot sa cred ca se intampla asta Ce se va intampla in continuare?)

Gradul de intelegere al relatarilor despre traume si aspecte psihopatologice

2.0 1.5 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2 -1 Trauma Pathology

R = -.72

Reading Level

Corelatii intre exprimarea relatarilor si aspectele psihopatologice

2 Weeks Grade Level 12 Weeks Grade Level

BDI STAI-S PSS

-0.55 -0.80* -0.35

-0.11 -0.46 -0.60*

* p < 0.05

Stres Post-Traumatic Cronic

Excluderea persistenta de tip cognitiv si comportamental a factorilor traumatici previne orice modificare a memoriei traumei prin : Limitarea activarii memoriei traumei Limitarea expunerii la informatii corective Limitarea exprimarii memoriei traumei impiedicand astfel organizarea memoriei

Model schematic al memorarii patologice a unui Viol ( Stres PostTraumatic Cronic )

Teama Eu
Spune Te iubesc Nu Misca Singura Tipat Simptomele Stresului Post-Traumatic

Viol
Suburbii Acasa

Necontrolat Barbat Foc de arma Inalt Arma

Chel

Confuza

Neputinta

Periculos

Perceptii eronate privind Stresul PostTraumatic

Lumea este extrem de periculoasa Oamenii nu sunt de incredere Nici un loc nu este sigur Sunt foarte neputincios Simptomele Stresului Post-Traumatic sunt un semn de slabiciune Alte persoane ar fi putut preveni trauma

Post-Traumatic Cognition Inventory Scale Scores by Participant Group

Median Scaled Scores

Suport empiric pentru Teoria Procesarii Emotionale : Factori estimativi ai unei recuperari lente
Perceptii negative despre propria persoana si lumea inconjuratoare O interpretare negativa a simptomelor Stresului Post-Traumatic (incompetenta propriei persoane) O evaluare negativa a reactiilor altor persoane (lumea este periculoasa) Excluderea factorilor care declanseaza trauma ( impiedica rectificarea perceptiilor negative despre propria persoana si lumea inconjuratoare

Suport Empiric pentru Teoria Pocesarii Emotionale: Factori estimativi ai unei recuperari lente (continuare)
Suprimarea primelor simptome; inlaturarea gandurilor (excludere de tip cognitiv) Reflectie constanta (sustragere de la o procesare corecta a memoriei si de la rectificarea perceptiilor negative ) Disociere permanenta (lipsa implicarii emotionale) O elaborare si organizare ineficienta a relatarii despre trauma

Factori care incurajeaza perceptii negative si evitarea contactului cu evenimentul traumatic

Evitarea contactului cu evenimentul traumatic este motivata de o surescitare intensa care in schimb este influentata de: Severitatea traumei Deficit biologic in dozarea senzatiei de surescitare (ex., cortizon scazut?) Perceptiile negative sunt influentate de : Istoricul medical traumatic anterior Prezenta unor cazuri psihopatologice in cadrul familiei Lipsa ajutorului social sau ineficienta acestuia

Factori care determina dezvoltarea Stresului Post-Traumatic

Factori pre-traumatici Idei despre propria persoana Idei despre lumea inconjuratoare Memorarea evenimentului traumatic Memorarea unor evenimente posttraumatice

Recuperarea este impiedicata

Atunci cand trauma distorsioneaza perceptia asupra propriei persoane ca fiind foarte capabila si cea despre lume ca fiind sigura SAU Cand trauma subliniaza o imagine a propriei persoane ca fiind neputincioasa si a lumii ca fiind extrem de periculoasa

Trauma Records
Fragmented memory of the trauma is constructed This memory record includes representations of: intense fear and confusion body state (e.g., physical pain, touch of penetrator, struggle) thoughts and ideas which reflect confusion (e.g., I cant believe it is happening) strong images of specific details

Post Trauma Events That Impede Emotional Processing

Lasting emotional disturbances (e.g., nightmares, sleeplessness) Disruption in daily functioning Reactions of others (e.g., get on with your life)

Schematic Model of Emotional Processing

Pre-Trauma Records Traumatic Event Trauma Records Self Schema Post-Trauma Events World Schema

Schemas

Post-Trauma Records

Recovery

Pathology

Schematic Model of Recovery Following Trauma

Pre-Trauma Records
Balanced, flexible premises about self and world

Traumatic Event Trauma Records

It was not my fault; I handled it as well as could be expected.

Schemas Self Schema

am mostly competent.

Post-Trauma Events World Schema

The world is mostly safe.

Post-Trauma Records
Some but not all people can be trusted; PTSD symptoms are normal and temporary.

Recovery

Schematic Model of Developing Pathology Following Trauma

Pre-Trauma Records
Rigid premises about self and world

Traumatic Event Trauma Records

It is my fault.

Schemas Self Schema

I am entirely incompetent.

Post-Trauma Events World Schema

The world is entirely dangerous.

Post-Trauma Records
People are untrustworthy; PTSD symptoms are dangerous.

Pathology

1038

Treatment of Chronic PTSD

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

Exposure Therapy
A set of techniques designed to help patients confront their feared objects, situations, memories, and images (e.g., systematic desensitization, flooding).

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

PTSD Treatments: Review

Exposure Therapy Anxiety Management Therapy Cognitive Therapy Combinations EMDR

PTSD Symptom Checklist Score In Combat Veterans

Conditions

Prolonged Exposure Therapy (PE) for PTSD

Breathing retraining: 10 minutes in session 1 Education about common reactions to trauma (25 minutes in session 2) Imaginal exposure (reliving) to the trauma memory (30-45 minutes during sessions 3-12) In vivo exposure to trauma reminders in life between sessions 9-12 weekly or twice weekly 90-minute sessions

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

PE Vs SIT Vs PE/SIT Vs WL
Percent Patients with PTSD

Post-Tx
Foa et al., 1999

6 Mo FU

Last Available FU (M = 10.7 mos.)

Post-Rx Effect Sizes* of PE vs SIT vs PE/SIT: PTSD

*Effect size compared to wait-list group at post-treatment

Foa et al., 1999

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 for partial responders (< 70% improvement)
Foa et al., in preparation

Percent of Patients With PTSD Diagnosis

Percen t

Post-Tx

Last FU
Foa et al., in preparation

Within Group Effect Sizes

PSS-I

BDI
Foa et al., in preparation

Rate of Improvement in Completers of 9 vs. 12 Sessions

35 30 25 20 15 10 5 0 Pre 2 4 6 8 10 12 Post Sessions 12 Sessions 9 Sessions

PDS Score

PE VS PE and CR With Torture Victims

Paunovic & Ost, 2001

Study with Men and Women Victims of Mixed Traumas

Treatments: Exposure (PE) Cognitive Restructuring (CR) PE + CR Relaxation Training Treatment consisted of 10 sessions conducted over 16 weeks

Marks et al., 1998

Good End State Functioning Post Treatment*

PE

SIT

PE/SIT

WL

PE

CR

PE/CR

Foa et al., 1999

Marks et al., 1998

* > 50% improved on PTSD; <7 BDI; <35 STAI-S

CT and EX vs. Combined Treatment

Mean Percent Change

Study Design
Continue Sertraline Only
(5 weeks)

Sertraline Only
(10 weeks)

Sertraline + PE
(5 week, 2x weekly therapy)

PTSD: Effect Sizes for SIP

Completer Sample (n=42)

Structured Interview (SIP)

Foa et al. In Progress

PE+SRT > SRT

PTSD: PE Following Partial or Excellent SRT Response

Completer Sample (n=42)
PE+SRT SRT 45 40 35 30 25 20 15 10 5 0 0

Partial

Excellent

SIP (0-68)

10

15
Weeks

10

15

Foa et al. In Progress

Excellent response equals > decrease of 2 SD

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

Effects of PE and CPT

Completer Sample
Self-reported PTSD Severity

Assessment Point

Resick et al., 2001

1034N

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

K8

The Effects of PE/SIT and EMDR on PTSD: PSS-SR

39 36 33 30 27 24 21 18 15 12 0
PE/SIT EMDR

Severity

Pre

Post

3 Mo FU 1153

Devilly & Spence, 1999

Good End State Functioning*

Percent Responders
*CAPS 50% ; BDI < 10; STAI-S < 40 Rothbaum, Astin, & Marsteller, ISTSS, 2001

At 6 Mo FU PE > EMDR; p <.02

Effects of Eye Movement in EMDR: IES

Pitman et al., 1996

1155

Effects of Eye Movement in EMDR: CAPS

Pitman et al., 1996

1156

Safety and Acceptability of Prolonged Exposure

Exacerbation of Symptoms
Minority of clients in treatment show a reliable exacerbation of symptoms
10.5% in PTSD symptoms 21.1% in Anxiety symptoms 9.2% in Depressive symptoms

Exacerbation of symptoms was not associated with:

treatment drop out poorer treatment outcome
Foa, Zoellner, Feeny, Hembree, & Alvarez (2002)

PTSD Severity and Exacerbation

(N = 76)
35 30 No Exacerbation Exacerbation

PTSD Severity

25 20 15 10 5 0 PreTx Week Week Week Week Post2 4 6 8 Tx

Symptom Worsening after Cognitive Behavioral Treatments

PE
n = 75 Worsening of PTSD 0 Worsening of PTSD, Dep. or Anx. Improve on PTSD 71 (95%) 16 (73%) 43 (94%) 16 (84%) 14 (36%) 1 (5%) 0 0 3 (8%)

PE/SIT
n = 22

PE/CR
n = 46

SIT
n = 19

WL
n = 39

5 (7%)

6 (27%)

3 (7%)

2 (10%)

20 (51%)

Worsening = Increase in symptoms by => 1 point Improve = Decrease in symptoms by => 7 points

Dropout Rate by Treatment Category

Treatment (25 studies)
EX Alone SIT or CT Alone EX plus CT or SIT EMDR Controls (Active and WL)

Total n
330 222 335 143 543

% Dropout
20.6% 22.1% 26.0% 18.9% 11.4%

No difference among active treatments: 2 (3, N= 1030) = 1.73, p = 0.631

Treating Patients with PTSD and AD PTSD: Symptom Changes Completers

Treating Patients with PTSD and AD Percent Days Drinking Completers

Treating Patients with PTSD and AD Alcohol Cravings Completers

Dissemination of Prolonged Exposure

Dissemination Model I: Training Community Clinicians

4- 5-day intensive training of community therapists by Penn experts
Ongoing weekly supervision by Penn experts

Model I: PE in Sexual Assault Survivors (n=123)

PSS-I Total

Expert
Foa et al., in progress

Community

Dissemination Model II: Training the Supervisor

3-4 week training of community supervisor at Penn 5-day intensive training of community therapists by Penn expert with assistance of community supervisor Community supervisor directly supervises community therapists and occasionally consults with Penn expert

Dissemination of PE With Israeli Combat and Terror Survivors (Tel Hashomer)

Nacasch et al., unpublished data

PSS-I Total

Dissemination of PE With Israeli Terror Survivors (Jerusalem)

Friedman et al., unpublished data

PSS-I Total

PE for PTSD received the 2001 Exemplary Substance Abuse Prevention Program Award from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) and was selected as a Model Program for national dissemination

Indications and Counterindications for Exposure Treatment

Indications Pervasive trauma-related anxiety and avoidance Anxiety about the PTSD symptoms themselves Fear of loss of control or going crazy Counterindications Psychosis, severe dissociative symptoms, PTSD symptoms related to realistic guilt and shame (e.g., murdering or raping during war)
1092

Emotional Processing During Therapy Requires:

Accessing of the fear structure (fear activation) Availability of corrective information

827

PTSD, Fear Expression, Anger and Emotional Processing

Pre-treatment
PTSD Symptoms .67 Phobic Reaction .44 .65

During Treatment

Post-treatment

Facial Fear Expression

.77

Percent Improvement (PTSD + Phobic + General Anxiety)

Anger

829

Mechanisms of Therapy for PTSD

Promotion of emotional engagement with the traumatic memories Modification of the erroneous cognitions underlying PTSD
1118

Cognitive Modifications During Exposure Therapy

Repeated reliving of the trauma promotes: Habituation of anxiety (disconfirming anxiety stays forever I will go crazy) Discrimination between remembering and re-encountering Differentiation of the trauma from similar but safe events (disconfirming the world is extremely dangerous) Association of PTSD symptoms with mastery rather than incompetence (disconfirming I am incompetent) Organization of the trauma narratives
1037

Effect of Treatment on PTSD Related Cognitions

Relationship between Changes in Cognitions and in PTSD after Exposure Therapy

PTCI PSSI Reexperiencing Avoidance Arousal Total Self .66 .60 .50 .63 World .46 .37 .42 .46 SelfBlame .27 .27 .30 .29 Total .59 .53 .50 .58

All p < .05. Foa & Rauch, in press

Schematic Model of a Pathological Trauma Memory

Afraid IMe
Alone Scream Freeze PTSD Symptoms

Uncontrollable Rape
Suburbs Home Shoot Gun Bald

Man
Tall

Say I love you

Confused

Incompetent

Dangerous

Conclusions
Several CBT programs are highly effective for PTSD: Stress inoculation training Cognitive therapy (more studies are needed) PE has received the widest empirical evidence Clinicians who are not experts in cognitive behavior therapy can successfully learn PE in short period of time

Early Psychological Interventions

Percentage of Victims with PTSD

Percentage

Assessment

Early Psychological Intervention

Crisis Interventions: Critical Incident Stress Debriefing (CISD; e.g. Mitchel, 1983) Psychological Debriefing (PD; e.g. Dyzegzov, 1986) Cognitive Behavioral Prevention Programs: Prolonged Exposure (PE) Prolonged Exposure + Stress Inoculation Training (PE/SIT)

Psychological Debriefing (PD)

A single session intervention Typically within 72 hours post-trauma Delivered in a group or individual setting Encourage a full narrative account of the trauma (facts, cognitions, feelings) Normalize emotional reactions Prepare for later emotional reactions

Different Strategies for Early Intervention

Very brief intervention for everyone (e.g., 1-session debriefing, not effective as an individual treatment)

Course of individual CBT for selected people at high risk of chronic symptoms (controlled trials: Foa, Bryant, Ehlers)

Impact of Event Scale (IES) in Women After Miscarriage

Intrusion
Severity

Avoidance

Lee et al., 1996

IES and CAPS Scores in MVA Victims

IES total
Severity

CAPS

Conlon et al., 1999

Impact of Event Scale (IES) in Burn Victims

Bisson et al., 1997

IES

Control < PD

Percentage of PTSD Diagnosis

Psych Debrief PTSD 3 Mo PTSD 13 Mo 21% 26% Control 15% 9% *

Bisson et al., 1997

*Control < PD

1214

Impact of Event Scale (IES) in MVA Victims

Hobbs et al., 1996

IES

Effects of PD on MVA Victims with High and Low Initial Impact of Event Scale
40 35 30 25

IES

20 15 10 5 0 Baseline 4 Months
PD/High Scorers PD/Low Scorers

3 Years
Control/High Scorers Control/Low Scorers

Mayou et al., 2000

Conclusion
The data on the usefulness of PD are equivocal with most studies failing to detect long term benefits One-session of PD, delivered within 48 hours post-trauma, may impede natural recovery Victims with severe initial reactions to the trauma may be especially vulnerable to the negative impact of PD

Possibly Misleading Assumptions in Early Intervention Research

Going over trauma memories is always helpful The earlier, the better The earlier, the easier or cheaper

Why are 1-session debriefing and exposure instructions not effective? Speculations
Wrong message: May make negative interpretation of symptoms worse in the long-term Too early: Very early exposure may interfere with natural recovery processes - automatic processes leading to fading memories - natural rhythm of processing the event intermittently (small doses, alternatingwith resuming everyday life)

CBT Prevention Program

Four to five weekly sessions Typically within 2-5 weeks post-trauma Delivered in individual setting Intervention Includes: Discussions of normal reactions to assault Breathing retraining Deep muscle relaxation Recounting the assault Cognitive restructuring Exposure in vivo assignments

CBT Vs Assessment Control

PTSD Symptom Severity

Foa et al., 1995

Comparison of PE/SIT and SC for MVA/Industrial Victims with ASD

Bryant et al., 1998

Impact of Event

PE/SIT < SC

1220

Comparison of PE, PE/SIT, and SC for MVA / Assault Victims with ASD
Impact of Event

Bryant et al., 1999

PE, PE/SIT < SC

1218

Good End State Functioning1

Percent Responders

* *

BP
Foa et al., 2001
1PSS-I

AC

SC

< 15; BDI < 10; BAI < 10

Conclusion
4-5 CBT sessions delivered at least two weeks after the trauma accelerate recovery Similar to treatment of chronic PTSD, Prolonged Exposure alone is as effective as more complex programs

1222-N

Assessment

Who should receive PE?

Individuals with chronic PTSD and related psychopathology following all types of trauma This includes individuals with comorbid problems (e.g., depression, other anxiety disorders, substance abuse, Axis II disorders)

Populations with whom PE has not yet been studied

Individuals with PTSD who also have current: Psychosis Dissociative Identity Disorders (e.g., multiple personality disorder) Serious self-injurious behavior (e.g., cutting, self-mutilating) Imminent threat of suicidal or homicidal behavior PTSD related to intentionally harming another person (e.g., murdering or raping)

Importance of Assessment
Conduct initial evaluation to:
Obtain detailed trauma history, determine index trauma Confirm diagnosis of PTSD (or at least presence of significant symptoms), and that PTSD is among the current primary problems Assess for presence of comorbid disorders

Assessment of Trauma-Related Psychopathology

Assessment of PTSD symptoms Interviewer measure PTSD Symptom Scale (PSS-I) Self-report measure Posttraumatic Diagnostic Scale (PDS)

Trauma-Related Psychopathology
Assessment of other disorders and symptoms Interviewer measures
SCID-IV, MINI

Self-report measures
Beck Depression Inventory (BDI) State-Trait Anxiety Inventory (STAI) Posttraumatic Cognitions Inventory (PTCI)

Assessment of Trauma-related Symptoms During and Pre-Post Treatment

Intra-therapy assessment
PDS, BDI, PTCI every other session Permits assessment of change during therapy; helpful for tracking progress and giving feedback to patient

Pre and Post-treatment assessment

Administer PSS-I interview to evaluate changes in trauma-related symptoms

PTSD Symptom Scale Interview (PSS-I)

Flexible, semi-structured interview to allow clinicians to make a diagnosis of PTSD Estimates severity of the symptoms When administering the PSSI, interviewers link the symptoms to a single identified target or index trauma Typically this is the trauma identified by patient as causing the most current distress, but the PSSI may be used to assess symptoms relative to any identifiable traumatic event

PSS-I
Interviewer should establish the time frame in which symptoms are to be reported (and may need to remind patient of this periodically) PSS-I has been found valid for assessing symptoms over the course of a month and over a two-week period The PSS-I could be used to assess symptoms over longer and shorter periods of time, but the validity of the interview under these conditions has not been examined

PSS-I
In scoring each item on the PSS-I the interviewer integrates all of the information obtained during the interview Final severity rating combines interviewers impressions of the frequency and the intensity with which the symptoms are experienced PSS-I manual offers guidelines for making such ratings for each symptom

Administration of PSS-I
Instructions:
I want to get a really good picture of how things
have been going for you in the past 2 weeks in terms of trauma related difficulties. So, today is (insert date)_, two weeks ago takes us back to (insert date)_, this is the period of time that I will focus on. Remember that throughout the interview I will be asking about difficulties related to the event that you identified as the most distressing, the (repeat event). Do you have any questions?