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 AnxietyUniversity 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

Perc

ent (

%)

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

Perc

ent (

%)

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

Perc

ent (

%)

Males Females

Rate of PTSD is Influenced by Rate of PTSD is Influenced by the Nature of the Traumathe Nature of the Trauma

0102030405060

Disaste

r

Acciden

t

Assault

Molestat

ion

Combat*Rape

Perc

ent (

%)

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

Perc

ent (

%)

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

Perc

ent (

%)

Rape Victims Non-Sexual Assault

Comorbidity with PTSDComorbidity with PTSD

0

20

40

60

80

100

MDDys

Phobia

Soc Anx

AgoraGAD PD Alc

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

Perc

ent (

%)

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

05

1015202530354045

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

PTSDDepression

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

020

4060

80100

Post-TxPerc

ent G

ood

End-

Stat

e Fu

nctio

ning

*

PE CR PE/CR RLX

Foa et al., 1999

020

4060

80100

Post-Tx FUPerc

ent G

ood

End-

Stat

e Fu

nctio

ning

*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

020406080

100

Post-Tx

6-MoFU

9-MoFU

Perc

ent G

ood

End-

Stat

e Fu

nctio

ning

*

PE CPT WL

Rothbaum et al., 2005

020406080

100

Post-Tx 6- Mo FUPe

rcen

t Goo

d En

d-St

ate

Func

tioni

ng*

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 – 81.0SC 7 39.3% 21.2 – 57.3WL 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

01020304050607080

Wk 0 Wk 12 36

CA

PS

Double blindacute

treatment

Open label continuation

treatment

Londborg et al., 2001

Response Status after 36 Response Status after 36 Weeks of SertralineWeeks of Sertraline

0102030405060

Wk 36

Perc

ent

Continuous Responder Eventual ResponderRelapser Non-Responder

Time to Discontinuation Due to Time to Discontinuation Due to Relapse or Clinical DeteriorationRelapse or Clinical Deterioration

Kap

lan-

Mei

er S

urvi

val

Prob

abili

ty

WeeksDavidson, 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

PTSD

Sev

erity

(PSS

-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

PTSD

Sev

erity

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

PTSD

Sev

erity

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

PTSD

Sev

erity

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)

0102030405060708090

Post 6-Mo FU

Perc

ent P

TSD

CBTPECBT+HypSC

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

Perc

ent 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

Perc

ent E

ndor

sing

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

sage

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